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Problem: Women in early labour are typically encouraged to delay maternity unit admission, but they may find this challenging without appropriate professional support. Background: Despite pre-pandemic research which identified potential advantages of video-calling in early labour, implementation of such service has not been reported. Aim: To explore mothers’ perspectives on potential use of video-calls during early labour. Methods: A multi-centre descriptive qualitative study was undertaken in UK and Italy. Ethical approval was gained and ethical processes were followed. Six virtual focus groups were conducted with 37 participants, 24 mothers who gave birth in the UK and 13 who gave birth in Italy. Line-by-line thematic analysis was performed and themes agreed. Findings: Two themes emerged: 1) women's expectations of video-calls’ content and features; 2) technological challenges and solutions. Mothers responded positively to the concept of video-calling in early labour. Receiving guidance, information on coping with pain and advice on timely access in early labour was perceived as key. Women highlighted the importance of accessible, reliable and user-friendly technology. Equitable access, technological literacy, acceptability and privacy were considered as challenges to implementation, with solutions proposed to overcome disparities. Discussion and conclusion: Guidance and training should be provided to midwives, with designated resources to build a service that is accessible, acceptable, safe, individualised and respectful for mothers and birth companions. Further research should explore feasibility, acceptability, clinical and cost-effectiveness.

Endometriosis can be associated with adverse pregnancy outcomes. We report six cases of endometriosis-related spontaneous hemoperitoneum diagnosed in pregnant and postpartum women over 13 years. Spontaneous hemoperitoneum in pregnancy mainly occurred in the second half of gestation. All women presented with acute abdominal pain; four of them needed an emergent surgery, two were managed expectantly. The median estimated blood loss was 4250 ml, four women required massive transfusion. Three out of six women had a known history of endometriosis, all of them had histologically confirmed endometriosis after surgery. No maternal or perinatal deaths occurred. In one case, reticence to perform a computed tomography scan led to delayed diagnosis. Since delay can lead to lethal consequences, high levels of suspicion for spontaneous hemoperitoneum should be maintained in cases of severe abdominal pain, even with a woman's negative history of endometriosis. Improved knowledge and regular interdisciplinary meetings are pivotal to ameliorate outcomes.

Objective: To investigate attitudes and risk perceptions towards the coronavirus disease 2019 (COVID-19) vaccine and reasons for hesitancy among pregnant women. Methods: A prospective survey study was conducted at a University Maternity Department. Participants included any pregnant woman aged 18 years or older, able to understand the Italian language, who accessed the antenatal clinic for a prenatal appointment. The survey comprised questions about sociodemographic characteristics, pregnancy vaccination history, and perception of risk related to the immunization for the woman herself and her infant. Results: A total of 538 women completed the questionnaire, 445 (82.7%) accepted COVID-19 vaccination. Women vaccinated against pertussis were three times more likely to take up the COVID-19 vaccine (odds ratio [OR] 3.19; 95% confidence interval [CI] 1.78–5.72). Having had COVID-19 during pregnancy (OR 0.24; 95% CI 0.11–0.54), and having a high-risk perception towards the immunization for the fetus (OR 0.18; 95% CI 0.09–0.34) were factors associated with vaccine hesitancy. Lack of safety data in pregnancy and the possibility of harm to the fetus were the main concerns. Conclusion: A trusting and supportive relationship with the healthcare professional to address fears, and the transmission of evidence-based information, are pivotal to guide women through an informed choice. Understanding the determinants implicated in women's decision making might guide towards effective public health strategies to boost vaccine acceptance.

Background Evidence on the safety and appropriateness of vaginal birth after caesarean (VBAC) appears clear, but knowledge about women's choice towards this mode of birth is limited. Aims To identify variables related to women's decision-making about whether to try for VBAC. Method and findings Cross-sectional study was conducted. Feelings of body failure towards the previous birth and the desire to have a vaginal birth were associated with maternal choice of VBAC. Women who perceived a repeated section as being dangerous for them opted for a VBAC (p=0.030). Opinion of women with the same experience and information found online were implicated into maternal decision-making. Conclusion This is the first Italian study to confirm that maternal choice is complex and involves many factors. Midwives and obstetricians should strive to provide an evidence-based midwifery care, in order to offer a VBAC as a safe birth option.

BackgroundThe diagnosis of the established labor is a crucial clinical decision, and it requires an accurate midwifery assessment. Regular uterine contractions and a cervical dilatation of 4-6 cm are commonly considered to diagnose active labor with a lack of knowledge regarding the role of maternal signs. This study aimed to build and to validate a predictive model based on maternal signs and symptoms to identify a cervical dilatation ³4 . MethodsA prospective observational study was conducted from May to September 2018 in a II Level Maternity Unit (development data), and from May to September 2019 in a I Level Maternity Unit (validation data). Singleton, at term pregnant women with cephalic presentation and presence of uterine activity were enrolled consecutively at the maternity triage or at the antenatal ward during the initial assessment to diagnose the stage of labor. Women

ObjectiveTo appraise the application of the 2018 European Society of Cardiology-adapted modified WHO (mWHO) classification to pregnant women with heart disease managed at our maternal–fetal medicine referral centre and to assess whether the lack of a multidisciplinary Pregnancy Heart team has influenced their outcomes.MethodsA retrospective cohort study including all pregnancies with heart disease managed at our centre between June 2011 and December 2020. Cardiac conditions were categorised in five classes according to the mWHO classification. An additional class, named X, was created for conditions not included in this classification. Outcomes were compared among all classes and factors potentially associated to cardiac complications were assessed.ResultsWe identified 162 women with 197 pregnancies, for a prevalence of 0.7%. Thirty-eight (19.3%) gestations were included in class X. Caesarean section was performed in 64.9% pregnancies in class X, a rate similar to that of class II, II-III, and III/IV, and mostly for obstetric indications; in turn, it was more commonly performed for cardiology reasons in class II–III and III/IV. Cardiac complications occurred in 10.7%, with class X and II pregnancies showing the highest number of events (n=30.8% and 34.6%, respectively). Multiple gestation and urgent caesarean section associated with a 5-fold and 6.5-fold increase in complication rates.ConclusionsEven in a maternal–fetal medicine referral centre, the lack of a multidisciplinary team approach to women with heart disease may negatively impact their outcomes.

Background Human milk is the best nutrition for all infants. When this is not available, the use of donor human milk through human milk banks (HMBs), is recommended. The aim of the study is to explore Italian women's knowledge and attitude towards human milk donation and HMB. Methods A web-based self-administered 20-item questionnaire was developed based on the literature review and distributed via the social networking site Facebook. Results 3290 women completed the survey. Of those 76.57% knew about the opportunity to donate human milk and 72.37% were aware of the existence of HMBs, most of them breastfed for more than 6 months. Altruism towards other mothers and having an abundant milk supply, were found to be the most important facilitators that should lead women to donate their own milk. The most important barrier was lack of information (91.25%). A high rate of women who breastfed longer than 6 months expressed issues related to collection and transportation; concerns regarding the time needed to express was reported mainly by women currently breastfeeding. Conclusions This is the first Italian study to investigate this topic. Advertising to inform the general public should be used to increase awareness, short sessions within the school programme might sensitize women from a very young age. Healthcare professionals should strive to divulgate appropriate information.

Purpose Delayed cord clamping for at least 60 s is recommended to improve neonatal outcomes. The aim of this study is to evaluate whether there are differences in cord BGA between samples collected after double clamping the cord or without clamping the cord, when blood collection occurs within 60 s from birth in both groups. Methods A cross-sectional study was carried out, collecting data from 6884 high-risk women who were divided into two groups based on the method of cord sampling (clamped vs unclamped). Results There were significant decrease in pH and BE values into unclamped group compared with the clamped group. This difference remained significant when considering pathological blood gas analysis parameters, with a higher percentage of pathological pH or BE values in the unclamped group. Conclusion Samples from the unclamped cord alter the acid–base parameters compared to collection from the clamped cord; however, this difference does not appear to be of clinical relevance. Findings could be due to the large sample size, which allowed to achieve a high power and to investigate very small numerical changes between groups, leading to a statistically significant difference in pH and BE between samples even when we could not appreciate any clinical relevant difference of pH or BE between groups. When blood gas analysis is indicated, the priority should be given to the timing of blood collection to allow reliable results, to assess newborns status at birth and intervene when needed.

Objective: To validate the Italian-language version of the Birth Satisfaction Scale-Revised (BSS-R) and report key measurement properties of the tool. To evaluate the impact of antenatal class attendance on BSS-R assessed birth satisfaction. Background: Maternal satisfaction is one of the standards of care defined by the World Health Organisation (WHO) to improve the quality of services. The BSS-R is a multi-dimensional self-report measure of the experience of labour and birth. Methods: Cross-sectional instrument evaluation design examining factor structure and key aspects of validity and reliability. Embedded between-subjects design to examine known-group discriminant validity and the impact of antenatal class attendance on BSS-R sub-scale and total scores as dependent variables. After giving birth, 297 women provided data for analysis. Results: The Italian version of the BSS-R (I-BSS-R) was the key study measure. The established three-factor and bi-factor models of the BSS-R were found to offer an excellent fit to the data. Comparison of the tri-dimensional measurement model and the bi-factor model of the BSS-R found no significant differences between models. Women who attended antenatal classes had significantly lower stress experienced during childbearing sub-scale scores (I-BSS-RSE), compared to those who did not. Good convergent, divergent validity and known-groups discriminant validity were established for the I-BSS-R. Internal consistency observations were found to be sub-optimal in this population. Conclusions: On all key psychometric indices, with the exception of internal consistency that requires further investigation, the I-BSS-R was found to be a valid translation of the original BSS-R. The impact of antenatal classes on birth satisfaction warrants further research.

Background Hospitalization of women in latent labour often leads to a cascade of unnecessary intrapartum interventions, to avoid potential disadvantages the recommendation should be to stay at home to improve women’s experience and perinatal outcomes. Aim The primary aim of this study was to investigate the association between hospital admission diagnosis (latent vs active phase) and mode of birth. The secondary aim was to explore the relationship between hospital admission diagnosis, intrapartum intervention rates and maternal/neonatal outcomes. Methods A correlational study was conducted in a large Italian maternity hospital. Data from January 2013 to December 2014 were collected from the hospital electronic records. 1.446 records of low risk women were selected. These were dichotomized into two groups based on admission diagnosis: ‘latent phase’ or ‘active phase’ of labour. Findings 52.7% of women were admitted in active labour and 47.3% in the latent phase. Women in the latent phase group were more likely to experience a caesarean section or an instrumental birth, artificial rupture of membranes, oxytocin augmentation and epidural analgesia. Admission in the latent phase was associated with higher intrapartum interventions, which were statistically correlated to the mode of birth. Conclusions Women admitted in the latent phase were more likely to experience intrapartum interventions, which increase the probability of caesarean section. Maternity services should be organized around women and families needs, providing early labour support, to enable women to feel reassured facilitating their admission in labour to avoid the cascade of intrapartum interventions which increases the risk of caesarean section.

IntroductionThe term placenta praevia defines a placenta that lies over the internal os, whereas the term low-lying placenta identifies a placenta that is partially implanted in the lower uterine segment with the inferior placental edge located at 1–20 mm from the internal cervical os (internal-os-distance). The most appropriate mode of birth in women with low-lying placenta is still controversial, with the majority of them undergoing caesarean section. The current project aims to evaluate the rate of vaginal birth and caesarean section in labour due to bleeding by offering a trial of labour to all women with an internal-os-distance >5 mm as assessed by transvaginal sonography in the late third trimester.Methods and analysisThe MODEL-PLACENTA is a prospective, multicentre, 1:3 matched case–control study involving 17 Maternity Units across Lombardy and Emilia-Romagna regions, Italy. The study includes women with a placenta located in the lower uterine segment at the second trimester scan. Women with a normally located placenta will be enrolled as controls. A sample size of 30 women with an internal-os-distance >5 mm at the late third trimester scan is needed at each participating Unit. Since the incidence of low-lying placenta decreases from 2% in the second trimester to 0.4% at the end of pregnancy, 150 women should be recruited at each centre at the second trimester scan. A vaginal birth rate ≥60% in women with an internal-os-distance >5 mm will be considered appropriate to start routinely admitting to labour these women.Ethics and disseminationEthical approval for the study was given by the Brianza Ethics Committee (No 3157, 2019). Written informed consent will be obtained from study participants. Results will be disseminated by publication in peer-reviewed journals and presentation in international conferences.Trial registration numberNCT04827433(pre-results stage)

Introduction The aim of this scoping review is to explore the concept of ‘vulnerability’ affecting pregnant women and to identify an appropriate definition of this term. Methods Five stages were adopted for conducting the scoping review. A literature search was undertaken between 1 October 2017 and 5 January 2018, using three databases. Relevant publications were appraised, and semantic content analysis was performed to identify emergent themes and four determinants of the vulnerability concept. This involved combining items that seem to address the same issue. Results Eleven publications were considered, and eight definitions of vulnerability were identified, and from these four themes emerged: poor health outcome or status; exposure to risk; complex social needs; and lack of resources. Further analysis of evidence found examples of groups of people considered to be vulnerable; they were reported into six matrices, mainly with social and psychological difficulties. From these, eleven themes arose. Following a semantic and content analysis of all themes, thirteen final themes were identified. They represent the characteristics associated with women considered to be vulnerable and are called indices of vulnerability. Semantic and content analysis allowed addressing the thirteen indices of vulnerability into four categories called determinants of the vulnerability concept: deficiency, need, risk exposure, and barriers. Conclusions The vulnerability could be defined as a lack of health, related to the presence of at least one of the four determinants. Midwives are the key to identify vulnerable women, offering appropriate care.

Background The experience of labour and birth is complex, multidimensional and subjective and has the potential to affect the women and their families physically and emotionally. However, there is a lack of research around maternal satisfaction in Italy. Aim To evaluate mothers’ satisfaction with their childbirth experience in relation to socio-demographic characteristics, obstetric history and intrapartum care variables. Methods A cross-sectional study involving 277 women who had given birth in a low risk maternity unit in Northern Italy was undertaken. Satisfaction with birth was measured using the Italian version of the Birth Satisfaction Scale-Revised (I-BSS-R). The scale comprises three Sub-Scales: quality of care provided, personal attributes of women and stress experienced during childbirth. Findings No socio-demographic variables were related to maternal satisfaction. Multiparous women had a higher satisfaction score (p = 0.020; CI:0.23;2.75). Antenatal class attendance was negatively associated with maternal satisfaction (p = 0.038; CI:−2.58; −0.07). Intrapartum variables that significantly reduced maternal satisfaction were: epidural usage (p = 0.000; CI:−4.66; −2.07), active phase >12 h (p = 0.000; CI:−6.01; −2.63), oxytocin administration (p = 0.000; CI:−5.08; −2.29) and vacuum assisted birth (p = 0.001; CI:−6.50; −1.58). Women with an intact perineum were more likely to be satisfied (p = 0.008; CI:−4.60; −0.69). Discussion In accordance with other research, we showed that intrapartum interventions are negatively associated with maternal outcomes and therefore also with maternal satisfaction with birth. The sub-scale that measured Quality of Care provided scored higher than the other two Sub-Scales. Conclusion Further studies on maternal satisfaction in Italy should be conducted, using the I-BSS-R with the aim to compare outcomes and understand what matters to women during childbirth.

Objective To explore midwives’ experiences of the management of the second stage of labour in women with epidural analgesia. Design Descriptive qualitative study using semi-structured face-to-face interviews. Participants Purposive sample of twelve midwives working in three Obstetric Units. Among them six were senior midwives with more than five years’ experience on labour ward and six were junior midwives with less than five years’ experience on labour ward. Findings The findings included four themes: a) timing of second stage of labour and maternal pushing; b) maternal positions and mobility; c) perspectives on epidural boluses; d) midwifery presence and support. The time ‘allowed’ by midwives for the passive phase of the second stage of labour ranged from zero to two hours, with some of them avoiding vaginal examinations to delay the recorded starting time of active pushing. The semi-sitting and the lithotomy positions were the most used respectively in labour and at birth. Some midwives encouraged the kneeling position or the lateral position. Regarding the management of the epidural bolus during the second stage of labour, the interviewees’ opinions were divided between favourable and unfavourable to the administration of analgesic boluses after the full cervical dilatation. Midwives reported their experiences of providing different care to women with epidural analgesia when compared to women without epidural, mainly due to a more medicalised approach and the midwives’ sense of ‘usefulness’ when caring for women not experiencing labour pain. Conclusions and implications for practice To our knowledge, this was the first study on this topic conducted in an Italian setting. Despite the consistent body of evidence on the effects of epidural analgesia in the second stage on birth outcomes, the lack of clear guidelines, the presence of different hospital protocols and Obstetricians’ opinion, introduce uncertainty in midwifery practice and lead midwives with feelings of ‘uselessness’. Across the four themes, midwives frequently had to negotiate a space for their professional autonomy with other healthcare professionals, whilst adhering to the Obstetric Units’ protocols. An influencing factor on the care provided to women with epidural was the years of midwife's experience on labour ward. Further research and the development of comprehensive midwifery care guidelines on the management of the second stage of labour in women with an epidural analgesia appears essential.

The women’s decision to uptake prenatal testing is complex, involving different factors. We conducted a Cross Sectional study to investigate variables influencing this choice, with particular attention to socio-demographic, obstetric history and midwifery care variables. Background: With the increased routinization of prenatal testing, there has been a corresponding attention to parents’ decision-making. We are interested to explore those factors affecting the couple’s choice to improve antenatal care and enable parents to be aware and to make an informed choice. Methods and findings: A sample of 448 consecutive women with a low-risk of having fetal abnormalities was interviewed to collect socio-demographic, obstetric history and antenatal care information. We identified that factors related to the use of non-invasive testing were: previous miscarriage, received antenatal counselling on prenatal testing, number of antenatal appointments and lack of maternal knowledge about prenatal testing. Regarding invasive prenatal testing factors increasing the use were: maternal age, single status and antenatal counselling.