Trends and recurrence of placenta praevia: a population-based study.

We determined recent trends and recurrence rates of placenta praevia in 790,366 deliveries in NSW. From 2001 to 2009, the rate of placenta praevia increased by 26%, from 0. 69% to 0. 87% (trend P < 0.001). The placenta praevia recurrence rate in a second birth was 4.8%. Two-thirds of the increase in placenta praevia was accounted for by trends in known risk factors, and the unexplained portion may reflect changes in unidentified risk factors or in the threshold for placenta praevia diagnosis.

Birth at hospitals with co-located paediatric units for infants with correctable birth defects.

OBJECTIVES: To determine the percentage of liveborn infants with selected antenatally identifiable and correctable birth defects who were delivered at hospitals with co-located paediatric surgical units (co-located hospitals). Additionally, to determine the survival rates for these infants. PATIENTS AND METHODS: Data were from linked New South Wales hospital discharge records from 2001 to 2004. Livebirths with one of the selected defects were included if they underwent an appropriate surgical repair, or died during the first year of life. Infants with multiple lethal birth defects were excluded. Deliveries at co-located hospitals were identified, but no data on antenatal diagnosis were available. RESULTS: The study identified 287 eligible livebirths with the selected defects. The highest rates of delivery at co-located hospitals were for gastroschisis (88%), exomphalos (71%), spina bifida (63%) and diaphragmatic hernia (61%), and the lowest for transposition of the great arteries (43%) and oesophageal atresia (40%). Mothers resident outside of metropolitan areas, where the co-located hospitals are located, had a similar rate of delivery at co-located hospitals as metropolitan women. For the non-metropolitan mothers of infants with a birth defect, this represented a 30-fold increase over the baseline delivery rate of 1.8%. Post-surgery survival rates were 87% or higher. Overall survival rates were > or = 86% except for infants with a diaphragmatic hernia. CONCLUSIONS: Delivery rates at co-located hospitals were high for mothers of infants with these correctable birth defects. Regionalised health care appears to work well for these pregnancies, as women living outside metropolitan areas had a similar rate of delivery at co-located hospitals to that of urban women.

Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study.

OBJECTIVE: To examine the diagnostic accuracy of clinical examination to determine fetal presentation in late pregnancy. DESIGN: Cross sectional analytic study with index test of clinical examination and reference standard of ultrasonography. SETTING: Antenatal clinic in tertiary obstetric hospital in Sydney, Australia. PARTICIPANTS: 1633 women with a singleton pregnancy between 35 and 37 weeks' gestation attending antenatal clinics. INTERVENTION: Fetal presentation assessed by clinical examination during routine antenatal care, followed by ultrasonography to confirm the diagnosis. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive values of clinical examination compared with ultrasonography. Diagnostic rates by maternal characteristics. RESULTS: Ultrasonography identified non-cephalic presentation in 130 (8%) women, comprising 103 (6.3%) with breech and 27 (1.7%) with transverse or oblique lie. Sensitivity of clinical examination for detecting non-cephalic presentation was 70% (95% confidence interval 62% to 78%) and specificity was 95% (94% to 96%). The positive predictive value and negative predictive value were 55% and 97%, respectively. CONCLUSIONS: Clinical examination is not sensitive enough for detection and timely management of non-cephalic presentation.

Trends in postpartum haemorrhage.

OBJECTIVE: To assess trends and outcomes of postpartum haemorrhage (PPH) in New South Wales (NSW). METHODS: A population-based descriptive study of all 52,151 women who had a PPH either during the hospital stay for the birth of their baby or requiring a re-admission to hospital between 1994 and 2002. Data were obtained from the de-identified computerised census of NSW hospital in-patients and analysed to examine trends over time. The outcome measures included maternal death, hysterectomy, admission to intensive care unit (ICU), transfusion and major maternal morbidity, including procedures to reduce blood supply to the uterus, acute renal failure and postpartum coagulation defects. RESULTS: From 1994 to 2002 both the number and adjusted (for under-reporting) rate of PPH during the birth admission increased from 8.3% of deliveries to 10.7%. The rate of PPH adjusted for maternal age and mode of delivery was similar to the unadjusted rate. There was a sixfold increase in the rate of transfusions from 1.9% of women who haemorrhaged to 11.7%. Hospital readmissions for PPH declined from 1.2% of deliveries to 0.9%. These were statistically significant changes. There were no significant changes in the rate of hysterectomies, procedures to reduce blood supply to the uterus, admissions to ICU, acute renal failure or coagulation defects. CONCLUSION: The increased rate of PPH during the birth admission is concerning. The increase in PPH could not be explained by increasing maternal age or caesarean sections. Linked birth and hospital discharge data could determine whether the increase in PPH is caused by other changes in obstetric practices or

Systematic review of adverse outcomes of external cephalic version and persisting breech presentation at term.

The aim of this study was to determine the frequency of adverse maternal and fetal outcomes of both external cephalic version (ECV) and persisting breech presentation at term. We conducted a systematic review of the literature using Medline, Embase and All Evidence Based Medicine (EBM) Reviews databases. Data were extracted from studies that compared women who had an ECV from 36 weeks' gestation with a similar control group of women enrolled at the same gestational age, eligible for, but who did not have an ECV. Eleven studies with a total of 2503 women were included. Adverse outcomes related to ECV were rarely reported and in most studies there was no evidence that relevant outcomes were ascertained among similar women who did not have an ECV. There was no increased risk of antepartum fetal death associated with ECV, but numbers were small. There were no reported cases of uterine rupture, placental abruption, prelabour rupture of membranes or cord prolapse, but these outcomes were not examined among controls. Onset of labour within 24 h and nuchal cord was non-significantly higher among women who had an ECV compared with those with a persisting breech. Despite limited reporting and small numbers, the results of our review suggest that adverse maternal and fetal outcomes of both ECV and persisting breech presentation are rare. Only with improved reporting and collection of safety data on ECV and persisting breech presentation can we provide high-quality information to assist informed decision making by pregnant women with a breech presentation at term.

Risk of complications in a second pregnancy following caesarean section in the first pregnancy: a population-based study.

OBJECTIVE: To estimate the risks of maternal and perinatal morbidity and mortality in a second pregnancy, attributable to caesarean section in a first pregnancy. DESIGN AND SETTING: Cross-sectional analytic study of hospital births in New South Wales, based on linked population databases. PARTICIPANTS: 136 101 women with one previous birth who gave birth to a singleton infant in NSW in 1998-2002. MAIN OUTCOME MEASURES: Crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for maternal and perinatal morbidity and mortality. RESULTS: 19% of mothers had a caesarean section in their first pregnancy. Compared with mothers who had had primary vaginal births, mothers who had had primary caesarean section and underwent labour in the second birth were at increased risk of uterine rupture (aOR, 12.3; 95% CI, 5.0-30.1; P < 0.0001), hysterectomy (3.5; 1.5-8.4; P < 0.01), postpartum haemorrhage (PPH) following vaginal delivery (1.6; 1.4-1.7; P < 0.0001), manual removal of placenta (1.3; 1.1-1.6; P < 0.01), infection (6.2; 4.7-8.2; P < 0.0001) and intensive care unit (ICU) admission (3.1; 2.1-4.7; P < 0.0001); among mothers who did not undergo labour (ie, had an elective caesarean section), there was a lower risk of PPH (0.6; 0.5-0.7; P < 0.0001) and ICU admission (0.4; 0.3-0.5; P < 0.0001). For infants there was increased risk of preterm delivery (1.2; 1.1-1.3; P < 0.0001) and neonatal intensive care unit admission following labour (1.6; 1.4-1.9; P < 0.0001) in the birth after primary caesarean section. The occurrence of stillbirth was not modified by labour. CONCLUSIONS: Caesarean section in a first pregnancy confers additional risks on the second pregnancy, primarily associated with labour. These should be considered at the time caesarean section in the first pregnancy is being considered, particularly for elective caesarean section for non-medical reasons.

Placenta praevia: maternal morbidity and place of birth.

BACKGROUND: International guidelines recommend that women with placenta praevia should be delivered by an experienced operator at a hospital with an on-site blood bank. AIM: To determine the risk factors, level of care at the birth hospital and incidence of maternal morbidity for women with placenta praevia. METHODS: Data were obtained from linked hospital separation and perinatal databases for 375,790 women giving birth in a NSW hospital, 1998-2002. We defined clinically significant placenta praevia as those women who were delivered by Caesarean section at or after 26 weeks gestation. Outcomes for women with and without placenta praevia were compared. Among women with placenta praevia, antenatal predictors of maternal morbidity were assessed. RESULTS: A total of 1612 (4.3/1000) women had significant placenta praevia. Women with placenta praevia were more likely to be older, have a prior Caesarean section, require general anaesthetic for delivery and deliver preterm. Among women with placenta praevia, 61% delivered in hospitals with 24-h on site blood banks, 33% in hospitals with on-call blood bank services after hours and 6% in hospitals with no blood bank. Two hundred and twenty three (14%) women with placenta praevia suffered a major morbidity (OR = 15.0, 95%CI 12.9-17.4). The proportion of this morbidity that occurred among women delivered electively at term was 40% in hospitals with 24 h blood banks and 55% in other hospitals (P = 0.06). CONCLUSIONS: For women with placenta praevia, the risk of major morbidity is high, yet 39% deliver in hospitals without immediate access to a 24-h blood bank. Australian guidelines on the appropriate level of care for women with placenta praevia are needed.