A mixed methods study to explore women and clinicians' response to pain associated with suturing second degree perineal tears and episiotomies [PRAISE].

BACKGROUND: perineal suturing is a common event which affects women across a variety of international settings. Women have expressed pain related to perineal trauma in the postnatal period but little is known about pain during suturing. In addition, there is a lack of evidence to identify how professional decisions are made about pain management during the suturing process. OBJECTIVE: to explore women and clinicians' response to pain during the suturing of second degree tears and episiotomies. DESIGN: mixed method feasibility study which included observation, questionnaires and interviews. SETTING: a Hospital Trust in Northwest England. PARTICIPANTS: 40 women and 21 clinicians participated. MEASUREMENTS AND FINDINGS: mild, moderate and severe pain was measured via the McGill Pain Questionnaire-Short Form (MCPQ-SF). Psychological distress was identified via the Hospital Anxiety and Depression Scale (HADS). Semi-structured face to face interviews identified three themes, Psychological distress and future functioning; Variation in practice and Style of communication. KEY CONCLUSIONS: women who experienced psychological distress during previous or current childbirth scored higher on HADS and MCPQ-SF, and appeared to express more concerns about future functioning and healing. Variation in practice exists and style of communication had the potential to make the difference for women. IMPLICATIONS FOR PRACTICE AND RESEARCH: the process of suturing is complex and is not a standalone event for a woman. It is crucial that health professionals consider previous and subsequent experience of perineal suturing. Future research aims to develop a decision tree to support pain management during suturing.

Women's experiences of outpatient induction of labour with remote continuous monitoring.

OBJECTIVE: to gain insight into women's experiences and preferences for induction in the home as part of a trial investigating the feasibility and acceptability of outpatient induction of labour with remote monitoring. DESIGN: a qualitative study using semi-structured individual interviews. Interview transcripts were subjected to thematic analysis to identify the dominant themes regarding women's experiences of outpatient induction. SETTING: a large maternity hospital in the North West of England. PARTICIPANTS: fifteen women who participated in the main trial of outpatient induction of labour with remote continuous monitoring. FINDINGS: three main themes were identified; the need for women to 'labour within their comfort zone'; their desire to achieve 'the next best thing to a normal labour' and the importance of a 'virtual presence' to offer remote reassurance. CONCLUSIONS: women's preference for the outpatient setting of induction of labour is dominated by their need to labour within their comfort zone. Outpatient induction offered women the familiarity and freedom of the home environment, and the resulting physical and emotional comforts helped women cope better with their labour and improved their birth experiences. While remote monitoring offered some reassurance, women still depended on effective communication from hospital staff to provide the virtual presence of a health professional in the home. IMPLICATIONS: the combination of slow-release prostaglandin and a remote monitoring device may provide low risk women with an improved induction and labour experience. While ongoing studies continue to explore further the safety of interventions at home, this study has importantly considered women's views and confirmed that induction at home is not only acceptable to women but also that the outpatient experience is preferable to long inpatient inductions.

Home labour induction with retrievable prostaglandin pessary and continuous telemetric trans-abdominal fetal ECG monitoring.

OBJECTIVE: To evaluate the feasibility of continuous telemetric trans-abdominal fetal electrocardiogram (a-fECG) in women undergoing labour induction at home. STUDY DESIGN: Low risk women with singleton term pregnancy undergoing labour induction with retrievable, slow-release dinoprostone pessaries (n = 70) were allowed home for up to 24 hours, while a-fECG and uterine activity were monitored in hospital via wireless technology. Semi-structured diaries were analysed using a combined descriptive and interpretive approach. RESULTS: 62/70 women (89%) had successful home monitoring; 8 women (11%) were recalled because of signal loss. Home monitoring lasted between 2-22 hours (median 10 hours). Good quality signal was achieved most of the time (86%, SD 10%). 3 women were recalled back to hospital for suspicious a-fECG. In 2 cases suspicious a-fECG persisted, requiring Caesarean section after recall to hospital. 48/51 women who returned the diary coped well (94%); 46/51 were satisfied with home monitoring (90%). CONCLUSIONS: Continuous telemetric trans-abdominal fetal ECG monitoring of ambulatory women undergoing labour induction is feasible and acceptable to women.

Infant skin-cleansing product versus water: a pilot randomized, assessor-blinded controlled trial.

BACKGROUND: The vulnerability of newborn babies' skin creates the potential for a number of skin problems. Despite this, there remains a dearth of good quality evidence to inform practice. Published studies comparing water with a skin-cleansing product have not provided adequate data to inform an adequately powered trial. Nor have they distinguished between babies with and without a predisposition to atopic eczema. We conducted a pilot study as a prequel to designing an optimum trial to investigate whether bathing with a specific cleansing product is superior to bathing with water alone. The aims were to produce baseline data which would inform decisions for the main trial design (i.e. population, primary outcome, sample size calculation) and to optimize the robustness of trial processes within the study setting. METHODS: 100 healthy, full term neonates aged <24 hours were randomly assigned to bathing with water and cotton wool (W) or with a cleaning product (CP). A minimum of bathing 3 times per week was advocated. Groups were stratified according to family history of atopic eczema. Transepidermal water loss (TEWL), stratum corneum hydration and skin surface pH were measured within 24 hours of birth and at 4 and 8 weeks post birth. Measurements were taken on the thigh, forearm and abdomen. Women also completed questionnaires and diaries to record bathing practices and medical treatments. RESULTS: Forty nine babies were randomized to cleansing product, 51 to water. The 95% confidence intervals (CI) for the average TEWL measurement at each time point were: whole sample at baseline: 10.8 g/m(2)/h to 11.7 g/m(2)/h; CP group 4 weeks: 10.9 g/m(2)/h to 13.3 g/m(2)/h; 8 weeks: 11.4 g/m(2)/h to 12.9 g/m(2)/h; W group 4 weeks:10.9 g/m(2)/h to 12.2 g/m(2)/h; 8 weeks: 11.4 g/m(2)/h to 12.9 g/m(2)/h. CONCLUSION: This pilot study provided valuable baseline data and important information on trial processes. The decision to proceed with a superiority trial, for example, was inconsistent with our data; therefore a non-inferiority trial is recommended.

Women's views of high risk pregnancy under threat of preterm birth.

OBJECTIVE: To gain an understanding of the experiences of pregnant women at risk of having a preterm birth (PTB) who were attending a specialist preterm antenatal clinic and to elicit their views on treatment to prevent PTB. STUDY DESIGN: A qualitative interpretive approach was adopted, utilizing focus groups and one-to-one interviews. The semi-structured interview schedule focused on two main areas; risk and treatment for preterm birth. Fourteen pregnant women were recruited from a preterm antenatal clinic at a major tertiary referral centre in the North West of England. All interviews were audio recorded, with consent, and transcribed verbatim before carrying out thematic analysis. RESULTS: Analysis revealed 3 main themes. Women struggled with 'balancing the risks' associated with the threat of preterm birth, they developed 'personal coping strategies to survive the pregnancy' and they watched as the strain made their 'whole family crumble'. CONCLUSION: Women's journey through pregnancy after a previous PTB experience is one of emotional and physical endurance. Women embrace the 'high risk' identity as it offers the opportunity for regular assessment and clinical reassurance. However, emotional and psychological needs must also be addressed to reduce stress and anxiety. By setting mutually agreed short term goals, significant milestones can be reached so that women feel they are successfully progressing through a high risk pregnancy through a series of 'baby steps'.