(Anesth Analg. 2019;128(6):e93–e96) Pain management during childbirth has long been the focus of many researchers in the anesthesiology field, as an estimated 60% of laboring women receive neuraxial analgesia for their pain. Because epidural analgesia can have multiple side effects, some women elect to have an unmedicated birth either independently or with medical therapies. One option for unmedicated labor assistance is immersive virtual reality (VR) distraction to provide a pleasant environment for the patient as well as a diversion from labor pain. Current technological advances have made VR more accessible than in previous years, and this study aimed to analyze the efficacy of immersive VR analgesia as a labor pain treatment. The investigators intended to discover if VR distraction would result in significantly reduced pain scores for unmedicated labor compared with patients with no VR distraction, as well as examine potential benefits in regards to pain management, anxiety, nausea, and patient satisfaction.

IMPORTANCE Urinary incontinence (UI) guidelines recommend behavioral interventions as first-line treatment using individualized approaches. A one-time, group-administered behavioral treatment (GBT) could enhance access to behavioral treatment.OBJECTIVE To compare the effectiveness, cost, and cost-effectiveness of GBT with no treatment for UI in older women. DESIGN, SETTING, AND PARTICIPANTS Multisite randomized clinical trial (the Group LearningAchieves Decreased Incidents of Lower Urinary Symptoms [GLADIOLUS] study), conducted from July 7, 2014, to December 31, 2016. The setting was outpatient practices at 3 academic medical centers. Community-dwelling women 55 years or older with UI were recruited by mail and screened for eligibility, including a score of 3 or higher on the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), symptoms of at least 3 months' duration, and absence of medical conditions or treatments that could affect continence status. Of 2171 mail respondents, 1125 were invited for clinical screening; 463 were eligible and randomized; 398 completed the 12-month study. INTERVENTIONSThe GBT group received a one-time 2-hour bladder health class, supported by written materials and an audio CD. MAIN OUTCOMES AND MEASURESOutcomes were measured at in-person visits (at 3 and 12 months) and by mail or telephone (at 6 and 9 months). The primary outcome was the change in the ICIQ-SF score. Secondary outcome measures assessed UI severity, quality of life, perceptions of improvement, pelvic floor muscle strength, and costs. Evaluators were masked to group assignment.RESULTS Participants (232 in the GBT group and 231 in the control group) were aged 55 to 91 years (mean [SD] age, 64 [7] years), and 46.2% (214 of 463) were African American. In intent-to-treat analyses, the ICIQ-SF scores for GBT were consistently lower than control across all time points but did not achieve the projected 3-point difference. At 3 months, the difference in differences was 0.96 points (95% CI, −1.51 to −0.41 points), which was statistically significant but clinically modest. The mean (SE) treatment effects at 6, 9, and 12 months were 1.36 (0.32), 2.13 (0.33), and 1.77 (0.31), respectively. Significant group differences were found at all time points in favor of GBT on all secondary outcomes except pelvic floor muscle strength. The incremental cost to achieve a treatment success was $723 at 3 months; GBT dominated at 12 months. CONCLUSIONS AND RELEVANCEThe GLADIOLUS study shows that a novel one-time GBT program is modestly effective and cost-effective for reducing UI frequency, severity, and bother and improving quality of life. Group-administered behavioral treatment is a promising first-line approach to enhancing access to noninvasive behavioral treatment for older women with UI.TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02001714

Most of what is known about the meaning women assign to the experience of childbirth in the United States is based primarily on studies of Euro American, highly educated, married women of middle to higher income levels. Yet almost half a million adolescents give birth annually. This exploratory, qualitative study was conducted with 25 adolescents in an alternative school, partnered with the juvenile justice system, who had given birth. An open-ended question format was used for the interviews, and analysis was conducted by using extended case methodology. The study revealed a number of differences between the existing literature reports about women's interpretations of birth and the meanings assigned to childbirth experiences by the adolescents in this study. A key difference was the relationship between the pain of childbirth and responsibility for their child. The results provide an entrée into understanding unique characteristics of giving birth as an adolescent and potential roles health care providers can play to promote a positive experience.

Objective To determine which maternal characteristics or birth events independently predict severity of levator ani muscle (LA) tears at first vaginal birth in a longitudinal/observational investigation in a tertiary care hospital. Sample Ninety primiparas with at least one at risk for LA tear inclusion factor at vaginal birth: maternal age ≥ 33 years, second stage ≥ 150 minutes, macrosomia, instrumented delivery, and/or anal sphincter laceration were studied. Methods Magnetic Resonance Imaging (MRI) was obtained early postpartum (mean ± sd 48.9 ± 21.6 days) to identify LA tear. Severity of LA muscle fiber loss was graded on an ordinal scale of: “0” as no loss, “1” as <50% unilateral loss, “2” as ≥50% unilateral or <50% bilateral loss, and “3” as ≥50% bilateral loss. Data were analyzed using proportional odds modeling. Inclusion factors were explored as predictors of LA tear severity and at analysis episiotomy, time spent actively pushing, epidural, and oxytocin were also considered. The main outcome measures of interest included grading of severity of LA muscle fiber loss on an ordinal scale. Results Respective counts/percentages of women within each 0 thru 3 ordered category of LA tear severity were: “0” = 58(64%), “1” = 9(10%), “2” = 15(17%), and “3” = 8(9%). Estimates and 95% CI for significant demographic or obstetric univariate predictors of LA tear severity level were age, OR 1.093 (CI 1.012 - 1.180), p = 0.023; and time spent in active pushing, OR 1.089 (CI 1.005 - 1.180), p = 0.038. The other factors considered were not significant. There were too few women with forceps deliveries to analyze. Conclusion: In our enriched sample of primiparous women, 26% showed a significant LA tear. Maternal age and time spent actively pushing independently predict LA tear severity.

The World Health Organization recognizes access to clean and safe toilets as crucial for public health. This study explored U.S. adolescent and adult cisgender women’s lived experiences accessing toilets in schools, workplaces, and public spaces. As part of the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium, we conducted 44 focus groups with female participants (n = 360; ages 11–93). Focus groups were stratified by age (11–14, 15–17, 18–25, 26–44, 45–64, 65+) and conducted across 7 geographically diverse U.S. sites from July 2017–April 2018. Using a transdisciplinary approach, we conducted conventional qualitative coding informed by our PLUS conceptual framework and used content analysis processes to identify salient themes. Across settings, toilet access was restricted by “gatekeepers” (i.e., individuals who control access to toilets). In contrast, self-restricting toilet use (deciding not to use the toilet despite biologic need to urinate) was based on internalized norms to prioritize school and job responsibilities over urination. In public spaces, self-restricting use was largely in response to lack of cleanliness. Across the life course, participants perceived gender disparities in the ability to easily access public toilets. Further research is needed to determine if and how these factors impact bladder health across the life course.