Operative technique at caesarean delivery and risk of complete uterine rupture in a subsequent trial of labour at term. A registry case-control study

To estimate the relation of single-layer closure at previous caesarean delivery, and other pre-labour and intra-partum risk factors for complete uterine rupture in trial of vaginal birth after a caesarean (TOLAC) at term.Population-based case-control study. We identified all women (n = 39 742) recorded in the Danish Medical Birth Registry (DMBR) during a 12-year period (1997-2008) with a singleton pregnancy at term and TOLAC. Among these, all women with a complete uterine rupture were identified (cases). Information from the registry was validated against medical records. Controls were selected in the DMBR as the following two births with TOLAC at term and no uterine rupture. Detailed information from cases and controls was collected from manual review of medical records. Main outcome measure was complete uterine rupture during TOLAC at term.Upon validation, 175 cases and 272 controls met the above criteria. After adjustment for possible confounding factors there was no association between single layer closure and uterine rupture (aOR 1.38, CI: 0.88-2.17). Significant risk factors were: Induction with an unfavourable cervix (aOR 2.10 CI: 1.19-3.71), epidural (aOR 2.17 CI 1.31-3.57), augmentation by oxytocin for more than one hour (aOR 2.03 CI: 1.20-3.44), and birth weight ≥ 4000g (aOR 2.65 CI 1.05-6.64). Previous vaginal delivery (aOR 0.41 CI: 0.25-0.68) and inter-delivery interval of more than 24 months (aOR 0.38 CI: 0.18-0.78) reduced the risk of uterine rupture.Single-layer uterine closure did not remain significantly associated to uterine rupture during TOLAC at term after adjustment for confounding factors. Induction of labour with an unfavourable cervix, birth weight ≥ 4000g and indicators of prolonged labour were all major risk factors for uterine rupture

The effect of primary delivery of the anterior compared with the posterior shoulder on perineal trauma: a study protocol for a randomized controlled trial

BACKGROUND: Approximately 85% of vaginal deliveries are accompanied by perineal trauma. The objective of this trial is to compare the incidence and degree of perineal trauma after primary delivery of the anterior compared with the posterior shoulder during vaginal birth. The hypothesis is that primary delivery of the posterior shoulder reduces the rate and degree of perineal trauma. METHODS/DESIGN: This is a single-centre, randomized controlled trial, with computer-generated randomization in a 1:1 allocation ratio. Women planning their first vaginal delivery (n = 650) are randomized to primary delivery of either the anterior or posterior shoulder. The primary outcome is any perineal trauma. Additional outcomes are the perineal injury subtypes, postpartum bleeding, umbilical artery pH, Apgar score at 5 minutes and any neonatal birth trauma. Perineal trauma is assessed by a midwife or doctor blinded to the method of shoulder delivery. All midwives are trained in the two methods of shoulder delivery and in the grading of perineal tears. The trial is being undertaken at a Danish community hospital with 1,600 yearly deliveries. Data will be analyzed according to the intention-to-treat principle. Recruitment started in January 2013 and the trial is planned to proceed for 24 months. DISCUSSION: Most delivery assistance techniques are based on tradition and heritage and lack objective evidence. This trial provides an example of how vaginal delivery techniques can be evaluated in a randomized controlled trial. The results of this trial will clarify the role that delivery of the shoulders has on perineal trauma and thereby provide knowledge to recommendations on birthing technique. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01937546

Breech delivery at a University Hospital in Tanzania

Background There is a global increase in rates of Cesarean delivery (CD). A minor factor in this increase is a shift towards CD for breech presentation. The aim of this study was to analyze breech births by mode of delivery and investigate short-term fetal and maternal outcomes in a low-income setting. Methods The study design was cross-sectional and the setting was Muhimbili National Hospital (MNH), Dar-es-Salaam, Tanzania. Subjects were drawn from a clinical database (1999–2010) using the following inclusion criteria: breech presentation, birth weight ≥ 2,500 g, single pregnancy, fetal heart sound at admission, and absence of pregnancy-related complication as indication for CD. Of 2,765 mothers who had a breech delivery, 1,655 met the inclusion criteria. Analyses were stratified by mode of delivery, taking into account also other birth characteristics. The outcome measures were perinatal death (stillbirths + in-hospital neonatal deaths) and moderate asphyxia. Maternal outcomes, such as death, hemorrhage, and length of hospital stay, were also described. Results The CD rate for breech presentation increased from 28 % in 1999 to 78 % in 2010. Perinatal deaths were associated with vaginal delivery (VD) (adjusted odds ratio (aOR) 6.2; 95 % confidence interval (CI) 3.0–12.6) and referral (aOR 2.1; 95 % CI 1.1–3.9), but not with parity, birth weight, or delivery year. Overall perinatal mortality was 5.8 % and this did not decline, due to an increase in stillbirths among vaginal breech deliveries. Mothers with CD had more hemorrhage compared to those with VD. One mother died in association with CD, and one died in association with VD. Conclusion A breech VD, compared to a breech CD, in this setting was associated with adverse perinatal outcome. However, despite a significant increase in CD rate, no overall improvement was observed due to an increase in stillbirths among VD

Can Intrapartum Cardiotocography Predict Uterine Rupture among Women with Prior Caesarean Delivery?:A Population Based Case-Control Study

OBJECTIVE: To compare cardiotocographic abnormalities recorded during labour in women with prior caesarean delivery (CD) and complete uterine rupture with those recorded in controls with prior CD without uterine rupture. STUDY DESIGN: Women with complete uterine rupture during labour between 1997 and 2008 were identified in the Danish Medical Birth Registry (n = 181). Cases were validated by review of medical records and 53 cases with prior CD, trial of labour, available cardiotocogram (CTG) and complete uterine rupture were included and compared with 43 controls with prior CD, trial of labour and available CTG. The CTG tracings were assessed by 19 independent experts divided into groups of three different experts for each tracing. The assessors were blinded to group, outcome and clinical data. They analyzed occurrence of defined abnormalities and classified the traces as normal, suspicious, pathological or pre-terminal according to international guidelines (FIGO). RESULTS: A pathological CTG during the first stage of labour was present in 77% of cases and in 53% of the controls (OR 2.58 [CI: 0.96–6.94] P = 0.066). Fetal tachycardia was more frequent in cases with uterine rupture (OR 2.50 [CI: 1.0–6.26] P = 0.053). Significantly more cases showed more than 10 severe variable decelerations compared with controls (OR 22 [CI: 1.54–314.2] P = 0.022). Uterine tachysystole was not correlated with the presence of uterine rupture. CONCLUSION: A pathological cardiotocogram should lead to particular attention on threatening uterine rupture but cannot be considered a strong predictor as it is common in all women with trial of labour after caesarean delivery

COVID-19 in pregnancy—characteristics and outcomes of pregnant women admitted to hospital because of SARS-CoV-2 infection in the Nordic countries

cited By 0Introduction Population-based studies about the consequences of SARS-CoV-2 infection (COVID-19) in pregnancy are few and have limited generalizability to the Nordic population and healthcare systems. Material and methods This study examines pregnant women with COVID-19 in the five Nordic countries. Pregnant women were included if they were admitted to hospital between 1 March and 30 June 2020 and had a positive SARS-CoV-2 PCR test Results In the study areas, 214 pregnant women with a positive test were admitted to hospital, of which 56 women required hospital care due to COVID-19. The risk of admission due to COVID-19 was 0.4/1000 deliveries in Denmark, Finland and Norway, and 3.8/1000 deliveries in the Swedish regions. Women hospitalized because of COVID-19 were more frequently obese (p < 0.001) and had a migrant background (p < 0.001) compared with the total population of women who delivered in 2018. Twelve women (21.4%) needed intensive care. Among the 56 women admitted due to COVID-19, 48 women delivered 51 infants. Preterm delivery (n = 12, 25%, p < 0.001) and cesarean delivery (n = 21, 43.8%, p < 0.001) were more frequent in women with COVID-19 compared with women who delivered in 2018. No maternal deaths, stillbirths or neonatal deaths were reported. Conclusions The risk of admission due to COVID-19 disease in pregnancy was low in the Nordic countries. A fifth of the women required intensive care and we observed higher rates of preterm and cesarean deliveries. National public health policies appear to have had an impact on the risk of admission due to severe COVID-19 disease in pregnancy. Nordic collaboration is important in collecting robust data and assessing rare outcomes.Peer reviewe