Intrapartum and neonatal mortality among low-risk women in midwife-led versus obstetrician-led care in the Amsterdam region of the Netherlands: a propensity score matched study.

OBJECTIVE: To compare intrapartum and neonatal mortality in low-risk term women starting labour in midwife-led versus obstetrician-led care. STUDY DESIGN: We performed a propensity score matched study using data from our national perinatal register, completed with data from medical files. We studied women without major risk factors with singleton pregnancies who gave birth at term between 2005 and 2008 in the Amsterdam region of the Netherlands. Major risk factors comprised non-vertex position of the fetus, previous Caesarean birth, hypertension, (gestational) diabetes mellitus, post-term pregnancy (≥42 weeks), prolonged rupture of membranes (>24 hours), vaginal bleeding in the second half of pregnancy or induced labour. Groups were devided by midwife-led versus obstetrician-led care at the onset of labour. The primary outcome was intrapartum and neonatal (<28 days) mortality. Secondary outcomes included obstetric interventions, 5 min Apgar scores<7 and neonatal intensive care admittance for >24 hours. RESULTS: We studied 57 396 women. Perinatal mortality occurred in 30 of 46 764 (0.64‰) women in midwife-led care and in 2 of 10 632 (0.19‰) women in obstetrician-led care (OR 3.4, 95% CI 0.82 to 14.3). A propensity score matched analysis in a 1:1 ratio with 10 632 women per group revealed an OR for perinatal mortality of 4.0 (95% CI 0.85 to 18.9). CONCLUSION: Among low-risk women, midwife-led care at the onset of labour was associated with a statistically non-significant higher mortality rate.

Prenatal diagnosis of fetal intracranial hemorrhage at 25 weeks of gestation.

OBJECTIVE: To determine whether magnetic resonance imaging (MRI) can give further information for the prenatal diagnosis of intracranial hemorrhage, when ultrasound (US) is not conclusive. METHODS: We report on a fetus in the 26th week of gestation with a grade-III hemorrhage in the right cerebral hemisphere, which was suspected on US examination and specified by MRI examination in a patient with pre-eclampsia. RESULTS: Doppler measurement of the umbilical artery, which showed the absence of end diastolic velocity, was indicative of placental insufficiency. The MRI specified the findings found by US examination and confirmed the poor outcome of the fetus. Labor was induced by prostaglandins in the 27th week of gestation. Postmortem examination showed a female fetus with a grade-III intracranial hemorrhage in the center of the right hemisphere with a diameter of 4 cm. A hemorrhage was also found in the subarachnoid space and in the occipital region of the left hemisphere. CONCLUSION: We suggest that fetuses at high risk of developing hypoxia should be sonographically evaluated and MRI should be considered when intracranial echogenicities are seen.