"I guess baby was just too comfy in there ": A qualitative study of women's experiences of elective late-term induction of labour.

BACKGROUND: The frequency of induction of labour (IOL) in late-term pregnancy has increased significantly, but little is known about how women with uncomplicated pregnancies experience IOL for late-term indication alone. AIM: To explore how women with uncomplicated pregnancies experienced late-term IOL. METHODS: Qualitative interviews were conducted with 23 women who all had labour induced on late-term indication only. Participants were recruited from two Danish hospitals who offered an outpatient induction regime. The women were interviewed 4-8 weeks after birth. Data were analysed using thematic analysis. RESULTS: All women had hoped for a spontaneous birth. Prolonged pregnancy was understood as the body/baby "not being ready", but generally, the women were not worried at that point. Most women felt adequately informed about the reasons for IOL, but some requested more information and time to consider their options. The majority considered IOL to be both an offer and a recommendation. One-third of the participants were initially hesitant but chose/accepted IOL because of weariness from pregnancy and the impatience to deliver a healthy child. The opportunity of outpatient induction was generally appreciated as it allowed the women to continue everyday activities while waiting for labour to begin. Nineteen women reported having a good birthing experience. Two women felt that negative birthing experiences were partly related to IOL. CONCLUSIONS: Most women considered the late-term IOL to be a positive experience. Some women requested more information and time to consider alternatives. These women should be provided with supported opportunities to consider the options.

What women want and why. Women's preferences for induction of labour or expectant management in late-term pregnancy.

BACKGROUND: Both induction of labour at 41 weeks and expectant management until 42 weeks are common management strategies in low-risk pregnancy since there is no consensus on the optimal timing of induction in late-term pregnancy for the prevention of adverse outcomes. Our aim was to explore maternal preference for either strategy and the influence on quality of life and maternal anxiety on this preference. METHODS: Obstetrical low-risk women with an uncomplicated pregnancy were eligible when they reached a gestational age of 41 weeks. They were asked to fill in questionnaires on quality of life (EQ6D) and anxiety (STAI-state). Reasons of women's preferences for either induction or expectant management were explored in a semi-structured questionnaire containing open ended questions. RESULTS: Of 782 invited women 604 (77.2%) responded. Induction at 41 weeks was preferred by 44.7% (270/604) women, 42.1% (254/604) preferred expectant management until 42 weeks, while 12.2% (74/604) of women did not have a preference. Women preferring induction reported significantly more problems regarding quality of life and were more anxious than women preferring expectant management (p<0.001). Main reasons for preferring induction of labour were: "safe feeling" (41.2%), "pregnancy taking too long" (35.4%) and "knowing what to expect" (18.6%). For women preferring expectant management, the main reason was "wish to give birth as natural as possible" (80.3%). CONCLUSION: Women's preference for induction of labour or a policy of expectant management in late-term pregnancy is influenced by anxiety, quality of life problems (induction), the presence of a wish for natural birth (expectant management), and a variety of additional reasons. This variation in preferences and motivations suggests that there is room for shared decision making in the management of late-term pregnancy.

Management of late-term pregnancy in midwifery- and obstetrician-led care.

Management of late-term pregnancy in midwifery- and obstetrician-led care. BACKGROUND: Since there is no consensus regarding the optimal management in late-term pregnancies (≥41.0 weeks), we explored the variety of management strategies in late-term pregnancy in the Netherlands to identify the magnitude of this variety and the attitude towards late-term pregnancy. METHODS: Two nationwide surveys amongst all midwifery practices (midwifery-led care) and all hospitals with an obstetric unit (obstetrician-led care) were performed with questions on timing, frequency and content of consultations/surveillance in late-term pregnancy and on timing of induction. Propositions about late-term pregnancy were assessed using Likert scale questions. RESULTS: The response rate was 40% (203/511) in midwifery-led care and 92% (80/87) in obstetrician-led care. All obstetric units made regional protocols with their collaborating midwifery practices about management in late-term pregnancy. Most midwifery-led care practices (93%) refer low-risk women at least once for consultation in obstetrician-led care in late-term pregnancy. The content of consultations varies among hospitals. Membrane sweeping is performed more in midwifery-led care compared to obstetrician-led care (90% vs 31%, p < 0.001). Consultation at 41 weeks should be standard care according to 47% of midwifery-led care practices and 83% of obstetrician-led care units (p < 0.001). Induction of labour at 41.0 weeks is offered less often to women in midwifery-led care in comparison to obstetrician-led care (3% vs 21%, p < 0.001). CONCLUSIONS: Substantial practice variation exists within and between midwifery-and obstetrician-led care in the Netherlands regarding timing, frequency and content of antenatal monitoring in late-term pregnancy and timing of labour induction. An evidence based interdisciplinary guideline will contribute to a higher level of uniformity in the management in late- term pregnancies.

Women's experiences of postterm induction of labor: A systematic review of qualitative studies.

BACKGROUND: Over the last decade, induction of labor (IOL) in postterm pregnancies has increased. Studies have shown the medical advantages of postterm IOL, but less is known about the perspectives of the pregnant women. This review aimed to summarize the current qualitative evidence on women's experience of postterm IOL. METHODS: A systematic literature search was performed in three databases. A total of 3193 publications were identified, but only eight studies met the inclusion criteria. Thematic analysis guided the data extraction and synthesis. The Confidence in the Evidence for Reviews of Qualitative research (CERQual) approach was used to assess confidence in the findings. RESULTS: Three major findings were identified. First, for some women, IOL required a shift in expectations because the hope of spontaneous labor had to be given up. Second, the IOL decision was considered a recommendation from health care professionals and was experienced as a nondecision. Finally, the induction process was experienced as a sequential set of steps where the women were expected to fit into the existing hospital organization. The CERQual assessment suggested moderate confidence in all findings. DISCUSSION: The negative experiences identified in this review can be greatly reduced by a communicative and patient-centered approach. To support informed choice and shared decision making, women need high-quality, unbiased information about IOL, alternative options, and potential outcomes, in addition to time for reflection on their personal values and preferences. Women may need a professionally initiated and supported opportunity to re-evaluate their hopes and expectations before IOL.

A pilot study to understand feasibility and acceptability of stool and cord blood sample collection for a large-scale longitudinal birth cohort.

BACKGROUND: Few data are available to guide biological sample collection around the time of birth for large-scale birth cohorts. We are designing a large UK birth cohort to investigate the role of infection and the developing immune system in determining future health and disease. We undertook a pilot to develop methodology for the main study, gain practical experience of collecting samples, and understand the acceptability of sample collection to women in late pregnancy. METHODS: Between February-July 2014, we piloted the feasibility and acceptability of collecting maternal stool, baby stool and cord blood samples from participants recruited at prolonged pregnancy and planned pre-labour caesarean section clinics at University College London Hospital. Participating women were asked to complete acceptability questionnaires. RESULTS: Overall, 265 women were approached and 171 (65%) participated, with ≥1 sample collected from 113 women or their baby (66%). Women had a mean age of 34 years, were primarily of white ethnicity (130/166, 78%), and half were nulliparous (86/169, 51%). Women undergoing planned pre-labour caesarean section were more likely than those who delivered vaginally to provide ≥1 sample (98% vs 54%), but less likely to provide maternal stool (10% vs 43%). Pre-sample questionnaires were completed by 110/171 women (64%). Most women reported feeling comfortable with samples being collected from their baby (<10% uncomfortable), but were less comfortable about their own stool (19% uncomfortable) or a vaginal swab (24% uncomfortable). CONCLUSIONS: It is possible to collect a range of biological samples from women around the time of delivery, and this was acceptable for most women. These data inform study design and protocol development for large-scale birth cohorts.

Being in limbo: Women's lived experiences of pregnancy at 41 weeks of gestation and beyond - A phenomenological study.

BACKGROUND: Globally, the prevalence of post term pregnancy (PTP) is about 5-10%, but the rate varies considerably between and within countries. PTP is defined as a pregnancy ≥294 days, but the definition is arbitrary. Many studies focusing on the prevalence, risks and management of PTP include pregnancies ≥41 gestational weeks (GW). However, qualitative interview studies concerning women's experiences of PTP are lacking. Therefore, the aim of this study was to describe women's lived experiences of a pregnancy ≥41 GW. METHOD: The study has a lifeworld research approach. Individual in-depth interviews were conducted from August 2013 to September 2014 with 10 healthy women with an expected normal pregnancy at GW 41 + 1-6 days in Gothenburg, Sweden. Interviews were conducted at the antenatal clinic or in the woman's home, depending on her preference. Data were analysed with a phenomenological reflective lifeworld approach. RESULT: The essence of women's experiences of a pregnancy at GW ≥ 41 was described as being in limbo, a void characterised by contradictions related to time, giving birth and the condition. Exceeding the estimated date of childbirth implied a period of up to 2 weeks that was not expected. The contradictory aspect was the notion that time passed both slowly and quickly. Negative feelings dominated and increased over time. The women experienced difficulty due to not being in complete control, while at the same time finding it a beneficial experience. Health care professionals focused solely on the due date, while the women felt neither seen nor acknowledged. Lack of information led to searches in social media. Previously, they had trusted the body's ability to give birth, but this trust diminished after GW 41 + 0. In this state of limbo, the women became more easily influenced by people around them, while in turn influencing others. CONCLUSIONS: Being in limbo represents a contradictory state related to time and process of giving birth, when women need to be listened to by healthcare professionals. An understanding of the importance of different information sources, such as family and friends, is necessary. It is vital that women are seen and acknowledged by midwives at the antenatal clinics. In addition, they should be asked how they experience waiting for the birth in order to create a sense of trust and confidence in the process.

Women's experience of post-term pregnancy.

In recent years, induction of labour has become increasingly common in many countries and has moved towards an earlier gestational age. The aim of this study was to describe how low-risk pregnant women experienced post-term pregnancy in a large university hospital in Denmark Qualitative interviews were carried out with 31 low-risk pregnant women. Pregnant women passing their estimated time of birth date experienced their last days of pregnancy as a countdown to induction, not as their last days of pregnancy. Categorisation of the women's pregnancy based on medical statistics, and a focus on medical issues caused the women to feel less involved, and contributed to them being willing to negotiate an earlier induction of labour to avoid being stigmatised as pathological patients.

Emotional state of primigravid women with pregnancy susceptible to prolongation.

OBJECTIVE: This study sought to know the perception of the emotional state of women with pregnancy susceptible to prolongation. METHODOLOGY: The research was conducted with qualitative descriptive methodology, founded on in-depth individual interviews of 7 gestants susceptible to prolongation, with ages between 21 and 32 years and duration of the pregnancy comprised between 40+5 and 41+4 weeks. RESULTS: The emotional state varies throughout the pregnancy; once the probable date of delivery has passed, the emotional well-being is altered by fear of pain during delivery, possible complications, and caring for the newborn, presenting a state of nervousness due to the imminent delivery. In addition, the women described the need for the presence of a companion during and after the delivery. CONCLUSION: Fear can affect negatively the subjective experience of the pregnancy during its final phase, the delivery process, and the transition to maternity in gestants with pregnancy susceptible to prolongation. These women need support and specific education from the midwife according to their individual needs.

Effects of depressive and anxiety symptoms during pregnancy on pregnant, obstetric and neonatal outcomes: a follow-up study.

Antenatal clinics can expect at least one in five pregnant women to experience mental health problems, especially depression and anxiety. The present study aims to estimate the effects of the antenatal depressive and anxiety symptoms on pregnant, obstetric and neonatal outcomes. This was a prospective cohort study of 527 pregnancies and their neonates. Whether the women were with or without symptoms of depression and anxiety was determined by the Hospital Anxiety and Depression Scale (HADS). All the participants were followed to delivery. The prevalence of antenatal depressive and/or anxiety was 11.0%. The antenatal depressive and/or anxiety symptoms during pregnancy can increase the risk of prolonged pregnancy (RR =4.080, 95% CI: 1.249-13.325), especially in primiparous women.

Overdue choices: how information and role in decision-making influence women's preferences for induction for prolonged pregnancy.

BACKGROUND: Enabling women to make informed decisions is a crucial component of consumer-focused maternity care. Current evidence suggests that health care practitioners' communication of care options may not facilitate patient involvement in decision-making. The aim of this study was to investigate the effect of specific variations in health caregiver communication on women's preferences for induction of labor for prolonged pregnancy. METHODS: A convenience sample of 595 female participants read a hypothetical scenario in which an obstetrician discusses induction of labor with a pregnant woman. Information provided on induction and the degree of encouragement for the woman's involvement in decision-making was manipulated to create four experimental conditions. Participants indicated preference with respect to induction, their perceptions of the quality of information received, and other potential moderating factors. RESULTS: Participants who received information that was directive in favor of medical intervention were significantly more likely to prefer induction than those given nondirective information. No effect of level of involvement in decision-making was found. Participants' general trust in doctors moderated the relationship between health caregiver communication and preferences for induction, such that the influence of information provided on preferences for induction differed across levels of involvement in decision-making for women with a low trust in doctors, but not for those with high trust. Many women were not aware of the level of information required to make an informed decision. CONCLUSIONS: Our findings highlight the potential value of strategies such as patient decision aids and health care professional education to improve the quality of information available to women and their capacity for informed decision-making during pregnancy and birth.

Women's experiences of being induced for post-date pregnancy.

AIM: To explore the women's experiences of being booked for induction of labour for a pregnancy greater than 41 weeks gestation. PARTICIPANTS: 23 primigravidae who were booked for induction: 18 were induced (induction group) and 5 went into spontaneous labour (comparison group). METHOD: Data were collected by a series of interviews from booking to after birthing: interpretative techniques analysed verbatim transcriptions. FINDINGS: Two dimensions of being in the process of induction were identified: (1) a sense of "Time's Up," when the natural, temporal aspects of pregnancy end with an imposed birth date and sequenced induction procedures and, (2) a required "Shift in Expectations" from the women's original plan for labour and birth. The women varied in their responses from welcoming the end of pregnancy to feeling that their body or their baby was not ready for birth. A lack of meaningful information regarding the process of induction was also identified. The comparison group focused their worry on the impact of induction on the baby whereas the induction group expressed concern about the effect on themselves and loss of a natural birth. Worries in both groups were dissipated by successfully birthing a healthy baby. IMPLICATIONS AND OUTCOMES: The findings sensitise midwives to women's possible responses to being booked for induction. Antenatal educators can use this knowledge to prepare women and their partners for required shifts in their birthing plan when induction is deemed necessary. Midwives can help women adapt their birth plans during the induction process.

Social induction of labour: experience in an urban teaching hospital in Nigeria.

PURPOSE: To document the experience with social induction of labour (IOL) and compare its outcome with electively induced labour for prolonged pregnancy. METHODS: A prospective matched case-control study. RESULT: Social IOL was significantly common in women of high social class (78.3 vs. 45.6%, P = 0.03) and the commonest indication was because the parturient was 'tired of pregnancy' (60.9%). There was no significant difference between both groups in the mean induction to delivery interval, caesarean section and instrumental delivery rates, 5-minute Apgar score <7 and early neonatal death. CONCLUSION: Social IOL in well-selected cases has comparable outcomes to elective IOL for prolonged pregnancy. There is still the need for evaluating the determinants of maternal request for social IOL and the development of guidelines to regulate its practice.

Feasibility study of a Latest Date of Delivery (LDD) system of managing pregnancy.

BACKGROUND: This study aimed to establish the acceptability of a Latest Date of Delivery (LDD) system of managing pregnancy. An LDD is the date at 42 weeks on which labour will be induced if a woman has not delivered by then. This study examined whether women under conventional expected date of delivery (EDD) management would find an LDD system acceptable in principle, and whether they would prefer it to the EDD system. An additional objective was to examine changes in state anxiety in late pregnancy, post-term, and after delivery. METHODS: This was a preliminary survey of women's attitudes towards an LDD system. Sixty-two women under normal pregnancy management completed questionnaires about the acceptability of an LDD system at 36 weeks gestation. In addition, questionnaires measuring state anxiety were completed at 36, 38, 40, and 41 weeks. RESULTS: The majority of women evaluated an LDD system positively, with 64% of women saying they would agree to an LDD and only 11.3% saying they would not. Forty percent of women said they would prefer an LDD to an EDD system and 36% said they were not sure. Women who had not delivered by 41 weeks had significantly more anxiety than those who had delivered. CONCLUSIONS: The LDD system appears to be acceptable to women and, for 40% of women, preferable to the EDD. Anxiety appears to increase as women go post-term, but problems of attrition mean the results regarding anxiety should be treated cautiously. Potential difficulties with implementing an LDD system are discussed.