Increased Survival Concomitant with Unchanged Morbidity and Cognitive Disability among Infants Born at the Limit of Viability before 24 Gestational Weeks in 2009-2019.

INTRODUCTION: The aim was to determine risk factors among mothers and outcomes for their children born at the limit of viability in 2009-2019, before and after the introduction of extended interventionist guidelines. METHODS: A retrospective cohort study of births at 22 + 0-23 + 6 gestational weeks in a Swedish Region in 2009-2015 (n = 119), as compared to 2016-2019 (n = 86) after the introduction of new national interventionist guidelines. Infant mortality, morbidity, and cognitive functions at 2 years corrected age according to the Bayley-III Screening Test were monitored. RESULTS: Maternal risk factors for extreme preterm birth were identified. The intrauterine fetal death rates were comparable. Among births at 22 weeks, the neonatal mortality tended to decrease (96 vs. 76% of live births (p = 0.05)), and the 2-year survival tended to increase (4 vs. 24% (p = 0.05)). Among births at 23 weeks, the neonatal mortality decreased (56 vs. 27% of live births (p = 0.01)), and the 2-year survival increased (42 vs. 64% (p = 0.03)). Somatic morbidity and cognitive disability at 2 years corrected age were unchanged. CONCLUSION: We identified maternal risk factors that emphasize the need for standardized follow-up and counseling for women at increased risk of preterm birth at the limit of viability. The increased infant survival concomitant with unchanged morbidity and cognitive disability highlight the importance of ethical considerations regarding interventionist approaches at threatening preterm birth before 24 weeks.

Continuous Support Promotes Obstetric Labor Progress and Vaginal Delivery in Primiparous Women - A Randomized Controlled Study.

Background: Obstetric labor and childbirth are mostly regarded as a physiological process, whereas social, cultural, psychological and transcendental aspects have received less attention. Labor support has been suggested to promote labor progress. The aim of this study was to investigate whether continuous labor support by a midwife promotes labor progress and vaginal delivery. Material and Methods: A randomized controlled study at a university hospital in Sweden in 2015-17. Primiparous women with singleton pregnancy and spontaneous labor onset were randomized to continuous support (n = 30) or standard care (n = 29) during delivery. The primary outcome was the duration of active labor. Secondary outcomes were delivery mode, women's need of labor analgesia and satisfaction with delivery, maternal cortisol levels, and neonatal morbidity. Results: Continuous support was followed by shorter active labor 11.0 ± 5.7 h compared to 13.7 ± 3.9 h with standard care (p = 0.001). Women in the continuous support group tended to have lower cortisol levels and low cortisol during the first (p = 0.02) and second (p = 0.04) stages of labor were correlated with shorter active labor. Continuous support was followed by spontaneous delivery in 73%, instrumental delivery in 24% and emergency cesarean section in 3% in contrast to standard care which was followed by spontaneous delivery in 62%, instrumental delivery in 24% and cesarean in 14% (p = 0.19). The continuous support group received combined analgesic methods more often (p = 0.04). Women's satisfaction with delivery and neonatal morbidity were comparable. Conclusion: Continuous labor support was followed by shorter active labor compared to standard care. Women with continuous support had a high rate of vaginal delivery and tended to have lower cortisol levels during all stages of active labor reflecting a lower stress level. Low cortisol was correlated to shorter active labor. Based on these results, we recommend continuous labor support for all primiparous women during active labor.

Duration of labor, delivery mode and maternal and neonatal morbidity after remifentanil patient-controlled analgesia compared with epidural analgesia.

OBJECTIVE: The objective of this study was to compare duration of active labor, delivery mode, maternal and neonatal morbidity and women's satisfaction with delivery after intravenous remifentanil patient-controlled analgesia (PCA) or standard epidural analgesia (EDA). Based on clinical observations, we hypothesized that women with PCA would have shorter labor. STUDY DESIGN: An observational study at a university hospital in Sweden 2009-16. Maternal and neonatal outcomes with PCA (n = 69) and EDA (n = 138) were compared. RESULTS: Women with PCA had shorter active labor 5.6 ± 3.3 compared to 8.5 ± 4.4 h (p < 0.001) with EDA, and a higher rate of spontaneous delivery 94% (65/69) compared to 65% (n = 90/138) with EDA (p < 0.001). Intrapartum temperature >38 °C (p = 0.001) and signs of fetal asphyxia (p < 0.001) were less common with PCA. No maternal or neonatal sedation was observed. The rates of transient oxygen desaturation <95%, bleeding > 1000 mL and women's satisfaction with delivery did not differ between the groups. CONCLUSION: PCA had several advantages over EDA, as it was associated with shorter active labor and a higher rate of spontaneous delivery without worsening maternal or neonatal morbidity or women's satisfaction with delivery. Therefore, we suggest an increased availability of PCA for labor analgesia. We recommend continuous one-to-one care and oxygen saturation monitoring for all women during active labor.

Oral versus vaginal prostaglandin for labor induction.

OBJECTIVE: To compare the efficacy and safety of oral prostaglandin (PG) in solution versus vaginal PG gel for labor induction. DESIGN: A retrospective study. METHODS: Data from original obstetric records at a university hospital in Sweden 2012-2013. RESULTS: In all women, oral PG resulted in vaginal birth (VB) < 24 h in 66% compared to 80% with vaginal PG (p < 0.001), and cesarean section (CS) in 19% versus 32% (p = 0.02). In primiparous women, oral PG was followed by VB <24 h in 54% compared to 71% (p = 0.01), and CS in 25% versus 41% (p = 0.03). In women with an unripe cervix, oral PG lead to VB <24 h in 66% compared to 79% (p = 0.01), and CS in 21% versus 33% (p = 0.04). Despite a longer induction to vaginal delivery interval with oral PG, the rates of obstetric bleeding, chorioamnionitis, and neonatal asphyxia were not increased. CONCLUSIONS: Oral PG in solution was less effective than vaginal PG gel in achieving VB <24 h. However, oral PG was safer, since it resulted in fewer CSs without increasing maternal morbidity or neonatal asphyxia.

Circulating maternal cortisol levels during vaginal delivery and elective cesarean section.

INTRODUCTION: Maternal S-cortisol levels increase throughout pregnancy and peak in the third trimester. Even higher levels are seen during the physical stress of delivery. Since analgesia for women in labor has improved, it is possible that maternal stress during labor is reduced. The aim of this study was to compare maternal S-cortisol during vaginal delivery and elective cesarean section. MATERIALS AND METHODS: Twenty healthy women with spontaneous vaginal delivery and healthy women (n = 20) undergoing elective cesarean section were included in the study. S-cortisol was measured during three stages of spontaneous vaginal delivery (tvd1, tvd2 and tvd3), as well as before and after elective cesarean section (tcs1 and tcs2). RESULTS: In the vaginal delivery group, mean S-cortisol at tvd1 was 1325 ± 521 nmol/L, at tvd2 1559 ± 591 nmol/L and at tvd3 1368 ± 479 nmol/L. In the cesarean section group, mean S-cortisol at tcs1 was 906 ± 243 nmol/L and at tcs2 831 ± 257 nmol/L. S-cortisol was higher in the vaginal delivery group at the onset of labor as compared to the cesarean section preoperative group (p = 0.006). There were also significant differences between S-cortisol levels postpartum as compared to postoperatively (p < 0.001). CONCLUSIONS: Maternal S-cortisol was higher during vaginal delivery compared to elective cesarean section, indicating higher stress levels. A reduction in the hydrocortisone dose at childbirth in women with adrenal insufficiency should be considered, particularly in women undergoing an elective cesarean section.

Changed indications for cesarean sections.

OBJECTIVE: The aim of this study was to investigate the indications for cesarean sections in the early 1990s as compared to the middle 2000s. DESIGN: Retrospective cohort study. METHODS: Data were collected from original obstetrical records in a tertiary hospital in 1992 and 2005. RESULTS: The total cesarean delivery rate rose from 11% to 20%. The main indications for an elective cesarean in 1992 were a pathological fetal lie or a uterine factor. The dominant indication for an elective cesarean in 2005 was a psychosocial indication defined as maternal fear of childbirth or maternal request without any co-existing medical indication. Presumed fetal compromise and prolonged labor remained the main indications for urgent and emergency cesareans. No apparent alterations in population characteristics could be identified for these years. CONCLUSIONS: The increased rate of elective cesareans for psychosocial indications would reflect altered attitudes towards mode of delivery in the childbearing population and among obstetricians. We suggest that extended support from community antenatal care should be provided and that standardized keys aiding a physician in decision-making procedures concerning the cesarean section practice should be developed.

Plasma membrane receptor mediated MAPK signaling pathways are activated in human uterine cervix at parturition.

BACKGROUND: Cervical ripening resembles an inflammatory reaction. Estrogens induce leukocyte migration into tissue and factors promoting cervical remodeling and labor, although the mechanisms are only partially known. The aim of this study was to investigate whether plasma membrane receptor mediated pathways, known to be activated by estrogens and proinflammatory compounds, are involved in cervical ripening before labor. METHODS: The expression and distribution of mitogen activated protein kinases (MAPK), which transduce extracellular signals into intracellular responses through phosphorylation, and their intracellular targets transcription factors c-Jun and c-Fos proteins (AP-1) were analysed in cervical biopsies from term pregnant women (TP), immediately after parturition (PP), and from non-pregnant women (NP). Immunohistochemistry and RT-PCR techniques were used. RESULTS: Cell-specific alterations in the immunostaining pattern for MAPK were observed. The expressions of activated, phosphorylated MAPK forms pERK1/2, pJNK and p38MAPK were significantly increased in cervical stroma until TP and pERK1/2 expression was significantly enhanced in PP group. c-Jun was significantly increased in cervical stroma and smooth muscle in TP as compared to NP group. c-Fos was significantly increased in stroma, squamous epithelium and glandular epithelium in PP as compared to TP group. CONCLUSION: We report, for the first time, cell-specific activation of pMAPKs and their targets transcription factors c-Fos and c-Jun (AP-1) proteins in human uterine cervix until term pregnancy, and immediately after parturition. These results suggest a role for MAPK activation in cervical ripening before labor.