Maternal outcomes at 3 months after planned caesarean section versus planned vaginal birth for twin pregnancies in the Twin Birth Study: a randomised controlled trial

OBJECTIVE: To compare outcomes at 3 months post partum for women randomised to give birth by planned caesarean section (CS) or by planned vaginal birth (VB) in the Twin Birth Study (TBS). DESIGN: We invited women in the TBS to complete a 3-month follow-up questionnaire. SETTING: Two thousand and eight hundred and four women from 25 countries. POPULATION: Two thousand and five hundred and seventy women (92% response rate). METHODS: Women randomised between 13 December 2003 and 4 April 2011 in the TBS completed a questionnaire and outcomes were compared using an intention-to-treat approach. MAIN OUTCOME AND MEASURES: Breastfeeding, quality of life, depression, fatigue and urinary incontinence. RESULTS: We found no clinically important differences between groups in any outcome. In the planned CS versus planned VB groups, breastfeeding at any time after birth was reported by 84.4% versus 86.4% (P = 0.13); the mean physical and mental Short Form (36) Health Survey (SF-36) quality of life scores were 51.8 versus 51.6 (P = 0.65) and 46.7 versus 46.0 (P = 0.09), respectively; the mean Multidimensional Assessment of Fatigue score was 20.3 versus 20.8 (P = 0.14); the frequency of probable depression on the Edinburgh Postnatal Depression Scale was 14.0% versus 14.8% (P = 0.57); the rate of problematic urinary incontinence was 5.5% versus 6.4% (P = 0.31); and the mean Incontinence Impact Questionnaire-7 score was 20.5 versus 20.4 (P = 0.99). Partner relationships, including painful intercourse, were similar between the groups. CONCLUSION: For women with twin pregnancies randomised to planned CS compared with planned VB, outcomes at 3 months post partum did not differ. The mode of birth was not associated with problematic urinary incontinence or urinary incontinence that affected the quality of life. Contrary to previous studies, breastfeeding at 3 months was not increased with planned VB. TWEETABLE ABSTRACT: Planned mode of birth for twins doesn't affect maternal depression, wellbeing, incontinence or breastfeeding

A qualitative interview study into experiences of management of labor pain among women in midwife-led care in the Netherlands

Contains fulltext : 175631.pdf (publisher's version ) (Open Access)INTRODUCTION: Many pregnant women are concerned about the pain they will experience in labor and how to deal with this. This study's objective was to explore women's postpartum perception and view of how they dealt with labor pain. METHODS: Semistructured postpartum interviews were analyzed using the constant comparison method. Using purposive sampling, we selected 17 women from five midwifery practices across the Netherlands, from August 2009 to September 2010. RESULTS: Women reported that control over decision making during labor (about dealing with pain) helped them to deal with labor pain, as did continuous midwife support at home and in hospital, and effective childbirth preparation. Some of these women implicitly or explicitly indicated that midwives should know which method of pain management they need during labor and arrange this in good time. DISCUSSION: It may be difficult for midwives to discriminate between women who need continuous support through labor without pain medication and those who genuinely desire pain medication at a certain point in labor, and who will be dissatisfied postpartum if this need is unrecognized and unfulfilled

Effect of spontaneous pushing versus valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials

To critically evaluate any benefit or harm for the mother and her baby of Valsalva pushing versus spontaneous pushing in the second stage of labour. Electronic databases from MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were systematically searched (last search May 2010). The reference lists of retrieved studies were searched by hand and an internet hand search of master theses and dissertations was performed. No date or language restriction was used. Randomised controlled trials that compared instructed pushing with spontaneous pushing in the second stage of labour were considered. Studies were evaluated independently for methodological quality and appropriateness for inclusion by two authors (MP and JB). The primary outcome was instrumental/operative delivery. Other outcomes were length of labour, any perineal repair, bladder function, maternal satisfaction. Infant outcomes included low Apgar score < 7 after 5 minutes, umbilical arterial pH <7.2, admission to neonatal intensive care unit and serious neonatal morbidity or perinatal death. Three randomised controlled studies covering 425 primiparous women met the inclusion criteria. Women who used epidural analgesia were excluded in all three studies. No statistical difference was identified in the number of instrumental/operative deliveries (three studies; 425 women; relative risk 0.70; 95% CI 0.34-1.43), perineal repair, postpartum haemorrhage. Length of labour was significantly shorter in women who used the Valsalva pushing technique (three studies; 425 women; mean difference 18.59 minutes; 95% CI 0.46-36.73 minutes). Neonatal outcomes did not differ significantly. Urodynamic factors measured 3 months postpartum were negatively affected by Valsalva pushing. Measures of first urge to void and bladder capacity were decreased (one study; 128 women; mean difference respectively 41.50 ml, 95% CI 8.40-74.60, and 54.60 ml, 95% CI 13.31-95.89). AUTHORS' CONCLUSION: The evidence from our review does not support the routine use of Valsalva pushing in the second stage of labour. The Valsalva pushing method has a negative effect on urodynamic factors according to one study. The duration of the second stage of labour is shorter with Valsalva pushing but the clinical significance of this finding is uncertain. The primary studies are sparse, diverse and some flawed. Further research seems warranted. In the mean time supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practic

Maternal cytomegalovirus infection prevention: the role of Dutch primary care midwives.

Objective: to assess the knowledge of cytomegalovirus (CMV) infection among Dutch primary care midwives, and clinical approaches to informing women about CMV. Design: cross-sectional study, using self-administered questionnaires. Participants: 330 Dutch primary care midwives. Setting: primary midwifery care practices across the Netherlands. Main outcome: Midwives׳ knowledge of CMV transmission routes and maternal symptoms, and clinical practice behaviours regarding CMV, the information typically provided or reasons for not informing pregnant women about CMV. Findings: the overall median knowledge score was 8.0 out of a maximum possible score of 13.0. Of all participants, 10.6% reported always informing pregnant women about CMV infection prevention and 41.0% reported never informing pregnant women. The main reason indicated for not informing pregnant women was lack of knowledge about preventive methods (45.7%). Conclusion: Dutch primary care midwives have limited knowledge of CMV infection. Improvement in providing education to pregnant women about strategies to prevent CMV is necessary. (aut. ref.

Observational study to assess pregnant women’s knowledge and behaviour to prevent toxoplasmosis, listeriosis and cytomegalovirus.

Background: Toxoplasmosis, listeriosis and cytomegalovirus (CMV) can negatively affect pregnancy outcomes, but can be prevented by simple precautions of pregnant women. Literature suggests that pregnant women are not always adequately informed by their care provider about preventable infectious diseases and most pregnant women have a low level of knowledge regarding these topics. There is not much information about the actual risk behaviour of pregnant women. The purpose of this study was to assess knowledge and risk behaviour related to toxoplasmosis, listeriosis and CMV infection prevention in pregnant women. Methods: A cross-sectional survey among pregnant women from twenty midwifery practices across the Netherlands that participated in the DELIVER study, between October 2010 and December 2010. The questionnaire items covered respondents’ knowledge of preventive practices in general, risk behaviour, and sources of received information. Results: Of the 1,097 respondents (response 66.0%), 75.3% had heard, read or seen information about toxoplasmosis, 61.7% about listeriosis and 12.5% about CMV. The majority reported having heard about these infections from their care providers or read about these in printed media or on the Internet. Respondents showed limited knowledge about preventive practices for toxoplasmosis, listeriosis or CMV infection. Regarding toxoplasmosis, risk behaviour was more prevalent among respondents who had a high level of education, had the Dutch nationality, did not take folic acid during their first trimester, and had ever worked in a children day-care setting. Regarding listeriosis, risk behaviour was more prevalent among respondents who where in their third trimester. Regarding CMV infections, risk behaviour was less prevalent among respondents who were in their third trimester of pregnancy. Conclusion: Of the respondents, a substantial part did not have knowledge about preventive practices to avoid listeriosis, toxoplasmosis and CMV infections during pregnancy. Many pregnant women are appropriately avoiding risk behaviour, without knowing what they are avoiding. Advising pregnant women about behaviours and life-style habits to prevent infectious diseases remains important and information about preventive practices need to be complete and adequate. However, it may be less important to give pregnant women specific infectious diseases information. More attention towards CMV is necessary. (aut. ref.

Midwifery - a vital path to quality maternal and newborn care:the story of the Lancet Series on Midwifery

Objective: To re-assess the work and workload of primary care midwives in the Netherlands. Background: In the Netherlands most midwives work in primary care as independent practitioners in a midwifery practice with two or more colleagues. Each practice provides 24/7 care coverage through office hours and on-call hours of the midwives. In 2006 the results of a time registration project of primary care midwives were published as part of a 4-year monitor study. This time registration project was repeated, albeit on a smaller scale, in 2010. Method: As part of a larger study (the Deliver study) all midwives working in 20 midwifery practices kept a time register 24 hours a day, for one week. They also filled out questionnaires about their background, work schedules and experiences of workload. A second component of this study collected data from all midwifery practices in the Netherlands and included questions about practice size (number of midwives and number of clients in the previous year). Findings: In 2010, primary care midwives actually worked on average 32.6 hours per week and approximately 67% of their working time (almost 22 hours per week) was spent on client-related activities. On average a midwife was on-call for 39 hours a week and almost 13 of the 32.6 hours of work took place during on-call-hours. This means that the total hours that an average midwife was involved in her work (either actually working or on-call) was almost 59 hours a week. Compared to 2004 the number of hours an average midwife was actually working increased by 4 hours (from 29 to 32.6 hours) while the total number of hours an average midwife was involved with her work decreased by 6 hours (from 65 to 59 hours). In 2010, compared to 2001–2004, the midwives spent proportionally less time on direct client care (67% vs. 73%), although in actual number of hours this did not change much (22 vs. 21). In 2009 the average workload of a midwife was 99 clients at booking, 56 at the start of labour, 33 at childbirth, and 90 clients in postpartum care. Conclusion: The midwives worked on average more hours in 2010 than they did in 2004 or 2001, but spent these extra hours increasingly on non-client-related activities. (aut.ref.

Perinatal mortality rate in the Netherlands compared to other European countries: a secondary analysis of Euro-PERISTAT data

Objective: the poor perinatal mortality ranking of the Netherlands compared to other European countries has led to questioning the safety of primary care births, particularly those at home. Primary care births are only planned at term. We therefore examined to which extent the perinatal mortality rate at term in the Netherlands contributes to its poor ranking. Design: secondary analyses using published data from the Euro-PERISTAT study. Setting and participants: women that gave birth in 2004 in the 29 European regions and countries called 'countries' included in the Euro-PERISTAT study (4,328,441 women in total and 1,940,977 women at term). Methods: odds ratios and 95% confidence intervals were calculated for the comparison of perinatal mortality rates between European countries and the Netherlands, through logistic regression analyses using summary country data. Main outcome measures: combined perinatal mortality rates overall and at term. Perinatal deaths below 28 weeks, between 28 and 37 weeks and from 37 weeks onwards per 1000 total births. Findings: compared to the Netherlands, perinatal mortality rates at term were significantly higher for Denmark and Latvia and not significantly different compared to seven other countries. Eleven countries had a significantly lower rate, and for eight the term perinatal mortality rate could not be compared. The Netherlands had the highest number of perinatal deaths before 28 weeks per 1000 total births (4.3). Key conclusions: the relatively high perinatal mortality rate in the Netherlands is driven more by extremely preterm births than births at term. Although the PERISTAT data cannot be used to show that the Dutch maternity care system is safe, neither should they be used to argue that the system is unsafe. The PERISTAT data alone do not support changes to the Dutch maternity care system that reduce the possibility for women to choose a home birth while benefits of these changes are uncertain. © 2013 Elsevier Ltd