Wide differences in mode of delivery within Europe: risk-stratified analyses of aggregated routine data from the Euro-Peristat study

Join point trends of instrumental vaginal deliveries and cesarean sections at the Lagos University Teaching Hospital, Lagos, Nigeria (2002-2017)

OBJECTIVE

To determine the trends of instrumental vaginal delivery (IVD) and cesarean section (CS) at the Lagos University Teaching Hospital (LUTH), Nigeria, over 16 years, from 2002 to 2017.

METHODS

A retrospective cross-sectional study. The case records of all women who had IVD and CS during the study period were reviewed. The trends in the IVD and CS rates were evaluated using join point regression modeling. The average annual percent change (AAPC) and annual percent change (APC) with associated 95% confidence interval of segmental trends were calculated.

RESULTS

The overall IVD rate was 1.36%. Vacuum delivery rate was higher than forceps (0.79% vs 0.57%). The CS rate was 44.9 per 100 deliveries; the rate increased by about 3.7% per annum. CS rates were 7.1-89.9 times the IVD rates within the study period. The number of IVDs performed in the hospital declined by about 83.02%, from 53 cases in 2002 to nine cases in 2017. Forceps delivery declined at a faster rate than vacuum delivery between 2002 and 2017 (AAPC for forceps: -12.6% [-17.5 to -7.5], P < 0.001 vs AAPC for vacuum: -6.2% [-14.3 to 2.7], P = 0.200). The commonest indication for IVD was prolonged second stage of labor (47/162, 29.01%) and shortening of the second stage of labor for maternal conditions (47/162, 29.01%).

CONCLUSION

IVD rates are low and declining at LUTH. There is need to train accoucheurs on the safe use of IVDs to potentially reduce the CS rate.

Analysis of the obstetrician's posture and movements during a simulated forceps delivery

BACKGROUND

The objective of this study was to identify and qualify, by means of a three-dimensional kinematic analysis, the postures and movements of obstetricians during a simulated forceps birth, and then to study the association of the obstetricians' experience with the technique adopted.

METHOD

Fifty-seven volunteer obstetricians, 20 from the Limoges and 37 from the Poitiers University hospitals, were included in this multi-centric study. They were classified into 3 groups: beginners, intermediates, and experts, beginners having performed fewer than 10 forceps deliveries in real conditions, intermediates between 10 and 100, and experts more than 100. The posture and movements of the obstetricians were recorded between December 2020 and March 2021 using an optoelectronic motion capture system during simulated forceps births. Joint angles qualifying these postures and movements were analysed between the three phases of the foetal traction. These phases were defined by the passage of a virtual point associated with the forceps blade through two anatomical planes: the mid-pelvis and the pelvic outlet. Then, a consolidated ascending hierarchical classification (AHC) was applied to these data in order to objectify the existence of groups of similar behaviours.

RESULTS

The AHC distinguished four different postures adopted when crossing the first plane and three different traction techniques. 48% of the beginners adopted one of the two raised posture, 22% being raised without trunk flexion and 26% raised with trunk flexion. Conversely, 58% of the experts positioned themselves in a "chevalier servant" posture (going down on one knee) and 25% in a "squatting" posture before initiating traction. The results also show that the joint movement amplitude tends to reduce with the level of expertise.

CONCLUSION

Forceps delivery was performed in different ways, with the experienced obstetricians favouring postures that enabled observation at the level of the maternal perineum and techniques reducing movement amplitude. The first perspective of this work is to relate these different techniques to the traction force generated. The results of these studies have the potential to contribute to the training of obstetricians in forceps delivery, and to improve the safety of women and newborns.

An Analysis of the Mode of Delivery, Risk Factors, and Subgroups with High Caesarean Birth Rates Using Robson Classification System

OBJECTIVE

We aimed to understand the utilization of the mode of delivery and related risk factors. Further aimed to apply the Robson classification system to evaluate the data quality and analyze the CS rates in subgroups.

METHODS

We conducted a retrospective descriptive study by reviewing the medical records of all women who delivered at the State Hospital in 2019. A proforma was developed for extracting data from patient records. All women with six obstetric parameters were categorized into Robson groups to determine the absolute and relative contributions of each group to the overall CS rate.

RESULTS

Of 797 deliveries, 401 (50.2%) were CSs. Being older, being Turkish Cypriot, having preterm births, previous CS, multiple fetuses, and having breech or transverse fetal presentations were related to having higher risks of CS. The most common medical indication for CSs (52.3%) was a history of previous CSs. Robson Group 5 contributed the most (50.7%) to the overall CS rate, with the highest absolute contribution of 21.8%. Group 10 and Group 8 were the second and third highest contributors to the overall CS rate, with relative contributions of 25.3% and 9.0%, respectively.

CONCLUSIONS

Findings revealed the substandard quality of obstetric data and a noticeably high overall CS rate. The top priority should be given to improving the quality of medical records. It underscored the necessity of implementing the Robson classification system as a standard clinical practice to enhance data quality, which helps to effectively evaluate and monitor the CS rates in obstetric populations.

Does structured obstetric management play a role in the delivery mode and neonatal outcome of twin pregnancies?

PURPOSE

While the optimal delivery method of twin pregnancies is debated, the rate of cesarean deliveries is increasing. This retrospective study evaluates delivery methods and neonatal outcome of twin pregnancies during two time periods and aims to identify predictive factors for the delivery outcome.

METHODS

553 twin pregnancies were identified in the institutional database of the University Women's Hospital Freiburg, Germany. 230 and 323 deliveries occurred in period I (2009-2014) and period II (2015-2021), respectively. Cesarean births due to non-vertex position of the first fetus were excluded. In period II, the management of twin pregnancies was reviewed; adjusted and systematic training with standardized procedures was implemented.

RESULTS

Period II showed significantly lower rates of planned cesarean deliveries (44.0% vs. 63.5%, p < 0.0001) and higher rates of vaginal deliveries (68% vs. 52.4%, p = 0.02). Independent risk factors for primary cesarean delivery were period I, maternal age > 40 years, nulliparity, a history with a previous cesarean, gestational age < 37 completed weeks, monochorionicity and increasing birth weight difference (per 100 g or > 20%). Predictive factors for successful vaginal delivery were previous vaginal delivery gestational age between 34 and 36 weeks and vertex/vertex presentation of the fetuses. The neonatal outcomes of period I and II were not significantly different, but planned cesareans in general were associated with increased admission rates to the neonatal intensive care units. Inter-twin interval had no significant impact on neonatal outcome.

CONCLUSION

Structured regular training of obstetrical procedures may significantly reduce high cesarean rates and increase the benefit-risk ratio of vaginal deliveries.

A new classification allowing assessment of instrumental vaginal-birth practices

BACKGROUND

Instrumental vaginal birth, a very common intervention in obstetrics, concerns nearly one in eight women in France. Instrumentally assisted vaginal childbirth can be for maternal and/or fetal indications. Although it reduces recourse to caesarean section, it is subject to risks. Practices concerning instrumental birth are disparate, varying among different practitioners, maternity units and countries, and it is essential to be able to evaluate them. Our objective was to create a classification tool of women requiring instrumental birth to facilitate the analysis of practices within our maternity unit as well as to enable temporal and geographical comparisons.

MATERIALS AND METHODS

We propose a simple and robust classification based on the same principles as Robson's classification. It is made up of seven totally inclusive and mutually exclusive groups. Our classification was refined and validated using the Delphi method by a panel of 14 experts from throughout France, and tested in our maternity unit using data from throughout 2021.

RESULTS

The seven clinically relevant groups are based on five obstetric criteria (multiplicity, presentation, gestational age, previous type of birth, induction of labor). To classify each woman in a group, five successive questions are posed in a predefined order. The classification has been validated by the experts with highly satisfactory overall agreement.

CONCLUSION

In order to improve the quality of care, we propose a tool to standardize the evaluation of instrumental vaginal birth practice (called the "Isère classification", after the county where we work in south-eastern France). It will also facilitate the comparison the practices among different maternity units in a network, a country or even among different countries.

Trends in caesarean section rates in Europe from 2015 to 2019 using Robson's Ten Group Classification System: A Euro-Peristat study

OBJECTIVE

To assess changes in caesarean section (CS) rates in Europe from 2015 to 2019 and utilise the Robson Ten Group Classification System (TGCS) to evaluate the contribution of different obstetric populations to overall CS rates and trends.

DESIGN

Observational study utilising routine birth registry data.

SETTING

A total of 28 European countries.

POPULATION

Births at ≥22 weeks of gestation in 2015 and 2019.

METHODS

Using a federated model, individual-level data from routine sources in each country were formatted to a common data model and transformed into anonymised, aggregated data.

MAIN OUTCOME MEASURES

By country: overall CS rate. For TGCS groups (by country): CS rate, relative size, relative and absolute contribution to overall CS rate.

RESULTS

Among the 28 European countries, both the CS rates (2015, 16.0%-55.9%; 2019, 16.0%-52.2%) and the trends varied (from -3.7% to +4.7%, with decreased rates in nine countries, maintained rates in seven countries (≤ ± 0.2) and with increasing rates in 12 countries). Using the TGCS (for 17 countries), in most countries labour induction increased (groups 2a and 4a), whereas multiple pregnancies (group 8) decreased. In countries with decreasing overall CS rates, CS tended to decrease across all TGCS groups, whereas in countries with increasing rates, CS tended to increase in most groups. In countries with the greatest increase in CS rates (>1%), the absolute contributions of groups 1 (nulliparous term cephalic singletons, spontaneous labour), 2a and 4a (induction of labour), 2b and 4b (prelabour CS) and 10 (preterm cephalic singletons) to the overall CS rate tended to increase.

CONCLUSIONS

The TGCS shows varying CS trends and rates among countries of Europe. Comparisons between European countries, particularly those with differing trends, could provide insight into strategies to reduce CS without clinical indication.

The Environmental Exposures in Lebanese Infants (EELI) birth cohort: an investigation into the Developmental Origins of Health and Diseases (DOHaD)

The EELI Study is a longitudinal birth cohort launched in 2021 in Lebanon to examine the long-term impact of environmental exposures on the health of prospective Lebanese mothers and infants and disease outcomes. This article delineates the adopted study design and protocols, current progress, and contextual considerations for the planning and launching of a birth cohort in a resource-limited setting. A sample of n = 135 pregnant women expecting to give birth at the Hôtel-Dieu de France University Hospital has been recruited since the study launch. Over 500 variables have been recorded for each participant, and over 1000 biological specimens have been processed and stored in a biobank for further analysis. The EELI study establishes methodological and logistic basis to explore the concept of the exposome and its implementation and to establish a toolkit of the SOPs and questionnaires that can be employed by the other countries in the Eastern Mediterranean region.

Antimicrobial resistance prevalence in bloodstream infection in 29 European countries by age and sex: An observational study

BACKGROUND

Antibiotic usage, contact with high transmission healthcare settings as well as changes in immune system function all vary by a patient's age and sex. Yet, most analyses of antimicrobial resistance (AMR) ignore demographic indicators and provide only country-level resistance prevalence values. This study aimed to address this knowledge gap by quantifying how resistance prevalence and incidence of bloodstream infection (BSI) varied by age and sex across bacteria and antibiotics in Europe.

METHODS AND FINDINGS

We used patient-level data collected as part of routine surveillance between 2015 and 2019 on BSIs in 29 European countries from the European Antimicrobial Resistance Surveillance Network (EARS-Net). A total of 6,862,577 susceptibility results from isolates with age, sex, and spatial information from 944,520 individuals were used to characterise resistance prevalence patterns for 38 different bacterial species and antibiotic combinations, and 47% of these susceptibility results were from females, with a similar age distribution in both sexes (mean of 66 years old). A total of 349,448 isolates from 2019 with age and sex metadata were used to calculate incidence. We fit Bayesian multilevel regression models by country, laboratory code, sex, age, and year of sample to quantify resistant prevalence and provide estimates of country-, bacteria-, and drug-family effect variation. We explore our results in greater depths for 2 of the most clinically important bacteria-antibiotic combinations (aminopenicillin resistance in Escherichia coli and methicillin resistance in Staphylococcus aureus) and present a simplifying indicative index of the difference in predicted resistance between old (aged 100) and young (aged 1). At the European level, we find distinct patterns in resistance prevalence by age. Trends often vary more within an antibiotic family, such as fluroquinolones, than within a bacterial species, such as Pseudomonas aeruginosa. Clear resistance increases by age for methicillin-resistant Staphylococcus aureus (MRSA) contrast with a peak in resistance to several antibiotics at approximately 30 years of age for P. aeruginosa. For most bacterial species, there was a u-shaped pattern of infection incidence with age, which was higher in males. An important exception was E. coli, for which there was an elevated incidence in females between the ages of 15 and 40. At the country-level, subnational differences account for a large amount of resistance variation (approximately 38%), and there are a range of functional forms for the associations between age and resistance prevalence. For MRSA, age trends were mostly positive, with 72% (n = 21) of countries seeing an increased resistance between males aged 1 and 100 years and a greater change in resistance in males. This compares to age trends for aminopenicillin resistance in E. coli which were mostly negative (males: 93% (n = 27) of countries see decreased resistance between those aged 1 and 100 years) with a smaller change in resistance in females. A change in resistance prevalence between those aged 1 and 100 years ranged up to 0.51 (median, 95% quantile of model simulated prevalence using posterior parameter ranges 0.48, 0.55 in males) for MRSA in one country but varied between 0.16 (95% quantile 0.12, 0.21 in females) to -0.27 (95% quantile -0.4, -0.15 in males) across individual countries for aminopenicillin resistance in E. coli. Limitations include potential bias due to the nature of routine surveillance and dependency of results on model structure.

CONCLUSIONS

In this study, we found that the prevalence of resistance in BSIs in Europe varies substantially by bacteria and antibiotic over the age and sex of the patient shedding new light on gaps in our understanding of AMR epidemiology. Future work is needed to determine the drivers of these associations in order to more effectively target transmission and antibiotic stewardship interventions.

Prenatal counseling of an isolated fetal small head circumference during the second trimester expert ultrasound examination

OBJECTIVE

To evaluate perinatal and postnatal outcomes of fetuses with an isolated small head circumference (HC) on expert ultrasound examination in the second trimester for further recommendations in prenatal care.

STUDY DESIGN

In a retrospective cohort we included singleton-pregnancies with a fetal HC > -3.0 SD and ≤ -1.64 SD determined on expert ultrasound examination between 18 and 24 weeks of gestational age. Three subgroups were determined: "isolated small HC (ISHC)", "small HC plus abdominal circumference (AC) ≤ p10 (SHC+)" and "small HC plus AC ≤ p10 and Doppler abnormalities (SHC + D)". After ultrasound examination, genetic testing was sometimes offered and postnatally genetic tests were performed on indication.

RESULTS

We included 252 pregnancies: 109 ISHC, 104 SHC+, and 39 SHC + D. In the ISHC and SHC+ subgroup, 96 % of the fetuses were born alive and did not die neonatal. In the SH + D group this was only 38 %. In the SHC+ subgroup, less fetuses were delivered vaginal (non-instrumental) compared to the ISHC subgroup (61 % vs. 73 %, p < 0.01). In the ISHC and SHC+ subgroup s some fetuses were diagnosed with congenital defects (4 % vs. 10 %, p = 0.08) and with a genetic anomaly (6.4 % vs. 7.7 %, p = 0.13) after 24 weeks or postnatally. In SHC + D subgroups 5 % presented with congenital defects and 2.6 % with a genetic anomaly.

CONCLUSION

We conclude that fetuses with a small HC without structural anomalies on second trimester expert ultrasound require follow-up and special medical attention. We recommend differentiating between ISHC, SHC+, and SHC + D for prenatal counseling. Genetic testing and referral to a clinical geneticist should be considered.

A systematic review and a meta-analysis on the incidence of obstetric anal sphincter injuries during vaginal delivery

AIM

The incidence of obstetric anal sphincter injuries (OASIS) has increased in the past two decades despite improved awareness of the risk factors. This study aimed to define the incidence of OASIS in women with different features (instrumental delivery or other variables).

METHODS

A systematic review was conducted on articles reporting the incidence of OASIS. This review aims to examine the association of instrumentation and OASIS by performing a formal systematic review of the published literature. Databases used for the research were MEDLINE, Embase, CINAHL and 'Maternity and infant care' databases.

RESULTS

Two independent reviewers screened the selected articles. 2326 duplicates were removed from the total of 4907 articles. The remaining 2581 articles were screened for title and abstract. 1913 articles were excluded due to irrelevance. The remaining 300 were screened as full text. Primiparity associated with the use of forceps were the features associated with the highest incidence of OASIS in the selected articles (19.4%). OASIS in all women had an overall incidence of 3.8%. The incidence of OASIS in all women by geographical region was the highest (6.5%) in North America.

CONCLUSIONS

There are various factors that impact on the incidence of OASIS and the combination of some of these, such as the use of forceps in primiparas, resulted in the highest incidence of OASIS. The lack of international consensus is limiting the improvements that can be done to reduce OASIS rates and improve best clinical practice.

Peripartum Hysterectomy Outcomes: Our Eleven-Year Experience at a Tertiary Care Hospital

Aim

To investigate the outcomes of peripartum hysterectomies (PHs) conducted to prevent maternal morbidity and mortality at a tertiary care hospital with 15,000 deliveries per year.

Method

Patients who underwent PHs during delivery and/or within 24 h of delivery between the years 2011-2022 were retrospectively evaluated. Hysterectomies not performed in the peripartum period, cases that were managed by methods such as balloon tamponade, compression suture, or arterial ligation rather than hysterectomy, and hysterectomies performed before 20 weeks were excluded. Obstetric and demographic characteristics of the cases, as well as indications and outcomes of PH, were investigated.

Results

Among the 130 patients who underwent PH, 4 (3.04%) patients delivered vaginally, 1 (0.7%) patient delivered vaginally after cesarean section, 12 (9.2%) patients delivered by primary cesarean section, and 113 (86.9%) patients delivered by secondary cesarean section. Placenta accreta spectrum disorder was the reason for PH in 54.6% (n = 71) of the cases while 16.1% (n = 21) underwent PH due to uterine atony. The PH rate was 0.75 per 1000 births, and the maternal mortality rate was 7.6 per 1000 hysterectomies in this study.

Conclusion

Obstetricians in developed/ing countries support the active management of the third stage of labor mainly to mitigate the preventable risk factors of post-/peri-partum hemorrhage. The current study suggests that obstetricians need to focus on the placenta in order to reduce PH.

Apgar Score and Neurodevelopmental Outcomes at Age 5 Years in Infants Born Extremely Preterm

Importance

The Apgar score is used worldwide as an assessment tool to estimate the vitality of newborns in their first minutes of life. Its applicability to estimate neurodevelopmental outcomes in infants born extremely preterm (EPT; <28 weeks' gestation) is not well established.

Objective

To investigate the association between the Apgar score and neurodevelopmental outcomes in infants born EPT.

Design, Setting, and Participants

This cohort study was conducted using data from the Effective Perinatal Intensive Care in Europe-Screening to Improve Health in Very Preterm Infants in Europe (EPICE-SHIPS) study, a population-based cohort in 19 regions of 11 European countries in 2011 to 2012. Clinical assessments of cognition and motor function at age 5 years were performed in infants born EPT and analyzed in January to July 2023.

Exposures

Apgar score at 5 minutes of life categorized into 4 groups (0-3, 4-6, 7-8, and 9-10 points).

Main Outcomes and Measures

Cognitive and motor outcomes were assessed using the Wechsler Preschool and Primary Scale of Intelligence test of IQ derived from locally normed versions by country and the Movement Assessment Battery for Children-Second Edition. Parents additionally provided information on communication and problem-solving skills using the Ages and Stages Questionnaire, third edition (ASQ-3). All outcomes were measured as continuous variables.

Results

From the total cohort of 4395 infants born EPT, 2522 infants were live born, 1654 infants survived to age 5 years, and 996 infants (478 females [48.0%]) followed up had at least 1 of 3 outcome measures. After adjusting for sociodemographic variables, perinatal factors, and severe neonatal morbidities, there was no association of Apgar score with IQ, even for scores of 3 or less (β = -3.3; 95% CI, -10.5 to 3.8) compared with the score 9 to 10 category. Similarly, no association was found for ASQ-3 (β = -2.1; 95% CI, -24.6 to 20.4). Congruent results for Apgar scores of 3 or less were obtained for motor function scores for all children (β = -4.0; 95% CI, -20.1 to 12.1) and excluding children with a diagnosis of cerebral palsy (β = 0.8, 95% CI -11.7 to 13.3).

Conclusions and Relevance

This study found that low Apgar scores were not associated with longer-term outcomes in infants born EPT. This finding may be associated with high interobserver variability in Apgar scoring, reduced vitality signs and poorer responses to resuscitation after birth among infants born EPT, and the association of more deleterious exposures in the neonatal intensive care unit or of socioeconomic factors with greater changes in outcomes during the first 5 years of life.

Developing and testing a protocol using a common data model for federated collection and analysis of national perinatal health indicators in Europe

Context: International comparisons of the health of mothers and babies provide essential benchmarks for guiding health practice and policy, but statistics are not routinely compiled in a comparable way. These data are especially critical during health emergencies, such as the coronavirus disease (COVID-19) pandemic. The Population Health Information Research Infrastructure (PHIRI) project aimed to promote the exchange of population data in Europe and included a Use Case on perinatal health. Objective: To develop and test a protocol for federated analysis of population birth data in Europe. Methods: The Euro-Peristat network with participants from 31 countries developed a Common Data Model (CDM) and R scripts to exchange and analyse aggregated data on perinatal indicators. Building on recommended Euro-Peristat indicators, complemented by a three-round consensus process, the network specified variables for a CDM and common outputs. The protocol was tested using routine birth data for 2015 to 2020; a survey was conducted assessing data provider experiences and opinions. Results: The CDM included 17 core data items for the testing phase and 18 for a future expanded phase. 28 countries and the four UK nations created individual person-level databases and ran R scripts to produce anonymous aggregate tables. Seven had all core items, 17 had 13-16, while eight had ≤12. Limitations were not having all items in the same database, required for this protocol. Infant death and mode of birth were most frequently missing. Countries took from under a day to several weeks to set up the CDM, after which the protocol was easy and quick to use. Conclusion: This open-source protocol enables rapid production and analysis of perinatal indicators and constitutes a roadmap for a sustainable European information system. It also provides minimum standards for improving national data systems and can be used in other countries to facilitate comparison of perinatal indicators.

Regional practice variation in induction of labor in the Netherlands: Does it matter? A multilevel analysis of the association between induction rates and perinatal and maternal outcomes

BACKGROUND

Practice variation in healthcare is a complex issue. We focused on practice variation in induction of labor between maternity care networks in the Netherlands. These collaborations of hospitals and midwifery practices are jointly responsible for providing high-quality maternity care. We explored the association between induction rates and maternal and perinatal outcomes.

METHODS

In a retrospective population-based cohort study, we included records of 184,422 women who had a singleton, vertex birth of their first child after a gestation of at least 37 weeks in the years 2016-2018. We calculated induction rates for each maternity care network. We divided networks in induction rate categories: lowest (Q1), moderate (Q2-3) and highest quartile (Q4). We explored the association of these categories with unplanned caesarean sections, unfavorable maternal outcomes and adverse perinatal outcomes using descriptive statistics and multilevel logistic regression analysis corrected for population characteristics.

FINDINGS

The induction rate ranged from 14.3% to 41.1% (mean 24.4%, SD 5.3). Women in Q1 had fewer unplanned caesarean sections (Q1: 10.2%, Q2-3: 12.1%; Q4: 12.8%), less unfavorable maternal outcomes (Q1: 33.8%; Q2-3: 35.7%; Q4: 36.3%) and less adverse perinatal outcomes (Q1: 1.0%; Q2-3: 1.1%; Q4: 1.3%). The multilevel analysis showed a lower unplanned caesarean section rate in Q1 in comparison with reference category Q2-3 (OR 0.83; p = .009). The unplanned caesarean section rate in Q4 was similar to the reference category. No significant associations with unfavorable maternal or adverse perinatal outcomes were observed.

CONCLUSION

Practice variation in labor induction is high in Dutch maternity care networks, with limited association with maternal outcomes and no association with perinatal outcomes. Networks with low induction rates had lower unplanned caesarean section rates compared to networks with moderate rates. Further in-depth research is necessary to understand the mechanisms that contribute to practice variation and the observed association with unplanned caesarean sections.

The Impact of Mode of Birth, and Episiotomy, on Postpartum Sexual Function in the Medium- and Longer-Term: An Integrative Systematic Review

(1) Background: Sexual function can be affected up to and beyond 18 months postpartum, with some studies suggesting that spontaneous vaginal birth results in less sexual dysfunction. This review examined the impact of mode of birth on sexual function in the medium- (≥6 months and <12 months postpartum) and longer-term (≥12 months postpartum). (2) Methods: Literature published after January 2000 were identified in PubMed, Embase and CINAHL. Studies that compared at least two modes of birth and used valid sexual function measures were included. Systematic reviews, unpublished articles, protocols and articles not written in English were excluded. Quality was assessed using the Newcastle Ottawa Scale. (3) Results: In the medium-term, assisted vaginal birth and vaginal birth with episiotomy were associated with worse sexual function, compared to caesarean section. In the longer-term, assisted vaginal birth was associated with worse sexual function, compared with spontaneous vaginal birth and caesarean section; and planned caesarean section was associated with worse sexual function in several domains, compared to spontaneous vaginal birth. (4) Conclusions: Sexual function, in the medium- and longer-term, can be affected by mode of birth. Women should be encouraged to seek support should their sexual function be affected after birth.

Association between timing and duration of breech presentation during pregnancy and developmental dysplasia of the hip: A case-control study

This case-control study investigated the association between timing and duration of breech presentation in pregnancy and developmental dysplasia of the hip (DDH). Children with DDH aged 3 years or younger (n = 191) were compared with healthy controls (n = 209). Data on outcome, exposure and, covariates were collected using a parents' self-report online questionnaire. Term children with breech presentation at one or more check-ups after 30.0 weeks gestation had a twofold higher risk of developing DDH compared to children who had never presented in breech (OR 2.01; 95% CI [1.28, 3.15]). The strength of the association increased with duration of breech presentation (5-8 weeks: OR 2.65; 95% CI [1.36, 5.18]; 9-12 weeks: OR 3.63; 95% CI [1.82, 7.24]). Children who had presented in breech at least once in gestational period 37.0-birth had a 3.24 (95% CI [1.86, 5.65]) times higher risk of DDH, whereas the risk for children with breech presentation in gestational period 30.0-36.6 only was not increased. Also after adjusting for confounders, children who had presented in breech after gestational week 37.0-birth had a more than threefold higher risk of DDH (OR 3.33; 95% CI [1.81, 6.13]) compared to children who were never in breech or in gestational period 30.0-36.6 only.

Implementing midwifery continuity of care models in regional Australia: A constructivist grounded theory study

PROBLEM/BACKGROUND

Strong international evidence demonstrates significantly improved outcomes for women and their babies when supported by midwifery continuity of care models. Despite this, widespread implementation has not been achieved, especially in regional settings.

AIM

To develop a theoretical understanding of the factors that facilitate or inhibit the implementation of midwifery continuity models within regional settings.

METHODS

A Constructivist Grounded Theory approach was used to collect and analyse data from 34 interviews with regional public hospital key informants.

RESULTS

Three concepts of theory emerged: 'engaging the gatekeepers', 'midwives lacking confidence' and 'women rallying together'. The concepts of theory and sub-categories generated a substantive theory: A partnership between midwives and women is required to build confidence and enable the promotion of current evidence; this is essential for engaging key hospital stakeholders to invest in the implementation of midwifery continuity of care models.

DISCUSSION

The findings from this research suggest that midwives and women can significantly influence the implementation of midwifery continuity models within their local maternity services, particularly in regional settings. Midwives' reluctance to transition is based on a lack of confidence and knowledge of what it is really like to work in midwifery continuity models. Similarly, women require education to increase awareness of continuity of care benefits, and a partnership between women and midwives can be a strong political force to overcome many of the barriers.

CONCLUSION

Implementation of midwifery continuity of care needs a coordinated ground up approach in which midwives partner with women and promote widespread dissemination of evidence for this model, directed towards consumers, midwives, and hospital management to increase awareness of the benefits.

Clinicians' views of factors influencing decision-making for CS for first-time mothers-A qualitative descriptive study

Clinicians' perspectives of the reasons for performing caesarean section (CS) are fundamental to deepening knowledge and understanding of factors influencing decision-making for CS. The aim of this study was to explore midwives' and obstetricians' views of factors influencing decision-making for CS for first-time mothers. A qualitative descriptive study with semi-structured one-to-one audio-recorded interviews was used to gather data from clinicians (15 midwives and 20 senior obstetricians). Following research ethics committee approval, clinicians, who were directly involved in the decision-making process for CS during the period of data collection, were purposively selected from three maternity units in the Republic of Ireland between June 2016 to July 2017. The interviews were transcribed verbatim and analysed thematically. Three interrelated themes with several subthemes reflective of clinicians' views and experiences emerged following data analysis. These were: 'A fear factor' describing clinicians' fear of adverse outcomes and subsequent litigation, 'Personal preferences versus a threshold-clinician driven factors emphasising the influence of clinicians' personal beliefs, and 'Standardised versus individualised care-a system perspective' explaining the effects of, or lack of, organisational policy and its direct and indirect impact on the decision-making process. Findings show that decisions to perform a CS are, on occasion, based on clinicians' personal beliefs and interpretation, similar to findings from other published literature. Consideration of broader issues related to organisational, socio-cultural and political context is essential when seeking solutions to the rising CS rates. The findings will enable clinicians to reflect on their day-to-day practice, in order to look for modifiable factors that influence their decision-making, and help women understand the multitude of factors that can lead to a decision to perform a CS. Findings will also contribute to the development of the 'next step action' and assist in devising future intervention studies to reduce any unnecessary CSs.

Individual and country-level variables associated with the medicalization of birth: Multilevel analyses of IMAgiNE EURO data from 15 countries in the WHO European region

OBJECTIVE

To investigate potential associations between individual and country-level factors and medicalization of birth in 15 European countries during the COVID-19 pandemic.

METHODS

Online anonymous survey of women who gave birth in 2020-2021. Multivariable multilevel logistic regression models estimating associations between indicators of medicalization (cesarean, instrumental vaginal birth [IVB], episiotomy, fundal pressure) and proxy variables related to care culture and contextual factors at the individual and country level.

RESULTS

Among 27 173 women, 24.4% (n = 6650) had a cesarean and 8.8% (n = 2380) an IVB. Among women with IVB, 41.9% (n = 998) reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% (n = 4048) had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalization. For example, women who reported having a cesarean, IVB, or episiotomy reported not feeling treated with dignity more frequently than women who did not have those interventions (odds ratio [OR] 1.37; OR 1.61; OR 1.51, respectively; all: P < 0.001). Country-level variables contributed to explaining some of the variance between countries.

CONCLUSION

We recommend a greater emphasis in health policies on promotion of respectful and patient-centered care approaches to birth to enhance women's experiences of care, and the development of a European-level indicator to monitor medicalization of reproductive care.

Vacuum births and barriers to its use: An observational study in governmental hospitals in Sierra Leone

OBJECTIVES

Assisted vaginal births (AVD) can prevent unnecessary caesarean sections (CS). The number of CS is increasing rapidly in sub-Saharan Africa; these are still associated with high perioperative mortality rates. The aim of this study is to define the proportion of AVD in governmental hospitals in Sierra Leone and examine barriers to its use.

DESIGN

Retrospective observational study of AVD between September 2016 and August 2017.

SETTING

A representative selection of Sierra Leonean governmental hospitals (n=11). PARTICIPANT AND INTERVENTION: (a) Data were collected from labour ward records. (b) Health workers involved in labour management were questioned.

PRIMARY AND SECONDARY OUTCOME MEASURES

(a) Number of spontaneous, assisted vaginal and caesarean births. (b) Potential barriers to use vacuum-assisted births.

RESULTS

(a) Total annual numbers of registered births, AVD and CS were 16 833, 631 (3.7%) and 4642 (27.6%). The proportion of vacuum births ranged from 0.0% to 5.1% across facilities. The proportion of CS ranged from 6.5% to 33.4%. (b) The most frequently reported reasons for limited vacuum use were lack of equipment (25/72; 35%) and insufficient training (18/72; 25%).

CONCLUSIONS

The proportion of AVD was particularly low in district facilities, and according to healthcare workers this was mostly due to lack of equipment and insufficient training. Implementing relevant training programmes on the use of vacuum devices and increasing the availability of working devices may increase the proportion of vacuum births in government hospitals in Sierra Leone. This could reduce the number of unnecessary CS.

Pregnancy-associated desmoid fibromatosis: A Dutch multi-centre retrospective study

INTRODUCTION

The development of desmoid fibromatosis (DF) is associated with pregnancy. The current treatment consensus recommends active surveillance (AS). However, data in pregnancy-associated DF is scarce and it is uncertain whether AS is the best management strategy for this DF-subgroup. The aim of this study was to describe demographic, tumor, obstetric, treatment characteristics and treatment outcome in pregnancy-associated DF.

METHODS

Female DF patients who were 18-50 years old at time of diagnosis (2000-2020) and had a history (≤5 years) of pregnancy at time of diagnosis were included.

RESULTS

Overall, 62 patients were included. The most common locations were abdominal wall (74%), pelvis (10%) and extremities (10%). Mutational analysis was conducted in 31 patients of which 94% had CTNNB1-mutations. Ten patients (16%) were diagnosed during pregnancy, while the remainder were diagnosed after pregnancy with a median time from delivery to diagnosis of 19 months (1-60). The frontline management was AS in 38 patients (61%) of whom 12 (33%) developed progressive disease and surgery in 23 patients (37%). In total, 30 patients underwent surgery and five had local recurrence (17%). Positive resection margins were no prognostic factor. Nine patients received systemic treatment in second- or third-line.

CONCLUSIONS

Pregnancy-associated DF generally has an indolent behavior, where our results underscore the difficulty of establishing a clear definition of this entity. This study shows that AS should be the frontline management strategy for pregnancy-associated DF. When active treatment is indicated, surgery is a good option with low recurrence rates, even with positive (R1) resection margins.

Comparison of First Childbirth Characteristics between Elite Judo Athletes and Non-Athletes: The Preliminary Retrospective Case-Control Study

It has been speculated that elite athletes are more likely to have obstetric interventions during labor and delivery. So far, the impact of many years of competitive sports participation on childbirth characteristics has not been well-established. This preliminary retrospective case-control study aimed to determine whether the first labors of elite judo competitors required obstetric interventions more frequently and were longer than those of non-athletes. The study comprised 32 parous women: 16 elite judo athletes and 16 non-athletes. Women were included if they had access to the following obstetric data (from their first childbirth hospital discharge reports and/or first child's health record books): induction and augmentation of labor, mode of delivery, the duration of labor and its second stage, episiotomy, perineal tear, and the neonate's Apgar score. Electronic surveys were completed concerning childbirth characteristics, level of "eliteness" (judo athletes), and recreational physical activity (non-athletes). The statistical analysis showed no significant between-group differences in any of the first childbirth outcomes under analysis. The preliminary results indicate elite judo practice before first pregnancy had no negative impact on the rates of labor induction and augmentation, delivery mode, duration of labor, the rates of episiotomy and perineal tear, and the neonate's Apgar score. Due to the small sample size, the conclusions should be considered with caution.

Twin birth: The maternal experience

OBJECTIVE

Twin birth is a special setting for women giving birth, and the experience of childbirth can be different from singleton birth. The objective of this study was to evaluate and compare the childbirth experiences of twin mothers and singleton mothers. We also aimed to identify the risk factors of a negative childbirth experience in the whole study population.

METHODS

All live diamniotic twin deliveries in the study hospital of at least 35⁺⁰ weeks of gestation with a plan of vaginal birth were included in this matched groups study from August 2015 to August 2019. For every twin birth, two singleton birth controls were selected and matched with parity, the actual mode of birth, and gestational weeks at birth. Six weeks after birth, a Childbirth Experience Questionnaire (CEQ) was sent to mothers, and 72 twin mothers and 126 singleton mothers returned the questionnaire.

RESULTS

The twin mothers' overall childbirth experience was positive. They reported a significantly lower opportunity to choose the birthing position (p < 0.001). Otherwise, there were no differences in the CEQ mean total scores between the study groups. Intrapartum cesarean section raised the risk of a negative childbirth experience and there was a high level of satisfaction with midwifery care among the whole study population.

CONCLUSION

The overall maternal experience in planned vaginal twin birth was positive. Twin mothers felt less often able to choose their birthing position, otherwise the childbirth experience did not differ from that of singleton mothers.

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 <7 at 5 minuteutes. Rates of each outcome and contribution of each group to the total outcome rate were calculated.

RESULTS

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.

Antenatal care policy in high-income countries with a universal health system: A scoping review

The availability, effectiveness, and access to antenatal care are directly linked with good maternal and neonatal outcomes, making antenatal care an important determinant in health. But to be effective, care must always be appropriate, not excessive, not insufficient. Perinatal outcomes vary within and between countries, raising questions about practices, the use of best evidence in clinical decisions and the existence of clear and updated guidance. Through a scoping review methodology, this study aimed to map the available antenatal care policies for low-risk pregnant women in high-income countries with a universal health system, financed by the government through tax payments. Following searches on the main databases and grey literature, the authors identified and analysed ten antenatal care policies using a previously piloted datachart: Australia, Denmark, Finland, Iceland, Italy, Norway, Portugal, Spain, Sweden and the United Kingdom. Some policies were over 10 years old, some recommendations did not present a rationale or context, others were outdated, or were simply different approaches in the absence of strong evidence. Whilst some recommendations were ubiquitous, others differed either in the recommendation provided, the timing, or the frequency. Similarly, we found wide variation in the methods/strategy used to support the recommendations provided. These results confirm that best evidence is not always assimilated into policies and clinical guidance. Further research crossing these differences with perinatal outcomes and evaluation of cost could be valuable to optimise guidance on antenatal care. Similarly, some aspects of care need further rigorous studies to obtain evidence of higher quality to inform recommendations.

Intra-abdominal Adhesions among Patients Undergoing Repeat Caesarean Section in Department of Obstetrics and Gynaecology of a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Adhesions are one of the common complications encountered after caesarean section whose risk increases with the number of caesarean deliveries. This study aimed to find out the prevalence of intra-abdominal adhesions among patients undergoing repeat caesarean section in a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted on 74 pregnant women undergoing repeat caesarean section in the Department of Obstetrics and Gynaecology of a tertiary care centre from July, 2021 to December, 2021 after receiving the ethical approval from the Institutional Review Committee (Reference number: 2107202103). Pregnant women who met the eligibility criteria were included in the study. Convenience sampling was done. The severity of the adhesions was classified using the Tulandi and Lyell classification. Data were analysed using the Statistical Package for the Social Sciences version 26.0 software. Point estimate at 90% Confidence Interval was calculated along with frequency and percentage for binary data along with mean and standard deviation for continuous data.

Results

Out of 74 women undergoing repeat caesarean section, 55 (74.32%) (65.99-82.65 at 90% Confidence Interval) had developed intra-abdominal adhesions.

Conclusions

Our study showed that the prevalence of intra-abdominal adhesions among patients undergoing repeat caesarean section was higher when compared to similar studies conducted in similar settings.

Keywords

postoperative complications; repeat caesarean section; surgical adhesions.

Induction of labor in twin pregnancies - A retrospective cohort study

OBJECTIVE

To investigate outcomes in spontaneous and induced twin deliveries. Secondary aims were to study impact of delivery interval and breech presentation of the first twin.

METHODS

This retrospective cohort study comprised 354 twin deliveries at a tertiary Norwegian hospital. Spontaneous labor onset and induction of labor were compared in women with planned vaginal delivery and gestational age ≥ 34 weeks. The main outcome was intrapartum cesarean section. Secondary outcomes were umbilical arterial pH and five-minute Apgar scores.

RESULTS

Among the induced labors, 63/229 (27.5%) women underwent intrapartum cesarean section, compared to 45/125 (36%) in spontaneous labors (P = 0.10). Odds ratio for intrapartum cesarean section in induced labors was 0.65 (95% CI 0.40-1.04) after adjusting for maternal age and parity. Median umbilical arterial pH was significantly lower in the second twins in both spontaneous and induced labors, 7.28 (6.94-7.43) vs. 7.32 (7.16-7.42), and 7.27 (6.90-7.48) vs. 7.29 (7.08-7.45), respectively. pH < 7.00 rarely occurred. Second twins born after a delivery interval > 30 min had a significantly higher frequency of pH < 7.10 than those with a shorter interval, P < 0.01. No significant difference was found in frequency of pH < 7.10 between breech-presenting and cephalic-presenting first twins (P = 0.65). One unexpected intrapartum fetal death occurred after labor induction.

CONCLUSION

Our results support spontaneous onset and induction of labor as safe. Intrapartum cesarean section rates did not differ significantly between spontaneous and induced labors. Delivery interval > 30 min was associated with a lower pH in the second twin.

Factors Associated with Vaginal/Cesarean Birth Attitudes among Medical Students

Background: Polish perinatal care is facing a high, ever-increasing cesarean section (CS) rate that is currently at 43%. Crucially, reports have revealed that the attitudes, experiences, and skills of clinicians directly contribute to this elevated CS rate. Methods: This cross-sectional study, which included 748 Polish medical students, aimed to identify medical students’ attitudes regarding birth methods. A descriptive questionnaire was distributed via the academic email addresses of surveyed medical students. Group comparisons were performed using Welch’s t-test for continuous data or a Chi-squared test for categorical data. We also used the Mann–Whitney U test and Kruskal–Wallis H test. Results: Midwifery students (96.2%) were the most unified group of students, with most agreeing that VB (vaginal birth) presents a safer option for women at low risk for VB-related complications vs. cesarean section. Of Medical Faculty students, 68% believed that fewer complications typically occur during vaginal birth than during CS. Students in their final vs. initial years of study furthermore considered VB more beneficial for women than CS. Conclusions: An important factor identified at the individual clinician level is the presence of leadership and executive support. For medical students, we can interpret this as support from their trainers and supervisors.

Pregnancy in juvenile idiopathic arthritis: maternal and foetal outcome, and impact on disease activity

Objective:

This retrospective cohort study describes the modulation of disease activity during gestation and in the year following delivery as well as maternal and neonatal outcomes in a monocentric cohort of women with juvenile idiopathic arthritis (JIA).

Methods:

Disease activity was assessed using DAS28-CRP before conception and every 3 months during pregnancy and in the first year postpartum. The risk of complicated pregnancies was measured applying a generalized estimating equation model. Changes in disease activity during gestation and in the first year postpartum were assessed in a linear mixed model for repeated measures.

Results:

Thirty-one women (49 pregnancies) with persisting JIA and at least one conception were enrolled. Adjusted DAS28-CRP levels remained stable from preconception through the first trimester, but increased significantly in the second and decreased not significantly in the third. In the postpartum, adjusted disease activity peaked at 3 months after delivery, stabilized at 6 months to decrease at 1 year, although not significantly. Preconceptional DAS28-CRP and number of biological drugs predicted disease activity fluctuation during gestation. The number of biological drugs and the length of gestational exposure to biologics significantly predicted pregnancy morbidity. In particular, JIA women had a higher probability of preterm delivery compared with healthy and disease controls. Adjusted for breastfeeding and DAS28-CRP score in the third trimester, postconceptional exposure to biologics was inversely related with disease activity in the postpartum: the longer the patient continued treatment, the lower the probability of experiencing an adverse pregnancy outcome.

Conclusion:

These data offer novel insights on how treatment affects disease activity during pregnancy and postpartum as well as obstetric outcomes in women with JIA.

Once a cesarean, always a cesarean? Obstetricians’ approach to counselling for Trial of Labor After Cesarean (TOLAC)

BACKGROUND

Despite no observed increase in obstetrical complication rates, cesarean delivery rates are increasing worldwide. A significant proportion of planned cesarean deliveries are performed for patients with 1 previous cesarean delivery who opt for an elective repeat cesarean delivery rather than a trial of labor after cesarean delivery. The facilitation of informed decision-making by healthcare professionals may influence patient choices and could affect the trial of labor after cesarean delivery uptake rates.

OBJECTIVE

This study aimed to assess how obstetricians in the Middle Eastern region approach counseling of patients with a previous cesarean delivery concerning birth choices in the current pregnancy.

STUDY DESIGN

This was a prospective survey-based study. An online survey of obstetricians in the 2 largest state maternity hospitals in Doha, Qatar, was conducted with participation offered voluntarily. The survey gathered background demographic data and investigated the obstetrician's awareness of factors that could influence the success of the trial of labor after cesarean delivery and the obstetrician's approach to counseling women. The data collected were transferred to SPSS (version 23.0; IBM Corp, Armonk, NY) for analysis. Descriptive statistics were performed, and nonparametric analysis of continuous variables and chi-squared analysis of discrete variables were cross-referenced with gender, length of time of specialist qualification, and personal family experience of cesarean delivery.

RESULTS

Most respondents had training in the Middle East and generally practiced obstetrics in this region, and >80% of the respondents had more than 5 years of experience in the specialty. The obstetrician's gender or length of experience did not significantly influence the attitude to the assessment of risks and benefits. Furthermore, there was little consensus among the group about factors that were the most and the least important for the success of the trial of labor after cesarean delivery. The group emphasized the importance of the patient's wishes in choosing the mode of birth. If a relative contraindication to the trial of labor after cesarean delivery was present, half of the obstetricians would emphasize the various negatives of the approach to the patient during counseling. Most participants favored a dedicated trial of labor after cesarean delivery clinic to reduce cesarean delivery rates. The participants did not feel that supporting the trial of labor after cesarean delivery would be improved with legal department support.

CONCLUSION

Obstetricians had different approaches in the counseling for trial of labor after cesarean delivery, and this can influence the patients’ acceptance of the trial of labor after cesarean delivery, thereby affecting cesarean delivery rates.

The risk of childhood brain tumors associated with delivery interventions: A Danish matched case-control study

BACKGROUND

Head trauma has been associated with increased brain tumor risk in adults. Instrument assisted delivery can be a cause of head trauma in newborns. The goal of this study was to determine if instrument-assisted deliveries influenced the odds of childhood brain tumors in Denmark.

METHODS

We conducted a matched case-control study of childhood (<20 years) brain tumors in Denmark born between 1978 and 2013 and diagnosed 1978-2016. A total of 1678 brain tumor cases were identified and 25 controls were matched to each case based on the child's sex and birth date (N = 40,934). Conditional logistic regression was used to estimate effects (odds ratios (OR) and 95% confidence intervals (95%CI)) for variables of interest.

RESULTS

Compared to children birthed by spontaneous vaginal delivery, children who later developed ependymomas (N = 118) had a greater likelihood of having experienced vacuum assisted deliveries (OR=1.74, 95% CI 1.02-2.96). Forceps use was low, and declined across the study period. We did not observe an overall increase in all CNS tumors (combined) with either vacuum delivery (OR=0.99, 95% CI 0.84-1.18) or forceps delivery (OR=1.26, 95% CI 0.78-2.03).

CONCLUSION

Our findings suggest an association between vacuum assisted deliveries and ependymomas.

Maternal and neonatal trauma following operative vaginal delivery

Background:

Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel. However, opportunities for training in OVD have declined and, given these shifts in practice, the safety of OVD is unknown. We estimated incidence rates of trauma following OVD in Canada, and quantified variation in trauma rates by instrument, region, level of obstetric care and institutional OVD volume.

Methods:

We conducted a cohort study of all singleton, term deliveries in Canada between April 2013 and March 2019, excluding Quebec. Our main outcome measures were maternal trauma (e.g., obstetric anal sphincter injury, high vaginal lacerations) and neonatal trauma (e.g., subgaleal hemorrhage, brachial plexus injury). We calculated adjusted and stabilized rates of trauma using mixed-effects logistic regression.

Results:

Of 1 326 191 deliveries, 38 500 (2.9%) were attempted forceps deliveries and 110 987 (8.4%) were attempted vacuum deliveries. The maternal trauma rate following forceps delivery was 25.3% (95% confidence interval [CI] 24.8%–25.7%) and the neonatal trauma rate was 9.6 (95% CI 8.6–10.6) per 1000 live births. Maternal and neonatal trauma rates following vacuum delivery were 13.2% (95% CI 13.0%–13.4%) and 9.6 (95% CI 9.0–10.2) per 1000 live births, respectively. Maternal trauma rates remained higher with forceps than with vacuum after adjustment for confounders (adjusted rate ratio 1.70, 95% CI 1.65–1.75) and varied by region, but not by level of obstetric care.

Interpretation:

In Canada, rates of trauma following OVD are higher than previously reported, irrespective of region, level of obstetric care and volume of OVD among hospitals. These results support a reassessment of OVD safety in Canada.

Social support needs of first-time parents in the early-postpartum period: A qualitative study

Background

The early postpartum period is a critical time for first-time parents as they adapt to their new role. Perceived lack of social support is a risk factor for developing mental health problems. Insufficient or inappropriate professional support for both parents has been reported by many studies. Social support that appropriately meets parents' needs is an important protective factor for parents' wellbeing; however, little is known about the social support needs of both first-time parents.

Aims and objectives

To describe both first-time parents' formal social support needs in the early postpartum period.

Method

Individual semi-structured interviews were conducted with first-time parents recruited on the postpartum ward of a Swiss university hospital. Thematic analysis was used to identify themes and sub-themes.

Results

Fifteen mothers and eleven fathers were interviewed. Twelve themes were identified. Mothers' themes were "experiencing postpartum changes," "creation of a family unit," "self-esteem," "emotional needs," "difficulty in communicating their needs," and "the postpartum stay." Fathers' themes were "to be included in care procedures on the postpartum ward," "to be reassured," "to anticipate their postpartum stay" and "to consider their need as non-priority." Parental shared needs were: "to care for their newborn," and "returning home."

Conclusion

Mothers' and fathers' needs differed. Mothers needed more emotional support than fathers and fathers considered themselves as the main support for their partner. Fathers wanted to be integrated in the care of their newborn.

A push for evidence: An effective training in operative birth

Effective training in operative birth should be the only type of operative birth that trains the junior obstetricians who are exposed to it. Although it remains difficult to fully characterise, effective training in operative birth is likely to include (i) realistic, local, integrated simulation training and (ii) hands-on senior support for an extended period of time. To further improve skills training in operative birth, an evaluation of the real-world effectiveness of current training should take place, a core outcome set for clinical trials should be developed, and real-time reporting and tracking of practitioner-specific outcome measures should be implemented.

Obstetrical Soft Tissue Trauma during Spontaneous Vaginal Birth in the Romanian Adolescent Population-Multicentric Comparative Study with Adult Population

Romania is a country with high rates of adolescent births, associating scarce comprehensive obstetrical management with this specific population. This research aims to assess soft tissue trauma after vaginal birth in teenage mothers compared to their adult counterparts. A retrospective case-control study was conducted for one year in two hospitals. All vaginal deliveries were considered; the age cut-off value was considered at 20 years old for case and control groups. Lacerations were divided into three subgroups, considering the involved anatomical region; group I: labial and periurethral lacerations, group II: vaginal and perineal lacerations, and group III: cervical lacerations. There were 1498 women included in the study: 298 young mothers and 1200 adults. Teenagers were more likely to have an episiotomy during vaginal delivery compared to adult women: 56% versus 26.7% (p = 0.00, Pearson Chi-square) and a 1.89 times increased risk for developing additional group II lacerations: p = 0.01, Pearson Chi-square test with Bonferroni correction: OR = 1.89, 95% CI: 1.18–3.02. Group II lacerations were the most frequent type of birth trauma in both study groups. Fetal weight ≥4000 g was associated with a two times higher risk for vaginal and perineal lacerations when age criterion was not considered (OR = 1.98, 95% CI: 1.13–3.47, p = 0.01). The incidence of group I and II lacerations increased with age: from 0% and 9.1% between 10 and 14 years old to 6% and 26.2% between 18 and 19 years old. All groups of lacerations were more often identified in the case group, compared to the adult group. Fetal macrosomia and spontaneously ruptured membranes at admission could not be documented as risk factors for obstetrical injury in young mothers. Episiotomy performed in teenagers was not a protective procedure for group II lacerations.

Obstetrician involvement in planned midwife-led births: a cohort study in an obstetric department of a University Hospital in Switzerland

Background

Healthy women with low risk singleton pregnancies are offered a midwife-led birth model at our department. Exclusion criteria for midwife-led births include a range of abnormalities in medical history and during the course of pregnancy. In case of complications before, during or after labor and birth, an obstetrician is involved. The purpose of this study was 1) to evaluate the frequency of and reasons for secondary obstetrician involvement in planned midwife-led births and 2) to assess the maternal and neonatal outcome.

Methods

We analyzed a cohort of planned midwife-led births during a 14 years period (2006-2019). Evaluation included a comparison between midwife-led births with or without secondary obstetrician involvement, regarding maternal characteristics, birth mode, and maternal and neonatal outcome. Statistical analysis was performed by unpaired t-tests and Chi-square tests.

Results

In total, there were 532 intended midwife-led births between 2006 and 2019 (2.6% of all births during this time-period at the department). Among these, 302 (57%) women had spontaneous vaginal births as midwife-led births. In the remaining 230 (43%) births, obstetricians were involved: 62% of women with obstetrician involvement had spontaneous vaginal births, 25% instrumental vaginal births and 13% caesarean sections. Overall, the caesarean section rate was 5.6% in the whole cohort of women with intended midwife-led births. Reasons for obstetrician involvement primarily included necessity for labor induction, abnormal fetal heart rate monitoring, thick meconium-stained amniotic fluid, prolonged first or second stage of labor, desire for epidural analgesia, obstetrical anal sphincter injuries, retention of placenta and postpartum hemorrhage. There was a significantly higher rate of primiparous women in the group with obstetrician involvement. Arterial umbilical cord pH < 7.10 occurred significantly more often in the group with obstetrician involvement, while 5′ Apgar score < 7 did not differ significantly. The overall transfer rate of newborns to neonatal intensive care unit was low (1.3%).

Conclusion

A midwife-led birth in our setting is a safe alternative to a primarily obstetrician-led birth, provided that selection criteria are being followed and prompt obstetrician involvement is available in case of abnormal course of labor and birth or postpartum complications.

Forceps and vacuum: one goal, two entities

Damage to the pelvic floor during pregnancy and vaginal delivery is an inevitable consequence of the natural birthing process. As this damage is associated with functional and anatomical problems in later life, minimizing pelvic floor damage during pregnancy and vaginal delivery may serve as an important factor in the prevention of these unwanted sequelae. Operative vaginal delivery using forceps or vacuum extractor is common practice to achieve or expedite vaginal birth for maternal or fetal indications such as maternal exhaustion or fetal distress. However, operative vaginal delivery is associated with more extensive damage to the pelvic floor and perineal structures with forceps carrying a stronger risk compared to vacuum. The evidence on this subject is discussed with possible suggestions to minimize pelvic floor damage as much as possible.

Preferences of women with low obstetric risk for cesarean or vaginal birth in Poland: Areas for intervention

BACKGROUND

In Poland, the rate of cesarean birth (CB) is 43%, which is much higher than the European average of 27%. Optimizing the CB birth rate is of critical importance, especially among women with low-risk pregnancies. However, the determinants of cesarean preference among low-risk women in Poland have not been well explored.

METHODS

This cross-sectional study included 1011 pregnant women and aimed to identify associations between selected determinants of women's preferences for CB vs. vaginal birth (VB) in Poland. A descriptive questionnaire was distributed online, and a theoretical model was validated against empirically gathered data. Group comparisons were performed using the Welch t test for continuous data or chi-square test for categorical data. All statistical analyses were performed using R (R Core Team, 2018).

RESULTS

The mean age of women preferring CB (30.46 years) was 1.25 years higher than that of women preferring VB (29.21 years). Pregnant women who expressed a preference for CB tended to be multigravid, inhabited cities, and were characterized by higher levels of anxiety and depression. Moreover, the majority of women who underwent a previous CB asserted their intention to repeat the procedure for the current pregnancy.

CONCLUSIONS

The primary factors that were correlated with high CB preference among the low-risk group included age, previous childbirth experiences, and anxiety. The underlying reasons that drive birth preferences remain poorly understood. However, women who have previously undergone difficult childbirth experiences and are afraid of pain require specialized care.

Outcomes of the novel Odon Device in indicated operative vaginal birth

BACKGROUND

No new method of assisting vaginal birth has been introduced into clinical practice since the development of the vacuum extractor in the 1950s. The Odon Device is a new device that employs a circumferential air cuff over the fetal head to assist birth. In this study, the Odon Device has been used to assist vaginal birth for standard clinical indications.

OBJECTIVE

This study aimed to investigate the clinical impact, safety, and acceptability of the Odon Device to women, their babies, and clinicians and to assess the feasibility of recruiting women to an interventional intrapartum research study.

STUDY DESIGN

This is a nonrandomized, single-arm interventional feasibility study of the Odon Device for operative vaginal birth undertaken in a single maternity unit: Southmead Hospital, Bristol, United Kingdom. The Odon Device was used to assist birth in 40 women who required the birth to be assisted for suspected fetal compromise and/or prolonged second stage of labor. The primary clinical outcome was the proportion of births successfully assisted with the Odon Device, and the primary feasibility outcome was the proportion of eligible women who were approached and who agreed to participate. Neonatal outcome data were reviewed at day 28, and maternal outcomes were investigated up to day 90.

RESULTS

Between October 2018 and January 2019, 298 of 384 approached, eligible women (77.6%) consented to participate. Of these women, 40 received the intervention-the use of the Odon Device. Birth was assisted in all cephalic (occiput anterior, occiput transverse, and occiput posterior) fetal positions, at all stations at or below the ischial spine and with or without regional analgesia. The Odon Device was effective in 19 of 40 cases (48%). Of the 40 births, 21 (52.5%) required additional assistance: 18 of 40 births (45%) were completed using nonrotational forceps, 1 of 40 births (3%) required rotational forceps, and 2 of 40 births (5%) required an emergency cesarean delivery. There was no serious maternal or neonatal adverse event related to the use of the device, and there was no serious adverse device effect. There were 4 devices (10%) that were ineffective because of a manufacturing fault. Furthermore, 39 of 40 women (98%) reported a high birth perception score. All practitioners were able to use the device as intended, although some steps in using the device were reported to be easier to perform (setup and deflation of air chamber) than others (application of the device and withdrawal of the applicator).

CONCLUSION

Recruitment to an interventional study of a new device for operative vaginal birth was feasible; 78% of eligible women were willing to participate, often expressing an aspiration for an alternative to forceps and vacuum. The success rate of the Odon Device was lower than reported success rates of vacuum and forceps; however, in this study, the device had been used to assist birth for standard clinical indications. There was no significant maternal or neonatal safety concern associated with the use of the device, although the number of births studied was small. Further feasibility study to establish iterative changes to the device, technique, and clinical indications is necessary.

Twin TOLAC is an independent risk factor for adverse maternal and neonatal outcome

PURPOSE

To determine factors associated with a successful twin trial of labor after Cesarean delivery (TOLAC).

METHODS

A retrospective cohort study was conducted at a single medical center in a population highly motivated for TOLAC (> 80%). The effect of maternal demographic and obstetric characteristics on the likelihood of twin TOLAC success was analyzed. Maternal complications and combined adverse outcome (uterine rupture, Apgar < 7 at 5 min, and umbilical cord pH < 7.1) were compared between singleton and twin TOLAC groups.

RESULTS

Ninety-five women with a twin gestation and one previous Cesarean delivery comprised the study group. Five thousand seven hundred and three women with a singleton gestation and one previous Cesarean delivery comprised the control group. 30.5% and 83% of women with twin and singleton gestation, respectively, underwent a trial of labor. Women in the twin TOLAC group were significantly less likely to succeed and less likely to have a spontaneous unassisted vaginal delivery compared to women in the singleton TOLAC group. Maternal age less than 35 years, parity greater than two, and at least one previous VBAC increased the likelihood of TOLAC success. Statistically significant differences were found between the twin TOLAC and the singleton TOLAC group for uterine rupture, maternal complications, and for combined adverse outcome.

CONCLUSIONS

Twin TOLAC is not common, even in parturients highly motivated for TOLAC. Our results demonstrate that even in a selected population, women undergoing twin TOLAC are less likely to have a successful spontaneous vaginal delivery and have a higher risk for uterine rupture, maternal complications, and combined adverse perinatal outcome than women undergoing TOLAC with a singleton gestation. Demographic and obstetric risk factors were identified which can aid the attending obstetrician in the counseling of these challenging cases.

Childbirth Care among SARS-CoV-2 Positive Women in Italy

The new coronavirus emergency spread to Italy when little was known about the infection’s impact on mothers and newborns. This study aims to describe the extent to which clinical practice has protected childbirth physiology and preserved the mother–child bond during the first wave of the pandemic in Italy. A national population-based prospective cohort study was performed enrolling women with confirmed SARS-CoV-2 infection admitted for childbirth to any Italian hospital from 25 February to 31 July 2020. All cases were prospectively notified, and information on peripartum care (mother–newborn separation, skin-to-skin contact, breastfeeding, and rooming-in) and maternal and perinatal outcomes were collected in a structured form and entered in a web-based secure system. The paper describes a cohort of 525 SARS-CoV-2 positive women who gave birth. At hospital admission, 44.8% of the cohort was asymptomatic. At delivery, 51.9% of the mothers had a birth support person in the delivery room; the average caesarean section rate of 33.7% remained stable compared to the national figure. On average, 39.0% of mothers were separated from their newborns at birth, 26.6% practised skin-to-skin, 72.1% roomed in with their babies, and 79.6% of the infants received their mother’s milk. The infants separated and not separated from their SARS-CoV-2 positive mothers both had good outcomes. At the beginning of the pandemic, childbirth raised awareness and concern due to limited available evidence and led to “better safe than sorry” care choices. An improvement of the peripartum care indicators was observed over time.

Operative vaginal delivery: all you should know

Over the last three decades, the decrease in operative vaginal delivery (OVD) has lead to an increase in the rate of cesarean sections, giving rise to intense debate amongst healthcare providers. As the use of vacuum and forceps requires personnel be adequately trained so as to become familiar with the correct use of instruments, the lack of skilled and experienced instructors may well lead to this technique being discarded in the near future. The aim of this study was to review the literature, compare the recommendations from international OVD guidelines and to illustrate the correct technique of obstetrical vacuum and forceps application to promote OVD among clinicians as a safe way of delivery.

Timing of term elective cesarean section and adverse neonatal outcomes: A multi-center retrospective cohort study

Background

Rate of cesarean section (CS), including elective CS has globally increased. Studies have found that term elective CS before 39 weeks of gestation is associated with increased risk of adverse respiratory outcomes.

Objective

To determine the rate of elective CS and examine the association between timing of elective term CS and adverse neonatal outcomes in a large population of Lebanese women.

Methods

A Multi-Center Study was conducted using data from the National Collaborative Perinatal Neonatal Network database. Simple and multivariable logistic regression models were used to examine the association between timing of term elective CS and adverse neonatal outcomes. Some of the neonatal adverse outcomes we examined included respiratory distress syndrome, admission to the NICU, and a composite of respiratory outcomes.

Results

A total of 28,997 low risk mothers who delivered through primary and repeat elective CS were included in the study. Uncomplicated elective planned term CS constituted 25% of all CS deliveries in Lebanon. Primary and repeat CS at 37 weeks of gestation increased the odds of most of the studied adverse neonatal outcomes. There were few associations between CS and adverse neonatal outcomes at 38 weeks of gestation.

Conclusions

Term primary and repeat cesarean delivery prior to 39 weeks of gestation is associated with respiratory and other adverse neonatal outcomes. Delaying birth 1–2 weeks till 39 weeks of gestation can prevent 64–77% of adverse respiratory outcomes.