Objectives
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. We sought to identify the current definitions, prevalence, risk factors and preventive interventions for PPH.
Methods
We searched the National Guideline Clearinghouse, the Cochrane Library, PubMed and Ichushi Web beginning through November 2011. We performed a systematic literature review. After title and abstract screening, study quality was assessed.
Results
Blood loss from genital tract of 500mL or more in the first 24 hours after the delivery is defined as PPH. Recently in Japan, 800mL or more was diagnostic criteria for abnormal bleeding after vaginal delivery. Severe PPH was defined as 1000 mL or more and was more important in terms of maternal health. The prevalence of PPH, (blood loss over 1000 mL after vaginal delivery), in Japan was 2-5 %. Risk factors identified during pregnancy were: macrosomia, recurrence of PPH, multiple gestation, grandmultiparous (4 and more), maternal age over 35 years, low-lying placenta, polyhydramnios, antepartum hemorrhage, obesity (BMI is 25 and over), severe anemia, uterine myoma, and history of cesarean-section, PIH (Pregnancy Induced Hypertension), post-term delivery. Prolonged first and second stage labor, prolonged third stage labor, chorioamninitis, induction of labor, assisted delivery retained placenta, anomaly of the rotation, vaginal laceration and Kristeller maneuver were risk factors identified during delivery. Effective preventive interventions were active management strategies to promote uterine contractions in the third stage of labor; especially prophylactic uterotonics, nipple stimulation for induction of labor, breast feeding after the delivery of baby.
Conclusions
PPH is no longer unusual in Japan. It appears that some PPH cases are preventable by risk screening and preventive interventions. Based on the results of this literature review we should develop PPH prevention guidelines for midwives.

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Purpose
This study examines the reliability and validity of a newly developed scale measuring wives' satisfaction with husbands' supportiveness during pregnancy, and tests the scale's usability.
Methods
Participants were couples undergoing their first pregnancy. Among the 800 couples recruited, 376 responded to the questionnaire and 277 were included in the analysis.
The "Scale of wives' satisfaction with husbands' supportiveness during pregnancy" assessed the wife's perceptions of supportiveness and the husband's perceptions of supportiveness. The content validity was confirmed. Couples were asked to indicate if they agreed or disagreed with each test item, using a 5-point Likert-type scale. The Quality of Marriage Index (QMI) and the Subjective Well-Being Inventory (SUBI) were used to examine the criterion-related validity of the scale.
Results
Three factors emerged from factor analysis: "Empathy for wives' feelings and health," "Support in doing housework," and "Communication between the couple relating to the birth of their baby." These factors were found to be suitable components of the scale. The correlation (r) between the wives' scale and the QMI was between .20 and .63 (p<.01-.05), while that between the husbands' scale and the QMI was between .25 and .50 (p<.01-.05). The correlation between the wives' scale and the SUBI was between .20 and .53 (p<.01-.05). These results confirm the criterion-related validity of the scale. The Cronbach's alpha coefficient was between .76 and .86 (the wife's scale), and between .80 and .86 (the husband's scale). The split-half reliability coefficient was between .86 and .91 (the wife's scale), and between .86 and .90 (the husband's scale), which indicated a high internal consistency.
Conclusion
The reliability and validity of the newly developed scale were tested by analyzing the couples' perceptions. Internal consistency was found to be high, and the validity of the scale was confirmed. The developed scale will contribute to supporting individual couples during pregnancy and it was indicated that useful in critical situations.

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Purpose
The purpose of this study was to identify intrapartum factors that are associated with the prevalence of urinary incontinence in the early postpartum period (3-5 days after delivery) and 3 months after delivery and to compare the prevalence of urinary incontinence after spontaneous delivery with its prevalence after assisted delivery and clarify the difference.
Subjects and Methods
A retrospective cohort study was conducted with 421 parturients who had given birth to a single full-term infant by vaginal delivery on obstetrics and gynecology units in metropolitan Tokyo as the subjects. After conducting a self-report questionnaire survey in regard to urinary incontinence in the early postpartum period, the responders were followed up for 3 months and requested to reply to the same questionnaire again. Intrapartum information was obtained from the medical records, and factors associated with urinary incontinence at the two points in time were assessed by means of a multivariate logistic regression analysis.
Results
Replies to the early questionnaire were obtained from 403 of the 421 puerperants, and the prevalence was 30.8%. Replies to the questionnaire at 3 months after delivery were obtained from 286 patients (follow-up rate: 71.0%), and 44.7% of those who had early urinary incontinence had symptoms. Early urinary incontinence was more common in primipara (p=0.013). The rate was higher among women who had urinary incontinence during pregnancy (p=0.004), and early urinary incontinence was more common in women who had undergone an episiotomy (p=0.006). By contrast, BMI when not pregnant and the presence or absence of urinary incontinence during pregnancy were associated with urinary incontinence 3 month after delivery (p=0.045 and p<0.001, respectively), and there were no significant associations with any of the intrapartum factors. The prevalence of early urinary incontinence was significantly lower in the spontaneous delivery group than in the assisted delivery group (p<0.001), but there was no difference between the two groups at 3 months after delivery.
Conclusions
About half of the patients with early urinary incontinence also had symptoms at 3 months after delivery. Early urinary incontinence occurred in a high percentage of the primipara and it was more common in women who had undergone an episiotomy.
The prevalence of early urinary incontinence was lower in the spontaneous delivery group than in the assisted delivery group, and spontaneous delivery was beneficial in maintaining pelvic floor function, but there was no difference at 3 months after delivery, and the influence of delivery had waned.

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Purpose
This study examined relationships between cold sensitivity in women and perinatal outcomes using the cold sensitivity severity scale as a subjective and a laser tissue blood flowmeter as an objective parameter to measure cold sensitivity.
The subjects and Methods
This study involved measuring peripheral blood flow at the tip of the index fingers of both hands, and a questionnaire survey regarding cold sensitivity during non-pregnancy using a cold sensitivity scale which consisted of 4 factors and 8 items, involving 125 term pregnant women (76 primi- and 49 multiparas). Their course of pregnancy and delivery was transcribed from their medical records after childbirth.
Results
No significant difference was observed between the results of the cold sensitivity severity scale and peripheral blood flow in term pregnant women (r=-0.036, p=0.687). In primiparas who obtained high scores on the cold sensitivity severity scale, many of them had cervical dilation of 3 cm or less on hospital admission (p=0.014).
When the subjects were compared between groups with low and high peripheral blood flow, many subjects in the low-flow group had a low blood pressure (p=0.047) and low pulse rate (p=0.024) during pregnancy. In addition, a prolonged second stage of labor was frequently observed in primiparas in the low-flow group (p=0.016), and a low blood flow and higher age were indicated as factors contributing to a prolonged second stage of labor, even after eliminating the effects of confounding factors using logistic regression analysis.
Conclusion
Poor circulation during term pregnancy may contribute to a prolonged second stage of labor in primiparas. However, blood flow during term pregnancy and cold sensitivity during non-pregnancy were not associated with each other.

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Objectives
This study sought to clarify various factors related to past and current experience of breastfeeding in regard to exclusive breastfeeding by multiparas who have breastfed in the first month after delivery, and to ascertain the level of impact those factors had on exclusive breastfeeding. This study also sought to elucidate the factors determining exclusive breastfeeding.
Subjects and methods
Of 20 facilities asked to participate in this study, 16 consented. In these facilities, a survey was conducted to multiparas 1 to 2 months after a full-term singleton delivery. Subjects were 635 mothers who had no serious complications after delivery and who began breastfeeding while in the hospital. A questionnaire was devised by identifying factors associated with choosing breastfeeding and with continuing to breastfeed based on previous studies and a review of the literature. Questions and phrasing were re-examined by 6 researchers in related fields and midwives in order to improve content validity. To ascertain the time that was required to answer the questionnaire and to assess face validity, a pre-test was given to 10 multiparas and the above-mentioned 6 specialists to finalize the questionnaire.
Results
Five hundred and one responses (response rate: 78.9%) were collected. Of them, 485 responses (valid response rate: 76.4%) were analyzed.
Preliminary analysis revealed factors influencing exclusive breastfeeding. These factors were adjusted as covariates when logistic regression analysis was performed. Results indicated that several factors were significantly associated: choosing in the 36th of pregnancy to breastfeed exclusively after delivery, not feeling as if one did not have enough milk [to breastfeed], not using a baby bottle or pacifier, having an older sibling who was exclusively breastfed, and having an older sibling who was breastfed prior to a medical checkup at 1 month of age.
Conclusion
The factor that had the greatest impact on exclusive breastfeeding by multiparas in the first month after delivery was choosing in the 36th of pregnancy to breastfeed exclusively. Results suggested that multiparas who had breastfed need support so that in advance of delivery they can "choose to breastfeed exclusively" and firmly decide to raise their current child on breast milk.

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Purpose
This study aimed to understand the professional autonomy of midwives and identify influential factors regarding the collaborative relationship of midwives and obstetricians. Through these analyses, it finally attempted to gain suggestions for a desired direction to improve current maternity care systems by finding ways of enhancing collaboration between the two professions.
Method
This study employed a cross-sectional, quantitative approach using self-administered questionnaires that were sent to and collected from randomly-selected, full-time midwives with over three years working experience who are currently practicing midwifery at medical facilities providing parturient care. Quantitative analysis was carried out based on the basic attributes of the responding midwives and the levels of their professional autonomy, collaboration with obstetricians in medical care decision-making, and satisfaction in the decision-making process.
Results
A total of 578 midwives responded to the questionnaire (total response rate: 59.5%).
Midwifery autonomy showed positive correlations with age, position, years of midwifery experience, years of current employment, and the number of midwifery cases. Collaboration between midwives and obstetricians was positively correlated with the position of midwives and the number of midwifery cases.
Midwives with a higher autonomy level showed a high level of collaboration with obstetricians, which revealed a positive correlation between professional autonomy and collaboration.
In addition, midwives practicing at in-hospital birth centers were found to mark higher in professional autonomy and significantly higher in collaboration with obstetricians, compared with those working outside of hospitals.
Conclusion
The results suggest that the accumulation of midwifery clinical practice and experience is one of the factors necessary to nurture the professional autonomy of midwives. They also suggest that, to further promote the collaborative relationship with obstetricians, midwives should develop qualities and abilities required of team leaders, acquire proficient midwifery skills, and enhance midwifery autonomy as a medical profession. In particular, midwives at in-hospital birth centers showed high levels of professional autonomy and collaboration with obstetricians, which are considered indispensable for maternity care. This suggests that the increased use of midwives with professional autonomy and ability to work with other professions will contribute a great deal to the development of an effective maternity care system for mothers and newborns.

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Objectives
The purpose of this study was to examine the experiences of midwifery students with puerperants during delivery through birth reviews at the beginning (number of times assisting labor: 1-3) and completion (10) of a labor assistance practicum. The results were analyzed to gain educational insight into care related to childbirth experiences of postpartum women.
Methods
Participants were seven senior nursing major students at A University who chose an elective course in midwifery. These students were divided into two groups of 3 and 4. Focus group interviews were conducted at the completion of the first and second half of the practicum. Results were analyzed using the methods described by Vaughn et al.
Results
Three themes were raised by students as topics in the practicum. In performing birth reviews and self-evaluations, the topics were "care related to reflecting on the childbirth experience," "difficulty of performing birth reviews," and "understanding one's task for the next delivery" in the first half of the practicum, and "care related to integrating the childbirth experience" and "one's current inexperience" in the second half of the practicum. With respect to what one noticed/realized during birth reviews, the topics were "an understanding of puerperants through assumptions" and "the reason and need for birth reviews" in the first half of the practicum, and "lack of a big picture understanding of the delivery process," "midwifery care and puerperant diversity," and "the need to meet individual needs" in the second half of the practicum. Regarding impressions of performing birth reviews, students felt both "uncomfortable with favorable evaluations and a sense of accomplishment" in the first half of the practicum, and "enthusiasm due to favorable evaluations" in the second half of the practicum.
Conclusions
Birth reviews began with reflecting on the childbirth experience and, by the end of the practicum, carrying out care by integrating experiences. Birth reviews also provided opportunities for students to realize the effects brought about by such reviews, and made them aware of the diversity in midwifery care. It is important that teaching staff recognize the degree of student understanding of the objective and significance of birth reviews and understanding of their patients, and provide support for clarifying and supplementing deficiencies in tasks.

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Purpose
This study evaluated women's mental and physical health during the postpartum period and after they had participated in a program designed to improve women's health.
Methods
The subjects were 135 mothers two-six months after delivery who participated in a post-partum program. The two-hour weekly program, included: aerobic exercise, communication skills, and self-care, and lasted four consecutive weeks. The measurement tools included the Edinb-urg Postnatal Depression scale (EPDS), subjective well-being scale, andauthor created question such as participants' motives, degree of satis-faction, and poor physical condition. The survey was conducted three times: 1st and 4th week of the program, and one month after programcompletion. Repeated ANOVA was performed for the three survey poin-ts.
Results
There were 112 (83.0%) women continuing to program completion, followed 90 (80.4%) women one month after program completion. Participation motives were high for physical needs, and low for needs related to mental or social aspects. Needs related to mental and social aspects were satisfied by participation in the program. There was statistical significance (p<.001) for changes in total points for poor physical condition, improvement at the 4th session, and the effect continued until one month after program completion.
A significant difference (p=.002) was found for changes in total points for subjective well-being, with the score increasing at each survey. Change in the EPDS score indicating the degree of depression was significant (p<.001), with the degree of depression reduced at the 4th session, and that condition continued at the one month completion. The proportion of EPDS scores of 9 points (indicating depression) or higher was 23 mothers (20.5%) at the first session of the program, compared to 11 mothers (9.8%) at the 4th session of the program, indicating a significant decrease (p<.025).
Conclusions
Participants who completed in the program improved poor physical condition, increased subjective well-being, and reduced the degree of depression, and these changes continued at one month after program completion. It is possible the postpartum program contributed to improve in the mother' physical and mental health, and postpartum depression. The next step is repeat the program using a control group.

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Purpose
To analyze the relationship among hiesho, premature delivery, premature rupture of membranes, weak pains, prolonged labor, and atonic bleeding.
Subjects and method
The study design was an exploratory descriptive study with subjects and also a retrospective cohort study. The study was conducted from October 2009 to October 2010 at six general hospitals equipped to handle premature infants and with obstetric and pediatric departments, in the Greater Tokyo Metropolitan Area. The subjects were 2,810 Japanese women in hospital after delivery. The study was carried out by collecting data from questionnaire surveys and medical records. By their submitting answers to the questionnaire, subjects were assumed to have given approval to be included in the study.
Results
Analysis was conducted on 2,810 women. Structural equation modeling was used to create a path diagram with five factors of hiesho and abnormal delivery as observed variables. Path coefficients were 0.11 (p<0.001) from hiesho to premature delivery, 0.12 (p<0.001) from hiesho to premature rupture of membranes, 0.15 (P<0001) from hiesho to weak pains, 0.14 (P<0.001) from hiesho to atonic bleeding, and 0.13 (P<0.001) from hiesho to prolonged labor. In each case hiesho had a positive influence. Path coefficients were 0.05 (p=0.013) from premature rupture of membranes to premature delivery, 0.07 (p<0.001) from premature rupture of membranes to weak pains, and 0.08 (P<0.001) from weak pains to atonic bleeding. The path coefficient between errors of weak pains and prolonged labor was 0.24 (p<0.001), showing that the two factors influenced each other.
Conclusion
Hiesho has an influence on all abnormalities of delivery: premature delivery, premature rupture of membranes, weak pains, prolonged labor, and atonic bleeding. Among these, premature rupture of membranes has an influence on premature delivery, premature rupture of membranes has an influence on weak pains, and weak pains have an influence on atonic bleeding. Weak pains and prolonged labor influence each other.

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Purpose
The purpose of this study is to explore the relationships between maternal hydration status and negative pregnancy outcomes using bioelectrical impedance analysis.
Methods
The participants were healthy singleton pregnant women between the 28th to 30th weeks of gestation. Data collection was conducted during prenatal visits three times: 28-30 weeks, 32-34 weeks, and 36-39 weeks. Bioelectrical impedance measurements were performed using a tetrapolar multifrequency impedance analyzer. Data regarding the results of prenatal visits and pregnancy outcomes were collected by a self-reported questionnaire and medical chart review.
Results
Initially, 30 women volunteered to participate in the longitudinal study though, one of the participants withdrew for personal reasons. Thus, data from 29 participants were analyzed.
The results of prenatal visits which relate to the impedance (Z) were maternal weight, hematocrit values, and pulse pressure. During 28-30 weeks of gestation, lower Z correlated to higher maternal weight (r=-0.415, p<0.05). For 32-34 weeks of gestation, higher Z correlated to higher hematocrit values (r=0.388, p<0.05) and higher pulse pressure (r=0.464, p<0.05).
Examining the relationship between Z and pregnancy outcomes, higher average Z was measured in the group of women who experienced inadequate uterine contractions than women who did not (N=4, p<0.05). The lower average Z was detected in women who delivered after 41 weeks of gestation (N=4, p<0.05) and in those who had episodes of higher blood pressure (130mmHg< of systolic pressure and/or 85mmHg< of diastolic pressure) 2 hours after their deliveries (N=5, p<0.01). The average Z were measured around 500Ω or 520Ω in women who did not experience those negative outcomes. Thus, there is a possibility for a range of Z for pregnant women that indicates negative pregnancy outcomes.
Conclusions
Possible correlations of impedance values with the check-up results of prenatal visits and negative pregnancy outcomes were found in this study. Also suggested is a possibility for a range of Z during pregnancy that does not lead to negative pregnancy outcomes. Further studies with more elaborate study designs and larger sample sizes are needed to verify these findings.

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Purpose
The purpose of the study was to assess the thoughts and feelings of midwives collaborating with physicians to conduct prenatal health check-ups
Methods
The present study was a qualitative descriptive study. Between July and August 2010, semi-structured interviews of five midwives working in hospitals in the Kanto area who provide midwifery outpatient services, including health check-ups for pregnant women, were conducted. Codes were allocated to the interview results, and they were compared, analyzed, and organized according to the theme and story line.
Results
When working together with physicians to conduct prenatal health check-ups, midwives felt a "sense of responsibility to provide midwifery outpatient services and were in fear of overlooking abnormal signs". At the same time, they thought that "the task is challenging because they can acquire experiences and improve their skills" in midwifery outpatient practice. They felt "a sense of security when collaborating with physicians to provide pregnant women with outpatient services in midwifery practice", and recognized that "standards for midwifery outpatient services serve as a link between midwives and physicians". However, regarding collaboration with physicians in the implementation of maternal health check-ups, midwives had "difficulty and dilemma sharing their roles with physicians in providing pregnant women with care because it should be managed cooperatively". Some midwives thought that "they caused inconvenience to patients when they felt hesitant in the presence of a physician", and others had "difficulty providing midwifery outpatient care in the presence of a physician - a superior health care professional". Some midwives even thought that "midwifery outpatient services are a useful tool for physicians in outpatient practice".
Conclusion
When collaborating with physicians to conduct prenatal health check-ups, midwives felt a sense of responsibility and were afraid of overlooking abnormal signs, although they considered the task as challenging and felt a sense of security in the presence of a physician. However, midwives had difficulty and faced with a dilemma when they had to share their roles with physicians in providing care, and they were hesitant to make their own decisions.

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