Normal Birth als onderzoeksterrein

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Normal Birth als onderzoeksterrein

• Normal Birth an area of research

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My office
Europe
and my colleagues
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Antenatal care in Germany

• Lead professional obstetrician
• Shared care midwife/ obstetrician
• Covered by Health insurance
• Maternity document Mutterpass
• Standard antenatal care

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Hospital birth in Germany

• Private and public hospitals
• Employed midwives
• Contracted midwives
• Midwife presence
• required by law

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Homebirth and birth centre care

• Independent midwives only
• Team structure possible
• Costs mainly covered by health insurance
• Approx 1
• Quality assurance for
• out-of-hospital-births

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Research during Normal Birth
Outcome
Duration
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Research during Normal Birth
Outcome
Duration
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Randomised Studies
Outcome
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Intrapartum factors influencing birth duration
Amniotomy
Epidural
Support
Vertical positioning
Admission
Duration
Groß MM Antes G. Wissenschaftliche Evidenz aus
systematischen Übersichtsarbeiten zum Gebären. Z
Geburtsh Neonatol 2003 207 17-23
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Research during Normal Birth
Outcome
Duration
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Process orientated care
Outcome
Duration
Pain
Wellbeing
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Wellbeing during labour
Gross MM Hecker H Keirse MJNC. An evaluation of
pain and fitness during labor and its
acceptability to women. Birth 2005 32 122-128
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New Interest in Labour Progression
Troendle Zhang, US-NIH
Vahratian A et al. 2006 methodological
challenges in studying labour progression
suggested how to assess the duration from one
cervical centimeter to the result of the next
vaginal examination (as an independent
factor) Vahratian A et al. 2006 impact of parity
on course of labor difference between primiparae
and multiparae Vahratian A et al. 2005 risk of
caesarean delivery in electively induced
primiparae is 2.3 higher compared to non induced
primiparae, epidural is used as a time-varying
covariate Hoffman MK et al. 2006 comparison of
labour progression between induced and non
induced multiparous women
Smith, UK-Cambridge
Smith G 2001 first time that time to event
analysis is used in the field of human
reproduction (normal duration of human
pregnancy) Smith G et al. 2003 caesarean
section and risk of unexplained stillbirth in
subsequent pregnancy. Lancet 362 1779-1784 Smith
G 2005 review on estimating risks of perinatal
death, indeed labor itself can be treated as the
event
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and how long will it take?
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Research question
The aim of the current study was to investigate
how intrapartum interventions are associated with
labour duration.
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Methods
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Germany
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• Setting of the ProGeb-Study
• -a state-wide longitudinal study on
  process-oriented care during the childbearing
  process,
• -96 hospitals with maternity services in Lower
  Saxony,
• -64,000 births per year,
• -involves a detailed documentation,
• -contact to midwifery teams.

Data Collection Hospital-based births 6
months Out-of-hospital births 12 months
47 maternity units in hospitals (n3963) 11 free
standing birth centres (n232) 46 home birth
midwives (n243) total n 4438

• Informed Consent
• Approvals
• by the Ethics Committee of Hanover Medical
  University
• by the State-wide Ethics Committee for Public
  Hospitals in Lower Saxony
• Support / Logistics
• Centre for Quality and Management in Health Care
  of the Medical Chamber of Lower Saxony
• Inclusion
• Cephalic presentation in singleton pregnancies gt
  34 weeks

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Data Management in the ProGeb Study
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Hospital Births
Out-of-hospital-Births

Demographic data      
Maternal age in years median (min/ max) 28 (14.5/ 43.5) 31.5 (18/ 45) 31.5 (18/ 45) 31.5 (18/ 45) 31.5 (18/ 45) 30 (15/44) 30 (15/44) 30 (15/44) 33 (19/ 46) 33 (19/ 46)      
Worked during pregnancy n () 601 (66.2) 316 (38.8) 316 (38.8) 316 (38.8) 316 (38.8) 125 (67.2) 125 (67.2) 125 (67.2) 130 (45.8) 130 (45.8)      
A-level vs. other school degrees n () 247(32.2) 213 (33.2) 213 (33.2) 213 (33.2) 213 (33.2) 129 (72.9) 129 (72.9) 129 (72.9) 185 (69.0) 185 (69.0)      
Country of origin Germany vs. other n () 1,435(85.2) 1,205 (80.2) 1,205 (80.2) 1,205 (80.2) 1,205 (80.2) 179 (95.7) 179 (95.7) 179 (95.7) 276 (96.5) 276 (96.5)      
Mode of antenatal care      
Antenatal classes n () 752 (70.5) 385 (40.2) 385 (40.2) 385 (40.2) 385 (40.2) 160 (86.0) 160 (86.0) 160 (86.0) 145 (50.7) 145 (50.7)      
Midwife chosen by woman n () 242 (20.0) 176 (15.8) 176 (15.8) 176 (15.8) 176 (15.8) 175 (93.6) 175 (93.6) 175 (93.6) 265 (92.7) 265 (92.7)      
(Partially) provided by midwife n () 182 (17.5) 137 (14.6) 137 (14.6) 137 (14.6) 137 (14.6) 171 (91.9) 171 (91.9) 171 (91.9) 270 (94.1) 270 (94.1)      
General obstetrical data      
No antenatal risk associated factors n () 1169 (55.9) 1007 (53.8) 1007 (53.8) 1007 (53.8) 1007 (53.8) 129 (69.0) 129 (69.0) 129 (69.0) 199 (69.1) 199 (69.1)      
SROM before onset of labour n () 531 (25.5) 295 (15.8) 295 (15.8) 295 (15.8) 295 (15.8) 33 (19.5) 33 (19.5) 33 (19.5) 34 (12.1) 34 (12.1)      
Low workload (lt3) vs. high (gt3) n () 343 (64.2) 371 (74.3) 371 (74.3) 371 (74.3) 371 (74.3) 83 (51.2) 83 (51.2) 83 (51.2) 160 (73.7) 160 (73.7)      
Newborn-related data      
Gender (male) n () 1065 (51.0) 952 (50.9) 952 (50.9) 952 (50.9) 952 (50.9) 91 (48.7) 91 (48.7) 91 (48.7) 153 (53.1) 153 (53.1)      
Birth weight (gram) median (min/ max) 3423 3538 3538 3538 3538 3500 3500 3500 3650 3650      
Length (cm) median (min/ max) 52 (41.5/ 59) 52 (40.5/ 61.5) 52 (40.5/ 61.5) 52 (40.5/ 61.5) 52 (40.5/ 61.5) 52 (44/ 58) 52 (44/ 58) 52 (44/ 58) 53 (44/ 60) 53 (44/ 60)      
Head circumference (cm) median (min/ max) 35 (26.5/ 40.5) 35 (28/ 39.5) 35 (28/ 39.5) 35 (28/ 39.5) 35 (28/ 39.5) 35 (32/ 39.5) 35 (32/ 39.5) 35 (32/ 39.5) 35 (26/ 39) 35 (26/ 39)      
np (n2090) mp (n1873) np (n187)
mp (n288)
Some variables have missing data.
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Hospital Births
Out-of-hospital-Births

Birth    
Births without induction, oxytocin, epidural, episiotomy n () 321 (15.3) 321 (15.3) 859 (45.9) 859 (45.9) 135 (72.2) 135 (72.2) 135 (72.2) 135 (72.2) 135 (72.2) 262 (91.0) 262 (91.0)    
Spontaneous birth n () 1497 (71.6) 1497 (71.6) 1764 (94.2) 1764 (94.2) 165 (88.2) 165 (88.2) 165 (88.2) 165 (88.2) 165 (88.2) 283 (98.3) 283 (98.3)    
Operative vaginal delivery n () 216 (10.3) 216 (10.3) 31 (1.7) 31 (1.7) 5 (2.7) 5 (2.7) 5 (2.7) 5 (2.7) 5 (2.7) 0 (0) 0 (0)    
Caesarean section n () 377 (18.0) 377 (18.0) 78 (4.2) 78 (4.2) 11 (5.9) 11 (5.9) 11 (5.9) 11 (5.9) 11 (5.9) 4 (1.4) 4 (1.4)    
Newborn    
APGAR 10 (5 min.) n () 1727 (82.7) 1727 (82.7) 1642 (87.7) 1642 (87.7) 144 (79.1) 144 (79.1) 144 (79.1) 144 (79.1) 144 (79.1) 239 (83.3) 239 (83.3)    
Birth asphyxia (pH lt7.20) n () 483 (23.3) 483 (23.3) 265 (14.3) 265 (14.3) n/a n/a n/a n/a n/a n/a n/a    
Neonatal resuscitation required n () 125 (6.0) 125 (6.0) 67 (3.5) 67 (3.5) 11 (5.9) 11 (5.9) 11 (5.9) 11 (5.9) 11 (5.9) 6 (2.1) 6 (2.1)    
Admission to NICU n () 140 (6.7) 140 (6.7) 79 (4.2) 79 (4.2) 9 (4.8) 9 (4.8) 9 (4.8) 9 (4.8) 9 (4.8) 3 (1.0) 3 (1.0)    
Mother    
Intact perineum n () 815 (39.0) 815 (39.0) 984 (47.1) 984 (47.1) 88 (47.1) 88 (47.1) 88 (47.1) 88 (47.1) 88 (47.1) 160 (55.6) 160 (55.6)    
Perineal tears n () 412 (19.7) 412 (19.7) 595 (31.8) 595 (31.8) 74 (39.6) 74 (39.6) 74 (39.6) 74 (39.6) 74 (39.6) 120 (41.7) 120 (41.7)    
Anal sphincter damage n () 58 (2.8) 58 (2.8) 22 (1.2) 22 (1.2) 4 (2.1) 4 (2.1) 4 (2.1) 4 (2.1) 4 (2.1) 6 (2.1) 6 (2.1)    
Postpartum hemorrhage(gt1000ml) n () 26 (1.2) 26 (1.2) 12 (0.6) 12 (0.6) 3 (1.6) 3 (1.6) 3 (1.6) 3 (1.6) 3 (1.6) 3 (1.0) 3 (1.0)    
np (n2090) mp (n1873) np (n187)
mp (n288)
Some variables have missing data.
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Hospital Births
Out-of-hospital-Births

Interventions/ events during labour and birth    
Spontaneous onset of labour (SOL) n () 1478 (70.7) 1478 (70.7) 1478 (70.7) 1412 (75.4) 1412 (75.4) 174 (93) 174 (93) 174 (93) 174 (93) 174 (93) 269 (93.4) 269 (93.4) 269 (93.4) 269 (93.4)    
Intrapartal spontaneous rupture of membranes (SRM) n () 810 (38.8) 810 (38.8) 810 (38.8) 772 (41.2) 772 (41.2) 110 (65.1) 110 (65.1) 110 (65.1) 110 (65.1) 110 (65.1) 209 (74.4) 209 (74.4) 209 (74.4) 209 (74.4)    
Presence of midwife sum of all intervals (hours) median (min/ max) 4.4 (0.2/ 35.45) 4.4 (0.2/ 35.45) 4.4 (0.2/ 35.45) 2.25 (0.05/ 22.2) 2.25 (0.05/ 22.2) 4.3 (0.0/ 23.5) 4.3 (0.0/ 23.5) 4.3 (0.0/ 23.5) 4.3 (0.0/ 23.5) 4.3 (0.0/ 23.5) 2.2 (0.0/ 20.1) 2.2 (0.0/ 20.1) 2.2 (0.0/ 20.1) 2.2 (0.0/ 20.1)    
Vertical positioning in 1st stage per duration of 1st stage () median (min/ max) 33.3 (0/ 100) 33.3 (0/ 100) 33.3 (0/ 100) 42.9 (0/ 100) 42.9 (0/ 100) 54.2 (0/ 100) 54.2 (0/ 100) 54.2 (0/ 100) 54.2 (0/ 100) 54.2 (0/ 100) 61.2 (0/ 100) 61.2 (0/ 100) 61.2 (0/ 100) 61.2 (0/ 100)    
Vertical positioning in 2nd stage per duration of 2nd stage () median (min/ max) 23.0 (0/ 100) 23.0 (0/ 100) 23.0 (0/ 100) 32.5 (0/ 100) 32.5 (0/ 100) 56.3 (0/ 100) 56.3 (0/ 100) 56.3 (0/ 100) 56.3 (0/ 100) 56.3 (0/ 100) 33.3 (0/ 100) 33.3 (0/ 100) 33.3 (0/ 100) 33.3 (0/ 100)    
Transfer to hospital during labour n () n/a n/a n/a n/a n/a 49 (26.2) 49 (26.2) 49 (26.2) 49 (26.2) 49 (26.2) 13 (4.5) 13 (4.5) 13 (4.5) 13 (4.5)    
Duration of first stage in vaginal births (hours) median (min/ max) 7.05 (0.5/ 63.8) 7.05 (0.5/ 63.8) 7.05 (0.5/ 63.8) 4.15 (-0.05/ 91.6) 4.15 (-0.05/ 91.6) 7.6 (0.9/ 40.5) 7.6 (0.9/ 40.5) 7.6 (0.9/ 40.5) 7.6 (0.9/ 40.5) 7.6 (0.9/ 40.5) 4.1 (0.2/ 55.7) 4.1 (0.2/ 55.7) 4.1 (0.2/ 55.7) 4.1 (0.2/ 55.7)    
Duration of second stage in spontaneous vaginal births (hours) median (min/ max) 0.75 (0/ 4.45) 0.75 (0/ 4.45) 0.75 (0/ 4.45) 0.2 (0/ 3.6) 0.2 (0/ 3.6) 1.0 (0/ 9.8) 1.0 (0/ 9.8) 1.0 (0/ 9.8) 1.0 (0/ 9.8) 1.0 (0/ 9.8) 0.2 (0/ 4.0) 0.2 (0/ 4.0) 0.2 (0/ 4.0) 0.2 (0/ 4.0)    

np (n2090) mp (n1873) np (n187)
mp (n288)
Some variables have missing data.

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Hospital Births
Out-of-hospital-Births

Non-pharmacological interventions
Intermittent auscultation (yes/ no) n () 105 (5.0) 105 (5.0) 60 (3.2) 60 (3.2) 60 (3.2) 170 (90.9) 170 (90.9) 170 (90.9) 170 (90.9) 170 (90.9) 267 (92.7) 267 (92.7) 267 (92.7)
ECG (0/ gt1 time) n () 2051 (98.4) 2051 (98.4) 1817 (97.3) 1817 (97.3) 1817 (97.3) 67 (35.8) 67 (35.8) 67 (35.8) 67 (35.8) 67 (35.8) 76 (26.4) 76 (26.4) 76 (26.4)
Immersion in water (0/ gt1) n () 545 (29.0) 545 (29.0) 245 (15.3) 245 (15.3) 245 (15.3) 126 (67.4) 126 (67.4) 126 (67.4) 126 (67.4) 126 (67.4) 128 (44.4) 128 (44.4) 128 (44.4)
Massage n () 137 (22.5) 137 (22.5) 92 (16.5) 92 (16.5) 92 (16.5) 46 (24.6) 46 (24.6) 46 (24.6) 46 (24.6) 46 (24.6) 66 (22.9) 66 (22.9) 66 (22.9)
Complementary remedies n () 410 (19.6) 410 (19.6) 275 (14.7) 275 (14.7) 275 (14.7) 108 (57.8) 108 (57.8) 108 (57.8) 108 (57.8) 108 (57.8) 92 (31.9) 92 (31.9) 92 (31.9)
Vaginal exam (0-2/ gt2) n () 214 (10.0) 214 (10.0) 379 (19.3) 379 (19.3) 379 (19.3) 52 (27.8) 52 (27.8) 52 (27.8) 52 (27.8) 52 (27.8) 133 (46.2) 133 (46.2) 133 (46.2)
Intrapartal amniotomy n () 718 (34.4) 718 (34.4) 783 (41.8) 783 (41.8) 783 (41.8) 24 (14.2) 24 (14.2) 24 (14.2) 24 (14.2) 24 (14.2) 34 (12.1) 34 (12.1) 34 (12.1)
Initiation of active pushing n () 1383 (66.2) 1383 (66.2) 1261 (67.3) 1261 (67.3) 1261 (67.3) 69 (36.9) 69 (36.9) 69 (36.9) 69 (36.9) 69 (36.9) 94 (32.6) 94 (32.6) 94 (32.6)
Fundal pressure n () 412 (19.7) 412 (19.7) 116 (6.2) 116 (6.2) 116 (6.2) 7 (3.7) 7 (3.7) 7 (3.7) 7 (3.7) 7 (3.7) 2 (0.7) 2 (0.7) 2 (0.7)
Hands-off for perineum protection n () 13 (0.6) 13 (0.6) 7 (0.4) 7 (0.4) 7 (0.4) 14 (7.5) 14 (7.5) 14 (7.5) 14 (7.5) 14 (7.5) 44 (15.3) 44 (15.3) 44 (15.3)
Episiotomy n () 871 (41.7) 871 (41.7) 290 (15.5) 290 (15.5) 290 (15.5) 24 (12.8) 24 (12.8) 24 (12.8) 24 (12.8) 24 (12.8) 4 (1.4) 4 (1.4) 4 (1.4)
Pharmacological interventions
Oxytocin augmentation of labour n () 1096 (52.4) 1096 (52.4) 505 (27.6) 505 (27.6) 505 (27.6) 6 (3.2) 6 (3.2) 6 (3.2) 6 (3.2) 6 (3.2) 0 (0.0) 0 (0.0) 0 (0.0)
Pharmacological analgesia n () 1325 (63.4) 1325 (63.4) 809 (43.2) 809 (43.2) 809 (43.2) 16 (8.6) 16 (8.6) 16 (8.6) 16 (8.6) 16 (8.6) 11 (3.8) 11 (3.8) 11 (3.8)
Regional anesthesia n () 727 (34.8) 727 (34.8) 233 (12.4) 233 (12.4) 233 (12.4) 2 (1.1) 2 (1.1) 2 (1.1) 2 (1.1) 2 (1.1) 1 (0.3) 1 (0.3) 1 (0.3)

np (n2090) mp (n1873) np
(n187) mp (n288)
Some variables have missing data.

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Hospital Births
Out-of-hospital-Births

Median time difference (min/ max) between onset of labour defined by midwife (reference) and Median time difference (min/ max) between onset of labour defined by midwife (reference) and Median time difference (min/ max) between onset of labour defined by midwife (reference) and  
spontaneous rupture of membranes before onset of labour) spontaneous rupture of membranes before onset of labour) spontaneous rupture of membranes before onset of labour) -6.4 (-1162.5/ -0.05) -6.4 (-1162.5/ -0.05) -4.7 (-117.7/ -0.15) -4.7 (-117.7/ -0.15) -4.7 (-117.7/ -0.15) -5.0 (-40.0/ -0.3) -5.0 (-40.0/ -0.3) -6.3 (-40.0/ -0.5) -6.3 (-40.0/ -0.5) -6.3 (-40.0/ -0.5)  
inrapartal spontaneous rupture of membranes (hours) inrapartal spontaneous rupture of membranes (hours) inrapartal spontaneous rupture of membranes (hours) 4.6 (0/ 61.75) 4.6 (0/ 61.75) 3.15 (0/ 90.9) 3.15 (0/ 90.9) 3.15 (0/ 90.9) 6.0 (0/ 37.8) 6.0 (0/ 37.8) 3.8 (0/ 53.8) 3.8 (0/ 53.8) 3.8 (0/ 53.8)  
onset of care (hours) onset of care (hours) onset of care (hours) 0.5 (-116.95/ 65.05) 0.5 (-116.95/ 65.05) 0.7 (-78.6/ 72.1) 0.7 (-78.6/ 72.1) 0.7 (-78.6/ 72.1) 3.0 (-19.5/ 27.5) 3.0 (-19.5/ 27.5) 1.8 (-16.9/ 48.0) 1.8 (-16.9/ 48.0) 1.8 (-16.9/ 48.0)  
intrapartal amniotomy (hours) intrapartal amniotomy (hours) intrapartal amniotomy (hours) 5.75 (0.1/ 54.95) 5.75 (0.1/ 54.95) 3.55 (0.0/ 64.5) 3.55 (0.0/ 64.5) 3.55 (0.0/ 64.5) n/c n/c n/c n/c n/c  
oxytocin augmentation (hours) oxytocin augmentation (hours) oxytocin augmentation (hours) 6.0 (0.0/ 53.35) 6.0 (0.0/ 53.35) 3.8 (0.0/ 74.0) 3.8 (0.0/ 74.0) 3.8 (0.0/ 74.0) n/c n/c n/c n/c n/c  
epidural anesthesia (hours) epidural anesthesia (hours) epidural anesthesia (hours) 4.7 (-3.5/ 49.95) 4.7 (-3.5/ 49.95) 3.35 (-3.75/ 27.95) 3.35 (-3.75/ 27.95) 3.35 (-3.75/ 27.95) n/c n/c n/c n/c n/c  
np (n2090) mp (n1873) np (n187)
mp (n288)
Some variables have missing data.
25
Midwife chosen by woman (in)
Out-of-Hospital-Births n (Nulliparae) 187
n (Multiparae) 286 Hospital Births n
(Nulliparae 596 n (Multiparae) 544
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Antenatal Care provided by Midwife (in)
Out-of-Hospital-Births n (Nulliparae) 187
n (Multiparae) 288 Hospital Births n
(Nulliparae 596 n (Multiparae) 544
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Perineal Protection (in)
Out-of-Hospital-Births n (Nulliparae) 187
n (Multiparae) 288 Hospital Births n
(Nulliparae 2090 n (Multiparae) 1873
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Transfer rates to Hospital
Out-of-Hospital-Births    Out-of-Hospital-Births    Out-of-Hospital-Births    Out-of-Hospital-Births   
Nulliparae  Nulliparae  Multiparae  Multiparae 
n n
49 26,2 13 4,5
187 100,0 288 100,0
AUG n (E) 187 n (M) 288
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Symptoms of onset of labour
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Diagnosing onset of labour
"Diarrhoea, stomach ache, vaginal cramps,
back pain, all at the same time."
Gastro-intestinal
Non-recurrent pain
Gross MM et al. Womens Recognition of the
Spontaneous Onset of Labor. Birth 2003 30
267-271
31
units
women
Percent
Recurrent pain
38.5
60.8
Frequencies
Non-recurrent
24.9
30.9
of
Symptoms
Watery loss
12.7
21.7
Bloody loss
8.9
15.2
Digestive
2.7
4.6
Emotional
3.0
5.1
Sleeping
6.0
7.4
Others
3.3
5.5
Total number
369
217
Gross MM et al. Womens Recognition of the
Spontaneous Onset of Labor. Birth 2003 30
267-271
32
Interval between onset of labour defined by
midwife vs. woman
Duration of labour Nullip n550 Multip n505
1st duration as defined by women in labour Md (min, max) 11h (1.25h, 5.7d) 6.5h (48m, 9.6d)
1st duration as defined by midwives Md (min, max) 7h (1h, 2.2d) 4h (12m, 4.2d)
Interval between onset of labour defined by woman vs. midwife - Md in hours (min, max in hours, days) 2h (-5.5d, 1.5d) 45m (-9.4d, 19h)
Joint agreement on labour onset woman vs. midwife n () 158 (28.5) 199 (29.4)
33
Interval between symptoms and onset of labour
defined by midwife vs. nullipara
Emotional symptoms
Rupture of membranes
Burian RA et al. Onset of Labor Womens
Experiences and Midwives Assessment in Relation
to First Stage Duration. In Preparation
34
Hazard ratio related to onset of labour defined
by midwife vs. nullipara
adjusted for confounders
Burian RA et al. Onset of Labor Womens
Experiences and Midwives Assessment in Relation
to First Stage Duration. In Preparation
35
Presence of midwife
36
Cumulative presence of midwife since onset of
care
37
Total Duration of Midwife PresenceStarting
point first occasion of care during active
labour
of births
Ayerle GM et al. Midwife Attendance during Labour
and its Relation to Interventions and Mode of
Birth. In Preparation
38
Midwife Presence per Duration of Birth (percent)
Starting point first occasion of care during
active labour
of births
Ayerle GM et al. Midwife Attendance during Labour
and its Relation to Interventions and Mode of
Birth. In Preparation
39
Intrapartum varying interventions
40

Intrapartum varying Interventions
Amniotomy, Oxytocin, Epidural Analgesia
t
41
When are Interventions performed?



Nulliparae n2090
Amniotomy, Oxytocin, Epidural


3h
42
When are Interventions performed?



Nulliparae n2090
Multiparae n1873
Amniotomy, Oxytocin, Epidural

3h
3h
43
Steps of Data Analysis for 1st and 2nd stage
1. Univariate Analysis 2. Multivariate Analysis
I Demographic factors, risk- associated
factors, child-related factors, induction 3.
Multivariate Analysis II All significant factors
4. Multivariate Analysis III Backward
selection
44

Modelling 1st Stage Nulliparae
After Backward Selection
Variable HR p-Value Clinical Interpretation
Gestational Age years 0.985 lt0.001 First Stage ?
No antepartum risks 1.279 lt0.001 First Stage ?
Oxytocin Induction 0.756 0.011 First Stage ?
Fetal Birthweight 100g 0.987 0.021 First Stage ?
Intrapartum Amniotomy 2.727 lt0.001 First Stage ?
Epidural Analgesia 0.515 0.006 First Stage ?
Epidural Analgesia Time 1.380h 0.004 Association ? with ? Time
Intrapartum Oxytocin Time 1.279 lt0.001 Association ? with ? Time
45

Modelling 1st Stage - Nulliparae
Ful Cervical Dilation
Intrapartum Oxytocin
Epidural Analgesia

46

Modelling 1st Stage - Nulliparae
Ful Cervical Dilation
Caesarean during 1st Stage
Intrapartum Oxytocin
Epidural Analgesia

47

Modelling Second Stage Nulliparae
Intrapartum Amniotomy
Spontaneous Birth

Epidural Analgesia

48

Vaginal-operative Birth
Modelling Second Stage Nulliparae
Intrapartum Oxytocin

Intrapartum Amniotomy
Spontaneous Birth

Epidural Analgesia

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Vaginal-operative Birth
Modelling Second Stage Nulliparae
Intrapartum Oxytocin

Intrapartum Amniotomy
Spontaneous Birth

Epidural Analgesia

Caesarean Section
Oxy
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Effective intrapartum Care
Qutcome ? Quality ?

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Effective intrapartum Care
Qutcome ? Quality ?
Process ? Quality ?
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The Process of Birth
Maternal Wellbeing Multiple Dimensions
Modelling
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Contributors
German Research Council MHH Dep. of OG,
Repro.Med. Prof. Dr. Peter Hillemanns Centre
for Quality and Management in Health Care at the
Medical Chamber of Lower Saxony Paul
Wenzlaff Bärbel Lorenz Standing Perinatal
Committee of Lower Saxony Prof. Dr. Rüdiger
Rauskolb Ruhruniversität Bochum Dr. Ulrich
Pötter Prof. Dr. G. Rohwer
Midwifery Association of Lower Saxony Elmire
Frick, Uschi Fietz Former Staff Katja Stahl,
Gertrud Ayerle, Susanne Simon, Dr. Cornelia
Frömke, Christiane Schwarz Students Kirstin
Hähnlein, Kathy Radtke Midwifery Students
Hildesheim Anna Ritter Oldenburg Maren
Gerlach, Alexandra Zahner Braunschweig Thuine
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