Published by Wiley
Online ISSN: 1523-536X
Print ISSN: 0730-7659
Discipline: Nursing
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Birth: Issues in Perinatal Care is a multidisciplinary, refereed journal devoted to issues and practices in the care of childbearing women, infants, and families. It is written by and for professionals in maternal and neonatal health, nurses, midwives, physicians, public health workers, doulas, social scientists, childbirth educators, lactation counselors, epidemiologists, and other health caregivers and policymakers in perinatal care.



Recent publications
The effects of pregnancy on the maternal cardiorespiratory system include increases in oxygen consumption, cardiac output, heart rate, stroke volume, and plasma volume. The increase in oxygen reserve seen in early pregnancy is reduced later, suggesting that maternal exercise may present a greater physiologic stress in the third trimester. Evidence suggests that weight-bearing exercise produces a greater decrease in oxygen reserve than nonweight-bearing exercise. Furthermore, to maintain a heart rate below 140 beats per minute during pregnancy, the intensity of weight-bearing exercise must be reduced. Nonweight-bearing, water-based exercise results in smaller fetal heart rate changes and a lower maternal heart rate than the same exercise performed on land. Exercising in the supine position in late pregnancy has raised concerns because cardiac output in the supine position is lower than in the lateral position at rest, presumably because the gravid uterus partially obstructs the inferior vena cava. Sustained exercise produces a training effect on the mother, although reported associations between this effect and the experience of labor are not consistent. Short-term changes in fetal heart rate provide circumstantial evidence that physical activity can influence the fetus. Acute effects of exercise that can potentially affect the fetus include hyperthermia, changes in uteroplacental flow, reduced levels of maternal glucose, and increased uterine contractions. Moderate to high levels of sustained maternal exercise have been associated with reduced birthweight. Much research remains to be done on the effects of specexercise regimens during pregnancy, the effects on previously sedentary women, and the long-term health consequences to the offspring of women who perform vigorous exercise during pregnancy. (BIRTH 21:2, June 1994)
This study describes the accuracy of Leopold maneuvers as a screening procedure for fetal malpresentation. The frequency of fetal malpresentation ranges from 15 percent at 32 weeks to 4 percent at term. We prospectively determined fetal presentation by performing Leopold maneuvers on 150 women, followed by a fetal ultrasound examination for comparison. Experienced certified nurse-midwives performed the maneuvers with high sensitivity (88%), specificity (94%), positive predictive value (74%), and negative predictive value (97%) in a population with a 17 percent frequency of fetal malpresentation. We conclude that the maneuvers used by experienced clinicians can be effective as a screening tool for fetal malpresentation, particularly in settings where ultrasound may not be readily available. (BIRTH 20:3, September 1993)
Studies demonstrated that support during labor and birth has a positive impact on childbirth outcomes, and that women reported they received little supportive care from nurses during parturition. This study piloted a work sampling method that was adapted to determine the proportion of time the average intrapartum nurse at a Toronto teaching hospital spends in supportive care activities. Supportive care was operationally defined within four categories of activities: emotional support, physical comfort measures, instruction/information, and advocacy. Work sampling was an effective method of measuring support as a specific aspect of direct intrapartum care. The proportion of time that nurses spent in supportive versus all other activities was 9.9 percent (95% confidence interval 7.5% and 12%), based on a sample of 616 random observations of 18 nurses. Findings are discussed in terms of the social and political factors that affect the meaning and value of the supportive activities of work by obstetric nurses.
Dramatic improvements in the hospital management of perinatal loss have taken place in the past 20 years. However, there has been no critical examination of current approaches. Four possible hazards of current hospital practice are described: 1) Institutionalization of bereavement: Instead of offering parents an empathic awareness of the unique dimensions of their perinatal loss, caregivers often interact according to detailed behavioral protocols. 2) Idealization of contact with the dead baby: This approach may equate actual physical contact with the dead child with the more complicated and variable process of mourning. 3) Homogenization of grief: Counselors tend to denigrate different grief responses by focusing on a preconceived grief reaction. Thus, they may mistakenly label many such reactions pathologic if they deviate from the rigidly prescribed "norm." 4) Lecturing the bereaved: Telling parents the "right" thing to do may deprive them of a crucial aspect of the process that empowers parents after they experience the helplessness associated with perinatal loss — that of making their own decisions. These problems are illustrated by a clinical vignette, and alternative approaches are explored. Peer Reviewed http://deepblue.lib.umich.edu/bitstream/2027.42/67970/2/10.1177_000992289203100611.pdf
In a trend similar to continuous electronic fetal monitoring, many hospitals are incorporating central fetal monitoring into labor and delivery suites. The objective of this study was to investigate whether the use of central fetal monitoring had an effect on neonatal outcomes or cesarean section rate. This retrospective study involved patient data from deliveries occurring at Women and Children's Hospital of Buffalo, Buffalo, New York, between the years 2000 and 2003. In the period from January 1, 2000, to December 31, 2001, central fetal monitoring was available, whereas in the period from February 1, 2002, to December 31, 2003, it was unavailable. Data on deliveries at Women and Children's Hospital of Buffalo were obtained using the Western New York Perinatal Data System, which is an electronic data set based on birth certificate information. The method of delivery, admission to the neonatal intensive care unit, and 5-minute Apgar scores less than 7 were compared for deliveries occurring with and without the use of central fetal monitoring. These outcomes were further subdivided into full-term and preterm deliveries. Three thousand five hundred and twelve deliveries used central monitoring and 3,007 deliveries did not. For full-term deliveries, in the years with central fetal monitoring compared with the years without it, no differences in the cesarean section rate (13.4 vs 14.5%, not significant [NS]), the admission rate in neonatal intensive care unit (3.3 vs 3.3%, NS), or the incidence of Apgar score less than 7 (0.6 vs 0.5%, NS) were observed. For preterm deliveries, comparing the years with central fetal monitoring with the years without, no differences in the cesarean section rate (21.3 vs 21.3%, NS), the admission rate in neonatal intensive care unit (17.7 vs 20.1%, NS), or the incidence of Apgar score less than 7 (7.0 vs 6.5%, NS) were observed. Analyses pooling all deliveries also failed to show any differences in any of the parameters. No statistically significant difference was demonstrated in the rates of cesarean section, admission to the neonatal intensive care unit, or incidence of Apgar scores of less than 7 associated with the use of central fetal monitoring. Therefore, we could not identify any benefit to the use of central fetal heart rate monitoring.
It is acknowledged that health professionals have difficulty with breaking bad news. However, relatively little research has been conducted on the experiences of women who have had a fetal anomaly detected at the routine pregnancy ultrasound examination. The study objective was to explore women's experiences of encounters with caregivers after the diagnosis of fetal anomaly at the routine second trimester ultrasound scan. The theoretical perspective of symbolic interactionism guided this study design. A purposive sample of 38 women, at low risk of fetal abnormality, who received a diagnosis of a fetal abnormality in a tertiary referral center in Ireland, were recruited to participate. An in-depth interview was conducted within 4-6 weeks of the diagnosis. Data were collected between April 2004 and August 2005 and analyzed using the constant comparative method. Six categories in relation to women's encounters with caregivers emerged: information sharing, timing of referral, getting to see the expert, describing the anomaly, availability of written information, and continuity of caregiver. Once an anomaly was suspected, women wanted information quickly, including prompt referral to the fetal medicine specialist for confirmation of the diagnosis. Supplementary written information was seen as essential to enhance understanding and to assist women in informing significant others. Continuity of caregiver and empathy from staff were valued strongly. The way in which adverse diagnoses are communicated to parents leaves room for improvement. Health professionals should receive specific education on how to break bad news sensitively to a vulnerable population. A specialist midwifery or nursing role to provide support for parents after diagnosis is recommended.
The cesarean section rate continues to rise in many countries with routine access to medical services, yet this increase is not associated with improvement in perinatal mortality or morbidity. A large number of commentaries in the medical literature and media suggest that consumer demand contributes significantly to the continued rise of births by cesarean section internationally. The objective of this article was to critically review the research literature concerning women's preference or request for elective cesarean section published since that critiqued by Gamble and Creedy in 2000. A search of key databases using a range of search terms produced over 200 articles, of which 80 were potentially relevant. Of these, 38 were research-based articles and 40 were opinion-based articles. A total of 17 articles fitted the criteria for review. A range of methodologies was used, with varying quality, making meta-analysis of findings inappropriate, and simple summaries of results difficult to produce. The range and quality of studies had increased since 2001, reflecting continuing concern. Women's preference for cesarean section varied from 0.3 to 14 percent; however, only 3 studies looked directly at this preference in the absence of clinical indications. Women's preference for a cesarean section related to psychological factors, perceptions of safety, or in some countries, was influenced by cultural or social factors. Research between 2000 and 2005 shows evidence of very small numbers of women requesting a cesarean section. A range of personal and societal reasons, including fear of birth and perceived inequality and inadequacy of care, underpinned these requests.
Increased medicalization of childbirth in Mexico has not always translated into more satisfactory childbirth experiences for women. In developed countries, pregnant women often prepare written birth plans, outlining how they would like their childbirth experiences to proceed. The notion of expressing childbirth desires with a birth plan is novel in the developing world. We conducted an exploratory study to assess the feasibility and acceptability of introducing birth plans in a hospital serving low-socioeconomic status Mexicans and to document women's and health practitioners' perspectives on the advantages and barriers in implementing a birth plan program. We invited 9 pregnant women to prepare birth plans during their antenatal care visits. The women also participated in interviews before and after childbirth. We also conducted in-depth interviews with 4 women who had given birth in the past year, and with 2 nurses, 2 social workers, and 1 physician to learn about their perspectives on the benefits and challenges of implementing a birth plan program. All 9 women who completed a birth plan found the experience highly satisfying, despite the fact that in some cases, their childbirths did not proceed as they had specified in their plans. Interviewed practitioners believed that birth plans could improve the childbirth experience for women and health care practitioners, but facilities often lacked space and financial incentives for birth plan programs. Our findings suggest that birth plans are acceptable and feasible in this study population. Facility administrators would need to commit to provide the physical space and financial incentives necessary to ensure successful implementation.
The belief that many women demand cesarean sections in the absence of clinical indications appears to be pervasive. The aim of this study was to examine whether, and in what context, maternal requests for cesarean section are made. Quantitative and qualitative methods were used. The overall study comprised 4 substudies: 23 multiparous and 41 primiparous pregnant women were asked to complete diaries recording events related to birth planning and expectations; 44 women who had considered, or been asked to consider, cesarean section during pregnancy were interviewed postnatally; 24 consultants and registrars in 3 district hospitals and 1 city hospital were interviewed; 5 consultants with known strong views about cesarean section were also interviewed; and 785 consultants from the United Kingdom and Eire completed postal questionnaires. No woman requested cesarean section in the absence of, what she considered, clinical or psychological indications. Fear for themselves or their baby appeared to be major factors behind women's requests for cesarean section, coupled with the belief that cesarean section was safest for the baby. Most obstetricians reported few requests for cesarean section, but nevertheless, cited maternal request as the most important factor affecting the national rising cesarean section rate. Several obstetricians discussed the significance of women's fears and the importance of taking the time to talk to women about these fears. Existing evidence for large numbers of women requesting cesarean sections in the absence of clinical indications is weak. This study supports the thesis that these women comprise a small minority. Psychological issues and maternal perceptions of risk appear to be significant factors in many maternal requests. Despite this finding, maternal request is perceived by obstetricians to be a major factor in driving the cesarean section rate upward.
Background: High cesarean birth rates are an international concern. The role of patterns of nursing care responsibility in preventing or contributing to cesarean births has been understudied. Our study sought to identify and describe indicators of continuity of nursing care responsibility during labor and to explore whether any association between these indicators and risk of cesarean birth could be identified empirically using an existing data set. Methods: We obtained a representative sample of low-risk women giving birth in an intrapartum unit at a university hospital in Quebec, Canada, with approximately 3,700 births per year. To be considered for inclusion, women needed to have been primiparous, carrying singletons in vertex position, and at 37 weeks' gestation or more. All women giving birth over a 13-month period were assessed for eligibility using the hospital's birth log. Data were extracted from the medical records of every second eligible birth, including information related to patterns of nursing care responsibility, maternal and infant characteristics, obstetric procedures, non-health-related risk factors, and type of birth. Results: Data on all variables of interest were available for 467 women. These women were cared for by 1-17 nurses, care responsibility changed hands for them from 1 to 28 times, and the mean length of labor for which the same nurse was responsible for a woman ranged from 10 to 1,045 minutes. After controlling for length of labor, maternal age, maternal height, infant weight, gestational age, induction, type of rupture, and epidural analgesia, the odds ratio for cesarean birth due to number of nurses was 1.17 (95% CI 1.04, 1.32); 1 or more nurses switch per 2 hours (i.e., number of times care responsibilities changed hands), 1.04 (95% CI 0.62, 1.74); and 33 percent or more of the labor attended by the same nurse, 0.74 (95% CI 0.42, 1.30). Conclusions: An association was observed between number of nurses caring for a laboring woman and risk of cesarean delivery. Estimates of the association of other patterns of nursing care responsibility on cesarean birth were not sufficiently precise to draw conclusions.
One of the United Nations' Millennium Development Goals for 2015 is to reduce the maternal mortality ratio by three fourths. Ninety-nine percent of maternal deaths occur in developing countries, and the World Health Organization encourages investigations in these settings to determine the risk factors of maternal deaths. Our aim was to identify these risk factors in a hospital-based study in Mexico. The study was conducted at the Hospital of Obstetrics and Gynecology at the Mexican Institute of Social Security in Leon, Guanajuato, Mexico, from January 1, 1992, to March 31, 2004. Women were divided into groups of 110 individuals who had died during pregnancy, delivery, or postpartum, and 440 women who survived the postpartum period. We used a logistic regression analysis to find the significant risk factors for maternal deaths. Odds ratios with 95% t confidence intervals were estimated. The maternal mortality ratio was 47.3 per 100,000 live births. The main causes of death were hemorrhage (30.9%), preeclampsia/eclampsia (28.2%), and septic shock (10.9%). Six factors were significantly associated with maternal death: age (OR = 1.09, 95% CI = 1.00-1.18), marital status (OR = 16.2, 95% CI = 1.3-196.1), number of antenatal visits (OR = 1.3, 95% CI = 1.0-1.6), preexisting medical conditions (OR = 23.3, 95% CI = 6.6-81.6), obstetric complications in previous pregnancies (OR = 28.3, 95% CI = 4.9-163.0), and mode of delivery (OR = 1.6, 95% CI = 1.0-2.4). Socioeconomic, medical, and obstetric risk factors are associated with maternal deaths in Mexico.
Obstetric practice has witnessed a worldwide trend of increasing cesarean section rates in recent years. Similar trends have been observed in Lebanon, according to 2 studies conducted in 1996 and 1999. The objective of the present study was to assess the differences in predictors of cesarean delivery among nulliparous women in a "control hospital" with a low cesarean delivery rate (12.5%) and the rest of the National Collaborative Perinatal Neonatal Network (NCPNN) "study hospitals" with a higher cesarean delivery rate (31.4%). Data were collected by the NCPNN database, which covers deliveries at 9 major hospitals located in the Greater Beirut area. Data analysis was performed on the 6,668 consecutive deliveries occurring between January 1, 2001, and December 31, 2002, at the NCPNN participating centers. The questionnaires included items that cover parental sociodemographic characteristics and maternal and newborn health characteristics. Sources of data included direct interviews with mothers after delivery and before hospital discharge and reviews of obstetric and nursery medical charts. Chi-square tests and t tests were performed for categorical and continuous clinical predictors of cesarean section. Logistic regression was performed to determine the odds of having a cesarean section for the study hospitals when compared with the control hospital. Odds ratios and 95% confidence intervals are reported. Variables in the study hospitals that correlated with a higher cesarean delivery rate were male obstetricians, day of the week, and mode of payment compared with the control hospital. In a country with a high cesarean section rate, 1 hospital met World Health Organization criteria for acceptable cesarean section rates, with no compromise in neonatal outcome. Further studies are needed to investigate potential policies to decrease the high cesarean section rate.
The frequencies of several common antenatal disorders increased in the U.S. Collaborative Perinatal Project when women had low pregnancy weight gains. The case fatality rates of a much wider spectrum of antenatal disorders increased with low weight gains. There is indirect evidence that these high case fatality rates were mainly due to sub-optimal maternal blood volume expansion, with resultant low blood flow from the uterus to the placenta. Metabolic acidosis, related to maternal fasting, may also have contributed to the perinatal mortality associated with low weight gain. To avoid acidosis, women should be advised not to fast during pregnancy. There is evidence that maternal overnutrition during pregnancy sometimes predisposes to hypertension. This type of hypertension is relatively benign by comparison with the hypertension associated with low pregnancy weight gains. Finally, dietary deficiency of zinc appears to predispose to amniotic fluid bacterial infections, a major cause of preterm labor and delivery. (BIRTH 10:2, Summer 1983)
Bilirubin metabolism is reviewed and neonatal jaundice of various types is described. The need for quick, accurate tests for unbound, unconjugated bilirubin is discussed in relation to new suggestions that lower levels of this specific portion of bilirubin may cause damage in the newborn The benefits and risks of present treatments are evaluated.
The recumbent positions for labor and lithotomy position for birth serve the needs of the attendant rather than the needs of the woman and fetus. Various upright positions have been chosen for birth in most cultures. The advantages of upright and ambulant positions, with full mobility during labor, include avoidance of supine hypotension, aortic and uterine artery compression, cord compression FHR patterns, and inefficient contractions which are more painful. A birth stool or chair allows mothers to push more effectively and to use the great elasticity of the pelvis during delivery.
FDA testimony regarding the validity of the Brackbill-Broman research showing long-term effects of obstetric medications resulted in a conclusion that the study did not support long term effects, but that a subcommittee would be named to consider whether short-term drug effects warrant patient informed consent warnings. Action to encourage such warnings is described, both at the FDA and on the state legislative level.
A 10-week sex education program was designed for 55 students who were 14 to 15 years old. A 25-item check list of sexual concerns was given at the beginning and end of the course. The course had little effect in reducing the number of students expressing concern on listed topics, and several topics were of more concern after the course than before. The use of list to measure the impact of such programs is discussed.
Among the health regions of Britain, admissions to special care baby units (SCBUs) vary from 15% to 27% of live born children. These variations in admission rates do not correlate with the percentage of low birth-weight babies born in each region, nor with the perinatal mortality rate. However, they correlate positively with the provision of cots for special newborn care and with how close the baby was to such a facility when born. A large number of full-term babies are admitted with no disease, but simply for observation. These babies come predominately from deliveries in consultant obstetric units which also have SCBUs, so that admissions for observation are most probable for the group of babies receiving the highest standards of care and therefore are least in need of it. Some of the disadvantages of unnecessary admissions are described. A change in admission policy at one SCBU resulted in the number of full-term babies admitted to SCBU dropping from 928 in 1972 to 163 in 1975. The effects of pressures to fill the cots in such units, of competition between units, and of other factors influencing admission are discussed.
The behavior of seven fathers immediately after the births of their children in a home-like birth environment was videotaped by remote control cameras. Seven repetitiously exhibited behaviors were independently quantified by trained observers, using a continuous flow, slow motion video play-back technique. The first three minutes of neonate-oriented paternal behavior were examined for stability, to see if they emerged in uniform sequence, and were compared with the same behaviors shown in later minutes. The results indicate that initial father-newborn behaviors were stable. All the fathers showed the same sequence in the emergence of behaviors toward their new babies. After hovering and hand pointing behavior, contacts were made with the tips of the fingers, followed by palm contact with the newborn. These findings suggest that the repertoire of paternal behavior at initial encounters with their newborns may be species-characteristic of the human father, and may function to establish the father-to-newborn affectional bond.
Mothers having difficulty with breastfeeding often find a lack of acknowledgement of the normal ambivalence about many aspects of the early mothering experience. Mothers, who need themselves to be nurtured, instead find people anxious to give advice which is biased by their own experience or dogmas. The “helpers” too easily conclude that what worked for them, or what seems “natural,” is correct for mothers in general. They are quick to make negative judgments about women who do not follow the idealized model.
Prenatal neuromuscular dissociation relaxation skill of 31 women was measured both using rater judgment and biofeedback equipment. A correlation of .88 was obtained when the two rating methods were compared. Prenatal relaxation skill achievement was significantly related to mothers’reports of medication used in childbirth. The authors conclude that childbirth educators can be trained to give reliable feedback to clients on achievement of relaxation skill and that achievement of neuromuscular dissociation relaxation skill may be predictive of the use of medication in childbirth.
This is a summary of a 180-page Administrative Petition to the FDA and the DHHS to alleviate domestic formula misuse and to provide informed infant feeding choices, especially among low-income, minority women. This summary documents the low and declining rates of breastfeeding among poor women, and the illnesses and costs of medical treatment in formula-fed infants in the U.S. The practices of the infant formula industry and their effects on the attitudes of medical caregivers towards breastfeeding are described. The Petition, with over 500 references, was filed on June 17, 1981. It is available from Room 2323, Raybum House Office Bldg., Washington D.C. 20500.
Ways to lower the incidence of the two most frequent indications for cesarean, repeat cesarean and dystocia, were recommended by the NIH Consensus Development Task Force in September, 1980. This paper describes the recommendations and criticisms of the work of the Task Force.
Using three case histories, a review of malnutrition caused by calorie and salt restriction and diuretics is made, with special note of the relationship between these factors and toxemia, low birth weight and other obstetric complications. A survey of women entering prenatal classes in four geographic areas of the US is reported. We found that between 24 percent and 79 percent of women entering prenatal classes are actually dieting to hold the line at their seventh month weight gains. Up to 66 percent of women were told nothing as to an ideal weight gain by their doctors, and as many as 10% thought the weight gain given was too high. We found that about half of all women surveyed reached whatever they thought was the maximum weight gain by the seventh month of pregnancy, and then dieted to hold the line; up to 7 percent were trying to lose weight. Sodium restriction is still being prescribed for between 12 and 49 percent of women in the communities surveyed. Diuretics for late pregnancy edema are seldom prescribed. The physiology of protein-calorie restriction and salt depletion are reviewed, with recommendations for action on the part of childbirth educators.
Twenty women matched for parity, pregnancy and delivery criteria, medical history and infant outcome were randomly given their wrapped or naked babies to hold during the first hour after birth. At 36 hours after delivery and again at 3 months, an observer who was unaware of whether early contact had been skin-to-skin or with the wrapped baby recorded maternal attachment behaviors while the mother was breastfeeding (36 hours) or playing with her baby (3 months). There were no significant differences in the maternal attachment behaviors of the two groups 36 hours after delivery or 3 months after delivery. It is suggested that in other studies which showed more maternal attachment behaviors after skin-to-skin contact in the first hours and days after birth, it may have been the amount and timing of contact which accounted for observed differences in maternal behaviors, rather than whether the contact was skin-to-skin or with the wrapped newborn.
In the Dublin trial a hypothesis tested (and sustained) was that electronic fetal monitoring (EFM) reduces the risk of neonatal seizures. Only secondary analyses of the data suggest that this benefit was concentrated in labors of more than 5 hours and those in which oxytocin was used. Claims that EFM is only protective under these conditions, and claims of superior methods of monitoring the fetus or interpreting fetal heart rates tracings, must themselves be tested in formal clinical experiments.
Among Vietnamese families receiving maternity care in the United States are people with at least five different social backgrounds and religious beliefs. Maternity care is affected by these, and many traditional cultural beliefs and customs regarding pregnancy and birth.
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Top-cited authors
Josephine M Green
  • The University of York
J. Christopher Glantz
  • University of Rochester
Penny Simkin
  • Bastyr University
Stephanie Brown
  • Murdoch Children's Research Institute
Eugene Declercq
  • Boston University