Indications for cesarean section on maternal request--guidelines for counseling and treatment.

AIM: The aim was to find scientific evidence and, based on this, to develop national medical guidelines in Sweden for cesarean section on mother's request. BACKGROUND: More than 17% of all births in Sweden in 2008 were cesarean sections, compared to 5% at the beginning of the 1970s. About 8% of the cesarean sections were performed at mother's request. The predominant reason for this preference is fear of childbirth. When deciding whether to perform an elective cesarean section, the obstetrician must emphasize the long- and short-term health consequences for the mother and her baby, as well as weigh the risks associated with the procedure itself against not performing the procedure. Clarification is needed to determine for which conditions it is appropriate to comply with the mother's request. MATERIALS AND METHOD: A literature review was conducted to identify factors that were relevant as an argument to meet the request for cesarean section on maternal request. The authors analyzed these factors individually to determine. FINDINGS: The guidelines suggest that it is appropriate to comply with a woman's request for cesarean section if the reason for her request is deemed sufficiently serious and if, after participating in a counseling program, the woman persists in her request for cesarean section. CONCLUSION: A request for cesarean section where no medical indication is present should not be met without considerations concerning the safety of the mother and her baby, while also weighing the risk of adverse outcomes for mother and baby.

Nitroglycerin for management of retained placenta: a multicenter study.

The primary aim was to determine if sequential administration of oxytocin and nitroglycerin is effective for management of retained placenta when performed by obstetricians with no experience of the method. Secondary aims were to examine possible adverse effects of nitroglycerin. One hundred and five women with retained placenta were randomly selected to receive either 1 mg nitroglycerin or placebo tablets sublingually if intravenous oxytocin had failed to expel the placenta. At two of the hospitals some of the midwives were familiar with the use of nitroglycerin. The other midwives and all the participating obstetricians had no clinical experience of the method. In the treatment group, detachment of placenta following nitroglycerin occurred in 37.3% of the women compared to 20.4% in the placebo group (P = 0.056). In the two hospitals with some experience of the method, placenta was removed in 9 of 19 (47.4%) women in the nitroglycerin group compared to 3 of 17 (15.0%) women in the placebo group. No adverse effects of clinical importance were registered. Although the difference between the two groups did not reach statistical significance, the higher success rate in the two hospitals with some experience could indicate that clinical experience is of importance in order to achieve placental detachment.

Women's experiences after early versus postponed oxytocin treatment of slow progress in first childbirth--a randomized controlled trial.

OBJECTIVE: The aim was to compare the childbirth experiences of primiparous women with slow labour progress who had received early versus postponed oxytocin augmentation. METHODS: The population included healthy primiparous women with slow labour progress after a normal pregnancy and spontaneous onset of active labour at term who had taken part in a randomized controlled trial at two delivery units in Sweden comparing early versus postponed oxytocin augmentation. A total of 536 women were sent the Childbirth Experience Questionnaire (CEQ) one month postpartum. The 22-item questionnaire assesses four domains of the childbirth experience. Main outcomes were the four domains of the CEQ: Own capacity, Professional support, Perceived safety and Participation. RESULTS: There were no significant differences between the women in the early and expectant oxytocin treatment groups in any of the four domains; however, operative births were associated with significantly worse childbirth experiences. Almost every third woman in both groups had negative and depressing memories from the childbirth process. CONCLUSIONS: Early oxytocin augmentation for slow labour progress does not appear to be more beneficial than expectant management regarding women's perceptions of childbirth one month postpartum. Given the risks for the foetus associated with oxytocin treatment, prudent expectant management seems to be a safe and viable alternative.

Childbirth experience questionnaire (CEQ): development and evaluation of a multidimensional instrument.

BACKGROUND: Negative experiences of first childbirth increase risks for maternal postpartum depression and may negatively affect mothers' attitudes toward future pregnancies and choice of delivery method. Postpartum questionnaires assessing mothers' childbirth experiences are needed to aid in identifying mothers in need of support and counselling and in isolating areas of labour and birth management and care potentially in need of improvement. The aim of this study was to develop and evaluate a questionnaire for assessing different aspects of first-time mothers' childbirth experiences. METHODS: Childbirth domains were derived from literature searches, discussions with experienced midwives and interviews with first-time mothers. A draft version of the Childbirth Experience Questionnaire (CEQ) was pilot tested for face validity among 25 primiparous women. The revised questionnaire was mailed one month postpartum to 1177 primiparous women with a normal pregnancy and spontaneous onset of active labor and 920 returned evaluable questionnaires. Exploratory factor analysis using principal components analysis and promax rotation was performed to identify dimensions of the childbirth experience. Multitrait scaling analysis was performed to test scaling assumptions and reliability of scales. Discriminant validity was assessed by comparing scores from subgroups known to differ in childbirth experiences. RESULTS: Factor analysis of the 22 item questionnaire yielded four factors accounting for 54% of the variance. The dimensions were labelled Own capacity, Professional support, Perceived safety, and Participation. Multitrait scaling analysis confirmed the fit of the four-dimensional model and scaling success was achieved in all four sub-scales. The questionnaire showed good sensitivity with dimensions discriminating well between groups hypothesized to differ in experience of childbirth. CONCLUSION: The CEQ measures important dimensions of the first childbirth experience and may be used to measure different aspects of maternal satisfaction with labour and birth.

Identification of latent phase factors associated with active labor duration in low-risk nulliparous women with spontaneous contractions.

OBJECTIVE: The aim of this prospective study was to identify latent phase predictors of active labor duration. DESIGN: Prospective clinical study. SETTING: Two delivery units in Sweden. SAMPLE: Healthy nulliparous women with a normal pregnancy, spontaneous onset of active labor at term, and a cervical dilatation of 4 cm or more on admission to the delivery ward (n = 2,072). METHODS: The women were asked to answer questions concerning their food and fluid intake, amount of rest and sleep during the preceding 24 hours and to assess their labor pain, sense of security and expectations of the childbirth on a visual analog scale (VAS). Duration and intervals of contractions, cervical dilatation, and position of the fetal head were noted by the midwife. A multiple regression analysis was performed with active labor duration as the outcome variable. MAIN OUTCOME MEASURE: Predictive factors of active labor duration. RESULTS: Normal food intake during the preceding 24 hours was associated with short labor duration. A long latent phase, low levels of assessed labor pain and few hours of rest and sleep during the preceding 24 hours were significant independent predictors of extended active labor duration, when high birth weight, long contraction intervals, slight cervical dilatation, intact membranes within 2 hours of admission, high maternal age and malposition of the fetal head were controlled for. CONCLUSION: New findings are that latent phase duration as well as food intake and the amount of rest and sleep during the preceding 24 hours are independent predictors of labor duration.

A comparison of high- versus low-intensity, high-frequency transcutaneous electric nerve stimulation for painful postpartum uterine contractions.

BACKGROUND: Breast-feeding in the postpartum period is known to induce intense uterine contractions with pain in the lower abdomen. AIMS: The primary aim of this study was to compare the effects of high and low intensity, high frequency Transcutaneous Electric Nerve Stimulation (TENS) on pain and discomfort of postpartum uterine contractions. The secondary aim was to evaluate discomfort experienced from the stimulation itself. METHODS: Twenty-one newly delivered women participated in this single-blind trial, 12 women received high intensity, high-frequency TENS (HI TENS) and 9 women received low intensity, high-frequency TENS (LI TENS). The electrodes were placed abdominally on each side of the uterus. Stimulation was done during one minute. Visual analogue scales were used to evaluate the intensity of the pain before and after stimulation. A verbal scale was used to estimate sensation of discomfort before, during and after stimulation. RESULTS: The median decrease in pain ratings before and after treatment by VAS was larger in the HI TENS group -49 mm (95% CI -66.5--33.2) than in the LI TENS group -21 mm (95% CI -39.0--20.0). The reduction of pain was most pronounced in the HI TENS group (median difference 28 (95% CI was 14.0-53.0). Furthermore, the HI TENS group experienced significantly less discomfort of the uterine contractions after stimulation (p<0.01) but they also experienced more discomfort of the stimulation than women in the LI TENS group (p<0.01). CONCLUSION: The women treated with HI TENS, experienced significantly less postpartum pain and discomfort to those treated with LI TENS even though the discomfort from the stimulation with HI TENS was greater.

United States multicenter clinical usage study of the STAN 21 electronic fetal monitoring system.

OBJECTIVE: The fetal electrocardiogram system for electronic fetal monitoring (EFM) (STAN S21, Neoventa Medical, Moelndal, Sweden) has led to improved perinatal outcomes in other countries. We aimed to assess the ability of United States (US) obstetricians to use this system appropriately for intrapartum care. STUDY DESIGN: A prospective nonrandomized trial was conducted in 6 sites. Enrollment required a singleton vertex fetus, >36 weeks' gestation, with indications for direct fetal monitoring during first stage of labor. Appropriate use was measured by negative predictive value (NPV) of nonintervention for fetuses with nonreassuring fetal heart rate (FHR) patterns, normal STAN readings, and normal neonatal outcomes with umbilical cord arterial pH >7.12; and percent agreement (PA) for intervention decisions with 3 STAN experts who conducted retrospective case reviews blinded to outcome. RESULTS: Five hundred and thirty patients were enrolled. An NPV of 95.2% was achieved while PA between investigators and STAN experts was 84%, and 90%, for intervention and nonintervention, respectively. No fetus with metabolic acidosis requiring intervention was missed by US clinicians. CONCLUSION: US clinicians used the STAN system appropriately in a manner similar to that of experienced STAN users.

STAN in clinical practice--the outcome of 2 years of regular use in the city of Gothenburg.

OBJECTIVE: The purpose of this study was to monitor the introduction of the STAN-methodology (Noventa Medical, Moelndal, Sweden). STUDY DESIGN: This was a prospective observational study covering the total population of deliveries at term during 2 years. Four thousand eight hundred and thirty out of 14,687 term pregnancies were monitored using the STAN S 21 fetal heart monitor and the associated clinical guidelines. Cord artery metabolic acidosis, neonatal outcome, and rates of operative deliveries for fetal distress were assessed. RESULTS: The annual rate of STAN usage increased from 28.1% to 37.7% and was associated with a significant reduction in metabolic acidosis rate in the total population from 0.76% to 0.44% (P < .05). The compliance with the clinical guidelines increased in cases requiring intervention. The rates for moderate/severe hypoxic neonatal encephalopathy were consistently low, 0.55 and 0.68 per 1000 deliveries, respectively, and corresponding to previous findings. The rate of operative delivery did not change during the 2 years in the total population. CONCLUSION: Increasing STAN usage provided consistent improvements in fetal outcome equalling those noted in the Swedish randomized controlled trial (RCT) without increasing operative interventions for fetal distress.

Risk factors for obstetric brachial plexus palsy among neonates delivered by vacuum extraction.

OBJECTIVE: The risk of obstetric brachial plexus palsy (OBPP) is increased in infants delivered instrumentally. The aim of this study was to identify risk factors for OBPP and to evaluate the association between possible risk factors linked to the duration of the vacuum extraction procedure and the subsequent risk. METHODS: A population-based retrospective design was adopted. Using a national registry of operative vaginal deliveries linked to the Medical Birth Registry in Sweden, we evaluated by univariate and multiple logistic regression analyses the risk factors for OBPP in 13,716 women delivered by vacuum extraction. The variables assessed in the multiple logistic regression analysis were shoulder dystocia, fetal birth weight of 3,999 g or greater, fundal pressure, number of tractions, vacuum application time, parity, vacuum silicone cup, epidural anesthesia, and fetal head at the level of the ischial spines at vacuum application time. RESULTS: Obstetric brachial plexus palsy was recorded in 153 (1.1%) infants. The following variables increased significantly the risk of OBPP in the newborn: shoulder dystocia (odds ratio 16.0; 95% confidence interval 8.9-28.7), fetal birth weight of 3,999 g or greater (7.1; 4.8-10.5), and administration of fundal pressure (1.6; 1.1-2.3). The probability of the risk of OBPP in vacuum-assisted deliveries increased in relation to vacuum extraction time (minutes). CONCLUSION: Shoulder dystocia in the setting of vacuum extraction is a prominent risk factor for OBPP in the newborn. The risk of OBPP increases with the time required for vacuum extraction. LEVEL OF EVIDENCE: II-3.

High birthweight and shoulder dystocia: the strongest risk factors for obstetrical brachial plexus palsy in a Swedish population-based study.

BACKGROUND: Obstetrical brachial plexus palsy (OBPP) is a serious form of neonatal morbidity. OBJECTIVE: The aim of this work was to study the incidence of OBPP and to analyze its risk factors. METHODS: This is a population-based retrospective case-control study. All deliveries recorded in the Swedish Medical Birth Registry between 1987 and 1997 (n = 1 213 987) were investigated. Cases (n = 2399) with OBPP were compared to all other cases. RESULTS: The incidence of OBPP increased from 0.17 in 1987 to 0.27% in 1997 (p = 0.002). During the same time period, the mean birthweight increased from 3483 to 3525 g. Birthweight increasing from 4000 g was associated with a progressive rise in OBPP risk. Other significant risk factors associated with the injury were shoulder dystocia, breech presentation in vaginal delivery, operative vaginal delivery, diabetes mellitus, induction of labor, protracted active phase, secondary arrest of dilatation, and epidural anesthesia. Cesarean section was associated with a decreased risk of OBPP. If 5000 g is chosen as cut-off for cesarean section, 85% of the infants in this weight class are underestimated using ultrasonography. Approximately, 331 abdominal deliveries have to be performed to avoid one case of OBPP. CONCLUSIONS: Shoulder dystocia and infant birthweight of 4500 g and more are the strongest risk factors for OBPP in a Swedish population.

[Unexpected out-of-hospital deliveries--experiences from the Gothenburg area. Centralized obstetrical care requires competent ambulance staff]. / Oväntad förlossning utanför sjukhus--erfarenheter från Göteborgsregionen. Centraliserad förlossningsvård kräver kompetent ambulanspersonal.

One hundred and sixty-seven women gave birth before arrival at the hospital during a six-year period in the Göteborg area. Most of these women had given birth before. The actual delivery most often started at term during the night, proceeded normally but rapidly and the neonatal outcome was good. Sixty-two per cent of the women delivered at home. Complicated lacerations or major hemorrhages were uncommon. The distance to the delivery ward was one of the risk factors for prehospital delivery. This is important to take into consideration in the ongoing process of centralizing the delivery clinics. Basic knowledge in obstetrics is mandatory for the ambulance personnel, as well as regular observation visits to the delivery ward and practice in birth simulators.

Monocyte chemotactic protein-1 in cervical and amniotic fluid: relationship to microbial invasion of the amniotic cavity, intra-amniotic inflammation, and preterm delivery.

OBJECTIVE: The purpose of this study was to evaluate the role of monocyte chemotactic protein-1 in cervical and amniotic fluid in women in preterm labor and with preterm premature rupture of membranes. STUDY DESIGN: Women with singleton pregnancies (