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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.
Study Evaluates Effects of Midwifery Care Practices
on Lacerations of the Genital Tract at Birth
Albers, L. L., Sedler, K. D., Bedrick, E. J., Teaf, D., Peralta, P.
(2005). Midwifery care measures in the second stage of labor and reduction
of genital tract trauma at birth: a randomized trial. Journal of
Midwifery and Women’s Health, 50(5), 365-372 . [Abstract] Summary: This randomized controlled trial
compared the effectiveness of two techniques commonly used by midwives to
prevent lacerations of the genital tract at birth. The study took place in
a large teaching hospital where the episiotomy rate among both physicians
and nurse-midwives is below 1% and where the midwives’ management of the
second stage of labor routinely involves constant presence, verbal
encouragement, and an emphasis on a slow, controlled birth of the baby’s
head.
Over 1200 clients of a large nurse-midwifery service
were randomized into three study groups. In one group, the midwife applied
warm compresses to the perineum and external genitalia continuously during
pushing and fetal descent. In a second group, the midwife performed
perineal massage with a water-based lubricant during and between pushes.
In the third group (the control group) the midwife did not touch the
woman’s external genitalia at all until the baby’s head crowned.
Demographic and clinical variables were similar, and 98% of those enrolled
in the study upon hospital admission had spontaneous vaginal
births.
Twenty-three percent of all participants had no genital
tract trauma, defined as no tissue separation whatsoever. Only 10 women
(0.8%) had episiotomies, most often for severe fetal heart rate
abnormalities. Only 14 women (1%) experienced anal sphincter trauma (a
third- or fourth- degree tear), and 2 women (0.2%) experienced a cervical
tear. A remarkably high 73% had no trauma or minor trauma not
needing suturing.
No differences were found among the study groups
in the likelihood or severity of genital tract trauma. Nulliparous women
and those giving birth to infants weighing ≥4000g (about 9lbs.) were much
more likely to tear. Two care practices resulted in significantly fewer
tears: birth in a sitting position and birth of the baby’s head between
(rather than with) contractions.
Significance for Normal Birth: This study
compared warm compresses and perineal massage with no measures during
second stage to prevent spontaneous lacerations during vaginal birth.
Although neither intervention reduced the likelihood or severity of
lacerations, this study still provides important evidence and suggests
that the care practices that support normal birth may also minimize
tearing. Almost one in four women who participated in this study
experienced no genital tract trauma at all, and nearly half of the
participants had trauma that was minor enough not to require
suturing. These figures are exceptional when compared with data from
studies conducted in settings where medical management is the
norm.
An important finding in this well-designed study was
that the upright sitting position and birthing the baby's head between
contractions appeared to minimize tearing. The continuous support of a
patient midwife, emphasis on the gentle and controlled birth of the baby's
head, and the conservative use of episiotomy no doubt contributed to the
excellent outcomes. Increasing access to midwifery care and encouraging
non-supine positions (especially sitting) at the time of birth decreases
women's risk for genital tract trauma.
Labor Induction Contributes to
Increased Medical Costs
Allen, V. M., O’Connell, C. M., Farrell, S. A., Baskett, T. F.
(2005) Economic implications of method of delivery. American Journal
of Obstetrics and Gynecology, 193, 192-197. [Abstract] Summary: In this study, researchers
assessed how type of labor (induced or spontaneous) and mode of birth
influence the costs of maternity care in low-risk nulliparous childbearing
women. Data were collected from a birth register that included
information for all births occurring in the Canadian province of Nova
Scotia. The study focused on the low-risk nulliparous women who gave
birth at a tertiary level maternity facility in Halifax County from
1985-2002. Costs that were assessed included staff wages, anesthesia and
labor induction agents, and supplies such as delivery packs, catheters,
and syringes. Costs associated with maternal readmission to the
hospital and for intensive care for the mother or infant were also
captured. Importantly, the fee for obstetrical care paid to the
physicians in this setting is identical regardless of mode of birth.
Also, midwifery care is not available to childbearing women in Nova
Scotia.
Of the 27,613 births included in the analysis, 5233
resulted from induced labors. Women with induced labors were twice
as likely (27.3% vs. 13.0%) to undergo cesarean section as the group of
women who began labor spontaneously. Additionally, their infants
were significantly more likely to require admission to the NICU compared
both with women beginning labor spontaneously and with women undergoing
cesarean section prior to labor. As a result of these and other
factors, the average costs associated with induction of labor ($1715) were
significantly higher than those associated with both spontaneous onset of
labor ($1474) and cesarean birth without labor ($1532).
When the
researchers looked at the average costs of different modes of birth
independent of type of labor, spontaneous vaginal birth ($1340) was
significantly less costly than assisted vaginal birth ($1594), cesarean
without labor ($1532), and cesarean in labor ($2137). These figures are
sure to be higher in the United States where care is more expensive and
where there tend to be financial incentives for physicians to perform
operative births.
Significance for Normal Birth: The liberal
use of maternity care practices when the evidence shows they are harmful
puts women and infants at risk and wastes our increasingly scarce health
care resources. Despite the known risks and higher costs, almost one in
five inductions in the United States are done for the convenience of
maternity care providers and/or their clients (Declercq et al. 2002). We all pay for these elective
inductions through higher insurance premiums, shrinking employee benefits
packages, and higher taxes to support the ever-growing number of uninsured
people.
Further research is needed to compare the overall
costs of medicalized birth with those of normal birth. In the meantime,
this study provides important economic data to bolster the already strong
case against unnecessary induction of labor.
Women Report High Satisfaction with Decision to Attempt
VBAC Regardless of Mode of Birth
Cleary-Goldman, J.,
Cornelisse, K., Simpson, L. L., Robinson, J. N. (2005). Previous cesarean
delivery: understanding and satisfaction with mode of delivery in a
subsequent pregnancy in patients participating in a formal vaginal birth
after cesarean counseling program. American Journal of Perinatology,
22(4), 217-221. [Abstract] Summary: This prospective study evaluated
patient satisfaction with the subsequent birth experience in women who
previously gave birth by cesarean section. The researchers also studied
the effect of participation in a formal, one-on-one counseling program on
women’s understanding of the risks and benefits of a trial of labor.
The study took place in a large tertiary care hospital where a
formal, funded VBAC counseling program was available to all women eligible
for a trial of labor after previous cesarean section.
The 95
participating women completed prenatal questionnaires about their previous
cesarean births and attended one-on-one VBAC counseling sessions. A second
survey, completed immediately postpartum, evaluated the women’s recent
birth experiences and included seven multiple-choice questions assessing
knowledge about the benefits and risks of VBAC. Additional medical and
demographic data were obtained by detailed chart
review.
Twenty-seven percent of the study participants planned
VBACs and gave birth vaginally while 19% planned VBAC but underwent repeat
cesareans in labor. An additional 17% planned VBAC but underwent
repeat cesarean sections before labor because their obstetricians no
longer deemed them medically eligible for trials of labor.
Thirty-seven percent of the study participants chose elective repeat
cesarean delivery.
All four groups reported greater patient
satisfaction with the current birth than with the primary cesarean
section, with the largest improvement observed in women having planned
vaginal births. All of these women rated their postpartum recovery as
better than that following their primary cesarean sections and stated that
they would undergo a trial of labor again. Of the women who
underwent repeat cesarean section during labor, 92% were pleased that they
had attempted VBAC, with a median score for satisfaction with their
decision of 4 on a 5-point scale. Ninety-two percent of all
participants scored perfectly on the postpartum test of VBAC risks and
benefits
Significance for Normal Birth: Restrictive
hospital policies and physician practices have sharply reduced access to
VBAC in recent years, but even where eligible women have access to this
option, many choose elective repeat cesarean section. Some women may
make this choice to avoid feelings of disappointment should a VBAC labor
end in another cesarean. The results of this study suggest that fear
of an unplanned repeat cesarean need not be a barrier to choosing VBAC. A
high proportion (92%) of women who planned VBAC but underwent a cesarean
in labor were still satisfied with their decision to attempt
VBAC.
Women having planned VBACs gave the highest satisfaction
ratings to their birth experience. However, physicians referred only
30% of VBAC-eligible women to the counseling program, and these were
disproportionately Hispanic women and clinic patients. The VBAC rate
was a disappointingly low 59%, although VBAC rates over 70% are commonly
reported. It is likely that a more supportive environment for VBAC
would have resulted in substantially greater numbers of women both
planning and having VBACs.
Labor Support from a Student Nurse Doula May Result in
Lower Use of Epidural Analgesia
Van Zandt, S. E., Edwards, L., Jordan, E. T. (2005). Lower epidural
anesthesia use associated with labor support by student nurse doulas:
implications for intrapartal nursing practice. Complementary Therapies
in Clinical Practice, 11, 153-160. [Abstract] Summary: In this retrospective pilot study,
researchers evaluated the effect on epidural use of labor support
interventions performed by student nurses trained as doulas. Training was
provided in an elective, baccalaureate-level course that focused on
physical, emotional and informational labor support rather than labor and
birth nursing care. As part of their training, students were paired
with childbearing women who desired doula support and agreed to have a
student nurse-doula present at their birth.
The study
examined the experiences of the 89 women who had vaginal births
accompanied by student nurse doulas during the study period
(1999-2002). The doulas collected demographic, medical and
obstetrical data on standardized birth record forms and noted which
labor-support interventions they performed. Interventions that are
commonly provided by nurses such as providing a beverage, positioning the
woman or making eye contact were considered “standard” while interventions
not usually performed by labor and birth nurses in the study settings,
such as continuous presence, massage, counter pressure, and use of a birth
ball, were considered “complementary”. The total number of
interventions in each category provided a cumulative score that reflected
the variety of labor support techniques used by the doula.
Epidural
analgesia was used in 67.4% of births. In a statistical model that
adjusted for parity (number of previous births) and other confounding
variables, length of labor and number of complementary doula interventions
were significantly associated with epidural use. Women with longer
labors were 23% more likely to have an epidural than those with shorter
labors. Women who had more than 5 complementary interventions were
38% less likely to use an epidural than those who received 5 or fewer.
Significance for Normal Birth: While
one-on-one nursing care in active labor has not been found to decrease
epidural use, the continuous support of a doula, who provides
informational, emotional and physical support throughout labor and birth,
has been shown to be beneficial in several randomized controlled trials.
This disparity has been blamed on the increasingly
technology-intensive environment in which maternity nurses provide care.
In this environment, supportive measures such as massage and encouraging
ambulation are eclipsed by continuous electronic fetal monitoring,
medication administration and management of intravenous lines. In this
intriguing pilot study, student nurses were given special training to
provide complementary interventions intended to support normal birth and
enhance the comfort and confidence of the laboring woman. They attended
births in the doula role and were not expected to perform nursing tasks or
interventions.
In this study, a higher number of
complementary interventions provided by the doulas was associated with a
lower rate of epidural use. Further research is warranted to determine the
nature of the association. It is possible that the student nurses, when
given the skills and the freedom to provide such supportive care to
laboring women, successfully induced a “doula effect.” Whether this
effect will persist after the students enter the work force as maternity
nurses remains to be studied.
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