Risk factors for surgical site infection following cesarean delivery: A hospital-based case–control study

Introduction Cesarean section is the single most important risk factor for postpartum infection. Where the rest of the world shows increasing trends, the cesarean section rates are low in Norway and risk factors for infection after cesarean section may differ in high and low cesarean section settings. The goal of this study was to examine independent risk factors for surgical site infection after cesarean delivery in a setting of low cesarean section rates. Material and methods We conducted a hospital-based case-control study at Haukeland University Hospital. We included women who presented to our hospital with surgical site infection after cesarean section during the years 2014–2016 (n = 75). Controls were selected at a ratio of 2:1 (n = 148). Cases and controls were compared with respect to maternal and pregnancy characteristics using uni- and multivariable logistic regression models. Main outcome measures were anticipated risk factors for surgical site infection. Results The occurrence of surgical site infection was 0.4% and 5.4% after elective and emergency cesarean section, respectively. Compared to women without surgical site infection, women with surgical site infection were almost thrice more obese before pregnancy (OR 2.8, 95% CI 1.2–7.0), four times more likely to have preexisting psychiatric conditions (OR 4.4, 95% CI 1.1–17.6), and five times more likely to receive blood transfusion (OR 5.1, 95% CI 1.4–18.8). Signs of infection during labor was a marginally significant risk factor for surgical site infection (OR 2.0, 95% CI 1.0–5.4). Conclusions Emergency cesarean section was a significant risk factor for surgical site infection. Pregestational obesity, preexisting psychiatric conditions, and blood transfusion during or following delivery, were independent risk factors for surgical site infection. Signs of infection during labor was a marginally significant risk factor. Women with either of these risk factors should be carefully monitored and evaluated for signs of infection in the postpartum period.publishedVersio

Recurrence of postpartum hemorrhage, maternal and paternal contribution, and the effect of offspring birthweight and sex: a population-based cohort study

Purpose: This study examines individual aggregation of postpartum hemorrhage (PPH), paternal contribution and how offspring birthweight and sex influence recurrence of PPH. Further, we wanted to estimate the proportion of PPH cases attributable to a history of PPH or current birthweight. Methods: We studied all singleton births in Norway from 1967 to 2017 using data from Norwegian medical and administrational registries. Subsequent births in the parents were linked. Multilevel logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CI) for PPH defined as blood loss > 500 ml, blood loss > 1500 ml, or the need for blood transfusion in parous women. Main exposures were previous PPH, high birthweight, and fetal sex. We calculated adjusted population attributable fractions for previous PPH and current high birthweight. Results: Mothers with a history of PPH had three- and sixfold higher risks of PPH in their second and third deliveries, respectively (adjusted OR 2.9; 95% CI 2.9–3.0 and 6.0; 5.5–6.6). Severe PPH (> 1500 ml) had the highest risk of recurrence. The paternal contribution to recurrence of PPH in deliveries with two different mothers was weak, but significant. If the neonate was male, the risk of PPH was reduced. A history of PPH or birthweight ≥ 4000 g each accounted for 15% of the total number of PPH cases. Conclusion: A history of PPH and current birthweight exerted strong effects at both the individual and population levels. Recurrence risk was highest for severe PPH. Occurrence and recurrence were lower in male fetuses, and the paternal influence was weak.publishedVersio

Recurrence of postpartum hemorrhage in relatives: A population-based cohort study

Introduction Studies on the family aggregation of postpartum hemorrhage (PPH) are scarce and with inconsistent results, and to what extent current birthweight influences recurrence between relatives remains to be studied. Further, family aggregation of PPH has been studied from an individual, but not from a public heath perspective. We aimed to investigate family aggregation of PPH in Norway, how birthweight influences these effects, and to estimate the proportion of PPH cases attributable to a family history of PPH and current birthweight. Material and methods Using data from the Medical Birth Registry of Norway, Statistics Norway, and Central Population Registry of Norway we identified individuals as newborns, parents, grandparents, and full and half-siblings, and studied 1 002 687 mother–offspring, 841 164 father–offspring, and 761 011 both-parents–offspring pairs. We used multilevel logistic regression to calculate odds ratios (OR) with 95% CI. Results If the birth of the mother but not of the father involved PPH, then the OR of PPH (>500 mL) in the next generation was 1.44 (95% CI 1.39–1.49). If the birth of the father but not of the mother involved PPH, then OR was 1.12 (95% CI 1.08–1.16). These effects were stronger in severe PPH. Recurrence between siblings was highest between full sisters (OR 1.47, 95% CI 1.41–1.52), followed by maternal half-sisters, paternal half-sisters, and partners of full brothers. A family history of PPH or birthweight of 4000 g or more accounted for ≤5% and 15% of the total number of PPH cases, respectively. Conclusions A history of PPH in relatives influenced the recurrence risk of PPH in a dose–response pattern consistent with the anticipated proportion of shared genes. The recurrence was highest through the maternal line.publishedVersio

Epidemiological aspects of Obstetric Anal Sphincter Injuries. A population-based study in Norway

Aims: Obstetric anal sphincter injuries (OASIS) are serious complications of vaginal childbirth and may result in severe consequences such as dyspareunia, anal- and urinary incontinence. In Norway and other Scandinavian countries, the reported occurrence of these injuries has increased during the past decades. The aims of this thesis were first to validate the registration of OASIS in two Norwegian databases, the Medical Birth Registry of Norway (MBRN) and Patient Administration System (PAS). Secondly, we wanted to investigate risk factors and secular trends of OASIS in Norway in 1967-2004 and whether changes in risk factors over time could explain the trends. Thirdly, we wanted to study the obstetric history of a woman with OASIS in terms of recurrence risk, likelihood of having a subsequent delivery and mode of delivery. Finally, we wanted to assess possible familial aggregation of OASIS among relatives. Methods: All four papers are historic cohort studies. In paper I, data on OASIS cases occurring at Haukeland University Hospital during 1990-92 and 2000-02 were derived from PAS and MBRN. The registration of OASIS was validated by comparing these two registries with patient hospital records as the gold standard. Papers II-IV were population-based studies based on data from MBRN 1967-2008. We used contingency tables, logistic regression, Cox proportional hazards regression and stratification to explore associations between various exposures and outcomes, to assess interactions and to adjust for confounders. Results: The sensitivity and specificity of the MBRN database to detect OASIS were 85.3% and 99.5% in 1990–92, 91.8% and 99.7% in 2000–02, respectively. The positive and negative predictive values of OASIS in the MBRN were 91.4% and 99.1% in 1990-92 and 95.4% and 99.4% in 2000–02. The sensitivity and specificity of the PAS database were correspondingly 52.1% and 99.0% in 1990–92 and 84.6% and 98.5% in 2000–02. The positive and negative predictive values of OASIS in PAS database were 75.8% and 97.1% in 1990–92 and 92.7% and 98.9% in 2000-02. The reported occurrence of OASIS increased from 0.5% in 1967 to 4.1% in 2004. After adjustment for changes in demographic and other risk factors, the increase of OASIS persisted, although significantly reduced. OASIS were associated with maternal age 30 years or more, vaginal birth order 1, previous caesarean delivery, instrumental delivery, diabetes type 1, gestational diabetes, induction of labour by prostaglandin, large maternity units, birth weight 3,500 g or more, head circumference 35 cm or more and African or Asian women’s country of birth. Only in birth order 1 with instrumental delivery, episiotomy seemed to protect perineum against OASIS; otherwise it either increased the risk of OASIS or gave no protection against OASIS. Women with a history of OASIS in the first and the two first deliveries had four and ten fold increased risk of OASIS in the subsequent delivery, respectively. Populationattributable risk percentage of OASIS in second and third delivery due to previous OASIS was 10% and 15%, respectively. Recurrence of OASIS was high in large maternity units, in forceps delivery and with birth weight 3,500 g or more in the current delivery. However, instrumental delivery did not further increase the excess recurrence risk observed in heavy newborns. A man who fathered a child whose delivery was complicated by OASIS in one woman was more likely to father another child with OASIS delivery in another woman, if the mothers delivered at the same maternity unit. The subsequent delivery rate was not different in women with and without previous OASIS, whereas women with previous OASIS were more often scheduled to caesarean delivery. The risk of OASIS was increased two fold if a woman’s mother or sister had sustained OASIS and to a less extent if her partner’s mother or sister had sustained OASIS, and not if her brother’s partner had sustained OASIS. Conclusions: The validity of the registration of OASIS in MBRN is sufficiently high to justify epidemiological studies on OASIS based on data from this registry. The risk of OASIS increased noticeably in 1967-2004 in Norway. Changes in observed risk factors could only partially explain this increase. Most of observed risk factors such as birth order 1 and high maternal age were non-modifiable and women with such risk factors should be paid more attention at delivery for minimising their risk of OASIS. Instrumental delivery was a dominant risk factor, but the majority of OASIS cases occurred in non-instrumental vaginal deliveries. Consequently, training in both instrumental and non-instrumental deliveries with focus on reducing the speed of the birth, support of perineum and axis of birth canal should be an essential part of the national and local training programme for birth attendants. Women with a history of OASIS had a high recurrence risk in second and third delivery. Therefore, emphasis should be placed on counselling women after an initial OASIS. A history of OASIS had little or no impact on subsequent delivery rate. However, women with previous OASIS more frequently had planned caesarean delivery. Our findings in paper IV suggest that maternal and to a less extent paternal factors contribute to the risk of OASIS. The higher maternal than paternal recurrence of OASIS indicate maternal rather than paternal genetic susceptibility for OASIS. These observations must be cautiously interpreted since bias due to unmeasured confounding may have impacted the findings

Risk factors for surgical site infection following cesarean delivery: A hospital-based case–control study

Introduction Cesarean section is the single most important risk factor for postpartum infection. Where the rest of the world shows increasing trends, the cesarean section rates are low in Norway and risk factors for infection after cesarean section may differ in high and low cesarean section settings. The goal of this study was to examine independent risk factors for surgical site infection after cesarean delivery in a setting of low cesarean section rates. Material and methods We conducted a hospital-based case-control study at Haukeland University Hospital. We included women who presented to our hospital with surgical site infection after cesarean section during the years 2014–2016 (n = 75). Controls were selected at a ratio of 2:1 (n = 148). Cases and controls were compared with respect to maternal and pregnancy characteristics using uni- and multivariable logistic regression models. Main outcome measures were anticipated risk factors for surgical site infection. Results The occurrence of surgical site infection was 0.4% and 5.4% after elective and emergency cesarean section, respectively. Compared to women without surgical site infection, women with surgical site infection were almost thrice more obese before pregnancy (OR 2.8, 95% CI 1.2–7.0), four times more likely to have preexisting psychiatric conditions (OR 4.4, 95% CI 1.1–17.6), and five times more likely to receive blood transfusion (OR 5.1, 95% CI 1.4–18.8). Signs of infection during labor was a marginally significant risk factor for surgical site infection (OR 2.0, 95% CI 1.0–5.4). Conclusions Emergency cesarean section was a significant risk factor for surgical site infection. Pregestational obesity, preexisting psychiatric conditions, and blood transfusion during or following delivery, were independent risk factors for surgical site infection. Signs of infection during labor was a marginally significant risk factor. Women with either of these risk factors should be carefully monitored and evaluated for signs of infection in the postpartum period

The effectiveness of teaching children\'s executive functions through play, combined with transdiagnostic interventions of mothers\' emotional problems, on anxiety, depression and sleep quality of children with learning disabilities

Background and Aims: Improving executive functions through play is one of the ways to improve learning in children with learning problems, whose definite effectiveness needs clinical investigation. The purpose of this study was to investigate the effectiveness of teaching children's executive functions through play combined with transdiagnostic interventions of mothers' emotional problems on anxiety, depression, and sleep quality of these children. Materials and Methods: This semi-experimental research was conducted with a pretest-posttest and follow-up (two months) design on 42 children aged 7 to 9 years in two experimental groups and one control group. Experiment groups received the training of executive functions in a game way. The mothers of the children in the 2nd experimental group were taught the integrated protocol of transdiagnostic interventions, while the mothers of the 1st experimental group did not receive training as they were considered the control group of mothers in the 2nd experimental group. The data were analyzed in SPSS version 25 software using the analysis of variance test with repeated measures (α=0.05). Results: Significant differences were observed between the intervention groups and the control group in the variable of sleep quality in the follow-up and post-test phase (P<0.001), in the anxiety variables in the post-test phase (P=0.04) and follow-up (P=0.05), and in the variable of depression (P<0.001). It was found that the intervention improved the quality of children's sleep and boosted anxiety and depression indices in both intervention groups, and this effect was greater in the group of children and mothers (P<0.001) Conclusion: The training of executive functions in the form of play with the transdiagnostic interventions of mothers' emotional problems was effective on the psychological symptoms and sleep quality of children with learning disabilities, which can be a part of the training program for educators to solve these problems

Low risk pregnancies after a cesarean section: Determinants of trial of labor and its failure

Introduction: In pregnancies after a previous cesarean section (CS), a planned repeat CS delivery has been associated with excess risk of adverse outcome. However, also the alternative, a trial of labor after CS (TOLAC), has been associated with excess risks. A TOLAC failure, involving a non-planned CS, carries the highest risk of adverse outcome and a vaginal delivery the lowest. Thus, the decision regarding delivery mode is pivotal in clinical handling of these pregnancies. However, even with a high TOLAC rate, as seen in Norway, repeat CSs are regularly performed for no apparent medical reason. The objective of the present study was to assess to which extent demographic, socioeconomic, and health system factors are determinants of TOLAC and TOLAC failure in low risk pregnancies, and whether any effects observed changed with time. Materials and methods: The study group comprised 24 645 second deliveries (1989–2014) after a first delivery CS. Thus, none of the women had prior vaginal deliveries or more than one CS. Included pregnancies were low risk, cephalic, single, and had gestational age ≥ 37 weeks. Data were obtained from the Medical Birth Registry of Norway (MBRN). The exposure variables were (second delivery) maternal age, length of maternal education, maternal country of origin, size of the delivery unit, health region (South-East, West, Mid, North), and maternal county of residence. The outcomes were TOLAC and TOLAC failure, as rates (%), relative risk (RR) and relative risk adjusted (ARR). Changes in determinant effects over time were assessed by comparing rates in two periods, 1989–2002 vs 2003–2014, and including these periods in an interaction model. Results: The TOLAC rate was 74.9%, with a TOLAC failure rate of 16.2%, resulting in a vaginal birth rate of 62.8%. Low TOLAC rates were observed at high maternal age and in women from East Asia or Latin America. High TOLAC failure rates were observed at high maternal age, in women with less than 11 years of education, and in women of non-western origin. The effects of health system factors, i.e. delivery unit size and administrative region were considerable, on both TOLAC and TOLAC failure. The effects of several determinants changed significantly (P 39 years became weaker, the association between short education and TOLAC failure became stronger, and the association between TOLAC failure and small size of delivery unit became stronger. Conclusion: Low maternal age, high education, and western country of origin were associated with high TOLAC rates, and low TOLAC failure rates. Maternity unit characteristics (size and region) contributed with effects on the same level as individual determinants studied. Temporal changes were observed in determinant effects