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Italian Journal
of
Gynaecology
& Obstetrics
The Official Journal of the
Società Italiana di Ginecologia e Ostetricia
(SIGO)
March 2019 - Vol. 31 - N. 1 - ISSN 2385 - 0868
Quarterly
Partner-Graf 1
Italian Journal
of
Gynaecology
& Obstetrics
The Official Journal of the
Società Italiana di Ginecologia e Ostetricia
(SIGO)
Quarterly
Partner-Graf
Editor in Chief Vizza Enrico, Roma Editors Cicinelli Ettore, Bari Ghezzi Fabio, Varese Parazzini Fabio, Milano Editorial Board Chiantera Vito, Palermo Chiofalo Benito, Messina Corrado Giacomo, Roma De Franciscis Pasquale, Napoli Ercoli Alfredo, Novara Fanfani Francesco, Chieti Ferati Maurizio, Varese Franchi Massimo, Verona Gallotta Valerio, Roma Gambacciani Marco, Pisa Jorizzo Gianfranco, Vicenza Meroni Mario, Milano Rossitto Cristiano, Roma Scibilia Giuseppe, Catania Soligo Marco, Milano Solima Eugenio, Milano Surico Daniela, Novara Svelato Alessandro, Milano Trojano Giuseppe, Bari Vignali Michele, Milano Editorial Staff Zerbinati Roberto Zerbinati Serena Management, Administrative office Partner-Graf Srl - Via F. Ferrucci, 73 - 59100 Prato Tel 0574 527949 - Fax 0574 636250 E-mail: info@partnergraf.it The Italian Journal of Gynaecology & Obstetrics is a digital magazine. You can download it freely from: www.italianjournalofgynaecologyandobstetrics.com or www.italianjog.com
It. J. Gynaecol. Obstet.
2019, 31: N. 1
Table of contents 5
Vaginal deliveries after Cesarean section: heterogeneity of outcome according to
the hospital policies in Italy 7
Rosita Verteramo, Venelia Picarelli, Silvia Labianco, Yasmin Sara Ismail, Piergiorgio Iannone,
Ugo Indraccolo, Rosaria Cappadona, Danila Morano, Ruby Martinello, Pantaleo Greco
Breastfeeding promotion in Campania: what happens in childbirth centres? 13
Letizia Capasso, Clara Coppola, Roberta Albachiara, Marta Palma, Chiara Colinet, Speranza Cioffi,
Francesco Raimondi
Psychological risk factors in childbirth 17
Chiara Maiorani, Marco di Mario, Charles Zaiontz, M. Caterina (Ambrosi) Zaiontz
Body mass index and impact on semen quality of men attending an infertility
clinic 31
Donatella Mangione, Rosaria Schillaci, Concetta Scazzone, Antonio Perino, Alessandra Vassiliadis
Contraceptive history in women who undergo voluntary termination of pregnancy 37
Jennifer C. Tortorella, Nicola Bagetta, Maria Isabello, Giuseppina Amendola, Costantino Di Carlo
Mayer-Rokitansky-Kuster-Hauser syndrome: associated anomalies in a cohort of
77 patients 43
Alessandro Bulfoni, Francesca Motta, Giada Frontino, Daniela Alberico, Luigi Fedele
Holmium: Yag laser vaporization of low grade papillary carcinoma of bladder
during pregnancy: A case report 53
Vincenzo Spina, Andrea Rocchegiani, Pietro Cignini, Milan M. Terzic, Sanja Terzic, Felice Patacchiola,
Cristina Fabiani, Marta Mancini, Camilla Certelli, Vincenzo Bulzomì
Robotic aortic lymphadenectomy during multiquadrant surgery for gynecological
cancers with the new “Da Vinci Xi” system 59
Mariano C. Di Donna, Alessandro Lucidi, Valerio Gallotta, Giulio Sozzi, Francesco Fanfani, Marco
Petrillo, Giuseppe Vizzielli, Anna Fagotti, Vito Chiantera, Giovanni Scambia
5
It. J. Gynaecol. Obstet.
2019, 31: N. 1 Editorial
Circulating cell-free DNA in cancer management
Circulating cell-free DNA (cfDNA) is defined as extracellular DNA occurring in blood serum or
plasma. CfDNA provides rapid, cost-effective, and non-invasive “liquid biopsy” surrogates, and is
considered as a potential biomarker for the detection and monitoring of various human diseases, such
as stroke, myocardial infarction, sepsis, as well as some chronic conditions such as cancer. CfDNA
molecules are double-stranded molecules with low molecular weight than genomic DNA, in the
form of short fragments (between 70 and 200 base pairs in length) and/or long fragments up to 21 kb.
Cell death is suggested to be the major source of cfDNA. Under normal physiologic circumstances,
apoptotic and necrotic cells are cleared by infiltrating phagocytes and cfDNA levels are relatively low.
Usually, cfDNA is removed from blood by liver and kidney, and its half-life is 10 to 15 min. Nevertheless,
not all cfDNA originates from cell death. Live cells spontaneously release newly synthesized DNA as
part of a homeostatically regulated system.
Cancer patients generally have much higher levels of cfDNA than healthy individuals, but the levels
vary widely, from 0.01% to more than 90%. CfDNA content rapidly increased accumulation in blood
during tumor development is caused mainly by an excessive DNA release by apoptotic and necrotic
cells. The variability of cfDNA levels in cancer patients likely associates with tumor burden, stage,
vascularity, cellular turnover, and response to therapy. It is worth to note that cfDNA content is elevated
in various other disorders, such as infectious and autoimmune diseases, stroke, infarction and trauma,
thus specific approaches and accurate methodologies are needed to discriminate the source of cfDNA.
For blood-based genomic profiling and detection of minute amounts of cfDNA deriving specifically
from tumour tissues new technologies have been developed, such as Next Generation Sequencing (NGS)
and Droplet Digital PCR (ddPCR), but these require proof-reading measures to avoid artefacts and needs
to be controlled very well to minimize bias. However, the presence of very low amounts of cfDNA in
blood samples from early-stage cancer patients, and assessment of the possible clinical significance
of the resulting data, is still a challenge. There are also several technical difficulties challenging the
practical application of kind of analysis in cancer screening, mainly because of the technical complexity
and high cost associated.
Recently, new methodologies for accurate cfDNA measurements directly from plasma or serum
have been developed, such as the cfDNA staining using specific fluorochromes and Alu-quantitative
real-time PCR (qPCR). These methods do not require prior DNA purification, overcoming artifacts
associated with DNA isolation, and may represent simple and not expensive novel clinical tools for
routine patient management.
Challenges for routine implementation of liquid biopsy tests include the necessity of development of
a multi-marker approach that takes into account the source of cfDNA and the correlation between the
quality and the quantity of cfDNA, and clinic-pathological features of cancer patients. Further analysis
are needed in order to better optimize the accuracy and reliability of cfDNA measurements and validate
it as a useful, non-expensive and non-invasive tool for guiding personalized cancer therapy.
Finally, future orientations should include the cost assessment, the accuracy and reproducibility of
liquid biopsy in comparison with current “solid biopsy” performance to provide clinically important
actionable information for precision oncology approaches.
Prof. Enrico Vizza
Editor in Chief
6
Italian Journal of
Gynaecology & Obstetrics
March 2019 - Vol. 31 - N. 1 - Quarterly - ISSN 2385 - 0868
Vaginal deliveries after Cesarean section: heterogeneity of outcome
according to the hospital policies in Italy
Rosita Verteramo1, Venelia Picarelli1, Silvia Labianco1, Yasmin Sara Ismail1, Piergiorgio
Iannone1, Ugo Indraccolo1, Rosaria Cappadona1, Danila Morano1, Ruby Martinello1, Pantaleo
Greco1
Department of Morphology, Surgery and Experimental Medicine, Section of Obstetrics and Gynecology,
1
University of Ferrara, Italy.
ABSTRACT SOMMARIO
Objective: assessing the characteristics of some Italian Scopo: valutare le caratteristiche di alcune donne
women with previous Cesarean section and to establish Italiane con pregresso taglio Cesareo e stabilire ciò che
predictors for failure of trial of labour after Cesarean. It predice il fallimento del travaglio di parto dopo Cesareo.
was hypothesized that local policies of facilities could É stato ipotizzato che le politiche locali delle maternità
affect the success of trial of labour after Cesarean. potrebbero condizionare il successo del travaglio di
Methods: retrospective study included 328 pregnant parto dopo Cesareo.
women at term, with one previous Cesarean section Metodi: studio retrospettivo includente 328 donne
and a cephalic singleton pregnancy, enrolled in four a termine, con un pregresso taglio Cesareo ed un
hospitals of the Emilia Romagna, Italy. Multivariate feto cefalico singolo, arruolate in quattro ospedali
logistic regression models was built and assessment of dell’Emilia Romagna (Italia). Sono stati costruiti dei
heterogeneity of data (Q-statistic) was also performed. modelli logistici multivariati ed è stata anche effettuata
Results: the factors involved in the failure of vaginal birth la statistica Q per valutare l’eterogeneità dei dati.
after Cesarean seems to be the ones already reported in Risultati: i fattori che influiscono sul fallimento del parto
literature. However, even the hospital where patients vaginale dopo Cesareo sembrano essere i medesimi
delivered matters on the vaginal birth after Cesarean. riportati in letteratura. Tuttavia, anche l’ospedale in
Very high heterogeneity among hospitals was found. cui le pazienti partoriscono influisce sul parto vaginale
Conclusions: local policies about the management dopo Cesareo. È stata riscontrata una eterogeneità
of women with previous Cesarean section affect the molto alta fra ospedali.
proportion of vaginal birth after Cesarean. This finding Conclusioni: le politiche locali sul management delle
is a concern if rates of vaginal births after Cesarean are donne con pregresso taglio Cesareo influiscono sulla
compared among Italian hospitals and worldwide. proporzione di parti vaginali dopo Cesareo in Italia.
Questo riscontro è un problema se vengono confrontate
le frequenze dei parti vaginali dopo Cesareo fra ospedali
Keywords: labour; vaginal birth after cesarean; trial of Italiani e nel mondo.
labor; caesarean section.
Corresponding Author: Ugo Indraccolo
u.indraccolo@ospfe.it
Copyright 2019, Partner-Graf srl, Prato
DOI: 10.14660/2385-0868-102 7
It. J. Gynaecol. Obstet. Trial of labour after Cesarean section
2019, 31: N. 1
INTRODUCTION
In the last years the rate of Cesarean section is the one firstly reported by Grobman et al,
(CS) deliveries has increased worldwide and regarding women with one prior low transverse
a major concern has grown for the higher Cesarean and singleton vertex presentation
risks of maternal mortality and morbidity (1,2). after 36 6/7 weeks’ gestation(12). Annesi et al.(13)
Consequences of the rise in Cesarean rates include validated the Grobman’s nomogram(12) on Italian
elevated risks of complications such as placenta population, reporting a rate of successful VBAC
accreta, placenta praevia, placental abruption, of 77.9%. Factors correlated to successful VBAC
and stillbirth in subsequent pregnancies, although were Asian ethnicity, previous vaginal delivery
the stillbirth rate has remained stable over the or a previous vaginal delivery after Cesarean
last three decades(1,3). An average rate of CS of section(13). Annesi et al.(13), therefore, concluded
21.1% in developed countries is reported in the that the Grobman et al.(12) nomogram could be
literature(4,5). Europe shows the highest incidence, applied to Italian population too. As the sample
in particular: Cyprus has the highest overall of Annesi et al.(13) is not representative of the
Cesarean rate with 52.2%, followed by Italy with whole Italian population, the Authors of the
38.0%, Romania with 36.9%, and Portugal with present article would check if the Annesi et al.(13)
36.3%. Germany, Hungary, Luxembourg, Malta, conclusion is correct. We hypothesize that the
Poland, and Switzerland also have rates of 30% or policies of hospitals could affect the outcome of
higher. Only the Netherlands, Slovenia, Finland, trial of labour after Cesarean, thereby depicting an
Sweden, Iceland, and Norway have rates below heterogeneity of the outcomes of the trial of labour
20%. Between 2004 and 2010, an increase of after Cesarean.
Cesarean rate has been observed in all countries;
in Italy the increase was under 0.2%(1).
The most significant factor contributing to MATERIALS AND METHODS
overall increased CS rate is the repeated CS after Women delivering in four hospitals of the
one or more previous CSs. However, women Emilia Romagna (Italy) (Sant’Anna Hospital of
with a successful vaginal birth after previous Cona – Ferrara, hospital of Ravenna, hospital of
Cesarean delivery show lower morbidity than Lugo, hospital of Faenza) from January 2015 to
women undergoing an elective repeated Cesarean December 2015 were retrospectively screened.
delivery(6). This sample is similar to the one of the Annesi et
Trial of labor after previous Cesarean delivery al.(13), as it came from the same Emilia Romagna
should be offered to women to successfully population. Out of 4324 deliveries, 2941 (68%)
achieve vaginal birth after Cesarean delivery. women had a spontaneous vaginal birth, 140
Several guidelines recommend that vaginal (3.2%) had operative deliveries and 1243 (28.8%)
birth after Cesarean (VBAC) may be offered to had a Cesarean section. These outcomes are also
women with a singleton pregnancy of cephalic similar to the ones of Annesi et al.(13) Authors of
presentation at 37+0 weeks or beyond who have the current study enrolled women with singleton
had a single previous lower segment Cesarean pregnancy at term with only one prior low-
delivery, with or without a history of previous transverse Cesarean section in their medical
vaginal birth(5,7,8,9,10). Women who have had two history. Demographic and obstetrical data were
or more prior lower segment Cesarean deliveries extracted from the patient electronic medical
may be offered VBAC after counselling by a senior records: age, education, body mass index, history
obstetrician. Counselling should be done on the of vaginal birth, indication for Cesarean, outcome
risk of uterine rupture, on maternal morbidity and of trial of labor after Cesarean. Obesity was
on the individual likelihood of successful VBAC defined as a body mass index ≥30.
(e.g. given a history of prior vaginal delivery). The descriptive statistics were reported as
Success of reported VBAC is consistently high, means and standard deviations for the continuous
ranging from 72 % to 75% according to the variables, while rates have been used for categorical
RCOG(5); it is estimated that 60–80 % of appropriate variables. Inferential statistics were performed
candidates who attempt VBAC will be successful by using univariate tests and mulitivariable
delivering according to the American Congress of logistic regression model (backward stepwise,
Obstetricians and Gynecologists (ACOG)(5,11). conditional). To check if the model of Annesi et
Several models are available to predict the al.(13) is overall appropriate in the present sample,
probability of successful trial of labour after it would be awaited that same results of Annesi
8 Cesarean. The most utilized and validated model et al.(13) would be found by building multivariate
Trial of labour after Cesarean section R. Verteramo et al.
logistic regression models with the dependent RESULTS
and independent variables set according to the Three-hundred-twenty-eight patients had
ones reported by Annesi et al.(13) (Model I). As had one or more previous CS. Table 1 reports
the present sample is smaller than the one of rates of dependent variables along whit
Annesi et al.(13), the independent variables of the univariate comparisons. Two-hundred-thirty-
logistic regression model were simplified. They five patients underwent CS (69.5% of the total
were: Italian nationality (yes/no), age (continuous deliveries). Among patients undergone CS, 104
variable), previous Cesarean section without (44.3%) requested the Cesarean delivery (no
vaginal delivery (yes/no), university degree (yes/ other indication than previous Cesarean) while
no), obesity (yes/no). The dependent variable was indication (additional to previous Cesarean)
the VBAC. Moreover, it was built another logistic for repeated Cesarean section was found in 131
regression model (Model II) by adding another (55.7%) out of 235 CS.
independent variable: the hospital where the Table 2 reports outcomes of delivery on the
delivery occurred among the hospital of Ferrara 328 patients, disaggregated for hospitals. The
(reference category), Ravenna, Faenza and Lugo. proportion of CS on maternal request (CSMR) is
Heterogeneity among the proportions of VBAC also reported in Table 2.
in each hospital was calculated by applying the Among variables resulted involved in the
Cochrane’ Q-statistic. Fixed model was assumed. VBAC reported by Annesi et al.(13), increasing
Statistical analyses were performed by using age, previous CS without previous vaginal
SPSS 16.0 for obtaining logistic regression models, deliveries reduce the odds ratio of VBAC, while
while the Q-statistic was computed by using the university degree increases the odds ratio of a
OpenOffice.org calc.3.3. Significance was set at p VBAC (Table 3 – Model I). By introducing also
level ≤0.05. the hospital where the delivery has occurred, it
Table 1.
Descriptive statistics.
VBAC CS
p
(n = 93) (n = 235)
Italian nationality 63 (67.7%) 164 (69.8%) n.s.
Age 33.0 ±5.48 34.3 ±5.63 n.s.
Previous Cesarean section without
66 (71.0%) 219 (93.2%)
It. J. Gynaecol. Obstet. Trial of labour after Cesarean section
2019, 31: N. 1
results that the hospital of Lugo and Faenza have the VBAC rate are related to the structure of
an higher odds ratio of VBAC (Table 4 – Model the maternity care system in the country, to the
II).By appling the Q-statistics, it was highlighted liaison between midwives and obstetricians and
an high hetherogeneity among hospitals for to the care offered during pregnancy and birth(17).
VBAC (I2 95.9%). The hetrogeneity was resolved Italian pregnant women, some Gynecologists and
partitioning the variance of VBAC rate among other stakeholders feel that the CSMR is overall
hospitals in wich an higher CSMR is observed appropriate(2) and it is already reported by other
(Ravenna and Faenza) and hospitals in which Authors that Italian hospital would concede the
a lower CSMR is observed (Ferrara and Lugo), Cesareans most likely than others according to
pTrial of labour after Cesarean section R. Verteramo et al.
Table 3.
VBAC – Model I.
Unadjusted odds ratio Adjusted odds ratio
95% confidence intervals 95% confidence intervals
p p
1.448 1.448
Italian nationality 0.766-2.737 0.766-2.737
0.254 0.254
0.909 0.918
Age 0.862-0.959 0.873-0.965
0.001 0.001
0.124 0.132
Previous Cesarean section without previous
0.058-0.264 0.064-0.274
vaginal deliveryIt. J. Gynaecol. Obstet. Trial of labour after Cesarean section
2019, 31: N. 1
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12Italian Journal of
Gynaecology & Obstetrics
March 2019 - Vol. 31 - N. 1 - Quarterly - ISSN 2385 - 0868
Breastfeeding promotion in Campania: what happens in childbirth
centres?
Letizia Capasso1, Clara Coppola1, Roberta Albachiara1, Marta Palma1, Chiara Colinet1, Speranza
Cioffi1 e Francesco Raimondi1 on behalf of Campania Section of Italian Society of Neonatology
University Federico II of Naples, Dept. of Translational Medicine, Section of Neonatology.
1
Campania section of Italian Society of Neonatology are: Attilio Romano, Alessandro Scoppa, Letizia
Capasso, Roberto Cinelli, Raffaele Coppola, Antonio Criscuolo, Sergio Maddaluno and Elena Bernabei.
ABSTRACT SOMMARIO
Italian Ministry of Public Health and the most Nel 2015 il Ministero della Salute insieme con le
important Scientific Societies held a technical meeting principali società scientifiche ha emanato un documento
in 2015 to subscribe a unifying document, containing tecnico contenente raccomandazioni sulla promozione
recommendations on the best practice in breastfeeding. dell’allattamento materno. Lo scopo di questo lavoro
Objective of this study is to evaluate childbirth centres’ è quello di valutare l’adesione dei centri nascita in
adherence in Campania region to such recommendations Campania alle politiche di promozione dell’allattamento
on breastfeeding promotion. This is descriptive, al seno. Si tratta di uno studio descrittivo
observational study through a email questionnaire osservazionale, basato sulla somministrazione, a tutti
send to each childbirth centre in Campania region, i centri nascita campani di un questionario a risposta
structured in 4 items (centres characteristics, health chiusa, erogato tra Dicembre 2016 e Gennaio 2017.
professionals’ formation, structure organization, L’analisi da noi condotta rappresenta una fotografia
promoting breastfeeding programme) regard breast della situazione attuale campana, mettendo in luce
feeding promotion. Our results show that childbirth l’organizzazione dei punti nascita in relazione alla
centres appear quite updated in perinatal care (birthing promozione dell’allattamento materno. Le strutture
classes, precocious skin to skin contact, rooming sanitarie analizzate in parte hanno recepito la necessità
in, 24-hour-open nursery) although they need to be di riorganizzare l’assistenza perinatale (corsi pre parto,
further improved. In conclusion, we identified as contatto skin to skin precoce, rooming in, nido aperto,)
field of improvement for breastfeeding promotion in modo da favorire la promozione dell’allattamento
in Campania as recommended by Public Minister of materno ma è necessaria una ulteriore implementazione
Health that “rooming in “ needs to be 24/24H, the di tale riorganizzazione. In conclusione abbiamo
skin to skin contact needs to be extended to the first 2 individuato come aree da implementare per migliorare
hours. Moreover, two areas must be improved too: on l’aderenza alle raccomandazioni sulla promozione
obstetrician side, to reduce the caesarean delivery rate dell’allattamento materno in Campania che il rooming
(nowadays the highest in Italy), and on the paediatric in deve essere 24/24 H, il contatto skin to skin deve
one, to avoid faulty behaviours (excessive use of glucose essere preferibilmente per le prime 2 ore dopo il
solution and of formula milk before breast feeding parto. Tale miglioramento non può prescindere dal
initiation). ridurre il tasso dei tagli cesarei, tra i più alti in Italia
e di centri nascita con meno di 1000 parti per quanto
Keywords: breast feeding; neonate; birth centre riguarda la parte ostetrica ma è necessario anche un
organization. maggior impegno nell’evitare da parte dei pediatri la
prescrizione di latte o glucosata in attesa della montata
lattea se non strettamente necessario.
Corresponding Author: Letizia Capasso
letizia.capasso@gmail.com
Copyright 2019, Partner-Graf srl, Prato
DOI: 10.14660/2385-0868-103 13It. J. Gynaecol. Obstet. Report on promotion of breastfeeding in birth centres of Campania region
2019, 31: N. 1
INTRODUCTION
Breastfeeding is nowadays widely 54 (46,3%) organized classes for physicians, nurses
recommended, thanks to WHO and scientific and other operators, to update in theme of EBF
societies’ effort in promoting breastfeeding, based and how to promote it. Sixty-one of interviewed
on solid, published researches(1,2). However, people stated to be aware of the Position Statement
exclusively breastfeeding (EBF) prevalence isn’t content and 55,5% of centres (30/54) have an
barely sufficient in Italy. Italian Ministry of Public internal protocol on EBF (Table 2). In the second
Health and the most important Scientific Societies cluster of question, we evaluated structural and
held a technical meeting in 2015, to subscribe a organizational characteristics, and routinely
unifying document, containing recommendations practice in neonatal feeding. We found out that the
on the best practice in breastfeeding (operators’ so-called “skin to skin procedure” (which consists
learning, moms’ self-efficacy and ways of in keep in contact mother and newborn, soon after
promoting EBF) (3,4). Although, updated data childbirth), considered fundamental for mother-
are needed to assess the effectiveness of these son bonding, is adopted in 81% of delivery. This
interventions and the real adherence to such rate refers predominantly to spontaneous delivery
recommendations. Objective of this study is to than caesarean sections and for few minutes after
evaluate childbirth centres’ adherence in Campania birth. Fifty units (92,89%) allow rooming in, that
region to recommendations on breastfeeding only for the 42,6% of them is a 24 hours rooming
promotion, established by the main Italian in. In the remaining centres, the mean duration
scientific society (SIN, SIP, SIPPs.) with the Italian of rooming in is about 14 hours per day (from a
Ministry of Public Health. Recommendations minimum of 2 to a maximum of 20 hours). The
are summarized in one document, “The Position 72,2% of childbirth centres have a 24-hours-
Statement on Breastfeeding and use of human open nursery (39/54) where mothers can visit
milk, 2015”(4). their babies whenever they want (Table 3). In
50 cases (92,6%) there are operators (i.e. nurses)
dedicated to education and mothers’ care during
MATERIALS AND METHODS breastfeeding. We also found out that 46.3% of
In our descriptive, observational study, we neonatal care units use glucose solution waiting
send by email a questionnaire to each childbirth for breastfeeding initiation, while the 25.9% of
centre (54/54) in our region, structured in 4 items units use formulated milk. In addition, 44 centres
(centres characteristics, health professionals’ on 54 usually prescribe formula if a weight loss
formation, structure organization, promoting greater than 10% is observed, while 7 on 54
breastfeeding programme) regard breast feeding usually suggest formula even in case of lower
promotion. We interviewed, by phone or email weight loss. Almost half of centres (52%, 28/54)
from December 2016 to January 2017, chiefs or set up an appointment to check out weight and
physician in charge of every nursery in Campania. auxological parameters, generally within 6 days
All data collected have been analysed using from discharge (53,6% of cases), in 28,6% of centres
parametrical analysis, through statistical software after the first week and in 14,3% of centres (4/28)
SPSS version 21. timing is not well defined. We also evaluated
arrangement and quality of every unit promotion
programme with the last part of our questionnaire.
RESULTS Thirty-one neonatal care unit (57,4%) set up
Our analysis reached the overall childbirth birthing classes for pregnant women, during
centres in Campania (54 structures); 74% of them which there is a session dedicated to BF. In 51,85%
are public health centres. 51,8% of them counts an of centres mothers received empowerment on
annual birth rate over 1000, despite Italian public BF with information materials, which are often
health programme has planned to close centres paper brochures (24 cases), seldom multimedia
with less than 1000 births/year. The average system (1 case) or both (2 cases). Forty-five on
prevalence of caesarean sections (CS) has been 54 neonatologists interviewed judged mothers’
56% in 2016, with a minimum of 24% registered compliance to BF quite good when a correct
in only one birth centre and a maximum of 90% educational programme during peripartum and
in three different structures (Table 1). According puerperal period has been done.
to the health professionals’ formation, 25 unit on
14Report on promotion of breastfeeding in birth centres of Campania region L. Capasso et al.
Table 1. DISCUSSION
Main characteristics of the birth centres in Campania region.
The latest data about national birth rate have
been collected by Italian Institute of Statistics
(ISTAT) in 2013 and 2015(6). There are not available
regional data, except for CEDAP 2014 report(7).
Our study represents a collection of updated
(2016) complete regional data on birth centres and
promotion of breastfeeding in Campania region.
Despite the regional public health planning, in
Campania there are still too small childbirth
centres, which count less than 1000 newborns
per year (51,85%); also, there is also a high rate
of caesarean delivery, around 56% of delivery. It
is probably a consequence of the high numbers
of small birth centres even if the trend of CS is in
reduction, compared to the 58,9% registered two
years ago. Reduction of CS is a goal of regional
health service that will improve also the rate of
breastfeeding after birth as universally recognized
Table 2. because natural delivery allows more the skin-to-
Health Professionals’ formation on breast feeding promotion in skin contact and the initiation of BF.
Campania. We proved that there are classes and
educational programmes dedicated to physicians
and nurses on BF, in almost half of our regional
structures (46%), and there is a sufficient
consciousness of ministerial recommendations on
breastfeeding promotion and diffusion of internal
operative protocols. These strategies need to be
implemented to most all the birth centres because
fundamental to improve EBF. These features
are indeed recognized to be necessary to join
the “Baby Friendly Hospital Initiative – BFHI”,
promoted by Unicef.
Part of our questionnaire (Table 3) evaluated
organisational matters in hospitals/health centres
because published data stress the relationship
between these aspects and the quality of care and
BF(9,10). Our data show a wide spread of “skin to
Table 3. skin” procedure (performed in 81% of centres) but
Main characteristics of the birth centres in Campania region. it is predominantly for spontaneous delivery and
Skin to skin refers predominantly to spontaneous delivery and for
only few minutes after birth. only for few minutes after birth not for the first
2 hours as suggested in guidelines for promotion
of breastfeeding. Such as the culture of “rooming
in” needs implementation because the most of
birth centres (92,89%) have rooming in but less
than one half of the centres have rooming in
24/24 that is one of the principal determinant
for implementation of breast feeding. Indeed,
the use of breast milk need to be implemented
also in Neonatal Intensive Care Unit were since
the beginning because the premature babies
are depleted of Immunoglobulins to fight the
infections and the colostrum is the only source
for mucosal IgA that aren’t producted in neonatal
period(11,12,13). 15It. J. Gynaecol. Obstet. Report on promotion of breastfeeding in birth centres of Campania region
2019, 31: N. 1
Although local health units made remarkable of the adherence to “The Position Statement on
efforts in these fields, other improvements are Breastfeeding and Use of Human Milk, 2015” of
essential in first neonatal care to promote BF, Ministry of Health. We gave voice to operators’
especially in nutritional choices. While ministerial point of view of any birth centre of the region.
guidelines do not support artificial nutrition in Regional childbirth centres regard EBF promotion
first hours/days of life if not strictly necessary, we appear quite updated in perinatal care (rooming
found out that lots of centres use glucose solution in, 24-hour-open nursery, birthing classes)
or formula while waiting for breastfeeding although they need to be further improved.
initiation. In addition, some neonatologists usually Especially “rooming in“ needs to be 24/24H,
prescribe formula milk for baby with weight the skin to skin contact needs to be extended to
loss lower than 10%, and this behaviour is not the first 2 hours after birth with the accurate
advisable. A positive result can be registered about monitoring of the safety of mothers and child. Two
birthing classes, organized in 31 childbirth unit on areas must be improved too: on obstetrician side,
54, with a distinct section for EBF, very useful to to reduce the caesarean delivery rate (nowadays
educate parents and promote EBF; moreover about the highest in Italy), and on the paediatric one, to
one half of the centres give informative papers to avoid faulty behaviours (excessive use of glucose
mothers to support breastfeeding. These strategies solution and of formula milk before BF initiation).
improve mothers’ compliance to EBF, according to Right now, there is not any other similar regional
health professionals. study on promotion of BF in birth centres to make
In conclusion, although this research has some a comparison. We hope that our results could
limits, such as the phone interview, which could be enriched and completed in the next years, to
be not objective, we strongly believe in this work, evaluate the overall accomplish of public health
as a picture of the actual situation in Campania politic choices in our Region.
REFERENCES
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strategy for infant and young child feeding. Geneva: 9) Chung M, Raman G, Trikalinos T, Lau J, Ip
WHO; 2003. Available from: www.who.int/nutrition/ S Interventions in primary care to promote
publications/infantfeeding/ 9241562218/en/. breastfeeding: an evidence review for the U.S.
2) American Association of Pediatrics Policy statement. Preventive Services Task Force. Ann Intern Med. 2008
Breastfeeding and the use of human milk. Pediatrics Oct 21;149(8):565
2012; 129:827-41. 10) Kronborg et al., Health visitors and breastfeeding
3) Tavolo tecnico operativo interdisciplinare per la support: influence of knowledge and self-efficacy, Eur.
promozione dell’allattamento al seno - Report del 10 J. Public Health, 2008 Jun; 18(3):283-8 Epub 2007 Dec 26
dicembre 2014; revisione dell’11 maggio 2015 11) Capasso L, Borrelli AC, Parrella C, Lama S, Ferrara
4) D’Avanzo et al., Allattamento al seno e uso del T, Coppola C, Catania MR, Iula VD, Raimondi F. Are
latte materno/umano Position Statement 2015 di IgM-enriched immunoglobulins an effective adjuvant
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di Neonatologia (SIN), Società Italiana delle Cure 12) Capasso L, Borrelli AC, Ferrara T, Coppola C,
Primarie Pediatriche (SICuPP), Società Italiana di Cerullo J, Izzo F, Caiazza R, Lama S, Raimondi F.
Gastroenterologia Epatologia e Nutrizione Pediatrica Immunoglobulins in neonatal sepsis: has the final
(SIGENP) word been said? Early Hum Dev. 2014 Sep;90 Suppl
5) L. Lauria et al. Prevalence of breastfeeding in Italy: 2:S47-9.
a population based follow-up study. Ann Ist Super 13) Capasso L, Borrelli AC, Pirozzi MR, Bucci L,
Sanità 2016 | Vol. 52, No. 3: 457-461 Albachiara R, Ferrara T, Raimondi F. IgM and IgA
6) Epicentro, ISTAT, Allattamento al seno Aspetti enriched polyclonal immunoglobulins reduce
epidemiologici, http://www.epicentro.iss.it/ short term mortality in extremely low birth weight
argomenti/allatt infants (ELBW) with sepsis: a retrospective cohort
7) M. Triassi et al., Rapporto sulla Natalità in Campania study. Minerva Pediatr. 2018 Feb 19. doi: 10.23736/
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16 8) Comitato Italiano per l’UNICEF Onlus, Standard perItalian Journal of
Gynaecology & Obstetrics
March 2019 - Vol. 31 - N. 1 - Quarterly - ISSN 2385 - 0868
Psychological risk factors in childbirth
Chiara Maiorani1, Marco di Mario2, Charles Zaiontz3, M. Caterina (Ambrosi) Zaiontz4
1
Psychologist, Psychotherapist, Independent researcher.
2
Department of Obstetrics (Director)-Maggiore Hospital, Lodi, Post graduate school of specialization in
obstetrics and gynecologyUniversity of Pavia.
3
Independent researcher.
4
Psychology Unit, IES Abroad c/o Università Cattolica del Sacro Cuore, Milano.
ABSTRACT SOMMARIO
Objectives: The purpose of this study was to investigate Lo scopo della presente ricerca è investigare l’influenza
the influence that psychosocial risk factors in pregnant di fattori psico-sociali nelle gestanti sulle complicanze
women have on medical complications during child mediche al parto e del post-partum. Questo studio è
delivery and in the post-partum period. basato su un campione di 500 gestanti. Il protocollo si basa
Methods: This study was based on a sample of principalmente su questionari standardizzati (SCID-
500 pregnant women. The protocol consists of a II, PDPI, PPQ-Modified) ed è diviso in quattro sezioni
questionnaire based on standardized questionnaires somministrato nel terzo trimestre di gravidanza (parti 1
(SCID-II, PDPI, PPQ-Modified), divided into four e 2 indagano il tipo di personalità e la presenza di fattori
sections, administered in the third trimester of rischio insorti durante la gravidanza) al parto (parte 3 è
pregnancy (part I and II investigate personality type and costituita da una scheda di registrazione compilata con
risk factors arising during pregnancy), at child delivery i dati contenuti nella cartella clinica) e 2 mesi dopo il
(part III compiles data from the clinical file) and two parto (parte 4 è costituita da un questionario che rileva
months post-partum (part IV identifies the presence of la presenza del Disturbo Post traumatico da stress
post-partum post-traumatic stress disorder, PP-PTSD). post-partum, PP-PTSD). Le analisi hanno rilevato una
The statistical analyses found significant correlations correlazione tra fattori psicosociali e dati demografici
between identifiedpsycho-social and demographic con le complicanze durante il travaglio e il PP-PTSD.
information and complications during labour and post- Le correlazioni più significative emerse sono state (1) la
partum PTSD. settimana in cui avviene il parto e la nazionalità, (2) il
Results: The most significant correlationswere (1) Birth PP-PTSD e il profilo di personalità Borderline, l’Ansia e
Week with Nationality, (2) PP-PTSD with Borderline la Depressione e lo stato generale di salute (3) PP-PTSD
personality, Anxiety, Depression and overall Health, e la soddisfazione lavorativa e (4) le preoccupazioni il
(3)PP-PTSD with work satisfaction and (4) the need tipo di personalità Borderline e l’utilizzo dell’epidurale.
for Epidural with Worries and Borderline personality. Utilizzando la regressione logica emerge che l’età è
Logistic regression models were developed to predict predittiva del tipo di parto, il livello globale di salute
Birth Type from Age; PP-PTSD from Overall Health and autopercepito. Il tipo di personalità Borderline è
Borderline personality; and the need for Epidurals from predittiva del PP-PTSD, unitamente alle preoccupazioni
Borderline personality and Worries. rispetto al parto predittive dell’utilizzo dell’epidurale.
Conclusions: The study shows that a number of psycho- Lo studio mostra la significatività dell’impatto di fattori
social factors in expectant mothers do impact aspects of psico-sociali identificabili sull’esperienza del parto.
the childbirth experience.
Keywords: post partum; post traumatic stress disorder;
epidural; borderline personality.
Corresponding Author: Chiara Maiorani
chiaramaiorani@gmail.com
Copyright 2019, Partner-Graf srl, Prato
DOI: 10.14660/2385-0868-104 17It. J. Gynaecol. Obstet. Psychological risk factors in childbirth
2019, 31: N. 1
INTRODUCTION
The World Health Organization defines Health the couple towards the family have an important
as “a state of complete physical, mental and social preventive potential on the well-being of the
well-being and not merely the absence of disease individual and of the newly formed family.
or infirmity”(8). According to WHO, medical The research project aims to bridge the gap
clinical practice is moving towards humanization between obstetrics and perinatal psychology in
of care, and so attention should be given not order to integrate the study and assessment of
only to organic factors, but also to psychological, psychological and social aspects with the medical
relational and social aspects. Based on these aspects and improve the stages of diagnostic
considerations, we devised a research project with investigation and therapeutic protocols.
the aim of investigating the possible correlation The M.A.T.E.R. project (Maternal Adjustment
between medical and social and psychological Transcultural Empowerment Representation) was
aspects in the childbirth experience. therefore developed. This project has led to the
In Italy, the perinatal psychology scenario introduction of a comprehensive psychological
is rather multifaceted. Clinical care is mostly approach to perinatal care in the Department of
entrusted to local services and the network Obstetrics and Genecology at “Maggiore Hospital”
between local and hospital services does not in Lodi, Italy.
always guarantee continuity of care and also a The psychological framework of reference
sufficiently long follow-up on individual cases. that guided our clinical practice was the
On the other hand, the transition to motherhood transcultural model (7) that conceptualizes
is a focal point in the life of the future mother transition to motherhood as a dynamic process
and child, a moment of vulnerability that can in which physical, mental and social factors
activate or reactivate psychological discomfort. interact within a context strongly influenced by
Childbirth is a life event that carries potential risks culture. The transcultural approach is based on
and complications. The psychological distress empowerment through psychoeducation and the
of the mother, her insecurity or self-perception analysis of representation structured through life
of incapacity may therefore have negative experience in a cultural context. The transcultural
influences on the attachment bond with the child. psychoeducational model provides the clinical
Attachment theory(6,7,8), as well as highlighting framework upon which the intervention is
the central role of the parent-child relationship structured. “Informed consent” was obtained
in the development of the mental functioning in from all the participants, which helped the
the child, also addresses an additional perspective clinicians secure a better therapeutic alliance and
which entails that when parents assume the compliance.
parental role they act on the basis of expectations The purpose of this research was to investigate
and modalities that refer to past experiences with the influence of personality types, stressful and
their attachment figures. It is an unconscious belief traumatic events in pregnant women on child
system in which the primary relational experiences delivery complications and the adjustment process
of the individual are integrated and synthesized(29). in the post-partum period.
These cognitive and emotional models are In the statistical analysis, for every complication
then stored from birth and constitute a wealth of identified the researchers analyzed
implicit relational memories. Such memories can • the correlation between the complications
be reactivated at any time by conditioning the in child delivery and risk factors or
emotions and behavioural reactions and the way demographic factors
of processing information without awareness of • the combination of risk factors and
memory(27,19). complications in child delivery
Numerous studies have examined the
relationship between post partum depression and
dysfunctional attachment, demonstrating that METHODS
maternal depression is associated with an irritable The present study was carried out at the
and/or inconsistent mode of care. During the Obstetrics Department of the Maggiore hospital in
vis-a-vis mother-child interaction the success of Lodi, Italy in the following timeframes:
the adaptive reciprocity is modulated by mutual • Collection of protocol: from November
adaptation intent(10). 2012 to January 2015
Targeted diagnostic and therapeutic actions • Collection of clinical data from the
18 in this phase of transition of the woman and of hospital records: from January 2013 toPsychological risk factors in childbirth C. Maiorani et al.
February 2015 rekindling of the traumatic event.
• Data entry (and revision): from July 2013 The MATER questionnaires were administered
to July 2015 starting from the third trimester of pregnancy.
• Statistical Analysis: from September 2015 The questionnaire was structured according to the
to November 2015 principles of the bio-psycho-social-cultural model
• Results: December 2015 and was divided into the following four sections:
The study is based on a sample of 500 Section I: Investigates a woman’s self-perception
pregnant women, most of whom were Italian, of health before pregnancy in order to identify
who were participants in a preparatory course personality-bound risk factors using the criteria
for child delivery conducted at the hospital. of the SCID-II questionnaire, presence/absence
The questionnaire was administrated by the of stressful and/or traumatic events, quality of
psychologist during the first meeting of this course. relationship and demographic factors.
The questionnaire was proposed to all the course Section II: Investigates the possible presence of
participants, but participation was voluntary. The risks that arise during pregnancy.
procedures followed were in accordance with Section III: Focuses on delivery, exploring
the ethical standards of the hospital and with the the presence of pre- and post-natal complications
Helsinki Declaration of 1975, as revised in 1983. involving clinical data from the hospital’s records.
The study uses a protocol which consists of an Section IV: Aims at identifying possible
extensive questionnaire called M.A.T.E.R. that is medical complications in the post-partum
based primarily on the following standardized period and the presence of Post-Partum Post
questionnaires: Traumatic Stress Disorder (PP-PTSD) through the
• Structured Clinical Interview for DSM IV administration of PPQ-Modified, functioning as a
for Axis II Personality Disorders (SCID-II)(15) preliminary assessment for post-partum PTSD.
• Postpartum Depression Predictors Sample characteristics: The study was based
Inventory (PDPI)(5) on a sample of 500 women, although not all
• Postpartum Personality Questionnaire the women answered all the questions in the
(PPQ-Modified)(9). questionnaire. The following is a summary
The criteria for choosing these questionnaires of the characteristics of the sample. We begin
were the following: with demographics: age; marital, education
• Self-administered and employment status; job satisfaction and
• The number of items (the scale had to be nationality.
complete and the total number of items Age: The age of the women in the study varied
had to be such to allow the administration from 17 to 45, with 91.2% between 26 and 40. The
in 30-40 minutes. average age was 32.2, with a median of 33.
• The scale had already been successfully Marital status: 64.4% of the women were
used in other research in Italian contexts married, an additional 29.0% were living with
• They had to have the most international their partner and 6.6% were single, divorced or
possible validation widowed.
The self-administered SCID-II questionnaire Economic status: Of the 479 women providing
provides an overview of the type(s) the expectant their economic status, the split among low, low-
motherpersonality, investigates the presence median, median, median-high and high was 2.9%,
of dependent, avoidant, obsessive, paranoid, 11.1%, 69.7%, 15.4% and 0.8%.
depressive, borderline personality traits. Educational level: The highest educational
The Post partum Depression Predictors level obtained split among elementary school,
Inventory (PDPI) is a check list that helps detect the high school, graduated high school, 4-year college
presence of potential risk factors for post partum degree, 5-year college degree and graduate degree
depression such as marital status, socio-economic was 1.2%, 8.4%, 46.0%, 11.4%, 22.1% and 10.8%.
difficulties, and the impact of an unexpected and Employment: The split among full-time
unplanned pregnancy. employment, part-time employment, self-
The Post partum Post-traumatic Stress Disorder employment, occasional, student and unemployed
Questionnaire (PPQ-Modified) is a questionnaire was 69.5%, 10.2%, 7.0%, 1.2% and 1.6%.
composed of 14 yes/no questions that detect Job satisfaction: Of the 472 women responding
the presence of post traumatic symptoms in to this question, 24.4% were very satisfied with
post-partum, such as an increase in arousal, the their job, 60.0% were somewhat satisfied, 11.0%
avoidance of aspects related to childbirth and the were not very satisfied 4.7% and were dissatisfied. 19It. J. Gynaecol. Obstet. Psychological risk factors in childbirth
2019, 31: N. 1
Nationality: Of the 487 women who responded An aggregate score of 0 to 40 was calculated
to this question, 91.4% were Italian. One (0.2%) based on the weights for each type of stressor as
was from Eastern Europe and all the rest were follows: financial problems (3), relational problems
from Northern or Western Europe. Of those with (5), personal health (4), scholastic (2), migration (5),
a partner, 93.1% were of the same nationality as health of a dear one (4), moving (2), work loss (5),
their partner. work change (4) and death of a dear one (6).
Demographic summary: Based on the above Based on the aggregate score, an assessment
characteristics, the “typical” subject was a 32 was made as follows: 0-9: little stress, 10-20:
years-old Italian woman, married to an Italian moderate stress and 21-40: very stressed.
man, employed full-time, somewhat satisfied Worries: Each woman in the study was asked
with her job, of median economic status, and with to rate the following eight types of worries during
a high school or college degree. labour from 0 to 7, where 0 = no worry and 7 =
Overall health: The subjects were asked to rate extremely high level of worry: start of labour,
their overall health from 1 (best) to 5 (worst). 25% admission to hospital, labour, moment of birth,
gave themselves a rating of 1, 69.4% a rating of 2, pain, complication for the mother, complication
5.6% a rating of 3 and no one a rating of 4 or 5. for the baby and post-birth.
Personality disturbances: The women were An aggregate score of 0 to 56 was then
asked questions to evaluate whether they had calculated. Based on the aggregate score, an
any of seven personality disturbances (based on assessment was made as follows: 0-34: little worry,
SCID II). The distribution of responses is shown 35-42: moderate worry and 43-56: very worried.
in Table 1. Table 3 displays the distribution of the 500
Post-partum depression: Three factors women into the three assessment categories for
predictive of post-partum depression were stressors and worries.
evaluated using standard PDPI scores. The results Note that for stressors the distribution is
are shown in Table 2. heavily skewed towards little stress, with 27.6%
Stressors: Each woman in the study was asked of the women scoring 0. For worries, 19.6% of the
whether she was experiencing any of 10 types women had a score of 0; excluding these women,
of stressors, where 1 = she was experiencing the the remaining sample for worries was more
stressor and 0 = she was not experiencing the normally distributed with a mean of 32.8.
stressor.
Table 1.
Personality Disturbances.
Avoidance Dependence OCD Depression Paranoid Narcissistic Borderline
Absence of
82.8% 94.0% 43.2% 92.0% 86.0% 94.2% 73.3%
disturbance
Disturbance,
below 7.4% 3.8% 15.2% 5.0% 4.4% 3.4% 8.0%
threshold
Disturbance,
above 9.8% 2.2% 41.6% 3.0% 9.6% 2.4% 18.7%
threshold
Table 2. Table 3.
Sleep Disorder, Anxiety and Trauma. Stressors and Worries.
Sleep
Anxiety Trauma Stressors Worries
Disorder
Absence of
81.3% 42.6% 49.1%
disturbance Little 74.8% 60.9%
Disturbance,
below 16.9% 44.2% 49.1%
threshold Moderate 23.2% 22.8%
Disturbance,
above 1.8% 13.3% 1.8% Very 2.0% 16.2%
threshold
20Psychological risk factors in childbirth C. Maiorani et al.
Post-partum PTSD: Following their delivery, blood. 22.7% lost 501-1,000 ml and 3.5% more than
each woman in the study answered 14 questions 1,000 ml.
to assess their risk for post-partum PTSD. They For fetal pH, the baseline is more than 7. For
gave a score of 0, 1, 2, 3 or 4 to each question. The 3.4% of the women the pH was 7, while for 0.5%
scores were then added to yield an aggregate score the pH was between 6 and 7. None had a pH less
between 0 and 56. Note that 246 of the 500 women than 6.
did not participate in this part of the study. Satisfaction with the questionnaire: The
The highest score obtained was 29, the lowest women were asked to rate their satisfaction
0, with most scores in the range 0 to 8. The mean with the questionnaire. Of the 493 women who
score was 5.6. An aggregate score of 0-18 was responded, only 7 (1.4%) were not satisfied with
viewed as low risk and 19 or higher as high risk. the questionnaire. The other 466 women (98.6%)
Only 3.4% of the women were at high risk. In were satisfied with the questionnaire.
fact, only 13.0% of the women had a score of 12
or higher.
Breast feeding: 252 of the 500 women in the RESULTS
study answered the question about breast feeding We performed various statistical analyses
their baby. 54.4% said they would use breast- to determine whether there is an association
feeding, 32.5% said they would use formula and between (1) age, nationality, personality factors
13.1% said they would use a combination of both. (OCD, paranoid, narcissistic and borderline), PDPI
Clinical Complications: Following the birth of factors, overall health, job satisfaction, worries
the baby, the medical staff assessed various aspects and stressors and (2) medical complications, post-
of each woman’s labour and birth, especially partum PTSD and breast-feeding.
those related to complications. These results are The analysis was done using the Real Statistics
summarized in Table 4. statistical software package (www.real-statistics.
Here, the baseline for the birth week (or com) based on the following tests/models:
number of weeks of pregnancy) is 37-41 weeks. two sample t test, Mann-Whitney test, Chi-
Only 2.8% of the births were in 35-36 weeks, 2.8% square independence test (Pearson’s, Maximum
in 30-34 weeks, none earlier and 10.8% in more Likelihood and Fisher exact test), ANOVA,
than 41 weeks. Welch’s ANOVA, Games-Howell, Contrasts and
For birth type, the baseline is spontaneous. Logistic Regression. Generally, we tested for
10.6% of the women had an elective Caesarean, statistical significance with 95% confidence (i.e.
13.8% had an urgent Caesarean and 3.8% required alpha = 0.05).
vacuum extraction. Age comparisons: Columns 2 and 3 of
The baseline for labour duration is 0-12 hours. Table 5 summarize the p-values of the t and
6.3% of the labours lasted 13-15 hours and 0.5% Mann-Whitney tests used to determine whether
lasted more than 15 hours. there was a substantial difference in the ages of the
69.0% of the women in the sample did not use women who had medical complications (baseline
oxytocin in the first stage of labour (baseline), vs. non-baseline) and post-partum PTSD (low risk
while 31.0% did. Also 52.0% of the women did not vs high risk).
have an epidural (baseline), while 48.0% did. Columns 4 and 5 of Table 5 summarize the
The baseline for laceration is no episiotomy. p-values of the ANOVA and Welch’s ANOVA tests
80.8% had an episiotomy, 7.6% had vaginal used to determine whether there is a substantial
perineal lacerations of the first or second degree difference in the ages of the women among the
and 7.6% had vaginal perineal lacerations of the various categories of Birth Week, Birth Type,
third degree. Laceration and Hemorrhage complications as well
For hemorrhaging, the baseline is 0-500 ml of as among the three categories of breast-feeding.
Table 4.
Clinical Complications.
Birth Labor
Birth Type Oxytocin Epidural Laceration Hemorrhage Fetal pH
Week Duration
Baseline 83.6% 71.8% 93.1% 69.0% 52.0% 11.1% 73.8% 96.4%
Outside
16.4% 28.2% 6.9% 31.0% 48.0% 88.9% 26.2% 3.6%
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