Dataset Information

Care during the third stage of labour: a postal survey of UK midwives and obstetricians.

ABSTRACT:

Background

There are two approaches to care during the third stage of labour: Active management includes three components: administration of a prophylactic uterotonic drug, cord clamping and controlled cord traction. For physiological care, intervention occurs only if there is clinical need. Evidence to guide care during the third stage is limited and there is variation in recommendations which may contribute to differences in practice. This paper describes current UK practice during the third stage of labour.

Methods

A postal survey of 2230 fellows and members of the Royal College of Obstetricians and Gynaecologists (RCOG) and 2400 members of the Royal College of Midwives was undertaken. Respondents were asked about care during the third stage of labour, for vaginal and caesarean births and their views on the need for more evidence to guide care in the third stage. The data were analysed in Excel and presented as descriptive statistics.

Results

1189 (53%) fellows and members of the RCOG and 1702 (71%) midwives responded, of whom 926 (78%) and 1297 (76%) respectively had conducted or supervised births in the last year. 93% (863/926) of obstetricians and 73% (942/1297) of midwives report 'always or usually' using active management. 66% (611/926) of obstetricians and 33% (430/1297) of midwives give the uterotonic drug with delivery of the anterior shoulder; this was intramuscular Syntometrine(R) for 79% (728/926) and 86% (1118/1293) respectively. For term births, 74% (682/926) of obstetricians and 41% (526/1297) of midwives clamp the cord within 20 seconds, as do 57% (523/926) and 55% (707/1297) for preterm births. Controlled cord traction was used by 94% of both obstetricians and midwives. For caesarean births, intravenous oxytocin was the uterotonic used by 90% (837/926) of obstetricians; 79% (726/926) clamp the cord within 20 seconds for term births as do 63% (576/926) for preterm births.Physiological management was used 'always or usually' by 2% (21/926) of obstetricians and 9% (121/1297) of midwives. 81% (747/926) of obstetricians and 89% (1151/1297) of midwives thought more evidence from randomised trials was needed; the most popular question was when is best to clamp the cord.

Conclusions

Active management of the third stage of labour is widely used by both obstetricians and midwives in the UK. Syntometrine(R) is usually used for vaginal births and oxytocin for caesarean births; when this is given and when the cord is clamped varies.

SUBMITTER: Farrar D

PROVIDER: S-EPMC2885994 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:BackgroundThe Pregnancy Remote Monitoring (PREMOM) study enrolled pregnant women at increased risk of developing hypertensive disorders of pregnancy and investigated the effect of remote monitoring in addition to their prenatal follow-up.ObjectiveThe objective of this study was to investigate the perceptions and experiences of remote monitoring among mothers, midwives, and obstetricians who participated in the PREMOM study.MethodsWe developed specific questionnaires for the mothers, midwives, and obstetricians addressing 5 domains: (1) prior knowledge and experience of remote monitoring, (2) reactions to abnormal values, (3) privacy, (4) quality and patient safety, and (5) financial aspects. We also questioned the health care providers about which issues they considered important when implementing remote monitoring. We used a 5-point Likert scale to provide objective scores. It was possible to add free-text feedback at every question.ResultsA total of 91 participants completed the questionnaires. The mothers, midwives, and obstetricians reported positive experiences and perceptions of remote monitoring, although most of them had no or little prior experience with this technology. They supported a further rollout of remote monitoring in Belgium. Nearly three-quarters of the mothers (34/47, 72%) did not report any problems with taking the measurements at the required times. Almost half of the mothers (19/47, 40%) wanted to be contacted within 3 to 12 hours after abnormal measurement values, preferably by telephone.ConclusionsAlthough most of midwives and obstetricians had no or very little experience with remote monitoring before enrolling in the PREMOM study, they reported, based on their one-year experience, that remote monitoring was an important component in the follow-up of high-risk pregnancies and would recommend it to their colleagues and pregnant patients.Trial registrationClinicalTrials.gov NCT03246737; https://clinicaltrials.gov/ct2/show/NCT03246737 (Archived by WebCite at http://www.webcitation.org/76KVnHSYY).

Project description:Both nationally and internationally, midwives' practices during the second stage of labour vary. A midwife's practice can be influenced by education and cultural practices but ultimately it should be informed by up-to-date scientific evidence. We conducted a systematic review of the literature to retrieve evidence that supports high quality intrapartum care during the second stage of labour. A systematic literature search was performed to September 2019 in collaboration with a medical information specialist. Bibliographic databases searched included: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Maternity and Infant Care Database and The Cochrane Library, resulting in 6,382 references to be screened after duplicates were removed. Articles were then assessed for quality by two independent researchers and data extracted. 17 studies focusing on midwives' practices during physiological second stage of labour were included. Two studies surveyed midwives regarding their practice and one study utilising focus groups explored how midwives facilitate women's birthing positions, while another focus group study explored expert midwives' views of their practice of preserving an intact perineum during physiological birth. The remainder of the included studies were primarily intervention studies, highlighting aspects of midwifery practice during the second stage of labour. The empirical findings were synthesised into four main themes namely: birthing positions, non-pharmacological pain relief, pushing techniques and optimising perineal outcomes; the results were outlined and discussed. By implementing this evidence midwives may enable women during the second stage of labour to optimise physiological processes to give birth. There is, however, a dearth of evidence relating to midwives' practice, which provides a positive experience for women during the second stage of labour. Perhaps this is because not all midwives' practices during the second stage of labour are researched and documented. This systematic review provides a valuable insight of the empirical evidence relating to midwifery practice during the physiological second stage of labour, which can also inform education and future research. The majority of the authors were members of the EU COST Action IS1405: Building Intrapartum Research Through Health (BIRTH). The study protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO; Registration CRD42018088300) and is published (Verhoeven, Spence, Nyman, Otten, Healy, 2019).

Project description:BackgroundThere is general agreement that oxytocin given either through the intramuscular or intravenous route is effective in reducing postpartum blood loss. However, it is unclear whether the subtle differences between the mode of action of these routes have any effect on maternal and infant outcomes. This is an update of a review first published in 2012.ObjectivesTo determine the comparative effectiveness and safety of oxytocin administered intramuscularly or intravenously for prophylactic management of the third stage of labour after vaginal birth.Search methodsWe searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 September 2017) and reference lists of retrieved studies.Selection criteriaRandomised trials comparing intramuscular with intravenous oxytocin for prophylactic management of the third stage of labour after vaginal birth. We excluded quasi-randomised trials.Data collection and analysisTwo review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.Main resultsThree studies with 1306 women are included in the review and compared intramuscular versus intravenous oxytocin administered just after the birth of the anterior shoulder or soon after the birth of the baby. Studies were carried out in hospital settings in Turkey and Thailand and recruited women with singleton, term pregnancies. Overall, the included studies were at moderate risk of bias: none of the studies provided clear information on allocation concealment or attempted to blind staff or women. For GRADE outcomes the quality of the evidence was very low, with downgrading due to study design limitations and imprecision of effect estimates.Only one study reported severe postpartum haemorrhage (blood loss 1000 mL or more) and showed no clear difference between the intramuscular and intravenous oxytocin groups (risk ratio (RR) 0.11, 95% confidence interval (CI) 0.01 to 2.04; 256 women; very low-quality evidence). No woman required hysterectomy in either group in one study (no estimable data, very low-quality evidence), and in another study one woman in each group received a blood transfusion (RR 1.00, 95% CI 0.06 to 15.82; 256 women; very low-quality evidence). Other important outcomes (maternal death, hypotension, maternal dissatisfaction with the intervention and neonatal jaundice) were not reported by any of the included studies. There were no clear differences between groups for other prespecified secondary outcomes reported (postpartum haemorrhage 500 mL or more, use of additional uterotonics, retained placenta or manual removal of the placenta).Authors' conclusionsVery low-quality evidence indicates no clear difference between the comparative benefits and risks of intramuscular and intravenous oxytocin when given to prevent excessive blood loss after vaginal birth. Appropriately designed randomised trials with adequate sample sizes are needed to assess whether the route of prophylactic oxytocin after vaginal birth affects maternal or infant outcomes. Such studies could be large enough to detect clinically important differences in major side effects that have been reported in observational studies and should also consider the acceptability of the intervention to mothers and providers as important outcomes.

Project description:BackgroundWomen of childbearing age feel great about giving birth, but the pain could be excruciating depending on their pain tolerances. Midwives requires obstetrical knowledge and skills such as pain management during labour and safety. We explored midwives' perspectives on the utilisation of pharmacological pain alleviation interventions during labour in selected hospitals in Matjhabeng Municipality, Free State province, South Africa. A qualitative study was undertaken, involving a sample of ten midwives, using a semi-structured interview guide. The interviews were audio-recorded and transcribed verbatim. Tesch's open coding data analysis method was applied to analyse the data. The midwives were restricted to use Pethidine and Phenergan prescribed by doctors for labour pain relief, which disrupted labour pain management and obliged them either to wait for a physician or follow telephone instructions. According to the midwives, women taking Pethidine and Phenergan encountered adverse effects and discomfort. Midwives identified high workload, inadequate personnel, lack of skill and knowledge, lack of medication availability, and lack of infrastructure as the primary challenges of administering pharmacological methods to women in labour. The lack of standing orders, which delays the administration of medications pending a physician's prescription, constituted an additional difficulty. In the instance that Pethidine and Phenergan were unavailable or ineffective for some women, the midwives recommended that women be administered alternative pharmacological pain relievers. They also advocated for institutionalization of pharmacological guidelines allowing them to use their discretion when treating labour pain. Midwives can only utilise a few standardised and regulated pharmacological medications for labour pain management. The midwives' ability to administer pharmacological pain relief during labour was hampered by a high workload burden, insufficient staff, lack of skill and understanding, drug unavailability, and inadequate infrastructure. Midwives advocated for supported guidelines that would allow them to treat labour pain at their discretion. Intersectoral stakeholders are required to improve midwife skills and attitudes. Health facilities need to train and supply analgesics to midwives. Midwives ought to be familiar with pharmacological pain relievers.

Project description:With an growing number of people on a strict plant-based diet, its potential effect on pregnancy and lactation becomes increasingly important. It is, however, unclear how obstetric caregivers currently handle and think about a strict plant-based diet in pregnancy. The aim of the study was therefore to evaluate the self-reported knowledge and advice given by Dutch obstetric caregivers and dietitians when treating pregnant women on a strict plant-based diet. A cross-sectional study was performed by sending an online survey to Dutch midwife practices, obstetricians, and dietitian practices. Descriptive statistics are reported. A total of 121 midwives, 179 obstetricians, and 111 dietitians participated in this study. The majority of midwives (80.2%) and obstetricians (93.9%) considered a strict plant-based diet to be a significant risk factor for nutrient deficiency during pregnancy. Maternal dietary preferences, including a potential strict plant-based diet, were discussed at the first prenatal appointment by 59.5% of midwives and 24.1% of obstetricians. A self-reported lack of knowledge concerning the strict plant-based diet was mentioned by 66.1% of midwives and 75.4% of obstetricians. Obstetric caregivers mostly considered the identification of this dietary habit and subsequent referral to a dietitian or a reliable website as optimal care for pregnant women on the strict plant-based diet. However, only 38.7% of dietitians indicated to have sufficient knowledge to counsel these women. Although obstetric caregivers thought that a strict plant-based diet in pregnancy may lead to increased risks of nutritional deficiencies, the majority report to have insufficient knowledge to provide adequate advice. Only a minority referred these women to dietitians, of whom a minority indicated to have adequate knowledge on this specific diet. These results suggest that current care is suboptimal for an increasing number of pregnant women. Women on a strict plant-based diet could benefit from increased knowledge about this topic among obstetric caregivers and dietitians, as well as from clear guidelines regarding this diet during pregnancy.

Project description:BackgroundAs part of a decades-long process of restructuring primary care, independent (also known as community) healthcare workers are being encouraged to work in groups to facilitate their coordination and continuity of care in France. French independent midwives perform about half of the early prenatal interviews that identify mothers' needs during pregnancy and then refer them to the appropriate resources. The French government, however, structured the COVID-19 pandemic response around public health institutions and did not directly mobilise these community healthcare workers during the lockdown phase. These responses have raised questions about their role within the healthcare system in crises. This survey's main objectives were to estimate the proportion of independent midwives who experienced new difficulties in referring women to healthcare facilities or other caregivers and in collaborating with hospitals during the first stage of this pandemic. The secondary objective was to estimate the proportion, according to their mode of practice, of independent midwives who considered that all the women under their care had risked harm due to failed or delayed referral to care.MethodsWe conducted an online national survey addressed to independent midwives in France from 29 April to 15 May 2020, around the end of the first lockdown (17 March-11 May, 2020).ResultsOf the 5264 registered independent midwives in France, 1491 (28.3%) responded; 64.7% reported new or greater problems during the pandemic in referring women to health facilities or care-providers, social workers in particular, and 71.0% reported new difficulties collaborating with hospitals. Nearly half (46.2%) the respondents considered that all the women in their care had experienced, to varying degrees, a lack of or delay in care that could have affected their health. This proportion did not differ according to the midwives' form of practice: solo practice, group practice with other midwives only, or group practice with at least two types of healthcare professionals.ConclusionsThe pandemic has degraded the quality of pregnant women's care in France and challenged the French model of care, which is highly compartmentalised between an almost exclusively independent primary care (community) sector and a predominantly salaried secondary care (hospital) sector.