Objective : To examine whether intrapartum care and delivery of low risk women in a midwife managed delivery unit differs from that in a consultant led labour ward. Design : Pragmatic randomised controlled trial. Subjects were randomised in a 2:1 ratio between the midwives unit and the labour ward. Setting : Aberdeen Maternity Hospital, Grampian. Subjects—2844 low risk women, as defined by existing booking criteria for general practitioner units in Grampian. 1900 women were randomised to the midwives unit and 944 to the labour ward. Main outcome measures : Maternal and perinatal morbidity. Results : Of the women randomised to the midwives unit, 647 (34%) were transferred to the labour ward antepartum, 303 (16%) were transferred intrapartum, and 80 (4%) were lost to follow up. 870 women (46%) were delivered in the midwives unit. Primigravid women (255/596, 43%) were significantly more likely to be transferred intrapartum than multigravid women (48/577, 8%). Significant differences between the midwives unit and labour ward were found in monitoring, fetal distress, analgesia, mobility, and use of episiotomy. There were no significant differences in mode of delivery or fetal outcome. Conclusions : Midwife managed intrapartum care for low risk women results in more mobility and less intervention with no increase in neonatal morbidity. However, the high rate of transfer shows that antenatal criteria are unable to determine who will remain at low risk throughout pregnancy and labour.

The diagnosis of labor onset has been described as one of the most important judgments in maternity care. There is compelling evidence that the duration of both latent and active phase labor are clinically important and require consistent approaches to measurement. In order to measure the duration of labor phases systematically, we need standard definitions of their onset. We reviewed the literature to examine definitions of labor onset and the evidentiary basis provided for these definitions. Five electronic databases were searched using predefined search terms. We included English, French and German language studies published between January 1978 and March 2014 defining the onset of latent labor and/or active labor in a population of healthy women with term births. Studies focusing exclusively on induced labor were excluded. We included 62 studies. Four ‘types’ of labor onset were defined: latent phase, active phase, first stage and unspecified. Labor onset was most commonly defined through the presence of regular painful contractions (71 % of studies) and/or some measure of cervical dilatation (68 % of studies). However, there was considerable discrepancy about what constituted onset of labor even within ‘type’ of labor onset. The majority of studies did not provide evidentiary support for their choice of definition of labor onset. There is little consensus regarding definitions of labor onset in the research literature. In order to avoid misdiagnosis of the onset of labor and identify departures from normal labor trajectories, a consistent and measurable definition of labor onset for each phase and stage is essential. In choosing standard definitions, the consequences of their use on rates of maternal and fetal morbidity must also be examined.

Considerable debate surrounds the influence media have on first-time pregnant women. Much of the academic literature discusses the influence of (reality) television, which often portrays birth as risky, dramatic and painful and there is evidence that this has a negative effect on childbirth in society, through the increasing anticipation of negative outcomes. It is suggested that women seek out such programmes to help understand what could happen during the birth because there is a cultural void. However the impact that has on normal birth has not been explored.

We disagree with Hundley et al’s conclusion that there is ‘quality evidence’ to support misoprostol use. In an otherwise thorough review of misoprostol for prevention of postpartum haemorrhage (PPH) among women in low resource countries, the authors pay insufficient attention to design weaknesses and lack of generalisability of findings, overemphasizing tests of statistical significance and study type. Furthermore, the SIGN-GRADE criteria expose critical limitations in all of the studies included, both randomised and non-randomised. These are such that there are no good grounds, on this evidence, to support misoprostol use