The second stage of labour - the use of interventions and women's experiences

AbstractThe overall aim of this thesis was to explore women´s experiences of the second stage of labour, midwifery practices and the use of interventions.Methods: Study I is a retrospective cohort study where 764 medical records from 2017 were reviewed. Women in Robson group 1 were included. Descriptive and analytic statistics were used to describe the use of oxytocin and to compare mode of birth in Robson group 1. Study II included 21 women with spontaneous vaginal births from 37 gestational weeks who were interviewed about their experiences of the second stage of labour four to ten weeks after birth. Thematic analysis based on descriptive phenomenology was used to analyse data. In study III and IV data from a follow-up questionnaire sent to women one month after birth were used. Inclusion criteria were women opting for their first vaginal birth from 37 gestational weeks with a singleton pregnancy. Study III is a multicentre randomised controlled trial which included 2221 women who were randomised to being assisted by one or by two midwives in the late second stage of labour with the aim of reducing severe perineal trauma. Women’s experiences of the second stage of labour were measured using Likert scales and were analysed according to intention to treat. Study IV is an observational study using data from 2233 women who responded to the follow-up questionnaire sent to women one month after birth. Midwifery practices and interventions used during the second stage were evaluated in relation to informed consent and experiences of the second stage of labour. Analyses were performed with univariate and multivariable logistic regression.Main findings: In study I, oxytocin for labour augmentation was used in 64.1% of the births. Adherence to recommendations and a shorter time treated with oxytocin was associated with a greater likelihood of vaginal birth. In study II women’s experiences of the second stage of labour were described in three themes: “An experience of upheaval”, representing intensity, power and pain. “The importance of trusting relationships” emphasizes the meaning of relationships. “Becoming a mother” describes feelings during the final moments of birth. Study III showed that women’s experiences of the second stage of labour did not differ between women who were randomised to assistance by one or by two midwives in the late second stage of labour. In study IV, provided informed consent to midwifery practices and interventions during the second stage was reported by 17.6% of the women. Informed consent was associated with more positive experiences of the second stage and less discomfort and/or pain from vaginal examinations, episiotomy, perineal massage and catheterization of the bladder. Conclusions: This thesis provides evidence about how the second stage of labour can be experienced by women and how provided informed consent affects women’s experiences during this stage. Being assisted by an additional midwife during the late second stage did not to affect women’s experiences which is of importance as this intervention reduces severe perineal trauma. The findings from this thesis also shed light on a routine use of interventions as well as an overuse of oxytocin for labour augmentation. In conclusion, this thesis contributes to a deeper understanding of how individualized care can be enabled in the significant and transformative life-event of becoming a mother. Key words: Birth experience, interventions, midwifery practices, synthetic oxytocin, the second stage of labou

Management of oxytocin for labour augmentation in relation to mode of birth in Robson group 1

Objective: To compare mode of birth in Robson group 1 according to administration of oxytocin for labour augmentation. Design and participants: A retrospective review of 724 medical records from women in Robson group 1 was performed. The outcome measurements were: mode of birth in relation to presence of labour dystocia when initiating augmentation with oxytocin, duration of augmentation with oxytocin, increase of the oxytocin infusion according to recommendations and cervical dilation when initiating augmentation with oxytocin. Setting: The review was based on medical records from a medium-sized tertiary level obstetric unit in southern Sweden, with approximately 3700 births per year. Data was collected between January 2017 and October 2017. Measurements and Findings: Oxytocin for labour augmentation was used in 64.1% of the births. Oxytocin administered according to the national recommendations was related to a greater likelihood of vaginal birth than when these recommendations were not followed. Only 47.8% of the women who underwent a caesarean section was treated according to recommendations. Receiving augmentation with oxytocin at a later stage of labour was related to a greater likelihood of a vaginal birth. The total time treated with oxytocin was significantly longer in women who had an assisted vaginal birth or a caesarean section than those who had a vaginal birth with augmentation. Key conclusions: Oxytocin for labour augmentation was over-used in Robson group 1. Oxytocin early in labour, a long duration of stimulation with oxytocin and a slower increase of the infusion than recommended had a relationship with caesarean section. Implication for practice: Due to risks for adverse maternal and neonatal outcomes when using oxytocin for labour augmentation, caregivers should implement strict protocols for its use. According to a high use of oxytocin there is a need to describe women's experiences of labour augmentation in labour dystocia but also when received despite normal labour progress

Den prematura förlossningen - föräldrars upplevelse En kvalitativ studie

Problembeskrivning: Vid prematur förlossning befinner sig blivande föräldrar i en utsatt och sårbar situation samtidigt som livet står i en förändringsfas. För barnet innebär den prematura förlossningen risk för sjuklighet och dödlighet. Vetskapen kan innebära en påfrestning för föräldrarna under förlossningen. Syfte: Syftet var att belysa föräldrars upplevelser av en prematur vaginal förlossning, där barnet levde. Metod: En kvalitativ metod med induktiv ansats användes, där 13 nyblivna föräldrar intervjuades. Insamlat material bearbetades med innehållsanalys. Resultat: Fem huvudkategorier utkristalliserades; Personalens åtgärder, Förlossningsförloppet, Personalens inverkan på föräldrarna, Förälderns möjlighet att påverka förlossningssituationen och Barnets hälsa. Slutsats: Föräldrarna vid en prematur förlossning befinner sig ofta i ett chockartat tillstånd varför det är viktigt att de ges upprepad och tydlig information. Därtill visade sig lugn och professionell personal samt bemötande vara viktiga komponenter för föräldrarnas välbefinnande

Women's experiences of the second stage of labour

Background: The second stage of labour is generally considered as an intensive part of labour. Despite this, knowledge about women's experiences of the second stage of labour is scant. Aim: To explore experiences of the second stage of labour in women with spontaneous vaginal birth. Methods: This is a qualitative study where twenty-one women with a spontaneous birth at term, were interviewed four to ten weeks after birth. Data were analysed using qualitative thematic analysis based on descriptive phenomenology. The participating women had experienced a vaginal birth; some for the first time, having previously given birth by caesarean section and some with a previous vaginal birth. Findings: Three themes emerged: “An experience of upheaval” which represents the women's experiences of intensity, power and pain during the second stage of labour. “The importance of trusting relationships” signifies the meaning of women's relationships during the second stage of labour. “Becoming a mother” which is characterised by feelings of accomplishment and the experience of the final moments of birth. Conclusion: During the second stage of labour women experienced overwhelming sensations which made evident the importance of trusting relationships with those involved in the birth. The women were in a transformative state between pregnancy and motherhood where experiences of being involved and being provided with information and guidance were all considered crucial. Continuous support should be offered to women during the second stage of labour

The Effect of Two Midwives During the Second Stage of Labour to Reduce Severe Perineal Trauma (Oneplus) : A Multicentre, Randomized Controlled Trial in Sweden

In many high-income countries, severe perinatal trauma (SPT), affecting the anal sphincter muscle complex, has been on the rise over the last decade. However, effective strategies to prevent SPT are scarce. In randomized controlled trials, only perineal warm compresses and massage have shown benefit. Other cohort studies have shown that prevention models involving several components can decrease the occurrence of SPT, including a stepped-wedge design that reduced SPT from 3.3% to 3.0%. In Scandinavia, a preventive strategy called collegial assistance has been used to help prevent SPT. This strategy involves 2 midwiveswho assist thewoman in the second stage of labor, with the second midwife primarily focused on preventing SPT. The aim of this study was to compare the rate of SPT in pregnancies managed by collegial assistance versus a single midwife. This Oneplus study was a randomized, controlled, unmasked trial, conducted at 5 obstetric units in Sweden between December 10, 2018, and March 21, 2020. Included were adult women with uncomplicated singleton pregnancies at >37 weeks of gestation, who were carrying their first child or having their first vaginal birth after cesarean delivery. Excluded were women who had multiple pregnancies, had intrauterine fetal demise, were undergoing a planned cesarean section, or were at <37 weeks' gestation.Women were randomly assigned to either the intervention group with 2 midwives in attendance during active second stage labor or standard care with 1 midwife. All midwives were asked to document the preventive methods used in case report forms. A total of 3750 women were included in the final analysis-with 1879 women receiving collegial assistance and 1871 women receiving standard care. Of the women who gave birth spontaneously, 1546 were in the intervention group and 1513 in the standard care group. Severe perinatal trauma occurred less frequently in the intervention group than the standard care group (3.9% vs 5.7%; odds ratio, 0.68; 95% confidence interval, 0.49-0.97; P = 0.025). In the intervention group, 0.2% had fourth-degree tears compared with 0.5% in the standard care group. The median time for collegial assistance was 15 minutes (interquartile range, 10-20 minutes). The use of perineal warm compresses was similar in the intervention group and standard care group (86.4% vs 85.7%, respectively). No differences were observed in birth positions, manual perineal protection, neonatal outcomes, or secondary maternal outcomes. In conclusion, the attendance of a second midwife dedicated to preventing SPT during the second stage of labor significantly reduced the risk of injury

The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden

BackgroundSevere perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife.MethodsIn this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18–47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096.FindingsBetween Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49–0·97).InterpretationThe presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time