Search

Purpose Shoulder dystocia is an obstetric emergency with severe complications. Our objective was to evaluate the major pitfalls in the diagnostics of shoulder dystocia, diagnostic descriptions documented in medical records, use of obstetric maneuvers, and their correlations to Erb’s and Klumpke’s palsy and the use of ICD-10 code 066.0. Methods A retrospective, register-based case–control study included all deliveries (n = 181 352) in Hospital District of Helsinki and Uusimaa (HUS) area in 2006–2015. Potential shoulder dystocia cases (n = 1708) were identified from the Finnish Medical Birth Register and the Hospital Discharge Register using ICD-10 codes O66.0, P13.4, P14.0, and P14.1. After thorough assessment of all medical records, 537 shoulder dystocia cases were confirmed. Control group consisted of 566 women without any of these ICD-10 codes. Results The pitfalls in the diagnostic included suboptimal following of guidelines for making the diagnosis of shoulder dystocia, subjective interpretation of diagnostic criteria, and inexact or inadequate documentation in medical records. The diagnostic descriptions in medical record were highly inconsistent. The use of obstetric maneuvers was suboptimal among shoulder dystocia cases (57.5%). Overall, the use of obstetric maneuvers increased during the study period (from 25.7 to 97.0%, p Conclusion There are diagnostic pitfalls, which could be addressed by education regarding shoulder dystocia guidelines, by improved use obstetric maneuvers, and more precise documentation. The increased use of obstetric maneuvers was associated with lower rates of Erb’s palsy and improved coding of shoulder dystocia.

INTRODUCTION Shoulder dystocia has remained an unpredictable and feared emergency in obstetrics. Some risk factors have been identified but nevertheless there is a lack of risk evaluation tools in clinical practice. The aim of this study was to evaluate the incidence and risk factors of shoulder dystocia in the Finnish population and to develop a shoulder dystocia risk score tool. MATERIAL AND METHODS This retrospective, population-based study included all deliveries in Finland between 2004 and 2017 (n = 800 484). The annual numbers of shoulder dystocia diagnoses were gathered from nationwide Finnish Medical Birth Register and Hospital Discharge Register. The incidence of shoulder dystocia was calculated in subgroups according to the mode of delivery, maternal diabetes status, body mass index (BMI), age, parity and gestational age. Based on these numbers, a shoulder dystocia risk score tool was created. RESULTS The overall incidence of shoulder dystocia was 0.18%. It increased significantly during the study period from 0.10% to 0.32% (P

Background and aimsCaesarean section (CS)-birth and maternally administered intrapartum antibiotics (IP) affect colonization of the neonate. We compared the effects of CS delivery and IP antibiotics on infant gut microbiota development and wellbeing over the first year. To understand the developing community dynamics, we focused on absolute bacterial abundance estimates over relative abundances.MethodsWe studied 144 healthy infants born between gestational weeks 37-42 vaginally without antibiotics (N=58), with IP penicillin (N=25) or cephalosporin (N=13), or by CS with IP cephalosporin (N=34) or other antibiotics (N=14). Gut microbiota composition and temporal development was analysed at 5-7 time points during the first year of life using 16S rRNA gene amplicon sequencing, complemented with qPCR to obtain absolute abundance estimates in 92 infants. A mediation analysis was carried out to identify taxa linked to gastrointestinal function and discomfort (crying, defecation frequency and signs of gastrointestinal symptoms) and birth interventions.ResultsBased on absolute abundance estimates, depletion ofBacteroidesspp. was specific to CS birth while decreased bifidobacteria and increased Bacilli were common to CS birth and exposure to IP antibiotics in vaginal delivery. Abundance of numerous taxa differed between the birth modes among cephalosporin-exposed infants. Penicillin had a milder impact on the infant gut microbiota than cephalosporin. The effects of both CS birth and IP antibiotics on infant gut microbiota associated with increased gastrointestinal symptoms during the first months.ConclusionCS birth and maternal IP antibiotics have both specific and overlapping effects on infant gut microbiota development. The resulting microbiota deviations were found to associate with gastrointestinal symptoms in infancy.What You Need to KnowBackground and ContextBirth mode and maternal intrapartum antibiotics affect infant’s gut microbiota development but their relative contribution, and effects on absolute bacterial abundances and infant health remain unknown.New FindingsUtilizing quantitative microbiota profiling, we identified shared and unique microbiota effects of birth mode and intrapartum antibiotics which explained up to 54% of variation in parent-reported gastrointestinal symptoms in infants.LimitationsDue to the limited sample sizes, especially during the first weeks of life, stratified analyses according to antibiotic dosing could not be performed, and the results on gastrointestinal symptom-microbiota-associations are tentative.ImpactBirth mode overrules the effects of maternal antibiotics on infant microbiota development, while both birth mode and maternal antibiotic use are associated to common functional gastrointestinal symptoms in infancy.Lay summaryCaesarean-section birth and maternal antibiotics during vaginal birth affect infant’s gut microbiota and may increase gastrointestinal discomfort.

INTRODUCTION To evaluate the effect of method of induced abortion and other abortion-associated variables on the incidence of fear of childbirth in subsequent pregnancy. MATERIAL AND METHODS This population-based register study cohort includes all nulliparous women with their first pregnancy ending in an induced abortion in 2000-2015 and subsequent pregnancy with live singleton delivery between 2000 and 2017 (n = 21 479). Data were derived from three national registers maintained by the Finnish Institute for Health and Welfare. We divided the study population in three cohorts: (a) medical and (b) surgical abortion during first trimester (≤84 days of gestation), and (c) medical abortion during second trimester (85-168 days of gestation). Primary outcome measures were the incidence of registry-identified fear of childbirth and cesarean delivery related to it. RESULTS The overall incidence of fear of childbirth was 5.6% (n = 1209). Altogether, 19.2% (n = 4121) of women underwent cesarean delivery. The odds were elevated especially for elective cesarean delivery (odds ratio [OR] 9.30, 95% CI 7.95-10.88, P

Summary Infants born by vaginal delivery are colonized with maternal fecal microbes. Cesarean section (CS) birth disturbs mother-to-neonate transmission. In this study (NCT03568734), we evaluated whether disturbed intestinal microbiota development could be restored in term CS-born infants by postnatal, orally delivered fecal microbiota transplantation (FMT). We recruited 17 mothers, of whom seven were selected after careful screening. Their infants received a diluted fecal sample from their own mothers, taken 3 weeks prior to delivery. All seven infants had an uneventful clinical course during the 3-month follow-up and showed no adverse effects. The temporal development of the fecal microbiota composition of FMT-treated CS-born infants no longer resembled that of untreated CS-born infants but showed significant similarity to that of vaginally born infants. This proof-of-concept study demonstrates that the intestinal microbiota of CS-born infants can be restored postnatally by maternal FMT. However, this should only be done after careful clinical and microbiological screening.

The changes in emotions, subjective fear of childbirth, and personal goals were examined during a group intervention to treat fear of childbirth (FOC). The objective was to gain a more detailed understanding of the changes occurring during the group intervention of FOC. The changes in emotions, subjective FOC, and personal goals were studied in primiparous pregnant women with severe FOC participating in a group intervention (n = 105). The group intervention contained six sessions during pregnancy and one after childbirth. At every session, the participants filled in a questionnaire regarding their experiences of current positive and negative emotions and the subjective FOC. The participants also set and reported their personal goals in their preparation for childbirth and parenthood. The negative emotions decreased from the beginning of the intervention. The change became significant after the fourth session. The amount of positive emotions increased but became statistically significant only after the delivery. The subjective FOC decreased significantly from the beginning of the intervention. Personal goals shifted from being mainly self-related to being mostly related to parenthood. The group intervention decreased FOC and promoted changes in emotions and personal goals that foster emotional preparedness for childbirth. It seems that the decrease in FOC was made possible through gaining a better capacity to regulate emotions, especially negative emotions. As negative emotions and fear decreased, personal goals simultaneously changed in the direction known to be adaptive for the new life situation as a parent of a newborn.

Background Little is known about the psychological status of partners of women with severe fear of childbirth (FOC). In this longitudinal study from Helsinki University Central Hospital, we investigated FOC, depression, and posttraumatic stress in the partners of women with severe FOC, and possible effects of group psychoeducation and mode of birth.Methods: During pregnancy, 250 partners of nulliparous women with severe FOC participated, 93 in the intervention group and 157 in the control group. At 3 months postpartum, 52 partners in the intervention group and 93 in the control group participated. Both the partners and the childbearing women filled in the Wijma Delivery Expectancy/Experience Questionnaire and the Edinburgh Postnatal Depression Scale mid‐pregnancy as well as 3 months postpartum, when they also filled in the Traumatic Event Scale. Results Partners of women with severe FOC reported less antenatal and postnatal FOC and fewer depressive symptoms than the childbearing women. No partner reached the threshold of severe FOC. No partner reported a possible posttraumatic stress disorder. Group psychoeducation with relaxation was not associated with better or worse psychological well‐being of the partners. An emergency cesarean delivery was associated with a more fearful delivery experience in the partners. Conclusion Partners of nulliparous women with severe FOC neither seem to suffer from severe FOC nor reported posttraumatic stress symptoms after childbirth. They reported better psychological well‐being than the mothers both during pregnancy and after delivery. An unexpected cesarean may be a negative experience even for partners of childbearing women. peerReviewed

Previous studies on the treatment of women with fear of childbirth have focused on the delivery mode. Women with fear of childbirth often suffer from anxiety and/or depression, and treatment therefore also needs to target postnatal psychological well-being and the early mother-infant relationship.Three hundred and seventy-one nulliparous women out of 4575 scored ≥100 in prospective screening (Wijma Delivery Expectancy Questionnaire, W-DEQ-A), indicating severe fear of childbirth. These women were randomised to psychoeducative group intervention with relaxation (n = 131; six sessions during pregnancy, one postnatal) or to conventional care (n = 240) by community nurses (referral if necessary). Psycho-emotional and psychosocial evaluations [Edinburgh Postnatal Depression Scale (EPDS), social support, Maternal Adjustment and Attitudes (MAMA), Traumatic Events Scale (TES) and the Wijma Delivery Experience Questionnaire (W-DEQ-B)] were completed twice during pregnancy and/or 3 months postpartum.Postnatal maternal adjustment (MAMA mean score 38.1 ± 4.3 versus 35.7 ± 5.0, p = 0.001) and childbirth experience (mean W-DEQ-B sum score 63.0 ± 29 versus 73.7 ± 32, p = 0.008) were better in the intervention group compared with controls. In hierarchical regression, social support, participating in intervention, and less fearful childbirth experience predicted better maternal adjustment. The level of postnatal depressive symptoms was significantly lower in the intervention group (mean sum score 6.4 ± 5.4 versus 8.0 ± 5.9 p = 0.04). There were no differences in the frequency of post-traumatic stress symptoms between the groups.In nulliparous women with severe fear of childbirth, participation in a targeted psychoeducative group resulted in better maternal adjustment, a less fearful childbirth experience and fewer postnatal depressive symptoms, compared with conventional care.

Objective To determine how infertility and subsequent assisted reproductive treatment (ART) affect a woman's childbirth experience. Design Prospective multicenter case-control study. Setting We recruited women pregnant with a singleton fetus after either ART (n = 324) or spontaneous conception (n = 304) from five infertility clinics and one university maternity clinic in Finland. Methods We studied their childbirth experience with the Delivery Satisfaction Scale. We compared how psychosocial and obstetric factors affected satisfaction and dissatisfaction with childbirth between and within the ART and the control group. Logistic regression was then used to analyse the most important contributors to the experienced dissatisfaction. Results Dissatisfaction with childbirth was as common in the ART group (11%) as in the control (10%) group. In the ART group, the women's education level, cesarean section (CS) and their partner's absence from the delivery were associated with dissatisfaction. In the control group, significant factors for dissatisfaction were nulliparity, severe pregnancy-related anxiety, emergency CS, recalled intense pain and the partner's absence from the delivery. According to adjusted logistic regression analysis of the whole sample, the independent risk factors were elective CS [odds ratio (OR) 5.7; 95% confidence interval (CI) 2.2–14.1] and emergency CS (OR 2.9; 95% CI 1.3–6.5), recalled intense pain (OR 6.8; 95% CI 3.3–16.2) and the partner's absence from the delivery (OR 2.7; 95% CI 1.1–7.3). Conclusion ART is not a risk factor for dissatisfaction with childbirth by itself. However, the contributors to an unsatisfactory childbirth differ partly between women conceiving with ART and those conceiving spontaneously.

Background A complication of cesarean section delivery is its interference with the normal intestinal colonization of the infant, affecting the development of immune system in early life—a process that has been associated with long-term morbidity, such as allergy and diabetes. We evaluated, in CS-delivered infants, whether the normal intestinal microbiome and its early life development could be restored by immediate postnatal transfer of maternal fecal microbiota to the newborn. Methods Seventeen healthy mothers with planned elective CS were recruited and screened thoroughly for infections, after which 7 mothers were included in the study. A fecal sample was processed according to a transplantation protocol and an aliquot (3–7 mg) was orally administered in breast-milk to the newborn during the first feeding. The infants were followed and fecal samples were gathered during the first 12 weeks of age and subsequently at the age of 8–18 months. Results The bacterial communities in the fecal samples of the mothers and their offspring were analyzed by sequencing of 16S rRNA amplicons from isolated fecal DNA and compared with that of 11 nontreated CS-delivered infants and 34 vaginally delivered infants. The fecal microbiota at 3 and 12 weeks was similar between treated CS and vaginally delivered infants, in contrast to that of the untreated CS-delivered infants both in overall composition (P = 0.001, Figure) and development of early-life signature bacteria, i.e., bacteroides and bifidobacteria and clostridia (P < 0.0001). Conclusion The seeding of maternal fecal microbes to the newborn intestine can be safely and successfully mimicked in elective CS by transferring a small amount of maternal fecal microbiome orally to the newborn infant. In these infants, this process results in a microbial development that is highly similar to that of the vaginally born infants, and provides support for the hypothesis that microbial colonization in early life results from a maternal fecal transfer. Disclosures All Authors: No reported Disclosures.

Objective To compare the numbers of vaginal deliveries and delivery satisfaction among women with fear of childbirth randomised to either psychoeducation or conventional surveillance during pregnancy. Design Randomised controlled trial. Setting Maternity unit of Helsinki University Central Hospital. Population Fear of childbirth was screened during early pregnancy by the Wijma Delivery Expectancy Questionnaire (W-DEQ-A). Of 4575 screened nulliparous women, 371 (8.1%) scored ≥100, showing severe fear of childbirth. Methods Women with W-DEQ-A ≥100 were randomised to intervention (n = 131) (psychoeducative group therapy, six sessions during pregnancy and one after childbirth) or control (n = 240) (care by community nurses and referral if necessary) groups. Obstetric data were collected from patient records and delivery satisfaction was examined by questionnaire. Main outcome measures Delivery mode and satisfaction. Results Women randomised to the intervention group more often had spontaneous vaginal delivery (SVD) than did controls (63.4% versus 47.5%, P = 0.005) and fewer caesarean sections (CSs) (22.9% versus 32.5%, P = 0.05). SVD was more frequent and CSs were less frequent among those who actually participated in intervention (n = 90) compared with controls who had been referred to consultation (n = 106) (SVD: 65.6% versus 47.2%, P = 0.014; CS: 23.3% versus 38.7%, P = 0.031). Women in intervention more often had a very positive delivery experience (36.1% versus 22.8%, P = 0.04, n = 219). Conclusions To decrease the number of CSs, appropriate treatment for fear of childbirth is important. This study shows positive effects of psychoeducative group therapy in nulliparous women with severe fear of childbirth in terms of fewer CSs and more satisfactory delivery experiences relative to control women with a similar severe fear of childbirth.

Please cite this paper as: Rouhe H, Salmela-Aro K, Gissler M, Halmesmaki E, Saisto T. Mental health problems common in women with fear of childbirth. BJOG 2011;118:1104–1111. Objective To investigate whether women with fear of childbirth have more mental health problems than women of childbearing age in general. Design Register-based retrospective study. Setting The maternity clinic of Helsinki University Central Hospital. Population In all, 2405 women referred for consultation because of fear of childbirth during 1996–2002 and 4676 comparable control women. Methods Data were linked to the Medical Birth Register, the Hospital Discharge Register and the Drug Reimbursement Register 5–12 years before and after the initial childbirth (during 1990–2008). Main outcome measures Prevalence of psychiatric care as evidenced by the use of psychotropic medication, and episodes of either psychiatric inpatient or outpatient care in women with fear of childbirth compared with nonfearful controls. Results Women with fear of childbirth had significantly more often had psychiatric care (54.0% versus 33.6%, P

Please cite this paper as: Rahkonen L, Rutanen E-M, Nuutila M, Sainio S, Saisto T, Paavonen J. Elevated levels of decidual insulin-like growth factor binding protein-1 in cervical fluid in early and mid-pregnancy are associated with an increased risk of spontaneous preterm delivery. BJOG 2010;117:701–710. Objective To study whether elevated levels of decidual insulin-like growth factor binding protein-1 (IGFBP-1) in the cervical fluid of unselected asymptomatic women in early or mid-pregnancy are associated with spontaneous preterm delivery (PTD). Design Prospective population-based cohort study. Setting Maternity Clinics, University Central Hospital, Helsinki, Finland. Population A total of 5180 unselected pregnant women. Methods Cervical swab samples were collected during the first and second trimester ultrasound screening. The concentration of IGFBP-1 was measured by immunoenzymometric assay, which detects the decidual phosphoisoforms of IGFBP-1 (phIGFBP-1). Concentrations of 10 micrograms/l or more were considered to be elevated. Main outcome measure Spontaneous PTD. Results In the first trimester, 24.5% of women, and in the mid-second trimester, 20.2% of women, had an elevated cervical fluid phIGFBP-1 level. The rates of spontaneous PTD before 32 and before 37 weeks of gestation were higher in women with an elevated cervical fluid phIGFBP-1 level, compared with women who had cervical phIGFBP-1 of

The aim of this three-wave cross-lagged longitudinal study was to examine the prospective relationships between women’s goal-related spousal support and their relationship satisfaction during the transition to parenthood. Two-hundred and forty-six Finnish women who were either married or cohabited (45% primiparous; 55% multiparous) filled in questionnaires on personal projects (Little, 1983) and related spousal support, relationship satisfaction (Spanier, 1976), and background data three times: in their early pregnancy; one month before childbirth; and three months after childbirth. Among the primiparous women the results showed a cumulative cycle of goal-related spousal support and relationship satisfaction: goal-related spousal support in early pregnancy predicted higher relationship satisfaction just before childbirth, and, vice versa, relationship satisfaction in early pregnancy predicted higher goal-related spousal support just before childbirth. In turn, among the multiparous women only relationship satisfaction predicted goal-related support later on. In addition, the results showed that women perceived low spousal support for individualistic goals, such as self-related goals, and high support for shared goals, such as family-related goals.

Exposure to illicit drugs in utero is associated with low birth weight and premature birth. Therefore, maintenance therapy for opioid dependence during pregnancy has been recommended to help withdrawal from street drugs, in order to improve maternal health and decrease risks to the fetus.In 2002-2005, 67 pregnancies of 66 buprenorphine users were followed prospectively in an outpatient multidisciplinary antenatal setting by an obstetrician, a midwife, a psychiatric nurse and a social worker. Decreasing doses or even abstinence from buprenorphine was encouraged. Outcome measures were daily buprenorphine dose, fetal growth, gestational age at birth, mode of delivery, birth weight, Apgar scores, umbilical pH values, and occurrence of neonatal abstinence syndrome [NAS]. National statistics were used as reference values.The daily dose of buprenorphine decreased by 2.3 mg (median, range increase of 8 mg to decrease of 24 mg). There were no more incidences of premature birth, cesarean section, low Apgar scores (or = 6) or umbilical artery pH7.05 at birth than in the national register, despite the lower birth weight. A total of 91% of the infants needed treatment in a neonatal care unit, 76% had NAS, and 57% needed morphine replacement therapy. Seven infants were taken into care directly from the maternity hospital. Two sudden infant deaths occurred later.The pregnancies and deliveries of buprenorphine-using women were uneventful, but severe NAS and need for morphine replacement therapy was seen in 57% of the buprenorphine-exposed newborns. A high number of sudden infant deaths occurred.

The birth of a child is a demanding family life situation. This longitudinal study investigated to what extent spouses' depressive symptoms and marital dissatisfaction associated with pregnancy and childbirth (and their changes over time) were characteristic of the spousal relationship and/or the individual spouses. Pregnant women (N= 320) and their spouses (N = 259) were examined twice before and twice following childbirth. Results indicated that changes in depressive symptoms and marital satisfaction during pregnancy were characteristic of the spousal relationship, whereas changes after birth were characteristic of both the relationship and the individual spouses. Couples with initially high marital satisfaction reported a later decrease, whereas those with initially low satisfaction reported an increase.

To compare the prevalence and predictors of severe fear of childbirth and pregnancy-related anxiety in groups of assisted reproduction treatment (ART) and spontaneously conceiving women with singleton pregnancies.The ART group (n = 367, nulliparous 260) represented a cohort from five Finnish infertility clinics in 1999. The control group (n = 379, nulliparous 135) was enrolled in this study by consecutive sampling the same year. Fear of childbirth was assessed by means of the revised version of the Fear-of-Childbirth Questionnaire and pregnancy-related anxiety by means of the Pregnancy Anxiety Scale at gestational week 20 +/- 3.2 (mean+/-standard deviation).The frequency of severe fear of childbirth and anxiety (classified as total scores in the 90th percentile or higher in the revised Fear of Childbirth Questionnaire and Pregnancy Anxiety Scale) did not differ between the groups. Nulliparity was associated with more frequent severe anxiety only in the controls. In nulliparous participants, a partnership of more than 5 years decreased the risk of severe fear of childbirth (odds ratio 0.3, 95% confidence interval 0.2-0.7). In the nulliparous ART group, a long duration of infertility (7 or more years) increased the risk of severe fear of childbirth (odds ratio 4.4, 95% confidence interval 1.2-16.9).Women conceiving after ART do not experience severe fear of childbirth or pregnancy-related axiety more often than spontaneously conceiving controls. However, a long duration of infertility is an independent risk factor regarding severe fear of childbirth.II-2.

Inherited thrombophilias, suggested to be risk factors for ovarian hyperstimulation syndrome and known to be associated with venous thromboembolism during pregnancy, may also increase the risk for preeclampsia (PE). We describe the case of a 29-year-old woman with primary infertility with no history of thrombosis, hypertension or renal disorders. In her first pregnancy, achieved by frozen embryo transfer, she developed severe early-onset (23rd gestational week) PE with heavy proteinuria, and at the same time was found to have enlarged ovaries with hyperreactio luteinalis. After admission we found that she was a heterozygotic carrier of the factor V Leiden mutation. After administering low molecular weight heparin (LMWH) therapy, her blood pressure normalized, proteinuria diminished and her d-dimer values returned to that of a normal pregnant level. The fetus grew normally. Her ovaries normalized during the pregnancy, as determined by ultrasound examinations. At term she delivered spontaneously a normal weight, healthy girl. Previously, only prophylactic LMWH, in subsequent pregnancy, have been administered in patients with thrombophilia and a history of severe PE. We describe a case of spontaneous hyperreactio luteinalis, where the clinical characteristics of PE improved after beginning LMWH therapy in severe, very early onset PE. Inherited thrombophilia, spontaneous hyperreactio luteinalis and PE may be associated phenomena.

Background. Women suffering from fear of labor have reduced pain tolerance during a cold pressor test (CPT) during and after pregnancy. Methods. We compared levels of norepinephrine, adrenocorticotropin (ACTH), cortisol and beta-endorphin before and during the CPT up to 60 min in 20 normotensive women with and 20 without fear of labor at 37.4 ± 0.2 (mean ± SE) gestational weeks and at 41.9 ± 1.6 weeks after delivery. Results. Baseline levels of norepinephrine in the pregnant fear group (1.63 ± 0.18 nmol/L) were higher ( p = 0.068) than in controls (1.38 ± 0.14 nmol/L) but after delivery they were lower in the fear group (1.75 ± 0.31 nmol/L vs. 2.31 ± 0.26 nmol/L, p = 0.064). ACTH, cortisol and beta-endorphin did not differ between pregnant and nonpregnant groups. The CPT caused a 28.4% smaller response in norepinephrine in the pregnant fearful women than in controls, whereas the responses of ACTH and beta-endorphin were similar between groups during and after pregnancy. The CPT caused no significant respo...

Severe fear of childbirth complicates 6% to 10% of parturients and is manifested as nightmares, physical complaints and difficulties in concentrating on work or on family activities. Very often fear of childbirth leads to request for an elective cesarean section (CS). In Finland, Sweden, and the United Kingdom, fear of childbirth or maternal request is the reason for about 7-22% of CS births. Fear of childbirth is as common in nulliparous as in parous women. Fear of labor pain is strongly associated with the fear of pain in general, and a previous complicated childbirth or inadequate pain relief are the most common reasons for requesting a CS among parous women. Previous psychological morbidity and a great number of daily stressors expose a woman to a great risk of fear of childbirth. Fear of childbirth is not an isolated problem but associated with the woman's personal characteristics, mainly general anxiety, low self-esteem, and depression, and dissatisfaction with their partnership, and lack of support. Also the partners of women with fear have a certain pattern of low psychological well-being, resulting in low life-satisfaction, dissatisfaction with partnerships, and depression. A vivid debate about the woman's right to choose the mode of delivery is going on in obstetric literature, but discussion on the reasons for women to request a CS, or on the possibilities to help them overcome the fear of vaginal childbirth is scanty. Preliminary Swedish and Finnish reports demonstrated the results of treatment during pregnancy, when more than half of the women withdrew their request after being able to discuss their anxiety and fear, and vaginal deliveries after treatment were successful.

Objective Fear of childbirth is a common reason for seeking cesarean section. It is important to consider outcomes and costs associated with alternative treatment and delivery mode. We compared well-being and costs of group psychoeducation and conventional care for fear of childbirth. Design Randomized controlled trial. Population A total of 371 nulliparous women scoring over the 95th centile in the Wijma Delivery Expectancy Questionnaire (W-DEQ) during the first trimester. Setting Finland, data from obstetrical patient records and questionnaires. Methods Randomization to group psychoeducation with relaxation (six sessions during pregnancy, one after childbirth, n = 131), or surveillance and referral on demand (n = 240). Main outcome measures All costs in maternity care during pregnancy, delivery and postnatally according to Diagnoses Related Groups. Life satisfaction and general well-being 3 months after childbirth (by a Satisfaction with Life Scale and Well-being Visual Analogue Scale). Results The groups did not differ in total direct costs (€3786/woman in psychoeducative group and €3830/woman in control group), nor in life satisfaction or general well-being. Although only 76 (30%) of the women assigned to the surveillance were referred to special maternity care and 36 (15%) attended advanced prenatal classes, costs in the psychoeducation group did not exceed the costs of the controls, mostly because of the greater number of uncomplicated vaginal deliveries (63% vs. 47%, p = 0.005). Conclusions Through an association with safer childbirth and equal well-being after delivery, psychoeducative group treatment for nulliparous women with fear of childbirth can be a recommended choice for the same overall costs as conventional treatment.

OBJECTIVE: To compare intensive and conventional therapy for severe fear of childbirth. METHODS: In Finland, 176 women who had fear of childbirth were randomly assigned at the 26th gestational week to have either intensive therapy (mean 3.8 ± 1.0 sessions with obstetrician and one with midwife) or conventional therapy (mean 2.0 ± 0.6 sessions), with follow-up 3 months postpartum. Pregnancy-related anxiety and concerns, satisfaction with childbirth, and puerperal depression were assessed with specific questionnaires. Power analysis, based on previous studies, showed that 74 women per group were necessary to show a 50% reduction in cesarean rates. RESULTS: Birth-related concerns decreased in the intensive therapy group but increased in the conventional therapy group (linear interaction between the group and birth-concerns P = .022). Labor was shorter in the intensive therapy group (mean ± standard deviation 6.8 ± 3.8 hours) compared with the conventional group (8.5 ± 4.8 hours, P = .039). After intervention, 62% of those originally requesting a cesarean ( n = 117) chose to deliver vaginally, equally in both groups. Cesarean was more frequent for those who refused to fill in the questionnaires than for those who completed them (57% compared with 27%, P = .001). In the log-linear model, parous women who had conventional therapy and refused to fill in the questionnaires chose a cesarean more often than expected (standardized residual 2.54, P = .011). There were no differences between groups in satisfaction with childbirth or in puerperal depression. CONCLUSION: Both kinds of therapy reduced unnecessary cesareans, more so in nulliparous and well-motivated women. With intensive therapy, pregnancy- and birth-related anxiety and concerns were reduced, and labors were shorter.

Objectives To examine the personal characteristics and socio-economic background of women and their partners fearing vaginal childbirth. Design Questionnaire survey by the 30th week of pregnancy. Setting Sixteen outpatient maternity centres in the capital area of Finland. Participants Two hundred and seventy-eight women and their partners. Main outcome measures Personality traits, socio-economic factors, life and partnership satisfaction and pregnancy- and delivery-associated anxiety and fear. Results The more anxiety, neuroticism, vulnerability, depression, low self-esteem, dissatisfaction with the partnership, and lack of social support the women reported, the more they showed pregnancy-related anxiety and fear of vaginal delivery. In multiple regression analyses psychological variables of the woman contributed most to the prediction of pregnancy-related anxiety (increase in R2=0.20, P

To examine the extent to which personality characteristics, depression, fear and anxiety about pregnancy and delivery, and socio-economic background, predict disappointment with delivery and the risk of puerperal depression.Two hundred and eleven women filled in questionnaires measuring personality traits, socio-economic factors, and marital satisfaction once before and once after the 30th week of pregnancy, and 2 3 months after delivery, when obstetric data about pregnancy and delivery was also collected.The women who were disappointed with their delivery or suffered from puerperal depression had been more depressed already in early pregnancy. Regression analysis showed that the strongest predictors of disappointment with delivery were labor pain (increase in R2 = 0.14, p0.001) and emergency Cesarean (increase in R2 = 0.18, p0.001). Puerperal depression was predicted by depression (increase in R2 = 0.16, p0.001), and by personal traits such as general anxiety, vulnerability and neuroticism (increase in R2 = 0.32, p0.001), both before 30 weeks of pregnancy and prior to the delivery (for depression increase in R2 = 0.05, p0.001, and for anxiety and vulnerability increase in R2 = 0.04, p0.01). The strongest predictors were depression at both time points before delivery (beta = 0.51, p0.001, and beta = 0.39, p0.001). Pregnancy- and delivery-related anxiety prior to the delivery also predicted puerperal depression, but complications of the pregnancy and delivery did not.Depression in early pregnancy predicts disappointment with the delivery and is a strong predictor of puerperal depression.

To investigate how women's and men's personal goals change during the transition to parenthood, the authors studied 348 women (152 primiparous and 196 multiparous) and 277 of their partners at 3 times: early in pregnancy, 1 month before the birth, and 3 months afterward. At each measurement, participants completed the Personal Project Analysis questionnaire (B. R. Little, 1983). The results showed that during pregnancy women became more interested in goals related to childbirth, the child's health, and motherhood and less interested in achievement-related goals. After the birth women were more interested in family- and health-related issues. These changes were more substantial among the primiparous than among the multiparous mothers. Although the men's personal goals changed during the transition to parenthood, these changes were less substantial than those found among the women.

Objective: To identify factors associated with fear of childbirth during and after first labor. Methods: We analyzed first deliveries of 100 primiparas who reported severe fear of vaginal childbirth during their second pregnancies and 200 age- and parity-matched controls who reported no later fear of delivery. The main outcome measures were previous miscarriages, participation in birth-education classes, support during labor, length of first delivery, pain relief, obstetric complications, welfare of the newborn, and time between deliveries. Results: The prevalence of emergency cesarean (adjusted odds ratio [OR] 26.9, confidence interval [CI] 11.9, 61.1) and vacuum extraction (adjusted OR 4.5, CI 2.2, 9.3) during first delivery was much higher in subjects than controls. Labor lasted longer in cases than in controls during the first (10.5 hours versus 7.8 hours, P = .016) and second stages (62 minutes versus 47 minutes, P = .002). They received epidural analgesia more often, but its timing and the amount used were not different between groups. Of the group with fear, 44% could not define any specific cause for fear and regarded the entire delivery as frightening. Conclusion: Emergency cesarean and vacuum extraction during first deliveries were associated with secondary fear of delivery. Emergency obstetric procedures cannot be avoided, so prevention of fear might require more education on causes and consequences of cesarean or vacuum extraction, eg, in birth classes and at postpartum visits.

Vein of Galen aneurysmal malformation (VGAM) is a rare congenital arteriovenous malformation of the choroid plexus situated within the roof of the third ventricle. If large, it leads to an extracardiac left-to-right shunt featuring as a high output heart failure in the neonate. In our case of VGAM, hypoxic-ischemic brain lesions due to the steal phenomenon could be demonstrated prenatally. In a multidisciplinary clinical setting, withdrawal of active care and initiation of good end-of-life care was decided on and carried through.

Fear of childbirth casts a shadow in 10% of the pregnancies. It can cause fear, mental illnesses and previous experiences of violence or bad experiences in giving birth. It is treated at the phobia clinic with the support of a midwife and an obstetrician. Psychoeducative group therapy intended for primigravid women has proven to be the most effective form of therapy. In addition to obstetric assessment, its cornerstones include hearing and supporting of the phobic patient. For most women fearing childbirth, proper therapy will encourage them and abandon their wish for cesarean section. Nobody should, however, be forced into vaginal delivery.

This RCT intervention among nulliparous pregnant women with an intense fear of childbirth sought to promote preparedness for childbirth and to enhance positive parenting. Pregnant women (n = 8,611) filled in a ‘fear of childbirth’ questionnaire. Nulliparous women with severe fear of childbirth (n = 355) were randomized into intervention (n = 131; 41 refused) and control (n = 224) groups. They rated themselves on a preparedness scale in middle and late pregnancy, and on a motherhood scale three months after childbirth. The intervention included six psycho-education group sessions during pregnancy and one after childbirth. This intervention increased the mothers’ preparedness for childbirth, which predicted an increase in positive motherhood.

A total of 800 patients were randomized at the 9th to 11th week of pregnancy either for transcervical chorionic villus sampling (CVS) on the day of trial entry or for amniocentesis (AC) at the 16th week. The indication for fetal karyotyping was maternal age in 94 per cent of the cases; the mean maternal age was 39.2 years. An adequate sample was obtained in 98.3 per cent of the cases in the CVS group and in all cases in the AC group. Retesting was indicated in 3.3 per cent of the CVS cases. An abnormal karyotype was found in 6.1 per cent of the CV samples and in 4.5 per cent of the amniotic fluid samples. There was one false-positive chromosome result in both groups. Twelve (3.1 per cent) miscarriages occurred by the 22nd week of pregnancy in the CVS group in pregnancies intended to continue. No difference was seen between the groups for total fetal loss rates. The number of surviving infants in the CVS group was 92.2 per cent and in the AC group 91.7 per cent (rate difference 0.5 per cent (95 per cent confidence interval − 3.3 to 4.3)). In our study, both the diagnostic accuracy and the risk of fetal loss were equal in the CVS and AC groups.

To evaluate the performance of cervical phosphorylated insulin-like growth factor binding protein-1 (phIGFBP-1) testing and cervical length measurement separately and in combination with physician's clinical judgment in prediction of preterm birth among patients with self-reported uterine contractions and intact membranes.We enrolled a total of 246 women between 22 and 34 weeks of gestation.The initial evaluation included cervical length measurement using transvaginal ultrasonography. Short cervix was defined as25 mm. A swab sample was obtained from the cervix for phIGFBP-1. Admission was used as a clinical marker of an increased risk of preterm deliveryor=34 weeks. The diagnostic performances of the tests and clinician's judgment, as well as likelihood ratios (LRs) were calculated.Deliveryor=34 weeks and within 14 days.The overall rate of spontaneous preterm deliveryor=34 weeks was 4.1% (10/246). Short cervix, positive phIGFBP-1 test, combination of both, and clinician's judgment were all associated with preterm deliveryor=34 weeks or within 14 days (p0.01). The negative predictive values for deliveryor=34 weeks were 97.4, 97.6, 97.1, and 98.7%, respectively, and within 14 days 98.7, 99.0, 98.3, and 99.6%, respectively. The corresponding positive LRs for deliveryor=34 weeks were 6.8, 3.8, 75.0, 14.9, and within 14 days 9.7, 5.5, 107.3, 17.1. The negative LRs were 0.6, 0.6, 0.7, 0.3 and 0.5, 0.3, 0.6, 0.2.The rapid phIGFBP-1-test has a high negative predictive value for preterm delivery, comparable to that of ultrasonographic cervical length measurement.

Objective To examine fear of childbirth according to parity, gestational age, and obstetric history. Design A questionnaire study. Population and setting 1400 unselected pregnant women in outpatient maternity clinics of a university central hospital. Methods Visual analogue scale (VAS) and Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) and preferred mode of delivery. Main outcome measures W-DEQ and VAS scores according to parity, gestational age, obstetric history, and preferred mode of delivery. Results The W-DEQ and VAS scores were higher in nulliparous (W-DEQ 72.0 ± 20.0 [mean ± SD] and VAS 4.7 [median]) than parous women (65.4 ± 21.9; 3.2, P < 0.001 for both W-DEQ and VAS). Higher W-DEQ and VAS scores were found for those beyond 21 weeks of gestation compared with those before (W-DEQ 71.6 ± 23.0 versus 66.6 ± 20.0, P < 0.001; VAS 4.7 versus 3.2, P < 0.001). Caesarean section was preferred mode of delivery for 8.1% and these women scored higher on fear (W-DEQ 87.6 ± 26.5, VAS median 7.0) than those who preferred vaginal delivery (W-DEQ 61.8 ± 18.7, VAS 2.7, P < 0.001, respectively). Those with a previous caesarean scored higher on fear (W-DEQ 73.2 ± 23.5, VAS 5.1) than parous women without previous caesarean (W-DEQ 63.3 ± 20.8, VAS 2.9, P < 0.001, respectively). Those with a history of a vacuum extraction (VE) (W-DEQ 70.6 ± 19.7, VAS 5.0) had higher fear scores than those without (W-DEQ 64.8 ± 22.0, P < 0.05 and VAS 3.0, P < 0.001). Conclusion Severe fear of childbirth was more common in nulliparous women, in later pregnancy, and in women with previous caesarean section or VE. Caesarean section as a preferred mode of childbirth was strongly associated with high score in both W-DEQ and VAS.

Longitudinal study on the predictors of parental stress in mothers and fathers of toddlers.To study whether anxiety, depression, or marital problems increase the parenting stress in parents of toddlers.At early pregnancy, 2 - 3 months, and 2 - 3 years after delivery, 214 low-risk couples filled in questionnaires on their marital relationship, social support, child's temperament, and self-evaluated competence in routine care-taking. In hierarchical regression analyses, they were used as predictors of parental stress.Those mothers who in early pregnancy had adequate social support, adaptive social strategies, and high self-esteem, and who had given birth vaginally, enjoyed breastfeeding, and whose spouse supported breastfeeding reported less stress 2 - 3 years later. Pregnancy-related anxiety, depression, general anxiety, neuroticism, and vulnerability in early pregnancy, as well as child's temperament and low self-estimated competence in routine care-taking measured at both 2 - 3 months and 2 - 3 years after childbirth predicted parental stress. Depression and living alone in early pregnancy, and the child-related variables (temperament and care-taking, measured both at 2 - 3 months and 2 - 3 years after childbirth) predicted high parenting stress in fathers of toddlers.Parental stress in toddlers' parents was predicted both by the temperament of the child, and by the parents' depression, self-esteem, and anxiety, as well as by lack of support and low self-evaluated competence in routine care-taking.

A 32-year-old G6P5 (hepatitis B carrier, of African origin) with a spontaneous twin pregnancy gave birth at the 37th gestational week. Four hours later she collapsed. Upon an emergency laparotomy, right liver lobe rupture and later massive liver necrosis were diagnosed. Four days later, a liver transplantation was performed. She was discharged from the hospital 38 days after her delivery, four laparotomies, and having received 179 units of red blood cells, 221 units of fresh frozen plasma, 144 units of platelets, and various separate clotting concentrates. As a result of immune suppression medication, she later developed diabetes, sarcoma Kaposi, a Pneumocystis carinii pneumonia, and coenurosis. Four years later, she is, however, in a relatively good condition.

To estimate the prevalence of a history of physical and sexual abuse in adulthood among gynecological patients and the association with general and reproductive health.A cross-sectional questionnaire study on abusive experiences of gynecologic outpatients in a tertiary hospital. The total sample size was 691.Of all women, 42.4% had experienced moderate or severe physical or sexual abuse as an adult. One hundred forty-seven (21.6%) women reported physical abuse, 84 (12.3%) sexual abuse, and 58 (8.5%) both. The abused and nonabused women did not differ in mean age, education, or parity. Sexually abused women and those who were both sexually and physically abused reported poor general health significantly more often (P=.005 and P=.001, respectively) than the nonabused. They also rated their sex life as significantly worse than the nonabused women (P=.002 and P=.012, respectively). Over half of abused women had experienced common physical complaints during the previous 12 months compared with one third of the nonabused (P.001). Two thirds of both the abused and the nonabused women preferred that their gynecologist not ask directly about abuse.Abusive experiences were common in gynecologic outpatients. Women with abusive experiences had ill health and poor sexual life more often than the controls. In contrast to the results of previous studies, most of the women did not want to be asked about abuse by their gynecologist.

Women suffering from fear of labor have reduced pain tolerance during a cold pressor test (CPT) during and after pregnancy.We compared levels of norepinephrine, adrenocorticotropin (ACTH), cortisol and beta-endorphin before and during the CPT up to 60 min in 20 normotensive women with and 20 without fear of labor at 37.4 +/- 0.2 (mean +/- SE) gestational weeks and at 41.9 +/- 1.6 weeks after delivery.Baseline levels of norepinephrine in the pregnant fear group (1.63 +/- 0.18 nmol/L) were higher (p = 0.068) than in controls (1.38 +/- 0.14 nmol/L) but after delivery they were lower in the fear group (1.75 +/- 0.31 nmol/L vs. 2.31 +/- 0.26 nmol/L, p = 0.064). ACTH, cortisol and beta-endorphin did not differ between pregnant and nonpregnant groups. The CPT caused a 28.4% smaller response in norepinephrine in the pregnant fearful women than in controls, whereas the responses of ACTH and beta-endorphin were similar between groups during and after pregnancy. The CPT caused no significant response in cortisol. Pregnant fearful women had higher diastolic blood pressure (85.6 +/- 4.5 mmHg, mean +/- SE) than the controls (74.9 +/- 3.4 mmHg, p = 0.065).Women with fear of labor were characterized by changes in norepinephrine but not in ACTH, cortisol or beta-endorphin before and during the CPT, indicating a normal pituitary-adrenal axis function.

Two cross-lagged longitudinal studies were carried out to investigate the extent to which the adjustment of personal goals to match the particular stage-specific demands of the transition to motherhood has consequences for women's depressive symptoms. In Study 1. 348 women filled out a revised version of Little's (1983) Personal Project Analysis and a revised version of Beck's Depression Inventory (A. T. Beck. C. H. Ward. M. Mendelsohn, L. Mock,J. Erlaugh. 1961) 4 times: during early pregnancy, 1 month before childbirth, 3 months after childbirth. and 2 years after childbirth. In Study 2. 140 women who reported high levels of fear of childbirth filled out identical measures during early pregnancy, 1 month before childbirth, and 3 months after childbirth. The results showed that an increase in family-related goals during pregnancy and after the birth of the child predicted a decline in women's depressive symptoms. By contrast, an increase in self-focused goals predicted an increase in women's depressive symptoms.

To compare intensive and conventional therapy for severe fear of childbirth.In Finland, 176 women who had fear of childbirth were randomly assigned at the 26th gestational week to have either intensive therapy (mean 3.8 +/- 1.0 sessions with obstetrician and one with midwife) or conventional therapy (mean 2.0 +/- 0.6 sessions), with follow-up 3 months postpartum. Pregnancy-related anxiety and concerns, satisfaction with childbirth, and puerperal depression were assessed with specific questionnaires. Power analysis, based on previous studies, showed that 74 women per group were necessary to show a 50% reduction in cesarean rates.Birth-related concerns decreased in the intensive therapy group but increased in the conventional therapy group (linear interaction between the group and birth-concerns P =.022). Labor was shorter in the intensive therapy group (mean +/- standard deviation 6.8 +/- 3.8 hours) compared with the conventional group (8.5 +/- 4.8 hours, P =.039). After intervention, 62% of those originally requesting a cesarean (n = 117) chose to deliver vaginally, equally in both groups. Cesarean was more frequent for those who refused to fill in the questionnaires than for those who completed them (57% compared with 27%, P =.001). In the log-linear model, parous women who had conventional therapy and refused to fill in the questionnaires chose a cesarean more often than expected (standardized residual 2.54, P =.011). There were no differences between groups in satisfaction with childbirth or in puerperal depression.Both kinds of therapy reduced unnecessary cesareans, more so in nulliparous and well-motivated women. With intensive therapy, pregnancy- and birth-related anxiety and concerns were reduced, and labors were shorter.