Do pregnant women prefer timing of elective cesarean section prior to versus after 39 weeks of gestation? Secondary analyses from a randomized controlled trial.

OBJECTIVE: To evaluate women's preferences for timing of elective cesarean section (ECS) scheduled prior to versus after 39 completed weeks. METHODS: Secondary analyses from a randomized controlled open-label trial were conducted at seven Danish tertiary hospitals from March 2009 to June 2011 with inclusion of singleton pregnant women with a healthy fetus. The women were allocated by a computerized telephone system to ECS scheduled at 38(+3) weeks or 39(+3) weeks of gestation. Dissatisfaction with timing of ECS and preferred timing of the procedure in a proposed future ECS delivery were evaluated. Data analyses were done by intention-to-treat, using logistic regression. RESULTS: A total of 1196 women (94%) completed an online questionnaire at follow-up eight weeks postpartum. In the 38 weeks group, 61 (10%) women 601 were dissatisfied with the timing of their ECS, whereas in the 39 weeks group 157 (26%) of 595 were dissatisfied (adjOR 3.18, 95% CI 2.30; 4.40). The proportion of women who preferred the same timing in a future ECS were 272 (45%) in the 38 weeks group compared to 232 (39%) in the 39(+3) weeks group (adjOR 0.75, 95% CI 0.60; 0.95). CONCLUSIONS: The women in this trial preferred ECS scheduled prior to 39 weeks of gestation.

Elective caesarean section at 38 weeks versus 39 weeks: neonatal and maternal outcomes in a randomised controlled trial.

OBJECTIVES: To investigate whether elective caesarean section before 39 completed weeks of gestation increases the risk of adverse neonatal or maternal outcomes. DESIGN: Randomised controlled multicentre open-label trial. SETTING: Seven Danish tertiary hospitals from March 2009 to June 2011. POPULATION: Women with uncomplicated pregnancies, a single fetus, and a date of delivery estimated by ultrasound scheduled for delivery by elective caesarean section. METHODS: Perinatal outcomes after elective caesarean section scheduled at a gestational age of 38 weeks and 3 days versus 39 weeks and 3 days (in both groups ±2 days). MAIN OUTCOME MEASURES: The primary outcome was neonatal intensive care unit (NICU) admission within 48 hours of birth. Secondary outcomes were neonatal depression, NICU admission within 7 days, NICU length of stay, neonatal treatment, and maternal surgical or postpartum adverse events. RESULTS: Among women scheduled for elective caesarean section at 38⁺³ weeks 88/635 neonates (13.9%) were admitted to the NICU, whereas in the 39⁺³ weeks group 76/637 neonates (11.9%) were admitted (relative risk [RR] 0.86, 95% confidence interval [95% CI] 0.65-1.15). Neonatal treatment with continuous oxygen for more than 1 day (RR 0.31; 95% CI 0.10-0.94) and maternal bleeding of more than 500 ml (RR 0.79; 95% CI 0.63-0.99) were less frequent in the 39 weeks group, but these findings were insignificant after adjustment for multiple comparisons. The risk of adverse neonatal or maternal outcomes, or a maternal composite outcome (RR 1.1; 95% CI 0.79-1.53) was similar in the two intervention groups. CONCLUSIONS: This study found no significant reduction in neonatal admission rate after ECS scheduled at 39 weeks compared with 38 weeks of gestation.

Ear acupuncture or local anaesthetics as pain relief during postpartum surgical repair: a randomised controlled trial.

OBJECTIVE: To evaluate two methods of pain relief during postpartum surgical repair in regard to effectiveness, wound healing and patient evaluation. DESIGN: A randomised controlled trial testing a pragmatic set-up of brief training of clinicians. SETTING: Delivery ward at a Danish district hospital with approximately 1600 annual deliveries. POPULATION: Primiparous women with a vaginal delivery at term who needed surgical repair of lacerations to the labia or the vagina, perineal lacerations of first or second degree or mediolateral episiotomies. METHODS: The trial was set up to evaluate the effect of a brief 2-hour hands-on training in the use of ear acupuncture. All midwives (n = 36) in the department had previous experience in using acupuncture for obstetric pain relief. Pain and wound healing were evaluated using validated scores. Data collection was performed by research assistants blinded towards treatment allocation. Randomisation was computer assisted. A total of 207 women were randomised to receive ear acupuncture (105) and local anaesthetics (102), respectively. MAIN OUTCOME MEASURES: The primary outcome was pain during surgical repair. Secondary outcomes were wound healing at 24-48 hours and 14 days postpartum, participant satisfaction, revision of wound or dyspareunia reported 6 months postpartum. RESULTS: Pain during surgical repair was more frequently reported by participants allocated to ear acupuncture compared with participants receiving local anaesthetics (89 versus 54%, P < 0.01). Pain intensity during surgical repair was also reported higher (Visual Analogue Scale score 3.5 versus 1.5, P < 0.01). The ear acupuncture group received more additional pain relief during repair (53 versus 19%, P < 0.01). No difference was observed in wound healing at 24-48 hours or 14 days postpartum. Revision of wounds was rare, and no difference occurred in this trial. Comparable proportions of participants reported dyspareunia at 6 months. Patient satisfaction with the allocated pain-relief method was lower in the ear acupuncture group (69 versus 91%, P < 0.01) and fewer women would recommend the method to a friend (74 versus 91%, P < 0.01). CONCLUSIONS: Ear acupuncture as used in this trial was less effective for pain relief compared with a local anaesthetic. No difference was observed in wound healing, need for revision of wound or dyspareunia. Patient satisfaction with allocated pain-relief method was lower in the ear acupuncture group.

Postpartum perineal repair performed by midwives: a randomised trial comparing two suture techniques leaving the skin unsutured.

OBJECTIVE: To compare a continuous suture technique with interrupted stitches using inverted knots for postpartum perineal repair of second-degree lacerations and episiotomies. DESIGN: A double-blind randomised controlled trial. SETTING: A Danish university hospital with more than 4800 deliveries annually. POPULATION: A total of 400 healthy primiparous women with a vaginal delivery at term. METHOD Randomisation was computer-controlled. Structured interviews and systematic assessment of perineal healing were performed by research midwives blinded to treatment allocation at 24-48 hours, 10 days and 6 months postpartum. Pain was evaluated using a visual analogue scale and the McGill Pain Questionnaire. Wound healing was evaluated using the REEDA scale and by assessment of gaping wounds >0.5 cm. Analysis complied with the intention-to-treat principle. MAIN OUTCOME MEASURES: The primary outcome was perineal pain 10 days after delivery. Secondary outcomes were wound healing, patient satisfaction, dyspareunia, need for resuturing, time elapsed during repair and amount of suture material used. RESULTS: A total of 400 women were randomised; 5 women withdrew their consent, leaving 395 for follow up. The follow-up rate was 98% for all assessments after delivery. No difference was seen in perineal pain 10 days after delivery. No difference was seen in wound healing, patient satisfaction, dyspareunia or need for resuturing. The continuous suture technique was significantly faster (15 versus 17 minutes, P = 0.03) and less suture material was used (one versus two packets, P < 0.01). CONCLUSION: Interrupted, inverted stitches for perineal repair leaving the skin unsutured appear to be equivalent to the continuous suture technique in relation to perineal pain, wound healing, patient satisfaction, dyspareunia and need for resuturing. The continuous technique, however, is faster and requires less suture material, thus leaving it the more cost-effective of the two techniques evaluated.