Characteristics of mother and delivery
A total of 178 deliveries were observed out of 1090 eligible vaginal deliveries at the study site during the one-month observation period. Eight cases were withdrawn due to switching to emergency caesarean section, therefore 170 cases were eligible for analysis. During the study period, 25 medical doctors, 28 midwives and 25 nurses were observed throughout their intrapartum practice out of 28 doctors, 31 midwives and 27 nurses working in the ward, respectively. A comparison of the characteristics of study participants (n=170) and non-observed cases (n=920) is shown in Table 1. The proportion of primiparous women was significantly higher in the observed group than in the non-observed group. There were no statistical differences in median age and proportion of assisted vaginal delivery in the two groups.
The characteristics of parturient woman, delivery process, and maternal and neonatal outcomes are shown in Table 2. Proportions of term deliveries and women without any complications were 88.8% and 78.2%, respectively. Duration of the 2nd stage was categorized as more or less than 30 minutes according to a consensus among the health providers interviewed. The median duration of the 2nd stage was 19 minutes. Most mothers delivered spontaneously, while vacuum extraction or forceps were applied in 16 cases (9.4%). Time of delivery at dayshift (6am to 6pm) or night shift (6pm to 6am) were almost equivalent. A midwife was the most common birth attendant for vaginal delivery. The prevalence of 3rd or 4th degree of perineal or vaginal lacerations (OASIS) was 17.1%. Twenty-eight babies (16.5%) required resuscitation or admission to neonatal intensive care unit due to asphyxia, tachypnoea or mother’s comorbidity. There was one intrapartum foetal death.
Description of intrapartum care during the 2nd and 3rd stage of labour
Table 3 presents a description of intrapartum care during the 2nd and 3rd stages of labour.
Position during the 2nd stage of labour: The position at the birth of baby was upright in all the mothers.
Method of pushing: The Valsalva Manoeuvre, to encourage mothers to keep pushing without breathing, was applied in 25.9% of mothers.
Episiotomy: Episiotomy was performed to 57.6% of all mothers by the median method, and to 1.8% by the medio-lateral method. Local anaesthesia for episiotomy was rarely used (only to 1 woman). The episiotomy rate was 92.0% in the primiparas subgroup.
Fundal Pressure: Fundal pressure was performed on 31.2% of participating mothers. The manoeuvre of fundal pressure involved the healthcare provider placing their forearm on the fundus and grasping the handle located on the side of the delivery bed with another hand, forming a “T-shape”, then applying pressure. 62.3% of the fundal pressure was initiated within 30 minutes of full dilatation or after the mother was transferred to the delivery bed.
Foetal heart rate monitoring: More than half of mothers did not receive FHR monitoring during the 2nd stage. The median frequency and interval of the intermittent auscultation was once (IQR 1-2) and 19 minutes (IQR 13-32), respectively.
Labour augmentation by oxytocin: Oxytocin injection either by intramuscular or intravenous was performed in 24 women. No observation of uterine contraction was conducted in all the cases during or immediately after the injection.
Prophylactic use of oxytocin during the third stage of labour: All 170 cases received intramuscular injection of oxytocin. However, 21 cases (12.4%) did not receive the full defined dose (10 IU) as recommended in the national guideline, since 2 to 5 units of oxytocin were already injected for labour augmentation during the 2nd stage.
Delayed umbilical cord clamping: Delayed umbilical cord clamping is recommended in the national guideline when the baby does not require any resuscitation. However, it was applied in only 50.0% of deliveries out of 138 cases observed (three missing data among 141 cases).
Controlled cord traction: Most of the placental deliveries were conducted using CCT (98.8%). Suprapubic counter pressure was applied in 93.4% of the CCT cases.
Uterine massage: After the delivery of placenta, uterine massage was performed to 11 women (6.5%).
Perception of the potentially harmful practice and the evidence behind the guidelines
We conducted semi-structured interviews with 16 medical doctors, 19 midwives and 4 nurses. We recruited all the healthcare providers each time episiotomy or fundal pressure was observed, although one medical doctor was unable to be interviewed because she did not have time. Some providers were interviewed several times. For FGDs, 6 doctors, 5 nurses and 6 midwives participated. The participants were selected using convenience sampling based on their availability. Three sessions were organised separately for medical doctors, midwives, and nurses. Each FGD lasted about 1.5 hours.
Interviews and FGDs with healthcare providers explored their understanding and perceptions of conducting the potentially harmful practices.
Perception of the episiotomy for primiparas: Healthcare providers reported that primiparas without episiotomy were at risk for OASIS due to the characteristic of their vagina and perineum, such as “small”, “not elastic”, “contracted” and “tight”, and that episiotomy was a protective measure against severe, zigzag or multiple laceration. Some doctors and midwives also said that such laceration is “difficult to suture” and “takes time to repair”, while they were tending to many deliveries. “Large baby” was one of the reasons to perform episiotomy. Providers assessed the size of the baby by the fundal height, however the criteria to evaluate the size of baby differed by person, ranging from 28cm to 32cm. On the other hand, providers reported recognising negative effects of episiotomy, such as “infection”, “pain” and “blood loss”.
Perception of fundal pressure: Although all healthcare providers knew fundal pressure was not recommended in the guidelines, they believed it was effective to “help the baby’s head descending”, “accelerate the 2nd stage” or “hasten the delivery” from their experiences. Reported reasons for performing fundal pressure included; “foetal head descending is not improving”, “long or prolonged 2nd stage” and “weak maternal pushing and maternal effort failed” described as “mother stopped pushing in few seconds”. Because of trust in its effectiveness, fundal pressure was often selected as the first option to hasten the second stage of labour in order to avoid vacuum extraction or caesarean section. Healthcare providers reported that the equipment for vacuum extraction is single-use and costly, therefore, it is better to avoid using it in order to reduce out-of-pocket payment for the patient. They also mentioned that emergency caesarean section is often difficult because of the lack of operation room availability. Healthcare providers reported recognizing the negative effects of fundal pressure such as “pain”, “uterine rupture” and “hematoma or bruise of abdomen”.
Long duration of the 2nd stage: “Long or prolonged 2nd stage” was one of the reasons to apply fundal pressure, and a “long duration” was described from 30 minutes to 2 hours for primiparas, and 30 minutes to 1 hour for multiparas.
Factors associated with healthcare providers performing potentially harmful practices
Table 4 and 5 show results of bivariate and multivariable analyses on the relationship between maternal, foetal and environmental factors and episiotomy and fundal pressure, respectively. We arbitrarily selected the explanatory variables in the multiple logistic regression model separately for episiotomy and fundal pressure. The number of explanatory variables were limited to six in episiotomy and five in fundal pressure based on the number of women who performed those practices.
The following factors were associated with episiotomy; primipara (adjusted odds ratio: aOR 62.3), duration of the second stage of labour more than 30 minutes (aOR 4.6) and assisted vaginal delivery by vacuum extraction or forceps (aOR 15.0). Having maternal complications was negatively associated (aOR 0.10). No associations were found with fundal height and foetal heart rate monitoring.
The following factors were associated with implementation of fundal pressure; primipara (aOR 3.0), labour augmentation by oxytocin (aOR 3.3) and assisted vaginal delivery (aOR 4.8). No significant association was found with duration of the second stage of labour and foetal heart rate monitoring.
We omitted ‘Birth Attendant’ from the multiple regression analyses, because of collinearity between the birth attendant and mode of delivery. Instrumental delivery, such as vacuum extraction, is usually positively associated with practices of episiotomy and fundal pressure. Therefore, mode of delivery was included a priori in our analysis. However, vacuum extraction and forceps delivery can be performed only by medical doctors in the study site. If we include birth attendant, which was categorized as ‘medical doctor’ or ‘midwife or nurse’, in the model, it automatically produced ‘zero cell’, weakning the validity of the analyses.
Associated factors for OASIS
As presented in Table 2, 17.1% of women got OASIS: 11.8% third degree and 5.3% fourth degree tear. Table 6 shows the result of bivariate and multivariate analyses of the relationship between maternal, foetal and care-related factors and OASIS. Although parity, duration of the second stage and labour augmentation by oxytocin have significant relationships with occurrence of OASIS in the univariate analysis, these factors were omitted in the multivariate model, because these factors have collinearity with the Valsalva manoeuvre (method of pushing), episiotomy and fundal pressure. Assisted vaginal delivery (aOR 6.0), baby’s weight more than 3500g (aOR 7.8), episiotomy (aOR 26.4) and fundal pressure (aOR 6.2) were positively associated with OASIS. There was no association with the method of pushing.