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Aim: To develop evidence‐based clinical algorithms for the assessment and management of spontaneous, uncomplicated labour and vaginal birth. Population: Pregnant women at any stage of labour, with singleton, term pregnancies considered to be at low risk of developing complications. Setting: Health facilities in low‐ and middle‐income countries. Search Strategy: We searched for relevant published algorithms, guidelines, systematic reviews and primary research studies on Cochrane Library, PubMed, and Google on terms related to spontaneous, uncomplicated labour and childbirth up to 01 June 2023. Case scenarios: Three case scenarios were developed to cover assessments and management for spontaneous, uncomplicated first, second and third stage of labour. The algorithms provide pathways for definition, assessments, diagnosis, and links to other algorithms in this series for management of complications. Conclusions: We have developed three clinical algorithms to support evidence‐based decision making during spontaneous, uncomplicated labour and vaginal birth. These algorithms may help guide health care staff to institute respectful care, appropriate interventions where needed, and potentially reduce the unnecessary use of interventions during labour and childbirth. Evidence‐based clinical algorithms may help support respectful, high quality intrapartum care. [Correction added on 23 August 2024, after first online publication: The Abstract has been updated to structure layout in this version.] [ABSTRACT FROM AUTHOR]

Aims: To develop evidence‐based clinical algorithms for assessment and management of abnormal maternal pulse and blood pressure during the intrapartum period. Population: Low risk singleton, term, pregnant women in labour. Setting: Institutional births in low‐ and middle‐income countries. Search strategy: A review of the literature was performed to retrieve evidence‐based guidelines, systematic reviews, and papers on maternal pulse and blood pressure during labour. We searched a number of international clinical guidelines and PubMed using the corresponding key terms in November 2018 and updated the search in May 2020. Case scenarios: Four common intrapartum case scenarios of abnormal pulse and blood pressure were identified for which algorithms were developed: hypertension, hypotension, tachycardia and bradycardia. Algorithms were constructed after reviewing guidelines and relevant papers, with input from a panel of experts. Thresholds for upper and lower limits of normal maternal pulse and blood pressure measurements are defined, evidence‐based interventions for the initial management of abnormal parameters are described (resuscitation and monitoring) and guidance is provided on exploration of the potential causes for each case scenario, with links to pathways for their management. Conclusions: Evidence‐based algorithms to support the identification, and management of deviations in pulse and blood pressure during intrapartum care have been developed for hypertension, hypotension, tachycardia and bradycardia. The algorithms focus on initial resuscitation and monitoring, with an exploration of causes and early identification of underlying maternal conditions. These algorithms will help provide a standardised approach to investigation and management of these abnormal parameters to guide clinical practice. Algorithms for abnormal maternal pulse and blood pressure during labour allow standardised approach to early identification and management of complications. Algorithms for abnormal maternal pulse and blood pressure during labour allow standardised approach to early identification and management of complications. [ABSTRACT FROM AUTHOR]

Aim: The development of an evidence‐based algorithm for the clinical management of deviations in maternal temperature during labour and childbirth. Population: Pregnant women at any stage of labour, with singleton, term (37–42 weeks) pregnancies at low risk of developing complications. Setting: Health facilities in low‐ and middle‐income countries. Search strategy: We searched for international guidelines and prioritised WHO guidelines. In addition, we searched for other sources of evidence in the Cochrane Database of Systematic Reviews, EMBASE, MEDLINE and CINAHL until June 2020. Studies were prioritised according to the hierarchy of evidence. Case scenarios: Two case scenarios were identified: maternal hyperthermia and hypothermia. We developed a single algorithm including both, due to commonalities in diagnosis, monitoring and management of underlying causes. The underlying conditions covered in the pathway include maternal sepsis and infection, chorioamnionitis, pyelonephritis, lower urinary tract and respiratory infections. Key decision points in the algorithm are suspicion of condition, definition, differential diagnosis, monitoring and management. Conclusions: We present an evidence‐based algorithm to assist healthcare professionals in making decisions about appropriate clinical management of deviations in maternal temperature. Research is needed to assess the views of healthcare professionals and women accessing healthcare on the feasibility of implementing the algorithm. An evidence‐based intrapartum care algorithm to support management of deviations in maternal temperature in labour and childbirth. #sepsis #maternitycare. An evidence‐based intrapartum care algorithm to support management of deviations in maternal temperature in labour and childbirth. #sepsis #maternitycare. [ABSTRACT FROM AUTHOR]

Objective: To estimate the prevalence of obstructed labour, associated risk factors and outcomes across a network of referral hospitals in Nigeria. Design: Retrospective observational study. Setting: A total of 54 referral‐level hospitals across the six geopolitical regions of Nigeria. Population: Pregnant women who were diagnosed with obstructed labour during childbirth and subsequently underwent an emergency caesarean section between 1 September 2019 and 31 August 2020. Methods: Secondary analysis of routine maternity care data sets. Random‐effects multivariable logistic regression was used to ascertain the factors associated with obstructed labour. Main outcome measures: Risk factors for obstructed labour and related postpartum complications, including intrapartum stillbirth, maternal death, uterine rupture, postpartum haemorrhage and sepsis. Results: Obstructed labour was diagnosed in 1186 (1.7%) women. Among these women, 31 (2.6%) cases resulted in maternal death and 199 (16.8%) cases resulted in postpartum complications. Women under 20 years of age (OR 2.03, 95% CI 1.50–2.75), who lacked formal education (OR 1.88, 95% CI 1.55–2.30), were unemployed (OR 1.94, 95% CI 1.57–2.41), were nulliparous (OR 2.11, 95% CI 1.83–2.43), did not receive antenatal care (OR 3.34, 95% CI 2.53–4.41) or received antenatal care in an informal healthcare setting (OR 8.18, 95% CI 4.41–15.14) were more likely to experience obstructed labour. Ineffective referral systems were identified as a major contributor to maternal death. Conclusions: Modifiable factors contributing to the prevalence of obstructed labour and associated adverse outcomes in Nigeria can be addressed through targeted policies and clinical interventions. [ABSTRACT FROM AUTHOR]

Aim: To develop evidence‐based clinical algorithms for management of common intrapartum urinary abnormalities. Population: Women with singleton, term pregnancies in active labour and immediate postnatal period, at low risk of complications. Setting: Healthcare facilities in low‐ and middle‐income countries. Search strategy: A systematic search and review were conducted on the current guidelines from WHO, NICE, ACOG and RCOG. Additional search was done on PubMed and The Cochrane Database of Systematic Reviews up to May 2020. Case scenarios: Four common intrapartum urinary abnormalities were selected: proteinuria, ketonuria, glycosuria and oliguria. Using reagent strip testing, glycosuria was defined as ≥2+ on one occasion or of ≥1+ on two or more occasions. Proteinuria was defined as ≥2+ and presence of ketone indicated ketonuria. Oliguria was defined as hourly urine output ≤30 ml. Thorough initial assessment using history, physical examination and basic investigations helped differentiate most of the underlying causes, which include diabetes mellitus, dehydration, sepsis, pre‐eclampsia, shock, anaemia, obstructed labour, underlying cardiac or renal problems. A clinical algorithm was developed for each urinary abnormality to facilitate intrapartum management and referral of complicated cases for specialised care. Conclusions: Four simple, user‐friendly and evidence‐based clinical algorithms were developed to enhance intrapartum care of commonly encountered maternal urine abnormalities. These algorithms may be used to support healthcare professionals in clinical decision‐making when handling normal and potentially complicated labour, especially in low resource countries. Evidence‐based clinical algorithms developed to guide intrapartum management of commonly encountered urinary abnormalities. An evidence‐based clinical algorithm was developed to enhance intrapartum management of commonly encountered urinary abnormalities. [ABSTRACT FROM AUTHOR]

Aim: To develop clinical algorithms for the assessment and management of slow progress of labour. Population: Low‐risk singleton, term, pregnant women in labour. Setting: Institutional births in low‐ and middle‐income countries. Search strategy: We systematically reviewed the literature on normal labour progression, and guidance on clinical management of abnormally slow progression from 1 December 2015 to 1 October 2020 from relevant international guidelines, Cochrane reviews and primary research studies in PubMed by searching for international and national guidance documents, electronic databases and published systematic reviews using relevant keywords. Case scenarios: We developed two clinical algorithms: one for abnormally slow labour progression and arrest during first stage and one for the second stage. The algorithms provide definitions of suspected and confirmed slow progress of labour or arrest, initial assessment and ongoing monitoring, differential diagnosis, and management of the abnormalities, as well as links to other algorithms for labour management. Conclusions: Identifying abnormal progress of labour is often challenging. These algorithms may help healthcare providers identify abnormal labour progress and institute prompt management or referral where needed but also reduce misdiagnosis and unnecessary use of interventions to accelerate labour. Evidence‐based clinical algorithms may help and standardize early identification and management of abnormally slow labour progress or arrest. Evidence‐based clinical algorithms may help and standardize early identification and management of abnormally slow labour progress or arrest. [ABSTRACT FROM AUTHOR]

Objective: To construct algorithms with a sequential decision analysis pathway for monitoring of the fetal heart rate and managing fetal heart rate bradycardia, late decelerations and tachycardia during labour. Population: Low‐risk pregnant women in labour with singleton cephalic term pregnancies. Setting: Institutional births in low‐ and middle‐income countries. Search strategy: We sought relevant published clinical algorithms, guidelines and randomised trials/reviews by searching the Cochrane Library, PubMed and Google on the terms: "fetal AND heart AND rate AND algorithm AND (labour OR intrapartum)", up to March 2020. Case scenarios: The two scenarios included were fetal heart rate bradycardia or late decelerations (potentially related to uterine rupture, placental abruption, cord prolapse, maternal hypotension, uterine hyperstimulation or unexplained) and fetal heart rate tachycardia (potentially related to maternal hyperthermia, infection, dehydration or unexplained). The algorithms provide pathways for definition, assessment, diagnosis, interventions to correct the abnormalities and ongoing monitoring leading to mode of birth, and linking to other algorithms in the series. Conclusions: The algorithms provide a framework for monitoring and managing fetal heart rate bradycardia, late decelerations and tachycardia during labour. We emphasise the inherent diagnostic inaccuracy of fetal heart rate monitoring, the tendency to over‐diagnose fetal compromise, the need to consider fetal heart rate information in the context of other clinical features and the need to engage in informed, shared, family‐centred decision‐making. We note the need for further research on methods of fetal assessment during labour including clinical fetal arousal testing and the rapid biophysical profile test. Decision analysis algorithms for fetal bradycardia, late decelerations and tachycardia highlight diagnostic limitations. Decision analysis algorithms for fetal bradycardia, late decelerations and tachycardia highlight diagnostic limitations. [ABSTRACT FROM AUTHOR]

Aim: To develop algorithms as decision support tools for identifying, managing and monitoring abnormal uterine activity during labour. Population: Women with singleton, term (37–42 weeks) pregnancies in active labour at admission. Setting: Institutional birth settings in low‐ and middle‐income countries (the algorithm may be applicable to any health facility). Search strategy: PubMed was searched up to January 2020 using keywords. We also searched The Cochrane Library, and international guidelines from World Health Organization (WHO), National Institute for Health and Care Excellence (NICE), American College of Obstetricians and Gynecologists (ACOG) and French College of Gynaecologists and Obstetricians (CNGOF). Case scenarios: Algorithms were developed for two case scenarios: uterine hypoactivity and excessive uterine contractions. Key themes in the algorithm are: diagnosis, identification of probable causes, assessment of maternal and fetal condition and labour progress, monitoring and management. Conclusion: The algorithms for uterine hypoactivity and excessive uterine contractions have been developed to facilitate safe and effective management of abnormal uterine activity during labour. Research is needed to assess the views of healthcare professionals and women accessing healthcare to explore the feasibility of implementing these algorithms, and impact on labour outcomes. An evidence‐based algorithm to support clinical management of abnormal uterine activity during labour. An evidence‐based algorithm to support clinical management of abnormal uterine activity during labour. [ABSTRACT FROM AUTHOR]

Objective Design Setting Sample Methods Main outcome measures Results Conclusion Warm water immersion during labour provides women with analgesia and comfort. This cohort study aimed to establish among women using intrapartum water immersion analgesia, without antenatal or intrapartum risk factors, whether waterbirth is as safe for them and their babies as leaving the water before birth.Cohort study with non‐inferiority design.Twenty‐six UK NHS maternity services.A total of 73 229 women without antenatal or intrapartum risk factors, using intrapartum water immersion, between 1 January 2015 and 30 June 2022. The analysis excluded 12 827 (17.5%) women who received obstetric or anaesthetic interventions before birth.Non‐inferiority analysis of retrospective and prospective data captured in NHS maternity and neonatal information systems.Maternal primary outcome: obstetric anal sphincter injury (OASI) by parity; neonatal composite primary outcome: fetal or neonatal death, neonatal unit admission with respiratory support or administration of antibiotics within 48 hours of birth.Rates of the primary outcomes were no higher among waterbirths compared with births out of water: rates of OASI among nulliparous women (waterbirth: 730/15 176 [4.8%] versus births out of water: 641/12 210 [5.3%]; adjusted odds ratio [aOR] 0.97, one‐sided 95% CI, −∞ to 1.08); rates of OASI among parous women (waterbirth: 269/24 451 [1.1%] versus births out of water 144/8565 [1.7%]; aOR 0.64, one‐sided 95% CI −∞ to 0.78) and rates of the composite adverse outcome among babies (waterbirth 263/9868 [2.7%] versus births out of water 224/5078 [4.4%]; aOR 0.65, one‐sided 95% CI −∞ to 0.79).Among women using water immersion during labour, remaining in the pool and giving birth in water was not associated with an increase in the incidence of adverse primary maternal or neonatal outcomes. [ABSTRACT FROM AUTHOR]

Objective: To investigate the association between clinical and laboratory characteristics of chorioamnionitis in deliveries at term gestation with adverse neonatal outcomes. Design: Retrospective cohort study. Setting: The study is based on data from the Swedish Pregnancy Register, enriched with clinical data extracted from medical charts. Sample: A cohort of 500 term singleton deliveries in Stockholm County with registered diagnosis of chorioamnionitis (based on the assessment of the responsible obstetrician) in the Swedish Pregnancy Register between 2014 and 2020. Methods: Logistic regression was used to estimate odds ratios (ORs) as a measurement of the association between clinical and laboratory characteristics and neonatal complications. Main outcome measures: Neonatal infection and asphyxia‐related complications. Results: The prevalence of neonatal infection and asphyxia‐related complications was 10% and 22%, respectively. First leukocyte count in the second tertile (OR 2.14, 95% CI 1.02–4.49), maximum C‐reactive protein (CRP) level in the third tertile (OR 4.01, 95% Cl 1.66–9.68) and positive cervical culture (OR 2.22, 95% Cl 1.10–4.48) were associated with an increased risk of neonatal infection. Maximum level of CRP in the third tertile (OR 1.93, 95% Cl 1.09–3.41) and fetal tachycardia (OR 1.63, 95% Cl 1.01–2.65) were associated with an increased risk of asphyxia‐related complications. Conclusions: Elevated inflammatory laboratory markers were associated with both neonatal infection and asphyxia‐related complications, and fetal tachycardia was associated with asphyxia‐related complications. Based on these findings, the incorporation of maternal CRP in the management of chorioamnionitis should be considered, and a continuous communication between obstetric and neonatal care extending past the delivery time point endorsed. [ABSTRACT FROM AUTHOR]

Objective: To investigate maternal lactate concentrations in labour and the puerperium. Design: Reference study. Setting: Tertiary obstetric unit. Population: 1279 pregnant women with good perinatal outcomes at term. Methods: Electronic patient records were searched for women who had lactate measured on the day of delivery or in the following 24 hours, but who were subsequently found to have a very low likelihood of sepsis, based on their outcomes. Main outcome measures: The normative distribution of lactate and C‐reactive protein (CRP), differences according to the mode of birth, and the proportion of results above the commonly used cut‐offs (≥2 and ≥4 mmol/l). Results: Lactate varied between 0.4–5.4 mmol/l (median 1.8 mmol/l, interquartile range [IQR] 1.3–2.5). It was higher in women who had vaginal deliveries than caesarean sections (median 1.9 vs. 1.6 mmol/l, pdiff < 0.001), demonstrating the association with labour (particularly active pushing in the second stage). In contrast, CRP was more elevated in women who had caesarean sections (median 71.8 mg/l) than those who had vaginal deliveries (33.4 mg/l, pdiff < 0.001). In total, 40.8% had a lactate ≥2 mmol/l, but 95.3% were <4 mmol/l. Conclusions: Lactate in labour and the puerperium is commonly elevated above the levels expected in healthy pregnant or non‐pregnant women. There is a paucity of evidence to support using lactate or CRP to make decisions about antibiotics around the time of delivery but, as lactate is rarely higher than 4 mmol/l, this upper limit may still represent a useful severity marker for the investigation and management of sepsis in labour. [ABSTRACT FROM AUTHOR]

Objective: To explore the duration of the active phase of the second stage of labour in relation to maternal pre‐pregnant body mass index (BMI). Design: Retrospective cohort study. Setting: Labour wards of three Norwegian university hospitals, 2012–2019. Population: Nulliparous and parous women without previous caesarean section with a live singleton fetus in cephalic presentation and spontaneous onset of labour, corresponding to the Ten Group Classification System (TGCS) group 1 and 3. Methods: Women were stratified to BMI groups according to WHO classification, and estimated median duration of the active phase of the second stage of labour was calculated using survival analyses. Caesarean sections and operative vaginal deliveries during the active phase were censored. Main outcome measures: Estimated median duration of the active phase of second stage of labour. Results: In all, 47 942 women were included in the survival analyses. Increasing BMI was associated with shorter estimated median duration of the active second stage in both TGCS groups. In TGCS group 1, the estimated median durations (interquartile range) were 44 (26–75), 43 (25–71), 39 (22–70), 33 (18–63), 34 (19–54) and 29 (16–56) minutes in BMI groups 1–6, respectively. In TGCS group 3, the corresponding values were 11 (6–19), 10 (6–17), 10 (6–16), 9 (5–15), 8 (5–13) and 7 (4–11) minutes. Increasing BMI remained associated with shorter estimated median duration in analyses stratified by oxytocin augmentation and epidural analgesia. Conclusion: Increasing BMI was associated with shorter estimated median duration of the active second stage of labour. This article includes Author Insights, a video abstract available at https://vimeo.com/bjogabstracts/authorinsights17186. Linked article This article is commented on by Whitney A. Booker, pp. 2175 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471‐0528.17185 [ABSTRACT FROM AUTHOR]

Objective: To assess the association between hospital‐level rates of induction of labour and emergency caesarean section, as measures of 'practice style', and rates of adverse perinatal outcomes. Design: National study using electronic maternity records. Setting: English National Health Service. Sample Hospitals providing maternity care to women between April 2015 and March 2017. Main outcome measures: Stillbirth, admission to a neonatal intensive care unit and babies receiving mechanical ventilation. Results: Among singleton term births, the risk of stillbirth was 0.15%, the risk of admission to a neonatal intensive care unit was 5.4% and the risk of mechanical ventilation 0.54%. There was considerable between‐hospital variation in the rate of induction of labour (minimum 17.5%, maximum 40.7%) and in the rate of emergency caesarean section (minimum 5.6%, maximum 17.1%). Women who gave birth in hospitals with a higher rate of induction of labour had better perinatal outcomes. For each 5%‐point increase in induction, there was a decrease in the risk of term stillbirth of 9% (OR 0.91, 95% CI 0.85–0.97) and a decrease in the risk of mechanical ventilation of 14% (OR 0.86, 95% CI 0.79–0.94). There was no significant association between hospital‐level induction of labour rates and neonatal unit admission at term (p > 0.05). There was no significant association between hospital‐level rates of emergency caesarean section and adverse perinatal outcomes (all with p > 0.05). Conclusions: There is considerable between‐hospital variation in the use of induction of labour and emergency caesarean section. Hospitals with a higher rate of induction had a lower risk of adverse birth outcomes. A similar association was not found for caesarean section. Linked article: This article is commented on by Eric Jauniaux, pp. 1907 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471‐0528.17277 This article includes Author Insights, a video abstract available at: https://vimeo.com/bjogabstracts/authorinsights17193 [ABSTRACT FROM AUTHOR]

Background: There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors. Objective: To explore the incidence rate of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion. Search strategy: We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019. Study eligibility criteria: A study was included if LA was assessed by an imaging modality after the first vaginal birth or caesarean section. Case series and reports were not included. Data collection and analysis: RevMan v5.3 was used for the meta‐analyses and SW SAS and STATISTICA packages were used for type and timing of imaging analyses. Results: We included 37 primary non‐randomised studies from 17 countries and involving 5594 women. Incidence rates of LA were 1, 15, 21, 38.5 and 52% following caesarean, spontaneous, vacuum, spatula and forceps births, respectively, with no differences by imaging modality. Odds ratio of LA following spontaneous birth versus caesarean section was 10.69. The odds ratios for LA following vacuum and forceps compared with spontaneous birth were 1.66 and 6.32, respectively. LA was more likely to occur unilaterally than bilaterally following spontaneous (P < 0.0001) and vacuum‐assisted (P = 0.0103) births but not forceps. Incidence was higher if assessment was performed in the first 4 weeks postpartum. Conclusions: LA incidence rates following caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. Ultrasound and magnetic resonance imaging were comparable tools for LA diagnosis. Levator avulsion incidence rates after caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. Levator avulsion incidence rates after caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. This article includes Author Insights, a video abstract available at: https://vimeo.com/bjog/authorinsights16837 [ABSTRACT FROM AUTHOR]

Objective: To assess whether delivery mode and duration of labour in a first labour of spontaneous onset is associated with gestational length, delivery mode and neonatal outcome in the subsequent pregnancy. Study design: Retrospective analysis of prospectively collected data. Setting: 15 Maternity units in North West London (1988–2000). Population: 30 840 women with spontaneous onset of labour in pregnancy 1 and a subsequent birth reported in the same database. Methods: Assessment of outcomes by mode of delivery in pregnancy 1, restricting the analysis to the difference in the gestational length between pregnancy 1 and 2. Main outcome measures: Gestational length, mode of delivery and neonatal unit admission in pregnancy 2. Results: Caesarean section (CS) in the first or second stage of labour in pregnancy 1 was associated with pregnancy 2 being a median of 5 and 8 days shorter and a preterm birth rate of 6.0% and 10.1%, respectively, whereas following a normal or instrumental vaginal birth in pregnancy 1, the median duration was similar, with preterm delivery rates of 4.5% and 3.9%. In all, 56.2% of women with a CS in pregnancy 1 had a repeat CS and 12.5% of their babies were admitted to a neonatal unit, compared with 5.3% of women with vaginal birth. Longer labours were associated with shorter gestations in pregnancy 2. Conclusions: Compared with vaginal birth, an emergency CS in the first‐term pregnancy is associated with a shorter gestational length, increased rate of repeat CS and increased risk of NNU admission in the next pregnancy. An emergency caesarean section in the first‐term pregnancy affects the duration and outcome of the next pregnancy. An emergency caesarean section in the first‐term pregnancy affects the duration and outcome of the next pregnancy. [ABSTRACT FROM AUTHOR]

Objectives: To explore how childbirth-related blood loss is evaluated and excessive bleeding recognised; and to develop and test a theory of postpartum haemorrhage (PPH) diagnosis.Design: Two-phase, exploratory, sequential mixed methods design using focus groups, interviews and a pilot, randomised crossover study.Setting: Two hospitals in North West England.Sample: Women (following vaginal birth with and without PPH), birth partners, midwives and obstetricians.Methods: Phase 1 (qualitative): 8 focus groups and 20 one-to-one, semi-structured interviews were conducted with 15 women, 5 birth partners, 11 obstetricians, 1 obstetric anaesthetist and 19 midwives (n = 51). Phase 2 (quantitative): 11 obstetricians and ten midwives (n = 21) completed two simulations of fast and slow blood loss using a high-fidelity childbirth simulator.Results: Responses to blood loss were described as automatic, intuitive reactions to the speed, nature and visibility of blood flow. Health professionals reported that quantifying volume was most useful after a PPH diagnosis, to validate intuitive decisions and guide ongoing management. During simulations, PPH treatment was initiated at volumes at or below 200 ml (fast mean blood loss 79.6 ml, SD 41.1; slow mean blood loss 62.6 ml, SD 27.7). All participants treated fast, visible blood loss, but only half treated slow blood loss, despite there being no difference in volumes (difference 18.2 ml, 95% CI -5.6 to 42.2 ml, P = 0.124).Conclusions: Experience and intuition, rather than blood loss volume, inform recognition of excessive blood loss after birth. Women and birth partners want more information and open communication about blood loss. Further research exploring clinical decision-making and how to support it is required.Tweetable Abstract: During a PPH, clinical decision-making is intuitive with clinicians treating as soon as excessive loss is recognised. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether the use of intrauterine tocodynamometry versus external tocodynamometry (IT versus ET) during labour reduces operative deliveries and improves newborn outcome. As IT provides more accurate information on labour contractions, the hypothesis was that it may more appropriately guide oxytocin use than ET. Design: Randomised controlled trial. Setting: Two labour wards, in a university tertiary hospital and a central hospital. Population: A total of 1504 parturients with singleton pregnancies, gestational age ≥37 weeks and fetus in cephalic position: 269 women with uterine scars, 889 nulliparas and 346 parous women with oxytocin augmentation. Methods: Participants underwent IT (n = 736) or ET (n = 768) during the active first stage of labour. Main outcome measures: Primary outcome: rate of operative deliveries. Secondary outcomes: duration of labour, amount of oxytocin given, adverse neonatal outcomes. Results: Operative delivery rates were 26.9% (IT) and 25.9% (ET) (odds ratio 1.05, 95% CI 0.84–1.32, P = 0.663). The ET to IT conversion rate was 31%. We found no differences in secondary outcomes (IT versus ET). IT reduced oxytocin use during labours with signs of fetal distress, and trial of labour after caesarean section. Conclusions: IT did not reduce the rate of operative deliveries, use of oxytocin, or adverse neonatal outcomes, and it did not shorten labour duration. IT (versus ET) reduced oxytocin use in high‐risk labours but did not influence operative delivery rate or adverse neonatal outcomes. IT (versus ET) reduced oxytocin use in high‐risk labours but did not influence operative delivery rate or adverse neonatal outcomes. [ABSTRACT FROM AUTHOR]

Objective: To compare clinical outcomes following induction of labour (IOL) using a balloon catheter and going home, versus prostaglandin (PG) as an inpatient.Design: Randomised controlled trial.Setting: Eight Australian maternity hospitals.Population: Women with uncomplicated term singleton pregnancies undergoing IOL for low-risk indications including post-term, advanced maternal age and 'social' reasons.Methods: Between September 2015 and October 2018, 347 women were randomised to a balloon outpatient group and 348 to a PG inpatient group. The PG group received Dinoprostone, either 2 mg gel or 10 mg controlled-release tape. The balloon group had a double-balloon catheter inserted and went home.Main Outcome Measures: The primary outcome was a composite neonatal measure comprising nursery admission, intubation/cardiac compressions, acidaemia, hypoxic ischaemic encephalopathy, seizure, infection, pulmonary hypertension, stillbirth or death. Clinical and process outcomes are reported.Results: There were no statistically significant differences in the primary outcome comparing balloon with PG (18.6% versus 25.8%; relative risk = 0.77, 95% CI 0.51-1.02; P = 0.070), cord arterial pH <7.10 (3.5% versus 9.2%; P = 0.072), nursery admissions (12.6% versus 15.5%; P = 0.379), neonatal antibiotic use (12.1% versus 17.6%; P = 0.103), or mode of birth. Nulliparous women in the balloon group had lower rates of the primary outcome (20.4% versus 31.0%;P = 0.032); Parous women were less likely to have an unassisted vaginal birth (77.6% versus 92.3%; P = 0.045).Conclusions: Balloon catheters may be a superior method of cervical priming for nulliparous women, whereas this may not be the case for parous women. It is feasible that nulliparous women go home after commencing balloon catheter IOL, and the likelihood of adverse outcomes is low.Tweetable Abstract: Multicentre trial shows outpatient induction using balloon catheter is safe and feasible for nulliparous women. [ABSTRACT FROM AUTHOR]

The transcription factor nuclear factor kappa B (NFκB) controls the expression of over 400 genes, some of which are associated with reproductive events. During implantation, immune cells accumulate in the maternal-fetal interface; they secrete inflammatory mediators under the control of NFĸB, the level of which also rises. NFĸB is then downregulated to maintain gestation, but its level rises again before birth to manage prostaglandin, cytokine, and chemokine synthesis, and to stimulate uterine contraction. This review summarises the current state of knowledge about NFκB and its role in the molecular regulation of processes related to pregnancy development.Tweetable Abstract: This review examines the current state of knowledge about role of NFκB in the development of pregnancy. [ABSTRACT FROM AUTHOR]

Objective: To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia.Design: Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice.Setting: Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital.Population: Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention month (1 October 2015 until 31 January 2016) [corrected].Methods: Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively).Main Outcome Measures: Stillbirths and neonates with 5-minute Apgar score ≤5.Results: Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53-0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41-0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60-240) to 74 minutes (IQR 30-130) (Mann-Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37-0.81) and timely use improved.Conclusion: Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. TWEETABLE ABSTRACT: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital PLAIN LANGUAGE SUMMARY: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th-12th month of use. Such a 'before-after' study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines. [ABSTRACT FROM AUTHOR]

Objectives: To identify factors that are associated with a relatively low caesarean section (CS) rate by examining the CS rate in various subgroups in the Netherlands.Design: Cross-sectional analysis.Settings: the Netherlands.Population: A total of 685 452 births in the Netherlands Perinatal Registry from 2007 to 2010.Methods: A modified classification system for CS was used to categorise all women into ten groups. Labour management, mode of delivery, maternal and neonatal morbidity and mortality were assessed according to these ten groups.Main Outcome Measures: Caesarean section, labour induction, instrumental delivery, postpartum haemorrhage, perineal laceration, duration of second stage of labour, Apgar score, fetal and neonatal mortality.Results: Total CS rate was 15.6%. Term, nulliparous and parous women with a singleton pregnancy of a fetus in cephalic position and spontaneous onset of labour had CS rates of 9.6 and 1.9% and instrumental birth rates of 19.4 and 2.4%, respectively; 17.3% of births were induced. Among women with a previous CS and term, singleton pregnancies with a fetus in cephalic presentation, 71% had trial of labour, of which 75% had a successful vaginal birth. Of women with multiple gestation, 43% had CS. Women with CS due to 'failure to progress' in the second stage of labour had a median duration of second-stage pushing of almost 2 hours in nulliparas and >90 minutes in parous women.Conclusions: Several obstetric practice patterns may have contributed to the relatively low overall CS rate in the Netherlands: a relatively low CS rate in term, singleton pregnancies of a fetus in cephalic position and spontaneous onset of labour, relatively low rate of labour induction, a high rate of a trial of labour after a previous CS, the use of vacuum and forceps, and a high proportion of women being taken care of by midwives.Tweetable Abstract: The Netherlands has several practice patterns that may have contributed to its relatively low CS rate. [ABSTRACT FROM AUTHOR]

Objective: To study the association between duration of second stage of labour and risks of maternal complications (infection, urinary retention, haematoma or ruptured sutures) in the early postpartum period.Design: Population-based cohort study.Setting and Sample: We included 72 593 mothers with singleton vaginal deliveries at ≥37 weeks of gestation in cephalic presentation, using the obstetric database from the Stockholm-Gotland region in Sweden, 2008-12.Methods: Logistic regression analysis. Odds ratios (ORs) with 95% confidence intervals (95% CI) were calculated and adjustments were made for maternal age, body mass index, height, smoking, cohabitation, gestational age, labour induction, epidural analgesia and oxytocin augmentation.Results: Rates of any complication varied by parity from 7.3% in parous women with previous caesarean section, 4.8% in primiparas and 1.7% in parous women with no previous caesarean section. Compared with a second stage <1 hour, the adjusted ORs for any complication (95% CI) in primiparas were for 1 to <2 hours 1.28 (1.11-1.47); 2 to <3 hours 1.54 (1.32-1.79), 3 to <4 hours 1.63 (1.38-1.93) and ≥4 hours 2.08 (1.74-2.49). The corresponding adjusted ORs for parous women without previous caesarean were 2.27 (1.78-2.90), 2.97 (2.09-4.22), 3.65 (2.25-5.94) and 3.16 (1.44-6.94), respectively. The adjusted ORs for women with previous caesarean were for 1 to <2 hours 1.62 (1.13-2.32); 2 to <3 hours 1.56 (1.00-2.43), 3 to <4 hours 2.42 (1.52-3.87), and ≥4 hours 2.31 (1.25-4.24).Conclusions: Risks of maternal complications in the postpartum period increase with duration of second stage of labour also after accounting for maternal, pregnancy and delivery characteristics. Special attention has to be given to parous women with previous caesarean deliveries. [ABSTRACT FROM AUTHOR]

Background: The possibility to predict the delivery date is a question frequently raised by pregnant women. However, a clinician has currently little to predict when a woman at term will deliver.Objective: To evaluate the predictive accuracy of transvaginal ultrasound (TVU) cervical length (CL) for spontaneous onset of labour in singleton gestation enrolled at term by a meta-analysis.Search Strategy: We performed a literature search in electronic databases.Selection Criteria: We included only studies assessing the accuracy of TVU CL in prediction of spontaneous onset of labour in singleton gestations with vertex presentation who were enrolled at term.Data Collection and Analysis: The primary outcome was the accuracy of CL for prediction of spontaneous labour within 7 days. Pooled sensitivities and specificities were calculated.Main Results: Five studies including 735 singleton gestations were included. For the prediction of spontaneous labour within 7 days for CL <30 mm the pooled sensitivity was 64% and pooled specificity was 60%. The higher the CL, the better the sensitivity; the lower the CL, the better the specificity. A woman with a singleton gestation at term and a TVU CL of 30 mm has a <50% chance of delivering within 7 days, while one with a TVU CL of 10 mm has an over 85% chance of delivery within 7 days.Conclusions: TVU CL at term has moderate value in predicting the onset of spontaneous labour. A woman with a TVU CL of 10 mm or less has a high chance of delivering within a week.Tweetable Abstract: Cervical length at term has moderate value in predicting the onset of spontaneous labour. [ABSTRACT FROM AUTHOR]

Objective To compare the efficacy of fentanyl administered via the subcutaneous (s.c.) or intranasal (i.n.) route with intramuscular (i.m.) pethidine in labouring women requesting analgesia. Design A randomised controlled trial three-armed, parallel-design. Setting A regional hospital and the largest tertiary maternity centre in South Australia. Sample One hundred and fifty-six healthy parturients birthing at term. Methods Women were randomised to receive s.c. fentanyl ( n = 53), i.n. fentanyl ( n = 52), or i.m. pethidine ( n = 51). The outcomes were analysed by intention-to-treat. Main outcome measures Pain scores measured before and 30 minutes after opioid administration. Results All groups reported clinically significant reductions in pain scores (mean range 1.2-1.6; P < 0.001), with no significant differences between groups. Significantly more women in the fentanyl groups reported satisfaction with using the study drug again, compared with women receiving i.m. pethidine (82.9% i.n. fentanyl, 80.6% s.c. fentanyl, and 44.0% i.m. pethidine; P < 0.01). Women in the fentanyl groups experienced less sedation (i.n. fentanyl 7.3%, s.c. fentanyl 2.9%, i.m. pethidine 44%; P ≤ 0.03), shorter labours by at least 2 hours ( P < 0.05), and fewer difficulties establishing breastfeeding (78.8% i.m. pethidine, 39.4% i.n. fentanyl, and 44.0% s.c. fentanyl; P < 0.01). Neonates in the pethidine group were more likely to require nursery admission ( P < 0.02). Conclusions Fentanyl administered by s.c. and i.n. routes is as efficacious in relieving labour pain as i.m. pethidine, but resulted in greater satisfaction, less sedation, shorter labour, fewer nursery admissions, and fewer difficulties in establishing breastfeeding. Fentanyl appears to be a suitable alternative to pethidine when providing parenteral pain relief to labouring women. [ABSTRACT FROM AUTHOR]

Objective To explore the variation in hospital caesarean section (CS) rates for nulliparous women, to determine whether different case-mix, labour and delivery, and hospital factors can explain this variation and to examine the association between hospital CS rates and outcomes. Design Population-based cohort study. Setting New South Wales, 2009-2010. Population Nulliparous women with singleton cephalic live births at term. Methods Random effect multilevel logistic regression models using linked hospital discharge and birth data. Main outcome measures Prelabour and intrapartum CS rates following spontaneous labour or labour induction; maternal and neonatal severe morbidity rates. Results Of 67 239 nulliparous women, 4902 (7.3%) had a prelabour CS, 39 049 (58.1%) laboured spontaneously, and 23 288 (34.6%) had labour induced. Overall, there were 18 875 (28.1%) CSs, with labour inductions twice as likely to result in an intrapartum CS compared with women with a spontaneous onset of labour (34.0% versus 15.5%). After adjusting for differences in case-mix, labour and delivery, and hospital factors, the overall variation in CS rates decreased by 78% for prelabour CSs, 52% for intrapartum CSs following spontaneous labour and 9% following labour induction. Adjusting for labour and delivery practices increased the unexplained variation in intrapartum CSs. The adjusted rates of severe maternal and neonatal morbidity were not significantly different across CS rate quintile groups, except for women in spontaneous labour, where the hospitals in the lowest CS quintile had the lowest neonatal morbidity rate. Conclusions Differences in clinical practice were substantial contributors to variation in intrapartum CS rates. Our findings suggest that CS rates in some hospitals could be lowered without adversely affect pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Approximately 60% of women who labour in the USA receive some form of neuraxial analgesia, but concerns have been raised regarding whether it negatively impacts the labour and delivery process. In this review, we attempt to clarify what has been established as truths, falsities and uncertainties regarding the effects of this form of pain relief on labour progression, negative and/or positive. Additionally, although the term 'epidural' has become synonymous with neuraxial analgesia, we discuss two other techniques, combined spinal-epidural and continuous spinal analgesia, that are gaining popularity, as well as their effects on labour progression. [ABSTRACT FROM AUTHOR]

Objective To determine the use of pharmacologic analgesia during childbirth when antenatal hypnosis is added to standard care. Design Randomised controlled clinical trial, conducted from December 2005 to December 2010. Setting The largest tertiary referral centre for maternity care in South Australia. Population A cohort of 448 women at >34 weeks of gestation, with a singleton pregnancy and cephalic presentation, planning a vaginal birth. Exclusions were: the need for an interpreter; pre-existing pain; psychiatric illness; younger than 18 years; and previous experience of hypnosis for childbirth. Methods All participants received usual care. The group of women termed Hypnosis + CD (hypnotherapist guided) were offered three antenatal live hypnosis sessions plus each session's corresponding audio CD for further practise, as well as a final fourth CD to listen to during labour. The group of women termed CD only (nurse administered) were played the same antenatal hypnosis CDs as group 1, but did not receive live hypnosis training. The control group participants were given no additional intervention or CDs. Main outcome measure Use of pharmacological analgesia during labour and childbirth. Results No difference in the use of pharmacological analgesia during labour and childbirth was found comparing hypnosis + CD with control (81.2 versus 76.2%; relative risk, RR 1.07; 95% confidence interval, 95% CI 0.95-1.20), or comparing CD only with control (76.9 versus 76.2%, RR 1.01, 95% CI 0.89-1.15). Conclusions Antenatal group hypnosis using the Hypnosis Antenatal Training for Childbirth ( HATCh) intervention in late pregnancy does not reduce the use of pharmacological analgesia during labour and childbirth. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Adams S, Eberhard-Gran M, Eskild A. Fear of childbirth and duration of labour: a study of 2206 women with intended vaginal delivery. BJOG 2012;119:1238-1246. Objective To assess the association between fear of childbirth and duration of labour. Design A prospective study of women from 32 weeks of gestation through to delivery. Setting Akershus University Hospital, Norway. Population A total of 2206 pregnant women with a singleton pregnancy and intended vaginal delivery during the period 2008-10. Methods Fear of childbirth was assessed by the Wijma Delivery Expectancy Questionnaire (W-DEQ) version A at 32 weeks of gestation, and defined as a W-DEQ sum score ≥ 85. Information on labour duration, use of epidural analgesia and mode of delivery was obtained from the maternal ward electronic birth records. Main outcome measures Labour duration in hours: from 3-4 cm cervical dilatation and three uterine contractions per 10 minutes lasting ≥1 minute, until delivery of the child. Results Fear of childbirth (W-DEQ sum score ≥ 85) was present in 7.5% (165) of women. Labour duration was significantly longer in women with fear of childbirth compared with women with no such fear using a linear regression model (crude unstandardised coefficient 1.54; 95% confidence interval 0.87-2.22, corresponding to a difference of 1 hour and 32 minutes). After adjustment for parity, counselling for pregnancy concern, epidural analgesia, labour induction, labour augmentation, emergency caesarean delivery, instrumental vaginal delivery, offspring birthweight and maternal age, the difference attenuated, but remained statistically significant (adjusted unstandardised coefficient 0.78; 95% confidence interval 0.20-1.35, corresponding to a 47-minute difference). Conclusion Duration of labour was longer in women with fear of childbirth than in women without fear of childbirth. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Taher S, Inder J, Soltan S, Eliahoo J, Edmonds D, Bennett P. Prostaglandin E2 vaginal gel or tablets for the induction of labour at term: a randomised controlled trial. BJOG 2011;118:719-725. To compare the effectiveness of prostaglandin E2 (dinopristone) vaginal gel versus vaginal tablets for the induction of labour at term. Randomised controlled clinical trial. University maternity hospital in London. Pregnant women with cephalic presentation undergoing induction of labour after 37 weeks of gestation. Prostaglandin E2 vaginal tablets (3 mg) or vaginal gel (1 mg/2 mg) was administered at 6-hourly intervals until the cervix was suitable for amniotomy. Induction to delivery interval, in minutes; rate of failed induction of labour requiring caesarean delivery. Eighty-two women received prostaglandin gel; 83 women received vaginal tablets. There were significant differences between the two treatment groups in the primary outcomes. The mean induction to delivery interval was significantly shorter in women who received the gel (1400 minutes, 690-2280 minutes, versus 1780 minutes, 960-2640 minutes; P = 0.03). The rate of failed induction of labour was significantly higher in women who received tablets (10.84 versus 1.22%; P = 0.01). Subanalysis showed that these differences were only representative of differences in the groups of primigravid women. There were no significant differences in any of the secondary outcomes, including the number of women who required syntocinon augmentation, the rate of uterine hyperstimulation, the need for epidural analgesia, meconium staining of liquor, the need for fetal blood sampling, or delivery by caesarean section. There were no differences in adverse maternal and neonatal outcomes. Prostaglandin E2 vaginal gel is superior to vaginal tablets for the induction of labour. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Walsh J, Mahony R, Armstrong F, Ryan G, O'Herlihy C, Foley M. Ethnic variation between white European women in labour outcomes in a setting in which the management of labour is standardised-a healthy migrant effect? BJOG 2011;118:713-718. To test the hypothesis that women from Eastern European countries have lower caesarean delivery rates and higher spontaneous labour rates relative to Irish women in a setting in which the management of labour is standardised. A retrospective review of prospectively collected data. Tertiary referral centre, Dublin, Ireland. All Irish and Eastern European term nulliparous women who laboured and delivered in 2008. A comparison of labour outcomes between women from Ireland and women from Eastern European countries. The principal outcomes measured were the gestational age at onset of labour, whether labour was spontaneous or induced, the need for oxytocin augmentation, duration of labour, mode of delivery, epidural use and birthweight. Of 2556 Irish ( n = 2041) and Eastern European ( n = 511) term cephalic singleton labours in the calendar year 2008, women from Eastern Europe were significantly more likely to labour spontaneously (74.6% versus 65.9%, P < 0.001), required less epidural analgesia (68.4% versus 59.7%) and were significantly less likely to require delivery by caesarean section (8.6% versus 15.7%, P < 0.001) than Irish women. This is despite no significant difference between the two groups with regard to mean birthweight (3581 g versus 3569 g, P = 0.6) or macrosomia (birthweight over 4000 g) (18% versus 16%, P = 0.4). There were significant differences in maternal age at delivery (27.2 years versus 29.2 years, P < 0.001) and body mass index (BMI) (24.1 kg/m versus 25.4 kg/m, P < 0.001) between the two groups. These findings confirm our hypothesis that economic migrants from Eastern European countries exhibit a so-called 'healthy migrant effect' in terms of obstetric outcomes. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Kaambwa B, Bryan S, Gray J, Milner P, Daniels J, Khan K, Roberts T. Cost-effectiveness of rapid tests and other existing strategies for screening and management of early-onset group B streptococcus during labour. BJOG 2010;117:1616-1627. To determine the cost-effectiveness of alternative screening and prevention strategies, including rapid intrapartum testing, for prevention of early-onset neonatal group B streptococcus (GBS) infection in the UK. A decision model was developed to investigate the cost-effectiveness of screening and prevention strategies for GBS. A strategy of doing nothing was also considered. Deterministic and probabilistic sensitivity analyses were carried out. Two large UK based obstetric units. Test accuracy data were obtained from a primary study of rapid tests at the onset of labour and risk factors from 1400 women. Incremental health sector costs per case of early-onset GBS death avoided. Compared with a strategy of do nothing, the incremental cost-effectiveness ratio was £32,000 per Early-Onset GBS Disease avoided and £427,000 per Early-Onset GBS Death avoided for the strategy of providing routine intrapartum antibiotic prophylaxis to all women without prior screening; Based on their current sensitivity, specificity and cost, screening using rapid tests was dominated by other more cost-effective strategies. The most cost-effective strategy was shown to be the provision of routine intrapartum antibiotic prophylaxis to all women without prior screening but, given broader concerns relating to antibiotic use, this is unlikely to be acceptable. In its absence, intrapartum antibiotic prophylaxis directed by screening with enriched culture becomes cost-effective. The current strategy of risk-factor-based screening is not cost-effective compared with screening based on culture. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Banda G, Kafulafula G, Nyirenda E, Taulo F, Kalilani L. Acceptability and experience of supportive companionship during childbirth in Malawi. BJOG 2010;117:937–945. Objective To study the acceptability and experience of supportive companionship during childbirth by mothers, health professionals and supportive companions. Design Cross-sectional surveys before and after introducing supportive companionship. Setting Maternity facilities in Blantyre City, Malawi. Population Mothers who had normal deliveries before discharge from hospital, health professionals in health facilities and women from the community, who had given birth before and had interest in providing or had provided support to fellow women during childbirth. Methods Combined qualitative and quantitative methods. Main outcome measure Perceptions on labour companionship among participants. Results The majority of supported women (99.5%), companions (96.6%) and health professionals (96%) found the intervention beneficial, mainly for psychological and physical support to the labouring woman and for providing assistance to healthcare providers. Some companions (39.3%) unwillingly accompanied the women they were supporting and 3.5% of companions mentioned that their presence in the labour ward was an opportunity for them to learn how to conduct deliveries. Conclusion Supportive companionship for women during childbirth is highly acceptable among mothers and health professionals, and the community in Malawi, but should be governed by clear guidelines to avoid potential harm to labouring women. Women require information regarding the need for a supportive companion and their expected role before they present at a health facility in labour. Such notification will provide an opportunity for the pregnant woman to identify someone of their choice who is ready and capable of safely taking up the role of a companion. [ABSTRACT FROM AUTHOR]

Saliva progesterone and oestriol concentrations were determined weekly from 24 weeks of gestation in women at increased risk of preterm delivery. Samples were analysed from 28 women with spontaneous onset of labour and delivery before 37 weeks of gestation, and 64 who delivered at term. Saliva progesterone was lower in the 12 women delivering before 34 weeks than in those delivering later , between 34 and 37 weeks ( P = 0.007) or at term ( P = 0.009). Measurement of saliva progesterone may be of value in the prediction of early preterm labour and in determining which women might benefit from progesterone supplementation. [ABSTRACT FROM AUTHOR]

Objective To evaluate the occurrence and nature of suboptimal intrapartum care in cases with metabolic acidosis in the newborn, and to estimate the degree to which this may be prevented. Design Case–control study. Clinical audit. Setting Delivery units at two university hospitals in Sweden. Population Out of 28 486 deliveries, 161 neonates ≥34 weeks of gestational age were born with metabolic acidosis. Methods Cases ( n = 161): umbilical artery pH < 7.05 and base deficit ≥12 mmol/l. Controls ( n = 322): pH ≥ 7.05 and Apgar score ≥7 at 5 minutes. Obstetric characteristics and oxytocin administration were recorded. The last 2 hours of electronic fetal monitoring before delivery were evaluated blinded to outcome. Intrapartum management was analysed for suboptimal care by using predefined criteria. Main outcome measure Suboptimal intrapartum care. Results Case and control comparisons displayed an occurrence of suboptimal care in 49.1% versus 13.0% ( P < 0.001), oxytocin misuse in 46.6% versus 13.0% ( P < 0.001), a failure to respond to a pathological cardiotocographic pattern in 19.9% versus 1.2% ( P < 0.001) and suboptimal care related to vacuum deliveries in 3.1% versus 0.3% ( P < 0.01) respectively. Conclusion Metabolic acidosis at birth is often associated with suboptimal intrapartum care. The high rate of suboptimal care with regard to oxytocin use and fetal surveillance illustrate a gap between guidelines and clinical practice. Metabolic acidosis and related neonatal morbidity could potentially be prevented in 40–50% of cases. The adherence to guidelines must be checked. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to investigate the occurrence of hyponatraemia following delivery, with a hypothesis that hyponatraemia has a high prevalence in labouring women. Design Prospective observational study. Setting Consultant-led delivery suite in County Hospital, Kalmar, Sweden. Sample A total of 287 pregnant women at term (37 full gestational weeks). Methods Oral fluids were allowed during labour. Blood samples were collected on admission, after delivery, and from the umbilical artery and vein. Main outcome measure Hyponatraemia defined as plasma sodium ≤130 mmol/l after delivery. Results Hyponatraemia was found in 16 (26%) of the 61 mothers who received more than 2500 ml of fluid during labour. Two-thirds of fluids were orally ingested. Decrease in plasma sodium concentration during labour correlated with duration of labour and the total fluid volume administered. Analysis by multivariate logistic regression showed that hyponatraemia was significantly correlated with fluid volume ( P < 0.001) but not with oxytocin administration or epidural analgesia. Hyponatraemia correlated significantly with prolonged second stage of labour, instrumental delivery, and emergency caesarean section for failure to progress ( P = 0.002). Conclusions Hyponatraemia is not uncommon following labour. Tolerance to a water load is diminished during labour; therefore, even moderate fluid volumes may cause hyponatraemia. Women should not be encouraged to drink excessively during labour. Oral fluids, when permitted, should be recorded, and intravenous administration of hypotonic fluids should be avoided. When abundant drinking is unrecognised or intravenous fluid administration liberal, life-threatening hyponatraemia may develop. The possibility that hyponatraemia may influence uterine contractility merits further investigation. [ABSTRACT FROM AUTHOR]

Background Oxytocin is widely used to speed up slow labour, especially in nulliparous women, but randomised trials, apart from one reported only in abstract, have been too small to exclude important effects. Objective To test the hypothesis that early use of oxytocin reduces the need for caesarean delivery. Design A randomised controlled trial. Setting Twelve obstetric units within the Northern and Yorkshire regions in the North East of England. Participants A total of 412 low-risk nulliparous women in spontaneous labour at term, who had been diagnosed with primary dysfunctional labour were recruited from January 1999 to December 2001. Intervention Immediate oxytocin administration (active group) or oxytocin withheld for up to 8 hours (conservative group). Main outcome measures Caesarean section and operative vaginal delivery rates. The length of labour measured from the time of randomisation to delivery. The rate of maternal Edinburgh Postnatal Depression Scale (EPDS) greater than 12 (major depression) within 48 hours of delivery. Results The caesarean section rates were 13.5% active versus 13.7% controls (OR 0.98, 95% CI 0.6–1.7). Operative delivery, 24.5% versus 30.9% (OR 0.73, 95% CI 0.5–1.1). The median (interquartile range) randomisation to delivery interval in the active group was 5 hours 52 minutes (3:57–8:28) and in the conservative group 9 hours 8 minutes (5:06–13:16) ( P < 0.001). The rate of EPDS >12 was 20% in the active arm versus 15% among controls (OR 1.26, 95% CI 0.7–2.2). There was one perinatal death in each group and no major differences in perinatal outcomes. Conclusions Among nulliparous women with primary dysfunctional labour, early use of oxytocin does not reduce caesarean section or short-term postnatal depression. However, it shortens labour considerably and may reduce operative vaginal deliveries. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to describe the variation of normal maternal temperature during labour. Design A prospective cohort study. Setting Two hospitals in Amsterdam, the Netherlands. Population All women with a live singleton pregnancy and a gestational age of 36 weeks or more admitted to the delivery ward from June 2000 to January 2002. Methods Maternal temperature was measured rectally every 2–3 hours from admission until the beginning of second stage, and 1-hour postpartum. Normal labour ( n = 843) was defined as gestational age ≥37 weeks, spontaneous onset of labour, rupture of membranes <18 hours before birth, normal progress of labour without the need for augmentation or epidural analgesia and spontaneous vaginal delivery of a healthy infant. The remaining group was classified as abnormal ( n = 2209). Main outcome measures Rectal measured temperature in degrees Celsius. Results The mean temperature during labour in the complete study population increased from 37.1°C at the beginning of labour to 37.4°C after 22 hours. Temperature in the abnormal labour group was equal to the normal labour group during the first 3 hours of labour ( P > 0.05) but increased thereafter. Conclusions At the beginning of labour, temperature was 37.1°C. Temperature increased slowly during labour and was 37.4°C (2SD 1.2) after 22 hours. The upper 2SD limit for normal temperature did not follow a circadian pattern and time of day is not relevant for the classification of normal versus elevated temperature. [ABSTRACT FROM AUTHOR]

Objective To determine whether hyoscine butylbromide shortens the first stage of labour, without an increase in maternal or neonatal complications. Design Randomised, double-blinded, controlled trial. Setting The Antenatal clinics and Labour and Delivery ward of the University Hospital of the West Indies, Kingston, Jamaica. Population Women in spontaneous labour at term. Methods Either drug or placebo was given intravenously once the women entered active labour. Main outcome measures The duration of the first stage of labour. Secondary outcomes included comparisons of the duration of the second and third stages of labour, blood loss at delivery, rate of caesarean section, and APGAR scores in the neonates between the two groups. Results A total of 129 women yielded data for analysis. Of these, 69 women received the placebo and 60 received hyoscine butylbromide. The mean time for the first stage in the control group was 228 minutes, compared with 156 minutes in the drug group, representing a decrease of 31.7% ( P = 0.001). There was no significant change in the duration of the second and third stages of labour, and no difference in blood loss or in APGAR scores. There was a slight (but statistically insignificant) increase in the caesarean section rate. Conclusion Hyoscine butylbromide is effective in significantly reducing the duration of the first stage of labour, and it is not associated with any obvious adverse outcomes in mother or neonate. [ABSTRACT FROM AUTHOR]

Objective To determine risk factors for Erb’s palsy, with a focus on graphic labour patterns. Design A case–control study. Setting New York City. Sample A total of 45 consecutive cases of Erb’s palsy and 90 controls. Methods Pregnancies and labours of neonatal Erb’s palsy cases were compared with 90 controls using univariate and multiple logistic regression analysis. Main outcome measures Erb’s palsy and shoulder dystocia. Results Mothers of children with Erb’s palsy had a higher term body mass index and more gestational diabetes than those of controls. Even cases without diabetes had higher blood glucose values after a 50-g glucose challenge than did controls. Cases had a higher birthweight and a lower ratio of head-to-thoracic circumference than controls. Shoulder dystocia occurred in 67% of cases and in 2% of controls ( P= 0.001). Only 46% of labours had a completely normal dilatation pattern. In a multiple logistic regression model, variables independently associated with brachial plexus injury were long deceleration phase of labour, long second stage, high birthweight, black race, and high neonatal or maternal body mass. Conclusions Erb’s palsy was frequently preceded by abnormal labour and shoulder dystocia; however, a substantial proportion of cases occurred after normal labour and delivery. Predictive models will be necessary to determine to what extent careful monitoring of the terminal portion of dilatation and of fetal descent and incorporation of maternal body mass and race (all independent risk factors in this study) will help identify fetuses at risk for brachial plexus palsy. [ABSTRACT FROM AUTHOR]

Objective To find whether low-to-high frequency (LF/HF) ratio of fetal heart rate (FHR) variability changes in relation to a significant ST-event during delivery, and if the change is predictive of metabolic acidosis of the newborn. Design A case–control study. Setting Data from a multicentre project. Subjects Acidotic and control fetuses with abnormal cardiotocography together with a ST-event in fetal electrocardiogram (ECG). Methods We studied intrapartum FHR variability with spectral analysis from 34 fetuses with a significant ST-event in the fetal ECG. LF/HF ratio of FHR variability was measured within a period of 1 hour before and 1 hour after a significant ST-event. Sensitivity and specificity of the change in LF/HF ratio of FHR variability in prediction of metabolic acidosis (pH ≤ 7.05 and base deficit value > 12.0 mmol/l) of the newborn were described by means of the receiver operating characteristic curve. Main outcome measures Change in LF/HF ratio of FHR in relation to a significant ST-event. Results We found that a relative change in LF/HF ratio greater than 30% in relation to a significant ST-event predicted cord arterial metabolic acidosis with a sensitivity of 89% (95% CI 68–100%) and specificity of 80% (95% CI 64–96%). Conclusions Relative changes in LF/HF ratio of FHR variability in relation to a significant ST-event are more pronounced in fetuses born with metabolic acidosis. [ABSTRACT FROM AUTHOR]

Objectives We aimed to determine the feasibility of conducting a randomised controlled trial (RCT) on the use of aromatherapy during labour as a care option that could improve maternal and neonatal outcomes. Design RCT comparing aromatherapy with standard care during labour. Setting District general maternity unit in Italy. Sample Two hundred and fifty-one women randomised to aromatherapy and 262 controls. Methods Participants randomly assigned to administration of selected essential oils during labour by midwives specifically trained in their use and modes of application. Main outcome measures Intrapartum outcomes were the following: operative delivery, spontaneous delivery, first- and second-stage augmentation, pharmacological pain relief, artificial rupture of membranes, vaginal examinations, episiotomy, labour length, neonatal wellbeing (Apgar scores) and transfer to neonatal intensive care unit (NICU). Results There were no significant differences for the following outcomes: caesarean section (relative risk [RR] 0.99, 95% CI: 0.70–1.41), ventouse (RR 1.5, 95% CI: 0.31–7.62), Kristeller manoeuvre (RR 0.97, 95% CI: 0.64–1.48), spontaneous vaginal delivery (RR 0.99, 95% CI: 0.75–1.3), first-stage augmentation (RR 1.01, 95% CI: 0.83–1.4) and second-stage augmentation (RR 1.18, 95% CI: 0.82–1.7). Significantly more babies born to control participants were transferred to NICU, 0 versus 6 (2%), P= 0.017. Pain perception was reduced in aromatherapy group for nulliparae. The study, however, was underpowered. Conclusion This study demonstrated that it is possible to undertake an RCT using aromatherapy as an intervention to examine a range of intrapartum outcomes, and it provides useful information for future sample size calculations. [ABSTRACT FROM AUTHOR]

Objective To assess the influence of body mass index (BMI) on the performance of epidural analgesia in labour and the subsequent mode of delivery. Design A retrospective audit of prospectively collected quality assurance data. Setting The delivery suite of Leeds General Infirmary, Leeds, UK. This is a 4500-delivery teaching hospital unit. Population All women receiving epidural analgesia during labour in our unit between April 1997 and December 2005. Methods Epidural recipients were divided into BMI groups according to World Health Organization (WHO) categories and compared for indices of epidural performance and mode of delivery. Main outcome measures Midwife and patient satisfaction scores with epidural analgesia, epidural resite rates, and mode of delivery. Results Data from 13 299 epidural recipients were analysed. Using WHO definitions, 22.8% were of normal body mass, 41.9% were overweight, 31.9% obese, and 3.4% morbidly obese. Epidurals were more likely to fail as BMI increased, as judged by midwife satisfaction scores ( P < 0.001) and epidural resite rates ( P < 0.01). This trend was not seen for maternal satisfaction scores using the WHO BMI categories. However, if women with BMI below 30 kg/m2 were grouped together, a significant trend was found ( P < 0.01). BMI had no influence on vaginal instrumental deliveries, but caesarean section rates rose from 11.5% in women of normal BMI to 29.2% in the morbidly obese women ( P < 0.001). Conclusions Obesity increases the incidence of analgesic failure and the need for resite of epidurals. The caesarean section rate among epidural recipients increases dramatically as BMI rises. [ABSTRACT FROM AUTHOR]

Objective To compare two upright delivery positions at the second stage of labour in healthy primiparous women with regard to duration of the second stage of labour and maternal experience. Design A randomised controlled trial. Setting A county hospital delivery ward. Sample Primiparous subjects ( n= 271) were randomly allocated to a kneeling ( n= 138) or a sitting ( n= 133) position during the second stage of labour. A postpartum questionnaire was answered by 264/271 women (97%) participating in the trial. Methods Primiparous subjects were randomised to a kneeling or sitting delivery position during second stage of labour. Analysis was performed on an intention-to-treat basis. Main outcome measure Duration of the second stage of labour. Results A comparison of the duration of the second stage of labour (kneeling 48.5 minutes ± 27.6 SD, sitting 41 minutes ± 23.4 SD) revealed no significant difference between the groups. A sitting position during the second stage of labour was associated with a higher level of delivery pain ( P < 0.01), a more frequent perception of the second stage as being long ( P= 0.002), less comfort for giving birth ( P= 0.03) and more frequent feelings of vulnerability ( P= 0.05) and exposure ( P= 0.02). There were no significant differences in the frequency of sphincter ruptures although a sitting position was associated with a higher degree of postpartum perineal pain ( P < 0.001) ( Table 3 ). Conclusions Kneeling and sitting upright during the second stage of labour do not significantly differ from one another in duration of the second stage of labour. In healthy primiparous women, a kneeling position was associated with a more favourable maternal experience and less pain compared with a sitting position. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effect of a first trimester ultrasound dating scan on the rate of induction of labour for prolonged pregnancy. Design Randomised controlled trial to include 400 women in each arm of the trial. Setting Participating general practices and a district general teaching hospital. Population Women attending their general practitioner in the first trimester to confirm pregnancy, in whom a first trimester ultrasound scan was not indicated. Methods Women randomised to the study group (scan group) underwent an ultrasound dating scan between 8 and 12 weeks, measuring crown-rump length. The estimated date of delivery (EDD) was changed if there was a discrepancy of more than 5 days from the gestation, calculated from the last menstrual period (LMP). For the remaining women (no-scan group), gestation was determined using the LMP. Main outcome measures The rate of induction of labour for prolonged pregnancy. Results Due to circumstances beyond the researchers’ control, recruitment was abandoned when 463 women had been enrolled. The EDD was adjusted in 13 (5.7%) women in the scan group and in 2 (0.9%) in the no-scan group. There was no difference in the rate of induction for prolonged pregnancy between the scan (19 [8.2%]) and the no-scan (17 [7.4%]) groups (relative risk 1.10; 95% CI 0.59–2.07). Conclusions Acknowledging the reduced numbers recruited for study, it is concluded that there is no evidence that a first trimester ultrasound dating scan reduces the rate of induction of labour for prolonged pregnancy and may result in a more expensive healthcare strategy. [ABSTRACT FROM AUTHOR]

The study aim was to identify the time from a decision to perform a fetal blood sample to the result of the test being available. A total of 100 consecutive fetal scalp blood samples taken on women in labour were identified from the blood gas analysers on the delivery suite. Eighty-nine percent of attempts yielded a result. The median time taken was 18 minutes (interquartile range 12–25 minutes). In 9% of women, the result took longer than 30 minutes. This is important clinically when repeated testing is required or in the second stage when operative vaginal delivery is achievable. Furthermore, when retrospectively analysing cases with a poor outcome, the time to obtain a result needs to be taken into account when determining the time at which a baby could have been delivered. [ABSTRACT FROM AUTHOR]