Self‐Rated “No‐” and “Low‐” Risk Pregnancy: A Comparison of Outcomes for Women in Obstetric‐Led and Midwife‐Led Units in England

ABSTRACT: Background: Debate in the United Kingdom about place of birth often concerns obstetric‐led units and midwife‐led units and relates to notions of risk and safety. Outcomes for these two types of unit are often not comparable because of the restricted selection criteria for midwife‐led units. The purpose of this study was to compare outcomes for women intending to give birth in these different types of unit and whose self‐rated pregnancy risk level was “none” or “low.” Methods: Self‐completion questionnaires were distributed to mothers 8 days after the birth in 9 units (6 midwife led 3 obstetric led) over a 6‐month period. Results: Completed questionnaires were received from 432 women (midwife led = 294, obstetric led = 138). Mothers in midwife‐led units spent shorter times in labor in the unit (p < 0.01), received less analgesia (p < 0.01) and had fewer interventions (p < 0.01), and were more likely to have a normal delivery (p < 0.01) than women in obstetric‐led units. Similar differences were found for both primiparous and multiparous women. In terms of the number of midwives attending each woman, analysis of covariance suggested different models of care depending on type of unit (p < 0.05) and parity (p < 0.01). Conclusions: Since these mothers’ self‐rated risk level was none or low, some comparability of outcomes is permissible. It appears that models of care are significantly different in obstetric‐led units compared with midwife‐led units, leading to greater likelihood of intrapartum intervention, need for analgesia, and assisted or operative delivery. A randomized controlled trial examining such units would permit a conclusive examination of these outcomes. (BIRTH 34:4 December 2007)     

Factors Associated With Non‐Normal Birth Outcomes for Low‐Risk Women in an Inner‐City Hospital

Introduction: The purpose of this study was to examine factors associated with normal versus non‐normal birth outcomes for low‐risk women who were admitted for care in spontaneous labor. Methods: The birth records of 93 women were reviewed. Results: At the completion of the fourth stage of labor, 61% of births (n = 57) met the criteria for normal, while 39% of births (n = 36) had non‐normal outcomes. On bivariate analysis, variables associated with non‐normal outcomes included nulliparity (odds ratio [OR], 9.10; 95% confidence interval [CI], 3–28; P <.0001), lower average centimeters of dilation at admission (t‐score 4.422; P <.001), use of pharmacologic pain relief, including narcotics and epidural anesthesia (OR, 5.03; 95% CI, 2–16; P = .005), and birth attended by a physician versus a certified nurse‐midwife (OR, 3.60; 95% CI, 2–9; P = .004). In a multivariate analysis, nulliparity (OR, 6.07; 95% CI, 2–19; P = .002) and lower average centimeters of dilation at admission (OR, 0.63; 95% CI, 0.5–0.9; P = .005) were independently associated with non‐normal outcome. Discussion: The development of clinical guidelines aimed at reducing admissions of women in early labor may reduce non‐normal outcomes, particularly for nulliparous women.     

Trends in Midwife‐Attended Births in the United States, 1989‐2009

Introduction: Data on attendance at birth by midwives in the United States have been available on the national level since 1989. Rates of certified nurse‐midwife (CNM)–attended births more than doubled between 1989 (3.3% of all births) and 2002 (7.7%) and have remained steady since. This article examines trends in midwife‐attended births from 1989 to 2009. Methods: The data in this report are based on records gathered as part of the US National Standard Certificate of Live Birth from a public use Web site, Vital Stats ( http://www.cdc.gov/nchs/VitalStats.htm ), that allows users to create and download specialized tables. Results: Between 2007 and 2009, the proportion of all births attended by CNMs increased by 4% from 7.3% of all births to 7.6% and a total of 313,516. This represents a decline in total births attended by CNMs from 2008 but a higher proportion of all births because total US births dropped at a faster rate. The proportion of vaginal births attended by CNMs reached an all‐time high of 11.4% in 2009. There were strong regional patterns to the distribution of CNM‐attended births. Births attended by “other midwives” rose to 21,787 or 0.5% of all US births, and the total proportion of all births attended by midwives reached an all‐time high of 8.1%. The race/ethnicity of mothers attended by CNMs has shifted over the years. In 1990, CNMs attended a disproportionately high number of births to non‐white mothers, whereas in 2009, the profile of CNM births mirrors the national distribution in race/ethnicity. Discussion: Midwife‐attended births in the United States are increasing. The geographic patterns in the distribution of midwife‐attended births warrant further study.     

Role of pituitary adenylate cyclase‐activating polypeptide in modulating hypothalamic‐pituitary system

Background

Pituitary adenylate cyclase‐activating polypeptide (PACAP) is a multifunctional peptide that is isolated and identified from the ovine hypothalamus, whose effects and mechanisms have been elucidated in numerous studies. The PACAP and its receptor are widely expressed, not only in the hypothalamus but also in peripheral organs.

Methods

The studies on the role of PACAP in the hypothalamic‐pituitary system, including those by the authors, were summarized.

Results

In the pituitary gonadotrophs, PACAP increases the gonadotrophin α‐, luteinizing hormoneβ‐, and follicle‐stimulating hormone β‐subunit expression and the expression of gonadotropin‐releasing hormone (GnRH) receptor and its own receptor, PAC1R. Moreover, a low‐frequency GnRH pulse increases the expression of PACAP and PAC1R more than a high‐frequency GnRH pulse in the gonadotrophs. The PACAP stimulates prolactin synthesis and secretion and increases PAC1R in the lactotrophs. In the hypothalamus, PACAP increases the expression of the GnRH receptors, although it is unable to increase the expression of GnRH in the GnRH‐producing neurons.

Conclusion

The PACAP not only acts directly in each hormone‐producing cell, it possibly might regulate hormone synthesis via the expression of its own receptors or those of other hormones.     

Newborn Temperature During Skin‐to‐Skin Breastfeeding in Couples Having Breastfeeding Difficulties

Abstract: Background: Kangaroo (skin‐to‐skin contact) care facilitates the maintenance of safe temperatures in newborn infants. Concern persists that infants will become cold while breastfeeding, however, especially if in skin‐to‐skin contact with the mother. This concern might be especially realistic for infants experiencing breastfeeding difficulties. The objective was to measure temperature during a study of mothers and infants who were having breastfeeding difficulties during early postpartum and were given opportunities to experience skin‐to‐skin contact during breastfeeding. Method: Forty‐eight full‐term infants were investigated using a pretest‐test‐posttest study design. Temporal artery temperature was measured before, after, and once during 3 consecutive skin‐to‐skin breastfeeding interventions and 1 intervention 24 hours after the first intervention. Results: During skin‐to‐skin contact, most infants reached and maintained temperatures between 36.5 and 37.6 °C, the thermoneutral range, with only rare exceptions. Conclusions: The temperatures of study infants reached and remained at the thermoneutral range during breastfeeding in skin‐to‐skin contact. The data suggest that mothers may have the ability to modulate their infant's temperature during skin‐to‐skin contact if given the opportunity. Hospital staff and parents can be reassured that, with respect to their temperature, healthy newborn infants, with or without breastfeeding difficulties, may safely breastfeed in skin‐to‐skin contact with their mothers. (BIRTH 32:2 June 2005)     

Randomized Controlled Trial of Hands‐and‐Knees Positioning for Occipitoposterior Position in Labor

ABSTRACT: Background: Hands‐and‐knees positioning during labor has been recommended on the theory that gravity and buoyancy may promote fetal head rotation to the anterior position and reduce persistent back pain. A Cochrane review found insufficient evidence to support the effectiveness of this intervention during labor. The purpose of this study was to evaluate the effect of maternal hands‐and‐knees positioning on fetal head rotation from occipitoposterior to occipitoanterior position, persistent back pain, and other perinatal outcomes. Methods: Thirteen labor units in university‐affiliated hospitals participated in this multicenter randomized, controlled trial. Study participants were 147 women laboring with a fetus at ≥37 weeks’ gestation and confirmed by ultrasound to be in occipitoposterior position. Seventy women were randomized to the intervention group (hands‐and‐knees positioning for at least 30 minutes over a 1‐hour period during labor) and 77 to the control group (no hands‐and‐knees positioning). The primary outcome was occipitoanterior position determined by ultrasound following the 1‐hour study period and the secondary outcome was persistent back pain. Other outcomes included operative delivery, fetal head position at delivery, perineal trauma, Apgar scores, length of labor, and women's views with respect to positioning. Results: Women randomized to the intervention group had significant reductions in persistent back pain. Eleven women (16%) allocated to use hands‐and‐knees positioning had fetal heads in occipitoanterior position following the 1‐hour study period compared with 5 (7%) in the control group (relative risk 2.4; 95% CI 0.88–6.62; number needed to treat 11). Trends toward benefit for the intervention group were seen for several other outcomes, including operative delivery, fetal head position at delivery, 1‐minute Apgar scores, and time to delivery. Conclusions: Maternal hands‐and‐knees positioning during labor with a fetus in occipitoposterior position reduces persistent back pain and is acceptable to laboring women. Given this evidence, hands‐and‐knees positioning should be offered to women laboring with a fetus in occipitoposterior position in the first stage of labor to reduce persistent back pain. Although this study demonstrates trends toward improved birth outcomes, further trials are needed to determine if hands‐and‐knees positioning promotes fetal head rotation to occipitoanterior and reduces operative delivery. (BIRTH 32:4 December 2005)