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Background Miscarriage is a traumatic life event that involves over forty thousand Italian women every year. Women affected by this loss can have long-term psychological consequences. For this reason, it is paramount to identify women at risk of developing such complications to ensure they receive proper support. The aim of this study is to perform a translation into Italian and a validation of the Revised Impact of Miscarriage Scale (RIMS), which is a valuable support for healthcare professionals to assess women after a miscarriage.Methods Double-translation technique was performed. A sample of 665 women completed the survey for the validation process which included RIMS, the Perinatal Grief Scale (PGS) and NSESSS. These last two instruments are usually used to assess the impact of perinatal loss on women’s life.Results The Italian version of RIMS (RIMS-IT) has good internal consistency (Cronbach’s alpha value 0,89). Factor analysis was conducted to confirm the construct validity and three factors were extracted. They reflected the factorial analysis of the original version. Scores of RIMS, PGS, and NSESSS were strongly correlated.Conclusions RIMS-IT can be a valuable support for clinicians and researchers to identify women at risk of developing psychiatric symptoms and to analyse factors involved in the onset of these complications.

INTRODUCTION A higher degree of midwives’ empowerment is associated with greater job satisfaction and better midwifery care outcomes for women and their families. Empowered midwives are able to better empower women who in turn have a positive influence on the midwives’ empowerment. The aim of this study was the translation, cultural adaptation, and validation of the perceptions of empowerment in midwifery scale-revised (PEMS-R) in a group of Italian midwives. METHODS The World Health Organization (WHO) method was adopted to achieve the PEMS-R Italian version. This process involved five steps: 1) forward translation, 2) expert panel translation, 3) back-translation, 4) pre-testing and cognitive interviewing, and 5) final version. The test’s internal consistency and validity were assessed by following international guidelines. Internal consistency was examined through Cronbach’s alpha (α) coeflcient. RESULTS The PEMS-R-IT was administered to 147 Italian midwives from northern Italy. Factor analysis of the 19 items, extracted 4 factors that explained 74.96% of the variance. The Student’s t-test for independent samples was used to identify a possible correlation between a higher/lower perception of empowerment and: 1) the education level, and 2) the years of experience of recruited midwives. No statistically significant differences were obtained in either case. The PEMS-R-IT was found to have a good internal consistency for each of its 4 subscales. CONCLUSIONS The PEMS-R-IT is a valid and reliable tool, useful to assess midwives’ empowerment. It can be used in both clinical practice and research in order to investigate the level of empowerment of midwives within the Italian national context.

Problem The COVID-19 pandemic has significantly challenged maternity provision internationally. COVID-19 positive women are one of the childbearing groups most impacted by the pandemic due to drastic changes to maternity care pathways put in place. Background Some quantitative research was conducted on clinical characteristics of pregnant women with COVID-19 and pregnant women’s concerns and birth expectations during the COVID-19 pandemic, but no qualitative findings on childbearing women’s experiences during the pandemic were published prior to our study. Aim To explore childbearing experiences of COVID-19 positive mothers who gave birth in the months of March and April 2020 in a Northern Italy maternity hospital. Methods A qualitative interpretive phenomenological approach was undertaken. Audio-recorded semi-structured interviews were conducted with 22 women. Thematic analysis was completed using NVivo software. Ethical approval was obtained from the research site’s Ethics Committee prior to commencing the study. Findings The findings include four main themes: 1) coping with unmet expectations; 2) reacting and adapting to the ‘new ordinary’; 3) ‘pandemic relationships’; 4) sharing a traumatic experience with long-lasting emotional impact. Discussion The most traumatic elements of women’s experiences were the sudden family separation, self-isolation, transfer to a referral centre, the partner not allowed to be present at birth and limited physical contact with the newborn. Conclusion Key elements of good practice including provision of compassionate care, presence of birth companions and transfer to referral centers only for the most severe COVID-19 cases should be considered when drafting maternity care pathways guidelines in view of future pandemic waves.

Problem Several maternity units worldwide have rapidly put in place changes to maternity care pathways and restrictive preventive measures in the attempt to limit the spread of COVID-19, resulting in birth companions often not being allowed to be present at birth and throughout hospital admission. Background The WHO strongly recommends that the emotional, practical, advocacy and health benefits of having a chosen birth companion are respected and accommodated, including women with suspected, likely or confirmed COVID-19. Aim To explore the lived experiences of the partners of COVID-19 positive childbearing women who gave birth during the first pandemic wave (March and April 2020) in a Northern Italy maternity hospital. Methods A qualitative study using an interpretive phenomenological approach was undertaken. Audio-recorded semi-structured interviews were conducted with 14 partners. Thematic data analysis was conducted using NVivo software. Ethical approval was obtained from the relevant Ethics Committee prior to commencing the study. Findings The findings include five main themes: (1) emotional impact of the pandemic; (2) partner and parent: a dual role; (3) not being present at birth: a ‘denied’ experience; (4) returning to ‘normality’; (5) feedback to ‘pandemic’ maternity services and policies. Discussion and conclusion Key elements of good practice to promote positive childbirth experiences in the context of a pandemic were identified: presence of a birth companion; COVID-19 screening tests for support persons; timely, proactive and comprehensive communication of information to support persons; staggered hospital visiting times; follow-up of socio-psychological wellbeing; antenatal and postnatal home visiting; family-centred policies and services.

Objectives: During the first wave of the COVID-19 pandemic, the Region of Lombardy in Italy and its Regional Emergency Service (Azienda Regionale Emergenza Urgenza [AREU]) created a dedicated 24/7 free phone service to help the Lombard population. After an invitation from their professional order, local midwives collaborated on the AREU project as volunteers to address the needs of women from antenatal to postnatal periods. The aim of this article was to explore the experiences of midwives who volunteered in the AREU project. Study design: This was a qualitative study using an interpretative phenomenological approach (IPA). Methods: The experiences of midwives volunteering in AREU (N = 59) were explored using audio diaries. Written diaries were also offered as an alternative. Data collection took place between March and April 2020. Midwives were provided with semistructured guidance that indicated the main areas of interest of the study. The diaries were thematically analysed following a temporal criterion; a final conceptual framework was created from emerging themes and subthemes. Results: The following five themes were identified: (1) choosing to join the volunteer project, (2) the day-to-day difficulties, (3) strategies to cope with the unexpected, (4) professional relationships and (5) reflecting on the personal experience. Conclusions: This is the first study to investigate the experiences of Italian midwives who volunteered in a public health project during a pandemic/epidemic. According to participants, taking part in the volunteer activities was informed by and impacted on both their professional and personal lives. Overall, the experiences of midwives who volunteered in AREU were positive and of humanitarian value. Providing midwifery services within a multidisciplinary team for the benefit of public health represented both a challenge and personal/professional enrichment.

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.

Purpose: Little is known on the potential effects of abnormal gestational weight gain (GWG) among low-risk, healthy pregnant women with no comorbidities or gestational complications. We investigated perinatal outcomes of these pregnancies according to GWG as per the 2009 National Academy of Medicine (NAM) recommendations. Materials and Methods: A retrospective analysis of prospectively collected data of low-risk pregnant women giving birth at term between January 2016 and December 2020. Inclusion criteria were normal pregestational body mass index (pBMI) (18.5-24.9 kg/m2) and no pregestational or gestational complication. Self-reported prepregnancy weight was used to calculate pBMI; GWG was the difference between maternal weight at childbirth and prepregnancy weight. Women were classified according to the 2009 NAM guidelines for GWG: insufficient (iGWG, [removed]16 kg). Logistic regression analysis with aGWG as referent was performed to independently estimate dose-response associations. Results: During the study period, there were 4,127 (33.1%) births fulfilling the inclusion criteria. Fifty-two percent of women gained outside the recommended range: 33.5% had iGWG and 18.7% had eGWG. iGWG women were 40% more likely to have early-term births and small for gestational age neonates. In turn, eGWG women displayed increased odds of prolonged pregnancy (adjusted odds ratio [aOR] 1.32), cesarean section in labor (aOR 1.50), high-degree perineal tears (aOR 2.04), postpartum hemorrhage ≥1,000 mL (aOR 1.54), and large for gestational age newborns (aOR 1.83). Conclusion: Our data show that abnormal GWG independently associates with heightened risk of adverse outcomes among healthy, low-risk pregnant women with normal pBMI and no comorbidity or gestational complication.

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.

PurposeLittle is known on the potential effects of abnormal GWG among low-risk, healthy pregnant women with no comorbidities or gestational complications.We investigated perinatal outcomes of these pregnancies according to GWG as per the 2009 National Academy of Medicine (NAM) recommendations.MethodsA retrospective analysis of prospectively collected data of low-risk pregnant women giving birth after 370/7 weeks’ gestation at our center between 1/2016 and 12/2020. Only women with normal pregestational BMI (pBMI) (18.5-24.9 Kg/m2) and no pre- or gestational complications were included. Self-reported prepregnancy weight was used to calculate pBMI; GWG was the difference between maternal weight at childbirth and prepregnancy weight. Women were classified according to the 2009 NAM guidelines for GWG: insufficient (iGWG, 16 Kg). Logistic regression analysis with aGWG as referent was performed to independent estimate dose-response associations.ResultsDuring the study period, there were 4,127 (33.1%) births fulfilling the inclusion criteria. Fifty-two percent of women gained outside the recommended range: 33.5% had iGWG and 18.7% eGWG. iGWG women were 40% more likely to have early-term births and SGA neonates. In turn, eGWG women displayed increased odds of prolonged pregnancy (aOR 1.32), cesarean section in labor (aOR 1.50), high-degree perineal tears (aOR 2.04, postpartum hemorrhage >1000 mL (aOR 1.54), and LGA newborns (aOR 1.83).ConclusionOur data show that abnormal GWG can independently associate with heightened risk of adverse outcomes among healthy, low-risk pregnant women with normal pBMI and no comorbidities or gestational complications.

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

Problem: The COVID-19 pandemic has significantly challenged maternity provision internationally. Rapid and radical changes were implemented, with midwives facing anxiety and moral distress if not able to provide optimal and woman-centred care in line with professional values. Background: Healthcare professionals’ stress and burnout are commonly reported during other global emergencies, which may eventually contribute to reduced quality of care. There is lack of evidence of the challenges faced by midwives in Italy during the COVID-19 pandemic. Aim: To explore midwives’ experiences of providing care to women and families during the COVID-19 pandemic. Methods: Qualitative interpretive phenomenological approach, using semi-structured interviews and thematic analysis. The sample included 15 midwives. Ethical approval was obtained. Findings: Four themes were identified: 1) adjusting to the ever-evolving organisation of care; 2) physical, psychological and relational challenges; 3) support network; 4) deferred sense of awareness. Discussion: Midwives faced professional and personal challenges during the pandemic, displaying feelings of fear, anxiety, uncertainty, discomfort, lack of support and knowledge with potential long-term effects. Adjusting to the continuous, rapid and drastic re-organisation of maternity services was particularly challenging. Factors facilitating a safe, supportive and empowering workplace included support from colleagues and managers, access to appropriate PPE, reliable guidelines, good communication and emotional support. Positive aspects of personal and professional development included communication skills, establishment of trusting relationships, sense of empowerment and teamwork. Conclusion: In the context of a pandemic, optimisation of midwives’ physical, emotional and psychological wellbeing should be considered. Timely and comprehensive guidelines and appropriate resources should be provided to assist midwives in facilitating family-centred respectful maternity care and preserving childbirth as a bio-psychosocial event.

The BLUES project: implementing innovative practices in screening and home care for women with perinatal depression Introduction Perinatal depression is frequent (1 woman out of 10 during the perinatal period), nonetheless to this day the screening is incomplete and the treatment gap is high. Materials and methods The BLUES project was financed by the Italian Ministry of Health and implemented in 10 Local Health Units of Lombardy Region. It had the goals of improving screening and implementing home visiting for women with perinatal depression. As far as the first goal, a smartphone app searchable by authorized professionals has been developed for transmitting screening tools (Edinburgh Postnatal Depression Scale - EPDS - and Whooley questions) to a cloud database; the app was also connected to a free website informing on mental health during the perinatal period. As far as the second goal, a home visiting programme was implemented according to the WHO Thinking Healthy method. A total of 110 professionals (most midwives), working in the family care centers, attended a structured training course in the Thinking Healthy approach and then applied the intervention to women during the perinatal period. The effectiveness and feasibility of the intervention were assessed at its completion (pre-post comparisons). Results The smartphone app and the related website were successfully activated in family care centers in the Province of Lecco (Lombardy, Italy). 39 women responding to selection criteria (EPDS ≥ 10 and a diagnosis of depression) were recruited for the home visiting intervention: 31 of them have completed the Thinking Healthy program. A clinically significant reduction of the EPDS scores was assessed in 80% of the women with moderate depressive symptoms (EPDS score ≥ 12). Both women and professionals evaluated the intervention useful and acceptable. Conclusions The BLUES project improved the screening using e-tools and implemented home visiting following the Thinking Healthy method. The process of task shifting from mental health sector to midwives was successful, while professionals met difficulties in balancing home visiting activities and routine activities.

Objective: To determine the impact on perinatal health of changes in social policies and obstetric care implemented to curb SARS-CoV-2 transmission. However, robust data on the topic are lacking since most of the studies has examined only the first few months of the outbreak. Methods: A retrospective analysis of prospectively collected data on uninfected and asymptomatically infected women giving birth between March and November 2020 and in the same time frame of 2019 at our tertiary care center in Lombardy, northern Italy. Perinatal outcomes were compared according to the year (2019 versus 2020) and to the trimester (March–May, June–August, September–November) of childbirth, corresponding to the three phases of the pandemic (first wave, deceleration, second wave) and covering a 9-month period. Results: We identified increased rates of gestational diabetes mellitus, spontaneous preterm birth, and neuraxial analgesia in 2020 versus 2019, with different temporal distributions: gestational diabetes mellitus and spontaneous preterm birth were more prevalent during the deceleration and the second wave phase, whereas epidural analgesia was more prevalent during the first wave. Conclusion: By assessing a prolonged time frame of the pandemic, we show that pandemic-related control measures, as applied in Lombardy, impacted relevant perinatal outcomes of women giving birth at our center.

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.

Problem: The world is fighting against the COVID-19 pandemic and an infodemic; Italy is one of the most severely affected countries.\ud Background: The internet represents a popular source of health information. In Italy, its use amongst pregnant women and new\ud mothers has increased during the lockdown. No research has examined the nationally accessible information related to childbirth\ud in these unprecedented circumstances.\ud Aim: To explore online information accessible to Italian users concerning childbirth and coronavirus-related issues.\ud Methods: A mixed methods exploration of the web was conducted involving searches on Google, peer discussion forums and midwifery association webpages. Data were analysed both quantitatively and qualitatively. A cross-consultation analysis of themes was\ud performed to identify macro categories of information.\ud Findings: A total of 720 results from free searches, 635 interventions from 97 forums and 68 posts from four midwifery association webpages were analysed. Informative/divulging sources were the most prevalent in Google; pregnancy-related topics appeared\ud more in discussion forums and midwifery association webpages. ‘Prevention’; ‘risks and outcomes’; ‘users’ experiences’ and ‘reorganisation of maternity services’ represent the cross-consultation categories of information.\ud Discussion: Google emerges as the main contributor to the infodemic; national systems of alert and ranking of web sources are\ud needed. Women’s pragmatic needs are more likely to be addressed by peer-discussion forums and midwifery association webpages\ud during and after COVID-19.\ud Conclusion: This is the first study to investigate childbirth-related web information during COVID-19 in Italy; findings may impact\ud on education, research and practice.

Aim: To evaluate mothers’ satisfaction with childbirth experience in a cohort of women who delivered during COVID pandemia and to compare them to a pre-COVID cohort. Design: We performed a cross-sectional study in a low-risk Maternity Unit. Methods: Women who delivered during COVID-19 pandemic were compared to a pre-COVID cohort recruited in 2018 in the same setting. Italian version of the Birth Satisfaction Scale-Revised (I-BSS-R) was used. Results: Three hundred and seventy-seven women were included (277 pre-COVID and 100 during COVID pandemic). No differences in terms of satisfaction at birth were reported (I-BSS-R mean 27.0, SD 5.3 versus mean 27.6, SD 6.1, p 0.34), despite an increased rate of active intrapartum interventions. Intrapartum variables that significantly reduced satisfaction were the same in the two groups: epidural analgesia (p&nbsp

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.

Objectives: To evaluate the incidence and assess clinical factors that can predict the occurrence of postpartum urinary retention (PPUR). PPUR is a puerperal condition defined as the inability to void over 6 hours after birth or after catheter removal in case of cesarean section, requiring catheterization. Lack of prompt diagnosis of this condition may lead to severe sequelae, including infection, chronic voiding difficulties, and renal failure. Methods: This retrospective cohort study analyzed all deliveries from January 2011 to December 2017 in a single Italian university hospital. We used multivariate logistic regression to develop a predictive score for PPUR. Results: By multivariate logistic regression, our analysis shows as minor (odds ratio [OR] < 2) risk factors for PPUR: non-Caucasian ethnicity (OR = 1.46, CI = 1.05-2.03), nulliparity (OR = 1.47, CI = 1.01-2.14), body mass index (BMI) at the end of the pregnancy 2) risk factors for PPUR. Using our final model (area under curve = 0.84), we created a nomogram for PPUR absolute risk calculation. Specifically, a 116-point cutoff might be used to identify high-risk patients who deserve more intensive micturition monitoring. Conclusions: Our study identified non-Caucasian ethnicity, nulliparity, and a BMI

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.

Objective: To compare mothers’ satisfaction at birth and intrapartum care during COVID-19 pandemic compared to a pre-COVID cohort. Design: Prospective cohort study Setting: Low risk maternity unit in Northern Italy Population: Women who delivered during COVID-19 pandemic compared to a pre-COVID cohort recruited in the same setting in February-May, 2018. Methods: Italian version of the Birth Satisfaction Scale-Revised (I-BSS-R) was used. Main Outcome Measures: Satisfaction at birth in relation to socio-demographic characteristics, obstetric history and intrapartum care variables. Results: 377 women were included (277 pre-COVID and 100 during COVID pandemic). A higher rate of induction [40%, COVID versus 25% pre-COVID, p 0.004], fewer active phases >12 h [6% COVID versus 15% pre-COVID, p 0.018] and more acceleration with oxytocin [35% COVID versus 24.9% pre-COVID, p 0.05] were found. No differences in terms of satisfaction at birth were reported (I-BSS-R mean 27.0, SD 5.3 versus mean 27.6, SD 6.1, p 0.34). Intrapartum variables that significantly reduced maternal satisfaction were the same in the two groups: epidural analgesia (p 12 h and CS in labor. Conclusions: No differences were reported concerning global satisfaction at birth, despite an increased rate of active intrapartum intervention. Keywords: Childbirth experience, COVID-19, intrapartum intervention

Objective: to describe the use of spontaneous maternal postures during labour, in a low-risk population with a diagnosis of occiput posterior (OP) position at the beginning of the active labour. Methods: a retrospective observational study with 336 women. Results: 249 babies (85.6%) rotated in occiput anterior (OA) at birth. The majority of the foetuses rotated during the second stage of labour; the squatting position (60.6%) was the posture most commonly used, followed by the lateral one (53%). Discussion: women with a baby in OP should be encouraged to move spontaneously during labour as babies could be facilitated to rotate in OA.

Background Contemporary higher education requires that all midwifery students have insight and understanding of global health practice and demonstrate intercultural sensitivity. However, the mobility models currently offered do not often fit the lives of large numbers of midwifery students. Objectives To investigate midwifery students' international physical mobility activities and factors that affect mobility; to determine midwifery students' learning needs and preferences for related e-learning packages. Design Multi-centre, descriptive quantitative survey. Settings Four European Higher Education Institutions based in the United Kingdom, Estonia, Italy and the Netherlands offering an undergraduate midwifery programme. Participants The sample included 205 midwifery students from Italy (n = 93), the Netherlands (n = 51); United Kingdom (n = 35) and Estonia (n = 26). Methods Data were collected in June–July 2020 through an online cross-sectional, bespoke questionnaire and analysed using summary statistical analysis. Results There is a high level of interest across a range of mobility opportunities, especially those of shorter duration. Barriers to mobility comprised finance, caring responsibilities, concerns about fitting mobility activities into the midwifery programme, negative impact on studies and language barriers. The most frequently identified facilitators of mobility included professional perspectives such as interest in other cultures and midwifery in other settings and an endorsement that mobility would add value to their development as a midwife. When engaging in virtual learning, the most preferred resources mentioned by the students were videos, video calls with peers, choice quiz and discussion forum. Conclusions The barriers identified require new approaches to enable all midwifery students to benefit from transnational learning. The survey findings provide insights into midwifery students' perspectives from which a new mobility model can be developed.

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.

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.

Objective: To investigate women’s decision to undergo non-invasive and/or invasive tests for prenatal diagnosis depending on the procedure-related risk and the risk of carrying a foetus with Down syndrome (DS). Both risks are rated in terms of numerical relevance and acceptability. Method: A sample of 448 consecutive women with low-risk pregnancies were interviewed to collect social and clinical variables and to determine their perceptions of the risks of invasive procedure-related miscarriage and carrying a foetus with DS. The risks were scored numerically in terms of their relevance and acceptability using a 10-point rating scale. Results: The factors related to the use of non-invasive tests were age ≥35 years, not being treated at a public service, rating the risk of carrying a foetus with DS as having high numerical relevance and low acceptability, and rating the risk of miscarriage as having high acceptability. These relationships were still present when the use of invasive tests was considered, except in terms of the numerical relevance of the risk of carrying a foetus with DS. Conclusion: Perceived acceptability affects the interpretation of a given risk more than the numerical relevance of the risk.

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.

Objective: The aim of this study is to explore first-time mothers' experiences of early labour in Italian maternity care services when admitted to hospital or advised to return home after maternity triage assessment. Setting: The study was conducted in a second-level maternity hospital in northern Italy with an obstetric unit for both low- and high-risk women. Participants: The participants included 15 first-time mothers in good general health with spontaneous labour at term of a low-risk pregnancy who accessed maternity triage during early labour, and were either admitted to hospital or advised to return home. Design: A qualitative interpretive phenomenological study was conducted. A face-to-face recorded semi-structured interview was conducted with each participant 48-72 h after birth. Findings: Four key themes emerged from the interviews: (a) recognising signs of early labour; (b) coping with pain at home; (c) seeking reassurance from healthcare professionals; and (d) being admitted to hospital versus returning home. Uncertainty about the progression of labour and the need for reassurance were cited by women as the main reasons for hospital visit in early labour. An ambivalent feeling was reported by the participants when admitted to hospital in early labour. In fact, while the women felt reassured in the first instance, some women subsequently felt dissatisfied due to the absence of one-to-one dedicated care during early labour. When advised to return home, a number of women reported feelings of disappointment, anger, fear, discouragement and anxiety about not being admitted to hospital; however, some of these women reported a subsequent feeling of comfort due to being at home and putting in place the suggestions made by the midwives during the maternity triage assessment. The guidance provided by midwives during triage assessment seemed to be the key factor influencing women[U+05F3]s satisfaction when advised either to return home or to stay at the hospital during early labour. Conclusions and implications for practice: During antenatal classes and clinics, midwives should provide clear information and advice about early labour in order to increase women[U+05F3]s confidence and self-efficacy, and decrease their anxiety and fear. During early labour, appropriate maternity care services should be offered according to individual needs. When home visits are not provided by midwives, a telephone triage run by midwives should be considered as a routine service for the first point of contact with women during early labour.