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Normal Birth als onderzoeksterrein

Normal Birth als onderzoeksterrein. Normal Birth – an area of research. My office…. Europe. and my colleagues …. Antenatal care in Germany. Lead professional: obstetrician Shared care: midwife/ obstetrician Covered by Health insurance Maternity document: Mutterpass

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Normal Birth als onderzoeksterrein

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  1. Normal Birth als onderzoeksterrein Normal Birth – an area of research

  2. My office… Europe and my colleagues …

  3. Antenatal care in Germany • Lead professional: obstetrician • Shared care: midwife/ obstetrician • Covered by Health insurance • Maternity document: Mutterpass • Standard antenatal care

  4. Hospital birth in Germany • Private and public hospitals • Employed midwives • Contracted midwives • Midwife presence • required by law

  5. Homebirth and birth centre care • Independent midwives only • Team structure possible • Costs mainly covered by health insurance • Approx 1% • Quality assurance for • out-of-hospital-births

  6. Research during Normal Birth Outcome Duration

  7. Research during Normal Birth Outcome Duration

  8. Intervention Controls Randomised Studies Outcome

  9. Intrapartum factors influencing birth duration Amniotomy Epidural Support Vertical positioning Admission Duration Groß MM Antes G. Wissenschaftliche Evidenz aus systematischen Übersichtsarbeiten zum Gebären. Z Geburtsh Neonatol 2003; 207: 17-23

  10. Research during Normal Birth Outcome Duration

  11. Process orientated care Outcome Duration Pain Wellbeing

  12. Wellbeing during labour Gross MM Hecker H Keirse MJNC. An evaluation of pain and “fitness” during labor and its acceptability to women. Birth 2005; 32: 122-128

  13. New Interest in Labour Progression Troendle & Zhang, US-NIH Vahratian A et al. 2006; “methodological challenges in studying labour progression”; suggested how to assess the duration from one cervical centimeter to the result of the next vaginal examination (as an independent factor) Vahratian A et al. 2006; impact of parity on course of labor; difference between primiparae and multiparae Vahratian A et al. 2005; risk of caesarean delivery in electively induced primiparae is 2.3 higher compared to non induced primiparae, epidural is used as a time-varying covariate Hoffman MK et al. 2006; comparison of labour progression between induced and non induced multiparous women Smith, UK-Cambridge Smith G 2001; first time that “time to event analysis” is used in the field of human reproduction (“normal duration of human pregnancy”) Smith G et al. 2003; caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 362: 1779-1784 Smith G 2005; review on estimating risks of perinatal death, “indeed labor itself can be treated as the event”

  14. …and how long will it take?

  15. Research question The aim of the current study was to investigate how intrapartum interventions are associated with labour duration.

  16. Methods

  17. Germany

  18. Setting of the ProGeb-Study -a state-wide longitudinal study on process-oriented care during the childbearing process, -96 hospitals with maternity services in Lower Saxony, -64,000 births per year, -involves a detailed documentation, -contact to midwifery teams. Data Collection Hospital-based births: 6 months Out-of-hospital births: 12 months 47 maternity units in hospitals (n=3963) 11 free standing birth centres (n=232) 46 home birth midwives (n=243) total n= 4438 • Informed Consent • Approvals • by the Ethics Committee of Hanover Medical University • by the State-wide Ethics Committee for Public Hospitals in Lower Saxony • Support / Logistics • Centre for Quality and Management in Health Care of the Medical Chamber of Lower Saxony • Inclusion • Cephalic presentation in singleton pregnancies > 34 weeks

  19. Data Management in the ProGeb Study

  20. Hospital Births Out-of-hospital-Births np (n=2090) mp (n=1873) np (n=187) mp (n=288) Some variables have missing data.

  21. Hospital Births Out-of-hospital-Births np (n=2090) mp (n=1873) np (n=187) mp (n=288) Some variables have missing data.

  22. Hospital Births Out-of-hospital-Births np (n=2090) mp (n=1873) np (n=187) mp (n=288) Some variables have missing data.

  23. Hospital Births Out-of-hospital-Births np (n=2090) mp (n=1873) np (n=187) mp (n=288) Some variables have missing data.

  24. Hospital Births Out-of-hospital-Births np (n=2090) mp (n=1873) np (n=187) mp (n=288) Some variables have missing data.

  25. Midwife chosen by woman (in%) Out-of-Hospital-Births: n (Nulliparae) = 187; n (Multiparae) = 286 Hospital Births: n (Nulliparae = 596; n (Multiparae) = 544

  26. Antenatal Care provided by Midwife (in%) Out-of-Hospital-Births: n (Nulliparae) = 187; n (Multiparae) = 288 Hospital Births: n (Nulliparae = 596; n (Multiparae) = 544

  27. Perineal Protection (in%) Out-of-Hospital-Births: n (Nulliparae) = 187; n (Multiparae) = 288 Hospital Births: n (Nulliparae = 2090; n (Multiparae) = 1873

  28. Transfer rates to Hospital AUG: n (E) = 187; n (M) = 288

  29. Symptoms of onset of labour

  30. Diagnosing onset of labour "Diarrhoea, stomach ache, vaginal cramps, back pain, all at the same time." Gastro-intestinal Non-recurrent pain Gross MM et al. Women‘s Recognition of the Spontaneous Onset of Labor. Birth 2003; 30: 267-271

  31. Percent units women Recurrent pain 38.5 60.8 Frequencies Non-recurrent 24.9 30.9 of Symptoms Watery loss 12.7 21.7 Bloody loss 8.9 15.2 Digestive 2.7 4.6 Emotional 3.0 5.1 Sleeping 6.0 7.4 Others 3.3 5.5 Total number 369 217 Gross MM et al. Women‘s Recognition of the Spontaneous Onset of Labor. Birth 2003; 30: 267-271

  32. Interval between onset of labour defined by midwife vs. woman

  33. Interval between symptoms and onset of labour defined by midwife vs. nullipara Emotional symptoms Rupture of membranes Burian RA et al. Onset of Labor: Women’s Experiences and Midwives’ Assessment in Relation to First Stage Duration. In Preparation

  34. Hazard ratio related to onset of labour defined by midwife vs. nullipara adjusted for confounders Burian RA et al. Onset of Labor: Women’s Experiences and Midwives’ Assessment in Relation to First Stage Duration. In Preparation

  35. Presence of midwife

  36. Cumulative presence of midwife since onset of care

  37. Total Duration of Midwife PresenceStarting point: first occasion of care during active labour % of births Ayerle GM et al. Midwife Attendance during Labour and its Relation to Interventions and Mode of Birth. In Preparation

  38. Midwife Presence per Duration of Birth (percent)Starting point: first occasion of care during active labour % of births Ayerle GM et al. Midwife Attendance during Labour and its Relation to Interventions and Mode of Birth. In Preparation

  39. Intrapartum varying interventions

  40. Intrapartum varying Interventions Amniotomy, Oxytocin, Epidural Analgesia t

  41. When are Interventions performed? Nulliparae n=2090 Amniotomy, Oxytocin, Epidural 3h

  42. When are Interventions performed? Nulliparae n=2090 Multiparae n=1873 Amniotomy, Oxytocin, Epidural 3h 3h

  43. Steps of Data Analysis for 1st and 2nd stage 1. Univariate Analysis 2. Multivariate Analysis I: Demographic factors, risk- associated factors, child-related factors, induction 3. Multivariate Analysis II: All significant factors 4. Multivariate Analysis III: Backward selection

  44. Modelling 1st Stage – Nulliparae After Backward Selection

  45. Modelling 1st Stage - Nulliparae Ful Cervical Dilation Intrapartum Oxytocin Epidural Analgesia

  46. Modelling 1st Stage - Nulliparae Ful Cervical Dilation Caesarean during 1st Stage Intrapartum Oxytocin Epidural Analgesia

  47. Modelling Second Stage – Nulliparae Intrapartum Amniotomy Spontaneous Birth Epidural Analgesia

  48. Vaginal-operative Birth Modelling Second Stage – Nulliparae Intrapartum Oxytocin Intrapartum Amniotomy Spontaneous Birth Epidural Analgesia

  49. Vaginal-operative Birth Modelling Second Stage – Nulliparae Intrapartum Oxytocin Intrapartum Amniotomy Spontaneous Birth Epidural Analgesia Caesarean Section Oxy

  50. Effective intrapartum Care • Qutcome  = Quality 

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