Use of contraception and attitudes towards contraceptive use in Swedish women: an internet-based nationwide survey.

PURPOSE: Explore contraceptive use, unmet need of and attitudes towards contraceptive use in Sweden. Secondly, to investigate knowledge of contraceptives, prevalence and outcomes of unintended pregnancies. MATERIALS AND METHODS: Internet based e-survey of Swedish women aged 16-49. The e-survey contained 49 questions with both spontaneous and multi-choice character on demographics, contraceptive use, knowledge of and attitudes towards contraception, importance of monthly bleeding, and experience of unintended pregnancy. The e-survey was closed when reaching the estimated sample size of 1000 respondents. RESULTS: A total of 1016 women participated, whereof 62.4% used contraception, 31.8% did not and 5.8% had stopped in the last 12 months. Unmet need for contraception was estimated at 17.2%. At least one unintended pregnancy was experienced by 19.9%. All women rated effectiveness as the most important characteristic of a contraceptive method. CONCLUSIONS: Use of contraception in Swedish women remains low, 62.4%, and the unmet need for contraception has increased to 17.2%. Method effectiveness and health benefits of hormonal contraception should be emphasised during contraceptive counselling, and actions are needed to target groups with low use of effective contraception as well as to reach those who never seek contraception.KEY MESSAGEClose to one third of Swedish women do not use contraception and one fifth have experienced at least one unintended pregnancy. Unmet need for contraception is high despite easy access and subsidies for young women.

Is there an increased risk of cesarean section in obese women after induction of labor? A retrospective cohort study.

BACKGROUND: Obesity is increasing in Sweden and is also of huge global concern. Obesity increases the risk of complications during pregnancy and the need for the induction of labor. Induction of labor increases the number of complications during delivery, leading to women with more negative birth experience. This study investigated how maternal body mass index (BMI) during antenatal care enrollment affects labor outcomes (proportion of cesarean section at induction of labor). METHOD: This was a retrospective cohort study of 3772 women with mixed parity and induction of labor at Soderhospital, Stockholm, in 2009-2010 and 2012-2013. The inclusion criteria were simplex, ≥34 gestational weeks, cephalic presentation and no previous cesarean section. The women were grouped according to BMI, and statistical analyzes were performed to compare the proportion of cesarean sections after induction of labor. The primary outcome was the proportion of cesarean section after induction of labor divided by group of maternal BMI. The secondary outcomes were postpartum hemorrhage >1000 ml, time of labor, fetal outcome data, and indication for emergency cesarean section. RESULT: The induction of labor in women with a high BMI resulted in a significantly increased risk of cesarean section, with 18.4-24.1% of deliveries, depending on the BMI group. This outcome persisted after adjustment in women with BMI 25-29.9 (aOR 1.4; 95% CI; 1.1-1.7) and BMI 30-34.9 (aOR 1.5; 95% CI; 1.1-2.1). There was also a significantly higher risk for CS among primiparous women (aOR 3.6; 95% CI; 2.9-45) and if the newborn weighted ≥ four kilos (aOR 1.6; 95% CI; 1.3-2.0). CONCLUSION: Our findings show that a higher BMI increased the risk of cesarean section after induction of labor in the groups with BMI 25-34.9. Parity seems to be the strongest risk factor for CS regardless other variables.

Body mass index and labor outcome associated with the level of amniotic fluid lactate. A cross-sectional study of women with labor dystocia.

INTRODUCTION: Obesity is a globally growing problem. Labor dystocia is associated with obstetric complications, especially among obese pregnant women. Previous studies have shown an association between the level of lactate produced by uterine myocytes during contractions and the level of lactate in the amniotic fluid (AFL). A relationship between a high level of AFL and labor dystocia has also been demonstrated. However, it is still unknown whether the observation applies to all women with labor dystocia, regardless of body mass index (BMI). Aims: This study investigated whether there was any difference in the level of AFL in the three BMI groups and whether there was a difference in labor outcomes between high and low AFL in the different groups. MATERIALS AND METHODS: This cross-sectional study included 1683 women from three different countries. Healthy nulliparous women in active labor were included, and they were grouped according to BMI as normal weighted (<25), overweight (≥25-29), and obese (≥30), respectively. AFL was categorized as high (≥10.1 mmol/l) and low (<10.1 mmol/l). The main outcome was the frequency of cesarean section. RESULTS: No difference in AFL levels was found between the three BMI groups at delivery (mean values of 8.2 vs. 8.3 vs. 8.4 mmol/l, p = .3). Obese women with high AFL had a higher frequency of cesarean section than normal-weighted women (16.2 vs. 20.7 vs. 29.2%). Other risk factors associated with cesarean section varied among the different BMI groups. CONCLUSIONS: This study showed no difference in the mean level of AFL between women with different BMIs. Further, high AFL was associated with a higher frequency of cesarean section in all three BMI groups, suggesting that the level of AFL can in the future be used as a predictor of labor outcome among women with labor dystocia despite their BMI.

Women's expectations and experiences of labor induction - a questionnaire-based analysis of a randomized controlled trial.

BACKGROUND: Although labor induction is a commonly used procedure in obstetrical care, there are limited data on its psycho-emotional effects on the woman. This study analysed the expectations and experiences of women in different routes of labor induction. The study's primary aim was to compare women's delivery experience if induced by orally administrated misoprostol (OMS) compared with misoprostol vaginal insert (MVI). Secondly, an evaluation of women's general satisfaction with induced labor was made, and factors associated with a negative experience. METHODS: Primiparous women (n = 196) with a singleton fetus in cephalic presentation, ≥ 37 weeks of gestation, with a Bishop's score ≤ 4 planning labor induction were randomly allocated to receive either OMS (Cytotec®) or MVI (Misodel®). Data were collected by validated questionnaires, the Wijma Delivery Expectation/Experience Questionnaire (A + B). The pre-labor part of the survey (W-DEQ version A) was given to participants to complete within 1 hour before the start of induction, and the post-labor part of the questionnaire (W-DEQ version B) was administered after birth and collected before the women were discharged from hospital. RESULTS: It was found that 11.8% (17/143) reported a severe fear of childbirth (W-DEQ A score ≥ 85). Before the induction, women with extreme fear had 3.7 times increased risk of experiencing labor induction negatively (OR 3.7 [95% CI, 1.04-13.41]). CONCLUSION: No difference was identified between OMS and MVI when delivery experience among women induced to labor was analysed. Severe fear of childbirth before labor was a risk factor for a negative experience of labor induction. TRIAL REGISTRATION: Clinical trial register number NCT02918110 . Date of registration on May 31, 2016.

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.

Induction of labor after one previous Cesarean section in women with an unfavorable cervix: A retrospective cohort study.

OBJECTIVE: Uterine rupture is a well-known but unusual complication in vaginal deliveries with a Cesarean section in the history. The risk of uterine rupture is at least two-fold when labor is induced. In Sweden, women are allowed to deliver vaginally after one previous Cesarean section, regardless if labor starts spontaneously or is induced. The aim of the study is to compare the proportion of uterine ruptures between the three methods (balloon catheter, Minprostin® and Cytotec®) for induction of labor in women with an unfavorable cervix and one previous Cesarean section. MATERIAL AND METHODS: Retrospective cohort study of all women with one previous Cesarean section and induction of labor with an unfavorable cervix at the four largest clinics in Stockholm during 2012-2015. Inclusion criteria: Women with a previous Cesarean section and induction of labor with a viable fetus, cephalic presentation, singleton, at ≥34 w, (n = 910). RESULTS: 3.0% (27/910) of the women with induction of labor had a uterine rupture, 91% of them had no previous vaginal delivery. The proportion of uterine ruptures was 2.0% (6/295) with orally administrated Cytotec®, 2.1% (7/335) with balloon catheter and 5.0% (14/ 281) when Minprostin® was used. CONCLUSIONS: No difference in the proportion of uterine ruptures was shown when orally administrated Cytotec® and balloon catheter were compared (p = 0.64). Orally administrated Cytotec® and balloon catheter give a high success rate of vaginal deliveries (almost 70%) despite an unfavorable cervix.

Labor Induction with Orally Administrated Misoprostol: A Retrospective Cohort Study.

INTRODUCTION: One great challenge in obstetric care is labor inductions. Misoprostol has advantages in being cheap and stable at room temperature and available in resource-poor settings. MATERIAL AND METHODS: Retrospective cohort study of 4002 singleton pregnancies with a gestational age ≥34 w at Sodersjukhuset, Stockholm, during 2009-2010 and 2012-2013. Previously used methods of labor induction were compared with misoprostol given as a solution to drink, every second hour. Main outcome is as follows: Cesarean Section (CS) rate, acid-base status in cord blood, Apgar score < 7,5', active time of labor, and blood loss > 1500 ml (PPH). RESULTS: The proportion of CS decreased from 26% to 17% when orally given solution of misoprostol was introduced at the clinic (p < 0.001). No significant difference in the frequency of low Apgar score (p = 0.3), low aPh in cord blood (p = 0.1), or PPH (p = 0.4) between the different methods of induction was studied. After adjustment for different risk factor for CS the only method of induction which was associated with CS was dinoproston⁎⁎ (Propess®) (aor = 2.9 (1.6-5.2)). CONCLUSION: Induction of labor with misoprostol, given as an oral solution to drink every second hour, gives a low rate of CS, without affecting maternal or fetal outcome.

Induction of labor in women with a uterine scar.

OBJECTIVE: To evaluate the frequency of uterine rupture following induction of labor in women with a previous cesarean section. Misoprostol was compared to other methods of induction. METHODS: A retrospective cohort study of 208 women attempting induction of labor after one previous cesarean section. Delivery data were collected retrospectively and compared. Group 1(2009-2010) was compared with Group 2 (2012-2013). In Group 1, the main method of induction was vaginal PGE2 (prostaglandin-E2), amniotomy, oxytocin or a balloon catheter. In Group 2, the dominant method of induction was an oral solution of misoprostol. MAIN OUTCOME MEASURES: frequency of uterine rupture in the two groups. RESULTS: Nine cases (4.3%) of uterine rupture occurred. There was no significant difference in the frequency of uterine rupture following the change of method of induction from PGE2, amniotomy, oxytocin or mechanical dilatation with a balloon catheter to orally administered misoprostol (4.1 versus 4.6%, p = 0.9). All ruptures occurred in women with no prior vaginal delivery. CONCLUSION: The shift to oral misoprostol as the primary method of induction in women with a previous cesarean section did not increase the frequency of uterine rupture in the cohort studied.

Skin conductance activity in post-term pregnancies.

OBJECTIVE: The pain threshold in humans rises during late pregnancy, and the woman becomes less sensitive to stress. The aim of this study was to investigate whether monitoring the sympathetic nervous system response to stimuli by skin conductance activity might be a useful predictor of spontaneous onset of labour in post-term pregnancies. STUDY DESIGN: A prospective observational study. Fifty-two healthy pregnant women were consecutively asked for inclusion in the study at their post-term pregnancy examination. Initially, a Ctg (cardiotocography) registration was performed, followed by 5 min of skin conductance measurement including a "cold pressor test". Finally, a vaginal examination with a cervical assessment were performed according to clinical guidelines. RESULTS: A statistically significant lower pain reaction during the period of provocation was seen in deliveries close to spontaneous onset of labour compared with induced deliveries with an non-spontaneous onset of labour before 294 days (p = 0.02). Sixty-three per cent (19/30) of the women with spontaneous onset had a negative value at provocation compared with 30% (6/20) in the induced group. CONCLUSIONS: Decreased response to pain stimuli, as an indication of decreased activity in the sympathetic nervous system, has a correlation to spontaneous onset of labour in post-term pregnancies.