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Oral tramadol versus oral celecoxib for analgesia after mediolateral episiotomy repair in obese primigravidae: a randomized controlled trial. Int Urogynecol J 2020; 32:2465-2472. [PMID: 32691120 DOI: 10.1007/s00192-020-04411-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS A variety of pharmacological and non-pharmacological interventions have been investigated, with the goal of relieving pain after post-episiotomy repair. We aimed to compare the efficacy of tramadol versus celecoxib orally in reducing pain after mediolateral episiotomy repair in obese primigravidae undergoing spontaneous vaginal delivery. METHODS We conducted a randomized double-blinded trial in Cairo University hospital, Cairo, Egypt, from October 2018 to December 2019. We randomly assigned 200 women into two groups: group A (n = 100) received one tramadol tablet 100 mg orally whereas group B (n = 100) received one celecoxib tablet 200 mg orally. Our primary outcome was pain score using a 10-cm visual analog scale at different time intervals. Our secondary outcomes were the overall satisfaction score and drug side effects. RESULTS After mediolateral episiotomy repair, the pain scores at 1, 2, and 4 h were significantly lower in the tramadol group than in the celecoxib group (p < 0.001). However, there were no significantly differences in pain scores at 8 and 12 h between the two groups (p = 0.50 and 0.48 respectively). Women's satisfaction score was significantly higher in the tramadol group than in the celecoxib group (p < 0.001). Fewer participants in the tramadol group needed additional analgesics than in the celecoxib group; however, the difference was not significant (p = 0.17). Drug adverse effects were comparable in the two groups. CONCLUSIONS Primigravid women who received tramadol 100 mg orally after mediolateral episiotomy repair had lower pain scores and were more satisfied than women who received celecoxib 200 mg orally. Both drugs were well tolerated, with few side effects.
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Seijmonsbergen-Schermers A, van den Akker T, Beeckman K, Bogaerts A, Barros M, Janssen P, Binfa L, Rydahl E, Frith L, Gross MM, Hálfdánsdóttir B, Daly D, Calleja-Agius J, Gillen P, Vika Nilsen AB, Declercq E, de Jonge A. Variations in childbirth interventions in high-income countries: protocol for a multinational cross-sectional study. BMJ Open 2018; 8:e017993. [PMID: 29326182 PMCID: PMC5780680 DOI: 10.1136/bmjopen-2017-017993] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 11/21/2017] [Accepted: 11/22/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION There are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women. METHODS AND ANALYSIS This multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country. ETHICS AND DISSEMINATION The Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals.
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Affiliation(s)
- Anna Seijmonsbergen-Schermers
- Department of Midwifery Science, AVAG, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Katrien Beeckman
- Nursing and Midwifery Research Unit, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussel, Belgium
| | - Annick Bogaerts
- Department of Development and Regeneration KU Leuven, University of Leuven, Leuven, Belgium
- Faculty of Medicine and Health Sciences, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium
- Faculty of Health and Social Work, Research Unit Healthy Living, Uc Leuven-Limburg, Leuven, Belgium
| | - Monalisa Barros
- Universidade Estadual do Sudoeste da Bahia, Vitória da Conquista, Brazil
| | | | - Lorena Binfa
- Department of Women's and New Born Health Promotion-School of Midwifery Faculty of Medicine, University of Chile, Santiago, Chile
| | - Eva Rydahl
- Department of Midwifery, Metropolitan University College, Copenhagen, Denmark
| | - Lucy Frith
- Department of Health Services Research, The University of Liverpool, Liverpool, UK
| | - Mechthild M Gross
- Midwifery Research and Education Unit, Department of Obstetrics, Gynaecology and Reproductive Medicine, Hannover Medical School, Hannover, Germany
| | - Berglind Hálfdánsdóttir
- Midwifery Programme, Faculty of Nursing, School of Health Sciences, University of Iceland, Reykjavík, Iceland
| | - Deirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Jean Calleja-Agius
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Tal-Qroqq, Malta
| | - Patricia Gillen
- Institute of Nursing and Health Research, Ulster University, Jordanstown, UK
| | | | - Eugene Declercq
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Ank de Jonge
- Department of Midwifery Science, VU University Medical Center, Amsterdam, The Netherlands
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Seijmonsbergen-Schermers AE, Sahami S, Lucas C, Jonge AD. Nonsuturing or Skin Adhesives versus Suturing of the Perineal Skin After Childbirth: A Systematic Review. Birth 2015; 42:100-15. [PMID: 25864727 DOI: 10.1111/birt.12166] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Suturing of perineal trauma after childbirth can cause problems such as pain, discomfort because of tight sutures, the need for suture removal, and dyspareunia. It is unclear whether leaving the perineal skin unsutured or using skin adhesives might prevent these problems. METHODS CENTRAL, MEDLINE, EMBASE, CINAHL, and prospective trial registers until January 2013 were searched for (quasi-)randomized controlled trials comparing nonsuturing of the perineal skin or skin adhesives versus suturing of the skin when repairing a second-degree perineal tear or episiotomy. Primary outcome measure was short-term and long-term pain and need for analgesic medication. RESULTS Four randomized and two quasi-randomized controlled trials (involving 2,922 women) with heterogeneity in contexts, designs, and methodological quality were included. Nonsuturing of the skin leads to less short-term and long-term pain compared to suturing and an increased rate of skin separation. Skin adhesives lead to less short-term pain without an increased rate of skin separation. Nonsuturing or skin adhesives lead to less complaints and there are no other adverse effects. CONCLUSIONS Nonsuturing of the skin or the use of skin adhesives appears preferable in terms of pain. Nonsuturing could lead to more short-term skin separation when no adhesives are used, but there is no evidence for the clinical importance of skin separation. There is a need for studies with a follow-up of at least 6 months, in which pain is measured homogeneously and for studies comparing the use of skin adhesives with nonsuturing of the skin with the focus on long-term cosmetic results.
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Affiliation(s)
- Anna E Seijmonsbergen-Schermers
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Saloomeh Sahami
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Cees Lucas
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Ank de Jonge
- Department of Midwifery Science, AVAG and the EMGO Institute of Health and Care Research, VU University Medical Centre, Amsterdam, the Netherlands
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Kyser KL, Lu X, Santillan D, Santillan M, Caughey AB, Wilson MC, Cram P. Forceps delivery volumes in teaching and nonteaching hospitals: are volumes sufficient for physicians to acquire and maintain competence? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:71-6. [PMID: 24280847 PMCID: PMC4317267 DOI: 10.1097/acm.0000000000000048] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
PURPOSE The decline in the use of forceps in operative deliveries over the last two decades raises questions about teaching hospitals' ability to provide trainees with adequate experience in the use of forceps. The authors examined (1) the number of operative deliveries performed in teaching and nonteaching hospitals, and (2) whether teaching hospitals performed a sufficient number of forceps deliveries for physicians to acquire and maintain competence. METHOD The authors used State Inpatient Data from nine states to identify all women hospitalized for childbirth in 2008. They divided hospitals into three categories: major teaching, minor teaching, and nonteaching. They calculated delivery volumes (total operative, cesarean, vacuum, forceps, two or more methods) for each hospital and compared data across hospital categories. RESULTS The sample included 1,344,305 childbirths in 835 hospitals. The mean cesarean volumes for major teaching, minor teaching, and nonteaching hospitals were 969.8, 757.8, and 406.9. The mean vacuum volumes were 301.0, 304.2, and 190.4, and the mean forceps volumes were 25.2, 15.3, and 8.9. In 2008, 31 hospitals (3.7% of all hospitals) performed no vacuum extractions, and 320 (38.3%) performed no forceps deliveries. In 2008, 13 (23%) major teaching and 44 (44%) minor teaching hospitals performed five or fewer forceps deliveries. CONCLUSIONS Low forceps delivery volumes may preclude many trainees from acquiring adequate experience and proficiency. These findings highlighted broader challenges, faced by many specialties, in ensuring that trainees and practicing physicians acquire and maintain competence in infrequently performed, highly technical procedures.
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Affiliation(s)
- Kathy L Kyser
- Dr. Kyser is a perinatologist, Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland. Ms. Lu is a data analyst, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Dr. Donna Santillan is research assistant professor, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Dr. Mark Santillan is assistant professor, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Dr. Caughey is professor and chair, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon. Dr. Wilson is professor and associate dean of graduate medical education, University of Iowa Hospitals and Clinics and University of Iowa Carver College of Medicine, Iowa City, Iowa. Dr. Cram is professor, University of Toronto, and director, Division of General Internal Medicine, Mt. Sinai/UHN, Toronto, Ontario, Canada
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Seijmonsbergen-Schermers AE, Geerts CC, Prins M, van Diem MT, Klomp T, Lagro-Janssen ALM, de Jonge A. The use of episiotomy in a low-risk population in the Netherlands: a secondary analysis. Birth 2013; 40:247-55. [PMID: 24344705 DOI: 10.1111/birt.12060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND To examine the episiotomy incidence and determinants and outcomes associated with its use in primary care midwifery practices. METHODS Secondary analysis of two prospective cohort studies (n = 3,404). RESULTS The episiotomy incidence was 10.8 percent (20.9% for nulliparous and 6.3% for parous women). Episiotomy was associated with prolonged second stage of labor (adj. OR 12.09 [95% CI 6.0-24.2] for nulliparous and adj. OR 2.79 [1.7-4.6] for parous women) and hospital birth (adj. OR 1.75 [1.2-2.5] for parous women). Compared with episiotomy, perineal tears were associated with a lower rate of postpartum hemorrhage in parous women (adj. OR 0.58 [0.4-0.9]). Fewer women with perineal tears reported perineal discomfort (adj. OR 0.35 [0.2-0.6] for nulliparous and adj. OR 0.22 [0.1-0.3] for parous women). Among nulliparous women episiotomy was performed most frequently for prolonged second stage of labor (38.8%) and among parous women for history of episiotomy or prevention of major perineal trauma (21.1%). CONCLUSIONS The incidence of episiotomy is high compared with some low-risk settings in other Western countries. Episiotomy was associated with higher rates of adverse maternal outcomes. Restricted use of episiotomy is likely to be beneficial for women.
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Affiliation(s)
- A E Seijmonsbergen-Schermers
- Department of Midwifery Science, AVAG and the EMGO Institute of Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
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Memon HU, Handa VL. Vaginal childbirth and pelvic floor disorders. ACTA ACUST UNITED AC 2013; 9:265-77; quiz 276-7. [PMID: 23638782 DOI: 10.2217/whe.13.17] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Childbirth is an important event in a woman's life. Vaginal childbirth is the most common mode of delivery and it has been associated with increased incidence of pelvic floor disorders later in life. In this article, the authors review and summarize current literature associating pelvic floor disorders with vaginal childbirth. Stress urinary incontinence and pelvic organ prolapse are strongly associated with vaginal childbirth and parity. The exact mechanism of injury associating vaginal delivery with pelvic floor disorders is not known, but is likely multifactorial, potentially including mechanical and neurovascular injury to the pelvic floor. Observational studies have identified certain obstetrical exposures as risk factors for pelvic floor disorders. These factors often coexist in clusters; hence, the isolated effect of these variables on the pelvic floor is difficult to study.
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Affiliation(s)
- Hafsa U Memon
- Department of Gynecology & Obstetrics, Johns Hopkins School of Medicine, MD, USA.
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Evolución del porcentaje de episiotomía en un hospital comarcal entre los años 2003–2009. Factores de riesgo de los desgarros graves de periné. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2013. [DOI: 10.1016/j.gine.2012.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Regardless of where they give birth, women living in non-metropolitan areas are less likely to have an epidural than their metropolitan counterparts. Women Birth 2013; 26:e77-81. [DOI: 10.1016/j.wombi.2012.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 11/29/2012] [Accepted: 12/02/2012] [Indexed: 11/21/2022]
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Abstract
Obstetric and gynecologic emergencies are common reasons for emergency department visits. Therefore, emergency physicians must be proficient in the management and treatment of these emergencies. This article reviews critical procedures and provides an overview of each procedure and the indications, contraindications, technique, and potential complications.
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Affiliation(s)
- Farah Lone
- Department of Obstetrics and Gynaecology; Croydon University Hospital; 530 London Road; Croydon; Surrey; CR7 7YE; UK
| | - Abdul Sultan
- Department of Obstetrics and Gynaecology; Croydon University Hospital; 530 London Road; Croydon; Surrey; CR7 7YE; UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology; Croydon University Hospital; 530 London Road; Croydon; Surrey; CR7 7YE; UK
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Steiner N, Weintraub AY, Wiznitzer A, Sergienko R, Sheiner E. Episiotomy: the final cut? Arch Gynecol Obstet 2012; 286:1369-73. [DOI: 10.1007/s00404-012-2460-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 07/03/2012] [Indexed: 11/30/2022]
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Kyser KL, Lu X, Santillan DA, Santillan MK, Hunter SK, Cahill AG, Cram P. The association between hospital obstetrical volume and maternal postpartum complications. Am J Obstet Gynecol 2012; 207:42.e1-17. [PMID: 22727347 DOI: 10.1016/j.ajog.2012.05.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 03/23/2012] [Accepted: 05/10/2012] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The purpose of this study was to examine the relationship between delivery volume and maternal complications. STUDY DESIGN We used administrative data to identify women who had been admitted for childbirth in 2006. Hospitals were stratified into deciles that were based on delivery volume. We compared composite complication rates across deciles. RESULTS We evaluated 1,683,754 childbirths in 1045 hospitals. Decile 1 and 2 hospitals had significantly higher rates of composite complications than decile 10 (11.8% and 10.1% vs 8.5%, respectively; P < .0001). Decile 9 and 10 hospitals had modestly higher composite complications as compared with decile 6 (8.8% and 8.5% vs 7.6%, respectively; P < .0001). Sixty percent of decile 1 and 2 hospitals were located within 25 miles of the nearest greater volume hospital. CONCLUSION Women who deliver at very low-volume hospitals have higher complication rates, as do women who deliver at exceedingly high-volume hospitals. Most women who deliver in extremely low-volume hospitals have a higher volume hospital located within 25 miles.
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Browne M, Jacobs M, Lahiff M, Miller S. Perineal injury in nulliparous women giving birth at a community hospital: reduced risk in births attended by certified nurse-midwives. J Midwifery Womens Health 2010; 55:243-9. [PMID: 20434084 DOI: 10.1016/j.jmwh.2009.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2008] [Revised: 11/06/2009] [Accepted: 11/06/2009] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Our objective was to determine if there is a difference in rates of perineal injury sustained by nulliparous women attended by obstetricians compared with certified nurse-midwives (CNMs) at a US community hospital. METHODS We analyzed retrospective data for 2819 women who spontaneously gave birth to singleton, vertex, term, live infants between 2000 and 2005. The independent variable was attendant type (obstetrician or CNM). The main outcome variables were intact perineum, episiotomy, and spontaneous perineal lacerations. Multivariate logistic regression was used to adjust for six potential confounders: macrosomia, maternal age, epidural anesthesia, oxytocin administration, medical insurance status, and ethnicity. RESULTS The odds ratios (ORs) for obstetrician-attended births versus CNM-attended births were significant for a spontaneous minor perineal laceration versus intact perineum (OR = 1.82; 95% confidence interval [CI], 1.33-2.48), spontaneous major laceration versus intact perineum (OR = 2.29; 95% CI, 1.13-4.66), and episiotomy use versus no perineal injury, with or without extension (OR = 2.94; 95% CI, 2.01-4.29). DISCUSSION We found that the prevalence and severity of perineal injury, both spontaneous and from episiotomy use, were significantly lower in CNM-attended births.
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Affiliation(s)
- Maureen Browne
- Department of Genetics, Kaiser Permanente Northern California, 280 West MacArthur Blvd., Oakland, CA 94611, USA.
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Kokanalı D, Ugur M, Kuntay Kokanalı M, Karayalcın R, Tonguc E. Continuous versus interrupted episiotomy repair with monofilament or multifilament absorbed suture materials: a randomised controlled trial. Arch Gynecol Obstet 2010; 284:275-80. [PMID: 20680312 DOI: 10.1007/s00404-010-1620-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Accepted: 07/20/2010] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare different repair techniques and different suture materials for episiotomy. METHODS 160 women having vertex delivery with right-mediolateral episiotomy were randomly allocated to four groups. In the groups where continuos technique was performed, vaginal mucosa, perineal muscles and the skin were sutured continuously. In the groups of interrupted technique, vaginal mucosa was sutured with continuous sutures, then muscle layers and skin were closed by interrupted sutures. Two different types of synthetic absorbed suture material were used: monofilament type is in form of polyglycolide-co-caprolactone and multifilament one is polyglactin 910-Rapide. Perineal pain during different activities on the first and tenth day postpartum and also during sexual intercourse 6 weeks after the delivery was questioned by visual analogous scale (VAS). Furthermore, repair time, amount of suture and episiotomy complications were investigated in each groups. RESULTS On the first day after delivery, the perineal pain scores, the repair time, the amount of suture were statistically less in the continuous technique groups. The differences between the pain at tenth day and during sexual intercourse 6 weeks after the delivery were statistically same. CONCLUSIONS The continuous suturing techniques for episiotomy closure, compared to interrupted methods, are associated with less short-term pain, are quicker and also need less suture material.
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Affiliation(s)
- Demet Kokanalı
- Dr. Zekai Tahir Burak Woman's Health Education and Research Hospital, Ankara, Turkey.
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Nicholson WK, Witter F, Powe NR. Effect of hospital setting and volume on clinical outcomes in women with gestational and type 2 diabetes mellitus. J Womens Health (Larchmt) 2010; 18:1567-76. [PMID: 19764843 DOI: 10.1089/jwh.2008.1114] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Efforts to improve health care outcomes in the United States have led some organizations to recommend specific hospital settings or case volumes for complex medical diagnoses and procedures. But there are few studies of the effect of setting and volume on maternal outcomes, particularly in complicated conditions, such as diabetes. Our objective was to estimate the effect of hospital setting and volume on childbirth morbidity and length of stay in pregnancies complicated by type 2 and gestational diabetes. METHODS We analyzed Maryland hospital discharge data during 1999-2004. The dependent variables were primary cesarean delivery, episiotomy, a composite variable for severe maternal morbidity, and hospital length of stay. The independent variables were hospital setting (community, non-teaching hospitals, community, teaching hospitals, and academic medical centers) and tertiles of annual hospital diabetes delivery volume. Multivariable regression analysis was used to assess the relation of hospital setting with each outcome, adjusting for hospital volume and maternal case mix. RESULTS 5,507 deliveries with type 2 (15%) and gestational (85%) diabetes were analyzed. Primary cesarean delivery rates among women with any diabetes did not vary across settings. After adjustment for volume and patient case mix, the likelihood of severe maternal morbidity was higher among deliveries at academic centers compared to community, non-teaching hospitals (odds ratio [OR], 2.1; 95% confidence interval: 1.0, 4.2). Academic centers had a protective effect (OR, 0.3; 95% CI: 0.2, 0.7) and community teaching hospitals had a borderline protective effect (OR, 0.8; 95% CI: 0.7, 1.0) on episiotomy, compared to community, non-teaching hospitals. Length of stay was greater at academic centers and community, teaching hospitals compared to community, non-teaching hospitals (5.4 days, 3.5 days vs. 2.8 days, respectively). We did not identify an independent association between hospital diabetes volume and clinical outcomes after adjustment for case mix. CONCLUSIONS Among women with type 2 and gestational diabetes, hospital setting is associated with a higher likelihood of severe maternal morbidity and length of stay, independent of volume. Patient case mix accounts for some of the variation across settings. The volume-outcome relationship found with other complex medical conditions or procedures was not found among diabetic pregnancies. Further investigations are needed to explain variations in outcomes across hospital settings and volumes.
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Affiliation(s)
- W K Nicholson
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA.
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Weber AM. Episiotomy use has changed. Am J Obstet Gynecol 2009; 201:e17-8; author reply e18. [PMID: 19286146 DOI: 10.1016/j.ajog.2008.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2008] [Accepted: 12/29/2008] [Indexed: 10/21/2022]
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Frankman EA, Wang L, Bunker CH, Lowder JL. Episiotomy in the United States: has anything changed? Am J Obstet Gynecol 2009; 200:573.e1-7. [PMID: 19243733 DOI: 10.1016/j.ajog.2008.11.022] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Revised: 10/06/2008] [Accepted: 11/17/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of the study was to describe episiotomy rates in the United States following recommended changes in clinical practice. STUDY DESIGN The National Hospital Discharge Survey, a federal data set sampling inpatient hospitals, was used to obtain data based on International Classification of Diseases, Clinical Modification, 9th revision, diagnosis and procedure codes from 1979 to 2004. Age-adjusted rates of term, singleton, vertex, live-born spontaneous vaginal delivery, operative vaginal delivery, cesarean delivery, episiotomy, and anal sphincter laceration were calculated. Census data for 1990 for women 15-44 years of age was used for age adjustment. Regression analysis was used to evaluate trends in episiotomy. RESULTS The rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004. Anal sphincter laceration with spontaneous vaginal delivery declined from 5% in 1979 to 3.5% in 2004. Rates of anal sphincter laceration with operative delivery increased from 7.7% in 1979 to 15.3% in 2004. The age-adjusted rate of operative vaginal delivery declined from 8.7 in 1979 to 4.6 in 2004, whereas cesarean delivery rates increased from 8.3 in 1979 to 17.2 per 1000 women in 2004. CONCLUSION Routine episiotomy has declined since liberal usage has been discouraged. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds to a sharp increase in cesarean delivery, which may indicate that practitioners are favoring cesarean delivery for difficult births.
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Affiliation(s)
- Elizabeth A Frankman
- Division of Urogynecology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Kudish B, Sokol RJ, Kruger M. Trends in major modifiable risk factors for severe perineal trauma, 1996-2006. Int J Gynaecol Obstet 2008; 102:165-70. [PMID: 18420204 DOI: 10.1016/j.ijgo.2008.02.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 02/25/2008] [Accepted: 02/25/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine what effect the major modifiable risk factors for severe perineal trauma have had on the rates of this trauma over time. METHODS A retrospective observational cohort study of singleton vaginal deliveries taken from a perinatal database for the period 1996 through 2006. RESULTS A total of 46,239 singleton vertex vaginal deliveries met the inclusion criteria. Major risk factors for severe perineal trauma were increased maternal age (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.1-1.5), non-African American ethnicity (OR 1.5, 95% CI 1.3-1.7), nulliparity (OR 4.8, 95% CI 4.11-5.6), fetal birth weight (OR 2.2, 95% CI 1.9-2.4), forceps (OR 8.3, 95% CI 5.4-10.8), vacuum (OR 2.9, 95% CI 1.9-4.4), and midline episiotomy (OR 5.7, 95% CI 5.0-6.4). Evaluation of the changes in rates of these factors over the study period revealed that the decline in the rates of episiotomy and the use of forceps accounted for a reduction in severe lacerations of more than 50%. CONCLUSION Reduction of severe perineal trauma by restricted use of the 2 modifiable clinical variables, episiotomy and forceps, is evident over time.
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Affiliation(s)
- Bela Kudish
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington Hospital Center, Washington DC 20010, USA.
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Mueller-Heubach E. The pursuit of evidence. Am J Obstet Gynecol 2007; 196:366-72. [PMID: 17403425 DOI: 10.1016/j.ajog.2006.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 12/11/2006] [Indexed: 10/23/2022]
Affiliation(s)
- Eberhard Mueller-Heubach
- Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Minaglia SM, Ozel B, Gatto NM, Korst L, Mishell DR, Miller DA. Decreased rate of obstetrical anal sphincter laceration is associated with change in obstetric practice. Int Urogynecol J 2007; 18:1399-404. [PMID: 17390092 DOI: 10.1007/s00192-007-0353-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Accepted: 03/04/2007] [Indexed: 10/23/2022]
Abstract
A study was conducted to describe the rate of obstetrical anal sphincter laceration in a large cohort of women and to identify the characteristics associated with this complication. Data from all vaginal deliveries occurring between January 1996 and December 2004 at one institution were used to compare women with and without anal sphincter lacerations. Among 16,667 vaginal deliveries, 1,703 (10.2%) anal sphincter lacerations occurred. Regression models suggested that episiotomy (OR 1.36; 95% CI 1.16, 1.58), vacuum delivery (OR 3.19; 95% CI 2.69, 3.79), and forceps delivery (OR 2.79; 95% CI 1.94, 4.02) were each associated with the increased risk of anal sphincter laceration. Year of delivery was associated with a decreased risk of anal sphincter laceration (OR 0.94; 95% CI 0.92, 0.96) with the rate of laceration decreasing from 11.2% to 7.9% during the study period. Episiotomy and operative vaginal delivery are significant, modifiable risk factors. Changes in obstetric practice may have contributed to the dramatic reduction in anal sphincter laceration during the study period.
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Affiliation(s)
- Steven M Minaglia
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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Abstract
Routine interventions during labor and birth, such as perineal shaving and enemas before vaginal delivery, continuous intrapartum electronic fetal monitoring (EFM), and episiotomy are prevalent in Taiwan, but they may not always be necessary. Numerous studies investigating these interventions have failed to find absolute benefits for women with uncomplicated and low-risk pregnancies. No evidence-based benefits support routine perineal shaving or enemas during labor for reducing the risk of perineal wound infection or neonatal infection. The use of EFM is associated with an increased rate of operative interventions (vacuum, forceps, cesarean delivery) but does not result in a significant decrease in the incidence of perinatal death or cerebral palsy. Routine episiotomy does not have demonstrable advantages over restrictive episiotomy in the frequency or severity of perineal damage or pelvic relaxation.
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Affiliation(s)
- Chen-Yu Chen
- Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
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Nicholson WK, Fox HE, Cooper LA, Strobino D, Witter F, Powe NR. Maternal race, procedures, and infant birth weight in type 2 and gestational diabetes. Obstet Gynecol 2006; 108:626-34. [PMID: 16946224 DOI: 10.1097/01.aog.0000231682.84615.b3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the relation between race and cesarean delivery, episiotomy, and low birth weight infants in pregnancies with type 2 and gestational diabetes mellitus and to identify factors that might explain racial differences. METHODS Population-based, cross-sectional study of 1999-2004 Maryland hospital discharge data. Hospitalizations for delivery of pregnancies with type 2 and gestational diabetes mellitus were identified and matched to infants. The independent variable was maternal race. Dependent variables were cesarean delivery, episiotomy, and low infant birth weight. Stepwise logistic regression models were developed to estimate the independent effect of race on use of each procedure and infant birth weight, after adjusting for sociodemographic, hospital, and clinical factors. RESULTS We examined 6,310 deliveries for pregnancies with type 2 (15%) and gestational (85%) diabetes. Before adjustment, black race was associated with a higher odds of cesarean delivery (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.24-1.58) and low birth weight infants (OR 1.94, 95% CI 1.57-2.40) compared with white race. Adjustment for racial differences in preeclampsia and fetal heart rate abnormalities accounted for a modest degree of the racial variation in outcomes. With full adjustment, black race was still associated with a higher odds of cesarean delivery (OR 1.38, 95% CI 1.20-1.60) and low birth weight (OR 1.81, 95% CI 1.41-2.34) and a lower odds of episiotomy (OR 0.45, 95% CI 0.36-0.57). CONCLUSION In pregnancies with diabetes, adjustment for sociodemographic, hospital, and clinical factors only partially explains racial differences in procedure use and infant low birth weight.
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Affiliation(s)
- Wanda K Nicholson
- Department of Gynecology and Obstetrics, Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA.
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Abstract
The era of routine episiotomy is gradually ending. Previously perceived benefits gradually have been disproved as evidence-based scientific clinical studies have shown the detrimental effects of episiotomy; however, circumstances always will exist in which prudent clinical judgment may dictate the necessity for an episiotomy. In most of these situations, however, an episiotomy often can be avoided. Perhaps more hospital perinatal review committees should evaluate episiotomy rates and strive to convince their staff to reduce their rates. We can learn to be more patient and allow the natural forces of labor to gradually stretch the perineum. In reviewing the extensive volume of published literature on episiotomy and perineal-vaginal trauma, the best advice lies in the dictum "Don't just do something, sit there!"
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Affiliation(s)
- John R Scott
- Woman's Clinic, 853 North Church Street, Suite 720, Spartanburg, SC 29303, USA.
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Clemons JL, Towers GD, McClure GB, O'Boyle AL. Decreased anal sphincter lacerations associated with restrictive episiotomy use. Am J Obstet Gynecol 2005; 192:1620-5. [PMID: 15902167 DOI: 10.1016/j.ajog.2004.11.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether restrictive episiotomy use was associated with decreases in anal sphincter lacerations and the risk of anal sphincter laceration attributable to episiotomy. STUDY DESIGN This was a retrospective database study. Rates of episiotomy, anal sphincter laceration (third- or fourth-degree tear), and other confounding variables were compared among vaginal deliveries before (1999) and after (2002) restrictive episiotomy use was implemented at our institution. Logistic regression was used to estimate the odds ratio of anal sphincter laceration that was due to episiotomy and other variables. RESULTS The episiotomy rate decreased 56% (37% to 17%, P < .001) between 1999 and 2002, whereas the anal sphincter laceration rate decreased 44% (9.7% to 5.4%, P < .001). There were no changes in age, race, nulliparity, prolonged second stage of labor, operative vaginal deliveries, birth weight, or macrosomia, although oxytocin use and epidural use decreased slightly (37% to 31%, P < .001, and 80% to 76%, P = .02, respectively). The adjusted odds ratio of anal sphincter laceration attributable to episiotomy decreased 55%, from 6.5 (95% CI: 3.8, 11.1) to 2.9 (95% CI: 1.7, 5.0), between 1999 and 2002. Conversely, the adjusted odds ratios of anal sphincter laceration attributable to the other independent risk factors all increased or remained the same: operative vaginal delivery, which increased from 4.4 (95% CI: 2.7, 6.9) to 6.3 (95% CI: 3.6 11.1); nulliparity, from 2.9 (95% CI: 1.8, 4.8) to 2.9 (95% CI: 1.4, 5.9); macrosomia, from 1.9 (95% CI: 1.1, 3.4) to 2.6 (95% CI: 1.3, 5.4); and prolonged second stage, from 2.0 (95% CI: 1.3, 3.0) to 2.1 (95% CI: 1.2, 3.7). CONCLUSION With restrictive episiotomy use, the episiotomy rate, anal sphincter laceration rate, and risk of anal sphincter laceration attributable to episiotomy were all reduced by approximately 50%.
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Affiliation(s)
- Jeffrey L Clemons
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Wash 98431, USA.
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Abstract
Fecal incontinence affects between 1% and 16% of women, with prevalence increasing with age. The most common cause of fecal incontinence in otherwise healthy women is damage to the anal sphincter(s) during childbirth. As such, the most important tool in the "treatment" of fecal incontinence is its prevention, which should be the first research priority for gynecologists. Routine midline (median) episiotomy has no place in modern obstetrics; when episiotomy must be performed for obstetric indications, use of mediolateral episiotomy should result in fewer anal sphincter injuries than use of midline episiotomy. Additional research questions that gynecologists hope to address are as follows. (1) When anal sphincter injury occurs at delivery, what is the most effective method of repair? Even when repair is performed, women frequently have symptoms of altered bowel function ranging from fecal urgency to frank fecal incontinence. (2) Is it possible to improve the relatively poor results of a strictly surgical repair? Does pelvic muscle rehabilitation (performed either after vaginal delivery or after secondary repair remote from delivery) add significantly to the outcome of women after anal sphincteroplasty? (3) Another more general research priority is to understand the shared and independent factors in the pathophysiology of fecal and urinary incontinence so as to identify modifiable risk factors in women.
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Affiliation(s)
- Anne M Weber
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Women's Hospital, Pittsburgh, Pennsylvania 15213, USA.
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Howden NLS, Weber AM, Meyn LA. Episiotomy Use Among Residents and Faculty Compared With Private Practitioners. Obstet Gynecol 2004; 103:114-8. [PMID: 14704254 DOI: 10.1097/01.aog.0000103997.83468.70] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe trends in episiotomy use among residents, faculty, and private practitioners at an academic institution. METHODS We reviewed data from the Magee Obstetric Medical and Infant database, containing details of every delivery at Magee-Womens Hospital since 1995. The study population was women who had spontaneous or operative vaginal delivery of a singleton, liveborn, vertex-presenting infant, at 37 weeks or more, from 1995 to 2000 (completed data set years). The first delivery recorded for a patient in the database was analyzed. Residents and faculty were described as "academic" practitioners. Data were analyzed with the Fisher exact test, chi2 test for linear trend, and logistic regression models. RESULTS There were 27702 women with 15190 episiotomies, for an episiotomy rate of 54.8%. The rate of episiotomies decreased from 59.7% to 45.0% during the study period (P <.001). Independent risk factors for episiotomy included age 30 years or more, white race, higher educational status, married, nulliparity, and history of cesarean delivery. The strongest predictor of episiotomy use was practitioner type, with women attending private physicians having an adjusted 7-fold increased risk of episiotomy (odds ratio 7.1; 95% confidence interval 6.5, 7.7). Patient characteristics related to practitioner type included age, race, educational status, marital status, nulliparity, and mode of delivery (P <.001). CONCLUSION High rates of episiotomy use were found among private practitioners, despite current evidence-based literature that supports restricted use of episiotomy.
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Affiliation(s)
- Nancy L S Howden
- University of Pittsburgh Health Sciences Center, Magee-Womens Hospital, Department of Obstetrics, Gynecology, and Reproductive Sciences, Pittsburgh, Pennsylvania 15213, USA.
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Wildman K, Blondel B, Nijhuis J, Defoort P, Bakoula C. European indicators of health care during pregnancy, delivery and the postpartum period. Eur J Obstet Gynecol Reprod Biol 2003; 111 Suppl 1:S53-65. [PMID: 14642320 DOI: 10.1016/j.ejogrb.2003.09.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To describe variation across Europe in PERISTAT indicators of health care in the perinatal period, and to assess the comparability of these indicators. STUDY DESIGN The PERISTAT feasibility study provides the source for this descriptive study, covering 15 European countries. Comparative analysis includes descriptions of births following management of sub-fertility, timing of first antenatal visit, onset of labour, mode of delivery, place of birth, preterm births in units without NICU, and breast-feeding uptake. RESULTS There is broad variation in the availability to provide data on perinatal indicators, and in perinatal health care across the European Union. CONCLUSIONS This paper describes the challenge of identifying indicators that are meaningful and robust for the full distribution of health care systems represented in the European Union. Further work is needed to ensure that the implementation of each indicator is comparable across member states.
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Affiliation(s)
- Katherine Wildman
- INSERM Unité 149, Epidiomiological Research Unit on Perinatal and Women's Health, 123 Boulevard Port-Royal, 75014 Paris, France.
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