Factors Associated with the Choice of Delivery without Epidural Analgesia in Women at Low Risk in France

ABSTRACT: Background: Regional anesthesia is used for three‐fourths of the deliveries in France. Epidural analgesia during labor is supposed to be available to all women at low risk. The purpose of our study was to examine how the choice of delivery without an epidural varied in this context according to women’s characteristics, prenatal care, and type of maternity unit. Methods: The 2003 National Perinatal Survey in France collected data about a representative sample of births. We selected 8,233 women who were at low risk and therefore should have been able to choose whether or not to deliver without epidural analgesia. Women were interviewed in the maternity unit after delivery. The factors associated with women’s choice to deliver without epidural analgesia were studied with multivariable analyses. Results: Of the 2,720 women who gave birth without epidural analgesia, 37 percent reported that they had not wanted one; other reasons were labor occurring too quickly (43.9%), medical contraindication (3.3%), and unavailability of an anesthesiologist (2.8%). The reported decision to deliver without epidural analgesia was closely associated with high parity. It was also more frequent among women in an unfavorable social situation (not cohabiting, no or low‐qualified job) and among women who gave birth in nonuniversity public hospitals, in small‐ or medium‐sized maternity units, and in maternity units without an anesthesiologist always on site. Conclusions: Unfavorable social situation and organizational factors are associated with the reported choice to give birth without epidural analgesia. This finding suggests that women are not always in a position to make a real choice. It would be useful to improve the understanding of how pregnant women define their preferences and to know how these preferences change during pregnancy and labor. (BIRTH 35:3 September 2008)     

Do maternity care provider groups have different attitudes towards birth?

OBJECTIVE: To compare family physicians', obstetricians' and midwives' self-reported practices, attitudes and beliefs about central issues in childbirth. DESIGN: Mail-out questionnaire. SETTING/POPULATION; All registered midwives in the province, and a sample of family physicians and obstetricians in a maternity care teaching hospital. Response rates: 91% (n = 50), 69% (n = 97) and 89% (n = 34), respectively. METHODS: A postal survey. MAIN OUTCOME MEASURES: Twenty-three five-point Likert scale items (strongly agree to strongly disagree) addressing attitudes toward routine electronic fetal monitoring, induction of labour, epidural analgesia, episiotomy, doulas, vaginal birth after caesarean section (VBACs), birth centres, provision educational material, birth plans and caesarean section. RESULTS: Cluster analysis identified three distinct clusters based on similar response to the questions. The 'MW' cluster consisted of 100% of midwives and 26% of the family physicians. The 'OB' cluster was composed of 79% of the obstetricians and 16% of the family physicians. The 'FP' cluster was composed of 58% the family physicians and 21% the obstetricians. Members of the 'OB' cluster more strongly believed that women had the right to request a caesarean section without maternal/fetal indications (P < 0.001), that epidurals early in labour were not associated with development of fetal malpositions (P < 0.001) and that increasing caesarean rates were a sign of improvement in obstetrics (P < 0.001). The 'OB' cluster members were more likely to say they would induce women as soon as possible after 41 3/7 weeks of gestation (P < 0.001) and were least likely to encourage the use of birth plans (P < 0.001). The 'MW' cluster's views were the opposite of the 'OBs' while the 'FP' cluster's views fell between the 'MW' and 'OB' clusters. CONCLUSIONS: In our environment, obstetricians were the most attached to technology and interventions including caesarean section and inductions, midwives the least, while family physicians fell in the middle. While generalisations can be problematic, obstetricians and midwives generally follow a defined and different approach to maternity care. Family physicians are heterogeneous, sometimes practising more like midwives and sometimes more like obstetricians.     

The Attitudes of Canadian Maternity Care Practitioners Towards Labour and Birth: Many Differences but Important Similarities

ObjectiveCollaborative, interdisciplinary care models have the potential to improve maternity care. Differing attitudes of maternity care providers may impede this process. We sought to examine the attitudes of Canadian maternity care practitioners towards labour and birth.MethodsWe performed a cross-sectional web- and paper-based survey of 549 obstetricians, 897 family physicians (400 antepartum only, 497 intrapartum), 545 nurses, 400 midwives, and 192 doulas.ResultsParticipants responded to 43 Likert-type attitudinal questions. Nine themes were identified: electronic fetal monitoring, epidural analgesia, episiotomy, doula roles, Caesarean section benefits, factors decreasing Caesarean section rates, maternal choice, fear of vaginal birth, and safety of birth mode and place. Obstetrician scores reflected positive attitudes towards use of technology, in contrast to midwives’ and doulas’ scores. Family physicians providing only antenatal care had attitudinal scores similar to obstetricians; family physicians practising intrapartum care and nurses had intermediate scores on technology. Obstetricians’ scores indicated that they had the least positive attitudes towards home birth, women’s roles in their own births, and doula care, and they were the most concerned about the consequences of vaginal birth. Midwives’ and doulas’ scores reflected opposing views on these issues. Although 71% of obstetricians supported regulated midwifery, 88.9% were against home birth. Substantial numbers of each group held attitudes similar to dominant attitudes from other disciplines.ConclusionTo develop effective team practice, efforts to reconcile differing attitudes towards labour and birth are needed. However, the overlap in attitudes between disciplines holds promise for a basis upon which to begin shared problem solving and collaboration.     

Older Maternal Age and Intervention in Labor: A Population‐Based Study Comparing Older and Younger First‐Time Mothers in Victoria,Australia

Background: In Australia, birth rates for women aged 35 years or more are significant and increasing and a considerable percentage are first births. This study investigated the effect of maternal age on interventions in labor and birth for primiparous women aged 35 to 44 years compared with primiparous women aged 25 to 29 years. Methods: All primiparous women who gave birth in Victoria, Australia, in 2005 and 2006 (n = 57,426) were included in this population‐based cross‐sectional study. Women were stratified by admission status (private/public). Main outcome measures were induction of labor, augmentation of labor, use of epidural analgesia, and method of birth. Multivariate logistic regression was used to explore the relationship between maternal age and cesarean adjusted for confounders. Results: Older women were more likely to give birth by cesarean section whether admitted as public or private patients. For private patients, total cesarean rates were 31.8 percent (25–29 yr), 46.0 percent (35–39 yr), and 60.0 percent (40–44 yr; p < 0.001) compared with 27.5, 41.6, and 53.4 percent for public patients (p < 0.001). Older women who experienced labor were more likely to have an instrumental vaginal birth or an emergency cesarean section than younger women. Both were more common in women admitted as private patients. Age‐related trends were also seen for induction of labor and use of epidural analgesia. Rates were higher for private patients. Rates of induction were (37.8, 40.2, and 42.5%) for private patients compared with (32.1, 36.7, and 40.1%) for public patients and rates for epidural were (45.3, 49.9, and 48.1%) among private patients compared with (33.3, 38.8, and 39.3%) among public patients. Conclusions: Interventions in labor and birth increased with maternal age, and this effect was seen particularly for cesarean section among women admitted privately. These findings were not fully explained by the complications we considered. (BIRTH 38:1 March 2011)     

Epidural analgesia and severe perineal tears: a literature review and large cohort study

Abstract

Objective: Our objectives were to study the association between epidural analgesia and risk of severe perineal tears (SPT), and identify additional risk factors for SPT.

Methods: We conducted a historical cohort study of women with term delivery between 2006 and 2011. Inclusion criteria were an uncomplicated singleton pregnancy, cephalic presentation and vaginal delivery. Multivariate logistic regression models were constructed to study the association between epidural analgesia and SPT, controlling for potential confounders. Additional models studied the association between prolonged second stage and instrumental labor and SPT.

Results: During the study period, 61?308 eligible women gave birth, 31?631 (51.6%) of whom received epidural analgesia. SPT occurred in 0.3% of births. Deliveries with epidural had significantly higher rates of primiparity, induction and augmentation of labor, prolonged second stage of labor, instrumental births and midline episiotomies. The univariate analysis showed a significant association between the use of epidural and SPT (OR: 1.78, 95% CI: 1.34–2.36); however, this association disappeared when parity was introduced (OR: 0.95, 95% CI: 0.69–1.29). Instrumental deliveries and prolonged second stage of labor were both strongly associated with SPT (ORs of 1.82 and 1.77)

Conclusions: Epidural analgesia was not associated with SPT once confounding factors were controlled for.     

How Do Physicians and Midwives Manage the Third Stage of Labor?

ABSTRACT: Background: Current practice guidelines recommend active management of the third stage of labor. We compared practices of three maternity care provider disciplines in management of third‐stage labor and the justifications for their approach. Methods: This study is a cross‐sectional survey of maternity practitioners in usual practice settings in British Columbia. All 199 obstetricians, all 82 midwives, and a random sample of family physicians practicing intrapartum maternity care (one‐third, or 346) were surveyed The three main outcome measures by discipline were the method preferred in managing third‐stage labor, the reasons given for the chosen method, and views on the appropriateness of the current third‐stage labor guideline. Results: The overall response rate was 57.8 percent. Response rates indicating that the participants were “aware of guideline” were the following: obstetricians, 85.3 percent; family physicians, 53.7 percent; and midwives, 97.8 percent. Response rates indicating that the participants “agreed with guideline” were the following: obstetricians, 95.2 percent; family physicians, 97.6 percent; and midwives, 51.2 percent. Response rates indicating that “oxytocin should be given with anterior shoulder” were the following: obstetricians, 71.1 percent; family physicians, 68.3 percent; and midwives, 26.7 percent. Response rates indicating that “routine active management of third stage of labor should be the norm” were the following: obstetricians, 79.2 percent; family physicians, 60.2 percent; and midwives, 17 percent. All results were statistically significant (p < 0.01). Conclusions: A major difference was found between physicians and midwives in the management of third‐stage labor. Physicians routinely implemented active management of the third stage of labor; midwives preferred expectant approaches, principally based on women’s preference. Provincial data did not show differences in postpartum hemorrhage or transfusion rates by practitioner type. (BIRTH 35:3 September 2008)     

Trends in labour and birth interventions among low-risk women in New South Wales

OBJECTIVE: To examine recent trends in obstetric intervention rates among women at low-risk of poor pregnancy outcome. DESIGN: Cross-sectional analytic study SETTING AND POPULATION: A population of 336,189 women categorised as low-risk of a poor pregnancy outcome who gave birth to a live singleton in NSW from 1 January 1990 to 31 December 1997. MAIN OUTCOME MEASURES: Obstetric intervention rates including oxytocin induction and augmentation of labour, epidural analgesia, instrumental births, caesarean section and episiotomy METHODS: Trends over time were assessed by fitting trend-lines to numbers of births or by trends in proportions. Unconditional logistic regression was used to assess the impact of epidural analgesia on instrumental birth over time. RESULTS: Rates of operative births did not rise despite increases in maternal age and use of epidural analgesia. Instrumental births declined over time from 26% to 22% among primiparas and 5% to 4% among multiparas. There was also a shift to vacuum extraction rather than forceps. Although instrumental birth was strongly associated with epidural analgesia, the strength of the association declined over the study period, for primiparas from an adjusted odds ratio of 7.2 to 5.2 and for multiparas from 13.2 to 10.3. CONCLUSIONS: Increased use of epidural analgesia for labour has been a feature of the management of birth at term during the 1990s. The decline in the strength of association between epidural analgesia and instrumental birth may reflect improved epidural techniques and management of epidural labour, and recognition of the adverse maternal outcomes associated with forceps and vacuum births.     

Maternal epidural analgesia and rates of maternal antibiotic treatment in a low-risk nulliparous population.

BACKGROUND: Epidural analgesia is associated with an increased rate of fever in prospective randomized trials. While the evidence suggests that epidural fever is not infectious, epidural analgesia has been associated with increased rates of antibiotic use, the indications that prompt treatment have not been examined. METHODS: We analyzed 1235 nulliparous women with singleton term pregnancies presenting in labor with a temperature of < 99.5 degrees F. Antibiotic use during labor was categorized by indication. RESULTS: A total of 59.6% of women received epidural analgesia. The rate of antibiotic use was significantly higher in women receiving epidural analgesia (28 vs 10.8%). After adjusting for confounders using logistic regression, epidural analgesia was associated with a relative risk of 2.6 (95% CI 2.0, 3.4) for antibiotic treatment. The majority of the increased risk was due to significantly higher rates of antibiotic treatment for presumed chorioamnionitis (9.0 vs 0.4%) in the epidural analgesia group. CONCLUSION: Epidural-related fever results in excess maternal antibiotic treatment for presumed chorioamnionitis.     

Nulliparas' Preferences for Epidural Analgesia: Their Effects on Actual Use in Labor

Background: Few studies have directly examined the reasons for choices of pain relief during labor. The purpose of this study was to investigate if women's preferences for epidural analgesia in labor have an impact on the use of intrapartum epidural analgesia. Methods: Nulliparous women attending childbirth classes completed questionnaires about their antenatal preferences for the use of intrapartum epidural analgesia. Data on actual use of analgesia was obtained by chart review. The analysis included 303 women with either spontaneous or induced labor at term. Results: The 185 women who planned to receive epidural analgesia had a markedly higher rate of epidural use (91%) than the 110 women who hoped to avoid it (57%) ( p= 0.001). Of 237 epidurals administered, 169 (71%) were planned during the antenatal period. Among women receiving epidural analgesia, those planning to receive it tended to have more frequent early administration (≤ 3 cm cervical dilation) than women who unsuccessfully tried to avoid epidural use (54% vs. 24%, p= 0.003). Conclusion: In our population of nulliparas, a woman's antenatal plan to receive epidural analgesia is strongly associated with her likelihood of receiving it. Women who plan to receive epidural analgesia have earlier administration.     

The Effects of Whirlpool Baths in Labor: A Randomized,Controlled Trial

ABSTRACT: Background : Showers and tubs in labor were not generally used in our center: When three whirlpool baths (Jacuzzis) were ordered as part of our renovations, a randomized, controlled trial was initiated to explore their effects on narcotic and epidural requirements. Methods : This study employed an intent-to-treat design, and the sample size was estimated to account for the fact that some women would be unable to use the tub. The experimental group of 393 women was offered the tub during labor and the control group of 392 women received conventional care. Results : No births occurred in the tub. The tub group required fewer pharmacologic agents than controls (66% vs 59%, p = 0.06), experienced fewer deliveries by forceps and vacuum (p = 0.019), and were more likely to have an intact perineum than the standard-care group (p = 0.019). Labor was longer for the tub group (p = 0.003), who coincidentally were more primiparous and in earlier labor on admission. No differences were noted in the low rates of maternal and newborn signs of infection in women with ruptured membranes. A subset of mothers expressed satisfaction with the tub experience and labor support. The cesarean rate among both groups was lower (8.9%) than our overall rate (16.6%) during the study period. Conclusions : Whirlpool baths in labor have positive effects on analgesia requirements, instrumentation rates, condition of the perineum, and personal satisfaction. Further study of the effects on labor length, pain, influence of labor support, and psychological outcomes is being planned.     

Epidural analgesia in primigravidae in spontaneous labour at term: a prospective study

OBJECTIVES: To prospectively study the intervention rate, duration of labour, malpositions, fetal outcome, maternal satisfaction, voiding complications and adverse events in healthy primigravidae in spontaneous labour at term following epidural analgesia. METHODS: A prospective randomized study involving 55 patients in the epidural group and 68 in the control pethidine--inhalational entonox group. RESULTS: There were significantly more obstetric interventions (instrumental deliveries) in the epidural group (p < 0.01). The total duration of labour and the duration of the second stage was prolonged in the epidural group (p < 0.01). There were more malpositions at the second stage of labour in the epidural group (p < 0.02). There were no differences in fetal outcome (Apgar scores and Special Care Nursery admissions). Patients in the epidural group were consistently happier with their method of pain relief (p < 0.01). Two patients required blood patches while another 2 patients had persistent backache post epidural analgesia. CONCLUSION: Epidural analgesia in primigravidae in spontaneous labour at term led to an increased instrumental delivery rate, prolonged duration of labour, greater rate of malpositions in the second stage, increased oxytocin requirements but with no difference in fetal outcomes but with happier mothers as compared to the control group.     

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)     

Ethnic disparity in the success of vaginal birth after cesarean delivery

Objective.?To estimate whether maternal race/ethnicity is independently associated with successful vaginal birth after cesarean delivery (VBAC).

Study design.?A retrospective cohort study from January 1, 1997 to July 30, 2002 of women with singleton pregnancies and a previous cesarean delivery. The odds ratio (OR) for successful VBAC as a function of ethnicity was corrected for age >35 years, parity, weight gain, diabetes mellitus, hospital site, prenatal care provider, gestational age, induction, labor augmentation, epidural analgesia, and birth weight >4000 g.

Results.?Among 54 146 births, 8030 (14.8%) occurred in women with previous cesarean deliveries. The trials of labor rates were similar among Caucasian (46.6%), Hispanic (45.4%), and African American (46.0%) women. However, there was a significant difference among ethnic groups for VBAC success rates (79.3% vs. 79.3% vs. 70.0%, respectively). When compared to Caucasian women, the adjusted OR for VBAC success was 0.37 (95% confidence interval (CI) 0.27–0.50) for African American women and 0.63 (95% CI 0.51–0.79) for Hispanic women.

Conclusion.?African American and Hispanic women are significantly less likely than Caucasian women to achieve successful VBAC.     

A randomised double-blind comparison of epidural fentanyl versus fentanyl and bupivicaine for pain relief in the second stage of labour

OBJECTIVES: To compare the effectiveness of two different methods for epidural analgesia in the second stage of labour-fentanyl alone versus the usual mixture of bupivicaine and fentanyl. DESIGN: A double-blind, randomised, controlled trial. SETTING: An English maternity hospital. SAMPLE: Eighty nulliparous women in the second stage of labour. METHODS: After successful institution of epidural analgesia with a continuous infusion of bupivicaine/fentanyl mixture in the first stage of labour, the patients were randomised at full dilatation to receive either continuation of the same solution or a change to a fentanyl-only solution given at the same rate. MAIN OUTCOME MEASURES: Mode of delivery, duration of the second stage and quality of analgesia. RESULTS: There was no difference in the number of instrumental deliveries (30%vs 27.5%) or the duration of the second stage (141 vs 147 minutes) between the bupivicaine/fentanyl and fentanyl groups, respectively. The bupivicaine/fentanyl group demonstrated a lower need for rescue epidural analgesia (1 vs 6, RR 0.2, 95% CI 0.02-1.3) and significantly fewer high pain scores (11 vs 20, RR 0.6, 95% CI 0.3-1.0). CONCLUSION: Second stage epidural analgesia with fentanyl did not alter delivery outcomes or labour duration but resulted in poorer analgesia.     

Need for and consequences of episiotomy in vaginal birth: a critical approach

Objective

to describe and explain the short-term effects of lateral episiotomy, and determine the factors associated with more/less common use of episiotomy.

Design

prospective cross-sectional survey using a postal questionnaire.

Setting

the study was conducted at two university hospitals and one regional hospital in Finland between October and December 2006. The hospitals were chosen using cluster sampling. The sample consisted of 1000 vaginal births, and data were collected using questionnaires which were completed by midwives or student midwives. The overall response rate was 88%.

Participants

midwives or student midwives who took care of the women in labour provided information about childbearing women (n=879), obstetric factors and details of staff experience.

Findings

episiotomies were more common among primiparous than multiparous women (55% vs 12%, p?0.001). More common use of episiotomy was also associated with induced births compared with spontaneous births in primiparous women (66% vs 53%, p=0.036), assisted vaginal births in all women (89% vs 25%, p?0.001), and a prolonged active second stage of labour and epidural analgesia (17% vs 10%, p=0.036) in multiparous women. Correspondingly, episiotomies were less common among primiparous (44% vs 57%, p=0.041) and multiparous (7% vs 16%, p=0.003) women using spontaneous pushing compared with coached pushing. In the active second stage of labour, alternative birth positions (lateral, squatting, all fours, sitting) were associated with less common use of episiotomy than half-sitting or lithotomy positions among primiparous women (22% vs 48% vs 85%, p?0.001). There were no differences between primiparous women with and without episiotomy in low Apgar score at 1 minute (10.6% vs 6.4%, p=0.131) or 5 minutes (1.8% vs 1.1%, p=0.557), or between multiparous women with and without episiotomy in low Apgar score at 1 minute (1.9% vs 2.2%, p=0.855) or 5 minutes (0% vs 0.5%, p=0.603). There were more first- and second-degree perineal injuries as well as injuries to the vagina, labia minora and urethra in births performed without episiotomies among primiparous women (p?0.001). Correspondingly, third-degree perineal injuries were more common if episiotomy was performed in both primiparous (2.2% vs 1.6%) and multiparous women (3.7% vs 0%). The maternity hospital was the most significant determinant of the episiotomy rate (odds ratio 1 vs 1.9 vs 2.6, p=0.049).

Key conclusions

episiotomy rates can be reduced without causing harm to women or newborn babies. Episiotomies can be avoided if induction and vacuum assistance are used sparingly, and if spontaneous pushing techniques and alternative birth positions (lateral, sitting, squatting, all fours) are used more often during labour.     

Effect of early versus conventional epidural analgesia during labor on cytokine production

Abstract

Objective.?To compare the effect of early epidural analgesia (EEA) vs. conventional epidural analgesia (CEA) on cytokine production in mother and neonate.

Methods.?Healthy parturients with uncomplicated term pregnancies were randomized into two groups: EEA – parturients who would receive epidural analgesia before onset of pain and the control group, CEA – parturients who would receive epidural analgesia after onset of pain. Cytokines were measured in maternal blood at randomization Visual Analog Scale (VAS) < 30], 24 h postpartum, and in cord blood.

Results.?Forty-one women were studied. Epidural was performed in EEA when VAS was 23 ± 10 and in CEA when VAS was77 ± 10 (p < 0.0001). Background data were similar except for ruptured membranes at admission (EEA 15%, CEA 46.6%; p?=?0.03), transient hypotension (EEA 20%, CEA 0%; p?=?0.03), and meconium (EEA 25%, CEA 0%; p?=?0.01). No significant differences were found in cytokine levels between groups at any time. Interleukin (IL)-6 levels changed significantly only in the control group (p?=?0.046). There was significant correlation between baseline maternal IL-6 level and cord blood level in CEA (r?=?0.59, p?=?0.005), while no significant correlation existed in EEA (r?=?0.33, p?=?0.16).

Conclusion.?Although there was no significant difference in cytokine levels between the groups, EEA prevented the significant increase in IL-6 during labor and interrupted IL-6 fetal-maternal dependency.     

Effects of combined spinal–epidural analgesia on first stage of labor: a cohort study

Background: Neuraxial anesthesia is considered as the gold standard in the control labor of pain. Its variants are epidural analgesia and combined spinal–epidural analgesia. Few studies, as yet, have investigated the duration of labor as a primary outcome. Some authors have suggested that combined spinal–epidural analgesia may reduce labor duration but at the moment the benefit of shortening labor is uncertain. The main aim of this study was to compare combined spinal–epidural with epidural analgesia in terms of their effect on duration of stage I labor, maternal, and neonatal outcomes.

Methods: A prospective cohort study was conducted. Parturients who requested analgesia at cervical dilatation <6?cm were included. Analgesia was either epidural with low concentration levobupivacaine or combined spinal epidural with subarachnoid sufentanil. The primary outcome was the length of stage I labor. Onset and quality of analgesia, mode of delivery, effects on uterine activity and use of oxytocin, fetal heart rate abnormalities and uterine hyperkinesia, maternal, and neonatal complications were also considered.

Results: We enrolled 400 patients: 176 in the combined spinal–epidural group and 224 in the epidural group. Patients in the two treatment groups were similar with regard to demographic characteristics, parity, and incidence of obstetric comorbidities, labor induction, oxytocin infusion, Bishop score, and Visual Analogue Score (VAS) at analgesia request. Duration of stage I labor did not differ, at 195 (120–300) minutes for both the groups (p?=?.7). Combined spinal–epidural was associated with less reduction in uterine contractility after initial administration: 15.34 versus 39.73%, (p?p?=?.002). Onset of analgesia was quicker for combined spinal–epidural analgesia: 31 versus 20%, with VAS <4 after 5?minutes, (p?Conclusions: Combined spinal–epidural with subarachnoid sufentanil may not reduce the duration of stage I labor, but in our study it appeared to affect uterine contractility less. It also had a more rapid onset and was more effective, without any concomitant increase in maternal or neonatal complications.     

Influence of timing of admission in labour and management of labour on method of birth: Results from a randomised controlled trial of caseload midwifery (COSMOS trial)

Objectiveto explore the relationship between the degree to which labour is established on admission to hospital and method of birth.Backgrounda recent randomised controlled trial found fewer caesarean sections (CS) in women allocated to caseload midwifery (19.4%) compared with standard care (24.9%). There is interest in exploring what specific aspects of the care might have resulted in this reduction.Settinga large tertiary-level maternity service in Melbourne, Australia.ParticipantsEnglish-speaking women with no previous caesarean section at low risk of complications in pregnancy were recruited to a randomised controlled trial. Trial participants whose management did not include a planned caesarean and who were admitted to hospital in spontaneous labour were included in this secondary analysis of trial data (n=1532).Methodsthis secondary analysis included women admitted to hospital in spontaneous labour who were randomised to caseload midwifery compared with those randomised to standard care with regard to timing of admission in labour, augmentation of labour and use of epidural analgesia. In a further analysis randomised groups were pooled to examine predictors of caesarean section for first births only using multiple logistic regression.Resultsnulliparous women randomised to standard care were more likely to have labour augmented than those having caseload care (54.2% and 45.5% respectively, p=0.008), but were no more likely to use epidural analgesia. They were admitted earlier in labour, spending 1.1 hours longer than those in the caseload arm in hospital before the birth (p=0.003). Parous women allocated to standard care were more likely than those in the caseload arm to use epidural analgesia (10.0% and 5.3% respectively, p=0.047), but were no more likely to have labour augmented. They were also admitted earlier in labour, with a median cervical dilatation of 4 cm compared with 5 cm in the caseload arm (p=0.012).Pooling the two randomised groups of nulliparous women, and after adjusting for randomised group, maternal age and maternal body mass index, early admission to hospital was strongly associated with caesarean section. Admission before the cervix was 5 cm dilated increased the odds 2.4-fold (95%CI 1.4, 4.0; p=0.001). Augmentation of labour and use of epidural analgesia were each strongly associated with caesarean section (adjusted odds ratios 3.10 (95%CI 2.1, 4.5) and 5.77 (95%CI 4.0, 8.4) respectively.Conclusionthese findings that women allocated to caseload care were admitted to hospital later in labour, and that earlier admission was strongly associated with birth by caesarean section, suggest that remaining at home somewhat longer in labour may be one of the mechanisms by which caseload care was effective in reducing caesarean section in the COSMOS trial.     

Team Midwifery Care in a Tertiary Level Obstetric Service: A Randomized Controlled Trial

Background: In 1996 a new model of maternity care characterized by continuity of midwifery care from early pregnancy through to the postpartum period was implemented for women attending Monash Medical Centre, a tertiary level obstetric service, in Melbourne, Australia. The objective of this study was to compare the new model of care with standard maternity care. Methods: In a randomized controlled trial, 1000 women who booked at the antenatal clinic and met the eligibility criteria were randomly allocated to receive continuity of midwifery care (team care) from a group of seven midwives in collaboration with obstetric staff, or care from a variety of midwives and obstetric staff (standard care). The primary outcome measures were procedures in labor, maternal outcomes, neonatal outcomes, and length of hospital stay. Results: Women assigned to the team care group experienced less augmentation of labor, less electronic fetal monitoring, less use of narcotic and epidural analgesia, and fewer episiotomies but more unsutured tears. Team care women stayed in hospital 7 hours less than women in standard care. More babies of standard care mothers were admitted to the special care nurseries for more than 5 days because of preterm birth, and more babies of team care mothers were admitted to the nurseries for more than 5 days with intrauterine growth retardation. No differences occurred in perinatal mortality between the two groups. Conclusions: Continuity of midwifery care was associated with a reduction in medical procedures in labor and a shorter length of stay without compromising maternal and perinatal safety. Continuity of midwifery care is realistically achievable in a tertiary obstetric referral service.     

Maternal Attitudes to Amniotomy and Labor Duration: A Survey in Early Pregnancy

Background: Although maternal choice increasingly influences intrapartum care, little is known about maternal attitudes about many outcomes and interventions, particularly the length of labor. Early amniotomy decreases the length of labor and particularly the frequency of prolonged (> 12 hr) labor but is often avoided by health professionals. The objective of this survey was to assess the attitudes of women in a major Dublin teaching hospital about the length of labor, amniotomy, and epidural analgesia. Methods: An anonymous, structured, self-completed questionnaire was given to 438 women at their booking visit to the hospital antenatal clinic in February 1998. Participants could ring “agree,”“disagree,”“don't know,” or “don't care” to seven different statements. Results: The questionnaire was returned by 398 (92%) women; demographic details were similar to those for the overall hospital population. Of these, 73.5 percent of women wanted a quick labor; 82 percent wanted it to last less than 12 hours. Nearly one-half specifically wanted epidural analgesia. Only 13 percent wished to avoid amniotomy; significantly more multiparas disagreed with “avoiding amniotomy.” Conclusions: Many women want a quick and painless labor, and do not object to the interventions that help achieve this.