Nigel Lee

Cross sectional study of Australian midwives knowledge and use of sterile water injections for pain relief in labour

BACKGROUND The effectiveness of sterile water injections (SWI) to relieve back pain in labour is supported by a number of randomised controlled trials. Although the procedure is available in a number of Australian maternity units, there is no information regarding the use of SWI by midwives, in terms of knowledge and availability, clinical application or technique used. Neither is there any data on midwives who do not use SWI nor the specific challengers and barriers encountered by midwives introducing SWI. METHOD An invitation to participate in an online survey was emailed to 4700 members of the Australian College of Midwives (ACM) and 484 members of CRANAplus (Remote Health Organisation). Nine hundred and seventy midwives completed the survey (19%). RESULTS Four hundred and seven (42.5%) midwives currently used SWI in their practice and five hundred and fifty-one (57.5%) indicated they did not. Eighty-six percent (n=478/548) indicated they would consider using SWI and 90% (n=500/547) were interested in obtaining further information about SWI. The main reasons cited for not using SWI was the lack of a policy or guideline (n=271, 57.5%) and being unable to access workshops or resource material (n=68, 14.4%). CONCLUSION This study indicates that SWI is not being used by the majority of midwives participating in the study, although there is a strong desire by midwives to learn about and explore its use. Greater access to information and workshops on SWI is highlighted. In response to the findings of this survey the authors are currently developing an online resource and training to support units to introduce SWI.

Comparison of a single vs. a four intradermal sterile water injection for relief of lower back pain for women in labour: A randomised controlled trial

OBJECTIVE sterile water injections are a simple, safe, effective, non-pharmacological technique for relieving back pain in labour, however the number of injections required to achieve optimal analgesia is unknown. The objective of this trial was to evaluate the degree and duration of analgesia provided by a single injection of sterile water, compared to four injections. DESIGN randomised controlled non-inferiority trial. PARTICIPANTS AND SETTING three hundred and five women in labour at term, requesting analgesia for back pain were recruited from two metropolitan hospitals in Brisbane, Australia. INTERVENTION participants were randomly assigned to receive either one (n=147) or four (n=158) sterile water injections. OUTCOME MEASURES difference in self-reported pain measured using a visual analogue scale (VAS) between baseline and 30 mins post-intervention. The clinically acceptable margin of difference was defined as ≤ 1 cm on the VAS between the single injection compared to four injection technique. Secondary outcomes include VAS score on injection and 10, 60, 90 and 120 mins post-intervention, analgesia use, mode of birth and maternal satisfaction. FINDINGS the mean difference in the pre and post (30 mins) injection scores between two groups was -1.48 cm (95% CI -2.10, -0.86) in favour of the FI technique, however the injection pain associated with the FI was significantly greater than that of the SI technique (p<0.001). There were no significant differences between the two groups in terms of other analgesic use, mode of birth or maternal satisfaction. CONCLUSION the four injection technique was associated with increased level of analgesia at 30 mins post-intervention compared to the single injection, but also a greater degree of injection pain.

A randomised non-inferiority controlled trial of a single versus a four intradermal sterile water injection technique for relief of continuous lower back pain during labour

BackgroundAlmost one third of women suffer continuous lower back pain during labour. Evidence from three systematic reviews demonstrates that sterile water injections (SWI) provide statistically and clinically significant pain relief in women experiencing continuous lower back pain during labour. The most effective technique to administer SWI is yet to be determined. Therefore, the aim of this study is to determine if the single injection SWI technique is no less effective than the routinely used four injection SWI method in reducing continuous lower back pain during labour.Methods/designThe trial protocol was developed in consultation with an interdisciplinary team of clinical researchers. We aim to recruit 319 women presenting at term, seeking analgesia for continuous severe lower back pain during labour. Participants will be recruited from two major maternity hospitals in Australia. Randomised participants are allocated to receive a four or single intradermal needle SWI technique. The primary outcome is the change in self-reported pain measured by visual analogue scale at baseline and thirty minutes post intervention. Secondary outcomes include VAS change scores at 10, 60, 90 and 120 min, analgesia use, mode of birth and maternal satisfaction.Statistical analysisSample size was calculated to achieve 90% power at an alpha of 0.025 to detect a non-inferiority margin of ≤ 1 cm on the VAS, using a one-sided, two-sample t-test. Baseline demographic and clinical characteristics will be analysed for comparability between groups. Differences in primary (VAS pain score) and secondary outcomes between groups will be analysed by intention to treat and per protocol analysis using Students t-test and ANOVA.ConclusionThis study will determine if a single intradermal SWI technique is no less effective than the routinely used four injection technique for lower back pain during labour. The findings will allow midwives to offer women requesting SWI during labour an evidence-based alternative technique more easily administered by staff and accepted by labouring women.Trial RegistrationACTRN12609000964213

'Facing the wrong way': Exploring the Occipito Posterior position/back pain discourse from women's and midwives perspectives

OBJECTIVE to explore back pain in labour from the perspectives of women and midwives. DESIGN a qualitative study, which generated data through individual semi-structured interviews with postnatal women and focus groups with midwives. Data were analysed thematically. SETTING two metropolitan maternity units in Queensland, Australia. PARTICIPANTS nine postnatal women and 11 midwives, all of whom had participated in a randomized controlled trial investigating the use of sterile water injections for back pain in labour. FINDINGS two major themes were identified, including back pain in labour: accounts, rationalisations and coping strategies, and fetal position: destabilising the Occipito Posterior-back pain discourse. KEY CONCLUSIONS back pain may be severe in labour, may impact negatively upon women׳s labour and birth experiences, and interfere with their ability to cope as planned. The assumed relationship between fetal position and back pain in labour is a dominant discourse, albeit one which is lacking in empirical credibility. Nonetheless, the information provided to women by maternity professionals tended to reiterate customary practices and beliefs rather than factual knowledge. Increasingly, women refer to other sources, which may challenge the information provided by health professionals. IMPLICATIONS FOR PRACTICE Back pain in labour is an under-researched area and the lack of solid evidence underpinning the advice provided to women has implications for labour management, and possibly for maternal and fetal outcomes. Care providers might usefully consider back pain as multifactorial, not always associated with OP position, and continue to seek evidence-based management strategies which address women׳s needs.

No pain, no gain: the experience of women using sterile water injections

PROBLEM/BACKGROUND Sterile water injections (SWI) are gaining popularity amongst women and midwives for the relief of back pain in labour. However the brief but intense pain associated with the injection has been cited as a deterrent to use and may negatively affect the birth experience. AIM To explore womens experiences of using sterile water injections as analgesia for back pain in labour. DESIGN A qualitative study, which generated data through individual semi-structured interviews with postnatal women. Data were analysed thematically. SETTING Two metropolitan maternity units in Queensland, Australia. PARTICIPANTS Nine postnatal women who had participated in a randomised controlled trial investigating the use of sterile water injections for back pain in labour FINDINGS: Three major themes were identified including sterile water injections as a non-pharmacological injection; balancing injection pain against expectations of pain relief; the analgesic effect of sterile water injections. KEY CONCLUSIONS Women in this study largely viewed sterile water injections as an effective analgesia with few side effects. The pain associated with the injection of sterile water was weighed against the likelihood of rapid, effective pain relief. Women used the period of analgesia to support their objectives, be this a period of respite during the labour or to enhance the ability to focus on the birth experience. Information on SWI provided by health professionals should also balance realistic descriptions of the injection pain with prospect of analgesia.

Impact on Caesarean section rates following injections of sterile water (ICARIS) : a multicentre randomised controlled trial

AbstractBackgroundSterile water injections have been used as an effective intervention for the management of back pain during labour. The objective of the current research is to determine if sterile water injections, as an intervention for back pain in labour, will reduce the intrapartum caesarean section rate.Methods/designDesign: A double blind randomised placebo controlled trial Setting: Maternity hospitals in Australia Participants: 1866 women in labour, ≥18 years of age who have a singleton pregnancy with a fetus in a cephalic presentation at term (between 37 + 0 and 41 + 6 weeks gestation), who assess their back pain as equal to or greater than seven on a visual analogue scale when requesting analgesia and able to provide informed consent. Intervention: Participants will be randomised to receive either 0.1 to 0.3 millilitres of sterile water or a normal saline placebo via four intradermal injections into four anatomical points surrounding the Michaelis’ rhomboid over the sacral area. Two injections will be administered over the posterior superior iliac spine (PSIS) and the remaining two at two centimetres posterior, and one centimetre medial to the PSIS respectively. Main outcome measure:Proportion of women who have a caesarean section in labour. Randomisation: Permuted blocks stratified by research site. Blinding (masking):Double-blind trial in which participants, clinicians and research staff blinded to group assignment. Funding:Funded by the National Health and Medical Research Council Trial registration:Australian New Zealand Clinical Trials Registry (No ACTRN12611000221954).DiscussionSterile water injections, which may have a positive effect on reducing the CS rate, have been shown to be a safe and simple analgesic suitable for most maternity settings. A procedure that could reduce intervention rates without adversely affecting safety for mother and baby would benefit Australian families and taxpayers and would reduce requirements for maternal operating theatre time. Results will have external validity, as the technique may be easily applied to maternity populations outside Australia. In summary, the results of this trial will contribute High level evidence on the impact of SWI on intrapartum CS rates and provide evidence of the analgesic effect of SWI on back pain.

Comparing Different Partograph Designs for Use in Standard Labor Care: A Pilot Randomized Trial

Backgound Partographs are used in many labour settings to provide a pictorial overview of a woman’s cervical dilation pattern in the first stage of labor and to alert clinicians to slow progress possibly requiring intervention. Recent reviews called for large trials to establish the efficacy of partographs to improve birth outcomes whilst highlighting issues of clinician compliance with use. Previous studies have also reported issues with participant recruitment related to concerns regarding the possibility of a longer labour. Objectives We sought to compare a standard partograph with an action line, to a newly designed partograph with a stepped line, to determine the feasibility of recruitment to a larger clinical trial. Methods A pragmatic, single-blind randomised trial wherein low-risk, nulliparous women in spontaneous labour at term were randomized to an action-line or stepped-line partograph. First stage labour management was guided by the allocated partograph. Primary outcomes included the proportion of eligible women recruited, reasons for failed recruitment and compliance with partograph use. Secondary outcomes included rates of intervention, mode of birth, maternal and neonatal outcomes. Results Of the 384 potentially eligible participants, 38% (149/384) were approached. Of these 77% (116/149) consented, with 85% (99/116) randomized, only nine women approached (6%) declined to participate. A further 9% (14/149) who were consented antenatally were not eligible at onset of labor and 7% (10/149) of women approached in the birth suite but did not meet the inclusion criteria. Compliance with partograph completion was 65% (action) versus 84% (dystocia line). Conclusions for Practice Participant recruitment to a larger randomized controlled trial comparing new labour management guidelines to standard care is feasible. Effective strategies to improve partograph completion compliance would be required to maintain trial fidelity.

Perineal injury associated with hands on/hands poised and directed/undirected pushing: A retrospective cross-sectional study of non-operative vaginal births, 2011–2016

BACKGROUND Clinicians hand position and advised pushing techniques may impact on rates of perineal injury. OBJECTIVE To assess the association of four techniques used in management of second stage with risk of moderate and severe perineal injury. DESIGN Retrospective cross-sectional study. SETTING A metropolitan maternity hospital and a private maternity hospital in Brisbane, Australia. PARTICIPANTS Term women with singleton, cephalic presentation experiencing a non-operative vaginal birth from January 2011 to December 2016. METHODS The research sites perinatal database recorded data on clinicians approach to instructing women during second stage and hand position at birth. Women were identified from matching the inclusion criteria (n = 26,393) then grouped based on combinations of hands-on, hand- poised, directed and undirected pushing. The associations with perineal injury were estimated using odds ratios obtained by multivariate analysis. Primary outcomes were the risk of moderate and severe perineal injury. The significance was set at 0.001. RESULTS In Nulliparous women there was no difference in the risk of moderate or severe perineal injury between the different techniques. In multiparous women the use of a hands-on/directed approach was associated with a significant increase in the risk of moderate (AOR 1.18, 95% CI 1.10-1.27, p < 0.001) and severe perineal injury (AOR 1.50, 95% CI 1.20-1.88, p < 0.001) compared to hands-poised/undirected. CONCLUSIONS A hands poised/undirected approach could be utilised in strategies for the prevention of moderate and severe perineal injury.

Knowledge and use of sterile water injections amongst midwives in the United Kingdom: A cross-sectional study

BACKGROUND The use of sterile water injections (SWI) for the relief of pain in labour is popular amongst midwives in countries such as Sweden and Australia. Anecdotal reports suggest the procedure is used less commonly in the United Kingdom (UK) and that a number of barriers to introducing the practice may exist. OBJECTIVE The objective of this study was to explore the awareness and use of SWI amongst midwives in the UK. DESIGN A cross-sectional study using an internet-based questionnaire. PARTICIPANTS Midwives with Nursing and Midwifery Council Registration and currently practicing. SETTING The questionnaire was distributed via the Royal College of Midwives Facebook page and Twitter account. Invitations to participate were also sent to Heads of Midwifery to distribute to staff. FINDINGS Three hundred and ninety-eight midwives completed the survey. Eighty-two percent of midwives did not use SWI in practice although 69% would consider learning the procedure. There was considerable variation in techniques amongst midwives that did provide SWI. The lack of available practice guidelines and the advice from the National Institute for Health and Care Excellence to not use SWI were cited as the main barriers. KEY CONCLUSIONS SWI use is uncommon in the UK although midwives are interested in incorporating the procedure into practice. IMPLICATIONS FOR PRACTICE National guidance on SWI and the lack of information and training is restricting the use of the procedure in practice, despite SWI being widely used in other countries and being effective in the treatment of pain in labour.

Maternal and neonatal outcomes from a comparison of spontaneous and directed pushing in second stage

AIM To compare the effect of directed or spontaneous maternal pushing effort on duration of second stage labour, perineal injury and neonatal condition at birth. METHODS A retrospective cross-sectional design provided data for term women with singleton, cephalic presentation experiencing a non-operative vaginal birth without regional analgesia from January 2011 to December 2017 (n=69,066) Participants matching the inclusion criteria (n=19,212) were grouped based upon spontaneous or directed pushing. Propensity score matching was used to select equally sized cohorts of similar characteristics (n=10,000). The associations with outcomes of interest were estimated using odds ratios obtained by multivariate analysis. FINDINGS Directed pushing was associated with a longer duration of second stage labour for nulliparous (mean 14.4min [12.0-16.8]) and multiparous (mean 8.0min [6.8-9.2]) women, and an increased risk of prolonged 2nd stage of labour in multiparous women. The use of episiotomy in the directed pushing group was significantly higher both prior to and following PS matching and adjustment. Directed pushing was also associated with an significantly increased risk of neonatal resuscitation and nursery admission. There was no difference in rates of Apgar <7 recorded at 5min of age. CONCLUSION Directed pushing is associated with an increased duration of second stage labour and risk of adverse neonatal outcomes. Our study suggests that in the absence of regional analgesia women should be supported to follow their own expulsive urges.