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)     

Evidence‐Based Guidance for Self‐Administration of Injectable Contraception

The requirement of in‐person visits every 3 months for a health care provider to administer intramuscular depot medroxyprogesterone acetate (DMPA‐IM) is a significant barrier to its use, particularly in the wake of the coronavirus pandemic. Time and travel costs as well as scheduling conflicts also negatively impact the receipt of subsequent contraceptive injections, which can result in unintended pregnancies. Subcutaneous depot medroxyprogesterone acetate (DMPA‐SC) can be self‐administered by individuals at home, expanding contraceptive access, convenience, and reproductive autonomy. With 30% less progestin, DMPA‐SC improves upon the DMPA‐IM formulation while retaining efficacy. As part of comprehensive contraceptive counseling, health care providers should consider offering DMPA‐SC to eligible individuals interested in self‐administration. Using a case study approach, evidence‐based recommendations are reviewed for the off‐label use of self‐administered DMPA‐SC in the United States.     

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.     

Establishment of a trans‐vaginal ultrasound‐guided pinpoint transfer method

Purpose

Through the use of the trans‐vaginal ultrasound‐guided pinpoint transfer method, the aim was to ensure the safety of the embryo being transferred in cases of difficult cervixes. It also was aimed to be able to stop embryo transfers in difficult cases and to be able to restart the process under anesthesia or cryopreservation.

Methods

A new type of transfer catheter was developed. With this method, after reaching the internal os, the embryologist begins the loading of the embryo into the inner catheter. Then, the embryo transfer begins. Under the guidance of the trans‐vaginal ultrasonography, the optimal position for implantation is selected.

Results

Out of 666 cases, 14 were difficult cervixes. This transfer method enabled 221 of the 666 patients to become pregnant successfully, which was a success rate of 33.2%.

Conclusion

From start to finish, this method takes only 2 min. It is simple, fast, and reliable, with a high satisfaction rate amongst patients.     

Pregnancy‐Associated Stroke

Cerebrovascular accident, or stroke, is the fourth leading cause of death for all women and the eighth leading cause of pregnancy‐associated death. The physiologic changes of pregnancy increase the risk of cerebrovascular accident for women. With current incidence rates, a facility with 3300 births per year can anticipate caring for one woman with a pregnancy‐related stroke at least every 2 years. All maternity care providers must be able to assess women experiencing stroke‐like symptoms and initiate timely care to mitigate brain tissue damage, decrease long‐term morbidity, and prevent mortality. The 2 main types of stroke, ischemic and hemorrhagic, have similar presenting symptoms but very different pathophysiology and treatment. This article reviews assessment and initial treatment of pregnant and postpartum women experiencing stroke and provides guidance for subsequent maternity and primary care to assist front‐line perinatal care providers who may be the first to treat affected women or may resume primary care after diagnosis.