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In this cluster-randomized trial in Uttar Pradesh, India, a coaching-based implementation of a WHO-based Safe Childbirth Checklist over a period of 8 months increased adherence to essential birth practices but did not reduce maternal or perinatal mortality or maternal morbidity.

In this randomized trial comparing delivery strategies in women with twin gestation, planned cesarean section did not significantly increase or decrease the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery. Because of assisted reproductive technologies, twin pregnancy occurs more frequently now than in the past, and it complicates 2 to 3% of all births. 1 , 2 Twins are at higher risk for an adverse perinatal outcome than singletons. 3 , 4 Planned cesarean section, as compared with planned vaginal delivery, may reduce this risk. 5 Although a small, randomized, controlled trial did not show better perinatal outcomes with planned cesarean section than with planned vaginal delivery, 6 several cohort studies have shown a reduced risk of adverse perinatal outcomes for both twins, or for the second twin, when twins at or near term were delivered . . .

There is an ongoing debate concerning which guidelines and monitoring tools are most beneficial for assessing labour progression, to help prevent use of intrapartum caesarean section (ICS). The WHO partograph has been used for decades with the assumption of a linear labour progression; however, in 2010, Zhang introduced a new guideline suggesting a more dynamic labour progression. We aimed to investigate whether the frequency of ICS use differed when adhering to the WHO partograph versus Zhang's guideline for labour progression. We did a multicentre, cluster-randomised controlled trial at obstetric units in Norway, and each site was required to deliver more than 500 fetuses per year to be eligible for inclusion. The participants were nulliparous women who had a singleton, full-term fetus with cephalic presentation, and who entered spontaneous active labour. The obstetric units were treated as clusters, and women treated within these clusters were all given the same treatment. We stratified these clusters by size and number of previous caesarean sections. The clusters containing the obstetric units were then randomly assigned (1:1) to the control group, which adhered to the WHO partograph, or to the intervention group, which adhered to Zhang's guideline. The randomisation was computer-generated and was done in the Unit of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway, and investigators in this unit had no further involvement in the trial. Our study design did not enable masking of participants or health-care providers, but the investigators who were analysing the data were masked to group allocation. The primary outcome was use of ICS during active labour (cervical dilatation of 4–10 cm) in all participating women. The Labour Progression Study (LaPS) is registered with ClinicalTrials.gov, number NCT02221427. Between Aug 1, 2014, and Sept 1, 2014, 14 clusters were enrolled in the LaPS trial, and on Sept 11, 2014, seven obstetric units were randomly assigned to the control group (adhering to the WHO partograph) and seven obstetric units were randomly assigned to the intervention group (adhering to Zhang's guideline). Between Dec 1, 2014, and Jan 31, 2017, 11 615 women were judged to be eligible for recruitment in the trial, which comprised 5421 (46·7%) women in the control group units and 6194 (53·3%) women in the intervention group units. In the control group, 2100 (38·7%) of 5421 women did not give signed consent to participate and 16 (0·3%) women abstained from participation. In the intervention group, 2181 (35·2%) of 6194 women did not give signed consent to participate and 41 (0·7%) women abstained from participation. 7277 (62·7%) of 11 615 eligible women were therefore included in the analysis of the primary endpoint. Of these women, 3305 (45·4%) participants were in an obstetric unit that was randomly assigned to the control group (adhering to the WHO partograph) and 3972 (54·6%) participants were in an obstetric unit that was randomly assigned to the intervention group (adhering to Zhang's guideline). No women dropped out during the trial. Before the start of the trial, ICS was used in 9·5% of deliveries in the control group obstetric units and in 9·3% of intervention group obstetric units. During our trial, there were 196 (5·9%) ICS deliveries in women in the control group (WHO partograph) and 271 (6·8%) ICS deliveries in women in the intervention group (Zhang's guideline), and the frequency of ICS use did not differ between the groups (adjusted relative risk 1·17, 95% CI 0·98–1·40; p=0·08; adjusted risk difference 1·00%, 95% CI −0·1 to 2·1). We identified no maternal or neonatal deaths during our study. We did not find any significant difference in the frequency of ICS use between the obstetric units assigned to adhere to the WHO partograph and those assigned to adhere to Zhang's guideline. The overall decrease in ICS use that we observed relative to the previous frequency of ICS use noted in these obstetric units might be explained by the close focus on assessing labour progression more than use of the guidelines. Our results represent an important contribution to the discussion on implementation of the new guideline. Østfold Hospital Trust.

Background As a quality marker and a tool for benchmarking between units, a visual analogue scale (VAS) (ranging from 1 to 10) to estimate woman’s satisfaction with childbirth was introduced in 2014. This study aimed to assess how obstetric interventions and complications affected women’s satisfaction with childbirth. Methods A retrospective cohort study including 16,775 women with an available VAS score who gave birth between January 2016 and December 2017. VAS score, maternal and obstetric characteristics were obtained from electronic medical records and crude and adjusted odds ratios (aOR) were calculated. Results The total prevalence of dissatisfaction with childbirth (VAS 1–3) was 5.7%. The main risk factors for dissatisfaction with childbirth were emergency cesarean section, aOR 3.98 95% confidence interval (CI) 3.27–4.86, postpartum hemorrhage ≥2000 ml, aOR 1.85 95%CI 1.24–2.76 and Apgar score < 7 at five minutes, aOR 2.95 95%CI 1.95–4.47. The amount of postpartum hemorrhage showed a dose-response relation to dissatisfaction with childbirth. Moreover, labor induction, instrumental vaginal delivery, and obstetric anal sphincter injury were significantly associated with women’s dissatisfaction with childbirth. A total number of 4429/21204 (21%) women giving birth during the study period had missing values on VAS. A comparison of characteristics between women with and without a recorded VAS score was performed. There were statistically significant differences in maternal age and maternal BMI between the study population and excluded women due to missing values on VAS. Moreover, 64% of the women excluded were multiparas, compared to 59% in the study population. Conclusions Obstetric interventions and complications, including emergency cesareans section and postpartum hemorrhage, were significantly related to dissatisfaction with childbirth. Such events are common and awareness of these associations might lead to a more individualized care of women during and after childbirth.

Introduction and Hypothesis The objective was to evaluate the safety and effectiveness of an intrapartum electromechanical pelvic floor dilator designed to reduce the risk of levator ani muscle (LAM) avulsion during vaginal delivery. Methods A multicenter, randomized controlled trial enrolled nulliparous participants planning vaginal delivery. During the first stage of labor, participants were randomized to receive the intravaginal device or standard-of-care labor management. The primary effectiveness endpoint was the presence of full LAM avulsion on transperineal pelvic-floor ultrasound at 3 months. Three urogynecologists performed blinded interpretation of ultrasound images. The primary safety endpoint was adverse events (AEs) through 3 months. Results A total of 214 women were randomized to Device ( n  = 113) or Control ( n  = 101) arms. Of 113 Device assignees, 82 had a device placed, of whom 68 delivered vaginally. Of 101 Control participants, 85 delivered vaginally. At 3 months, 110 participants, 46 Device subjects who received full device treatment, and 64 Controls underwent ultrasound for the per-protocol analysis. No full LAM avulsions (0.0%) occurred in the Device group versus 7 out of 64 (10.9%) in the Control group ( p  = 0.040; two-tailed Fisher’s test). A single maternal serious AE (laceration) was device related; no neonate serious AEs were device related. Conclusions The pelvic floor dilator device significantly reduced the incidence of complete LAM avulsion in nulliparous individuals undergoing first vaginal childbirth. The dilator demonstrated an acceptable safety profile and was well received by recipients. Use of the intrapartum electromechanical pelvic floor dilator in laboring nulliparous individuals may reduce the rate of LAM avulsion, an injury associated with serious sequelae including pelvic organ prolapse.

The discrepancy regarding maternal mortality continues to be a health concern between developing and developed countries. The majority of global maternal deaths occur in developing countries, specifically, in the sub-Sahara African region which alone accounts for more than half of these deaths. It has been indicated that utilization of the partograph was significantly associated with improved maternal and neonatal outcomes of labour and that is why the World Health Organization recommends the universal use of the tool during labour. Therefore, this study has assessed the level of partograph use and its associated factors among obstetric caregivers in East Gojam Zone, Northwest Ethiopia. A health facility based cross-sectional study was conducted among randomly selected obstetric caregivers in Northwest Ethiopia. The data were collected using a self-administered questionnaire and a clinical observation checklist. The data were entered into Epidata version 3.1, and cleaned and analyzed using SPSS version 24.0 statistical software. About three quarters, or 198 (72.53%), of the obstetric caregivers, had attained diploma level of education. However, 153 (56.04%) of the obstetric caregivers had what was considered to be good knowledge about the partograph, but utilization of the tool was slightly lower than their level of knowledge, 147 (53.85%). Utilization of the partograph was significantly higher among obstetric caregivers holding a Bachelor of Science degree and above, than Diploma holders (AOR (95% C.I) 2.07 (1.15-3.75)) and the use was higher among those who were regularly working in the delivery ward compared to those regularly working in the Adult Outpatient Department (AOR (95% C.I): 2.25 (1.07-4.72)). Moreover, caregivers who had a good knowledge about the partograph and who had received on the job training in obstetric care were also more likely to use the partograph during labour and delivery (AOR (95% C.I): 1.79 (1.05-3.06) and 4.85 (2.63-8.96)) respectively. The results of this study revealed that although more than half of obstetric caregivers had a good knowledge of the partograph, the actual utilization of the tool was slightly lower than the knowledge they had. Therefore, in this study, we suggest that providing on the job obstetric care training for obstetric caregivers, about the partograph in particular, would improve partograph utilization.

Background In order to reduce the complications of perineal damage and the pain caused by it for the mother, this study was conducted to determine the effect of warm perineal compress on perineal trauma (1st-, 2nd-, 3rd-, and 4th-degree perineal tears), postpartum pain, intact perineum (primary outcomes), episiotomy, length of the second stage, and APGAR score at 1 and 5 min after childbirth (secondary outcome). Methods PubMed, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, Web of Science, SID, Magiran, and ClinicalTrials.gov were searched to identify the relevant articles from inception to November 1, 2022, with language restriction (only English and Persian). A manual search was also performed. Risk of bias 2 (RoB2) and ROBIN-I were employed to evaluate the quality of the included papers. Meta-analysis was conducted using RevMan 5.3. Heterogeneity was assessed using I 2 . In cases with high heterogeneity, subgroup analysis was utilized based on the parity and ethnicity, and time of pain measurement after delivery also a random-effects model was used instead of a fixed-effects model. Trial sequential analysis (TSA) was performed for the primary outcomes. The certainty of evidence was assessed using the GRADE approach. Results A total number of 228 articles were found in databases. Of these articles, eighty-six were screened by title, 27 by abstract, and 21 by full text. Finally, 14 articles were included, of which ten were RCT and four were non-RCT. Meta-analysis results revealed that warm perineal compress significantly reduced perineal pain (RR 0.23, 95% CI 0.08–0.66; P = 0.0006), average pain (SMD − 0.73, 95% CI 1.23 to − 0.23; P = 0.004), second-degree perineal tear (RR 0.65, 95% CI 0.54–0.79; P˂0.00001), third-degree perineal tear (RR 0.32, 95% CI 0.15–0.67; P = 0.003), fourth-degree perineal tear (RR 0.11, 95% CI 0.01–0.87; P = 0.04), episiotomy (RR 0.63, 95% CI 0.46–0.86; P = 0.004), and intact perineum significantly increased (RR 3.06, 95% CI 1.79–5.22; P < 0.0001) compared to the control group. However, there was no statistically significant difference in terms of first-degree tear (RR 1.04, 95% CI 0.86–1.25; P = 0.72), length of the second stage of labor (MD − 0.60, 95% CI − 2.43 to 1.22; P = 0.52), the first minute (MD − 0.03, 95% CI − 0.07 to 0.02; P = 0.24) and the fifth minute Apgar score (MD − 0.02, 95% CI − 0.07 to 0.03; P = 0.46) between the two groups. Conclusion Warm perineal compress administered during the second stage of labor reduce postpartum pain, second and third-degree perineal tears, and episiotomy rate while it increases the incidence of intact perineum compared to the control group.

Abusive treatment of women during childbirth has been documented in low-resource countries and is a deterrent to facility utilization for delivery. Evidence for interventions to address women's poor experience is scant. We assessed a participatory community and health system intervention to reduce the prevalence of disrespect and abuse during childbirth in Tanzania. We used a comparative before-and-after evaluation design to test the combined intervention to reduce disrespect and abuse. Two hospitals in Tanga Region, Tanzania were included in the study, 1 randomly assigned to receive the intervention. Women who delivered at the study facilities were eligible to participate and were recruited upon discharge. Surveys were conducted at baseline (December 2011 through May 2012) and after the intervention (March through September 2015). The intervention consisted of a client service charter and a facility-based, quality-improvement process aimed to redefine norms and practices for respectful maternity care. The primary outcome was any self-reported experiences of disrespect and abuse during childbirth. We used multivariable logistic regression to estimate a difference-in-difference model. At baseline, 2,085 women at the 2 study hospitals who had been discharged from the maternity ward after delivery were invited to participate in the survey. Of these, 1,388 (66.57%) agreed to participate. At endline, 1,680 women participated in the survey (72.29% of those approached). The intervention was associated with a 66% reduced odds of a woman experiencing disrespect and abuse during childbirth (odds ratio [OR]: 0.34, 95% CI: 0.21-0.58, p < 0.0001). The biggest reductions were for physical abuse (OR: 0.22, 95% CI: 0.05-0.97, p = 0.045) and neglect (OR: 0.36, 95% CI: 0.19-0.71, p = 0.003). The study involved only 2 hospitals in Tanzania and is thus a proof-of-concept study. Future, larger-scale research should be undertaken to evaluate the applicability of this approach to other settings. After implementation of the combined intervention, the likelihood of women's reports of disrespectful treatment during childbirth was substantially reduced. These results were observed nearly 1 year after the end of the project's facilitation of implementation, indicating the potential for sustainability. The results indicate that a participatory community and health system intervention designed to tackle disrespect and abuse by changing the norms and standards of care is a potential strategy to improve the treatment of women during childbirth at health facilities. The trial is registered on the ISRCTN Registry, ISRCTN 48258486. ISRCTN Registry, ISRCTN 48258486.