Prelabour rupture of the membranes at or near term. Clinical and epidemiological studies

Objectives: To study: (1) the risks and benefits for women with prelabourrupture of the membranes (PROM) after 34 weeks of gestation managed withdifferent expectant periods from 24 to 72 hours; (2) perinatal infectiousmorbidity in the different groups and the association between demographic,intrapartum and postpartum variables and neonatal sepsis; (3) theinfluence of bath on infectious morbidity in mothers and neonates in womenwith PROM; (4) the false negative rate using a sterile speculum examination for thediagnosis of rupture of the membranes (ROM) compared to Diamine oxidase(DAO); (5) possible risks for the mother and the baby when the women wereallowed to return home without further controls if amniotic fluid was notvisible at the speculum examination; (6) the prevalence and risk factorsfor PROM in an urban Swedish population.Material and methods: Studies I-III were based on a randomised studycomparing two different regimens in women with PROM. Women withoutcontractions within two hours (n=1012) were randomised to induction thefollowing morning after PROM ("early induction group") or induction twodays later ("late induction group"). Digital examination of the cervix wasavoided until onset of active labour. Labour was induced with oxytocin ifno spontaneous contractions occurred or if chorioamnionitis or fetaldistress was detected.Study IV was based on women admitted for suspected rupture of themembranes after 34 weeks of gestation in which no amniotic fluid wasvisible at the sterile speculum examination. A test for DAO was performed.No further controls were performed if amniotic fluid was not visible atthe speculum examination. Neonatal and obstetric outcome was recordedprospectively. Study V was based on a sample of 2880 women randomlyselected from the national population register. They had delivered 2270times at hospitals in the Göteborg area and 2242 of these case recordswere found. The case records were systematically analysed for theoccurrence of PROM and potential risk factors for PROM. Two thousand twohundred and eight of these deliveries occurred after 34 weeks ofgestation. The analyses were based on these 2208 deliveries.Results: There were no differences in the frequency of neonatal ormaternal infections if the mother were randomised to early or lateinduction. No differences were found in the frequency of caesareansections between the randomised groups. In nulliparous women ventouseextraction was more often used in the "early induction group" compared tothe "late induction group", 14% and 7% respectively (p<0.05). There was nodifference in the incidence of neonatal infections between the groups.Clinical neonatal sepsis was associated with time from PROM to deliveryover 32 hours, caesarean section, parous women and gestational age between34 and 36 weeks. The false negative rate of a speculum examination of thediagnosis of rupture of the membranes in women without amniotic fluidvisible at a speculum examination was 12%. This study did not show anyfalse negative speculum examination. The prevalence of PROM after 34 weeksstepwise regression analysis risk factors for PROM were age at delivery"35 years, primiparity, premature contractions, PROM in a previouspregnancy and bleeding in the first trimester

A step towards better audit : The Robson Ten Group classification system for outcomes other than cesarean section

Introduction The Robson Ten Group Classification System is widely used for the audit of cesarean section (CS) rates. However, CS rate alone is a poor quality indicator and should be balanced with other obstetric endpoints. The aim of this study was to evaluate whether Swedish national data on obstetric outcomes other than CS, stratified by the Robson classification, could be analyzed in a useful way. Material and methods All births in Sweden from 2017 through 2020 recorded in the nationwide Swedish Pregnancy Register were categorized using the Robson classification with subdivision of some groups. Five outcomes were explored: CS, operative vaginal delivery, postpartum hemorrhage, obstetric anal sphincter injury (OASIS) and Apgar score The largest Robson groups were nulliparous and multiparous women with single-term cephalic pregnancies, unscarred uterus and spontaneous labor. Intrapartum CS rates were highest for multiple pregnancies, women with induced labor after previous CS, and nulliparous women with induced labor. Nulliparous women and multiparous women with a previous CS with attempted vaginal birth had the highest operative vaginal delivery and OASIS rates. The postpartum hemorrhage rate was highest for multiple pregnancies and transverse lie, followed by prelabor CS in nulliparous and multiparous women with single-term cephalic pregnancies and unscarred uterus. The highest rates of Apgar score <7 at 5 minute were observed in preterm deliveries, multiple pregnancies, transverse lie and breech presentation. The largest contribution to the total CS rate was made by women with previous CS delivered by prelabor CS, and nulliparous women with induced or spontaneous labor. The largest contribution to all other outcomes was made by nulliparous women with spontaneous or induced labor and, notably, multiparous women with spontaneous labor and unscarred uterus. Conclusions The Robson classification provides a useful framework for analyzing CS rates along with rates of operative vaginal delivery, OASIS, postpartum hemorrhage and low Apgar score. Parallel interpretation of several outcomes allows a systematic and multidimensional audit, helpful for families and healthcare professionals, and can be used for comparisons, assessment of trends and subpopulations

Treatments of pelvic girdle pain in pregnant women: adverse effects of standard treatment, acupuncture and stabilising exercises on the pregnancy, mother, delivery and the fetus/neonate

Abstract Background Previous publications indicate that acupuncture is efficient for the treatment of pelvic girdle pain, PGP, in pregnant women. However, the use of acupuncture for PGP is rare due to insufficient documentation of adverse effects of this treatment in this specific condition. The aim of the present work was to assess adverse effects of acupuncture on the pregnancy, mother, delivery and the fetus/neonate in comparison with women that received stabilising exercises as adjunct to standard treatment or standard treatment alone. Methods In all, 386 women with PGP entered this controlled, single-blind trial. They were randomly assigned to standard treatment plus acupuncture (n = 125), standard treatment plus specific stabilising exercises (n = 131) or to standard treatment alone (n = 130) for 6 weeks. Acupuncture that may be considered strong was used and treatment was started as early as in the second trimester of pregnancy. Adverse effects were recorded during treatment and throughout the pregnancy. Influence on the fetus was measured with cardiotocography (CTG) before-during and after 43 acupuncture sessions in 43 women. A standardised computerized method to analyze the CTG reading numerically (Oxford 8000, Oxford, England) was used. After treatment, the women rated their overall experience of the treatment and listed adverse events if any in a questionnaire. Data of analgesia and oxytocin augmentation during labour, duration of labour, frequency of preterm birth, operative delivery, Apgar score, cord-blood gas/acid base balance and birth weight were also recorded. Results There were no serious adverse events after any of the treatments. Minor adverse events were common in the acupuncture group but women rated acupuncture favourably even despite this. The computerized or visually assessed CTG analyses of antenatal recordings in connection with acupuncture were all normal. Conclusion This study shows that acupuncture administered with a stimulation that may be considered strong led to minor adverse complaints from the mothers but had no observable severe adverse influences on the pregnancy, mother, delivery or the fetus/neonate.</p

Implementation of a revised classification for intrapartum fetal heart rate monitoring and association to birth outcome : A national cohort study

Introduction: A revised intrapartum cardiotocography (CTG) classification was introduced in Sweden in 2017. The aims of the revision were to adapt to the international guideline published in 2015 and to adjust the classification of CTG patterns to current evidence regarding intrapartum fetal physiology. This study aimed to investigate adverse neonatal outcomes before and after implementation of the revised CTG classification. Material and Methods: A before-and-after design was used. Cohort I (n = 160 210) included births from June 1, 2014 through May 31, 2016 using the former CTG classification, and cohort II (n = 166 558) included births from June 1, 2018 through May 31, 2020 with the revised classification. Data were collected from the Swedish Pregnancy and Neonatal Registers. The primary outcome was moderate to severe neonatal hypoxic ischemic encephalopathy (HIE 2-3). Secondary outcomes were birth acidemia (umbilical artery pH &lt;7.05 and base excess &lt; -12 mmol/L or pH &lt;7.00), A-criteria for neonatal hypothermia treatment, 5-min Apgar scores &lt;4 and &lt;7, neonatal seizures, meconium aspiration, neonatal mortality and delivery mode. Logistic regression was used (period II vs period I), and results are presented as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs). Results: There were no statistically significant differences in HIE 2-3 (aOR 1.27; 95% CI 0.97-1.66), proportion of neonates meeting A-criteria for hypothermia treatment (aOR 0.96; 95% CI 0.89-1.04) or neonatal mortality (aOR 0.68; 95% CI 0.39-1.18) between the cohorts. Birth acidemia (aOR 1.36; 95% CI 1.25-1.48), 5-min Apgar scores &lt;7 (aOR 1.27; 95% CI 1.18-1.36) and &lt;4 (aOR 1.40; 95% CI 1.17-1.66) occurred more often in cohort II. The absolute risk difference for HIE 2-3 was 0.02% (95% CI 0.00-0.04). Operative delivery (vacuum or cesarean) rates were lower in cohort II (aOR 0.82; 95% CI 0.80-0.85 and aOR 0.94; 95% CI 0.91-0.97, respectively). Conclusions: Although not statistically significant, a small increase in the incidence of HIE 2-3 after implementation of the revised CTG classification cannot be excluded. Operative deliveries were fewer but incidences of acidemia and low Apgar scores were higher in the latter cohort. This warrants further in-depth analyses before a full re-evaluation of the revised classification can be made

Case mix adjustment of health outcomes, resource use and process indicators in childbirth care : A register-based study

Background: Unwarranted variation in care practice and outcomes has gained attention and inter-hospital comparisons are increasingly being used to highlight and understand differences between hospitals. Adjustment for case mix is a prerequisite for meaningful comparisons between hospitals with different patient populations. The objective of this study was to identify and quantify maternal characteristics that impact a set of important indicators of health outcomes, resource use and care process and which could be used for case mix adjustment of comparisons between hospitals. Methods: In this register-based study, 139 756 deliveries in 2011 and 2012 were identified in regional administrative systems from seven Swedish regions, which together cover 67 % of all deliveries in Sweden. Data were linked to the Medical birth register and Statistics Sweden's population data. A number of important indicators in childbirth care were studied: Caesarean section (CS), induction of labour, length of stay, perineal tears, haemorrhage > 1000 ml and post-partum infections. Sociodemographic and clinical characteristics deemed relevant for case mix adjustment of outcomes and resource use were identified based on previous literature and based on clinical expertise. Adjustment using logistic and ordinary least squares regression analysis was performed to quantify the impact of these characteristics on the studied indicators. Results: Almost all case mix factors analysed had an impact on CS rate, induction rate and length of stay and the effect was highly statistically significant for most factors. Maternal age, parity, fetal presentation and multiple birth were strong predictors of all these indicators but a number of additional factors such as born outside the EU, body mass index (BMI) and several complications during pregnancy were also important risk factors. A number of maternal characteristics had a noticeable impact on risk of perineal tears, while the impact of case mix factors was less pronounced for risk of haemorrhage > 1000 ml and post-partum infections. Conclusions: Maternal characteristics have a large impact on care process, resource use and outcomes in childbirth care. For meaningful comparisons between hospitals and benchmarking, a broad spectrum of sociodemographic and clinical maternal characteristics should be accounted for

Perinatal complications in patients with unisutural craniosynostosis : An international multicentre retrospective cohort study

Purpose Craniosynostosis may lead to hampered fetal head molding and birth complications. To study the interaction between single suture craniosynostosis and delivery complications, an international, multicentre, retrospective cohort study was performed. Materials and methods All infants born between 2006 and 2012 in the Netherlands and Sweden with sagittal or metopic suture synostosis were included. All births were included as a reference population. The primary outcome measure was rate of medically assisted labor. The secondary outcomes included method of conception, term of birth and fetal position. Results We included 152 trigonocephaly patients, 272 scaphocephaly patients and 1.954.141 controls. A higher rate of assisted reproductive technology (ART) was found in patients with trigonocephaly (13%) and scaphocephaly (7%) compared to controls (3%, p < 0.001). Scaphocephaly resulted in more postterm births (8% vs 4%, p < 0.001). Trigonocephaly patients showed more preterm births (11% vs 6%, p < 0.001), breech position was more frequent (10% vs 4%, p = 0.003) and labor was more often induced. Rate of assisted delivery, including cesarean section, was significantly higher in both patient groups. Conclusions Scaphocephaly leads to more postterm births and an increased rate of cesarean sections. Trigonocephaly is related to ART, and in addition higher rates of breech position and cesarean section are found. Prenatal detection of single suture craniosynostosis could improve perinatal care

Neonatal outcomes associated with mode of subsequent birth after a previous caesarean section in first pregnancy: a Swedish population-based study between 1999-2015

Objective - To investigate neonatal outcomes within 28 days in the subsequent birth in women who gave birth to their first baby by caesarean section (CS). Design and setting - National retrospective population-based register study. A cohort of 94 451 neonates who were born in Sweden between 1999 and 2015 as a second child to a mother who had her first birth by emergency or planned caesarean. Methods - Data were retrieved from the national registers held by Statistics Sweden and the National Board of Health and Welfare. Logistic regression was used to calculate unadjusted and adjusted ORs (aOR) with 95% CIs for each outcome. Main outcome measures - Neonatal infection, neonatal asphyxia/respiratory distress, neonatal hospital care and neonatal death within 28 days. Results - Emergency CS and instrumental vaginal birth were associated with a doubled risk of neonatal infection (aOR 2.0) and planned CS with a decreased risk (aOR 0.7) compared with spontaneous vaginal birth. Compared with spontaneous vaginal birth, an increased risk of birth asphyxia and/or respiratory distress was identified with all other modes of birth (aOR 2.2–3.2). Emergency CS and instrumental vaginal birth, but not planned CS, were associated with neonatal hospital care (aOR 1.8 and 1.7) and an increased mortality rate during the neonatal period (aOR 2.9 and 3.2), compared with spontaneous vaginal birth. Conclusions - In childbirth following a previous birth by CS, spontaneous vaginal birth appears to confer better neonatal outcomes within 28 days after birth overall than other modes of birth