Debra Bick

Faecal incontinence after childbirth

Objective To measure the prevalence and severity of postpartum faecal incontinence, especially new incontinence, and to identify obstetric risk factors.

Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial

BACKGROUND Epidural analgesia is the most effective labour pain relief but is associated with increased rates of instrumental vaginal delivery and other effects, which might be related to the poor motor function associated with traditional epidural. New techniques that preserve motor function could reduce obstetric intervention. We did a randomised controlled trial to compare low-dose combined spinal epidural and low-dose infusion (mobile) techniques with traditional epidural technique. METHODS Between Feb 1, 1999, and April 30, 2000, we randomly assigned 1054 nulliparous women requesting epidural pain relief to traditional (n=353), low-dose combined spinal epidural (n=351), or low-dose infusion epidural (n=350). Primary outcome was mode of delivery, and secondary outcomes were progress of labour, efficacy of procedure, and effect on neonates. We obtained data during labour and interviewed women postnatally. FINDINGS The normal vaginal delivery rate was 35.1% in the traditional epidural group, 42.7% in the low-dose combined spinal group (odds ratio 1.38 [95% CI 1.01-1.89]; p=0.04); and 42.9% in the low-dose infusion group (1.39 [1.01-1.90]; p=0.04). These differences were accounted for by a reduction in instrumental vaginal delivery. Overall, 5 min APGAR scores of 7 or less were more frequent with low-dose technique. High-level resuscitation was more frequent in the low-dose infusion group. INTERPRETATION The use of low-dose epidural techniques for labour analgesia has benefits for delivery outcome. Continued routine use of traditional epidurals might not be justified.BACKGROUND: Epidural analgesia is the most effective labour pain relief but is associated with increased rates of instrumental vaginal delivery and other effects, which might be related to the poor motor function associated with traditional epidural. New techniques that preserve motor function could reduce obstetric intervention. We did a randomised controlled trial to compare low-dose combined spinal epidural and low-dose infusion (mobile) techniques with traditional epidural technique. METHODS: Between Feb 1, 1999, and April 30, 2000, we randomly assigned 1054 nulliparous women requesting epidural pain relief to traditional (n=353), low-dose combined spinal epidural (n=351), or low-dose infusion epidural (n=350). Primary outcome was mode of delivery, and secondary outcomes were progress of labour, efficacy of procedure, and effect on neonates. We obtained data during labour and interviewed women postnatally. FINDINGS: The normal vaginal delivery rate was 35·1% in the traditional epidural group, 42·7% in the low-dose combined spinal group (odds ratio 1·38 [95% CI 1·01–1·89]; p=0·04); and 42·9% in the low-dose infusion group (1·39 [1·01–1·90]; p=0·04). These differences were accounted for by a reduction in instrumental vaginal delivery. Overall, 5 min APGAR scores of 7 or less were more frequent with low-dose technique. High-level resuscitation was more frequent in the low-dose infusion group. INTERPRETATION: The use of low-dose epidural techniques for labour analgesia has benefits for delivery outcome. Continued routine use of traditional epidurals might not be justified.

What influences the uptake and early cessation of breast feeding

OBJECTIVE To examine obstetric, maternal and social factors associated with the uptake and early cessation of breast feeding and womens reasons for altering from breast to bottle feeding. DESIGN Women who responded to a postal questionnaire on long-term postpartum health were contacted and asked to participate in a home-based interview. In addition to health problems, the interview obtained information on baby feeding and a number of social factors. Women were also asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Obstetric and maternal data were obtained from maternity records. SETTING Deliveries from a large maternity hospital in Birmingham. PARTICIPANTS 906 women were interviewed at a mean of 45 weeks after delivery. FINDINGS 63% of the women said they had breast fed, but 40% of these stopped within three months of delivery. Many of the women gave physical problems with lactation as reasons for stopping. The factors found to be predictors of early cessation were: return to work within three months of birth; regular childcare support from other female relatives, and a high EPDS score. Non-initiation of breast feeding was predicted by a different set of factors: multiparity; general anaesthetic (GA); and unmarried status. DISCUSSION AND CONCLUSION Despite evidence of the benefits of breast feeding, this remains an unacceptable long-term option for many women, and for over one-third it is never attempted. Factors within the womans social environment were found to influence early cessation. Women who had a GA during or immediately following labour and delivery were less likely to initiate breast feeding. IMPLICATIONS FOR PRACTICE If breast-feeding incidence and duration are to increase, more attention should be paid to establishing early, successful breast feeding and countering the negative influences of factors within the social environment.

A systematic review of structured compared with non-structured breastfeeding programmes to support the initiation and duration of exclusive and any breastfeeding in acute and primary health care settings

Policies and guidelines have recommended that structured programmes to support breastfeeding should be introduced. The objective of this review was to consider the evidence of outcomes of structured compared with non-structured breastfeeding programmes in acute maternity care settings to support initiation and duration of exclusive breastfeeding. Quantitative and qualitative studies were considered. Primary outcomes of interest were initiation of breastfeeding and duration of exclusive breastfeeding. Studies that only considered community-based interventions were excluded. An extensive search of literature published in 1992-2010 was undertaken using identified key words and index terms. Methodological quality was assessed using checklists developed by the Joanna Briggs Institute. Two independent reviewers conducted critical appraisal and data extraction; 26 articles were included. Because of clinical and methodological heterogeneity of study designs, it was not possible to combine studies or individual outcomes in meta-analyses. Most studies found a statistically significant improvement in breastfeeding initiation following introduction of a structured breastfeeding programme, although effect sizes varied. The impact on the duration of exclusive breastfeeding and duration of any breastfeeding to 6 months was also evident, although not all studies found statistically significant differences. Despite poor overall study quality, structured programmes compared with standard care positively influence the initiation and duration of exclusive breastfeeding and any breastfeeding. In health care settings with low breastfeeding initiation and duration rates, structured programmes may have a greater benefit. Few studies controlled for any potential confounding factors, and the impact of bias has to be considered.

Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group

We compared breastfeeding initiation and duration in 1054 nulliaparae randomised to bupivacaine Control epidural, Combined Spinal Epidural or Low Dose Infusion and 351 matched non‐epidural comparisons. Women were interviewed after delivery and completed a postal questionnaire at 12 months. Regression analysis determined factors which independently predicted breastfeeding initiation. Breastfeeding duration was subjected to Kaplan–Meier analysis. A similar proportion of women in each epidural group initiated breastfeeding. Women with no epidural did not report a higher initiation rate relative to epidural groups and those who received pethidine reported a lower initiation rate than control epidural (p = 0.002). Older age groups (p < 0.001) and non‐white ethnicity (p < 0.026) were predictive of breastfeeding. Epidural fentanyl dose, delivery mode and trial group were not predictive. Mean duration for breastfeeding was similar across epidural groups (Control 13.3, Combined Spinal Epidural 15.5, Low Dose Infusion 15.0 weeks). Our data do not support an effect of epidural fentanyl on breastfeeding initiation.

Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review

BackgroundDemand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system.MethodsThe protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis.ResultsThirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems.ConclusionsDemand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.

A qualitative study of the experiences and expectations of women receiving in-patient postnatal care in one English maternity unit

BackgroundStudies consistently highlight in-patient postnatal care as the area of maternity care women are least satisfied with. As part of a quality improvement study to promote a continuum of care from the birthing room to discharge home from hospital, we explored womens expectations and experiences of current in-patient care.MethodsFor this part of the study, qualitative data from semi-structured interviews were transcribed and analysed using content analyses to identify issues and concepts. Women were recruited from two postnatal wards in one large maternity unit in the South of England, with around 6,000 births a year.ResultsTwenty women, who had a vaginal or caesarean birth, were interviewed on the postnatal ward. Identified themes included; the impact of the ward environment; the impact of the attitude of staff; quality and level of support for breastfeeding; unmet information needs; and womens low expectations of hospital based postnatal care. Findings informed revision to the content and planning of in-patient postnatal care, results of which will be reported elsewhere.ConclusionsWomens responses highlighted several areas where changes could be implemented. Staff should be aware that how they inter-act with women could make a difference to care as a positive or negative experience. The lack of support and inconsistent advice on breastfeeding highlights that units need to consider how individual staff communicate information to women. Units need to address how and when information on practical aspects of infant care is provided if women and their partners are to feel confident on the womans transfer home from hospital.

How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice

BackgroundThe accurate assessment and appropriate repair of birth related perineal trauma require high levels of skill and competency, with evidence based guideline recommendations available to inform UK midwifery practice. Implementation of guideline recommendations could reduce maternal morbidity associated with perineal trauma, which is commonly reported and persistent, with potential to deter women from a future vaginal birth. Despite evidence, limited attention is paid to this important aspect of midwifery practice. We wished to identify how midwives in the UK assessed and repaired perineal trauma and the extent to which practice reflected evidence based guidance. Findings would be used to inform the content of a large intervention study.MethodsA descriptive cross sectional study was completed. One thousand randomly selected midwives were accessed via the Royal College of Midwives (RCM) and sent a questionnaire. Study inclusion criteria included that the midwives were in clinical practice and undertook perineal assessment and management within their current role. Quantitative and qualitative data were collated. Associations between midwife characteristics and implementation of evidence based recommendations for perineal assessment and management were examined using chi-square tests of association.Results405 midwives (40.5%) returned a questionnaire, 338 (83.5%) of whom met inclusion criteria. The majority worked in a consultant led unit (235, 69.5%) and over a third had been qualified for 20 years or longer (129, 38.2%). Compliance with evidence was poor. Few (6%) midwives used evidence based suturing methods to repair all layers of perineal trauma and only 58 (17.3%) performed rectal examination as part of routine perineal trauma assessment. Over half (192, 58.0%) did not suture all second degree tears. Feeling confident to assess perineal trauma all of the time was only reported by 116 (34.3%) midwives, with even fewer (73, 21.6%) feeling confident to perform perineal repair all of the time. Two thirds of midwives (63.5%) felt confident to perform an episiotomy. Midwives qualified for 20 years or longer and those on more senior clinical grades were most likely to implement evidence based recommendations and feel confident about perineal management.ConclusionsThere are considerable gaps with implementation of evidence to support management of perineal trauma.

Attendance, content and relevance of the six week postnatal examination

OBJECTIVE to describe the attendance and content of the six week postnatal examination, and associate the examinations performed with relevant delivery factors and postpartum symptoms. DESIGN survey of 1278 women who responded to a postal questionnaire sent 6-7 months after delivery, as part of a wider study investigating the severity, effect and extent of long-term health problems after childbirth. Questions about attendance and content of the postnatal examination were included. Data obtained from the women were linked to the obstetric case notes. SETTING a large maternity hospital in Birmingham. PARTICIPANTS all women who had delivered between April and September 1992, except for those who had had a neonatal death and, due to lack of funding for translators, Asian women. FINDINGS the majority of women (91%) attended for their postnatal examination and 93% of these had an abdominal and 70% a vaginal examination. Women who had a vaginal delivery and perineal trauma were significantly more likely to have a vaginal examination but still over two-thirds of those with an intact perineum and almost half delivered by elective caesarean section also had this. Only 16% of women had a blood test. Those who had a PPH, a low third day Hb or reported a new postpartum onset of fatigue were more likely to have a blood test, but three-quarters of the women with these risk factors did not have blood taken. DISCUSSION AND CONCLUSION women are prepared to attend for postnatal assessment but many have examinations without obvious reason, whilst other tests which might be helpful for certain conditions are infrequently used. Substantial postpartum morbidity is known to exist and this is not routinely assessed at the postnatal assessment. IMPLICATIONS FOR PRACTICE the present six week postnatal examination does not appear to meet the health needs of women after childbirth: its content and timing should be reviewed.

A national survey of obstetric early warning systems in the United Kingdom: five years on

The Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists’ Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas.