Childbirth experiences in women with polycystic ovary syndrome: A cohort study.

INTRODUCTION: Women with polycystic ovary syndrome (PCOS) have more pregnancy complications like gestational diabetes, hypertension, and preterm labor than other women. Metformin has been used in an attempt to improve pregnancy outcomes. Our study aims to explore childbirth experiences in women with PCOS compared with a reference population. It also explores the potential influence of metformin, obesity, pregnancy complications, and the duration and mode of birth on childbirth experiences. MATERIAL AND METHODS: This study is a cohort study combining data from two randomized trials conducted in Norway, Sweden and Iceland. The PregMet2 study (ClinicalTrials.gov, NCT01587378) investigated the use of metformin vs. placebo in pregnant women with PCOS. The Labour Progression Study (ClinicalTrials.gov, NCT02221427) compared the WHO partograph to Zhang's guidelines for progression of labor and were used as the reference population. A total of 365 women with PCOS and 3604 reference women were included. Both studies used the Childbirth Experience Questionnaire (CEQ). Main outcome measures were total CEQ score and four domain scores. The CEQ scores were compared using Mann-Whitney U test for women in Robson group 1 with PCOS (n = 131) and reference women (n = 3604). CEQ scores were also compared between metformin-treated (n = 180) and placebo-treated (n = 185) women with PCOS, and for different subgroups of women with PCOS. RESULTS: There was no difference in total CEQ score between women with PCOS and reference women-Wilcoxon-Mann-Whitney (WMW)-odds 0.96 (95% confidence interval [CI] 0.78-1.17). We detected no difference in CEQ scores between the metformin- and placebo-treated women with PCOS (WMW-odds 1.13, 95% CI 0.89-1.43). Complications in pregnancy did not affect CEQ (WMW-odds 1, 95% CI 0.76-1.31). Higher body mass index (WMW-odds 0.75, 95% CI 0.58-0.96), longer duration of labor (WMW-odds 0.69, 95% CI 0.49-0.96), and cesarean section (WMW-odds 0.29, 95% CI 0.2-0.42) were associated with lower CEQ scores in women with PCOS. CONCLUSIONS: Women with PCOS experience childbirth similarly to the reference women. Metformin did not influence childbirth experience in women with PCOS, neither did pregnancy complications. Obesity, long duration of labor or cesarean section had a negative impact on childbirth experience.

Antenatal pelvic floor muscle training and urinary incontinence: a randomized controlled 7-year follow-up study.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence is common postpartum. Our aims were to assess whether antenatal exercise including pelvic floor muscle training (PFMT) has long-term effects on urinary incontinence (UI) and to explore factors associated with UI 7 years postpartum. METHODS: A follow-up of a two-centre randomized controlled trial performed at St. Olavs Hospital and Stavanger University Hospital, Norway. In the original trial women were randomized to a 12-week structured exercise protocol including PFMT or standard antenatal care during pregnancy. Link to an electronic questionnaire was sent by postal mail 7 years postpartum. Prevalence of UI was assessed with Sandvik severity index and compared between groups. Factors associated with UI were studied using multivariable logistic regression analysis. RESULTS: The response rate was 35% (298/855). UI was reported by 78 (51%) in the intervention group and 63 (57%) in the control group (p = 0.539). In the multivariable logistic regression analyses, women with UI at inclusion had a five-fold increase in odds of UI at 7 years (OR 5.4, 95% CI 2.6, 11.5). Engaging in regular exercise was not significantly associated with UI at 7 years; however, UI was associated with lower exercise intensity (OR 2.4, 95% CI 1.2, 4.6). CONCLUSIONS: We found no group differences of antenatal exercise including PFMT on UI after 7 years among the responders. UI in pregnancy increased the risk of long-term UI. Regular exercise was not associated with UI at 7 years; however, women with UI were more than twice as likely to exercise at lower intensity than continent women.

The effect of Zhang's guideline vs the WHO partograph on childbirth experience measured by the Childbirth Experience Questionnaire in the Labor Progression Study (LaPS): A cluster randomized trial.

INTRODUCTION: Childbirth experience is an increasingly recognized and important measure of quality of obstetric care. Previous research has shown that it can be affected by intrapartum care and how labor is followed. A partograph is recommended to follow labor progression by recording cervical dilation over time. There are currently different guidelines in use worldwide to follow labor progression. The two main ones are the partograph recommended by the World Health Organization (WHO) based on the work of Friedman and Philpott and a guideline based on Zhang's research. In our study we assessed the effect of adhering to Zhang's guideline or the WHO partograph on childbirth experience. Zhang's guideline describes expected normal labor progression based on data from contemporary obstetric populations, resulting in an exponential progression curve, compared with the linear WHO partograph. The choice of labor curve affects the intrapartum follow-up of women and this could potentially affect childbirth experience. MATERIAL AND METHODS: The Labor Progression Study (LaPS) study was a prospective, cluster randomized controlled trial conducted at 14 birth centers in Norway. Birth centers were randomized to either follow Zhang's guideline or the WHO partograph. Nulliparous women in active labor, with one fetus in cephalic presentation at term and spontaneous labor onset were included. At 4 weeks postpartum, included women received an online login to complete the Childbirth Experience Questionnaire (CEQ). Total score on the CEQ, the four domain scores on the CEQ, and scores on the individual items on the CEQ were compared between the two groups. RESULTS: There were 1855 women in the Zhang group and 1749 women in the WHO partograph group. There was no difference in the total or domain CEQ scores between the two groups. We found statistically significant differences for two individual items; women in the Zhang group scored lower on positive memories and feeling of control. CONCLUSIONS: Based on our findings on childbirth experience there is no reason to prefer Zhang's guideline over the WHO partograph.

Maternal body mass index and risk of obstetric, maternal and neonatal outcomes: A cohort study of nulliparous women with spontaneous onset of labor.

INTRODUCTION: This study investigates associations between maternal body mass index (BMI) early in pregnancy and obstetric interventions, maternal and neonatal outcomes. MATERIAL AND METHODS: This is a cohort study of nulliparous women originally included in a cluster randomized controlled trial carried out at 14 Norwegian obstetric units between 2014 and 2017. The sample included 7189 nulliparous women with a singleton fetus, cephalic presentation and spontaneous onset of labor at term, denoted as group 1 in the Ten-Group Classification System. The women were grouped according to the World Health Organization BMI classifications: underweight (BMI <18.5), normal weight (BMI 18.5-24.9), pre-obesity (BMI 25.0-29.9), obesity class I (BMI 30.0-34.9), and obesity classes II and III (BMI ≥35.0). We used binary logistic regression to estimate crude and adjusted odds ratios (ORs) of the interventions and outcomes, with associated 95% confidence intervals (CIs), comparing women in different BMI groups with women of normal weight. RESULTS: We found an increased risk of intrapartum cesarean section in women of obesity class I and obesity classes II and III, with adjusted OR of 1.70 (95% CI 1.21-2.38) and 2.31 (95% CI 1.41-3.77), respectively. Women in obesity groups had a gradient of risk of epidural analgesia and use of continuous CTG (including STAN), with adjusted OR of 2.39 (95% CI 1.69-3.38) and 3.28 (95% CI 1.97-5.48), respectively. Women in obesity classes II and III had higher risk of amniotomy (adjusted OR = 1.42, 95% CI 1.02-1.96), oxytocin augmentation (adjusted OR = 1.54, 95% CI 1.11-2.15), obstetric anal sphincter injuries (adjusted OR = 2.21, 95% CI 1.01-4.85) and postpartum hemorrhage ≥1000 mL (adjusted OR = 2.20, 95% CI 1.29-3.78). We found a reduced likelihood of spontaneous vaginal delivery for pre-obese women (adjusted OR = 0.85, 95% CI 0.74-0.97) and no associations between maternal BMI and neonatal outcomes. CONCLUSIONS: Obese women in Ten-Group Classification System group 1 had increased risks of obstetric interventions and maternal complications. There was a gradient of risk for intrapartum cesarean section, with the highest risk for women in obesity classes II and III. No associations between maternal BMI and neonatal outcomes were observed.

The frequency of intrapartum caesarean section use with the WHO partograph versus Zhang's guideline in the Labour Progression Study (LaPS): a multicentre, cluster-randomised controlled trial.

BACKGROUND: There is an ongoing debate concerning which guidelines and monitoring tools are most beneficial for assessing labour progression, to help prevent use of intrapartum caesarean section (ICS). The WHO partograph has been used for decades with the assumption of a linear labour progression; however, in 2010, Zhang introduced a new guideline suggesting a more dynamic labour progression. We aimed to investigate whether the frequency of ICS use differed when adhering to the WHO partograph versus Zhang's guideline for labour progression. METHODS: We did a multicentre, cluster-randomised controlled trial at obstetric units in Norway, and each site was required to deliver more than 500 fetuses per year to be eligible for inclusion. The participants were nulliparous women who had a singleton, full-term fetus with cephalic presentation, and who entered spontaneous active labour. The obstetric units were treated as clusters, and women treated within these clusters were all given the same treatment. We stratified these clusters by size and number of previous caesarean sections. The clusters containing the obstetric units were then randomly assigned (1:1) to the control group, which adhered to the WHO partograph, or to the intervention group, which adhered to Zhang's guideline. The randomisation was computer-generated and was done in the Unit of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway, and investigators in this unit had no further involvement in the trial. Our study design did not enable masking of participants or health-care providers, but the investigators who were analysing the data were masked to group allocation. The primary outcome was use of ICS during active labour (cervical dilatation of 4-10 cm) in all participating women. The Labour Progression Study (LaPS) is registered with ClinicalTrials.gov, number NCT02221427. FINDINGS: Between Aug 1, 2014, and Sept 1, 2014, 14 clusters were enrolled in the LaPS trial, and on Sept 11, 2014, seven obstetric units were randomly assigned to the control group (adhering to the WHO partograph) and seven obstetric units were randomly assigned to the intervention group (adhering to Zhang's guideline). Between Dec 1, 2014, and Jan 31, 2017, 11 615 women were judged to be eligible for recruitment in the trial, which comprised 5421 (46·7%) women in the control group units and 6194 (53·3%) women in the intervention group units. In the control group, 2100 (38·7%) of 5421 women did not give signed consent to participate and 16 (0·3%) women abstained from participation. In the intervention group, 2181 (35·2%) of 6194 women did not give signed consent to participate and 41 (0·7%) women abstained from participation. 7277 (62·7%) of 11 615 eligible women were therefore included in the analysis of the primary endpoint. Of these women, 3305 (45·4%) participants were in an obstetric unit that was randomly assigned to the control group (adhering to the WHO partograph) and 3972 (54·6%) participants were in an obstetric unit that was randomly assigned to the intervention group (adhering to Zhang's guideline). No women dropped out during the trial. Before the start of the trial, ICS was used in 9·5% of deliveries in the control group obstetric units and in 9·3% of intervention group obstetric units. During our trial, there were 196 (5·9%) ICS deliveries in women in the control group (WHO partograph) and 271 (6·8%) ICS deliveries in women in the intervention group (Zhang's guideline), and the frequency of ICS use did not differ between the groups (adjusted relative risk 1·17, 95% CI 0·98-1·40; p=0·08; adjusted risk difference 1·00%, 95% CI -0·1 to 2·1). We identified no maternal or neonatal deaths during our study. INTERPRETATION: We did not find any significant difference in the frequency of ICS use between the obstetric units assigned to adhere to the WHO partograph and those assigned to adhere to Zhang's guideline. The overall decrease in ICS use that we observed relative to the previous frequency of ICS use noted in these obstetric units might be explained by the close focus on assessing labour progression more than use of the guidelines. Our results represent an important contribution to the discussion on implementation of the new guideline. FUNDING: Østfold Hospital Trust.

The Labor Progression Study: The use of oxytocin augmentation during labor following Zhang's guideline and the WHO partograph in a cluster randomized trial.

INTRODUCTION: This study aims to investigate the use of oxytocin augmentation during labor in nulliparous women following Zhang's guideline or the WHO partograph. MATERIAL AND METHODS: This is a secondary analysis of a cluster randomized controlled trial in 14 birth-care units in Norway, randomly assigned to either the intervention group, which followed Zhang's guideline, or to the control group, which followed the WHO partograph, for labor progression. The participants were nulliparous women who had a singleton full-term fetus in a cephalic presentation and spontaneous onset of labor, denoted as group 1 in the Ten Group Classification System. RESULTS: Between December 2014 and January 2017, 7277 participants were included. A total of 3219 women (44%) received augmentation with oxytocin during labor. Oxytocin was used in 1658 (42%) women in the Zhang group compared with 1561 (47%) women in the WHO group. The adjusted relative risk for augmentation with oxytocin was 0.98 (95% CI 0.84-1.15; P = .8) in the Zhang vs WHO group, with an adjusted risk difference of -0.8% (95% CI -7.8 to 6.1). The participants in the Zhang group were less likely to be augmented with oxytocin before reaching 6 cm of cervical dilatation (24%) compared with participants in the WHO group (28%), with an adjusted relative risk of 0.84 (95% CI 0.75-0.94; P = .003). Oxytocin was administered for almost 20 min longer in the Zhang group than in the WHO group, with an adjusted mean difference of 17.9 min (95% CI 2.7-33.1; P = .021). In addition, 19% of the women in the Zhang group and 23% in the WHO group received augmentation with oxytocin without being diagnosed with labor dystocia. CONCLUSIONS: Although no significant difference in the proportion of oxytocin augmentation was observed between the 2 study groups, there were differences in how oxytocin was used. Women in the Zhang group were less likely to receive oxytocin augmentation before 6 cm of cervical dilatation. The duration of augmentation with oxytocin was longer in the Zhang group than in the WHO group.

Study protocol: the Labor Progression Study, LAPS - does the use of a dynamic progression guideline in labor reduce the rate of intrapartum cesarean sections in nulliparous women? A multicenter, cluster randomized trial in Norway.

BACKGROUND: The increasing rate of intrapartum cesarean sections is subject of attention and concern as it is associated with adverse outcomes. Labor dystocia is one of the most frequent indications for cesarean sections even though there is no consensus on criteria for labor dystocia. Traditionally the progression of labor follows guidelines based on Friedman's curve from the mid 1950s. In 2010 Zhang presented a new labor curve and a dynamic guideline for labor progression based on contemporary research. The main aim of this trial is to evaluate whether adhering to Zhang's guideline for labor progression, changes the intrapartum cesarean section rate in nulliparous women without jeopardising maternal and neonatal outcomes compared to a traditional guide line called the 4-h action line based on Friedman's curve. METHODS/DESIGN: A multicenter cluster randomized trial including 14 birth care units in Norway is conducted. Seven units are randomized to use the 4-h action line guideline for labor progression and seven units are randomized to use Zhang's new dynamic guideline for labor progression, for all nulliparous women with a singleton fetus in a cephalic presentation and spontaneous onset of labor at term. Clinical outcomes are compared between the groups. The determination of the sample size (number of clusters and individuals) is based on a power calculation of intrapartum cesarean section, which is 9.2% in the study population (p1). Further, we expect that the intrapartum cesarean section rate will be 6.7% (p2) which is a 25% reduction, when using the new guideline. With a chosen significance level of 0.05, a power of 80% and p1 = 9.2% and p2 = 6.9%, we should include at least 14 clusters and 6582 individuals. DISCUSSION: Clinical consequences when using the guideline by Zhang have, to the best of our knowledge, not been investigated earlier. The results will provide a strong basis to make a qualified decision on whether it is beneficial to introduce a dynamic labor progression curve in contemporary obstetrics both nationally and internationally. TRIAL REGISTRATION: Clinicaltrials, NCT02221427.

Intrapartum fetal monitoring practices in Norway: A population-based study.

OBJECTIVE: To describe intrapartum fetal monitoring methods used in all births in Norway in 2019-2020, assess adherence to national guidelines, investigate variation by women's risk status, and explore associations influencing monitoring practices. METHODS: A nationwide population-based study. We collected data about all pregnancies with a gestational age ≥ 22 weeks during 2019-2020 from the Medical Birth Registry of Norway. We used descriptive analyses, stratified for risk status, to examine fetal monitoring methods used in all deliveries. Univariable and multivariable logistic regression models were used to determine factors associated with monitoring with cardiotocography (CTG) in low-risk, straightforward births. RESULTS: In total, 14 285 (14%) deliveries were monitored with only intermittent auscultation (IA), 46214 (46%) with only CTG, and 33417 (34%) with IA and CTG combined. Four percent (2 067/50 533) of women with risk factors were monitored with IA only. Half (10589/21 282) of the low-risk women with straightforward births were monitored with CTG. Maternal and fetal characteristics, size of the birth unit and regional practices influenced use of CTG monitoring in this group. CONCLUSIONS: Most births are monitored with CTG only, or combined with IA. Half the women with low-risk pregnancies and straightforward births were monitored with CTG although national guidelines recommending IA.

Association of oxytocin augmentation and duration of labour with postpartum haemorrhage: A cohort study of nulliparous women.

OBJECTIVE: Both duration of labour and use of oxytocin for augmentation are known risk factors for postpartum haemorrhage but distinguishing between the significance of these factors is complex. In this study, we aimed to investigate the association between both labour duration and oxytocin augmentation, for postpartum haemorrhage. DESIGN: A cohort study based on a secondary analysis of a cluster-randomised trial. PARTICIPANTS AND SETTING: Term nulliparous women with a single foetus in cephalic presentation, spontaneous onset of active labour and a vaginal birth. The participants were originally included in cluster-randomised trial conducted in Norway from December 1, 2014, to January 31, 2017, that aimed to compare the frequency of intrapartum caesarean sections when adhering to the WHO partograph versus Zhang's guideline. MEASUREMENTS: The data were analysed through four statistical models. Model 1 investigated the effect of oxytocin augmentation as a dichotomous variable (yes/no); Model 2 investigated the effect of the duration of oxytocin augmentation; Model 3 investigated the effect of the maximum dose of oxytocin; and Model 4 investigated the effect of both the duration of augmentation and the maximum dose of oxytocin. All four models included duration of labour divided into five time-intervals. We used binary logistic regression to estimate the odds ratios of postpartum haemorrhage, defined as blood loss of ≥ 1000 ml, including a random intercept for hospital and mutually adjusting for oxytocin augmentation and labour duration in addition to maternal age, maternal marital status, maternal higher education level, maternal smoking habits in the first trimester, maternal body mass index and birth weight. FINDINGS: Model 1 found a significant association between the use of oxytocin and postpartum haemorrhage. In Model 2, oxytocin augmentation of ≥ 4.5 h was associated with postpartum haemorrhage. In Model 3, we found an association between a maximum dose of oxytocin of ≥ 20 mU/min and postpartum haemorrhage. Model 4 showed that a maximum dose of oxytocin ≥ 20 mU/min was associated with postpartum haemorrhage both for those augmented < 4.5 h and for those augmented ≥ 4.5 h. Duration of labour was associated with postpartum haemorrhage in all models if lasting ≥ 16 h. KEY CONCLUSIONS: We found both oxytocin augmentation and labour duration to be associated with postpartum haemorrhage. Oxytocin doses of ≥ 20 mU/min and a labour duration of ≥ 16 h showed an independent association. IMPLICATION FOR PRACTICE: The potent drug oxytocin should be carefully administered, as doses of ≥ 20 mU/min were associated with an increased risk of PPH, regardless of the duration of oxytocin augmentation.

Association between one-to-one midwifery care in the active phase of labour and use of pain relief and birth outcomes: A cohort of nulliparous women.

OBJECTIVE: To investigate the association between one-to-one midwifery care and birth outcomes with pain relief as the primary outcome. Secondary outcomes include obstetric and neonatal outcomes, such as mode of birth and Apgar score. DESIGN: A cohort study of women originally included in a cluster randomised trial. SETTING AND PARTICIPANTS: The analysis is based on data from The Labour Progression Study (LaPS), a cluster randomised controlled trial (RCT) including 7,277 women, conducted in fourteen obstetric units in Norway, between 2014 and 2017. The participants were nulliparous with a singleton full-term foetus in a cephalic presentation and spontaneous onset of labour. In this cohort, 7,103 women with information about on one-to-one midwifery care were included. MEASUREMENTS AND FINDINGS: Logistic regression analysis show that nulliparous women receiving one-to-one midwifery care in the active phase of labour are less likely to have an epidural analgesia, adjusted OR of 0.81 (95% CI 0.72,0.91), less likely to be given nitrous oxide, adjusted OR of 0.77 (95% CI 0.69,0.85), and they more often received massages, adjusted OR of 1.76 (95% CI 1.47,2.11), compared with women not receiving one-to-one midwifery care. Descriptive analyses show that women receiving one-to-one midwifery care in the active phase of labour are less likely to have a caesarean section (5.8% vs. 7.2%) and they are less likely to have an operative vaginal birth (16.5% vs. 23.7%). No significant differences were observed between the groups in terms of low Apgar scores at five minutes. KEY CONCLUSIONS: We found that one-to-one midwifery care in the active phase of labour may be associated with birth outcomes, including decreased use of epidural analgesia and a decreased rate of caesarean sections and operative vaginal birth. IMPLICATIONS FOR PRACTICE: The results of this study could encourage midwives to be present during the active phase of labour to promote physiological birth.

Associations between cervical dilatation on admission and mode of delivery, a cohort study of Norwegian nulliparous women.

OBJECTIVE: To investigate associations between cervical dilatation at hospital admission and mode of delivery. METHODS: A cohort study with data from a cluster-randomised controlled trial, the Labour Progression Study. The study population of 6511 nulliparous women with a singleton fetus in cephalic presentation with spontaneous onset of labour at term, was divided into two groups: <4 cm and ≥ 4 cm cervical dilatation on admission. Binary logistic regression comparing mode of delivery was used to estimate crude and adjusted OR with associated 95% CI. RESULTS: Of the total study population, 56.7% were admitted with < 4 cm cervical dilatation and 43.3% with ≥ 4 cm. Women admitted with ≥ 4 cm had a significantly higher chance of spontaneous delivery, with adjusted OR of 1.28 (95% CI: 1.14-1.44), and a significantly lower risk of caesarean sections, with an adjusted OR of 0.51 (95% CI: 0.41-0.64). For operative vaginal delivery, there were no significant difference between the study groups. Intrapartum interventions as epidural analgesia and augmentation with oxytocin were lower among women admitted with ≥ 4 cm cervical dilatation. CONCLUSION: The study found a significantly higher chance of spontaneous delivery among women admitted with ≥ 4 cm. More research is needed to investigate why so many women are admitted early in labour, and how these women can be better cared for to increase their chances of a spontaneous delivery.

Associations between duration of active second stage of labour and adverse maternal and neonatal outcomes: A cohort study of nulliparous women with spontaneous onset of labour.

OBJECTIVE: To investigate associations between the duration of the active second stage of labour and adverse maternal and neonatal outcomes. METHOD: This cohort study is based on data from a cluster randomised controlled trial (RCT) undertaken at 14 Norwegian birth clinics in Norway from 2014 to 2017. The final sample involved 6804 nulliparous women with a singleton fetus, cephalic presentation, spontaneous onset of labour at term, vaginal delivered and with an active second stage of labour. The women were grouped to active second stage of labour ≤ 60 min and active second stage of labour > 60 min. Binary logistic regression was used to estimate crude and adjusted odds ratios (ORs) of the maternal and neonatal outcomes with an associated 95% confidence intervals (CIs), comparing women in the two groups. RESULTS: There was an increased risk of postpartum haemorrhage > 1000 ml with an adjusted OR 1.31 (95% CI: 1.01-1.69) when the active second stage of labour exceeded 60 min. There was no significant difference in the risk of obstetric anal sphincter injuries (adjusted OR 0.93 [95% CI: 0.65-1.39]), Apgar scores < 7 at 5 min age (adjusted OR 1.13 [95% CI: 0.65-1.97]) or admission to the neonatal intensive care unit (adjusted OR 1.46 [95% CI: 0.61-3.51]) between the study groups. CONCLUSION: Women with an active second stage of labour that exceeds 60 min had an increased risk of postpartum haemorrhage > 1000 ml. We found no association between duration of active stage of labour and obstetric anal sphincter injuries or adverse neonatal outcomes.

The Labour Progression Study (LaPS): Duration of labour following Zhang's guideline and the WHO partograph - A cluster randomised trial.

OBJECTIVE: To investigate labour duration in different phases of labour when adhering to Zhang's guideline for labour progression compared with the WHO partograph. DESIGN: A secondary analysis of a cluster randomised controlled trial. SETTING: Fourteen Norwegian birth care units, each with more than 500 deliveries per year constituted the clusters. PARTICIPANTS: A total of 7277 nulliparous women with singleton foetus in a cephalic presentation and spontaneous onset of labour at term were included. INTERVENTION: Seven clusters were randomised to the intervention group that adhered to Zhang's guideline (n = 3972) and seven to the control group that adhered to the WHO partograph (n = 3305) for labour progression. MEASUREMENTS: The duration of labour from the first registration of cervical dilatation (≥ 4 cm) to the delivery of the baby and the duration of the first and second stages of labour; the time-to-event analysis was used to compare the duration of labour between the two groups after adjusting for baseline covariates. FINDINGS: The adjusted median duration of labour was 7.0 h in the Zhang group, compared with 6.2 h in the WHO group; the median difference was 0.84 h with 95% confidence interval [CI] (0.2-1.5). The adjusted median duration of the first stage was 5.6 h in the Zhang group compared with 4.9 h in the WHO group; the median difference was 0.66 h with 95% CI (0.1-1.2). The corresponding adjusted median duration of the second stage was 88 and 77 min; the median difference was 0.18 h with 95% CI (0.1-0.3). KEY CONCLUSIONS: The women who adhered to Zhang's guideline had longer overall duration and duration of the first and second stages of labour than women who adhered to the WHO partograph. IMPLICATIONS FOR PRACTICE: Understanding the variations in the duration of labour is of great importance, and the results offer useful insights into the different labour progression guidelines, which can inform clinical practice.

Mothers' experiences of skin-to-skin care of healthy full-term newborns--a phenomenology study.

OBJECTIVES: Previous reports have shown that skin-to-skin contact immediately after birth is the optimal form of care for a full-term, healthy infant and its mother. As this is rarely researched the aim of this study was to explore experiences of skin-to-skin care in healthy mothers of healthy, full-term infants in the first days after birth. STUDY DESIGN: Using a lifeworld phenomenological approach, 20 women who had childbirth in hospital and were practising skin-to-skin care were interviewed 1-2 weeks after birth. Analysis of all interview texts was directed towards discovering qualitative meanings through a process of identifying meaning units. These were then clustered and analysed with the aim of describing themes of meaning and the essence of the phenomenon. FINDINGS: The mothers wanted to give their newborn child the best possible care and the skin-to-skin care started a positive spiral. A mutual interaction developed which acted as a generator releasing energy to the mother who wanted to continue the practice which in terms increased mother-infant affinity. Happiness, peace and satisfaction were expressed by the newborns; also a child who was crying or troublesome exhibited a positive response to skin-to-skin care. CONCLUSION: The study provides insight and knowledge which should guide attitudes and promote practices of this simple healthcare intervention; skin-to-skin contact care to healthy infants born at term. Healthcare professionals should support affinity between a mother and her newborn through facilitation and the provision of information about its benefits.