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OBJECTIVE: The aim was to compare the childbirth experiences of primiparous women with slow labour progress who had received early versus postponed oxytocin augmentation. METHODS: The population included healthy primiparous women with slow labour progress after a normal pregnancy and spontaneous onset of active labour at term who had taken part in a randomized controlled trial at two delivery units in Sweden comparing early versus postponed oxytocin augmentation. A total of 536 women were sent the Childbirth Experience Questionnaire (CEQ) one month postpartum. The 22-item questionnaire assesses four domains of the childbirth experience. Main outcomes were the four domains of the CEQ: Own capacity, Professional support, Perceived safety and Participation. RESULTS: There were no significant differences between the women in the early and expectant oxytocin treatment groups in any of the four domains; however, operative births were associated with significantly worse childbirth experiences. Almost every third woman in both groups had negative and depressing memories from the childbirth process. CONCLUSIONS: Early oxytocin augmentation for slow labour progress does not appear to be more beneficial than expectant management regarding women's perceptions of childbirth one month postpartum. Given the risks for the foetus associated with oxytocin treatment, prudent expectant management seems to be a safe and viable alternative.

BACKGROUND: Previous studies indicate that analysis of the ST waveform of the fetal electrocardiogram provides information on the fetal response to hypoxia. We did a multicentre randomised controlled trial to test the hypothesis that intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis results in an improved perinatal outcome compared with cardiotocography alone. METHODS: At three Swedish labour wards, 4966 women with term fetuses in the cephalic presentation entered the trial during labour after a clinical decision had been made to apply a fetal scalp electrode for internal cardiotocography. They were randomly assigned monitoring with cardiotocography plus ST analysis (CTG+ST group) or cardiotocography only (CTG group). The main outcome measure was rate of umbilical-artery metabolic acidosis (pH 12 mmol/L). Secondary outcomes included operative delivery for fetal distress. Results were first analysed according to intention to treat, and secondly after exclusion of cases with severe malformations or with inadequate monitoring. FINDINGS: The CTG+ST group showed significantly lower rates of umbilical-artery metabolic acidosis than the cardiotocography group (15 of 2159 [0.7%] vs 31 of 2079 [2%], relative risk 0.47 [95% CI 0.25-0.86], p=0.02) and of operative delivery for fetal distress (193 of 2519 [8%] vs 227 of 2447 [9%], 0.83 [0.69-0.99], p=0.047) when all cases were included according to intention to treat. The differences were more pronounced after exclusion of 291 in the CTG+ST group and 283 in the CTG group with malformations or inadequate recording. INTERPRETATION: Intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis increases the ability of obstetricians to identify fetal hypoxia and to intervene more appropriately, resulting in an improved perinatal outcome.

Some investigators believe that active management of labor with early amniotomy and oxytocin augmentation reduces the caesarean section rate, but this view has not been supported in several meta-analyses. Observational data have shown an association between use of oxytocin treatment in labors lasting less than 12 hours and adverse neonatal outcomes. This prospective randomized trial compared the effect of early and delayed intervention with oxytocin on obstetrical and neonatal outcomes in nulliparous women with spontaneous but prolonged labor at 3 Swedish delivery wards. The study subjects were healthy nulliparous women with normal pregnancies, a singleton fetus, spontaneous onset of active labor with regular contractions, an effaced cervix dilated between 4 and 9 cm, no progress in cervical dilatation for 2 hours and no further progress 1 hour after amniotomy. A total of 630 study women were randomized to either an early oxytocin group (infused within 20 minutes, n = 314) or to an expectant group (postponement of oxytocin infusion for 3 hours, n = 316). The primary study outcome was mode of delivery (spontaneous vaginal, instrumental vaginal, or caesarean). Primary analysis was according to intention to treat. No significant differences were found between the two treatment groups in the caesarean section rate: 29 of 314 (9.2%) in the early oxytocin group versus 34 of 316 (10.8%) in the expectant group (odds ratio [OR], 0.8; 95% confidence interval [CI], 0.5―1.6), or in the instrumental vaginal delivery rate: 54 of 314 (17.2%) in the early oxytocin group versus 38 of 316 (12%) in the expectant group (OR, 1.5; 95% CI, 0.97-2.4). The duration of labor was shortened by 90 minutes in the early oxytocin group compared to the expectant group (P < 0.001). No other differences in risk or benefit between the two study groups were observed. These findings are consistent with data from other studies showing that early use of oxytocin does not decrease the caesarean section rate but does reduce the duration of labor.

Background. The aim of the study was to focus on aspects of the decision-making process among women having first and repeat abortion, in comparision with women continuing their pregnancies with or without having experienced abortions. Methods. In a study of 401 pregnant women, (simple random sample) 20-29 years of age, 137 having first abortion (A1), 64 repeat abortion (A2), 142 continuing their pregnancies with no experience of abortion (B1) and 58 continuing, having experienced abortion(s) (B2), were given a questionnaire and were interviewed. Results. The pregnancy evoked ambivalent feelings in all groups. One third of the women in the A-groups and about 25% of those in the B-groups had ambivalent feelings. More than half of the women decided to have an abortion upon first finding out they were pregnant, and after a few weeks of thought most of them had decided to have the abortion. More than half of the women having an abortion said it was rather or very difficult to make a decision. Among these subjects, women having had contact with social services found it significantly harder to make this decision. A majority agreed with their partners on having an abortion. A majority did not feel influenced by someone else when deciding about the abortion. However, 10% in the Al-group and 6% in the A2-group felt much or comparatively much influenced by someone else. Conclusions. Counselling seems to be important among a considerable number of women finding it hard to make a decision about abortion. Special attention is required for women feeling influenced by someone else and/or having pronounced social problems.

Available standard intrauterine growth curves based on birthweights underestimate foetal growth in preterm period. New growth curves are presented based on data from four Scandinavian centres for 759 ultrasonically estimated foetal weights in 86 uncomplicated pregnancies. Mean weight of boys exceeded that of girls by 2-3%. A uniform SD value of 12% of the mean weight was adopted for the standard curves as the true SD varied non-systematically between 9.1 and 12.4%. Applied to an unselected population of 8663 singleton births, before 210 days of gestation, 32% of birthweights were classified as small-for-gestational age (SGA; i.e. below mean - 2 SD); the corresponding figures were 11.1% for gestational ages between 210 and 258 days, and 2.6% for ages of 259 days or longer. The new growth curves reveal better the true distribution of SGA foetuses and neonates, and are suggested for use in perinatological practice.

BACKGROUND: Breast-feeding in the postpartum period is known to induce intense uterine contractions with pain in the lower abdomen. AIMS: The primary aim of this study was to compare the effects of high and low intensity, high frequency Transcutaneous Electric Nerve Stimulation (TENS) on pain and discomfort of postpartum uterine contractions. The secondary aim was to evaluate discomfort experienced from the stimulation itself. METHODS: Twenty-one newly delivered women participated in this single-blind trial, 12 women received high intensity, high-frequency TENS (HI TENS) and 9 women received low intensity, high-frequency TENS (LI TENS). The electrodes were placed abdominally on each side of the uterus. Stimulation was done during one minute. Visual analogue scales were used to evaluate the intensity of the pain before and after stimulation. A verbal scale was used to estimate sensation of discomfort before, during and after stimulation. RESULTS: The median decrease in pain ratings before and after treatment by VAS was larger in the HI TENS group -49 mm (95% CI -66.5--33.2) than in the LI TENS group -21 mm (95% CI -39.0--20.0). The reduction of pain was most pronounced in the HI TENS group (median difference 28 (95% CI was 14.0-53.0). Furthermore, the HI TENS group experienced significantly less discomfort of the uterine contractions after stimulation (p

OBJECTIVE: The purpose of this study was to monitor the introduction of the STAN-methodology (Noventa Medical, Moelndal, Sweden). STUDY DESIGN: This was a prospective observational study covering the total population of deliveries at term during 2 years. Four thousand eight hundred and thirty out of 14,687 term pregnancies were monitored using the STAN S 21 fetal heart monitor and the associated clinical guidelines. Cord artery metabolic acidosis, neonatal outcome, and rates of operative deliveries for fetal distress were assessed. RESULTS: The annual rate of STAN usage increased from 28.1% to 37.7% and was associated with a significant reduction in metabolic acidosis rate in the total population from 0.76% to 0.44% (P < .05). The compliance with the clinical guidelines increased in cases requiring intervention. The rates for moderate/severe hypoxic neonatal encephalopathy were consistently low, 0.55 and 0.68 per 1000 deliveries, respectively, and corresponding to previous findings. The rate of operative delivery did not change during the 2 years in the total population. CONCLUSION: Increasing STAN usage provided consistent improvements in fetal outcome equalling those noted in the Swedish randomized controlled trial (RCT) without increasing operative interventions for fetal distress.

Obstetrical brachial plexus palsy (OBPP) is a serious form of neonatal morbidity.The aim of this work was to study the incidence of OBPP and to analyze its risk factors.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.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.Shoulder dystocia and infant birthweight of 4500 g and more are the strongest risk factors for OBPP in a Swedish population.

One hundred and sixty-seven women gave birth before arrival at the hospital during a six-year period in the Göteborg area. Most of these women had given birth before. The actual delivery most often started at term during the night, proceeded normally but rapidly and the neonatal outcome was good. Sixty-two per cent of the women delivered at home. Complicated lacerations or major hemorrhages were uncommon. The distance to the delivery ward was one of the risk factors for prehospital delivery. This is important to take into consideration in the ongoing process of centralizing the delivery clinics. Basic knowledge in obstetrics is mandatory for the ambulance personnel, as well as regular observation visits to the delivery ward and practice in birth simulators.

Objective The purpose of this study was to evaluate the role of monocyte chemotactic protein-1 in cervical and amniotic fluid in women in preterm labor and with preterm premature rupture of membranes. Study design Women with singleton pregnancies (≤34 weeks) in preterm labor (n = 75 women), with preterm premature rupture of membranes (n = 47 women), and at term (n = 45 women) who were undergoing elective cesarean delivery were included. Cervical and amniotic fluid were sampled. Results Monocyte chemotactic protein-1 in cervical and amniotic fluid was higher in women in preterm labor than in women at term. Cervical monocyte chemotactic protein-1 in women in preterm labor was associated with microbial invasion of the amniotic cavity, intra-amniotic inflammation, delivery within 7 days, and at ≤34 weeks. Amniotic monocyte chemotactic protein-1 correlated to microbial invasion of the amniotic cavity in women with preterm premature rupture of membranes, intra-amniotic inflammation in preterm labor, preterm premature rupture of membranes, delivery within 7 days, and delivery at ≤34 weeks in women in preterm labor. Conclusion Monocyte chemotactic protein-1 in cervical and amniotic fluid levels are elevated in preterm labor and preterm premature rupture of membranes and correlate to intra-amniotic infection/inflammation.

In a simple random sample study of 404 women 20 to 29 years of age, 201 applying for abortion and 203 continuing their pregnancies, all were interviewed personally and requested to complete a questionnaire. The aim of the study was to analyse the use and experience of contraceptives among the abortion applicants in this age group, and to compare their experience with that of women in a matched control group. The most important reasons given for desisting in the use of contraceptives were the experience of side effects, worry about the side effects, and the "human failure" factor involved even with methods of contraception such as pills, which generally are regarded as safe. This study demonstrates that women living alone without any permanent relationship, having a strained economy or having previously had an abortion, need particular and detailed contraceptive advice plus continued close follow-up. To improve the continuation rate, precise contraception counselling focusing on both positive and adverse effects to reduce worry seems essential.A 1988 study in Sweden compared the experiences of contraceptives among 201 women, 20-29 years old, electing to undergo legal abortion with those of 203 age- and residence-matched pregnant controls. The researchers also wanted to study the contraceptive experiences of 20-29 year old women choosing abortion. All study subjects attended the family planning clinic of the University Hospital or maternity centers in Goteborg. Cases who had undergone at least 1 other previous legal abortion (A2) were more likely to report side effects from their chosen contraceptive than the controls (51% vs. 29%; p .01). Both these women and those undergoing their first legal abortion (A1) experienced contraceptive side effects more frequently than controls (p = or .01). Women in the abortion groups who had side effects were more likely to discontinue their current contraceptive method than those in the control group who had side effects (90.8% vs. 20.3%). The abortion groups were more likely to have side effects and fear side effects from the use of oral contraceptives (OCs) than the control group (33% for A1 and 45% for A2 vs. 22%; p .01). The most popular contraceptive used by all groups was OCs (79-84%). Among all 404 women, 77 (19%) became pregnant despite contraception use. Women in the abortion groups were more likely to be using a contraceptive when they conceived than controls (33.6% for A1 and 32.8% for A2 vs. 4.9%). Controls were more likely to be married or living together and had longer relationships than the abortion groups (95% vs. 33-44% and 5 vs. 1.5-2.5 years, respectively). Women in the abortion groups tended to have a poor economic situation (39-42% vs. 17% for controls). These findings show that family planning practitioners need to provide individualized and detailed contraceptive counseling, with continued follow-up, to women not in a permanent relationship, in a poor economic situation, or with a history of previous abortion.

Fetal heart rate (FHR) and fetal electrocardiogram (ECG) recordings were obtained from a scalp electrode with maternal thigh as reference and used for ST waveform analysis in 201 patients in labour. Nearly 45% had suspicious or abnormal FHR traces whilst only 27% had T/QRS ratio greater than 0.25 (mean +/- 2 SD). A normal T/QRS ratio identified 99.3% of fetuses with normal buffering capacity in cord artery blood. Of 13 infants with a cord artery blood pH less than 7.15, standard bicarbonate was less than 15.0 mmol/l in five who had an average T/QRS ratio less than 0.25 throughout labour. Of the eight with respiratory acidosis, five had an increase in T/QRS ratio greater than 0.25 for longer than 20 minutes prior to delivery, in two the ratio increased during the last few minutes and one had no change (pH 7.14). Persistent elevation of T/QRS in the first stage of labour identified those with decrease in buffer capacity in cord arterial blood (sensitivity of 94.1%). Acute hypoxia was recognized by the rapid rise in T/QRS. The specificity of T/QRS to identify fetuses at risk increased by combining the ST waveform analysis with FHR changes.

Study design: A randomized controlled study. If labor was prolonged during the active phase with no further opening of the cervix for two hours, the subject were randomly allocated to either labor augmentation by means of oxytocin (standard care group= SG) or expectancy (expectant care group=EG). If the women in the EG after the 3 hours still did not progress in their labor, a reassessment regarding the need for labor augmentation was done. 454 of the studied women filled out a questionnaire, one month postpartum including the following items: level of sense of security, pain, sense of control, experience of their own role in labor, and satisfaction with healthcare. The fathers answered questions about their experience of being a supporting person during labor. A comparison was performed between the randomized groups and a selected group of nulliparous women delivered without oxytocin augmentation regarding if there was a state of low-spiritedness one month postpartum.

ULATION-BASED STUDY JUN ZHANG, BRADY HAMILTON, JOYCE MARTIN, ANN TRUMBLE, National Institutes of Health, Epidemiology Branch, Bethesda, MD National Center for Health Statistics, Hyattsville, MD National Institutes of Health, Bethesda, MD OBJECTIVE: The number of multifetal pregnancies has increased dramatically. Cases such as premature rupture of the membranes of one fetus, single fetal demise, and premature labor in extreme preterm are encountered more often than before. Delaying delivery of the remaining fetus(es) is feasible in some cases. However, benefits and risks of this procedure have yet to be established. STUDY DESIGN: We used the U.S. 1995-98 Matched Multiple Birth File to examine infant survival after delayed interval delivery. We identified 200 twin pregnancies in which the first twin was delivered between 17 and 29 weeks of gestation and the second twin was delivered at least 24 hours later. We individually matched the delayed deliveries with 374 twin pregnancies in which delivery of second twin was not delayed. Perinatal outcomes and infant survival were compared between the delayed and non-delayed twins. RESULTS: Among the 200 pregnancies with delayed delivery, the mean gestational age at first delivery was 23 weeks and the median duration of delay was 6 days (ranging from 2 to 107 calendar days). With every week of delay in delivery, the fetus gained 131 grams on average (95% CI: 115-147 g). 56% of the delayed second twins survived to 1 year of age (95% CI: 50-64%) while only 24% of the non-delayed second twins did so (95% CI: 20-29%) (P < 0.001). The delayed twins also had significantly higher Apgar scores at 5 minutes. However, delayed delivery was also associated with 11% of risk (95% CI: 6-16%) for fetal death of the remaining twin before 24 weeks. CONCLUSION: Delaying delivery of the remaining fetus(es) before 30 weeks of gestation improves infant survival by more than twofold and, probably, reduces long-term child morbidity by increasing birthweight and Apgar score at 5 minutes.

The ST waveform of the fetal electrocardiogram (ECG) was examined in 10 chronically instrumented fetal lambs from 115 days to term. Averaged ST waveforms were plotted at 5-minute intervals in six fetuses for 2 to 22 days. No diurnal or other rhythms were seen. To correct for changes in signal gain the amplitude of the T wave was measured relative to the amplitude of the QRS complex. The T/QRS ratio was normally less than 0.30. Persistently elevated ST waveforms with a T/QRS range 0.32 to 0.65 preceded fetal death by some days in three fetuses and were associated with anemia and/or hypotension in a further three. In these animals hypoxia produced a further rise in the ST waveform (mean T/QRS, from 0.48 to 0.81) and all died during labor. In lambs with a normal ST waveform there were differences in the response to hypoxia over 1 hour for a similar fall in P o2 . In eight experiments the ST segment and T wave increased (mean T/QRS, from 0.17 to 0.59) and promptly reverted to normal with normoxia. There was a significant rise in mean arterial blood pressure, plasma lactate, and glucose and a fall in pH. In four experiments there was little change (mean T/QRS, from 0.19 to 0.25), with a small rise in plasma lactate suggesting that these lambs were able to maintain aerobic myocardial metabolism. Overall there was a strong correlation of the T/QRS ratio to the rate of rise of lactate. These findings complement previous results in the acute fetal lamb preparation and suggest that ST waveform elevation expressed as the T/QRS ratio identifies a change to anaerobic myocardial metabolism.