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Background: Severe postpartum haemorrhage (PPH) is a serious clinical problem that is increasing in incidence. Aim: To identify risk factors for severe PPH. Materials and Methods: Population‐based retrospective cohort study of all women who gave birth in Victoria in 2009–2013 using the validated Victorian Perinatal Data Collection. Three multivariable logistic regression models estimated the adjusted risk of severe PPH. Adjusted odds ratios (aOR) and their 95% confidence intervals are reported. The primary outcome was severe PPH (estimated blood loss of ≥1500 mL). Results: Severe PPH occurred in 1.4% of all births (n = 5122). Maternal characteristics significantly associated with severe PPH included: multiple pregnancy; older maternal age; overweight/obesity; first births. Other risk factors included placental complications, macrosomia, instrumental vaginal birth, third and fourth degree perineal lacerations, in‐labour caesarean section, birth at a gestation other than 37–41 weeks, duration of labour 12 to <24 h, and use of oxytocin infusions in labour. Planned pre‐labour caesarean section was associated with reduced odds of severe PPH. Severe PPH also occurred in 0.7% (n = 104) of women with none of the identified risk factors. Conclusions: Numerous risk factors for severe PPH are identified but some cases are not modifiable or predictable. Limiting use of oxytocin infusions in labour to cases with clear indications, and strategies to prevent severe perineal lacerations would prevent some severe PPHs. Close surveillance of all women in the hours immediately following birth is crucial to detect and manage excessive blood loss and reduce severe PPH and associated morbidity. [ABSTRACT FROM AUTHOR]

Background: Increasing incidence and severity of postpartum haemorrhage, together with postpartum haemorrhage‐associated morbidities, have been reported in many high‐resource countries. In‐depth analysis of such factors in Victorian births since 2002 was lacking. Aims: Our aim was to determine the incidence and trends for primary postpartum haemorrhage (World Health Organization and International Classification of Diseases 10th revision, Australian Modification definitions) for all confinements in Victoria, Australia, for the years 2003–2013 and the incidence and trends for severe postpartum haemorrhage (≥1500 mL) for 2009–2013. Materials and methods: In this population‐based cross‐sectional study de‐identified data from the Victorian Perinatal Data Collection were analysed for confinements (excluding terminations) from 2003 to 2013 (n = 764 244). Perinatal information for all births ≥20 weeks (or of at least 400 g birthweight if gestation was unknown) were prospectively collected. Results: One in five women (21.8%) who gave birth between 2009 and 2013 experienced a primary postpartum haemorrhage and one in 71 women (1.4%) experienced a severe primary postpartum haemorrhage. The increasing trends in incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage, blood transfusion, admission to an intensive care or high dependency unit and peripartum hysterectomy were significant (P < 0.001). Women who had an unassisted vaginal birth had the lowest incidence of primary postpartum haemorrhage. The highest incidence was experienced by women who had an unplanned caesarean section birth. Women who had a forceps birth had the highest incidence of severe primary postpartum haemorrhage. Conclusions: The incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage and associated maternal morbidities have increased significantly over time in Victoria. [ABSTRACT FROM AUTHOR]

The National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Stillbirth and the Perinatal Society of Australia and New Zealand (PSANZ) have recently partnered in updating an important clinical practice guideline, Care of pregnant women with decreased fetal movements. This guideline offers 12 recommendations and a suggested care pathway, with the aim to improve the quality of care for women reporting decreased fetal movements through an evidence‐based approach. Adoption of the guideline by clinicians and maternity hospitals could result in earlier identification of higher‐risk pregnancies, improved perinatal health outcomes for women and their babies, and reduced stillbirth rates. [ABSTRACT FROM AUTHOR]

Background: The postpartum haemorrhage (PPH) rate in Victoria in 2009 for women having their first birth, based on information reported to the Victorian Perinatal Data Collection (VPDC), was 23.6% (primiparas). Prior to 2009 PPH was collected via a tick box item on the perinatal form. Estimated blood loss (EBL) volume is now collected and it is from this item the PPH rate is calculated. Periodic assessment of data accuracy is essential to inform clinicians and others who rely on these data of their quality and limitations. Aims: This paper describes the results of a state‐wide validation study of the accuracy of EBL volume and EBL‐related data items reported to VPDC. Materials and methods: PPH data from a random sample of 1% of births in Victoria in 2011 were extracted from source medical records and compared with information submitted to the VPDC. Accuracy was determined, together with sensitivity, specificity, positive predictive value and negative predictive value for dichotomous items. Results: Accuracy of reporting for EBL ≥ 500 mL was 97.2% and for EBL ≥ 1500 mL was 99.7%. Sensitivity for EBL ≥ 500 mL was 89.0% (CI 83.1‐93.0) and for EBL ≥ 1500 mL was 71.4% (CI 35.9–91.8). Blood product transfusion, peripartum hysterectomy and procedures to control bleeding were all accurately reported in >99% of cases. Conclusions: Most PPH‐related data items in the 2011 VPDC may be considered reliable. Our results suggest EBL ≥ 1500 mL is likely to be under‐reported. Changes to policies and practices of recording blood loss could further increase accuracy of reporting. [ABSTRACT FROM AUTHOR]

Background: The effect of intrapartum analgesia on post-partum maternal back and neck pain, headache and migraine, is uncertain. Aims: To determine if nulliparous women having epidural analgesia during labour have a similar incidence of the above-mentioned post-partum symptoms compared with women managed using other forms of pain relief. Methods: Secondary analysis of cohort data from a randomised trial in which nulliparous women intending to deliver vaginally were randomised to either epidural analgesia (EPI) or continuous midwifery support (CMS) at admission for delivery. Because of high cross-over rates, groups were initially defined by the randomised treatment allocation and the actual treatment received (CMS–CMS n = 185, EPI–CMS n = 117, EPI–EPI n = 376 and CMS–EPI n = 314). Univariate analysis showed no difference between groups, so final analysis was based on the actual treatment received. Results: Six hundred and ninety women received epidural analgesia (EPIDURAL) and 302 received other methods of pain relief including CMS. Back pain was common before, during and after pregnancy, and risk factors for post-partum back pain at six months were back pain prior to pregnancy or at two months post-partum. Epidural analgesia, mode of delivery, spontaneous or induced labour, birthweight and back pain during pregnancy had no significant relationship with post-partum back pain at six months. Headache was significantly more common in the EPIDURAL group during pregnancy and at two months post-partum, but not at six months. Migraine was not associated with intrapartum analgesia. Conclusions: This analysis supports previous research suggesting that epidural analgesia is not a significant risk factor for persisting post-partum back pain, headache or migraine. [ABSTRACT FROM AUTHOR]

To assess maternal satisfaction with childbirth and intrapartum pain relief in nulliparous women labouring at term. Prospective randomised clinical trial comparing epidural and non-epidural analgesic techniques on term labour outcomes in nulliparous women. Within 24 h of delivery the women were surveyed regarding their opinions about the birthing experience and the allocated analgesic regimen. A postal survey was conducted 6 months post-partum to assess opinions about intrapartum analgesia in a subsequent pregnancy. A total of 992 women were randomised to receive continuous midwifery support (CMS) or epidural (EPI) analgesia on presentation for delivery. There was a high crossover rate from CMS to EPI (61.2%) and a lesser non-compliance rate in the EPI group (27.8%). The early post-partum recollections revealed a high satisfaction with epidural analgesia and lower satisfaction with alternative pain relief measures. Ten percent of women in the CMS group reported negative feelings about their allocated pain relief compared with 1% in the EPI group ( P < 0.001), and 10% of all women reported negative feelings about their overall childbirth experience. At the 6-month post-partum survey factors associated with the planned use of epidural analgesia in a subsequent pregnancy were induction of labour (odds ratio (OR) 2.4, 95% confidence interval (CI) 1.2, 4.7) and prior utilisation of epidural analgesia (OR 28.1, 95% CI 14.5, 54.7). Maternal satisfaction with intrapartum analgesia was significantly higher with epidural analgesia than non-epidural analgesic techniques. Overall satisfaction scores for labour and delivery were high regardless of analgesic approach, reflecting the multiple issues other than pain relief that are involved in the childbirth experience. [ABSTRACT FROM AUTHOR]

Although the labour and delivery outcomes of epidural analgesia have been investigated extensively, the effects on breast-feeding success are not clearly identified. To investigate the effects of intrapartum epidural analgesia on breast-feeding duration. Nulliparous women enrolled in a randomised trial investigating labour and delivery outcomes of intrapartum epidural analgesia were asked about breast-feeding outcomes. Breast-feeding duration was ascertained by a self-report at 2 and 6 months post-partum. Breast-feeding outcomes were analysed as a prospective observational study because of high cross-over rates (43.4%) in the original randomised controlled trial. A total of 992 women were recruited to the trial with 690 (69.6%) receiving epidural analgesia in labour. Breast-feeding was initiated by 95% ( n = 946). At 2 and 6 months, 625 (63.5%) and 401 (40.7%), respectively, were still breast-feeding. Intrapartum analgesia (trend P-value = 0.036), mode of delivery ( P < 0.001), age ( P < 0.001), education ( P < 0.001), and smoking in pregnancy ( P < 0.001) showed univariate associations with breast-feeding duration. In the subgroup of women with spontaneous onset of labour and vaginal deliveries, after controlling for other obstetric and demographic factors, epidural analgesia but not narcotic analgesia was significantly associated with reduced breast-feeding duration (adjusted hazard ratio 1.44, 95% confidence interval 1.04–1.99). Nulliparous women have a high use of epidural analgesia in labour. Nulliparous women who choose epidural analgesia are more likely to breast-feed for shorter durations. Further exploration of the factors underlying this association should be undertaken. [ABSTRACT FROM AUTHOR]

Background Aims Materials and Methods Results Conclusions Obstetric ultrasound is an important tool, aiding in screening, diagnosis, and surveillance throughout pregnancy.To explore obstetric doctors', midwives', and sonographers' experiences and views of obstetric ultrasound in Victoria, Australia. To investigate the increasing role of obstetric ultrasound for clinical management, and the adequacy of resources and training for appropriate use of ultrasound in clinical management.This cross‐sectional study forms part of a multi‐national CROss‐Country Ultrasound Study (CROCUS) exploring the views of consumers and health professionals from high‐, middle‐ and low‐income countries. Qualitative studies conducted in several countries informed the construction of a quantitative survey. These quantitative surveys were distributed to 16 hospitals across regional and metropolitan Victoria, Australia. Descriptive statistics were analysed from the responses.There were 354 questionnaires returned from 106 doctors, 222 midwives, and 26 sonographers. Overall, 72% of respondents held concerns about the potential loss of focus on clinical skills with increasing ultrasound use. Midwives were more concerned about the contribution of ultrasound to medicalisation of pregnancy than were doctors (P < 0.001). Many respondents noted that geographical factors (71%), rather than income levels (53%) influenced access to obstetric ultrasound. Over 90% of doctors and midwives believed additional training for their respective professions in ultrasound would enhance its reach and effectiveness.Our survey findings confirm that clinicians place high levels of trust in the diagnostic findings of obstetric ultrasound antenatal care in Australia. Access to routine ultrasound could be improved for women in rural and lower‐income areas. [ABSTRACT FROM AUTHOR]

A response by the authors to a letter to the editor about their article "Intrapartum analgesia and its association with post-partum back pain and headache in nulliparous women," in the 2006 is presented.