1A. Consider all birthplace options, recognizing that birth experiences are enhanced in home, birth center, or hospital settings that support parent's informed choices for the labor, birthing, and postpartum process.
References:
Abstract 1:
Premise: Low-risk women received an increase in medical interventions during childbirth at tertiary hospital settings compared to Level I or II hospitals.
Research Question: Do women with low-risk pregnancies receive excess medical procedures that vary by hospital type?
Background: The majority of women have healthy pregnancies. Medical interventions in a low-risk group are in large part unnecessary.
Study Design: Stratified sampling across hospital levels was used to investigate the relation of the hospital level and the use of medical interventions, including electronic fetal monitoring, labor induction, and cesarean delivery.
Variables: Hospital level, gestational age, location of mother’s residence, mother’s age, mother’s education, birth weight, hours of labor, prenatal care, parity, cultural background, martial status, race, and complications.
Subjects: Hospitals ranged from Level I-III. Included were 4,477 low-risk births. Inclusion criteria included having a predicted gestational age of 37-42 weeks, mother’s age of 18-35 years, first to fourth baby, eight or more years of education, prenatal care beginning by the fifth month and including at least 5 visits, and no known obstetric or medical complications. No differences existed across hospital levels for birth weight, gestational age, or duration of labor. Differences in mother’s age, years of education, number of prenatal visits, parity, race, and marital status were present but not of a magnitude to confound the relation between hospital level and the obstetric procedures of interest.
Findings: Increased fetal monitoring, inductions, and cesarean births in low-risk women were associated with the level of the hospital, with tertiary hospitals using the most interventions and secondary hospitals using an intermediate amount of interventions. Additionally, inductions increased with the mother’s age and if her status was single. Cesarean births increased with the mother’s age and nonwhite status.
Research reviewed by Rochelle Gower, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 2:
Premise: Many women receive unnecessary interventions during childbirth. Higher medical costs are associated with the use of unnecessary obstetrical interventions.
Research Question: What type of care do women receive at birth centers?
Background: The goal of the birth center is to achieve satisfaction and safety in the birthing experience, reduce interventions, and to reduce costs.
Variables: Age, parity, gestation, race, culture, education, finances, prenatal care, and care provider.
Subjects: A total of 11,814 women admitted to 84 birth centers for intrapartum care. High proportions of the women were low-income Hispanics.
Data Collection: The National Birth Center Study was conducted by the National Association of Childbearing Centers. The care in 84 birth centers was included in the study--over half of the birth centers known to be in operation between 1985-1987. Data were collected on each woman on a prenumbered, four-part form completed 1) during the woman’s first prenatal visit, 2) when the woman was admitted to the hospital, 3) when the woman was discharged or being transferred to a hospital, and 4) during the woman’s 4- to 6-week checkup. The forms were completed by the women’s care providers and data collection was supervised by a specially trained member of the staff at each birth center. Completed forms were returned monthly for review. Each woman received a socio-demographic risk score, a behavioral/lifestyle risk score, and a medical/obstetric risk score. Comparisons with national data were also done.
Findings: Most birthing center care differed from standard hospital care in several ways:
Primagravidas had longer labors and required more interventions than multiparas.
Research reviewed by Rochelle Gower, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 3:
Premise: Routine enemas in labor are not supported by research.
Research Questions: Does an enema decrease the duration of labor? Does it decrease the incidence of fecal contamination during delivery? Does it decrease postpartum infections with intestinal bacteria among mothers and infants?
Background: For many years, women admitted to the hospital to deliver their babies were routinely subjected to enemas while in the early stages of labor. This practice was based on the assumption that administering enemas had three major benefits: decreasing the length of labor, keeping the field for delivery free of fecal matter, and preventing postpartum infections.
Subjects: A total of 274 at-term women who entered a British hospital for delivery of singleton infants were studied. A group of 149 subjects were assigned to the control group (enema group), and 125 subjects were assigned to the experimental group (no enema group).
Study Design: Randomized control trial. Women in the experimental group were given small-volume, disposable phosphate enemas. The randomized study assigned patients to the control or study group based on whether their hospital ID numbers were odd or even. Patients who required cesarean sections were excluded. A similar percentage of primiparae and multiparae existed in each study group.
Findings: Length of labor showed no significant difference between the enema and no-enema group. In either group, 84 % of study subjects did not have a soiling incident during the first stage of labor. In the second stage of labor, however, only 61% of the study group and 65% of the control group remained free of fecal contamination. This difference between the two groups was not statistically significant. For either group, if soiling did occur, it was minimal. In the nonenema group, if soiling did occur, it tended to be solid and thus easily removed. The enema group, on the other hand, had more liquid stools, which were more difficult to clean. There were seven cases of neonatal infections in each group. The study results concluded that the routine use of enemas for all laboring women could not be supported.
Research reviewed by Ursula Fitzgerald, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 4:
Premise: Routine enemas in labor are not supported by research.
Research Questions: Do enemas speed up labor? Do they reduce the incidence of fecal contamination? Do they decrease the risk of postpartum infections among mothers and babies? How do women in labor really feel about receiving enemas?
Background: Drayton and Rees attempted to duplicate Romney and Gordon’s (1981) research on enemas using a randomized controlled study format.
Subjects: Two hundred twenty-two women who entered the University of Wales, Cardiff, labor and delivery unit during the time of the study agreed to participate. All were at or beyond 37 weeks of gestation and carried a single fetus. Expecting mothers with conditions complicating delivery such as heart disease, diabetes, hemorrhage, or pre-eclampsia were excluded from the study.
Study Design: Subjects were randomly assigned to the experimental (no enema) or the control (enema) group. Primigravidae were studied separately from multipravidae. Low-volume phosphate enemas were used. Duration of labor was timed. Assessment of fecal contamination was divided between first and second stages of labor. Soiling was evaluated using a 0-3 point scale. A score of 0 represented no fecal soiling, while 1 represented minimal contamination, 2 represented no more than two stools, and 3 represented frequent stools. Infections found among neonates were evaluated for the presence of fecal bacteria. To assess participants’ subjective feelings about being given enemas, interviews were conducted by a research midwife within 24 hours of delivery.
Findings: Length of labor was not significantly affected by the administration of an enema. For the multiparous women, the length of labor was almost identical in both groups. Thus, the hypothesis that enemas speed labor could not be supported. Minimal fecal soiling occurred in about 8% in either group and went unnoticed by the laboring woman in most cases. Six percent of the enema group and 4% of the no-enema group encountered fecal contamination at grades 2 and 3. During the second stage of labor, 56% of the experimental group and 78% of the control group remained clean. This difference was statistically significant. However, most of the recorded incidences fell into category 1 (minimal). As it was mostly formed stool, it could be easily removed. It was concluded, therefore, that enemas can reduce the incidence of fecal contamination during the second stage of labor. However, it was also noted that when contamination did occur after enema administration, it became more difficult to manage due to its consistency. In the experimental group, infection rates among neonates were similar to those found among the control group. Only one neonate in each group, however, was infected with fecal bacteria. None of the mothers in either group contracted a perineal wound infection. It was thus concluded that, while enemas can reduce the overall incidence of soiling during labor, a correlation to subsequent postpartum infections could not be established.
Research reviewed by Ursula Fitzgerald, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond VA.
Abstract 5:
Premise: Two controversial management policies exist concerning artificial rupture of membranes.
Research Question: Should the fetal membranes of women in normal labor be ruptured or be left intact as long as possible?
Background: In Ireland, the membranes are ruptured routinely. In Denmark, the membranes are left intact as long as possible. Routine artificial rupture of membranes in women in labor at term is a controversial topic and the outcomes need to be compared.
Subjects: A total of 1,132 women.
Study Design: Six hundred forty-five women in labor at term had routine amniotomy performed, while 487 women in labor at term had only selective amniotomy. Duration of labor, Apgar scores, fetal morbidity and maternal morbidity, mode of delivery, epidural rates, and total number of vaginal examinations in the first stage of labor after amniotomy were measured.
Findings: A policy of routine amniotomy in labor had no measurable advantage over selective amniotomy for parous women, but shortened labor in nulliparous women. There was a higher cesarean section rate and there were more vaginal examinations after membrane rupture in the group with routine amniotomy.
Research reviewed by Kelly Talbert, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 6:
Premise: Few well-controlled research data exist to judge the effectiveness of routine amniotomy.
Research Hypotheses: What is the outcome of labors that are managed with the intention to leave the membranes intact, compared to the practice of routine elective artificial rupture of the membranes?
Background: The decision whether, or when, to rupture the membranes in uncomplicated labor is a longstanding obstetric controversy.
Subjects: Three hundred sixty-two women in spontaneous labor with intact membranes and no evidence of fetal distress, between 37 and 42 weeks gestation.
Study Design: Prospective randomized controlled trial of low-risk women admitted in spontaneous labor, with intact membranes. The duration of each phase of labor, epidural rate, prevalence of an abnormal cardiotocograph, method of delivery, and neonatal outcome were measured.
Findings: Routine artificial rupture of membranes results in shorter labor, but with more epidurals, suggesting that labor is more painful. Fewer fetal heart rate abnormalities occurred if the membranes were left intact. The occurrence of fetal heart rate abnormalities did not adversely affect fetal condition at birth. No differences in postpartum pyrexia were noted between the groups of mothers.
Research reviewed by Kelly Talbert, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 7:
Premise: Early artificial rupture of membranes is frequently practiced in the belief that labor will be shortened.
Research Hypotheses: Does early amniotomy increase the hourly rate of fetal heart rate record abnormalities? Does early amniotomy affect neonatal outcome?
Background: Previous researchers have reported an association between membrane rupture and fetal heart rate abnormalities.
Subjects: A total of 925 women presenting at term in spontaneous labor with intact membranes and a cervical dilation of <6cm.
Study Design: The hourly rates of early, mild variable, severe variable, late decelerations, and cesarean section rates were recorded in the groups with routine amniotomy and in the group in which amniotomy was only performed if there was a medical indication.
Findings: Amniotomy may result in an increase in the frequency of severe variable decelerations with no evidence of worsened neonatal outcomes. Early amniotomy is linked with an increase in cesarean section for fetal distress in facilities where the diagnosis of fetal compromise is based primarily on electronic monitoring. The risk benefit ratio should be carefully considered by maternal and birth setting characteristics.
Research reviewed by Kelly Talbert, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 8:
Premise: Midline episiotomy and severe vaginal lacerations are correlated. When the number of episiotomies declined, the level of intact perinea rose.
Research Hypothesis: A correlation exists between vaginal and perineal morbidity and episiotomies performed during vaginal deliveries.
Background: Episiotomies were popularized in the 1920s. However, a lack of scientific evidence exists to support the supposed benefits of episiotomy.
Subjects: A total of 17,483 women who had spontaneous vaginal deliveries at term of a single fetus in cephalic presentation during the years of 1976-1994 at the University of California, San Francisco Moffitt Hospital.
Study Design: Examination of episiotomy rates and trauma to perinea and vagina for 17,483 women who had spontaneous vaginal deliveries using time series analysis.
Findings: From January 1976 to December 1994, the use of episiotomy declined from 86.8% to 10.4 %. The decline of episiotomies coincided with a decline in third- and fourth-degree lacerations from 9.0% to 4.2%, equaling a 53% reduction in severe lacerations. The number of minor vaginal lacerations increased.
Research reviewed by Tamatha Cales, RN, while a student at Virginia Commonwealth University, School of Nursing in Richmond, VA.
Abstract 9:
Premise: Postpartum anal incontinence is a debilitating condition and episiotomies may contribute to this condition.
Research Questions: 1) To what extent does the risk of postpartum anal incontinence vary by degree and type of perineal trauma, and does episiotomy predispose to postpartum anal incontinence? 2) Do women who have episiotomies have a different risk of anal incontinence than women allowed to tear spontaneously to the same degree?
Background: From 6% to 10% of women experience problems with defecation postpartum and 13% to 20% lose control of flatus. Having a midline episiotomy may predispose women to having fecal and anal incontinence.
Subjects: Primiparous women who had vaginal, live, full-term births between August 1, 1996, and February 8, 1997, at the Brigham and Women’s Hospital in Boston. A total of 626 women categorized into three groups (episiotomy, no episiotomy and a tear, and no episiotomy and no or a first-degree tear) participated.
Study Design: A questionnaire was mailed to the women at approximately six months postpartum. Each individual was sent a letter that explained the interest in medical problems that may occur after a vaginal delivery, but did not specify the interest related to episiotomy. The questionnaire asked the participants to recall any problems with fecal and flatus incontinence at three months postpartum and to specify any problems they may be experiencing now at six months postpartum.
Findings: Approximately 10% of women who had episiotomies were experiencing fecal incontinence three months postpartum. Less than 5% of tear and intact groups experienced fecal incontinence. At six months postpartum, fecal incontinence was 1/2 of what was reported at three months postpartum for both groups. Flatus incontinence was experienced by 33% of women who had episiotomies at three months postpartum, and 25% experienced flatus incontinence at six months postpartum. The corresponding rates for nonepisiotomies were 20% and 13%. The effect of episiotomies was not influenced by association with operative or complicated deliveries.
Research reviewed by Tamatha Cales, RN, while a student at Virginia Commonwealth University, School of Nursing in Richmond, VA.
Abstract 10:
Premise: High cesarean rates are highly influenced by the practice style of physicians if they do not view birth as a natural event.
Research Question: Is the individual clinician a major determinant to the method of delivery?
Background: The number of cesarean births is high, increasing from 5% in 1960 to more than 25% by the late 1980s.
Subjects: A total of 1,533 affluent woman at low risk of obstetrical complications who were cared for by 11 obstetricians in a single community hospital for a 12-month period.
Study Design: Demographics and perinatal outcomes of the women were studied prospectively from patient logbook in a community hospital in an affluent suburb in Detroit. After the 12-month study period, all 11 physicians completed a survey that assessed the influence of recent medical and legal experience on the their individual practitioners.
Findings: The mean cesarean-section rate for all 11 physicians was 26.9%, with a range from 19.1%-42.3%. However, when the repeat cesarean sections were excluded, the mean cesarean-section rate was 17.2%, with a range of 9.6%-31.8%. Only nulliparity had a greater effect on the primary cesarean-section rate (2.4 % increase in explanation of the variance P<0.00001) than the individual physician (13.7 % increase in the explanation of the variance P<0.001). The results support the idea that the individual clinician is a major factor in determining the method of delivery.
Research reviewed by Ruthie Forehand, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 11:
Premise: Cesarean sections may lead to long-term effects on subsequent pregnancies.
Research Question: Is cesarean section a modest risk factor for ectopic pregnancy and an important risk factor for placental problems in subsequent pregnancies?
Background: The large numbers of cesarean sections performed in many countries have raised concerns and questions regarding the risks of maternal morbidity and intended infant benefits. The long-term effects of cesarean section are unclear and few studies exist exploring these risks.
Subjects: A total of 16,938 women having had a cesarean section with a matched control group.
Study Design: Records from two nationwide registries in Finland were retrospectively studied: the birth register and the hospital inpatient register. Women (n=16,938) having had a cesarean section (exposed women) and a matched control group were identified from the registry. From 1987 to 1993, the first subsequent pregnancy occurrence and outcome were determined from the hospital inpatient register and from the birth register.
Findings: Among exposed women, the first subsequent pregnancy was more often an ectopic pregnancy. This information suggests that cesarean section is a modest risk factor for subsequent ectopic pregnancies. The risk of placenta previa increases with parity and, in this study, was only observed among exposed women who were having their second child. More studies should investigate the long-term effect of cesarean births.
Research reviewed by Laura Sims, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.