Tina Lavender

A prospective study of women's views of factors contributing to a positive birth experience.

OBJECTIVE To explore the aspects of a womans childbirth experience which she perceived as being important. DESIGN As part of a large randomised trial, which assessed the timing of intervention in prolonged labour, womens views were explored using a specifically-designed questionnaire. The questionnaire, which was administered on the second postnatal day, incorporated a rating scale followed by an open question. The responses to the open question are presented in this paper. SETTING Regional teaching hospital in the north west of England. SAMPLE 615 primigravid women received a copy of the questionnaire. Of the 519 women who returned the questionnaire, 412 women answered the relevant section, the findings of which are presented in this paper. ANALYSIS The responses to the open-ended question were analysed by the generation of themes from the most frequently occurring responses. MAIN FINDINGS The main themes which emerged were support, information, intervention, decision making, control, pain relief and trial participation. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Most women are able to identify important contributors to a positive intrapartum experience. Midwives have an important role in identifying these contributors and supporting women to fulfil their individual needs.

Advanced maternal age and adverse pregnancy outcome: evidence from a large contemporary cohort.

Background Recent decades have witnessed an increase in mean maternal age at childbirth in most high-resourced countries. Advanced maternal age has been associated with several adverse maternal and perinatal outcomes. Although there are many studies on this topic, data from large contemporary population-based cohorts that controls for demographic variables known to influence perinatal outcomes is limited. Methods We performed a population-based cohort study using data on all singleton births in 2004–2008 from the North Western Perinatal Survey based at The University of Manchester, UK. We compared pregnancy outcomes in women aged 30–34, 35–39 and ≥40 years with women aged 20–29 years using log-linear binomial regression. Models were adjusted for parity, ethnicity, social deprivation score and body mass index. Results The final study cohort consisted of 215,344 births; 122,307 mothers (54.19%) were aged 20–29 years, 62,371(27.63%) were aged 30–34 years, 33,966(15.05%) were aged 35–39 years and 7,066(3.13%) were aged ≥40 years. Women aged 40+ at delivery were at increased risk of stillbirth (RR = 1.83, [95% CI 1.37–2.43]), pre-term (RR = 1.25, [95% CI: 1.14–1.36]) and very pre-term birth (RR = 1.29, [95% CI:1.08–1.55]), Macrosomia (RR = 1.31, [95% CI: 1.12–1.54]), extremely large for gestational age (RR = 1.40, [95% CI: 1.25–1.58]) and Caesarean delivery (RR = 1.83, [95% CI: 1.77–1.90]). Conclusions Advanced maternal age is associated with a range of adverse pregnancy outcomes. These risks are independent of parity and remain after adjusting for the ameliorating effects of higher socioeconomic status. The data from this large contemporary cohort will be of interest to healthcare providers and women and will facilitate evidence based counselling of older expectant mothers.

'Weighing up and balancing out': a meta-synthesis of barriers to antenatal care for marginalised women in high-income countries.

Background  In high‐resource settings around 20% of maternal deaths are attributed to women who fail to receive adequate antenatal care. Epidemiological evidence suggests many of these women belong to marginalised groups often living in areas of relative deprivation. Reasons for inadequate antenatal attendance have yet to be fully evaluated.

Parenteral opioids for labor pain relief: a systematic review.

Parenteral opioids are commonly used for labor pain relief and have been the subject of research for many years. The objectives of this review were to determine the safety and effectiveness of parenteral opioids in this context. Of 85 trials systematically reviewed, 48 comprising more than 9800 were included, but the number of trials contributing data to individual outcome measures is very limited. Epidural provides better pain relief. However, if women opt for systemic analgesia, no strong preference for any of the opioids can be recommended. Pethidine is the most commonly used opioid worldwide, and although there are considerable doubts about its analgesic effectiveness and concerns about its potential maternal, fetal, and neonatal side effects, it has the virtue of familiarity and low cost. There is as yet no convincing research evidence to show that alternative opioids are better. In view of the large number of women who receive opioids in labor and the paucity of research evidence about the relative effectiveness and side effects of different opioids and opioids compared with other methods (apart from epidural), well-designed and suitably sized trials of pethidine versus the main alternatives that address substantive outcomes for mothers and babies are strongly recommended.

Vaginal progesterone prophylaxis for preterm birth (the OPPTIMUM study): a multicentre, randomised, double-blind trial

Summary Background Progesterone administration has been shown to reduce the risk of preterm birth and neonatal morbidity in women at high risk, but there is uncertainty about longer term effects on the child. Methods We did a double-blind, randomised, placebo-controlled trial of vaginal progesterone, 200 mg daily taken from 22–24 to 34 weeks of gestation, on pregnancy and infant outcomes in women at risk of preterm birth (because of previous spontaneous birth at ≤34 weeks and 0 days of gestation, or a cervical length ≤25 mm, or because of a positive fetal fibronectin test combined with other clinical risk factors for preterm birth [any one of a history in a previous pregnancy of preterm birth, second trimester loss, preterm premature fetal membrane rupture, or a history of a cervical procedure to treat abnormal smears]). The objective of the study was to determine whether vaginal progesterone prophylaxis given to reduce the risk of preterm birth affects neonatal and childhood outcomes. We defined three primary outcomes: fetal death or birth before 34 weeks and 0 days gestation (obstetric), a composite of death, brain injury, or bronchopulmonary dysplasia (neonatal), and a standardised cognitive score at 2 years of age (childhood), imputing values for deaths. Randomisation was done through a web portal, with participants, investigators, and others involved in giving the intervention, assessing outcomes, or analysing data masked to treatment allocation until the end of the study. Analysis was by intention to treat. This trial is registered at ISRCTN.com, number ISRCTN14568373. Findings Between Feb 2, 2009, and April 12, 2013, we randomly assigned 1228 women to the placebo group (n=610) and the progesterone group (n=618). In the placebo group, data from 597, 587, and 439 women or babies were available for analysis of obstetric, neonatal, and childhood outcomes, respectively; in the progesterone group the corresponding numbers were 600, 589, and 430. After correction for multiple outcomes, progesterone had no significant effect on the primary obstetric outcome (odds ratio adjusted for multiple comparisons [OR] 0·86, 95% CI 0·61–1·22) or neonatal outcome (OR 0·62, 0·38–1·03), nor on the childhood outcome (cognitive score, progesterone group vs placebo group, 97·3 [SD 17·9] vs 97·7 [17·5]; difference in means −0·48, 95% CI −2·77 to 1·81). Maternal or child serious adverse events were reported in 70 (11%) of 610 patients in the placebo group and 59 (10%) of 616 patients in the progesterone group (p=0·27). Interpretation Vaginal progesterone was not associated with reduced risk of preterm birth or composite neonatal adverse outcomes, and had no long-term benefit or harm on outcomes in children at 2 years of age. Funding Efficacy and Mechanism Evaluation (EME) Programme, a Medical Research Council (MRC) and National Institute for Health Research (NIHR) partnership. The EME Programme is funded by the MRC and NIHR, with contributions from the Chief Scientist Office in Scotland and National Institute for Social Care and Research in Wales.

Choice and birth method : mixed-method study of caesarean delivery for maternal request

Objective  To explore whether women view decision‐making surrounding vaginal or caesarean birth as their choice.

The maternity experience for women with a body mass index ≥ 30 kg/m2: a meta-synthesis.

Please cite this paper as: Smith D, Lavender T. The maternity experience for women with a body mass index ≥ 30 kg/m2: a meta‐synthesis. BJOG 2011;118:779–789.

Effect of olive and sunflower seed oil on the adult skin barrier: implications for neonatal skin care.

Natural oils are advocated and used throughout the world as part of neonatal skin care, but there is an absence of evidence to support this practice. The goal of the current study was to ascertain the effect of olive oil and sunflower seed oil on the biophysical properties of the skin. Nineteen adult volunteers with and without a history of atopic dermatitis were recruited into two randomized forearm‐controlled mechanistic studies. The first cohort applied six drops of olive oil to one forearm twice daily for 5 weeks. The second cohort applied six drops of olive oil to one forearm and six drops of sunflower seed oil to the other twice daily for 4 weeks. The effect of the treatments was evaluated by determining stratum corneum integrity and cohesion, intercorneocyte cohesion, moisturization, skin‐surface pH, and erythema. Topical application of olive oil for 4 weeks caused a significant reduction in stratum corneum integrity and induced mild erythema in volunteers with and without a history of atopic dermatitis. Sunflower seed oil preserved stratum corneum integrity, did not cause erythema, and improved hydration in the same volunteers. In contrast to sunflower seed oil, topical treatment with olive oil significantly damages the skin barrier, and therefore has the potential to promote the development of, and exacerbate existing, atopic dermatitis. The use of olive oil for the treatment of dry skin and infant massage should therefore be discouraged. These findings challenge the unfounded belief that all natural oils are beneficial for the skin and highlight the need for further research.

Partogram action line study: A randomised trial

Objective To assess the effect of three different partograms on caesarean section and maternal satisfaction.

Dysfunctional labour: a randomised trial

Sixty‐one women making slow progress in the active phase of spontaneous labour with intact membranes were randomised to oxytocin and amniotomy, amniotomy only or expectant management. The data show that oxytocin significantly increases the rate of cervical dilatation and shortens prolonged labour, when compared with amniotomy alone and expectant management (P= 0.144 and 0–0.06, respectively). The impact on the operative delivery rate and neonatal outcome is difficult to assess due to the small number of relevant adverse outcomes. Women reported higher satisfaction score in the two groups where intervention followed the diagnosis of dysfunctional labour.