Induction of labor and cesarean birth in lower-risk nulliparous women at term: A retrospective cohort study.

OBJECTIVE: To evaluate whether induction of labor (IOL) is associated with cesarean birth (CB) and perinatal mortality in uncomplicated first births at term compared with expectant management outside the confines of a randomized controlled trial. METHODS: Population-based retrospective cohort study of all births in Victoria, Australia, from 2010 to 2018 (n = 640,191). Preliminary analysis compared IOL at 37 weeks with expectant management at that gestational age and beyond for uncomplicated pregnancies. Similar comparisons were made for IOL at 38, 39, 40, and 41 weeks of gestation and expectant management. The primary analysis repeated these comparisons, limiting the population to nulliparous women with uncomplicated pregnancies and excluding those with a medical indication for IOL. We compared perinatal mortality between groups using Chi-square tests and multivariable logistic regression for all other comparisons. Adjusted odds ratios and 99% confidence intervals were reported. p < 0.01 denoted statistical significance. RESULTS: Among nulliparous, uncomplicated pregnancies at ≥37 weeks of gestation in Victoria, IOL increased from 24.6% in 2010 to 30.0% in 2018 (p < 0.001). In contrast to the preliminary analysis, the primary analysis showed that IOL in lower-risk nulliparous women was associated with increased odds of CB when performed at 38 (aOR 1.23(1.13-1.32)), 39 (aOR 1.31(1.23-1.40)), 40 (aOR 1.42(1.35-1.50)), and 41 weeks of gestation (aOR 1.43(1.35-1.51)). Perinatal mortality was rare in both groups and non-significantly lower in the induced group at most gestations. DISCUSSION: For lower-risk nulliparous women, the odds of CB increased with IOL from 38 weeks of gestation, along with decreased odds of perinatal mortality at 41 weeks only.

Designing a Midwife-Led Birth Center Program Based on the MAP-IT Model: A Sequential Explanatory Mixed-Methods Study.

BACKGROUND: In recent decades, medical supervision of the labor and delivery process has expanded beyond its boundaries to the extent that in many settings, childbirth has become a medical event. This situation has influenced midwifery care. One of the significant barriers to midwives providing care to pregnant women is the medicalization of childbirth. So far, the policies and programs of the Ministry of Health to reduce medical interventions and cesarean section rates have not been successful. Therefore, the current study aims to be conducted with the purpose of "Designing a Midwife-Led Birth Center Program Based on the MAP-IT Model". METHODS/DESIGN: The current study is a mixed-methods sequential explanatory design by using the MAP-IT model includes 5 steps: Mobilize, Assess, Plan, Implement, and Track, providing a framework for planning and evaluating public health interventions in a community. It will be implemented in three stages: The first phase of the research will be a cross-sectional descriptive study to determine the attitudes and preferences towards establishing a midwifery-led birthing center focusing on midwives and women of childbearing age by using two researcher-made questionnaires to assess the participants' attitudes and preferences toward establishing a midwifery-led birthing center. Subsequently, extreme cases will be selected based on the participants' average attitude scores toward establishing a midwifery-led birthing center in the quantitative section. In the second stage of the study, qualitative in-depth interviews will be conducted with the identified extreme cases from the first quantitative phase and other stakeholders (the first and second steps of the MAP-IT model, namely identifying and forming a stakeholder coalition, and assessing community resources and real needs). In this stage, the conventional qualitative content analysis approach will be used. Subsequently, based on the quantitative and qualitative data obtained up to this stage, a midwifery-led birthing center program based on the third step of the MAP-IT model, namely Plan, will be developed and validated using the Delphi method. DISCUSSION: This is the first study that uses a mixed-method approach for designing a midwife-led maternity care program based on the MAP-IT model. This study will fill the research gap in the field of improving midwife-led maternity care and designing a program based on the needs of a large group of pregnant mothers. We hope this program facilitates improved eligibility of midwifery to continue care to manage and improve their health easily and affordably. ETHICAL CODE: IR.MUMS.NURSE.REC. 1403. 014.

In recent decades, medical management of the labor and delivery process has extended beyond its limitations to the extent that in many settings, childbirth has become a medical event. This situation has influenced midwifery care. The global midwifery situation indicates that one in every five women worldwide gives birth without the support of a skilled attendant. One of the significant barriers to midwives providing care to pregnant women is the medicalization of childbirth. In industrialized countries, maternal and infant mortality rates have decreased over the past 60 years due to medical or social reasons. So far, the policies and programs of the Ministry of Health to diminish medical interventions and cesarean section rates have not been successful. Midwifery models in hospital care contain midwives who support women's choices and diverse ideas about childbirth on the one hand, and on the other hand, they must adhere to organizational guidelines as employees, primarily based on a medical and pathological approach rather than a health-oriented and midwifery perspective. Therefore, the current study aims to be conducted with the purpose of "Designing a midwifery-led birth centered maternity program based on the MAP-IT model". It is a Model for Implementing Healthy People 2030, (Mobilize, Assess, Plan, Implement, Track), a step-by-step method for creating healthy communities. Using MAP-IT can help public health professionals and community changemakers implement a plan that is tailored to a community's needs and assets.

Reference ranges of uterine artery pulsatility index from first to third trimester based on serial Doppler measurements: longitudinal cohort study.

OBJECTIVE: To provide gestational-age (GA)-specific reference ranges for mean uterine artery (UtA) pulsatility index (PI) based on longitudinal data assessment throughout pregnancy. METHODS: This was a prospective longitudinal cohort study of singleton low-risk pregnancies with adequate health and nutritional status at the time of enrolment and without fetal anomaly, receiving prenatal care between January 2018 and July 2021 at the Maternal Fetal Medicine Unit of IRCCS San Raffaele Scientific Institute, Milan, Italy. Women were recruited at ≤ 12 + 6 weeks' gestation and underwent serial standardized ultrasound monitoring, including UtA-PI measurement, by experienced certified operators until delivery. Association of UtA-PI with GA was modeled with fractional polynomial regression. Equations for mean ± SD of the estimated curves were calculated, as well as GA-specific reference charts of centiles for UtA-PI from 10 + 0 to 39 + 0 gestational weeks. RESULTS: We included 476 healthy, low-risk pregnant women and a total of 2045 ultrasound scans (median, 4 (range, 3-9) per patient) were available for analysis. Mean UtA-PI was 1.84 ± 0.55, 1.07 ± 0.38 and 0.78 ± 0.23 in the first, second and third trimesters of pregnancy, respectively. Goodness-of-fit assessment revealed that second-degree smoothing was the most accurate fractional polynomial for describing the course of UtA-PI throughout gestation; therefore, it was modeled in a multilevel framework for the construction of UtA-PI curves. We observed a rapid and substantial decrease in mean UtA-PI before 16 weeks, with subsequent smoother decrement of the slope and more stable values from 20 until 39 weeks. The 3rd , 5th , 10th , 25th , 50th , 75th , 90th , 95th and 97th centiles according to GA for UtA-PI are provided, as well as equations to allow calculation of any value as a centile. CONCLUSIONS: UtA-PI shows a progressive non-linear decrease throughout pregnancy. The new reference ranges for GA-specific mean UtA-PI constructed using rigorous methodology may have a better performance compared with previous models for screening for placenta-associated diseases in the early stages of pregnancy and for evaluating the potential risk for pregnancy-induced hypertension and/or small-for-gestational age later in pregnancy. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Adverse infant outcomes following low-risk pregnancies in England: a retrospective cohort study.

BACKGROUND: There are limited data describing adverse infant outcomes in infants born to women with a low risk of complications during pregnancy, such as those who may be enrolled in maternal immunization trials. This retrospective study estimated incidence proportions of infant outcomes in different cohorts of liveborn infants in England between 2005 and 2017. METHODS: The incidence proportions of 10 infant outcomes were calculated for liveborn infants from pregnancies represented in the Clinical Practice Research Datalink (CPRD) Mother-Baby Link (MBL) and linkage to Hospital Episode Statistics (HES). Three infant cohorts were designed: (1) the all pregnancies infants cohort (N = 185,119), (2) the all pregnancies with a gestational age (GA) ≥ 24 weeks infants cohort (N = 183,869), and (3) the low-risk pregnancies infants cohort (LR infants cohort, N = 121,871), which included pregnancies with a GA ≥ 24 weeks and no diagnosis of predefined high-risk medical conditions until 24 weeks GA. RESULTS: The most common adverse infant outcome in the three infant cohorts was macrosomia (e.g., 1,085.9/10,000 live births in the LR infants cohort), followed by minor congenital anomalies (e.g., 800.6/10,000 in the LR infants cohort), very low/low birth weight (e.g., 400.6/10,000 in the LR infants cohort), and major congenital anomalies (e.g., 270.4/10,000 in the LR infants cohort). The incidence proportions for early-onset sepsis, very low/low birth weight, and minor and major congenital anomalies were lower in the LR infants than in the other cohorts (non-overlapping confidence intervals [CIs]). The incidence proportions of neonatal death, infant death, late-onset sepsis, macrosomia, small for GA, and large for GA were similar between cohorts (overlapping CIs). CONCLUSIONS: This study generated background rates of adverse infant outcomes from liveborn infants of all and low-risk pregnancies represented in the CPRD Pregnancy Register MBL and linkage to HES. The results indicate lower incidence proportions of several adverse infant outcomes in infants from low-risk pregnancies compared to all pregnancies, illustrating the importance of considering maternal risk factors. These background rates may facilitate the interpretation of safety data from maternal immunization trials and of pharmacovigilance data from maternal vaccines. They may also be of interest for other interventions studied in pregnant women.

Offspring school performance at age 12 after induction of labor vs non-intervention at term: A linked cohort study.

INTRODUCTION: The incidence of induction of labor, for both medical reasons and as an elective procedure, has been rising and a further increase in induction of labor following the ARRIVE trial may be expected. The effects of induction of labor at term on childhood neurodevelopment, however, are not well studied. We aimed to study the influence of elective induction of labor for each week of gestation separately from 37 to 42 weeks on offspring school performance at 12 years of age after uncomplicated pregnancies. MATERIAL AND METHODS: We performed a population-based study among 226 684 liveborn children from uncomplicated singleton pregnancies, born from 37+0 to 42+0 weeks of gestation in cephalic presentation in 2003-2008 (no hypertensive disorders, diabetes or birthweight ≤p5) in the Netherlands. Children with congenital anomalies, of non-white mothers and born after planned cesarean section were excluded. Birth records were linked with national data on school achievement. We compared, using a fetus-at-risk approach and per week of gestation, school performance score and secondary school level at age 12 in those born after induction of labor to those born after non-intervention, ie spontaneous onset of labor in the same week plus all those born at later gestations. Education scores were standardized to a mean of 0 and a standard deviation of 1 and adjusted in the regression analyses. RESULTS: For each gestational age up to 41 weeks, induction of labor was associated with decreased school performance scores compared with non-intervention (at 37 weeks -0.05 SD, 95% confidence interval [CI] -0.10 to -0.01 SD; adjusted for confounding factors). After induction of labor, fewer children reached higher secondary school level (at 38 weeks 48% vs 54%; adjusted odds ratio [aOR] 0.88, 95% CI 0.82-0.94). CONCLUSIONS: In women with uncomplicated pregnancies at term, consistently, at every week of gestation from 37 to 41 weeks, induction of labor is associated with lower offspring school performance at age 12 and lower secondary school level compared with non-intervention, although residual confounding may remain. These long-term effects of induction of labor should be incorporated in counseling and decision making.

Home births as a "right" of female patients in the context of medicine, legislation and court jurisprudence.

Currently, in the Czech Republic and Slovakia, more and more women prefer a planned home birth to a hospital birth, despite the fact that the hospital provides a safe environment for laboring women, thanks to the possibility to intervene at any time in case of complications. These women consider childbirth a natural process, while obstetric care is often considered unnecessary. According to the World Health Organization, birth can only be defined as physiological after birth. Even though women can give birth without medical assistance, it is not possible to identify in advance the mothers and newborns who will need some kind of intervention during childbirth. Although a planned home birth is associated with fewer maternal interventions and the probability of a spontaneous vaginal birth, compared to a planned hospital birth, the risk of neonatal death is two- to three-times higher.

Woman-Centered Care: Standardized Outcomes Measure.

Background and Objectives: Patient- or woman-centered care, prioritizing women's perspectives, needs, and preferences, is a widely recommended approach to enhance the quality of maternity care services. It aligns with the broader principles of patient-centered care, emphasizing the importance of a collaborative and respectful relationship between healthcare providers and women. This study evaluates low-risk pregnancies managed by midwives and obstetrician-gynecologists in Lithuania using patient-reported outcome measures and patient-reported experience measures. Materials and Methods: A prospective cohort study was conducted between September 2022 and April 2023. Data were collected through patient-reported questionnaires. Results: A total of 153 pregnant women who had singleton, low-risk pregnancies participated in the study, of whom 24.8% had their pregnancies supervised by a midwife, and 75.2% of the participants had their pregnancies supervised by an obstetrician-gynecologist. The study found no statistically significant differences in assessed patient-reported outcome measures and patient-reported experience measures between both models of care. Conclusions: Adopting patient-centered approaches enables healthcare systems to understand and address women's specific needs and preferences, fostering high-quality and woman-centered care. This research adds to the growing evidence supporting midwife-led care and emphasizes the importance of personalized, woman-centered approaches in maternity care, ultimately enhancing maternal health outcomes and promoting positive experiences for low-risk pregnant women. The quality of care provided by midwives remains uncompromised and equivalently proficient compared to the care provided by collaborative teams.

The impact of Covid-19 restrictions on depressive symptoms in low-risk and high-risk pregnant women: a cross-sectional study before and during pandemic.

BACKGROUND: The COVID-19 social restrictions have increased the risk for depression compared to the previous period in Italian women with Low-Risk Pregnancy (LRP). lLess is known about the impact of COVID-19 restrictions on High-Risk Pregnancy (HRP). This study aimed: 1) to explore levels of depression in women who become pregnant before and during COVID-19 pandemic, distinguishing between LRP and HRP; 2) to analyze the impact of COVID-19 restrictions on pregnancy experience in LRP and HRP. METHODS: A before-during COVID-19 pandemic cross-sectional study was carried out on 155 pregnant women (Mean age = 34.18), between 23 and 32 weeks of gestation. 77 women were recruited before COVID-19 pandemic (51.9% LRP; 48.1% HRP) and 78 women were recruited during COVID-19 pandemic (51.3% LRP; 48.7% HRP). HRP group was enrolled during hospitalization for high-risk pregnancy. Participants filled out Edinburgh Postnatal Depression Scale. Moreover, only COVID-19 group answered an open-ended question about the impact of restriction on pregnancy experience. RESULTS: HRP women reported higher levels of depressive symptoms than LRP. No difference emerged for COVID (before/during) but an interaction effect between COVID-19 and obstetric condition was found. The qualitative results showed the impact of restrictions on emotions and concerns. CONCLUSION: Respect to the previous period, LRP women during COVID-19 presented an increased risk for depressive symptoms than HRP. The HRP women during COVID-19 seemed to use hospitalization as a resource to find a social support network with other pregnant women and to be reassured on the clinical ongoing of pregnancy.

Facilitating safety evaluation in maternal immunization trials: a retrospective cohort study to assess pregnancy outcomes and events of interest in low-risk pregnancies in England.

BACKGROUND: Maternal characteristics like medical history and health-related risk factors can influence the incidence of pregnancy outcomes and pregnancy-related events of interest (EIs). Data on the incidence of these endpoints in low-risk pregnant women are needed for appropriate external safety comparisons in maternal immunization trials. To address this need, this study estimated the incidence proportions of pregnancy outcomes and pregnancy-related EIs in different pregnancy cohorts (including low-risk pregnancies) in England, contained in the Clinical Practice Research Datalink (CPRD) Pregnancy Register linked to Hospital Episode Statistics (HES) between 2005 and 2017. METHODS: The incidence proportions of 7 pregnancy outcomes and 15 EIs were calculated for: (1) all pregnancies (AP) represented in the CPRD Pregnancy Register linked to HES (AP cohort; N = 298 155), (2) all pregnancies with a gestational age (GA) ≥ 24 weeks (AP24+ cohort; N = 208 328), and (3) low-risk pregnancies (LR cohort; N = 137 932) with a GA ≥ 24 weeks and no diagnosis of predefined high-risk medical conditions until 24 weeks GA. RESULTS: Miscarriage was the most common adverse pregnancy outcome in the AP cohort (1 379.5 per 10 000 pregnancies) but could not be assessed in the other cohorts because these only included pregnancies with a GA ≥ 24 weeks, and miscarriages with GA ≥ 24 weeks were reclassified as stillbirths. Preterm delivery (< 37 weeks GA) was the most common adverse pregnancy outcome in the AP24+ and LR cohorts (742.9 and 680.0 per 10 000 pregnancies, respectively). Focusing on the cohorts with a GA ≥ 24 weeks, the most common pregnancy-related EIs in the AP24+ and LR cohorts were fetal/perinatal distress or asphyxia (1 824.3 and 1 833.0 per 10 000 pregnancies), vaginal/intrauterine hemorrhage (799.2 and 729.0 per 10 000 pregnancies), and labor protraction/arrest disorders (752.4 and 774.5 per 10 000 pregnancies). CONCLUSIONS: This study generated incidence proportions of pregnancy outcomes and pregnancy-related EIs from the CPRD for different pregnancy cohorts, including low-risk pregnancies. The reported incidence proportions of pregnancy outcomes and pregnancy-related EIs are largely consistent with external estimates. These results may facilitate the interpretation of safety data from maternal immunization trials and the safety monitoring of maternal vaccines. They may also be of interest for any intervention studied in populations of pregnant women.

Study protocol for a modified antenatal care program for pregnant women with a low risk for adverse outcomes-a stepped wedge cluster non-inferiority randomized trial.

BACKGROUND: It is crucial to provide care based on individual needs. Swedish health care is obliged to give care on equal conditions for the entire population. The person with the greatest need should be given the most care, and the health care system should strive to be cost-efficient. Medical and technical advances have been significant during the last decades and the recent Covid-19 pandemic has caused a shift in health care, from in-person visits to virtual visits. The majority of pregnant women with a low risk assessment have an uncomplicated antenatal course without adverse events. These women probably receive excessive and unnecessary antenatal care. This study will investigate if an antenatal care program for healthy pregnant women with a low risk for adverse outcomes could be safely monitored with fewer in-person visits to a midwife, and with some of them replaced by virtual visits. METHODS: This is a non-inferiority trial where a stepped wedge cluster randomized controlled design will be used. Data collection includes register data and questionnaires that concern antenatal, obstetric and neonatal outcomes, patient- and caregiver-reported experiences, healthcare-economy, and implementation aspects. The modified antenatal care (MAC) study is performed in parts of the southeast of Sweden, which has approximately 8200 childbirths annually. At the start of the study, all antenatal care centers included in the study will use the same standard antenatal care (SAC) program. In the MAC program the in-person visits to a midwife will be reduced to four instead of eight, with two additional virtual meetings compared with the SAC program. DISCUSSION: This presented study protocol is informed by research knowledge. The protocol is expected to provide a good structure for future studies on changed antenatal care programs that introduce virtual visits for healthy pregnant women with a low risk for adverse outcomes, without risking quality, safety, and increased costs. TRIAL REGISTRATION: The study is registered the 21th of April 2021 in the ISRCTN registry with trial ID: ISRCTN14422582 , retrospectively registered.

Psychological health associated with prenatal screening in low-risk pregnancy for chromosomal aneuploidy.

AIMS: The aim of this study was to assess the psychological health associated with prenatal screening in low-risk pregnancy for chromosomal aneuploidy. METHODS: This longitudinal study was performed on 310 low-risk pregnancies for chromosomal aneuploidies. Using the standard DASS-21 questionnaire, levels of stress, anxiety, and depression were assessed-prior to the recommended time for the first-trimester screening test (T1), after the first-trimester tests on the second referral (T2) concurrently with the request for the second-trimester tests (T3)-and compared between women undergoing the prenatal screening and in women refusing it. RESULTS: The results showed that the mean of stress, anxiety, and depression levels were not different between groups at T1; but the level of the stress, depression, and anxiety were higher in the screening group than the non-screening group. The effect of group on changes in the stress, depression, and anxiety levels was significant. CONCLUSION: The results revealed that the prenatal screening program in low-risk pregnancies for chromosomal aneuploidy can be followed by rising psychological symptoms and this psychological burden should be conceded on prenatal screening tests for pregnant women.

Routine Ultrasound at 30th-33rd weeks versus 30th-33rd and 35th-37th weeks in Low-Risk Pregnancies: A Randomized Trial.

INTRODUCTION: The aim of this study was to evaluate the accuracy of 35-37 weeks' ultrasound for fetal growth restriction (FGR) detection and the impact of 30th-33rd weeks versus 30th-33rd and 35th-37th weeks' ultrasound on perinatal outcomes. METHODS: This was a randomized controlled trial that enrolled 1,061 low-risk pregnant women: 513 in the control group (routine ultrasound performed at 30th-33rd weeks) and 548 in the study group (with an additional ultrasound at 35th-37th weeks). FGR was defined as a fetus with an estimated fetal weight (EFW) below the 10th percentile. p values < 0.05 were considered statistically significant. RESULTS: The ultrasound at 35-37 weeks had an overall accuracy of FGR screening of 94%. Spearman's correlation coefficient between EFW and birthweight centile was higher for at 35-37 weeks' ultrasound (ρ = 0.75) compared with 30-33 weeks' ultrasound (ρ = 0.44). The study group had a lower rate of operative vaginal deliveries (24.4% vs. 39.3%, p = 0.005) and cesarean deliveries for nonreassuring fetal status (16.8% vs. 38.8%, p < 0.001). DISCUSSION/CONCLUSION: A later ultrasound (35-37 weeks) had a high accuracy for detection of FGR and had a higher correlation between EFW and birthweight centiles. Furthermore, it was also associated with lower adverse perinatal outcomes compared to an earlier ultrasound.

Overuse of antenatal visits and ultrasounds in low-risk women: A national population-based study.

BACKGROUND: A better understanding of the overuse of antenatal care is needed to improve its organisation to deal with limited medical resources and doctor shortages. OBJECTIVES: To assess the proportion of women who overuse antenatal care and the associations of overuse with maternal characteristics and the qualifications of healthcare providers. METHODS: We used the 2016 National Perinatal Survey, a cross-sectional population-based survey, performed in all maternity units in France, including 13,132 women. Based on the French national guidelines, 6-8 antenatal visits were defined as adequate, 9-11 as high use, and ≥12 as overuse, while 3 ultrasounds were considered adequate, 4-5 as high use, and ≥6 as overuse. We performed binary modified Poisson regressions-with adequate care as the reference-including maternal social and medical characteristics and the healthcare professionals' qualifications. RESULTS: After women with inadequate care were excluded, 19.2% of low-risk women had at least 12 visits and 30.5% at least 6 ultrasounds. Overuse of visits was associated with primiparity, average to high income, less than good psychological well-being, and care by an obstetrician. The risks of overuse of ultrasounds were higher among primiparous, women with average to high income and those receiving care from a public-sector obstetrician (adjusted relative risk 1.17, 95% CI, 1.13, 1.21) or private obstetrician (adjusted relative risk 1.12, 95% CI, 1.07, 1.16), compared with a public-sector midwife. CONCLUSIONS: Antenatal care overuse is very common in France and associated with some maternal characteristics and also the qualification of care provider. Antenatal care should be customised according to women's needs, in particular for primiparae and those with poor well-being, and available medical resources.

Routine third-trimester ultrasound for the detection of small-for-gestational age in low-risk pregnancies (ROTTUS study): randomized controlled trial.

OBJECTIVE: To compare the proportion of small-for-gestational-age (SGA) infants detected by routine third-trimester ultrasound vs those detected by selective ultrasound based on serial symphysis-fundus height (SFH) measurements (standard care) in low-risk pregnancy. METHODS: This was an open-label randomized controlled trial conducted at a hospital in Kenya between May 2018 and February 2020. Low-risk pregnant women were randomly allocated (ratio of 1:1) to routine ultrasound for fetal growth assessment between 36 + 0 and 37 + 6 weeks' gestation (intervention group) or to standard care, which involved a selective growth scan on clinical suspicion of fetal growth abnormality based on serial SFH measurements (control group). During ultrasound examination, fetal growth was assessed by measurement of the abdominal circumference (AC), and AC < 10th centile was used to diagnose a SGA fetus. The main prespecified outcomes were the detection of neonatal SGA, defined as birth weight < 10th centile, and of severe neonatal SGA, defined as birth weight < 3rd centile. The predictive performance of routine third-trimester ultrasound and selective ultrasound based on serial SFH measurements was determined using receiver-operating-characteristics (ROC)-curve analysis. RESULTS: Of 566 women assessed for eligibility, 508 (89.8%) were randomized, of whom 253 were allocated to the intervention group and 255 to the control group. Thirty-six babies in the intervention group and 26 in the control group had a birth weight < 10th centile. The detection rate of SGA infants by routine third-trimester ultrasound vs that by standard care was 52.8% (19/36) vs 7.7% (2/26) (P < 0.001) and the specificity was 95.5% (191/200) and 97.9% (191/195), respectively (P = 0.08). The detection rate of severe SGA was 66.7% (12/18) by routine ultrasound vs 8.3% (1/12) by selective ultrasound based on SFH measurements (P < 0.001), with specificities of 91.7% (200/218) and 98.1% (205/209), respectively (P = 0.006). The area under the ROC curve of routine third-trimester ultrasound in prediction of SGA was significantly greater than that of selective ultrasound based on SFH measurements (0.92 (95% CI, 0.87-0.96) vs 0.68 (95% CI, 0.58-0.77); P < 0.001). CONCLUSIONS: In low-risk pregnancy, routine ultrasound performed between 36 + 0 and 37 + 6 weeks is superior to selective ultrasound based on serial SFH measurements for the detection of true SGA, with high specificity. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Chromosome microarray analysis should be offered to all invasive prenatal diagnostic testing following a normal rapid aneuploidy test result.

Chromosomal microarray analysis (CMA) has now replaced karyotyping in the analysis of prenatal cases with a fetal structural anomaly, whereas in those pregnancies undergoing invasive prenatal diagnosis with a normal fetal ultrasound, conventional karyotyping is still performed. The aims of this study were to establish the diagnostic yield of CMA in prenatal diagnosis, and to provide new data that might contribute to reconsider current practices. We reviewed 2905 prenatal samples with a normal rapid aneuploidy detection test referred for evaluation by CMA testing. Our study revealed pathogenic and reported susceptibility copy number variants associated with syndromic disorders in 4.8% (n = 138/2905) of cases, being 2.8% (n = 81/2905) the estimated added diagnostic value of CMA over karyotyping. Clinically significant CMA abnormality was detected in 5.4% (107/1975) of the fetuses with ultrasound anomalies and in 1.4% (5/345) of those considered as low-risk pregnancies. Our series shows that in prenatal samples, CMA increases 2-fold the diagnostic yield achieved by conventional karyotyping.

Maternal and neonatal outcome of births planned in alongside midwifery units: a cohort study from a tertiary center in Germany.

BACKGROUND: For healthy women entering birth after uneventful pregnancy, midwife-led models of care have the potential to reduce interventions and increase the vaginal birth rate. In Germany, 98.4% of women are giving birth in consultant-led obstetric units. Alongside midwifery units (AMU) have been established in 2003. We compared the outcome of women registered for planned birth in the AMU at our hospital with a matched group of low-risk women who gave birth in standard obstetric care during the same period of time. METHODS: We used a retrospective cohort study design. The study group consisted of all women admitted to labor ward who had registered for birth in AMU from 2010 to 2017. For the control group, low-risk women were selected; additionally, matching was performed for parity. Mode of birth was chosen as primary outcome parameter for the mother. For the neonate, a composite primary outcome (5-min Apgar < 7 or umbilical cord arterial pH < 7.10 or transfer to specialist neonatal care) was defined. Secondary outcomes included epidural anesthesia, duration of the second stage of labor, episiotomy, obstetric injury, and postpartum hemorrhage. Non-inferiority was assessed, and multiple logistic regression analysis was performed. RESULTS: Six hundred twelve women were admitted for labor in AMU, the control group consisted of 612 women giving birth in standard obstetric care. Women in the study group were on average older and had a higher body mass index (BMI); birthweight was on average 95 g higher. Non-inferiority could be established for the primary outcome parameters. Epidural anesthesia and episiotomy rates were lower, and the mean duration of the second stage of labor was shorter in the study group; second-degree perineal tears were less common, higher-order obstetric lacerations occurred more frequently. Overall, 50.3% of women were transferred to standard obstetric care. Regression analysis revealed effects of parity, age and birthweight on the chance of transfer. CONCLUSION: Compared to births in our consultant-led obstetric unit, the outcome of births planned in the AMU was not inferior, and intervention rates were lower. Our results support the integration of AMU as a complementary model of care for low-risk women.

The "Cocoon," first alongside midwifery-led unit within a Belgian hospital: Comparison of the maternal and neonatal outcomes with the standard obstetric unit over 2 years.

OBJECTIVES: Our aim was to compare maternal and neonatal outcomes of women with a low-risk pregnancy attending the "Cocoon," an alongside midwifery-led birth center and care pathway, with women with a low-risk pregnancy attending the traditional care pathway in a tertiary care hospital in Belgium. METHODS: We performed a retrospective cohort study of maternal and neonatal outcomes of women with a low-risk pregnancy who chose to adhere to the Cocoon pathway of care (n = 590) and women with a low-risk pregnancy who chose the traditional pathway of care (n = 394) from March 1, 2014, to February 29, 2016. We performed all analyses using an intention-to-treat approach. RESULTS: In this setting, the cesarean birth rate was 10.3% compared with 16.0% in the traditional care pathway (adjusted odds ratios [aOR] 0.42 [95% CI 0.25-0.69]), the induction rate was 16.3% compared with 30.5% (0.46 [0.30-0.69]), the epidural analgesia rate was 24.9% compared with 59.1% (0.15 [0.09-0.22]), and the episiotomy rate was 6.8% compared with 14.5% (0.31 [0.17-0.56]). There was no increase in adverse neonatal outcomes. Intrapartum and postpartum transfer rates to the traditional pathway of care were 21.1% and 7.1%, respectively. CONCLUSIONS: Women planning their births in the midwifery-led unit, the Cocoon, experienced fewer interventions with no increase in adverse neonatal outcomes. Our study gives initial support for the introduction of similar midwifery-led care pathways in other hospitals in Belgium.

Associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women.

BACKGROUND: Admission in early labor is associated with increased likelihood of cesarean birth, but the context in which this occurs is unclear. Previous research has explored the relationship between dilatation at admission and the use of single intrapartum interventions; however, the majority of women in the United States receive multiple intrapartum interventions. The objective of this study was to examine the associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women with spontaneous onset of labor. METHODS: This was a cross-sectional, observational study of 21 858 nulliparous, singleton, term vertex births that occurred from 2002 to 2007 across nine hospitals in the Consortium on Safe Labor. Outcome measures included the individual and combined use of intrapartum interventions (amniotomy, epidural anesthesia, oxytocin augmentation) and birth mode. RESULTS: In this sample, 92.0% of women received at least one intrapartum intervention and 22.7% received all three interventions. After propensity score adjustment, women were more than twice as likely to receive the combination of amniotomy-epidural-oxytocin when admitted at 0-3 cm (RR 2.83 [95% CI 2.45-3.27]) and 4-5 cm (2.49 [2.15-2.89]) compared to 6-10 cm. Adjusted likelihood of cesarean birth was five times greater for women admitted at 0-3 cm (5.26 [4.36-6.34]) and two times greater for women admitted at 4-5 cm (2.27 [1.86-2.77]) compared to 6-10 cm. CONCLUSIONS: To promote normal physiologic birth, low-risk, nulliparous women should be engaged in shared decision-making about timing of admission after spontaneous onset of labor.

Midwife-led maternity care in Ireland - a retrospective cohort study.

BACKGROUND: Midwife-led maternity care is shown to be safe for women with low-risk during pregnancy. In Ireland, two midwife-led units (MLUs) were introduced in 2004 when a randomised controlled trial (the MidU study) was performed to compare MLU care with consultant-led care (CLU). Following study completion the two MLUs have remained as a maternity care option in Ireland. The aim of this study was to evaluate maternal and neonatal outcomes and transfer rates during six years in the larger of the MLU sites. METHODS: MLU data for the six years 2008-2013 were retrospectively analysed, following ethical approval. Rates of transfer, reasons for transfer, mode of birth, and maternal and fetal outcomes were assessed. Linear-by-Linear Association trend analysis was used for categorical data to evaluate trends over the years and one-way ANOVA was used when comparing continuous variables. RESULTS: During the study period, 3,884 women were registered at the MLU. The antenatal transfer rate was 37.4% and 2,410 women came to labour in the MLU. Throughout labour and birth, 567 women (14.6%) transferred to the CLU, of which 23 were transferred after birth due to need for suturing or postpartum hemorrhage. The most common reasons for intrapartum transfer were meconium stained liquor/abnormal fetal heart rate (30.3%), delayed labour progress in first or second stage (24.9%) and woman's wish for epidural analgesia (15.1%). Of the 1,903 babies born in the MLU, 1,878 (98.7%) were spontaneous vaginal births and 25 (1.3%) were instrumental (ventouse/forceps). Only 25 babies (1.3%) were admitted to neonatal intensive care unit. All spontaneous vaginal births from the MLU registered population, occurring in the study period in both the MLU and CLU settings (n = 2,785), were compared. In the MLU more often 1-2 midwives (90.9% vs 69.7%) cared for the women during birth, more women had three vaginal examinations or fewer (93.6% vs 79.9%) and gave birth in an upright position (standing, squatting or kneeling) (52.0% vs 9.4%), fewer women had an amniotomy (5.9% vs 25.9%) or episiotomy (3.4% vs 9.7%) and more women had a physiological management of third stage of labour (50.9% vs 4.6%). CONCLUSIONS: Midwife-led care is a safe option that could be offered to a large proportion of healthy pregnant women. With strict transfer criteria there are very few complications during labour and birth. Maternity units without the option of MLU care should consider its introduction.

Perinatal and maternal outcomes at term in low-risk pregnancies according to NICE criteria: comparison between a tertiary obstetrical hospital and midwife-attended units.

PURPOSE: The aim of this study was to evaluate the perinatal and maternal outcomes at term at a single tertiary, university hospital in women with low-risk pregnancies. PATIENTS AND METHODS: We performed a retrospective cohort study of women with low-risk pregnancies, who delivered at University Women's Hospital Magdeburg between January 2010 and December 2014. Data were compared with data published by Brocklehurst et al. 2011. RESULTS: Of the 6052 women investigated, 2014 were classified as low risk according to the NICE criteria and were eligible for analysis. In 94.8%, a spontaneous vertex birth was observed. There were only 2 (0.1%) perinatal complications and 52 (2.5%) maternal complications. Ventouse delivery, forceps delivery, and caesarean sections were performed in 2.5, 1, and 3.1% of the cases, respectively. Episiotomy was performed in 37.7% of women. The third and fourth degree perineal trauma were observed in 0.3% of births investigated. Complications during the third stage of labour and blood transfusions were observed in 0.25 and 0.2%, respectively. In comparison with the births at home, we had lower rate of fetal complications for nulliparous women, but not for multiparous women, lower rate for blood transfusions, third and fourth degree perineal trauma and forceps delivery, and higher rate of spontaneous vertex birth, epidural analgesia, and episiotomy. The rate of vacuum extractions and caesarean sections were similar between both the places of birth. CONCLUSIONS: The tertiary-level obstetric unit is safe place of birth for women with low-risk pregnancies.