Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births.

OBJECTIVE: To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care. DESIGN: A nationwide cohort study. SETTING: The entire Netherlands. POPULATION: A total of 529,688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321,307 (60.7%) intended to give birth at home, 163,261 (30.8%) planned to give birth in hospital and for 45,120 (8.5%), the intended place of birth was unknown. METHODS: Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics. MAIN OUTCOME MEASURES: Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit. RESULTS: No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16). CONCLUSIONS: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.

Evaluation of 280,000 cases in Dutch midwifery practices: a descriptive study.

OBJECTIVE: To assess the nature and outcome of intrapartum referrals from primary to secondary care within the Dutch obstetric system. DESIGN: Descriptive study. SETTING: Dutch midwifery database (LVR1), covering 95% of all midwifery care and 80% of all Dutch pregnancies (2001-03). POPULATION: Low-risk women (280,097) under exclusive care of a primary level midwife at the start of labour either with intention to deliver at home or with a personal preference to deliver in hospital under care of a primary level midwife. METHODS: Women were classified into three categories (no referral, urgent referral and referral without urgency) and were related to maternal characteristics and to neonatal outcomes. MAIN OUTCOME MEASURES: Distribution of referral categories, main reasons for urgent referral, Apgar score at 5 minutes, perinatal death within 24 hours and referral to a paediatrician within 24 hours. RESULTS: In our study, 68.1% of the women completed childbirth under exclusive care of a midwife, 3.6% were referred on an urgency basis and 28.3% were referred without urgency. Of all referrals, 11.2% were on an urgency basis. The main reasons for urgent referrals were fetal distress and postpartum haemorrhage. The nonurgent referrals predominantly took place during the first stage of labour (73.6% of all referrals). Women who had planned a home delivery were referred less frequently than women who had planned a hospital delivery: 29.3 and 37.2%, respectively (P < 0.001). On average, the mean Apgar score at 5 minutes was high (9.72%) and the peripartum neonatal mortality was low (0.05%) in the total study group. No maternal deaths occurred. Adverse neonatal outcomes occurred most frequently in the urgent referral group, followed by the group of referrals without urgency and the nonreferred group. CONCLUSIONS: Risk selection is a crucial element of the Dutch obstetric system and continues into the postpartum period. The system results in a relatively small percentage of intrapartum urgent referrals and in overall satisfactory neonatal outcomes in deliveries led by primary level midwives.

Extraamniotic prostaglandin F2 alpha for intrauterine death and fetal abnormality.

Prostaglandin F2 alpha was administered extraamniotically for termination of pregnancy in 15 cases of intrauterine fetal death between 18 and 39 wk gestation and in 10 cases of fetal abnormality or hydatidiform mole between 16 and 28 wk gestation. Although delivery was achieved with minimal side effects in all cases, the best results were obtained in patients with intrauterine fetal death. It is concluded that discontinuous extraamniotic prostaglandin therapy constitutes a safe and effective approach for the active management of intrauterine fetal death.

PIP: Prostaglandin F2alpha (PGF2alpha) was administered extraamniotically for pregnancy termination in 15 cases of intrauterine fetal death between 18-39 weeks gestation and in 10 cases of fetal abnormality or hydatidiform mole between 16-28 weeks gestation. After thorough cleansing of the cervix a No. 16 Foley catheter was inserted and retained in the extraamniotic space by means of the balloon, inflated with 10 ml of saline. PGF2alpha tromethamine salt (Prostin F2alpha, Upjohn Netherland, was diluted to an aqueous solution of 0.25 mg PGF2alpha/ml and administered via the catheter at 1 hour intervals. Treatment was started with 0.5 mg (2 ml) and the initial dosage was increased by increments of 0.25 mg to a maximum of 1 mg/hour if uterine contractility did not ensue. Temperature, pulse rate, and blood pressure were checked regularly. Antibiotherapy (ampicillin) was routinely given at the beginning of the study but later abandoned. Pethidine was used as an analgesic whenever required. Abortion or delivery was achieved in all 25 cases studied. In all but 1 of the patients with intrauterine fetal death, delivery occurred within 24 hours and the placenta was delivered spontaneously and complete in 11 of the 15 patients (73%). There was no relationship between the duration of fetal death and induction delivery interval. In cases with an abnormal but living fetus or hydatidiform mole, abortion was frequently incomplete and the mean induction abortion interval (24.4 hours) was 10 hours longer than that observed in cases of intrauterine fetal death (14.5 hours). 5 of the 10 patients required intravenous oxytocin from a cervical dilatation of 3-6 cm onwards and from 14-30 hours after the start of PGF2alpha administration. In these cases abortion always followed within 3 hours of starting the oxytocin infusion. Side effects were moderate in both groups of patients and pyrexia of 38 degrees Centigrade or more was never encountered. None of the patients showed any signs of intrauterine infection. Blood loss exceeded 500 ml in 4 of the 25 patients studied (16%), but only 1 patient, with a molar pregnancy, lost as much as 1000 ml. Discontinuous extraamniotic prostaglandin therapy constitutes a safe and effective approach for the active management of intrauterine fetal death.

Coagulation changes during management of fetal death with 15(s)-15-methylprostaglandin F2 alpha.

Changes in the coagulation mechanism were studied during and after 15(S)-15-methylprostaglandin F2 alpha (15-me-PGF2 alpha) administration for termination of pregnancy because of intrauterine fetal death after 20 wk pregnancy. 12 patients, of whom 2 were under and 6 over 28 wk, were studied. 2-Hourly intramuscular administration of 250 microgram 15-me-PGF2 alpha resulted in expulsion in a median time of 9 h (range: 2-24.3 h). Although the drug may have some inhibitory effect on platelet aggregation, its influence on coagulation and the hemostatic mechanism was negligible.

Confidential enquiry into maternal deaths in The Netherlands 1983-1992.

OBJECTIVE: To determine the causes of maternal death in The Netherlands. STUDY DESIGN: Nationwide Confidential Enquiry into the Causes of Maternal Deaths during the period 1983-1992. RESULTS: Of 192 direct and indirect maternal deaths, 154 (80%) were available for the Enquiry. The most frequent direct causes were (pre-)eclampsia, thrombo-embolism, obstetrical haemorrhage and sepsis. Cerebro- and cardiovascular disorders were the most frequent indirect causes of death. Age above 35 years and parity 3 or more are related to higher maternal mortality. Women from non-caucasian origin are more prone to death in comparison to caucasian women. Autopsy was performed in 88 cases (57%). Of the 24 women where labour started at home, the place of birth played a significant role in delay in four. CONCLUSIONS: More efforts should be made to have a higher percentage than 80% available for the Confidential Enquiry as in the UK where only 1-4% of deaths are not available for similar purposes. Also, the autopsy rate of 57% is much lower than in the UK (82%). Special strategies should be developed to improve maternal health of populations at higher risk such as women of high age and parity and immigrant populations.

Twenty-two years of intra-uterine intraperitoneal transfusions.

Over a period of 22 years, 154 fetuses were treated with 270 intra-uterine intraperitoneal transfusions. The patients were divided into three groups, according to the period they were treated. The overall percentage of surviving infants increased from 33% during the first period to 58% in the last period. In the group of infants that were not hydropic at the time of the first transfusion, the survival rate increased from 35 to 83%. In the group of children that were hydropic during the first transfusion, the survival rate during the first and last period was 24 and 42%, respectively. The percentage of fetuses that needed their first transfusion before the 26th week of pregnancy increased from 15 to 32% during the study period. Only 13% of these children survived. Lately, the intravascular approach has been introduced. Intravascular transfusions seem to be very effective, especially in early pregnancies and in hydropic fetuses. Application of the two techniques each in the most appropriate situation might offer optimal results for the near future.

[The benefit of external version in full-term breech presentation]. / Het nut van uitwendige versie bij stuitligging à terme.

We report a randomised controlled trial of external version in 52 women with breech presentation after 36 weeks' gestation; 83% gave informed consent to undergo the management to which they had been randomized. Only 5% of initial attempts without tocolysis succeeded, but 31% of the failures subsequently had a successful version under tocolysis. External version resulted in a small decrease in the frequency of breech presentation at birth (64% vs. 74%), and in an unexpected increase in the caesarean section rate (28% vs. 11%). The increase in caesarean section rate could be attributed to failed versions, which apparently greatly influenced the choice between abdominal and vaginal delivery. Our findings and data from similar research suggest that benefits of external version at term may not apply to populations with a low caesarean rate, unless versions are carried out with maximal efficiency (which, on the basis of available data, would imply tocolysis) or so indifferently that failed attempts do not influence the choice between abdominal and vaginal delivery.

[Vaginal delivery following cesarean section]. / Vaginale baring na sectio caesarea.

An analysis is presented of the outcome of labour in 462 women with a previous caesarean section, who delivered in the department of obstetrics of Leiden University Hospital in the period 1977-1986. Elective repeat section was performed in 26% of these women, while 83% of those accepted for a trial of labour had a vaginal delivery. In 196 women with a history of a previous caesarean section (1984-1986) a retrospective analysis was made of the influence of the indication for the previous caesarean section with respect of the outcome of labour in the following pregnancy. A trial of labour had the highest chance of success in those who had had a previous caesarean section because of a breech presentation. Sixty-five percent of women who had had a prior caesarean section because of cephalopelvic disproportion or failure to progress delivered by the vaginal route after a trial of labour. Foetal weight estimation by ultrasound could not predict the outcome of a trial of labour. It is concluded that a trial of labour after a previous caesarean section, even when the operation was performed because of cephalopelvic disproportion or failure to progress, is safe and rational.

[Blood group immunization: results of treatment of fetal anemia with intra-uterine intravascular blood transfusion in the Netherlands, 1987-1995]. / Bloedgroepimmunisatie: resultaten van behandeling van foetale anemie met intra-uteriene intravasculaire bloedtransfusie in Nederland, 1987-1995.

OBJECTIVE: To evaluate outcome of red cell alloimmunized pregnancies treated with intravascular intrauterine blood transfusions. DESIGN: Retrospective. METHODS: Medical records of all women and neonates treated with intrauterine transfusions in the period March 1987-December 1995, were reviewed. Survival rates of the infants were analysed in relation to both gestational age and the presence or absence of hydrops at the time of the first transfusion. RESULTS: In 153 pregnancies 155 foetuses underwent 462 transfusions (median: 3; range: 1-7). Patients were immunized against RhD in 88%. Kell in 7% and Rhe in 5% of the cases. Overall survival rate was 83%. No difference in survival rate was found between children with the first transfusion early (< or = 26 weeks) or late (> 26 weeks) in pregnancy. Survival rate for foetuses without hydrops was significantly higher than for those with hydrops (90% versus 73%). The mildly hydropic foetuses had a significantly higher survival rate than the severely hydropic foetuses (94% versus 53%). Absence of intrauterine reversal of hydrops was associated with a bad outcome. CONCLUSION: Intravascular transfusion is an effective and safe procedure for correction of foetal anaemia provided it is performed by an experienced multidisciplinary team. In contrast to gestational age at first transfusion severity of hydrops is predictive for successful treatment, so timely institution of treatment is of paramount importance.

[Prenatal fetal blood group determination using chorionic villi biopsy]. / Prenatale foetale-bloedgroepbepaling met behulp van chorionvilli-biopsie.

The presence or absence of Rhesus D, c and Kell antigens on foetal red blood cells was determined in the first trimester of pregnancy on erythrocytes obtained by chorionic villi sampling. Pregnancies in 15 severely sensitized women (9 Rh D, 5 Kell and I Rh c) with a poor obstetric history and a partner heterozygous for the offending antigen were examined. A conclusive diagnosis could be made in 13 of the 15 cases studied.