Grounded in Community: Development of a Birth Justice-Focused Volunteer Birth Companion Program.

Continuous labor support is an evidence-based practice demonstrated to improve birth outcomes, particularly when provided by a trained doula or birth companion. Access to doula services designed to meet the needs of historically underserved and diverse communities can mitigate the negative effects of structural racism and health disparities in perinatal care. Unfortunately, continuous labor support by a companion of choice is not universally supported. This leaves individuals with limited resources unable to access services from a trained doula. Volunteer birth companion programs are one model for increasing access to continuous labor support by bringing the community into the hospital. This article describes a birth justice-focused volunteer birth companion program that evolved out of a multistakeholder collaboration between community birth workers, local reproductive justice organizations, and hospital-based providers, staff, and administrators in direct response to community needs. This program is unique in its collaborative development, grounding in core values, and design of a reproductive justice-focused curriculum that includes training in diversity, inclusion, and care for clients with a history of trauma or perinatal substance use. Key takeaways include recommendations to center client needs, consider sustainability, and embrace flexibility and change. Discussion includes recognition of the strengths and limitations of a volunteer-based model, including acknowledgment that volunteer birth work, while filling an important gap, necessitates the privilege of having sufficient time, economic freedom, and social support. Ensuring universal insurance coverage for doula services has the potential to increase access to continuous labor support, improve birth outcomes, and diversify the birth workforce.

Bibliometric Network Analysis on Rapid-Onset Opioids for Breakthrough Cancer Pain Treatment.

BACKGROUND AND OBJECTIVES: Proper breakthrough cancer pain (BTcP) management is of pivotal importance. Although rapid-acting, oral and nasal transmucosal, fentanyl formulations (rapid-onset opioids, ROOs) are licensed for BTcP treatment, not all guidelines recommend their use. Presumably, some research gaps need to be bridged to produce solid evidence. We present a bibliometric network analysis on ROOs for BTcP treatment. METHODS: Documents were retrieved from the Web of Science (WOS) online database. The string was "rapid onset opioids" or "transmucosal fentanyl" and "breakthrough cancer pain". Year of publication, journal metrics (impact factor and quartile), title, document type, topic, and clinical setting (in-patients, outpatients, and palliative care) were extracted. The software tool VOSviewer (version 1.6.17) was used to analyze the semantic network analyzes, bibliographic coupling, journals analysis, and research networks. RESULTS: 502 articles were found in WOS. A declining trend in published articles from 2014 to 2021 was observed. Approximately 50% of documents regard top quartile (Q1) journals. Most articles focused on ROOs efficacy, but abuse and misuse issues are poorly addressed. With respect to article type, we calculated 132 clinical investigations. The semantic network analysis found interconnections between the terms "breakthrough cancer pain," "opioids," and "cancers." The top co-cited article was published in 2000 and addressed pain assessment. The largest number of partnerships regarded the United States, Italy, and England. CONCLUSION: In this research area, most articles are published in top-ranked journals. Nevertheless, paramount topics should be better addressed, and the implementation of research networks is needed.

Role development in midwifery education: A place for simulation.

OBJECTIVE: simulation-based learning is increasingly seen as an effective strategy to develop student nurse-midwives into effective healthcare team members. A gap exists concerning the use of simulation to promote role transition/development of the student midwife. The purpose of this paper is to describe an evolving simulation curriculum aimed at role development of the student midwife as well as technical skills training. SETTING: the University of New Mexico, College of Nursing and the Interprofessional Healthcare Simulation Center. PARTICIPANTS: this program involves students enrolled in the Masters in Nursing Program, Midwifery Concentration and students enrolled in the pre-licensure Bachelor of Science in Nursing program. FINDINGS: simulation allows for an opportunity to focus on communication skills with other team members, practicing the importance of clear delegation of responsibilities in high-stress situations. CONCLUSIONS: the value of practicing the necessary communication skills, as well as the opportunity to engage in simulated delegation of tasks, is an important aspect of midwifery role development.

Initiating Intrapartum Nitrous Oxide in an Academic Hospital: Considerations and Challenges.

A 50%-50% mixture of nitrous oxide and oxygen has long been used for managing pain during labor in many countries, but only recently has this intrapartum analgesic technique become popular in the United States. Nitrous oxide is considered minimal sedation and a safe pain management alternative. Many facilities are now interested in providing laboring women this analgesic option. The process of establishing use of nitrous oxide in a large institution can be complicated and may seem daunting. This brief report describes the challenges that occurred during the process of initiating nitrous oxide for pain management during childbirth at an academic medical center and discusses various committee roles. Nurses at the University of New Mexico Hospital now directly oversee the administration of nitrous oxide to women in labor in accordance to an established guideline. Despite limited available research, the guideline also allows offering nitrous oxide as a pain management technique for women with opioid dependence. Key components of the guideline and specifics related to education, cost, and safety are reviewed.

Sexual function changes during pregnancy.

INTRODUCTION AND HYPOTHESIS: We describe changes in sexual activity and function among pregnant nulliparous women. METHODS: This secondary analysis evaluated sexual activity and function with the Female Sexual Function Index (FSFI) at baseline in the first (T1), second (T2) and early third (T3) trimester. Evaluation was repeated in T3 after 36 completed weeks of gestation. Data were assigned to the trimester in which they were collected and compared across trimesters. FSFI items were dichotomized into favorable and unfavorable responses. ANOVA and logistic regression models were used to compare values across trimesters, taking into account repeated measurements. Pair-wise comparisons of trimesters were done when there were significant overall differences. Significance was set at p < 0.05. We adjusted for baseline differences. RESULTS: Of 627 women, four did not give sexual function data. Baseline data were collected in 124 women in T1, 403 in T2, and 96 in early T3. Of these 623 women, 496 (80 %) gave data again in T3. The participants' mean age was 24.2 ± 5.1 years and 44.5 % were Hispanic. Rates of sexual activity (T1 94 %, T2 90 %, T3 77 %; p < 0.001) and mean FSFI scores decreased as pregnancy progressed (T1 26.5 ± 7.7, T2 25.6 ± 9.0, T3 21.5 ± 10.3; T1/T2 vs. T3, p < 0.001). Using the FSFI cut-off score for sexual dysfunction of 26.55, women in T3 were more likely to report dysfunction than women in T2 (57 % vs. 37 %, p < 0.001). For specific FSFI questions, the proportions of women reporting favorable responses did not change between T1 and T2 (all p > 0.05) and the proportions of women with a favorable response decreased for all questions between T2 and T3. CONCLUSIONS: As pregnancy progresses, women report poorer sexual function.

Perineal body stretch during labor does not predict perineal laceration, postpartum incontinence, or postpartum sexual function: a cohort study.

INTRODUCTION AND HYPOTHESIS: The perineum stretches naturally during obstetrical labor, but it is unknown whether this stretch has a negative impact on pelvic floor outcomes after a vaginal birth (VB). We aimed to evaluate whether perineal stretch was associated with postpartum pelvic floor dysfunction, and we hypothesized that greater perineal stretch would correlate with worsened outcomes. METHODS: This was a prospective cohort study of primiparous women who had a VB. Perineal body (PB) length was measured antepartum, during labor, and 6 months postpartum. We determined the maximum PB (PBmax) measurements during the second stage of labor and PB change (ΔPB) between time points. Women completed functional questionnaires and had a Pelvic Organ Prolapse Quantification (POP-Q) system exam 6 months postpartum. We analyzed the relationship of PB measurements to perineal lacerations and postpartum outcomes, including urinary, anal, and fecal incontinence, sexual activity and function, and POP-Q measurements. RESULTS: Four hundred and forty-eight women with VB and a mean age of 24 ± 5.0 years with rare (5 %) third- or fourth-degree lacerations were assessed. During the second stage of labor, 270/448 (60 %) had perineal measurements. Mean antepartum PB length was 3.7 ± 0.8 cm, with a maximum mean PB length (PBmax) during the second stage of 6.1 ± 1.5 cm, an increase of 65 %. The change in PB length (ΔPB) from antepartum to 6 months postpartum was a net decrease (-0.39 ± 1.02 cm). PB change and PBmax were not associated with perineal lacerations or outcomes postpartum (all p > 0.05). CONCLUSIONS: PB stretch during labor is unrelated to perineal laceration, postpartum incontinence, sexual activity, or sexual function.

The relationship of 3-D translabial ultrasound anal sphincter complex measurements to postpartum anal and fecal incontinence.

INTRODUCTION AND HYPOTHESIS: We aimed to determine whether anal sphincter complex (ASC) measurements on translabial ultrasound (TL-US) were related to anal incontinence (AI) or fecal incontinence (FI) symptoms 6 months postpartum. METHODS: A prospective cohort of primiparous women underwent TL-US 6 months after a vaginal birth (VB) or cesarean delivery (CD). Muscle thickness was measured at 3, 6, 9, and 12 o'clock positions of the external anal sphincter (EAS), the same four quadrants of the internal anal sphincter (IAS) at proximal, mid, and distal levels, and at the bilateral pubovisceralis muscle (PVM). Measurements were correlated to AI and FI on the Wexner Fecal Incontinence Scale, with sub-analyses by mode of delivery. The odds ratio (OR) of symptoms was calculated for every 1 mm increase in muscle thickness (E1MIT). RESULTS: A total of 423 women (299 VB, 124 CD) had TL-US 6 months postpartum. Decreased AI risk was associated with thicker measurements at the 6 o'clock (OR 0.74 E1MIT) and 9 o'clock proximal IAS (OR 0.71 E1MIT) in the entire cohort. For CD women, thicker measurements of the 9 o'clock proximal IAS were associated with decreased risk of AI (OR 0.56 E1MIT) and thicker distal 6 o'clock IAS measurements were related to a decreased risk of FI (OR 0.37 E1MIT). For VB women, no sphincter measurements were significantly related to symptoms, but thicker PVM measurements were associated with increased risk of AI (right side OR 1.32 E1MIT; left side OR 1.21 E1MIT). CONCLUSIONS: ASC anatomy is associated with AI and FI in certain locations; these locations vary based on the patient's mode of delivery.

Anal sphincter complex: 2D and 3D endoanal and translabial ultrasound measurement variation in normal postpartum measurements.

INTRODUCTION AND HYPOTHESIS: Women may experience anal sphincter anatomy changes after vaginal birth (VB) or Cesarean delivery (CD). Therefore, accurate and acceptable imaging options to evaluate the anal sphincter complex (ASC) are needed. ASC measurements may differ between translabial (TLUS) and endoanal (EAUS) ultrasound imaging and between 2D and 3D US. The objective of this analysis was to describe measurement variation between these modalities. METHODS: Primiparous women underwent 2D and 3D TLUS imaging of the ASC 6 months after VB or CD. A subset of women also underwent EAUS measurements. Measurements included internal anal sphincter (IAS) thickness at proximal, mid, and distal levels and the external anal sphincter (EAS) at 3, 6, 9, and 12 o'clock positions, as well as bilateral thickness of the pubovisceralis muscle (PVM). RESULTS: There were 433 women presenting for US: 423 had TLUS and 64 had both TLUS and EAUS of the ASC. All IAS measurements were significantly thicker on TLUS than EAUS (all p < 0.01), while EAS measurements were significantly thicker on EAUS (p < 0.01). PVM measurements with 3D or 2D imaging were similar (p > 0.20). On both TLUS and EAUS, there were multiple sites where significant asymmetry existed in left versus right measurements. CONCLUSIONS: US modality used to image the ASC introduces small but significant changes in measurements, and the direction of the bias depends on the muscle and location being imaged.

Does a large infant head or a short perineal body increase the risk of obstetrical perineal trauma?

BACKGROUND: Perineal trauma after vaginal delivery can have significant long-term consequences. It is unknown if a larger infant head circumference or smaller maternal perineal anatomy are risk factors for perineal trauma after vaginal delivery. METHODS: We conducted a prospective cohort study of low-risk nulliparous women. Data collected included maternal characteristics, antepartum Pelvic Organ Prolapse Quantification measurements of the perineal body and genital hiatus, labor characteristics, perineal trauma, and infant head circumference. Perineal trauma was defined as trauma that extended into the muscles of the perineum (second-degree or deeper). Univariate and multivariate logistic models were created to calculate odds ratios (OR) and 95 percent confidence intervals (CI). RESULTS: We observed 448 vaginal births. Multivariate analysis demonstrated a significant association between infant head circumference at birth and perineal trauma: OR 1.22 for each increase of 1 cm in head circumference (95% CI 1.05-1.43). There was no association between perineal body or genital hiatus length and perineal trauma. CONCLUSIONS: In nulliparous low-risk women a larger infant head circumference at birth increases the likelihood of perineal trauma, although the effect is modest. Antenatal perineal body and genital hiatus measurements do not predict perineal trauma. These results do not support alteration in mode of delivery or other obstetric practices.

Impact of nulliparous women's body mass index or excessive weight gain in pregnancy on genital tract trauma at birth.

INTRODUCTION: The purpose of this study was to explore the impact of body mass index (BMI) or pregnancy weight gain on the presence, site, and severity of genital tract trauma at childbirth in nulliparous women. METHODS: The present study is a subanalysis of a prospective cohort of healthy nulliparous women recruited during pregnancy and followed through birth. Weight gain during pregnancy and prepregnancy BMI were recorded. At birth, women underwent detailed mapping of genital tract trauma. For analyses, women were dichotomized into obese (BMI ≥ 30) versus nonobese (BMI < 30) at baseline as well as into those who gained weight as recommended by the Institute of Medicine (IOM) and those who gained more than the recommended amount to determine the impact of obesity or excessive weight gain on rates of genital tract trauma. RESULTS: Data from 445 women were available for analysis. Presence and severity of genital tract trauma did not vary between obese and nonobese women (51% vs 53%, P = .64). Likewise, women who had more than the IOM-recommended weight gain did not have a higher incidence of perineal lacerations (52% versus 53% with perineal lacerations, P = .69). Obese women were more likely to gain in excess of the IOM guidelines during pregnancy (75% vs 50% excessive weight gain in obese vs nonobese women, respectively; P < .001). DISCUSSION: A woman's BMI or excessive weight gain in pregnancy did not influence her risk of genital tract trauma at birth.

Postpartum translabial 2D and 3D ultrasound measurements of the anal sphincter complex in primiparous women delivering by vaginal birth versus Cesarean delivery.

INTRODUCTION AND HYPOTHESIS: Consensus on normal translabial ultrasound (TL-US) anal sphincter complex measurements for postpartum women is lacking. We aimed to evaluate normative measurements in 2D and 3D TL-US for the anal sphincter complex (ASC) at 6 months postpartum and compare these measurements in women who had a vaginal birth (VB) and in those who had a Cesarean delivery (CD). METHODS: A large, prospective cohort of primiparous women underwent 2D and 3D TL-US 6 months after their first delivery. For normative sphincter measurements, we excluded women with third- or fourth-degree lacerations or with sphincter interruption on TL-US. Measurements included the sphincter thickness at the 3, 6, 9, and 12 o'clock positions of the external anal sphincter (EAS) and the internal anal sphincter (IAS) at proximal, mid, and distal levels. We also measured the mean coronal diameter of the pubovisceralis muscle (PVM). RESULTS: 696 women consented to participate, and 433 women presented for ultrasound imaging 6 months later. Women who sustained a third- or fourth-degree laceration had significantly thicker EAS measurements at 12 o'clock. Sphincter asymmetry was common (69 %), but was not related to mode of delivery. Only IAS measurements at the proximal and distal 12 o'clock position were significantly thicker for CD patients. There were no significant differences in the EAS or PVM measurements between VB and CD women. CONCLUSIONS: There appear to be few differences in normative sphincter ultrasound measurements between primiparous patients who had VB or CD.

Does the severity of spontaneous genital tract trauma affect postpartum pelvic floor function?

We describe the impact of genital trauma on pelvic floor function in a low-risk cohort of women after vaginal birth. Questionnaires (Present Pain Intensity Scale, Incontinence Impact Questionnaire, Fecal Incontinence Score, and Intimate Relationship Scale) were completed up to 12 weeks postpartum. Severity of trauma was recorded at delivery. Overall follow-up was 444/565 (79%). Major trauma (trauma that involved perineal muscles or required suturing) occurred in 20%; 20% delivered intact. At 12 weeks, 10% complained of perineal pain; 24% reported anal (AI) and 27% urinary incontinence (UI). Women with trauma were no more likely than those intact to complain of UI or AI, sexual inactivity, or perineal pain postpartum (all P=NS). Women with major trauma had weaker pelvic floor exercise strength than those who delivered intact or with minor trauma (odds ration 3.06, 95% confidence interval 1.41-6.63). Pelvic floor complaints postpartum were common but not associated with severity of genital trauma in a cohort of low-risk women.

Does epidural analgesia affect the rate of spontaneous obstetric lacerations in normal births?

The precise relationship between epidural use and genital tract lacerations in normal childbirth is unclear. Data from a clinical trial on measures to lower genital tract trauma in vaginal birth were used for a secondary analysis. The goal was to assess whether epidurals affect the rate of spontaneous obstetric lacerations in normal vaginal births. Maternal characteristics and intrapartum variables were compared in women who did and did not use an epidural in labor, and also in those with and without any sutured lacerations following vaginal birth. Variables that were statistically different in both cases were entered into regression equations for simultaneous adjustment. Epidural use was not an independent predictor of sutured lacerations. Predictors of sutured lacerations included nulliparity, a prolonged second stage, being non-Hispanic white, and an infant birthweight greater than 4000 grams. Elements of midwifery management need further research.