Does prolonged labor affect the birth experience and subsequent wish for cesarean section among first-time mothers? A quantitative and qualitative analysis of a survey from Norway

Abstract

Background Prolonged labor might contribute to a negative birth experience and influence first-time mothers’ attitudes towards future pregnancies. Previous studies have not adjusted for possible confounding factors, such as operative delivery, induction and postpartum hemorrhage. We aimed to determine the impact of prolonged labor on birth experience and a wish for cesarean section in subsequent pregnancies. Methods A survey including the validated “Childbirth Experience Questionnaire”. First-time mothers giving birth between 2012 and 2014 at a Norwegian university hospital participated. Data from deliveries were collected. Regression analysis and thematic content analysis were performed. Results 459 (71%) women responded. Women with labor duration > 12 h had significantly lower scores on two out of four sub-items of the questionnaire: own capacity (p = 0.040) and perceived safety (p = 0.023). Other factors contributing to a negative experience were: Cesarean section vs vaginal birth: own capacity (p = 0.001) and perceived safety (p = 0.007). Operative vaginal vs spontaneous birth: own capacity (p = 0.001), perceived safety (p < 0.001) and participation (p = 0.047). Induced vs spontaneous start: own capacity (p = 0.039) and participation (p = 0.050). Postpartum hemorrhage ≥500 ml vs < 500 ml: perceived safety (p = 0.002) and participation (p = 0.031). In the unadjusted analysis, prolonged labor more than doubled the risk (odds ratio (OR) 2.66, 95%CI 1.42–4.99) of a subsequent wish for cesarean delivery. However, when adjustments were made for mode of delivery and induction, emergency cesarean section (OR 8.86,95%CI 3.85–20.41) and operative vaginal delivery (OR 3.05, 95%CI 1.46–6.38) remained the only factors significantly increasing the probability of wanting a cesarean section in subsequent pregnancies. The written comments on prolonged labor (n = 46) indicated four main themes: Difficulties gaining access to the labor ward. Being left alone during the unexpectedly long, painful early stage of labor. Stressful operative deliveries and worse pain than imagined. Lack of support and too little or contradictory information from the staff. Conclusions Women with prolonged labors are at risk of a negative birth experience. Prolonged labor per se did not predict a wish for a cesarean section in a subsequent pregnancy. However, women with long labors more often experience operative delivery, which is a risk factor of a later wish for a cesarean section.

Outpatient Cervical Ripening With Misoprostol in Low-Risk Pregnancies

“…Women were offered outpatient cervical ripening if the following criteria were met: (1) cephalic fetal position by ultrasound, (2) category 1 fetal heart rate tracing, (3) estimated fetal weight by physical examination or ultrasound under 4000 g, ( 4) estimated gestational age 39 weeks and optimally dated (confirmed by 22-week or earlier ultrasound), (5) low-risk pregnancy (diet dependent diabetes, advanced maternal age, and obesity with BMI <45 were allowed), ( 6) maternal report of adequate fetal movements, (7) amniotic fluid between 2 and 8 cm as documented by maximum vertical pocket method on ultrasound, (8) modified Bishop score ≤ 7, (9) adequate transportation to and from the hospital and staying less than 30 minutes from our institution, and (10) agrees to outpatient induction. Women with medical, obstetric, or gynecologic comorbidities (e.g., hypertensive disorder, pre-gestational diabetes, insulin-dependent diabetes, seizure disorder, lupus, etc.…”

“…However, an increased rate of elective induction may place an operational burden on labor and delivery units [4,5]. Induction in women with less than optimal or "unripe" cervix may result in a prolonged inpatient stay, increased medical expense, and stress and exhaustion to the patient and her support people [6,7]. Strategies such as outpatient cervical ripening may help to reduce the operational burden of elective induction but are under-studied [8][9][10][11].…”

Forbedringspotensial i den norske fødselsomsorgen

“…Gaudernack et al's studie viste at fokus på bruken av ristimulerende medikamenter førte til noe reduksjon, samt at det kan vaere behov for endrede retningslinjer for bruk av ristimulerende medikamenter (Gaudernack, Frøslie, Michelsen, Voldner, & Lukasse, 2018). Men fødselsvarighet kan påvirke kvinnens opplevelse negativt (Gaudernack, Michelsen, Egeland, Voldner, & Lukasse, 2020). Vi ser her ulike hensyn som kan tenkes å skape faglige dilemmaer.…”

“…Terskelen for å gripe inn og valget mellom tang, sugekopp eller keisersnitt, er ifølge Helsedirektoratet, uberettiget (sic) geografisk fordelt (Helsedirektoratet, 2020). Tang og sugekopp øker risikoen for at kvinnen ønsker keisersnitt ved neste fødsel (Gaudernack et al, 2020). At fødselsforløp vurderes forskjellig både med hensyn til når det skal gripes inn og hvordan, kan kanskje indikere at synet på fødsel er kulturelt betinget; at det kan eksistere ulike fagkulturer på ulike sykehus (Blix, 2010)?…”

Maternal Childbirth Experience and Time in Labor - A Population-Based Cohort Study

“…To reduce the incidence of emergency CS due to failure to progress, new guidelines on normal labor progression has been published by the WHO 1 and the American College of Obstetricians and Gynecologists (ACOG) 17 , allowing a slower progress in the beginning of the active phase of labor compared with the traditional guidelines by Friedman 18 . However, a long time in labor may increase the risk of a negative childbirth experience, which in turn may lead to a future demand of CS in the following pregnancy 19,20 .…”