Unassisted Vaginal Birth Research Articles

Using a birth ball to reduce pain perception in the latent phase of labour: a randomised controlled trial

BackgroundAdmission in the latent phase of labour is associated with higher rates of obstetric intervention. Women are frequently admitted due to pain. This study aimed to determine whether using a birth ball at home in the latent phase of labour reduces pain perception on admission. MethodA prospective, pragmatic randomised controlled trial of 294 low risk pregnant women aged 18 and over planning a hospital birth. An animated educational video was offered at 36 weeks’ gestation along with a birth ball. The primary outcome was pain on a Visual Analogue Scale on admission in labour. Participants who experienced a spontaneous labour were invited to respond to an online questionnaire 6 weeks’ postpartum. ResultsThere were no differences in the mean pain scores; (6.3 versus 6.5; 90%CI −0.72 to 0.37 p = 0.6) or mean cervical dilatation on admission (4.7 cm versus 5.0 cm; 95% CI −1.1 to 0.5 p = 0.58). More Intervention participants were admitted in active labour (63.6% versus 55.7%; p = 0.28) and experienced an unassisted vaginal birth (70.3% v. 65.8%; p = 0.07) with fewer intrapartum caesarean sections (7.5% v. 17.9%; p = 0.07) although the trial was not powered to detect these differences in secondary outcomes. Most participants found the birth ball helpful (89.2%) and would use it in a future labour (92.5%). ConclusionUsing the birth ball at home in the latent phase is a safe and acceptable strategy for labouring women to manage their labour, potentially postpone admission and reduce caesarean section. Further research is warranted.

Success rate of repeated cycles of induction in labour in a UK clinical setting: A cohort study

Background: Births are increasingly started artificially using medications such as prostaglandin, oxytocin, or other mechanical methods, a process known as induction of labour (IOL). The aim of the study was to identify the success rate of a repeat cycle of induction of labour (IOL) with prostaglandins, and any association between smoking and patient response to prostaglandin. Methods: This was a retrospective cohort study set in Basildon and Thurrock University Hospital, UK. IOL data from patients were collected between 1 January 2021 and 30 March 2021. Data were retrieved from hospital records and categorised by prostaglandin cycle(s), administration of oxytocin, artificial rupture of membranes (ARM), spontaneous rupture of membranes (SROM), smoking status, patient BMI, age, ethnicity, gestation age, Bishop score, and delivery method (assisted, unassisted, or Caesarean (C-)section). The data were analysed using Chi-square, binomial and multinomial logistic regression. The success rate was interpreted from relative frequencies of delivery method (unassisted, assisted or C-section). Results: Unassisted vaginal delivery (n =121; 48.0%) was the most common outcome with prostaglandin IOL followed by C-section (n = 105 41.7%). Only 10.3% had an assisted vaginal delivery. Of those who had a repeated IOL cycle, 85.7% had a C-section. There was no difference in prostaglandin administration by smoking status or any association between smoking status and mode of delivery in IOL. Conclusions: Repeat cycle of IOL does not enhance the vaginal delivery with only 14.3% unassisted vaginal births. There was no evidence that smoking impacted on response to prostaglandins or method of delivery.

A case–control study on maternal and early neonatal outcomes in instrumental delivery in a tertiary referral hospital

Background: A vaginal delivery is the safest and most common type of childbirth. It accounts for 80% of births worldwide. This includes both normal birth and operative vaginal delivery. The operative vaginal delivery rates vary from 3% to 13%. The term “normal birth” in academic literature has been used as an unassisted vaginal birth without induction of labor; epidural, spinal, or general anesthesia; or episiotomy. A birth in which the operator uses forceps, a vacuum device, or another instrument to extract the fetus from the vagina, with or without concurrent maternal pushing is called operative vaginal delivery. Aims and Objectives: The aims and objectives of the study are to compare the maternal and neonatal outcomes of normal delivery and operative vaginal delivery. Materials and Methods: The prospective case–control study was conducted in a tertiary care center in South India. The study group consists of 393 instrumental and 391 normal deliveries. The American College of Obstetricians and Gynecologists guidelines were used to define outlet vacuum and outlet forceps. Women who had normal vaginal delivery were matched for age and parity was selected as control. All data were collected using a structured interview schedule. Data were analyzed to meet the aims and objectives of the study. Results: The incidence of vaginal laceration was 4.3% in the instrumental delivery group and 1.3% in the normal delivery group. Other complications in the above groups include post-partum hemorrhage (PPH) (3.8% vs. 1.3%), puerperal complications (7.9% vs. 3.9%), 1-min Apgar >7 (88.7% vs. 95.1%), cephalohematoma (1.5%-1.8% vs. nil), and hyperbilirubinemia (6.4% vs. 4.3%). All the above differences were statistically significant. Conclusion: Significant maternal complications identified in operative vaginal deliveries were vaginal lacerations and PPH. Neonatal complications identified were low Apgar score at 1 min, cephalohematoma, hyperbilirubinemia, and facial marks.

A direct comparison of patient-reported outcomes and experiences in alternative models of maternity care in Queensland, Australia.

We aimed to directly compare women's pregnancy to postpartum outcomes and experiences across the major maternity models of care offered in Queensland, Australia. We conducted secondary analyses of self-reported data collected in 2012 from a state-wide sample of women who had recently given birth in Queensland (response rate = 30.4%). Logistic regression was used to estimate the odds of outcomes and experiences associated with three models (GP Shared Care, Public Midwifery Continuity Care, Private Obstetric Care) compared with Standard Public Care, adjusting for relevant maternal characteristics and clinical covariates. Of 2,802 women, 18.2% received Standard Public Care, 21.7% received GP Shared Care, 12.9% received Public Midwifery Continuity Care, and 47.1% received Private Obstetric Care. There were minimal differences for women in GP Shared Care. Women in Public Midwifery Continuity Care were less likely to have a scheduled caesarean and more likely to have an unassisted vaginal birth, experience freedom of mobility during labour and informed consent processes for inducing labour, vaginal examinations, fetal monitoring and receiving Syntocinon to birth their placenta, and report highest quality interpersonal care. They had fewer vaginal examinations, lower odds of perineal trauma requiring sutures and anxiety after birth, shorter postpartum hospital stays, and higher odds of a home postpartum care visit. Women in Private Obstetric Care were more likely to have their labour induced, a scheduled caesarean birth, experience informed consent processes for caesarean, and report highest quality interpersonal care, but less likely to experience unassisted vaginal birth and informed consent for Syntocinon to birth their placenta. There is an urgent need to communicate variations between maternity models across the range of outcome and experiential measures that are important to women; build more rigorous comparative evidence for Private Midwifery Care; and prioritise experiential and out-of-pocket cost comparisons in further research to enable woman-centred informed decision-making.

Term induction of labour in nulliparous women: When to draw the line?

ObjectiveThere exists uncertainty surrounding the most effective and efficient means of inducing labour, particularly in the setting of an unfavourable cervix. This study aims to determine the merit of repeating dinoprostone administration when a single application has failed to render the cervix favourable for amniotomy.Study designRetrospective analysis of a consecutive cohort of nulliparous women who underwent term induction of labour in a tertiary referral centre in Ireland was conducted over a 12- month period (December 2019 to January 2021). The time-interval from dinoprostone administration to delivery and the incidence of complicated birth, associated with single and sequential dinoprostone dosing, were determined. Comparisons were made using the Chi-square test and logistic regression adjusting for gestational age delivery.Results586 nulliparous women underwent term induction of labour during the study period. Administration of a single dose of dinoprostone or amniotomy alone were associated with the greatest prospect of an uncomplicated vaginal birth when compared to sequential dinoprostone dosing. Nonetheless, just one in four nulliparous women undergoing induction of labour experienced an unassisted and uncomplicated vaginal birth. The median [interquartile range] for time interval from induction to delivery or decision for caesarean delivery was 0.4 [0.3–0.6] days in those who underwent amniotomy alone, compared to 1.1 [0.7–1.5] days, 1.8 [1.4–2.2] days and 2.2 [2.0–2.6] days for those with 1, 2 or 3 doses of dinoprostone, respectively (p < 0.001 between all groups; Figure 1)ConclusionThese contemporaneous data indicate that in circumstances where more than a single dose of dinoprostone is required for cervical priming in a nulliparous woman, the incidence of an uncomplicated vaginal delivery decreased from more than half of women to less than one third. Over one third of women who were administered either a single dose of dinoprostone or more than one dose experienced an emergency intrapartum Caesarean delivery or a complicated vaginal birth. These findings are relevant to nulliparous women undergoing induction of labour in the setting of an unfavourable cervix and should be incorporated into shared decision-making consultations, particularly when repeat administration of dinoprostone is being considered.

Further validation of the birth satisfaction scale-revised: Factor structure, validity, and reliability

The Birth Satisfaction Scale-Revised is a short but valid and reliable robust measure of different aspects of birth satisfaction. This study aimed to test factor structure, validity and reliability of the Croatian version of the Birth Satisfaction Scale-Revised. In the cross-sectional study, a convenient online sample of 552 women completed questionnaires in the first year postpartum. The Birth Satisfaction Scale-Revised, subscale Satisfaction with Delivery from the Childbirth Perception Questionnaire, and a set of questions on demographic and obstetric data were administered. The results showed the excellent fit of both the three-factor model (Stress experienced during labour, Women's personal attributes, Quality of care) and two-factor model (with Stress and Women's attributes combined into one factor), with no significant difference between the two models. Furthermore, bi-factor modeling revealed a general factor of childbirth experience, which explains the variance of items from Stress and Women's attributes subscales. The internal consistency was high for the total scale and Quality of care, while acceptable for the other two subscales. Convergent and divergent validity was high. Known-group discriminant validity showed that women who gave birth by unassisted vaginal birth and planned caesarean section reported higher levels of birth satisfaction. In conclusion, both empirical findings and theoretical background suggest a three-factor model as the better solution for the Birth Satisfaction Scale-Revised conceptualization. As the Croatian version of the Birth Satisfaction Scale-Revised was shown to be valid and reliable, it is recommended for use to measure birth satisfaction both for research and practical purposes.

Obstetric interventions and pregnancy outcomes during the COVID-19 pandemic in England: A nationwide cohort study.

BackgroundThe COVID-19 pandemic has disrupted maternity services worldwide and imposed restrictions on societal behaviours. This national study aimed to compare obstetric intervention and pregnancy outcome rates in England during the pandemic and corresponding pre-pandemic calendar periods, and to assess whether differences in these rates varied according to ethnic and socioeconomic background.Methods and findingsWe conducted a national study of singleton births in English National Health Service hospitals. We compared births during the COVID-19 pandemic period (23 March 2020 to 22 February 2021) with births during the corresponding calendar period 1 year earlier. The Hospital Episode Statistics database provided administrative hospital data about maternal characteristics, obstetric inventions (induction of labour, elective or emergency cesarean section, and instrumental birth), and outcomes (stillbirth, preterm birth, small for gestational age [SGA; birthweight < 10th centile], prolonged maternal length of stay (≥3 days), and maternal 42-day readmission). Multi-level logistic regression models were used to compare intervention and outcome rates between the corresponding pre-pandemic and pandemic calendar periods and to test for interactions between pandemic period and ethnic and socioeconomic background. All models were adjusted for maternal characteristics including age, obstetric history, comorbidities, and COVID-19 status at birth. The study included 948,020 singleton births (maternal characteristics: median age 30 years, 41.6% primiparous, 8.3% with gestational diabetes, 2.4% with preeclampsia, and 1.6% with pre-existing diabetes or hypertension); 451,727 births occurred during the defined pandemic period. Maternal characteristics were similar in the pre-pandemic and pandemic periods. Compared to the pre-pandemic period, stillbirth rates remained similar (0.36% pandemic versus 0.37% pre-pandemic, p = 0.16). Preterm birth and SGA birth rates were slightly lower during the pandemic (6.0% versus 6.1% for preterm births, adjusted odds ratio [aOR] 0.96, 95% CI 0.94–0.97; 5.6% versus 5.8% for SGA births, aOR 0.95, 95% CI 0.93–0.96; both p < 0.001). Slightly higher rates of obstetric intervention were observed during the pandemic (40.4% versus 39.1% for induction of labour, aOR 1.04, 95% CI 1.03–1.05; 13.9% versus 12.9% for elective cesarean section, aOR 1.13, 95% CI 1.11–1.14; 18.4% versus 17.0% for emergency cesarean section, aOR 1.07, 95% CI 1.06–1.08; all p < 0.001). Lower rates of prolonged maternal length of stay (16.7% versus 20.2%, aOR 0.77, 95% CI 0.76–0.78, p < 0.001) and maternal readmission (3.0% versus 3.3%, aOR 0.88, 95% CI 0.86–0.90, p < 0.001) were observed during the pandemic period. There was some evidence that differences in the rates of preterm birth, emergency cesarean section, and unassisted vaginal birth varied according to the mother’s ethnic background but not according to her socioeconomic background. A key limitation is that multiple comparisons were made, increasing the chance of false-positive results.ConclusionsIn this study, we found very small decreases in preterm birth and SGA birth rates and very small increases in induction of labour and elective and emergency cesarean section during the COVID-19 pandemic, with some evidence of a slightly different pattern of results in women from ethnic minority backgrounds. These changes in obstetric intervention rates and pregnancy outcomes may be linked to women’s behaviour, environmental exposure, changes in maternity practice, or reduced staffing levels.

Factors Associated With Normal Physiologic Birth for Women Who Labor In Water: A Secondary Analysis of A Prospective Observational Study.

IntroductionResearch to understand factors associated with normal physiologic birth (unassisted vaginal birth, spontaneous labor onset without epidural analgesia, spinal, or general anesthetic, without episiotomy) is required. Laboring and/or giving birth in water has been shown to be associated with a high proportion of physiologic birth but with little understanding of factors that may influence this outcome. This study explored factors associated with normal physiologic birth for women who labored in water.MethodsWe conducted a secondary analysis of a UK‐based prospective observational study of 8064 women at low risk of childbirth complications who labored in water. Consecutive women were recruited from birth settings in England, Scotland, and Northern Ireland. Planned place of birth, maternal characteristics, intrapartum events, and maternal and neonatal outcomes were measured. Univariable and multivariable logistic regression modelling explored factors associated with normal physiologic birth.ResultsIn total, 5758 (71.4%) of women who labored in water had a normal physiologic birth. Planned birth in the community (adjusted odds ratio [aOR], 2.58; 95% CI, 2.22‐2.99) or at an alongside midwifery unit (aOR, 1.21; 95% CI, 1.04‐1.41) was positively associated with normal physiologic birth compared with planned birth in an obstetric unit. Duration of second stage (aOR, 0.66; 95% CI, 0.62‐0.70), duration in the pool [aOR, 0.93; 95% CI, 0.90‐0.96), and birth weight of the neonate (aOR, 0.74; 95% CI, 0.65‐0.85) were negatively associated with normal physiologic birth. Parity was not associated with normal physiologic birth in multivariate analyses.DiscussionOur findings largely reflected wider research, both in and out of water. We found midwifery‐led birth settings may increase the likelihood of normal physiologic birth among healthy women who labor in water, irrespective of parity. This association supports growing evidence demonstrating the importance of planned place of birth on reducing intervention rates and adds to research on labor and birth in water.

Incidence of second-stage (fully dilated) cesarean sections and how best to represent it: A multicenter analysis.

To gather multicenter data on the incidence of second-stage cesarean sections and suggest alternative methods by which the data can be represented. Retrospective, observational study over a 12-month study period. Numbers of term, singleton live births were collated from each of six maternity units. Data were separated by mode of delivery-unassisted vaginal birth, assisted (instrumental) vaginal delivery and elective, first-stage, and second-stage cesarean sections. Second-stage cesarean sections were expressed as a proportion of all deliveries, of all laboring women (i.e. excluding elective cesarean sections), and all women who reach full dilatation (i.e. excluding elective and first-stage cesarean sections). Of the 28867 deliveries included in the analysis, 493 of these were second-stage cesarean sections. This represented an incidence of 1.7% of all deliveries, 2.0% of all women in labor, and 2.5% of all women who reach full dilatation. Second-stage cesarean sections continue to be common. Safe delivery of a deeply impacted fetal vertex is essential in modern obstetric practice.

Performance of Integrated Emergency Surgical Officers at Mizan-Tepi University Teaching Hospital, Mizan-Aman, Ethiopia: A Retrospective Cohort Study.

Introduction Surgical physician extenders are used in Ethiopia and sub-Saharan Africa where there is a lack of surgical providers. Methods We tested characteristics associated with and outcomes of births attended by an integrated emergency surgical officers (IESOs) as compared to midwives and physician providers. Results Of 1,000 women in our convenience sample, data on birth attendant was missing on 5 women (0.5%). Of the remaining women, almost three-fourths (73.6%, n = 732) of women were attended by a midwife, almost a quarter were attended by an IESO (24.4%, n = 243), 10 women were attended by a physician with a General Practitioner level of training (1.0%), 5 women were delivered by an Ob/Gyn resident (0.5%), and 5 women were attended by an Ob/Gyn (0.5%). Women had a higher likelihood of being attended by an IESO than a midwife if they underwent forceps-assisted (RR 88.4, p < 0.05), vacuum-assisted (RR 45.2, p < 0.05), or cesarean birth (RR 161.8, p < 0.05) as compared to an unassisted vaginal birth. IESOs are performing more operative vaginal and cesarean births than other delivery providers. Outcomes of their deliveries are worse than those of midwives, but this is likely due to the acuity level of the patients and not the provider type.

Pregnancy outcomes at Mizan-Tepi University Teaching Hospital: A Comparison to the Ethiopian Demographic and Health Surveys.

Background:To compare outcomes at Mizan-Tepi University Teaching Hospital to national and regional data and to plan quality improvement and research studies based on the results.Methods:This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1, 000 women who delivered at Mizan-Tepi University Teaching Hospital.Results:Our convenience sample was young (median age 24 years) with a primarily school level or less of education (68.6%). Only about 5% of women had a history of prior cesarean birth, 2.1% reported they were human immunodeficiency virus seropositive, and the median number of prenatal visits was four. Women were commonly admitted in spontaneous labor (84.5%), transferred from another facility (49.2%; 96.8% of which were referred from a health center), and had their fetal heart rate auscultated on admission (94.7%). Only 5.2% of women did not deliver within twenty-four hours and the cesarean birth prevalence was 23.4%. Many women were delivered by midwives (73.2%; all unassisted vaginal births), 89.2% were term deliveries, and 92.5% of neonatal birthweights were 2500 grams or heavier. Less than five percent of women delivered stillbirths (4.3%) and 5.7% of livebirths experienced neonatal death by the day of discharge. There were no maternal deaths in the cohort.Conclusion:The prevalence of stillbirth and neonatal death were the most notable findings, while there was no maternal death in the cohort.

Intrapartum Basal Ganglia-Thalamic Pattern Injury and Radiologically Termed "Acute Profound Hypoxic-Ischemic Brain Injury" Are Not Synonymous.

Human cases of acute profound hypoxic-ischemic (HI) injury (HII), in which the insult duration timed with precision had been identified, remains rare, and there is often uncertainty of the prior state of fetal health. A retrospective analysis of 10 medicolegal cases of neonatal encephalopathy-cerebral palsy survivors who sustained intrapartum HI basal ganglia-thalamic (BGT) pattern injury in the absence of an obstetric sentinel event. Cardiotocography (CTG) admission status was reassuring in six and suspicious in four of the cases. The median time from assessment by admission CTG or auscultation to birth was 687.5 minutes (interquartile range [IQR]: 373.5-817.5 minutes), while the median time interval between first pathological CTG and delivery of the infant was 179 minutes (IQR: 137-199.25 minutes). The mode of delivery in the majority of infants (60%) was by unassisted vaginal birth; four were delivered by delayed caesarean section. The median (IQR) interval between the decision to perform a caesarean section and delivery was 169 minutes (range: 124-192.5 minutes). The study shows that if a nonreassuring fetal status develops during labor and is prolonged, a BGT pattern HI injury may result, in the absence of a perinatal sentinel event. Intrapartum BGT pattern injury and radiologically termed "acute profound HI brain injury" are not necessarily synonymous. A visualized magnetic resonance imaging (MRI) pattern should preferably solely reflect the patterns description and severity, rather than a causative mechanism of injury. · BGT HI injury pattern on MRI may develop in the absence of a perinatal sentinel event.. · BGT pattern injury may not be synonymous with "acute profound HI brain injury.". · MRI pattern and severity thereof should be described rather than a causative mechanism of injury..

Induction of labour using prostaglandin E2 as an inpatient versus balloon catheter as an outpatient: a multicentre randomised controlled trial.

To compare clinical outcomes following induction of labour (IOL) using a balloon catheter and going home, versus prostaglandin (PG) as an inpatient. Randomised controlled trial. Eight Australian maternity hospitals. Women with uncomplicated term singleton pregnancies undergoing IOL for low-risk indications including post-term, advanced maternal age and 'social' reasons. Between September 2015 and October 2018, 347 women were randomised to a balloon outpatient group and 348 to a PG inpatient group. The PG group received Dinoprostone, either 2mg gel or 10mg controlled-release tape. The balloon group had a double-balloon catheter inserted and went home. The primary outcome was a composite neonatal measure comprising nursery admission, intubation/cardiac compressions, acidaemia, hypoxic ischaemic encephalopathy, seizure, infection, pulmonary hypertension, stillbirth or death. Clinical and process outcomes are reported. There were no statistically significant differences in the primary outcome comparing balloon with PG (18.6% versus 25.8%; relative risk=0.77, 95% CI 0.51-1.02; P=0.070), cord arterial pH <7.10 (3.5% versus 9.2%; P=0.072), nursery admissions (12.6% versus 15.5%; P=0.379), neonatal antibiotic use (12.1% versus 17.6%; P=0.103), or mode of birth. Nulliparous women in the balloon group had lower rates of the primary outcome (20.4% versus 31.0%;P=0.032); Parous women were less likely to have an unassisted vaginal birth (77.6% versus 92.3%; P=0.045). Balloon catheters may be a superior method of cervical priming for nulliparous women, whereas this may not be the case for parous women. It is feasible that nulliparous women go home after commencing balloon catheter IOL, and the likelihood of adverse outcomes is low. Multicentre trial shows outpatient induction using balloon catheter is safe and feasible for nulliparous women.

Evidence of overuse? Patterns of obstetric interventions during labour and birth among Australian mothers

BackgroundThere is global concern for the overuse of obstetric interventions during labour and birth. Of particular concern is the increasing amount of mothers and babies experiencing morbidity and mortality associated with caesarean section compared to vaginal birth. In high-income settings, emerging evidence suggests that overuse of obstetric intervention is more prevalent among wealthier mothers with no medical need of it. In Australia, the rates of caesarean section and other obstetric interventions are rising. These rising rates of intervention have been mirrored by a decreasing rate of unassisted non-instrumental vaginal deliveries. In the context of rising global concern about rising caesarean section rates and the known health effects of caesarean section on mothers and children, we aim to better characterise the use of obstetric intervention in the state of Queensland, Australia by examining the characteristics of mothers receiving obstetric intervention. Identifying whether there is overuse of obstetric interventions within a population is critical to improving the quality, value and appropriateness of maternity care.MethodsThe association between demographic characteristics (at birth) and birth delivery type were compared with chi-square. The percentage of mothers based on their socioeconomic characteristics were reported and differences in percentages of obstetric interventions were compared. Multivariate analysis was undertaken using multiple logistic regression to assess the likelihood of receiving obstetric intervention and having a vaginal (non-instrumental) delivery after accounting for key clinical characteristics.ResultsIndigenous mothers, mothers in major cities and mothers in the wealthiest quintile all had higher percentages of all obstetric interventions and had the lowest percentages of unassisted (non-instrumental) vaginal births. These differences remained even after adjusting for other key sociodemographic and clinical characteristics.ConclusionsDifferences in obstetric practice exist between economic, ethnic and geographical groups of mothers that are not attributable to medical or lifestyle risk factors. These differences may reflect health system, organisational and structural conditions and therefore, a better understanding of the non-clinical factors that influence the supply and demand of obstetric interventions is required.

Good birth narratives: Diverse South African women's perspectives

BackgroundThere is currently a substantial international research focus on issues relating to childbirth distress, traumatic birth and negative birth experiences. Less research attention has been paid to women's narratives or accounts of positive or affirming birth experiences, particularly in the South African context. The aim of this article is to explore the ingredients of a 'good birth' experience from the perspectives of South African women's birth narratives. MethodsAn exploratory, qualitative research design using unstructured interviewing and a narrative methodological framework was used to explore women's perspectives about the ingredients of a 'good birth' experience. Sixty-one participants were obtained via convenience sampling. The sample including 35 low-income black women and 26 middle-class, predominantly white women, aged 18–45 years who had recently given birth to an infant. Thirty-three women gave birth in the public healthcare system, with 25 of these women having vaginal deliveries and eight reporting a caesarean section. Two women had unassisted vaginal births while in transit to public healthcare facilities. Twenty-six women gave birth in the private healthcare system; 15 participants had a planned homebirth with a private midwife, nine had an elective caesarean section, one woman had an emergency caesarean section and another participant gave birth vaginally (with epidural) in a private hospital. FindingsLess than half of the women (n = 26) narrated positive birth experiences. Almost half of the women (n = 30) narrated distressing birth experiences while five women reported neutral birth experiences. This paper focuses only on women's 'good birth' narratives (n = 26). Good and affirming birth narratives were characterized by the following three themes, namely: (1) a sense of presence, (2) physical and ontological safety and (3) respectful care. ConclusionThe bodily and corporeal aspects of the birth experience were found to be central to women's 'good birth' narratives. A key conclusion is that maternal healthcare provision needs to be reimagined in ways which acknowledge, centre and respect the unique and vulnerable corporeality of birthing women, regardless of type of birth.

Vaginal Birth and Pelvic Floor Trauma

Over the last two to three decades, a growing body of research has shown that vaginal childbirth is more traumatic to mothers than generally assumed. Apart from obstetric anal sphincter tears which have been extensively studied, trauma to the levator ani muscle is a form of maternal injury that is less well recognised and often undiagnosed. In the context of an increasing push towards vaginal birth, this article will review the recent literature to better inform health care providers regarding the significance of pelvic floor trauma. Imaging studies have shown that levator avulsion, where the puborectalis muscle has detached from the os pubis, occurs in up to 1/3 of vaginally primiparous women, depending on demographic factors and obstetric management. Forceps is a well-established risk factor for levator avulsion with an odds ratio of 4–5 compared to vacuum, which does not seem to convey additional risk over unassisted vaginal birth. Levator injuries are significantly associated with pelvic organ prolapse and treatment failure. Such trauma can also lead to significant psychological morbidity, up to and including post-traumatic stress disorder. Antenatal prediction does not appear feasible. Modification of obstetric practice by abandoning forceps would significantly reduce pelvic floor trauma and the future need for prolapse surgery. Vaginal childbirth is more traumatic than commonly assumed. Levator trauma is associated with significant physical and psychological morbidity. Perinatal health care providers need to understand and recognise the significance of maternal birth trauma and its potential impact on women’s health.

Does it get better with age? Women’s experience of communication in maternity care

BackgroundCommunication with maternity care providers is one of the strongest predictors of the perceived quality of maternity care. There is evidence that older mothers experience better communication than younger mothers, but no evidence for why this occurs. AimTo identify differences between younger (<35 years) and older (35+ years) mother’s perceived quality of communication and any apparent age-related differences. MethodsWe analysed cross-sectional data from 2504 first-time mothers in the Having a Baby in Queensland Survey 2012. Binary logistic regression assessed associations between maternal age and perceived optimal communication (information, participation, and connection) from care providers during women’s most recent pregnancy and birth. Multivariable logistic regression modelling determined the effect of potential confounders (model of care, mode of birth, maternal age, and risk perceptions) on associations between age and communication quality. FindingsAfter adjustment for confounders, older mothers were more likely to report experiencing optimal information (e.g., not receiving conflicting information) and connection with caregivers (e.g., comfortable asking questions) in both pregnancy and birth. There were no age-related differences in the perception of participation. Model of care and mode of birth were more influential than maternal age in predicting communication perceptions. Women who used midwifery or private obstetric models and had unassisted vaginal births were more likely to perceive optimal communication. ConclusionGiven the benefits of communication on maternity care, redressing these age-related differences should be a focus of future communication training for care providers to ensure that women receive optimal communication, regardless of their age.

Incidence, trends and severity of primary postpartum haemorrhage in Australia: A population-based study using Victorian Perinatal Data Collection data for 764244 births.

Increasing incidence and severity of postpartum haemorrhage, together with postpartum haemorrhage-associated morbidities, have been reported in many high-resource countries. In-depth analysis of such factors in Victorian births since 2002 was lacking. Our aim was to determine the incidence and trends for primary postpartum haemorrhage (World Health Organization and International Classification of Diseases 10th revision, Australian Modification definitions) for all confinements in Victoria, Australia, for the years 2003-2013 and the incidence and trends for severe postpartum haemorrhage (≥1500mL) for 2009-2013. In this population-based cross-sectional study de-identified data from the Victorian Perinatal Data Collection were analysed for confinements (excluding terminations) from 2003 to 2013 (n=764244). Perinatal information for all births ≥20weeks (or of at least 400g birthweight if gestation was unknown) were prospectively collected. One in five women (21.8%) who gave birth between 2009 and 2013 experienced a primary postpartum haemorrhage and one in 71 women (1.4%) experienced a severe primary postpartum haemorrhage. The increasing trends in incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage, blood transfusion, admission to an intensive care or high dependency unit and peripartum hysterectomy were significant (P<0.001). Women who had an unassisted vaginal birth had the lowest incidence of primary postpartum haemorrhage. The highest incidence was experienced by women who had an unplanned caesarean section birth. Women who had a forceps birth had the highest incidence of severe primary postpartum haemorrhage. The incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage and associated maternal morbidities have increased significantly over time in Victoria.

Ante- and intrapartum risk factors for neonatal hypoxic ischemic encephalopathy

Purpose: To identify obstetrical risk factors for the diagnosis of neonatal hypoxic ischemic encephalopathy (HIE). A secondary aim was to determine the incidence of HIE. Materials and methods: A retrospective cohort study including 36,086 women with singleton term pregnancies giving live births in Sweden between 2009 and 2013. Cases of HIE were identified from three different sources. Risk factors for HIE were evaluated using univariate and multivariate analyses. Cases of HIE were extracted from available Swedish Medical Health registers to determine incidence. Results: A diagnosis of HIE was associated with: acute obstetrical events, mode of delivery other than unassisted vaginal birth, abnormal CTG admission test, and nulliparity. The incidence of HIE was 1.7/1000 infants born. Conclusions: Acute obstetrical events will always occur, and some of the risk factors for these events are not responsive to interventions, but a careful risk assessment could lower the risk associated with acute obstetrical events. By alertness to early symptoms and timely measures taken by a trained staff at the delivery unit, damage could be reduced.

Maternal age is a risk factor for caesarean section following induction of labour.

In Australia, more than 20% of women giving birth are 35years or older. Advanced maternal age (AMA) is a risk factor for stillbirth, and many clinicians now recommend induction of labour (IOL) at around term gestation. The aim of this study is to determine if AMA is associated with emergency caesarean section (CS) following IOL. A retrospective cohort study was undertaken using routinely collected de-identified data. Live-born, singleton, cephalic, non-anomalous pregnancies undergoing IOL between 37+0 and 42+0weeks were included. Previous CS and privately insured admission status were excluded. Mode of delivery was compared for women ≥38years (AMA) and women <38years. The primary outcome was birth by CS. Bivariate and multivariate logistic regression analyses wereundertaken. A total of 7459 women were included (≥38years n=718, 9.6%; <38years n=6741, 90.4%). AMA women had similar rates of unassisted vaginal births (OR 1.15, 95% CI 0.98-1.35, P=0.080) and CS (OR 1.08, 95% CI 0.90-1.30, P=0.407) but fewer instrumental deliveries (OR 0.69, 95% CI 0.55-0.87, P=0.002) compared to women <38years. When controlled for confounders, AMA was independently associated with a two-fold increase in birth by CS following IOL (adjusted OR 2.29; 95% CI 1.64-3.20; P<0.001). There were no differences in neonataloutcomes. Following IOL, AMA was associated with a two-fold increased likelihood of birth by CS in both nulliparous and multiparous women. However, the majority of AMA women birthed vaginally. Clinicians may find this information useful when counselling older women who are undergoing term IOL.