Physiological Birth Research Articles

Barriers to women's access to alongside midwifery units in England

BackgroundAlongside midwifery units (AMUs) are managed by midwives and proximate to obstetric units (OUs), offering a home-like birth environment for women with straightforward pregnancies. They support physiological birth, with fast access to medical care if needed. AMUs have good perinatal outcomes and lower rates of interventions than OUs. In England, uptake remains lower than potential use, despite recent changes in policy to support their use. This article reports on experiences of access from a broader study that investigated AMU organisation and care. MethodsOrganisational case studies in four National Health Service (NHS) Trusts in England, selected for variation geographically and in features of their midwifery units. Fieldwork (December 2011 to October 2012) included observations (>100 h); semi-structured interviews with staff, managers and stakeholders (n = 89) and with postnatal women and partners (n = 47), on which this paper reports. Data were analysed thematically using NVivo10 software. ResultsWomen, partners and families felt welcome and valued in the AMU. They were drawn to the AMUs’ environment, philosophy and approach to technology, including pain management. Access for some was hindered by inconsistent information about the existence, environment and safety of AMUs, and barriers to admission in early labour. ConclusionsKey barriers to AMUs arise through inequitable information and challenges with admission in early labour. Most women still give birth in obstetric units and despite increases in the numbers of women birthing on AMUs since 2010, addressing these barriers will be essential to future scale-up.

Оцінювання цитокінового статусу жінок з невиношуванням вагітності

During pregnancy, a unique new equilibrium state appears between the systems of the specific and nonspecific mothers immunity. Besides, the cytokine cascade is launched, which includes proinflammatory and anti-inflammatory factors of influence. The balance between these two groups of mediators determines the nature of the course and outcome of the gestation process. The objective: to determine the role of mediators of pro-inflammatory and anti-inflammatory reactions of gestation intercourse in patients with miscarriage. Materials and methods. The main group (the first group) was made up of 153 pregnant women with miscarriage. The control group (the second group) consisted of 25 relatively healthy women with a physiological course of pregnancy and a complcated obstetric and gynecological anamnesis, with one and more physiological births in anamnesis. The concentration of cytokines IL-1 β, IL-6, IL-8, IL-10, TNF- α in the blood and their content in cervical mucus by solid-phase immune-enzyme analysis was determined. Results. Consequences of previous pregnancies having a background of inflammatory complications of genital and extragenital genesis create conditions for long-term persistence of latent infection, including in the uterine cavity and cervical canal, followed by infection of the fetus, and contribute to the development of immune imbalance during gestation, which leads to a cascade of homeostasis disorders with the development of complications of the pregnancy intercourse and perinatal pathology. Thus, the presence of clinical symptoms of the threat of premature abortion occurs in the context of an increase in the concentration of proinflammatory cytokines (IL-6, IL-8, TNF- α and IL-1 β) in serum.Reducing the concentration of IL-10 in non-pregnant women, relative to such in control group, throughout the entire pregnancy in the blood and its content in cervical mucus indicates a violation of the balance of pro– and anti-inflammatory cytokines in the direction of pro-inflammatory reactions and violation of the local immune response. Conclusions. In women with a loss in the first trimester there is a pro-inflammatory activity of the immune response, which is an important pathogenetic factor in the development of abortion in different gestational periods. Key words: miscarriage, proinflammatory cytokines, anti-inflammatory cytokines.

FEATURES OF THE COURSE OF THE PERINATAL PERIOD AND DELIVERIESDURING PREGNANCY WITH A SINGLE UMBILICAL ARTERY OF THE FETUS

Among the anomalies in the number of vessels of the umbilical cord,thesingle umbilical artery (SUA) is most often found. A significant impact of SUA on the course of such pregnancy and deliveries is expected. The article presents some peculiarities of the deliveries and condition of newborns after pregnancies with SUA compared with pregnant women with three umbilical cord vessels and physiological deliveries. The objective of the workwasto analyze the peculiarities of the perinatal period and deliveries after pregnancy with SUA, to conduct a comparative analysis of the revealed features with the corresponding indicators among pregnant women with two umbilical arteries and physiological births. Thestudygroupconsistedof 31 pregnant women with a SUA (study group)and control group – 62 pregnant women with 2 arteries of the umbilical cord. According to our data, pregnant womenwith SUA were hospitalized earlier and spent more time in the maternity hospital, although the terms of delivery did not differ between the two study groups, although there was a tendency to an earlier term of delivery in pregnant women with SUA. Among pregnant women with SUA, deliveries were premature in 4 women (12.9 %). No differences were found between pregnant women with SUA and control group in such indicators as early discharge of amniotic fluid, anthropometric indicators of pregnant women, entanglement of umbilical cord, pelvic presentation, rupture of the perineum or episiotomy during deliveries. The duration ofI, II and III periods of deliveries also did not differ significantly between the two study groups. Weakness of patrimonial activity was more often in women with SUA, accounting for 12.9 % of all deliveries, compared to 3.2 % in the control group. Fetal hypoxia in deliveries was observed in 25.8 % of cases among pregnant women with SUA, and in 4.8 % among pregnant women in the control group. Fetal distress in deliveries was estimated at 4 (12.9 %) and 4 caesarean sections were performed. Physiological childbirth occurred in all cases in the control group. In the SUA group, the infant weight was significantly lower than the control group children, but the Apgar score at 1 and 5 minutes did not differ between the two study groups. Cardio-respiratory depression, risk of neurological disorders, and congenital malformations (esophageal atresia, Gothic palate, and syndactylium) were more frequently reported in the SUA group. Long-term hospitalization of pregnant women, weakness in delivery, premature birth, fetal hypoxia in delivery, fetal distress and incidence of cesarean delivery are much more common in SUA group. The weight of newborns from pregnancies with SUA is significantly lower, however, the infants' status on the Agar scale after pregnancies with SUA did not differ from those of children in the control group. Cardiovascular depression, the risk of neurological disorders, and congenital malformations (esophageal atresia, Gothic palate, and syndactyly) were more common in the SUA group.

Quality Improvement Project in the School of Nursing to Support Physiologic Birth Support

An elective pilot course to teach doula skills and provide hands-on experience, titled “Supporting Physiologic Labor and Childbirth for Nurses,” was created within a school of nursing for prelicensure students. The purpose was to teach physical and emotional labor support techniques to promote low-intervention birth. The school partnered with the university hospital to provide doula services for women who were admitted while they were in labor and who wanted labor support. To enhance current maternal nursing curricula by offering an elective course modeled on evidence-based doula care and skills to support physiologic childbirth by using the Doulas of North America International model of care and curriculum. Twelve prelicensure students enrolled in an elective two-credit course that incorporated the Doulas of North America International curriculum, enhanced with additional seminars. They provided labor support for a minimum of four 8-hr shifts at the partner hospital. Data were collected before and after the course to measure differences in student knowledge of labor support techniques. Data were also collected from students, clients, and providers to describe techniques used and effectiveness of labor support as well as labor and birth outcomes. Eleven of the 12 students completed the course. The students reported an increase of more than 50% in competence in providing emotional and breastfeeding support, community resources, and supporting patients of diverse backgrounds. Students also reported a 47% increase in competence in providing physical labor support and a 32% increase in knowledge about postpartum mood disorders. Clients, providers, and students reported high effectiveness of physical and emotional support, incorporation of partner–family, and overall usefulness. Nursing students interested in maternity care benefited from learning comprehensive labor support techniques, and their services were valued by women giving birth and providers. This innovative pilot course offers a replicable and scalable approach for other schools to enhance their curricula.

Birthing the placenta: women\u2019s decisions and experiences

BackgroundPrevious research examining the birth of the placenta has focussed on quantitative outcomes comparing active and expectant (physiological) management. However, it is also important to understand women’s experiences of birthing the placenta.MethodsThe participant group consisted of 11 women who had expectant management, eight who had active management and one who was unsure. Participants were interviewed in-depth and the data analysed using thematic analysis.ResultsSeven themes were identified in the data relating to before, during and after the birth of the placenta. Before birth themes focused on making decisions and included ‘doing the research’ and ‘natural birth’. During the birth of the placenta themes were ‘boundaries of time’, ‘focusing on baby’ and ‘sensations’. After the birth themes consisted of ‘looking’ and ‘keeping’.ConclusionMost of the women considered a physiological birth of the placenta to be an intrinsic element of natural birth. Active management was considered to be an intervention used if complications occurred. In contrast, women who chose active management did not consider the placenta to be an important element of natural birth, and chose active management in order to prevent complications. Decisions about birthing the placenta were informed by Internet sources and previous personal experiences rather than care providers. During the birth of the placenta care providers managed the boundaries of time whilst women focused on their baby. The sensations women described were consistent across both types of management. Women valued seeing their placenta and having the opportunity to keep it, and placenta encapsulation was popular. The findings of this study contribute the experiences of women to the body of knowledge informing practice during the birth of the placenta.

Healthy Birth Practice #1: Let Labor Begin on Its Own.

Current evidence and professional organizations identify letting labor begin on its own as one of the most important strategies for promoting normal, physiologic birth. It also prevents iatrogenic prematurity and the need for high-tech medical interventions required for labor induction. Because the American College of Obstetricians and Gynecologists (ACOG) now states that it is reasonable for obstetric care providers to offer induction at 39 weeks to low-risk nulliparous women, it is more important than ever for childbirth educators to be familiar with best evidence on letting labor begin on its own.

Safe Childbirth: A Call to Action.

Since the publication of Lamaze's Six Healthy Birth Practice papers in 2014, there has been increasing concern with the safety of the current maternity care system. A doubling of the maternal mortality rate in the United States and the continued high cesarean rate, as well as ongoing research that supports physiologic birth and identifies the risks of interfering with the physiologic process, has resulted in updated guidelines for care and has spurred advocacy efforts to transform maternity care. This article presents a number of these advocacy efforts.

Do midwifery International clinical placements influence students’ practice and employment decisions?

AimThe aim of this study was to investigate whether an International two-week clinical maternity placement enhances, and is beneficial, to midwifery students’ future practice and employment decisions during the final year of an undergraduate degree. BackgroundInternational placements are common in undergraduate pre-registration nursing midwifery university curricula, with the emphasis on preparing students to work with diverse women in multicultural environments whilst incorporating cultural competence. However, little is known as to whether an International placement influences future graduate’s work place choice. MethodsUsing a qualitative approach, focus groups were undertaken with 16 final year midwifery students from a University in Western Australia who had experienced a two-week International clinical midwifery placement in Tanzania (Africa) or Manilla (Philippines). Data was analysed using thematic analysis. FindingsThe results of the study revealed eight over-arching themes that revealed an increase in midwifery student’s confidence; an awareness of the need to consolidate knowledge and skills, reinforcement of their own career aspirations, midwifery beliefs and trust in women and physiological birth. ConclusionThis study confirms the benefits of overseas clinical placements, which provide opportunities beyond developing cultural sensitivity. Midwifery students are challenged to develop not only practical competence, but confidence to trust in themselves and the process of physiological birth. These experiences validate theoretical learning and provide opportunity to reflect on the possibilities of future employment and decision making as a midwife.

Reintegrating modern birth practice within ancient birth process: What high cesarean rates ignore about physiologic birth

Reintegrating modern birth practice within ancient birth process: What high cesarean rates ignore about physiologic birth

Associations among cervical dilatation at admission, intrapartum care, and birth mode in low‐risk, nulliparous women

Admission in early labor is associated with increased likelihood of cesarean birth, but the context in which this occurs is unclear. Previous research has explored the relationship between dilatation at admission and the use of single intrapartum interventions; however, the majority of women in the United States receive multiple intrapartum interventions. The objective of this study was to examine the associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women with spontaneous onset of labor. This was a cross-sectional, observational study of 21858 nulliparous, singleton, term vertex births that occurred from 2002 to 2007 across nine hospitals in the Consortium on Safe Labor. Outcome measures included the individual and combined use of intrapartum interventions (amniotomy, epidural anesthesia, oxytocin augmentation) and birth mode. In this sample, 92.0% of women received at least one intrapartum intervention and 22.7% received all three interventions. After propensity score adjustment, women were more than twice as likely to receive the combination of amniotomy-epidural-oxytocin when admitted at 0-3cm (RR 2.83 [95% CI 2.45-3.27]) and 4-5cm (2.49 [2.15-2.89]) compared to 6-10cm. Adjusted likelihood of cesarean birth was five times greater for women admitted at 0-3cm (5.26 [4.36-6.34]) and two times greater for women admitted at 4-5cm (2.27 [1.86-2.77]) compared to 6-10cm. To promote normal physiologic birth, low-risk, nulliparous women should be engaged in shared decision-making about timing of admission after spontaneous onset of labor.

Exploring stakeholder's perception about factors affecting on implementation of physiologic birth plan: A qualitative approach

Context: Following the increase in cesarean section rate in Iran, the Ministry of Health and Medical Education has planned a program for the promotion of normal birth. The plan named as “physiologic birth” that is equal with “spontaneous labor.” Aims: This study aims to explain factors affecting the implementation of “physiologic birth plan from stakeholders” view. Setting and Design: In this qualitative study, purposive samples of 21 health-care stakeholders (2 men and 19 women) were interviewed in 2016. The participants included three obstetricians and gynecologists, six midwives, three managers and experts in charge of the plan at the Mazandaran University of Medical Science, and nine women who gave birth under the physiological delivery (Spontaneous Labor) plan. Materials and Methods: Face-to-face semi-structured interviews and one focus group discussion were employed to collect the study data. Statistical Analysis Used: Qualitative content analysis method was used. Results: From the data analysis, the main theme “integrity of designing and implementation” and five subthemes as the influencing factors, namely, The “inadequate resources,” “ambiguity in tasks and roles,” “attention to psychosocial atmosphere,” “considering of the delivery culture,” and “incomprehensive training and updating the plan,” were extracted. Conclusion: This research suggests that the success behind implementing a plan in health-care system including the physiological delivery plan depends on the factors that are requiring should be identified and investigated from the designing stage to the implementation stage and after that. Thus, health system policymakers and planners are required to pay attention to diverse above-mentioned aspects in its designing and implementation.

Natural Childbirth after the Previous Caesarian Section is a Solved Problem

Тhe rapid increase in the frequency of сesarian section (CS) observed in recent years (up to 60% in some countries) is alarming and reduces the reproductive potential of the population. The operated uterus remains the main indication for CS (up to 40%). This is the factor which may allow reducing the frequency of the CS by subsequent delivering through the birth canal. A comparative analysis of maternal and neonatal outcomes enabled the authors to develop a two-stage delivery technology for patients with a caesarean scar, including the usage of the programmed delivery method. The presented algorithm confirmed the validity of vaginal delivery in such patients, and reduced the number of complications up to 4 times. Neonatal morbidity in children born through the birth canal in such patients was comparable to physiological birth.

Facility Design: Reimagining Approaches to Childbirth in Hospital and Birth Center Settings.

Few maternity care clinicians are aware of the current regulations that guide design standards for childbirth facilities in the United States or the regulatory history. There is considerable variance among state regulations as well as oversight of facility standards for healthcare settings. Understanding evidence-based recommendations on how facility design affects health outcomes is critical to reversing the rise in maternal mortality and morbidity. A variety of measures can be implemented that promise to improve user satisfaction, quality of care, and efficiency for all who engage in the childbirth environment. Recommendations for change include broader assessment to better understand how clinicians and consumers simultaneously maneuver within a complex system. Key metrics include evaluation of workflow within available space, patient acuity and census patterns, integration of evidence-based recommendations, and options that promote physiologic birth. For the changes to succeed, human centered design must be implemented and diverse clinicians and consumers engaged in all phases of planning and implementation. Exploring characteristics and outcomes of low-risk women who receive care in a freestanding birth center or the European alongside maternity unit provides opportunity to reimagine and address improvements for inpatient, hospital birth.

Challenging the status quo: Women's experiences of opting for a home birth in Andalucia, Spain

ObjectiveTo explore the perceptions, beliefs and attitudes of women who opted for a home birth in Andalusia (Spain). BackgroundHome birth is currently an unusual choice among Spanish women. It is not an option covered by the Spanish National Health Service and women who opt for a home birth have to pay for an independent midwife. DesignA qualitative study with a phenomenological approach was adopted. All participants who took part in this study had chosen to have a home birth and given written consent to take part in the study. MethodsData collection was conducted in 2015–16. Face-to-face, semi-structured interviews were undertaken with women who chose a home birth in the last 5 years. FindingsThe sample consisted of thirteen women. Seven themes were created through analysis: 1. Getting informed about home birth; 2. Home birth as a choice, despite feeling unsupported; 3. The best way to have a personalized and a physiological birth; 4. Seeking a healing and empowering experience 5. The need for emotional safety, establishing a relationship and trusting the midwife; 6. Preparing for birth and working on fears; 7. Inequality of access (because of financial implications). ConclusionsWomen opted to plan birth at home because they wanted a personalised birth and control over their decision-making in labour, which they felt would not have been afforded to them in hospital settings. Andalusian maternity care leaders should strive to ensure that all pregnant women receive respectful and high-quality personalised care, by appropriately trained staff, both in the hospital and in the community.

Women's Perceptions of Prenatal Influences on Maternal Confidence for Physiologic Birth

A physiologic approach to labor and birth is preferred for most women. The United States spends more on birth than any other country. Cesarean rates are currently 32%, and approximately 23% of women with a singleton pregnancy experience induction or augmentation of labor. Most physiologic birth research has focused on care during labor and birth. The purpose of this study was to describe women's perceptions of the care processes, support, and information received during pregnancy that helped them feel confident for physiologic labor and birth. Using a qualitative descriptive design with 2 phases, women were recruited from an urban area and a smaller city in Minnesota. Phase 1 included focus groups with women who had given birth within the previous 6 months. They participated in a discussion about experiences that helped them feel confident for labor and birth. In Phase 2, women who had a physiologic birth, which was defined as term pregnancy, spontaneous labor, no epidural analgesia, and vaginal birth, participated in individual interviews. Focus group and individual interview recordings were transcribed and analyzed using Glaser's constant comparative approach. Thirty-eight women participated in 9 focus groups. Seventeen women had a physiologic birth; 14 participated in individual interviews. Themes derived from the analysis included confidence in the face of uncertainty, belief in the normalcy of birth and the body's ability to birth, research on my own, supportive care partnership, on the same page, and sources of information and support. Women who experienced physiologic birth believed that this was possible and expected. They sought information, including searching on their own, from maternity care providers and a broader support system. Relationships with their maternity care providers were important. Prenatal care focused on women's strengths and abilities, while also monitoring pregnancy health and safety, may help reduce unnecessary interventions, improve outcomes, and reduce costs.

‘I felt like I could do anything!’ Writing the phenomenon of ‘transcendent birth’ through autoethnography

Objective: To discuss the concept of ‘transcendent birth’, an as yet poorly articulated and under recognised psychosocial wellness phenomenon of childbirth. Design: an auto-ethnographical examination of the primary authors’ journaled experiences as a student midwife and childbearing woman. Setting: three maternity care units in South Eastern Australia as well as the home of the primary author. Findings: The phenomenon of transcendent birth is linked with physiologic birth. Maternity care can hinder or facilitate physiologic birth, and therefore transcendent birth. Key conclusions: Transcendent birth is more likely in maternity care models which value the childbearing woman and physiologic birth. Implications for practice: Women's access to transcendent birth is demarcated by women's position in society, cultural knowledge of transcendent birth and the valuing of transcendent birth as a maternity care outcome.

Optimal settings for childbirth.

Many studies highlight how health is influenced by the settings in which people live, work, and receive health care. In particular, the setting in which childbirth takes place is highly influential. The physiological processes of women's labor and birth are enhanced in optimal ("salutogenic," or health promoting) environments. Settings can also make a difference in the way maternity staff practice. This paper focuses on how positive examples of Italian birth places incorporate principles of healthy settings. The "Margherita" Birth Center in Florence and the Maternity Home "Il Nido" in Bologna were purposively selected as cases where the physical-environmental setting seemed to reflect an embedded model of care that promotes health in the context of childbirth. Narrative accounts of the project design were collected from lead professional and direct inspections performed to elicit the key salutogenic components of the physical layout. Comparisons between cases with a standard hospital labor ward layout were performed. Cross-case similarities emerged. The physical characteristics mostly related to optimal settings were a result of collaborative design decisions with stakeholders and users, and the resulting local intention to maximize safe physiological birth, psychosocial wellbeing, facilitate movement and relaxation, prioritize space for privacy, intimacy, and favor human contact and relationships. The key elements identified in this paper have the potential to inform further investigations for the design or renovation of all birth places (including hospitals) in order to optimize the salutogenic component of any setting in any country.

A Qualitative Study on Midwives' Perceptions of Physiologic Birth in Singapore.

Midwives are advocates for parturients, and their actions and attitudes can influence a woman's experience during childbirth. Hence, it is valuable to examine midwives' perceptions of physiologic birth in an obstetric-led environment. A descriptive, qualitative study design was utilized. Semistructured face-to-face interviews were conducted with 10 registered midwives from the birthing suite of a public hospital in Singapore. Data were analyzed using thematic analysis. Three major themes were (1) perceptions of physiologic birth, (2) perceived facilitators of physiologic birth, and (3) perceived barriers to physiologic birth. Interestingly, senior midwives in this study experienced more negative outcomes with physiologic birth, resulting in apprehension and reduced confidence levels. This study contributed to the understanding of midwives' perceptions regarding facilitators and barriers to physiologic birth. Factors such as supporting birthing team and antepartum education could be useful in supporting physiologic birth. However, advanced age of some of the midwives was found in this study to be a barrier to physiologic birth.

Women’s psychological experiences of physiological childbirth: a meta-synthesis

ObjectiveTo synthesise qualitative studies on women’s psychological experiences of physiological childbirth.DesignMeta-synthesis.MethodsStudies exploring women’s psychological experiences of physiological birth using qualitative methods were eligible. The research group searched the following databases:...

An exploration of Western Australian rural midwives’ decision to rescind their midwifery registration

The aim of this study was to investigate whether an International two-week clinical maternity placement enhances, and is beneficial, to midwifery students’ future practice and employment decisions during the final year of an undergraduate degree.International placements are common in undergraduate pre-registration nursing midwifery university curricula, with the emphasis on preparing students to work with diverse women in multicultural environments whilst incorporating cultural competence. However, little is known as to whether an International placement influences future graduate’s work place choice.Using a qualitative approach, focus groups were undertaken with 16 final year midwifery students from a University in Western Australia who had experienced a two-week International clinical midwifery placement in Tanzania (Africa) or Manilla (Philippines). Data was analysed using thematic analysis.The results of the study revealed eight over-arching themes that revealed an increase in midwifery student’s confidence; an awareness of the need to consolidate knowledge and skills, reinforcement of their own career aspirations, midwifery beliefs and trust in women and physiological birth.This study confirms the benefits of overseas clinical placements, which provide opportunities beyond developing cultural sensitivity. Midwifery students are challenged to develop not only practical competence, but confidence to trust in themselves and the process of physiological birth. These experiences validate theoretical learning and provide opportunity to reflect on the possibilities of future employment and decision making as a midwife.