Investigation of an increase in postpartum haemorrhage in Canada.

OBJECTIVE: To investigate the cause of a recent increase in hysterectomies for postpartum haemorrhage in Canada. DESIGN: Retrospective cohort study. SETTING: Canada between 1991 and 2004. POPULATION: All hospital deliveries in Canada as documented in the database of the Canadian Institute for Health Information (excluding incomplete data from Quebec, Manitoba and Nova Scotia). METHODS: Deliveries with postpartum haemorrhage by subtype were identified using International Classification of Diseases codes, while hysterectomies were identified using procedure codes. Changes in determinants of postpartum haemorrhage (all postpartum haemorrhage and that requiring hysterectomy) were examined, and crude and adjusted period changes were assessed using logistic models. MAIN OUTCOME MEASURES: Postpartum haemorrhage, postpartum haemorrhage with hysterectomy, postpartum haemorrhage with blood transfusion and postpartum haemorrhage by subtype. RESULTS: Rates of postpartum haemorrhage increased from 4.1% in 1991 to 5.1% in 2004 (23% increase, 95% CI 20-26%), while rates of postpartum haemorrhage with hysterectomy increased from 24.0 in 1991 to 41.7 per 100,000 deliveries in 2004 (73% increase, 95% CI 27-137%). These increases were because of an increase in atonic postpartum haemorrhage, from 29.4 per 1000 deliveries in 1991 to 39.5 per 1000 deliveries in 2004 (34% increase, 95% CI 31-38%). Adjustment for temporal changes in risk factors did not explain the increase in atonic postpartum haemorrhage but attenuated the increase in atonic postpartum haemorrhage with hysterectomy. CONCLUSIONS: There has been a recent, unexplained increase in the frequency, and possibly the severity, of atonic postpartum haemorrhage in Canada.

Misoprostol versus oxytocin for the reduction of postpartum blood loss.

OBJECTIVE: To compare the effect of 400 mug of oral misoprostol with 5 U of intravenous oxytocin in the reduction of postpartum blood loss and prevention of postpartum hemorrhage. METHODS: In a prospective, double-blind, randomized controlled trial conducted in a tertiary maternity hospital 622 women received either 400 mug of oral misoprostol or 5 U of intravenous oxytocin after delivery of the anterior shoulder or within 1 min of delivery. The primary outcome was a hematocrit drop of 10% or greater 24 h postpartum. The secondary outcomes were a hemoglobin drop of 30 mg/L or greater, the use of additional oxytocin, an estimated blood loss greater than 1000 mL, manual removal of the placenta, a blood transfusion, and shivering and fever (>or=38 degrees C) as adverse effects of misoprostol. RESULTS: There was no difference between the 2 groups regarding the primary outcome (a >or=10% hematocrit drop occurred in 3.4% and 3.7% of the participants in the oxytocin and misoprostol groups, P=0.98). The rate of use of additional oxytocin was higher in the misoprostol group (51% versus 40.5%, P=0.01). Shivering was confined to the misoprostol group (6.8%), and fever occurred in 12.5% of the women in the misoprostol group and 0.3% of the women in the oxytocin group. CONCLUSION: The routine use of 400 microg of oral misoprostol was no less effective than 5 U of intravenous oxytocin in reducing blood loss after delivery, as assessed by change in postpartum hematocrit. The adverse effects of misoprostol were mild and self-limiting.

Predictors of respiratory depression at birth in the term infant.

OBJECTIVE: To evaluate predictive factors for respiratory depression at birth in infants >/=37 weeks. DESIGN: A population-based cohort study of respiratory depression at birth at term and post-term. SETTING: Nova Scotia, Canada. POPULATION: All 126 604 nonanomalous, singleton deliveries >/=37 weeks in cephalic presentation from 1988-2002. METHODS: An analysis of maternal, antenatal, intrapartum, and neonatal factors associated with respiratory depression at birth >/=37 weeks. MAIN OUTCOME MEASURES: A composite outcome of delay in initiating and maintaining respiration after birth, 5-minute Apgar score

Severe obstetric maternal morbidity: a 15-year population-based study.

Using a provincial perinatal database for 15 years, 1988-2002. Cases were identified with one or more of the following markers of severe maternal morbidity: blood transfusion > or = 5 units, emergency hysterectomy, uterine rupture, eclampsia, intensive care (ICU) admission. There were 159,896 mothers delivered of whom 313 (2.0/1000) had 385 markers of severe morbidity (257 had one, 42 had two, 12 had three, and two had four). The following rates of morbidity were recorded: blood transfusion > or = 5 units 119 (0.74/1000); emergency hysterectomy 88 (0.55/1000); uterine rupture 49 (0.31/1000); eclampsia 46 (0.28/1000); ICU 83 (0.52/1000). There was a statistically significant association between multiparity > or = 1, and emergency hysterectomy and uterine rupture; between age > or = 35 years, and emergency hysterectomy, uterine rupture and ICU; and between caesarean delivery and blood transfusion > or = 5 units, emergency hysterectomy, uterine rupture, eclampsia and ICU. The main contributing obstetric complications were haemorrhage (64.7%) and complications of hypertensive disorders (16.8%).

Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term.

OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with spontaneous labor. METHODS: A 14-year, population-based, cohort study (1988-2001) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women at term undergoing spontaneous labor for planned vaginal delivery with singleton, cephalic presentation and nulliparous women delivering by cesarean without labor. RESULTS: From a total of 18,435 pregnancies, which satisfied inclusion and exclusion criteria, 721 were cesarean deliveries without labor. There were no maternal deaths or transfers for intensive care. There was no difference in wound infection, blood transfusion, or intraoperative trauma. Women undergoing cesarean deliveries without labor were more likely to have puerperal febrile morbidity (relative risk [RR] 2.2; 95% confidence interval [CI] 1.1, 4.5; P=.03), but were less likely to have early postpartum hemorrhage (RR 0.6; 95% CI 0.4, 0.9; P=.01) compared with women entering spontaneous labor. Subgroup analyses of maternal outcomes in women delivering by spontaneous and assisted vaginal delivery and cesarean delivery in labor were also performed. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups. CONCLUSION: The increased maternal morbidity in elective cesarean delivery compared with spontaneous onset of labor is limited to puerperal febrile morbidity. Maternal morbidity is increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.

Emergency obstetric hysterectomy.

A population-based review (1988-2000) of 142,634 deliveries found an incidence of emergency obstetric hysterectomy of 0.53 per 1000 deliveries. The relative risk for caesarean versus vaginal delivery was 18.32 (10.26, 32.71) P<0.001. Previous caesarean delivery occurred in 47.4% and 22.4% were primiparous. Causes and morbidity were ascertained in a hospital-based study (1980-2001) of 64 emergency hysterectomies in 110,537 deliveries. The main indications for hysterectomy were abnormal placentation (50%) and atonic postpartum haemorrhage (32.8%). Blood transfusion was needed in 84.4% and intensive care in 26.6%. There were no maternal deaths. Potential alternatives to hysterectomy for massive obstetric haemorrhage are discussed.

History of the Atlantic Society of Obstetricians and Gynaecologists.

The origins and development of the Atlantic Society of Obstetricians and Gynaecologists from 1961-2001 is outlined.

Parturition and urinary incontinence in primiparas.

OBJECTIVE: To estimate the incidence and relative risk of postpartum urinary incontinence in primiparas. METHODS: Over 3 years (1996-1998), healthy nulliparas with no significant history of urinary tract abnormalities were prospectively enrolled. Power analysis indicated that 452 women must complete the study. Participants completed a questionnaire about urinary, fecal, and flatal incontinence. At 6 weeks' and 6 months' postpartum, the same questionnaire was mailed to participants. Statistical analysis consisted of chi-square and Fisher exact tests for nominal variables and analysis of variance and Kruskal-Wallis tests for interval variables. Logistic regression tested independence of variables. RESULTS: A total of 690 primiparas were enrolled in the study and 595 delivered at our hospital: 147 (25%) cesareans, 333 (56%) spontaneous vaginal deliveries, and 115 (19%) instrumental vaginal deliveries. Median birth weight was 3489 g. Urinary incontinence rate at 6 months was 26%. Vaginal delivery was associated with a higher incidence of urinary incontinence (relative risk, 2.8) compared with cesarean. Forceps delivery increased the risk of urinary incontinence (relative risk, 1.5) compared with spontaneous vaginal delivery. There was no significant difference between cesareans done before and during labor. None of the obstetric risk factors were independently significant. CONCLUSION: Cesarean delivery at any stage of labor reduces postpartum urinary incontinence. With multivariable analysis, obstetric risk factors are not significant.

Combined vaginal-cesarean delivery of twin pregnancies.

OBJECTIVE: To estimate the incidence and factors associated with combined vaginal-cesarean delivery in twin pregnancies. METHODS: We studied all twin births weighing 500 g or more during a 20-year period (1980-1999) at a tertiary care center. Major anomalies, monoamniotic and conjoined twins, and antepartum fetal deaths were excluded. RESULTS: During this 20-year period, 105,987 women delivered, of whom 1565 (1.5%) had twins. Of these, 1151 twin sets fulfilled the study criteria. The mode of delivery was vaginal in 653 (56.8%), cesarean in 448 (38.9%), and vaginal-cesarean in 50 (4.3%). During the 20 years there was a statistically significant increase in combined vaginal-cesarean and elective cesarean deliveries, with a decrease in vaginal deliveries. Parity, gestational age, and birth weight discordance (>25%) were not associated with combined delivery. Compared with vaginal delivery, the nonvertex second twin was associated with a twofold higher risk of cesarean delivery (relative risk [RR] 2.3; 95% confidence interval [CI] 1.3, 3.8; P =.002); and an interdelivery interval of over 60 minutes with an eightfold higher risk (RR 8.2; CI 4.6,14.6; P <.001). Vaginal-cesarean delivery had a 22-fold higher use of general anesthesia compared with vaginal delivery (RR 21.8; CI 5.4, 88.5; P <.001). CONCLUSION: There has been a significant increase in combined vaginal-cesarean and elective cesarean deliveries among twin gestations, with a decrease in vaginal births. Vaginal-cesarean delivery is associated with nonvertex second twin and a prolonged interdelivery interval.

Perioperative morbidity of hysterectomy for benign gynaecological disease.

This study reviews the perioperative surgical and associated morbidity of abdominal and vaginal hysterectomy for benign gynaecological disease. Over a 5-year period, 199296, there were 2088 hysterectomies; 1244 (60%) abdominal and 844 (40%) vaginal. The surgical morbidity for abdominal hysterectomy (6.2%) was twice that of vaginal hysterectomy (3.2%). The associated morbidity for abdominal hysterectomy (4.0%) was four times that of vaginal hysterectomy (0.9%). Additional surgical procedures (other than salpingo-oophorectomy) performed at the time of hysterectomy increased morbidity by 20% in association with abdominal hysterectomy and by 46% with vaginal hysterectomy. Serious morbidity associated with hysterectomy for benign disease was low.

Naegele's rule: a reappraisal.

The origin of Naegele's rule to calculate the expected date of confinement is reviewed. It is possible that the rule has been misinterpreted, resulting in an earlier estimated date of delivery with implications for induction of labour for post dates pregnancy.

Outcome of the next labour in women who had a vaginal delivery in their first pregnancy.

This study reviews the outcome of the next labour in women who are delivered vaginally in their first pregnancy. The influence of the method of delivery in the first pregnancy and of factors in both the first and next labour on the type of delivery in the second pregnancy, are recorded in a group of 13,813 women. Those delivered spontaneously and by vacuum, low forceps and mid-forceps in their first pregnancy had a 96%, 91%, 88% and 82% chance, respectively, of spontaneous delivery in their next pregnancy. The type of labour (spontaneous, induced or augmented) in the first pregnancy had minimal influence on the method of delivery in the second pregnancy. Compared with spontaneous onset, induction and augmentation of labour in the second pregnancy reduced the chance of spontaneous delivery by 6% and 18%, respectively.