Risk factors for the recurrence of obstetrical anal sphincter injury and the role of a mediolateral episiotomy: an analysis of a national registry.

OBJECTIVE: The assessment of risk factors, including mediolateral episiotomy (MLE), for the recurrence of obstetric anal sphincter injury (rOASI). DESIGN: Population-based cohort study. SETTING: Data from the nationwide database of the Dutch Perinatal Registry (Perined). POPULATION: A cohort of 391 026 women at term, of whom 9943 had an OASI in their first delivery and had a second vaginal delivery of a liveborn infant in cephalic position. METHODS: Possible risk factors were tested for statistical significance using univariate and multivariate logistic regression analysis. MAIN OUTCOME MEASURES: Rate of rOASI. RESULTS: The rate of rOASI was 5.8%. Multivariate analysis identified a birthweight of ≥4000 g (adjusted OR, aOR, 2.1, 95% CI 1.6-2.6) and a duration of second stage of ≥30 minutes (aOR 1.8, 95% CI 1.4-2.3) as statistically significant risk factors for rOASI. Mediolateral episiotomy was associated with a statistically significant lower rate of rOASI in spontaneous vaginal delivery (SVD) (aOR 0.4, 95% CI 0.3-0.5) and in operative vaginal delivery (OVD) (aOR 0.2, 95% CI 0.1-0.5). CONCLUSIONS: Women with a history of OASI have a higher rate of OASI in their next delivery. Duration of the second stage of ≥30 minutes and a birthweight of ≥4000 g are significantly associated with an increased rate of rOASI. Mediolateral episiotomy is associated with a significantly lower rate of rOASI in both SVD and OVD. TWEETABLE ABSTRACT: Mediolateral episiotomy is associated with a significant lower recurrence rate of OASI in women with an OASI in their first delivery.

The risk of intrapartum/neonatal mortality and morbidity following birth at 37 weeks of gestation: a nationwide cohort study.

OBJECTIVE: To assess intrapartum/neonatal mortality and morbidity risk in infants born at 37 weeks of gestation compared with infants born at 39-41 weeks of gestation. DESIGN: Nationwide cohort study. SETTING: The Netherlands. POPULATION: A total of 755 198 women delivering at term of a singleton without congenital malformations during 2010-14. METHODS: We used data from the national perinatal registry (PERINED). Analysis was performed with logistic regression and stratification for the way labour started and type of care. MAIN OUTCOME MEASURES: Intrapartum or neonatal mortality up to 28 days and adverse neonatal outcome (neonatal mortality, 5-minute Apgar <7, and/or neonatal intensive care unit admission). RESULTS: At 37 weeks of gestation intrapartum/neonatal mortality was 1.10‰ compared with 0.59‰ at 39-41 weeks (P < 0.0001). Adjusted odds ratio (aOR) for 37 weeks compared with 39-41 weeks was 1.84 (95% CI) 1.39-2.44). Adverse neonatal outcome at 37 weeks was 21.4‰ compared with 12.04‰ at 39-41 weeks (P < 0.0001) with an aOR 1.63 (95% CI 1.53-1.74). Spontaneous start of labour at 37 weeks of gestation was significantly associated with increased intrapartum/neonatal mortality with an aOR of 2.20 (95% CI 1.56-3.10), in both primary (midwifery-led) care and specialist care. Neither induction of labour nor planned caesarean section showed increased intrapartum/neonatal mortality risk. CONCLUSIONS: Birth at 37 weeks of gestation is independently associated with a higher frequency of clinically relevant adverse perinatal outcomes than birth at 39-41 weeks. In particular, spontaneous start of labour at 37 weeks of gestation doubles the risk for intrapartum/neonatal mortality. Extra fetal monitoring is warranted. TWEETABLE ABSTRACT: Birth at 37 weeks of gestation gives markedly higher intrapartum/neonatal mortality risk than at 39-41 weeks, especially with spontaneous start of labour.

Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study.

OBJECTIVE: To study the effect of an intervention based on Crew Resource Management team training, including a tool for structured communication, on adverse perinatal and maternal outcomes. DESIGN: Stepped wedge. SETTING: The Netherlands. POPULATION OR SAMPLE: Registry data of 8123 women referred from primary care to a hospital during childbirth, at ≥ 32.0 weeks of singleton gestation and with no congenital abnormalities, in the period 2012-15. METHODS: Obstetric teams of five hospitals and their surrounding primary-care midwifery practices participated in the intervention. In total, 49 team training sessions were organised for 465 care professionals (75.5% participated). Adverse perinatal and maternal outcomes before, during and after the intervention were analysed using multivariate logistic regression analyses. MAIN OUTCOME MEASURES: Adverse Outcome Index (AOI-5), a composite measure involving; intrapartum or neonatal death, admission to neonatal intensive care unit, Apgar < 7 at 5 minutes, postpartum haemorrhage and/or perineal tear. RESULTS: In total, an AOI-5 score was reported in 11.3% of the study population. No significant difference was found in the incidence of the AOI-5 score after the intervention compared with before the intervention (OR 1.07: 95% CI 0.92-1.24). CONCLUSIONS: We found no effect of the intervention on adverse perinatal and maternal outcomes for women who were referred during childbirth. Team training is appreciated in practice, but evidence on the long-term impact is still limited. Upcoming studies should build on previous research and consider more sensitive outcome measures. TWEETABLE ABSTRACT: A cluster randomised team training intervention showed no effect on adverse perinatal and maternal outcomes for women referred during childbirth.