Drug Exposure During Pregnancy: A Case-Control Study from a Primary Care Database

Objective

Drug exposure during pregnancy is frequent, even more during first trimester as pregnant women might not be aware of their condition. We used available electronic health records (EHRs) to describe the use of medications during the first trimester in pregnant women and to compare drug exposure between those women who had an abortion (either elective or spontaneous) compared to those who had live births.

Materials and Methods

Case-control study of abortions, either elective or spontaneous (cases), and live birth pregnancies (controls) in Sistema d'Informació per al Desenvolupament de la Investigació en Atenció Primària (Catalan Primary Health electronic health records) from 2012 to 2020. Exposure to drugs during first trimester of pregnancy was considered to estimate the association with abortion by conditional logistic regression and adjusted by health conditions and other drugs exposure.

Results

Sixty thousand three hundred fifty episodes of abortions were matched to 118,085 live birth pregnancy episodes. Cases had higher rates of alcohol intake (9.9% vs. 7.2%, p < 0.001), smoking (4.5% vs. 3.6%, p < 0.001), and previous abortions (9.9% vs. 7.8%, p < 0.001). Anxiety (30.3% and 25.1%, p < 0.001), respiratory diseases (10.6% and 9.2%, p < 0.001), and migraine (8.2% and 7.3%, p < 0.001), for cases and controls, respectively, were the most frequent baseline conditions. Cases had lower rate of drug exposure, 40,148 (66.5%) versus 80,449 (68.1%), p < 0.001. Association with abortion was found for systemic antihistamines (adjusted odds ratio [ORadj] 1.23, 95% confidence interval [CI] 1.19-1.27), antidepressants (ORadj 1.11, 95% CI 1.06-1.17), anxiolytics (ORadj 1.31, 95% CI 1.26-1.73), and nonsteroidal anti-inflammatory drugs (ORadj 1. 63, 95% CI 1.59-1.67).

Conclusions

These high rates of drug exposures during the first trimester of pregnancy highlights the relevance of informed prescription to women with childbearing potential.

Community Support Persons and Mitigating Obstetric Racism During Childbirth

PURPOSE

We undertook a study to assess whether presence of community support persons (CSPs), with no hospital affiliation or alignment, mitigates acts of obstetric racism during hospitalization for labor, birth, and immediate postpartum care.

METHODS

We conducted a cross-sectional cohort study, measuring 3 domains of obstetric racism as defined for, by, and with Black birthing people: humanity (violation of safety and accountability, autonomy, communication and information exchange, and empathy); kinship (denial or disruption of community and familial bonds that support Black birthing people); and racism in the form of anti-Black racism and misogynoir (weaponization of societal stereotypes and scripts in service provision that reproduce gendered anti-Black racism in the hospital). We used a novel, validated instrument, the Patient-Reported Experience Measure of Obstetric Racism (the PREM-OB Scale suite), and linear regression analysis to determine the association between CSP presence during hospital births and obstetric racism.

RESULTS

Analyses were based on 806 Black birthing people, 720 (89.3%) of whom had at least 1 CSP present throughout their labor, birth, and immediate postpartum care. The presence of CSPs was associated with fewer acts of obstetric racism across all 3 domains, with statistically significant reductions in scores in the CSP group of one-third to two-third SD units relative to the no-CSP group.

CONCLUSIONS

Our findings suggest that CSPs may be an effective way to reduce obstetric racism as part of quality improvement initiatives, emphasizing the need for democratizing the birthing experience and birth space, and incorporating community members as a way to promote the safety of Black birthing people in hospital settings.Annals "Online First" article.

Cervical dilation assessment in simulators compared to a visual tool: A randomized study

OBJECTIVE

to verify the correct assessment rate when using direct visual comparison in the cervical dilation measures in hard-consistency cervix simulation models.

METHOD

an open-label and randomized study conducted with 63 Obstetrics students that were designated either to use direct visual comparison in a dilation guide or not. The students estimated cervical dilation blindly in simulators with different dilations. The primary outcome was the correct assessment rate.

RESULTS

the students performed 141 tests. A higher correct assessment rate was found in the Experimental Group than in the Control Group (47.3% versus 27.2%; p<0.001; Odds Ratio = 2.41; 95% Confidence Interval = 1.62-3.58).

CONCLUSION

the direct visual comparison increased precision of the cervical dilation assessment in cervix simulation models, with the possibility of being beneficial in laboratory training. Brazilian Registry of Clinical Trials No. U1111-1210-2389.

Support actions undertaken for the woman by companions in public maternity hospitals

OBJECTIVE

to identify the support actions undertaken for the woman during labor, birth, cesarean section and the postpartum period.

METHOD

a transversal study, undertaken in three public maternity hospitals, with a sample of 1,147 companions. The data were collected through interviews and were analyzed using descriptive statistics. The support actions were classified in four dimensions: emotional, physical, informational and relating to intermediation.

RESULTS

the majority of interviewees were the partner/father of the baby (76.7%). In labor, birth and the postpartum period, the actions of emotional support - such as calming, encouraging and praising, were performed by more than 80.0% of the companions; informational support, by approximately 70.0%; and intermediation by fewer than 65.0% of them. In childbirth, the emphasis on physical support was observed in assisting with walking (84.4%), and in changing position (90.4%).

CONCLUSION

the companions participate actively in the birth process, performing actions of support in the four dimensions. Emotional support is the most frequent, followed by physical and informational support, mainly during labor and birth. The results contribute to valuing the companion from the woman's social network in the birth scenario and to the recognition of his/her role as a provider of support.

Evaluation of the Nursing Care Offered during the Parturition Process. Controlled Clinical Trial of an Intervention based on Swanson's Theory of Caring versus Conventional Care

OBJECTIVES

This work sought to compare the evaluation of the nursing care provided during the parturition process in the intervention group based on Swanson's theory of caring versus that of the control group that received conventional care.

METHODS

Preventive-type controlled clinical trial conducted in a tier II hospital in San Gil, Santander (Colombia). During the parturition process, the intervention group received care based on Swanson's theory of caring (n=20) and the control group received conventional care (n=23). During immediate postpartum, the mothers were applied the Professional care rating scale by Swanson, validated into Spanish in Colombia.

RESULTS

Assessment of professional care in the intervention group was Excellent with an average for the scale total of 59.8 points of a possible maximum of 60 points, while in the control group it was Good with 50.2 (p<0.0001). In the 15 items that make up the scale and in both subscales (Compassionate Healer and Competent Healer) higher scores were also observed in the intervention group compared to those of the control group. Conclusion. The intervention derived from Swanson's theory of caring was associated to a better evaluation of professional nursing care by women during the parturition process.

Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being

BACKGROUND

The goal of fetal monitoring in labour is the early detection of a hypoxic baby. There are a variety of tools and methods available for intermittent auscultation (IA) of the fetal heart rate (FHR). Low- and middle-income countries usually have only access to a Pinard/Laënnec or the use of a hand-held Doppler device. Currently, there is no robust evidence to guide clinical practice on the most effective IA tool to use, timing intervals and length of listening to the fetal heart for women during established labour.

OBJECTIVES

To evaluate the effectiveness of different tools for IA of the fetal heart rate during labour including frequency and duration of auscultation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (19 September 2016), contacted experts and searched reference lists of retrieved articles.

SELECTION CRITERIA

All published and unpublished randomised controlled trials (RCTs) or cluster-RCTs comparing different tools and methods used for intermittent fetal auscultation during labour for fetal and maternal well-being. Quasi-RCTs, and cross-over designs were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

All review authors independently assessed eligibility, extracted data and assessed risk of bias for each trial. Data were checked for accuracy.

MAIN RESULTS

We included three studies (6241 women and 6241 babies), but only two studies are included in the meta-analyses (3242 women and 3242 babies). Both were judged as high risk for performance bias due to the inability to blind the participants and healthcare providers to the interventions. Evidence was graded as moderate to very low quality; the main reasons for downgrading were study design limitations and imprecision of effect estimates. Intermittent Electronic Fetal Monitoring (EFM) using Cardiotocography (CTG) with routine Pinard (one trial)There was no clear difference between groups in low Apgar scores at five minutes (reported as < six at five minutes after birth) (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.24 to 1.83, 633 babies, very low-quality evidence). There were no clear differences for perinatal mortality (RR 0.88, 95% CI 0.34 to 2.25; 633 infants, very low-quality evidence). Neonatal seizures were reduced in the EFM group (RR 0.05, 95% CI 0.00 to 0.89; 633 infants, very low-quality evidence). Other important infant outcomes were not reported: mortality or serious morbidity (composite outcome), cerebral palsy or neurosensory disability. For maternal outcomes, women allocated to intermittent electronic fetal monitoring (EFM) (CTG) had higher rates of caesarean section for fetal distress (RR 2.92, 95% CI 1.78 to 4.80, 633 women, moderate-quality evidence) compared with women allocated to routine Pinard. There was no clear difference between groups in instrumental vaginal births (RR 1.46, 95% CI 0.86 to 2.49, low-quality evidence). Other outcomes were not reported (maternal mortality, instrumental vaginal birth for fetal distress and or acidosis, analgesia in labour, mobility or restriction during labour, and postnatal depression). Doppler ultrasonography with routine Pinard (two trials)There was no clear difference between groups in Apgar scores < seven at five minutes after birth (reported as < six in one of the trials) (average RR 0.76, 95% CI 0.20 to 2.87; two trials, 2598 babies, I2 = 72%, very low-quality evidence); there was high heterogeneity for this outcome. There was no clear difference between groups for perinatal mortality (RR 0.69, 95% CI 0.09 to 5.40; 2597 infants, two studies, very low-quality evidence), or neonatal seizures (RR 0.05, 95% CI 0.00 to 0.91; 627 infants, one study, very low-quality evidence). Other important infant outcomes were not reported (cord blood acidosis, composite of mortality and serious morbidity, cerebral palsy, neurosensory disability). Only one study reported maternal outcomes. Women allocated to Doppler ultrasonography had higher rates of caesarean section for fetal distress compared with those allocated to routine Pinard (RR 2.71, 95% CI 1.64 to 4.48, 627 women, moderate-quality evidence). There was no clear difference in instrumental vaginal births between groups (RR 1.35, 95% CI 0.78 to 2.32, 627 women, low-quality evidence). Other maternal outcomes were not reported. Intensive Pinard versus routine Pinard (one trial)One trial compared intensive Pinard (a research midwife following the protocol in a one-to-one care situation) with routine Pinard (as per protocol but midwife may be caring for more than one woman in labour). There was no clear difference between groups in low Apgar score (reported as < six this trial) (RR 0.90, 95% CI 0.35 to 2.31, 625 babies, very low-quality evidence). There were also no clear differences identified for perinatal mortality (RR 0.56, 95% CI 0.19 to 1.67; 625 infants, very low-quality evidence), or neonatal seizures (RR 0.68, 95% CI 0.24 to 1.88, 625 infants, very low-quality evidence)). Other infant outcomes were not reported. For maternal outcomes, there were no clear differences between groups for caesarean section or instrumental delivery (RR 0.70, 95% CI 0.35 to 1.38, and RR 1.21, 95% CI 0.69 to 2.11, respectively, 625 women, both low-quality evidence)) Other outcomes were not reported.

AUTHORS' CONCLUSIONS

Using a hand-held (battery and wind-up) Doppler and intermittent CTG with an abdominal transducer without paper tracing for IA in labour was associated with an increase in caesarean sections due to fetal distress. There was no clear difference in neonatal outcomes (low Apgar scores at five minutes after birth, neonatal seizures or perinatal mortality). Long-term outcomes for the baby (including neurodevelopmental disability and cerebral palsy) were not reported. The quality of the evidence was assessed as moderate to very low and several important outcomes were not reported which means that uncertainty remains regarding the use of IA of FHR in labour.As intermittent CTG and Doppler were associated with higher rates of caesarean sections compared with routine Pinard monitoring, women, health practitioners and policy makers need to consider these results in the absence of evidence of short- and long-term benefits for the mother or baby.Large high-quality randomised trials, particularly in low-income settings, are needed. Trials should assess both short- and long-term health outcomes, comparing different monitoring tools and timing for IA.

Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non-reassuring fetal heart rate trace

BACKGROUND

Fetal scalp blood sampling for lactate estimation may be considered following identification of an abnormal or non-reassuring fetal heart rate pattern. The smaller volume of blood required for this test, compared with the more traditional pH estimation, may improve sampling rates. The appropriate use of this practice mandates systematic review of its safety and clinical effectiveness prior to widespread introduction.

OBJECTIVES

To evaluate the effectiveness and risks of fetal scalp lactate sampling in the assessment of fetal well-being during labour, compared with no testing or alternative testing.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015).

SELECTION CRITERIA

All published and unpublished randomised and quasi-randomised trials that compared fetal scalp lactate testing with no testing or alternative testing to evaluate fetal status in the presence of a non-reassuring cardiotocograph during labour.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures of the Cochrane Pregnancy and Childbirth Group. Two review authors independently assessed the studies.

MAIN RESULTS

The search identified two completed randomised controlled trials (RCTs) and two ongoing trials. The two published RCTs considered outcomes for 3348 mother-baby pairs allocated to either lactate or pH estimation of fetal blood samples when clinically indicated in labour. Overall, the published RCTs were of low or unclear risk of bias. There was a high risk of performance bias, because it would not have been feasible to blind clinicians or participants.No statistically significant between-group differences were found for neonatal encephalopathy (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.32 to 3.09, one study, 2992 infants) or death. No studies reported neonatal seizures. We had planned to report death with other morbidities, for example, neonatal encephalopathy; however, the data were not available in a format suitable for this, therefore death due to congenital abnormality was considered alone. The three reported neonatal deaths occurred in babies with diaphragmatic hernias (n = 2) or congenital cardiac fibrosis (n = 1). All three babies had been randomised to the pH group and were not acidaemic at birth.There were no statistically significant differences for any of the pre-specified secondary fetal/neonatal/infant outcomes for which data were available. This included low Apgar score at five minutes (RR 1.13, 95% CI 0.76 to 1.68, two studies, 3319 infants) and admission to neonatal intensive care units (RR 1.02, 95% CI 0.83 to 1.25, one study, 2992 infants), or metabolic acidaemia (RR 0.91, 95% CI 0.60 to 1.36, one study, 2675 infants) considered within the studies, either overall or where data were available for those where fetal blood sampling had occurred within 60 minutes of delivery.Similar proportions of fetuses underwent additional tests to further evaluate well-being during labour, including scalp pH if in the lactate group or scalp lactate if in the pH group (RR 0.22, 95% CI 0.04 to 1.30, two studies, 3333 infants;Tau² 1.00, I² = 58%). Fetal blood sampling attempts for lactate and pH estimation were successful in 98.7% and 79.4% of procedures respectively in the one study that reported this outcome.There were no significant between-group differences in mode of birth or operative birth for non-reassuring fetal status, either for all women, or within the group where the fetal blood sample had been taken within 60 minutes of delivery (for example, caesarean section for all enrolled, RR 1.09, 95% CI 0.97 to 1.22, two studies, 3319 women; operative delivery for non-reassuring fetal status for all enrolled RR 1.02, 95% CI 0.93 to 1.11, one study, 2992 women).Neither study reported on adverse effects of fetal scalp lacerations or maternal anxiety.

AUTHORS' CONCLUSIONS

When further testing to assess fetal well-being in labour is indicated, fetal scalp blood lactate estimation is more likely to be successfully undertaken than pH estimation. Further studies may consider subgroup analysis by gestational age, the stage of labour and sampling within a prolonged second stage of labour. Additionally, we await the findings from the ongoing studies that compare allocation to no fetal blood sample with sampling for lactate and address longer-term neonatal outcomes, maternal satisfaction with intrapartum fetal monitoring and an economic analysis.

Admission tests other than cardiotocography for fetal assessment during labour

BACKGROUND

Evidence on the benefits of admission tests other than cardiotocography in preventing adverse perinatal outcomes has not been established.

OBJECTIVES

To assess the effectiveness of admission tests other than cardiotocography in preventing adverse perinatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011).

SELECTION CRITERIA

Randomised (individual and cluster) controlled trials, comparing labour admission tests other than CTG for the prevention of adverse perinatal outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, quality and extracted data.

MAIN RESULTS

We included one study involving 883 women.Comparison of sonographic assessment of amniotic fluid index (AFI) on admission versus no sonographic assessment of AFI on admission. The incidence of cesarean section for fetal distress in the intervention group (29 of 447) was significantly higher than those of controls (14 of 436) (risk ratio (RR) 2.02; 95% confidence interval (CI) 1.08 to 3.77).The incidence of Apgar score less than seven at five minutes in the intervention group (10 of 447) was not significantly different from controls (seven of 436) (RR 1.39, 95% CI 0.54 to 3.63).The incidence of artificial oxytocin for augmentation of labour in the intervention group (213 of 447) was significantly higher than controls (132 of 436) (RR 1.57; 95% CI 1.32 to 1.87).The incidence of neonatal NICU admission in the intervention group (35 of 447) was not significantly different from the controls (33 of 436) (RR 1.03; 95% CI 0.66 to 1.63)

AUTHORS' CONCLUSIONS

There is not enough evidence to support the use of admission tests other than cardiotocography for fetal assessment during labour. Appropriate randomised controlled trials with adequate sample size of admission tests other than cardiotocography for fetal assessment during labour are required.

WITHDRAWN: Continuous electronic heart rate monitoring for fetal assessment during labor

BACKGROUND

Electronic fetal monitoring (EFM) is used in the management of labor and delivery in nearly three of four pregnancies in the United States. The apparent contradiction between the widespread use of EFM and expert recommendations to limit routine use indicates that a reassessment of this practice is warranted.

OBJECTIVES

To compare the efficacy and safety of routine continuous EFM during labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs).

SEARCH STRATEGY

We identified RCTs by searching MEDLINE and the register maintained by the Cochrane Pregnancy and Childbirth Group, and by contacting experts, and reviewing published references. Date of last search: January 2001.

SELECTION CRITERIA

Randomized controlled trials.

DATA COLLECTION AND ANALYSIS

Data were abstracted by one of us, and their accuracy was confirmed independently by a second person. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of eight outcomes.

MAIN RESULTS

Our search identified 13 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. Four trials that did not fulfil our selection criteria were excluded. The remaining nine trials included 18,561 pregnant women and their 18,695 infants in both high- and low-risk pregnancies from seven clinical centers in the United States, Europe, and Australia. Overall, a statistically significant decrease was associated with routine EFM for neonatal seizures (relative risk (RR) 0.51, 95% confidence interval (CI) 0.32-0.82). The protective effect for neonatal seizures was only evident in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores below four or seven, rate of admissions to neonatal intensive care units, perinatal deaths or cerebral palsy. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.41, 95% CI 1.23-1.61) and operative vaginal delivery (RR 1.20, 95% CI 1.11-1.30).

AUTHORS' CONCLUSIONS

The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. In view of the increase in cesarean and operative vaginal delivery, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use continuous EFM or intermittent auscultation during labor.

Caregiver support for women during childbirth

BACKGROUND

Social support may include advice or information, tangible assistance and emotional support.

OBJECTIVES

The objective of this review was to assess the effects of continuous support during labour (provided by health care workers or lay people) on mothers and babies.

SEARCH STRATEGY

I searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: April 1999.

SELECTION CRITERIA

Randomised trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed. Study authors were contacted for additional information.

MAIN RESULTS

Fourteen trials, involving more than 5000 women, are included in the Review. The continuous presence of a support person reduced the likelihood of medication for pain relief, operative vaginal delivery, caesarean delivery, and a 5-minute Apgar score less than 7. Continuous support was also associated with a slight reduction in the length of labour. Six trials evaluated the effects of support on mothers' views of their childbirth experiences; while the trials used different measures (overall satisfaction, failure to cope well during labour, finding labour to be worse than expected, and level of personal control during childbirth), in each trial the results favoured the group who had received continuous support.

REVIEWER'S CONCLUSIONS

Continuous support during labour from caregivers (nurses, midwives or lay people) appears to have a number of benefits for mothers and their babies and there do not appear to be any harmful effects.