Establishing a Volunteer Doula Program Within a Nurse‐Midwifery Education Program: A Winning Situation for Both Clients and Students

The use of labor doulas is beneficial for mothers and newborns, but availability and cost can be barriers. The Nashville Volunteer Doula Program was formed to provide labor support to clients of a faculty nurse‐midwifery practice. The volunteer doula pool is comprised of both nurse‐midwifery students who have trained as doulas and community doulas. Training and coordination of volunteers are managed by nurse‐midwifery students with faculty support. Students gain valuable exposure to providing supportive care during labor and birth, which augments their nurse‐midwifery education. This novel program operates at a low cost and offers benefits to students as well as women who use the doula service. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health     

Comfort and Satisfaction Among Women Who Used Different Options for Analgesia During Labor and Birth

ObjectiveTo determine if comfort and satisfaction with the birth experience differed among women who used nitrous oxide (N₂O), epidural analgesia, or no analgesia during labor and birth.DesignNonexperimental, cross-sectional, between-subjects.SettingMaternity care units in three U.S. Midwest hospitals from June to October 2019.ParticipantsA total of 84 women with spontaneous vaginal birth at term gestation (≥37 weeks).MethodsWomen were grouped according to self-selected pain management method: N₂O and oxygen (50%/50% mixture) only (n = 28), epidural analgesia (may have been in combination with other analgesia options; n = 28), or no analgesia (n = 28). We collected data within 6 hours after childbirth using the Birth Satisfaction Scale–Revised and the researcher-modified Childbirth Comfort Questionnaire. We analyzed data for differences in comfort and satisfaction scores among the three groups of women using analysis of variance.ResultsWe found no statistically significant differences related to comfort during labor and birth among women who used N₂O only, epidural analgesia, or no analgesia during labor and birth, F(2, 81) = 1.11, p = .34. We also found no statistically significant differences related to satisfaction with the birth experience among women who used N₂O only, epidural analgesia, or no analgesia during labor and birth, F(2, 81) = .084, p = .92.ConclusionOur finding of no statistically significant differences in comfort and satisfaction with the birth experience across groups highlights the need to present comprehensive pain management options to women for labor and birth, such as N₂O.     

A Randomized Controlled Trial of Continuous Labor Support for Middle‐Class Couples: Effect on Cesarean Delivery Rates

ABSTRACT: Background: Previous randomized controlled studies in several different settings demonstrated the positive effects of continuous labor support by an experienced woman (doula) for low‐income women laboring without the support of family members. The objective of this randomized controlled trial was to examine the perinatal effects of doula support for nulliparous middle‐income women accompanied by a male partner during labor and delivery. Methods: Nulliparous women in the third trimester of an uncomplicated pregnancy were enrolled at childbirth education classes in Cleveland, Ohio, from 1988 through 1992. Of the 686 prenatal women recruited, 420 met enrollment criteria and completed the intervention. For the 224 women randomly assigned to the experimental group, a doula arrived shortly after hospital admission and remained throughout labor and delivery. Doula support included close physical proximity, touch, and eye contact with the laboring woman, and teaching, reassurance, and encouragement of the woman and her male partner. Results: The doula group had a significantly lower cesarean delivery rate than the control group (13.4% vs 25.0%, p = 0.002), and fewer women in the doula group received epidural analgesia (64.7% vs 76.0%, p = 0.008). Among women with induced labor, those supported by a doula had a lower rate of cesarean delivery than those in the control group (12.5% vs 58.8%, p = 0.007). On questionnaires the day after delivery, 100 percent of couples with doula support rated their experience with the doula positively. Conclusions: For middle‐class women laboring with the support of their male partner, the continuous presence of a doula during labor significantly decreased the likelihood of cesarean delivery and reduced the need for epidural analgesia. Women and their male partners were unequivocal in their positive opinions about laboring with the support of a doula. (BIRTH 35:2 June 2008)     

Examining the Content Validity of the Birthing Unit Design Spatial Evaluation Tool Within a Woman‐Centered Framework

Introduction: The environment for birth influences women in labor. Optimal birthing environments have the potential to facilitate normal labor and birth. The measurement of optimal birth units is currently not possible because there are no tools. An audit tool, the Birth Unit Design Spatial Evaluation Tool (BUDSET), was developed to assess the optimality of birthing environments. The BUDSET is based on 4 domains (fear cascade, facility, aesthetics, support), each comprising design principles that are further differentiated into specific assessable design items. In the process of developing measurement tools, content validity must be established. The aim of this study was to establish the content validity of the BUDSET from the perspective of women and midwives. Methods: This was a mixed‐methods study with a survey assessing agreement with BUDSET items and in‐depth interviews. Survey results were analyzed using an item‐level content validity index and a survey‐level validity index. Interview data were analyzed using a directed content analysis approach. The study was conducted in 2 locations—a major maternity hospital and a midwifery research center, both in Australia. Study participants were 10 women and 2 midwifery academics. Results: The survey revealed that content‐related validity varied according to the BUDSET domain, with the domains of facility and support established as content valid by most participants. The domains of the fear cascade and aesthetic were less strong, particularly among pregnant women. Interview data analysis provided content validity evidence of both the fear cascade and aesthetic domains. A further 4 subthemes of fear cascade also were identified: foreign space, medical‐hospital‐emergency, being sterile/clinical, and protecting the woman from the environment. Content validity evidence for facility and support domains also was established. Discussion: This study has established that the BUDSET is content valid for assessing the optimality of birthing environments. Some further refinement of the tool is now possible.     

How Caregivers Manage Pain and Distress in Second‐Stage Labor

Innovative care interactions are needed when helping a woman who exhibits severe pain or distress during the second stage of labor. We describe how caregivers and laboring women interacted during second‐stage labor, with particular attention to how caregivers managed pain and distress. We used observational methods to perform a microanalysis of behaviors from video‐recorded data. Pain occurred during labor contractions, and distress (an emotional response to pain) manifested primarily between contractions. Four patterns of women's behavior were identified: 1) no pain or distress, 2) low‐level pain and/or distress, 3) focused working, and 4) severe pain and/or distress. Successful care was identified as enabling the woman to maintain herself in any state other than severe pain and/or distress. Particular modes of speech used by the caregiver enabled the attainment of successful care when the woman was not in severe pain or distress. When severe pain or distress existed, innovative caregiving transitioned the woman to another state. Successful intervention strategies included 1) giving innovative directions and 2) “talking down.” Ordinary modes of “birth talk” can be used when severe pain or distress is not manifested and when the primary care problem is to assist women with bearing down. Innovative care interactions are needed when faced with severe pain or distress. Managing labor pain is an ongoing focus of clinicians who provide care to women in labor. In addition to pain, women might also experience distress, an emotional response to the labor experience. Whether from choice or necessity, caregivers for laboring women need nonpharmacologic interventions and interpersonal skills that can help women endure labor and give birth. Labor is hard work, and even in precipitous labors most women require assistance. Care given to a laboring woman consists of employing comforting strategies that help her cope with the pain of uterine contractions. The purpose of these comfort strategies is to help the woman find needed resilience during labor. Most cultures have mechanisms for providing this kind of support. In this article, we identify patterns of behavior used by laboring women and describe successful and unsuccessful strategies used by caregivers to help these women deal with pain and distress during the second stage of labor.     

Nurse‐Midwives' Experiences with Planned Home Birth: Impact on Attitudes and Practice

Background: Health care providers' attitudes toward maternity care options influence the nature of informed decision‐making discussions and patient choice. A woman's choice of birth site may be affected by her provider's opinion and practice site. The objectives of this study were to describe American nurse‐midwives' attitudes toward, and experiences with, planned home birth, and to explore correlates and predictors of their attitudes toward planned home birth as measured by the Provider Attitudes towards Planned Home Birth (PAPHB) scale. Methods: A survey instrument, which incorporates the PAPHB and assesses demographic, education, practice, personal experience, and external barrier variables that may predict attitudes toward planned home birth practice, was completed by 1,893 nurse‐midwives. Bivariate analysis identified associations between variables and attitudes. Linear regression modeling identified predictors of attitudes. Results: Variables that significantly predicted favorable attitudes to planned home birth were increased clinical and educational experiences with planned home birth (p < 0.001), increased exposure to planned home birth (p < 0.001), and younger age (p < 0.001). External barriers that significantly predicted less favorable attitudes included financial (p = 0.03) and time (p < 0.001) constraints, inability to access medical consultation (p < 0.001), and fear of peer censure (p < 0.001). Willingness to practice in the home was correlated with factors related to nurse‐midwives' confidence in their management abilities and beliefs about planned home birth safety. Conclusions: The results suggest that nurse‐midwives' choice of practice site and comfort with planned home birth are strongly influenced by the nature and amount of exposure to home birth during professional education or practice experiences, in addition to interprofessional, logistic, and environmental factors. Findings from this research may inform interdisciplinary education and collaborative practice in the area of planned home birth.     

In‐Hospital Birth Center with the Same Medical Guidelines as Standard Care: A Comparative Study of Obstetric Interventions and Outcomes

Background: A challenge of obstetric care is to optimize maternal and infant health outcomes and the mother’s experience of childbirth with the least possible intervention in the normal process. The aim of this study was to investigate the effects of modified birth center care on obstetric procedures during delivery and on maternal and neonatal outcomes. Methods: In a cohort study 2,555 women who signed in for birth center care during pregnancy were compared with all 9,382 low‐risk women who gave birth in the standard delivery ward in the same hospital from March 2004 to July 2008. Odds ratios (OR) were calculated with 95% confidence interval (CI) and adjusted for maternal background characteristics, elective cesarean section, and gestational age. Results: The modified birth center group included fewer emergency cesarean sections (primiparas: OR: 0.69, 95% CI: 0.58–0.83; multiparas: OR: 0.34, 95% CI: 0.23–0.51), and in multiparas the vacuum extraction rate was reduced (OR: 0.42, 95% CI: 0.26–0.67). In addition, epidural analgesia was used less frequently (primiparas: OR: 0.47, 95% CI: 0.41–0.53; multiparas: OR: 0.25, 95% CI: 0.20–0.32). Fetal distress was less frequently diagnosed in the modified birth center group (primiparas: OR: 0.72, 95% CI: 0.59–0.87; multiparas: OR: 0.45, 95% CI: 0.29–0.69), but no statistically significant differences were found in neonatal hypoxia, low Apgar score less than 7 at 5 minutes, or proportion of perinatal deaths (OR: 0.40, 95% CI: 0.14–1.13). Anal sphincter tears were reduced (primiparas: OR: 0.73, 95% CI: 0.55–0.98; multiparas: OR: 0.41, 95% CI: 0.20–0.83). Conclusion: Midwife‐led comprehensive care with the same medical guidelines as in standard care reduced medical interventions without jeopardizing maternal and infant health. (BIRTH 38:2 June 2011)     

Influence of Laboring People's Mobility and Positional Changes on Birth Outcomes in Low-Dose Epidural Analgesia Labor: A Systematic Review with Meta-Analysis

Introduction

Freedom of movement has been identified as a key issue for pregnant individuals during the birthing process, even if they opt for epidural analgesia, which has relegated people to more static positions during birth for many years. The aims of this systematic review were to evaluate the influence of mobility and positional changes on perinatal and neonatal outcomes in people in labor with epidural analgesia, describe the range of movement interventions used during the first and second stage of labor, and describe the level of motor blockade among people with low-dose epidural analgesia.

Methods

Bibliographic databases (Web of Science, Cochrane, CINAHL) were consulted from December 2020 to January 2021. The articles selected were clinical trials and observational or analytical studies, the subject of which was mobilization during labor in people with epidural analgesia. The outcome measures were mode of birth, duration of labor, and extrauterine adaptation after birth. A narrative synthesis was used to describe the types of movements interventions employed during the stages of labor and the level of motor blockade among people with low-dose epidural analgesia.

Results

Ten articles were selected (8 clinical trials, one cross-sectional study, and one quasiexperimental study), with a total sample of 6086 individuals. A meta-analysis showed nonsignificant results between groups for mode of birth (relative risk [RR], 1.00; 95% CI, 0.87-1.14), duration of labor (RR, 1.64; 95% CI, -34.57 to 37.86), and extrauterine adaptation after birth (RR, 0.86; 95% CI, 0.39-1.93). There was heterogeneity among studies in the type of movement interventions used during the first and second stage of labor.

Discussion

Although no clear benefit was observed for mobilization in epidural labor, no detrimental effects were found either, so perinatal care providers should encourage mobilization if the laboring person so desires, throughout the entire childbirth process.     

Birth plans—Impact on mode of delivery,obstetrical interventions,and birth experience satisfaction: A prospective cohort study

Objective

To examine whether the presence of a birth plan was associated with mode of delivery, obstetrical interventions, and patient satisfaction.

Methods

This was a prospective cohort study of singleton pregnancies greater than 34 weeks’ gestation powered to evaluate a difference in mode of delivery. Maternal characteristics, antenatal factors, neonatal characteristics, and patient satisfaction measures were compared between groups. Differences between groups were analyzed using chi‐squared for categorical variables, Fisher exact test for dichotomous variables, and Wilcoxon rank sum test for continuous or ordinal variables.

Results

Three hundred women were recruited: 143 (48%) had a birth plan. There was no significant difference in the risk of cesarean delivery for women with a birth plan compared with those without a birth plan (21% vs 16%, adjusted odds ratio [adjOR] 1.11 [95% confidence interval (CI) 0.61‐2.04]). Women with a birth plan were 28% less likely to receive oxytocin (P < .01), 29% less likely to undergo artificial rupture of membranes (P < .01), and 31% less likely to have an epidural (P < .01). There was no difference in the length of labor (P = .12). Women with a birth plan were less satisfied (P < .01) and felt less in control (P < .01) of their birth experience than those without a birth plan.

Conclusion

Women with and without a birth plan had similar odds of cesarean delivery. Though they had fewer obstetrical interventions, they were less satisfied with their birth experience, compared with women without birth plans. Further research is needed to understand how to improve childbirth‐related patient satisfaction.     

Postpartum Perineal Pain in a Low Episiotomy Setting: Association with Severity of Genital Trauma,Labor Care,and Birth Variables

Background: Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative vaginal delivery. Methods: A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the present pain intensity (PPI) and visual analog scale (VAS) components of the validated short‐form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. Results: At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 ± 1.61 vs 1.48 ± 1.40; p < 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, p = 0.002) than women with minor or no trauma. By 3 months, average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non‐Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model, only trauma group and length of active pushing predicted the pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on the level of pain at discharge beyond its effect on the incidence of major trauma. Conclusions: Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain.