Using the Robson Classification to Explain the Fluctuations in Cesarean Section.

PURPOSE: As the rate of cesarean sections (CS) continues to rise in Flanders (northern part of Belgium), it is important to understand the reasons behind this evolution and to find ways to achieve appropriate CS rates. For this analysis, we categorized CS changes between 1992 and 2016, applying the Robson 10-Group Classification System (TGCS). We also applied the TGCS to analyze the information of the only clinics where between 2008 and 2016, the absolute CS rate had fallen by more than two percent. METHODS: This paper is based on a population-based cross-sectional study. Robson's TGCS was used to analyze CS rates for the years 1992, 2000, 2008, and 2016, using the Flemish population-based birth register. RESULTS: Between 1992 and 2016, the overall CS rate increased from 11.8% in 1992 to 20.9% in 2016. The major contributors to that increase were (a) single, cephalic nulliparous women, at term in spontaneous labor (Robson group 1); (b) single, cephalic nulliparous women, at term in induced labor or CS before labor (group 2); and (c) multiparous women with single cephalic at term pregnancy with history of CS (group 5). In the subgroup of the seven clinics where the collective CS rate had decreased from 23.2% in 2008 to 19.3% in 2016, the main contributors to this decrease were Robson groups 1 and 2. CONCLUSIONS: The CS increase in Flanders between 1992 and 2016 is mainly the result of the absolute CS increase in the childbirth of nulliparous women with a single cephalic baby at term in spontaneous or induced labor and in women with a single cephalic presentation at term and a previous CS. Further research in these aforementioned groups is needed to identify the real reasons for the CS increase.

Efficacy of strategies to increase participation in cervical cancer screening: GPs offering self-sampling kits for HPV testing versus recommendations to have a pap smear taken - A randomised controlled trial.

Background: Cervical cancer is preventable by early detection and treatment of pre-cancerous lesions. The current screening policy in Belgium (3-yearly cytology on Pap smears) covers 60% of the target population. Offering self-samples by GPs can overcome barriers for women who are currently not screened. Methods: Women aged 25­64 who did not have a Pap smear since three years and consulted a GP practice in a Flemish municipality between November 2014 and April 2015 were allocated in a 1:1 ratio to either the intervention arm where women were given a vaginal self-sampling kit or control arm where women were encouraged to make an appointment for having a Pap smear taken by a clinician. Results: Eighty-eight consenting women were randomised. 35 (78%) out of 45 women in the self-sampling arm participated in screening compared to 22 (51%) out of 43 women in the control arm (p = 0.009). This difference remained significant after adjusting for covariates (age category, education level, time interval since last Pap smear, past Pap smear-taker). Conclusion: GPs offering self-sampling kits resulted in a high participation. Larger trials should confirm this effect and evaluate feasibility of this approach.4. The authors would also like to include the following sentence in the acknowledgement "The laboratory AML (Antwerp, Belgium) is acknowledged for the free HPV testing on the self-samples."

Prelabour caesarean section following IVF/ICSI in older-term nulliparous women: too precious to push?

OBJECTIVE: To compare prelabour caesarean section (CS) rates in older nulliparous women with a term singleton baby in cephalic presentation conceiving spontaneously and through IVF/ICSI. When the latter women would ask for CS, how willing are gynaecologists to comply with that request? METHODS: A population-based retrospective (1995-2009) cohort study, conducted in Northern Belgium. A comparison of 1,866 nulliparous women pregnant after IVF/ICSI and 15,228 controls is made. An anonymous postal questionnaire is sent to all Belgian gynaecologists. RESULT: Both groups are comparable with respect to maternal age, gestational age, and birth weight. Prelabour CS is more often performed in women who conceived through IVF/ICSI compared to those who conceived spontaneously (9.2% versus 6.3%, P < 0.001). One in five gynaecologists agrees with the maternal request. CONCLUSION: IVF/ICSI pregnancies in older nulliparous women more often end in a prelabour CS and a substantial number of gynaecologists go along with a nonmedical reason for CS.

A 10-year follow-up after Kegel pelvic floor muscle exercises for genuine stress incontinence.

OBJECTIVE: To determine the outcome 10 years after an individual course of pelvic floor muscle (PFM) exercises for genuine stress incontinence. PATIENTS AND METHODS: Postal questionnaires were sent to 52 women who had undergone PFM training 10 years earlier, and their medical files were reviewed. The main outcome measures were the patients' self-assessment of therapy outcome, the frequency of PFM exercises at home, and the demand for surgery after physiotherapy. RESULTS: Forty-five women (87%; mean age 61 years) were suitable for analysis. On completing the course of PFM exercises, physiotherapy had been apparently successful in 24 (53%), and considered to have failed in 21 women (47%). Sixteen of the 24 successful patients remained satisfied with their urinary continence when reassessed 10 years later; two women had undergone surgery (8%). In the group where physiotherapy initially failed, five women (24%) who had not had surgery claimed to be much improved; 13 women (62%) had undergone surgery. Overall, women in whom the conservative treatment of stress incontinence had produced an improvement over the 10 years had practised PFM exercises more regularly (76%) than the others (55%; not significant). However, an active voluntary PFM contraction before a sudden intra-abdominal pressure rise ('perineal lock') appeared to be responsible for most of the success. CONCLUSIONS: When PFM training is initially successful, there is a 66% chance that the favourable results will persist for at least 10 years.

Pelvic floor exercises versus vaginal weight cones in genuine stress incontinence.

OBJECTIVE: To compare pelvic floor exercises and vaginal weight cones in the treatment of genuine stress incontinence. STUDY DESIGN: Randomised controlled trial. METHODS: Sixty ambulatory and fit white women (mean age 56 years) with urinary stress incontinence, treated by a single physiotherapist as outpatients during twelve weeks. Thirty women were allocated to a weekly session of pelvic floor exercises. Thirty were allocated to using cones, they were seen every two weeks. OUTCOME MEASURES: Objective: stress test, vaginal squeezing capacity. Subjective: urinary diary, visual analogue scales. RESULTS: Characteristics of both study groups were comparable. Unfortunately, there was an early withdrawal of fourteen (47%) women in the group treated with cones, and none in the other group. Therefore the pelvic floor exercise group was compared not only with the group intended to be treated with cones, but also with the selected group that only received cone therapy. No statistically significantly differences in outcome measures were found between the groups: 53% in the group assigned to pelvic floor exercises and 57% into the group assigned to cones, of which 50% in the group actually treated with cones, considered themselves as cured or improved to a significant degree. Long-term follow-up was not possible as all cone users refused continued exercises with cones once the twelve weeks had ended. CONCLUSION: Pelvic floor exercises and cones are equally effective in the treatment of genuine stress incontinence. Cones are cost and time saving. However, the low patient compliance with the cones importantly limits its clinical applicability, especially in the long run. Therefore, we do not recommend the use of cones.

Sweeping of the membranes at 39 weeks in nulliparous women: a randomised controlled trial.

OBJECTIVE: To determine whether weekly sweeping of the membranes from 39 weeks of gestation results in a reduction in the number of women reaching 41 completed weeks and subsequently in a reduction of the number of women who will need induction of labour. DESIGN: Randomised controlled trial. PARTICIPANTS: Two hundred and seventy-eight nulliparous women, who were seen at the antenatal clinic of a university teaching hospital, were randomly allocated at 39 weeks of gestation to receive on a weekly basis either sweeping of the membranes (n = 140) or a routine pelvic examination (n = 138). MAIN OUTCOME MEASURES: The time interval between randomisation and delivery, the incidence of prolonged pregnancy (i.e. > 41 completed weeks), and the incidence of induction of labour. RESULTS: In 24 women (17%) sweeping of the membranes was not possible. Fifty-three women (38%) in the sweeping group and 50 women (36%) in the control group were delivered within one week after randomisation. Women allocated to sweeping showed a trend towards having a shorter randomisation-delivery interval: 9.4 days versus 10.6 days in the controls (P = 0.087). Sweeping had no statistically significant effect on the mean duration of pregnancy (282.8 days in the sweeping group versus 283.8 days in the control group, P = 0.127). The need for induction of labour was significantly reduced in those women who underwent sweeping (11% versus 26%, P = 0.004), merely as a result of a decrease in the number of women that exceeded 41 weeks (19% versus 33%, P = 0.016). CONCLUSION: Sweeping of the membranes weekly from 39 weeks does not increase the number of women who will deliver within the first week but significantly decreases the number that will reach 41 weeks. Induction of labour then becomes less necessary.

Epidural analgesia for low risk labour determines the rate of instrumental deliveries but not that of caesarean sections.

We analysed retrospectively the link between the incidence of epidural analgesia and the frequency distribution of instrumental delivery, caesarean section, labour induction and parity in a selected group of women with a low risk labour profile in all (85) obstetric units in Flanders (Northern Belgium). A group of 104 932 women with presumed low risk labour profile was subjected to analysis. The main outcome measures were the incidence of obstetric intervention in each obstetric unit in relation to the extent of their use of epidural analgesia. There was a wide variation in the rate of epidural analgesia (3-75%), labour induction 'for convenience' (4-48%) and instrumental delivery (4-50%) among the Flemish obstetric units. The incidence of instrumental delivery in a given unit was greatly influenced by the rate of epidural analgesia and labour induction for convenience (P < 0.001). However, the incidence of caesarean section in a given unit was not determined by either the rates of epidural, labour induction, attempted instrumental delivery or the size of the unit.

Pelvic floor muscle exercises in genuine urinary stress incontinence.

Pelvic floor muscle exercises, in the treatment of genuine stress incontinence, have been used successfully since 1948. One may expect a significant improvement (warranting no further therapy), or cure rate of about 50%. These exercises have a long-lasting effect. Poorly motivated women should be discouraged to follow exercise sessions. An active co-operation between urogynecologist, physiotherapist and the patient is important in order to avoid undertreated and dissatisfied women. The option to be operated upon must be easily available.

A randomised controlled trial of early versus delayed use of amniotomy and oxytocin infusion in nulliparous labour.

OBJECTIVE: To compare routine amniotomy and early intravenous oxytocin (active management of labour) with a more selective use of amniotomy and oxytocin in women in true labour who received comparable continuous supportive midwifery care. DESIGN: Randomised controlled trial of nulliparous clinic patients in spontaneous labour at term. SETTING: Labour and delivery ward of a university teaching hospital. PARTICIPANTS: Three hundred and six parturients: 152 received active management of labour; 154 were more selectively managed. INTERVENTIONS: 1. Active management: early amniotomy, early use of oxytocin. 2. Selective intervention management: no routine amniotomy and more selective use of oxytocin. OUTCOME MEASURES: Use of oxytocin and amniotomy. Labour duration, mode of delivery. RESULTS: Maternal characteristics were comparable in both groups. Amniotomy was more often performed (91% versus 57%, P <0.01) and oxytocin more often used (53% versus 27%, P < 0.01) in the active management group. The first stage of labour, however, was only shortened by half an hour in the active management group (254 min versus 283 min, P = 0.087). Caesarean section rate (3.9% versus 2.6%), spontaneous vaginal delivery rate (78% versus 79%) and neonatal outcome were not significantly different between groups. CONCLUSION: Within a set-up of strict labour diagnosis and supportive midwifery care, routine amniotomy and early use of oxytocin offered no advantage over a more selective use of amniotomy and oxytocin in terms of mode of delivery and labour duration.

Singleton pregnancy after in vitro fertilization: expectations and outcome.

OBJECTIVE: To determine if singleton in vitro fertilization (IVF) pregnancies carry a higher risk for ante- and perinatal complications compared with naturally conceived pregnancies. METHODS: One hundred forty singleton pregnancies conceived by IVF and 140 matched control pregnancies conceived naturally were analyzed with respect to the incidence of antepartum complications and perinatal outcome. The study was conducted in a university hospital, and pregnancy and labor were managed according to a standardized protocol. RESULTS: Sixteen IVF pregnancies and two control pregnancies ended preterm (P < .01), resulting in the birth of infants with lower birth weight in the former group (P = .01). Except for placenta previa, which occurred four times in IVF pregnancies and not in the control group, no differences in antenatal events were found. Labor was more often induced in IVF pregnancies than in control pregnancies. Elective cesarean delivery for obstetric reasons was performed ten times in the IVF group and never in the controls (P < .01). However, once in labor, no differences in the rate of instrumental or cesarean delivery were found. There were eight minor congenital malformations in the IVF group and none in the control group (P < .01). CONCLUSION: Even when managed in a single center, IVF pregnancies carry a greater antenatal risk than matched controls. Once in labor, and managed in a similar fashion, the outcome does not differ from that of controls.

Pelvic floor muscle exercises: 5 years later.

OBJECTIVES: To determine the outcome of pelvic floor muscle exercises for genuine stress incontinence after 5 years. METHODS: Questionnaires were sent to 48 women, mean age 57 years, with troublesome stress incontinence treated as outpatients by a skilled female physiotherapist to elucidate a self-assessment of therapy outcome and to determine patients' compliance concerning fulfillment of home exercises and attitude toward physiotherapy. Patients' self-assessment responses indicated cured, much improved, some improvement, or unchanged/worse and incidence of anti-incontinence surgery after physiotherapy. RESULTS: The overall cure/much improvement rate for physiotherapy at the end of therapy was 54% and 5 years later it was 58% (confidence interval, 43 to 72); (P = 1.000, binomial test). Thirteen women (27%) underwent surgery. Seven unoperated women (15%) showed only some improvement or relapse and may have been undertreated. Severity of symptoms before therapy was an important factor in therapy outcome but not in therapy maintenance. Frequency of home practicing was comparable in those who had surgery afterward and those who had not. There was no clear linear relationship in long-term effect and frequency of home practicing. Severity of symptoms and behavioral changes bias this relationship. Physiotherapy was well tolerated, as 73% would still prefer it as first choice. Pelvic floor muscle exercises were recommended to friends or relatives by 77% of the patients. CONCLUSIONS: Once a certain level of incontinence is established with pelvic floor muscle exercises, that level is maintained over 5 years.

'To bathe or not to bathe' during the first stage of labor.

OBJECTIVE: Does a warm tub bath relieve labor pain? How is it experienced by the parturient? DESIGN: prospective randomised trial. SETTING: labor ward of a teaching hospital with a uniform active labor management. PARTICIPANTS: one hundred and ten nulliparous low risk women, at term, in true spontaneous labor. Fifty-four women had a bath, 56 women served as controls. MEAN OUTCOME MEASURES: labor pain (assessed by means of a visual analogue scale) and post partum patients' bathing experience (by means of a self-made questionnaire). RESULTS: The study group and the control group were comparable with respect to maternal age, weight, length, duration of gestation, cervical status and labor pain sensation before randomisation. Absolute values of labor pain were not statistically different between the two groups, yet this latter progressed differently: in the bathing group the initial pain sensation (V.A.S.) was 6.8, and this remained stable during the first 25 minutes (V.A.S. = 6.7) and then rose to 8.2 after a mean of 53 minutes. In the control group, labor pain rose progressively from 6.3 to 7.3 after 25 min and to 8.7 after a mean of 52 min (p < 0.01, Student t-test). There was no difference in the use of epidural analgesia. There were no differences in labor duration nor in the frequencies of either operative deliveries or neonatal complications. Eighty percent of the bathers experienced soothing of the pain and all but one reported body relaxation. Ninety percent wanted to bathe again during a next labor. CONCLUSION: Bathing provided no objective pain relief. It had, however, a temporal pain stabilizing effect possibly mediated through the improved ability to relax in between contractions. No side effects were found. It gives great satisfaction to users. Bathing, in conjunction with other forms of analgesia, is recommended.

Epidural analgesia in active management of labor.

OBJECTIVES: To examine the determinants of epidural analgesia in the active management of labor. To examine the association of epidural with instrumental delivery and cesarean section. STUDY DESIGN: Observational study in a teaching hospital with a uniform active labor management and availability of epidural analgesia on demand. A thousand consecutive nulliparous women at term, were assessed. RESULTS: Requests for epidural anesthesia were predominantly expressed at the time the patient was notified that spontaneous labor was going to be augmented by the administration of oxytocin, or later, when this latter treatment caused labor to be subjectively more arduous. In induced labor, the same observation applied to a greater degree, still. Operative delivery was significantly more frequent in patients with epidural. However, when the incidence of operative delivery was adjusted for the use of oxytocin, the significance between patients with epidural versus the others abated. CONCLUSION: The use of oxytocin in active management of labor results in a high demand for epidural when this is available on demand. This, however, need not be associated with an increased incidence of operative delivery.

Pelvic physiotherapy in genuine stress incontinence.

In a prospective cohort study, the effect of pelvic physiotherapy on genuine stress incontinence, factors that influence therapy outcome, and patients' attitudes toward physiotherapy were studied. The study group consisted of 52 ambulatory and mentally fit Caucasian women (mean age, 53 years), suffering from genuine stress incontinence and who had no contraindications for surgery. They had physiotherapy twice weekly for ten weeks. The aim of physiotherapy was strengthening the pelvic floor muscles under control of digital vaginal palpation. Therapy outcome was assessed by a questionnaire and by the patients' self-monitoring urinary diary recording pad changes (52) and number of leakage episodes (35) before treatment and at end of therapy. The questionnaire also served to determine how patients appreciated physiotherapy. Physiotherapy had a low cure rate (+/- 25%) but a high improvement rate causing a decreased demand for surgery. At follow-up (mean 14 months) its beneficial effect was maintained. To date, only 10 patients (19%) have undergone surgery. Severity of symptoms was the only limiting factor. We conclude that every woman with urinary stress incontinence is a potential candidate for physiotherapy but surgical treatment as an option must remain open. Overall, physiotherapy was well accepted since episodes of urinary incontinence were less frequent and therefore bearable; however, changes in patients' behavior play a role.

Premature rupture of membranes at term in nulliparous women: a hazard?

One hundred five consecutive women with premature rupture of the membranes (PROM) at term were managed expectantly for at least 24 hours. Seventy-six went into spontaneous labor, of whom 38 were augmented with oxytocin. Twenty-nine had labor induced. Subjects who delivered during the same study interval after artificial rupture of the membranes served as controls. There were no statistically significant differences in the frequency of amnionitis, endometritis, cystitis, neonatal infection, low Apgar score, low cord arterial blood pH, instrumental delivery, or cesarean delivery. Morbidity was seen most often in induced labor whether or not the membranes were ruptured for a long time. It is concluded that expectant management of PROM at term does not increase perinatal morbidity.

C-reactive protein in preterm labour: association with outcome of tocolysis and placental histology.

Tocolytics were administered in 66 consecutive women in uncomplicated preterm labour with intact fetal membranes (53 singleton and 13 twin pregnancies). C-reactive protein (CRP), a marker of infection, was determined daily and used retrospectively to investigate the role of subclinical infection in preterm labour and to predict the efficacy of tocolysis and the development of a clinical perinatal infection. CRP was also determined in 66 women in uncomplicated labour at term (53 singleton and 13 twin pregnancies). The placenta was examined for histological evidence of infection in all patients who were delivered before 36 weeks (n = 21) and in all women in the control group (n = 66). Elevated CRP levels were more often found in patients who were refractory to tocolysis, suggesting an underlying infectious morbidity. Placental infection was found in 62% of the preterm delivery group and in 12% of the control group. There was an association between elevated CRP levels and histological evidence of placental infection. However, confounding factors such as urinary tract infections limit the usefulness of the CRP test. Because CRP cannot predict clinical perinatal infection accurately, its clinical relevance is very limited.

Extradural analgesia during labour using alfentanil.

Sixteen primiparous patients requesting pain relief during labour received a continuous infusion of alfentanil 30 micrograms kg-1 h-1 via an extradural catheter. Supplementary (extradural) bolus doses (30 micrograms kg-1) were administered when deemed necessary. Excellent pain relief was rapidly obtained early in labour in all patients. However, analgesia was inadequate in the latter part of stage I and during the second stage in five of the 16 patients--notwithstanding several additional doses of alfentanil, and bupivacaine had to be administered. No serious maternal side-effects, except nausea, were encountered. Although all neonatal Apgar scores were between 7 and 10, the Amiel-Tison test clearly indicated the existence of neonatal hypotonia. The continuous extradural administration of alfentanil proved to be unsatisfactory for pain relief in labour.