Trends in postpartum hemorrhage and manual removal of the placenta and the association with childbirth interventions: A Dutch nationwide cohort study.

BACKGROUND: Because the cause of increasing rates of postpartum hemorrhage (PPH) and manual placental removal (MROP) is still unknown, we described trends in PPH, MROP, and childbirth interventions and examined factors associated with changes in rates of PPH and MROP. METHODS: This nationwide cohort study used national perinatal registry data from 2000 to 2014 (n = 2,332,005). We included births of women who gave birth to a term singleton child in obstetrician-led care or midwife-led care. Multivariable logistic regression analyses were used to examine associations between characteristics and interventions, and PPH ≥ 1000 mL and MROP. RESULTS: PPH rates increased from 4.3% to 6.6% in obstetrician-led care and from 2.5% to 4.8% in midwife-led care. MROP rates increased from 2.4% to 3.4% and from 1.0% to 1.4%, respectively. A rising trend was found for rates of induction and augmentation of labor, pain medication, and cesarean section, while rates of episiotomy and assisted vaginal birth declined. Adjustments for characteristics and childbirth interventions did not result in large changes in the trends of PPH and MROP. After adjustments for childbirth interventions, in obstetrician-led care, the odds ratio (OR) of PPH in 2014 compared with the reference year 2000 changed from 1.66 (95% CI 1.57-1.76) to 1.64 (1.55-1.73) among nulliparous women and from 1.56 (1.47-1.66) to 1.52 (1.44-1.62) among multiparous women. For MROP, the ORs changed from 1.51 (1.38-1.64) to 1.36 (1.25-1.49) and from 1.56 (1.42-1.71) to 1.45 (1.33-1.59), respectively. CONCLUSIONS: Rising PPH trends were not associated with changes in population characteristics and rising childbirth intervention rates. The rising MROP was to some extent associated with rising intervention rates.

Variations in use of childbirth interventions in 13 high-income countries: A multinational cross-sectional study.

BACKGROUND: Variations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and adverse outcomes, adjusted for population characteristics. METHODS AND FINDINGS: In this multinational cross-sectional study, existing data on 4,729,307 singleton births at ≥37 weeks in 2013 from Finland, Sweden, Norway, Denmark, Iceland, Ireland, England, the Netherlands, Belgium, Germany (Hesse), Malta, the United States, and Chile were used to describe variations in childbirth interventions and outcomes. Numbers of births ranged from 3,987 for Iceland to 3,500,397 for the USA. Crude data were analysed in the Netherlands, or analysed data were shared with the principal investigator. Strict variable definitions were used and information on data quality was collected. Intervention rates were described for each country and stratified by parity. Uni- and multivariable analyses were performed, adjusted for population characteristics, and associations between rates of interventions, population characteristics, and outcomes were assessed using Spearman's rank correlation coefficients. Considerable intercountry variations were found for all interventions, despite adjustments for population characteristics. Adjustments for ethnicity and body mass index changed odds ratios for augmentation of labour and episiotomy. Largest variations were found for augmentation of labour, pain relief, episiotomy, instrumental birth, and cesarean section (CS). Percentages of births at ≥42 weeks varied from 0.1% to 6.7%. Rates among nulliparous versus multiparous women varied from 56% to 80% versus 51% to 82% for spontaneous onset of labour; 14% to 36% versus 8% to 28% for induction of labour; 3% to 13% versus 7% to 26% for prelabour CS; 16% to 48% versus 12% to 50% for overall CS; 22% to 71% versus 7% to 38% for augmentation of labour; 50% to 93% versus 25% to 86% for any intrapartum pain relief, 19% to 83% versus 10% to 64% for epidural anaesthesia; 6% to 68% versus 2% to 30% for episiotomy in vaginal births; 3% to 30% versus 1% to 7% for instrumental vaginal births; and 42% to 70% versus 50% to 84% for spontaneous vaginal births. Countries with higher rates of births at ≥42 weeks had higher rates of births with a spontaneous onset (rho = 0.82 for nulliparous/rho = 0.83 for multiparous women) and instrumental (rho = 0.67) and spontaneous (rho = 0.66) vaginal births among multiparous women and lower rates of induction of labour (rho = -0.71/-0.66), prelabour CS (rho = -0.61/-0.65), overall CS (rho = -0.61/-0.67), and episiotomy (multiparous: rho = -0.67). Variation in CS rates was mainly due to prelabour CS (rho = 0.96). Countries with higher rates of births with a spontaneous onset had lower rates of emergency CS (nulliparous: rho = -0.62) and higher rates of spontaneous vaginal births (multiparous: rho = 0.70). Prelabour and emergency CS were positively correlated (nulliparous: rho = 0.74). Higher rates of obstetric anal sphincter injury following vaginal birth were found in countries with higher rates of spontaneous birth (nulliparous: rho = 0.65). In countries with higher rates of epidural anaesthesia (nulliparous) and spontaneous births (multiparous), higher rates of Apgar score < 7 were found (rhos = 0.64). No statistically significant variation was found for perinatal mortality. Main limitations were varying quality of data and missing information. CONCLUSIONS: Considerable intercountry variations were found for all interventions, even after adjusting for population characteristics, indicating overuse of interventions in some countries. Multivariable analyses are essential when comparing intercountry rates. Implementation of evidence-based guidelines is crucial in optimising intervention use and improving quality of maternity care worldwide.

Nonsuturing or Skin Adhesives versus Suturing of the Perineal Skin After Childbirth: A Systematic Review.

BACKGROUND: Suturing of perineal trauma after childbirth can cause problems such as pain, discomfort because of tight sutures, the need for suture removal, and dyspareunia. It is unclear whether leaving the perineal skin unsutured or using skin adhesives might prevent these problems. METHODS: CENTRAL, MEDLINE, EMBASE, CINAHL, and prospective trial registers until January 2013 were searched for (quasi-)randomized controlled trials comparing nonsuturing of the perineal skin or skin adhesives versus suturing of the skin when repairing a second-degree perineal tear or episiotomy. Primary outcome measure was short-term and long-term pain and need for analgesic medication. RESULTS: Four randomized and two quasi-randomized controlled trials (involving 2,922 women) with heterogeneity in contexts, designs, and methodological quality were included. Nonsuturing of the skin leads to less short-term and long-term pain compared to suturing and an increased rate of skin separation. Skin adhesives lead to less short-term pain without an increased rate of skin separation. Nonsuturing or skin adhesives lead to less complaints and there are no other adverse effects. CONCLUSIONS: Nonsuturing of the skin or the use of skin adhesives appears preferable in terms of pain. Nonsuturing could lead to more short-term skin separation when no adhesives are used, but there is no evidence for the clinical importance of skin separation. There is a need for studies with a follow-up of at least 6 months, in which pain is measured homogeneously and for studies comparing the use of skin adhesives with nonsuturing of the skin with the focus on long-term cosmetic results.

Decline in home births associated with faster increase in trend of postpartum haemorrhage and manual removal of the placenta.

In this study we explored the relationship between home birth rates and increasing rates of postpartum haemorrhage (PPH) and manual removal of the placenta (MROP). Data were used from the Dutch national perinatal registry (2000-2014) of women in midwife-led care. Adjusting for place of birth flattened the increasing trends of PPH and MROP. By adjusting for place of birth, the rising trend of MROP among multiparous women disappeared. This suggests that if home birth rates had not declined, PPH and MROP rates might not have increased as much. This study supports policies of enabling women to choose home births.

Differences in rates of severe perineal trauma between midwife-led and obstetrician-led care in the Netherlands: A nationwide cohort study.

Objective: To investigate trends and rates of severe perineal trauma (SPT), also known as obstetric anal sphincter injury (OASI), between midwife-led and obstetrician-led care in the Netherlands, and factors associated with SPT. Methods: This nationwide cohort study included registry data from 2000 to 2019 (n = 2,169,950) of spontaneous vaginal births of term, live, cephalic, single infants, without a (previous) caesarean section or assisted vaginal birth.First, trends of SPT and episiotomy were shown. Second, differences in SPT rates between midwife- and obstetrician-led care were assessed. Third, associations of care factors with SPT were examined. Multivariable logistic regression analyses were used to determine which factors were important in the associations. All outcomes were stratified for parity. Results: Over time, the SPT incidence increased mainly in midwife-led care and episiotomy rates decreased. Compared to midwife-led care, SPT rates were lower in obstetrician-led care among primiparous women (aOR 0.78; 99 % CI 0.74-0.81) and comparable among multiparous women (aOR 1.04; 99 % CI 0.99-1.10). Among women without epidural analgesia, these differences were smaller for primiparous women (aOR 0.88; 99 % CI 0.84-0.92), but the SPT rate was higher in obstetrician-led care among multiparous women (aOR 1.09; 99 % CI 1.03-1.15). Among women without shoulder dystocia, induction, augmentation, and pain medication, SPT rates were comparable among primiparous women, but higher among multiparous women in obstetrician-led care. In midwife-led care, SPT occurred more often among hospital versus home births. In obstetrician-led care, lower SPT incidences were found among births with epidural analgesia and for multiparous women with induction or augmentation. Conclusions: Among spontaneous vaginal births, induction, augmentation, and epidural analgesia in obstetrician-led care may be an explanatory factor for the higher incidence of SPT among primiparous women in midwife-led care. More research is needed to explain differences in SPT rates and to understand how SPT can be prevented, while maintaining a high intact perineum rate.

Regional variations in childbirth interventions and their correlations with adverse outcomes, birthplace and care provider: A nationwide explorative study.

BACKGROUND: Variations in childbirth interventions may indicate inappropriate use. Most variation studies are limited by the lack of adjustments for maternal characteristics and do not investigate variations in adverse outcomes. This study aims to explore regional variations in the Netherlands and their correlations with referral rates, birthplace, interventions, and adverse outcomes, adjusted for maternal characteristics. METHODS: In this nationwide retrospective cohort study, using a national data register, intervention rates were analysed between twelve regions among single childbirths after 37 weeks' gestation in 2010-2013 (n = 614,730). These were adjusted for maternal characteristics using multivariable logistic regression. Primary outcomes were intrapartum referral, birthplace, and interventions used in midwife- and obstetrician-led care. Correlations both between primary outcomes and between adverse outcomes were calculated with Spearman's rank correlations. FINDINGS: Intrapartum referral rates varied between 55-68% (nulliparous) and 20-32% (multiparous women), with a negative correlation with receiving midwife-led care at the onset of labour in two-thirds of the regions. Regions with higher referral rates had higher rates of severe postpartum haemorrhages. Rates of home birth varied between 6-16% (nulliparous) and 16-31% (multiparous), and was negatively correlated with episiotomy and postpartum oxytocin rates. Among midwife-led births, episiotomy rates varied between 14-42% (nulliparous) and 3-13% (multiparous) and in obstetrician-led births from 46-67% and 14-28% respectively. Rates of postpartum oxytocin varied between 59-88% (nulliparous) and 50-85% (multiparous) and artificial rupture of membranes between 43-52% and 54-61% respectively. A north-south gradient was visible with regard to birthplace, episiotomy, and oxytocin. CONCLUSIONS: Our study suggests that attitudes towards interventions vary, independent of maternal characteristics. Care providers and policy makers need to be aware of reducing unwarranted variation in birthplace, episiotomy and the postpartum use of oxytocin. Further research is needed to identify explanations and explore ways to reduce unwarranted intervention rates.

Which level of risk justifies routine induction of labor for healthy women?

Although induction of labor can be crucial for preventing morbidity and mortality, more and more women (and their offspring) are being exposed to the disadvantages of this intervention while the benefit is at best small or even uncertain. Characteristics such as an advanced maternal age, a non-native ethnicity, a high Body Mass Index, an artificially assisted conception, and even nulliparity are increasingly considered an indication for induction of labor. Because induction of labor has many disadvantages, a debate is urgently needed on which level of risk justifies routine induction of labor for healthy women, only based on characteristics that are associated with statistically significant small absolute risk differences, compared to others without these characteristics. This commentary contributes to this debate by arguing why induction of labour should not routinely be offered to all women where there is a small increase in absolute risk, and no any other medical risks or complications during pregnancy. To underpin our statement, national data from the Netherlands were used reporting stillbirth rates in groups of women based on their characteristics, for each gestational week from 37 weeks of gestation onwards.

[Better training in perineal injury is desirable]. / Betere training over perineumletsel gewenst.

Better training in perineal injury is desirable One of the most common complaints from women following childbirth is perineal pain, caused by perineal trauma. The episiotomy technique, the suture material chosen, the suture technique, and the knowledge and skills of the care-provider all influence healing and subsequent symptoms. Evidence-based techniques are associated with fewer symptoms and complications; however, the literature reveals that care-providers are often inexperienced, not well trained or not conscientious enough in: performing an accurate episiotomy; assessing perineal trauma; diagnosing anal-sphincter injuries; and evidence-based repair techniques. The angle at which an episiotomy is performed and the suture techniques used vary considerably, while the evidence shows emphatically which techniques are optimal. We believe that the responsibility for the improvement of knowledge and skills lies with the care-providers. Despite the absence of obligation, they should attend repeated training sessions, to guarantee the optimal quality of perineal care following childbirth.