Continuous intrapartum support to reduce primary cesarean

Background The average percentage of births by cesarean section worldwide in 2014 was 18.6% (range: 1.4% to 56.4%), and in Latin America and the Caribbean 40.5% [range: 5.5% - 55.6%]. In Mexico, the cesarean delivery rate remained above 40% in the period from 2008 to 2015, and without signs of decreasing, the World Health Organization recommends up to 15% maximum. The objective of the study was to decrease the rate of deliveries by cesarean, through continuous intrapartum support during the active phase until birth.


Background
The average percentage of births by cesarean section worldwide in 2014 was 18.6% (range: 1.4% to 56.4%), and in Latin America and the Caribbean 40.5% [range: 5.5% -55.6%] (1). In Mexico the average cesarean rate from 2008 to 2014 was 44.4% (2), in 2015 it was reported as 45%, (3), rates above the recommended range by the World Health Organization (WHO) that establishes a maximum of 15% (4).
Cesarean section has not been proven to be safer than normal vaginal delivery, nor to reduce the risk of complications such as urinary incontinence and uterine prolapse, (5) the cesarean section is not superior to normal vaginal delivery in terms of preserving sexual function normal (6) on the contrary, when the cesarean section rate exceeds the value of 15%, reproductive health risks begin to exceed the benefits (7). Page 3/17 The potential disadvantages found in observational studies, include a major risk in the morbidity or mortality of the mother (8), intraoperative risks, such as infection, organ damage or the need for blood transfusion, postpartum risks such as thromboembolic complications, complications related to subsequent pregnancies, such as uterine rupture, infertility, abnormalities of the placenta, a series of risks have also been described for babies born by elective cesarean section such as bronchial asthma, diabetes mellitus type I, or allergic rhinitis (9). Women who give birth by caesarean section are less likely to breastfeed or delay the initiation of breastfeeding. (10) (11), also cesarean sections are associated with a greater use of resources and duration of breastfeeding shorter compared to vaginal births (11).
It is better that the birth occurs through a normal vaginal delivery; However, it is common that childbirth to cause in the mother, anxiety (12), fear (13) or great physical strain (14), as well as mothers who experience pain, exhaustion and negative feelings in a stressful and prolonged delivery could delay the start of the breastfeeding. (15) Of the American women who require an initial cesarean delivery, more than 90% will have a subsequent cesarean, (16) The choice of a cesarean delivery in the first pregnancy results in a 0.3% increase in the risk of having a maternal adverse outcome. (17).
In addition, medically unnecessary cesarean deliveries increase health costs (18). It is estimated that if all medical interventions due to a previous diagnosis of cesarean section were reduced annually in Mexico, it would mean a reduction of 20.8% in cesarean sections in the country (19).
Different strategies have been devised to try to reduce cesarean deliveries, as the evaluation of prenatal classes (20), the QUARISMA trial (21), BASNEF model (22), avoiding the diagnosis of arrest of dilation before 6 cm (23), intervention to reduce both the incidence of anal sphincter tears and rate of cesarean sections (24), as well as continuous intrapartum support, which has been associated with better patient satisfaction and a statistically significant reduction in the rate of cesarean sections (25) (26) (27) (28) (29), in previous studies this support has been provided by a doula and her husband (30), midwives (31), female relative (32), relatives and professional staff (33). In Mexico, continuous intrapartum support is not common, the Mexican Institute of Social Security (IMSS) is the institution with the largest number of beneficiaries in the country, and due to limited economic, human and infrastructure resources, it is difficult to provide such support.
Therefore, it is necessary to find ways to carry out continuous intrapartum support in a simple and economical way to reduce the rate of caesarean sections in low-income countries.

Methods
The objective of the present study was to evaluate the intervention of intrapartum continuous support by a professional nurse with a university degree to reduce the nulliparous, term, singleton, vertex (NTSV) cesarean birth rate, in women pregnant less Sample and sampling. The sample size was calculated with the G-Power 3.1.9.2 program, for difference of means in two independent proportions (z test), with two tails, assuming, according to local statistical data, that the outcome of Caesarean section in nulliparous with usual obstetric care was 45% and in nulliparous with emotional support it was 20%, with 95% confidence and 80% of power, the sample size was 54 patients per group, Each group was integrated and studied at different but consecutive times to guarantee the independence of the information collected, due to the lack of capacity of the labor and delivery unit, to carry out the study of the groups in a parallel design, for each group was used systematic random sampling with a systematic jump of an element, each day the first participating patient was chosen and then the systematic jump was applied, one not, one yes, every day until the sample was completed, the principal investigator recruited and assigned the patients to the groups, finally, 55 women were included in the control group and 60 in the study group.

Procedure.
The control group received the usual obstetric care, without continuous intrapartum support. The study group received the usual obstetric care plus continuous intrapartum support that was provided by a Bachelor of Nursing and Obstetrics who received prior training by a professional doula.
Continuous intrapartum support was based on three basic aspects: 1) emotional support, 2) physical support and comfort measures and 3) information and advice.
The emotional support consisted in establishing an affective communication between the patient and the nurse in order to dispel fears and doubts and instill security in an environment of understanding, availability, respect and intimacy.
The physical support and comfort measures were provided through massage, tactile contact, assistance to adopt different positions for pain relief and the use of aromatherapy with essences of jasmine, mint and lavender.

Results
The total sample was 115 pregnant women, under 40 years (NTSV) who participated in the study, 55 in the control group without continuous intrapartum support and 60 in the experimental group with continuous intrapartum support.
Baseline characteristics. The two groups were homogeneous with respect to the initial interest characteristics (Table 1), since no statistically significant differences were found for maternal age (p = 0.436), dilatation on admission (p = 0.120), BMI before (p = 0.214).

Discussion
The continuous intrapartum support provided by professional nursing staff is an intervention that favored vaginal deliveries in the active phase and decreased labor time in NTSV patients, in a statistically significant manner. Previous studies of one-to-one support have been provided by a doula and husband (28), by midwives (29), female relative (30), family members and professional staff (31).
In the study conducted by McGrant (28), nulliparous women in the third trimester were enrolled at childbirth education classes, 420 met enrollment criteria, 224 women was randomly assigned to the experimental group, a doula arrived shortly after hospital admission and remained throughout the labor and delivery.
Together with the pregnant woman and her male partner, the doula group had a cesarean delivery rate significantly lower than the control group (13.4% vs. 25.0%, p = 0.002), and fewer women in the group of doulas received epidural analgesia (64.7% versus 76.0%, p = 0.008), In our study, the sample size was smaller and randomization was not done due to budget issues, as well as, women did not receive educational classes for childbirth, but a more significant reduction in cesarean rates was observed (1.7% compared to 29.1% p < 0.01), and low percentages of obstetric analgesia use, 13.3% (8 of 60) for the study group and 18.2% (10 of 55), for the control group, without significant difference.
In the randomized trial reported by Kashanian et al, (29), one-to-one intrapartum support was provided by a midwife; participants were nulliparous women who had not received labor education classes in the intervention group (n = 50) , continuous support was provided during delivery, the control group (n = 50) did not receive continuous support, the number of deliveries by cesarean delivery (8% versus 24%, p = 0.026) were significantly lower in the intervention group in comparison with the control group, our study was very similar in terms of sample size and education classes were not given for delivery, however, the reduction in cesarean delivery rate was higher than that reported by Kashanian.
Khresheh (30) in her nonrandomized comparative study with 226 NTSV women, reported continuous intrapartum support provided by a female relative, without nursing knowledge, or medicine, without finding statistically significant differences between groups for mode of delivery and duration of labor, contrary to the results of the present study in which the intrapartum continuous support was provided by a professional in the health area, without any previous relationship with the patient. It is recommended a standardization in the operational definition of the concepts to be measured, so that the results in clinical trials are more comparable, like the Robson classification system, recommended by the WHO (4), in addition, it is recommended to carry out more randomized clinical trials, with large samples, in countries with medium and low income, focused on the active phase and with support provided by a professional nurse giving priority to humanized delivery.

Conclusions
Continuous intrapartum support provided by a professional nurse (with a university degree) in the active phase is an effective intervention to reduce the rate of cesarean deliveries, and the time of labor in pregnant women under 40 years of age, (nulliparous, term, singleton, vertex). Consent to publication: Not applicable.

Abbreviations
Availability of data and materials: All the data generated in this study is available in the following link https://i0000.clarodrive.com/s/B87gCxXmS4DgyqK or be required to the author by correspondence (email: cardonaluzmaria@outlook.com).
Competing interests: The authors declare that they have no competing interests