Interventional program to reduce both the incidence of anal sphincter tears and rate of Caesarean sections.

OBJECTIVE: To estimate the ability of an intensive interventional program to decrease the number of obstetric anal sphincter injuries (OASIS), while simultaneously decreasing the rate of Caesarean sections (CS). STUDY DESIGN: The intervention, which aimed at decreasing the number of OASIS, started with a compulsory tutorial for all the midwives and physicians. At the same time, the clinic initiated a program to decrease the number of CS. We compared the outcomes before and after the intervention by calculating the risk ratios with 95% confidence intervals. The changes in selected outcomes were also tested using the test of relative proportions. The follow-up was extended for 1 year after the intervention. RESULTS: The number of deliveries by CS decreased significantly, as did the number of OASIS in all the subgroups, except for the multi-parous women. The rate of OASIS for instrumental deliveries (mostly by vacuum) decreased significantly (p < 0.003), as compared to pre-interventional period. The number of Grade 4 tears decreased significantly: from 0.4 ruptures per 100 deliveries before the start of the intervention to 0.1 ruptures after the start of the intervention (RR 0.37, 95% CI 0.14-0.98, p = 0.037). However, the OASIS and Grade 4 sphincter injuries increased with forceps delivery. The CS rate decreased from 17.7 to 15.0 per 100 deliveries (RR 0.85, 95% CI 0.78-0.93). The post-interventional follow-up period revealed a further decrease in the frequency of OASIS (to 1.28%, p < 0.001) and a stable CS rate (14.2%). CONCLUSION: The intervention significantly decreases the frequency of OASIS, in line with the results obtained for earlier interventions. At the same time, a decrease in CS rate was obtained.

STAN, a clinical audit: the outcome of 2 years of regular use in the city of Varberg, Sweden.

OBJECTIVE: To monitor and analyze (audit) the introduction of the STAN methodology in a district hospital. DESIGN: Retrospective study covering the total population of deliveries at term during 2004 and 2005. MATERIAL AND METHODS: 1,875 out of 3,193 term pregnancies (59%) were monitored using the STAN fetal heart monitor (Neoventa Medical, Moelndal, Sweden) and the associated clinical guidelines. Cord metabolic acidosis, neonatal outcome, and rates of operative deliveries for fetal distress were recorded. RESULTS: The overall cesarean section rate was significantly reduced in the STAN group. Emergency (crash) cesarean sections were significantly reduced from 1.51% to 0.27% in the cardiotocography- and STAN-monitored groups, respectively (OR 0.18, 95% CI 0.07-0.49). When cesarean section was performed only because of non-reassuring cardiotocography, cord acid base was significantly higher, 7.26 versus 7.19 (p<0.01), as compared to when STAN guidelines were followed. Total population rates for operative deliveries for fetal distress and cesarean section rates were 6.7% and 3.5% respectively. The corresponding metabolic acidosis rate was 0.5%. CONCLUSION: High STAN usage in a busy labor ward setting provided an outcome equaling that noted previously in a larger academic unit, demonstrating the safe implementation of the STAN methodology in a nonacademic unit.

Influence of maternal, obstetric and fetal risk factors on the prevalence of birth asphyxia at term in a Swedish urban population.

BACKGROUND: The influence of maternal, obstetric and fetal risk factors on the prevalence of birth asphyxia at term in a Swedish urban population. OBJECTIVE: To investigate risk factors for Apgar score-defined birth asphyxia, birth asphyxia with hypoxic-ischemic encephalopathy and birth asphyxia-related death/disability. MATERIAL AND METHODS: Retrospective case-control study in term neonates with birth asphyxia defined as Apgar score < 7 at 5 min. Cases originating from nonasphyctic causes (e.g. infection, maternal sedation) were excluded. Hypoxic-ischemic encephalopathy was diagnosed according to criteria by Sarnat. Maternal, obstetric and fetal risk factors were registered in 225 cases of birth asphyxia diagnosed in 42 203 live births occurring in the urban Swedish population studied. A matched control group was used for statistical evaluation. RESULTS: Asphyxia was associated with single civil status, OR = 7.1 (95%CI 2.0, 27.6); intrauterine meconium release, OR = 4.1 (95%CI 1.8, 9.8); operative delivery, OR = 8.7 (95%CI 3.4, 24.6); breech delivery, OR = 20.3 (95%CI 3.0, 416.5); oxytocin augmentation, OR = 2.9 (95%CI 1.4, 6.3); cord complication, OR = 15.8 (95%CI 2.1, 341.5); external compression to assist delivery OR = 6.2 (95%CI 1.3, 45.7); and cardiotocography score, OR = 0.5 (95%CI 0.4, 0.6). Normal fetal heart rate variability, OR = 0.4 (95%CI 0.2, 0.6), repeated late decelerations irrespective of amplitude or repeated variable decelerations, OR = 29.4 (95%CI 5.7, 540.8) or occasional late or variable decelerations, OR = 2.2 (95%CI 1.3, 3.8), and no accelerations, OR = 5.2 (95%CI 2.0, 16.4), were associated with asphyxia. Operative or instrumental delivery was more common in all three asphyxia groups compared with controls. Leanness was a risk factor for asphyxia and for hypoxic-ischemic encephalopathy. Maternal age, smoking and illnesses, time of delivery (day/night, seasonal) and previous caesarean section were not associated with birth asphyxia. CONCLUSIONS: An association between neonatal asphyxia and cardiotocography parameters, intrauterine meconium release, operative delivery, breech delivery, single civil status, oxytocin augmentation, cord complication, external compression to assist delivery and neonatal leanness was found. Abnormal fetal heart rate variability, repeated late decelerations irrespective of amplitude or repeated variable decelerations, occasional late or variable decelerations and no accelerations were associated with asphyxia.