Purpose
The aims of this study were:
1. to examine the effectiveness of decision support for immunization by a literature review and
2. to describe the web-based decision support instruments (decision aids) for immunization with the inclusion of the quality standards
Methods
Eligible studies using decision supports for immunization were retrieved with selected key words. Retrieved literature was analysed by whether the outcome (vaccination rate and quality of the decision) was improved by the support.
The type and content of immunization-related decision aids, accessible on the Internet, were described. The recent movement of creating international quality standards as a basis for the development and evaluation of those decision aids was also presented.
Results
Literature review: The retrieved six studies were all conducted in developed countries outside Japan of which, four were Randomized Controlled Trial (RCT) to assess the effectiveness of the intervention. All RCTs included the outcome measurement of vaccination status (vaccination rate, action, or intention). However, the participants' vaccination status was the secondary outcome in most of the studies and the psychological indicators such as decision conflict, anxiety, satisfaction, and confidence were drawn as the primary outcome to measure the quality of the decision.
Introduction to decision aids: The presented immunization-related decision aids were all developed in western countries and evaluated using the international quality standards (IPDAS checklist: the abbreviated version of International Patient Decision Aids Standards). Among six decision aids, only one instrument met all the checklist criteria.
Conclusion
Only a small number of studies were found regarding decision support for immunization, thus the impact of decision support is still limited. Further research is needed to elucidate the optimal timing of support, the effective support methods, and the appropriate outcome indicators for evaluation. The establishment of the international quality standards for decision aids is on-going movement. Those who develop and utilize decision aids need to do so in the light of the standards.

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Purpose
To epidemiologically investigate the relationship between a heavy for gestational age infant (HGA) and postpartum hemorrhage (PPH) resulting mainly from uterine atony.
Methods
This retrospective observational study included Japanese women at a single tertiary obstetric hospital in Tokyo metropolitan area. The inclusion criteria were as follows: 1) vaginal delivery between 2007 and 2010, 2) single delivery at term, 3) primipara, and 4) maternal age of ≥20 years. HGA is defined as an infant with a birth weight greater than the 90th percentile of the new intrauterine growth curves in Japan. The primary outcomes were PPH (blood loss, ≥500 ml) and severe PPH (SPPH; blood loss, ≥1,000 ml). Multiple logistic regression analysis was performed to calculate the odds ratio (OR) and 95% confidence interval (CI) of PPH and SPPH in association with HGA.
Results
Of the 2,340 women studied, PPH and SPPH were found to occur in 593 (25.3%) and 63 (2.7%) women, respectively. The results of the multivariate analyses indicated that HGA was significantly associated with PPH (adjusted OR 2.34, 95% CI 1.71-3.19) and SPPH (adjusted OR 2.43, 95% CI 1.21-4.86).
Conclusion
HGA was considered an independent risk factor for PPH that results mainly from uterine atony. Thus, physicians and midwives could identify women at risk for PPH from uterine atony before delivery.

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Objective
The purpose of this study is to describe, from narrative accounts of their experiences, what kinds of "turning points" there were and what went through the minds of women who maintained their sense of trust in the midwife, even while suffering through a serious situation caused by a midwifery accident, and what implications that has for nursing.
Methods
This is a life story study of two women who recognized that they were able to maintain a relationship of trust with the midwife even after a midwifery accident.
Data collection was conducted through having the women freely narrate their thoughts and feelings from the time of wanting to give birth at a midwife center, through to the present in chronological order, including the details of the midwifery accident. Following that, semi-structured interviews were conducted to investigate the mindset of the women at each step of the journey they described.
Results
When a crisis that threatened the life of her child developed, Ms. A was haunted by fear and anxiety regarding the aftereffects of the crisis, and deducing from the surrounding behavior that there had been a midwifery accident she searched for ways to confront the midwife.
However, as she was feeling regret and responsibility for choosing the midwifery owned maternity home, Ms. A could not lay all the blame upon the midwife alone. In the process of reconstructing the relationship with the midwife by continuing communication throughout the incident, and with the dispute findings having established a victim-perpetrator relationship, and the desire for the midwifery owned maternity home to resume business, Ms. A wanted a sense of closure in the form of compensation. Ms. A, having reconfirmed the importance of life and health through the midwifery accident, was searching for a new way of life.
Ms. B sensed from the attitude of the midwife that there was little possibility of her fetus being alive, and even while suffering shock, she deliberated on the fact that the midwife was also a healthcare worker like herself. She entrusted the delivery of the dead baby to the midwife who showed an unfailingly supportive attitude. With grief care, Ms. B was able to say a sufficient goodbye to the baby, and as a result of many conversations with the midwife, she came to have a deep-seated conviction that there was no-one to blame. Overcoming the loss, Ms. B acquired a family and a new view on life.
Conclusion
The women who maintained their sense of trust in the midwife even through a midwifery accident, did so based upon the relationship cultivated up until the time of the incident, as despite a temporarily shaken sense of trust in the midwife, the women felt they had been dealt with in good faith. It is essential for nurses to make efforts in the event of an incident occurring to recognize the process and 'turning points' that lead to conflict and the collapse of the relationship of trust, and to provide long-term continuing care.

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Purpose
The study explored and analyzed the influential factors in the promotion or inhibition of Nurse-Midwives' practice of alternative labor and delivery position (ALP).
Methods
The study used a cross-sectional descriptive design. The participants were midwives practicing care from first to third stage of labor in the last year. Instruments were: ALP Scale and the 2003 Japanese Institute for Labour Policy, Human Resource Management Checklist for job satisfaction. Comparisons were made between midwives practicing ALP (practicing midwives) and midwives not-practicing ALP (not-practicing midwives). The influential factors were analyzed by structural equation modeling.
The Ethics Review Committee of University and Hospitals approved the study.
Results
A response rate of 71.6% yielded valid 387 midwifery responses of which 124 (32.0%) were practicing and 263 (68.0%) were not practicing midwives. Although the majority (81.1%) was positive about ALP, the majority (60.3%) also practiced the recumbent maternal position in labor, so there was a difference between midwives' awareness and actual practice. In "innovation" by Rogers (2003), "Innovator" and "Early adopter" were consisted of Innovative group, "Early majority" "Late majority" "Laggards" were consisted of Conservative group. Innovative group was significantly higher the rate of practicing midwives, belonged homogeneous maternity ward, caring almost normal or low risk labor women. The analysis of influential factors by structural equation modeling indicated that, "dislike for innovation" and "confusion about ALP midwifery skills" negatively influenced practicing ALP. "Innovation" positively influenced practicing ALP. "Homogenous maternity wards" also positively influenced practicing ALP more than mixed wards.
Conclusion
Promoting factors of ALP were midwives' "innovation" and "homogeneous maternity ward". Inhibiting factors of ALP were "dislike for innovation" and "confusion about ALP midwifery skills".

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Purpose
Oxidative stress is defined as "the breakdown of balance between oxidative and antioxidant processes in the body". There are many studies on oxidative stress, and also reports on pregnancy-induced hypertension and gestational diabetes mellitus during the perinatal period. However, the changes in oxidative stress and antioxidants during the pregnancy period remain unclear. The aim of this study was to elucidate the relationship between changes in oxidative stress and antioxidative potency at 2 points during the pregnancy period, and to rank the oxidative stress and antioxidative potency during the pregnancy period.
Methods
The test group consisted of 44 women who were examined in a hospital in one prefecture, from whom consent was obtained after the study was explained. Blood samples were obtained twice, during the 16^th to 18^th weeks of pregnancy (as the 1^st stage in the pregnancy period) and during the 27^th to 29^th weeks of pregnancy (as the 2^nd stage in the pregnancy period). At the same time, we researched their pregnancy. The blood samples were assayed for reactive oxygen metabolites (d-ROMs) and biological antioxidant potential (BAP) by F.R.E.E. (Free Radical Elective Evaluator).
Results
Oxidative stress and antioxidative potency at the 1st stage during the pregnancy period were 521.2±100.6 U.CARR on the d-ROMs test and 2004.0±342.0 μM on the BAP test. In the 2^nd stage in the pregnancy period, the results were 539.1±114.9 U.CARR on the d-ROMs test and 1775.6±310.7 μM on the BAP test. Oxidative stress during the pregnancy period was over 501 U.CARR, indicating quite strong oxidative stress. Antioxidative potency during the pregnancy period was borderline at the 1^st stage, but dropped to a significantly low level (p=0.003) at the 2^nd stage.
Conclusion
We found that oxidative stress was high and antioxidative potency was low during the pregnancy period. Oxidative stress was higher and antioxidative potency was lower in pregnant women than in groups of smokers, people taking oral contraceptive, and obese people.

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