Development of a questionnaire for assessing the childbirth experience (QACE).

BACKGROUND: Due to its potential impact on women's psychological health, assessing perceptions of their childbirth experience is important. The aim of this study was to develop a multidimensional self-reporting questionnaire to evaluate the childbirth experience. METHODS: Factors influencing the childbirth experience were identified from a literature review and the results of a previous qualitative study. A total of 25 items were combined from existing instruments or were created de novo. A draft version was pilot tested for face validity with 30 women and submitted for evaluation of its construct validity to 477 primiparous women at one-month post-partum. The recruitment took place in two obstetric clinics from Swiss and French university hospitals. To evaluate the content validity, we compared item responses to general childbirth experience assessments on a numeric, 0 to 10 rating scale. We dichotomized two group assessment scores: "0 to 7" and "8 to 10". We performed an exploratory factor analysis to identify underlying dimensions. RESULTS: In total, 291 women completed the questionnaire (response rate = 61%). The responses to 22 items were statistically significant between the 0 to 7 and 8 to 10 groups for the general childbirth experience assessments. An exploratory factor analysis yielded four sub-scales, which were labelled "relationship with staff" (4 items), "emotional status" (3 items), "first moments with the new born," (3 items) and "feelings at one month postpartum" (3 items). All 4 scales had satisfactory internal consistency levels (alpha coefficients from 0.70 to 0.85). The full 25-item version can be used to analyse each item by itself, and the short 4-dimension version can be scored to summarize the general assessment of the childbirth experience. CONCLUSIONS: The Questionnaire for Assessing the Childbirth Experience (QACE) could be useful as a screening instrument to identify women with negative childbirth experiences. It can be used as both a research instrument in its short version and a questionnaire for use in clinical practice in its full version.

Maternal positioning to correct occipito-posterior fetal position in labour: a randomised controlled trial.

BACKGROUND: The occipito-posterior (OP) fetal head position during the first stage of labour occurs in 10-34% of cephalic presentations. Most will spontaneous rotate in anterior position before delivery, but 5-8% of all births will persist in OP position for the third stage of labour. Previous observations have shown that this can lead to an increase of complications, such as an abnormally long labour, maternal and fetal exhaustion, instrumental delivery, severe perineal tears, and emergency caesarean section. Usual care in the case of diagnosis of OP position is an expectant management. However, maternal postural techniques have been reported to promote the anterior position of the fetal head for delivery. A Cochrane review reported that these maternal positions are well accepted by women and reduce back pain. However, the low sample size of included studies did not allow concluding on their efficacy on delivery outcomes, particularly those related to persistent OP position. Our objective is to evaluate the efficacy of maternal position in the management of OP position during the first stage of labour. METHODS/DESIGN: A randomised clinical trial is ongoing in the maternity unit of the Geneva University Hospitals, Geneva, Switzerland. The unit is the largest in Switzerland with 4,000 births/year. The trial will involve 438 women with a fetus in OP position, confirmed by sonography, during the first stage of the labour. The main outcome measure is the position of the fetal head, diagnosed by ultrasound one hour after randomisation. DISCUSSION: It is important to evaluate the efficacy of maternal position to correct fetal OP position during the first stage of the labour. Although these positions seem to be well accepted by women and appear easy to implement in the delivery room, the sample size of the last randomised clinical trial published in 2005 to evaluate this intervention had insufficient power to demonstrate clear evidence of effectiveness. If the technique demonstrates efficacy, it would reduce the physical and psychological consequences of complications at birth related to persistent OP position. TRIAL REGISTRATION: ClinicalTrials.gov, http://www.clinicaltrials.gov: (no. NCT01291355).

Impact of mode of delivery on the birth experience in first-time mothers: a qualitative study.

BACKGROUND: The birth of a first child is an important event in a woman's life. Delivery psychological impacts vary depending on whether delivery has been positively or negatively experienced. Delivery experience determinants have been identified but the understanding of their expression according to the mode of delivery is poorly documented. The purpose of the study was to determine important elements associated with women's first delivery experience according to the mode of delivery: vaginal or caesarean section. METHODS: Qualitative approach using thematic content analysis of in-depth interviews conducted between 4 and 6 weeks' postpartum, in 24 primiparous women who delivered at Geneva University Hospital in 2012. RESULTS: Perceived control, emotions, and the first moments with the newborn are important elements for the experience of childbirth. Depending on the mode of delivery these are perceived differently, with a negative connotation in the case of caesarean section. Other elements influencing the delivery experience were identified among all participants, irrespective of the mode of delivery. They included representations, as well as the relationship with caregivers and the father in the delivery room, privacy, unexpected sensory experiences, and ownership of the maternal role. Women's and health professionals' representations sometimes led to a hierarchy based on the mode of delivery and use of analgesia. CONCLUSIONS: The mode of delivery directly impacts on certain key delivery experience determinants as perceived control, emotions, and the first moments with the newborn. The ability/inability of the woman to imagine a second pregnancy is a good indicator of the birth experience. Certain health professional gestures or attitudes can promote a positive delivery experience. We recommend to better prepare women during prenatal classes for the eventuality of a caesarean section delivery and to offer all women and, possibly, their partners, the opportunity to talk about the experience of childbirth during the postpartum period. The results of this study suggest that further research is required on the social representations of women and health professionals regarding the existence of a hierarchy associated with the mode of delivery.

Near birth experience: An exploratory study on the communication experiences with a hypothetical prenatal consciousness.

CONTEXT: Many cultures believe that the first traces of human consciousness during the incarnation may be present before birth. Practices based on this belief exist in many cultures. However, formal scientific inquiry into the possibility of communicating with prenatal consciousness has never been explored. OBJECTIVE: To evaluate if it is possible to communicate with a hypothetical prenatal consciousness of the fetus during pregnancy. DESIGN: This exploratory study used mixed methods and a triple-blind design. People (i.e., mediums) who could allegedly communicate with eleven pregnant women's prenatal consciousness (N=11) collected answers to ten questions that were then verified from parental reports. Ten mediums participated, with three to eight mediums providing answers per pregnant woman. RESULTS: More than 1,500 statements were generated from attempts to communicate with the prenatal consciousness. Quantitative analysis showed higher agreement in spontaneously reported information versus responses to structured questions, 69.40%, and 17.63%, respectively. These results did not differ by the number of mediums per pregnant woman (three to five versus six to eight). Qualitative analysis suggested that some sessions resulted in verifiable communication with the prenatal consciousness, while others did not. CONCLUSION: The results, while preliminary and requiring follow-up studies, suggest the possibility to interact with a prenatal consciousness during pregnancy and the potential of novel scientific investigations into altered states of consciousness.

Application of Honey to Reduce Perineal Laceration Pain during the Postpartum Period: A Randomized Controlled Trial.

Perineal lacerations affect between 35 and 85% of women during childbirth and may be responsible for postpartum pain. Honey has been demonstrated to have interesting properties that can promote wound healing. The aim was to evaluate the effectiveness of the application of honey to the perineum to reduce perineal pain during the early postpartum period. A randomized controlled trial including 68 women was conducted. In the intervention group, honey was applied to perineal lacerations for four days, in addition to standard care. The control group received only standard care. The primary outcome was pain intensity using the Visual Analog Scale and pain perception using the McGill Pain Questionnaire (QDSA). The secondary outcomes were a burning sensation, the use of a pain killer, and the women's satisfaction with the honey application. The intensity of pain was not significantly different between the groups on Day 1 (VAS 3.38 in the control group versus 3.34 in the intervention group, p = 0.65) or on Day 4 (VAS 2.28 versus 1.41, respectively, p = 0.09). There was no significant difference regarding the perception of pain with the QDSA. Despite this, most of the women in the intervention group (93%) were satisfied or very satisfied with the use of honey on their perineum.

First-time fathers' experience of childbirth: a cross-sectional study.

OBJECTIVES: The purposes of this study are to report first-time fathers' experiences of childbirth through three dimensions (professional support, worries and prenatal preparation) and to analyse the influence of sociodemographic, antenatal and obstetrical factors on the three dimensions. SETTING: Participants were recruited in France and Switzerland from two university hospitals that routinely manage high-risk pregnancies (level 3 - perinatal care level), with 4,000 to 5,000 annual births each. METHODS: This is a secondary analysis of a cross-sectional study. The data initially were collected for the cross-cultural validation of the First-Time Father Questionnaire (FTFQ) into French. Descriptive statistics were used to report the participants' characteristics and their questionnaire responses. Multivariate linear regression analysis was carried out to stress the positive or negative factors linked with fathers' experiences of childbirth. FINDINGS: Among 350 first-time fathers, 160 completed the FTFQ (response rate of 45.7%). The average age of the participants was 33 years old. We observed 12 questionnaire items with more than 20% unfavourable responses, seven of which involved the measurement of the worry dimension. Antenatal education and the prenatal-preparation dimension were positive factors linked with fathers' experiences. In addition, 57% of participants reported using one means of antenatal education, and 45% accessed information from family or friends. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The results suggest that first-time fathers need more professional support to foster positive experiences of childbirth. Their experiences of childbirth are associated with considerable worry. Antenatal classes specifically for fathers could reduce this worry and support the fatherhood process. Research should be carried out on these topics.

How does delivery method influence factors that contribute to women's childbirth experiences?

BACKGROUND: whether delivery method influences factors contributing to women's childbirth experience remains debated. OBJECTIVE: we compared subjective childbirth experience according to different delivery methods. DESIGN: this study used a cross-sectional design. SETTING: the setting comprised two university hospitals: one in Geneva, Switzerland and one in Clermont-Ferrand, France. PARTICIPANTS: a total of 291 primiparous women were recruited from July 2014 to January 2015 during their stay in the maternity wards. The mean age of the participants was 30.8 (SD=4.7) years, and most were Swiss or European (86%). METHODS: the 'Questionnaire for Assessing Childbirth Experience' was sent between four and six weeks after delivery. Clinimetric and psychometric approaches were used to assess childbirth experience according to delivery method. MEASUREMENTS AND FINDINGS: the mean scores of the four questionnaire dimensions varied significantly by delivery method. 'First moments with the newborn' was more negatively experienced by women from the caesarean section group compared to those who delivered vaginally (p<0.001). Similar results regarding the dimension of 'emotional status' were also observed, as women who delivered by caesarean section felt more worried, less secure, and less confident (p=0.001). 'Relationship with staff' significantly differed between groups (p=0.047) as more negative results were shown in the 'unexpected medical intervention groups' (i.e. emergency caesarean section and instrumental delivered vaginally). Women's 'feelings at one-month post partum' in the emergency caesarean section group were less satisfactory than the other groups. Delivery method and other obstetric variables explained only a low proportion of the total variance in the global scores (R2adjusted=0.18), which emphasized the importance of subjective factors in women's childbirth experience. KEY CONCLUSIONS: a comparison of best expected positive responses to each item (clinimetric approach) showed useful results for clinicians. This research indicated that delivery method influenced key factors (psychometric approach) of the childbirth experience. IMPLICATIONS FOR PRACTICE: delivery method should not be considered alone and health professionals should focus on what is important for women to foster a more positive experience. In addition, women who have had an emergency caesarean section require special attention during post partum.

Hypnosis for the control of pain associated with external cephalic version: a comparative study.

OBJECTIVE: To assess the effectiveness of hypnosis to reduce pain and facilitate external cephalic version (ECV). DESIGN: Cohort study. SETTING: Geneva University Hospitals, Switzerland. PARTICIPANTS: 63 women attempting ECV under hypnosis from 2010 to 2011 were compared with 122 women who received standard care from 2005 through 2008. INTERVENTION: Immediately after the ECV attempt, both groups completed the same questionnaire evaluating the participants' pain (visual analogue and verbal rating scales) and experience with the procedure. Physicians also completed a questionnaire that elicited their views on the effect of hypnosis on the intervention. A chi-squared test was used to compare differences in proportions, and the Mann-Whitney U test was used for differences in continuous variables. A thematic content analysis of the obstetricians' responses to the open question regarding their experience of hypnotist accompaniment was also performed. OUTCOME MEASURES: Pain evaluated by women (visual analogue and verbal rating scales) and success rate of ECV. RESULTS: Pain intensity reported by women did not significantly differ between the hypnosis group and the standard care group (visual analogue scale score, 6.0 versus 6.3, respectively; p=.25; difference for verbal rating scale, p=0.31. In 72% of cases, physicians reported that hypnosis facilitated the procedure. The success rates in both groups were not significantly different (30% with hypnosis compared with 38% without; p=.31). Most women in both groups found the ECV attempt painful and a source of anxiety but would undergo it again if necessary. CONCLUSION: Hypnosis accompaniment during ECV does not reduce pain intensity associated with the procedure or improve the probability of a successful version.

Recourse to alternative medicine during pregnancy: motivations of women and impact of research findings.

OBJECTIVES: The aims of this study were to gain a better understanding of the motivations of pregnant women utilizing moxibustion for breech presentation and to measure the impact of research results on these patients' treatment decisions regarding this alternative medicine technique. DESIGN: The study involved a statistical analysis of two self-administered questionnaires to 212 women who had previously participated in a randomized clinical trial on the efficacy of moxibustion; in addition, a qualitative thematic content analysis for open-ended questions was also performed. RESULTS: Most women (69%) reported treating themselves at least once with complementary and alternative medicine (CAM). Higher use of CAM was associated with higher education and Caucasian origin. Pregnancy was associated with a significant reduction in utilization of CAMs. After reading the results of a previous randomized clinical trial, which did not demonstrate efficacy of moxibustion, 60% of the women questioned expressed the intention of resorting to this technique in case of a subsequent pregnancy with a fetus in the breech position. The principal motivation was their desire to try anything that may possibly turn such fetuses to increase the chances of delivering them vaginally. CONCLUSIONS: It is important to consider the regard that pregnant women attribute to CAMs for self-care strategies. Despite a lack of scientific evidence supporting the use of moxibustion to address breech presentation, pregnant women consider CAMs, in general, to be safe and effective. Studies investigating the physical and psychologic effects of CAMs will enable clinicians to advise patients better about treatment options.

Breech presentation and choice of mode of childbirth: a qualitative study of women's experiences.

OBJECTIVE: To explore women's perceptions of their experience of the diagnosis of breech presentation and decision-making processes regarding the choice of mode of childbirth. DESIGN: A qualitative study was conducted using semi-structured interviews. Data were analysed thematically. SETTING: Department of Gynaecology and Obstetrics, University Hospitals of Geneva, Switzerland. PARTICIPANTS: seven primiparous and five multiparous women experiencing a singleton breech presentation for childbirth were interviewed. FINDINGS: Two concomitant and interdependent processes were identified. First, an emotional response ranging from the hope that the fetus would return to a normal vertex position to the acceptance of breech presentation and its consequences. Second, a decision-making process related to childbirth mode for breech presentation with the complex management of intra- and extra-personal factor influences. Women perceive information about the risks of vaginal childbirth of paramount importance compared with those associated with caesarean childbirth. When women choose vaginal childbirth, influences related to their personality and life history appear to predominate. Women often have the feeling of being alone to assume the choice of childbirth mode and possible complications. KEY CONCLUSIONS: The diagnosis of breech presentation should not be treated as a commonplace event. The role of caregivers needs to go beyond information on the risks and benefits of both modes of childbirth. Emphasis should be placed on listening to the expectations of pregnant women for childbirth, creating spaces for dialogue, and allowing additional time for reflection. Useful information material should be provided to give the women a feeling of shared decision-making.

Magnetic resonance imaging of the cervix in women at high risk for preterm delivery.

OBJECTIVES: To assess whether changes in signal intensity of cervical stroma layers on magnetic resonance imaging (MRI) are associated with spontaneous preterm delivery. METHODS: Prospective cohort study of women admitted for threatened late miscarriage or preterm delivery between 18 and 34 weeks of gestation. We performed T2-weighted low-field MRI of the uterine cervix among 100 women. Cervical stromal differentiation, defined as the contrast between signal intensities of the inner and outer cervical layers, was classified as high, intermediate, or low by a radiologist blinded to the participant's clinical report. The main outcome measure was the proportion of spontaneous preterm delivery. RESULTS: Thirty-six women had a spontaneous preterm delivery. The proportion of spontaneous preterm delivery for high, intermediate, and low stromal differentiation was 7/24 (29%), 21/64 (33%; risk ratio 1.1; 95% confidence interval [CI]: 0.6-2.3), and 8/12 (67%; risk ratio 2.3; 95% CI: 1.1-4.8), respectively. The risk of delivering within 7 days increased when stromal differentiation decreased, although the difference was not statistically significant. CONCLUSIONS: The risk of spontaneous preterm delivery is increased in women with low cervical stromal differentiation on MRI. This risk is also associated with short cervical length, a measurement easier and less costly to obtain by transvaginal ultrasound.

Moxibustion for breech version: a randomized controlled trial.

OBJECTIVE: To estimate the efficacy of moxibustion between 34 and 38 weeks of gestation to facilitate the cephalic version of fetuses in breech presentation and the acceptability of this method by women. METHODS: We conducted a randomized controlled trial in a Swiss university hospital maternity unit. We proposed to stimulate the acupoint BL 67 by moxibustion daily for 2 weeks for 212 consenting women between 34 and 36 weeks of gestation with a single fetus in breech presentation. We did the intervention three times weekly in the hospital and a teaching session and information leaflet on the technique for additional daily therapy at home. The control group received expectant management care. The availability of external cephalic version was maintained for both groups. The main outcome measure was the comparison of the proportion of women with cephalic presentation at delivery. RESULTS: Baseline characteristics were similar between groups, except more nulliparous women were randomized to moxibustion. The percentage of versions was similar between groups: 18% in the moxibustion group compared with 16% in the control group (relative risk 1.12, 95% confidence interval 0.62 to 2.03). Adjustment for the imbalance in parity did not change these results. The frequency of cesarean delivery was similar (64% compared with 58% in the moxibustion group and the control group, respectively). Acceptability of the intervention and women's perceptions of moxibustion were favorable. CONCLUSION: We observed no beneficial effect of moxibustion to facilitate the cephalic version of fetuses in breech presentation. Despite this lack of proven effectiveness, women had positive opinions on the intervention. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov,NCT00890474. LEVEL OF EVIDENCE: I.

Side-effects of moxibustion for cephalic version of breech presentation.

OBJECTIVES: Moxibustion, a Traditional Chinese Medicine technique related to acupuncture, was proposed to facilitate cephalic version of breech presentation. Several trials were conducted to evaluate the efficacy, but there are few reports on the safety of moxibustion. Our objective was to assess the side-effects and acceptability of this intervention. DESIGN: We are conducting a randomized controlled trial to evaluate the efficacy of moxibustion for breech version. The first 12 participants randomized in the moxibustion group had additional fetal surveillance by electronic monitoring. SUBJECTS: Pregnant women with a fetus in breech presentation are included in the trial between 34 and 36 weeks of gestation. INTERVENTIONS: We performed a cardiotocogram during 10 minutes before, 20 minutes during, and 10 minutes after each session. A maximum of 9 sessions were scheduled every other day, and stopped when cephalic version was diagnosed. The recordings were assessed by 3 independent readers using the Fischer scoring system. OUTCOME MEASURES: Fetal well-being was evaluated by the cardiotocogram; effect on the mother was evaluated by blood pressure recorded before and after each session; maternal views, contractions, and perceived changes in fetal movements were assessed using a questionnaire. RESULTS: A total of 65 cardiotocograms were analyzed. All scores were considered as normal, being at 8 or more on a 0-10 scale. Acceptability for the women and compliance to the intervention were good. No significant maternal or fetal side-effect was observed. CONCLUSIONS: We have not detected alterations of fetal and maternal well-being or other side-effects associated with moxibustion applied to the BL 67 for cephalic version of breech presentations. Moxibustion appears to be safe for both the mother and the fetus.