De-medicalization of birth by reducing the use of oxytocin for augmentation among first-time mothers - a prospective intervention study.

BACKGROUND: The use of synthetic oxytocin for augmentation of labor is rapidly increasing worldwide. Hyper-stimulation is the most significant side effect, which may cause fetal distress and operative delivery. We performed an intervention consisting of an educational program and modified guidelines to achieve a more appropriate use of oxytocin. METHODS: This prospective intervention study included 431 first-time mothers at term with spontaneous onset of labor before (October 2012 to May 2013), and 664 after the intervention (April 2014 to April 2015). Our outcomes were prevalence and duration of oxytocin treatment, mode of delivery, indication for operative delivery, episiotomy, anal sphincter tears, bleeding, labor duration, pain relief and the effect of oxytocin on mode of delivery. RESULTS: After the intervention, 52.9% were diagnosed with dystocia, compared with 68.9% before (p < 0.001). Oxytocin was not always used in accordance with the guidelines, but a significant reduction in oxytocin rates from 63.3% to 54.1% (p < 0.001) was obtained. More women without dystocia according to the existing guidelines were augmented after the intervention (18.9% vs 8.4%, p < 0.001). Assessing all labors, the median duration of oxytocin treatment was reduced by 72% (from 90 to 25 min) without increasing the median duration of labor (385 min in both groups). There was a moderate reduction in operative vaginal deliveries from 26.9 to 21.5% (p = 0.04), and dystocia as an indication for these deliveries increased (p = 0.01). There was a moderate increase in caesarean sections from 6.7 to 10.2% (p = 0.05), but no increase in dystocia as an indication for these deliveries. Women receiving oxytocin were more likely to have an operative vaginal birth, even after adjusting for birth weight, epidural analgesia and labor duration, OR: 2.1 (CI 1.1-4.0) before and OR 2.7 (CI 1.6-4.5) after the intervention. CONCLUSIONS: Our intervention led to a significant reduction in the use of oxytocin. However, more than half of the women remained diagnosed with dystocia. Operative vaginal births seem to be associated with oxytocin treatment. Therefore, augmentation with oxytocin should be used with caution and only when medically indicated. Even more modified guidelines for augmentation than the ones applied in this study might be appropriate.

Correction of an unexpected increasing trend in glucose measurements during 7 years recruitment to a cohort study.

OBJECTIVES: To study an unexpected, significant increase in glucose measurements during 7 year recruitment to a cohort study. DESIGN AND METHODS: Measurements of quality control solutions and blood glucose in pregnant women were done by Accu-Chek Sensor glucometer. Time-trends were analysed by regression models and control charts. RESULTS: Cohort measurements were de-trended by weighted linear regressions based on independent control values. CONCLUSIONS: Biologically implausible trends in data can be corrected by using independent control values.

The interleukins IL-6 and IL-1Ra: a mediating role in the associations between BMI and birth weight?

The biological mechanisms in the association between maternal body mass index (BMI) and birth weight are not well understood, but are likely to involve maternal plasma glucose levels and nutrient transport across the placenta, both important modulators of fetal growth. Adipose tissue contributes to circulating levels of interleukins that may affect glucose metabolism and possibly also placental transport of nutrients. We investigated possible mediating roles of Interleukin 6 (IL-6) and Interleukin 1 Receptor antagonist (IL-1Ra) in 208 pregnant women. Known and hypothesized dependencies between BMI in early pregnancy and fasting glucose, IL-1Ra and IL-6 at gestational weeks 30-32, and birth weight were specified in a path diagram. Standardized regression coefficients, expressing direct, indirect and total effects, were estimated by Bayesian path analysis. Mean (s.d.) BMI was 24.9 kg/m2 (4.2) and mean (s.d.) birth weight 3748 g (454). The total effect of BMI on birth weight was 0.24 (95% credibility interval (CrI) [0.12, 0.36]). The direct effect of IL-1Ra on birth weight was not statistically significant, but significant effects of BMI on IL-1Ra (0.61, 95% CrI [0.51, 0.72]), of IL-1Ra on fasting glucose (0.17, 95% CrI [0.01, 0.34]) and of fasting glucose on birth weight (0.14, 95% CrI [0.01, 0.27]) implied an indirect pathway from BMI via IL-1Ra on birth weight. Approximately 20% of the effect of BMI on birth weight was mediated through IL-1Ra. For IL-6, no such effects were found. Our results indicate that IL-1Ra may be a mediator in the association between BMI and birth weight.

Incomplete spinal cord injury, exercise and life satisfaction.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: This study investigates the role of physical exercise, perceived exercise mastery and fitness on life satisfaction of a sample of individuals with incomplete spinal cord injury (SCI). SETTING: Sunnaas Rehabilitation Hospital and the Norwegian School of Sport Sciences, Norway. METHODS: A questionnaire measuring life satisfaction, self-rated physical exercise and self-perceptions were mailed to persons with incomplete SCI. RESULTS: In total, 100 questionnaires were sent out and 69 respondents were included in the study. Of those, 68% performed physical activity regularly once or more a week. Participants who were exercising regularly once a week or more scored significantly higher on the summed life satisfaction scale (P=0.002) and on perceived fitness (P=0.004), but significantly lower on perceived exercise mastery (P=0.012) than those who were non-exercisers. CONCLUSION: Participants in this study with incomplete SCI who exercised regularly experienced a significantly higher life satisfaction and perceived exercise fitness, but lower perceived exercise mastery than their inactive peers. Perceived exercise fitness was the psychological variable that contributed meaningfully to life satisfaction in this study.

Effects of an antiatherogenic diet during pregnancy on markers of maternal and fetal endothelial activation and inflammation: the CARRDIP study.

OBJECTIVE: To study the effect of an antiatherogenic diet on maternal and cord blood concentrations of systemic biomarkers of endothelial cell activation, haemostasis and inflammation. DESIGN: Single blinded randomised controlled clinical trial. SETTING: Obstetric outpatient clinic and maternity unit of a university hospital in Norway. POPULATION: Nonsmoking pregnant women aged 21-38 years carrying a single fetus and with no previous pregnancy-related complications. METHODS: Subjects (n = 290) were randomised to continue their usual diet or to adopt a diet low in saturated fat and cholesterol from gestational week 17-20 to birth. Soluble forms of cellular adhesion molecules, high-sensitivity C-reactive protein (CRP) and haemostatic markers were measured at 17-20 weeks of gestation (baseline) and subsequently up to week 36. All the above, except CRP, were also measured in cord blood. MAIN OUTCOME MEASURES: Concentrations of maternal and fetal biomarkers and maternal CRP. RESULTS: All biomarkers except CRP levels increased significantly during the study period in both the intervention and control groups. None of the maternal or fetal biomarkers were influenced by the intervention (P > 0.05) except for a tendency to lower concentrations of cord blood tissue plasminogen activator antigen in the intervention group compared with the control group, median (interquartile range) 5.4 ng/ml (3.1-7.7) versus 5.8 ng/ml (3.5-11.8), P = 0.05. CONCLUSION: An antiatherogenic diet in pregnancy did not significantly influence maternal or fetal blood concentrations of a range of biomarkers for inflammation. Thus, the previously reported effects of a cholesterol-lowering diet on maternal lipid profile and preterm delivery (<37 complete weeks of gestation) do not seem to involve changes in the systemic inflammatory responses of pregnancy.