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Background: Current practice guidelines recommend active management of the third stage of labor. We compared practices of three maternity care provider disciplines in management of third-stage labor and the justifications for their approach. Methods: This study is a cross-sectional survey of maternity practitioners in usual practice settings in British Columbia. All 199 obstetricians, all 82 midwives, and a random sample of family physicians practicing intrapartum maternity care (one-third, or 346) were surveyed The three main outcome measures by discipline were the method preferred in managing third-stage labor, the reasons given for the chosen method, and views on the appropriateness of the current third-stage labor guideline. Results: The overall response rate was 57.8 percent. Response rates indicating that the participants were 'aware of guideline' were the following: obstetricians, 85.3 percent; family physicians, 53.7 percent; and midwives, 97.8 percent. Response rates indicating that the participants 'agreed with guideline' were the following: obstetricians, 95.2 percent; family physicians, 97.6 percent; and midwives, 51.2 percent. Response rates indicating that 'oxytocin should be given with anterior shoulder' were the following: obstetricians, 71.1 percent; family physicians, 68.3 percent; and midwives, 26.7 percent. Response rates indicating that 'routine active management of third stage of labor should be the norm' were the following: obstetricians, 79.2 percent; family physicians, 60.2 percent; and midwives, 17 percent. All results were statistically significant (p < 0.01). Conclusions: A major difference was found between physicians and midwives in the management of third-stage labor. Physicians routinely implemented active management of the third stage of labor; midwives preferred expectant approaches, principally based on women's preference. Provincial data did not show differences in postpartum hemorrhage or transfusion rates by practitioner type. (BIRTH 35:3 September 2008) [ABSTRACT FROM AUTHOR]

OBJECTIVE: To describe obstetric procedures (episiotomy, forceps, vacuum extraction, caesarean section) and maternal outcomes for patients who gave birth in an isolated, rural hospital. DESIGN: A retrospective cohort study. Study population: Women beyond 20 weeks' gestation who gave birth between Mar. 7, 1940, and June 9, 2001, inclusive, at the Bella Coola General Hospital (BCGH). MAIN OUTCOME MEASURES: Data collected included maternal age, date of delivery, mode of delivery (vaginal delivery v. cesarean section), whether an episiotomy was performed or not, if forceps or vacuum extraction were used, whether analgesia, sedation or anesthesia was used, and maternal mortality. RESULTS: There were 2373 deliveries, including 12 sets of twins. There were no maternal mortalities. Cesarean sections were not routinely performed until the 1970s. Since then, there has been an increase in cesarean section rates to 11% of all deliveries in the 1990s. In the 1940s 28% of deliveries involved an episiotomy. This increased to 47% in the 1970s and was followed by a sharp decline to 4% in the 1990s. There was an increase, followed by a more gradual decrease in the use of forceps, and there was a recent increase in the use of vacuum extraction. The changes in procedure rates appear to reflect best practice guidelines of the times. In the case of episiotomies, the data suggest rural physicians are capable of rapid incorporation of recent recommendations. Rates for all procedures tended to be lower than those reported elsewhere in Canada and the United States. Narcotics, sedatives, inhalation agents and regional anesthetics were used to relieve the pain of labour and delivery throughout the study period. CONCLUSIONS: Women giving birth in the low technology environment of the BCGH experienced relatively low obstetric procedural rates with excellent maternal outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To describe perinatal outcomes (mortality, weight, condition at birth) at an isolated, rural hospital. DESIGN: A retrospective cohort study. Study population: Neonates born to women beyond 20 weeks' gestation who delivered in the Bella Coola General Hospital (BCGH) between Mar. 7, 1940, and June 9, 2001, inclusive. MAIN OUTCOME MEASURES: Information collected from the labour and delivery case room record book includes Aboriginal status, date of delivery, birth weight, newborn mortality, and newborn condition at birth. RESULTS: There were 2373 deliveries, including 12 sets of twins. Total newborn mortality rates declined from approximately 4.7% in the 1940-1954 time period to 0.7% in the 1970-1984 time period and have remained near that level ever since. From 1940-1960 BCGH's perinatal mortality rate was higher than Canada's; it was lower than Canada's in the 1970s, higher in the 1980s and about the same for the 1990s. The condition of the vast majority (approximately 90%) of newborns was described as being 'good' at birth. Approximately 5% of newborns had birth weights < 2500 g, and this has not changed much over the years. In the 1951-1962 time period Aboriginal women had a higher percentage (8%) of infants with birth weight < 2500 g compared with non-Aboriginal women (5%), but this percentage has declined over time to the point where the rate for both groups is now around 5%. CONCLUSIONS: Women giving birth in the low technology environment of the BCGH experienced acceptable neonatal outcomes. Trends in perinatal mortality, morbidity and low-birth-weight rates mirror those recorded for Canada. [ABSTRACT FROM AUTHOR]

Background: Understanding the association between caregiver belief systems and practice patterns is an emerging area of research. We hypothesized an association between a maternity caregiver's belief system and his or her behavior. The study objective was to determine if a family physician's overall approach to maternity care, as measured by average use of epidural analgesia, was associated with maternal and fetal outcomes. Methods: Retrospective analysis was conducted of the births of three cohorts of 1992 nulliparous, low-riskwomen attended by 96 family physicians within an 18-month period in the department of family practice at the largest maternity hospital in Canada. Cohorts were based on the physicians' mean use of epidural analgesia for the women. Family physicians attending fewer than 5 births were excluded. The main outcome measures, by physician epidural utilization cohort, were maternal/newborn morbidity, procedure rates, consultation rates, and length of stay. Results: Family physicians were separated into cohorts based on their mean use of epidural analgesia at rates of: low, 0-30 percent (15 physicians, 263 births); medium, 31-50 percent (55 physicians,1323 births); and high, 51-100 percent (26 physicians, 406 births). After adjustment for maternal age and race, patients of low versus high epidural users were admitted at a later state of cervical dilation (mean 4.0 vs 3.1 cm), received less electronic fetal monitoring (76.4 vs 87.2) and oxytocin augmentation (12.2 vs 29.8), sustained fewer malpositions (occiput posterior or transverse)(23.2 vs 34.2), had fewer cesarean sections (14.0 vs 24.4), less obstetric consultation (47.9 vs 63.8), and fewer newborn special care admissions (7.2 vs 12.8). Conclusions: In our setting, high use of epidural analgesia is a marker for a style of practice characterized by malpositions leading to dysfunctional labors and higher intervention rates leading, in turn, to excess maternal/newborn morbidity. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented regarding the early use of epidural analgesia by women in delivery stage and its role in the increased rate of caesarean section.

Background: Studies of planned home births attended by registered midwives have been limited by incomplete data, nonrepresentative sampling, inadequate statistical power and the inability to exclude unplanned home births. We compared the outcomes of planned home births attended by midwives with those of planned hospital births attended by midwives or physicians.Methods: We included all planned home births attended by registered midwives from Jan. 1, 2000, to Dec. 31, 2004, in British Columbia, Canada (n = 2889), and all planned hospital births meeting the eligibility requirements for home birth that were attended by the same cohort of midwives (n = 4752). We also included a matched sample of physician-attended planned hospital births (n = 5331). The primary outcome measure was perinatal mortality; secondary outcomes were obstetric interventions and adverse maternal and neonatal outcomes.Results: The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00-1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00-1.43) among women attended by a midwife and 0.64 (95% CI 0.00-1.56) among those attended by a physician. Women in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29-0.36; assisted vaginal delivery, RR 0.41, 95% 0.33-0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28-0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49-0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife-attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14-0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24-0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21-0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09-1.85).Interpretation: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician. [ABSTRACT FROM AUTHOR]

Background: The impact of midwifery versus physician care on perinatal outcomes in a population of women planning birth in hospital has not yet been explored. We compared maternal and newborn outcomes between women planning hospital birth attended by a midwife versus a physician in British Columbia, Canada. Methods: All women planning a hospital birth attended by a midwife during the 2-year study period who were of sufficiently low-risk status to meet eligibility requirements for home birth as defined by the British Columbia College of Midwives were included in the study group (n = 488). The comparison group included women meeting the same eligibility requirements but planning a physician-attended birth in hospitals where midwives also practiced (n = 572). Outcomes were ascertained from the British Columbia Reproductive Care Program Perinatal Registry to which all hospitals in the province submit data. Results: Adjusted odds ratios for women planning hospital birth attended by a midwife versus a physician were significantly reduced for exposure to cesarean section (OR 0.58, 95% CI 0.39-0.86), narcotic analgesia (OR 0.26, 95% CI 0.18-0.37), electronic fetal monitoring (OR 0.22, 95% CI 0.16-0.30), amniotomy (OR 0.74, 95% CI 0.56-0.98), and episiotomy (OR 0.62, 95% CI 0.42-0.93). The odds of adverse neonatal outcomes were not different between groups, with the exception of reduced use of drugs for resuscitation at birth (OR 0.19, 95% CI 0.04-0.83) in the midwifery group. Conclusions: A shift toward greater proportions of midwife-attended births in hospitals could result in reduced rates of obstetric interventions, with similar rates of neonatal morbidity. (BIRTH 34:2 June 2007) [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVES: To evaluate the success of a competency-based nursing orientation programme for a single-room maternity care unit by measuring improvement in self-reported competency after six months. BACKGROUND: Single-room maternity care has challenged obstetrical nurses to provide comprehensive nursing care during all phases of the in-hospital birth experience. In this model, nurses provide intrapartum, postpartum and newborn care in one room. To date, an evaluation of nursing education for single-room maternity care has not been published. DESIGN: A prospective cohort design comparing self-reported competencies prior to starting work in the single-room maternity care and six months after. METHODS: Nurses completed a competency-based education programme in which they could select from a menu of learning methods and content areas according to their individual needs. Learning methods included classroom lectures, self-paced learning packages, and preceptorships in the clinical area. Competencies were measured by a standardized perinatal self-efficacy tool and a tool developed by the authors for this study, the Single-Room Maternity Care Competency Tool. A paired analysis was undertaken to take into account the paired (before and after) nature of the design. RESULTS: Scores on the perinatal self-efficacy scale and the single-room maternity care competency tool were improved. These differences were statistically significant. CONCLUSIONS: Improvements in perinatal and single-room maternity care-specific competencies suggest that our education programme was successful in preparing nurses for their new role in the single-room maternity care setting. This conclusion is supported by reported increases in nursing and patient satisfaction in the single-room maternity care compared with the traditional labour/delivery and postpartum settings. RELEVANCE TO CLINICAL PRACTICE: An education programme tailored to the learning needs of experienced clinical nurses contributes to improvements in nursing competencies and patient care. [ABSTRACT FROM AUTHOR]

BACKGROUND: The introduction of single room maternity care in the 1990s necessitated a new approach to nursing education and practice. A focus on perinatal nursing requires competence across the spectrum of labor, delivery, postpartum and newborn care. We sought to evaluate the nursing response to this change by comparing satisfaction with the workplace environment among single room maternity care nurses before and after they worked in the setting and among nurses working in traditional birth settings. METHODS: Six months before the opening of a pilot seven-bed single room maternity care unit, nurses who planned to work in the new unit completed a survey about their satisfaction with aspects of their work environment. Three months after the new unit opened the survey was repeated with this study group and also by a sample of nurses working in the delivery and postpartum areas. RESULTS: Responses indicated that single room maternity care nurses before and after working in the unit were significantly more satisfied with the physical setting, their ability to respond to patients' needs, their opportunity for teaching families, the nursing practice environment, peer support, and their perceived level of competency. They rated their satisfaction significantly higher than that of their colleagues in the traditional delivery and postpartum settings. CONCLUSIONS: The positive transition to single room maternity care by obstetrical nurses was demonstrated by their improved overall satisfaction with the work environment. Evaluation of the nurses' responses to changes in health care delivery has important implications for justifying new clinical approaches and planning for future changes. [ABSTRACT FROM AUTHOR]

Background: Preference for formula versus breast feeding among women of Chinese descent remains a concern in North America. The goal of this study was to develop an intervention targeting Chinese immigrant mothers to increase their rates of exclusive breastfeeding.Methods: We convened a focus group of immigrant women of Chinese descent in Vancouver, British Columbia to explore preferences for method of infant feeding. We subsequently surveyed 250 women of Chinese descent to validate focus group findings. Using a participatory approach, our focus group participants reviewed survey findings and developed a priority list for attributes of a community-based intervention to support exclusive breastfeeding in the Chinese community. The authors and focus group participants worked as a team to plan, implement and evaluate a Chinese language newborn feeding information telephone service staffed by registered nurses fluent in Chinese languages.Results: Participants in the focus group reported a strong preference for formula feeding. Telephone survey results revealed that while pregnant Chinese women understood the benefits of breastfeeding, only 20.8% planned to breastfeed exclusively. Only 15.6% were breastfeeding exclusively at two months postpartum. After implementation of the feeding hotline, 20% of new Chinese mothers in Vancouver indicated that they had used the hotline. Among these women, the rate of exclusive breastfeeding was 44.1%; OR 3.02, (95% CI 1.78-5.09) compared to women in our survey.Conclusion: Initiation of a language-specific newborn feeding telephone hotline reached a previously underserved population and may have contributed to improved rates of exclusive breastfeeding. [ABSTRACT FROM AUTHOR]