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BACKGROUND: Labor pain is a complex phenomenon, which is influenced by many factors. Therefore, an effective pain management during birth requires an assessment of the labor pains; however, there is currently no standardized and valid tool to assess labor pains. OBJECTIVE: The aim of this article is to demonstrate which assessment instruments are available for labor pains during a physiological birth and how comprehensibly they depict the pain. MATERIAL AND METHODS: The study is an integrative review of the literature based on a literature search conducted in the electronic databases PubMed and CINAHL. To ensure the quality of the review article, COSMIN, AMSTAR 2 and the instrument for assessment of qualitative research of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) were used as assessment instruments. RESULTS: Taking the various inclusion and exclusion criteria into consideration, five studies could be included. The following assessment instruments were identified: visual analog scale (VAS), the acceptance symptom assessment scale (ASAS), the angle labor pain questionnaire (A-LPQ), the rating scale of pain expression during childbirth (Escala de Valoración de la Expresión del Dolor durante el Trabajo de Parto, ESVADPA) and the coping with labor pain algorithm (CWLA). These were supplemented by a study on the perspectives of women. CONCLUSION: None of the assessment instruments found could assess the birth pain in its full complexity. Therefore, midwives have to rely on their competence to evaluate labor pain on an individual basis. Further research is necessary to identify the relevant influencing factors of labor pains and to be able to develop suitable instruments.

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Nitrous oxide, a potent greenhouse gas, is a common labour analgesic. One method which may reduce its carbon footprint is to 'crack' the exhaled gas into nitrogen and oxygen using catalytic destruction. In this quality improvement project, based on environmental monitoring and staff feedback, we assessed the impact of nitrous oxide cracking technology in the maternity setting. Mean ambient nitrous oxide levels were recorded during the final 30 minutes of uncomplicated labour in 36 cases and plotted on a run chart. Interventions were implemented in four stages, comprising: stage 1, baseline (12 cases); stage 2, cracking with nitrous oxide delivered and scavenged via a mouthpiece (eight cases); stage 3, cracking with nitrous oxide via a facemask with an air-filled cushion (eight cases); stage 4, cracking with nitrous oxide via a low-profile facemask, and enhanced coaching on the use of the technology (eight cases). The median ambient nitrous oxide levels were 71% lower than baseline in stage 2 and 81% lower in stage 4. Staff feedback was generally positive, though some found the technology to be cumbersome; successful implementation relies on effective staff engagement. Our results indicate that cracking technology can reduce ambient nitrous oxide levels in the obstetric setting, with potential for reductions in environmental impacts and occupational exposure.

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OBJECTIVE: To evaluate patient satisfaction with the informed consent process for elective cesarean delivery (CD), emergency CD, and operative vaginal delivery (OVD). METHODS: A cross-sectional, survey-based study was conducted among patients on the postpartum floor of our institution. Patients were approached after delivery to complete a previously pilot-tested questionnaire, based on validated literature. One hundred eighty-four surveys were included in the analysis. Levels of patient satisfaction were compared across modes of delivery using χ2 tests of independence. Secondary objectives included evaluating the relationship between satisfaction scores and the patient's recall of the consent process and emotional state during the consent process. RESULTS: A significant association was found between patient satisfaction with the consent process and mode of delivery (P < 0.001). Those in the elective and emergency CD groups were significantly more likely to express high rates of satisfaction compared with those in the OVD group (odds ratio [OR] 9.03; 95% CI 2.80-29.10 and OR 3.97; 95% CI 1.34-11.76, respectively). High levels of satisfaction were significantly more common among those who had greater recall of the consent process (OR 25.2; 95% CI 7.34-87.04) and those who reported low levels of distress during the process (OR 15.1; 95% CI 4.70-48.66). CONCLUSION: Informed consent during OVD is associated with lower rates of patient satisfaction compared with CD. Efforts are needed to improve the consent process for OVD to increase patient satisfaction and promote patient-centred care.

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OBJECTIVE: We evaluated the association between the presence of predelivery uterine contractions and transient tachypnoea of the newborn (TTN) in women undergoing an elective caesarean section. DESIGN: A retrospective cohort study. SETTING: National Hospital Organization Kofu National Hospital, which is a community hospital, between January 2011 and May 2019. PARTICIPANTS: The study included 464 women who underwent elective caesarean section. The exclusion criteria were missing data, twin pregnancy, neonatal asphyxia, general anaesthesia and elective caesarean section before term. PRIMARY AND SECONDARY OUTCOME MEASURES: Patients were grouped according to the presence or absence of uterine contractions on a 40-min cardiotocogram (CTG) performed within 6 hours before caesarean delivery. We performed a multivariable logistic regression analysis to examine the association between predelivery uterine contractions and TTN. RESULTS: The incidence of TTN was 9.9% (46/464), and 38.4% (178/464) of patients had no uterine contraction. The absence of uterine contractions was significantly associated with an increased risk of TTN (adjusted OR 2.04; 95% CI 1.09 to 3.82) after controlling for gestational diabetes mellitus, small for gestational age, male sex and caesarean section at 37 weeks. CONCLUSIONS: Accurate risk stratification using a CTG could assist in the management of infants who are at risk of developing TTN.

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OBJECTIVE: This study sought to describe how the implementation of recent labour guidelines may affect the cesarean delivery rate in a population in Alberta. METHODS: This retrospective study was conducted on primiparous women who were in labour with singleton term fetuses with cephalic presentation in Alberta from 2007 to 2016 (n = 181 738), and it used data from a perinatal database. Modelled cesarean delivery rates were calculated to determine the potential impact of the recent guidelines on the cesarean delivery rate by using the percentage of cesarean deliveries that occurred outside the threshold of the recent labour guidelines. RESULTS: A total of 21.7% of the cesarean deliveries for dystocia occurred outside of the guidelines related to the first stage of labour arrest for spontaneous labour (n = 9282), and 45.4% occurred outside of the guidelines related to the first stage of labour arrest for induced labours (n = 11 712). A total of 69.0% of the cesarean deliveries for dystocia occurred outside of the failed induction of labour guidelines (n = 4921), and 55.4% occurred outside of the second stage labour arrest guidelines (n = 6632). Assuming that the labour arrest guidelines are effective at reducing the cesarean delivery rate 25% of the time, the cesarean delivery rate for primiparous women in labour would be reduced from 22.5% to 20.7%. Assuming a 75% adherence/effectiveness rate, the cesarean delivery rate would be reduced to 17.1%. CONCLUSION: The recent labour guidelines have the potential to have a substantial impact on the intrapartum cesarean delivery rate in primiparous women with singleton fetuses with cephalic presentation at term if the guidelines are put into practice.

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BACKGROUND: Epidural-related maternal fever (ERMF) has been reported in ∼26% of labouring women. The underlying mechanisms remain unclear. We hypothesised that ERMF is promoted by bupivacaine disrupting cytokine production/release from mononuclear leucocytes [mononuclear fraction (MNF)]. We examined whether bupivacaine (i) reduces caspase-1 activity and release of the anti-pyrogenic cytokine interleukin (IL)-1 receptor antagonist (IL-1ra), and (ii) is pro-inflammatory through mitochondrial injury/IL-1ß. METHODS: In labouring women, blood samples were obtained before/after epidural analgesia was implemented. Maternal temperature was recorded hourly for the first 4 h of epidural analgesia. Time-matched samples/temperatures were obtained from labouring women without epidural analgesia, pregnant non-labouring, and non-pregnant women. The primary clinical outcome was change in maternal temperature over 4 h after the onset of siting epidural catheter/enrolment. The secondary clinical outcome was development of ERMF (temperature ≥ 38°C). The effect of bupivacaine/saline on apoptosis, caspase-1 activity, intracellular IL-1ra, and plasma IL-1ra/IL-1ß ratio was quantified in MNF from labouring women or THP-1 monocytes (using flow cytometry, respirometry, or enzyme-linked immunosorbent assay). RESULTS: Maternal temperature increased by 0.06°C h-1 [95% confidence interval (CI): 0.03-0.09; P=0.003; n=38] after labour epidural placement. ERMF only occurred in women receiving epidural analgesia (five of 38; 13.2%). Bupivacaine did not alter MNF or THP-1 apoptosis compared with saline control, but reduced caspase-1 activity by 11% (95% CI: 5-17; n=10) in MNF from women in established labour. Bupivacaine increased intracellular MNF IL-1ra by 25% (95% CI: 10-41; P<0.001; n=10) compared with saline-control. Epidural analgesia reduced plasma IL-1ra/IL-1ß ratio (mean reduction: 14; 95% CI: 7-30; n=30) compared with women without epidural analgesia. CONCLUSIONS: Impaired release of anti-pyrogenic IL-1ra might explain ERMF mechanistically. Immunomodulation by bupivacaine during labour could promote ERMF.

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Introdução: O processo de parturição passou por mudanças nas últimas décadas, sendo institucionalizado e abordado como um processo patológico. Porém, com a compreensão de que o parto não deve ser determinado somente pelas evidências científicas e pelo excesso de intervenções muitas vezes desnecessárias, mas que deve ser também determinado pela individualidade e necessidade da mulher, tornando-a protagonista e garantindo-lhe a humanização deste processo, surgiu a inquietação no que tange aos cuidados de enfermagem em relação às boas práticas de atenção ao parto e nascimento. Nesse sentido, elaborou-se a questão norteadora: Como sistematizar o cuidado de enfermagem à mulher em processo de parturição com base nas boas práticas de atenção ao parto e ao nascimento? Objetivo: Construir com os profissionais de enfermagem protocolos assistenciais para nortear os cuidados de enfermagem à mulher em processo de parturição embasando-se nas boas práticas de atenção ao parto e ao nascimento. Metodologia: Para delineamento metodológico deste estudo utilizou-se a Pesquisa Convergente Assistencial, realizada em um Centro Cirúrgico Obstétrico e Ginecológico de um hospital universitário do Sul do Brasil, no período de 6 de junho de 2017 a 31 de agosto de 2017. Contou com a participação de 36 profissionais de enfermagem que prestavam assistência direta e indireta à mulher em processo de parturição. A coleta de dados se deu por meio de oficinas temáticas, com apoio de um roteiro norteador, e utilizou-se nesta etapa o processo denominado Quatro Erres (Rs) proposto por Trentini e Paim (2014). Para análise dos dados foram seguidos os seis passos de John W. Creswell (2010), e foi apoiada com uso do software Iramuteq, em que se empregou o método da classificação hierárquica descendente (CHD). Resultados: Identificaram-se seis classes distintas; para cada classe atribuiu-se uma nomenclatura derivada da análise aprofundada, e denominaram-se: Classe 1 - Protocolos Assistenciais: repercussões, importância e contribuições; Classe 2 - 0 protagonismo, autonomia e privacidade da mulher no processo de parturição; Classe 3 - Dificuldades no processo de trabalho; Classe 4 - Processo de Nascer: o entendimento dos profissionais de enfermagem; Classe 5 - Contribuições no processo de cuidar para melhor nascer; e Classe 6 - Fragilidades/Limitações no processo de parturição. Considerações finais: Foi possível evidenciar neste estudo que os profissionais de enfermagem compreendem que a instituição de protocolos assistenciais garante a sistematização da assistência e que a integração dos profissionais de enfermagem na construção contribuiu no aprimoramento do conhecimento em relação aos cuidados de enfermagem à mulher em processo de parturição com base nas boas práticas de atenção ao parto e nascimento. O presente estudo alcançou o objetivo com a construção dos protocolos assistenciais de enfermagem para a mulher em processo de parturição, constituindo produto desta dissertação, indo ao encontro dos pressupostos do Programa de Mestrado Profissional e da Pesquisa Convergente Assistencial, fomentando e colaborando para que melhorias na prática assistencial sejam alcançadas, bem como o equilíbrio entre as evidências científicas, a humanização e protagonismo da mulher em processo de parturição.

Abstract: Introduction: In recent decades, the process of parturition has become institutionalised and it is being approached as a pathological process. The understanding that childbirth should not be considered merely from the standpoint of scientific evidence, the excessive number of unnecessary interventions, and the need to respect the individuality and desires of women to ensure their protagonism and a more humanised process have led to some concerns regarding nursing care and the best nursing practices in labour and childbirth. Consequently, the guiding question of this study was: how can we systematise nursing care for parturient women based on good care practices during labour and the birth? Objective: To build, with the nursing professionals, care protocols that can guide nursing care provided to women in the process of parturition based on good labour and childbirth practices. Methodology: The study design was based on a convergent care study conducted at an obstetric and gynaecological surgical centrein a university hospital in southern Brazil, from 6 June to 31 August 2017. The study was conducted with 36 nursing professionals who provided direct and indirect care to parturient women. Data were collected using thematic workshops with a guiding script and a process called the Four R's (4 Rs) proposed by Trentini and Paim (2014). Data were analysed according to the six steps of John W. Creswell (2010) and supported using Iramuteqsoftware based on top-down hierarchical clustering. Results: Six different classes were identified and each class was attributed a nomenclature derived from in-depth analysis, as follows: Class 1 - Care protocols: repercussions, importance, and contributions; Class 2 - Protagonism, autonomy, and privacy of parturient women; Class 3 - Difficulties in the work process; Class 4 - Birth process: the understanding of nursing professionals; Class 5 - Care contributions for a better birth; and Class 6 - Weaknesses/Limitations in parturition. Final considerations: Results showed the nursing professionals understand that the use of care protocols ensures the systématisation of care and the integration of nursing professionals in the construction of these protocols helped to improve knowledge of nursing care for parturient women based on the best labour and childbirth care practices. The objective of this study was reached with the construction of a nursing care protocol, the product of this dissertation, for parturient women, as required by the professional master's programme and convergent care research. Thus, this study fosters and contributes to the improvement of care practices and to finding a balance between scientific evidence, humanisation, and women's protagonism in the process of parturition.

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AIMS: To report on the opinions and reported practices of Australian obstetricians and general practice (GP) obstetricians, in the definition and management of spontaneous first stage of labour, in low-risk nulliparous women. MATERIALS AND METHODS: Cross-sectional survey sent electronically to all Australian Specialist obstetricians (FRANZCOG) and Diplomates. Respondents answered questions regarding care of nulliparous women in spontaneous labour at term across three domains: (i) practitioners' characteristics; (ii) current practice; (iii) opinion regarding joint statement by ACOG/SMFM (Society of Maternal Fetal Medicine) 'Safe prevention of primary caesarean section'. RESULTS: The dataset included responses from 664 participants, representing 29% of Specialists and 11% of Diplomates. Responses varied in the criteria used to define normal labour, and the diagnosis and management of prolonged labour. Clinicians with more post-qualification experience considered the minimal acceptable progress to be faster than those with fewer years of experience (P = 0.02). Clinicians working in higher acuity hospitals were more likely to augment labour for longer prior to recommending a caesarean section for active phase arrest, compared to those in lower acuity hospitals (P = 0.025). The majority of respondents (58.2%) already based their practice on the ACOG/SMFM 'Safe prevention of primary caesarean section' statement, or would now consider changing their practice. CONCLUSION: There is a lack of consensus among Australian obstetricians and GP obstetricians regarding definition of normal progress in first stage of labour and how to manage abnormal progress; however, many are open to new recommendations for practice.

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BACKGROUND: Fetal scalp lactate (FSL) is used when the cardiotocography (CTG) is not normal in an attempt to reduce the false-positive rate and the likelihood of unnecessary intervention. Whilst the test has almost a 100% negative predictive value, the positive predictive value of this test is very low. AIMS: To measure the effect of introducing consultant obstetrician review of every abnormal CTG prior to the decision to perform FSL. MATERIALS AND METHODS: A retrospective cohort study was performed using routinely collected de-identified data. Mode of birth outcomes for women who had a continuous CTG in labour were compared in two equal time periods, 12 months before and after a change in hospital policy. Change in hospital policy dictated that FSL was only performed on a pathological CTG after consultant obstetrician review of the CTG. RESULTS: Consultant obstetrician review of CTG prior to FSL was associated with fewer FSL performed (1.7% vs 3.5%; P ≤ 0.01), fewer babies acidaemic at birth pH < 7.1 (0.8% vs 2.2%; P < 0.01), fewer caesarean sections for presumed fetal distress (CS for FD) (6.6% vs 8.1%; P = 0.05) and fewer instrumental births (17.6% vs 20%; P = 0.04). When adjusted for confounders, the change in policy was independently associated with a reduced likelihood of CS for FD (adjusted odds ratios = 0.78 (0.63-0.97); P = 0.03). CONCLUSIONS: A hospital policy whereby a consultant obstetrician reviews abnormal CTGs prior to performing FSL may help to increase the pretest probability and reduce the rate of CS for FD, as well as instrumental birth and unnecessary FSL.

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There is a wide range of practice amongst obstetric anaesthetists when obtaining consent for women requesting labour epidural analgesia. This is the first prospective observational study recording the number and types of risks mentioned and whether the risk was quantified. Statements of benefits and alternatives to the procedure were also noted. Fourteen anaesthetists, each consulting a single patient, were recorded during the process of obtaining consent and inserting the epidural. The most commonly mentioned risks (median 7) were headache/dural puncture, failure/difficulty with insertion, nerve damage, bleeding/haematoma and infection/epidural abscess. There was no difference between consultants and trainees, although consultants showed greater variance. It was uncommon for anaesthetists to state a benefit (21%) or mention an alternative option (21%), but there was usually a quantitative statement of risk (71%). Data showed a deviation from the Australian and New Zealand College of Anaesthetists guidelines and these findings may encourage anaesthetists to reflect on their own practice and guide future research.

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RESUMO Objetivo Conhecer as vivências de mulheres primíparas em relação às práticas de cuidado prestadas por profissionais de enfermagem no parto normal. Método Estudo qualitativo, descritivo, realizado com dez mulheres primíparas, em uma maternidade no interior do Rio Grande do Sul, entre fevereiro e abril de 2014, por meio de entrevista individual semiestruturada. Os dados foram submetidos à análise de conteúdo temática pela proposta operativa. Resultados Os dados foram agrupados nas categorias: O medo de não conseguir e o incentivo da equipe de enfermagem; A vivência da dor no parto normal; Apoio versus distanciamento; Vivência boa ou ruim no parto? “No final tudo compensa!”. Conclusões O cuidado prestado se reflete na vivência e na forma como a mulher enfrenta os eventos que permeiam o processo parturitivo.

RESUMEN Objetivo conocer las experiencias de mujeres primerizas con respecto a las prácticas de atención prestados por los profesionales de enfermería en el parto normal. Método cualitativo, estudio descriptivo, llevado a cabo con diez mujeres primerizas, en una maternidad en el interior de Rio Grande do Sul, entre febrero y abril de 2014, a través de entrevistas semiestructuradas individuales. Los datos fueron analizados por análisis de contenido temático sobre la propuesta operativa. Resultados los datos se agruparon en categorías: El miedo al fracaso y el aliento del equipo de enfermería; La experiencia del dolor en el parto normal; Apoyo contra el distanciamiento; ¿Buena o mala experiencia en el parto? “Al final vale la pena”. Conclusiones la atención recibida refleja la experiencia y la forma en que las mujeres se enfrentan a acontecimientos que permean el proceso parturitivo.

ABSTRACT Objective to know the experiences of primiparous women regarding the care practices provided by nursing professionals during natural childbirth. Method a qualitative, descriptive study, conducted with ten primiparous mothers at a maternity hospital in the interior of Rio Grande do Sul, between February and April 2014, based on individual semi-structured interviews. The data were submitted to thematic content analysis according to the operative proposal. Results the data were grouped into the following categories: The fear of not being able to give birth naturally and the encouragement of the nursing staff; The experience of pain in natural childbirth; Support versus distance; Good or bad childbirth experience? “It was worth it in the end!” Conclusions the provided care has a direct impact on the experience and how the women cope with the process of childbirth.

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OBJECTIVES: Delivery care giving is undergoing excessive interventionism today, not supported by scientific evidence, neglecting organisational aspects and individualisation. This study analyses the perception of mothers during their delivery, postpartum and breastfeeding periods in the Galician Health Service, in order to inform and help to improve this service. MATERIAL AND METHODS: A total of 14 focus group meetings were held (one in each Galician public hospital), consisting of women who, in 2008, delivered by vaginal delivery or those who were not scheduled for a caesarean section. RESULTS: The process of birth analysis can identify a sequence of important elements both positive and negative, for mothers, and may lead to suggestions for improvement. Their experiences and opinions, especially in aspects such as participation in decision-making, mechanisation of labour and lactation, may help to conduct an assessment of the maternity ward operating. When investigating expectations and demands from users, information from perceived quality is received, and also mothers' experience is shared. CONCLUSIONS: Mothers call for humanity, empathy, information and participation. Facing the implementation of these elements, the key processes for working harder are the dilation stage and hospital staying.

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OBJECTIVES: This cross-sectional study was designed to examine the effects of the Valsalva Maneuver (VM) and its duration on the acid- base equilibrium of the neonate and its maternal repercussions during the expulsive stage of labor, after standard breathing and pushing instructions were given. METHODS: A convenience sample of women with low risk pregnancy (n=33; mean age 22.5±3.7y and gestational age 38.1±1.12wks) and their newborns were studied during the expulsive stage of vaginal labor. Coaching consisted of standard recommendations for breathing including prolonged VMs coordinated with pushing. Maternal outcomes included the need for uterus fundal pressure maneuver and episiotomy, perineal trauma and posture. Neonatal outcomes included blood gases sampled from the umbilical cord, and Apgar scores. Data were analyzed with the Fisher's exact test, chi-square test, and Pearson correlation coefficient. RESULTS: None of the maternal outcomes were associated with VM duration. With respect to neonatal outcomes, increased VM duration was associated with reduced venous umbilical pH (r=-0.40; p=0.020), venous base excess (r=-0.42; p=0.014) and with arterial base excess (r=-0.36; p=0.043). Expulsive stage time was negatively associated with umbilical venous and arterial pH. CONCLUSIONS: VM duration during fetal expulsion in labor negatively affects fetal acid-base equilibrium and potentially the wellbeing of the neonate. Our results support the need to consider respiratory strategies during labor, to minimize potential risk to the mother and neonate.

OBJETIVOS: O presente estudo de corte transversal teve como objetivo avaliar os efeitos da Manobra de Valsalva (MV) e sua duração no equilíbrio ácido-básico fetal e nas repercussões maternas durante o período expulsivo do parto, após instrução respiratória padronizada. MÉTODOS: Uma amostra de conveniência em gestantes de baixo risco (n=33, média de idade 22,5±3.7 anos e idade gestacional 38.1±1.12 semanas) e seus neonatos foi avaliada durante o período expulsivo do parto vaginal. O treinamento consistiu em recomendações padronizadas para respiração, incluindo MV prolongadas associadas ao puxo. Os desfechos maternos incluíram o uso da manobra de pressão para o fundo do útero, episiotomia, trauma perineal e postura. Os desfechos neonatais incluíram análise dos gases sanguíneos do cordão umbilical e valores de Apgar. Os dados foram analisados por meio do teste exato de Fisher, teste qui-quadrado e Coeficiente de Correlação de Pearson. RESULTADOS: Nenhum dos desfechos maternos foi associado com a duração da MV. No entanto, em relação aos desfechos neonatais, o aumento da duração da MV foi associado com redução do pH venoso umbilical (r=-0,40; p=0,020) e excesso de base (r=-0.42; p=0.014) e com o excesso de base arterial (r=-0,36; p=0,043). O tempo do período expulsivo do parto foi negativamente associado com o pH venoso e arterial. CONCLUSÕES: A duração da MV durante esse período do parto interfere negativamente no equilíbrio ácido-básico fetal e potencialmente no bem-estar do neonato. Esses resultados fornecem suporte para a necessidade de os fisioterapeutas considerarem estratégias de orientações respiratórias para o puxo durante o trabalho de parto para minimizar potenciais riscos para a mãe e o neonato.

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