A prospective cohort study of the morbidity associated with operative vaginal deliveries performed by day and at night

Association between Delivery during Off-Hours and the Risk of Severe Maternal Morbidity: A Nationwide Population-Based Cohort Study

This study evaluated the association between off-hour deliveries and the risk of severe maternal morbidity (SMM). Data regarding Korean deliveries between 2005 and 2019 obtained from the National Health Insurance Service were used. SMM was evaluated using an algorithm developed by the United States Centers for Disease Control and Prevention. Modified Poisson regression analyses were conducted to investigate the association between off-hour deliveries and SMM, with stratification by hospital region and the number of beds. Approximately 32.7% of the 3,076,448 nulliparous women in this study delivered during off-hours, including 2.6% who experienced SMM. Patients who delivered at night had the highest risk of SMM (weekday nights, adjusted risk ratio (aRR): 1.41, 95% confidence interval (CI): 1.38-1.44; weekend nights, OR: 1.40, 95% CI: 1.34-1.46). The SMM of night deliveries was higher at hospitals located in small cities and those with 100-499 beds (weekend night: small cities, aRR: 1.49, 95% CI: 1.40-1.59; 100-499 beds, aRR: 1.83, 95% CI: 1.67-2.01; weekday night: small cities, aRR: 1.46, 95% CI: 1.42-1.51; 100-499 beds, aRR: 1.70, 95% CI: 1.62-1.79). Therefore, nighttime deliveries are associated with a higher risk of SMM, especially at hospitals located in small cities and those with 100-499 beds.

Birth during off-hours: Impact of time of birth, staff´s seniority, and unit volume on maternal adverse outcomes-a population-based cross-sectional study of 87 065 deliveries

BACKGROUND

The aim of this study was to investigate whether time of birth, unit volume, and staff seniority impact the incidence of maternal complications in deliveries ≥34 + 0 gestational weeks.

METHODS

We conducted a population-based cross-sectional study of 87 065 deliveries occurring between 2004 and 2015 in ten public hospitals in Styria, Austria. A composite adverse maternal outcome measure of uterine atony, postpartum hysterectomy, postpartum bleeding, impaired wound healing, postpartum infections requiring antibiotic treatment, sepsis, or maternal death was used to compare outcomes by time of birth, unit volume, and staff seniority. Based on delivery data, generalized estimating equations (GEEs) were used to calculate the risk of maternal adverse outcomes.

RESULTS

Maternal adverse events occurred in 1.33% of deliveries. Incidence of maternal adverse events was highest for units with >1000 deliveries (adjusted OR 1.40; CI 95%: 1.16-1.69) and higher for perinatal centers (adjusted OR 1.35; CI 95%: 1.15-1.57) compared with reference units (500-1000 deliveries/year). Delivery during the daytime compared with the afternoon and nighttime did not affect the incidence of maternal complications (P = 0.765 and P = 0.136, respectively). Compared with resident-guided deliveries, the odds ratio for an adverse event was the same when a consultant attended the delivery (adjusted OR 1.13; CI 95%: 0.98-1.30) but lower in deliveries managed by midwives only (adjusted OR 0.21; CI 95%: 0.07-0.64).

CONCLUSION

Procedures performed during the night shift were not associated with increased complication rates. Delivery volume and high-volume centers were associated with the highest risk of maternal complications, and units with 500-1000 deliveries per year were the lowest. With increasing odds of pregnancy risks, these results change, and delivering in a high-volume center becomes at least as safe as delivering in a smaller unit.

Office hours and caesarean section: systematic review and Meta-analysis

BACKGROUND

Unnecessary caesarean births may be affected by physician factors, such as preferences, incentives and convenience. Delivery during office hours can be a valuable proxy for measuring such effects.

OBJECTIVE

To determine the effect of office hours on the decision for caesarean delivery by assessing the odds of caesarean during office hours compared to out-of-office hours.

SEARCH STRATEGY

We searched CINAHL, ClinicalTrials.gov , The Cochrane Library, PubMed, Scopus and Web of Science from the beginning of records through August 2021.

DATA COLLECTION AND ANALYSIS

Search results were screened by three researchers. First, we selected studies that reported odds ratios of caesareans, or data allowing their calculation, for office and out-of-office hours. We extracted data on the study population, study design, data sources, setting, type of caesarean section, statistical analysis, and outcome measures. For groups reporting the same outcome, we performed a standard inverse-variance random-effects meta-analysis, which enabled us to calculate the overall odds ratios for each group. For groups reporting varying outcomes, we performed descriptive analysis.

MAIN RESULTS

Meta-analysis of weekday vs weekend for any caesarean section showed higher odds of caesarean during weekdays in adjusted analysis 1.40 (95%CI 1.13, 1.72 from 1,952,691 births). A similar effect was observed in the weekday vs Sunday comparison (1.39, 95%CI 1.10, 1.75, 150,932 births). A lower effect was observed for emergency CS, with a slight increase in adjusted analysis (1.06, 95%CI 0.90, 1.26, 2,622,772 births) and a slightly higher increase in unadjusted analysis (1.15, 95%CI 1.03, 1.29, 12,591,485 births). Similar trends were observed in subgroup analyses and descriptive synthesis of studies examining other office hours outcomes.

CONCLUSIONS

Delivery during office hours is associated with higher odds for overall caesarean sections and little to no effect for emergency caesarean. Non-clinical factors associated with office hours may influence the decision to deliver by caesarean section. Further detailed investigation of the "office hours effect" in delivery care is necessary and could lead to improvements in care systems.

FUNDING

The authors received no direct funding for this study.

Time at birth and short-term outcomes among extremely preterm infants in Spain: a multicenter cohort study

The first hours after birth entail a window of opportunity to decrease morbidity and mortality among extremely preterm infants. The availability of staff and its tiredness vary depending on the timing and day of the week. We hypothesized that these circumstances may impact neonatal outcomes. We have conducted a multicenter cohort study with data obtained from the Spanish neonatal network database SEN1500, where staff doctors are in the house 24/7. The main study exposure was the time of birth; secondary exposures were cumulative work hours from the medical and nurses' shifts and day of the week. The primary outcome was survival to hospital discharge. Secondary outcomes included common preterm infants' in-hospital complications. Univariate and multivariate analysis adjusting for potential confounders was performed. All extremely preterm infants (N = 8798) born between 2011 and 2019 were eligible; 35.7% of them were admitted during the night shift. No differences were found between day and night births regarding survival or morbidity. No differences were found between weekdays and weekends or when considering cumulative worked hours in the shifts. Infants born during the night shift were more likely to be intubated at birth (OR 1.20, CI95% 1.06-1.37), receive surfactant (OR 1.24, CI95% 1.08-1.44), and having anemia requiring transfusion (OR 1.23, CI 95% 1.08-1.42).

CONCLUSION

the time of birth did not seem to affect mortality and morbidity of extremely preterm infants.

WHAT IS KNOWN

• The first hours after birth in extremely preterm infants are a very valuable opportunity to decrease mortality and morbidity. • Time and day of birth have long been linked to outcomes in preterm infants, with night shifts and weekends classically having higher rates of mortality and morbidity.

WHAT IS NEW

• In this study, no differences were found between day and night births regarding survival or major morbidity. • Infants born during the night shift were more likely to be intubated at birth, receive surfactant and having anemia requiring transfusion.

Maternal childbirth experience and time of delivery: a retrospective 7-year cohort study of 105 847 parturients in Finland

OBJECTIVES

To explore how the time of delivery influences childbirth experience.

DESIGN

A retrospective cohort study.

SETTING

Childbirth in the four Helsinki and Uusimaa Hospital District hospitals, Finland, from 2012 to 2018.

PARTICIPANTS

105 847 childbirths with a singleton live fetus.

MAIN OUTCOME MEASURES

Childbirth experience measured by Visual Analogue Scale (VAS).

RESULTS

The major difference in average childbirth experience measured by VAS was between primiparas (8.03; 95% CI 8.01 to 8.04) and multiparas (8.47; 95% CI 8.45 to 8.48). Risk ratio (RR) of the low VAS (≤5) was 2.3 when primiparas were compared with multiparas. Differences in VAS between distinct periods were found in two stages: annual and time of day. The decrease in VAS from 2012-2016 to 2017-2018 in primiparas was from 7.97 (95% CI 7.95 to 7.99) to 7.80 (95% CI 7.77 to 7.83) and from 2014-2016 to 2017-2018 in multiparas from 8.60 (95% CI 8.58 to 8.61) to 8.49 (95% CI 8.47 to 8.52). Corresponding RRs of low VAS were 1.3 for primiparas and 1.2 for multiparas. Hourly differences in VAS were detected in primiparas between office hours 08:00-15:59 (7.97; 95% CI 7.94 to 7.99) and other times (night 00:00-07:59; 7.91; 95% CI 7.88 to 7.94; and evening 16:00-23:59; 7.90; 95% CI 7.87 to 7.92). In multiparas differences in VAS were detected between evening (8.52; 95% CI 8.50 to 8.54) and other periods (night; 8.56; 95% CI 8.54 to 9.58; and office hours; 8.57; 95% CI 8.55 to 8.59).

CONCLUSION

The maternal childbirth experience depended on the time of delivery. Giving birth during the evening led to impaired childbirth experience in both primiparas and multiparas, compared with delivery at other times. The impact of labour induction on childbirth experience should be further examined. The reorganisation of delivery services and the reduction of birth preparations might affect annual VAS. VAS is a simple method of measuring the complex entity of childbirth experience, and our results indicate its ability to capture temporal variation.

Time of Birth and the Risk of Severe Unexpected Complications in Term Singleton Neonates

OBJECTIVE

To assess whether there is a relationship between evening, night, and weekend births and severe unexpected neonatal morbidity in low-risk term singleton births.

METHODS

We conducted a population-based, cross-sectional analysis. Severe unexpected neonatal morbidity as defined by the National Quality Forum specification 0716 was derived from linked birth certificate and hospital discharge summaries for 1,048,957 low-risk singleton term Californian births during 2011 through 2013. The association between the nursing shift (7 am-3 pm vs 3-11 pm and 11 pm -7 am) and weekday compared with weekend birth and the risk of severe unexpected neonatal morbidity was estimated using mixed effects logistic regression models.

RESULTS

Severe unexpected neonatal morbidity was higher among births during the 3-11 pm evening shift (2.1%) and the 11 pm-7 am night shift (2.1%), compared with those during the 7 am-3 pm day shift (1.8%). The adjusted odds ratios (ORs) were 1.10 (95% CI 1.06-1.13) for the evening shift and 1.15 (1.11-1.19) for the night shift. The adjusted ORs of severe unexpected neonatal morbidity were increased only on Sunday, as compared with other days (adjusted OR 1.08, 95% CI 1.02-1.14). When our analysis was by perinatal region, the increase was seen in four of the nine perinatal regions.

CONCLUSION

After risk adjustment, the risk of severe unexpected morbidity in the low-risk singleton California birth cohort was significantly increased on Sundays and births during evening and night shifts. These elevations were detected in only four of California's nine perinatal regions. Further analysis at the individual hospital level is warranted.

Association between time of delivery and poor perinatal outcomes -An evaluation of deliveries in a tertiary hospital, South-east Nigeria

OBJECTIVES

Nigeria account for a significant proportion of adverse perinatal outcome. Nigerian studies assessing impact of time of delivery on perinatal outcome are scarce. This study evaluates any associations between time of delivery and perinatal outcome.

METHODS

This was a cross-sectional study at the Federal Teaching Hospital, Abakaliki from 01 January 2016 to 30 June 2018. Data were analysed with IBM SPSS version 25.0.

RESULTS

A total of 4,556 deliveries were analysed. Majority (72.2%) delivered on week days and 27.8% on weekends. Over 90% had 1st and 5th minutes Apgar scores ≥7. There was statistical difference in NICU admission between morning and evening hours (p = 0.009) but not between morning and night hours (p = 0.795). ENND during evening was twice higher (1.2%) than morning (0.5%); p = 0.047 and night hours (0.6%); p = 0.623.There was no difference in the risk of fresh stillbirths between morning and evening (p = 0.560), as well as morning and night hours (p = 0.75), there was also no difference in fresh stillbirths between week days and weekends (p = 0.895). There was no difference in low Apgar scores at 1st minute between morning and evening (p = 0.053) and night (p = 0.221), and between weekdays and weekends (p = 0.524). Similarly, there was no difference in low 5th minute Apgar scores between morning and evening (p = 0.165) and night (p = 0.944), as well as between week days and weekends (p = 0.529). However, ENND was twice (p = 0.085) and 1.3 times higher (p = 0.526) for evening and night hours respectively, while there was no difference between weekends and week days (p = 0.652).

CONCLUSION

NICU admission and ENND were commoner during evening hours. However, work hours did not affect the rate of stillbirth and low Apgar scores during weekdays and weekends. It is pertinent for each obstetric unit to identify and modify factors responsible for unfavourable outcomes during various shifts, with the aim of improving perinatal health.

Medico-legal considerations and operative vaginal delivery

Women undergo operative vaginal delivery (OVD) as an alternative to caesarean section when complications arise in the second stage of labour. The perinatal mortality associated with OVD is very low, and most of the perinatal morbidity is minor. However, when serious adverse events occur, such as traumatic birth injury, shoulder dystocia, cerebral palsy and perinatal death, there are medico-legal implications. There is also the potential for litigation in relation to maternal pelvic floor injury, which is increased with OVD. Obstetricians performing and supervising OVDs need to be aware of the potential pitfalls and minimise the risk of adverse outcomes. Given that most obstetricians will be involved in adverse birth-related events, it is important that they are aware of the legal processes that may ensue. It is also important when reviewing adverse OVD-related outcomes that association is differentiated from causation. These issues are addressed in the current chapter with attention drawn to the Montgomery ruling, which redefines the legal standards expected in relation to informed consent.

Influence of time of delivery on risk of adverse neonatal outcome in different size of delivery units: a retrospective cohort study in Finland

PURPOSE

To evaluate the impact of time of birth on adverse neonatal outcome in singleton term hospital births.

MATERIALS AND METHODS

Medical Birth Register Data in Finland from 2005 to 2009. Study population was all hospital births (n = 263,901), excluding multiple pregnancies, preterm births <37 weeks, major congenital anomalies or birth defects, and antepartum stillbirths. Main outcome measures were either 1-minute Apgar score 0-3, 5-minute Apgar score 0-6, or umbilical artery pH <7.00, and intrapartum and early neonatal mortality. We calculated risk ratios (ARRs) adjusted for maternal age and parity, and 95% confidence intervals (CIs) to indicate the probability of adverse neonatal outcome outside of office hours in normal vaginal delivery, in vaginal breech delivery, in instrumental vaginal delivery, and in elective and nonelective cesarean sections. We analyzed different size-categories of maternity hospitals and different on-call arrangements.

RESULTS

Instrumental vaginal delivery had increased risk for mortality (ARR 3.31, 95%CI; 1.01-10.82) outside office hours. Regardless of hospital volume and on-call arrangement, the risk for low Apgar score or low umbilical artery pH was higher outside office hours (ARR 1.23, 95%CI; 1.15-1.30). Intrapartum and early neonatal mortality increased only in large, nonuniversity hospitals outside office hours (ARR 1.51, 95%CI; 1.07-2.14).

CONCLUSIONS

Compared to office hours, babies born outside office hours are in higher risk for adverse outcome. Demonstration of more detailed circadian effects on adverse neonatal outcomes in different subgroups requires larger data.

Is time of birth a predictor of adverse perinatal outcome? A hospital-based cross-sectional study in a low-resource setting, Tanzania

Background

Inconsistent evidence of a higher risk of adverse perinatal outcomes during off-hours compared to office hours necessitated a search for clear evidence of an association between time of birth and adverse perinatal outcomes.

Methods

A cross-sectional study conducted at a tertiary referral hospital compared perinatal outcomes across three working shifts over 24 h. A checklist and a questionnaire were used to record parturients’ socio-demographic and obstetric characteristics, mode of delivery and perinatal outcomes, including 5th minute Apgar score, and early neonatal mortality. Risks of adverse outcomes included maternal age, parity, referral status and mode of delivery, and were assessed for their association with time of delivery and prevalence of fresh stillbirth as a proxy for poor perinatal outcome at a significance level of p = 0.05.

Results

Off-hour deliveries were nearly twice as likely to occur during the night shift (odds ratio (OR), 1.62; 95% confidence interval (CI), 1.50–1.72), but were unlikely during the evening shift (OR, 0.58; 95% CI, 0.45–0.71) (all p < 0.001). Neonatal distress (O.R, 1.48, 95% CI; 1.07–2.04, p = 0.02), early neonatal deaths (OR, 1.70; 95% CI, 1.07–2.72, p = 0.03) and fresh stillbirths (OR, 1.95; 95% CI, 1.31–2.90, p = 0.001) were more significantly associated with deliveries occurring during night shifts compared to evening and morning shifts. However, fresh stillbirths occurring during the night shift were independently associated with antenatal admission from clinics or wards, referral from another hospital, and abnormal breech delivery (OR 1.9; 95% CI, 1.3–2.9, p = 0.001, for fresh stillbirths; OR, 5.0; 95% CI 1.7–8.3, p < 0.001, for antenatal admission; OR, 95% CI, 1.1–2.9, p < 0.001, for referral form another hospital; and OR 1.6; 95% CI 1.02–2.6, p = 0.004, for abnormal breech deliveries).

Conclusion

Off-hours deliveries, particularly during the night shift, were significantly associated with higher proportions of adverse perinatal outcomes, including low Apgar score, early neonatal death and fresh stillbirth, compared to morning and evening shifts. Labour room admissions from antenatal wards, referrals from another hospital and abnormal breech delivery were independent risk factors for poor perinatal outcome, particularly fresh stillbirths.

An international assessment of trainee experience, confidence, and comfort in operative vaginal delivery

AIM

The aim of this study was to assess Irish and Canadian obstetricians in training ("trainees") experience, confidence, and comfort in performing operative vaginal delivery (OVD).

STUDY DESIGN

Trainees in Obstetrics and Gynaecology in the University of Toronto and the Royal College of Physicians of Ireland (RCPI) were invited to participate in an anonymous online survey reviewing experience as primary operator of OVD. Trainee confidence and comfort was self-assessed based upon their last few OVDs.

RESULTS

The response rate was 55% amongst Canadian trainees (31/56) and 44% amongst Irish trainees (21/48). When comparing Irish with Canadian trainee experience, the median numbers of vacuum and forceps deliveries performed by Irish trainees as primary operator were reported to be higher [125 (range 10-150) vs 20 (range 5-40); p < 0.0001 (ventouse), 45 (range 10-150) vs 6 (range 1-12); p = 0.0001 (forceps)]. Despite this, trainee confidence between the groups did not differ [confidence score: 18.7 (SD 3.2) vs 17.8 (SD 3.5), p = 0.3]. There were some differences regarding comfort in certain aspects of OVD, most notably increased comfort in Irish trainees in pre-procedure assessment skills of OVD.

CONCLUSION

With falling OVD rates worldwide, training experience is declining. Despite higher numbers of OVD within the Irish trainee group, there was no difference in trainee confidence between the two groups. These results suggest that a high number of cases as primary operator may not be required to establish operator confidence in performing a procedure. Irish trainees self-reported more comfort in non-technical skills of OVD, suggesting a step-wise effect of experience on first technical and then non-technical skills.

Does Time of Delivery Influence the Risk of Neonatal Morbidity?

OBJECTIVE

To examine whether time of delivery influences the risk of neonatal morbidity among women with singleton pregnancies.

STUDY DESIGN

Secondary analysis of data from the Maternal Fetal Medicine Units Network Factor V Leiden Mutation study. We categorized time of delivery as day (07:00-16:59), evening (17:00-23:59), and overnight (midnight-06:59). Severe neonatal morbidity was defined by at least one of the following: respiratory distress syndrome, transient tachypnea of the newborn, sepsis, seizures, neonatal intensive care admission, or a 5-minute APGAR ≤3. We calculated frequencies of severe neonatal morbidity by time of delivery. Multivariate analysis was performed to determine whether time of delivery was independently associated with severe neonatal morbidity.

RESULTS

Among 4,087 women, 1,917 (46.9%) delivered during the day, 1,140 (27.9%) delivered in the evening, and 1,030 (25.2%) delivered overnight. We observed no significant differences in the rates of neonatal morbidity between delivery time periods (day: 12.3%; evening: 12.8%; overnight: 12.6%; p = 0.9). No significant association was observed between time of delivery and neonatal morbidity after adjustment for maternal, obstetric, and peripartum factors.

CONCLUSION

Our findings suggest that time of delivery is not associated with severe neonatal morbidity.