Gestational weight gain and adverse pregnancy outcomes in a nulliparous cohort

Objective

Excessive gestational weight gain (GWG) is an important contributing factor to the obesity epidemic in women and is associated with pregnancy complications. We investigated the relationship between GWG and caesarean delivery in labour, large for gestational age (LGA), small for gestational age (SGA) infants and pregnancy-induced hypertension by maternal pre-pregnancy body mass index (BMI) in a contemporary nulliparous cohort.

Study design

Using 2009 Institute of Medicine guidelines, participants in the SCOPE study (from Cork, Ireland, Auckland, New Zealand and Adelaide, Australia) were classified into GWG categories (low, normal and high) according to pre-pregnancy BMI. Maternal characteristics and pregnancy outcomes were compared between weight gain categories. SGA and LGA were defined as <10th and >90th customised birthweight centile. Multivariable analysis adjusted for confounding factors that impact on GWG including BMI.

Results

Of 1950 participants, 17.2% (n = 335) achieved the recommended GWG, 8.6% (n = 167) had low and 74.3% (n = 1448) had high GWG. Women with high GWG had increased rates of LGA infants [adjusted OR 4.45 (95% CI 2.49–7.99)] and caesarean delivery in labour [aOR 1.46 (1.03–2.07)]. SGA was increased in women with low GWG [aOR 1.79 (1.06–3.00)].

Conclusion

Three quarters of participants had high GWG, which was associated with an independent risk of LGA infants and caesarean in labour. Low GWG was associated with SGA infants. These adverse outcomes are potentially modifiable by achievement of normal GWG, which should be an important focus of antenatal care.     

Outcome measures in studies on the use of oxytocin for the treatment of delay in labour: A systematic review

Objectives

to identify primary and secondary outcome measures in randomised trials, and systematic reviews of randomised trials, measuring effectiveness of oxytocin for treatment of delay in the first and second stages of labour, and to identify any positive health-focussed outcomes used.

Design

eight relevant citation databases were searched up to January 2013 for all randomised trials, and systematic reviews of randomised trials, measuring effectiveness of oxytocin for treatment of delay in labour. Trials of active management of labour or partogram action lines were excluded. 1918 citations were identified. Two reviewers reviewed all citations and extracted data. Twenty-six individual trials and five systematic reviews were included. Primary and secondary outcome measures were documented and analysed using frequency distributions.

Findings

most frequent primary outcomes were caesarean section (n=15, 46%), length of labour (n=14, 42%), measurements of uterine activity (n=13, 39%) and mode of vaginal birth (n=9, 27%). Maternal satisfaction was identified a priori by one review and included as a secondary outcome by three papers. No further positive health-focussed outcomes were identified.

Key conclusions

outcomes used to measure the effectiveness of oxytocin for treatment of delay in labour are heterogeneous and tend to focus on adverse events.

Implications for practice

it is recommended that, in future randomised trials of oxytocin use for delay in labour, some women-centred and health-focussed outcome measures should be used, which may instil a more salutogenic culture in childbirth.     

First-time fathers' expectations and experiences of childbirth in relation to age

Objective

to investigate first-time fathers' expectations and experiences of childbirth and satisfaction with care in relation to paternal age.

Design

data from a randomised controlled trial of antenatal education were used for secondary analysis. Data were collected by questionnaires in mid-pregnancy and at three months after the birth. Comparisons by χ²-tests and Student's t-tests were made between men in three age groups: young men aged ≤27 years (n=188), men of average age 28–33 years (n=389) and men of advanced age ≥34 years (n=200).

Setting

the expectant fathers were recruited from 15 antenatal clinics spread over Sweden.

Participants

777 first-time fathers.

Findings

antenatal expectations and postnatal memory of the childbirth experience varied by paternal age. In mid-pregnancy, mixed or negative feelings about the upcoming birth were more prevalent in men of advanced age (29%) compared with men of average (26%) and young (18%) age (p<0.01), and they feared the event more than the youngest (mean on the Wijma Delivery Expectancy Questionnaire: advanced age 43.3; average age 42.9; young 38.7; p<0.01). The older men also assessed their partner's labour and birth as more difficult (advanced age 43%; average age 41%; young 32%; p=0.05) and had a less positive overall birth experience (advanced age 30%; average age 36%; young 43%; p<0.05). However, older fathers were more satisfied with care given during the intrapartum period: 52% were overall satisfied compared with 46% of the men of average age and 39% of young age (p=0.03).

Key conclusions

men of advanced age had more fearful and negative expectations during their partner's pregnancies and postnatally assessed the births as less positive and more difficult than younger men did. Despite this, older men were more satisfied with intrapartum care.

Implications for practice

knowledge about age-related differences in the expectations and experiences of first-time fathers may help midwives and doctors give more individualised information and support, with special attention to older men's expectations and experiences of the birth as such, and to younger men's perception of care.     

Childbirth and criteria for traumatic events

Objective

for some women childbirth is physically and psychologically traumatic and meets Criterion A1 (threat) and A2 (intense emotional response) for Posttraumatic Stress Disorder of the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV).This study differentiates Criterion A1 and A2 to explore their individual relationship to prevalence rates for posttraumatic stress, each other, and associated factors for childbirth trauma.

Design and setting

women were recruited at three hospitals from October 2008 to October 2009. Questionnaires were completed at recruitment and at 14 days post partum.

Participants

women in the third trimester of pregnancy (n=890) were recruited by a research midwife while waiting for their antenatal clinic appointment. Participants were over 17 years of age, expected to give birth to a live infant, not undergoing psychological treatment, and able to complete questionnaires in English.

Findings

this study found 14.3% of women met criteria for a traumatic childbirth. When the condition of A2 was removed, the prevalence rate doubled to 29.4%. Approximately half the women who perceived threat in childbirth did not have an intense negative emotional response. Predictors of finding childbirth traumatic were pre-existing psychiatric morbidity, being a first time mother and experiencing an emergency caesarean section.

Key conclusions

the fear response is an important diagnostic criterion for assessing psychologically traumatic childbirth. The identification of risk factors may inform maternity service delivery to prevent traumatic birth and postpartum approaches to care to address long-term negative consequences.

Implications for practice

prevention and treatment of traumatic childbirth are improved through knowledge of potential risk factors and understanding the woman's subjective experience.     

'Soothing the ring of fire': Australian women's and midwives' experiences of using perineal warm packs in the second stage of labour

Objective

to determine women's and midwives’ experiences of using perineal warm packs in the second stage of labour.

Design

as part of a randomised controlled trial (Warm Pack Trial), women and midwives were asked to complete questionnaires about the effects of the warm packs on pain, perineal trauma, comfort, feelings of control, satisfaction and intentions for use during future births.

Setting

two hospitals in Sydney, Australia.

Participants

a randomised controlled trial was undertaken. In the late second stage of labour, nulliparous women (n=717) giving birth were randomly allocated to having warm packs (n=360) applied to their perineum or standard care (n=357). Standard care was defined as any second stage practice carried out by midwives that did not include the application of warm packs to the perineum. Three hundred and two nulliparous women randomised to receive warm packs (84%) received the treatment. Questionnaires were completed by 266 (88%) women who received warm packs, and 270 (89%) midwives who applied warm packs to these women.

Intervention

warm, moist packs were applied to the perineum in the late second stage of labour.

Findings

warm packs were highly acceptable to both women and midwives as a means of relieving pain during the late second stage of labour. Almost the same number of women (79.7%) and midwives (80.4%) felt that the warm packs reduced perineal pain during the birth. Both midwives and women were positive about using warm packs in the future. The majority of women (85.7%) said that they would like to use perineal warm packs again for their next birth and would recommend them to friends (86.1%). Likewise, 91% of midwives were positive about using the warm packs, with 92.6% considering using them in the future as part of routine care in the second stage of labour.

Key conclusions

responses to questionnaires, eliciting experiences of women and midwives involved in the Warm Pack Trial, demonstrated that the practice of applying perineal warm packs in the late second stage of labour was highly acceptable and effective in helping to relieve perineal pain and increase comfort.

Implications for practice

perineal warm packs should be incorporated into second stage pain relief options available to women during childbirth.     

A comparison of Israeli Jewish and Arab women's birth perceptions

Background

birth is a normal physiological process, but can also be experienced as a traumatic event. Israeli Jewish and Arab women share Israeli residency, citizenship, and universal access to the Israeli medical system. However, language, religion, values, customs, symbols, and lifestyle differ between the groups.

Objectives

to examine Israeli Arab and Jewish women's perceptions of their birth experience, and to assess the extent to which childbirth details and perceptions predict satisfaction with the birth experience and the extent of assessing the childbirth as traumatic.

Methods

this study was conducted in two post partum units of two major public hospitals in the northern part of Israel. The sample included 171 respondents, including 115 Jewish Israeli and 56 Arab Israeli women who gave birth to their first (33%) or second (67%) child. Respondents described their childbirth experiences using a self-report questionnaire 24–48 hours after childbirth.

Findings

the Arab women were much less likely to attend childbirth preparation classes than the Jewish women (5% versus 24%). Forty-three per cent of the respondents reported feeling helpless, and 68% reported feeling lack of control during childbirth. Twenty per cent of the women rated their childbirth experience as traumatic, a rate much lower than the rate of medical indicators of traumatic birth (39%). The rate of self-reported traumatic birth was significantly higher among the Arab women than among the Jewish women (32% versus 14%). A higher percentage of the Arab women reported being afraid during labour (χ²=4.97, p<.05), expressed fear for their newborn's safety (χ²=12.44, p<.001), and reported that the level of medical intervention was excessive in their opinion, as compared to the Jewish women (χ²=5.09, p<.05; χ²=7.33, p<.01). However, both the Arab and Jewish women reported similar numbers of medical interventions and levels of satisfaction with their medical treatment.

Conclusions

despite universal access to the Israeli health care system, Arab Israeli women use fewer perinatal medical resources and subjectively report more birth trauma than Jewish Israeli women. Yet, they give birth in the same hospitals with the same practitioners and report similarly high levels of satisfaction with the medical services. Taking into account the fact that perceptions of the birth experience differ between ethno-cultural groups will enable professionals to better tailor intervention and support throughout childbirth in order to increase satisfaction and minimise trauma from the experience.     

Estimating maternal mortality and causes in South Africa: National and provincial levels

Objectives

maternal mortality estimates for South Africa have methodological weaknesses. This study uses the Growth Balance Method to adjust reported household female deaths and pregnancy-related deaths and the relational Gompertz model to adjust reported number of live births and estimate maternal mortality in South Africa at national and provincial level; examines the potential impact of HIV/AIDS prevalence; and investigates the recorded direct causes of maternal mortality.

Design

data from the 2001 Census, 2007 Community Survey and death registrations were utilised. Information on household deaths, including pregnancy-related deaths was collected from the aforementioned census and survey.

Setting

enumerated households in the 2001 Census and a nationally representative sample of 250,348 households in the 2007 Community Survey.

Participants

information about members of households who died in the preceding 12 months was collected, and of these deaths whether there were women aged 15–49 who died while pregnant or within 42 days after childbirth.

Findings

maternal mortality ratio of 764 per 100,000 live births in 2007, ranging from 102 per 100,000 live births in the Western Cape province to 1639 in the Eastern Cape. Maternal infections and parasitic diseases as well as other maternal diseases complicating pregnancy, childbirth and the puerperium are the major causes. The study found a weak correlation between provincial HIVprevalence and maternal mortality ratio.

Conclusion

despite strategies to improve maternal and child health, maternal mortality remains high in South Africa and it is unlikely that the Millennnium Developmemnt Goal of reducing maternal will be achieved.     

The occurrence of endometriosis with ovarian carcinomas is not purely coincidental

Objective

To explore the association between epithelial ovarian cancer (EOC) and common benign gynecological disorders.

Study design

The medical records of 226 patients with EOC treated at Peking Union Medical College Hospital between March 2011 and March 2012 were reviewed. Histological evaluations had been performed to determine the presence of coexisting pelvic endometriosis (n = 17), uterine leiomyoma (n = 66), adenomyosis (n = 22), or endometrial polyps (n = 17).

Results

Coexistence of endometriosis occurred in 35.3% and 36.4% of cases of the clear cell and endometrioid subtypes of EOC histology, respectively. Endometriosis was more likely associated with clear cell or endometrioid ovarian carcinoma, but less likely with high grade serous cancer. No differences were observed in the concurrence of uterine myoma, adenomyosis or endometrial polyps among the different subtypes of EOC.

Conclusions

In contrast to other common benign gynecological disorders, endometriosis showed close relationships with the clear cell and endometrioid subtypes of EOC specifically.     

Why are young Canadians afraid of birth? A survey study of childbirth fear and birth preferences among Canadian University students

Objective

to examine attitudes towards birth that may be common among young adults who have been socialised into a medicalised birth culture. Specifically, we were interested in examining factors that might be associated with fear of birth and preferences for elective obstetric interventions among the next generation of maternity care consumers.

Design

secondary analysis of an online survey of university students.

Setting

British Columbia, Canada.

Participants

students from the University of British Columbia (n=3680). A quarter of the sample comprised Asian students, which allowed for analysis of cultural differences in attitudes towards birth. Both male and female students participated in the study; results are reported for the full sample, and by gender.

Measurements

a six item fear of childbirth scale was developed, as well as a 4 item index that measures students' concerns over physical changes following pregnancy and birth and a 2 item scale that assesses students' attitudes towards obstetric technology.

Findings

as we hypothesised, students who were more fearful of birth preferred epidural anaesthesia and birth by CS. Worries over physical changes following pregnancy and birth, favourable attitudes towards obstetric technology, and exposure to pregnancy and birth information via the media were also significantly associated with a preference for CS. Fear of birth scores were highest among students who reported that the media had shaped their attitudes towards pregnancy and birth. Asian students had significantly higher fear of birth scores and were more likely to prefer CS, compared to Caucasian students.

Implications for practice

young adults are contemplating pregnancy and birth in an increasingly technology-dependent society. Educational programmes aimed at reducing fear of childbirth and concerns over physical changes following pregnancy and childbirth might contribute to vaginal birth intentions among young adults. Midwives may use the findings to identify and counsel nulliparas who exhibit fear of birth and other childbirth attitudes that may predispose them to choose elective obstetric interventions.     

Factors influencing the retention of midwives in the public sector in Afghanistan: A qualitative assessment of midwives in eight provinces

Objective

to examine factors that affect retention of public sector midwives throughout their career in Afghanistan.

Design

qualitative assessment using semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs).

Setting

health clinics in eight provinces in Afghanistan, midwifery education schools in three provinces, and stakeholder organisations in Kabul.

Participants

purposively sampled midwifery profession stakeholders in Kabul (n=14 IDIs); purposively selected community midwifery students in Kabul (n=3 FGDs), Parwan (n=1 FGD) and Wardak (n=1 FGD) provinces (six participants per FGD); public sector midwives, health facility managers, and community health workers from randomly selected clinics in eight provinces (n=48 IDIs); midwives who had left the public sector midwifery service (n=5 IDIs).

Measurements and findings

several factors affect a midwife throughout her career in the public sector, including her selection as a trainee, the training itself, deployment to her pre-assigned post, and working in clinics. Overall, appropriate selection is the key to ensuring deployment and retention later on in a midwife's career. Other factors that affect retention of midwives include civil security concerns in rural areas, support of family and community, salary levels, professional development opportunities and workplace support, and inefficient human resources planning in the public sector.

Key conclusions

Factors affecting midwife retention are linked to problems within the community midwifery education (CME) programme and those reflecting the wider Afghan context. Civil insecurity and traditional attitudes towards women were major factors identified that negatively affect midwifery retention.

Implications for practice

Factors such as civil insecurity and traditional attitudes towards women require a multisectoral response and innovative strategies to reduce their impact. However, factors inherent to midwife career development also impact retention and may be more readily modified.     

Insights into maternal mortality in Madang Province,Papua New Guinea

Objective

To assess the frequency, causes, and reporting of maternal deaths at a provincial referral hospital in coastal Papua New Guinea (PNG), and to describe delays in care.

Methods

In a structured retrospective review of maternal deaths at Modilon General Hospital, Madang, PNG, registers and case notes for the period January 2008 to July 2012 were analyzed to determine causes, characteristics, and management of maternal death cases. Public databases were assessed for underreporting.

Results

During the review period, there were 64 maternal deaths (institutional maternal mortality ratio, 588 deaths per 100 000 live births). Fifty-two cases were analyzed in detail: 71.2% (n = 37) were direct maternal deaths, and hemorrhage (n = 24, 46.2%) and infection (n = 16, 30.8%) were the leading causes of mortality overall. Women frequently did not attend prenatal clinics (n = 34, 65.4%), resided in rural areas (n = 45, 86.5%), and experienced delays in care (n = 45, 86.5%). Maternal deaths were underreported in public databases.

Conclusion

The burden of maternal mortality was found to be high at a provincial hospital in PNG. Most women died of direct causes and experienced delays in care. Strategies to complement current hospital and national policy to reduce maternal mortality and to improve reporting of deaths are needed.     

Chinese family adaptation during the postpartum period and its influencing factors: A questionnaire survey

Aim

this study aimed to explore new parents' views and experiences during their transition to parenthood.

Background

in China the one-child birth policy may bring more stress and challenges for the new parents due to the lack of experience and greater expectations of their new role. China is also at a stage of rapid economic and social development which creates new conditions for parenthood.

Methods

a cross-sectional survey was conducted from February to September 2009 among 232 mothers and fathers, yielding a 83.6% response rate (n=194 couples). The questionnaire included: the Family Assessment Device-General Function Scale, the Family Resources Scale, the Family Adaptation Scale, and the Chinese Perceived Stress Scale.

Results

there were no significant differences between mothers' adaptation and fathers' adaptation during the postpartum period, as well as their perceived stress, family function and family resources (p>0.05). Method of childbirth was not related to adaptation. About 29% of variance in mothers' adaptation could be explained by satisfaction with the infant's gender (B=0.295, p<0.001), fathers' adaptation (B=0.236, p<0.001), and family resources (B=0.179, p=0.016). About 42% of variance in fathers' adaptation could be explained by mothers' adaptation (B=0.268, p<0.001), satisfaction with marriage (B=0.248, p=0.002), satisfaction with the infant's gender (B=0.209, p<0.007), and family resources (B=0.206, p=0.002).

Conclusion

this study highlights the importance of family resources to family adaptation and antenatal and postnatal education programmes as part of family-centred care. The possible influences of culture and polices need to be considered by health-care professionals developing strategies to facilitate family adaptation to the early parenthood.     

Macrosomia has its roots in early placental development

Introduction

We sought to determine if early placental size, as measured by 3-dimensional ultrasonography, is associated with an increased risk of delivering a macrosomic or large-for-gestational age (LGA) infant.

Methods

We prospectively collected 3-dimensional ultrasound volume sets of singleton pregnancies at 11–14 weeks and 18–24 weeks. Birth weights were collected from the medical records. After delivery, the ultrasound volume set were used to measure the placental volume (PV) and placental quotient (PQ = PV/gestational age), as well as the mean placental and chorionic diameters (MPD and MCD, respectively). Placental measures were analyzed as predictors of macrosomia (birth weight ≥4000 g) and LGA (birth weight ≥90th percentile).

Results

The 578 pregnancies with first trimester volumes included 44 (7.6%) macrosomic and 43 (7.4%) LGA infants. 373 subjects also had second trimester volumes available. A higher PV and PQ were both significantly associated with macrosomia and LGA in both the first and second trimesters. Second trimester MPD was significantly associated with both outcomes as well, while second trimester MCD was only associated with LGA. The above associations remained significant after adjusting for maternal demographic variables such as race, ethnicity, age and diabetes. Adjusted models yielded moderate prediction of macrosomia and LGA (AUC: 0.71–0.77).

Conclusions

Sonographic measurement of the early placenta can identify pregnancies at greater risk of macrosomia and LGA. Macrosomia and LGA are already determined in part by early placental growth and development.     

Laparoscopic restaging of borderline ovarian tumours (BLOT): a retrospective study of 142 cases

Objectives

Primary objective: To analyse the impact of restaging, on recurrences and survival, in BLOT. Secondary objective: To cluster patients who could be exempted from restaging.

Study design

This retrospective study, included patients operated for a BLOT, between January 1990, and December 2007, in gynaecological surgery units of the University Hospital of Clermont-Ferrand.Two groups were evaluated: patients with and without optimal restaging.

Results

One hundred and forty-two patients were included. Optimal initial staging rate was 38.7% (n = 55). Among the eighty-seven women not initially staged, two groups were compared: restaged (n = 45) and non-restaged patients (n = 42). Mean follow-up was 80.5 months. Overall survival was 93.7%. Relapse rate was 7.7% (n = 11). Disease free survival (DFS) was 88% after a mean follow-up of 80.5 months. One death was noted.Optimal restaging rate was 31.7% (n = 45, 43 by laparoscopy). Mean follow-up was of 87.1 months among restaged patients, 84.5 months among non-restaged patients (p = 0.93).Relapse incidence was significantly higher in non restaged, than in restaged patients (p = 0.008). DFS was significantly longer among restaged than non-restaged patients, (p = 0.072). Younger age (p = 0.04), conservative treatment (p < 10⁻⁴) or non-diploidy (p = 0.04) increased the incidence of relapse.

Conclusions

When initial staging is missing, restaging improves the patients outcome in comparison to non-restaged groups. Laparoscopy is a valuable surgical option. This study suggests that a selected group of patients, older than 30 years old, submitted to a radical treatment, presenting a diploid, non micropapillar, mucinous BLOT, without visible implants during careful peritoneal inspection, could be exempted from restaging. They represented 11.6% of our population.     

Velocimetría Doppler del flujo sanguíneo de la arteria uterina y riesgo de muerte perinatal en preeclámpsicas

Objective

To determine the association between Doppler velocimetry values of uterine artery blood flow with the risk of perinatal death in preeclamptic patients.

Materials and method

We selected 80 patients with a diagnosis of preeclampsia. Preeclamptic patients were divided into those with perinatal deaths and those without. The variables analyzed were the pulsatility index, the resistance index, and the systolic/diastolic flow ratio of the uterine arteries.

Results

There were no differences in maternal age, height or weight between preeclamptic patients with or without perinatal deaths (p = ns), or between gestational age at the time of Doppler ultrasound and systolic and diastolic blood pressure (p = ns). The pulsatility index (1.206 ± 0.140) and resistance index (0.684 ± 0.098) of the uterine arteries were significantly higher in women with perinatal deaths than in those without (1.113 ± 0.109 and 0.605 ± 0.116, respectively; P<.05). No significant differences were found in mean values of the systolic/diastolic flow ratio of the uterine arteries (p = ns).

Conclusion

A high value of the pulsatility index and resistance index of the uterine arteries on Doppler velocimetry in preeclamptic patients is associated with an increased risk of perinatal death.     

Establishing midwifery in low-resource settings: Guidance from a mixed-methods evaluation of the Afghanistan midwifery education program

Background

the shortage of skilled birth attendants has been a key factor in the high maternal and newborn mortality in Afghanistan. Efforts to strengthen pre-service midwifery education in Afghanistan have increased the number of midwives from 467 in 2002 to 2954 in 2010.

Objective

we analyzed the costs and graduate performance outcomes of the two types of pre-service midwifery education programs in Afghanistan that were either established or strengthened between 2002 and 2010 to guide future program implementation and share lessons learned.

Design

we performed a mixed-methods evaluation of selected midwifery schools between June 2008 and November 2010. This paper focuses on the evaluation's quantitative methods, which included (a) an assessment of a sample of midwifery school graduates (n=138) to measure their competencies in six clinical skills; (b) prospective documentation of the actual clinical practices of a subsample of these graduates (n=26); and (c) a costing analysis to estimate the resources required to educate students enrolled in these programs.

Setting

for the clinical competency assessment and clinical practices components, two Institutes for Health Sciences (IHS) schools and six Community Midwifery Education (CME) schools; for the costing analysis, a different set of nine schools (two IHS, seven CME), all of which were funded by the US Agency for International Development.

Participants

midwives who had graduated from either IHS or CME schools.

Findings

CME graduates (n=101) achieved an overall mean competency score of 63.2% (59.9–66.6%) on the clinical competency assessment compared to 57.3% (49.9–64.7%) for IHS graduates (n=37). Reproductive health activities accounted for 76% of midwives' time over an average of three months. Approximately 1% of childbirths required referral or resulted in maternal death. On the basis of known costs for the programs, the estimated cost of graduating a class with 25 students averaged US$298,939, or US$10,784 per graduate.

Key conclusions

the pre-service midwifery education experience of Afghanistan can serve as a model to rapidly increase the number of skilled birth attendants. In such settings, it is important to ensure the provision of continued practice opportunities and refresher trainings after graduation to aid skill retention, a co-operative and supportive work environment that will use midwives for the reproductive health skills for which they were trained, and selection mechanisms that can identify the most promising students and post-graduation deployment options to maximise the return on the substantial educational investment.     

Modes of delivery of first and second twins as a function of their presentation. Study of 614 consecutive patients from 1992 to 2000

Objectives

To study modes of delivery and neonatal morbidity of twins as a function of their presentation.

Study design

The study related to 614 consecutive patients who gave birth to twins in the maternity ward of the Hôpital Robert Debré from 1992 to 2000. Group A (n = 529) included patients who gave birth after 33 weeks of gestation and group B (n = 85) before 33 weeks. The parameters studied were the mode of delivery, the need for intubation at birth, 5-min Apgar score <9, transfer to intensive care, death in the neonatal period. The chi-square test was used for statistical analysis.

Results

In group A, significantly more cesarean sections were performed for breech–breech (22.6%) and breech–vertex (16%) presentations than for vertex–vertex (10.3%) and vertex–breech (4.6%) presentations. In group B, there was no significant difference in the rate of vaginal delivery. Second vertex twins of group A had significantly higher frequencies of intubation (3%) at birth and transfer to intensive care (3%) than the vertex first twins born by vaginal delivery (p = 0.01). These percentages were not significantly different from those observed for the second twins born by planned Cesarean section before the start of labor (2.8 and 5.6%, respectively). In group B, neonatal parameters did not differ significantly with the type of presentation at delivery.

Conclusions

The type of presentation should not influence the choice of mode of delivery of twin pregnancies, whatever the gestational age.     

A study to promote breast feeding in the Helsinki Metropolitan area in Finland

Objective

the aim of this study was to assess the impact of providing intensified support for breast feeding during the perinatal period.

Design

a quasi-experimental design with non-equivalent control group.

Setting

three public maternity hospitals (two study, one control) in the Helsinki Metropolitan area in Finland.

Participants

a convenience sample of 705 mothers (431 in the intervention group, 274 in the control group).

Methods and intervention

in this study, families in the intervention group had access to intensified breast feeding support from midpregnancy, whereas those in the control group had access to normal care. Intensified support included lectures and workshops to health professionals, and families in the intervention group had access to more intensive support and counselling for breast feeding and a breast feeding outpatient clinic. Additionally, an internet-based intervention was only used in the intervention group, but not in the control group. Mothers in the control group received normal care from the midwifery and nursing professionals who were to continue their work normally. The data were analysed statistically.

Findings

altogether 705 women participated in the study. In the intervention group (n=431), 76% of the women breast fed exclusively throughout the hospital stay, compared to 66% of the mothers in the control group (n=274). In multivariate analysis, the likelihood of exclusive breast feeding at the time of responding (at hospital discharge or after that at home) was increased by the mother not being treated for an underlying illness or medical problem during pregnancy, being in the intervention group, having normal vaginal childbirth, high breast feeding confidence, positive attitude towards breast feeding, good coping with breast feeding, and 24-hour presence of the infant's father in the ward.

Key conclusions and implications for practice

the low exclusive breast feeding rates of newborns could be increased by using intensified breast feeding support. Mothers' health problems during pregnancy can decrease exclusive breast feeding.Mothers with health problems or other than normal childbirth should receive extra breast feeding support, and the presence of fathers in the ward should be encouraged.Intensified breast feeding counselling and support helps mothers to breast feed exclusively. This support should be available in a variety of forms, so that mothers can choose the type of support they need. As breast feeding counselling and support is intensified, more mothers succeed with exclusive breast feeding.     

Childbirth experience according to a group of Brazilian primiparas

Objective

to understand the meaning of the childbirth experience for Brazilian primiparas in the postpartum period.

Design

a qualitative approach using semi-structured interviews. Content analysis was used to derive the two themes that emerged from the discourses.

Setting

participants were recruited at four primary-level health-care units in Ribeirão Preto, Brazil. After providing written informed consent, an appointment was made for an interview at the participants' homes.

Participants

20 primiparas in the postpartum period, aged 15–26 years old, who attended the health-care units to vaccinate their infants and test for phenylketonuria.

Findings

two thematic categories emerged from the interviews: the meaning attributed to childbirth (with four subcategories) and perceptions of care. Among the participants, the childbirth experience was marked by the ‘fear of death’ and ‘losing the child’. The pain of giving birth was expected, and the moment of childbirth was associated with pain of high intensity.

Key conclusions

childbirth is considered synonymous with physical and emotional suffering, pain, fear and risk of death.

Implications for practice

this research indicates the need to break the current mechanistic model of care on which health professionals’ actions are based. Care during childbirth must be guided by the foundation that women are the subjects of childbirth actions, in an attempt to emphasise actions that grant them with the autonomy and empowerment needed to experience the situation.