Nulliparous women's lived experiences of the prolonged passive stage of labour: A thematic analysis based on descriptive phenomenology.

INTRODUCTION: Prolonged progress can occur in the first and second stages of labour and may contribute to a negative birth experience. However, previous studies have mainly focused on quantitative aspects or overall birth experience, and little is known about women's experiences of a prolonged passive second stage. OBJECTIVE: To describe the lived experiences of a prolonged passive second stage of labour in nulliparous women. METHODS: A qualitative study was conducted with 15 nulliparous women with a passive second stage lasting three hours or more. Data were analysed using thematic analysis based on descriptive phenomenology. RESULTS: The analysis resulted in four themes: "An unknown phase" that entailed remaining in a phase that the women lacked an awareness of. "Trust and mistrust in the body's ability" represents the mindset for vaginal birth as well as feelings of powerlessness and self-guilt. The theme "Loss of control" included experiences of frustration, fatigue, and having to deny bodily instincts. "Support through presence and involvement" signifies support through the midwife's presence in the birthing room, although there were also descriptions of emotional or physical absence. CONCLUSIONS: The findings contribute to the understanding of prolonged labour based on women's lived experiences and add to the body of knowledge about the prolonged passive second stage. This study highlights that women need support through information, presence, and encouragement to remain in control. It can be beneficial during birth preparation to include knowledge about the passive second stage together with unexpected or complicated situations during birth, such as prolonged labour.

Early suppression policies protected pregnant women from COVID-19 in 2020: A population-based surveillance from the Nordic countries.

INTRODUCTION: The Coronavirus 2019 Disease (COVID-19) pandemic reached the Nordic countries in March 2020. Public health interventions to limit viral transmission varied across different countries both in timing and in magnitude. Interventions indicated by an Oxford Stringency Index ≥50 were implemented early (March 13-17, 2020) in Denmark, Finland, Norway and Iceland, and on March 26, 2020 in Sweden. The aim of the current study was to assess the incidence of COVID-19-related admissions of pregnant women in the Nordic countries in relation to the different national public health strategies during the first year of the pandemic. MATERIAL AND METHODS: This is a meta-analysis of population-based cohort studies in the five Nordic countries with national or regional surveillance in the Nordic Obstetric Surveillance System (NOSS) collaboration: national data from Denmark, Finland, Iceland and Norway, and regional data covering 31% of births in Sweden. The source population consisted of women giving birth in the included areas March 1-December 31, 2020. Pregnant women with a positive SARS-CoV-2 PCR test ≤14 days before hospital admission were included, and admissions were stratified as either COVID-19-related or non-COVID (other obstetric healthcare). Information about public health policies was retrieved retrospectively. RESULTS: In total, 392 382 maternities were considered. Of these, 600 women were diagnosed with SARS-CoV-2 infection and 137 (22.8%) were admitted for COVID-19 symptoms. The pooled incidence of COVID-19 admissions per 1000 maternities was 0.5 (95% confidence interval [CI] 0.2 to 1.2, I2 = 77.6, tau2 = 0.68, P = 0.0), ranging from no admissions in Iceland to 1.9 admissions in the Swedish regions. Interventions to restrict viral transmission were less stringent in Sweden than in the other Nordic countries. CONCLUSIONS: There was a clear variation in pregnant women's risk of COVID-19 admission across countries with similar healthcare systems but different public health interventions to limit viral transmission. The meta-analysis indicates that early suppression policies protected pregnant women from severe COVID-19 disease prior to the availability of individual protection with vaccines.

Mode of delivery and birth outcomes in relation to the duration of the passive second stage of labour: A retrospective cohort study of nulliparous women.

OBJECTIVE: To investigate the mode of delivery and birth outcomes in relation to the duration of the passive second stage of labour in nulliparous women. METHODS AND FINDINGS: A retrospective cohort study of all nulliparous women (n = 1131) at two delivery units in Sweden. Maternal and obstetric data were obtained from electronic medical records during 2019. The passive second stage was defined as the complete dilation of the cervix until the start of the active second stage. The duration of the passive second stage was categorized into three groups: 0 to 119 min (0 to <2 h), 120-239 min (2- <4h) and ≥240 min (≥4h). Differences between the groups were examined using t-test and Chi2-tests and regression analyses were used to analyse adjusted odds ratio with 95% confidence intervals. The primary outcome was mode of delivery in relation to the duration of the passive second stage and the secondary outcomes covered a series of adverse maternal and neonatal birth outcomes. The rates of instrumental and caesarean deliveries increased as the duration of the passive second stage increased. A ≥4-hour duration of the passive second stage was associated with a nine-times increased risk of caesarean section, and a four-times risk of instrumental delivery compared to a duration of <2 hours in the adjusted analyses. No differences were found in the maternal birth outcomes. The risk of a 5-minute Apgar score <7 was increased in the 2-<4h group. A longer passive second stage was not associated with an increased risk of negative birth experience. CONCLUSIONS: Our study demonstrates an increased risk of operative delivery for a longer duration (>2h) of the passive second stage in nulliparous women, although most of the women gave birth by spontaneous vaginal delivery even after ≥4 hours. There was no evidence of an increased risk of adverse maternal outcomes in a longer duration of the passive second stage but there were indications of increased adverse neonatal outcomes. Assessment of fetal well-being is important when the duration of the passive phase is prolonged.

Prolonged passive second stage of labor in nulliparous women-Prevalence and risk factors: A historical cohort study.

INTRODUCTION: This study examined the prevalence of and risk factors for a prolonged passive second stage of labor in nulliparous women. MATERIAL AND METHODS: This was a historical cohort study of all nulliparous women (n = 1131) at two delivery units in Sweden. Maternal and obstetric data were obtained from electronic medical records during 2019. Duration of the passive second stage was measured as time from retracted cervix to start of pushing. Prolonged passive second stage was defined as ≥2 h. Prevalence was calculated and associations between prolonged passive second stage and maternal, obstetric and neonatal characteristics and potential risk factors were assessed using logistic regression models. RESULTS: The prevalence of prolonged passive second stage was 37.6%. Factors associated with an increased risk of prolonged passive second stage were epidural analgesia (adjusted odds ratio [aOR] 3.93; 95% confidence interval [CI] 2.90-5.34), malpresentation (aOR 2.26; 95% CI 1.27-4.05), maternal age ≥ 30 years (aOR 2.00; 95% CI 1.50-2.65) and birthweight ≥ 4 kg (aOR 1.50; 95% CI 1.05-2.15). Maternal body mass index ≥30 (aOR 0.52; 95% CI 0.34-0.79) and noncohabiting (aOR 0.51; 95% CI 0.30-0.89) reduced the odds of prolonged passive second stage. CONCLUSIONS: A prolonged passive second stage of labor in nulliparous women is common (n = 425 [38%]). We found epidural analgesia, malpresentation, maternal age ≥ 30 years and birthweight ≥4 kg to be major risk factors associated with an increased risk of a prolonged passive second stage. Birth outcomes for prolonged passive second stage need to be investigated to strengthen evidence for the management of the second stage of labor.

Fusion imaging in brain structure measurements on a fetus phantom, combining real-time ultrasound with magnetic resonance imaging.

OBJECTIVES: To assess synchronisation of MRI and US in measuring foetus phantom head structures; inter-method, intra- and inter-observer differences on biparietal diameter (BPD), head diameter, anterio-posterior head diameter (HAP) and lateral ventricle structures (VS). METHODS: Fusion Imaging (FI) has been performed by combining MRI and US simultaneously. Axial scans of 1.5 Tesla MRI on a foetus phantom were acquired and uploaded on a US machine (EPIQ 7G, Philips). A PercuNav US tracker allowed the system to recognise and display the position of the transducer. A fetal phantom tracker was used as a phantom reference. Real-time US of the phantom head was performed by synchronising the uploaded MRI images using different landmarks. Synchronisation has been assessed by taking measurements after rotating the US probe by 90. Measurements were taken by three different observers twice. Differences in measurements between MRI and US, inter-, intra-observer differences in all measurements were assessed. RESULTS: BPD, HAP and VS measurements before rotation were 0.13 ± 0.06 cm, 0.46 ± 0.09 cm and 0.4 ± 0.23 cm (width) and mean 0.6 ± 0.25 cm (length) larger at MRI than at US using any number of landmarks. After US probe rotation VS were 0.3 ± 0.24 cm in width and 0.3 ± 0.27 cm in length. Intra- and inter-observer differences in all measurements were small. CONCLUSIONS: FI showed good synchronisation in measurements. BPD, HAP and VS were larger at MRI than US, likely a result of the way images are generated. Intra-, inter-observer differences between measurements were small. This can be important when reporting geometric measures from FI.

COVID-19 in pregnancy-characteristics and outcomes of pregnant women admitted to hospital because of SARS-CoV-2 infection in the Nordic countries.

INTRODUCTION: Population-based studies about the consequences of SARS-CoV-2 infection (COVID-19) in pregnancy are few and have limited generalizability to the Nordic population and healthcare systems. MATERIAL AND METHODS: This study examines pregnant women with COVID-19 in the five Nordic countries. Pregnant women were included if they were admitted to hospital between 1 March and 30 June 2020 and had a positive SARS-CoV-2 PCR test ≤14 days prior to admission. Cause of admission was classified as obstetric or COVID-19-related. RESULTS: In the study areas, 214 pregnant women with a positive test were admitted to hospital, of which 56 women required hospital care due to COVID-19. The risk of admission due to COVID-19 was 0.4/1000 deliveries in Denmark, Finland and Norway, and 3.8/1000 deliveries in the Swedish regions. Women hospitalized because of COVID-19 were more frequently obese (p < 0.001) and had a migrant background (p < 0.001) compared with the total population of women who delivered in 2018. Twelve women (21.4%) needed intensive care. Among the 56 women admitted due to COVID-19, 48 women delivered 51 infants. Preterm delivery (n = 12, 25%, p < 0.001) and cesarean delivery (n = 21, 43.8%, p < 0.001) were more frequent in women with COVID-19 compared with women who delivered in 2018. No maternal deaths, stillbirths or neonatal deaths were reported. CONCLUSIONS: The risk of admission due to COVID-19 disease in pregnancy was low in the Nordic countries. A fifth of the women required intensive care and we observed higher rates of preterm and cesarean deliveries. National public health policies appear to have had an impact on the risk of admission due to severe COVID-19 disease in pregnancy. Nordic collaboration is important in collecting robust data and assessing rare outcomes.

[Postpartum hemorrhage and need of blood transfusions]. / Postpartumblödningar med blodtransfusioner har ökat.

Postpartum hemorrhage is responsible for one fourth of the maternal mortality worldwide. In high resource countries there is an increasing trend in frequency of postpartum hemorrhage and need of blood transfusions. The reason for this increase is probably multifactorial. Major bleeding requires massive blood transfusion (MT), defined as transfusion of >10 units of erythrocytes within 24 hours. In Sweden the incidence of MT due to obstetric hemorrhage is reported to be 53 per 100 000 deliveries and the majority of the cases are due to placental complications, such as placenta previa and placenta accreta. These placental complications have increased over the past years as a consequence of a higher rate of cesarean deliveries. To reduce the number of deliveries requiring blood transfusion postpartum, prophylactic measures such as identification of women at increased risk, optimizing management of hemorrhage and evaluating the effect of every transfused unit of erythrocytes is important.

[High prenatal detection rates of complex congenital heart defects (CHD)]. / Fler medfödda hjärtfel upptäcks med utökad screening i tre steg.

AIM: To analyze prenatal detection rates of complex CHD after the implementation of an expanded three-tiered screening model at the Skane University Hospitals in Lund and Malmö in 2015.  Methods: Retrospective review of pregnancies screened from January 1, 2015 and being born by June 30, 2018. Complex CHD was defined as needing intervention in the first year of life.  Results: In 27675 screened pregnancies, 51 out of 65 (78 %) cases of complex CHD were detected prenatally. Exclusion of isolated ventricular septal defects yielded detection rates of 93 %. All patients needing surgery within 30 days, potential univentricular hearts and D-transposition of the great arteries were identified, whilst detection rates for tetralogy of Fallot, atrioventricular septal defect and coarctation were about 90 %. CONCLUSION: Our three-tiered model results in high detection rates of complex CHD with optimized resource utilization.

Incidence and risk factors of transfusion reactions in postpartum blood transfusions.

Postpartum hemorrhages with blood transfusions are increasing in many high-resource countries. Currently, up to 3% of all women receive blood transfusion postpartum. Most blood transfusions are safe and, in many cases, are lifesaving, but there are significant concerns about adverse reactions. Pregnancy is associated with higher levels of leukocyte antibodies and has a modulating effect on the immune system. Our objective was to investigate whether blood transfusions postpartum are accompanied by an increased risk for transfusion reactions (TRs) compared with transfusions given to nonpregnant women. We included all women who gave birth in Stockholm County, Sweden between 1990 and 2011. Data from the Swedish National Birth Registry were linked to the Stockholm Transfusion Database and included information on blood components administered and whether a TR occurred in women who received blood transfusions postpartum. Background controls were nonpregnant women who received blood transfusions during the study period. The study cohort consisted of 517 854 women. Of these, 12 183 (2.4%) received a blood transfusion. We identified 96 events involving a TR postpartum, giving a prevalence of 79 per 10 000 compared with 40 per 10 000 among nonpregnant women (odds ratio, 2.0; 95% confidence interval, 1.6-2.5). Preeclampsia was the single most important risk factor for TRs (odds ratio, 2.1; 95% confidence interval, 1.7-2.6). We conclude that special care should be taken when women with preeclampsia are considered for blood transfusion postpartum, because our findings indicate that pregnancy is associated with an increased risk for TRs.

Thromboembolism and in vitro fertilization - a systematic review.

INTRODUCTION: There is no accepted consensus on thromboprophylaxis in relation to in vitro fertilization (IVF). We aimed to study the frequency of thromboembolism and to assess thromboprophylaxis in relation to IVF. MATERIAL AND METHODS: We performed a systematic review. All study designs were accepted except single case reports. Language of included articles was restricted to English. RESULTS: Of 338 articles, 21 relevant articles (nine cohort studies, six case-control studies, three case series, and three reviews of case series) were identified. The antepartum risk of venous thromboembolism (VTE) after IVF is doubled (odds ratio 2.18, 95% CI 1.63-2.92), compared with the background pregnant population. This is due to a 5- to 10-fold increased risk during the first trimester in IVF pregnancies, in turn related to a very high risk of VTE after ovarian hyperstimulation syndrome (OHSS), i.e. up to a 100-fold increase, or an absolute risk of 1.7%. The interval from embryo transfer to VTE was 3-112 days and the interval from embryo transfer to arterial thromboembolism was 3-28 days. No robust study on thromboprophylaxis was found. CONCLUSIONS: The antepartum risk of VTE after IVF is doubled, compared with the background pregnant population, and is in turn related to a very high risk of VTE after OHSS in the first trimester. We recommend that IVF patients with OHSS be prescribed low-molecular-weight heparin during the first trimester, whereas other IVF patients should be given thromboprophylaxis based on the same risk factors as other pregnant women.

The Nordic Obstetric Surveillance Study: a study of complete uterine rupture, abnormally invasive placenta, peripartum hysterectomy, and severe blood loss at delivery.

OBJECTIVE: To assess the rates and characteristics of women with complete uterine rupture, abnormally invasive placenta, peripartum hysterectomy, and severe blood loss at delivery in the Nordic countries. DESIGN: Prospective, Nordic collaboration. SETTING: The Nordic Obstetric Surveillance Study (NOSS) collected cases of severe obstetric complications in the Nordic countries from April 2009 to August 2012. SAMPLE AND METHODS: Cases were reported by clinicians at the Nordic maternity units and retrieved from medical birth registers, hospital discharge registers, and transfusion databases by using International Classification of Diseases, 10th revision codes on diagnoses and the Nordic Medico-Statistical Committee Classification of Surgical Procedure codes. MAIN OUTCOME MEASURES: Rates of the studied complications and possible risk factors among parturients in the Nordic countries. RESULTS: The studied complications were reported in 1019 instances among 605 362 deliveries during the study period. The reported rate of severe blood loss at delivery was 11.6/10 000 deliveries, complete uterine rupture was 5.6/10 000 deliveries, abnormally invasive placenta was 4.6/10 000 deliveries, and peripartum hysterectomy was 3.5/10 000 deliveries. Of the women, 25% had two or more complications. Women with complications were more often >35 years old, overweight, with a higher parity, and a history of cesarean delivery compared with the total population. CONCLUSION: The studied obstetric complications are rare. Uniform definitions and valid reporting are essential for international comparisons. The main risk factors include previous cesarean section. The detailed information collected in the NOSS database provides a basis for epidemiologic studies, audits, and educational activities.