Systematic Review of Nulliparous Women’s Views of Planned Cesarean Birth: The Missing Component in the Debate about a Term Cephalic Trial

Abstract: Background: The suggestion that planned cesarean birth is gaining acceptance among women has led some physicians to advocate the need for a trial of primary planned cesarean section versus planned vaginal birth in healthy women with singleton cephalic pregnancies at term. This paper reviews published studies of nulliparous women’s views of mode of birth collected in the antenatal period, examining why women may express a preference for cesarean birth and exploring implications for the debate about the need for a trial. Methods: A systematic literature review was undertaken of Cochrane, CINAHL, EMBASE, MEDLINE, and PsycINFO using the MeSH heading “cesarean section” and four free text spellings of “cesarean,” or “birth” or “delivery,” near truncated synonyms of 17 words meaning expressed preference. Studies of nulliparous women with a medical indication for cesarean birth, studies where a woman’s preference for mode of birth was reported in the postpartum period, surveys of midwives or obstetricians, and opinion and non‐English language papers were all excluded. Results: Nine papers were included in the review, which reported rates of women expressing a preference for cesarean birth that ranged from 0 to 100 percent at recruitment. However, the papers raised specific methodological, conceptual, and cultural issues that may have influenced women’s preferences for mode of birth in the populations studied. These issues included the timing and frequency of data collection, complexity of factors determining individual women’s decision making, and influence of societal norms. Conclusions: Little evidence is available that an increasing cultural acceptance of cesarean delivery will bring about support for a trial among pregnant nulliparous women. Further qualitative research investigating the influence of both obstetric and psychosocial factors on women’s views of vaginal and cesarean birth is required. (BIRTH 33:3 September 2006)     

Prevalence of Low Back Pain,Pelvic Girdle Pain,and Combination Pain in a Pregnant Ontario Population

Objective

The purpose of the current pilot study is to determine the point and period prevalence of site-specific back pain, low back pain (LBP), pelvic girdle pain (PGP), and combined pain (Combo Pain) in pregnant women at a large urban centre in Ontario.

Women’s Experiences of Care and Their Concerns and Needs Following a Significant Primary Postpartum Hemorrhage

Abstract: Background: In the context of rising rates of postpartum hemorrhage and little data about its effect on women, this study aimed to describe the experiences of care, and the concerns and needs of women after a significant postpartum hemorrhage. Methods: A cohort of 206 women with a primary postpartum hemorrhage of 1,500 mL or more and/or a peripartum fall in hemoglobin concentration to 7 g/dL or less and/or of 4 g/dL or more was recruited from 17 major hospitals in Australasia. Women rated their satisfaction with care and provided written responses to questions in postpartum questionnaires completed in the first week and at 2 and 4 months postpartum. Results: In relation to care in hospital, consistently over 20 percent women responded that their needs for information, acknowledgment, and reassurance were only met sometimes, rarely, or never. Sixty‐two percent reported that they were given adequate information about their likely physical recovery, and 48 percent about their likely emotional recovery. Four major themes were identified in response to the open‐ended questions: adequacy of care, emotional responses to the experience, implications for the future, and concerns for their baby. Conclusions: This study is an important step in identifying the negative impact of experiencing a significant postpartum hemorrhage during childbirth for women who survive. Our results suggest that health professionals should pay greater attention to these women’s informational and emotional needs. (BIRTH 38:4 December 2011)     

A novel and dedicated multidisciplinary service to manage breech presentation at term; 3 years of experience in a tertiary care maternity unit

Objective: In order to provide uniform and unbiased multidisciplinary counselling on the options available, including vaginal breech delivery (VBD) and external cephalic version (ECV), the latter of which could then be performed, a weekly Breech Clinic was introduced to a tertiary care maternity unit in Northern Ireland in June 2013, replacing the traditional ECV Clinic introduced in June 2012.

Methods: Retrospective data collection was undertaken using clinic proformas, Northern Ireland Maternity System data and case notes of women who attended the clinics (ECV and Breech) from June 2012 to May 2015.

Results: There were 434 referrals to the clinic over the 3-year period; 356 women attended. The proportion of women attending increased from 69% to 85% since the introduction of the Breech Clinic. Two hundred and thirty-two were deemed eligible and 179 of these underwent ECV after counselling. Although the proportion of women undergoing ECV decreased from 69% to 46%, 11 women opted for and achieved VBD during the 2 years of the Breech Clinic, compared with one woman in the year of the ECV Clinic. Seventy-one of the attempted ECVs were successful, with 61 women having a normal vaginal delivery. Notably, the success rate of ECV increased from 33% to 42%. The number of caesarean sections performed solely for breech at term decreased from 199 in the 12 months before the introduction of ECV clinic, to 188 during the ECV clinic, and 154 in the final 12 months of Breech Clinic.

Conclusions: A dedicated service to counsel women on the management of breech presentation can decrease caesarean sections for breech presentation through increased uptake and success of ECV, and encouraging suitable women to opt for VBD when ECV is unsuccessful, contraindicated or declined.     

Institutional Processes and Individual Responses: Women’s Experiences of Care in Relation to Cesarean Birth

Abstract: Background: Cesarean section is an increasingly common mode of birth, and although clinical care has improved and the risks reduced, less attention has been paid to the effect of the procedure and the care received. The aim of this study was to gain a better understanding by investigating individual women’s recent experiences and reflections on their care. Methods: Views of women who had recently undergone cesarean birth were obtained in a study in which a random sample of women was selected by means of birth registrations in England and invited to complete a questionnaire 3 months after the birth. Text responses to open‐ended questions about care during labor and birth, the postnatal period in hospital, and anything else women wished to say about their maternity care were analyzed using qualitative methods. Results: A response rate of 63 percent was achieved; 23 percent of women (n = 682) had a cesarean section birth, 53 percent of which were because of unforeseen problems in labor. A total of 66 percent of women who had a cesarean section responded to one or more open questions. Anticipated themes that were confirmed related to expectations, uncertainty, emotional reactions, pain and discomfort, explanations, support, and adjustment. Emerging themes included “being heard,”“how it might have been different,”“wasted effort,”“just another mother,”“wounds and hurt feelings,” and “needing to talk.” Conclusions: Women responded as individuals and despite different clinical circumstances, the role of the staff and the institutions in which care was provided were key factors in the way most women constructed their cesarean section experience. The themes described present a powerful argument and reminder about why health professionals working in maternity care need to continue to listen to women. (BIRTH 37:2 June 2010)     

Impact of First Childbirth on Changes in Women’s Preference for Mode of Delivery: Follow‐up of a Longitudinal Observational Study

ABSTRACT: Background: A woman’s childbirth experience has an influence on her future preferred mode of delivery. This study aimed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth. Methods: This prospective longitudinal observational study involved two units that provide obstetric care in Hong Kong. A mail survey was sent to 259 women 6 months after their first childbirth. These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies. Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section. Results: Twenty‐four percent (23.8%, 95% CI 18.4–29.3) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth. Determinants found to be positively associated with this change included actual delivery by elective cesarean section (OR 106.3, 95% CI 14.7–767.4) intrauterine growth restriction (OR 19.5, 95% CI 1.1–353.6), actual delivery by emergency cesarean section (OR 8.4, 95% CI 3.4–20.6), higher family income (OR 3.2, 95% CI 1.1–8.8), use of epidural analgesia (OR 2.6, 95% CI 1.0–6.8), and higher trait anxiety score (OR 1.1, 95% CI 1.0–1.3). The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth (24.4%). Conclusions: A significant proportion of women changed their preferred mode of delivery after their first childbirth. Apart from reducing the number of cesarean sections in nulliparous women, prompt provision of education to women who had complications and investigations into fear factors during vaginal birth might help in reducing women’s wish to change to elective cesarean section. (BIRTH 35:2 June 2008)