Effectiveness of intrapartum fetal surveillance to improve maternal and neonatal outcomes: a systematic review and network meta-analysis
Background: Cesarean delivery is the most common surgical procedure worldwide. Intrapartum fetal surveillance is routinely offered to improve neonatal outcomes, but the effects of different methods on the risk of emergency cesarean deliveries remains uncertain. We conducted a systematic review and network meta-analysis to evaluate the effectiveness of different types of fetal surveillance.
Results: We included 33 trials (118 863 patients) evaluating intermittent auscultation with Pinard stethoscope/handheld Doppler (IA), cardiotocography (CTG), computerized cardiotocography (cCTG), CTG with fetal scalp lactate (CTG-lactate), CTG with fetal scalp pH analysis (CTG-FBS), CTG with fetal pulse oximetry (FPO-CTG), CTG with fetal heart electrocardiogram (CTG-STAN) and their combinations. Intermittent auscultation reduced the risk of emergency cesarean deliveries compared with other types of surveillance (IA v. CTG: RR 0.83, 95% CI 0.72-0.97; IA v. CTG-FBS: RR 0.71, 95% CI 0.63-0.80; IA v.CTG-lactate: RR 0.77, 95% CI 0.64-0.92; IA v. FPO-CTG: RR 0.75, 95% CI 0.65-0.87; IA v.FPO-CTG-FBS: RR 0.81, 95% CI 0.67-0.99; cCTG-FBS v. IA: RR 1.21, 95% CI 1.04-1.42), except STAN-CTG-FBS (RR 1.17, 95% CI 0.98-1.40). There was a similar reduction observed for emergency cesarean deliveries for fetal distress. None of the evaluated methods was associated with a reduced risk of neonatal acidemia, neonatal unit admissions, Apgar scores or perinatal death.
Interpretation: Compared with other types of fetal surveillance, intermittent auscultation seems to reduce emergency cesarean deliveries in labour without increasing adverse neonatal and maternal outcomes.
Experiences of maternity care among women at increased risk of preterm birth receiving midwifery continuity of care compared to women receiving standard care: Results from the POPPIE pilot trial
PLOS ONE, 16(4): e0248588
Midwifery continuity of care models for women at low and mixed risk of complications have been shown to improve women’s experiences of care. However, there is limited research on care experiences among women at increased risk of preterm birth. We aimed to explore the experiences of care among women with risk factors for preterm birth participating in a pilot trial (POPPIE) of a midwifery continuity of care model which included a specialist obstetric clinic.
Compared with standard maternity care, women at increased risk of PTB who received midwifery continuity of care were more likely to report increased perceptions of trust, safety and quality of care.
Maternal and Neonatal Morbidity and Mortality Among Pregnant Women With and Without COVID-19 Infection The INTERCOVID Multinational Cohort Study
JAMA Pediatrics, doi:10.1001/jamapediatrics.2021.1050
Objective: To evaluate the risks associated with COVID-19 in pregnancy on maternal and neonatal outcomes compared with not-infected, concomitant pregnant individuals.
Design, Setting, and Participants: In this cohort study that took place from March to October 2020, involving 43 institutions in 18 countries, 2 unmatched, consecutive, not-infected women were concomitantly enrolled immediately after each infected woman was identified, at any stage of pregnancy or delivery, and at the same level of care to minimize bias. Women and neonates were followed up until hospital discharge.
Main Outcomes and Measures: The primary outcome measures were indices of (maternal and severe neonatal/perinatal) morbidity and mortality; the individual components of these indices were secondary outcomes. Models for these outcomes were adjusted for country, month entering study, maternal age, and history of morbidity.
Results: A total of 706 pregnant women with COVID-19 diagnosis and 1424 pregnant women without COVID-19 diagnosis were enrolled, all with broadly similar demographic characteristics (mean [SD] age, 30.2 [6.1] years
Conclusions and Relevance: In this multinational cohort study, COVID-19 in pregnancy was associated with consistent and substantial increases in severe maternal morbidity and mortality and neonatal complications when pregnant women with and without COVID-19 diagnosis were compared. The findings should alert pregnant individuals and clinicians to implement strictly all the recommended COVID-19 preventive measures.
Human milk banks in the response to COVID-19: a statement of the regional human milk bank network for Southeast Asia and beyond
This statement reflects the expert opinion of the Regional Human Milk Bank Network for Southeast Asia and Beyond on the need to revisit national guidelines based on the best evidence for breastfeeding during the COVID-19 pandemic, to incorporate human milk bank services in national obstetric and newborn care guidelines for COVID-19 where possible, and to ensure that operations of human milk banks are adapted to meet the needs of the current pandemic and to sustain donor human milk supply in the long-term. The Network also recommends sustained engagement with the global human milk bank community.
Prospective cohort study of water immersion for labour and birth compared with standard care in an Irish maternity setting
BMJ Open, 10(12): e038080 doi: 10.1136/bmjopen-2020-038080 https://bmjopen.bmj.com/content/10/12/e038080
To examine the birth outcomes for women and babies following water immersion for labour only, or for labour and birth.
A cohort of 190 low-risk women who used water immersion; 100 gave birth in water and 90 laboured only in water. A control group of 190 low-risk women who received standard care.
Women choosing water immersion for labour or birth were no more likely to experience adverse birth outcomes than women receiving standard care and rated their birth experiences more highly.
Comparative analgesic efficacy and safety of intermittent local anaesthetic epidural bolus for labour: a systematic review and meta-analysis
Obstetric Anaesthesia, 125(4):560-579
Continuous epidural infusion (CEI) is commonly used for labour analgesia, but concerns over potential motor block, second-stage labour complications, and ineffective analgesia in late labour have prompted examining intermittent epidural bolus (IEB) as an alternative. However, evidence comparing these modalities is conflicting. The meta-analysis evaluates the analgesic efficacy of CEI vs IEB.
Editor’s key points
It’s Not Yeast: Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain
Breastfeeding Medicine. doi: 10.1089/bfm.2020.0160
Health care providers treating lactating women for nipple and breast pain often attribute symptoms to Candida albicans infection. However, multiple other conditions may present with pain, erythema, and pruritis. We explored the experience of a breastfeeding medicine practice that received referrals for patients failing antifungal therapy and who desired further evaluation for alternative diagnoses.
While persistent nipple and breast pain in breastfeeding is often attributed to Candida, this cohort demonstrates that providers should consider multiple other conditions in their differential diagnosis. Accurate, timely diagnosis is crucial, as pain is a risk factor for premature cessation of breastfeeding. Symptomatic resolution occurs on appropriate therapy.
Antenatal interventions for preventing stillbirth, fetal loss and perinatal death: an overview of Cochrane systematic reviews
Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD009599. DOI: 10.1002/14651858.CD009599.pub2
While most interventions were unable to demonstrate a clear effect in reducing stillbirth or perinatal death, several interventions suggested a clear benefit, such as balanced energy/protein supplements, midwife‐led models of care, training versus not training traditional birth attendants, and antenatal cardiotocography. Possible benefits were also observed for insecticide‐treated anti‐malarial nets and community‐based intervention packages, whereas a reduced number of antenatal care visits were shown to be harmful. However, there was variation in the effectiveness of interventions across different settings, indicating the need to carefully understand the context in which these interventions were tested.
Prevention, detection and management of other healthcare problems
The Calming Effect of Maternal Breast Milk Odor on Term Infant: A Randomized Controlled Trial
Breastfeeding Medicine, 15(11): 724-730.http://doi.org/10.1089/bfm.2020.0116
This study was carried out to assess the effect of the odor of breast milk and formula milk on reducing the acute pain of newborn infants during the heel-prick blood sampling.
The pain threshold and heart rates of the newborn in the breast milk group were significantly lower than those in the formula milk group (p < 0.001). Salivary cortisol in the formula milk group increased and oxygen saturation levels in these infants decreased significantly more as compared to the breast milk group (p < 0.05).
The odor of breast milk may be helpful in reducing the pain of newborn during heel-prick blood sampling.
Cochrane Library Interventions for leg cramps in pregnancy (Review)
Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD010655. DOI: 10.1002/14651858.CD010655.pub3
We searched for evidence in September 2019 and identified eight randomised controlled studies, with a total of 576 women who were 14 to 36 weeks pregnant, comparing either magnesium, calcium, calcium-vitamin D or vitamin B with placebo or no treatment, and comparing vitamin C with calcium. All treatments were given as tablets to be chewed or swallowed.
It is not clear from the evidence reviewed whether any of the oral interventions (magnesium, calcium, calcium-vitamin D, vitamin B vitamin D or vitamin C) provide an effective and safe treatment for leg cramps in pregnancy. Supplements may have different effects depending on women’s usual intake of these substances. No trials considered therapies such as muscle stretching, massage, relaxation or heat therapy.
Birth models of care and intervention rates: The impact of birth centres.
Health Policy, in press https://doi.org/10.1016/j.healthpol.2020.10.001
Facilitators and barriers to the implementation of a physiological approach during labour and birth: A systematic review and thematic synthesis
To explore facilitators and barriers to the implementation of a physiological approach to care during labour and birth in obstetric settings.
To explore how facilitators and barriers located at three levels: organisation, professional groups (midwives and obstetricians) and women, interact to influence the implementation of a physiological approach
Contrary to evidence-based guidelines that recommend a physiological approach, a risk-based approach informs practices in obstetric units. Primary research has mainly identified barriers to implementing a physiological approach at a professional level, and this has been studied largely from a midwifery perspective. To aid comprehensive investigations of facilitators and barriers and their interactive influences, this review identifies important research gaps for study across all levels: organisation, professionals (midwives and obstetricians) and women.
Efficacy and safety of breast milk eye drops in infants with eye discharge
Acta Paediatricia, in Press
Breast milk (BM) contains various protective components, such as immunoglobulins, lactoferrin, lysozyme, oligosaccharides, and immune cell subsets. We evaluated the effectiveness of BM eye drops in infants with eye discharge in a randomised controlled study.
This study demonstrated that BM is no less effective than ophthalmic solution in infants with eye discharge aged ≤ 6 months. The results suggested that the use of breast milk as eye drops could be considered as a first‐line treatment for infants aged ≤ 6 months with eye discharge.
Women’s perceptions of COVID-19 and their healthcare experiences: a qualitative thematic analysis of a national survey of pregnant women in the United Kingdom
BMC Pregnancy Childbirth, 20, 600: https://doi.org/10.1186/s12884-020-03283-2
The aim of this national survey was to explore pregnant women’s perceptions of COVID-19 and their healthcare experiences.
One thousand four hundred fifty-one participants replied to the online questionnaire. Participants provided significant insight into the perceived barriers to seeking healthcare during this pandemic. These include ‘not wanting to bother anyone’, ‘lack of wider support from allied healthcare workers’ and the influence of the media. Other concerns included the use of virtual clinics antenatally and their acceptability to patients, the presence of birthing partners, and the way in which information is communicated about rapidly changing and evolving services.
Maternal childbirth experience in induced and spontaneous labour measured in a visual analog scale and the factors influencing it; a two year cohort study.
BMC Pregnancy and Childbirth, 20:415: https://doi.org/10.1186/s12884-020-03106-4
Poor maternal childbirth experience plays a role in family planning and subsequent pregnancies. The aim of this study was to compare childbirth experiences in induced and spontaneous labor and to investigate the factors influencing the childbirth experience.
Poor childbirth experience was associated with labor induction, primiparity, operative delivery, and labor complications, such as post-partum hemorrhage and maternal infections. These results highlight the aspects of care for which patient experience may be improved by additional support and counselling.
How much synthetic oxytocin is infused during labour? A review and analysis of regimens used in 12 countries.
PLoS ONE, 15(7): e0227941. https://doi.org/10.1371/journal.pone.0227941
To compare synthetic oxytocin infusion regimens used during labour, calculate the International Units (IU) escalation rate and total amount of IU infused over eight hours.
Current variations in oxytocin regimens for induction and augmentation of labour are inexplicable. It is crucial that the appropriate minimum infusion regimen is administered because synthetic oxytocin is a potentially harmful medication with serious consequences for women and babies when inappropriately used. Estimating the total amount of oxytocin IU received by labouring women, alongside the institution’s mode of birth and neonatal outcomes, may deepen our understanding and be the way forward to identifying the optimal infusion regimen.
Birth as a neuro-psycho-social event: An integrative model of maternal experiences and their relation to neurohormonal events during childbirth.
PLoS ONE, 15(7): e0230992. https://doi.org/10.1371/journal.pone.0230992
Psychological aspects of labor and birth have received little attention within maternity care service planning or clinical practice. The aim of this paper is to propose a model demonstrating how neurohormonal processes, in particular oxytocinergic mechanisms, not only control the physiological aspects of labor and birth, but also contribute to the subjective psychological experiences of birth. In addition, sensory information from the uterus as well as the external environment might influence these neurohormonal processes thereby influencing the progress of labor and the experience of birth.
By listening to women’s experiences and by observing women during childbirth, factors that contribute to an optimized process of labor, such as the mothers’ wellbeing and feelings of safety, may be identified. These observations support the integrative role of endogenous oxytocin in coordinating the neuroendocrine, psychological and physiological aspects of labor and birth, including oxytocin mediated. decrease of pain, fear and stress, support the need for midwifery one-to-one support in labour as well as the need for maternity care that optimizes the function of these neuroendocrine processes even when birth interventions are used. Women and their partners would benefit from understanding the crucial role that endogenous oxytocin plays in the psychological and neuroendocrinological process of labor.
Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review.
Women and Birth, 33(5):411-418
Nine randomised controlled trials and 26 non-experimental studies were included. Meta-analysis of pooled data from RCTs in mixed- and high-risk populations found no statistically significant differences in perinatal mortality rates. The majority of non-experimental research was at critical risk of bias and should not be relied on to inform practice. Cardiotocograph monitoring during preterm labour was associated with a higher incidence of cerebral palsy.
Research evidence failed to demonstrate perinatal benefits from intrapartum cardiotocograph monitoring for women at risk for poor perinatal outcome.
There is an urgent need for well-designed research to consider whether intrapartum cardiotocograph monitoring provides benefits.
Guideline on anaesthesia and sedation in breastfeeding women 2020
Breastfeeding has many health benefits for the mother and infant. Women who are breastfeeding may require anaesthesia or sedation. Concerns regarding the passage of drugs into breast milk may lead to inconsistent advice from professionals. This can sometimes result in the interruption of feeding for 24 hours or longer after anaesthesia, or expressing and discarding (‘pumping and dumping’) breast milk; this may contribute to early cessation of breastfeeding. However, there are data regarding the transfer of most anaesthetic drugs into breast milk. We advise that breastfeeding is acceptable to continue after anaesthesia and should be supported as soon as the woman is alert and able to feed, without the need to discard breast milk. We provide evidence-based information on the pharmacokinetics of drugs commonly used during anaesthesia so that professionals can undertake a risk-benefit discussion with the woman. We advise the development of local policies that aid logistical planning and guide staff to facilitate breastfeeding during the woman’s hospital stay.