Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births.

OBJECTIVE: To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care. DESIGN: A nationwide cohort study. SETTING: The entire Netherlands. POPULATION: A total of 529,688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321,307 (60.7%) intended to give birth at home, 163,261 (30.8%) planned to give birth in hospital and for 45,120 (8.5%), the intended place of birth was unknown. METHODS: Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics. MAIN OUTCOME MEASURES: Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit. RESULTS: No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16). CONCLUSIONS: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.

Evaluation of 280,000 cases in Dutch midwifery practices: a descriptive study.

OBJECTIVE: To assess the nature and outcome of intrapartum referrals from primary to secondary care within the Dutch obstetric system. DESIGN: Descriptive study. SETTING: Dutch midwifery database (LVR1), covering 95% of all midwifery care and 80% of all Dutch pregnancies (2001-03). POPULATION: Low-risk women (280,097) under exclusive care of a primary level midwife at the start of labour either with intention to deliver at home or with a personal preference to deliver in hospital under care of a primary level midwife. METHODS: Women were classified into three categories (no referral, urgent referral and referral without urgency) and were related to maternal characteristics and to neonatal outcomes. MAIN OUTCOME MEASURES: Distribution of referral categories, main reasons for urgent referral, Apgar score at 5 minutes, perinatal death within 24 hours and referral to a paediatrician within 24 hours. RESULTS: In our study, 68.1% of the women completed childbirth under exclusive care of a midwife, 3.6% were referred on an urgency basis and 28.3% were referred without urgency. Of all referrals, 11.2% were on an urgency basis. The main reasons for urgent referrals were fetal distress and postpartum haemorrhage. The nonurgent referrals predominantly took place during the first stage of labour (73.6% of all referrals). Women who had planned a home delivery were referred less frequently than women who had planned a hospital delivery: 29.3 and 37.2%, respectively (P < 0.001). On average, the mean Apgar score at 5 minutes was high (9.72%) and the peripartum neonatal mortality was low (0.05%) in the total study group. No maternal deaths occurred. Adverse neonatal outcomes occurred most frequently in the urgent referral group, followed by the group of referrals without urgency and the nonreferred group. CONCLUSIONS: Risk selection is a crucial element of the Dutch obstetric system and continues into the postpartum period. The system results in a relatively small percentage of intrapartum urgent referrals and in overall satisfactory neonatal outcomes in deliveries led by primary level midwives.

Substandard care in immigrant versus indigenous maternal deaths in The Netherlands.

As part of the Confidential Enquiry into the Causes of Maternal Deaths in The Netherlands, substandard care was assessed in immigrant versus indigenous maternal deaths. Except for substandard care related to the women's and relatives' decisions, substandard care factors were hypothesised to occur in similar frequency among both groups of women. The results, however, indicate that substandard care factors related to all aspects of care were disproportionately more frequent in immigrant women. More research into the interpretation of these worrying data is needed.

Survival of donor cells 25 years after intrauterine transfusion.

Persistence of donor leukocytes in the circulation of recipients of intrauterine transfusion (IUT) has been observed up to 5 years after birth. The aim of this study was to determine whether transfusions with nonirradiated, nonleukocyte-depleted donor blood during the fetal period resulted in long-term immunomodulation of the recipient. Twenty-four surviving IUT recipients between 1966 and 1976 were tested for autoimmune disease and autoantibodies at follow-up. Ten had sex-mismatched donors and were therefore informative for chimerism studies using fluorescence in situ hybridization (FISH). Seven female recipients could be tested for chimerism using a Y- chromosome-specific polymerase chain reaction (PCR) because they received at least 1 IUT from a male donor. Nine recipients could be studied for cytotoxic T-lymphocyte precursor (CTLp) and helper T-lymphocyte precursor (HTLp) frequencies because the original donors were available for testing. All surviving IUT recipients were in good health at the time of the examination, and routine laboratory testing revealed no abnormalities. None of the IUT recipients were chimeric as determined by FISH analysis, but Y-chromosome-specific sequences were detected by PCR in 6 of the 7 women. However, the CTLp and HTLp frequencies of the IUT recipients against the donors were comparable to those of the controls. The current study provides evidence that IUT can result in the persistence of donor cells in the recipient for a period longer than 20 years but that it is not associated with immunotolerance or with signs of chronic antigenic stimulation. (Blood. 2000;95:2709-2714)

[Blood group immunization: results of treatment of fetal anemia with intra-uterine intravascular blood transfusion in the Netherlands, 1987-1995]. / Bloedgroepimmunisatie: resultaten van behandeling van foetale anemie met intra-uteriene intravasculaire bloedtransfusie in Nederland, 1987-1995.

OBJECTIVE: To evaluate outcome of red cell alloimmunized pregnancies treated with intravascular intrauterine blood transfusions. DESIGN: Retrospective. METHODS: Medical records of all women and neonates treated with intrauterine transfusions in the period March 1987-December 1995, were reviewed. Survival rates of the infants were analysed in relation to both gestational age and the presence or absence of hydrops at the time of the first transfusion. RESULTS: In 153 pregnancies 155 foetuses underwent 462 transfusions (median: 3; range: 1-7). Patients were immunized against RhD in 88%. Kell in 7% and Rhe in 5% of the cases. Overall survival rate was 83%. No difference in survival rate was found between children with the first transfusion early (< or = 26 weeks) or late (> 26 weeks) in pregnancy. Survival rate for foetuses without hydrops was significantly higher than for those with hydrops (90% versus 73%). The mildly hydropic foetuses had a significantly higher survival rate than the severely hydropic foetuses (94% versus 53%). Absence of intrauterine reversal of hydrops was associated with a bad outcome. CONCLUSION: Intravascular transfusion is an effective and safe procedure for correction of foetal anaemia provided it is performed by an experienced multidisciplinary team. In contrast to gestational age at first transfusion severity of hydrops is predictive for successful treatment, so timely institution of treatment is of paramount importance.

Blood gas and pH in the human fetus with severe anemia.

Leiden University Hospital is the national referral center for the management of fetal isoimmunization in The Netherlands. In this observational study, blood gas and acid-base measurements from 286 pretransfusion samples and 214 paired posttransfusion samples of 113 fetuses were analyzed. In umbilical arterial blood, we found a significant positive correlation between the degree of anemia and pH, as well as a significant negative correlation between degree of anemia and pO2. However, umbilical venous blood gas and pH remained virtually unchanged even in severe anemia. During intrauterine transfusion with unbuffered adult red cells, there was a small but statistically significant decrease of pH and pO2 in fetal blood. We conclude that severe fetal anemia is associated with decreased umbilical arterial pH, but that umbilical venous pH remains normal until shortly before death.

Confidential enquiry into maternal deaths in The Netherlands 1983-1992.

OBJECTIVE: To determine the causes of maternal death in The Netherlands. STUDY DESIGN: Nationwide Confidential Enquiry into the Causes of Maternal Deaths during the period 1983-1992. RESULTS: Of 192 direct and indirect maternal deaths, 154 (80%) were available for the Enquiry. The most frequent direct causes were (pre-)eclampsia, thrombo-embolism, obstetrical haemorrhage and sepsis. Cerebro- and cardiovascular disorders were the most frequent indirect causes of death. Age above 35 years and parity 3 or more are related to higher maternal mortality. Women from non-caucasian origin are more prone to death in comparison to caucasian women. Autopsy was performed in 88 cases (57%). Of the 24 women where labour started at home, the place of birth played a significant role in delay in four. CONCLUSIONS: More efforts should be made to have a higher percentage than 80% available for the Confidential Enquiry as in the UK where only 1-4% of deaths are not available for similar purposes. Also, the autopsy rate of 57% is much lower than in the UK (82%). Special strategies should be developed to improve maternal health of populations at higher risk such as women of high age and parity and immigrant populations.

[The benefit of external version in full-term breech presentation]. / Het nut van uitwendige versie bij stuitligging à terme.

We report a randomised controlled trial of external version in 52 women with breech presentation after 36 weeks' gestation; 83% gave informed consent to undergo the management to which they had been randomized. Only 5% of initial attempts without tocolysis succeeded, but 31% of the failures subsequently had a successful version under tocolysis. External version resulted in a small decrease in the frequency of breech presentation at birth (64% vs. 74%), and in an unexpected increase in the caesarean section rate (28% vs. 11%). The increase in caesarean section rate could be attributed to failed versions, which apparently greatly influenced the choice between abdominal and vaginal delivery. Our findings and data from similar research suggest that benefits of external version at term may not apply to populations with a low caesarean rate, unless versions are carried out with maximal efficiency (which, on the basis of available data, would imply tocolysis) or so indifferently that failed attempts do not influence the choice between abdominal and vaginal delivery.

Management of severe hemolytic disease with ultrasound-guided intravascular fetal transfusions.

Between January 1987 and March 1989, 22 fetuses with severe hemolytic disease were treated with 64 ultrasound-guided intrauterine intravascular transfusions. Eighteen infants survived and are doing well. In 12 fetuses, hydropic changes were present at the first transfusion; 9 of these survived. In 8 of the 10 fetuses with a gestational age less than 26 weeks, intrauterine treatment was successful.

Twenty-two years of intra-uterine intraperitoneal transfusions.

Over a period of 22 years, 154 fetuses were treated with 270 intra-uterine intraperitoneal transfusions. The patients were divided into three groups, according to the period they were treated. The overall percentage of surviving infants increased from 33% during the first period to 58% in the last period. In the group of infants that were not hydropic at the time of the first transfusion, the survival rate increased from 35 to 83%. In the group of children that were hydropic during the first transfusion, the survival rate during the first and last period was 24 and 42%, respectively. The percentage of fetuses that needed their first transfusion before the 26th week of pregnancy increased from 15 to 32% during the study period. Only 13% of these children survived. Lately, the intravascular approach has been introduced. Intravascular transfusions seem to be very effective, especially in early pregnancies and in hydropic fetuses. Application of the two techniques each in the most appropriate situation might offer optimal results for the near future.

[Prenatal fetal blood group determination using chorionic villi biopsy]. / Prenatale foetale-bloedgroepbepaling met behulp van chorionvilli-biopsie.

The presence or absence of Rhesus D, c and Kell antigens on foetal red blood cells was determined in the first trimester of pregnancy on erythrocytes obtained by chorionic villi sampling. Pregnancies in 15 severely sensitized women (9 Rh D, 5 Kell and I Rh c) with a poor obstetric history and a partner heterozygous for the offending antigen were examined. A conclusive diagnosis could be made in 13 of the 15 cases studied.

[Vaginal delivery following cesarean section]. / Vaginale baring na sectio caesarea.

An analysis is presented of the outcome of labour in 462 women with a previous caesarean section, who delivered in the department of obstetrics of Leiden University Hospital in the period 1977-1986. Elective repeat section was performed in 26% of these women, while 83% of those accepted for a trial of labour had a vaginal delivery. In 196 women with a history of a previous caesarean section (1984-1986) a retrospective analysis was made of the influence of the indication for the previous caesarean section with respect of the outcome of labour in the following pregnancy. A trial of labour had the highest chance of success in those who had had a previous caesarean section because of a breech presentation. Sixty-five percent of women who had had a prior caesarean section because of cephalopelvic disproportion or failure to progress delivered by the vaginal route after a trial of labour. Foetal weight estimation by ultrasound could not predict the outcome of a trial of labour. It is concluded that a trial of labour after a previous caesarean section, even when the operation was performed because of cephalopelvic disproportion or failure to progress, is safe and rational.

Management of serious alloimmunization in pregnancy.

In the past 40 years, tremendous advances in the treatment of hemolytic disease have been made. The perinatal mortality has been reduced considerably. Rh immunoprophylaxis has decreased the incidence of Rh immunization to around 6 per 100,000 live births. Nevertheless, treatment of severe hemolytic disease is still essential. Increased reliability of diagnostic procedures have made early detection and optimal treatment of hemolytic disease possible. Treatment by plasmapheresis is still controversial. Although believed to be beneficial by some authors, conclusive evidence of its efficacy has not been obtained. With preterm induction of birth at 32 weeks of gestation, the chances for survival are 95%. Improvement of techniques and the use of modern real-time ultrasound equipment have made intrauterine intraperitoneal transfusion, in experienced hands, a relatively safe and successful procedure. Intravascular transfusion appears beneficial in early pregnancy. Combination of both techniques will probably be the answer for the future. The development of neonatal intensive care facilities has made a major contribution to the survival of children with haemolytic disease. The relative low incidence of haemolytic disease has made it imperative that treatment should take place in centers where experience and special skill are available.