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Introduction The Robson Ten Group Classification System is widely used for the audit of cesarean section (CS) rates. However, CS rate alone is a poor quality indicator and should be balanced with other obstetric endpoints. The aim of this study was to evaluate whether Swedish national data on obstetric outcomes other than CS, stratified by the Robson classification, could be analyzed in a useful way. Material and methods All births in Sweden from 2017 through 2020 recorded in the nationwide Swedish Pregnancy Register were categorized using the Robson classification with subdivision of some groups. Five outcomes were explored: CS, operative vaginal delivery, postpartum hemorrhage, obstetric anal sphincter injury (OASIS) and Apgar score The largest Robson groups were nulliparous and multiparous women with single-term cephalic pregnancies, unscarred uterus and spontaneous labor. Intrapartum CS rates were highest for multiple pregnancies, women with induced labor after previous CS, and nulliparous women with induced labor. Nulliparous women and multiparous women with a previous CS with attempted vaginal birth had the highest operative vaginal delivery and OASIS rates. The postpartum hemorrhage rate was highest for multiple pregnancies and transverse lie, followed by prelabor CS in nulliparous and multiparous women with single-term cephalic pregnancies and unscarred uterus. The highest rates of Apgar score

Objective To assess the cost-effectiveness of induction of labour (IOL) at 41 weeks of gestation compared with expectant management until 42 weeks of gestation. Design A cost-effectiveness analysis alongside the Swedish Post-term Induction Study (SWEPIS), a multicentre, randomised controlled superiority trial. Setting Fourteen Swedish hospitals during 2016-2018. Population Women with an uncomplicated singleton pregnancy with a fetus in cephalic position were randomised at 41 weeks of gestation to IOL or to expectant management and induction at 42 weeks of gestation. Methods Health benefits were measured in life years and quality-adjusted life years (QALYs) for mother and child. Total cost per birth was calculated, including healthcare costs from randomisation to discharge after delivery, for mother and child. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in mean cost between the trial arms by the difference in life years and QALYs, respectively. Sampling uncertainty was evaluated using non-parametric bootstrapping. Main outcome measures The cost per gained life year and per gained QALY. Results The differences in life years and QALYs gained were driven by the difference in perinatal mortality alone. The absolute risk reduction in mortality was 0.004 (from 6/1373 to 0/1373). Based on Swedish life tables, this gives a mean gain in discounted life years and QALYs of 0.14 and 0.12 per birth, respectively. The mean cost per birth was euro4108 in the IOL group (n = 1373) and euro4037 in the expectant management group (n = 1373), with a mean difference of euro71 (95% CI -euro232 to euro379). The ICER for IOL compared with expectant management was euro545 per life year gained and euro623 per QALY gained. Confidence intervals were relatively wide and included the possibility that IOL had both lower costs and better health outcomes. Conclusions Induction of labour at 41 weeks of gestation results in a better health outcome and no significant difference in costs. IOL is cost-effective compared with expectant management until 42 weeks of gestation using standard threshold values for acceptable cost per life year/QALY. Tweetable abstract Induction of labour at 41 weeks of gestation is cost-effective compared with expectant management until 42 weeks of gestation.

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.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.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/mThe 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.

Introduction Induction of labor is increasing. A common indication for induction of labor is late term and postterm pregnancy at 41 weeks or more. We aimed to evaluate if there are any differences regarding efficacy, safety, and women's childbirth experience between oral misoprostol and transvaginal balloon catheter for cervical ripening in women with a low-risk singleton pregnancy and induction of labor at 41+0 to 42+0 to 1 weeks of gestation. Material and methods In this observational study, based on data from the Swedish Postterm Induction Study (SWEPIS), a multicenter randomized controlled trial, a total of 1213 women with a low-risk singleton pregnancy at 41 to 42 weeks of gestation were induced with oral misoprostol (n = 744) or transvaginal balloon catheter (n = 469) at 15 Swedish delivery hospitals. The primary efficacy outcome was vaginal delivery within 24 h and primary safety outcomes were neonatal and maternal composite adverse outcomes. Secondary outcomes included time to vaginal delivery and mode of delivery. Women's childbirth experience was assessed with the Childbirth Experience Questionnaire (CEQ 2.0) and visual analog scale. We present crude and adjusted mean differences and relative risks (RR) with 95% CI. Adjustment was performed for a propensity score based on delivery hospital and baseline characteristics including Bishop score. Results Vaginal delivery within 24 h was significantly lower in the misoprostol group compared with the balloon catheter group (46.5% [346/744] versus 62.7% [294/469]; adjusted RR 0.76 95% CI 0.640.89]). Primary neonatal and maternal safety outcomes did not differ between groups (neonatal composite 3.5% [36/744] vs 3.2% [15/469]; adjusted RR 0.77 [95% CI 0.31-1.89]; maternal composite 2.3% [17/744] versus 1.9% [9/469]; adjusted RR 1.70 [95% CI 0.58-4.97]). Adjusted mean time to vaginal delivery was increased by 3.8 h (95% CI 1.3-6.2 h) in the misoprostol group. Non-operative vaginal delivery and cesarean delivery rates did not differ. Women's childbirth experience was positive overall and similar in both groups. Conclusion Induction of labor with oral misoprostol compared with a transvaginal balloon catheter was associated with a lower probability of vaginal delivery within 24 h and a longer time to vaginal delivery. However, primary safety outcomes, non-operative vaginal delivery, and women's childbirth experience were similar in both groups. Therefore, both methods can be recommended in women with low-risk postdate pregnancies.

ObjectiveTo investigate neonatal outcomes within 28 days in the subsequent birth in women who gave birth to their first baby by caesarean section (CS).Design and settingNational retrospective population-based register study. A cohort of 94 451 neonates who were born in Sweden between 1999 and 2015 as a second child to a mother who had her first birth by emergency or planned caesarean.MethodsData were retrieved from the national registers held by Statistics Sweden and the National Board of Health and Welfare. Logistic regression was used to calculate unadjusted and adjusted ORs (aOR) with 95% CIs for each outcome.Main outcome measuresNeonatal infection, neonatal asphyxia/respiratory distress, neonatal hospital care and neonatal death within 28 days.ResultsEmergency CS and instrumental vaginal birth were associated with a doubled risk of neonatal infection (aOR 2.0) and planned CS with a decreased risk (aOR 0.7) compared with spontaneous vaginal birth. Compared with spontaneous vaginal birth, an increased risk of birth asphyxia and/or respiratory distress was identified with all other modes of birth (aOR 2.2–3.2). Emergency CS and instrumental vaginal birth, but not planned CS, were associated with neonatal hospital care (aOR 1.8 and 1.7) and an increased mortality rate during the neonatal period (aOR 2.9 and 3.2), compared with spontaneous vaginal birth.ConclusionsIn childbirth following a previous birth by CS, spontaneous vaginal birth appears to confer better neonatal outcomes within 28 days after birth overall than other modes of birth.

Cardiotocography (CTG) is a widely used method for assessing fetal wellbeing during labor. It is well-known that CTG has high sensitivity but low specificity. To avoid unnecessary operative interventions, adjunctive methods such as fetal blood sampling (FBS) are used. Few studies have looked into whether FBS can be used during second stage of labor, and in that case, which of the methods (lactate or pH) are preferred.To evaluate clinical effectiveness of measuring lactate versus pH in preventing birth acidemia when FBS was performed during second stage of labor.Secondary analysis of a randomized controlled trial . Thousand three hundred and thirty-eight women with a singleton pregnancy, cephalic presentation, gestational age ≥34 weeks, and indication for FBS during second stage of labor were included.Metabolic acidemia (pH7.05 and base deficit12 mmol/l) or pH7.00 in cord arterial blood at birth.A composite outcome (metabolic acidemia, pH7 or Apgar score4), and rates of operative deliveries.Metabolic acidemia occurred in 4.1% in the lactate versus 5.1% in the pH group (relative risk (RR): 0.80; 95% confidence interval (CI): 0.48-1.35) and pH7 in 1.4% versus 2.8% (RR: 0.51, 95% CI: 0.23-1.13). Composite outcome was found in 3.8 versus 4.9%, respectively (RR: 0.76; 95% CI: 0.46-1.26). No difference in total operative interventions was found. More cesarean deliveries were performed in the lactate group (16.5 vs. 12.4%; RR: 1.33; 95% CI: 1.02-1.74).When analyzing lactate or pH in fetal scalp blood during second stage of labor neonatal outcomes were comparable. The frequency of total operative interventions was similar but more cesarean deliveries were performed in the lactate group.

Introduction Cesarean section (CS) rate is a well-established indicator of performance in maternity care and is also related to resource use. Case mix adjustment of CS rates when performing comparisons between hospitals is important. The objective of this study was to estimate case mix adjusted variation in CS rate between hospitals in Sweden. Material and methods In total, 139 756 deliveries in 2011 and 2012 were identified in administrative systems in seven regions covering 67% of all deliveries in Sweden. Data were linked to the Medical birth register and population data. Twenty-three different sociodemographic and clinical characteristics were used for adjustment. Analyses were performed for the entire study population as well as for two subgroups. Logistic regression was used to analyze differences between hospitals. Results The overall CS rate was 16.9% (hospital minimum–maximum 12.1–22.6%). Significant variations in CS rate between hospitals were observed after case mix adjustment: hospital odds ratios for CS varied from 0.62 (95% CI 0.53–0.73) to 1.45 (95% CI 1.37–1.52). In nulliparous, cephalic, full-term, singletons the overall CS rate was 14.3% (hospital minimum–maximum: 9.0–19.0%), whereas it was 4.7% for multiparous, cephalic, full-term, singletons with no previous CS (hospital minimum–maximum: 3.2–6.7%). In both subgroups significant variations were observed in case mix adjusted CS rates. Conclusions Significant differences in CS rate between Swedish hospitals were found after adjusting for differences in case mix. This indicates a potential for fewer interventions and lower resource use in Swedish childbirth care. Best practice sharing and continuous monitoring are important tools for improving childbirth care.

OBJECTIVE The objective of this study was to estimate case mix adjusted variations in central indicators of health outcomes in childbirth care and to assess whether hospitals who perform well on one indicator also perform well on others. DESIGN Register-based study using regional administrative data, linked to clinical data and population data. SETTING Twenty-one hospitals in seven Swedish regions covering 67% of deliveries in Sweden. PARTICIPANTS The study included 139 756 women who gave birth in 2011 and 2012. INTERVENTION(S) N/A. MAIN OUTCOME MEASURE(S) Four indicators of health outcomes were studied: obstetric anal sphincter injuries (OASIS), haemorrhage >1000 ml, postpartum infection and Apgar

We aimed to characterize the clinical course with focus on pharmacological management of peripartum cardiomyopathy (PPCM) in Sweden.Twenty-four consecutive patients were retrospectively identified among women presenting with PPCM in Western Sweden. Of these, 14 had concomitant preeclampsia. There was only one fatality. The mean (standard deviation) left ventricular ejection fraction (LVEF) at diagnosis was 35.0 ± 9.9%. Ten women, 47.6%, required intensive care unit (ICU) admission. All patients received β-blockers (BB) and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACE-I/ARB), which were tapered off over a mean/median period of 3.3/2.5 years with only one case of worsening heart failure. The mean follow-up for medication was 7.9 ± 2.6 years. Early and late/non-recovery was defined as New York Heart Association (NYHA) functional class I and NYHA II-IV at one year, respectively. Late recovery was associated with larger LVEDD at diagnosis (56.8 versus 62.4 mm) was associated with late recovery, p = .02.PPCM had an overall good prognosis in this cohort. Left ventricular dilation at presentation was a predictor of worse prognosis. Concurrent preeclampsia was common, but was associated with better prognosis. Medication was safely discontinued in 75% of patients.

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 Observational data shows that postterm pregnancy (≥42 gestational weeks, GW) and late term pregnancy (≥41 GW), as compared to term pregnancy, is associated with an increased risk for adverse outcome for the mother and infant. Standard care in many countries is induction of labour at 42 GW. There is insufficient scientific support that induction of labour at 41 GW, as compared with expectant management and induction at 42 GW will reduce perinatal mortality and morbidity without an increase in operative deliveries, negative delivery experiences or higher costs. Large randomised studies are needed since important outcomes; such as perinatal mortality and hypoxic ischaemic encephalopathy are rare events. Methods/Design A total of 10 038 healthy women ≥18 years old with a normal live singleton pregnancy in cephalic presentation at 41 GW estimated with a first or second trimester ultrasound, who is able to understand oral and written information will be randomised to labour induction at 41 GW (early induction) or expectant management and induction at 42 GW (late induction). Women will be recruited at university clinics and county hospitals in Sweden comprising more than 65 000 deliveries per year. Primary outcome will be a composite of stillbirth, neonatal mortality and severe neonatal morbidity. Secondary outcomes will be other adverse neonatal and maternal outcomes, mode of delivery, women’s experience, cost effectiveness and infant morbidity up to 3 months of age. Data on background variables, obstetric and neonatal outcomes will be obtained from the Swedish Pregnancy Register and the Swedish Neonatal Quality Register. Data on women’s experiences will be collected by questionnaires after randomisation and 3 months after delivery. Primary analysis will be intention to treat. The statistician will be blinded to group and intervention. Discussion It is important to investigate if an intervention at 41 GW is superior to standard care in order to reduce death and lifelong disability for the children. The pregnant population, >41 GW, constitutes 15–20 % of all pregnancies and the results of the study will thus have a great impact. The use of registries for randomisation and collection of outcome data represents a unique and new study design. Trial registration The study was registered in Current Controlled Trials, ISRCTN26113652 the 30th of March 2015 (DOI 10.1186/ISRCTN26113652).

Acta Obstet Gynecol Scand 2002; 81: 909-917. © Acta Obstet Gynecol Scand 81 2002 Background. The influence of maternal, obstetric and fetal risk factors on the prevalence of birth asphyxia at term in a Swedish urban population. Objective. To investigate risk factors for Apgar score-defined birth asphyxia, birth asphyxia with hypoxic-ischemic encephalopathy and birth asphyxia-related death/disability. Material and methods. Retrospective case-control study in term neonates with birth asphyxia defined as Apgar score < 7 at 5 min. Cases originating from nonasphyctic causes (e.g. infection, maternal sedation) were excluded. Hypoxic-ischemic encephalopathy was diagnosed according to criteria by Sarnat. Maternal, obstetric and fetal risk factors were registered in 225 cases of birth asphyxia diagnosed in 42 203 live births occurring in the urban Swedish population studied. A matched control group was used for statistical evaluation. Results. Asphyxia was associated with single civil status, OR = 7.1 (95%CI 2.0, ...

Objective To evaluate cervical length in asymptomatic women with singleton pregnancies in the second trimester by means of transvaginal ultrasonography, and to examine the relation between cervical length and spontaneous preterm delivery. Design Observational, prospective study. Setting A university hospital and a county hospital in Western Sweden. Population A total of 2122 asymptomatic women with live singleton pregnancies without fetal anomalies. Methods Cervical length was measured at between 16 and 23 weeks of gestation by means of transvaginal ultrasonography. Data were analysed using logistic regression analysis. Main outcome measures Cervical length in relation to spontaneous preterm delivery

Objective. To investigate the views and experiences of Swedish women regarding antenatal, delivery and postpartum care.Study design. A random sample of women from the birth cohorts 1955, 1959, 1963, 1967 and 1971 resident in the city of Goteborg (n=2880) was invited by letter to complete a questionnaire regarding antenatal, delivery and postpartum care.Results. The overall response rate was 73% and 1130 (54%) of the 2109 responders had given birth to at least one child. Eighty-one percent of parous women answered that checking blood and urine samples, fetal heart rate, and the measurement of fundal height were the most important procedures in antenatal care. A majority had a positive attitude towards the use of electronic fetal heart rate monitoring (parous 85%; nulliparous 84%). Sixty percent of parous women were aware that ultrasound examination was voluntary and a majority (90%) had a positive attitude towards ultrasound scanning. Forty-three percent of parous women wanted antenatal clinics to be open ...

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.

One thousand three hundred eighty-five women with PROM (prelabor rupture of the membranes) participated in a prospective randomized study. Women with PROM were randomized to induction the following morning after PROM (early induction group) or induction two days later (late induction group). If contractions started within 2 hours after admission these women were included in the short latency group. All neonatal infections were classified as verified sepsis (positive culture) or clinical sepsis. The aim of the study was to compare the perinatal infectious outcome between the groups with different expectant managements in women with PROM and to study the association between demographic, intrapartum and postpartum variables and neonatal sepsis. In the short latency group one neonate had a proven sepsis while four neonates with proven sepsis were found in the early induction group. No proven sepsis was detected in the late induction group. Univariate analyses showed a significant association between clinical sepsis and: induction of labor (OR = 2.94, 95% CI 1.30-6.68), established labor 24.1-32 hours after ROM (OR = 5.89, 95% CI 1.68-20.63), established labor32 hours after ROM (OR = 4.59, 95% CI 1.52-13.87), time from ROM to delivery32 hours (OR = 5.07, 95% CI 1.40-18.39), cesarean section (OR = 11.03, 95% CI 4.10-29.68), chorioamnionitis before or during delivery (OR = 27.14, 95% CI 2.38-309.16), endometritis (OR = 18.08, 95% CI 1.82-179.87), CRP over 20 mg/l in the umbilical cord (OR = 17.12, 95% CI 5.68-52.12) and Apgar score7 after 1, 5 or 10 minutes. In a stepwise logistic regression analysis a significant association was found between clinical sepsis and cesarean section (OR = 10.08, 95% CI = 3.26-31.20), time from ROM to delivery32 h (OR = 3.74, 95% CI 1.62-8.62), gestational age 34-36 weeks (OR = 3.16, 95% CI 1.11-8.96) and parous women (OR = 2.41, 95% CI 1.04-5.57). In conclusion, this study indicates that that there was no difference in the incidence of neonatal infections between those with early and late induction. Clinical neonatal sepsis was associated with time from PROM to delivery over 32 hours, cesarean section, parous women and gestational age between 34 and 36 weeks.

Objective To compare obstetric and perinatal outcome between two different expectant managements in women with prelabour rupture of the membranes (PROM). Design A randomised study. Participants One thousand three hundred and eighty-five women with rupture of the membranes at 34 to 42 weeks without contractions. Interventions Women without contractions 2 h after admission were randomised to early induction the following morning after PROM (early induction group) or induction two days later (late induction group). Women with contractions starting within 2 h after admission were included in the calculations as a short latency group. Digital examinations of the cervix were avoided until onset of active labour. Labour was induced with oxytocin in both groups if no spontaneous contractions occurred or if chorioamnionitis or fetal distress was detected. Main outcome measures The frequency of spontaneous deliveries, operative deliveries, maternal and neonatal infections. Results In nulliparous women, a higher rate of spontaneous deliveries was found in the late induction group (89%) compared with the early induction group (81%) (P < 0.05). The ventouse extraction rate was 7 % and 14% respectively (P < 0.05). A low (2-4%) caesarean section rate was recorded and did not differ between the groups. Endometritis was detected in six women after delivery. Sixty-one children were treated with antibiotics, and no difference could be detected between the groups. Conclusions A higher rate of spontaneous deliveries was found among nulliparous women with prolonged latency as compared with brief latency prior to induction. A protocol of no digital examination before labour was associated with infrequent maternal and fetal morbidity, regardless of latency.

Objective To evaluate whether colposcopically directed cervical biopsies during pregnancy are associated with surgical/obstetric complications and to examine the natural course (regression, persistence, progression) of dysplasia during pregnancy. Design Prospective clinical study. Setting and population University Hospital and 251 pregnant women with atypical cervical cytology in early pregnancy. Methods The patients were investigated by colposcopically directed punch biopsies, colposcopically directed loop-biopsies or LEEP-cones. The histology results during pregnancy were compared with those after delivery to evaluate the natural course of dysplastic lesions during pregnancies. Postoperative complications were recorded. Obstetric outcome was recorded and compared with the 54 919 other births in the same geographical area during the study period. Main outcome measures Persistence, regression and progression of cervical dysplasia, surgical complications after diagnostic procedure, incidence of preterm birth, mode of delivery. Results Only a minor part (12.3%) of the dysplastic lesions showed progression during pregnancy, with 54.6 and 33.1% showing persistence and regression, respectively. No surgically related postoperative bleeding that needed surgical (diathermy/suture) treatment occurred and the miscarriage rate was low (0.8%). There were no differences in mode of delivery, preterm birth or other obstetrical variables between the study group and the large control cohort. Conclusion Investigation of atypical cytology during pregnancy with biopsy including large loop excisions is a safe procedure with regard to surgical complications and obstetrical outcome. There is a high rate of persistence and regression of dysplasia during pregnancy.

Birth asphyxia is a perinatal occurrence that, in serious cases, may lead to permanent adverse consequences or death. This retrospective case-control study of term neonates with birth asphyxia, defined as a 5-minute Apgarscore less than 7, had as its goal to explore risk factors for birth asphyxia itself, related hypoxic-ischemic encephalopathy (HIE), and asphyxia-related disability and death. Infants who died of nonasphyxial causes, such as infection or maternal sedation, were not included. Among more than 42,000 live births reviewed for the years 1985 through 1991 in an urban Swedish population were 225 cases of birth asphyxia that were matched with nonasphyxial control cases. The study group included 75 infants with both asphyxia and HIE. Surviving infants were followed for 18 months or longer, and those viewed as neurologically disabled were followed for 1.5 to 3 years longer. Twenty-two infants in the asphyxia group died or developed asphyxia-related neurological disability. Rates of birth asphyxia, pure birth asphyxia, and asphyxia-related HIE during the 7-year review period were, respectively, 6.9, 5.4, and 1.9 per 1000 live births. The asphyxia-related mortality rate was 0.26 per 1000 live births, and the rate of neurological impairment at the 18-month follow-up was 0.2 per 1000. Factors associated with birth asphyxia included single marital status (odds ratio [OR] = 7.1), intrauterine meconium release (OR = 4.1), operative delivery (OR = 8.7), breech delivery (OR = 20.3), and oxytocin augmentation (OR = 2.9). Other associated parameters were cord complications (OR = 15.8) and external compression to aid delivery (OR = 6.2). Significant cardiotocographic (CTG) correlates included repeated late decelerations (OR = 29.4), occasional late or variable decelerations (OR = 2.2), and a lack of accelerations (OR = 5.2). All groups of infants with asphyxia were delivered operatively or instrumentally more often than were the matched control infants. No association was evident between asphyxia and maternal age, smoking, illnesses, time of delivery (day vs. night or seasonal), or previous cesarean delivery. Independent risk factors for HIE included intrauterine meconium release, CTG score, and operative delivery. This is one of the few population-based studies of risk factors for asphyxia and perhaps the first to separately examine risk factors for pure asphyxia, HIE, and asphyxia-related death and disability. Asphyxia was strongly associated with CTG abnormalities, particularly the absence of baseline variability. CTG monitoring definitely is indicated for women given oxytocin augmentation, one of the factors associated with asphyxia in this study.

Background Previous publications indicate that acupuncture is efficient for the treatment of pelvic girdle pain, PGP, in pregnant women. However, the use of acupuncture for PGP is rare due to insufficient documentation of adverse effects of this treatment in this specific condition. The aim of the present work was to assess adverse effects of acupuncture on the pregnancy, mother, delivery and the fetus/neonate in comparison with women that received stabilising exercises as adjunct to standard treatment or standard treatment alone. Methods In all, 386 women with PGP entered this controlled, single-blind trial. They were randomly assigned to standard treatment plus acupuncture (n = 125), standard treatment plus specific stabilising exercises (n = 131) or to standard treatment alone (n = 130) for 6 weeks. Acupuncture that may be considered strong was used and treatment was started as early as in the second trimester of pregnancy. Adverse effects were recorded during treatment and throughout the pregnancy. Influence on the fetus was measured with cardiotocography (CTG) before-during and after 43 acupuncture sessions in 43 women. A standardised computerized method to analyze the CTG reading numerically (Oxford 8000, Oxford, England) was used. After treatment, the women rated their overall experience of the treatment and listed adverse events if any in a questionnaire. Data of analgesia and oxytocin augmentation during labour, duration of labour, frequency of preterm birth, operative delivery, Apgar score, cord-blood gas/acid base balance and birth weight were also recorded. Results There were no serious adverse events after any of the treatments. Minor adverse events were common in the acupuncture group but women rated acupuncture favourably even despite this. The computerized or visually assessed CTG analyses of antenatal recordings in connection with acupuncture were all normal. Conclusion This study shows that acupuncture administered with a stimulation that may be considered strong led to minor adverse complaints from the mothers but had no observable severe adverse influences on the pregnancy, mother, delivery or the fetus/neonate.

To evaluate the association between obstetric brachial plexus palsy and obstetrical maneuvers during the second stage of delivery.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.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.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.

To compare obstetric outcome after a bath offered to women on two different occasions during the first stage of labour. The aim of the study was to determine whether an early bath affected the progress of labour and the use of analgesia when compared with a late bath during the first stage of labour.A randomised prospective pilot-study.The delivery ward at Ostra Hospital in Göteborg.Two hundred women, at low obstetric risk.The women were randomised to either the 'early bath group' or the 'late bath group'. The women in the 'early bath group' had a bath before a cervical dilatation of 5 cm, while the women in the 'late bath group' had a bath after the cervix was 5 cm dilated.The women in the 'early bath group' had a longer time period from established labour to delivery (9.8 hours) compared to the 'late bath group' (8.5 hours) (p0.004). A higher proportion of women in the 'early bath group' needed oxytocin administration (57%) compared to the 'late bath group' (30%) (p0.01). Epidural analgesia was used by 27% of the women in the 'early bath group' and by 9% in the 'late bath group' (p0.001). One baby in the 'early bath group' had clinical signs of infection and required antibiotic treatment. No cases of amnionitis or endometritis were present in the women.The findings suggest that a bath during the first stage of labour should preferably be used after a cervical dilatation of 5 cm to avoid prolonged labour, and an increased use of oxytocin and epidural analgesia.

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.

Objectives To compare the efficacy of standard treatment, standard treatment plus acupuncture, and standard treatment plus stabilising exercises for pelvic girdle pain during pregnancy. Design Randomised single blind controlled trial. Settings East Hospital, Gothenburg, and 27 maternity care centres in Sweden. Participants 386 pregnant women with pelvic girdle pain. Interventions Treatment for six weeks with standard treatment (n = 130), standard treatment plus acupuncture (n = 125), or standard treatment plus stabilising exercises (n = 131). Main outcome measures Primary outcome measure was pain (visual analogue scale); secondary outcome measure was assessment of severity of pelvic girdle pain by an independent examiner before and after treatment. Results After treatment the stabilising exercise group had less pain than the standard group in the morning (median difference = 9, 95% confidence interval 1.7 to 12.8; P = 0.0312) and in the evening (13, 2.7 to 17.5; P = 0.0245). The acupuncture group, in turn, had less pain in the evening than the stabilising exercise group (-14, -18.1 to -3.3; P = 0.0130). Furthermore, the acupuncture group had less pain than the standard treatment group in the morning (12, 5.9 to 17.3; P < 0.001) and in the evening (27, 13.3 to 29.5; P < 0.001). Attenuation of pelvic girdle pain as assessed by the independent examiner was greatest in the acupuncture group. Conclusion Acupuncture and stabilising exercises constitute efficient complements to standard treatment for the management of pelvic girdle pain during pregnancy. Acupuncture was superior to stabilising exercises in this study.

The aim of this study was to investigate the influence of maternal age on perinatal and obstetric outcome in women aged 40-44 years and those 45 years or older and to estimate whether adverse outcome was related to intercurrent illness and pregnancy complications.National prospective, population-based, cohort study in women aged 40-44 years and those 45 years or older and in a control group of women aged 20-29 years who delivered during the period 1987-2001. Adjusted odds ratios (OR) were calculated after adjustments for significant malformations, maternal pre-existing diseases, and smoking. Main outcome measures were perinatal mortality, intrauterine fetal death, neonatal death, preterm birth, and preeclampsia.During the 15-year period, there were 1,566,313 deliveries (876,361 women were 20-29 years of age, 31,662 were 40-44 years, and 1,205 wereor = 45 years). Perinatal mortality was 1.4%, 1.0%, and 0.5% in women 45 years or older, 40-44, and 20-29 years, respectively. Adjusted OR for perinatal mortality was 2.4 (95% confidence interval [CI] 1.5-4.0) in women aged 45 years or older, compared with 1.7 (95% CI 1.5-1.9) in women 40-44 years. Adjusted OR for intrauterine fetal death was 3.8 (95% CI 2.2-6.4) in women aged 45 years or older, compared with 2.1 (95% CI 1.8-2.4) in women 40-44 years. Preterm birth, gestational diabetes, and preeclampsia were more common among women 40-44 years of age and those 45 years or older. Perinatal mortality was increased in women with intercurrent illness or pregnancy complications compared with women without these conditions, but there was no evidence that these factors became more important with increasing age.Perinatal mortality, intrauterine fetal death, and neonatal death increased with age. There was also an increase in intercurrent illnesses and pregnancy complications with increasing age, but this did not entirely explain the observed increase in perinatal mortality with age.II-3

To ascertain the occurrence and distribution of various types of I-IV degree tears, during childbirth, and analyze risk factors for perineal II degree tears.A total of 2883 consecutive vaginal deliveries, during 1995-97 at Sahlgrenska University Hospital in Göteborg Sweden, were included. All tears were classified according to an especially designed protocol, and risk factors for II degree tears were evaluated by use of univariate and logistic regression analysis.Only 6.6% of nulliparous parturients had no detectable tear as compared to 34.2% in parous women. Almost half of the women suffered from a II degree tear during birth, and a higher proportion of nulliparous (16.6%) than parous (9.4%) women had extensive perineal lacerations. In addition, nulliparous were more likely than parous parturients to be subjected to a perineotomy (18.1% versus 5.6%). Stepwise logistic regression analysis revealed that the following factors remained independently associated with II degree tear: slight perineal edema, high infant weight, excellent visualization of perineum, increasing age of the mother, excellent cooperation of the women, protracted second phase (60 min) and duration of second phase30 min.The majority of women (78%) undergoing childbirth had a tear and 47.1% suffered from perineal lacerations. Nulliparous women were more likely to have severe perineal lacerations or episiotomies. Similar risk factors were found for II degree tears as previously shown for III/IV degree tears.

Aims: To determine the prevalence, recurrence rate and to identify risk factors for prelabor rupture of the membranes (PROM) after 34 completed weeks in an urban Swedish population. Methods: In a retrospective cohort study a sample of 2880 women aged 25-41 years, resident in the city of Goteborg, was randomly selected from the population register According to information from the national Medical Birth Register (MBR), 1507 of these 2880 women had given birth 2736 times. 2270 of these deliveries had occurred in hospitals in the city of Goteborg and case records for 2242 of these deliveries were found. The case records were systematically analyzed for the occurrence of PROM and potential risk factors for PROM. 2208 of these deliveries occurred after 34 weeks of gestation. The further analyses were based on these 2208 deliveries. Results: The prevalence of PROM after 34 week of gestation in this urban Swedish population was 12.9% and about 20% of the women in the population had experienced PROM at least once. In the multiple stepwise regression analysis, risk factors for PROM were primiparity, premature contractions, PROM in a previous pregnancy and bleeding in the first trimester. Conclusions: PROM is a common complication at of near term. The risk factors for PROM found in this rep resentative study are difficult to influence and thus pro vide no guidance about how pregnancies should be managed to reduce the occurrence of PROM in the fu ture.

Objective To evaluate intrapartum risk factors for anal sphincter tear. Design A prospective observational study. Setting Delivery unit at the University Hospital in Goteborg, Sweden. Participants 2883 consecutive women delivered vaginally during the period between 1995 and 1997. Information was obtained from patient records and from especially designed protocols which were completed during and after childbirth. Main outcome measures Anal sphincter (third and fourth degree) tear. Results Anal sphincter tear occurred in 95 of 2883 women (3.3%). Univariate analysis demonstrated that the risk of anal sphincter tear was increased by nulliparity, high infant weight, lack of manual perineal protection, deficient visualisation of perineum, severe perineal oedema, long duration of delivery and especially protracted second phase and bear down, use of oxytocin, episiotomy, vacuum extraction and epidural anaesthesia. After analysis with stepwise logistic regression, reported as odds ratio, 95% confidence interval, the following factors remained independently associated with anal sphincter tear: slight perineal oedema (0.40, 0.26–0.64); manual perineal protection (0.49, 0.28–0.86); short duration of bear down (0.47, 0.24–0.91); no visualisation of perineum (2.77, 1.36–5.63); parity (0.59, 0.40–0.89); and high infant weight (2.02, 1.30–3.16). Analysis of variance showed that manual perineal protection had a stronger influence on lowering the frequency, and lack of visualisation of perineum and infant weight had a stronger influence on raising the frequency, of anal sphincter tears in nulliparous compared with parous women. Conclusions Perineal oedema, poor ocular surveillance of perineum, deficient perineal protection during delivery, protracted final phase of the second stage, parity and high infant weight all constitute independent risk factors for anal sphincter tear. Such information is essential in order to reduce perineal trauma during childbirth.

To determine the false negative rate of a sterile speculum examination for the diagnosis of rupture of the membranes in women not in labor and without visible amniotic fluid at speculum examination. Furthermore, possible risks to the mother and the baby after suspected rupture of the membranes were analyzed.In women not in labor with suspected rupture of the membranes between gestational weeks 34 and 42, a sterile speculum examination was performed. If no amniotic fluid was visible, a test for Diamine oxidase was carried out. The results of tests were not known to the obstetricians or the women. The women were allowed to return home with no further controls if no amniotic fluid was visible at the speculum examination. Neonatal and obstetric outcome was recorded prospectively.Of 27,502 deliveries, 2,099 women not in labor attended the delivery ward for suspected rupture of the membranes after week 34. Amniotic fluid was visualized in 1,580 women. In 519 women in whom no amniotic fluid was seen at the speculum examination, the Diamine oxidase test was negative in 456 and positive in 63. Antibiotics were given to eleven children (2.4%) in the group with a negative Diamine oxidase and to one infant (1.6%) in the positive Diamine oxidase group (p0.05). No differences in obstetric outcome were recorded.The false negative rate of a speculum examination for the diagnosis of rupture of the membranes in women without amniotic fluid visible at a speculum examination was 12% when Diamine oxidase was used as the standard for the diagnosis of rupture of the membranes. This study did not show any disadvantages for mothers and infants if the women were sent home after a false negative speculum examination. The value of biochemical methods in the management of women not in labor with rupture of the membranes after thirty-four weeks of gestation could be questioned.

To evaluate the influence of a bath on infectious morbidity in mothers and neonates in women with prelabor rupture of the membranes after 34 weeks of gestation.A nonrandomized study of 1385 healthy women. During the first stage of labor 538 women wanted a bath while 847 did not. The women awaited spontaneous contractions up to 24 or 72 hours after the membranes had ruptured before labor was induced with oxytocin. Digital examinations of the cervix were avoided until onset of active labor or until the time induction was planned. For statistical analysis Fisher's exact test was used.Chorioamnionitis during labor occurred in 1.1% of the women in the bath group and in 0.2% in the reference group (p = 0.06). Postpartum endometritis was found in three cases both in the bath group (0.6%) and in the reference group (0.4%) (p = 0.68). The frequency of neonates receiving antibiotics was 3.7% and 4.8% respectively (p = 0.43).A tub bath did not increase the risk of maternal or neonatal infection after premature rupture of the membranes and prolonged latency.

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.

WITH PREGNANCY-RELATED PELVIC PAIN: A RANDOMISED SINGLE BLIND CONTROLLED TRIAL LARS LADFORS, HELEN ELDEN, MONIKA FAGEVIK OLSEN, HANS-CHRISTIAN OSTGAARD, HENRIK HAGBERG, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Perinatal Center, Gothenburg, Sweden, Sahlgrenska University Hospital, Department of Physiotherapy, Gothenburg, Sweden, Sahlgrenska University Hospital, Department of Orthopaedics, Gothenburg, Sweden, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Perinatal Center, Gothenburg, Sweden, Sweden OBJECTIVE: At present, there is no cure for pelvic girdle pain (PGP) during pregnancy. The aim was to evaluate short and long-term efficacy of acupuncture and specific stabilizing exercises as adjunct to standard treatment compared to standard treatment alone on pain, days of sick leave and disability. STUDY DESIGN: In all, 386 pregnant women entered the trial after physical examination by an independent observer to confirm isolated PGP. The women were randomly assigned to standard treatment plus acupuncture (ACU), standard treatment plus specific stabilizing exercise (SSE) or to a control group (C). The main outcome measures were pain and days of sick leave. Analysis were performed by intention to treat. RESULTS: The ACU group had less pain (VAS scores) than controls in the morning (P = .0003) and in the evening (P= .0003). The differences remained during follow-up and were even more pronounced 3 months after treatment. The ACU group had lower rates in VAS compared to the SSE group (P = .0114). The SSE group, in turn, had lower rates in VAS than controls in the morning (P = .0186) and in the evening (P = .0432). We found no differences regarding sick leave at any time. No adverse effects of the treatments were recorded. CONCLUSION: Acupuncture as well as specific stabilizing exercises constitutes efficient complements to standard treatment to reduce pain and discomfort and improve the ability to perform daily activities among pregnant women with isolated PGP. Acupuncture alleviates PGP more effectively than specific stabilizing exercise or standard treatment.

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.