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SUMMARY OF RECOMMENDATIONS 1. Episiotomy should be performed by indication only, and not routinely (Moderate quality evidence +++-; Strong recommendation). Accepted indications for episiotomy are to shorten the second stage of labor when there is suspected fetal hypoxia (Low quality evidence ++–; Weak recommendation); to prevent obstetric anal sphincter injury in vaginal operative deliveries, or when obstetric sphincter injury occurred in previous deliveries (Moderate quality evidence +++-; Strong recommendation) 2. Mediolateral or lateral episiotomy technique should be used (Moderate quality evidence +++-; Strong recommendation). Labor ward staff should be offered regular training in correct episiotomy techniques (Moderate quality evidence +++-; Strong recommendation). 3. Pain relief needs to be considered before episiotomy is performed, and epidural analgesia may be insufficient. The perineal skin needs to be tested for pain before an episiotomy is performed, even when an epidural is in place. Local anesthetics or pudendal block need to be considered as isolated or additional pain relief methods (Low quality evidence ++–; Strong recommendation). 4. After childbirth the perineum should be carefully inspected, and the anal sphincter palpated to identify possible injury (Moderate quality evidence +++-; Strong recommendation). Primary suturing immediately after childbirth should be offered and a continuous suturing technique should be used when repairing an uncomplicated episiotomy (High quality evidence ++++; Strong recommendation). [ABSTRACT FROM AUTHOR]

OF RECOMMENDATIONS1. Episiotomy should be performed by indication only, and not routinely (Moderate quality evidence +++-; Strong recommendation). Accepted indications for episiotomy are to shorten the second stage of labor when there is suspected fetal hypoxia (Low quality evidence ++-; Weak recommendation); to prevent obstetric anal sphincter injury in vaginal operative deliveries, or when obstetric sphincter injury occurred in previous deliveries (Moderate quality evidence +++-; Strong recommendation)2. Mediolateral or lateral episiotomy technique should be used (Moderate quality evidence +++-; Strong recommendation). Labor ward staff should be offered regular training in correct episiotomy techniques (Moderate quality evidence +++-; Strong recommendation).3. Pain relief needs to be considered before episiotomy is performed, and epidural analgesia may be insufficient. The perineal skin needs to be tested for pain before an episiotomy is performed, even when an epidural is in place. Local anesthetics or pudendal block need to be considered as isolated or additional pain relief methods (Low quality evidence ++-; Strong recommendation).4. After childbirth the perineum should be carefully inspected, and the anal sphincter palpated to identify possible injury (Moderate quality evidence +++-; Strong recommendation). Primary suturing immediately after childbirth should be offered and a continuous suturing technique should be used when repairing an uncomplicated episiotomy (High quality evidence ++++; Strong recommendation). [ABSTRACT FROM AUTHOR]

Objective To determine the association between 5-min Apgar score and umbilical cord artery carbon dioxide tension ( pCO2). Design Observational study. Setting European hospital labor wards. Population Data from 36 432 newborns ≥36 gestational weeks were obtained from three sources: two trials of monitoring with fetal electrocardiogram (the Swedish randomized controlled trial and the European Union Fetal ECG trial) and Mölndal Hospital data. After validation of the acid-base values, 25 806 5-min Apgar scores were available for analysis. Methods Validation of the umbilical cord acid-base values was performed to obtain reliable data. 5-min Apgar score was regressed against cord artery pCO2 in a polynomial multilevel model. Main outcome measures Five-min Apgar score, umbilical cord pCO2, pH, and base deficit. Results Overall, a higher cord artery pCO2 was found to be associated with lower 5-min Apgar scores. However, among newborns with moderate acidemia, lower umbilical cord artery pCO2 (≤median pCO2 for the specific cord artery pH) was associated with lower 5-min Apgar scores, with a relative risk of 2.0 (95% confidence interval: 1.4-2.8) for 5-min Apgar scores 0-6. Conclusions Metabolic acidosis affects the newborn's vitality more than respiratory acidosis. In addition, elevated levels of pCO2 may be beneficial for fetuses with moderate acidemia, and thus cord artery pCO2 is a factor that should be considered when assessing the compromised newborn. [ABSTRACT FROM AUTHOR]

Aim: To assess the effect of time of active pushing (TAP) on neonatal outcome., Materials and Methods: The study population (n=36,432) was taken from a Swedish randomized control trial on intrapartum monitoring, a European Union fetal electrocardiogram trial, and from Mölndal Hospital. After validation of acid-base samples and TAP, 22,812 cases were accepted for analysis., Results: The median active TAP was 36 min for P0 and 13 min for P≥1 (P<0.001). After adjustments for parity, epidural, labor induction, birth weight, and gender, pushing for 15-29 min (n=6589) relative to pushing for <15 min (n=7264) increased the OR of a cord artery pH of <7.00 to 3.20 (95% CI 1.7-6.0), and that of a base deficit in extracellular fluid of >12 mmol/L to 3.5 (95% CI 1.3-9.0). The group with a cord artery pH of <7.00 had a longer TAP than the group with pH≥7.00: median (5th-95th percentile), 38 (9-107) min vs. 23 (5-87) min, P<0.001. The probability of a spontaneous vaginal delivery decreased significantly with every subsequent increase of 30 min in TAP (P<0.05)., Conclusion: The risks of severe acidemia, metabolic acidosis, and deteriorated neonatal outcome gradually increased with the length of TAP (>15 min), while the probability of a spontaneous vaginal delivery decreased with the duration of pushing. We suggest active physiological evaluation of the labor progress together with continuous electronic fetal monitoring during pushing irrespective of guideline thresholds.