| 1. |
- Edqvist, Malin, et al.
(author)
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The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus) : a multicentre, randomised controlled trial in Sweden
- 2022
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In: The Lancet. - 0140-6736 .- 1474-547X. ; 399:10331, s. 1242-1253
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Journal article (peer-reviewed)abstract
- BACKGROUND: Severe perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife.METHODS: In this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18-47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096.FINDINGS: Between Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49-0·97).INTERPRETATION: The presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time.
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| 2. |
- Edqvist, Malin, et al.
(author)
-
The Effect of Two Midwives During the Second Stage of Labour to Reduce Severe Perineal Trauma (Oneplus) : A Multicentre, Randomized Controlled Trial in Sweden
- 2022
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In: Obstetrical and Gynecological Survey. - : Ovid Technologies (Wolters Kluwer Health). - 0029-7828 .- 1533-9866. ; 77:9, s. 513-515
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Journal article (peer-reviewed)abstract
- In many high-income countries, severe perinatal trauma (SPT), affecting the anal sphincter muscle complex, has been on the rise over the last decade. However, effective strategies to prevent SPT are scarce. In randomized controlled trials, only perineal warm compresses and massage have shown benefit. Other cohort studies have shown that prevention models involving several components can decrease the occurrence of SPT, including a stepped-wedge design that reduced SPT from 3.3% to 3.0%. In Scandinavia, a preventive strategy called collegial assistance has been used to help prevent SPT. This strategy involves 2 mid-wives who assist the woman in the second stage of labor, with the second midwife primarily focused on preventing SPT. The aim of this study was to compare the rate of SPT in pregnancies managed by collegial assistance versus a single midwife. This Oneplus study was a randomized, controlled, unmasked trial, conducted at 5 obstetric units in Sweden between December 10, 2018, and March 21, 2020. Included were adult women with uncomplicated singleton pregnancies at >37 weeks of gestation, who were carrying their first child or having their first vaginal birth after cesarean delivery. Excluded were women who had multiple pregnancies, had intrauterine fetal demise, were undergoing a planned cesarean section, or were at <37 weeks' gestation. Women were randomly assigned to either the intervention group with 2 midwives in attendance during active second stage labor or standard care with 1 midwife. All midwives were asked to document the preventive methods used in case report forms. A total of 3750 women were included in the final analysis-with 1879 women receiving collegial assistance and 1871 women receiving standard care. Of the women who gave birth spontaneously, 1546 were in the intervention group and 1513 in the standard care group. Severe perinatal trauma occurred less frequently in the intervention group than the standard care group (3.9% vs 5.7%; odds ratio, 0.68; 95% confidence interval, 0.49-0.97; P = 0.025). In the intervention group, 0.2% had fourth-degree tears compared with 0.5% in the standard care group. The median time for collegial assistance was 15 minutes (interquartile range, 10-20 minutes). The use of perineal warm compresses was similar in the intervention group and standard care group (86.4% vs 85.7%, respectively). No differences were observed in birth positions, manual perineal protection, neonatal outcomes, or secondary maternal outcomes. In conclusion, the attendance of a second midwife dedicated to preventing SPT during the second stage of labor significantly reduced the risk of injury.
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| 3. |
- Edqvist, Malin, et al.
(author)
-
The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus) : a multicentre, randomised controlled trial in Sweden
- 2022
-
In: The Lancet. - : Elsevier. - 0140-6736 .- 1474-547X. ; 399:10331, s. 1242-1253
-
Journal article (peer-reviewed)abstract
- BackgroundSevere perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife.MethodsIn this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18–47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096.FindingsBetween Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49–0·97).InterpretationThe presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time.FundingThe Swedish Research Council for Health, Working Life and Welfare; Jan Hains Research Foundation; and Skane County Council's Research and Development Foundation.
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| 4. |
- Tern, Helena
(author)
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Collegial midwifery assistance during the active second stage of labour
- 2023
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Doctoral thesis (other academic/artistic)abstract
- AbstractSevere perineal trauma (SPT) is a serious complication following vaginal birth. To reduce its incidence rate, various preventive strategies have been implemented in Swedish obstetric units. Collegial midwifery assistance (CMA), involving an additional midwife being present during the active second stage of labour, is a clinical practice that was evaluated in the Oneplus trial, which proved a 30% reduction in SPT. The primary aim of this thesis was to investigate midwives’ and women’s experiences of collegial assistance during the active second stage of labour. The secondary aim was to obtain an improved understanding of the learning embedded within this clinical practice. The four papers included in this thesis are part of the Oneplus trial. Paper I has a qualitative design, using reflexive thematic analysis based on five focus group interviews with midwives (n=37). Papers II, III, and IV have quantitative designs using data from the Oneplus trial. In Papers II and IV, data was collected from clinical registration forms (CRFs) completed by the primary and second midwife after each birth (n=1430) and local databases. Paper III is a cohort study based on data from a questionnaire completed by women one-month postpartum, local databases, and CRFs (n=1050). For Papers II, III, and IV, we performed descriptive statistics as well as univariable and multivariable logistic regression analyses. In Paper I, four key themes were constructed: (i) challenging the professional role, (ii) a balancing act between different roles, (iii) not just why and how - but who, (iv) a potential arena for learning. In Paper II, the majority of the midwives fully agreed on items related to perceived confidence and considered having a colleague present to be a positive experience (61% and 56% respectively). Midwives with less than two years of work experience were more likely to fully agree on feeling confident (aOR 9.18, 95% CI 6.28-13.41) and experiencing the presence of a colleague as positive (aOR 4.04 % CI 2.83-5.78). Paper III showed that the clinical practice was well received by women, with 36% strongly agreeing that they felt safe and 43% expressing willingness to have CMA in the event of a subsequent birth. Women who experienced fear of birth, who had a lower level of education, and who did not have Swedish as their mother tongue showed higher levels of satisfaction with CMA. Midwives with less than two years of work experience reported new learning in three out of four births (76%) and those with over 20 years of work experience reported learning in one out of five births (22%). The importance of various factors influencing learning differed for primary and second midwives and were also influenced by the level of work experience. Our findings indicated that the CMA intervention was a well-accepted clinical practice among both midwives and women giving birth. CMA was found to provide valuable support and professional learning, which was especially pronounced among early career midwives. Experiences were complex and influenced by various factors, and the findings can be used to facilitate implementation and guide future practice.
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| 5. |
- Tern, Helena, et al.
(author)
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Midwives’ experiences of professional learning when practicing collegial midwifery assistance during the active second stage of labour : data from the oneplus trial
- 2024
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In: BMC Pregnancy and Childbirth. - 1471-2393. ; 24:1
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Journal article (peer-reviewed)abstract
- Background: Learning is a lifelong process and the workplace is an essential arena for professional learning. Workplace learning is particularly relevant for midwives as essential knowledge and skills are gained through clinical work. A clinical practice known as ‘Collegial Midwifery Assistance’ (CMA), which involves two midwives being present during the active second stage of labour, was found to reduce severe perineal trauma by 30% in the Oneplus trial. Research regarding learning associated with CMA, however, is lacking. The aim was to investigate learning experiences of primary and second midwives with varying levels of work experience when practicing CMA, and to further explore possible factors that influence their learning. Methods: The study uses an observational design to analyse data from the Oneplus trial. Descriptive statistics and proportions were calculated with 95% confidence intervals. Stratified univariable and multivariable logistic regression analysis were performed. Results: A total of 1430 births performed with CMA were included in the study. Less experienced primary midwives reported professional learning to a higher degree (< 2 years, 76%) than the more experienced (> 20 years, 22%). A similar but less pronounced pattern was seen for the second midwives. Duration of the intervention ≥ 15 min improved learning across groups, especially for the least experienced primary midwives. The colleague’s level of experience was found to be of importance for primary midwives with less than five years’ work experience, whereas for second midwives it was also important in their mid to late career. Reciprocal feedback had more impact on learning for the primary midwife than the second midwife. Conclusions: The study provides evidence that CMA has the potential to contribute with professional learning both for primary and second midwives, for all levels of work experience. We found that factors such as the colleague’s work experience, the duration of CMA and reciprocal feedback influenced learning, but the importance of these factors were different for the primary and second midwife and varied depending on the level of work experience. The findings may have implications for future implementation of CMA and can be used to guide the practice.
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| 6. |
- Tern, Helena, et al.
(author)
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Primary midwives' experiences of collegial midwifery assistance during the active second stage of labor : Data from the Oneplus trial
- 2023
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In: Birth. - 0730-7659. ; 50:4, s. 868-876
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Journal article (peer-reviewed)abstract
- Background: Collegial midwifery assistance during the active second stage of labor that involves a second midwife being present has been shown to reduce severe perineal trauma (SPT) by 30%. The aim of this study was to investigate primary midwives' experiences of collegial midwifery assistance with the purpose of preventing SPT during the active second stage of labor. Methods: This study uses an observational design with data from a multicenter randomized controlled trial (Oneplus). Data consist of clinical registration forms completed by the midwives after birth. Descriptive statistics as well as univariable and multivariable logistic regression were used to analyze the data. Results: The majority of the primary midwives felt confident (61%) and were positive (56%) toward the practice. Midwives with less than 2 years' work experience were more likely to completely agree they felt confident (aOR 9.18, 95% CI: 6.28–13.41) and experience the intervention as positive (aOR 4.04, 95% CI: 2.83–5.78) than those with over 20 years' work experience. Factors such as duration of time spent in the birthing room by the second midwife, opportunity for planning and if the second midwife provided support were further associated with the primary midwife's experience of the practice as being positive. Conclusions: Our findings indicate that having a second midwife present during the active second stage of labor was an accepted practice, with the majority of primary midwives feeling confident and positive toward the intervention. This was especially pronounced among midwives with less than 2 years' work experience.
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| 7. |
- Tern, Helena, et al.
(author)
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Swedish midwives’ experiences of collegial midwifery assistance during the second stage of labour: A qualitative study
- 2023
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In: Women and Birth. - : Elsevier BV. - 1878-1799 .- 1871-5192. ; 36:1, s. 72-79
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Journal article (peer-reviewed)abstract
- BackgroundThere has been an increased focus on clinical practice that may reduce severe perineal trauma due to awareness of the associated morbidity. Knowledge regarding the best practice to reduce these injuries is limited. Collegial midwifery assistance during the second stage of labour that involves an additional midwife being present has recently been implemented into many Swedish birth units with the aim of reducing severe perineal trauma. However, no studies have been conducted to evaluate midwives’ experiences and views of this practice.AimThe aim of this study was to explore midwives’ experiences of collegial midwifery assistance during the second stage of labour.MethodsA qualitative study was undertaken with five focus groups conducted with 37 midwives who were part of a multisite randomised controlled trial. The data was analysed with reflexive thematic analysis.FindingsFour key themes were generated: (i) “challenging the professional role”; (ii) “a balancing act between different roles”; (iii) “not just why and how - but who”; (iv) “a potential arena for learning”.ConclusionThis practice enabled valuable collegial support and learning. The midwives’ experiences were multifaceted and influenced by several factors, including norms and culture in the birth units as well as personal relationships and the midwives’ views on their role and childbirth. Staffing should be adapted in clinical practice to optimise the conditions for collegial support and learning while avoiding unintended consequences.
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| 8. |
- Tern, Helena, et al.
(author)
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Women's experiences of being assisted by two midwives during the active second stage of labour : Secondary outcomes from the Oneplus trial
- 2024
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In: Sexual and Reproductive Healthcare. - 1877-5756. ; 39, s. 100926-
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Journal article (peer-reviewed)abstract
- Background: ‘Collegial Midwifery Assistance’ (CMA) is a clinical practice aiming to reduce severe perineal trauma (SPT) during childbirth. This practice involves two midwives being present during the active second stage of labour rather than one, which is the case in standard care. The effectiveness of CMA was evaluated in the Oneplus trial and a 30% reduction in SPT was shown. Aim: The aim was to investigate the experience of women who received the CMA intervention in the trial and to explore factors influencing their experiences. Methods: A cohort study using data from the Oneplus trial and a one-month postpartum follow-up questionnaire. Descriptive statistics, univariable and multivariable logistic regression analyses were performed. Results: A total of 1050 women who received the CMA intervention responded to the questionnaire. Of these, 35.8% reported that they strongly agreed with feeling safe during the second stage of labour and 42.6% were inclined to have an additional midwife present at a subsequent birth. The intervention was favourably received by women who experienced fear of birth, who were non-native Swedish speakers, and had lower educational attainment. Furthermore, women were more positive towards CMA the longer the intervention lasted. Conclusions: The results of this study suggest that the CMA intervention is accepted well by women and can be safely implemented into standard care. The duration of the CMA intervention was an important factor that influenced women's experiences and should be used to guide future practice.
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