Long term backache after childbirth: prospective search for causative factors.

OBJECTIVES--To assess in a prospective randomised study the association between motor block resulting from high and low dose epidural infusions of bupivacaine in labour and the incidence of long term backache after childbirth, and to compare the incidence of backache in women not receiving epidural analgesia. DESIGN--Women requesting epidural analgesia in labour between October 1991 and March 1994 were randomised to receive infusions of either bupivacaine alone or low dose bupivacaine with opioid. Data were collected during labour and the immediate postpartum period from these women and from women recruited at random over the same time from those who had laboured without epidural analgesia. A postal questionnaire about symptoms was sent three months after childbirth to all women. Further data were collected one year after childbirth from those who had reported new backache at three months. SETTING--St Thomas''s Hospital, London. SUBJECTS--599 women were recruited, of whom 450 (75%) replied to a follow up questionnaire. RESULTS--152 women (33.8% of responders) reported backache lasting three months after delivery and, of these, 33 (7.3%) had not previously suffered with backache. There were no significant differences between the treatment groups in the incidence of postnatal backache overall or of new backache or any symptoms after childbirth. Among all demographic, obstetric, and epidural variables examined the only factors significantly associated with backache after childbirth were backache before and during pregnancy. CONCLUSIONS--The incidence of new long term backache was not significantly increased in women who received epidural analgesia in labour. Motor block resulting from epidural local anaesthetic administration was not a significant factor in the development of backache.     

Active management of labour: current knowledge and research issues.

OBJECTIVES--To review the evidence that the package of labour interventions collectively called "active management"--namely, strict diagnostic criteria for labour, early amniotomy, early use of oxytocin, and continuous professional support--reduce rates of caesarean sections and operative vaginal delivery in first labours. DESIGN--Review of observational data, supplemented by evidence from four separate overviews of relevant randomised trials previously published as part of the Cochrane Collaboration pregnancy and childbirth database. RESULTS--Observational data do not permit a clear conclusion. There have been no randomised trials of the total package of active management or of the use of strict diagnostic criteria alone, but trials of early amniotomy, early oxytocin, and these interventions combined do not suggest that these interventions are effective in reducing rates of caesarean sections or operative vaginal deliveries. In contrast, the provision of continuous professional support in labour seems to reduce both types of operative delivery, although the effect on caesarean sections is confined to those settings where non-professional companions are not normally present in labour. CONCLUSIONS--Delivery units should endeavour to provide continuous professional support in labour, but routine use of amniotomy and early oxytocin is not recommended.     

疤痕子宫妊娠妇女经产道分娩的可行性、安全性和相关危险因素分析

目的:探讨疤痕子宫妊娠妇女经产道分娩的可行性、安全性和相关危险因素。方法:选择疤痕子宫妊娠妇女120例,根据分娩方式的不同分为剖宫产组(80例)与自然分娩组(40例),观察再次剖宫产的原因与两组的预后情况。结果:再次剖宫产的指征主要为疤痕子宫(患者拒绝试产)、产程异常、胎儿窘迫、前置胎盘等。自然分娩组的产时出血量明显少于剖宫产组(P0.05),产后出血与产后感染发生率也均明显低于剖宫产组(P0.05)。两组的5分钟Apgar评分对比差异无统计学意义,但自然分娩组新生儿黄疸与新生儿湿肺发生情况明显低于剖宫产组(P0.05)。自然分娩组的分娩满意度为97.50%,剖宫产组为83.75%,自然分娩组明显高于剖宫产组(P0.05)。结论:疤痕子宫妊娠妇女经产道分娩可行性好,能减少对于产妇与新生儿的影响,安全性佳,但也要根据产妇的实际情况进行具体选择。     

Inducing labour with vaginally administered prostaglandin E2.

In 50 consecutive pregnant women at a 125-bed community hospital with 1000 deliveries annually, labour was induced with prostaglandin E2 administered intravaginally. There were no stillbirths or neonatal deaths, and complications in the mothers were few. In nine women (18%) oxytocin was subsequently administered because of a failure of labour to progress; in spite of this, cesarean section was required in two (4%) of the patients. The overall cesarean section rate was 6%. Prostaglandins have been used routinely to induce labour in the United Kingdom for several years. This noninvasive method is safe, effective and well received by women in a community hospital setting, including those wanting "natural childbirth".     

Labour is still painful after prepared childbirth training.

Labour pain was measured with the McGill Pain Questionnaire in 87 primiparas and 54 multiparas. The average intensity of labour pain ranked among the most intense pains recorded with the questionnaire. However, the pain scores had a wide range and were influenced by several medical and social variables. They were significantly higher for the primiparas than for the multiparas. Moreover, high pain levels were associated with a history of menstrual difficulties and lower socioeconomic status. The primiparas who had received prepared childbirth training had lower pain scores than those who had received no such training. Nevertheless, the effects of prepared childbirth training were relatively small, and most patients (81%) who received it requested epidural anesthesia. Because many women who received training suffered severe pain during labour, prepared childbirth training and epidural anesthesia should be regarded as compatible, complementary procedures.     

Assessing long term backache after childbirth.

OBJECTIVES--To investigate the factors associated with long term backache after childbirth, to assess all women reporting new onset long term backache, and to investigate any relation with pain relief in labour. DESIGN--Data collected from obstetric records and postal questionnaires or telephone interviews on morbidity after childbirth from all women delivering their first baby between March 1990 and February 1991, followed by analysis of data collected from outpatient consultations. SETTING--St Thomas''s Hospital, London. SUBJECTS--Questionnaires were sent to 1615 women who had delivered their first baby in the defined period; 1015 either replied by post or were contacted by telephone. RESULTS--299 women (29.5% of responders) reported backache lasting more than six months and of these 156 (15.4%) said they had had no back problems previously. Those women who had received epidural analgesia in labour were significantly more likely to report new onset backache (17.8%; 95% confidence interval 14.8% to 20.8%) than those who did not (11.7%; 8.6% to 14.8%). Younger women, unmarried women, and those reporting other antenatal symptoms were significantly more likely to report new long term backache. The 156 women reporting new backache were asked to attend an outpatient clinic and 36 (23%) did so. The majority had a postural backache which was not severe. Psychological factors were present in 14 women. CONCLUSIONS--Though new long term backache is reported more commonly after epidural analgesia in labour, it tends to be postural and not severe. There were no differences in the nature of the backache between those who had or had not received epidural analgesia in labour.     

Anisotropic effects of the levator ani muscle during childbirth

Pelvic floor dysfunction and pelvic organ prolapse have been associated with damage to the levator ani (LA) muscle, but the exact mechanisms linking them remain unknown. It has been postulated that factors such as vaginal birth and ageing may contribute to long-term, irreversible LA muscle damage. To investigate the biomechanical significance of the LA muscle during childbirth, researchers and clinicians have used finite element models to simulate the second stage of labour. One of the challenges is to represent the anisotropic mechanical response of the LA muscle. In this study, we investigated the effects of anisotropy by varying the relative stiffness between the fibre and the matrix components, whilst maintaining the same overall stress–strain response in the fibre direction. A foetal skull was passed through two pelvic floor models, which incorporated the LA muscle with different anisotropy ratios. Results showed a substantial decrease in the magnitude of the force required for delivery as the fibre anisotropy was increased. The anisotropy ratio markedly affected the mechanical response of the LA muscle during a simulated vaginal delivery. It is apparent that we need to obtain experimental data on muscle mechanics in order to better approximate the LA muscle mechanical properties for quantitative analysis. These models may advance our understanding of the injury mechanisms of pelvic floor during childbirth.     

Lumbar epidural analgesia in labour: relation to fetal malposition and instrumental delivery.

The incidence of instrumental delivery and malposition immediately before delivery was compared in patients who were given lumbar epidural analgesia and those who were not. Instrumental delivery was five times more common and a malposition of the fetal head was more than three times as common in the epidural group as in women who did not receive regional analgesia. Similar incidences were found even when the epidural was electively chosen before labour in the absence of medical indications. The instrumental delivery rate was affected by parity, the length of the second stage of labour, and the return of sensation by the second stage but not by other factors studied. The high incidence (20%) of malposition associated with epidural analgesia was not affected by any of the factors studied. The psychological and physical disadvantages of malposition and instrumental delivery have yet to be assessed. In the meantime, when there are no medical indications for epidural analgesia, the advantages of pain relief should be weighed against those of a normal spontaneous delivery.     

Effects of Recruiting Midwives into a Family Physician Program on Women's Awareness and Preference for Mode of Delivery and Caesarean Section Rates in Rural Areas of Kurdistan

BackgroundThe accepted rate rate of caesarean section is 15%. It is expected that an increase in the density of midwives in the family physician program lead to a decrease in this indicator. This study aimed to compare the rates of caesarean section and women''s awareness and preference for mode of delivery before and after the implementation of the family physician program in health centres with and without an increase in midwives density.MethodsIn this cross-sectional study, using multistage cluster sampling method a total of 668 mothers with two-month-old children were selected from among all mothers with two-month-old children who were living in rural areas of Kurdistan province. Using the difference-in-differences model and Matchit statistical model, the factors associated with caesarean section rates and women''s awareness and preference for mode of delivery were compared in centres with and without an increase in midwives density after the implementation of the family physician program. To compare the changes before and after the program, we used the data collected from the same number of women in 2005 as the baseline.ResultsAfter adjusting for baseline data collected in 2005, the resutls showed no significant change in caesarean section rates and women''s awareness and preference for mode of delivery in the centres with and without an increase in midwives density after the implementation of the family physician program. The Matchit model showed a significant mean increase 14%(0.03–0.25) in women’s awareness of the benefits of natural childbirth between 2005 and 2013 in health centres where the density of midwives increased compared with health centres where it did not. The difference-in-differences model showed that the odds ratio of women’s preference for caesarean section decreased by 41% among participants who were aware of the benefits of natural childbirth, (OR = 0.59, 95% CI: (0.22–0.85); P>0.001).ConclusionsThe results of this study showed that an increase in the density of midwives in the family physician program led to an increase in women''s awareness of the benefits of natural childbirth. An increase in women’s awareness of the benefits of natural childbirth was associated with a decreased preference for caesarean section, however this reduction did not have a significant impact on caesarean section rates; possibly, this finding might be attributed to the complexity of this problem that needs a mixed strategy involving various stockholders.     

孕妇不良情绪、生活事件与妊娠结局以及分娩方式的关系研究

目的:探讨孕妇不良情绪、生活事件对妊娠结局以及分娩方式的影响。方法:选择2017年3月至2018年7月在海南省三亚市人民医院进行分娩的孕妇232例,搜集孕妇的基本资料,调查孕妇的生活事件及抑郁、焦虑状态,并记录孕妇的妊娠结局以及分娩方式,分析孕妇不良情绪、生活事件与妊娠结局以及分娩方式之间的关系。结果:在232例孕妇中,焦虑情绪孕妇有24例,占10.34%;抑郁孕妇有86例,占37.07%;发生生活事件的孕妇有69例,占29.74%。受到生活事件刺激、存在抑郁及焦虑的孕妇出现不良妊娠结局的概率均高于正常孕妇(P0.05)。剖宫产孕妇负性生活事件发生次数高于自然分娩的孕妇,而正性生活事件发生次数低于自然分娩的孕妇(P0.05)。剖宫产孕妇焦虑、抑郁的发生率均高于自然分娩的孕妇(P0.05)。结论:孕妇的不良情绪及生活事件普遍存在,可导致不良妊娠结局的发生并且对分娩方式产生一定的影响,应引起家庭及社会的重视。     

Is your enema really necessary?

Two hundred and seventy-four women admitted for delivery of singleton infants were studied for the effects of a preparatory enema on faecal contamination, duration of labour, and the incidence of infection in the newborn. Altogether 149 of the women were given an enema (controls) and 125 were not. The two groups showed no significant difference in the degree of faecal contamination during the first and second stages of labour, and the incidences of gross contamination were similar. Contamination after an enema was especially difficult to control, since it was more likely to be fluid. Seven neonates in each group showed evidence of infection, bowel organisms being isolated from four in the no-enema group and two in the control group. Durations of labour, though not strictly comparable, were similar in the two groups. The findings suggest that when preparing for normal labour the enema should be reserved for women who have not had their bowels open in the past 24 hours and have an obviously loaded rectum on initial pelvic examination.     

Total matrix metalloproteinase-8 serum levels in patients labouring preterm and patients with threatened preterm delivery

Preterm labour and prematurity are still a main cause of perinatal morbidity nowadays. The aim of our study was to assess the role of MMP-8 as a predictive marker of preterm delivery. Four groups of patients were involved to the study: I - pregnant women at 24-34 weeks of gestation with any symptoms of threatened preterm labour; II - threatened preterm labour patients between 24-34 weeks of gestation; III - preterm vaginal delivery patients; IV - healthy term vaginal delivery patients. Serum concentration of total MMP-8 was measured using two enzyme-linked immunosorbent assays. There were no significant differences in the median concentrations of total MMP-8 between physiological pregnancy and threatened preterm labour patients with existing uterine contractility. No significant differences of total MMP-8 were either found between healthy term and preterm labouring patients. The studies on a larger population are needed to reject the hypothesis that preterm labour is connected with increased MMP-8 plasma concentrations of women in preterm labour and threatened preterm delivery.     

Women's views on the impact of operative delivery in the second stage of labour: qualitative interview study

Objective To obtain the views of women on the impact of operative delivery in the second stage of labour.Design Qualitative interview study.Setting Two urban teaching hospitals in the United Kingdom.Participants Purposive sample of 27 women who had undergone operative delivery in the second stage of labour between January 2000 and January 2002.Key themes Preparation for birth, understandings of the indications for operative delivery, and explanation or debriefing after birth.Results The women felt unprepared for operative delivery and thought that their birth plan or antenatal classes had not catered adequately for this event. They emphasised the importance of maintaining an open mind about the management of labour. They had difficulty understanding the need for operative delivery despite a review by medical and midwifery staff before discharge. Operative delivery had a noticeable impact on women''s views about future pregnancy and delivery.Conclusions Women consider postnatal debriefing and medical review important deficiencies in current care. Those who experienced operative delivery in the second stage of labour would welcome the opportunity to have a later review of their intrapartum care, physical recovery, and management of future pregnancies.     

Maternal morbidity associated with in utero transfer.

OBJECTIVE--To determine the extent of maternal morbidity associated with in utero transfer. DESIGN--Retrospective study of 190 consecutive cases over two years. SETTING--Liverpool Maternity Hospital. PATIENTS--190 Pregnant women were transferred to the hospital under the in utero transfer arrangements from district general hospitals both within and outside the Mersey region. The women admitted were divided into two categories: those in threatened or established uncomplicated preterm labour and those who may or may not have been in threatened or established preterm labour but who had coexisting complicating factors affecting the mother or fetus, or both. INTERVENTIONS--Planned delivery of the fetus if indicated and arrangements for appropriate postpartum care of the mother. MAIN OUTCOME MEASURE--Assessment of the progress of labour and, if appropriate, resuscitation of the mother. RESULTS--Women who were transferred with no coexisting disease (124) had relatively uncomplicated deliveries whereas those transferred with coexisting diseases (66) exhibited considerable morbidity and 17 of these required prolonged intensive monitoring after delivery. CONCLUSIONS--In utero transfer in healthy mothers may have benefits for babies born very prematurely. If mothers have coexisting disease, however, the desirability of transfer should be reviewed urgently in the light of the considerable maternal morbidity associated with these problems. In these cases transfer may introduce an additional hazard.     

A glucose-controlled insulin infusion system for diabetic women during labour.

A glucose-controlled insulin infusion system was used to control blood glucose concentration during labour or caesarean section in six insulin-dependent diabetics. The mean blood glucose concentration during the four hours of labour immediately before delivery was 4.6-5.2 mmol/1 (82.9-93.7 mg/100 ml). Feedback control of insulin delivery by blood glucose concentration should decrease the risk of postpartum hypoglycaemia in the infant and allow normal obstetric management for the insulin-dependent diabetic in labour.     

Accidental dural puncture in obstetric patients and long term symptoms.

OBJECTIVE--To examine the association between accidental dural puncture and long term headache and related symptoms. DESIGN--Postal questionnaire survey to elucidate new symptoms occurring after childbirth, and linking of these to data in obstetric and anaesthetic case notes. Women were surveyed between 13 months and nine years after delivery. SETTING--Birmingham Maternity Hospital. SUBJECTS--4700 women who had delivered their most recent baby under epidural anaesthesia, 74 of whom had suffered an accidental dural puncture. MAIN OUTCOME MEASURES--Frequencies of new headache or migraine or neck ache starting within three months after childbirth and lasting over six weeks. RESULTS--Among the 74 women who had had an accidental dural puncture there were 17 (23%) who reported one or more of the above symptoms. By comparison, among those who had had an epidural anaesthetic but no recorded puncture, only 329 (7.1%) reported these symptoms. The duration of the headache or migraine or neck ache in the dural tap group ranged from nine weeks to over eight years. Ten of these women reported still unresolved symptoms. CONCLUSIONS--Conclusions on causality were tentative. Most women would remember a dural tap, and this might influence their reporting of subsequent symptoms attributable to the event. In addition, detailed characterisation of the symptoms was not available. Nevertheless, the findings provide a clear indication of the need for further study of the possible long term sequelae of accidental dural puncture.     

Is routine induction of labour at term ever justified?

Balancing the risks of prolonged gestation against those of induced labour is difficult. Risks to the fetus increase slightly after 42 weeks'' gestation but women having labour induced are more likely to have instrumental deliveries or babies with low Apgar scores. Since many women are now expressing a preference for minimal interference in childbirth the most acceptable management of post-term pregnancy seems to be increased fetal surveillance. Each case needs to be considered individually and it is important that the woman is involved in the decision to induce.     

The determinants of delivery care in Kenya

This paper examines the determinants of place of delivery and childbirth attendant in Kenya based on the 1993 Kenya Demographic and Health Survey data. The analysis utilizes multilevel logistic and multilevel multinomial regression models for the place of delivery and the type of childbirth attendant, respectively. The results show that delivery care in Kenya is determined by a wide range of factors: socioeconomic and cultural factors associated with the individual woman or her household, her demographic status or reproductive behavior relating to a specific birth, as well as availability and accessibility of health services within her community. In addition, a significant variation in delivery care behavior is observed between women and between communities, implying that there are unobserved factors within families and communities that have a significant effect on delivery care. The woman or family effect on delivery care is particularly strong, but varies by distance to the nearest delivery care facility.     

Margulis' Theory on Division of Labour in Cells Revisited

Division of labour is a marked feature of multicellular organisms. Margulis proposed that the ancestors of metazoans had only one microtubule organizing center (MTOC), so they could not move and divide simultaneously. Selection for simultaneous movement and cell division had driven the division of labour between cells. However, no evidence or explanation for this assumption was provided. Why could the unicellular ancetors not have multiple MTOCs? The gain and loss of three possible strategies are discussed. It was found that the advantage of one or two MTOC per cell is environment-dependent. Unicellular organisms with only one MTOC per cell are favored only in resource-limited environments without strong predatory pressure. If division of labour occurring in a bicellular organism just makes simultaneous movement and cell division possible, the possibility of its fixation by natural selection is very low because a somatic cell performing the function of an MTOC is obviously wasting resources. Evolutionary biologists should search for other selective forces for division of labour in cells.     

The history of the journal social biology: 1954 (Vol. 1) through 1999 (Vol. 46)

Abstract

This paper examines the determinants of place of delivery and childbirth attendant in Kenya based on the 1993 Kenya Demographic and Health Survey data. The analysis utilizes multilevel logistic and multilevel multinomial regression models for the place of delivery and the type of childbirth attendant, respectively. The results show that delivery care in Kenya is determined by a wide range of factors: socioeconomic and cultural factors associated with the individual woman or her household, her demographic status or reproductive behavior relating to a specific birth, as well as availability and accessibility of health services within her community. In addition, a significant variation in delivery care behavior is observed between women and between communities, implying that there are unobserved factors within families and communities that have a significant effect on delivery care. The woman or family effect on delivery care is particularly strong, but varies by distance to the nearest delivery care facility.