Short-term variation of the fetal heart rate as a marker of intraamniotic infection in pregnancies with preterm prelabor rupture of membranes: a historical cohort study.

INTRODUCTION: Intraamniotic infection (IAI) and subsequent early-onset neonatal sepsis (EONS) are among the main complications associated with preterm prelabor rupture of membranes (PPROM). Currently used diagnostic tools have been shown to have poor diagnostic performance for IAI. This study aimed to investigate whether the exposure to IAI before delivery is associated with short-term variation of the fetal heart rate in pregnancies with PPROM. METHODS: Observational cohort study of 678 pregnancies with PPROM, delivering between 24 + 0 and 33 + 6 gestational weeks from 2012 to 2019 in five labor units in Stockholm County, Sweden. Electronic medical records were examined to obtain background and exposure data. For the exposure IAI, we used the later diagnosis of EONS in the offspring as a proxy. EONS is strongly associated to IAI and was considered a better proxy for IAI than the histological diagnosis of acute chorioamnionitis, since acute chorioamnionitis can be observed in the absence of both positive microbiology and biochemical markers for inflammation. Cardiotocography traces were analyzed by a computerized algorithm for short-term variation of the fetal heart rate, which was the main outcome measure. RESULTS: Twenty-seven pregnancies were categorized as having an IAI, based on the proxy diagnosis of EONS after birth. Fetuses exposed to IAI had significantly lower short-term variation values in the last cardiotocography trace before birth than fetuses who were not exposed (5.25 vs 6.62 ms; unadjusted difference: -1.37, p = 0.009). After adjustment for smoking and diabetes, this difference remained significant. IAI with a later positive blood culture in the neonate (n = 12) showed an even larger absolute difference in STV (-1.65; p = 0.034), with a relative decrease of 23.5%. CONCLUSION: In pregnancies with PPROM, fetuses exposed to IAI with EONS as a proxy have lower short-term variation of the fetal heart rate than fetuses who are not exposed. Short-term variation might be useful as adjunct surveillance in pregnancies with PPROM.

A follow up on the feasibility after national implementation of magnesium sulfate for neuroprotection prior to preterm birth.

INTRODUCTION: The risk for brain injury manifested as cerebral palsy is higher in very preterm born children than in term. Prenatal administration of magnesium sulfate (MgSO4 ) has been shown to be neuroprotective and reduces the proportion of very preterm born children later diagnosed with cerebral palsy. A Swedish national clinical practice guideline was implemented in March 2020, stipulating the administration of a single intravenous dose of 6 g MgSO4 1-24 h prior to delivery before gestational age 32+0, aiming for 90% treatment coverage. The aim of this study was to evaluate the feasibility of this new clinical practice guideline in the first year of its implementation. MATERIAL AND METHODS: Data on MgSO4 treatment were collected by reviewing the medical charts of women who gave birth to live born children in gestational age 22+0-31+6 during the period of March 1, 2020 to February 28, 2021, at five Swedish university hospitals. Women with pre-eclampsia, eclampsia, or high elevated liver enzymes low platelets (HELLP) were excluded. RESULTS: A total of 388 women were eligible and 79% received treatment with MgSO4 . Of the 21% not receiving treatment, 9% did not receive treatment due to lack of knowledge about the clinical practice guideline, 9% were not possible to treat and 3% had missing data. The proportion treated increased from 72% to 87% from the first to the last 3 months. Of those treated, 81% received the drug within the stipulated timeframe (mean 8.7 h, median 3.4 h). CONCLUSIONS: There was a positive trend over time in the proportion of women receiving MgSO4 treatment, but the a priori target of 90% was not reached during the first year of implementation. Our findings indicate that this target could be reached with additional information to clinicians.

Changes in perinatal management and outcomes of extremely preterm infants born below 26 weeks of gestation in a tertiary referral hospital in Sweden: Comparison between 2004-2007 and 2012-2016.

INTRODUCTION: Perinatal management of extremely preterm births in Sweden has changed toward active care from 22-23 gestational weeks during the last decades. However, considerable regional differences exist. This study evaluates how one of the largest perinatal university centers has adapted to a more active care between 2004-2007 and 2012-2016 and if this has influenced infant survival. MATERIAL AND METHODS: In this historical cohort study, women admitted with at least one live fetus and delivered at 22-25 gestational weeks (stillbirths included) at Karolinska University Hospital Solna during April 1, 2004-March 31, 2007, and January 1, 2012-December 31, 2016, were compared regarding rates of obstetric and neonatal interventions, and infant mortality and morbidity. Maternal, pregnancy and infant data from 2004-2007 were obtained from the Extreme Preterm Infants in Sweden Study while data from 2012-2016 were extracted from medical journals and quality registers. The same definitions of interventions and diagnoses were used for both study periods. RESULTS: A total of 106 women with 118 infants during 2004-2007 and 213 women with 240 infants during 2012-2016 were included. Increases between the study periods were seen regarding cesarean delivery (overall rate 14% [17/118] during 2004-2007 vs. 45% [109/240] during 2012-2016), attendance of a neonatologist at birth (62% [73/118] vs. 85% [205/240]) and surfactant treatment at birth in liveborn infants (60% [45/75] vs. 74% [157/211]). Antepartum stillbirth rate decreased (13% [15/118] vs. 5% [12/240]) and the proportion of live births increased (80% [94/118] vs. 88% [211/240]) while 1-year survival (64% [60/94] vs. 67% [142/211]) and 1-year survival without major neonatal morbidity (21% [20/94] vs. 21% [44/211]) among liveborn infants did not change between the study periods. At 22 gestational weeks, interventions rates were still low during 2012-2016, most obvious regarding antenatal steroid treatment (23%), attendance of a neonatologist (51%), and intubation at birth (24%). CONCLUSIONS: Both obstetric and neonatal interventions at births below 26 gestational weeks increased between 2004-2007 and 2012-2016 in this single center study; however, at 22 gestational weeks they were still at a low level during 2012-2016. Despite more infants being born alive, 1-year survival did not increase between the study periods.

The effect of organizational belonging and profession on clinicians' attitudes toward supporting vaginal birth and interprofessional teamwork-a cross-sectional study.

INTRODUCTION: The aim of this study was to investigate the effect of organizational belonging and profession on clinicians' attitudes toward supporting vaginal birth and interprofessional teamwork in Swedish maternity care. MATERIAL AND METHODS: The study used a cross-sectional design, with a web-based survey sent to midwives, physicians and nurse assistants at five labor wards in Sweden. The survey consisted of two validated scales: the Swedish version of the Labor Culture Survey (S-LCS), measuring attitudes toward supporting vaginal birth, and the Assessment of Collaborative Environments (ACE-15), measuring attitudes toward interprofessional teamwork. Two-way ANOVA was conducted to assess the main effect of and interaction effect between organizational belonging and profession for the different subscales of the S-LCS and the ACE-15, together with Tukey's honest significant difference post-hoc analysis and partial eta squared to determine effect size. The relation between the subscales was assessed using the Pearson's correlation analysis. RESULTS: A total of 539 midwives, physicians and nurse assistants completed the survey. Organizational belonging significantly influenced attitudes toward supporting vaginal birth and interprofessional teamwork, with the largest effect for Positive team culture (F = 38.88, effect size = 0.25, p < 0.001). The effect of profession was strongest for the subscale Best practices (F = 59.43, effect size = 0.20, p < 0.001), with midwives being more supportive of strategies proposed to support vaginal birth than physicians and nurse assistants. A significant interaction effect was found for four of the subscales of the S-LCS, with the strongest effect for items reflecting the Unpredictability of vaginal birth (F = 4.49, effect size = 0.07, p < 0.001). Labor ward culture (unit microculture) specifically related to supporting vaginal birth was strongly correlated to interprofessional teamwork (r = 0.598, p < 0.001). CONCLUSIONS: In the current study, both organizational belonging and profession influenced attitudes toward supporting vaginal birth and interprofessional teamwork. Positive team culture was positively correlated to an organizational culture supportive of vaginal birth. Interventions to support vaginal births should include efforts to strengthen teamwork between professions, as well as considering women's values, preferences and informed choices.

Management of the active second stage of labor in waterbirths compared with conventional births - a prospective cohort study.

BACKGROUND: The management of the active second stage in labor and perineal protection varies between countries and is rarely described regarding waterbirths. The objective of this study was to describe how midwives manage the active second stage of labor in waterbirths compared to conventional births. A secondary aim was to compare clinical outcomes between the two groups. METHODS: A prospective cohort study, based on 323 women who gave birth at three clinics in Sweden, between Dec 2015-May 2019. The women were both primiparous and multiparous; 153 gave birth in water and 170 had a conventional uncomplicated birth. A protocol was completed by the attending midwife after birth, describing characteristics and management of the active second stage of labor as well as perineal protection. RESULTS: The active second stage of labor differed in several aspects between waterbirths and conventional births. Maternal pushing was spontaneous to a higher extent among women giving birth in water and the use of manual perineal protection was lower. The technique of manual perineal protection differed as well as birth positions. Giving birth in water was associated with less second-degree tears among primiparous women but with no differences among multiparas. CONCLUSIONS: In waterbirth, the midwife took the role of a more watchful attendee, making less interventions. Waterbirths were associated with less directed pushing and less manual perineal protection. However, there was still a widespread use of manual perineal protection, showing it is possible to use in the same way as in conventional births if needed.

Associations Between Maternal Distress, Cortisol Levels, and Perinatal Outcomes.

OBJECTIVE: Stress during pregnancy may decrease gestational age at birth and birth size. We aimed to investigate the associations between maternal subjective stress measures, salivary cortisol, and perinatal outcomes. METHODS: A cohort of pregnant women (n = 1693) was recruited from eight antenatal care clinics in Stockholm, Sweden. Questionnaires on subjective distress (perceived stress, worry, depression symptoms, sleep quality) and saliva samples for cortisol measurement (morning and evening) were collected in early and late pregnancy. Perinatal outcomes were birth weight, birth length, gestational age, and birth weight for gestational age. We used linear regression to estimate associations adjusted for maternal characteristics. RESULTS: All associations between subjective distress and cortisol levels were close to null and nonsignificant, for example, exp(ß) = 1.001 (95% confidence interval = 0.995 to 1.006) for the morning cortisol level and perceived stress in early pregnancy. Likewise, most associations between distress (subjective and cortisol) and perinatal outcomes were weak and not statistically significant, for example, ß = 1.95 (95% confidence interval = -4.16 to 8.06) for perceived stress in early pregnancy and birth weight. An exception was a statistically significant association between birth weight for gestational age and depression symptoms in early pregnancy, with somewhat higher weight with more symptoms (ß = 0.08; 95% CI = 0.04 to 0.13). The results were similar for stress in early and late pregnancy. CONCLUSIONS: We found no association between subjective distress and cortisol measures irrespective of when in pregnancy the measures were taken. Furthermore, we found no evidence for a longitudinal association between psychological measures of stress or cortisol with lower birth weight, birth weight for gestational age, or gestational age.

Induction of labour at 41 weeks of gestation versus expectant management and induction of labour at 42 weeks of gestation: A cost-effectiveness analysis.

OBJECTIVE: To assess the cost-effectiveness of induction of labour (IOL) at 41 weeks of gestation compared with expectant management until 42 weeks of gestation. DESIGN: A cost-effectiveness analysis alongside the Swedish Post-term Induction Study (SWEPIS), a multicentre, randomised controlled superiority trial. SETTING: Fourteen Swedish hospitals during 2016-2018. POPULATION: Women with an uncomplicated singleton pregnancy with a fetus in cephalic position were randomised at 41 weeks of gestation to IOL or to expectant management and induction at 42 weeks of gestation. METHODS: Health benefits were measured in life years and quality-adjusted life years (QALYs) for mother and child. Total cost per birth was calculated, including healthcare costs from randomisation to discharge after delivery, for mother and child. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in mean cost between the trial arms by the difference in life years and QALYs, respectively. Sampling uncertainty was evaluated using non-parametric bootstrapping. MAIN OUTCOME MEASURES: The cost per gained life year and per gained QALY. RESULTS: The differences in life years and QALYs gained were driven by the difference in perinatal mortality alone. The absolute risk reduction in mortality was 0.004 (from 6/1373 to 0/1373). Based on Swedish life tables, this gives a mean gain in discounted life years and QALYs of 0.14 and 0.12 per birth, respectively. The mean cost per birth was €4108 in the IOL group (n = 1373) and €4037 in the expectant management group (n = 1373), with a mean difference of €71 (95% CI -€232 to €379). The ICER for IOL compared with expectant management was €545 per life year gained and €623 per QALY gained. Confidence intervals were relatively wide and included the possibility that IOL had both lower costs and better health outcomes. CONCLUSIONS: Induction of labour at 41 weeks of gestation results in a better health outcome and no significant difference in costs. IOL is cost-effective compared with expectant management until 42 weeks of gestation using standard threshold values for acceptable cost per life year/QALY. TWEETABLE ABSTRACT: Induction of labour at 41 weeks of gestation is cost-effective compared with expectant management until 42 weeks of gestation.

Women's childbirth experiences in the Swedish Post-term Induction Study (SWEPIS): a multicentre, randomised, controlled trial.

OBJECTIVE: To compare childbirth experiences in women randomly assigned to either induction of labour at 41 weeks or to expectant management until 42 weeks, in the Swedish Post-term Induction Study. DESIGN: A register-based, multicentre, randomised, controlled, superiority trial. SETTING: Women were recruited at 14 hospitals in Sweden, 2016-2018. PARTICIPANTS: Women with an uncomplicated singleton pregnancy were recruited at 41 gestational weeks. INTERVENTIONS: The women were randomly assigned to induction of labour at 41 weeks (induction group, n=1381) or expectant management until 42 weeks (expectant management group, n=1379). OUTCOME MEASURES: As main outcome, women's childbirth experiences were measured using the Childbirth Experience Questionnaire version 2 (CEQ2), in 656 women, 3 months after the birth at three hospitals. As exploratory outcome, overall childbirth experience was measured in 1457 women using a Visual Analogue Scale (VAS 1-10) within 3 days after delivery at the remaining eleven hospitals. RESULTS: The total response rate was 77% (2113/2760). There were no significant differences in childbirth experience measured with CEQ2 between the groups (induction group, n=354; expectant management group, n=302) in the subscales: own capacity (2.8 vs 2.7, p=0.09), perceived safety (3.3 vs 3.2, p=0.06) and professional support (3.6 vs 3.5, p=0.38) or in the total CEQ2 score (3.3 vs 3.2, p=0.07), respectively. Women in the induction group scored higher in the subscale participation (3.6 vs 3.4, p=0.02), although with a small effect size (0.19). No significant difference was observed in overall childbirth experience according to VAS (8.0 (n=735) vs 8.1 (n=735), p=0.22). CONCLUSIONS: There were no differences in childbirth experience, according to CEQ2 or overall childbirth experience assessed with VAS, between women randomly assigned to induction of labour at 41 weeks or expectant management until 42 weeks. Overall, women rated their childbirth experiences high. TRIAL REGISTRATION NUMBER: ISRCTN26113652.

Efficacy and safety of oral misoprostol vs transvaginal balloon catheter for labor induction: An observational study within the SWEdish Postterm Induction Study (SWEPIS).

INTRODUCTION: Induction of labor is increasing. A common indication for induction of labor is late term and postterm pregnancy at 41 weeks or more. We aimed to evaluate if there are any differences regarding efficacy, safety, and women's childbirth experience between oral misoprostol and transvaginal balloon catheter for cervical ripening in women with a low-risk singleton pregnancy and induction of labor at 41+0 to 42+0 to 1 weeks of gestation. MATERIAL AND METHODS: In this observational study, based on data from the Swedish Postterm Induction Study (SWEPIS), a multicenter randomized controlled trial, a total of 1213 women with a low-risk singleton pregnancy at 41 to 42 weeks of gestation were induced with oral misoprostol (n = 744) or transvaginal balloon catheter (n = 469) at 15 Swedish delivery hospitals. The primary efficacy outcome was vaginal delivery within 24 h and primary safety outcomes were neonatal and maternal composite adverse outcomes. Secondary outcomes included time to vaginal delivery and mode of delivery. Women's childbirth experience was assessed with the Childbirth Experience Questionnaire (CEQ 2.0) and visual analog scale. We present crude and adjusted mean differences and relative risks (RR) with 95% CI. Adjustment was performed for a propensity score based on delivery hospital and baseline characteristics including Bishop score. RESULTS: Vaginal delivery within 24 h was significantly lower in the misoprostol group compared with the balloon catheter group (46.5% [346/744] vs 62.7% [294/469]; adjusted RR 0.76 95% CI 0.640.89]). Primary neonatal and maternal safety outcomes did not differ between groups (neonatal composite 3.5% [36/744] vs 3.2% [15/469]; adjusted RR 0.77 [95% CI 0.31-1.89]; maternal composite 2.3% [17/744] vs 1.9% [9/469]; adjusted RR 1.70 [95% CI 0.58-4.97]). Adjusted mean time to vaginal delivery was increased by 3.8 h (95% CI 1.3-6.2 h) in the misoprostol group. Non-operative vaginal delivery and cesarean delivery rates did not differ. Women's childbirth experience was positive overall and similar in both groups. CONCLUSIONS: Induction of labor with oral misoprostol compared with a transvaginal balloon catheter was associated with a lower probability of vaginal delivery within 24 h and a longer time to vaginal delivery. However, primary safety outcomes, non-operative vaginal delivery, and women's childbirth experience were similar in both groups. Therefore, both methods can be recommended in women with low-risk postdate pregnancies.

Maternal asthma and early fetal growth, the MAESTRO study.

BACKGROUND: Several maternal conditions can affect fetal growth, and asthma during pregnancy is known to be associated with lower birth weight and shorter gestational age. OBJECTIVE: In a new Swedish cohort study on maternal asthma exposure and stress during pregnancy (MAESTRO), we have assessed if there is evidence of early fetal growth restriction in asthmatic women or if a growth restriction might come later during pregnancy. METHODS: We recruited women from eight antenatal clinics in Stockholm, Sweden. Questionnaires on background factors, asthma status and stress were assessed during pregnancy. The participants were asked to consent to collection of medical records including ultrasound measures during pregnancy, and linkage to national health registers. In women with and without asthma, we studied reduced or increased growth by comparing the second-trimester ultrasound with first-trimester estimation. We defined reduced growth as estimated days below the 10th percentile and increased growth as days above the 90th percentile. At birth, the weight and length of the newborn and the gestational age was compared between women with and without asthma. RESULTS: We enrolled 1693 participants in early pregnancy and collected data on deliveries and ultrasound scans in 1580 pregnancies, of which 18% of the mothers had asthma. No statistically significant reduced or increased growth between different measurement points were found when women with and without asthma were compared; adjusted odds ratios for reduced growth between first and second trimester 1.11 95% CI (0.63-1.95) and increased growth 1.09 95% CI (0.68-1.77). CONCLUSION AND CLINICAL RELEVANCE: In conclusion, we could not find evidence supporting an influence of maternal asthma on early fetal growth in the present cohort: Although the relatively small sample size, which may enhance the risk of a type II error, it is concluded that a potential difference is likely to be very small.

Induction of labour at 41 weeks or expectant management until 42 weeks: A systematic review and an individual participant data meta-analysis of randomised trials.

BACKGROUND: The risk of perinatal death and severe neonatal morbidity increases gradually after 41 weeks of pregnancy. Several randomised controlled trials (RCTs) have assessed if induction of labour (IOL) in uncomplicated pregnancies at 41 weeks will improve perinatal outcomes. We performed an individual participant data meta-analysis (IPD-MA) on this subject. METHODS AND FINDINGS: We searched PubMed, Excerpta Medica dataBASE (Embase), The Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and PsycINFO on February 21, 2020 for RCTs comparing IOL at 41 weeks with expectant management until 42 weeks in women with uncomplicated pregnancies. Individual participant data (IPD) were sought from eligible RCTs. Primary outcome was a composite of severe adverse perinatal outcomes: mortality and severe neonatal morbidity. Additional outcomes included neonatal admission, mode of delivery, perineal lacerations, and postpartum haemorrhage. Prespecified subgroup analyses were conducted for parity (nulliparous/multiparous), maternal age (<35/≥35 years), and body mass index (BMI) (<30/≥30). Aggregate data meta-analysis (MA) was performed to include data from RCTs for which IPD was not available. From 89 full-text articles, we identified three eligible RCTs (n = 5,161), and two contributed with IPD (n = 4,561). Baseline characteristics were similar between the groups regarding age, parity, BMI, and higher level of education. IOL resulted overall in a decrease of severe adverse perinatal outcome (0.4% [10/2,281] versus 1.0% [23/2,280]; relative risk [RR] 0.43 [95% confidence interval [CI] 0.21 to 0.91], p-value 0.027, risk difference [RD] -57/10,000 [95% CI -106/10,000 to -8/10,000], I2 0%). The number needed to treat (NNT) was 175 (95% CI 94 to 1,267). Perinatal deaths occurred in one (<0.1%) versus eight (0.4%) pregnancies (Peto odds ratio [OR] 0.21 [95% CI 0.06 to 0.78], p-value 0.019, RD -31/10,000, [95% CI -56/10,000 to -5/10,000], I2 0%, NNT 326, [95% CI 177 to 2,014]) and admission to a neonatal care unit ≥4 days occurred in 1.1% (24/2,280) versus 1.9% (46/2,273), (RR 0.52 [95% CI 0.32 to 0.85], p-value 0.009, RD -97/10,000 [95% CI -169/10,000 to -26/10,000], I2 0%, NNT 103 [95% CI 59 to 385]). There was no difference in the rate of cesarean delivery (10.5% versus 10.7%; RR 0.98, [95% CI 0.83 to 1.16], p-value 0.81) nor in other important perinatal, delivery, and maternal outcomes. MA on aggregate data showed similar results. Prespecified subgroup analyses for the primary outcome showed a significant difference in the treatment effect (p = 0.01 for interaction) for parity, but not for maternal age or BMI. The risk of severe adverse perinatal outcome was decreased for nulliparous women in the IOL group (0.3% [4/1,219] versus 1.6% [20/1,264]; RR 0.20 [95% CI 0.07 to 0.60], p-value 0.004, RD -127/10,000, [95% CI -204/10,000 to -50/10,000], I2 0%, NNT 79 [95% CI 49 to 201]) but not for multiparous women (0.6% [6/1,219] versus 0.3% [3/1,264]; RR 1.59 [95% CI 0.15 to 17.30], p-value 0.35, RD 27/10,000, [95% CI -29/10,000 to 84/10,000], I2 55%). A limitation of this IPD-MA was the risk of overestimation of the effect on perinatal mortality due to early stopping of the largest included trial for safety reasons after the advice of the Data and Safety Monitoring Board. Furthermore, only two RCTs were eligible for the IPD-MA; thus, the possibility to assess severe adverse neonatal outcomes with few events was limited. CONCLUSIONS: In this study, we found that, overall, IOL at 41 weeks improved perinatal outcome compared with expectant management until 42 weeks without increasing the cesarean delivery rate. This benefit is shown only in nulliparous women, whereas for multiparous women, the incidence of mortality and morbidity was too low to demonstrate any effect. The magnitude of risk reduction of perinatal mortality remains uncertain. Women with pregnancies approaching 41 weeks should be informed on the risk differences according to parity so that they are able to make an informed choice for IOL at 41 weeks or expectant management until 42 weeks. Study Registration: PROSPERO CRD42020163174.

Characteristics and short-term obstetric outcomes in a case series of 67 women test-positive for SARS-CoV-2 in Stockholm, Sweden.

INTRODUCTION: The Stockholm region was the first area in Sweden to be hit by the pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The national guidelines on the care of women with a positive test for SARS-CoV-2 (detection with polymerase chain reaction [PCR]) recommend individualized antenatal care, mode of delivery based on obstetric considerations, and no routine separation of the mother and the newborn. Breastfeeding is encouraged, and although there is no specific recommendation regarding wearing a face mask to prevent viral transmission to the newborn while nursing, instructions are given to keep high hygiene standards. All studies based on cases tested on hospital admission will capture more women with pregnancy complications than in the general population. Our aim was to describe the clinical characteristics of SARS-CoV-2-positive women and their neonates, and to report short-term maternal and neonatal outcomes. MATERIAL AND METHODS: A retrospective case series with data from medical records including all test-positive women (n = 67) who gave birth to 68 neonates from 19 March to 26 April 2020 in Stockholm, Sweden. Means, proportions and percentages were calculated for clinical characteristics and outcomes. RESULTS: The mean age was 32 years, 40% were nulliparous and 61% were overweight or obese. Further, 15% had diabetes and 21% a hypertensive disease. Seventy percent of the women had a vaginal birth. Preterm delivery occurred in 19% of the women. The preterm deliveries were mostly medically indicated, including two women who were delivered preterm due to severe coronavirus disease 19 (COVID-19), corresponding to 15% of the preterm births. Four women (6%) were admitted to the intensive care unit postpartum but there were no maternal deaths. There were two perinatal deaths (one stillbirth and one neonatal death). Three neonates were PCR-positive for SARS-CoV-2 after birth. CONCLUSIONS: In this case series of 67 women testing positive for SARS-CoV-2 with clinical presentations ranging from asymptomatic to manifest COVID-19 disease, few women presented with severe COVID-19 illness. The majority had a vaginal birth at term with a healthy neonate that was negative for SARS-CoV-2.

Risk of negative birth experience in trial of labor after cesarean delivery: A population-based cohort study.

BACKGROUND: To improve care for women going through trial of labor after cesarean (TOLAC), we need to understand their birth experience better. We investigated the association between mode of delivery on birth experience in second birth among women with a first cesarean. METHODS: A population-based cohort study based on the Swedish Pregnancy Register with 808 women with a first cesarean and eligible for TOLAC in 2014-2017. Outcomes were mean birth experience measured by visual analogue scale (VAS) score from 1-10 and having a negative birth experience defined as VAS score ≤5. Linear and logistic regression analyses were performed with ß-estimates and odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Mean VAS score among women with an elective repeat cesarean (n = 251 (31%)), vaginal birth (n = 388 (48%)) or unplanned repeat cesarean (n = 169 (21%)) in second birth were 8.8 (standard deviation SD 1.4), 8.0 (SD 2.0) and 7.6 (SD 2.1), respectively. Compared to women having an elective repeat cesarean, women having an unplanned repeat cesarean delivery had five-fold higher odds of negative birth experience (adjusted OR 5.0, 95% CI 1.5-16.5). Women having a first elective cesarean and a subsequent unplanned repeat cesarean delivery had the highest odds of negative birth experience (crude OR 7.3, 95% CI 1.5-35.5). CONCLUSIONS: Most women with a first cesarean scored their second birth experience as positive irrespective of mode of delivery. However, the odds of a negative birth experience increased among women having an unplanned repeat cesarean delivery, especially when the first cesarean delivery was elective.

Testing the waters - A cross-sectional survey of views about waterbirth among Swedish health professionals.

BACKGROUND: For women with low risk births, waterbirth is an alternative that is requested and provided in approximately a hundred countries. However, in some countries, including Sweden, waterbirth is not generally available. AIM: To explore the experiences, knowledge and attitudes regarding waterbirth among midwives, obstetricians/gynaecologists and neonatologists. METHODS: A cross-sectional study was conducted in Sweden, using a web-based survey distributed via The Swedish Association of Midwives and the Heads of department of all Swedish maternity wards between April and June 2016. The respondents (n = 1609) answered a combination of Likert-scale and open-ended questions. The responses were analysed with descriptive statistics and quantitative content analyses. FINDINGS: Both midwives and physicians stated a lack of experience, knowledge and clinical guidelines related to attending and assisting waterbirths. Overall, midwives had more positive attitudes to waterbirth (38.8% vs 4.5%) as well as towards providing and implementing waterbirth, compared to physicians (71.0% vs 14.9%). Midwives stated significantly more benefits and fewer risks for women and babies, compared to physicians who requested more evidence. CONCLUSIONS: Opinions regarding waterbirth are to some extent based on attitudes rather than actual experience and knowledge. There are diverse interpretations of the strength of evidence and a lack of updating in the research field of waterbirth. As waterbirth is requested by women, health professionals need to update their knowledge in this topic in order to give coherent and evidence-based information and care to prospective parents.

Induction of labour at 41 weeks versus expectant management and induction of labour at 42 weeks (SWEdish Post-term Induction Study, SWEPIS): multicentre, open label, randomised, superiority trial.

OBJECTIVE: To evaluate if induction of labour at 41 weeks improves perinatal and maternal outcomes in women with a low risk pregnancy compared with expectant management and induction of labour at 42 weeks. DESIGN: Multicentre, open label, randomised controlled superiority trial. SETTING: 14 hospitals in Sweden, 2016-18. PARTICIPANTS: 2760 women with a low risk uncomplicated singleton pregnancy randomised (1:1) by the Swedish Pregnancy Register. 1381 women were assigned to the induction group and 1379 were assigned to the expectant management group. INTERVENTIONS: Induction of labour at 41 weeks and expectant management and induction of labour at 42 weeks. MAIN OUTCOME MEASURES: The primary outcome was a composite perinatal outcome including one or more of stillbirth, neonatal mortality, Apgar score less than 7 at five minutes, pH less than 7.00 or metabolic acidosis (pH <7.05 and base deficit >12 mmol/L) in the umbilical artery, hypoxic ischaemic encephalopathy, intracranial haemorrhage, convulsions, meconium aspiration syndrome, mechanical ventilation within 72 hours, or obstetric brachial plexus injury. Primary analysis was by intention to treat. RESULTS: The study was stopped early owing to a significantly higher rate of perinatal mortality in the expectant management group. The composite primary perinatal outcome did not differ between the groups: 2.4% (33/1381) in the induction group and 2.2% (31/1379) in the expectant management group (relative risk 1.06, 95% confidence interval 0.65 to 1.73; P=0.90). No perinatal deaths occurred in the induction group but six (five stillbirths and one early neonatal death) occurred in the expectant management group (P=0.03). The proportion of caesarean delivery, instrumental vaginal delivery, or any major maternal morbidity did not differ between the groups. CONCLUSIONS: This study comparing induction of labour at 41 weeks with expectant management and induction at 42 weeks does not show any significant difference in the primary composite adverse perinatal outcome. However, a reduction of the secondary outcome perinatal mortality is observed without increasing adverse maternal outcomes. Although these results should be interpreted cautiously, induction of labour ought to be offered to women no later than at 41 weeks and could be one (of few) interventions that reduces the rate of stillbirths. TRIAL REGISTRATION: Current Controlled Trials ISRCTN26113652.

[Maternal deaths in Sweden: Diagnostics and clinical management could be improved]. / Mödradöd i Sverige: Vården hade många gånger kunnat vara bättre - Lärdomar från 11 års extern kollegial granskning.

MM-ARG, the Swedish maternal maternity mortality group within SFOG (Swedish Society of Obstetrics and Gynecology) has, since 2008, surveyed and analysed maternal deaths in Sweden with the aim to find and give feedback on lessons learned to the medical professions.  MM-ARG consists of obstetricians, midwives and anesthetists and the strength of the working model is that the profession itself takes responsibility for the scrutiny.  A summary of 67 known maternal deaths from 2007‒2017 is presented. Direct causes of death are dominated by hypertensive disease/preeclampsia, followed by thromboembolic disease, sepsis and obstetric bleeding. Indirect death, where a known or unknown underlying disease is exacerbated by pregnancy, is dominated by cardiovascular disease. This review shows that the diagnostics and clinical management could be improved. Besides obstetrics/gynecology, maternal mortality affects other specialties and thus holds important lessons to many.

[Preterm delivery: an overview on prediction, prevention and treatment]. / Prediktion, prevention och behandlingsmetoder.

Due to a low level of understanding of mechanisms involved in spontaneous preterm delivery there is a lack of reliable biomarkers. Existing biomarkers have a low positive predictive value but a high negative predictive value. Use of tests with high negative predictive value will reduce unnecessary interventions and hospitalization of women with threatening preterm delivery. When given to the right pregnant women, antenatal corticosteroid treatment are still the most important obstetrical intervention and reduces both neonatal mortality and short- and long-term morbidity.Several ongoing national Swedish multicenter studies may increase the understanding of the roles of cervical length, preeclampsia screening and magnesium sulfate dosage in the context of preterm delivery in a Nordic setting. Major development has been achieved in prediction and prevention of preterm preeclampsia at the cost of a 10% screen positive rate.

Women's experiences of waterbirth compared with conventional uncomplicated births.

OBJECTIVE: To compare childbirth experiences between women having a waterbirth and women having an uncomplicated conventional birth. DESIGN: A prospective cohort study using the validated Childbirth Experience Questionnaire (CEQ) six weeks postpartum. The 22-item questionnaire assesses four domains of the childbirth experience; Own capacity, Professional support, Perceived safety and Participation. These four domains constituted the main outcome of the study. Further, supplementary questions about the second stage of labour were added to the web-questionnaire. SETTING: One city-located hospital in Stockholm and one small-town hospital in Southern Sweden offering waterbirth to low risk women. PARTICIPANTS: 215 women; 99 nulli- and 116 multiparas. 111 gave birth in water and 104 had an uncomplicated conventional birth. MEASUREMENTS AND FINDINGS: The total CEQ score did not differ between the groups, while women having a waterbirth scored significantly higher in the domain, "Own capacity" and lower in the domain, "Professional support". Women having a waterbirth rated less pain and higher scores of being in control in the second stage of labour. KEY CONCLUSIONS: A waterbirth seems to empower and enhance women's capacity for those who choose this alternative. Waterbirth can improve their birth experience and can possibly make women less dependent on the midwife. IMPLICATIONS FOR PRACTICE: To provide waterbirth could be a way of empowering women and giving them a positive birth experience.

Maternal anxiety, depression and asthma and adverse pregnancy outcomes - a population based study.

To evaluate associations between maternal anxiety or depression and adverse pregnancy outcomes, taking possible familial confounding and interaction with asthma into account, we conducted a cohort study of all singleton births in Sweden 2001-2013. We retrieved information about pregnancy, diagnoses of anxiety/depression, asthma, and prescribed medication from the Swedish Medical Birth, National Patient, and Prescribed Drug Registers. We estimated associations with regression models, performed cousin and sibling comparisons, and calculated interactions. In 950 301 identified pregnancies; 5.9% had anxiety/depression and 4.0% had asthma. Anxiety/depression was associated with adverse pregnancy outcomes (e.g. preeclampsia, adjusted Odds Ratio 1.17 (95% Confidence Interval 1.12, 1.22), instrumental delivery (1.14 (1.10, 1.18)), elective (1.62 (1.57, 1.68)) and emergency (1.32 (1.28, 1.35)) caesarean section (CS)). Their children had lower birth weight (-54 g (-59, -49)) and shorter gestational age (-0.29 weeks (-0.31, -0.28)). Associations were not confounded by familial factors and asthma did not modify the effect of anxiety/depression for outcomes other than elective CS, p < 0.001. In women with anxiety/depression diagnosis, untreated women had higher odds of elective CS compared to women on medication (1.30 (1.17, 1.43)). In conclusion, anxiety/depression should be considered when evaluating pregnant women's risk of complications such as preeclampsia and non-vaginal deliveries.