The Role of Passive Descent and Epidural Analgesia in Outcomes Associated With Prolonged Pushing Among Nulliparous Individuals in Midwifery Care.

INTRODUCTION: Efforts to reduce primary cesarean birth may include supporting longer second stages of labor. Although midwifery-led care is associated with lower cesarean use, little has been published on associated outcomes of prolonged second stage (≥3 hours of pushing) for nulliparous individuals in US hospital-based midwifery care. Epidural analgesia and the role of passive descent in midwifery-led care are also underexplored in relation to the second stage. In this study, we report the incidence of prolonged second stage stratified by epidural analgesia and/or passive descent. Secondary aims included calculating the odds of cesarean birth, obstetric anal sphincter injury (OASI), postpartum hemorrhage (PPH), and neonatal complications. METHODS: Data were collected prospectively from a single academic center in the United States from 2012 through 2019. Our cohort analysis of labors attended by midwives for nulliparous, term, singleton, and vertex pregnancies included both descriptive and inferential statistics comparing outcomes between prolonged versus nonprolonged pushing groups. We stratified the sample and quantified second stage outcomes by epidural analgesia and by use of passive descent. RESULTS: Of the 1465 births, 17% (n = 247) included prolonged pushing. Cesarean ranged from 2.2% without prolonged pushing to 26.7% with prolonged pushing. Fetal malposition, epidural analgesia, and longer passive descent were more common among those with prolonged active pushing. Despite these factors, neither odds for PPH nor poor neonatal outcomes were associated with prolonged pushing. Those with more than one hour of passive descent in the second stage who also had prolonged active pushing had lower odds for cesarean but higher odds for OASI relative to those who had little passive descent before pushing for more than 3 hours. DISCUSSION: Prolonged pushing occurred in nearly 2 of 10 nulliparous labors. Fetal malposition, epidural analgesia, and prolonged pushing were commonly observed with longer passive descent, cesarean, and OASI. Passive descent in these data likely reflects individualized midwifery care strategies when pushing was complicated by fetal malposition or other complexities.

Pain attitudes and pain outcomes among people with bleeding disorders: Results from community voices in research.

INTRODUCTION: Among people with bleeding disorders (PwBD), pain is a major problem and pain treatments are often ineffective. Understanding of psychological factors involved in pain processing is limited. Maladaptive pain attitudes are associated with worse pain outcomes and adaptive pain attitudes are associated with better outcomes in high pain conditions, but relationships between pain attitudes and pain outcomes are so far unexplored among PwBD. AIM: To investigate relationships between pain attitudes and pain outcomes among PwBD. METHODS: Pain attitudes were measured with the Survey of Pain Attitudes, containing two adaptive scales (Control and Emotion) and five maladaptive scales (Disability, Harm, Medication, Solicitude, Medical Cure). Adults with bleeding disorders, who had pain, and were enrolled in Community Voices in Research were eligible. Participants (n = 72) completed an online survey. Cross sectional associations between pain attitudes and pain outcomes (pain and prescribed pain medication use) were investigated using logistic regression. RESULTS: After adjustment for covariates, greater Control attitudes were associated with lower odds of more severe pain, and greater Disability, Harm, and Medication attitudes were all associated with higher odds of more severe pain and with higher odds of any prescribed pain medication use and opioid pain medication use. CONCLUSIONS: We presented compelling evidence of relationships between pain attitudes and pain outcomes in PwBD, though corroboration is needed from other populations. Our findings suggest that modification of pain attitudes presents a possible avenue for interventions to improve pain outcomes and increase patient satisfaction with pain management.

Comparison of placenta consumers' and non-consumers' postpartum depression screening results using EPDS in US community birth settings (n=6038): a propensity score analysis.

BACKGROUND: Preventing postpartum depression (PPD) is the most common self-reported motivation for human maternal placentophagy, yet very little systematic research has assessed mental health following placenta consumption. Our aim was to compare PPD screening scores of placenta consumers and non-consumers in a community birth setting, using propensity score matching to address anticipated extensive confounding. METHODS: We used a medical records-based data set (n = 6038) containing pregnancy, birth, and postpartum information for US women who planned and completed community births. We first compared PPD screening scores as measured by the Edinburgh Postpartum Depression Scale (EPDS) of individuals who consumed their placenta to those who did not, with regard to demographics, pregnancy characteristics, and history of mental health challenges. Matching placentophagic (n = 1876) and non-placentophagic (n = 1876) groups were then created using propensity scores. The propensity score model included more than 90 variables describing medical and obstetric history, demographics, pregnancy characteristics, and intrapartum and postpartum complications, thus addressing confounding by all of these variables. We then used logistic regression to compare placentophagic to non-placentophagic groups based on commonly-cited EPDS cutoff values (≥ 11; ≥ 13) for likely PPD. RESULTS: In the unmatched and unadjusted analysis, placentophagy was associated with an increased risk of PPD. In the matched sample, 9.9% of women who ate their placentas reported EPDS ≥ 11, compared to 8.4% of women who did not (5.5% and 4.8%, respectively, EPDS ≥ 13 or greater). After controlling for over 90 variables (including prior mental health challenges) in the matched and adjusted analysis, placentophagy was associated with an increased risk of PPD between 15 and 20%, depending on the published EPDS cutoff point used. Numerous sensitivity analyses did not alter this general finding. CONCLUSIONS: Placentophagic individuals in our study scored higher on an EPDS screening than carefully matched non-placentophagic controls. Why placentophagic women score higher on the EPDS remains unclear, but we suspect reverse causality plays an important role. Future research could assess psychosocial factors that may motivate some individuals to engage in placentophagy, and that may also indicate greater risk of PPD.

Muscle power predicts frailty status over four years: A retrospective cohort study of the National Health and Aging Trends Study.

Objectives: Muscle power is a critical measure of physical capacity in older adults, however the association between muscle power and frailty is not well explored. The purpose of this study is to estimate the association between muscle power and frailty in community-dwelling older adults in the National Health and Aging Trends Study from 2011-2015. Methods: Cross-sectional and prospective analyses were performed on 4,803 community-dwelling older adults. Mean muscle power was calculated using the five-time sit-to-stand test, height, weight, and chair height and dichotomized into high-watt and low-watt groups. Frailty was defined using the five Fried criteria. Results: The low watt-group had higher odds of pre-frailty and frailty at baseline year 2011. In prospective analyses, the low-watt group that was pre-frail at baseline had increased hazards of frailty (AHR 1.62, 95% CI 1.31, 1.99) and decreased hazards of non-frailty (AHR 0.71, 95% CI 0.59, 0.86). The low-watt group that was non-frail at baseline had increased hazards of pre-frailty (1.24, 95% CI 1.04, 1.47) and frailty (1.70, 1.07, 2.70). Conclusions: Lower muscle power is associated with higher odds of pre-frailty and frailty and increased hazards of becoming frail or pre-frail over four years in those who are pre-frail or non-frail at baseline.

Urbanization and physical activity in the global Prospective Urban and Rural Epidemiology study.

Urbanization may influence physical activity (PA) levels, although little evidence is available for low- and middle- income countries where urbanization is occurring fastest. We evaluated associations between urbanization and total PA, as well as work-, leisure-, home-, and transport-specific PA, for 138,206 adults living in 698 communities across 22 countries within the Prospective Urban and Rural Epidemiology (PURE) study. The 1-week long-form International PA Questionnaire was administered at baseline (2003-2015). We used satellite-derived population density and impervious surface area estimates to quantify baseline urbanization levels for study communities, as well as change measures for 5- and 10-years prior to PA surveys. We used generalized linear mixed effects models to examine associations between urbanization measures and PA levels, controlling for individual, household and community factors. Higher community baseline levels of population density (- 12.4% per IQR, 95% CI - 16.0, - 8.7) and impervious surface area (- 29.2% per IQR, 95% CI - 37.5, - 19.7), as well as the rate of change in 5-year population density (- 17.2% per IQR, 95% CI - 25.7, - 7.7), were associated with lower total PA levels. Important differences in the associations between urbanization and PA were observed between PA domains, country-income levels, urban/rural status, and sex. These findings provide new information on the complex associations between urbanization and PA.

Critical care in obstetrics: Clinical audit in the Republic of Ireland, 2014-2016.

INTRODUCTION: Admission to an Intensive Care Unit (ICU) in obstetrics is often used as a proxy for maternal near miss/severe maternal morbidity (MNM/SMM) events. Understanding incidence and management of pregnant or postpartum patients requiring critical care (CC) is thus important for continued improvement of maternity care. This study aims to describe provision of critical care in obstetrics in the Republic of Ireland. MATERIAL AND METHODS: The national clinical audit on critical care included 15 of 19 maternity units in Ireland (2014-2016). 960 pregnant or postpartum (within 42 days) individuals who required CC were included. Data were reported on all cases requiring level 2 or level 3 CC. We calculated basic descriptive statistics for diagnosis and process of care variables, and compared characteristics of women requiring level 2 care to those requiring level 3. Outcomes included diagnoses necessitating critical care; additional complications; level of care required; care process outcomes such as length of stay, consultation with non-obstetric specialties, location of maternal critical care, and neonatal care provision. RESULTS: Overall, the rate of critical care in obstetrics for these hospitals was 1 in 131 live births; 900 of the 960 cases required level 2 care only. Hypertensive disorders contributed to the need for critical care for 1 in 242; hemorrhage, 1 in 422; and infections, 1 in 926. A substantial minority (15.7%) had more than one diagnosis, accounting for 40% of level 3 care. Serious complications were rare (eg, hysterectomy, 1 in 3846). Parity, hospital size, and identification as high-risk antenatally (<50% cases) were associated with requiring level 3 care. Critical care was provided in multiple locations, including ICUs, HDUs, and operating theatres. Only 23.8% of patients received CC in an ICU, suggesting ICU admission is not an ideal method for identifying severe maternal morbidity. CONCLUSIONS: We reported rates of critical care admission and primary diagnoses within the range of other published estimates, but huge variability exists in the literature, and within our data. ICU admission in and of itself iss not a reliable proxy for having received level 2 or 3 obstetric critical care in Ireland.

The duration of spontaneous active and pushing phases of labour among 75,243 US women when intervention is minimal: A prospective, observational cohort study.

Background: Friedman's curve, despite acknowledged limitations, has greatly influenced labour management. Interventions to hasten birth are now ubiquitous, challenging the contemporary study of normal labour. Our primary purpose was to characterise normal active labour and pushing durations in a large, contemporary sample experiencing minimal intervention, stratified by parity, age, and body mass index (BMI). Methods: This is a secondary analysis of the national, validated Midwives Alliance of North America 4·0 (MANA Stats) data registry (n = 75,243), prospectively collected between Jan 1, 2012 and Dec 31, 2018 to describe labour and birth in home and birth center settings where common obstetric interventions [i.e., oxytocin, planned cesarean] are not available. The MANA Stats cohort includes pregnant people who intended birth in these settings and prospectively collects labour and birth processes and outcomes regardless of where birth or postpartum care ultimately occurs. Survival curves were calculated to estimate labour duration percentiles (e.g. 10th, 50th, 90th, and others of interest), by parity and sub-stratified by age and BMI. Findings: Compared to multiparous women (n = 32,882), nulliparous women (n = 15,331) had significantly longer active labour [e.g., median 7.5 vs. 3.3 h; 95th percentile 34.8 vs. 12.0 h] and significantly longer pushing phase [e.g., median 1.1 vs. 0.2 h; 95th percentile 5.5 vs. 1.1 h]. Among nulliparous women, maternal age >35 was associated with longer active first stage of labour and longer pushing phase, and BMI >30 kg/m² was associated with a longer active first stage of labour but a shorter pushing phase. Patterns among multiparous women were different, with those >35 years of age experiencing a slightly more rapid active labour and no difference in pushing duration, and those with BMI >30 kg/m² experiencing a slightly longer active labour but, similarly, no difference in pushing duration. Interpretation: Nulliparous women had significantly longer active first stage and pushing phase durations than multiparous women, with further variation noted by age and by BMI. Contemporary US women with low-risk pregnancies who intended birth in settings absent common obstetric interventions and in spontaneous labour with a live, vertex, term, singleton, non-anomalous fetus experienced labour durations that were often longer than prior characterizations, particularly among nulliparous women. Results overcome prior and current sampling limitations to refine understanding of normal labour durations and time thresholds signaling 'labour dystocia'. Funding: OHSU Nursing Innovation and OHSU University Shared Resources.

Prevalence and Predictors of Postpartum Cosleeping Practices after Midwife-Led Births in the US.

OBJECTIVE: To evaluate patterns of mother-infant sleeping behaviors among US-based mothers who received care from midwives and breastfed their infants the majority of time at 6 weeks postpartum. STUDY DESIGN: Infant sleep locations were reported for 24 915 mother-infant dyads followed through 6 weeks postpartum, following midwife-led singleton births. Using data derived from medical records, we used multinomial logistic regression to identify predictors of sleep location. RESULTS: The median maternal age was 31 years (IQR, 27-34 years). The majority were White (84.5%), reported having a partner or spouse (95%), had a community birth (87%), and reported bedsharing with their infant for part (13.2%) or most of the night (43.8%). In the adjusted analysis, positive predictors of always bedsharing included increasing maternal age (OR, 1.17; 95% CI, 1.13-1.21; per 5 years), cesarean birth (OR, 1.49; 95% CI, 1.18-1.86), Medicaid eligibility (OR, 1.76; 95% CI, 1.62-1.91), and maternal race/ethnicity (Black OR, 1.40 [95% CI, 1.09-1.79]; Latinx OR, 1.53 [95% CI, 1.35-1.74]; multiracial OR, 1.69 [95% CI, 1.39-2.07]). Negative predictors of bedsharing included having a partner/spouse (OR, 0.66; 95% CI, 0.56-0.77) and birth location in hospitals (OR, 0.56; 95% CI, 0.49-0.64) or birthing centers (OR, 0.48; 95% CI, 0.44-0.51). Partial breastfeeding dyads were less likely to bedshare than those who were exclusively breastfeeding (always bedsharing OR, 0.48 [95% CI, 0.41-0.56]; sometimes bedsharing OR 0.69 [95% CI, 0.56-0.83]). CONCLUSIONS: These data suggest that cosleeping is common among US families who choose community births, most of whom exclusively breastfeed through at least 6 weeks.

Current Resources for Evidence-Based Practice, May 2022.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of the roles of researchers and clinicians in fostering evidence-based practice, diagnostic test accuracy in suspected preeclampsia, and the effectiveness of decision-making tools in patients with pre-pregnancy morbidities.

Current Resources for Evidence-Based Practice, March 2022.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of systemic racism and its effect on maternal health in the United States and commentaries on reviews focused on barriers and facilitators to HPV vaccination and delayed cord clamping in preterm infants.

Maternal Physical Activity at Term and Spontaneous Labor: A Case-Crossover Study.

BACKGROUND: This study assessed associations between antenatal physical activity and the onset of spontaneous labor (SL). METHODS: Data were taken from 541 participants in the third pregnancy, infection, and nutrition study who had no contraindications to antenatal physical activity. An interviewer-administered questionnaire assessed labor triggers, gestational age at birth, and physical activity within the week (24 h to 7 d) and the 24-hour period (0-24 h) prior to SL. A case-crossover design examined the association between physical activity (recreational, occupational, or any) and the risk of onset of SL within the subsequent 24 hours. RESULTS: Overall, 21% (any), 26% (recreational), and 14% (occupational) of participants reported physical activity during the week; whereas 5% (any), 7% (recreational), and 3% (occupational) reported physical activity during the 24-hour period, prior to SL onset. Participants who reported any or occupational physical activity during the 24-hour period had a decreased likelihood of SL within the subsequent 24 hours, while participants who reported at least 30 minutes of recreational physical activity had an increased likelihood. Results remained consistent among early, full, or postterm participants. CONCLUSION: Recreational, but not occupational, physical activity at term may increase the likelihood of SL; however, the authors cannot rule out reverse causality.

Maternal hair cortisol concentrations across pregnancy and the early postpartum period in a Puerto Rican sample.

OBJECTIVE: Hair cortisol is a noninvasive, long-term biomarker of human stress. Strengths and weaknesses of this biomarker as a proxy measure of perinatal stress are not yet well understood. Hair cortisol data were collected from pregnant women in Puerto Rico to investigate maternal cortisol level variance across pregnancy. METHODS: In 2017, we recruited 86 pregnant women planning to birth at a large urban hospital. We aimed to collect four hair samples from each participant, one in each trimester and one in the postpartum period. RESULTS: Median cortisol in the first trimester (n = 82) was 5.7 picograms/milligram (pg/mg) (range: 1.0-62.4). In the second, third, and postpartum periods, the medians were 6.8 pg/mg (1.0-69.5), (n = 46), 20.1 pg/mg (5.6-89.0), (n = 30), and 14.1 pg/mg (1.7-39.8), (n = 9), respectively. These medians disguise a 10-fold and 50-fold variability for two participants. Our sample sizes declined sharply when Hurricane Maria caused major disruptions in services and participants' lives. CONCLUSION: Maternal hair cortisol concentrations were lower in the first and second trimester than the third trimester and early postpartum period. We also observed a wide range of variation in cortisol levels throughout pregnancy and in the postpartum period.

Meal patterning and the onset of spontaneous labor.

BACKGROUND: There is a lack of consensus in the literature about the association between meal patterning during pregnancy and birth outcomes. This study examined whether maternal meal patterning in the week before birth was associated with an increased likelihood of imminent spontaneous labor. METHODS: Data came from 607 participants in the third phase of the Pregnancy, Infection, and Nutrition Study (PIN3). Data were collected through an interviewer-administered questionnaire after birth, before hospital discharge. Questions included the typical number of meals and snacks consumed daily, during both the week before labor onset and the 24-hour period before labor onset. A self-matched, case-crossover study design examined the association between skipping one or more meals and the likelihood of spontaneous labor onset within the subsequent 24 hours. RESULTS: Among women who experienced spontaneous labor, 87.0% reported routinely eating three daily meals (breakfast, lunch, and dinner) during the week before their labor began, but only 71.2% reported eating three meals during the 24-hour period before their labor began. Compared with the week before their labor, the odds of imminent spontaneous labor were 5.43 times as high (95% CI: 3.41-8.65) within 24 hours of skipping 1 or more meals. The association between skipping 1 or more meals and the onset of spontaneous labor remained elevated for both pregnant individuals who birthed early (37-<39 weeks) and full-term (≥39 weeks). CONCLUSIONS: Skipping meals later in pregnancy was associated with an increased likelihood of imminent spontaneous labor, though we are unable to rule out reverse causality.

Current Resources for Evidence-Based Practice, January 2022.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of breastfeeding while employed and commentaries on reviews focused on mammography test characteristics and sexual health for gynecologic cancer survivors. It also includes a quick update on a USPSTF review for aspirin as pre-eclampsia prophylaxis.

Current Resources for Evidence-Based Practice, November 2021.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of autonomy and respect in maternity care and commentaries on reviews focused on whether to induce women who present with mild preeclampsia in the late preterm period and the extent to which urinary incontinence symptoms prevent women from participating in exercise. It also includes a brief update about the USPSTF guidelines on screening for gestational diabetes.

Current Resources for Evidence-Based Practice, September 2021.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes an assessment of safety of birth centers in the United States and commentaries on reviews focused on aspirin prophylaxis in pregnancy and the new gestational weight gain evidence summary from the United States Preventive Services Task Force.

Current Resources for Evidence-Based Practice, July 2021.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of how fetal monitoring may lead to overuse of birth-related interventions, commentaries on reviews focused on bedsharing, and women's lifetime estrogen exposure and risk of cardiovascular mortality.

Current Resources for Evidence-Based Practice, May 2021.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of the prenatal prediction of fetal macrosomia and commentaries on reviews focused on the effects of date palm and dill seed on labor outcomes and the current research available on SARS-CoV-2 and pregnancy outcomes.

Two-Year Test-Retest Reliability of the Breastfeeding Duration Question Used By the Pregnancy Risk Assessment Monitoring System (PRAMS): Implications for Research.

INTRODUCTION: A large literature exists on positive sequelae of breastfeeding, relying heavily on maternal self-reported infant feeding behaviors. Many such studies use PRAMS data, though estimates of reliability for the breastfeeding duration question on PRAMS have not been published. METHODS: We used data from Oregon PRAMS (respondents are a median 3.5 months postpartum) and PRAMS-2 (median 25 months) to assess test-retest reliability of maternal self-reported breastfeeding duration, among women who had weaned prior to completing the PRAMS survey. RESULTS: The sample-wide kappa for the paired, self-reported breastfeeding duration was 0.014, and the intraclass correlation coefficient was 0.17, both of which indicate poor agreement. More than 80% of women reported a longer duration on PRAMS-2; the median (interquartile range) difference was +1.0 (0.31 - 2.1) months. DISCUSSION: Recent literature on this topic from high-income countries falls into two categories: entirely retrospective versus "prospective" reliability assessments. Entirely retrospective assessments (both inquiries occur well after weaning) universally report exceedingly high reliability, whereas "prospective" assessments (women report infant feeding behavior during infancy, immediately after weaning, and some years later are asked to replicate their original answer) universally report poorer reliability. Interestingly, all "prospective" reliability studies, including ours, found that women over-report past breastfeeding durations by about 1 month upon the second inquiry. Researchers need not refrain from using maternal self-reported breastfeeding durations, because participants are largely still ranked correctly, relative to each other. However, such research efforts must avoid attempting to determine any optimal threshold duration.

Current Resources for Evidence-Based Practice, March 2021.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of men's experiences of pregnancy loss and commentaries on reviews focused on the effects of perineal massage on perineal trauma and air pollution and heat exposure on birth outcomes.