Birth Experiences, Predictor Factors and Some Maternal and Neonatal Outcomes with Labour Dystocia: A Mixed Methods Study

Abstract

ABSTRACT

Introduction: Prolonged labor, in addition to maternal and fetal/neonatal complications, can lead to female dissatisfaction with labor and delivery. Objective: To determine predictive factors of labor dystocia and birth satisfaction and better understanding of these factors by exploring woman experiences on prolonged labor. Methods: The present study was a mixed method study with an embedded approach. The first and second parts were quantitative studies that were conducted in Al-Zahra and Taleghani educational-medical centers in Tabriz. In the first part, an observational study was performed to determine the predictors of labor dystocia (LD) and predictors of low birth satisfaction. Second part was an interventional study (a pilot study) conducted to determine the effect of two methods of amniotomy (with early and with delayed infusion of oxytocin) in cases of LD on some maternal and neonatal outcomes. The third part of the study was a qualitative study conducted to explore the experiences of primiparous women with prolonged labor. In the observational section, 700 women with low-risk pregnancies matched by parity and hospital (350 women with LD and 350 women without dystocia), gestational age 370 to 406, hospitalized for vaginal delivery, with single fetus and cephalic presentation were included in the study. Socio-demographic characteristics and Spielberger questionnaires, as well as dehydration assessment form were completed in 4-6 cm cervical dilatation and Iranian version of the Revised Birth Satisfaction Scale (I-BSS-R) at 12-24 hours after delivery. Psychometric evaluation of the Iranian version of this scale was also performed in this study. Binary logistic regression model and multiple linear regression were used to determine predictors of LD and low birth satisfaction, respectively. The randomized clinical trial with three parallel arms was performed on 57 primiparous women and ANCOVA and binary logistic regression were used to determine the differences between the study groups. In the qualitative phase, women's experiences of prolonged labor were explored from the viewpoint of 13 women using in-depth individual interviews. Data analysis was performed using qualitative content analysis. Results: The predictors of LD were severe and moderate anxiety state, woman dehydration > 3 h and ≤ 3 h, insufficient support by the medical staff in the delivery room, remifentanil administration, labour induction, low income, woman height < 160 cm. The age group of 16-20 years was a protective factor.The proportion of the variance explained by all these factors was 75%. The results showed that I-BSS-R is a valid and reliable tool among Iranian women. The mean score of birth satisfaction was 23.8 (SD 6.4) from obtainable score of 0-40. Predictors of low birth satisfaction included: severe and moderate anxiety state, LD, insufficient support by staff, vaginal birth with episiotomy and tear, emergency C-section, being primiparous, labor induction with oxytocin, sexual violence and women dehydration. The proportion of variation in satisfaction score explained by all these factors was 76%. In the clinical trial, the duration of the first stage of labor in the early infusion group was 80.5 minutes shorter than the routine group and 112.3 minutes shorter than the delayed infusion group and the differences were statistically significant. Also, compared with the delayed group, duration of intervention to birth and postpartum hemoglobin level were significantly lower in the early infusion group. There were no statistically significant differences between the three study groups in terms of other maternal and neonatal outcomes. Analysis of the qualitative data led to the formation of 14 main categories, including the discomfort due to excessive prolonged labor, neglect of women's desires in authoritative one-way care, woman helplessness during labor and delivery following the excruciating pain, lack of perceived support of the woman by the staff, task-oriented care with no attention to individual patient needs, feeling fear and insecurity, acquired anxiety following the lack of individualization of the environment, disrespect and offensive behavior, violation of privacy, unfavorable hospital conditions, financial stress , the birth of a healthy baby as a facilitator for endurance of labor pains, the feeling of motherhood love, the end of suffering, and physical and mental suffering after childbirth. Conclusion:The controllable predictors, such as anxiety, maternal dehydration, and the lack of adequate support from medical staff during labour are strongly associated with the risk of LD and satisfaction of birth. The pre-labour predictors determined in the current study, such as excessive weight gain during pregnancy, maternal preference for CS, sexual violence during pregnancy, and daily exposure to tobacco smoke, which may need more comprehensive interventions for their control. Appropriate consultation with couple during pregnancy and encouraging to attend birth preparation classes may also reduce some factors such as violence, fear and anxiety. Therefore, it seems that responding to women’s physical, psychological, and supportive needs during labour could play a significant role in prevention and appropriate control of LD and birth satisfaction. In addition, reducing interventions, meeting women’s desire for information during pregnancy and childbirth, and women’s involvement in decision making which are in line with woman-centered models of childbirth care, in particular through midwife-led models, could enhance the birth satisfaction.