Increased incidence of shoulder dystocia but a declining incidence of obstetric brachial plexus palsy in vaginally delivered infants.

INTRODUCTION: Obstetric brachial plexus palsy (OBPP) is a serious form of neonatal morbidity. The primary aim of this population-based registry study was to examine temporal trends, 1997-2019, of OBPP in infants delivered vaginally in a cephalic presentation. The secondary aim was to examine temporal changes in the incidence of associated risk factors. MATERIAL AND METHODS: This was a population-based registry study including singleton, cephalic, vaginally delivered infants, 1997-2019, in Sweden. To compare changes in the incidence rates of OBPP and associated risk factors over time, univariate logistic regression was used and odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS: The incidence of OBPP in infants delivered vaginally in a cephalic presentation decreased from 3.1 per 1000 births in 1997 to 1.0 per 1000 births in 2019 (OR 0.31, 95% CI 0.24-0.40). Conversely, the incidence of shoulder dystocia increased from 2.0 per 1000 in 1997 to 3.3 per 1000 in 2019 (OR 1.64, 95% CI 1.34-2.01). Over time, the proportion of women with body mass index of 30 kg/m2 or greater increased (14.5% in 2019 compared with 8.0% in year 1997, OR 1.96, 95% CI 1.89-2.03), more women had induction of labor (20.5% in 2019 compared with 8.6% in 1997, OR 2.74, 95% CI 2.66-2.83) and epidural analgesia (41.2% in 2019 compared with 29.0% in 1997, OR 1.72, 95% CI 1.68-1.75). In contrast, there was a decrease in the rate of operative vaginal delivery (6.0% in 2019, compared with 8.1% in 1997, OR 0.72, 95% CI 0.69, 0.75) and in the proportion of infants with a birthweight greater than 4500 g (2.7% in 2019 compared with 3.8% in 1997, OR 0.70, 95% CI 0.66-0.74). The decline in the incidence of these two risk factors explained only a small fraction of the overall decrease in OBPP between 1997-2002 and 2015-219. CONCLUSIONS: The incidence of OBPP in vaginally delivered infants in a cephalic presentation at birth decreased during the period 1997-2019 despite an increase in important risk factors including shoulder dystocia.

Midwives' Management during the Second Stage of Labor in Relation to Second-Degree Tears-An Experimental Study.

INTRODUCTION: Most women who give birth for the first time experience some form of perineal trauma. Second-degree tears contribute to long-term consequences for women and are a risk factor for occult anal sphincter injuries. The objective of this study was to evaluate a multifaceted midwifery intervention designed to reduce second-degree tears among primiparous women. METHODS: An experimental cohort study where a multifaceted intervention consisting of 1) spontaneous pushing, 2) all birth positions with flexibility in the sacro-iliac joints, and 3) a two-step head-to-body delivery was compared with standard care. Crude and Adjusted OR (95% CI) were calculated between the intervention and the standard care group, for the various explanatory variables. RESULTS: A total of 597 primiparous women participated in the study, 296 in the intervention group and 301 in the standard care group. The prevalence of second-degree tears was lower in the intervention group: [Adj. OR 0.53 (95% CI 0.33-0.84)]. A low prevalence of episiotomy was found in both groups (1.7 and 3.0%). The prevalence of epidural analgesia was 61.1 percent. Despite the high use of epidural analgesia, the midwives in the intervention group managed to use the intervention. CONCLUSION: It is possible to reduce second-degree tears among primiparous women with the use of a multifaceted midwifery intervention without increasing the prevalence of episiotomy. Furthermore, the intervention is possible to employ in larger maternity wards with midwives caring for women with both low- and high-risk pregnancies.

Perineal injuries and birth positions among 2992 women with a low risk pregnancy who opted for a homebirth.

BACKGROUND: Whether certain birth positions are associated with perineal injuries and severe perineal trauma (SPT) is still unclear. The objective of this study was to describe the prevalence of perineal injuries of different severity in a low-risk population of women who planned to give birth at home and to compare the prevalence of perineal injuries, SPT and episiotomy in different birth positions in four Nordic countries. METHODS: A population-based prospective cohort study of planned home births in four Nordic countries. To assess medical outcomes a questionnaire completed after birth by the attending midwife was used. Descriptive statistics, bivariate analysis and logistic regression were used to analyze the data. RESULTS: Two thousand nine hundred ninety-two women with planned home births, who birthed spontaneously at home or after transfer to hospital, between 2008 and 2013 were included. The prevalence of SPT was 0.7 % and the prevalence of episiotomy was 1.0 %. There were differences between the countries regarding all maternal characteristics. No association between flexible sacrum positions and sutured perineal injuries was found (OR 1.02; 95 % CI 0.86-1.21) or SPT (OR 0.68; CI 95 % 0.26-1.79). Flexible sacrum positions were associated with fewer episiotomies (OR 0.20; CI 95 % 0.10-0.54). CONCLUSION: A low prevalence of SPT and episiotomy was found among women opting for a home birth in four Nordic countries. Women used a variety of birth positions and a majority gave birth in flexible sacrum positions. No associations were found between flexible sacrum positions and SPT. Flexible sacrum positions were associated with fewer episiotomies.

Women's experiences of fear of childbirth: a metasynthesis of qualitative studies.

Purpose: Women's experiences of pregnancy, labour and birth are for some pregnant women negative and they develop a fear of childbirth, which can have consequences for their wellbeing and health. The aim was to synthesize qualitative literature to deepen the understanding of women's experiences of fear of childbirth.Methods: A systematic literature search and a meta-synthesis that included 14 qualitative papers.Results: The main results demonstrate a deepened understanding of women's experiences of fear of childbirth interpreted through the metaphor "being at a point of no return". Being at this point meant that the women thought there was no turning back from their situation, further described in the three themes: To suffer consequences from traumatic births, To lack warranty and understanding, and To face the fear.Conclusions: Women with fear of childbirth are need of support that can meet their existential issues about being at this point of no return, allowing them to express and integrate their feelings, experiences and expectations during pregnancy, childbirth and after birth.Women with fear after birth, i.e., after an earlier negative birth experience, need support that enables them to regain trust in maternity care professionals and their willingness to provide them with good care that offers the support that individual women require. Women pregnant for the first time require similar support to reassure them that other's experiences will not happen to them.

Causes and outcomes in studies of fear of childbirth: A systematic review.

PROBLEM: Fear of childbirth negatively affects women during pregnancy and after birth. AIM: To summarise the findings of published studies regarding possible causes/predisposing factors and outcomes of fear of childbirth for childbearing women. DESIGN: A systematic review, searching five databases in March 2015 for studies on causes/predisposing factors and outcomes of fear of childbirth, as measured during pregnancy and postpartum. Quality of included studies was assessed independently by pairs of authors. Data were extracted independently by reviewer pairs and described in a narrative analysis. FINDINGS: Cross-sectional, register-based and case-control studies were included (n=21). Causes were grouped into population characteristics, mood-related aspects, and pregnancy and birth-related aspects. Outcomes were defined as mood-related or pregnancy and birth-related aspects. Differing definitions of fear of childbirth were found and meta-analysis could only be performed on parity, in a few studies. CONCLUSIONS: Stress, anxiety, depression and lack of social support are associated with fear during pregnancy. Need for psychiatric care and presence of traumatic stress symptoms are reported outcomes together with prolonged labour, longer labours, use of epidural and obstetric complications. Nulliparous and parous women have similar levels of fear but for different reasons. Since the strongest predictor for fear in parous women is a previous negative birth experience or operative birth, we suggest it is important to distinguish between fear of childbirth and fear after birth. Findings demonstrate the need for creating woman-centred birthing environments where women can feel free and secure with low risk of negative or traumatic birth experiences and consequent fear.

Risk factors for obstetric brachial plexus palsy among neonates delivered by vacuum extraction.

OBJECTIVE: The risk of obstetric brachial plexus palsy (OBPP) is increased in infants delivered instrumentally. The aim of this study was to identify risk factors for OBPP and to evaluate the association between possible risk factors linked to the duration of the vacuum extraction procedure and the subsequent risk. METHODS: A population-based retrospective design was adopted. Using a national registry of operative vaginal deliveries linked to the Medical Birth Registry in Sweden, we evaluated by univariate and multiple logistic regression analyses the risk factors for OBPP in 13,716 women delivered by vacuum extraction. The variables assessed in the multiple logistic regression analysis were shoulder dystocia, fetal birth weight of 3,999 g or greater, fundal pressure, number of tractions, vacuum application time, parity, vacuum silicone cup, epidural anesthesia, and fetal head at the level of the ischial spines at vacuum application time. RESULTS: Obstetric brachial plexus palsy was recorded in 153 (1.1%) infants. The following variables increased significantly the risk of OBPP in the newborn: shoulder dystocia (odds ratio 16.0; 95% confidence interval 8.9-28.7), fetal birth weight of 3,999 g or greater (7.1; 4.8-10.5), and administration of fundal pressure (1.6; 1.1-2.3). The probability of the risk of OBPP in vacuum-assisted deliveries increased in relation to vacuum extraction time (minutes). CONCLUSION: Shoulder dystocia in the setting of vacuum extraction is a prominent risk factor for OBPP in the newborn. The risk of OBPP increases with the time required for vacuum extraction. LEVEL OF EVIDENCE: II-3.

Severe breastfeeding difficulties: Existential lostness as a mother-Women's lived experiences of initiating breastfeeding under severe difficulties.

A majority of women in Sweden initiate breastfeeding but almost a quarter stop or wean the infant in the first few weeks after birth because of difficulties. In order to develop care that facilitates initiation of breastfeeding and enables mothers to realize their expectations concerning breastfeeding, it is necessary to understand what having severe breastfeeding difficulties means for women who experience them. The aim of this study is to describe the lived experiences of initiating breastfeeding under severe difficulties. A reflective lifeworld research design was used. Eight women, seven primiparous and one multipara, were interviewed within 2 months of giving birth. The essential meaning of the phenomenon is described as "Existential lostness as a mother forcing oneself into a constant fight". This pattern is further explicated through its constituents; shattered expectations, a lost time for closeness, being of no use to the infant, being forced to expose oneself, and gaining strength through sharing. The results show that mothers with severe breastfeeding difficulties feel alone and exposed because of their suffering and are lost in motherhood. Thus, adequate care for mothers should enhance the forming of a caring relationship through sharing rather than exposing.

Breastfeeding: An existential challenge-women's lived experiences of initiating breastfeeding within the context of early home discharge in Sweden.

For most Swedish women, breastfeeding is an essential part of the childbearing period. Yet, the meaning of breastfeeding from women's perspective is scantily explored. Therefore, the aim of this study is to describe women's lived experiences of initiating breastfeeding within the context of early home discharge. Eight women, two primiparous, and six multiparous were interviewed within 2 months after birth. A reflective lifeworld research design based on phenomenological philosophy was used during the data gathering and data analysis. The results show that the phenomenon, initiating breastfeeding, in spite of good conditions, i.e., early home discharge, is complex and entails an existential challenge. The essential meaning of the phenomenon is conceptualized as, "A movement from a bodily performance to an embodied relation with the infant and oneself as a mother." This pattern is further described in its five constituents: "Fascination in the first encounter," "Balancing the unknown," "Devoting oneself and enduring the situation," "Seeking confirmation in the unique," and "Having the entire responsibility." Caring for women initiating breastfeeding entails, from a caring science perspective, to help the mother meet insecurity and strengthen confidence to trust her ability to breastfeed the newborn infant. According to these findings, it is suggested in the discussion that it is time for health care professionals to reject the idea of breastfeeding merely as meals or eating for the infant. Instead, they ought to embrace its origin, namely as a way to closeness between mother and infant.

Comparison in obstetric management on infants with transient and persistent obstetric brachial plexus palsy.

The outcome of obstetric brachial plexus palsy depends on the severity of the lesion of the nerve fibers. The aim of the prospective study is to evaluate if differences in force used in downward traction on the fetal head correlate to the number of nerve roots affected. At final neurological examination at 18 months of age, complete neurological recovery occurred in 80 of 98 children (82%). Downward traction of the fetal head was applied more often and with greater force in the group with persistent damage. There was a significant correlation between the force used to the number of nerve roots affected. The risk of persistent obstetric brachial plexus palsy at age 18 months depended on obstetric management and increased significantly with increasing force used in downward traction of the fetal head.

Obstetric brachial plexus palsy: a prospective study on risk factors related to manual assistance during the second stage of labor.

BACKGROUND: To evaluate the association between obstetric brachial plexus palsy and obstetrical maneuvers during the second stage of delivery. METHODS: Prospective population-based case control study. Cases of obstetric brachial plexus palsy were compared with a randomly selected control group with regard to obstetric management. RESULTS: Five or more obstetrical maneuvers were used to deliver the infants in 82% in the obstetric brachial plexus palsy group versus 1.8% in the controls. Risk factors independently associated with obstetric brachial plexus palsy were force applied when downward traction was imposed on the fetal head (odds ratio 15.2; 95% confidence interval 8.4-27.7). The incidence of obstetric brachial plexus palsy in the infants in the population was 3.3 per thousand. At 18 months of age 16.1% (incidence of 0.05%) of children had residual functional deficits and downward traction with substantial force was applied in all these cases. CONCLUSIONS: Forceful downward traction applied to the head after the fetal third rotation represents an important risk factor of obstetric brachial plexus palsy in vaginal deliveries in cephalic presentation.

High birthweight and shoulder dystocia: the strongest risk factors for obstetrical brachial plexus palsy in a Swedish population-based study.

BACKGROUND: Obstetrical brachial plexus palsy (OBPP) is a serious form of neonatal morbidity. OBJECTIVE: The aim of this work was to study the incidence of OBPP and to analyze its risk factors. METHODS: This is a population-based retrospective case-control study. All deliveries recorded in the Swedish Medical Birth Registry between 1987 and 1997 (n = 1 213 987) were investigated. Cases (n = 2399) with OBPP were compared to all other cases. RESULTS: The incidence of OBPP increased from 0.17 in 1987 to 0.27% in 1997 (p = 0.002). During the same time period, the mean birthweight increased from 3483 to 3525 g. Birthweight increasing from 4000 g was associated with a progressive rise in OBPP risk. Other significant risk factors associated with the injury were shoulder dystocia, breech presentation in vaginal delivery, operative vaginal delivery, diabetes mellitus, induction of labor, protracted active phase, secondary arrest of dilatation, and epidural anesthesia. Cesarean section was associated with a decreased risk of OBPP. If 5000 g is chosen as cut-off for cesarean section, 85% of the infants in this weight class are underestimated using ultrasonography. Approximately, 331 abdominal deliveries have to be performed to avoid one case of OBPP. CONCLUSIONS: Shoulder dystocia and infant birthweight of 4500 g and more are the strongest risk factors for OBPP in a Swedish population.