Hala Phipps

Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians

Objective  To quantify the risk of morbidity from vaginal delivery (VD) that pregnant women would be prepared to accept before requesting an elective caesarean section and to compare these views with those of clinicians.

Does occiput posterior position in the second stage of labour increase the operative delivery rate

To assess the impact of occipito‐posterior position in the second stage of labour on operative delivery.

Willingness of pregnant women and clinicians to participate in a hypothetical randomised controlled trial comparing vaginal delivery and elective caesarean section

Background:  Elective caesarean section is controversial in the absence of compelling evidence of the relative benefits and harms compared with vaginal delivery. A randomised trial of the two procedures to compare outcomes for women and babies would provide the best quality scientific evidence to confirm this debate but it is not known whether such a trial would be feasible.

Can antenatal education influence how women push in labour

Background:  Antenatal education on the physiology of second stage of labour and effective pushing has not been studied in the literature. Anecdotal observation seems to indicate that some nulliparous women are (at least initially) unable to push effectively. A large proportion seem to reflexly contract the levator ani muscle when asked to push which may have the effect of slowing the progress of labour.

Persistent Occiput Posterior: OUTcomes following digital rotation: A pilot randomised controlled trial

To determine the feasibility of a multicentre randomised controlled trial (RCT) to investigate whether digital rotation of the fetal head from occiput posterior (OP) position in the second stage of labour reduces the risk of operative delivery (defined as caesarean section (CS) or instrumental delivery).

Management of occiput posterior position in the second stage of labour: A survey of obstetric practice in Australia and New Zealand

Issues in the management of the occipito posterior (OP) position have been the subject of clinical controversy over decades. Manual rotation has the potential to reduce operative delivery for fetal malposition.

Management of Occiput Posterior Position in the Second Stage of Labor: A Survey of Midwifery Practice in Australia

BACKGROUND The management of the occiput posterior (OP) position has been controversial for many years. Manual rotation can be performed by midwives and could reduce cesarean sections and instrumental births. We aimed to determine current midwifery views, knowledge, and practice of manual rotation. METHOD A de-identified, self-reported questionnaire was e-mailed to all Australian College of Midwives full members (n = 3,997). RESULTS Of 3,182 surveyed, 57 percent (1,817) responded, of whom 51 percent (920) were currently practicing midwifery. Seventy-seven percent of midwives thought that manual rotation at full dilatation was a valid intervention. Sixty-four percent stated the procedure was acceptable before instrumental delivery, but 30 percent were unsure. Most practicing midwives (93%) had heard of manual rotation, but only 18 percent had performed one in the last year. Midwives would support the routine performance of manual rotation for OP position if it reduced operative births from 68 to 50 percent and would support manual rotation for occiput transverse (OT) position if it reduced operative births from 39 to 25 percent. CONCLUSION This study indicates that manual rotation is considered acceptable by most midwives in Australia, yet is only performed by a minority. Midwives would be willing to perform prophylactic manual rotation if it was known to facilitate normal vaginal births suggesting a scope to introduce this procedure into widespread clinical practice.

Transverse occiput position: Using manual Rotation to aid Normal birth and improve delivery OUTcomes (TURN-OUT): A study protocol for a randomised controlled trial.

BackgroundFetal occiput transverse position in the form of deep transverse arrest has long been associated with caesarean section and instrumental vaginal delivery. Occiput transverse position incidentally found in the second stage of labour is also associated with operative delivery in high risk cohorts. There is evidence from cohort studies that prophylactic manual rotation reduces the caesarean section rate. This is a protocol for a double blind, multicentre, randomised, controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate.Methods/DesignEligible participants will be ≥37 weeks pregnant, with a singleton pregnancy, and a cephalic presentation in the occiput transverse position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 49%, for a reduction to 35%, an alpha value of 0.05 and a beta value of 0.2, 416 participants will need to be enrolled. Participants will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery. Secondary outcomes will be caesarean section, significant maternal mortality and morbidity, and significant perinatal mortality and morbidity.Analysis will be on an intention-to-treat basis. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, (protocol number: X110410).DiscussionThis trial addresses an important clinical question concerning a commonly used procedure which has the potential to reduce operative delivery and its associated complications. Some issues discussed in the protocol include methods of assessing risk of bias due to inadequate masking of a procedural interventions, variations in intervention efficacy due to operator experience and the recruitment difficulties associated with intrapartum studies.Trial registrationThis trial was registered with the Australian New Zealand Clinical Trials Registry (identifier: ACTRN12613000005752) on 4 January 2013.

When should women be recruited to intrapartum research projects? A retrospective review

To review and describe the impact of varied recruitment processes in two intrapartum studies.

Is neonatal head circumference related to caesarean section for failure to progress

There is global concern about rising caesarean section rates. Identification of risk factors could lead to preventative measures.