Leah L. Albers

Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial

Please cite this paper as: McLachlan H, Forster D, Davey M, Farrell T, Gold L, Biro M, Albers L, Flood M, Oats J, Waldenström U. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG 2012;119:1483–1492.

The length of active labor in normal pregnancies.

Objective To measure the length of active labor (first and second stages) in a low-risk population of non-Hispanic white, Hispanic, and American Indian women, and to identify any differences among these ethnic groups. Methods Descriptive statistics are presented for 1473 low-risk women at term who delivered at the University of New Mexico Hospital. Data examined by ethnicity included demographics, intrapartum care and complications, and duration of the active-phase, first stage (4 cm to complete cervical dilatation) and second stage (complete cervical dilatation to delivery) of labor. Results Compared with Friedmans criteria, 20% of these low-risk women had a prolonged active phase of the first stage, and 4% had a prolonged second stage, without excess maternal or infant morbidity. The mean length of active-phase, first-stage labor was 7.7 hours for nulliparas and 5.7 hours for multiparas (statistical limits 19.4 and 13.7 hours, respectively), with no differences according to ethnic group. The mean length of second stage was 53 minutes for nulliparas and 17 minutes for multiparas (statistical limits 147 and 57 minutes, respectively). American Indian nulliparas had significantly shorter second stages than non-Hispanic white women (P < .05). Conclusion Active labor in healthy women lasted longer than is widely appreciated. Upward revision of clinical expectations for the length of active labor is warranted.

The Duration of Labor in Healthy Women

OBJECTIVE:To measure the duration of active labor (first and second stages) in low-risk women whom received intrapartum care from certified nurse-midwives in nine hospital settings in the United States in 1996. Clinical factors and morbidity indicators associated with longer labors were also examined.DESIGN:An observational study was conducted with healthy women at term who did not receive oxytocin or epidurals (n = 2511). Descriptive statistics are reported for the duration of the active phase—first stage (4 cm to complete cervical dilatation) and second stage (complete to delivery)—by parity and for subgroups of women according to race/ethnicity, age, insurance, activity in labor, type of fetal heart monitoring, and narcotic analgesia. Logistic regression was also used to assess the contribution of each variable to longer labors with simultaneous adjustment of the other variables.RESULTS:The mean length of the active-phase, first stage was 7.7 hours for nulliparas and 5.6 hours for multiparas (statistical limits of 2 standard deviations from the mean were 17.5 and 13.8 hours, respectively). The mean length of second stage was 54 minutes for nulliparas and 18 minutes for multiparas (statistical limits 146 and 64 minutes, respectively). Variables associated with longer labors were electronic fetal monitoring, ambulation, maternal age over 30 years, and narcotic analgesia. Morbidity was not increased in longer labors.CONCLUSION: Normal labor in healthy women lasted longer than many clinicians expect. The criteria for distinguishing normal from abnormal labor, based on time, need revision.

Health problems after childbirth.

Of the entire maternity care cycle, the postpartum period occupies the lowest priority in practice, teaching, and research. Despite this, data from research outside the United States show that health problems after birth are very common, may persist over time, and are often under-recognized by care providers. Womens health would be favorably impacted by updating patterns of postpartum care, and by obtaining baseline population data in midwifery practices on the extent of postnatal morbidity.

Does Spontaneous Genital Tract Trauma Impact Postpartum Sexual Function

Changes in sexual function are common in postpartum women. In this comparative, descriptive study, a prospective cohort of midwifery patients consented to documentation of genital trauma at birth and assessment of sexual function at 3 months postpartum. The impact of spontaneous genital trauma on postpartum sexual function was the focus of the study. Trauma was categorized into minor trauma (no trauma or first-degree perineal or other trauma that was not sutured) or major trauma (second-, third-, or fourth-degree lacerations or any trauma that required suturing). Women who underwent episiotomy or operative delivery were excluded. Fifty-eight percent (326/565) of enrolled women gave sexual function data; of those, 276 (85%) reported sexual activity since delivery. Seventy percent (193) of women sustained minor trauma and 30% (83) sustained major trauma. Sexually active women completed the Intimate Relationship Scale (IRS), a 12-item questionnaire validated as a measure of postpartum sexual function. Both trauma groups were equally likely to be sexually active. Total IRS scores did not differ between trauma groups nor did complaints of dyspareunia. However, for two items, significant differences were demonstrated: women with major trauma reported less desire to be held, touched, and stroked by their partner than women with minor trauma, and women who required perineal suturing reported lower IRS scores than women who did not require suturing.

Factors related to perineal trauma in childbirth.

We conducted an observational cohort study in three nurse-midwifery services to identify patient characteristics and clinical care measures related to perineal trauma at birth. Data were collected on all women who began care with a nurse-midwife in labor, using an adaptation of the Nurse-Midwifery Clinical Data Set (n = 3,049). Study variables included demographics, perineal management techniques and position for birth, and other intrapartum care and events. Univariate and multivariate analyses showed that episiotomy was strongly related to fetal bradycardia, prolonged second stage, ethnic status, and maternal education level. Warm compresses and flexion/counter-pressure to slow delivery were protective. Spontaneous lacerations were influenced by these factors as well. The lateral position for birth was protective, and use of oils or lubricants and the lithotomy position increased lacerations, Multisite studies in nurse-midwifery practices may provide an ideal means of determining effective care measures in healthy populations.

The relationship of ambulation in labor to operative delivery

An abbreviated version of the Nurse-Midwifery Clinical Data Set was used to gather data on all women (n = 3,049) who began intrapartum care with a nurse-midwife in three sites. Demographic information, intrapartum care, and outcomes were recorded. The association of ambulation in labor with operative delivery was examined in a low-risk sample (n = 1,678) of women who did not receive care measures (epidural anesthesia, oxytocin induction or augmentation) that preclude mobility in labor. Women who ambulated for a significant amount of time during labor (compared with those who did not ambulate) had half the rate of operative delivery (2.7% vs. 5.5%).

Postpartum perineal pain in a low episiotomy setting: association with severity of genital trauma, labor care, and birth variables.

BACKGROUND Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative vaginal delivery. METHODS A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the present pain intensity (PPI) and visual analog scale (VAS) components of the validated short-form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. RESULTS At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 +/- 1.61 vs 1.48 +/- 1.40; p < 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, p = 0.002) than women with minor or no trauma. By 3 months, average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non-Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model, only trauma group and length of active pushing predicted the pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on the level of pain at discharge beyond its effect on the incidence of major trauma. CONCLUSIONS Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain.

Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum Functional Outcomes?

Background: To compare the postpartum pelvic floor function of women with sutured second-degree perineal lacerations, unsutured second-degree perineal lacerations, and intact perineums. Methods: A prospective cohort of nurse-midwifery patients consented to mapping of genital trauma at birth and an assessment of postpartum pelvic floor outcomes. Women completed validated questionnaires for perineal pain and urinary and anal incontinence at 12 weeks postpartum and underwent physical examination to assess pelvic floor strength and anatomy at 6 weeks postpartum. Results: One hundred seventy-two of 212 (80%) eligible women provided follow-up assessment data at 6 or 12 weeks postpartum. Women with an intact perineum (n = 89) used fewer analgesics (P < .002) and had lower pain scores at the time of hospital discharge than women with second-degree lacerations (sutured, n = 46; unsutured, n = 37; intact, n = 89) (P ≤ .02). The sutured group was more likely to use analgesics (52%) than the unsutured (35%) or intact (23%) groups at time of hospital discharge (P < .002), although pain scores were not different between sutured and unsutured groups. Postpartum reports of urinary or anal incontinence, sexual inactivity, or sexual function scores did not vary between groups. Weak pelvic floor exercise strength was more common among the women with second-degree lacerations compared with women with an intact perineum (53% vs. 28%; P = .03) but did not differ between sutured (58%) and unsutured (47%) groups (P = not significant). Likewise, perineal body or genital hiatus measurements did not vary between groups (P = not significant). Conclusions: Women with sutured lacerations report increased analgesic use at the time of hospital discharge compared with women with intact perineums or unsutured lacerations. At 12 weeks postpartum, no differences were noted between groups regarding complaints of urinary or anal incontinence, sexual inactivity, or sexual function.

Reducing genital tract trauma at birth: launching a clinical trial in midwifery

Genital tract trauma is a common outcome of vaginal birth, and can cause short-term and long-term problems for new mothers. Preventive measures have not been fully explicated. Midwives use a variety of hand maneuvers late in the second stage of labor, in the belief that genital trauma can be reduced. However, none of these care measures have been rigorously tested to determine if they are effective. A midwifery practice offers an ideal setting to study the relationship of hand techniques by the birth attendant to reduction of genital tract trauma.