Community Support Persons and Mitigating Obstetric Racism During Childbirth.

PURPOSE: We undertook a study to assess whether presence of community support persons (CSPs), with no hospital affiliation or alignment, mitigates acts of obstetric racism during hospitalization for labor, birth, and immediate postpartum care. METHODS: We conducted a cross-sectional cohort study, measuring 3 domains of obstetric racism as defined for, by, and with Black birthing people: humanity (violation of safety and accountability, autonomy, communication and information exchange, and empathy); kinship (denial or disruption of community and familial bonds that support Black birthing people); and racism in the form of anti-Black racism and misogynoir (weaponization of societal stereotypes and scripts in service provision that reproduce gendered anti-Black racism in the hospital). We used a novel, validated instrument, the Patient-Reported Experience Measure of Obstetric Racism (the PREM-OB Scale suite), and linear regression analysis to determine the association between CSP presence during hospital births and obstetric racism. RESULTS: Analyses were based on 806 Black birthing people, 720 (89.3%) of whom had at least 1 CSP present throughout their labor, birth, and immediate postpartum care. The presence of CSPs was associated with fewer acts of obstetric racism across all 3 domains, with statistically significant reductions in scores in the CSP group of one-third to two-third SD units relative to the no-CSP group. CONCLUSIONS: Our findings suggest that CSPs may be an effective way to reduce obstetric racism as part of quality improvement initiatives, emphasizing the need for democratizing the birthing experience and birth space, and incorporating community members as a way to promote the safety of Black birthing people in hospital settings.Annals "Online First" article.

Prevalence of risk stomach in laboring women allowed to unrestrictive oral intake: a comparative cross-sectional study.

BACKGROUND: Although restricting food intake during labor is recommended by guidelines, intrapartum starvation has not been popular in some regions. We conducted this comparative cross-sectional study to determine the prevalence of risk stomach in non-fasted laboring women compared with fasted non-laboring women using gastric ultrasound. METHODS: Ultrasound examination of the antrum was performed in 50 term fasted non-laboring women before elective cesarean delivery and 50 laboring women allowed to eat and drink during active labor. Examinations consisted of the qualitative (antral grades, 0-3) and quantitative evaluation (antral cross-sectional area and calculated gastric volume) in the supine and right lateral decubitus (RLD) position. A risk stomach was defined as an antral grade ≥ 2 or grade 1 with gastric volume ≥ 1.5 ml· kg- 1. RESULTS: No non-laboring women had grade ≥ 2, while 34 (68%) laboring women had grade ≥ 2. Nine (18%) non-laboring and 40 (80%) laboring women presented risk stomach (P < 0.001) (risk ratio: 4.4, 95% CI 2.4-8.2). Compared with non-laboring women, laboring women had larger antral area at "empty" stomach (grade 0) (437 mm2 vs.350 mm2 in supine, 571 mm2 vs.480 mm2 in RLD, P < 0.05) and cut-off values of antral area to discriminate a risk stomach (510 mm2 vs. 453 mm2 in supine, 670 mm2 vs. 605 mm2 in RLD). CONCLUSIONS: This study confirms a higher prevalence of risk stomach presents in laboring women under a liberal eating policy, gastric ultrasound is therefore useful for this risk population if general anesthesia is required unexpectedly.

Health Care Practitioners' Attitudes and Knowledge Regarding Trial of Labour After Cesarean Delivery (TOLAC): A Survey of Canadian Obstetrical Care Providers.

OBJECTIVES: To understand current attitudes and practice patterns of obstetrical care providers regarding trial of labour after cesarean (TOLAC) and to assess misconceptions regarding eligibility for and risks associated with TOLAC. METHODS: A survey was developed based on published literature, validated by a statistician, and piloted with Canadian obstetricians. French and English versions were distributed via the mailing list of the Society of Obstetricians and Gynaecologists of Canada and social media. Practising obstetrical care providers with an office antenatal practice were eligible to participate. Data were analyzed using descriptive statistics and correlational and multiple regression analyses. RESULTS: A total of 381 people responded, with representation from every Canadian province and territory. Obstetrician-gynaecologists (239, 63%), family physicians (100, 26%), and midwives (42, 11%) responded. Most participants (277, 78%) thought that TOLAC should be actively encouraged. Only 141 (40%) used a decision aid when counselling patients, although most respondents (250, 71%) thought it would be useful. Providers were less comfortable offering oxytocin induction compared with cervical foley or amniotomy (P < 0.001) and offering TOLAC to patients with an unknown uterine scar (P < 0.001). Providers in western Canada reported more comfort offering TOLAC to patients with more than 1 previous cesarean delivery compared with other regions. Two hundred nine participants (62%) reported that they had had at least 1 patient with a uterine rupture, with the minority of cases (13, 6%) resulting in litigation. CONCLUSIONS: This study offers new information on current national practice patterns and provider attitudes regarding TOLAC. These results can be used to guide future educational initiatives to increase TOLAC rates.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities.

OBJECTIVE: To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada. TARGET POPULATION: This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline. OUTCOMES: Safe and compassionate care for people with physical disabilities who are giving birth. BENEFITS, HARMS, AND COSTS: Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth. EVIDENCE: A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

Effectiveness of a childbirth massage programme for labour pain relief in nulliparous pregnant women at term: a randomised controlled trial.

INTRODUCTION: The effect of massage for pain relief during labour has been controversial. This study investigated the efficacy of a programme combining intrapartum massage, controlled breathing, and visualisation for non-pharmacological pain relief during labour. METHODS: This randomised controlled trial was conducted in two public hospitals in Hong Kong. Participants were healthy low-risk nulliparous Chinese women ≥18 years old whose partners were available to learn massage technique. Recruitment was performed at 32 to 36 weeks of gestation; women were randomised to attend a 2-hour childbirth massage class at 36 weeks of gestation or to receive usual care. The primary outcome variable was the intrapartum use of epidural analgesia or intramuscular pethidine injection. RESULTS: In total, 233 and 246 women were randomised to the massage and control groups, respectively. The use of epidural analgesia or pethidine did not differ between the massage and control groups (12.0% vs 15.9%; P=0.226). Linear-by-linear analysis demonstrated a trend whereby fewer women used strong pharmacological pain relief in the massage group, and a greater proportion of women had analgesic-free labour (29.2% vs 21.5%; P=0.041). Cervical dilatation at the time of pethidine/epidural analgesia request was significantly greater in the massage group (3.8 ± 1.7 cm vs 2.3 ± 1.0 cm; P<0.001). CONCLUSION: The use of a massage programme appeared to modulate pain perception in labouring women, such that fewer women requested epidural analgesia and a shift was observed towards the use of weaker pain relief modalities; in particular, more women in the massage group were analgesic-free during labour.

Misoprostol administered sublingually at a dose of 12.5 µg versus vaginally at a dose of 25 µg for the induction of full-term labor: a randomized controlled trial.

BACKGROUND: Labor induction is defined as any procedure that stimulates uterine contractions before labor begins spontaneously. The vaginal and oral routes of administration of misoprostol are those most used for the induction of labor in routine practice, with the recommended dose being 25 µg. Nevertheless, the sublingual route may reduce the number of vaginal examinations required, increasing patient comfort and lowering the risk of maternal and fetal infection. Based on a previous systematic review, the objective of this study was to compare the frequency of tachysystole as the main outcome measure when misoprostol is administered sublingually at the dose of 12.5 µg versus vaginally at a dose of 25 µg to induce labor in a full-term pregnancy with a live fetus. METHODS: A randomized, placebo-controlled, triple-blind clinical trial was conducted at two maternity hospitals in northeastern Brazil. Two hundred patients with a full-term pregnancy, a live fetus, Bishop score ≤ 6 and an indication for induction of labor were included. Following randomization, one group received 12.5 µg misoprostol sublingually and a vaginal placebo, while the other group received a sublingual placebo and 25 µg misoprostol vaginally. The primary outcome was the frequency of tachysystole. Student's t-test, the chi-square test of association and Fisher's exact test were used, as appropriate. Risk ratios and their 95% confidence intervals were calculated. RESULTS: The frequency of tachysystole was lower in the group using 12.5 µg misoprostol sublingually compared to the group using 25 µg misoprostol vaginally (RR = 0.15; 95%CI: 0.02-0.97; p = 0.002). Failure to achieve vaginal delivery within 12 and 24 h was similar in both groups. Sublingual administration was preferred to vaginal administration by women in both groups; however, the difference was not statistically significant. CONCLUSION: The effectiveness of labor induction with low-dose sublingual misoprostol was similar to that achieved with vaginal administration of the recommended dose; however, the rate of tachysystole was lower in the sublingual group, and this route of administration may prove a safe alternative. TRIAL REGISTRATION: Registration number: NCT01406392, ClinicalTrials.gov. Date of registration: August 1, 2011.

[Effect of induction on maternal and neonatal outcomes of vaginal birth after cesarean].

Objective: To investigate the effect of induction on maternal and neonatal outcomes of vaginal birth after cesarean section (VBAC). Methods: Retrospective cohort study. A total of 452 pregnant women who underwent trail of labor after cesarean section (TOLAC) from January 2015 to March 2019 of Beijing Obstetrics and Gynecology Hospital, Capital Medical University were enrolled. According to the mode of the onset of labor, those 331 women who underwent VBAC were divided into spontaneous labor group (n=280) and induction group(n=51). According to induction methods, the pregnant women in the induction group was divided into the low-dose oxytocin subgroup (n=35) and other method subgroup (n=16, 9 cases with cervical ripening by balloon and 7 cases combined with oxytocin). The effect of induction on labor duration and maternal and neonatal outcome in VBAC were analyzed. Results: No maternal and neonatal death occurred. There were 23.0% (76/331) with forceps, 15.1% (50/331) of postpartum hemorrhage, and 24.5% (81/331) of fetal distress. The gravidity, birth weight and the gestational weeks of delivery in the induction group were significantly higher than those in the spontaneous onset group [2.0 (2.0-3.0) vs 2.0(1.0-2.0) times, 39.0(38.0-40.0) vs 38.0(37.0-39.0) weeks, (3 467±372) vs (3 168±538) g, Z=-3.548,-3.892,-3.813, all P<0.01]. The duration of the second stage of labor was significantly longer than that of the spontaneous onset group [43(26-60) vs 30(17-49) min, Z=-2.145,P<0.05], but the duration of the first stage, the total duration of labor, the rate of forceps, the incidence of postpartum hemorrhage, the rate of perineal incision and the incidence of fetal distress were not obvious different (all P>0.05). The duration of the first stage and total duration in oxytocin group were significantly shorter than those other method group [260(210-435) vs 325(250-490) min, 450(355-620) vs 523(370-668) min, Z=-2.001,-1.913, all P<0.05]. There were not significantly different in the duration of second stage, mode of delivery, perineal injury, the rate of postpartum hemorrhage, and fetal distress in the two groups (all P>0.05). Conclusion: Pregnant women who have undergone TOLAC after caesarean section can be induced after fully evaluation. Although induction prolongs the labor duration, it does not affect the maternal and neonatal complication rate.

[Clinical study on the correlation between the duration of labor and postpartum hemorrhage].

Objective: To study the correlation between the duration of labor and postpartum hemorrhage. Methods: The delivery data of singleton first-term pregnant women who delivered vaginally at Beijing Obstetrics and Gynecology Hospital from January 1, 2017 to December 31, 2017 were collected, 3 104 cases met inclusion criteria. According to the duration of the first labor (t), they were divided into two groups: t≥8 hours was the observation group, t<8 hours was the control group. In order to ensure the baseline characteristics of the subjects in the two groups were balanced, propensity score matching (PSM) was adopted, with matching ratio 1∶1. Then the observation group was divided into four subgroups: group 8-12 h, group 12-16 h, group 16-20 h, group ≥20 h. According to the presence or absence of labor intervention (oxytocin use, artificial rupture of membranes, labor analgesia), the observation group and control group were divided into non-labor intervention observation group, non-labor intervention control group, labor intervention observation group, and labor intervention control group. The case data of 3 104 subjects were analyzed and the duration of labor and atonic postpartum hemorrhage rate of each subgroup were compared with the control group. Results: The duration of the second stage of labor and the first+second stages of labor in the observation group (median:0.8, 13.3 hours) and its subgroups were both longer than those in the control group (median:0.6, 5.1 hours), with statistically significant differences (all P<0.01). The rate of atonic postpartum hemorrhage in the observation group, group 16-20 h and group ≥20 h were higher than that in the control group [8.0%(124/1 552), 14.3%(41/287), 14.1%(12/85), 4.6%(72/1 552)], with significant statistical differences (all P<0.01). The duration of the second stage of labor and the first+second stages of labor in the observation group were both longer than those in the control group, regardless of the presence or absence of labor intervention, with statistically significant differences (all P<0.01). In both the observation group and the control group, the duration of the first stage of labor, the second stage of labor, and the first+second stages of labor with labor intervention were longer than those of the non-labor intervention, with significant statistical differences (all P<0.01). The rate of atonic postpartum hemorrhage in the observation group with labor intervention [8.7%(110/1 263)] was higher than that in the observation group without labor intervention [4.8%(14/289)], with a statistical difference (P<0.05). Conclusions: With the increase of the duration of the first stage of labor, the rate of atonic postpartum hemorrhage increases. The first stage of labor is closely related to the second stage of labor, and to a certain extent the duration of the second stage of labor increases with the length of the first stage of labor. With the increase of the duration of the first stage of labor, the rate of labor intervention and atonic postpartum hemorrhage also increase, which could serve as a clinical warning that excessive labor intervention may indicate a higher incidence of atonic postpartum hemorrhage.

Misoprostol administered sublingually at a dose of 12.5 µg versus vaginally at a dose of 25 µg for the induction of full-term labor: a randomized controlled trial protocol.

BACKGROUND: Various methods are currently used for the induction of labor. Nevertheless, the most effective method with the fewest side effects remains to be established. Misoprostol, administered vaginally, has been routinely used for this purpose; however, other forms of administration are being proposed, including the use of sublingual tablets. No studies have yet compared the effectiveness and safety of 12.5-µg misoprostol administered sublingually compared to a 25-µg vaginal dose of the drug for the induction of labor. METHODS: A triple-blind, multicenter, placebo-controlled, randomized clinical trial will be conducted in Brazil at the Instituto de Medicina Integral Prof. Fernando Figueira and at the Assis Chateaubriand Maternity Teaching Hospital of the Federal University of Ceará. A total of 140 patients with full-term pregnancies, a live fetus, a Bishop score ≤ 6 and a recommendation of induction of labor will be randomized to one of two groups. One group will receive 12.5-µg sublingual tablets of misoprostol and placebo vaginal tablets, while the other group will receive placebo sublingual tablets and vaginal tablets containing 25 µg of misoprostol. The principal endpoint is the rate of tachysystole. The secondary endpoints are vaginal delivery within 24 h of induction, uterine hyperstimulation, Cesarean section, severe neonatal morbidity or perinatal death, severe maternal morbidity or maternal death, and maternal preference regarding the route of administration of the drug. Student's t-test, and the chi-square test of association or Fisher's exact test, as appropriate, will be used in the data analysis. Risk ratios and their respective 95% confidence intervals will be calculated. DISCUSSION: Misoprostol has been identified as a safe, inexpensive, easily administered option for the induction of labor, with satisfactory results. An experimental study has shown that misoprostol administered sublingually at a dose of 25 µg appears to be effective and is associated with greater maternal satisfaction when labor is induced in women with an unfavorable cervix. Nevertheless, the rate of tachysystole remains high; therefore, further studies are required to determine the ideal dose and the ideal interval of time between doses. TRIAL REGISTRATION: ClinicalTrial.gov, NCT01406392 .

CERVICAL RIPENING BALLOON AS A METHOD OF PREINDUCTION - ONE CENTER STUDY.

- Cervical ripening can be promoted in many ways, but mechanical methods are among the oldest. Like all other methods, this one also has its pros and cons. Disadvantages compared to pharmacological methods include some maternal discomfort upon manipulation of the cervix, a theoretical increase in the risk of maternal and neonatal infection from the introduction of a foreign body, potential disruption of a low-lying placenta, and increase in the need of oxytocin induction of labor. The aim of the study was to evaluate the effect of using cervical ripening balloon in preinduction on the mode of delivery. This was a longitudinal, cohort, intervention, non-randomized one center study. Inclusion criteria were term pregnancies with gestational diabetes, oligohydramnios, intrauterine growth restriction, gestational hypertension/preeclampsia and pregnancies after 41 weeks of pregnancy. Preinduction of labor was performed in term pregnancies at Sestre milosrdnice University Hospital Center. Results in the first 150 women having undergone labor preinduction with cervical ripening balloon were included. Two-sided p values <0.05 were considered significant. Statistical analysis was done using SPSS Version 20.0. The study included 150 women; one woman was excluded from further analyses due to conversion of fetal presentation (head to breech). Indications for labor preinduction were as follows: gestational diabetes, oligohydramnios, intrauterine growth restriction, gestational hypertension/preeclampsia and pregnancies after 41 weeks of pregnancy. Women with normal vaginal delivery (96/149) had lower rates of gestational diabetes and oligohydramnios and used epidural analgesia more frequently. Women with dystocia (32/53) had a significantly longer labor duration and higher neonatal birth weight. In multivariate analysis, multiparity, greater cervical dilatation after balloon removal and use of epidural analgesia were associated with a decreased risk of cesarean section, while the presence of gestational diabetes and oligohydramnios was associated with an increased risk of cesarean section. We found this preinduction method safe and efficient, with a potential to increase the rate of vaginal deliveries.

Effect of Early Amniotomy on Delivery Outcome with/without Cervical Ripening: A Systematic Review and Meta-Analysis.

Background: Although shorter labors are the benefits of Early Amniotomy (EA), it may lead to risks such as non-reassuring fetal testing and cesarean delivery. Also, the effect of cervical ripening to induce labor before amniotomy is unknown. This systematic review and meta-analysis evaluated the effect of EA on the delivery outcome with or without cervical ripening. Materials and Methods: Bibliographic search was conducted without time limit until June 2020. PubMed, Scopus SID Magiran, Cochrane Library Science website, and ISI databases were searched with English and Farsi keywords, including amniotomy, delivery, induced, and pregnancy outcome. Results: The meta-analysis on ten clinical trials showed that the incidence of cesarean section was lower (0.89% VS 0.94; relative risk, 0.85; 95% confidence interval, 0.55-1.30) compared to the group without cervical ripening, and the time to induce labor was approximately 55 minutes (mean difference, 0.91 hour; 95% confidence interval, -1.43 to - 0.33). Conclusions: If EA is performed in women after cervical ripening, the incidence of cesarean section will not increase, and the duration of labor will be reduced. A shorter delivery time is associated with perinatal benefits and greater maternal satisfaction. Furthermore, EA with cervical ripening may reduce monitoring time in busy hospitals with limited medical staff.

Drug Exposure During Pregnancy: A Case-Control Study from a Primary Care Database.

Objective: Drug exposure during pregnancy is frequent, even more during first trimester as pregnant women might not be aware of their condition. We used available electronic health records (EHRs) to describe the use of medications during the first trimester in pregnant women and to compare drug exposure between those women who had an abortion (either elective or spontaneous) compared to those who had live births. Materials and Methods: Case-control study of abortions, either elective or spontaneous (cases), and live birth pregnancies (controls) in Sistema d'Informació per al Desenvolupament de la Investigació en Atenció Primària (Catalan Primary Health electronic health records) from 2012 to 2020. Exposure to drugs during first trimester of pregnancy was considered to estimate the association with abortion by conditional logistic regression and adjusted by health conditions and other drugs exposure. Results: Sixty thousand three hundred fifty episodes of abortions were matched to 118,085 live birth pregnancy episodes. Cases had higher rates of alcohol intake (9.9% vs. 7.2%, p < 0.001), smoking (4.5% vs. 3.6%, p < 0.001), and previous abortions (9.9% vs. 7.8%, p < 0.001). Anxiety (30.3% and 25.1%, p < 0.001), respiratory diseases (10.6% and 9.2%, p < 0.001), and migraine (8.2% and 7.3%, p < 0.001), for cases and controls, respectively, were the most frequent baseline conditions. Cases had lower rate of drug exposure, 40,148 (66.5%) versus 80,449 (68.1%), p < 0.001. Association with abortion was found for systemic antihistamines (adjusted odds ratio [ORadj] 1.23, 95% confidence interval [CI] 1.19-1.27), antidepressants (ORadj 1.11, 95% CI 1.06-1.17), anxiolytics (ORadj 1.31, 95% CI 1.26-1.73), and nonsteroidal anti-inflammatory drugs (ORadj 1. 63, 95% CI 1.59-1.67). Conclusions: These high rates of drug exposures during the first trimester of pregnancy highlights the relevance of informed prescription to women with childbearing potential.

Relationships Among Mode of Birth, Onset of Labor, and Bishop Score.

OBJECTIVE: To investigate mode of birth in relation to onset of labor and Bishop score. DESIGN: Retrospective observational cohort design. SETTING: A 434-bed Magnet redesignated community hospital. PARTICIPANTS: Nulliparous women, 18 years of age or older, who gave birth at 37 to 41 weeks gestation to live, singleton fetuses in the vertex presentation (N = 701). METHODS: We conducted a retrospective chart review and used chi-square analysis to measure the associations among mode of birth, onset of labor, and Bishop score. We used logistic regression to test the probability of cesarean birth for women undergoing elective induction of labor. RESULTS: Most participants (n = 531, 75.7%) gave birth vaginally. Significant findings included the following relationships: spontaneous onset of labor and vaginal birth (χ2 = 22.2, Ø = 0.18, p < .001) and Bishop score of greater than or equal to 8 and vaginal birth (χ2 = 4.9, Ø = .14, p = .028). Induction of labor was a significant predictor in cesarean birth when controlling for age and body mass index (OR = 2.1, 95% confidence interval [1.5, 3.1], p < .001). CONCLUSION: Reducing elective induction of labor in women with low-risk pregnancies may help lower the risk of cesarean birth. Clinically, Bishop score and mode of birth have a weak association, particularly when induction includes cervical ripening.

Women's views and experiences of augmentation of labour with synthetic oxytocin infusion: A qualitative evidence synthesis.

OBJECTIVE: To explore and synthesise women's views and experiences of augmentation of labour with synthetic oxytocin infusion. DESIGN: A qualitative evidence synthesis was conducted. The SPIDER acronym was used to develop the search terms and determine the inclusion criteria. Six bibliographic databases: MEDLINE, CINAHL, EMBASE, PsycINFO, Maternity and Infant Care and Web of Science Core Collection were searched in October 2021. Grey literature sources, EThOS, DART-Europe, and the World Health Organization's Clinical Trials Registry were searched, and reference lists of included studies were reviewed. Methodological quality of included studies was assessed using the Evidence for Policy and Practice Information and Co-ordinating (EPPI) Centre assessment tool. Data were synthesised thematically. The confidence of each review finding was assessed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). Research ethical approval was not required. SETTING AND PARTICIPANTS: Women of any age, parity, and cultural background who underwent augmentation of labour with synthetic oxytocin infusion were included. FINDINGS: A total of 9306 citations were retrieved. Twenty-five studies conducted across 14 countries met the inclusion criteria and contributed data. Three principal analytical themes emerged: feeling stuck; past and present shaping the future; and cause and effect of augmentation of labour. The decision to augment women's labour was often performed without their informed consent. Women's views and experiences of augmentation of labour were shaped according to their knowledge, beliefs and support received during labour. Irrespective of the context, women consistently associated augmentation of labour with pain. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Clinical guidelines on augmentation of labour need to be informed by research that includes women's views and experiences as a main outcome. Future research exploring the experience of augmentation of labour rather than the experience of labour dystocia would be beneficial. Increasing women's awareness and knowledge of augmentation of labour may help to ensure that their informed consent is obtained. Healthcare providers should discuss the effects, side effects and implications of augmentation of labour with women, ideally before labour.

Advanced Maternal Age as an Obstetric Risk Factor: Current Experience in a Hospital from Northwestern Spain.

INTRODUCTION: Studies updating the evidence in advanced maternal age as an independent factor of obstetric risk are needed. The aim of this study was to determine the prevalence of ≥ 35-years-old pregnant women who give birth in a Spanish hospital in Northwestern Spain, and to describe the incidence of maternal and perinatal morbidity and mortality. MATERIAL AND METHODS: Retrospective follow-up observational study including women ≥ 20 years-old who gave birth over one year (n = 1378). Data were collected from medical records, including socio-demographic characteristics, comorbidities, gestational conditions, variables related with the delivery and perinatal outcomes. Multivariable logistic regression analysis was performed to determine the association of advanced maternal age with obstetric and perinatal outcomes. RESULTS: Forty-two percent of pregnant women were ≥ 35 years old. In the multivariable analysis, advanced maternal age was associated with the likelihood of gestational diabetes (OR = 1.84; 95% CI = 1.10 - 3.07), hypothyroidism (OR = 2.11; 95% CI = 1.17 - 3.80), lower probability of an eutocic delivery (OR = 0.74; 95% CI = 0.56 - 0.98), and a hospital admission > four days (OR = 2.91; 95% CI = 1.95 - 4.35). An association with the rate of C-sections was not found (OR = 1.24; 95% CI = 0.89 - 1.72). CONCLUSION: A high prevalence of pregnant women of advanced maternal age was confirmed. There was a higher rate of comorbidities and longer hospital admissions in older women but not a higher rate of higher C-sections and other complications.

Introdução: São necessários estudos que atualizem as evidências sobre a idade materna avançada como fator independente de risco obstétrico. O objetivo deste estudo foi determinar a prevalência de mulheres grávidas com idade igual ou superior a 35 anos admitidas para o parto num hospital espanhol do Noroeste da Espanha, e descrever a incidência de morbilidade e mortalidade materna e perinatal. Material e Métodos: Estudo observacional retrospetivo que inclui mulheres com idade igual ou superior a 20 anos admitidas para o parto ao longo de um ano (n = 1378). Os dados foram recolhidos em prontuários médicos, incluindo características sociodemográficas, comorbilidades, patologia gestacional, variáveis relacionadas com o parto e resultados perinatais. Foi realizada uma análise de regressão logística multivariada para determinar a relação da idade materna avançada com os resultados obstétricos e perinatais. Resultados: Quarenta e dois por cento das mulheres grávidas tinham idade igual ou superior a 35 anos. Na análise multivariada, a idade materna avançada estava associada com maior probabilidade de diabetes gestacional (OR = 1,84; 95% CI = 1,10 - 3,07), hipotiroidismo (OR = 2,11; 95% CI = 1,17 - 3,80), menor probabilidade de parto eutócico (OR = 0,74; 95% CI = 0,56 - 0,98), e hospitalização superior a quatro dias (OR = 2,91; 95% CI = 1,95 - 4,35). Não foi encontrada uma associação com a taxa de cesarianas (OR = 1,24; 95% CI = 0,89 - 1,72). Conclusão: A elevada prevalência de mulheres grávidas com idade materna avançada foi confirmada. As mulheres mais velhas apresentaram maior número de comorbilidades e maior tempo de hospitalização, mas não apresentaram uma maior ocorrência de cesarianas e outras complicações.

A survey exploring women's use of mobile apps in labour in the United Kingdom.

OBJECTIVE: To examine women's use of mobile apps in labour in the United Kingdom. DESIGN: Cross-sectional online survey. Descriptive analysis on women's reported use of apps whilst in labour, using multiple choice questions to explore frequency of app use and reasons and experiences of using apps. Thematic analysis of a free text question explored experiences and opinions regarding app use in labour. SETTING: Social media. Two groups from Facebook.com and one group from Babycentre.co.uk PARTICIPANTS: A total of 749 women, surveyed over a one month period. MEASUREMENTS: Demographics of women; characteristics of women's labours and birth; access to smartphones and app; rates of app use in labour and reasons for use; experiences of app use in labour. FINDINGS: A total of 851 women responded, of which 749 were eligible. 431 (57.5%) reporting using an app in labour. No associations were found between age, ethnicity, education or mode of delivery and app use. Women who used an app were significantly more likely to have gone into labour spontaneously, and those who delivered between 40- 40+6 weeks gestation were significantly more likely to use an app. The majority of apps were used to monitor contractions, and most women found the apps useful and would recommend the apps they used. There was no association between number of labour ward attendances and app use, however women who used an app were significantly more likely to be admitted in more advanced labour. Qualitative comments found apps were viewed both as barriers and facilitators to the labour experience. KEY CONCLUSIONS: A large number of women are using apps in labour, with potential benefits. There is no consensus from women on the experience of app use. The use of technology should not replace an individual assessment on a laboring women however. Although national bodies support the use of apps in maternity, there is currently insufficient evidence and regulation to support the safety and efficacy of these recommendations. IMPLICATIONS FOR PRACTICE: Those working in maternity services should be aware many women are using apps in labour, and can consider this information as part of their assessment. Further work is needed to explore what women want from an app in labour, and to investigate whether app use can benefit a woman's experience of labour and improve outcomes.

Impact of Labor Epidural Analgesia on Maternal Satisfaction and Childbirth Expectations in a Tertiary Care Center in Portugal: A Prospective Study.

INTRODUCTION: In the current century, increasing importance has been given to the opinions, expectations and experiences of women using healthcare services. The fulfillment of expectations is determined by satisfaction. This study aims to analyze both expectations and satisfaction during childbirth regarding labor epidural analgesia among parturients, with a focus on myths. MATERIAL AND METHODS: A prospective observational study was conducted in parturients at the Centro Hospitalar Universitário Lisboa Norte - Santa Maria Hospital in Lisbon, Portugal, applying a questionnaire to 317 random women. SPSS v22.0 was used for data analysis. RESULTS: Three hundred questionnaires were returned, from women with a mean age of 31. Among the respondents, 46.3% had a college degree and 64% were employed, 46% were primiparas and only 14% had a previous anesthesiology appointment for childbirth purposes. The overall degree of satisfaction surrounding the birth experience was good/excellent for 87% of women. Labor epidural analgesia was performed on 96% of all patients, with an excellent/good outcome for 82.1% and a higher than expected results for 40.7% of them. Regarding the myths, 52.5% believed that epidural analgesia imposes a dose limit and 58.9% that it often causes permanent back pain. The level of education was significantly associated with some myths (p < 0.05), since women with a higher level of education do not believe most of them. DISCUSSION: This study supports the need for an evaluation of the current information that women have about labor epidural analgesia/childbirth. Women's individual needs can be met by multidisciplinary teams including Anesthesiology specialists. CONCLUSION: Maternal satisfaction with childbirth and analgesia is a complex and dynamic process that includes and is not limited to the relief of pain.

Introdução: As opiniões, expectativas e experiências das mulheres que utilizam os serviços de saúde têm vindo a alcançar crescente importância. O cumprimento das expectativas é determinado pela satisfação. Este estudo tem como objetivo analisar as expectativas e satisfação das mulheres durante o trabalho de parto em relação à analgesia epidural, com foco principal nos mitos. Material e Métodos: Foi realizado um estudo observacional e prospetivo em grávidas do Centro Hospitalar Universitário Lisboa Norte - Santa Maria Hospital, em Lisboa, Portugal, através da aplicação aleatória de um questionário a 317 mulheres. Foi utilizado o programa SPSS v.22 para análise estatística. Resultados: Foram obtidos 300 questionários, provenientes de mulheres com idade média de 31 anos. Entre as grávidas que responderam ao questionário, 46,3% possuíam diploma universitário e 64% estavam empregadas. Apenas 14% tiveram consulta prévia de Anestesiologia. O grau de satisfação em torno da experiência do parto foi bom/excelente para 87% das mulheres. A analgesia epidural foi realizada em 96% das grávidas, tendo 82,1% considerado a analgesia excelente e 40,7% avaliado como superior ao esperado. Em relação aos mitos, 52,5% acreditam que a técnica epidural apresenta uma dose limite e 58,9% consideram que a técnica acarreta dor permanente nas costas. O nível de escolaridade mostrou-se significativamente associado a alguns mitos (p < 0,05), uma vez que as mulheres com maior grau de escolaridade não acreditam na maioria destes. Discussão: Este estudo demonstra a necessidade da avaliação da informação que as mulheres possuem sobre a analgesia do trabalho de parto. As necessidades individuais devem ser geridas por equipas multidisciplinares que incluamanestesiologistas. Conclusão: A satisfação materna com o parto e respetiva analgesia é um processo complexo e dinâmico, que inclui e não se limita ao alívio da dor.

Analgesic considerations for induction of labor.

Induction of labor may be indicated to minimize maternal and fetal risks. The rate of induction is likely to increase as recent evidence supports elective induction at 39 weeks gestation. We review methods of induction and then analgesic options as they relate to indications and methods to induce labor. We specifically focus on parturients at high risk for anesthetic complications including those requiring anticoagulation, and those with cardiac disease, obesity, chorioamnionitis, prior spinal instrumentation, elevated intracranial pressure, known or anticipated difficult airway, thrombocytopenia, and preeclampsia. Guidelines regarding timing of anticoagulation dosing with neuraxial anesthetic techniques have been defined through consensus statements. Early epidural placement may be beneficial in patients with cardiac disease, obesity, anticipated difficult airway, and HELLP syndrome. Questions remain regarding how early is too early for epidural placement, what options are safest for patients with bacteremia, and what pain relief should be offered to those unable to tolerate cervical exams in early labor.

Nitrous Oxide for Labor Analgesia: What We Know to Date.

Background: Although nitrous oxide (N2O) has been used since the 1880s for labor analgesia, its popularity has only recently increased in the United States. In 2011, only 3 centers in the country offered N2O, but as of 2020, several hundred labor units have adopted its use. Methods: We reviewed the literature and summarize the mechanism of action, clinical uses, and efficacy of N2O for labor analgesia, as well as patient satisfaction related to its use. Results: N2O has several proposed mechanisms of action that make it a viable option for all 3 stages of labor and postpartum procedures. N2O has been shown to be a safe option for both mom and baby during labor and delivery. Studies support N2O as an analgesic for laboring. Even though 40% to 60% of women who use N2O convert to a labor epidural analgesia, satisfaction surveys indicate that analgesia is not the only factor contributing to the use of N2O during labor. Conclusion: The use of N2O has increased in labor and delivery units across the United States since 2011. Despite inferior analgesic properties compared to epidural analgesia, N2O offers a safe alternative for many parturients who want a greater sense of control and mobility.

The efficacy and safety of inflatable obstetric belts for management of the second stage of labor.

This study was designed to assess the effect of inflatable obstetric belts on uterine fundal pressure in the management of the second stage of labor. One hundred twenty-three nulliparas with a singleton cephalic pregnancy at term were randomized. Standard care was performed in the control group, and uterine fundal pressure by the Labor Assister (Baidy M-420/Curexo, Inc., Seoul, Korea) was utilized in addition to standard care in the active group. The Labor Assister is an inflatable obstetric belts that synchronized to apply uniform fundal pressure during a uterine contraction. The 62 women in the active group spent less time in the second stage of labor when compared to the 61 women in the control group (41.55+/-30.39 min vs. 62.11+/-35.99 min). There was no significant difference in perinatal outcomes between the two groups. In conclusion, the uterine fundal pressure exerted by the Labor Assister reduces the duration of the second stage of labor without attendant complications.