Postpartum haemorrhage trends in Sweden using the Robson ten group classification system: a population-based cohort study.

OBJECTIVE: To examine postpartum haemorrhage (PPH) trends in Sweden using the Robson classification system. DESIGN: Population-based cohort study. SETTING: Sweden. POPULATION: Deliveries in 2000-2016, classified as Robson groups 1-5 (singleton pregnancies in vertex presentation, from gestational weeks 37+0; n = 1 590 178). METHODS: We examined temporal trends in PPH between 2000 and 2016 overall, and within each Robson group, and performed logistic regression to examine the influence of changes in risk factors (maternal, comorbidity, obstetric practice and infant factors) over time. MAIN OUTCOME MEASURES: Postpartum haemorrhage, defined as an estimated blood loss of >1000 ml. RESULTS: The overall PPH rate increased from 5.4 to 7.3%, corresponding to a 37% (OR 1.37, 95% CI 1.32-1.42) increase over time. Rates varied between Robson groups, ranging from 4.5% in group 3 to 14.3% in group 4b. Increasing trends in PPH were found in all Robson groups except for groups 2b and 4b (prelabour caesarean deliveries). In the unstratified analysis, adjusting for maternal, comorbidity and obstetric practice factors slightly attenuated the risk of PPH in the later period (2013-2016), compared with the reference period (2000-2004; crude OR 1.26, 95% CI 1.24-1.29, adjusted OR 1.22, 95% CI 1.20-1.25). Within individual Robson groups, changes in risk factors did not explain increasing rates of PPH. CONCLUSIONS: Postpartum haemorrhage rates varied between Robson groups. Changes in risk factors could not explain the 37% increase in PPH for women in Robson groups 1-5 in Sweden, 2000-2016. TWEETABLE ABSTRACT: Changes in risk factors could not explain the increasing trend of PPH in Sweden, and rates of PPH varied widely between Robson groups.

The effect of twin-to-twin delivery time intervals on neonatal outcome for second twins.

BACKGROUND: The objective was to examine the effect of twin-to-twin delivery intervals on neonatal outcome for second twins. METHODS: This was a retrospective, hospital-based study, performed at a university teaching hospital in Western Sweden. Twin deliveries between 2008 and 2014 at ≥32 + 0 weeks of gestation, where the first twin was delivered vaginally, were included. Primary outcome was a composite outcome of metabolic acidosis, Apgar < 4 at 5 min or peri/neonatal mortality in the second twin. Secondary outcome was a composite outcome of neonatal morbidity. RESULTS: A total of 527 twin deliveries were included. The median twin-to-twin delivery interval time was 19 min (range 2-399 min) and 68% of all second twins were delivered within 30 min. Primary outcome occurred in 2.6% of the second twins. Median twin-to-twin delivery interval was 34 min (8-78 min) for the second twin with a primary outcome, and 19 min (2-399 min) for the second twin with no primary outcome (p = 0.028). Second twins delivered within a twin-to-twin interval of 0-30 min had a higher pH in umbilical artery blood gas than those delivered after 30 min (pH 7.23 and pH 7.20, p <  0.0001). Secondary outcome was not associated with twin-to-twin delivery interval time. The combined vaginal-cesarean delivery rate was 6.6% (n = 35) and the rate was higher with twin-to-twin delivery interval >  30 min (p <  0.0001). CONCLUSIONS: An association, but not necessarily a causality, between twin-to-twin delivery interval and primary outcome was seen. An upper time limit on twin-to-twin delivery time intervals may be justified. However, the optimal time interval needs further studies.

Early versus delayed oxytocin augmentation in nulliparous women with prolonged labour--a randomised controlled trial.

OBJECTIVE: To study the effects of early versus delayed oxytocin augmentation on the obstetrical and neonatal outcome in nulliparous women with spontaneous but prolonged labour. DESIGN: Randomised controlled study. SETTING: Two delivery units in Sweden. POPULATION: Healthy nulliparous women with normal pregnancies, spontaneous onset of active labour, a cervical dilatation of 4-9 cm and no progress in cervical dilatation for 2 hours and for an additional hour if amniotomy was performed due to slow progress. METHODS: Women (n = 630) were randomly allocated either to labour augmentation by oxytocin infusion (early oxytocin group) or to postponement of oxytocin augmentation for another 3 hours (expectant group). MAIN OUTCOME MEASURE: Mode of delivery (spontaneous vaginal or instrumental vaginal delivery or caesarean section) and time from randomisation to delivery. RESULTS: The caesarean section rate was 29 of 314 (9%) in the early oxytocin group and 34 of 316 (11%) in the expectant group (OR 0.8, 95% CI 0.5-1.4), and instrumental vaginal delivery 54 of 314 (17%) in the early oxytocin versus 38 of 316 (12%) in the expectant group (OR 1.5, 95% CI 0.97-2.4). Early initiation of oxytocin resulted in a mean decrease of 85 minutes in the randomisation to delivery interval. CONCLUSION: Early administration of oxytocin did not change the rate of caesarean section or instrumental vaginal delivery but shortened labour duration significantly in women with a 2-hour arrest in cervical dilatation. No other clear benefits or harms were seen between early and delayed administration of oxytocin.

Regression of pelvic girdle pain after delivery: follow-up of a randomised single blind controlled trial with different treatment modalities.

OBJECTIVE: An earlier publication showed that acupuncture and stabilising exercises as an adjunct to standard treatment was effective for pelvic girdle pain during pregnancy, but the post-pregnancy effects of these treatment modalities are unknown. The aim of this follow-up study was to describe regression of pelvic girdle pain after delivery in these women. DESIGN: A randomised, single blind, controlled trial. SETTING: East Hospital and 27 maternity care centres in Göteborg, Sweden. POPULATION: Some 386 pregnant women with pelvic girdle pain. METHODS: Participants were randomly assigned to standard treatment plus acupuncture (n=125), standard treatment plus specific stabilising exercises (n=131) or to standard treatment alone (n=130). PRIMARY OUTCOME MEASURES: pain intensity (Visual Analogue Scale). SECONDARY OUTCOME MEASURE: assessment of the severity of pelvic girdle pain by an independent examiner 12 weeks after delivery. RESULTS: Approximately three-quarters of all the women were free of pain 3 weeks after delivery. There were no differences in recovery between the 3 treatment groups. According to the detailed physical examination, pelvic girdle pain had resolved in 99% of the women 12 weeks after delivery. CONCLUSIONS: This study shows that irrespective of treatment modality, regression of pelvic girdle pain occurs in the great majority of women within 12 weeks after delivery.

Early or late bath during the first stage of labour: a randomised study of 200 women.

OBJECTIVE: To compare obstetric outcome after a bath offered to women on two different occasions during the first stage of labour. The aim of the study was to determine whether an early bath affected the progress of labour and the use of analgesia when compared with a late bath during the first stage of labour. DESIGN: A randomised prospective pilot-study. SETTING: The delivery ward at Ostra Hospital in Göteborg. PARTICIPANTS: Two hundred women, at low obstetric risk. INTERVENTIONS: The women were randomised to either the 'early bath group' or the 'late bath group'. The women in the 'early bath group' had a bath before a cervical dilatation of 5 cm, while the women in the 'late bath group' had a bath after the cervix was 5 cm dilated. MEASUREMENTS AND FINDINGS: The women in the 'early bath group' had a longer time period from established labour to delivery (9.8 hours) compared to the 'late bath group' (8.5 hours) (p < 0.004). A higher proportion of women in the 'early bath group' needed oxytocin administration (57%) compared to the 'late bath group' (30%) (p < 0.01). Epidural analgesia was used by 27% of the women in the 'early bath group' and by 9% in the 'late bath group' (p < 0.001). One baby in the 'early bath group' had clinical signs of infection and required antibiotic treatment. No cases of amnionitis or endometritis were present in the women. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The findings suggest that a bath during the first stage of labour should preferably be used after a cervical dilatation of 5 cm to avoid prolonged labour, and an increased use of oxytocin and epidural analgesia.

Prevalence and risk factors for prelabor rupture of the membranes (PROM) at or near-term in an urban Swedish population.

AIMS: To determine the prevalence, recurrence rate and to identify risk factors for prelabor rupture of the membranes (PROM) after 34 completed weeks in an urban Swedish population. METHODS: In a retrospective cohort study a sample of 2880 women aged 25-41 years, resident in the city of Göteborg, was randomly selected from the population register. According to information from the national Medical Birth Register (MBR), 1507 of these 2880 women had given birth 2736 times. 2270 of these deliveries had occurred in hospitals in the city of Göteborg and case records for 2242 of these deliveries were found. The case records were systematically analyzed for the occurrence of PROM and potential risk factors for PROM. 2208 of these deliveries occurred after 34 weeks of gestation. The further analyses were based on these 2208 deliveries. RESULTS: The prevalence of PROM after 34 week of gestation in this urban Swedish population was 12.9% and about 20% of the women in the population had experienced PROM at least once. In the multiple stepwise regression analysis, risk factors for PROM were primiparity, premature contractions, PROM in a previous pregnancy and bleeding in the first trimester. CONCLUSIONS: PROM is a common complication at or near term. The risk factors for PROM found in this representative study are difficult to influence and thus provide no guidance about how pregnancies should be managed to reduce the occurrence of PROM in the future.

Is a speculum examination sufficient for excluding the diagnosis of ruptured fetal membranes?

OBJECTIVE: To determine the false negative rate of a sterile speculum examination for the diagnosis of rupture of the membranes in women not in labor and without visible amniotic fluid at speculum examination. Furthermore, possible risks to the mother and the baby after suspected rupture of the membranes were analyzed. STUDY DESIGN: In women not in labor with suspected rupture of the membranes between gestational weeks 34 and 42, a sterile speculum examination was performed. If no amniotic fluid was visible, a test for Diamine oxidase was carried out. The results of tests were not known to the obstetricians or the women. The women were allowed to return home with no further controls if no amniotic fluid was visible at the speculum examination. Neonatal and obstetric outcome was recorded prospectively. RESULTS: Of 27,502 deliveries, 2,099 women not in labor attended the delivery ward for suspected rupture of the membranes after week 34. Amniotic fluid was visualized in 1,580 women. In 519 women in whom no amniotic fluid was seen at the speculum examination, the Diamine oxidase test was negative in 456 and positive in 63. Antibiotics were given to eleven children (2.4%) in the group with a negative Diamine oxidase and to one infant (1.6%) in the positive Diamine oxidase group (p>0.05). No differences in obstetric outcome were recorded. CONCLUSIONS: The false negative rate of a speculum examination for the diagnosis of rupture of the membranes in women without amniotic fluid visible at a speculum examination was 12% when Diamine oxidase was used as the standard for the diagnosis of rupture of the membranes. This study did not show any disadvantages for mothers and infants if the women were sent home after a false negative speculum examination. The value of biochemical methods in the management of women not in labor with rupture of the membranes after thirty-four weeks of gestation could be questioned.

Warm tub bath during labor. A study of 1385 women with prelabor rupture of the membranes after 34 weeks of gestation.

BACKGROUND: To evaluate the influence of a bath on infectious morbidity in mothers and neonates in women with prelabor rupture of the membranes after 34 weeks of gestation. METHODS: A nonrandomized study of 1385 healthy women. During the first stage of labor 538 women wanted a bath while 847 did not. The women awaited spontaneous contractions up to 24 or 72 hours after the membranes had ruptured before labor was induced with oxytocin. Digital examinations of the cervix were avoided until onset of active labor or until the time induction was planned. For statistical analysis Fisher's exact test was used. RESULTS: Chorioamnionitis during labor occurred in 1.1% of the women in the bath group and in 0.2% in the reference group (p = 0.06). Postpartum endometritis was found in three cases both in the bath group (0.6%) and in the reference group (0.4%) (p = 0.68). The frequency of neonates receiving antibiotics was 3.7% and 4.8% respectively (p = 0.43). CONCLUSION: A tub bath did not increase the risk of maternal or neonatal infection after premature rupture of the membranes and prolonged latency.

A randomised trial of two expectant managements of prelabour rupture of the membranes at 34 to 42 weeks.

OBJECTIVE: To compare obstetric and perinatal outcome between two different expectant managements in women with prelabour rupture of the membranes (PROM). DESIGN: A randomised study. PARTICIPANTS: One thousand three hundred and eighty-five women with rupture of the membranes at 34 to 42 weeks without contractions. INTERVENTIONS: Women without contractions 2 h after admission were randomised to early induction the following morning after PROM (early induction group) or induction two days later (late induction group). Women with contractions starting within 2 h after admission were included in the calculations as a short latency group. Digital examinations of the cervix were avoided until onset of active labour. Labour was induced with oxytocin in both groups if no spontaneous contractions occurred or if chorioamnionitis or fetal distress was detected. MAIN OUTCOME MEASURES: The frequency of spontaneous deliveries, operative deliveries, maternal and neonatal infections. RESULTS: In nulliparous women, a higher rate of spontaneous deliveries was found in the late induction group (89%) compared with the early induction group (81%) (P < 0.05). The ventouse extraction rate was 7% and 14% respectively (P < 0.05). A low (2-4%) caesarean section rate was recorded and did not differ between the groups. Endometritis was detected in six women after delivery. Sixty-one children were treated with antibiotics, and no difference could be detected between the groups. CONCLUSIONS: A higher rate of spontaneous deliveries was found among nulliparous women with prolonged latency as compared with brief latency prior to induction. A protocol of no digital examination before labour was associated with infrequent maternal and fetal morbidity, regardless of latency.

Anal sphincter tears: prospective study of obstetric risk factors.

OBJECTIVE: To evaluate intrapartum risk factors for anal sphincter tear. DESIGN: A prospective observational study. SETTING: Delivery unit at the University Hospital in Göteborg, Sweden. PARTICIPANTS: 2883 consecutive women delivered vaginally during the period between 1995 and 1997. Information was obtained, from patient records and from especially designed protocols which were completed during and after childbirth. MAIN OUTCOME MEASURES: Anal sphincter (third and fourth degree) tear. RESULTS: Anal sphincter tear occurred in 95 of 2883 women (3.3%). Univariate analysis demonstrated that the risk of anal sphincter tear was increased by nulliparity, high infant weight, lack of manual perineal protection, deficient visualisation of perineum, severe perineal oedema, long duration of delivery and especially protracted second phase and bear down, use of oxytocin, episiotomy, vacuum extraction and epidural anaesthesia. After analysis with stepwise logistic regression, reported as odds ratio, 95% confidence interval, the following factors remained independently associated with anal sphincter tear: slight perineal oedema (0.40, 0.26-0.64); manual perineal protection (0.49, 0.28-0.86); short duration of bear down (0.47, 0.24-0.91); no visualisation of perineum (2.77, 1.36-5.63); parity (0.59, 0.40-0.89); and high infant weight (2.02, 1.30-3.16). Analysis of variance showed that manual perineal protection had a stronger influence on lowering the frequency, and lack of visualisation of perineum and infant weight had a stronger influence on raising the frequency, of anal sphincter tears in nulliparous compared with parous women. CONCLUSIONS: Perineal oedema, poor ocular surveillance of perineum, deficient perineal protection during delivery, protracted final phase of the second stage, parity and high infant weight all constitute independent risk factors for anal sphincter tear. Such information is essential in order to reduce perineal trauma during childbirth.

A population based study of Swedish women's opinions about antenatal, delivery and postpartum care.

OBJECTIVE: To investigate the views and experiences of Swedish women regarding antenatal, delivery and postpartum care. STUDY DESIGN: A random sample of women from the birth cohorts 1955, 1959, 1963, 1967 and 1971 resident in the city of Göteborg (n=2880) was invited by letter to complete a questionnaire regarding antenatal, delivery and postpartum care. RESULTS: The overall response rate was 73% and 1130 (54%) of the 2109 responders had given birth to at least one child. Eighty-one percent of parous women answered that checking blood and urine samples, fetal heart rate, and the measurement of fundal height were the most important procedures in antenatal care. A majority had a positive attitude towards the use of electronic fetal heart rate monitoring (parous 85%; nulliparous 84%). Sixty percent of parous women were aware that ultrasound examination was voluntary and a majority (90%) had a positive attitude towards ultrasound scanning. Forty-three percent of parous women wanted antenatal clinics to be open until 8.00 p.m. A minority of both parous (4%) and nulliparous (4%) women were interested in home delivery. There were more parous (33%) than nulliparous (12%) women who expressed no anxiety at all about the next delivery. Seventy-nine percent of the parous women reported that they would like to have a planned visit with a delivery ward midwife before the next delivery. About 80% reported that they would feel very safe if their partners were present at the delivery (nulliparous 79%; parous 84%). Eighty-five percent preferred a single room or a room together with only one other woman in the postnatal ward. Seventy-two percent of the women wanted to stay 72 hours or less in the postpartum ward and 24% thought there had been too many visitors during the postnatal period. Over 80% were very positive towards breast-feeding. Approximately 80% of all women considered regular contractions up to twelve hours to be acceptable before delivery. CONCLUSIONS: This study has provided some useful information about women's opinion regarding antenatal, delivery and postpartum care which may be taken into account when instigating changes in the maternity care system.

Risk factors for neonatal sepsis in offspring of women with prelabor rupture of the membranes at 34-42 weeks.

One thousand three hundred eighty-five women with PROM (prelabor rupture of the membranes) participated in a prospective randomized study. Women with PROM were randomized to induction the following morning after PROM (early induction group) or induction two days later (late induction group). If contractions started within 2 hours after admission these women were included in the short latency group. All neonatal infections were classified as verified sepsis (positive culture) or clinical sepsis. The aim of the study was to compare the perinatal infectious outcome between the groups with different expectant managements in women with PROM and to study the association between demographic, intrapartum and postpartum variables and neonatal sepsis. In the short latency group one neonate had a proven sepsis while four neonates with proven sepsis were found in the early induction group. No proven sepsis was detected in the late induction group. Univariate analyses showed a significant association between clinical sepsis and: induction of labor (OR = 2.94, 95% CI 1.30-6.68), established labor 24.1-32 hours after ROM (OR = 5.89, 95% CI 1.68-20.63), established labor > 32 hours after ROM (OR = 4.59, 95% CI 1.52-13.87), time from ROM to delivery > 32 hours (OR = 5.07, 95% CI 1.40-18.39), cesarean section (OR = 11.03, 95% CI 4.10-29.68), chorioamnionitis before or during delivery (OR = 27.14, 95% CI 2.38-309.16), endometritis (OR = 18.08, 95% CI 1.82-179.87), CRP over 20 mg/l in the umbilical cord (OR = 17.12, 95% CI 5.68-52.12) and Apgar score < 7 after 1, 5 or 10 minutes. In a stepwise logistic regression analysis a significant association was found between clinical sepsis and cesarean section (OR = 10.08, 95% CI = 3.26-31.20), time from ROM to delivery > 32 h (OR = 3.74, 95% CI 1.62-8.62), gestational age 34-36 weeks (OR = 3.16, 95% CI 1.11-8.96) and parous women (OR = 2.41, 95% CI 1.04-5.57). In conclusion, this study indicates that that there was no difference in the incidence of neonatal infections between those with early and late induction. Clinical neonatal sepsis was associated with time from PROM to delivery over 32 hours, cesarean section, parous women and gestational age between 34 and 36 weeks.

Cerebral palsy in preterm infants: a population-based case-control study of antenatal and intrapartal risk factors.

UNLABELLED: Previous studies have indicated that foetomaternal infection increases the risk of spastic cerebral palsy (CP) in term infants, whereas this association appears to be less evident in preterm infants. The aim of this study was to analyse infection-related risk factors for spastic CP in preterm infants. A population-based series of preterm infants with spastic CP, 91 very preterm (<32 wk) and 57 moderately preterm (32-36 wk), born in 1983-90, were included and matched with a control group (n = 296). In total, 154 maternal, antenatal and intrapartal variables were retrieved from obstetric records. In the entire group, histological chorioamnionitis/pyelonephritis, long interval between rupture of membranes and birth, admission-delivery interval <4 h and Apgar scores of <7 at 1 min just significantly increased the risk of CP, and Apgar scores of <7 at 5 and 10 min were strongly associated with an increased risk. Abruptio placentae, Apgar scores <7 at 1 min and pathological non-stress test (reason for delivery) were significant risk factors of CP only in the moderately preterm and hemiplegic groups, whereas fever before delivery was a significant risk factor in the very preterm and spastic diplegic groups. Antibiotics during pregnancy was associated with CP only in the spastic diplegic CP group. CONCLUSION: Antenatal infections marginally increased the risk of CP. Low Apgar score and abruptio placentae were associated with CP, especially in moderately preterm infants with hemiplegic CP.