Introduction
Severe obstetric complications increase with the number of previous cesarean deliveries. In the Nordic countries most women have two children. We present the risk of severe obstetric ...complications at the delivery following a first elective or emergency cesarean and the risk by intended mode of second delivery.
Material and methods
A two‐year population‐based data collection of severe maternal complications in women with two deliveries in the Nordic countries (n = 213 518). Denominators were retrieved from the national medical birth registers.
Results
Of 35 450 first cesarean deliveries (17%), 75% were emergency and 25% elective. Severe complications at second delivery were more frequent in women with a first cesarean than with a first vaginal delivery, and rates of abnormally invasive placenta, uterine rupture and severe postpartum hemorrhage were higher after a first elective than after a first emergency cesarean delivery relative risk (RR) 4.1, 95% confidence intervals (CI) 2.0–8.1; RR 1.8, 95% CI 1.3–2.5; RR 2.3, 95% CI 1.5–3.5, respectively. A first cesarean was associated with up to 97% of severe complications in the second pregnancy. Induction of labor was associated with an increased risk of uterine rupture and severe hemorrhage.
Conclusion
Elective repeat cesarean can prevent complete uterine rupture at the second delivery, whereas the risk of severe obstetric hemorrhage, abnormally invasive placenta and peripartum hysterectomy is unchanged by the intended mode of second delivery in women with a first cesarean. Women with a first elective vs. an emergency cesarean have an increased risk of severe complications in the second pregnancy.
Background. The aim of this study was to examine the incidence and risk factors for anal sphincter tears (ASTs) at delivery. Methods. A national population-based study was conducted with data from ...the Medical Birth Register including all primiparas with singleton pregnancy, who gave birth vaginally in Sweden from 1994 to 2004 (n=365,886). Women with a third and fourth degree AST were compared with those who gave birth during the same period without incurring such tears. Results. The incidence of third degree AST increased by >60%, from 3.4% in 1994 to 5.2% in 2004 in spontaneous births, and from 8.7 to 14.8% in instrumental deliveries during the study period. The proportion of fourth degree AST increased from 0.3 to 0.55% in spontaneous births and from 0.8 to 1.4% in instrumental-assisted deliveries during the same period. Compared with non-instrumental delivery, vacuum extraction (VE) deliveries were related to an increased risk of AST. An infant birth weight of >4,000 g was also associated with an increased risk for both third and fourth degree AST. In addition, women born in Africa and Asia had significantly higher risk for both third and fourth degree AST compared to women born in Sweden. Conclusion. The incidence of third and fourth degree AST increased in both spontaneous births and instrumental deliveries. Instrumental delivery and an infant birth weight >4,000 g are the main risk factors for AST. Women from Africa and Asia have pronounced risks.
Objective
Concerns about differences in registration practices across countries have limited the use of routine data for international very preterm birth (VPT) rate comparisons.
Design
...Population‐based study.
Setting
Twenty‐seven European countries, the United States, Canada and Japan in 2010.
Population
A total of 9 376 252 singleton births.
Method
We requested aggregated gestational age data on live births, stillbirths and terminations of pregnancy (TOP) before 32 weeks of gestation, and information on registration practices for these births. We compared VPT rates and assessed the impact of births at 22–23 weeks of gestation, and different criteria for inclusion of stillbirths and TOP on country rates and rankings.
Main outcome measures
Singleton very preterm birth rate, defined as singleton stillbirths and live births before 32 completed weeks of gestation per 1000 total births, excluding TOP if identifiable in the data source.
Results
Rates varied from 5.7 to 15.7 per 1000 total births and 4.0 to 11.9 per 1000 live births. Country registration practices were related to percentage of births at 22–23 weeks of gestation (between 1% and 23% of very preterm births) and stillbirths (between 6% and 40% of very preterm births). After excluding births at 22–23 weeks, rate variations remained high and with a few exceptions, country rankings were unchanged.
Conclusions
International comparisons of very preterm birth rates using routine data should exclude births at 22–23 weeks of gestation and terminations of pregnancy. The persistent large rate variations after these exclusions warrant continued surveillance of VPT rates at 24 weeks and over in high‐income countries.
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International comparisons of VPT rates should exclude births at 22–23 weeks of gestation and terminations of pregnancy.
Tweetable
International comparisons of VPT rates should exclude births at 22–23 weeks of gestation and terminations of pregnancy.
Background
The Apgar score has been shown to be predictive of neonatal mortality in clinical and population studies, but has not been used for international comparisons. We examined population‐level ...distributions in Apgar scores and associations with neonatal mortality in Europe.
Methods
Aggregate data on the 5 minute Apgar score for live births and neonatal mortality rates from countries participating in the Euro‐Peristat project in 2004 and 2010 were analysed. Country level associations between the Apgar score and neonatal mortality were assessed using the Spearman rank correlation coefficient.
Results
Twenty‐three countries or regions provided data on Apgar at 5 minutes, covering 2 183 472 live births. Scores <7 ranged from 0.3% to 2.4% across countries in 2004 and 2010 and were correlated over time (ρ = 0.88, P < 0.01). There were large differences in healthy baby scores: scores of 10 ranged from 8.8% to 92.7% whereas scores of 9 or 10 ranged from 72.9% to 96.8%. Countries more likely to score 10 s, as opposed to 9 s, for healthy babies had lower proportions of Apgar <7 (ρ = −0.43, P = 0.04). Neonatal mortality rates were weakly correlated with Apgar score <7 (ρ = −0.06, P = 0.61), but differences over time in these two indicators were correlated (ρ =0.56, P = 0.02).
Conclusions
Large variations in the distribution of Apgar scores likely due to national scoring practices make the Apgar score an unsuitable indicator for benchmarking newborn health across countries. However, country‐level trends over time in the Apgar score may reflect real changes and merit further investigation.
Objective
To describe how terminations of pregnancy at gestational ages at or above the limit for stillbirth registration are recorded in routine statistics and to assess their impact on ...comparability of stillbirth rates in Europe.
Design
Analysis of aggregated data from the Euro‐Peristat project.
Setting
Twenty‐nine European countries.
Population
Births and late terminations in 2010.
Methods
Assessment of terminations as a proportion of stillbirths and derivation of stillbirth rates including and excluding terminations.
Main outcome measures
Stillbirth rates overall and excluding terminations.
Results
In 23 countries, it is possible to assess the contribution of terminations to stillbirth rates either because terminations are rare occurrences or because they can be distinguished from spontaneous stillbirths. Where terminations were reported, they accounted for less than 1.5% of stillbirths at 22+ weeks in Denmark, between 13 and 22% in Germany, Italy, Hungary, Finland and Switzerland, and 39% in France. Proportions were much lower at 24+ weeks, with the exception of Switzerland (7.4%) and France (39.2%).
Conclusions
Terminations represent a substantial proportion of stillbirths at 22+ weeks of gestation in some countries. Countries where terminations occur at 22+ weeks should publish rates with and without terminations in order to improve international comparisons and the policy relevance of stillbirth statistics.
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For valid comparisons of stillbirth rates, data about late terminations of pregnancy are needed.
Plain Language Summary
To compare stillbirth rates across countries, it is important to have uniform rules for registering and reporting these deaths. In Europe, stillbirth statistics include babies who die before birth and are delivered starting at 22 weeks of gestation, although a cut‐off of 24 weeks is used in some countries, such as the UK. One factor affecting the comparability of stillbirth statistics is whether they include spontaneous deaths as well as those after a medical termination of pregnancy because of major fetal defects or severe maternal complications. Regulations and reporting practices for terminations in late pregnancy vary between countries and may have a substantial effect on national stillbirth statistics.
Our first objective was to determine if terminations of pregnancy at or after 22 weeks are included in routine stillbirth statistics in 29 European countries participating in the Euro‐Peristat project (http://www.europeristat.com). In 15 countries, terminations were rarely carried out after the registration cut‐off (estimated at fewer than 4% of stillbirths). In another 8 countries, pregnancy terminations were reported and could be distinguished from spontaneous stillbirths. Our first conclusion is that the contribution of terminations to stillbirths is known in most European countries, with a few exceptions.
Our second objective was to examine the impact of terminations on stillbirth rates in Europe using routine statistics. In six countries, terminations account for over 10% of stillbirths at 22 weeks and beyond. At 24 weeks or beyond, terminations accounted for fewer than 5% of stillbirths, except in Switzerland (7%) and France (39%). Our second conclusion is that terminations can strongly affect some countries’ stillbirth rates, especially when rates are reported for births at 22 or more weeks.
Based on these results, we recommend that European stillbirth rates be reported overall and excluding terminations in order to improve the comparability of stillbirth rates between countries.
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For valid comparisons of stillbirth rates, data about late terminations of pregnancy are needed.
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Background: A challenge of obstetric care is to optimize maternal and infant health outcomes and the mother’s experience of childbirth with the least possible intervention in the normal process. ...The aim of this study was to investigate the effects of modified birth center care on obstetric procedures during delivery and on maternal and neonatal outcomes.
Methods: In a cohort study 2,555 women who signed in for birth center care during pregnancy were compared with all 9,382 low‐risk women who gave birth in the standard delivery ward in the same hospital from March 2004 to July 2008. Odds ratios (OR) were calculated with 95% confidence interval (CI) and adjusted for maternal background characteristics, elective cesarean section, and gestational age.
Results: The modified birth center group included fewer emergency cesarean sections (primiparas: OR: 0.69, 95% CI: 0.58–0.83; multiparas: OR: 0.34, 95% CI: 0.23–0.51), and in multiparas the vacuum extraction rate was reduced (OR: 0.42, 95% CI: 0.26–0.67). In addition, epidural analgesia was used less frequently (primiparas: OR: 0.47, 95% CI: 0.41–0.53; multiparas: OR: 0.25, 95% CI: 0.20–0.32). Fetal distress was less frequently diagnosed in the modified birth center group (primiparas: OR: 0.72, 95% CI: 0.59–0.87; multiparas: OR: 0.45, 95% CI: 0.29–0.69), but no statistically significant differences were found in neonatal hypoxia, low Apgar score less than 7 at 5 minutes, or proportion of perinatal deaths (OR: 0.40, 95% CI: 0.14–1.13). Anal sphincter tears were reduced (primiparas: OR: 0.73, 95% CI: 0.55–0.98; multiparas: OR: 0.41, 95% CI: 0.20–0.83).
Conclusion: Midwife‐led comprehensive care with the same medical guidelines as in standard care reduced medical interventions without jeopardizing maternal and infant health. (BIRTH 38:2 June 2011)
Fetal and neonatal mortality rates are essential indicators of population health, but variations in recording of births and deaths at the limits of viability compromises international comparisons. ...The World Health Organization recommends comparing rates after exclusion of births with a birth weight less than 1000 grams, but many analyses of perinatal outcomes are based on gestational age. We compared the effects of using a 1000-gram birth weight or a 28-week gestational age threshold on reported rates of fetal and neonatal mortality in Europe.
Aggregated data from 2004 on births and deaths tabulated by birth weight and gestational age from 29 European countries/regions participating in the Euro-Peristat project were used to compute fetal and neonatal mortality rates using cut-offs of 1000-grams and 28-weeks (2.8 million total births). We measured differences in rates between and within countries using the Wilcoxon signed rank test and 95% confidence intervals, respectively.
For fetal mortality, rates based on gestational age were significantly higher than those based on birth weight (p<0.001), although these differences varied between countries. The use of a 1000-gram threshold included 8823 fetal deaths compared with 9535 using a 28-week threshold (difference of 712). In contrast, the choice of a cut-off made little difference for comparisons of neonatal deaths (difference of 16). Neonatal mortality rates differed minimally, by under 0.1 per 1000 in most countries (p = 0.370). Country rankings were comparable with both thresholds.
Neonatal mortality rates were not affected by the choice of a threshold. However, the use of a 1000-gram threshold underestimated the health burden of fetal deaths. This may in part reflect the exclusion of growth restricted fetuses. In high-income countries with a good measure of gestational age, using a 28-week threshold may provide additional valuable information about fetal deaths occurring in the third trimester.
To audit the clinical management preceding peripartum hysterectomy and evaluate if peripartum hysterectomies are potentially avoidable and by which means.
We developed a structured audit form based ...on explicit criteria for the minimal mandatory management of the specific types of pregnancy and delivery complications leading to peripartum hysterectomy. We evaluated medical records of the 50 Danish women with peripartum hysterectomy identified in the Nordic Obstetric Surveillance Study 2009-2012 and made short narratives of all cases.
The most frequent indication for hysterectomy was hemorrhage. The two main initial causes were abnormally invasive placenta (26%) and lacerations (26%). Primary atony was third and occurred in 20%. Before hysterectomy another 26% had secondary atony following complications such as lacerations, retained placental tissue or coagulation defects. Of the 50 cases, 24% were assessed to be avoidable and 30% potentially avoidable. Hysterectomy following primary and secondary atony was assessed to be avoidable in 4/10 and 4/13 cases, respectively. Early sufficient suturing of lacerations and uterine ruptures, as well as a more widespread use of intrauterine balloons alone or in combination with uterine compression sutures (the sandwich model), could presumably have prevented about one fourth of the peripartum hysterectomies.
More than 50% of peripartum hysterectomies seem to be avoidable by simple measures. In order to minimize the number of unnecessary peripartum hysterectomies, obstetricians and anesthesiologists should investigate individual cases by structured clinical audit, and disseminate and discuss the results for educational purposes. An international collaboration is warranted to strengthen our recommendations and reveal if they are generally applicable.
Background
For safety reasons an in‐hospital birth center was replaced by a modified form of birth center care with the same medical guidelines and equipment as in standard care. The aim of this ...study was to investigate women's and men's satisfaction with modified care compared with standard care.
Methods
Women in both groups gave birth from July 2007 to July 2008. The same medical low‐risk criteria during pregnancy applied to both groups. Of those invited to the study, 547 (82.7%) women in modified birth center care and 445 (66.7%) men returned a questionnaire posted 2 months after the birth, and 786 (71.6%) women and 639 (58.2%) men in standard care. Odds ratios (ORs) for being satisfied were calculated with 95 percent confidence intervals (CIs) and adjusted for possible confounders. We also explored the effects of different components of care on overall satisfaction.
Results
Adjusted ORs for being satisfied overall were approximately doubled in the modified birth center group compared with the standard care group: antenatal care—OR: 2.1 (95% CI: 1.6–2.7) in women and OR: 2.2 (95% CI: 1.5–2.8) in men; intrapartum care—OR: 2.2 (95% CI: 1.7–2.9) in women and OR: 1.7 (95% CI: 1.3–2.4) in men; and postpartum care—OR: 1.7 in women (95% CI: 1.4–2.2) and OR: 2.1 (95% CI: 1.6–2.8) in men. Important explanations of these differences included perception of the midwife as being more supportive, the presence of a calmer environment and atmosphere (intrapartum), and the option for fathers to stay overnight (postpartum).
Conclusion
In‐hospital birth center with medical equipment on site increased overall satisfaction with all episodes of care compared with standard care. (BIRTH 39:2 June 2012)
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