Implications of vaginal instrumental delivery for children’s school achievement : a population-based linked administrative data study

JL is funded by a National Health and Medical Research Council (NHMRC) of Australia Partnership Project Grant (1056888) and Centre of Research Excellence (1099422). BWM is supported by a NHMRC Practitioner Fellowship (GNT1082548). BWM reports consultancy for ObsEva, Merck and Guerbet.Peer reviewedPostprin

Births in two different delivery units in the same clinic – A prospective study of healthy primiparous women

Background: Earlier studies indicate that midwife-led birth settings are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction. The generalizability of these studies to birth settings with low intervention rates, like those generally found in Norway, is not obvious. The aim of the present study was to compare intervention rates associated with labour in low-risk women who begin their labour in a midwife-led unit and a conventional care unit. Methods: Eligible participants were low-risk primiparas who met the criteria for delivery in the midwife-led ward regardless of which cohort they were allocated to. The two wards are localised at the same floor. Women in both cohorts received the same standardized public antenatal care by general medical practitioners and midwifes who were not involved in the delivery. After admission of a woman to the midwife-led ward, the next woman who met the inclusion criteria, but preferred delivery at the conventional delivery ward, was allocated to the conventional delivery ward cohort. Among the 252 women in the midwife-led ward cohort, 74 (29%) women were transferred to the conventional delivery ward during labour. Results: Emergency caesarean and instrumental delivery rates in women who were admitted to the midwife-led and conventional birth wards were statistically non-different, but more women admitted to the conventional birth ward had episiotomy. More women in the conventional delivery ward received epidural analgesia, pudental nerve block and nitrous oxide, while more women in the midwife-led ward received opiates and non-pharmacological pain relief. Conclusion: We did not find evidence that starting delivery in the midwife-led setting offers the advantage of lower operative delivery rates. However, epidural analgesia, pudental nerve block and episiotomies were less often while non-pharmacological pain relief was often used in the midwifeled ward

Overdiagnosis and rising rate of obstetric anal sphincter injuries (OASIS): time for reappraisal

OBJECTIVES: To identify the accuracy of clinically diagnosed OASIS using 3D endoanal ultrasound and compare symptoms and anal manometry measurements between those whose anal sphincters were adequately repaired to those who had persistent anal sphincter defects. METHODS: The endoanal scan images of women who sustained OASIS and attended the perineal clinic over a 10 year period (2003 - 2013) were re-analysed from data entered prospectively of women with clinically diagnosed and repaired OASIS. The St Mark's Incontinence Score (SMIS) as well as anal manometry measurements were included in the analysis. RESULTS: The images of 908 women were re-analysed. We found that there was no evidence of OASIS (Group A) = 64 (7%); external anal sphincter (EAS) scar alone (Group B) = 520 (57.3%); anal sphincter defect (Group C) = 324 (35.7%). Of the 324 women with a defect, 112 had an EAS defect and 90 had an internal anal sphincter (IAS) defect and 122 had a combined IAS + EAS defect. The SMIS was significantly higher in women with a defect (p = 0.018) but there was no significant difference in scores between women with an intact sphincter and women with a scar. Compared to the intact group, both the maximum resting (median and range [55 (29-86) vs 43.5 (8-106) mmHg; p < 0.001] and maximum squeeze pressures [103 (44-185) vs 73.5, (23-180); p < 0.001] were significantly lower in women with a defect but less so with a scar. The anal length was significantly shorter in woman with a defect [25 (10-40) vs 20 (10-40) mm]. CONCLUSIONS: Seven percent of women who had a clinical diagnosis of OASIS were wrongly diagnosed as they only had a second degree tear. We believe that this rate may differ from other units but training methods and competency assessment tools for the diagnosis and repair of OASIS need urgent reappraisal. The role of anal ultrasound in the immediate post-partum period needs further evaluation as it will be dependent on the expertise of the staff available to accurately interpret the images

Teenage parenthood : paternal characteristics and child health outcomes

This thesis had two general aims. The first was to describe and compare the social-economic and reproductive characteristics and involvement in pregnancy and childbirth of fathers of children born to teenage mothers in Stockholm (Papers I and II). The second aim was to study the risk of long-term morbidity in children born to teenage mothers, measured as injuries in pre-school children (Paper III) and psychiatric morbidity in adolescence and young adulthood (Paper IV). Methods: Papers I and II are descriptive comparative studies, based on the same study population and on the same instrument. Data were collected with questionnaires in 132 fathers of children born to teenage mothers and 132 fathers of children born to primiparas aged 25-29 years. All fathers were present on postnatal wards in Stockholm between May 1997 and April 1998. Papers III and IV are national cohort studies based on Swedish national registers. The study population in Paper III comprised all 800.190 children born in Sweden during 1987-93 who were followed prospectively in registers from birth to their seventh birthday regarding hospital admissions for unintentional and violent injuries. The study population in Paper IV included the 292.129 children born to primiparas in 1973-79. This group was followed prospectively during 1987-2002 regarding hospital admissions for substance abuse, suicide attempts, suicide deaths and schizophrenia. Results Papers I and II: A significantly larger proportion of fathers of children born to teenage mothers (Group A) compared to fathers in the control group (B), had a compromised social situation, including unstable family backgrounds, low educational attainment, illicit drug use and involvement in criminal activities. In addition, the Group A fathers more often had their sexual debut before 15 years of age and participated less in the family classes. Papers III and IV. After adjustments for social background factors, the pre-school children of teenage mothers had a 40 % increased risk for unintentional injury and a doubled risk for violent injuries compared to the children of older mothers. Also in a long-term perspective, the children of teenage mothers had an increased risk of substance abuse, suicide attempts and suicide deaths. In. contrast, the children of the oldest parents had the highest risk for schizophrenia. Conclusions: Many fathers of children born to teenage mothers showed problem behaviours, which may negatively influence their ability to engage in successful parenting. Owing to the findings of use of illicit drugs and violent crimes among the fathers and the increased risk of injuries in early childhood among the children of teenage mothers, we suggest that midwives should consider asking the teenage women about inflicted violence in early pregnancy. Moreover, midwives should consider developing separate family classes for young parents and also encouraging the expectant fathers to participate. This recommendation is also related to the finding of the increased risk of injury and psychiatric morbidity in the children of teenage mothers, which indicates that young parents might need intense information and education concerning child development and parenting in general. Owing to the findings of an increased risk for injury in the pre-school children of teenage mothers, we suggest that young parents should be given priority in injury prevention programmes

Risk of obstetric anal sphincter injury increases with maternal age irrespective of parity: a population-based register study

Abstract Background Obstetric anal sphincter injury (OASI) is a rare but serious outcome of vaginal birth. Based on concerns about the increasing number of women who commence childbearing later than previous generation, this study aimed at investigating age-related risk of OASI in women of different parity. Methods A population-based register study including 959,559 live singleton vaginal births recorded in the Swedish Medical Birth Register 1999 to 2011. In each parity group risks of OASI at age 25–29 years, 30–34 years, and ≥35 years compared with age < 25 years were investigated by logistic regression analyses, adjusted for year of birth, education, region of birth, smoking, Body Mass Index, infant birthweight and fetal presentation; and in parous women, history of OASI and cesarean section. Additional analyses also adjusted for mediating factors, such as epidural analgesia, episiotomy, and instrumental delivery, and maternal age-related morbidity. Results Rates of OASI were 6.6%, 2.3% and 0.9% in first, second and third births respectively. Age-related risk increased from 25-29 years in first births (Adjusted OR 1.66; 95% CI 1.59–1.72) and second births (Adjusted OR 1.78; 95% CI 1.58–2.01), and from 30-34 years in third births (Adjusted OR 1.60; 95% CI 1.00–2.56). In all parity groups the risk was doubled at age ≥ 35 years, compared with the respective reference group of women under 25 years. Adding mediating factors and maternal age-related morbidity only marginally reduced these risk estimates. Conclusion Maternal age is an independent risk factor for OASI in first, second and third births. Although age-related risks by parity are relatively similar, more nulliparous than parous women will be exposed to OASI due to the higher baseline rate