Caesarean section and risk of unexplained stillbirth in subsequent pregnancy

Background Caesarean section is associated with an increased risk of disorders of placentation in subsequent pregnancies, but effects on the rate of antepartum stillbirth are unknown. We aimed to establish whether previous caesarean delivery is associated with an increased risk of antepartum stillbirth. Methods We linked pregnancy discharge data from the Scottish Morbidity Record (1980–98) and the Scottish Stillbirth and Infant Death Enquiry (1985–98). We estimated the relative risk of antepartum stillbirth in second pregnancies using time-to-event analyses. Findings For 120 633 singleton second births, there were 68 antepartum stillbirths in 17 754 women previously delivered by caesarean section (2–39 per 10 000 women per week) and 244 in 102879 women previously delivered vaginally (1·44; p<0·001). Risk of unexplained stillbirth associated with previous caesarean delivery differed significantly with gestational age (p=0·04); the excess risk was apparent from 34 weeks (hazard ratio 2·23 [95% Cl 1·48–3·36]). Risk was not attenuated by adjustment for maternal characteristics or outcome of the first pregnancy (2·74 [1·74–4·30]). The absolute risk of unexplained stillbirth at or after 39 weeks' gestation was 1·1 per 1000 women who had had a previous caesarean section and 0·5 per 1000 in those who had not. The difference was due mostly to an excess of unexplained stillbirths among women previously delivered by caesarean section. Interpretation Delivery by caesarean section in the first pregnancy could increase the risk of unexplained stillbirth in the second. In women with one previous caesarean delivery, the risk of unexplained antepartum stillbirth at or after 39 weeks' gestation is about double the risk of stillbirth or neonatal death from intrapartum uterine rupture

Descriptive epidemiology of birth trauma in the United States in 2003

Sauber-Schatz EK, Markovic N, Weiss HB, Bodnar LM, Wilson JW, Pearlman MD. Descriptive epidemiology of birth trauma in the United States in 2003. Paediatric and Perinatal Epidemiology 2010; 24: 116–124.The rate of birth trauma in the US has been reported to range between 0.2 and 37 birth traumas per 1000 births. Because of the minimal number of population-based studies and the inconsistencies among the published birth trauma rates, the rate of birth trauma in the US remains unclear. This is a cross-sectional study that was conducted using 890 582 in-hospital birth discharges from the 2003 Healthcare Cost and Utilization Project Kids' Inpatient Database. A neonate was defined as having birth trauma if their hospital discharge record contained an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code from 767.0 to 767.9. Weighted data were used to calculate rates for all birth traumas and specific types of birth traumas, and rates and odds ratios by demographic, hospital and clinical variables. Weighted data represented a national estimate of 3 920 787 in-hospital births.Birth trauma was estimated to occur in 29 per 1000 births. The three most frequently diagnosed birth traumas were injuries to the scalp, other injuries to the skeleton and fracture of the clavicle. Significant univariable predictors for birth trauma included male gender, Asian or Pacific Islander race, living in urban or wealthy areas, being born in Western, urban and/or teaching hospital, a co-diagnosis of high birthweight, instrument delivery, malpresentation and other complications during labour and delivery. Birth trauma risk factors including those identified in this study may be useful to consider during labour and delivery. In conclusion, additional research is necessary to identify ways to reduce birth trauma and subsequent infant morbidity and mortality.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79198/1/j.1365-3016.2009.01077.x.pd

Methods for dealing with discrepant records in linked population health datasets: a cross-sectional study

BACKGROUND: Linked population health data are increasingly used in epidemiological studies. If data items are reported on more than one dataset, data linkage can reduce the under-ascertainment associated with many population health datasets. However, this raises the possibility of discrepant case reports from different datasets. METHODS: We examined the effect of four methods of classifying discrepant reports from different population health datasets on the estimated prevalence of hypertensive disorders of pregnancy and on the adjusted odds ratios (aOR) for known risk factors. Data were obtained from linked, validated, birth and hospital data for women who gave birth in a New South Wales hospital (Australia) 2000–2002. RESULTS: Among 250173 women with linked data, 238412 (95.3%) women had perfect agreement on the occurrence of hypertension, 1577 (0.6%) had imperfect agreement; 9369 (3.7%) had hypertension reported in only one dataset (under-reporting) and 815 (0.3%) had conflicting types of hypertension. Using only perfect agreement between birth and discharge data resulted in the lowest prevalence rates (0.3% chronic, 5.1% pregnancy hypertension), while including all reports resulted in the highest prevalence rates (1.1 % chronic, 8.7% pregnancy hypertension). The higher prevalence rates were generally consistent with international reports. In contrast, perfect agreement gave the highest aOR (95% confidence interval) for known risk factors: risk of chronic hypertension for maternal age ≥40 years was 4.0 (2.9, 5.3) and the risk of pregnancy hypertension for multiple birth was 2.8 (2.5, 3.2). CONCLUSION: The method chosen for classifying discrepant case reports should vary depending on the study question; all reports should be used as part of calculating the range of prevalence estimates, but perfect matches may be best suited to risk factor analyses. These findings are likely to be applicable to the linkage of any specialised health services datasets to population data that include information on diagnoses or procedures

Using hospital discharge data for determining neonatal morbidity and mortality: a validation study

<p>Abstract</p> <p>Background</p> <p>Despite widespread use of neonatal hospital discharge data, there are few published reports on the accuracy of population health data with neonatal diagnostic or procedure codes. The aim of this study was to assess the accuracy of using routinely collected hospital discharge data in identifying neonatal morbidity during the birth admission compared with data from a statewide audit of selected neonatal intensive care (NICU) admissions.</p> <p>Methods</p> <p>Validation study of population-based linked hospital discharge/birth data against neonatal intensive care audit data from New South Wales, Australia for 2,432 babies admitted to NICUs, 1994–1996. Sensitivity, specificity and positive predictive values (PPV) with exact binomial confidence intervals were calculated for 12 diagnoses and 6 procedures.</p> <p>Results</p> <p>Sensitivities ranged from 37.0% for drainage of an air leak to 97.7% for very low birthweight, specificities all exceeded 85% and PPVs ranged from 70.9% to 100%. In-hospital mortality, low birthweight (≤1500 g), retinopathy of prematurity, respiratory distress syndrome, meconium aspiration, pneumonia, pulmonary hypertension, selected major anomalies, any mechanical ventilation (including CPAP), major surgery and surgery for patent ductus arteriosus or necrotizing enterocolitis were accurately identified with PPVs over 92%. Transient tachypnea of the newborn and drainage of an air leak had the lowest PPVs, 70.9% and 83.6% respectively.</p> <p>Conclusion</p> <p>Although under-ascertained, routinely collected hospital discharge data had high PPVs for most validated items and would be suitable for risk factor analyses of neonatal morbidity. Procedures tended to be more accurately recorded than diagnoses.</p

Evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial [ISRCTN14570598]

The definitive version is available at www.blackwell-synergy.comObjectives To evaluate the effectiveness of a decision aid for women with a breech presentation compared with usual care. Design Randomised controlled trial. Setting Tertiary obstetric hospitals offering external cephalic version (ECV). Population Women with a singleton pregnancy were diagnosed antenatally with a breech presentation at term, and were clinically eligible for ECV. Methods Women were randomised to either receive a decision aid about the management options for breech presentation in addition to usual care or to receive usual care only with standard counselling from their usual pregnancy care provider. The decision aid comprised a 24-page booklet supplemented by a 30-minute audio-CD and worksheet that was designed for women to take home and review with a partner. Main outcome measures Decisional conflict (uncertainty), knowledge, anxiety and satisfaction with decision making, and were assessed using self-administered questionnaires. Results Compared with usual care, women reviewing the decision aid experienced significantly lower decisional conflict (mean difference −8.92; 95% CI −13.18, −4.66) and increased knowledge (mean difference 8.40; 95% CI 3.10, 13.71), were more likely to feel that they had enough information to make a decision (RR 1.30; 95% CI 1.14, 1.47), had no increase in anxiety and reported greater satisfaction with decision making and overall experience of pregnancy and childbirth. In contrast, 19% of women in the usual care group reported they would have made a different decision about their care. Conclusions A decision aid is an effective and acceptable tool for pregnant women that provides an important adjunct to standard counselling for the management of breech presentation.N Nassar, CL Roberts, CH Raynes-Greenow, A Barratt, B Pea

Effect of childbirth on the course of Crohn's disease; results from a retrospective cohort study in the Netherlands

Contains fulltext : 95846.pdf (publisher's version ) (Open Access)BACKGROUND: Pregnant women with Crohn's disease needs proper counselling about the effect of pregnancy and childbirth on their disease. However, Literature about the effect of childbirth on Crohn's disease is limited. This study examined the effect of childbirth on the course of Crohn's disease and especially perianal Crohn's disease. METHODS: This is a retrospective cohort study which was performed in a tertiary level referral hospital in the Netherlands. From the IBD database, female patients aged 18-80 years in 2004 were selected. Data analysis took place in the years 2005 and 2006. Eventually, 114 women with at least one pregnancy after the diagnosis of Crohn's disease were eligible for the study. Differences between groups were analyzed using Wilcoxon Mann Whitney tests and Chi-square analysis with 2 x 2 or 2 x 3 contingency tables. Two-tailed values were used and p values < 0.05 were considered statistically significant. RESULTS: 21/114 women (18%) had active luminal disease prior to pregnancy, with significantly more pregnancy related complications compared to women with inactive luminal disease (Odds ratio 2.8; 95% CI 1.0 - 7.4). Caesarean section rate was relatively high (37/114, 32%), especially in patients with perianal disease prior to pregnancy compared to women without perianal disease (Odds ratio 4.6; 95% CI 1.8 - 11.4). Disease progression after childbirth was more frequent in patients with active luminal disease prior to pregnancy compared to inactive luminal disease (Odds ratio 9.7; 95% CI 2.1 - 44.3). Progression of perianal disease seems less frequent after vaginal delivery compared with caesarean section, in both women with prior perianal disease (18% vs. 31%, NS) and without prior perianal disease (5% vs 14%, NS). There were no more fistula-related complications after childbirth in women with an episiotomy or second degree tear. CONCLUSION: A relatively high rate of caesarean sections was observed in women with Crohn's disease, especially in women with perianal disease prior to pregnancy. A protective effect of caesarean section on progression of perianal disease was not observed. However, this must be interpreted carefully due to confounder effect by indication for caesarean section