Impact of collegial midwifery assistance during second stage of labour on women's experience: a follow-up from the Swedish Oneplus randomised controlled trial.

OBJECTIVE: To compare experiences of the second stage of labour in women randomised to assistance by one or by two midwives to reduce severe perineal trauma (SPT). DESIGN: Analysis of a secondary outcome within the Swedish Oneplus multicentre randomised trial. SETTING: Five obstetric units in Sweden between December 2018 and March 2020. PARTICIPANTS: Inclusion criteria in the Oneplus trial were women opting for their first vaginal birth from gestational week 37+0 with a singleton pregnancy and a live fetus in the vertex presentation. Further inclusion criteria were language proficiency in Swedish, English, Arabic or Farsi. Exclusion criteria were multiple pregnancies, intrauterine fetal demise and planned caesarean section. Of the 3059 women who had a spontaneous vaginal birth, 2831 women had consented to participate in the follow-up questionnaire. INTERVENTIONS: Women were randomly assigned (1:1) to assistance by two midwives (intervention group) or one midwife (standard care) when reaching the second stage of labour. OUTCOME MEASURES: Data were analysed by intention to treat. Comparisons between intervention and standard care regarding experiences of the second stage of labour were evaluated with items rated on Likert scales. The Student's t-test was used to calculate mean differences with 95% CIs. RESULTS: In total 2221 (78.5%) women responded to the questionnaire. There were no statistically significant differences regarding women's experiences of being in control, feelings of vulnerability or pain. Women randomised to be assisted by two midwives agreed to a lesser extent that they could handle the situation during the second stage (mean 3.18 vs 3.26, 95% CI 0.01 to 0.15). Conducted subgroup analyses revealed that this result originated from one of the study sites. CONCLUSIONS: The intervention's lack of impact on the experience of the second stage is of importance considering the reduction in SPT when being assisted by two midwives. TRIAL REGISTRATION NUMBER: NCT03770962.

Informed consent to midwifery practices and interventions during the second stage of labor-An observational study within the Oneplus trial.

OBJECTIVES: To study informed consent to midwifery practices and interventions during the second stage of labor and to investigate the association between informed consent and experiences of these practices and interventions and women's experiences of the second stage of labor. METHODS: This study uses an observational design with data from a follow-up questionnaire sent to women one month after giving birth spontaneously in the Oneplus trial, a study aimed at evaluating collegial midwifery assistance to reduce severe perineal trauma. The trial was conducted between 2018-2020 at five Swedish maternity wards and trial registered at clinicaltrials.gov, no NCT03770962. The follow-up questionnaire contained questions about experiences of the second stage of labor, practices and interventions used and whether the women had provided informed consent. Evaluated practices and interventions were the use of warm compresses held at the perineum, manual perineal protection, vaginal examinations, perineal massage, levator pressure, intermittent catheterization of the bladder, fundal pressure, and episiotomy. Associations between informed consent and women's experiences were assessed by univariate and multivariable logistic regression. FINDINGS: Of the 3049 women participating in the trial, 2849 consented to receive the questionnaire. Informed consent was reported by less than one in five women and was associated with feelings of being safe, strong, and in control. Informed consent was further associated with more positive experiences of clinical practices and interventions, and with less discomfort and pain from interventions involving physical penetration of the genital area. CONCLUSION: The findings indicate that informed consent during the second stage is associated with feelings of safety and of being in control. With less than one in five women reporting informed consent to all practices and interventions performed by midwives, the results emphasize the need for further action to enhance midwives' knowledge and motivation in obtaining informed consent prior to performance of interventions.

Women's experiences of being assisted by two midwives during the active second stage of labour: Secondary outcomes from the Oneplus trial.

BACKGROUND: 'Collegial Midwifery Assistance' (CMA) is a clinical practice aiming to reduce severe perineal trauma (SPT) during childbirth. This practice involves two midwives being present during the active second stage of labour rather than one, which is the case in standard care. The effectiveness of CMA was evaluated in the Oneplus trial and a 30% reduction in SPT was shown. AIM: The aim was to investigate the experience of women who received the CMA intervention in the trial and to explore factors influencing their experiences. METHODS: A cohort study using data from the Oneplus trial and a one-month postpartum follow-up questionnaire. Descriptive statistics, univariable and multivariable logistic regression analyses were performed. RESULTS: A total of 1050 women who received the CMA intervention responded to the questionnaire. Of these, 35.8% reported that they strongly agreed with feeling safe during the second stage of labour and 42.6% were inclined to have an additional midwife present at a subsequent birth. The intervention was favourably received by women who experienced fear of birth, who were non-native Swedish speakers, and had lower educational attainment. Furthermore, women were more positive towards CMA the longer the intervention lasted. CONCLUSIONS: The results of this study suggest that the CMA intervention is accepted well by women and can be safely implemented into standard care. The duration of the CMA intervention was an important factor that influenced women's experiences and should be used to guide future practice.

The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden.

BACKGROUND: Severe perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife. METHODS: In this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18-47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096. FINDINGS: Between Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49-0·97). INTERPRETATION: The presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time. FUNDING: The Swedish Research Council for Health, Working Life and Welfare; Jan Hains Research Foundation; and Skane County Council's Research and Development Foundation.

Women's experiences of the second stage of labour.

BACKGROUND: The second stage of labour is generally considered as an intensive part of labour. Despite this, knowledge about women's experiences of the second stage of labour is scant. AIM: To explore experiences of the second stage of labour in women with spontaneous vaginal birth. METHODS: This is a qualitative study where twenty-one women with a spontaneous birth at term, were interviewed four to ten weeks after birth. Data were analysed using qualitative thematic analysis based on descriptive phenomenology. The participating women had experienced a vaginal birth; some for the first time, having previously given birth by caesarean section and some with a previous vaginal birth. FINDINGS: Three themes emerged: "An experience of upheaval" which represents the women's experiences of intensity, power and pain during the second stage of labour. "The importance of trusting relationships" signifies the meaning of women's relationships during the second stage of labour. "Becoming a mother" which is characterised by feelings of accomplishment and the experience of the final moments of birth. CONCLUSION: During the second stage of labour women experienced overwhelming sensations which made evident the importance of trusting relationships with those involved in the birth. The women were in a transformative state between pregnancy and motherhood where experiences of being involved and being provided with information and guidance were all considered crucial. Continuous support should be offered to women during the second stage of labour.

Management of oxytocin for labour augmentation in relation to mode of birth in Robson group 1.

OBJECTIVE: To compare mode of birth in Robson group 1 according to administration of oxytocin for labour augmentation. DESIGN AND PARTICIPANTS: A retrospective review of 724 medical records from women in Robson group 1 was performed. The outcome measurements were: mode of birth in relation to presence of labour dystocia when initiating augmentation with oxytocin, duration of augmentation with oxytocin, increase of the oxytocin infusion according to recommendations and cervical dilation when initiating augmentation with oxytocin. SETTING: The review was based on medical records from a medium-sized tertiary level obstetric unit in southern Sweden, with approximately 3700 births per year. Data was collected between January 2017 and October 2017. MEASUREMENTS AND FINDINGS: Oxytocin for labour augmentation was used in 64.1% of the births. Oxytocin administered according to the national recommendations was related to a greater likelihood of vaginal birth than when these recommendations were not followed. Only 47.8% of the women who underwent a caesarean section was treated according to recommendations. Receiving augmentation with oxytocin at a later stage of labour was related to a greater likelihood of a vaginal birth. The total time treated with oxytocin was significantly longer in women who had an assisted vaginal birth or a caesarean section than those who had a vaginal birth with augmentation. KEY CONCLUSIONS: Oxytocin for labour augmentation was over-used in Robson group 1. Oxytocin early in labour, a long duration of stimulation with oxytocin and a slower increase of the infusion than recommended had a relationship with caesarean section. IMPLICATION FOR PRACTICE: Due to risks for adverse maternal and neonatal outcomes when using oxytocin for labour augmentation, caregivers should implement strict protocols for its use. According to a high use of oxytocin there is a need to describe women's experiences of labour augmentation in labour dystocia but also when received despite normal labour progress.