Model of care and chance of spontaneous vaginal birth: a prospective, multicenter matched-pair analysis from North Rhine-Westphalia

Background Advantages of midwife-led models of care have been reported; these include a higher vaginal birth rate and less interventions. In Germany, 98.4% of women are giving birth in obstetrician-led units. We compared the outcome of birth planned in alongside midwifery units (AMU) with a matched group of low-risk women who gave birth in obstetrician-led units. Methods A prospective, controlled, multicenter study was conducted. Six of seven AMUs in North Rhine-Westphalia participated. Healthy women with a singleton term cephalic pregnancy booking for birth in AMU were eligible. For each woman in the study group a control was chosen who would have been eligible for birth in AMU but was booking for obstetrician-led care; matching for parity was performed. Mode of birth was chosen as primary outcome parameter. Secondary endpoints included a composite outcome of adverse outcome in the third stage and / or postpartum hemorrhage; higher-order obstetric lacerations; and for the neonate, a composite outcome (5-min Apgar < 7 and / or umbilical cord arterial pH < 7.10 and / or transfer to specialist neonatal care). Statistical analysis was by intention to treat. A non-inferiority analysis was performed. Results Five hundred eighty-nine case-control pairs were recruited, final analysis was performed with 391 case-control pairs. Nulliparous women constituted 56.0% of cases. For the primary endpoint vaginal birth superiority was established for the study group (5.66%, 95%-CI 0.42% – 10.88%). For the composite newborn outcome (1.28%, 95%-CI -1.86% - -4.47%) and for higher-order obstetric lacerations (2.33%, 95%-CI -0.45% - 5.37%) non-inferiority was established. Non-inferiority was not present for the composite maternal outcome (-1.56%, 95%-CI -6.69% - 3.57%). The epidural anesthesia rate was lower (22.9% vs. 41.1%), and the length of hospital stay was shorter in the study group (p < 0.001 for both). Transfer to obstetrician-led care occurred in 51.2% of cases, with a strong association to parity (p < 0.001). Request for regional anesthesia was the most common cause for transfer (47.1%). Conclusion Our comparison between care in AMU and obstetrician-led care with respect to mode of birth and other outcomes confirmed the superiority of this model of care for low-risk women. This pertains to AMU where admission and transfer criteria are in place and adhered to.

Intramuscular meperidine analgesia at the beginning of active phase shortens labor duration without adverse effects on obstetric lacerations

The primary objectives of this study were to evaluate the impact of intramuscular meperidine on shortening of the active phase of labor, the neonatal outcome and the rate and severity of perineal lacerations in term pregnant women in the first stage of labor. A total of 571 primiparous term pregnant women delivered vaginally were included into this retrospective study. In 437 of them, meperidine (100 mg IM) at the beginning of the active phase was administered and 134 women did not receive any meperidine dose. The length of labor phases, obstetric lacerations, and neonatal outcomes were recorded. The results of this study showed that meperidine could be used safely as an obstetric analgesic with its additional benefit of shortening the active phase of the first stage and second stage of labor without increased risk of obstetric lacerations and perinatal adverse outcomes. In case of limited use of neuraxial analgesia in a busy state maternity hospital, intramuscular meperidine administration as obstetric analgesia seems beneficial in reducing the length of the active phase of the first stage of labor and the second stage of labor without adversely affecting obstetric lacerations and neonatal outcomes.

Model of Care and Chance of Spontaneous Vaginal Birth: A Prospective, Multicenter Matched-Pair Analysis From North Rhine-Westphalia

BackgroundCompared to standard obstetric care, advantages of midwife-led models of care have been reported; these include a higher vaginal birth rate and less interventions. In Germany, 98.4% of women are giving birth in consultant-led obstetric units. We compared the outcome of birth planned in alongside midwifery units (AMU) in North Rhine-Westphalia (NRW) with a matched group of low-risk women who gave birth in standard obstetric care during the same period of time.MethodsA prospective, controlled, multicenter study was conducted. Six of the seven AMUs in NRW participated. Healthy women with a singleton term cephalic pregnancy booking for birth in AMU were eligible. For each woman in the study group a control was chosen who would have been eligible for birth in AMU but was booking for standard obstetric care at the same hospital at the same time; additionally, matching for parity was performed. Mode of birth was chosen as primary outcome parameter. Secondary endpoints included a composite outcome of abnormal third stage and / or postpartum hemorrhage; higher-order obstetric lacerations; and for the neonate, a composite outcome (5-minute Apgar <7 and / or umbilical cord arterial pH < 7.10 and / or transfer to specialist neonatal care). Statistical analysis was by intention to treat. A non-inferiority analysis was performed for the primary and all secondary endpoints.Results589 case-control pairs were recruited, corresponding to 13.6% of those assumed to be eligible; 198 cases were excluded. Final analysis was performed with 391 case-control pairs. Nulliparous women constituted 56.0% of cases. For the primary endpoint vaginal birth superiority was established for the study group (5.66, 90%-CI 1.26-10.04). Superiority was also confirmed for higher-order obstetric lacerations (2.33, 90%-CI 0.04-4.81). For the composite newborn outcome non-inferiority was established (1.28, 90%-CI 1.33-3.93). Non-inferiority was not present for the composite maternal outcome (-1.56, 90%-CI -5.86-2.75). The epidural anesthesia rate was lower (22.9% vs. 41.1%), and the length of hospital stay was shorter in the study group (p<0.001 for both).Transfer to standard obstetric care occurred in 51.2% of cases, with a strong association between parity and transfer (p<0.001). Request for regional anesthesia was the most common cause for transfer (47.1%). ConclusionOur comparison between care in AMU and standard obstetric care with respect to mode of birth and other outcomes confirmed the superiority of this model of care for low-risk women. Admission and transfer criteria were in place in all participating centers and strictly adhered to.

Incidence of Obstetric Lacerations and Episiotomy Following Labiaplasty

Background A significant proportion of patients seeking labiaplasty are nulliparous and may experience later changes to their labia following vaginal delivery. Objectives In the present study, the authors reported the long-term outcomes of a single surgeon’s patient cohort who had vaginal delivery after labiaplasty. Methods A retrospective chart review of the senior author’s database was conducted. All patients who underwent in-office labiaplasty from 2007 to 2018 were surveyed. The resulting cohort was stratified into patients who had delivered children prior to labiaplasty and those who delivered after labiaplasty. Results A total of 204 patients responded to a phone survey. Seventy patients had children prior to undergoing labiaplasty, and 33 had children after labiaplasty. The rate of vaginal delivery was lower in the women who had children before labiaplasty (82.6% vs 91.8%, P = 0.015). The tear/episiotomy rate for vaginal deliveries was lower in women who had children prior to labiaplasty compared with after labiaplasty (3.1% vs 17.8%, P &lt; 0.001). Among the women who had children only after labiaplasty, the reported tear/episiotomy rate was 7/39 vaginal deliveries (17.9%). Conclusion Patients in our cohort had over 90% success with vaginal deliveries after labiaplasty. For nulliparous patients contemplating the procedure, the data we present suggest the risk of episiotomy or vaginal tear risk with vaginal birth after labiaplasty is comparable with or lower than the general population, further supporting the safety of this procedure. For patients with previous delivery, the data are more limited but suggest no increased risk in this small cohort. Level of Evidence: 4

Análise de fatores associados à prática da episiotomia

RESUMOObjetivo: identificar os fatores que levam enfermeiros obstetras a realizarem uma episiotomia. Método: trata-se de uma revisão integrativa, com vistas a responder à questão norteadora << O que leva o enfermeiro obstetra a realizar uma episiotomia? >>. Para isso, realizou-se uma busca por evidências, entre 2005 a 2017, nas bases de dados LILACS e BDENF e na BIREME e SciELO, com os descritores: episiotomia, humanização da assistência e trabalho de parto, considerando os critérios de inclusão e exclusão pré-estabelecidos. Foram selecionados 9 artigos posteriormente submetidos à leitura, análise e organizados em figuras para discussão através de um instrumento adaptado e validado por Ursi 2005. Resultado: foi possível verificar que a maioria dos estudos se referem à prática da episiotomia como intimamente ligada a primiparidade, rigidez perineal, macrossomia e prematuridade. Conclusão: a literatura evidenciou que os principais fatores que levam os enfermeiros obstetras a realizarem a episiotomia são: primiparidade, à rigidez perineal, macrossomia e prematuridade. Com isso, foi possível verificar que a episiotomia não previne lacerações de 3º e 4º grau e a mesma está relacionada diretamente com a dispareunia. Isso contribui para uma preocupação científica em instituir tecnologias que auxiliem na fisiologia do parto preservando a integridade corporal. Descritores: Episiotomia; Trabalho de Parto; Lacerações; Períneo; Enfermagem Obstétrica; Parto Normal.ABSTRACTObjective: to identify factors that lead obstetric nurses to perform an episiotomy. Method: this is an integrative review, with a view to respond to the question << What leads the obstetric nurse to perform an episiotomy? >>. To do this, a search for evidence was performed, from 2005 to 2017, in the databases LILACS, BDENF, BIREME and SciELO, with the descriptors: episiotomy, care humanization and labor, considering the inclusion and exclusion criteria pre-established. Nine articles were selected, subsequently read, analyzed and organized into figures for discussion by means of an instrument adapted and validated by Ursi 2005. Results: most studies refer to the practice of episiotomy as intimately linked to primiparity, perineal rigidity, macrosomia, and prematurity. Conclusion: The literature showed that the main factors that lead obstetric nurses to perform the episiotomy are: primiparity, perineal rigidity, macrosomia, and prematurity. The episiotomy does not prevent lacerations of third and fourth grade and directly relates to dyspareunia. This contributes to a scientific concern to establish technologies that assist in the physiology of childbirth while preserving the integrity of the body. Descriptors: Episiotomy; Obstetric; Lacerations; Perineum; Obstetric Nursing; Natural Childbirth.RESUMENObjetivo: Identificar los factores que llevan los enfermeros obstétricos para realizar una episiotomía. Método: revisón integrativa, con miras a responder a la pregunta << Que lleva el enfermero obstétrico para realizar una episiotomía? >>. Para ello, realizamos una búsqueda de evidencias, de 2005 a 2017, en las bases de datos LILACS, BDENF, BIREME y SciELO, con los descriptores: episiotomía, humanización de la atención y trabajo de parto, mientras que los criterios de inclusión y exclusión pre-establecidos. Nueve artículos fueron seleccionados, sometidos posteriormente a la lectura, analizados y organizados en cifras para el debate por medio de un instrumento adaptado y validado por Ursi 2005. Resultados: Se pudo comprobar que la mayoría de los estudios se refieren a la práctica de la episiotomía como íntimamente ligada a primiparidad, rigidez perineal, macrosomía y prematuridad. Conclusión: La literatura mostró que los principales factores que conducen los enfermeros obstétricos para realizar la episiotomía son: primiparidad, la rigidez perineal, macrosomía y prematuridad. Con ello, fue posible verificar que la episiotomía no previene heridas de 3º y 4º grado y está directamente relacionada con la dispareunia. Esto contribuye a una preocupación científica para establecer tecnologías que ayudan a la fisiología del parto, preservando la integridad del cuerpo. Descriptores: Episiotomía; Trabajo de Parto; Laceraciones; Perineo; Enfermería Obstétrica; Parto Normal.