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Background Cervical cerclage is used in an attempt to reduce recurrence risk of preterm birth, but evidence for use is limited. Aims To compare pregnancy outcomes among women with a single previous midtrimester delivery when managed with or without a cervical cerclage. Materials and methods Population-based cohort study of all women in New South Wales, Australia with a singleton pregnancy ending in birth/miscarriage ≥14 and <28 weeks, between 2003 and 2011. Modified Poisson regression was used to compare outcomes in the next subsequent pregnancy, for women with a cerclage inserted <14 weeks, and those without cerclage. The primary outcome was gestational age <37 weeks at birth/miscarriage in the next pregnancy. Secondary outcomes included: maternal morbidity, preterm prelabour rupture of membranes ( PPROM), stillbirth/neonatal death and composite neonatal morbidity for liveborn infants ≥28 weeks. Adjusted risk ratios ( ARR) and 95% confidence intervals ( CI) were determined. Results Five thousand, six hundred and ninety-eight births/miscarriages were potential index deliveries. Of these, 2175 women had an eligible subsequent pregnancy: 108 received cerclage at <14 weeks gestation, 2067 did not. Women with cerclage were significantly more likely to deliver <37 weeks than those without (39.8% vs 19.3%, ARR 1.92, 95% CI 1.48-2.48), and had increased risks of PPROM ( ARR 4.38, 95% CI 2.62-7.32) and stillbirth/neonatal death ( ARR 2.20, 95% CI 1.02-4.73). Following cerclage, liveborn infants ≥28 weeks had double the risk of severe morbidity ( ARR 2.54, 95% CI 1.55-4.16). Conclusions In women with a single previous midtrimester delivery, cervical cerclage <14 weeks gestation in subsequent pregnancy was associated with worse pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Background American evidence suggests women are not well informed about the optimal duration of pregnancy or the earliest time for safe birth. Similar evidence does not exist in Australia. Aims To explore pregnant women's beliefs about the duration of pregnancy and the earliest time for safe birth, and to compare the results with US data. Methods A cross-sectional survey of pregnant women attending antenatal clinics at four public hospitals in Sydney, Australia, included information on maternal and pregnancy characteristics, and two questions exploring women's beliefs about the duration of pregnancy, and the earliest time for safe birth. Responses were grouped as: late preterm (34-36 weeks), early term (37-38 weeks) and full term (39-40 weeks). Results Of the 784 surveyed women, 52% chose 39-40 weeks as the duration of a full-term pregnancy, while for the earliest time for safe birth, 10% chose 39-40 weeks and 57% chose 37-38 weeks. Some maternal characteristics were associated with women's beliefs, including having a medical and/or pregnancy complication, country of birth, level of education, employment status and attending a tertiary hospital. The associations were different for each question. In comparison with US studies, Australian women were more likely to choose later gestations for both the duration of pregnancy and the earliest time for safe birth. Conclusions A significant proportion of women believe that full-term pregnancy and earliest time for safe birth occur before 39 weeks, suggesting opportunities for better communication about the benefits and risks of birthing at different gestations. [ABSTRACT FROM AUTHOR]

Background Incisional hernias occur at surgical abdominal incision sites, but the association with caesarean section (CS) has not been examined. Aim To determine whether CS is a risk factor for incisional hernia repair. Materials and Methods Population-based cohort study in Australia using linked birth and hospital data for women who gave birth from 2000 to 2011. Survival analysis was used to explore the association between CS and subsequent incisional hernia repair. Analyses were adjusted for confounding factors, including other abdominal surgery. The main outcome measure was surgical repair of an incisional hernia. Results Of 642,578 women, 217,555 (33.9%) had at least one CS and 1,554 (0.2%) women had a subsequent incisional hernia repair. The rate of incisional hernia repair in women who had ever had a caesarean section was 0.47%, compared to 0.12% in women who never had a caesarean section. After controlling for the duration of follow-up and known explanatory variables (eg other abdominal surgery, parity and multiple pregnancy), the adjusted hazard ratio (aHR) was 2.73 (95% confidence interval (CI) 2.45-3.06, P < 0.001). Incisional hernia repair risk increased with number of caesarean sections: women with two CS had a threefold increased risk of incisional hernia repair, which increased to sixfold after five CS (aHR = 6.29, 95% CI 3.99-9.93, P < 0.001) compared to women with no CS. Conclusions There was a strong association between maternal CS and subsequent incisional hernia repair, which increased as the number of CSs increased, but the absolute risk of incisional hernia repair was low. [ABSTRACT FROM AUTHOR]

Background: Low serum 25-hydroxyvitamin D [25(OH)D] concentrations during pregnancy have been associated with adverse pregnancy outcomes in a few studies but not in other studies. Objectives: We assessed the serum 25(OH)D concentration at 10-14 wk of pregnancy and its association with adverse pregnancy outcomes and examined the predictive accuracy. Design: In this nested case-control study, we measured serum 25(OH)D in 5109 women with singleton pregnancies who were attending first-trimester screening in New South Wales, Australia. Multivariate logistic regression was conducted to examine the association between low 25(OH)D concentrations and adverse pregnancy outcomes (small for gestational age, preterm birth, preeclampsia, gestational diabetes, miscarriage, and stillbirth). The predictive accuracy of models was assessed. Results: The median (IQR) 25(OH)D concentration for the total population was 56.4 nmol/L (43.3-69.8 nmol/L). Serum 25(OH)D concentrations showed significant variation by parity, smoking, weight, season of sampling, country of birth, and socioeconomic status. After adjustment for maternal and clinical risk factors, low 25(OH)D concentrations were not associated with most adverse pregnancy outcomes. The area under the receiver operating characteristic curve (AUC) and likelihood ratio for a composite of severe adverse pregnancy outcomes of 25(OH)D concentrations <25 nmol/L were 0.51 and 1.44, respectively, and, for risk factors alone, were 0.64 and 2.87, respectively. The addition of 25(OH)D information to maternal and clinical risk factors did not improve the ability to predict severe adverse pregnancy outcomes (AUC: 0.64; likelihood ratio: 2.32; P = 0.39). Conclusion: Low 25(OH)D serum concentrations in the first trimester of pregnancy are not associated with adverse pregnancy outcomes and do not predict complications any better than routinely assessed clinical and maternal risk-factor information. [ABSTRACT FROM AUTHOR]

Background Changes in clinical practice and in the characteristics of childbearing women have the potential to influence the rate of obstetric anal sphincter injuries ( OASIS). To date, little investigation has been undertaken to assess the effect of risk factor trends for the Australian population on OASIS rates. Aims To ascertain the OASIS rates amongst singleton vaginal births ≥37 weeks gestation in NSW, 2001 - 2009; to determine risk factor effect sizes and trends; and to compare predicted with observed OASIS rates. Methods Using two linked population-based data sets, risk factors for OASIS were determined by logistic regression. Contingency tables and predictive modelling were used to determine trends and predicted rates of OASIS, respectively. Results The OASIS rate increased from 2.2% in 2001 to 2.9% in 2009. Highest risks were for forceps deliveries without episiotomy (primiparas aOR 6.10, multiparas aOR 6.15), followed by multiparas with no previous vaginal birth ( aOR 5.61). High birthweight, vacuum delivery and Asian country of birth posed risks for all women. The greatest risk factor trends were increases in Asian country of birth and vacuum delivery, while the greatest trend amongst protective factors was an increase in maternal age ≥35 years for primiparas. Predicted OASIS rates were lower than observed rates. Conclusion In an environment of changing demographic and clinical risk factors, the OASIS rate has increased. This increase is only minimally explained by the identified risk factors and may be related to other unmeasured risk factors or a possible increase in clinical ascertainment and/or documentation of OASIS. [ABSTRACT FROM AUTHOR]

Aim To determine the trends in oxytocin use at a population level within New South Wales and to assess the maternal and neonatal morbidities associated with the use of oxytocin. Methods Trends in oxytocin use were assessed for women in NSW who were nulliparas at term with a singleton, cephalic fetus between 1998 and 2008. Maternal and neonatal morbidities were assessed in 2007-2008 using linked hospital and birth data with regression analysis. Oxytocin was also assessed by indication for use being either induction or augmentation of labour. Results The overall use of oxytocin increased from 10 291 (36.5%) of births in 1998 to 14 440 (45.4%) of births in 2008 ( P < 0.0001) with the increase entirely because of the increased use for induction of labour. The use of oxytocin was associated with an increase in regional analgesia (65 to 22%), instrumental delivery (21 to 18%) and caesarean section (29 to 14%) as compared to women who did not receive oxytocin in labour. Oxytocin was also associated with an increase in severe maternal adjusted odds ratios (( aOR) 1.48, 95% CI 1.30-1.68) and neonatal morbidity ( aOR 1.29, 95% CI 1.17-1.41). This increase in morbidity was maintained when both augmentation and induction were assessed separately. Conclusion Oxytocin has an important role in the management of labour. However, its use should be carefully monitored with standardised treatment regimes to minimise maternal and neonatal morbidity. [ABSTRACT FROM AUTHOR]

Aim: To determine induction trends and delivery, maternal and neonatal health outcomes by gestational age following induction at term for women having a first baby. Methods: Linked birth and hospital data were used to examine the rates of adverse maternal and neonatal health outcomes for the period 2001-2007, among the 212 389 nullipara with singleton cephalic-presenting fetuses delivering between 370 and 416 weeks of gestation. Rates of caesarean delivery, neonatal transfers and overall severe neonatal and maternal adverse outcomes were determined by gestational age. Results: Between 1990 and 2008, nulliparous term inductions as a proportion of all births increased from 5518 (6.8%) to 11 166 (12.5%). More than 60% of these inductions are performed before 41 weeks. Among induced nullipara, 30.4% delivered by caesarean section. Adverse neonatal outcomes and transfer rates were lowest at 39-40 weeks (overall 2.1 and 0.5%, respectively), regardless of labour onset. Maternal morbidity increased at 40 weeks (from 1.1 to 1.3%) for women in spontaneous labour, was relatively stable in those undergoing induction of labour between 37 and 40 weeks (1.8%) and decreased with gestational age until 40 weeks in those undergoing a prelabour caesarean delivery (from 3.1 to 0.8%). Conclusion: NSW has high rates of both induction and caesarean section following induction. This study highlights the changes to clinical practice that may help reduce the rate of caesarean births in nullipara. [ABSTRACT FROM AUTHOR]

Objective. To describe the rates of antenatal hospital admission during twin or higher order multifetal pregnancies, and the admission outcomes as discharge undelivered, transfer to higher care, or spontaneous or elective delivery. Methods. Cohort study using linked birth and hospital data. The cohort comprised women who gave birth to twins or higher order multiple infants of ≥ 24 weeks gestation in 2001--2008 and who were admitted to hospital in weeks 20--36 of the pregnancy. Results. In 63.4% of 10 779 twin pregnancies and 99.5% of 197 triplet and quadruplet pregnancies, the woman was admitted to hospital at least once in weeks 20--36 of the pregnancy, for a total 10 985 admissions. Almost half the admissions (46.3%) ended in discharge without delivery, 10.7% in transfer to higher care, 21.1% in spontaneous labour and birth, and 21.8% in elective delivery (induction or prelabour Caesarean section). The reason for admission was preterm labour in 34.2% of admissions. Conclusions. Hospital admission during pregnancy is common for women with multifetal pregnancies, with many of these admissions resulting in preterm birth. This is the first study to report the rate of pregnancy admissions for women with multifetal pregnancies, and provides a baseline for future studies of hospital use in this population. [ABSTRACT FROM AUTHOR]