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Background: The safety, efficacy, and cost-effectiveness of external cephalic version (ECV) for term breech presentation has been demonstrated. Clinical guidelines recommend ECV for all eligible women, but the uptake of this procedure in the Australian healthcare setting is unknown. This study aimed to describe ECV uptake in New South Wales, the most populous state of Australia, during 2002 to 2012.Methods: Data from routine hospital and birth records were used to identify ECVs conducted at ≥36 weeks' gestation. Women with ECV were compared to women who were potentially eligible for but did not have ECV. Eligibility for ECV was based on clinical guidelines. For those with ECV, birth outcomes following successful and unsuccessful procedures were examined.Results: In N = 32,321 singleton breech pregnancies, 10.5% had ECV, 22.3% were ineligible, and 67.2% were potentially eligible but did not undergo ECV. Compared to women who were eligible but who did not attempt ECV, those who had ECV were more likely to be older, multiparous, overseas-born, public patients at delivery, and to deliver in tertiary hospitals in urban areas (p < 0.01). Fewer women who underwent ECV smoked during pregnancy, fewer were morbidly obese, and fewer had a hypertensive disorder of pregnancy, compared to those who were eligible. Caesarean section occurred in 25.9% of successful compared to 95.6% of unsuccessful ECVs. Infant outcomes did not differ by ECV success.Conclusions: The majority of women with a breech presentation did not receive ECV. It is unclear whether this is attributable to issues with service provision or low acceptability among women. Policies to improve access to and information about ECV appear necessary to improve uptake among women with term breech presentation. Improved data collection around the diagnosis of breech presentation, ECV attempts, and outcomes may help to identify specific barriers to ECV uptake. [ABSTRACT FROM AUTHOR]

Background Trial evidence supports a policy of caesarean section for singleton breech presentations at term, but vaginal breech birth is considered a safe option for selected women. Aims To provide recent Australian data on outcomes associated with intended mode of delivery for term breech singletons in women who meet conservative eligibility criteria for vaginal breech birth. Materials and Methods Birth and hospital records from 2009 to 2012 in New South Wales were used to identify women with nonanomalous pregnancies who would be considered eligible for vaginal breech birth. Intended mode of delivery was inferred from labour onset and management. Results Of 10 133 women with term breech singleton pregnancies, 5197 (51.3%) were classified as eligible for vaginal breech delivery. Of these, 6.8% intended vaginal breech birth, 76.4% planned caesarean section and intention could not be determined for 16.8%. Women intending vaginal delivery had higher rates of neonatal morbidity (6.0% vs 2.1%), neonatal birth trauma (7.4% vs 0.9%), Apgar <4 at one minute (10.5% vs 1.1%), Apgar <7 at five minutes (4.3% vs 0.5%) and neonatal intensive care unit/special care nursery admissions (16.2% vs 6.6%) than those planning caesarean section. Increased perinatal risks remained after adjustment for maternal characteristics. Severe maternal morbidity (1.4% vs 0.7%) and post-partum readmission (4.6% vs 4.0%) were higher in the intended vaginal compared to planned caesarean births, but these differences were not statistically significant. Conclusions In a population of women classified as being eligible for vaginal breech birth, intended vaginal delivery was associated with higher rates of neonatal morbidity than planned caesarean section. [ABSTRACT FROM AUTHOR]

Background: Acute gastroenteritis (AGE) is a leading cause of infectious morbidity in childhood. Clinical studies have implicated caesarean section, early birth and formula feeding in modifying normal gut microbiota development and immune system homeostasis in early life. Rates of early birth and cesarean delivery are also increasing worldwide. This study aimed to investigate the independent and combined associations of the mode and timing of birth and breastmilk feeding with AGE hospitalisations in early childhood.Methods: Population-based record-linkage study of 893,360 singleton livebirths of at least 33 weeks gestation without major congenital conditions born in hospital, New South Wales, Australia, 2001-2011. Using age at first AGE hospital admission, Cox-regression was used to estimate the associations for gestational age, vaginal birth or caesarean delivery by labour onset and formula-only feeding while adjusting for confounders.Results: There were 41,274 (4.6 %) children admitted to hospital at least once for AGE and the median age at first admission was 1.4 years. Risk of AGE admission increased with decreasing gestational age (37-38 weeks: 15 % increased risk, 33-36 weeks: 25 %), caesarean section (20 %), planned birth (17 %) and formula-only feeding (18 %). The rate of AGE admission was highest for children who were born preterm by modes of birth other than vaginal birth following the spontaneous onset of labour and who received formula-only at discharge from birth care (62-78 %).Conclusions: Vaginal birth following spontaneous onset of labour at 39+ weeks gestation with any breastfeeding minimised the risk of gastroenteritis hospitalisation in early childhood. Given increasing trends in early planned birth and caesarean section worldwide, these results provide important information about the impact obstetric interventions may have on the development of the infant gut microbiota and immunity. [ABSTRACT FROM AUTHOR]

Background: Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity.Methods: The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060.Findings: Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7).Interpretation: In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term.Funding: Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney. [ABSTRACT FROM AUTHOR]

Background Delivery of small for gestational age (SGA) infants has been associated with increased risk of future maternal cardiovascular disease (CVD). However, whether the risk increases progressively with the greater severity of SGA and number of SGA infants has not been explored. Methods A population-based record linkage study was conducted among 812,732 women delivering live born, singleton infants at term between 1994 and 2011 in New South Wales, Australia. Birth records were linked to the mothers’ subsequent hospitalisation or death records to identify CVD events (coronary heart disease, cerebrovascular events, and chronic heart failure) after a median of 7.4 years. Cox proportional hazard regression was used to estimate adjusted hazard ratios (AHR) [95% confidence interval (CI)] for the associations between the severity (moderate or extreme) of SGA and number of SGA infants and subsequent risk of maternal CVD, accounting for maternal age at last birth, socioeconomic status, parity, smoking, (pre-gestational and gestational) diabetes, and (chronic and pregnancy) hypertension. Results Compared to mothers of non-SGA infants, AHRs [95%CI] of CVD among mothers of moderately and extremely SGA infants were 1.36 [1.23-1.49], and 1.66 [1.47-1.87], respectively, while AHRs among mothers with 1, 2, and ≥3 SGA infants were 1.42 [1.30-1.54], 1.65 [1.34-2.03], and 2.42 [1.52-3.85], respectively, indicating a dose-response relationship. AHRs of specific CVD categories showed a similar pattern. Conclusions Delivery of an SGA infant was associated with a dose-dependent increase in the risk of maternal CVD according to both the severity of SGA and number of previous SGA infants. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine short-term and longer-term outcomes for twins born at or near term, comparing prelabor cesarean delivery with birth after a trial of labor. METHODS: This study was conducted on a retrospective cohort of twin pregnancies delivered at 36 weeks of gestation or greater from 2000 to 2009. Pregnancies with an antenatal death, lethal anomaly, birth weight discordance 25% or more, or birth weight less than 2,000 g or more than 4,000 g were excluded. Outcomes included severe hypoxia, stillbirth and neonatal death, and hospital admissions or death during the first 5 years of life. RESULTS: Approximately 45% of 7,099 twin pregnancies were delivered by prelabor cesarean delivery. Compared with delivery after labor, prelabor cesarean delivery was associated with significantly reduced risks of adverse neonatal and child outcomes including severe birth hypoxia (0.08% compared with 0.75%, relative risk 0.10, 95% confidence interval [CI] 0.04-0.26), neonatal death (0.00% compared with 0.15%, relative risk 0.05, 95% CI 0.00-0.82), and death up to 5 years of age (0.16% compared with 0.40%, relative risk 0.41, 95% CI 0.20-0.85). Whereas total mortality for first twins was similar after labor (0.15%) compared with prelabor cesarean delivery (0.16%), total mortality was four times more common in second twins born after labor (0.64%) compared with second twins born after prelabor cesarean delivery (0.16%). CONCLUSION: Compared with prelabor cesarean delivery, twin pregnancies at and beyond 36 weeks of gestation delivered after labor have increased risks for birth outcomes associated with hypoxia, with second twins having significantly increased mortality up to 5 years of age. However, the absolute mortality rate for relatively uncomplicated twin pregnancies delivered at or near term is low and needs to be balanced against maternal morbidity. [ABSTRACT FROM AUTHOR]

To identify the greatest potential for reducing overall caesarean delivery rates, we used longitudinally linked data for women with consecutive births 2001-2009 to examine the likely impact of hypothetical risk-based scenarios. Among women with a first birth, singleton, vertex-presenting fetus at term, increasing the vaginal birth rate following induction of labour by 20% potentially has greatest impact, with a 12.1% relative decrease in the overall caesarean rate. The potential relative decrease in other scenarios ranged from 0.8 to 5.9%. [ABSTRACT FROM AUTHOR]

Background The extent to which complications or adverse outcomes in a first vaginal birth may contribute to mode of delivery in the next birth remains unclear. This study examines the impact of the first birth on subsequent mode of delivery. Methods The study population included women with a first vaginal birth and a consecutive second birth. Data were obtained from linked birth and hospital records for the state of New South Wales, Australia 2000-09. The primary outcome was the mode of delivery for the second birth. Planned caesarean was modelled using logistic regression; intrapartum caesarean and instrumental delivery were modelled using multinomial logistic regression. Results Of the 114 287 second births, 4.2% were planned caesarean, 3.0% were intrapartum caesarean and 4.8% were instrumental deliveries. Adjusted risk factors from the first birth for a planned second birth caesarean were third to fourth degree tear [odds ratio ( OR) = 5.0 [95% confidence interval ( CI) 4.6, 5.4]], severe neonatal morbidity ( OR = 3.2 [95% CI 2.9, 3.6]), perinatal death ( OR = 3.2 [95% CI 2.3, 4.4]), severe maternal morbidity ( OR = 2.8 [95% CI 2.3, 3.3]), instrumental delivery, large infant, labour induction, epidural use, use of oxytocin for augmentation and episiotomy. Important risk factors ( OR > 2) for intrapartum caesarean in the second birth were perinatal death or severe neonatal morbidity in the first birth. Risk factors for instrumental delivery in the second birth were perinatal death, preterm delivery and instrumental delivery. Conclusions Obstetrical interventions and adverse pregnancy outcomes in the first birth were associated with increased risk of operative delivery in the second birth. [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]

Access to skilled birth attendants and emergency obstetric care are thought to prevent early neonatal deaths. This study aims to examine the association between the type of delivery attendant and place of delivery and early neonatal mortality in Indonesia.Four Indonesia Demographic and Health Surveys from 1994, 1997, 2002/2003 and 2007 were used, including survival information from 52 917 singleton live-born infants of the most recent birth of a mother within a 5-year period before each survey. Cox proportional hazards regression models were used to obtain the hazard ratio for univariable and multivariable analyses.Our study found no significant reduction in the risk of early neonatal death for home deliveries assisted by the trained attendants compared with those assisted by untrained attendants. In rural areas, the risk of early neonatal death was higher for home deliveries assisted by trained attendants than home deliveries assisted by untrained attendants. In urban areas, a protective role of institutional deliveries was found if mothers had delivery complications. However, an increased risk was associated with deliveries in public hospitals in rural areas. Infants of mothers attending antenatal care services were significantly protected against early neonatal deaths, irrespective of the urban or rural setting. An increased risk of early neonatal death was also associated with male infants, infants whose size at birth was smaller than average and/or infants reported to be born early. A reduced risk was observed amongst mothers with high levels of education.Continuous improvement in the skills and the quality of the village midwives might benefit maternal and newborn survival. Efforts to strengthen the referral system and to improve the quality of delivery and newborn care services in health facilities are important, particularly in public hospitals and in rural areas. [ABSTRACT FROM PUBLISHER]

Background: Most women use some method of pain relief during labour. There is extensive research evidence available of pharmacological pain relief during labour; however this evidence is not readily available to pregnant women. Decision aids are tools that present evidence based information and allow preference elicitation. Methods: We developed a labour analgesia decision aid. Using a RCT design women either received a decision aid or a pamphlet. Eligible women were primiparous, ≥ 37 weeks, planning a vaginal birth of a single infant and had sufficient English to complete the trial materials. We used a combination of affective (anxiety, satisfaction and participation in decision-making) and behavioural outcomes (intention and analgesia use) to assess the impact of the decision aid, which were assessed before labour. Results: 596 women were randomised (395 decision aid group, 201 pamphlet group). There were significant differences in knowledge scores between the decision aid group and the pamphlet group (mean difference 8.6, 95% CI 3.70, 13.40). There were no differences between decisional conflict scores (mean difference -0.99 (95% CI -3.07, 1.07), or anxiety (mean difference 0.3, 95% CI -2.15, 1.50). The decision aid group were significantly more likely to consider their care providers opinion (RR 1.28 95%CI 0.64, 0.95). There were no differences in analgesia use and poor follow through between antenatal analgesia intentions and use. Conclusions: This decision aid improves women's labour analgesia knowledge without increasing anxiety. Significantly, the decision aid group were more informed of labour analgesia options, and considered the opinion of their care providers more often when making their analgesia decisions, thus improving informed decision making. [ABSTRACT FROM AUTHOR]

Background: Twin pregnancies have an elevated risk of adverse outcomes, particularly preterm twins. Aims: Describe the distribution of twin deliveries by hospital level, the associated perinatal and maternal morbidity, and determine predictors of perinatal morbidity and urgent transfer to a neonatal intensive care unit. Methods: Longitudinally linked New South Wales delivery and hospital records for the years 2001–2005 were used to identify perinatal and maternal morbidity/mortality in twin pregnancies. Regression analysis was used to examine predictive factors, including birth hospital volume. Results: At ≤ 32 weeks, 88.1% of twins were delivered in tertiary referral hospitals. By 34–35 weeks, only 39.7% of twins were delivered in tertiary units. Gestational age was the primary predictor of perinatal morbidity/mortality. Perinatal morbidity/mortality and maternal morbidity were lowest for deliveries at 38 weeks. There was no evidence that planned caesarean section at ≤ 38 weeks was protective against perinatal morbidity/mortality. There was an increased risk of perinatal morbidity/mortality (odds ratio (OR) = 2.22) for twins delivered at 33–35 weeks gestation at hospitals with < 500 deliveries per annum, and an increased risk of urgent neonatal transfer (OR = 2.06). Twin pairs for whom there was a ≥ 20% discordance in birthweight had an increased risk of morbidity/mortality at 36–38 weeks (OR = 1.79). Conclusions: Both infant and maternal morbidity increase from 39 weeks gestation. Delivery of twins before 36 weeks at smaller hospitals (< 500 deliveries per annum) should be avoided. A twin pregnancy where there is a ≥ 20% difference in estimated fetal weights should be considered for referral to a tertiary obstetric unit. [ABSTRACT FROM AUTHOR]

Administrative or population health data sets (PHDS), such as birth and hospital discharge data, are used increasingly to evaluate maternity care. Use of PHDS requires reliable identification of diagnoses and procedures. The aim of this study was to determine the accuracy and reliability of the reporting of diagnoses and procedures related to childbirth in both individual and linked, birth and ICD10-coded hospital discharge data. Data from a population-based validation study of 1200 women provided the ‘gold standard’ for labour and delivery events and were compared with the hospital discharge and birth databases. Reporting characteristics (sensitivity, specificity, positive and negative predictive values) were determined for: induction, augmentation and obstruction of labour, modes of delivery (including failed instrumental delivery), episiotomy, perineal tears and repairs, and manual removal of the placenta. Differences in reporting by mode of delivery were also examined. Of the 1184 records available for review, 25% had labour induced, 25% had labour augmented and, of those who laboured, 17% had obstructed labour reported. Fourteen per cent had an elective/planned caesarean section (CS) including 2% that went into labour prior to the planned date, and 11% had an emergency, unplanned CS including 2% who had no labour. With the exception of augmentation and obstruction of labour, failed instrumental delivery and manual removal, there were high levels of accuracy for reporting of diagnoses and procedures during labour and delivery. There were no significant differences in reporting by mode of delivery. The findings suggest that PHDS-reported induction of labour, mode of delivery, and 3rd and 4th degree tears and repairs can be reliably used to evaluate maternity care. Consistency in reporting in birth and hospital discharge data from different countries and over time suggests the findings are likely to be generalisable to high-income countries. [ABSTRACT FROM AUTHOR]

Background. Probabilistic information on outcomes of breech presentation is important for clinical decision-making. We aim to quantify adverse maternal and fetal outcomes of breech presentation at term. Methods. We conducted an audit of 1,070 women with a term, singleton breech presentation who were classified as eligible or ineligible for external cephalic version or diagnosed in labor at a tertiary obstetric hospital in Australia, 1997–2004. Maternal, delivery and perinatal outcomes were assessed and frequency of events quantified. Results. Five hundred and sixty (52%) women were eligible and 170 (16%) were ineligible for external cephalic version, 211 (20%) women were diagnosed in labor and 134 (12%) were unclassifiable. Seventy-one percent of eligible women had an external cephalic version, with a 39% success rate. Adverse outcomes of breech presentation at term were rare: immediate delivery for prelabor rupture of membranes (1.3%), nuchal cord (9.3%), cord prolapse (0.4%), and fetal death (0.3%); and did not differ by clinical classification. Women who had an external cephalic version had a reduced risk of onset-of-labor within 24 h (RR 0.25; 95%CI 0.08, 0.82) compared with women eligible for but who did not have an external cephalic version. Women diagnosed with breech in labor had the highest rates of emergency cesarean section (64%), cord prolapse (1.4%) and poorest infant outcomes. Conclusions. Adverse maternal and fetal outcomes of breech presentation at term are rare and there was no increased risk of complications after external cephalic version. Findings provide important data to quantify the frequency of adverse outcomes that will help facilitate informed decision-making and ensure optimal management of breech presentation. [ABSTRACT FROM AUTHOR]

Background: Preterm prelabour rupture of membranes (PPROM) complicates up to 2% of all pregnancies and is the cause of 40% of all preterm births. The optimal management of women with PPROM prior to 37 weeks, is not known. Furthermore, diversity in current clinical practice suggests uncertainty about the appropriate clinical management. There are two options for managing PPROM, expectant management (a wait and see approach) or early planned birth. Infection is the main risk for women in which management is expectant. This risk need to be balanced against the risk of iatrogenic prematurity if early delivery is planned. The different treatment options may also have different health care costs. Expectant management results in prolonged antenatal hospitalisation while planned early delivery may necessitate intensive care of the neonate for problems associated with prematurity. Methods/Design: We aim to evaluate the effectiveness of early planned birth compared with expectant management for women with PPROM between 34 weeks and 366 weeks gestation, in a randomised controlled trial. A secondary aim is a cost analysis to establish the economic impact of the two treatment options and establish the treatment preferences of women with PPROM close to term. The early planned birth group will be delivered within 24 hours according to local management protocols. In the expectant management group birth will occur after spontaneous labour, at term or when the attending clinician feels that birth is indicated according to usual care. Approximately 1812 women with PPROM at 34-366 weeks gestation will be recruited for the trial. The primary outcome of the study is neonatal sepsis. Secondary infant outcomes include respiratory distress, perinatal mortality, neonatal intensive care unit admission, assisted ventilation and early infant development. Secondary maternal outcomes include chorioamnionitis, postpartum infection treated with antibiotics, antepartum haemorrhage, induction of labour, mode of delivery, maternal satisfaction with care, duration of hospitalisation, and maternal wellbeing at four months postpartum.Discussion: This trial will provide evidence on the optimal care for women with PPROM close to term (34-37 weeks gestation). Consideration of both the clinical and economic sequelae of the management of PPROM will enable informed decision making and guideline development. [ABSTRACT FROM AUTHOR]

Background: International guidelines recommend that women with placenta praevia should be delivered by an experienced operator at a hospital with an on-site blood bank. Aim: To determine the risk factors, level of care at the birth hospital and incidence of maternal morbidity for women with placenta praevia. Methods: Data were obtained from linked hospital separation and perinatal databases for 375 790 women giving birth in a NSW hospital, 1998–2002. We defined clinically significant placenta praevia as those women who were delivered by Caesarean section at or after 26 weeks gestation. Outcomes for women with and without placenta praevia were compared. Among women with placenta praevia, antenatal predictors of maternal morbidity were assessed. Results: A total of 1612 (4.3/1000) women had significant placenta praevia. Women with placenta praevia were more likely to be older, have a prior Caesarean section, require general anaesthetic for delivery and deliver preterm. Among women with placenta praevia, 61% delivered in hospitals with 24-h on site blood banks, 33% in hospitals with on-call blood bank services after hours and 6% in hospitals with no blood bank. Two hundred and twenty three (14%) women with placenta praevia suffered a major morbidity (OR = 15.0, 95%CI 12.9–17.4). The proportion of this morbidity that occurred among women delivered electively at term was 40% in hospitals with 24 h blood banks and 55% in other hospitals ( P = 0.06). Conclusions: For women with placenta praevia, the risk of major morbidity is high, yet 39% deliver in hospitals without immediate access to a 24-h blood bank. Australian guidelines on the appropriate level of care for women with placenta praevia are needed. [ABSTRACT FROM AUTHOR]

Background. Epidural analgesia is associated with an increased risk of instrumental delivery. We, in this study, present a systematic review in order to assess the effectiveness of maintaining an upright position during the second stage of labor to reduce instrumental deliveries among women choosing epidural analgesia. The study population included women with uncomplicated pregnancies at term with epidural analgesia established in the first stage of labor. Methods. We searched MEDLINE, EMBASE, and CINAHL databases and the Cochrane Trials Register up to July 2003 and cross-checked the reference lists of published studies. Trial eligibility and outcomes were pre-specified. Group tabular data were obtained for each trial and were analyzed by using meta-analytic techniques. Results. Only two studies were included with data on 281 women (166 upright and 115 recumbent). Upright positions in the second stage were associated with a non-significant reduction in the risk of both instrumental delivery (relative risk (RR) = 0.77, 95% confidence interval (CI) 0.46-1.28) and cesarean section (RR =0.57, 95% CI = 0.28-1.16). Both studies reported a statistically significant reduction in labor duration associated with upright positions. Data on other outcomes, including perineal trauma, postpartum hemorrhage, maternal satisfaction, and infant well-being, were insufficient. Conclusions. There were insufficient data to show a significant benefit from upright positions in the second stage of labor for women who choose epidural or to evaluate safety aspects. However the magnitude of the reductions in instrumental delivery and cesarean section warrants an adequately powered randomized, controlled trial to fully evaluate the practice of upright positions in the second stage for women with an epidural. [ABSTRACT FROM AUTHOR]

New techniques for administering epidural analgesia allow increased mobility for labouring women with epidurals.To determine the effect of ambulation or upright positions in the first stage of labour among women with epidural analgesia on mode of delivery and other maternal and infant outcomes.We undertook a systematic review and meta-analysis of randomised controlled trials (RCT) of ambulation or upright positions versus recumbency in the first stage of labour among women with effective first-stage epidural analgesia in an uncomplicated pregnancy. Trials were identified by searching Medline, Embase and CINAHL databases and the Cochrane Trials Register to March 2004. Trial eligibility and outcomes were prespecified. Group tabular data were obtained for each trial and analysed using meta-analytic techniques.There were five eligible RCT, with a total of 1161 women. There was no statistically significant difference in the mode of delivery when women with an epidural ambulated in the first stage of labour compared with those who remained recumbent: instrumental delivery (relative risk (RR) = 1.16, 95% confidence interval (CI) 0.93–1.44) and Caesarean section (RR = 0.91, 95% CI 0.70–1.19). There were no significant differences between the groups in use of oxytocin augmentation, the duration of labour, satisfaction with analgesia or Apgar scores. There were no apparent adverse effects of ambulation, but data were reported by only a few trials.Although ambulation in the first stage of labour for women with epidural analgesia provided no clear benefit to delivery outcomes or satisfaction with analgesia, neither were there are any obvious harms. [ABSTRACT FROM AUTHOR]

To examine trends in the maternal characteristics and delivery of singleton preterm infants in an Australian population. Population-based descriptive study. New South Wales (NSW), Australia. The population included 37 500 singleton preterm births from 1 January 1990 to 31 December 1997. Data were obtained from the NSW Midwives’ Data Collection (MDC) and rates over time were calculated. Preterm birth by Caesarean section before the onset of labour or where labour was induced were considered to be medically indicated. Preterm rates, medically indicated preterm birth rates, mode of delivery and neonatal outcomes, and trends over time. Among singleton infants, there was no significant change over time in the rate of preterm birth (annual average 5.5%), preterm births that were medically indicated (annual average 29.3%) or neonatal outcomes of preterm births. The rate of indicated preterm birth varied by gestational age and was highest (39.7%) at 29–32 weeks’ gestation. Instrumental preterm births declined over time from 9.5 to 7.8% with a shift from forceps to vacuum use and episiotomy rates declined from 19.7 to 14.8%. Increases in the reported overall preterm rate (singletons and multiples) were not due to increased delivery of singleton infants. Changes in the management of singleton preterm births were similar to changes observed in term births such as decreasing forceps and episiotomy usage. It may be to time to reassess whether Australian clinicians would be willing to randomise patients to clinical trials of the best method of delivery for preterm infants. [ABSTRACT FROM AUTHOR]

Objective: To compare the risk profile of women receiving public and private obstetric care and to compare the rates of obstetric intervention among women at low risk in these groups.Design: Population based descriptive study.Setting: New South Wales, Australia.Subjects: All 171 157 women having a live baby during 1996 and 1997.Interventions: Epidural, augmentation or induction of labour, episiotomy, and births by forceps, vacuum, or caesarean section.Main outcome measures: Risk profile of public and private patients, intervention rates, and the accumulation of interventions by both patient and hospital classification (public or private).Results: Overall, the frequency of women classified as low risk was similar (48%) among those choosing private obstetric care and those receiving standard care in a public hospital. Among low risk women, rates of obstetric intervention were highest in private patients in private hospitals, lowest in public patients, and generally intermediate for private patients in public hospitals. Among primiparas at low risk, 34% of private patients in private hospitals had a forceps or vacuum delivery compared with 17% of public patients. For multiparas the rates were 8% and 3% respectively. Private patients were significantly more likely to have interventions before birth (epidural, induction or augmentation) but this alone did not account for the increased interventions at birth, particularly the high rates of instrumental births.Conclusions: Public patients have a lower chance of an instrumental delivery. Women should have equal access to quality maternity services, but information on the outcomes associated with the various models of care may influence their choices. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "Association of Prelabor Cesarean Delivery with Reduced Mortality in Twins Born Near Term" in the January 2015 issue is presented.

The authors comment on the article "Early Versus Late Epidural Analgesia and Risk of Instrumental Delivery in Nulliparous Women: A Systematic Review," by MM Wassen and colleagues published in the "British Journal of Obstetrics and Gynaecology." The authors cite the strengths of the study, which include the fact that it focused a clinical question and that the likelihood that all relevant studies were included. They also commend the study for appraising the validity of the included studies.

Objective: To examine seasonality of pregnancy hypertension rates, and whether they related to sunlight levels around conception. Study Design: Data were obtained for 424,732 singleton pregnancies conceived from 2001 through 2005 in Australia. We analyzed monthly rates of pregnancy hypertension and preeclampsia in relation to monthly solar radiation. Results: Pregnancy hypertension rates, by month of conception, were lowest in autumn (7.3%) and highest in spring (8.9%). Higher sunlight intensity before delivery, but not around conception, was associated with decreased pregnancy hypertension (r = −0.67). Increased sunlight around conception may correlate with decreased rates of early-onset preeclampsia (r = −0.51; P = .09). Conclusion: The correlation between sunlight after conception and pregnancy hypertension was opposite to that hypothesized; however, sunlight levels before delivery did correlate with lower hypertension rates. For sunlight or ambient temperature to explain seasonal variation, the plausible exposure window is the period before delivery, but this may not apply to early-onset preeclampsia. [ABSTRACT FROM AUTHOR]

Objective: To determine whether rates of obstetric anal sphincter injuries (OASIS) are continuing to increase and whether risk of OASIS according to mode of delivery is constant over time.Methods: In a retrospective population-based study, data were obtained for vaginal singleton vertex deliveries at 37-41 weeks of pregnancy among primiparous women in New South Wales, Australia, between January 2001 and December 2011. Annual OASIS rates were determined among non-instrumental, forceps, and vacuum deliveries with and without episiotomy. Multivariable logistic regression was used to determine adjusted odds ratios for each delivery mode category by year. Trends in adjusted odds ratios over time for each delivery category were compared.Results: OASIS occurred in 955 (4.1%) of 23 081 deliveries in 2001 and 1487 (5.9%) of 25 081 deliveries in 2011. After adjustment for known risk factors, the only delivery categories to show statistically significant increases in OASIS over the study period were non-instrumental deliveries without episiotomy (linear trend P<0.001) and forceps deliveries with episiotomy (linear trend P=0.004).Conclusion: Overall, OASIS rates have continued to increase. Known risk factors do not fully explain the increase in OASIS rates in non-instrumental deliveries without an episiotomy and in forceps deliveries with an episiotomy. [ABSTRACT FROM AUTHOR]

The article discusses the effect of trial of labor before a primary caesarean on the possibility of uterine rupture in case of vaginal birth after caesarean (VBAC) trial in the next birth. It examined the effects of trial labor and primary caesarean delivery on the risk of uterine rupture by studying a longitudinally linked birth records. Results showed that women have lower risk of uterine rupture in the following trial of labor, having labor before the primary caesarean delivery.