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Volume 4, Issue 5 Compiled and Edited by Amy Romano, MSN, CNM
Systematic
Review Finds Cesarean Section Does Not Prevent Severe Urinary Incontinence Warm
Perineal Compresses During Second Stage Associated
with Less Pain and Fewer Severe Tears
Listening to Mothers II Survey
Report Revised for 2007: The Six Care
Practices that Support Normal Birth Sign up for a Seminar or Workshop Support Normal Birth! Become a Member of Lamaze
International Unsubscribe from Research Summaries for Normal Birth Copyright 2007, Lamaze International, Inc.
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A comprehensive edition of each issue of Research Summaries for Normal Birth, including fuller discussions of research methods and results, will now appear in The Journal of Perinatal Education. Updated Cochrane Review Finds Artificially Rupturing Membranes Fails to Speed Labor Progress, May Be HarmfulSummary: In this Cochrane systematic review, researchers evaluated the effects of amniotomy (artificial rupture of the membranes) on labor progress and other outcomes in spontaneous labors. Fourteen trials involving 4893 women were included. No statistically significant differences were found in length of the first stage of labor in nulliparous women (those giving birth for the first time) or multiparous women (those having given birth previously). When the reviewers pooled the data from multiple trials, analysis revealed a statistically significant six minute difference in the mean length of second stage of labor in nulliparous women favoring amniotomy, a finding that has no clinical significance. No difference was found in second stage duration among multiparous women. Women in the amniotomy group were less likely to be diagnosed with dysfunctional labor, but not less likely to have a cesarean section. In fact, women who had amniotomies were 26% more likely to deliver by cesarean surgery, although this finding fell just short of achieving statistical significance. No differences were found in the need for artificial oxytocin to speed up labor, the need for pharmacological pain relief, or other maternal or neonatal outcomes. However, even after pooling data from multiple trials, the studies were not large enough to detect differences in rare adverse outcomes such as umbilical cord prolapse, severe morbidity, or mortality The reviewers commented on several methodological weaknesses of the body of scientific literature on amniotomy, including a high degree of crossover between treatment groups. In eight of the nine trials that reported on crossover, more than 30% of women randomly assigned to the "conserve membranes" group ultimately had amniotomies. This problem is common in obstetric research and acts to decrease differences between groups. Had there been less crossover, it is possible that a statistically significant difference in labor length favoring amniotomy would have been seen. It is likely, though, that the excess rate of cesarean surgeries in the amniotomy group would also have reached significance. The reviewers also noted that the available literature offers too little data to determine if the timing of membrane rupture or other contextual or clinical factors moderate the effect of amniotomy on labor progress. Based on research to date, the reviewers recommend against routine amniotomy and advise that women be told what the evidence reveals. Significance for The failure to find a significant difference in labor duration with amniotomy may be an artifact of methodological weaknesses in the included trials. Still, shorter labor only benefits mothers and babies if it prevents poor outcomes or reduces the need for cesarean surgery or other potentially harmful or uncomfortable interventions, and routine amniotomy provides none of these clinically important advantages. On the contrary, the findings of the systematic review raise the strong possibility that amniotomy increases the use of cesarean surgery. The Cochrane reviewers recommend further research to explore the relationship between amniotomy and clinically meaningful outcomes, as well as women’s satisfaction. In the meantime, women must be made aware that amniotomy offers no important benefits and may do harm. References Declercq, E., Sakala,
C., Corry, M. P., & Applebaum, S. (2006).
Listening to mothers II: Report of the second national U.S. Survey of women's
childbearing experiences. Continuous Labor Support from a Trained Family Member Shows Profound Effect on Attachment and Early Parenting in Underserved MothersSummary: In this
trial, researchers compared the outcomes of women whose labor support
companions had undergone a brief doula
training with similar women who labored with companions who had not undergone
any special training. Those assigned to the doula
care group identified one female friend or relative to provide continuous
labor support and, together with her chosen companion, attended a 4-hour
training course taught by a DONA-certified doula.
Topics included an overview of childbirth, how to assess labor progress,
coping strategies and comfort measures for labor, and supportive techniques
such as praise, reassurance, and anticipatory guidance. All participants in
both groups were low-risk, low-income women giving birth for the first time
at a tertiary-care hospital in This study was a follow-up to an earlier trial. That trial found beneficial effects of the doula training on obstetric outcomes and was summarized in a previous issue of Research Summaries for Normal Birth. In this secondary analysis, researchers conducted telephone interviews with the participants six to eight weeks after birth to evaluate the effect of doula training and subsequent labor support on maternal perceptions of the infant, self, and support from others. Of the 598 women recruited for the original trial, 494 completed the postpartum interviews. Compared with women who were accompanied by companions who had not undergone doula training, women allocated to the doula group were more likely to describe labor as "very easy," to report that labor was "much better" than they imagined, that they coped with labor "very easily," and that their birth experiences were "very good." They were also more likely to describe their babies as "very easy" and to believe that their babies cried less often than other babies. They were more likely to pick up their babies when they cried and to report that they were able to sense their babies' needs "very well." Regarding their own postpartum experience, they were more likely to say that the transition to motherhood had been "very easy" and to report that they had received support from others in the previous week. Women assigned to the doula group also scored more favorably on measures of self-worth including sense of self as a woman, sense of their bodies' physical strength, and ability to be a good mother. Finally, women in the doula care group were more likely to be satisfied with the medical center where they gave birth. Significance for This study's results suggest that beneficial effects may have arisen, at least in part, from the training itself, a finding that is relevant to childbirth educators. The training exposed both women and their chosen female companions to messages about the normalcy and transformative significance of labor and birth and provided them an opportunity to practice comfort measures and other skills. Childbirth educators may consider offering classes that expectant women can take with a female relative or friend, with the intention for the female companion to provide continuous support in labor. Summary: In this systematic review, researchers explored the relationship between mode of birth and postpartum urinary incontinence (UI). Reviewers identified all published studies that reported the frequency of postpartum UI symptoms by mode of birth and included those that provided follow-up for at least three months postpartum. Data were pooled for meta-analysis and the researchers calculated the number of cesarean surgeries that would need to be performed to prevent one case of UI ("number needed to prevent"). Each analysis was performed twice: first with data from cohort studies (studies that begin with the birth and follow participants forward in time to see who develops UI) and again with data from cross-sectional studies (studies that begin with women who have UI and evaluate what risk factors they have in common such as birth route). Separate analyses were performed for each type of incontinence (stress, urge, mixed, or unspecified) as well as for the occurrence of severe symptoms, defined as symptoms that occurred without strenuous activity or that required wearing a pad. Last, the reviewers separately analyzed whether parity (prior births or not) or timing of cesarean section (before or during labor) modified the effect of mode of birth on incontinence. The findings revealed that 10-15 cesarean surgeries would need to be performed to prevent one case of any degree of stress UI. However, 110 cesareans would have to be performed to prevent a single case of severe stress UI, and cesarean section offered no protection against severe stress UI persisting beyond a year. Regarding urge incontinence, cesarean delivery again offered some protection against experiencing any symptoms, but had no effect on severe symptoms or symptoms lasting beyond one year. Interestingly, the investigators did not find a consistent protective effect of elective cesarean surgery. In fact, although data were limited, in general there was a weak or no association with incontinence when elective cesarean sections were compared with births occurring vaginally or by cesarean section in labor. Pooled analysis of three studies reported that eight medically elective cesarean surgeries were needed to prevent one case of stress UI of any degree. The authors noted that the results of their review remained essentially unchanged even after excluding instrumental deliveries from the vaginal birth groups. However, they also cautioned that the included studies provided little information about their management of vaginal birth, so it is impossible to know for certain if modifiable labor management practices such as episiotomy, direct pushing, or epidural use contributed to postpartum incontinence in the study participants. They conclude that "the urinary incontinence benefits after cesarean section that we report are relatively small, and these differences are likely subject to considerable narrowing through attention to improving the management of vaginal birth" (p. 235). Significance for Although this review provides the best evidence to date about the association between mode of birth and UI, not one study compares physiologically managed vaginal birth with cesarean surgery. Previous research has demonstrated that common or routine conventional management practices are associated with more pelvic floor problems in the weeks and months after birth. These include episiotomy, directed pushing, instrumental vaginal delivery, and birth in the lithotomy or other supine positions. Continuous electronic fetal monitoring and epidural analgesia also increase risk because they increased the likelihood of instrumental vaginal delivery and episiotomy. Concern for the pelvic floor should begin, therefore, with promoting care practices that support normal birth, not cesarean surgery. Summary: In this randomized controlled trial, Australian researchers evaluated the effects of a warm perineal compress during second stage on the perineal outcomes of nulliparous women. Seven hundred seventeen women planning to give birth vaginally at two hospitals were randomly allocated to have warm compresses (360) or the control group (357). In the warm compress group, the attending midwife saturated a sterile perineal pad with tap water heated to 38º to 44ºC (100º to 111ºF) and held the pad against the woman's perineum continuously from when it began to be distended by the baby's head until birth. The compresses were reheated as needed throughout second stage. No information was provided about the perineal management in the control group except that warm compresses were not used. All births were attended by midwives, non-supine positions were common in both groups, epidural use was infrequent, and the standard practice was to let the epidural wear off in second stage. Researchers evaluated the frequency of lacerations requiring sutures, depth of laceration, and the women's reports of pain during the birth and at 1 and 2 days postpartum. Researchers also followed up at one and three months to assess the frequency of ongoing problems such as incontinence, persistent pain, and sexual problems as well as breastfeeding status. For the primary trial outcome—need for sutures—an independent midwife who was blind to the assignment of the study participant determined whether suturing was necessary and the researchers made statistical adjustments to control for duration of second stage, analgesia, position for birth, mode of birth, and infant birth weight. Use of a warm pack failed to decrease the likelihood of a laceration requiring sutures, which occurred in about 80% of women in both groups. However, women in the standard care were more than twice as likely to have a third or fourth degree (anal sphincter) tear (8.7% versus 4.2%) and also were much more likely to report that pain while giving birth was either "bad pain" (31% versus 25%) or "the worst pain in my life" (51% versus 34%). Women in the warm compress group also reported significantly less perineal pain on day 1 and 2 postpartum. In addition, the warm compress group was less likely to report urinary incontinence at three months postpartum (9.7% versus 22.4%). There were no other differences in outcomes at one or three months postpartum. Significance for This trial provides evidence that a warm compress in labor may decreases the likelihood of anal sphincter tears and significantly reduce pain both at the time of birth and in the postpartum period. However, rates of sutured trauma and severe trauma were high in both arms of this trial, even considering that the analysis was limited to nulliparous women and included many women of Asian origin, both of which increase the likelihood of trauma. The researchers did provide data on the use of episiotomy and instrumental vaginal delivery, which are both modifiable factors that increase genital tract trauma and associated long-term sequellae. In both cases, the rates were considerably lower than those reported in Listening to Mothers II (Declercq, Sakala, Corry, & Applebaum, 2006). However, it is possible that other aspects of second stage management or other factors that researchers did not measure may have contributed to excess genital tract trauma. An earlier study revealed that uncoached pushing and birthing the baby's head between, rather than with, contractions reduces the need for and severity of sutured trauma (Albers, Sedler, Bedrick, Teaf, & Peralta, 2006). Taken together, these studies suggest that physiologic management of second stage with nonpharmacologic pain management during crowning of the fetal head are acceptable to women and optimize perineal outcomes. References Albers, L. A., Sedler, K. D., Bedrick, E. J., Teaf, D., & Peralta, P. (2006). Factors related to genital tract trauma in normal spontaneous vaginal births. Birth, 33(2), 94 - 100. Declercq, E., Sakala,
C., Corry, M. P., & Applebaum, S. (2006).
Listening to mothers II: Report of the second national U.S. Survey of women's
childbearing experiences. |
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