Pre- and during-labour predictors of low birth satisfaction among Iranian women: a prospective analytical study.

BACKGROUND: Maternal childbirth dissatisfaction has short- and long-term negative effects on the mothers' health and life, as well as on relation with her child and family. Due to lack of studies in Iran and other counties, we aimed to determine pre- and during- labour predictors of low birth satisfaction. METHODS: Seven hundred women with low risk singleton pregnancy participated in this prospective analytical study. The participants were hospitalized for vaginal delivery with fetus in cephalic presentation and gestational age of 370-416 at two teaching centers in Tabriz (Iran). Woman characteristics, anxiety state (using Spielberger inventory) and dehydration were assessed at cervical dilatation of 4-6 cm. Iranian (Persian) birth satisfaction scale-revised was applied 12-24 h after birth. Multiple linear regression was used to determine the predictors. RESULTS: Excluding 26 women who were outliers, 674 women were analyzed. The mean birth satisfaction score was 23.8 (SD 6.5) from an attainable score of 0-40. The during-labour predictors of low birth satisfaction score were severe and moderate anxiety, labour dystocia, insufficient support by staff, vaginal birth with episiotomy and tear, emergency cesarean section, labour induction and labour augmentation with oxytocin, and woman dehydration. The pre-labour predictors included being primiparous, sexual and emotional violence during pregnancy, gestational age of 400-416, preference for cesarean section, no attendance at pregnancy classes, and insufficient household income. The proportion of the variance explained by the during-labour variables was 75%, by pre-labour variables was 14% and by overall was 76%. CONCLUSIONS: The controllable during-labour predictors explains most of the variance of the satisfaction score. It seems that responding to women's physical and psychological needs during labour and applying less interventions could improve women's childbirth satisfaction.

A qualitative meta-synthesis of women's experiences of labor dystocia.

PROBLEM: Researchers have prioritized understanding and differentiating the pathophysiologic mechanisms to improve precision in diagnosis and individualization of care, however the experiences of women with labor dystocia have been underexamined. BACKGROUND: Management of labor dystocia has been identified as an opportunity for reducing the rate of unnecessary cesarean births and the associated risks to women and their infants. This meta-synthesis explores women's experiences of labor dystocia to enrich the discussion of care practices and contextualize discussions of shared decision making in what is most meaningful to women. QUESTIONS: How does prolonged labor influence women's experience of birth and motherhood? What are women's experiences with decision-making about labor augmentation during prolonged labor? METHODS: Sandelowski and Barroso's meta-synthesis approach was used to analyze primary qualitative studies of women's experiences of labor dystocia. Through inductive thematic synthesis and reciprocal translation, themes identified in qualitative research, quotations, and coded meaning units were aggregated and interpreted into derived categories and themes. FINDINGS: Fourteen qualitative studies were analyzed. Women experienced labor dystocia as a transition from healthy labor to abnormal labor requiring medical support consistent with Transition Theory by Meleis. Six new categories and thirty themes were identified. Each category and theme reflects a distinct component of the experience of labor dystocia. DISCUSSION/CONCLUSION: There is wide variation in the way women experience labor dystocia. Facilitation of the transition from healthy labor to labor dystocia can be supported by a fluid, adaptable method of caring for women in the face of uncertainty and loss of choice.

Treatment-seeking for vaginal fistula in sub-Saharan Africa.

BACKGROUND: There is dearth of data regarding the treatment-seeking practice of women living with vaginal fistula. The paper describes the health-seeking behaviour of fistula cases in the sub-Saharan Africa (SSA) where the burden of the problem is high. METHODS: The data of 1,317 women who ever experienced fistula-related symptom were extracted from 16 national Demographic and Health Surveys carried out in SSA between 2010 and 2017. The association between treatment-seeking and basic socio-demographic characteristics was analysed via mixed-effects logistic regression and the outputs are provided using adjusted odds ratio (AOR) with 95% confidence intervals (CI). RESULTS: Among all women who had fistula-related symptom, 67.6% encountered the problem soon after delivery, possibly implying obstetric fistula. Fewer identified sexual assault (3.8%) and pelvic surgery (2.7%) as the underlying cause. In 25.8% of the cases clear-cut causes couldn't be ascertained and, excluding these ambiguous causes, 91.2% of the women possibly had obstetric fistula. Among those who ever had any kind of fistula, 60.3% (95% CI: 56.9-63.6%) sought treatment and 28.5% (95% CI: 25.3-31.6%) underwent fistula-repair surgery. The leading reasons for not seeking treatment were: unaware that it can be repaired (21.4%), don't know where to get the treatment (17.4%), economic constraints (11.9%), the fistula healed by itself (11.9%) and feeling of embarrassment (7.9%). The regression analysis indicated, teenagers as compared to adults 35 years or older [AOR = 0.31 (95% CI: 0.20-47)]; and women without formal education compared to women with formal education [AOR = 0.69 (95% CI: 0.51-0.93)], had reduced odds of treatment-seeking. In 25.9% of the women who underwent fistula-repair surgery, complete continence after surgery was not achieved. CONCLUSION: Treatment-seeking for fistula remains low and it should be improved through addressing health-system, psycho-social, economic and awareness barriers.

Use of an Early Labor Lounge to Promote Admission in Active Labor.

Professional maternity care organizations within the United States are aligned in the goal to prevent the first cesarean birth in nulliparous women with a term, singleton, vertex fetus. Currently, one in 3 women are at risk for having a cesarean birth. The most common reason for cesarean in the United States is labor dystocia. The evidence supports delaying admission to the birthing unit until active labor is established, thereby minimizing the inadvertent diagnosis of labor dystocia. Providers are familiar with the rationale supporting delayed admission to the birthing unit until active labor is established; however, there is very little evidence on how to effectively promote this delay. Provider apprehension and the lack of early labor support are challenges to sending women home to await the onset of active labor. Maternal anxiety, fear, pain, and unpreparedness also play a part in this reluctance. To address these obstacles, South Shore Hospital created an early labor lounge with stations aimed at instilling confidence in the birth team, promoting teamwork, facilitating relaxation, and reducing anxiety for laboring women. A literature review focusing on women's perceptions of promoting admission in active labor, maternal anxiety, and nonpharmacologic strategies for managing early labor are discussed within the context of the creation, implementation, and evaluation of an early labor lounge.

Tell me your story: recovering from a difficult birth.

The authors discuss their experience of running after birth workshops as an intervention for women struggling to come to terms with a difficult birth experience. Midwives can use this approach in their practice with women in the postnatal period and also when preparing for a subsequent birth or even during a labour that follows a challenging experience. This article explores the value of supporting women to tell their story and how to do that with suggestions to build on listening skills. It also offers suggestions for self care, so that midwives can be well resourced for emotional support.

Recurrent Shoulder Dystocia: Risk Factors and Counseling.

A prior history of delivery complicated by shoulder dystocia confers a 6-fold to nearly 30-fold increased risk of shoulder dystocia recurrence in a subsequent vaginal delivery, with most reported rates between 12% and 17%. Whereas prevention of shoulder dystocia in the general population is neither feasible nor cost-effective, directing intervention efforts at the particular subgroup of women with a prior history of shoulder dystocia has merit. Potentially modifiable risk factors and individualized management strategies that may reduce shoulder dystocia recurrence and its associated significant morbidities are reviewed.

Preventing primary cesarean births: midwifery care.

The incidence of cesarean birth in the United States is alarmingly high and cesareans are associated with added morbidities for women and newborns. Thus strategies to prevent cesarean particularly for low-risk, nulliparous women at term with a singleton fetus are needed. This article addresses evidence-based practices that may be used during intrapartum to avoid primary cesarean, including patience with progress in labor, intermittent auscultation, continuous labor support, upright positions, and free mobility. Second-stage labor practices, such delayed pushing and manual rotation of the fetus, are also reviewed. This package of midwifery-style care practices can potentially lower primary cesarean rates.

Diverse definitions of prolonged labour and its consequences with sometimes subsequent inappropriate treatment.

BACKGROUND: Prolonged labour very often causes suffering from difficulties that may have lifelong implications. This study aimed to explore the prevalence and treatment of prolonged labour and to compare birth outcome and women's experiences of prolonged and normal labour. METHOD: Women with spontaneous onset of labour, living in a Swedish county, were recruited two months after birth, to a cross-sectional study. Women (n = 829) completed a questionnaire that investigated socio-demographic and obstetric background, birth outcome and women's feelings and experiences of birth. The prevalence of prolonged labour, as defined by a documented ICD-code and inspection of partogram was calculated. Four groups were identified; women with prolonged labour as identified by documented ICD-codes or by partogram inspection but no ICD-code; women with normal labour augmented with oxytocin or not. RESULTS: Every fifth woman experienced a prolonged labour. The prevalence with the documented ICD-code was (13%) and without ICD-code but positive partogram was (8%). Seven percent of women with prolonged labour were not treated with oxytocin. Approximately one in three women (28%) received oxytocin augmentation despite having no evidence of prolonged labour. The length of labour differed between the four groups of women, from 7 to 23 hours.Women with a prolonged labour had a negative birth experience more often (13%) than did women who had a normal labour (3%) (P <0.00). The factors that contributed most strongly to a negative birth experience in women with prolonged labour were emergency Caesarean section (OR 9.0, 95% CI 1.2-3.0) and to strongly agree with the following statement 'My birth experience made me decide not to have any more children' (OR 41.3, 95% CI 4.9-349.6). The factors that contributed most strongly to a negative birth experience in women with normal labour were less agreement with the statement 'It was exiting to give birth' (OR 0.13, 95% CI 0.34-0.5). CONCLUSIONS: There is need for increased clinical skill in identification and classification of prolonged labour, in order to improve care for all women and their experiences of birthing processes regardless whether they experience a prolonged labour or not.

A randomized controlled trial on early induction compared to expectant management of nulliparous women with prolonged latent phases.

OBJECTIVE: To compare early induction and expectant management regarding delivery outcomes and the experience of delivery in nulliparous women with prolonged latent phases. DESIGN: Randomized controlled trial. SETTING: One delivery unit in a Swedish hospital. POPULATION: Nulliparous women at term experiencing continuous contractions impeding rest (women's report) and exceeding 18 h, a cervical dilation of less than 4 cm, intact membranes and with a singleton fetus in cephalic presentation. METHODS: The women were randomly allocated to either early induction (n = 65) or expectant management (n = 64). All participants received medication for therapeutic rest. The early induction group was induced five hours after medication, and the expectant group awaited spontaneous onset of labor. The Wijma Delivery Experience Questionnaire (W-DEQ version B) was filled in after delivery. MAIN OUTCOME MEASURES: The primary outcome was mode of delivery. Secondary outcomes included birth experience, duration of labor, postpartum hemorrhage, and neonatal outcomes. RESULTS: The cesarean section rate was 15 of 65 (23.1%) in the early induction group and 24 of 64 (37.5%) in the expectant group (p = 0.076, OR 2.00, 95% CI 0.93-4.31). No significant differences were shown regarding delivery, neonatal outcomes or birth experience. CONCLUSIONS: No significant differences were shown between the two groups in the rate of cesarean sections or the experience of delivery. According to the actual results, the power to detect a difference was only 45%. The cesarean section rate was high in both groups, regardless of intervention.

The association between labour variables and primiparous women's experience of childbirth; a prospective cohort study.

BACKGROUND: Studies have suggested several risk factors for a negative birth experience among primiparas. Factors that are mentioned frequently include labour dystocia, operative intervention such as acute caesarean section or vacuum extraction, or the infant being transferred to neonatal care. Another important factor mentioned is lack of support from the midwife. METHODS: A study was made of the deliveries of 446 healthy primiparas in a prospective cohort study performed at Soder Hospital, Stockholm, Sweden. Samples of amniotic fluid were collected at delivery and the levels of amniotic fluid lactate (AFL) were measured to give an indication of the metabolism of the uterine tissue. Obstetrical data were collected from birth records.Postpartum, all the women included in the study were asked to complete the Wijma Delivery Experience Questionnaire (W-DEQ B) that measures the experience of a woman's delivery. The main objective of the project was to study well-known as well as new factors associated with negative experience of childbirth among a group of healthy primiparas. RESULTS: Risk factors for reporting a higher level of negative childbirth experience were shown to be a high level of AFL (AOR 3.1, 95%, CI; 1.1-8.9), a longer latent phase (AOR 1.8, 95%, CI; 1.03-3.1), and a low Apgar score (<7 at 1 min) (AOR 13.3, 95%, CI; 1.6-111.0). Those women who had a negative birth experience wanted the midwife to be present more of the time during labour (p = 0.003). CONCLUSIONS: A high AFL level, as a marker of uterine metabolic status, and a longer latent phase are strongly associated with a negative experience of childbirth. A low 1 minute Apgar score of the newborn seems to have the strongest negative influence on the woman's experience of childbirth, even when the infant recovers immediately.

Fathers' experience of childbirth when non-progressive labour occurs and augmentation is established. A qualitative study.

OBJECTIVE: Augmentation with oxytocin during labour has increased in Western obstetrics over the last few decades. The aim of this study was to describe how fathers experienced childbirth when non-progressive labour occurred and augmentation was established. METHOD: A qualitative descriptive design. Ten fathers were interviewed 4-15 weeks post partum. The interviews were semi-structured and were analyzed using Braun and Clarke's thematic analysis. RESULTS: The analysis revealed three themes and four sub-themes. The themes were: (1) A rational approach to own role, (2) Labour and birth as uncontrollable processes and (3) Relief about the decision of augmentation. The fathers had a rational approach and felt powerless when the process of labour was uncontrollable. They felt they were not able to help their partners in pain when non-progressive labour occurred. They experienced relief when augmentation was established because of the subsequent progression of labour, and because it was then easier to find a role as a helper. CONCLUSION: This study demonstrates that fathers feel relieved when augumentation is established. In addition, the study underlines that fathers, in order to regain control after experiencing the non-progressive labour, need directions from the midwives to carry out appropriate and usefull tasks.

Tormented by ghosts from their past': a meta-synthesis to explore the psychosocial implications of a traumatic birth on maternal well-being.

BACKGROUND: women can experience an array of serious and enduring morbidities following a difficult or traumatic childbirth. These complications have a negative impact on maternal behaviours and infant and family well-being. OBJECTIVE: to undertake a meta-synthesis of existing qualitative research to explore the psychosocial implications of a traumatic birth on maternal well-being. METHOD: a systematic review across 10 databases was undertaken: Nursing and Allied Health Source, Medline, the Allied and Complementary Medicine Database (AMED), Embase, PsychINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), International Bibliography of Social Sciences (IBSS), Science Direct, Academic Search Complete and Health Management Information Consortium. Quality appraisal was conducted and Noblit & Hare's meta-ethnographic method adopted to identify first, second and third order constructs within the selected papers. FINDINGS: 13 papers were included in the final synthesis. Three third order constructs were identified and are described as 'consumed by demons' (through the intense negative emotions and responses they endured and the subsequent dysfunctional coping strategies employed); an 'embodied sense of loss' (through women's loss of self and family ideals) and 'shattered relationships' (which reflected the fractious and difficult relationships that women described with their infants and partners). A line of argument synthesis was developed which revealed how women are 'tormented by ghosts' from their past. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: this synthesis reveals how a traumatic birth experience can lead to women being drawn into a turmoil of devastating emotions that have long-term, negative repercussions on self-identity and relationships. Professionals require training, awareness and skill development to prevent against trauma and to enable them to identify and sensitively respond to women's psychosocial concerns. Further insights and research into the timing and type of interventions to resolve postnatal morbidity following a traumatic birth are needed.

Australian midwives' experience of delivering a counselling intervention for women reporting a traumatic birth.

OBJECTIVE: this paper describes midwives' experiences of learning new counselling skills and delivering a counselling intervention entitled 'Promoting Resilience on Mothers Emotions' (PRIME). DESIGN: a descriptive exploratory approach was used. Data collected included semi-structured interviews (n=42), midwife diary entries (18 pages) and web based postings (169 pages). Data were analysed using manual thematic method. SETTING: the intervention study was conducted in two tertiary maternity hospitals in the Australian states of Queensland (QLD) and Western Australia (WA) during a 17 month period, from August 2008 to December 2009. PARTICIPANTS: midwives were employed as research assistants and trained to deliver a counselling intervention to women reporting a traumatic birth experience. Eighteen of a possible 20 Australian midwives participated in this study. INTERVENTION: PRIME is a midwife-led counselling intervention based on cognitive-behavioural principles and designed to ameliorate trauma symptoms. It is offered face-to-face within 72 hours of childbirth and by phone around six weeks post partum. FINDINGS: participating midwives felt confronted by the level of emotional distress some women suffered as a consequence of their birth experience. Four major themes were extracted: The challenges of learning to change; Working with women in a different way; Making a difference to women and me; and A challenge not about to be overcome. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the advanced counselling skills the midwives acquired improved their confidence to care for women distressed by their birthing experience and to personally manage stressful situations they encountered in practice.

A case study of maternal response to the implied antepartum diagnosis of inevitable labor dystocia.

Two pregnant women, one obese and one of extremely small stature, received antepartum recommendations from their health care providers to schedule cesarean births. In response, both women sought providers who would support their desire to attempt vaginal birth. The women's perspectives on their birth experiences along with the pertinent medical record data from their pregnancies and births provide a reminder about the inherent normalcy of birth amid the current culture of interventive obstetrical practices.

The obstetric nightmare of shoulder dystocia: a tale from two perspectives.

PURPOSE: Shoulder dystocia is one of the most terrifying of obstetric emergencies. In this secondary analysis of two qualitative studies, the experiences of shoulder dystocia are compared and contrasted from two perspectives: the mothers and the labor and delivery nurses. METHOD: In the first study mothers' experiences of shoulder dystocia and caring for their children with obstetric brachial plexus injuries were explored. The second study explored secondary traumatic stress in labor and delivery nurses due to exposure to traumatic births. Krippendorff's content analysis technique of clustering was used to identify data that could be grouped together into themes. RESULTS: It was striking how similar the perspectives of mothers and their nurses were regarding a shoulder dystocia birth. Four themes emerged from the content analysis of these two data sets: (1) in the midst of the obstetric nightmare; (2) reeling from the trauma that just transpired; (3) enduring heartbreak: the heavy toll on mothers; and (4) haunted by memories: the heavy toll on nurses. CLINICAL IMPLICATIONS: Providing emotional support to the mother during shoulder dystocia births and afterward in the postpartum period has been acknowledged. What now needs to be added to best practices for shoulder dystocia are interventions for the nurses themselves. Support for labor and delivery nurses who are involved in this obstetric nightmare is critical.

The patient observer: eye-movement desensitization and reprocessing for the treatment of posttraumatic stress following childbirth.

BACKGROUND: No standard intervention with proved effectiveness is available for women with posttraumatic stress following childbirth because of insufficient research. The objective of this paper was to evaluate the possibility of using eye-movement desensitization and reprocessing treatment for women with symptoms of posttraumatic stress disorder following childbirth. The treatment is internationally recognized as one of the interventions of choice for the condition, but little is known about its effects in women who experienced the delivery as traumatic. METHODS: Three women suffering from posttraumatic stress symptoms following the birth of their first child were treated with eye-movement desensitization and reprocessing during their next pregnancy. Patient A developed posttraumatic stress symptoms following the lengthy labor of her first child that ended in an emergency cesarean section after unsuccessful vacuum extraction. Patient B suffered a second degree vaginal rupture, resulting in pain and inability to engage in sexual intercourse for years. Patient C developed severe preeclampsia postpartum requiring intravenous treatment. RESULTS: Patients received eye-movement desensitization and reprocessing treatment during their second pregnancy, using the standard protocol. The treatment resulted in fewer posttraumatic stress symptoms and more confidence about their pregnancy and upcoming delivery compared with before the treatment. Despite delivery complications in Patient A (secondary cesarean section due to insufficient engaging of the fetal head); Patient B (second degree vaginal rupture, this time without subsequent dyspareunia); and Patient C (postpartum hemorrhage, postpartum hypertension requiring intravenous treatment), all three women looked back positively at the second delivery experience. CONCLUSIONS: Treatment with eye-movement desensitization and reprocessing reduced posttraumatic stress symptoms in these three women. They were all sufficiently confident to attempt vaginal birth rather than demanding an elective cesarean section. We advocate a large-scale, randomized controlled trial involving women with postpartum posttraumatic stress disorder to evaluate the effect of eye-movement desensitization and reprocessing in this patient group.

Fear of childbirth and risk for birth complications in nulliparous women in the Danish National Birth Cohort.

OBJECTIVES: To examine the associations between fear of childbirth and emergency caesarean section and between fear of childbirth and dystocia or protracted labour and fetal distress. DESIGN: Prospective cohort study. SETTING: Danish National Birth Cohort. POPULATION: A total of 25 297 healthy nulliparous women in spontaneous labour with a single fetus in cephalic presentation at term following an uncomplicated pregnancy. METHODS: Data were collected during 1997-2003 from computer-assisted telephone interviews twice in pregnancy linked with national health registers. MAIN OUTCOME MEASURES: Risk for emergency caesarean section of women who feared childbirth; risk for dystocia/protracted labour or fetal distress of women who feared childbirth. RESULTS: Fear of childbirth in early (16 weeks, 6 +/- 29 days) and late (31 weeks, 4 +/- 21 days) pregnancy was associated with emergency caesarean section: OR, 1.23 (1.05-1.47) and 1.32 (1.13-1.55), respectively. When fear of childbirth was expressed at both interviews, the OR was 1.43 (1.13-1.80). Women who feared childbirth had an increased risk for dystocia or protracted labour (OR, 1.33; 1.15-1.54), but not for fetal distress (OR, 0.94; 0.72-1.23). CONCLUSIONS: Fear of childbirth during pregnancy was associated with dystocia and emergency caesarean section but not with fetal distress.

Women's experiences of becoming a mother after prolonged labour.

AIM: This paper is a report of a study to explore women's experiences of becoming a mother after prolonged labour. BACKGROUND: The negativity associated with a complicated labour such as prolonged labour can lead to a struggle to become a healthy mother and could restrict the process of becoming a mother. METHODS: Interviews were conducted in 2004 with 10 mothers who had been through a prolonged labour with assisted vaginal or caesarean delivery 1-3 months previously. Thematic content analysis was used. FINDINGS: Three themes were formulated, describing women's experiences as fumbling in the dark, struggling for motherhood and achieving confidence in being a mother. The difficulties and suffering involved in becoming a mother after a prolonged labour were interpreted to be like 'fumbling in the dark'. Women experienced bodily fatigue, accompanied by feelings of illness and detachment from the child. Having the child when in this condition entailed a struggle to become a mother. In spite of these experiences and the desire to achieve confidence in being a mother, the reassurance of these women regarding their capacity for motherhood was crucial: it was central to their happiness as mothers, encouraged interaction and relationship with the child, and contributed to their adaptation to motherhood. CONCLUSION: Women experiencing prolonged labour may be comparable with the experience of and recovery from illness, which could contribute to difficulties transitioning to motherhood and limit a woman's ability to be emotionally available for the child.