The prevalence and consequences of abdominal rectus muscle diastasis among Finnish women: an epidemiological cohort study.

PURPOSE: Post-pregnancy abdominal rectus diastasis (ARD) has raised attention in the field of surgery in recent years, but there is no consensus about when to consider surgery. Our aim was to find out what is the normal inter-rectus distance in fertile aged, female population in Finland and to examine whether there is a linea alba width that would predispose to diastasis-related problems after pregnancy. METHODS: For this prospective cohort study, women participating early pregnancy ultrasound in Helsinki University Hospital Department of Obstetrics and Gynecology during 1.1.2018-8.3.2019, were recruited. The width of linea alba was measured by ultrasound during the early pregnancy ultrasound. Symptoms were measured by questionnaire including Health-Related Quality of Life (RAND-36) and Oswestry Disability Index for back symptoms and disability. RESULTS: Linea alba width was measured in total of 933 women. The average inter-rectus distance (IRD) among nulliparous women was 1.81 ± 0.72 cm. After one previous pregnancy, the average linea alba width was 2.36 cm ± 0.83 cm and after more pregnancies 2.55 ± 1.09 cm. There was a positive correlation between previous pregnancies and the increased linea alba width (p = 0.00004). We did not perceive any threshold value of linea alba width that would predispose to back pain or movement control problems in this cohort, in which severe diastasis (over 5 cm) was rare. CONCLUSION: Mean inter-rectus distance in parous population exceeds stated normative values. Moderate ARD (3.0-5.0 cm) alone does not seem to explain low back pain or functional disability in population level. Severe post-pregnancy diastasis (over 5.0 cm) is rare.

Obstetric outcome after intervention for severe fear of childbirth in nulliparous women - randomised trial.

OBJECTIVE: To compare the numbers of vaginal deliveries and delivery satisfaction among women with fear of childbirth randomised to either psychoeducation or conventional surveillance during pregnancy. DESIGN: Randomised controlled trial. SETTING: Maternity unit of Helsinki University Central Hospital. POPULATION: Fear of childbirth was screened during early pregnancy by the Wijma Delivery Expectancy Questionnaire (W-DEQ-A). Of 4575 screened nulliparous women, 371 (8.1%) scored ≥ 100, showing severe fear of childbirth. METHODS: Women with W-DEQ-A ≥ 100 were randomised to intervention (n = 131) (psychoeducative group therapy, six sessions during pregnancy and one after childbirth) or control (n = 240) (care by community nurses and referral if necessary) groups. Obstetric data were collected from patient records and delivery satisfaction was examined by questionnaire. MAIN OUTCOME MEASURES: Delivery mode and satisfaction. RESULTS: Women randomised to the intervention group more often had spontaneous vaginal delivery (SVD) than did controls (63.4% versus 47.5%, P = 0.005) and fewer caesarean sections (CSs) (22.9% versus 32.5%, P = 0.05). SVD was more frequent and CSs were less frequent among those who actually participated in intervention (n = 90) compared with controls who had been referred to consultation (n = 106) (SVD: 65.6% versus 47.2%, P = 0.014; CS: 23.3% versus 38.7%, P = 0.031). Women in intervention more often had a very positive delivery experience (36.1% versus 22.8%, P = 0.04, n = 219). CONCLUSIONS: To decrease the number of CSs, appropriate treatment for fear of childbirth is important. This study shows positive effects of psychoeducative group therapy in nulliparous women with severe fear of childbirth in terms of fewer CSs and more satisfactory delivery experiences relative to control women with a similar severe fear of childbirth.

Mental health problems common in women with fear of childbirth.

OBJECTIVE: To investigate whether women with fear of childbirth have more mental health problems than women of childbearing age in general. DESIGN: Register-based retrospective study. SETTING: The maternity clinic of Helsinki University Central Hospital. POPULATION: In all, 2405 women referred for consultation because of fear of childbirth during 1996-2002 and 4676 comparable control women. METHODS: Data were linked to the Medical Birth Register, the Hospital Discharge Register and the Drug Reimbursement Register 5-12 years before and after the initial childbirth (during 1990-2008). MAIN OUTCOME MEASURES: Prevalence of psychiatric care as evidenced by the use of psychotropic medication, and episodes of either psychiatric inpatient or outpatient care in women with fear of childbirth compared with nonfearful controls. RESULTS: Women with fear of childbirth had significantly more often had psychiatric care (54.0% versus 33.6%, P < 0.001) during the study period. Fearful and nonfearful women differed from each other (P < 0.001) regarding psychiatric inpatient care (7.2% versus 3.6%), outpatient care (19.0% versus 9.8%) and the use of psychotropic medication (51.3% versus 31.3%). Mood and anxiety disorders were the most common psychiatric diagnoses in both groups. The major predictors for a need for psychiatric care after the initial childbirth were previous psychiatric care (adjusted odds ratio 4.5; 95% CI 4.0-5.1) and fear of childbirth (adjusted odds ratio 1.9; 95%CI 1.7-2.1). CONCLUSIONS: A remarkable mental morbidity was seen among women of childbearing age. Mental health problems were twice as common among women with a fear of childbirth as in nonfearful controls. Clinical practice on how to evaluate and treat women fearing childbirth should be developed.

Elevated levels of decidual insulin-like growth factor binding protein-1 in cervical fluid in early and mid-pregnancy are associated with an increased risk of spontaneous preterm delivery.

OBJECTIVE: To study whether elevated levels of decidual insulin-like growth factor binding protein-1 (IGFBP-1) in the cervical fluid of unselected asymptomatic women in early or mid-pregnancy are associated with spontaneous preterm delivery (PTD). DESIGN: Prospective population-based cohort study. SETTING: Maternity Clinics, University Central Hospital, Helsinki, Finland. POPULATION: A total of 5180 unselected pregnant women. METHODS: Cervical swab samples were collected during the first and second trimester ultrasound screening. The concentration of IGFBP-1 was measured by immunoenzymometric assay, which detects the decidual phosphoisoforms of IGFBP-1 (phIGFBP-1). Concentrations of 10 micrograms/l or more were considered to be elevated. MAIN OUTCOME MEASURE: Spontaneous PTD. Results In the first trimester, 24.5% of women, and in the mid-second trimester, 20.2% of women, had an elevated cervical fluid phIGFBP-1 level. The rates of spontaneous PTD before 32 and before 37 weeks of gestation were higher in women with an elevated cervical fluid phIGFBP-1 level, compared with women who had cervical phIGFBP-1 of <10 micrograms/l (1.1% versus 0.3% and 5.7% versus 3.2%, respectively). An elevated phIGFBP-1 level in the first trimester was an independent predictor for PTD before 32 and before 37 weeks of gestation, with odds ratios of 3.0 (95% CI 1.3-7.0) and 1.6 (95% CI 1.2-2.3), respectively. Cervical phIGFBP-1 levels of 10 micrograms/l or more in the first trimester predicted PTD before 32 and before 37 weeks of gestation, with sensitivities of 53.8% and 37.0%, respectively. The negative predictive values were 99.7% and 96.8%. CONCLUSIONS: Elevated cervical fluid phIGFBP-1 levels in the first trimester were associated with an increased risk of spontaneous PTD.

Fear of childbirth according to parity, gestational age, and obstetric history.

OBJECTIVE: To examine fear of childbirth according to parity, gestational age, and obstetric history. DESIGN: A questionnaire study. POPULATION AND SETTING: 1400 unselected pregnant women in outpatient maternity clinics of a university central hospital. METHODS: Visual analogue scale (VAS) and Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) and preferred mode of delivery. MAIN OUTCOME MEASURES: W-DEQ and VAS scores according to parity, gestational age, obstetric history, and preferred mode of delivery. RESULTS: The W-DEQ and VAS scores were higher in nulliparous (W-DEQ 72.0 +/- 20.0 [mean +/- SD] and VAS 4.7 [median]) than parous women (65.4 +/- 21.9; 3.2, P < 0.001 for both W-DEQ and VAS). Higher W-DEQ and VAS scores were found for those beyond 21 weeks of gestation compared with those before (W-DEQ 71.6 +/- 23.0 versus 66.6 +/- 20.0, P < 0.001; VAS 4.7 versus 3.2, P < 0.001). Caesarean section was preferred mode of delivery for 8.1% and these women scored higher on fear (W-DEQ 87.6 +/- 26.5, VAS median 7.0) than those who preferred vaginal delivery (W-DEQ 61.8 +/- 18.7, VAS 2.7, P < 0.001, respectively). Those with a previous caesarean scored higher on fear (W-DEQ 73.2 +/- 23.5, VAS 5.1) than parous women without previous caesarean (W-DEQ 63.3 +/- 20.8, VAS 2.9, P < 0.001, respectively). Those with a history of a vacuum extraction (VE) (W-DEQ 70.6 +/- 19.7, VAS 5.0) had higher fear scores than those without (W-DEQ 64.8 +/- 22.0, P < 0.05 and VAS 3.0, P < 0.001). CONCLUSION: Severe fear of childbirth was more common in nulliparous women, in later pregnancy, and in women with previous caesarean section or VE. Caesarean section as a preferred mode of childbirth was strongly associated with high score in both W-DEQ and VAS.

Fear of childbirth and pregnancy-related anxiety in women conceiving with assisted reproduction.

OBJECTIVE: To compare the prevalence and predictors of severe fear of childbirth and pregnancy-related anxiety in groups of assisted reproduction treatment (ART) and spontaneously conceiving women with singleton pregnancies. METHODS: The ART group (n = 367, nulliparous 260) represented a cohort from five Finnish infertility clinics in 1999. The control group (n = 379, nulliparous 135) was enrolled in this study by consecutive sampling the same year. Fear of childbirth was assessed by means of the revised version of the Fear-of-Childbirth Questionnaire and pregnancy-related anxiety by means of the Pregnancy Anxiety Scale at gestational week 20 +/- 3.2 (mean+/-standard deviation). RESULTS: The frequency of severe fear of childbirth and anxiety (classified as total scores in the 90th percentile or higher in the revised Fear of Childbirth Questionnaire and Pregnancy Anxiety Scale) did not differ between the groups. Nulliparity was associated with more frequent severe anxiety only in the controls. In nulliparous participants, a partnership of more than 5 years decreased the risk of severe fear of childbirth (odds ratio 0.3, 95% confidence interval 0.2-0.7). In the nulliparous ART group, a long duration of infertility (7 or more years) increased the risk of severe fear of childbirth (odds ratio 4.4, 95% confidence interval 1.2-16.9). CONCLUSION: Women conceiving after ART do not experience severe fear of childbirth or pregnancy-related axiety more often than spontaneously conceiving controls. However, a long duration of infertility is an independent risk factor regarding severe fear of childbirth. LEVEL OF EVIDENCE: II-2.

Patient-controlled epidural technique improves analgesia for labor but increases cesarean delivery rate compared with the intermittent bolus technique.

BACKGROUND: We tested the hypothesis that patient-controlled epidural analgesia for labor (PCEA) provides better analgesia and satisfaction than the intermittent bolus technique (bolus) without affecting the mode of delivery. METHODS: We randomized 187 parturients to receive labor analgesia using either the PCEA or bolus technique. The PCEA group received a starting bolus of 14 mg of bupivacaine and 60 micro g of fentanyl in a 15-ml volume, followed by a background infusion (bupivacaine 0.08% and fentanyl 2 microg ml(-1)) 5 ml h(-1) with a 5-ml bolus and 15-min lock-out interval. The bolus group received boluses of 20 mg of bupivacaine and 75 micro g of fentanyl in a 15-ml volume. RESULTS: Parturients in the PCEA group had significantly (P < 0.05-0.01) less pain during the first and second stages of labor. There was no difference in the spontaneous delivery rate between the groups, but the cesarean delivery rate was significantly (P < 0.05) higher (16.3% vs. 6.7%) in the PCEA group than in the bolus group. Bupivacaine consumption was significantly (P < 0.01) higher (11.2 mg h(-1) vs. 9.6 mg h(-1)) and the second stage of labor was significantly (P < 0.01) longer (70 min vs. 54 min) in the PCEA group than in the bolus group. Patient satisfaction was equally good in both groups. CONCLUSION: The PCEA technique provided better pain relief. This was associated with higher bupivacaine consumption, prolongation of the second stage of labor, and an increased rate of cesarean section.

A randomized controlled trial of intervention in fear of childbirth.

OBJECTIVE: To compare intensive and conventional therapy for severe fear of childbirth. METHODS: In Finland, 176 women who had fear of childbirth were randomly assigned at the 26th gestational week to have either intensive therapy (mean 3.8 +/- 1.0 sessions with obstetrician and one with midwife) or conventional therapy (mean 2.0 +/- 0.6 sessions), with follow-up 3 months postpartum. Pregnancy-related anxiety and concerns, satisfaction with childbirth, and puerperal depression were assessed with specific questionnaires. Power analysis, based on previous studies, showed that 74 women per group were necessary to show a 50% reduction in cesarean rates. RESULTS: Birth-related concerns decreased in the intensive therapy group but increased in the conventional therapy group (linear interaction between the group and birth-concerns P =.022). Labor was shorter in the intensive therapy group (mean +/- standard deviation 6.8 +/- 3.8 hours) compared with the conventional group (8.5 +/- 4.8 hours, P =.039). After intervention, 62% of those originally requesting a cesarean (n = 117) chose to deliver vaginally, equally in both groups. Cesarean was more frequent for those who refused to fill in the questionnaires than for those who completed them (57% compared with 27%, P =.001). In the log-linear model, parous women who had conventional therapy and refused to fill in the questionnaires chose a cesarean more often than expected (standardized residual 2.54, P =.011). There were no differences between groups in satisfaction with childbirth or in puerperal depression. CONCLUSION: Both kinds of therapy reduced unnecessary cesareans, more so in nulliparous and well-motivated women. With intensive therapy, pregnancy- and birth-related anxiety and concerns were reduced, and labors were shorter.

Psychosocial characteristics of women and their partners fearing vaginal childbirth.

OBJECTIVES: To examine the personal characteristics and socio-economic background of women and their partners fearing vaginal childbirth. DESIGN: Questionnaire survey by the 30th week of pregnancy. SETTING: Sixteen outpatient maternity centres in the capital area of Finland. PARTICIPANTS: Two hundred and seventy-eight women and their partners. MAIN OUTCOME MEASURES: Personality traits, socio-economic factors, life and partnership satisfaction and pregnancy- and delivery-associated anxiety and fear. RESULTS: The more anxiety, neuroticism, vulnerability, depression, low self-esteem, dissatisfaction with the partnership, and lack of social support the women reported, the more they showed pregnancy-related anxiety and fear of vaginal delivery. In multiple regression analyses psychological variables of the woman contributed most to the prediction of pregnancy-related anxiety (increase in R2 = 0.20, P < 0.001), the strongest predictor being general anxiety (beta = 0.28, P < 0.001). Lack of support contributed most to the prediction of severe fear of vaginal delivery (increase in chi2 = 13.66, P < 0.01), the strongest predictor being dissatisfaction with the partnership (Wald 8.61, P < 0.01). Life-dissatisfaction reported by the partner contributed to pregnancy-related anxiety and his dissatisfaction with the partnership contributed to the woman's fear of vaginal delivery. CONCLUSIONS: The personalities of a pregnant woman and her partner, and their relationship, influences the woman's attitude to her pregnancy and her forthcoming delivery.

Psychosocial predictors of disappointment with delivery and puerperal depression. A longitudinal study.

BACKGROUND: To examine the extent to which personality characteristics, depression, fear and anxiety about pregnancy and delivery, and socio-economic background, predict disappointment with delivery and the risk of puerperal depression. METHODS: Two hundred and eleven women filled in questionnaires measuring personality traits, socio-economic factors, and marital satisfaction once before and once after the 30th week of pregnancy, and 2 3 months after delivery, when obstetric data about pregnancy and delivery was also collected. RESULTS: The women who were disappointed with their delivery or suffered from puerperal depression had been more depressed already in early pregnancy. Regression analysis showed that the strongest predictors of disappointment with delivery were labor pain (increase in R2 = 0.14, p<0.001) and emergency Cesarean (increase in R2 = 0.18, p<0.001). Puerperal depression was predicted by depression (increase in R2 = 0.16, p<0.001), and by personal traits such as general anxiety, vulnerability and neuroticism (increase in R2 = 0.32, p<0.001), both before 30 weeks of pregnancy and prior to the delivery (for depression increase in R2 = 0.05, p<0.001, and for anxiety and vulnerability increase in R2 = 0.04, p<0.01). The strongest predictors were depression at both time points before delivery (beta = 0.51, p<0.001, and beta = 0.39, p<0.001). Pregnancy- and delivery-related anxiety prior to the delivery also predicted puerperal depression, but complications of the pregnancy and delivery did not. CONCLUSIONS: Depression in early pregnancy predicts disappointment with the delivery and is a strong predictor of puerperal depression.

Goal reconstruction and depressive symptoms during the transition to motherhood: evidence from two cross-lagged longitudinal studies.

Two cross-lagged longitudinal studies were carried out to investigate the extent to which the adjustment of personal goals to match the particular stage-specific demands of the transition to motherhood has consequences for women's depressive symptoms. In Study 1. 348 women filled out a revised version of Little's (1983) Personal Project Analysis and a revised version of Beck's Depression Inventory (A. T. Beck. C. H. Ward. M. Mendelsohn, L. Mock, & J. Erlaugh. 1961) 4 times: during early pregnancy, 1 month before childbirth, 3 months after childbirth. and 2 years after childbirth. In Study 2. 140 women who reported high levels of fear of childbirth filled out identical measures during early pregnancy, 1 month before childbirth, and 3 months after childbirth. The results showed that an increase in family-related goals during pregnancy and after the birth of the child predicted a decline in women's depressive symptoms. By contrast, an increase in self-focused goals predicted an increase in women's depressive symptoms.

Women's and men's personal goals during the transition to parenthood.

To investigate how women's and men's personal goals change during the transition to parenthood, the authors studied 348 women (152 primiparous and 196 multiparous) and 277 of their partners at 3 times: early in pregnancy, 1 month before the birth, and 3 months afterward. At each measurement, participants completed the Personal Project Analysis questionnaire (B. R. Little, 1983). The results showed that during pregnancy women became more interested in goals related to childbirth, the child's health, and motherhood and less interested in achievement-related goals. After the birth women were more interested in family- and health-related issues. These changes were more substantial among the primiparous than among the multiparous mothers. Although the men's personal goals changed during the transition to parenthood, these changes were less substantial than those found among the women.

Factors associated with fear of delivery in second pregnancies.

OBJECTIVE: To identify factors associated with fear of childbirth during and after first labor. METHODS: We analyzed first deliveries of 100 primiparas who reported severe fear of vaginal childbirth during their second pregnancies and 200 age- and parity-matched controls who reported no later fear of delivery. The main outcome measures were previous miscarriages, participation in birth-education classes, support during labor, length of first delivery, pain relief, obstetric complications, welfare of the newborn, and time between deliveries. RESULTS: The prevalence of emergency cesarean (adjusted odds ratio [OR] 26.9, confidence interval [CI] 11.9, 61.1) and vacuum extraction (adjusted OR 4.5, CI 2.2, 9.3) during first delivery was much higher in subjects than controls. Labor lasted longer in cases than in controls during the first (10.5 hours versus 7.8 hours, P = .016) and second stages (62 minutes versus 47 minutes, P = .002). They received epidural analgesia more often, but its timing and the amount used were not different between groups. Of the group with fear, 44% could not define any specific cause for fear and regarded the entire delivery as frightening. CONCLUSION: Emergency cesarean and vacuum extraction during first deliveries were associated with secondary fear of delivery. Emergency obstetric procedures cannot be avoided, so prevention of fear might require more education on causes and consequences of cesarean or vacuum extraction, eg, in birth classes and at postpartum visits.

Randomized trial comparing first-trimester transcervical chorionic villus sampling and second-trimester amniocentesis.

A total of 800 patients were randomized at the 9th to 11th week of pregnancy either for transcervical chorionic villus sampling (CVS) on the day of trial entry or for amniocentesis (AC) at the 16th week. The indication for fetal karyotyping was maternal age in 94 per cent of the cases; the mean maternal age was 39.2 years. An adequate sample was obtained in 98.3 per cent of the cases in the CVS group and in all cases in the AC group. Retesting was indicated in 3.3 per cent of the CVS cases. An abnormal karyotype was found in 6.1 per cent of the CV samples and in 4.5 per cent of the amniotic fluid samples. There was one false-positive chromosome result in both groups. Twelve (3.1 per cent) miscarriages occurred by the 22nd week of pregnancy in the CVS group in pregnancies intended to continue. No difference was seen between the groups for total fetal loss rates. The number of surviving infants in the CVS group was 92.2 per cent and in the AC group 91.7 per cent (rate difference 0.5 per cent (95 per cent confidence interval -3.3 to 4.3)). In our study, both the diagnostic accuracy and the risk of fetal loss were equal in the CVS and AC groups.