Continued versus discontinued oxytocin stimulation in the active phase of labour (CONDISOX): individual management based on artificial intelligence - a secondary analysis.

BACKGROUND: Current guidelines regarding oxytocin stimulation are not tailored to individuals as they are based on randomised controlled trials. The objective of the study was to develop an artificial intelligence (AI) model for individual prediction of the risk of caesarean delivery (CD) in women with a cervical dilatation of 6 cm after oxytocin stimulation for induced labour. The model included not only variables known when labour induction was initiated but also variables describing the course of the labour induction. METHODS: Secondary analysis of data from the CONDISOX randomised controlled trial of discontinued vs. continued oxytocin infusion in the active phase of induced labour. Extreme gradient boosting (XGBoost) software was used to build the prediction model. To explain the impact of the predictors, we calculated Shapley additive explanation (SHAP) values and present a summary SHAP plot. A force plot was used to explain specifics about an individual's predictors that result in a change of the individual's risk output value from the population-based risk. RESULTS: Among 1060 included women, 160 (15.1%) were delivered by CD. The XGBoost model found women who delivered vaginally were more likely to be parous, taller, to have a lower estimated birth weight, and to be stimulated with a lower amount of oxytocin. In 108 women (10% of 1060) the model favoured either continuation or discontinuation of oxytocin. For the remaining 90% of the women, the model found that continuation or discontinuation of oxytocin stimulation affected the risk difference of CD by less than 5% points. CONCLUSION: In women undergoing labour induction, this AI model based on a secondary analysis of data from the CONDISOX trial may help predict the risk of CD and assist the mother and clinician in individual tailored management of oxytocin stimulation after reaching 6 cm of cervical dilation.

Healing Architecture in Birthing Rooms: A Scoping Review.

AIM: The purpose of this scoping review is to map the knowledge about the multisensory birthing room regarding the birth experience and birth outcomes. BACKGROUND: The concept of multisensory birthing rooms is relatively novel, making it relevant to explore its impact. METHODS: Five databases were searched. The search was limited to articles in English, Danish, Norwegian, and Swedish. There were no time limitations. Fourteen relevant articles were identified providing knowledge about multisensory birthing rooms. RESULTS: Eight articles focused on birth experience, six articles focused on birth outcome, and one on the organization of the maternity care. Seven of the studies identified that sensory birthing rooms have a positive impact on the birth experience and one qualitative study could not demonstrate a better overall birth experience. Five articles described an improvement for selected birth outcomes. On the other hand, a randomized controlled trial study could not demonstrate an effect on either the use of oxytocin or birth outcomes such as pain and cesarean section. The definition and description of the concept weaken the existing studies scientifically. CONCLUSIONS: This scoping review revealed that multisensory birthing rooms have many definitions and variations in the content of the sensory exposure; therefore, it is difficult to standardize and evaluate the effect of its use. There is limited knowledge concerning the multisensory birthing room and its impact on the birth experience and the birth outcome. Multisensory birthing rooms may have a positive impact on the birth experience. Whereas there are conflicting results regarding birth outcomes.

Perinatal outcomes after therapeutic rest in the latent phase of labor: A cohort study.

INTRODUCTION: Therapeutic rest refers to the usage of medication to relieve pain in women in the latent phase of labor. Very few data are available to evaluate the safety and effect of its use. The objectives of this study were to compare perinatal and labor outcomes in women who were seeking hospital care during the latent phase of labor and who were treated either with or without therapeutic rest. MATERIAL AND METHODS: Retrospective cohort study with inclusion of nulliparous singleton pregnant women in the latent phase of labor presenting at the labor ward at Aarhus University Hospital, Denmark from May 13, 2018 to June 1, 2021. We identified two groups: women who were treated with therapeutic rest and women who were not. The primary outcomes were neonatal admission and neonatal resuscitation. Secondary outcomes included use of cardiotocography during labor, nonreactive fetal heart rate, meconium-stained amniotic fluid, pediatric delivery room assistance, umbilical cord arterial pH and standard base excess, Apgar score at 5 minutes, interventions during labor and mode of delivery. RESULTS: In our sample of 800 women in the latent phase of labor, 414 women (52%) were treated with therapeutic rest and 386 women (48%) were not. The most frequently used (n = 206) medication for therapeutic rest was a combination of paracetamol, triazolam and codeine. We found no significant difference in neonatal admission (9.2% vs 6.5%, adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 0.4-3.1) or neonatal resuscitation (2.4% vs 3.1%, aOR 0.7, 95% CI 0.1-4.0) between women treated with or without therapeutic rest. There were no differences between the two groups in other perinatal adverse outcomes, interventions during labor or mode of delivery. CONCLUSIONS: This study found no significant association between therapeutic rest and neonatal admission or resuscitation. Our findings indicate that therapeutic rest is a safe method for managing the latent phase of labor concerning neonatal health and does not increase the risk of labor complications.

Full-term induction of labor vs expectant management and cesarean delivery in women with obesity: systematic review and meta-analysis.

OBJECTIVE: This study aimed to review the literature comparing full-term induction of labor with expectant management in women with obesity on the risk of cesarean delivery and other adverse outcomes. DATA SOURCES: A literature search was performed on PubMed, EMBASE, Scopus, ClinicalTrials.gov, and the Cochrane Library. This study had no time, language, or geographic restriction. STUDY ELIGIBILITY CRITERIA: Studies were eligible if (1) they were cohort or randomized controlled trials, (2) they compared induction of labor at early or late term with expectant management, and (3) they included women with a body mass index of ≥30 kg/m2. Studies restricted to women with multiple pregnancy, premature rupture of membranes, or noncephalic presentation were excluded. The primary outcome was cesarean delivery. The secondary outcomes included maternal and neonatal mortality and morbidities and were evaluated. METHODS: The risk of bias was assessed by 2 authors using the Risk of Bias In Non-Randomized Studies of Interventions tool. Only studies assessed with low or moderate risk of bias contributed to the meta-analysis. Data were combined to pooled relative risks and 95% confidence intervals using random effects models. The quality of evidence was assessed for selected outcomes. RESULTS: Of the 232 studies identified, 13 were aligned with the inclusion criteria, and 4 cohort studies, including 216,318 women with induction of labor and 1,122,769 women managed expectantly, were included in the meta-analysis for the primary outcome. In women with obesity, full-term induction of labor was associated with a lower risk of cesarean delivery than expectant management (19.7% vs 24.5%; relative risk, 0.71; 95% confidence interval, 0.63-0.81). Moreover, this study found the same direction of the association for other selected outcomes: severe perineal lacerations (relative risk, 0.65; 95% confidence interval, 0.48-0.89), maternal infection (relative risk, 0.42; 95% confidence interval, 0.21-0.84), perinatal mortality (relative risk, 0.41; 95% confidence interval, 0.18-0.90), low Apgar score (relative risk, 0.48; 95% confidence interval, 0.26-0.91), meconium aspiration syndrome (relative risk, 0.40; 95% confidence interval, 0.28-0.56), and macrosomia (relative risk, 0.57; 95% confidence interval, 0.43-0.75). Conversely, induction of labor was associated with an increased risk of instrumental vaginal delivery (relative risk, 1.12; 95% confidence interval, 1.02-1.22). The quality of evidence ranged from low to very low. CONCLUSION: Full-term induction of labor in women with obesity may reduce the risk of cesarean delivery compared with expectant management, but the quality of the evidence is low.

Continued versus discontinued oxytocin stimulation in the active phase of induced labour: Factors associated with unexpectedly high rates of conversion to open label oxytocin in the CONDISOX trial.

OBJECTIVE: To examine the factors associated with unexpectedly high rates of conversion to open label oxytocin in the CONDISOX trial of continuation versus discontinuation of oxytocin infusion during induced labour. DESIGN: Secondary retrospective analysis of data from a prospective randomised controlled trial. SETTING: Nine hospitals in Denmark and one in the Netherlands between 8 April 2016 and 30 June 2020. POPULATION OR SAMPLE: 1200 women having labour induced. METHODS: Analysis of outcomes by actual management. MAIN OUTCOME MEASURES: Mode of delivery and associated variables. RESULTS: Switching to open label oxytocin (42.4% overall) was associated with nulliparity, an unripe cervix, larger babies and higher rates of delivery by caesarean section. CONCLUSIONS: In the CONDISOX trial, slow labour was associated with features suggesting a higher 'resistance to progress', often prompting the use of open-label oxytocin infusion rather than study medication.

Burst Spinal Cord Stimulation in Pregnancy: First Clinical Experiences.

OBJECTIVES: Spinal cord stimulation (SCS) is a treatment for chronic neuropathic pain. It is based on the delivery of electric impulses to the spinal cord, traditionally in a regular square-wave pattern ("tonic" stimulation) and, more recently, in a rhythmic train-of-five "BurstDR" pattern. The safety of active SCS therapy in pregnancy is not established, and recommendations are based on limited casuistic evidence. We present in this study clinical data on a case series of six women treated with burst SCS during pregnancy. In addition, we present the ultrasonographic flow measurements of fetal and uteroplacental blood flow in a pregnant patient. MATERIALS AND METHODS: Patients were included if they had been implanted with a full SCS system at Aarhus University Hospital, Denmark, between 2006 and 2020 and received active burst SCS stimulation during a pregnancy. Telephone interviews were conducted, including details on SCS therapy, medication, pregnancy course and outcome, and health status of the offspring. In one patient, the uteroplacental and fetal blood flow was assessed in gestational week 29 by Doppler flow measurements performed during both ON and OFF phases of the SCS system. RESULTS: Six patients were included with a total of 11 pregnancies. Three pregnancies ended in miscarriages, all in the same patient who had preexisting significant risk factors for miscarriage. Eight resulted in a live-born child with normal birth weight for gestational age; seven were born at term, and one was born late preterm, in gestational week 36. Ultrasonographic Doppler flow, measured in one patient, was normal and did not reveal any immediate changes between burst SCS ON and OFF. Seven children were reported healthy with normal neurodevelopment and one physically healthy but with developmental delays. CONCLUSIONS: The data presented in this study add to the accumulating evidence of the safety of SCS in pregnancy.

EAES rapid guideline: systematic review, meta-analysis, GRADE assessment, and evidence-informed European recommendations on appendicitis in pregnancy.

BACKGROUND: Clinical practice recommendations for the management of acute appendicitis in pregnancy are lacking. OBJECTIVE: To develop an evidence-informed, trustworthy guideline on the management of appendicitis in pregnancy. We aimed to address the questions of conservative or surgical management, and laparoscopic or open surgery for acute appendicitis. METHODS: We performed a systematic review, meta-analysis, and evidence appraisal using the GRADE methodology. A European, multidisciplinary panel of surgeons, obstetricians/gynecologists, a midwife, and 3 patient representatives reached consensus through an evidence-to-decision framework and a Delphi process to formulate the recommendations. The project was developed in an online authoring and publication platform (MAGICapp). RESULTS: Research evidence was of very low certainty. We recommend operative treatment over conservative management in pregnant patients with complicated appendicitis or appendicolith on imaging studies (strong recommendation). We suggest operative treatment over conservative management in pregnant patients with uncomplicated appendicitis and no appendicolith on imaging studies (weak recommendation). We suggest laparoscopic appendectomy in patients with acute appendicitis until the 20th week of gestation, or when the fundus of the uterus is below the level of the umbilicus; and laparoscopic or open appendectomy in patients with acute appendicitis beyond the 20th week of gestation, or when the fundus of the uterus is above the level of the umbilicus, depending on the preference and expertise of the surgeon. CONCLUSION: Through a structured, evidence-informed approach, an interdisciplinary panel provides a strong recommendation to perform appendectomy for complicated appendicitis or appendicolith, and laparoscopic or open appendectomy beyond the 20th week, based on the surgeon's preference and expertise. GUIDELINE REGISTRATION NUMBER: IPGRP-2022CN210.

Induction of labour at 39 weeks versus expectant management in low-risk obese women: study protocol for a randomised controlled study.

INTRODUCTION: Obesity is associated with many pregnancy complications, including both fetal macrosomia and prolonged labour. As a result, there is often also an increased risk of caesarean section. In other settings, labour induction near to term reduces adverse outcomes such as stillbirth and birth injury, without causing more caesarean deliveries. It has been suggested that induction will reduce adverse events in this setting too, but there have been no trials and the effect on caesarean section is unknown. The objective of this study is to compare induction of labour in gestational week 39 with expectant management on the risk of caesarean section in women with body mass index ≥30 kg/m2. METHODS AND ANALYSIS: An open label randomised controlled multicentre trial are conducted at Danish delivery departments with an in-house neonatal intensive care unit. Recruitment started October 2020. A total of 1900 women with a prepregnancy body mass index ≥30 kg/m2 are randomised in a 1:1 ratio to either labour induction at 39 weeks and 0 to 3 days of gestation or to expectant management; that is, waiting for spontaneous labour onset or induction if medically indicated. The primary outcome is caesarean section. Data will be analysed according to intention-to-treat. ETHICS AND DISSEMINATION: The Central Denmark Region Committee on Biomedical Research Ethics approved the study. The study is conducted in accordance with the ethical principles outlined in the latest version of the 'Declaration of Helsinki' and the 'Guideline for Good Clinical Practice' related to experiments on humans. The trial findings will be disseminated to participants, clinicians, commissioning groups and via peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT04603859.

Cesarean scar thickness in non-pregnant women as a risk factor for uterine rupture.

INTRODUCTION: Whether there is an association between residual myometrial thickness (RMT) after cesarean section (CS) and the risk of uterine rupture (UR) or uterine scar dehiscence at the subsequent delivery has been sparsely investigated. MATERIALS AND METHODS: Our cohort included 149 women with a first CS in whom we measured RMT by transvaginal ultrasonography 6-15 months after their delivery. We did a follow-up study on delivery outcomes in the women's subsequent births. The exposure was scar measurements in the non-pregnant uterus, and the primary outcome was a diagnosis of UR or dehiscence. We calculated likelihood ratios (LRs) with 95% confidence intervals of having UR or dehiscence with a thin RMT (<3 mm). RESULTS: Among the 149 women, 39 had a repeat CS (14 scheduled and 25 unscheduled procedures), and within these, we found one woman with UR and five women with uterine dehiscence. The proportion of women with a thin RMT was significantly higher among cases (4/6) than in controls (4/33); the LR was 5.5 (95% CI 1.9-16.2). CONCLUSIONS: The results suggest a significant association between a thin RMT as measured by transvaginal ultrasonography in the non-pregnant uterus after a first scheduled CS and the risk of UR or dehiscence at a subsequent delivery.

Continued versus discontinued oxytocin stimulation in the active phase of labour (CONDISOX): double blind randomised controlled trial.

OBJECTIVE: To determine whether discontinuing oxytocin stimulation in the active phase of induced labour is associated with lower caesarean section rates. DESIGN: International multicentre, double blind, randomised controlled trial. SETTING: Nine hospitals in Denmark and one in the Netherlands between 8 April 2016 and 30 June 2020. PARTICIPANTS: 1200 women stimulated with intravenous oxytocin infusion during the latent phase of induced labour. INTERVENTION: Women were randomly assigned to have their oxytocin stimulation discontinued or continued in the active phase of labour. MAIN OUTCOME MEASURE: Delivery by caesarean section. RESULTS: A total of 607 women were assigned to discontinuation and 593 to continuation of the oxytocin infusion. The rates of caesarean section were 16.6% (n=101) in the discontinued group and 14.2% (n=84) in the continued group (relative risk 1.17, 95% confidence interval 0.90 to 1.53). In 94 parous women with no previous caesarean section, the caesarean section rate was 7.5% (11/147) in the discontinued group and 0.6% (1/155)in the continued group (relative risk 11.6, 1.15 to 88.7). Discontinuation was associated with longer duration of labour (median from randomisation to delivery 282 v 201 min; P<0.001), a reduced risk of hyperstimulation (20/546 (3.7%) v 70/541 (12.9%); P<0.001), and a reduced risk of fetal heart rate abnormalities (153/548 (27.9%) v 219/537 (40.8%); P<0.001) but rates of other adverse maternal and neonatal outcomes were similar between groups. CONCLUSIONS: In a setting where monitoring of the fetal condition and the uterine contractions can be guaranteed, routine discontinuation of oxytocin stimulation may lead to a small increase in caesarean section rate but a significantly reduced risk of uterine hyperstimulation and abnormal fetal heart rate patterns. TRIAL REGISTRATION: ClinicalTrials.gov NCT02553226.

Early-term elective Caesarean sections did not increase the risk of behavioural problems at six to eight years of age.

AIM: Our aim was to explore the under-researched associations between an elective Caesarean section (C-section) at early-term or full-term gestation and behaviour at 6-8 years of age. METHODS: We identified 1220 eligible children born by elective C-sections at Danish hospital from 2009 to 2011. Their mothers were randomised to elective C-sections at either 38+3 (early-term) or 39+3 (full-term) weeks of gestation. From December 2017 to August 2018, the parents completed the Strengths and Difficulties Questionnaire. The results were adjusted for maternal education, parity and the child's sex. RESULTS: Of the 574 (45%) children followed up, 288 were delivered early-term and 286 were delivered full-term. The groups had similar baseline characteristics. There were no differences in the total difficulties score, subscale scores or the risk of being classified as having a possible or probable psychiatric disorder. Early-term boys had a lower risk of being classified as having a possible or probable psychiatric disorder and early-term girls had higher risk, but the results were not statistically significant. CONCLUSION: We found no difference in behaviour at 6-8 years of age between children born by elective C-section at early- versus full-term gestation.

[Christmas article: Please put your pants on - an RCT].

INTRODUCTION: It is common practice after a pelvic exam to ask a woman to put her pants on, before she is given verbal information. We aimed to compare short-term memory in undressed versus dressed women. METHODS: Thirty-six female Ob/Gyn doctors were randomised to receive verbal information while undressed and still in a lithotomy position, or once dressed again. The primary outcome was the proportion of items recalled from a 20-item list. RESULTS: We found no significant difference in recall; 58% in dressed women versus 62% in undressed women (p = 0.26). CONCLUSION: The memory of women is not affected by, whether or not they are dressed. FUNDING: none. TRIAL REGISTRATION: none.

Risk of recurrent acute fatty liver of pregnancy: survey from a social media group.

BACKGROUND: Acute fatty liver of pregnancy is a rare but serious complication in the last trimester of pregnancy or postpartum period. Data on the recurrence risk are largely unavailable, as only case reports or very small case series exist in which only 1 woman had recurrent acute fatty liver of pregnancy. OBJECTIVE: We aimed to estimate the risk of acute fatty liver of pregnancy recurrence and to compare disease severity and gestational age between primary and recurrent disease using patient-provided data from an acute fatty liver of pregnancy social media patient group. MATERIALS AND METHODS: We developed and distributed an electronic questionnaire through an international Facebook group called "Acute Fatty Liver of Pregnancy." The data collection took place from June 11, 2018, to August 17, 2018, using REDCap. Our main outcome measures were recurrence of acute fatty liver of pregnancy, severity with recurrence, and gestational age at delivery. RESULTS: A total of 69 women with previous acute fatty liver of pregnancy completed the questionnaire; 24 women had a subsequent delivery, of whom 5 women were diagnosed with acute fatty liver of pregnancy again. In 4 of 5 of these women (80%), acute fatty liver of pregnancy took a milder course, whereas in 1 woman it worsened in the next pregnancy. Women with acute fatty liver of pregnancy recurrence delivered at a median gestational age at 265 days (interquartile range, 242-287 days) in their first pregnancy with acute fatty liver of pregnancy as compared to delivery by a prelabor cesarean delivery at 245 days (interquartile range, 235-261 days) in their second pregnancy with acute fatty liver of pregnancy. Male fetal sex was not associated with an increased risk of recurrent acute fatty liver of pregnancy. CONCLUSION: One in 5 women reported having had recurrent acute fatty liver of pregnancy, with most cases being milder, possibly because of an earlier gestational age at delivery.

The Childbirth Experience Questionnaire (CEQ)-Validation of its use in a Danish-speaking population of new mothers stimulated with oxytocin during labour.

BACKGROUND: When determining optimal treatment regimens, patient reported outcomes including satisfaction are increasingly appreciated. It is well established that the birth experience may affect the postnatal attachment to the newborn and the management of subsequent pregnancies and deliveries. As we have no robust validated Danish tool to evaluate the childbirth experience exists, we aimed to perform a transcultural adaptation of the Childbirth Experience Questionnaire (CEQ) to a Danish context. METHODS: In accordance with the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN), we translated the Swedish-CEQ to Danish. The Danish-CEQ was tested for content validity among 10 new mothers. In a population of women who have had their labour induced, we then assessed the electronic questionnaire for validity and reliability using factor analytical design, hypothesis testing, and internal consistency. Based on these data, we determined criterion and construct responsiveness in addition to floor and ceiling effects. RESULTS: The content validation resulted in minor adjustments in two items. This improved the comprehensibility. The electronic questionnaire was completed by 377 of 495 women (76.2%). The original Swedish-CEQ was four-dimensional, however an exploratory factor analysis revealed a three-dimensional structure in our Danish population (Own capacity, Participation, and Professional support). Parous women, women who delivered vaginally, and women with a labour duration <12 hours had a higher score in each domain. The internal consistency (Cronbach's alpha) ranged between 0.75 and 0.89 and the ICC between 0.68-0.93. We found ceiling effects of 57.6% in the domain Professional support and of 25.5% in the domain Participation. CONCLUSION: This study offers transcultural adaptation of the Swedish-CEQ to a Danish context. The 3-dimensional Danish-CEQ demonstrates construct validity and reliability. Our results revealed significant ceiling effect especially in the domain Professional support, which needs to be acknowledged when considering implementing the Danish-CEQ into trials and clinical practice.

Medication used in Denmark in the latent phase of labor - Do we know what we are doing?

OBJECTIVE: To describe the various combinations of medication used in Denmark in the latent phase of labor (i.e. for therapeutic rest) and to estimate the frequency of use. METHODS: An informal e-mail survey based on personal information from Danish midwives or staff obstetricians. The main outcome measures were type and dosage of medications used individually or in combination ("cocktail") for therapeutic rest in Danish delivery wards during the latent phase of labor and also the frequency of their use. RESULTS: All twenty-one delivery wards in Denmark participated in the survey. The types and dosages of medication varied substantially. Two delivery wards used prescriptions on morphine with no other medication for therapeutic rest. The remaining 19/21 delivery wards (90%) used a standard "cocktail" with two to four different types of medications; 19/21 wards (90%) used a mild analgesic (paracetamol), 17/21 (81%) used anxiolytics/hypnotics, and 14/21 (64%) wards used a strong analgesic (opioid) in their basic cocktail. Ten delivery wards (48%) combined an opioid, a sedative, and paracetamol in their basic cocktail. Between 7% and 21% of all pregnant women were given a cocktail. CONCLUSION: In a small country, we found considerable national variation in the medication or combinations of medication used in the latent phase of labor, and polypharmacy was standard in the majority of the delivery wards.

CONDISOX- continued versus discontinued oxytocin stimulation of induced labour in a double-blind randomised controlled trial.

BACKGROUND: Oxytocin is an effective drug for induction of labour, but is associated with serious adverse effects of which uterine tachysystole, fetal distress and the need of immediate delivery are the most common. Discontinuation of oxytocin once the active phase of labour is established could reduce the adverse effects. The objective is to investigate how the caesarean section rate is affected when oxytocin stimulation is discontinued in the active phase of labour compared to labours where oxytocin is continued. METHODS: CONDISOX is a double-blind multicentre randomised controlled trial conducted at Danish and Dutch Departments of Obstetrics and Gynaecology. The first participant was recruited on April 8 2016. Based on a clinically relevant relative reduction in caesarean section rate of 7%, an alpha of 0.05, a beta of 80%, we aim for 1200 participating women (600 in each arm). The CONDISOX trial includes women at a gestational age of 37-42 complete weeks of pregnancy, who have uterine activity stimulated with oxytocin infusion for the induction of labour. Women are randomised when the active phase of labour becomes established, to study medication containing either oxytocin (continuous group) or placebo (discontinued group) infusion. Women are stratified by birth site, indication for oxytocin stimulation (induction of labour, prelabour rupture of membranes) and parity (nulliparous, parous +/- previous caesarean section). We will compare the primary outcome, caesarean section rate, in the two groups using a chi-square test with a p-value of 0.05. If superiority is not demonstrated, we have a pre-defined post hoc non-inferiority boundary (margin, delta) at 1.09. Secondary outcomes include duration of the active phase of labour, incidence of uterine tachysystole, postpartum haemorrhage, admission to the neonatal intensive care unit, Apgar score, umbilical arterial blood pH, and birth experience. DISCUSSION: The high frequency of oxytocin use and the potential risks of both maternal and fetal adverse effects of oxytocin emphasise the need to determine the optimal oxytocin regime for induction of labour. TRIAL REGISTRATION: NCT02553226 (registered September 17, 2015). Eudra-CT number: 2015-002942-30.

Long-term cognition and behavior in children born at early term gestation: A systematic review.

INTRODUCTION: Recent recommendations characterize deliveries at 37+0  weeks through 38+6  weeks as early term. We aimed to review the literature systematically on long-term cognition, school performance and behavior in children born early term (37+0 to 38+6 weeks) compared with full term (39+0  to 40+6 weeks). MATERIAL AND METHODS: The review was performed according to the PRISMA Statement. The final literature search was performed on 31 January 2019. We located studies in PubMed, Embase, CINAHL and Cochrane Library. Eligible studies were randomized controlled trials, cohort studies and case-control studies, with outcome assessment performed at 2-19 years. We collected information using a structured data form and evaluated study quality using the Newcastle-Ottawa Scale (NOS). RESULTS: We included 42 observational studies published between 2006 and 2018. No restriction on year of publication was made. The mean NOS score was 5.8 with a range from 3 to 9. Compared with children born full term, children born early term had a lower intelligence score in early adulthood and up to some 30% increased risk of attention-deficit/hyperactivity disorder. Furthermore, we found some 10%-40% increased risk of cognitive problems, some 25% higher risk of language impairments and another 8%-75% with poorer overall school performance. No meta-analysis was conducted due to heterogeneity in the outcome measures. Only 10 studies presented subgroup analyses in spontaneous deliveries or adjusted for type of labor onset/induction. CONCLUSIONS: Children born early term are at increased risk of cognitive deficits, poorer school performance and behavioral problems compared with children born full term.