Team performance during vacuum-assisted vaginal delivery: video review of obstetric multidisciplinary teams

Introduction

Vacuum extraction is generally considered an operator-dependent task, with most attention directed toward the obstetrician's technical abilities (1-3). Little is known about the effect of the team and non-technical skills on clinical outcomes in vacuum-assisted delivery. This study aimed to investigate whether the non-technical skills of obstetricians were correlated with their level of clinical performance via the analysis of video recordings of teams conducting actual vacuum extractions.

Methods

We installed between two or three video cameras in each delivery room at Aarhus University Hospital and Horsens Regional Hospital and obtained 60 videos of teams managing vacuum extraction. Appropriate consent was obtained. Two raters carefully reviewed the videos and assessed the teams' non-technical skills using the Assessment of Obstetric Team Performance (AOTP) checklist, rating all items on a Likert scale score from 1 to 5 (1 = poor; 3 = average; and 5 = excellent). This resulted in a total score ranging from 18 to 90. Two different raters independently assessed the teams' clinical performance (adherence to clinical guidelines) using the TeamOBS-Vacuum-Assisted Delivery (VAD) checklist, rating each item (0 = not done, 1 = done incorrectly; and 2 = done correctly). This resulted in a total score with the following ranges (low clinical performance: 0-59; average: 60-84; and high: 85-100). Interrater agreement was analyzed using intraclass correlation (ICC), and the risk of high or low clinical performance was analyzed on a logit scale to meet the assumption of normality.

Results

Teams that received excellent non-technical scores had an 81% probability of achieving high clinical performance, whereas this probability was only 12% among teams with average non-technical scores (p < 0.001). Teams with a high clinical performance often had excellent behavior in the non-technical items of "team interaction," "anticipation," "avoidance fixation," and "focused communication." Teams with a low or average clinical performance often neglected to consider analgesia, had delayed abandonment of the attempted vaginal delivery and insufficient use of appropriate fetal monitoring. Interrater reliability was high for both rater-teams, with an ICC for the non-technical skills of 0.83 (95% confidence interval [CI]: 0.71-0.88) and 0.84 for the clinical performance (95% CI: 0.74-0.90).

Conclusion

Although assisted vaginal delivery by vacuum extraction is generally considered to be an operator-dependent task, our findings suggest that teamwork and effective team interaction play crucial roles in achieving high clinical performance. Teamwork helped the consultant anticipate the next step, avoid fixation, ensure adequate analgesia, and maintain thorough fetal monitoring during delivery.

Developing the TeamOBS-vacuum-assisted delivery checklist to assess clinical performance in a vacuum-assisted delivery: a Delphi study with initial validation

Introduction

In Northern Europe, vacuum-assisted delivery (VAD) accounts for 6-15% of all deliveries; VAD is considered safe when conducted by adequately trained personnel. However, failed vacuum extraction can be harmful to both the mother and child. Therefore, the clinical performance in VAD must be assessed to guide learning, determine a performance benchmark, and evaluate the quality to achieve an overall high performance. We were unable to identify a pre-existing tool for evaluating the clinical performance in real-life vacuum-assisted births.

Objective

We aimed to develop and validate a checklist for assessing the clinical performance in VAD.

Methods

We conducted a Delphi process, described as an interactive process where experts answer questions until answers converge toward a "joint opinion" (consensus). We invited international experts as Delphi panelists and reached a consensus after four Delphi rounds, described as follows: (1) the panelists were asked to add, remove, or suggest corrections to the preliminary list of items essential for evaluating clinical performance in VAD; (2) the panelists applied weights of clinical importance on a Likert scale of 1-5 for each item; (3) each panelist revised their original scores after reviewing a summary of the other panelists' scores and arguments; and (4) the TeamOBS-VAD was tested using videos of real-life VADs, and the Delphi panel made final adjustments and approved the checklist.

Results

Twelve Delphi panelists from the UK (n = 3), Norway (n = 2), Sweden (n = 3), Denmark (n = 3), and Iceland (n = 1) were included. After four Delphi rounds, the Delphi panel reached a consensus on the checklist items and scores. The TeamOBS-VAD checklist was tested using 60 videos of real-life vacuum extractions. The inter-rater agreement had an intraclass correlation coefficient (ICC) of 0.73; 95% confidence interval (95% CI) of [0.58, 0.83], and that for the average of two raters was ICC 0.84 95% CI [0.73, 0.91]. The TeamOBS-VAD score was not associated with difficulties in delivery, such as the number of contractions during vacuum extraction delivery, cephalic level, rotation, and position. Failed vacuum extraction occurred in 6% of the video deliveries, but none were associated with the teams with low clinical performance scores.

Conclusion

The TeamOBS-VAD checklist provides a valid and reliable evaluation of the clinical performance of vaginal-assisted vacuum extraction.

Comparatively low rates of COVID-19 in women admitted in labor and their newborns prior to routine vaccination of pregnant women: insights from Denmark

Background: In a country with a high-test frequency, societal lockdown, and pregnancy leave granted from 28 gestational weeks, we investigated SARS-CoV-2 infection in women admitted in labor and their newborn in the pre-vaccine period.Material and methods: A total of 1042 women admitted for delivery in two Danish hospitals agreed to a plasma sample and nasopharyngeal, vaginal, and rectal swabs and to sampling of umbilical cord blood and a nasopharyngeal swab from their newborn at delivery. Plasma samples from women were examined for SARS-CoV-2 antibodies. If antibodies were detected, or the woman had a positive nasopharyngeal swab upon admission or had a household contact with symptoms consistent with COVID-19, SARS-CoV-2 PCR was performed on plasma and swab samples from mother and child.Results: Seventeen women (1.6%) were seropositive. Half the newborn (n = 9 (53%)) of seropositive mothers were also seropositive. None of the seropositive women or newborns had clinical signs of COVID-19 and all had SARS-CoV-2 PCR negative plasma and swab samples.Conclusion: Adherence to specific national guidelines pertaining to testing, self-imposed isolation, and cautious behaviors among pregnant women likely contributed to the exceptionally low prevalence of both prior and current COVID-19 infections detected at the time of childbirth preceding the routine vaccination of pregnant women in Denmark.

Healthcare providers' perceptions and expectations of video-assisted debriefing of real-life obstetrical emergencies: a qualitative study from Denmark

OBJECTIVES

Video-assisted debriefing (VAD) of real-life obstetrical emergencies provides an opportunity to improve quality of care, but is rarely used in clinical practice. A barrier for implementation is the expected mental reservations among healthcare providers. The aim of this study was to explore healthcare providers' perceptions and expectations of VAD of real-life events.

SETTING

Participants were recruited from two Labour and Delivery Units in Denmark. In both units, VAD of real-life obstetrical emergencies had never been conducted.

PARTICIPANTS

22 healthcare providers (10 physicians, 9 midwives and 3 nursing assistants). During the study period (August-October 2021), semi-structured, individual interviews were conducted. Interviews were analysed using thematic analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

A qualitative description of healthcare providers' perceptions and expectations of VAD of real-life events.

RESULTS

Three major themes were identified: (1) Video-assisted debriefing (VAD) as an opportunity for learning: All participants expected VAD to provide an opportunity for learning and improving patient care. All participants expected the video to provide a 'bigger picture', by showing 'what was actually done' instead of 'what we believed was done'. (2) Video-assisted debriefing (VAD) as a cause for concern: The primary concern for all participants was the risk of being exposed as less competent. Participants were concerned that being confronted with every minor detail of their clinical practice would enhance their self-criticalness. (3) Preconditions for video-assisted debriefing (VAD): Participants emphasised the importance of organisational support from management. In addition, creating a safe environment for VAD, for example, by using only expert debriefers was considered an essential precondition for successful implementation.

CONCLUSIONS

The risk of being exposed as less competent was a barrier towards VAD of real-life events. However, the majority found the educational benefits to outweigh the risk of being exposed.

Women and partners' experience of major postpartum haemorrhage: a qualitative study

OBJECTIVE

To examine women and their partners' experience of major postpartum haemorrhage (PPH).

DESIGN

A qualitative interview study.

SETTING

Two Labour and Delivery Units in Denmark.

POPULATION

Women who experienced major PPH (≥1 litre within 2 hours after vaginal birth).

METHODS

Semi-structured interviews were conducted with 15 women and nine partners (nine joint interviews, six individual interviews). Interviews were analysed using thematic analysis.

MAIN OUTCOME MEASURES

A qualitative description of women and their partners' experiences.

RESULTS

Three major themes were identified. (1) 'From birth to emergency' included factors that increased concern in women and their partners, such as 'incomprehensible' medical terminology, a tense atmosphere, and alarm call. Transfer to the operating theatre was experienced as the most devastating part of major PPH. (2) 'Feeling safe during an emergency' described factors that supported the women and their partners' management of the situation such as brief explanations from a few healthcare professionals and reassurance that the healthcare professionals were in control of the situation. The pain was experienced as severe, but acceptable. (3) 'Family unity challenged' described how family bonding was supported by positioning the partner at the head of the bed and by keeping the baby on the woman's chest.

CONCLUSIONS

Several factors such as small gestures from healthcare professionals and appropriate organisation of the PPH can make a difference to the woman and her partner's experience of major PPH. Particularly, efforts that support family bonding are greatly valued by women and their partners.

Risk factors for and pregnancy outcomes after SARS-CoV-2 in pregnancy according to disease severity: A nationwide cohort study with validation of the SARS-CoV-2 diagnosis

INTRODUCTION

We identified risk factors and outcomes associated with SARS-CoV-2 infection in pregnancy in a universally tested population according to disease severity and validated information on SARS-CoV-2 during pregnancy in national health registers in Denmark.

MATERIAL AND METHODS

Cohort study using data from national registers and medical records including all pregnancies between March 1, 2020 and February 28, 2021. We compared women with a validated positive SARS-CoV-2 test during pregnancy with non-infected pregnant women. Risk factors and pregnancy outcomes were assessed by Poisson and Cox regression models and stratified according to disease severity defined by hospital admission status and admission reason (COVID-19 symptoms or other). Using medical record data on actual period of pregnancy, we calculated predictive values of the SARS-CoV-2 diagnosis in pregnancy in the registers.

RESULTS

SARS-CoV-2 infection was detected in 1819 (1.6%) of 111 185 pregnancies. Asthma was associated with infection (relative risk [RR] 1.63, 95% confidence interval [CI] 1.28-2.07). Risk factors for severe COVID-19 disease requiring hospital admission were high body mass index (median ratio 1.06, 95% CI 1.04-1.09), asthma (RR 7.47, 95% CI 3.51-15.90) and gestational age at the time of infection (gestational age 28-36 vs < 22: RR 3.53, 95% CI 1.75-7.10). SARS-CoV-2-infected women more frequently had hypertensive disorders in pregnancy (adjusted hazard ratio [aHR] 1.31, 95% CI 1.04-1.64), early pregnancy loss (aHR 1.37, 95% CI 1.00-1.88), preterm delivery before gestational age 28 (aHR 2.31, 95% CI 1.01-5.26), iatrogenically preterm delivery before gestational age 37 (aHR 1.49, 95% CI 1.01-2.19) and small-for-gestational age children (aHR 1.28, 95% CI 1.05-1.54). The associations were stronger among women admitted to hospital for any reason. The validity of the SARS-CoV-2 diagnosis in relation to pregnancy in the registers compared with medical records showed a negative predictive value of 99.9 (95% CI 99.9-100.0) and a positive predictive value of 82.1 (95% CI 80.4-83.7).

CONCLUSIONS

Women infected with SARS-CoV-2 during pregnancy were at increased risk of hypertensive disorders in pregnancy, early pregnancy loss, preterm delivery and having children small for gestational age. The validity of Danish national registers was acceptable for identification of SARS-CoV-2 infection during pregnancy.

Cardiopulmonary Resuscitation Training for Healthcare Professionals: A Scoping Review

SUMMARY STATEMENT

The optimal strategy for training cardiopulmonary resuscitation (CPR) for healthcare professionals remains to be determined. This scoping review aimed to describe the emerging evidence for CPR training for healthcare professionals.We screened 7605 abstracts and included 110 studies in this scoping review on CPR training for healthcare professionals. We assessed the included articles for evidence for the following topics: training duration, retraining intervals, e-learning, virtual reality/augmented reality/gamified learning, instructor-learner ratio, equipment and manikins, other aspects of contextual learning content, feedback devices, and feedback/debriefing. We found emerging evidence supporting the use of low-dose, high-frequency training with e-learning to achieve knowledge, feedback devices to perform high-quality chest compressions, and in situ team simulations with debriefings to improve the performance of provider teams.

Teamwork and Adherence to Guideline on Newborn Resuscitation-Video Review of Neonatal Interdisciplinary Teams

BACKGROUND

Little is known about the importance of non-technical skills for the adherence to guidelines, when teams of midwives, obstetricians, anesthesiologists, and pediatricians resuscitate and support the transition of newborns. Non-technical skills are competences underpinning successful teamwork in healthcare. These are usually referred to as leadership, situational awareness, communication, teamwork, decision making, and coping with stress and fatigue.

OBJECTIVE

By review of videos of teams managing newborns with difficult transition, we aimed to investigate whether the level of the teams' non-technical skills was associated with the degree of adherence to guidelines for newborn resuscitation and transitional support at birth.

METHODS

Four expert raters independently assessed 43 real-life videos of teams managing newborns with transitional difficulties, two assessed the non-technical score and two assessed the clinical performance. Exposure was the non-technical score, obtained by the Global Assessment Of Team Performance checklist (GAOTP). GAOTP was rated on a Likert Scale 1-5 (1 = poor, 3 = average and 5 = excellent). The outcome was the clinical performance score of the team assessed according to adherence of the European Resuscitation Counsel (ERC) guideline for neonatal resuscitation and transitional support. The ERC guideline was adapted into the checklist TeamOBS-Newborn to facilitate a structured and simple performance assessment (low score 0-60, average 60-84, high 85-100). Interrater agreement was analyzed by intraclass correlation (ICC), Bland-Altman analysis, and Cohen's kappa weighted. The risk of high and low clinical performance was analyzed on the logit scale to meet the assumptions of normality and constant standard deviation.

RESULTS

Teams with an excellent non-technical score had a relative risk 5.5 [95% confidence interval (CI) 2.4-22.5] of high clinical performance score compared to teams with average non-technical score. In addition, we found a dose response like association. The specific non-technical skills associated with the highest degree of adherence to guidelines were leadership and teamwork, coping with stress and fatigue, and communication with parents. Inter-rater agreement was high; raters assessing non-technical skills had an interclass coefficient (ICC) 0.88 (95% CI 0.79-0.94); the neonatologists assessing clinical performance had an ICC of 0.81 (95% CI 0.66-0.89).

CONCLUSION

Teams with an excellent non-technical score had five times the chance of high clinical performance compared to teams with average non-technical skills. High performance teams were characterized by good leadership and teamwork, coping with stress, and fatigue and communication with parents.

Home management by remote self-monitoring in intermediate- and high-risk pregnancies: A retrospective study of 400 consecutive women

INTRODUCTION

Home management in general is considered to improve patient well-being, patient involvement and cost-effectiveness, for obstetric patients as well. But concerns regarding inclusion of intermediate- and high-risk pregnant women are an issue and a limitation for clinical implementation. This retrospective study evaluated the outcome and safety of extended remote self-monitoring of maternal and fetal health in intermediate- and high-risk pregnancies.

MATERIAL AND METHODS

The study reports on 400 singleton pregnancies complicated by preterm premature rupture of membranes (PPROM), fetal growth restriction, preeclampsia, gestational diabetes mellitus, high-risk of preeclampsia, or a history of previous fetal or neonatal loss. Remote self-monitoring was performed by pregnant women and included C-reactive protein, non-stress test by cardiotocography, temperature, blood pressure, heart rate, and a questionnaire concerning maternal and fetal wellbeing. Data were transferred to the hospital using a mobile device platform and evaluated by healthcare professionals. In case of non-reassuring registrations, the pregnant women were invited for assessment at the hospital. Primary outcome was perinatal death. Secondary outcomes were other maternal and perinatal complications.

RESULTS

No severe maternal complications were observed. Nine fetal or neonatal deaths occurred, all secondary to malformations, severe fetal growth restriction, extreme prematurity or lung hypoplasia in cases of PPROM before 24 weeks. Even in the latter group, fetal and neonatal survival was 78% (18/23) and rose to 97% (60/62) when PPROM occurred after a gestational age 23+6 weeks. None of the fetal or neonatal deaths were attributable to the home-management setting.

CONCLUSIONS

Home-monitoring including remote self-monitoring of fetal and maternal well-being in intermediate- and high-risk pregnancies seems to be a safe alternative to inpatient or frequent outpatient care, which sets the stage for a new way of thinking of hospital care. The implementation process included staff training workshops and development of patient enrollment practice with clarification of expectations and responsibilities, which can be crucial to the results.

The effects of obstetric emergency team training on patient outcome: A systematic review and meta-analysis

INTRODUCTION

Little is known about the optimal simulation-based team training in obstetric emergencies. We aimed to review how simulation-based team training affects patient outcomes in obstetric emergencies.

MATERIAL AND METHODS

Search Strategy: MEDLINE, Embase, Cochrane Library, and Cochrane Central Register of Controlled Trials were searched up to and including May 15, 2021.

SELECTION CRITERIA

randomized controlled trials (RCTs) and cohort studies on obstetric teams in high-resource settings comparing the effect of simulation-based obstetric emergency team training with no training on the risk of Apgar scores less than 7 at 5 min, neonatal hypoxic ischemic encephalopathy, severe postpartum hemorrhage, blood transfusion of four or more units, and delay of emergency cesarean section by more than 30 min.

DATA COLLECTION AND ANALYSIS

The included studies were assessed using PRISMA, EPCO, and GRADE.

RESULTS

We found 21 studies, four RCTs and 17 cohort studies, evaluating patient outcomes after obstetric team training compared with no training. Annual obstetric emergency team training may reduce brachial plexus injury (six cohort studies: odds ratio [OR] 0.47, 95% CI 0.33-0.68; one RCT: OR 1.30, 95 CI% 0.39-4.33, low certainty evidence) and suggest a positive effect; but it was not significant on Apgar score below 7 at 5 min (three cohort studies: OR 0.77, 95% CI 0.51-1.19; two RCT: OR 0.87, 95% CI 0.72-1.05, moderate certainty evidence). The effect was unclear for hypoxic ischemic encephalopathy, umbilical prolapse, decision to birth interval in emergency cesarean section, and for severe postpartum hemorrhage. Studies with in situ multi-professional simulation-based training demonstrated the best effect.

CONCLUSIONS

Emerging evidence suggests an effect of obstetric team training on obstetric outcomes, but conflicting results call for controlled trials targeted to identify the optimal methodology for effective team training.

Women's body mass index and oral administration of Misoprostol for induction of labor - A retrospective cohort study

Pregnant women who are obese are at greater risk of pregnancy complications, including preeclampsia, gestational diabetes, and macrosomia, leading to an increased likelihood of induced labor. Little is known about pregnant women with obesity and the dose of Misoprostol needed for induction of labor (IOL). To investigate whether the cumulative dose of Misoprostol needed for induction of labor (IOL) is associated with women's body mass index (BMI), we conducted a retrospective study of the use of oral Misoprostol for IOL at the Department of Obstetrics and Gynecology, Aarhus University Hospital - a tertiary referral delivery unit with 4800 deliveries a year. Data on IOL among 1637 women with singleton pregnancies was collected in the period January 1st, 2014, to October 4th, 2017. Low-risk women were induced in an outpatient setting. Primary outcomes were Misoprostol dose, time between start of induction (first dose of Angusta®) and completed delivery, and mode of delivery. Secondary outcomes were neonatal data as Apgar score and pH of the umbilical artery. In this study, we found the total dose of Misoprostol needed for induction increased significantly with increasing BMI (p < 0.005). The time to delivery and the risk of Cesarean section increased with rising BMI class. However, 76% of inductions among the women with obesity ended in a vaginal delivery. For the neonatal outcomes, a total of 16 children had an Apgar score below 7 at five minutes and 14 had a pH less than 7.0; none of these results differed significantly between BMI classes. The perinatal and maternal mortality rate was 0%.

SARS-CoV-2 infection in pregnancy in Denmark-characteristics and outcomes after confirmed infection in pregnancy: A nationwide, prospective, population-based cohort study

Introduction

Assessing the risk factors for and consequences of infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) during pregnancy is essential to guide clinical care. Previous studies on SARS‐CoV‐2 infection in pregnancy have been among hospitalized patients, which may have exaggerated risk estimates of severe outcomes because all cases of SARS‐CoV‐2 infection in the pregnant population were not included. The objectives of this study were to identify risk factors for and outcomes after SARS‐CoV‐2 infection in pregnancy independent of severity of infection in a universally tested population, and to identify risk factors for and outcomes after severe infection requiring hospital admission.

Material and methods

This was a prospective population‐based cohort study in Denmark using data from the Danish National Patient Register and Danish Microbiology Database and prospectively registered data from medical records. We included all pregnancies between March 1 and October 31, 2020 and compared women with a positive SARS‐CoV‐2 test during pregnancy to non‐infected pregnant women. Cases of SARS‐CoV‐2 infection in pregnancy were both identified prospectively and through register linkage to ensure that all cases were identified and that cases were pregnant during infection. Main outcome measures were pregnancy, delivery, maternal, and neonatal outcomes. Severe infection was defined as hospital admission due to coronavirus disease 2019 (COVID‐19) symptoms.

Results

Among 82 682 pregnancies, 418 women had SARS‐CoV‐2 infection during pregnancy, corresponding to an incidence of 5.1 per 1000 pregnancies, 23 (5.5%) of which required hospital admission due to COVID‐19. Risk factors for infection were asthma (odds ratio [OR] 2.19, 95% CI 1.41–3.41) and being foreign born (OR 2.12, 95% CI 1.70–2.64). Risk factors for hospital admission due to COVID‐19 included obesity (OR 2.74, 95% CI 1.00–7.51), smoking (OR 4.69, 95% CI 1.58–13.90), infection after gestational age (GA) 22 weeks (GA 22–27 weeks: OR 3.77, 95% CI 1.16–12.29; GA 28–36 weeks: OR 4.76, 95% CI 1.60–14.12), and having asthma (OR 4.53, 95% CI 1.39–14.79). We found no difference in any obstetrical or neonatal outcomes.

Conclusions

Only 1 in 20 women with SARS‐CoV‐2 infection during pregnancy required admission to hospital due to COVID‐19. Risk factors for admission comprised obesity, smoking, asthma, and infection after GA 22 weeks. Severe adverse outcomes of SARS‐CoV‐2 infection in pregnancy were rare.

Reduction in maternal mortality in Denmark over three decades

INTRODUCTION

Women very rarely die during pregnancy and childbirth in Denmark. Although maternal deaths are registered worldwide, various studies indicate that underreporting does occur. This paper presents validated Danish register data for two periods between 1985 and 2017.

METHODS

Maternal deaths were identified from 1985 to 1994 and from 2002 to 2017 by linking four national health registers, death certificates and notifications from maternity wards. A group of obstetricians categorised and assessed all medical records, classifying each case by cause of death.

RESULTS

Linkage of four registers yielded valid data, leading to the identification of 143 maternal deaths in the abovementioned periods. From 1985-1994 there were 73 deaths and 618,021 live births, resulting in a maternal mortality rate of 11.8 per 100,000 live births with a non-significant 2% annual increase (95% confidence interval (CI): -6.0-11.0%). From 2002 to 2017 there were 70 maternal deaths and 999,206 live births, resulting in a maternal mortality rate of 7.0 per 100,000 live births (95% CI: 5.5-8.9) with a significant 9% annual decrease (95% CI: 4.0-14.0%).

CONCLUSIONS

Overall maternal mortality decreased in the course of the two periods (n = 33 years), with a significant decrease during the last period. This is suggested to be a result of multiple clinical and organisational improvements as discussed in the paper.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

An audit of 70 maternal deaths

INTRODUCTION

Although women rarely die during pregnancy and childbirth in Denmark, keeping track of the maternal mortality rate and causes of death is vital in identifying learning points for future management of critical illness among obstetric patients and in pinpointing risk factors.

METHODS

We identified maternal deaths between 2002 and 2017 by linking four Danish national health registers, using death certificates and reports from hospitals. An audit group then categorised each case by cause of death before identifying any suboptimal care and learning points, which may serve as a foundation for national guidelines and educational strategies.

RESULTS

Seventy women died during pregnancy or within six weeks of a pregnancy in the study period. The most frequent causes of death were cardiovascular disease (n = 14), hypertensive disorder (n = 10), suicide (n = 10) and thromboembolism (n = 7). Suboptimal care was identified in 30 of the 70 cases.

CONCLUSIONS

Mortality from some of the most important causes of death decreased during the study period. No deaths from preeclampsia or thrombosis, two of the leading causes of death, were identified after 2011. In 2015-2017, suicide was the main cause of maternal death, which indicates that a stronger focus on vulnerability in pregnancy and childbirth is essential. Among the 70 deaths, 34% were potentially avoidable, indicating that it is essential continuously to focus on how to reduce severe maternal morbidity and mortality.

FUNDING

none TRIAL REGISTRATION. not relevant.

Pregnancy complications among refugee women: A systematic review

INTRODUCTION

Pregnancy is a time of increased vulnerability for women. Women of refugee background may be further challenged in pregnancy due to a complex series of physical, psychological and social factors. Previous studies show ambiguous results, with some showing increased the risk of prenatal complications in refugees compared with their native counterparts, whereas other studies report the opposite. With the current steep rise in the number of refugees and displaced persons worldwide, research is important to understand whether pregnancy disparities between this population and their native counterparts exist, and the causes. This systematic literature review aims to find out whether refugee women have a higher prevalence of adverse pregnancy outcomes and prenatal infections compared with native women.

MATERIAL AND METHODS

We conducted a literature search in the databases PubMed and Embase, supplemented with screening of reference lists and citations for relevant literature. We included studies published in English reporting risk of preeclampsia, spontaneous abortion and stillbirths, preterm birth, preterm prelabor rupture of membranes (PPROM) and adverse prenatal infectious diseases in women of refugee status. PROSPERO registration CRD42020205628.

RESULTS

We identified 19 articles eligible for inclusion: 12 were cross-sectional, six were cohort studies and one was a case-control study. The most frequently reported outcome in the literature was preterm birth (reported in 16 of the studies) and preeclampsia (reported in 11 of the studies). Refugees had increased risk of stillbirth (reported relative risk ranging from 1.20 to 2.24) and spontaneous abortion (reported relative risk ranging from 1.56 to 1.58), when compared with native women and a decreased risk of preeclampsia (reported relative risk ranging from 0.65 to 0.81).

CONCLUSIONS

The small number of articles eligible for inclusion in the review highlights the lack of research and knowledge on refugee health during pregnancy. Further research is required to understand and reduce disparities in pregnancy outcomes between refugee and non-refugee women.

Vitamin D and the risk of dystocia: A case-control study

BACKGROUND

Dystocia is one of the most common causes of cesarean section in nulliparous women. Studies have described the presence of vitamin D receptors in the myometrium, but it is still unclear whether vitamin D affects the contractility of the smooth muscles. We therefore aimed to determine the association between the vitamin D serum level at labor and the risk of dystocia.

METHOD

We conducted a case-control study between January 2012 and June 2017. Cases were primiparous women, with spontaneous onset of labor, who gave birth by cesarean section due to dystocia. Controls were primiparous women with a spontaneous vaginal delivery. We included 60 women (30 cases and 30 controls) in the analysis. The differences between cases and controls were assessed using chi-squared test for categorical variables and two-sample t-test or unequal t-test for continuous variables, as appropriate, after evaluation of whether they followed the normal distributions.

RESULTS

The mean serum 25-hydroxyvitamin D concentrations were 53.1nmol/l (95%CI; 45.2 to 60.9) among cases and 69.9nmol/l (95%CI; 57.5 to 82.4) among controls (P = 0.02). The mean plasma parathyroid hormone levels were 2.25 pmol/l and 2.38, respectively (P = 0.57). Even though 78% of all women reported taking a minimum of 10μg/day of vitamin D throughout pregnancy, 43% had vitamin D insufficiency, defined as serum 25-hydroxyvitamin D levels below 50nmol/l.

CONCLUSIONS

In a Danish group of women having a cesarean section due to dystocia, we found decreased vitamin D levels.

"I guess baby was just too comfy in there…": A qualitative study of women's experiences of elective late-term induction of labour

BACKGROUND

The frequency of induction of labour (IOL) in late-term pregnancy has increased significantly, but little is known about how women with uncomplicated pregnancies experience IOL for late-term indication alone.

AIM

To explore how women with uncomplicated pregnancies experienced late-term IOL.

METHODS

Qualitative interviews were conducted with 23 women who all had labour induced on late-term indication only. Participants were recruited from two Danish hospitals who offered an outpatient induction regime. The women were interviewed 4-8 weeks after birth. Data were analysed using thematic analysis.

RESULTS

All women had hoped for a spontaneous birth. Prolonged pregnancy was understood as the body/baby "not being ready", but generally, the women were not worried at that point. Most women felt adequately informed about the reasons for IOL, but some requested more information and time to consider their options. The majority considered IOL to be both an offer and a recommendation. One-third of the participants were initially hesitant but chose/accepted IOL because of weariness from pregnancy and the impatience to deliver a healthy child. The opportunity of outpatient induction was generally appreciated as it allowed the women to continue everyday activities while waiting for labour to begin. Nineteen women reported having a good birthing experience. Two women felt that negative birthing experiences were partly related to IOL.

CONCLUSIONS

Most women considered the late-term IOL to be a positive experience. Some women requested more information and time to consider alternatives. These women should be provided with supported opportunities to consider the options.

[Perinatal care of the extremely preterm infants]

In 2018, The Danish Society of Obstetrics and Gynecology and the Danish Paediatric Society agreed on a national consensus guideline on the treatment of imminent preterm delivery prior to 25 weeks. This review summarises the recommendations: at 22 weeks transfer to a tertiary hospital, at 23 weeks tocolysis, antenatal steroid and newborn resuscitation with parental consent, if the infant is viable, and at 24 weeks caesarean section due to foetal distress. Newborn resuscitation is standard of care, unless not indicated for other reasons at 24 weeks.

Women's experiences of postterm induction of labor: A systematic review of qualitative studies

BACKGROUND

Over the last decade, induction of labor (IOL) in postterm pregnancies has increased. Studies have shown the medical advantages of postterm IOL, but less is known about the perspectives of the pregnant women. This review aimed to summarize the current qualitative evidence on women's experience of postterm IOL.

METHODS

A systematic literature search was performed in three databases. A total of 3193 publications were identified, but only eight studies met the inclusion criteria. Thematic analysis guided the data extraction and synthesis. The Confidence in the Evidence for Reviews of Qualitative research (CERQual) approach was used to assess confidence in the findings.

RESULTS

Three major findings were identified. First, for some women, IOL required a shift in expectations because the hope of spontaneous labor had to be given up. Second, the IOL decision was considered a recommendation from health care professionals and was experienced as a nondecision. Finally, the induction process was experienced as a sequential set of steps where the women were expected to fit into the existing hospital organization. The CERQual assessment suggested moderate confidence in all findings.

DISCUSSION

The negative experiences identified in this review can be greatly reduced by a communicative and patient-centered approach. To support informed choice and shared decision making, women need high-quality, unbiased information about IOL, alternative options, and potential outcomes, in addition to time for reflection on their personal values and preferences. Women may need a professionally initiated and supported opportunity to re-evaluate their hopes and expectations before IOL.

Noise as a risk factor in the delivery room: A clinical study

Introduction

We aimed to investigate whether noise in delivery rooms is associated with impaired performance of obstetric teams managing major (≥1000 mL) postpartum hemorrhage.

Material and methods

We included video recordings of 96 obstetric teams managing real-life major postpartum hemorrhage. Exposure was noise defined as the occurrence of sound level pressures (SPL) above 90 dB. The outcome was high clinical performance assessed through expert ratings using the TeamOBS-PPH tool.

Results

The 23 teams unexposed to noise had a significantly higher chance of high clinical performance than the 73 teams exposed to noise: 91.3% (95% CI; 72.0–98.9) versus 58.9% (95% CI; 46.8–70.3) (p < 0.001). The results remained significant when adjusting for the following possible confounders: team size, non-technical performance, bleeding velocity, hospital type, etiology of bleeding, event duration and time of day. Typical sources of noise above 90 dB SPL were mother or baby crying, dropping of instruments, and slamming of cupboard doors.

Conclusion

Noise in delivery rooms may be an independent source of impaired clinical performance.

The impact of a national cardiotocography education program on neonatal and maternal outcomes: A historical cohort study

INTRODUCTION

Studies indicate an association between errors in cardiotocography (CTG) management and hypoxic brain injuries among newborns. Continuing professional education is recommended. We aimed to examine whether the implementation of a national interprofessional CTG education program in Denmark was associated with a decrease in risk of fetal hypoxia measured by umbilical cord pH < 7.00, 5-minute Apgar score <7 or neonatal therapeutic hypothermia. As a secondary aim, we assessed whether the educational intervention was associated with an increase in operative deliveries.

MATERIAL AND METHODS

We conducted a historical cohort study from 2009 to 2015 including all intended vaginal deliveries with liveborn singletons in cephalic presentation and gestational age ≥37 weeks. Data were retrieved from the Medical Birth Register and the National Patient Register. The study period was divided in three: pre-implementation (2009-2012), implementation (2013) and post-implementation (2014-2015). Using logistic regression we estimated odds ratios (OR) of fetal hypoxia outcomes using the pre-implementation period as reference. Analyses were adjusted for potential maternal, neonatal and delivery-associated confounders. Missing data were accounted for by multiple imputation.

RESULTS

In all, 331 282 deliveries were included. Overall risks of pH < 7.00, Apgar score <7 and therapeutic hypothermia were respectively 0.45%, 0.58% and 0.06%. Adjusted OR in the post-implementation period were 1.12 (95% confidence interval [CI] 1.00-1.26), 0.99 (95% CI 0.90-1.10) and 1.34 (95% CI 0.99-1.82) for the three outcomes, respectively. The pH missingness equaled 12.4%. Odds of emergency cesarean section was unaltered, whereas the odds of assisted vaginal delivery decreased by 14% (0.86, 95% CI 0.84-0.89).

CONCLUSIONS

Healthcare professionals are considered the weakest link of CTG technology. We did not find that increasing healthcare professionals' CTG interpretation skills affected the risk of fetal hypoxia. Missing data for pH values were substantial and represent a limitation of the study. We cannot with certainty rule out that missingness masked a true effect of the intervention. Our study indicates that assisted vaginal deliveries can be decreased without an increased risk of fetal hypoxia. Dilution of effect in a complex clinical setting, rare outcomes, insufficient intervention and a possible overestimation of the impact of errors in CTG management might explain the lack of effect.

The importance of non-technical performance for teams managing postpartum haemorrhage: video review of 99 obstetric teams

OBJECTIVE

Little is known about how teams' non-technical performance influences clinical performance in obstetric emergencies such as postpartum haemorrhage.

DESIGN

Video review - observational study.

SETTING

A university hospital (5000 deliveries) and a regional hospital (2000 deliveries) in Denmark.

POPULATION

Obstetric teams managing real-life postpartum haemorrhage.

METHODS

We systematically assessed 99 video recordings of obstetric teams managing real-life major postpartum haemorrhage. Exposure was the non-technical score (AOTP); outcomes were the clinical performance score (TeamOBS) and the delayed transfer to the operating theatre (defined as blood loss >1500 ml in the delivery room).

RESULTS

Teams with an excellent non-technical score performed significantly better than teams with a poor non-technical score: 83.7 versus 0.3% chance of a high clinical performance score (P < 0.001), 0.2 versus 80% risk of a low clinical performance score (P < 0.001), and 3.5 versus 31.7% risk of delayed transfer to the operating theatre (P = 0.008). The results remained robust when adjusting for potential confounders such as bleeding velocity, aetiology, time of day, team size, and hospital. The specific non-technical skills associated with high clinical performance were vigilance, role assignment, problem-solving, management of disruptive behavior, and leadership. Communication with the patient and closing the loop were of minor importance. All performance assessments showed good reliability: the intraclass correlation was 0.97 (95% CI 0.96-0.98) for the non-technical score and 0.84 (95% CI 0.76-0.89) for the clinical performance score.

CONCLUSION

Video review offers a new method and new perspectives for research in obstetric teams to identify how teams become effective and safe; the skills identified in this study can be included in future obstetric training programmes.

TWEETABLE ABSTRACT

Non-technical performance is important for teams managing postpartum haemorrhage; video review of 99 obstetric teams.

Receiving a prenatal diagnosis of Down syndrome by phone: a qualitative study of the experiences of pregnant couples

OBJECTIVES

To examine how pregnant couples experience receiving a prenatal diagnosis of Down syndrome (DS) by phone-a practice that has been routine care in the Central Denmark Region for years.

DESIGN

Qualitative interview study.

SETTING

Participants were recruited from hospitals in Central Denmark Region, Denmark.

PARTICIPANTS

Couples who had received a prenatal diagnosis of DS by phone and decided to terminate the pregnancy. They were recruited from the obstetric department where the termination was undertaken. During the study period (February 2016 to July 2017), 21 semistructured, audio-recorded interviews were conducted by an experienced anthropologist. Interviews were conducted 4-22 weeks after the diagnosis and analysed using thematic analysis.

RESULTS

A prearranged phone call was considered an acceptable practice. However, the first theme 'Expected but unexpected' shows how the call often came earlier than expected. Consequently, most women were not with their partner and were thus initially alone with their grief and furthermore responsible for informing their partner, which some considered difficult. The second theme 'Now what?' shows how during the phone calls, physicians were quick to enquire about the couples' agendas. As the majority had already decided to seek termination of pregnancy, the dialogue focused on related questions and arrangements. Only half of the couples received additional counselling.

CONCLUSION

A prearranged phone call was considered an acceptable and appropriate practice. However, some aspects of this practice (particularly related to the context of the call) showed to be less than optimal for the couples. To make sure that a diagnostic result is delivered in accordance with the couples' needs and requests, the context of the call could be addressed and agreed on in advance by physicians and couples.

Twin pregnancies treated with emergency or ultrasound-indicated cerclage to prevent preterm births

Introduction: Multiple gestations are high-risk pregnancies associated with an increased risk of neonatal morbidity and mortality, mainly due to preterm births. Numerous interventions have been attempted in order to delay the time of delivery and subsequently, prevent preterm births in twin gestations. To date, no really effective intervention has been found. Use of cerclage in twin pregnancies has been controversial. Recently, however, small retrospective cohort studies have shown a potentially positive effect with the use of cerclage in twin pregnancies. The aim of this study was to evaluate pregnancies and neonatal outcomes in twin gestations with a short cervix treated with cervical cerclage at a single University Hospital.Methods: This retrospective cohort study included all women - with twin gestation and a short cervix - who had an ultrasound indicated or emergency cervical cerclage at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark between January 1999 and May 2017. Cervical cerclage was offered to women before 26 weeks of gestation if: (1) the cervix at ultrasound was ≤20 mm without cervical dilatation (ultrasound-indicated cerclage), or (2) the cervix at ultrasound was ≤20 mm with cervical dilatation (emergency cerclage). Women with history-indicated cerclage placement or multifetal embryo reduction were excluded. A total of 65 women participated in the study.Results: The median gestational age at cerclage placement was 22.6 weeks with a median cervical length of 10 mm (range 0-20 mm). The frequency of preterm delivery before 32 weeks of gestation was 41.5% and 27.7% before 28 weeks. Median pregnancy latency was 77 days (range 4-148) and the median gestational age at delivery was 33.0 weeks. Gestational age at delivery was significantly lower among women with cervical dilatation and visible membranes than among women with a short cervix only (27.7 versus 33.6 weeks, p < .01) and so was the median pregnancy latency (48 versus 81 days, p < .05). Overall, neonatal survival was 91.5%.Conclusion: Cervical cerclage in twin pregnancies may prolong pregnancy even when placed on a very short or dilated cervix. In our study, the procedure was safe and without any serious complications. The overall neonatal survival rate was high.

Termination of pregnancy following a prenatal diagnosis of Down syndrome: A qualitative study of the decision-making process of pregnant couples

INTRODUCTION

In Denmark, first trimester screening has a very high uptake (>90%). If Down syndrome is diagnosed, termination rates are high (>95%). The aim of this study was to investigate the timing of the decision to terminate pregnancy following a diagnosis of Down syndrome and the factors influencing this decision.

MATERIAL AND METHODS

Semi-structured, qualitative interview study with 21 couples who had received a prenatal diagnosis of Down syndrome and decided to terminate the pregnancy. Participants were recruited from obstetric departments between February 2016 and July 2017. Data were analyzed using thematic analysis.

RESULTS

Five themes were identified: "initial decision-making", "consolidating the decision", "reasons and concerns shaping the termination of pregnancy decision", "the right decision is also burdensome", and "perceived influences in decision-making". For most couples, the initial decision to terminate pregnancy was made before or during the diagnostic process, but it was re-addressed and consolidated following the actual diagnosis. Imagining a family future with a severely affected Down syndrome child was the main factor influencing the termination of pregnancy decision. The decision was articulated as "right" but also as existentially burdensome for some, due to fear of regret and concern about ending a potential life. The decision to terminate pregnancy was considered a private matter between the couple, but was refined through interactions with clinicians and social networks.

CONCLUSION

All couples made an initial decision prior to receiving the Down syndrome diagnosis. Knowledge of the couple's initial decision may facilitate patient-centered communication during and after the diagnostic process. Couples may benefit from counseling to deal with grief and existential concerns.

Operative technique at caesarean delivery and risk of complete uterine rupture in a subsequent trial of labour at term. A registry case-control study

Objective

To estimate the relation of single-layer closure at previous caesarean delivery, and other pre-labour and intra-partum risk factors for complete uterine rupture in trial of vaginal birth after a caesarean (TOLAC) at term.

Study design

Population-based case-control study. We identified all women (n = 39 742) recorded in the Danish Medical Birth Registry (DMBR) during a 12-year period (1997–2008) with a singleton pregnancy at term and TOLAC. Among these, all women with a complete uterine rupture were identified (cases). Information from the registry was validated against medical records. Controls were selected in the DMBR as the following two births with TOLAC at term and no uterine rupture. Detailed information from cases and controls was collected from manual review of medical records. Main outcome measure was complete uterine rupture during TOLAC at term.

Results

Upon validation, 175 cases and 272 controls met the above criteria. After adjustment for possible confounding factors there was no association between single layer closure and uterine rupture (aOR 1.38, CI: 0.88–2.17). Significant risk factors were: Induction with an unfavourable cervix (aOR 2.10 CI: 1.19–3.71), epidural (aOR 2.17 CI 1.31–3.57), augmentation by oxytocin for more than one hour (aOR 2.03 CI: 1.20–3.44), and birth weight ≥ 4000g (aOR 2.65 CI 1.05–6.64). Previous vaginal delivery (aOR 0.41 CI: 0.25–0.68) and inter-delivery interval of more than 24 months (aOR 0.38 CI: 0.18–0.78) reduced the risk of uterine rupture.

Conclusion

Single-layer uterine closure did not remain significantly associated to uterine rupture during TOLAC at term after adjustment for confounding factors. Induction of labour with an unfavourable cervix, birth weight ≥ 4000g and indicators of prolonged labour were all major risk factors for uterine rupture.

Coping with worry while waiting for diagnostic results: a qualitative study of the experiences of pregnant couples following a high-risk prenatal screening result

BACKGROUND

It is well documented that pregnant women experience increased worry and uncertainty following a high-risk prenatal screening result. While waiting for diagnostic results this worry continues to linger. It has been suggested that high-risk women put the pregnancy mentally 'on hold' during this period, however, not enough is known about how high-risk women and their partners cope while waiting for diagnostic results. The aim of this study was to identify the strategies employed to cope with worry and uncertainty.

METHODS

Qualitative, semi-structured interviews with 16 high-risk couples who underwent diagnostic testing. The couples were recruited at a university hospital fetal medicine unit in Denmark. Data were analysed using thematic analysis.

RESULTS

All couples reported feeling worried and sad upon receiving a high-risk screening result. While waiting for diagnostic results, the couples focused on coming to their own understanding of the situation and employed both social withdrawal and social engagement as strategies to prevent worry from escalating. Additionally, couples used gratitude, reassuring reasoning and selective memory as means to maintain hopes for a good outcome. Discussions about what to do in case of an abnormal test result were notably absent in the accounts of waiting. This bracketing of the potential abnormal result allowed the couples to hold on to a 'normal' pregnancy and to employ an 'innocent-till-proven-guilty' approach to their worries about the fetus's health. None of the interviewed couples regretted having prenatal screening and all of them expected to have prenatal screening in a future pregnancy.

CONCLUSIONS

The couples in this study did not put the pregnancy mentally 'on hold'. Worry and uncertainty must be understood as managed through a diverse range of practical and emotional strategies that change and overlap in the process of waiting. Clinicians may support appropriate ways of coping with worry and waiting through empathetic and empowering clinical communication. In addition to providing adequate information and presenting options available, clinicians may support high-risk women/couples by encouraging them to seek their own personal understandings and management strategies as a way to gain some control in an uncertain situation.

'What do you think?' the collaborative practices of choice and care in a Danish obstetric ultrasound unit

This paper is based on ethnographic fieldwork at an obstetric ultrasound unit in Denmark and explores the few, intense minutes of clinical interaction following a high-risk screening result for Down's syndrome. The category of high-risk transforms the routine ultrasound into a situation of inescapable choice, where the health of the foetus is questioned and decisions must be made. The clinical interactions following a high-risk result are investigated as processes of production, and the concepts of logic of choice and the logic of care are employed as analytical tools for identifying different rationales at play in the situation. The analysis shows that sonographers and women/couples collaboratively engage in logics of choice and care. Their mutual aim is to make the high-risk results meaningful and manageable so that a decision can be made. In this process initiative is shifted back and forth. Through a logic of care, complexity is reduced and statistics transformed by emphasising certain interpretations and leaving others unspoken. However, the logic of choice is also collectively maintained by positioning the women/couples as decision-makers. It is argued that in the obstetric ultrasound unit, the logic of choice provides a powerful frame, with the logic of care filling in the gaps and discontinuities to facilitate decisions. In this context, the logics are complementary rather than competing, and thus the analysis add new perspectives to the original concepts. In sum, the logics of choice and care provide a valuable analytical tool for interpreting and understanding the complex and collaborative practices of clinical interaction.

Antibody response to influenza A(H1N1)pdm09 in vaccinated, serologically infected and unaffected pregnant women and their newborns

Objective

To evaluate the serological response in pregnant Danish women immunized during the 2009 pandemic by serologic infection or by vaccination with influenza A(H1N1) Pandemrix^® and describe levels of passively acquired maternal antibody in their offspring.

Design

Observational cohort study.

Setting

Department of Obstetrics, Aarhus University Hospital, Skejby, Denmark, October to December 2009.

Population

Pregnant women and their offspring

Methods

Serological analysis of antibodies to influenza A(H1N1)pdm09 by hemagglutination inhibition assay in 197 women and their offspring. Blood samples were collected consecutively at delivery from the mother and the umbilical cord. In a subgroup of 124 of the 197 women, an additional blood sample from gestational weeks 9–12 was available for analysis.

Main outcome measures

Seroconversion, geometric mean titer, geometric mean‐fold rise and protective antibodies.

Results

33 of the 124 subgroup women (27%) seroconverted during pregnancy, 79% after vaccination and 17% after serologic infection (p < 0.001). The geometric mean titer after delivery in non‐vaccinated, non‐serologically infected women was 17.1 (95%CI 15.7–18.6). The geometric mean titer increased significantly after serologic infection with H1N1 [76.5 (95%CI 51.3–113.9), p < 0.001] and after vaccination [589.6 (95%CI 339.3–1024.7), p < 0.001]. The geometric mean‐fold rise (mother at delivery/mother early pregnancy) was significantly higher after vaccination [2.23 (1.93–2.54)] than after serologic infection [1.73 (1.59–1.87), p = 0.013]. In newborns of vaccinated mothers, 89.5% had protective antibody levels compared with 15.8% in newborns of serologically infected mothers (p < 0.001).

Conclusions

Influenza vaccination during pregnancy confers passive immunity to the newborn.

Does screening for Down's syndrome cause anxiety in pregnant women? A systematic review

BACKGROUND

Prenatal screening for Down's syndrome and other chromosomal abnormalities is included in prenatal care programs in many countries. However, the potential association between prenatal screening and maternal anxiety remains an issue of debate.

OBJECTIVE

To systematically review and summarize the current scientific evidence on whether screening for Down's syndrome might cause anxiety in pregnant women with a negative or a false-positive screening result.

METHODS

Five databases (PubMed, Embase, Cinahl, PsychInfo and Cochrane) were systematically searched for randomized controlled trials or cohort studies comparing screening and no screening, or comparing different types of screening for Down's syndrome. The search was limited to studies published between September 2001 and April 2013. In all, 316 studies were identified through search of databases and 40 were included for full-text assessment. Two observers independently screened the articles and seven studies satisfied the inclusion criteria. They were subsequently assessed for risk of bias and level of evidence.

MAIN OUTCOME MEASURES

Quantitative measurements of maternal anxiety or worry.

RESULTS

Two studies compared anxiety in pregnant women who accepted or declined screening and showed no difference between groups. All studies described a decrease in anxiety following a screen-negative result. Four studies reported that women's anxiety levels increased significantly upon receiving a screen-positive result. However, after a normal diagnostic result, anxiety levels declined to the same level as for screen-negative women.

CONCLUSION

Studies using quantitative, validated measures to estimate anxiety showed no association between screening and residual anxiety.

Seasonal variation of dystocia in a large Danish cohort

Background

Dystocia is one of the most frequent causes of cesarean delivery in nulliparous women. Despite this, its causes are largely unknown. Vitamin D receptor (VDR) has been found in the myometrium. Thus, it is possible that vitamin D affects the contractility of the myometrium and may be involved in the pathogenesis of dystocia. Seasonal variation of dystocia in areas with distinct seasonal variation in sunlight exposure, like Denmark, could imply that vitamin D may play a role. This study examined whether there was seasonal variation in the incidence of dystocia in a Danish population.

Method

We used information from a cohort of 34,261 nulliparous women with singleton pregnancies, spontaneous onset of labor between 37 and 42 completed gestational weeks, and vertex fetal presentation. All women gave birth between 1992 and 2010 at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby. Logistic regression combined with cubic spline was used to estimate the seasonal variation for each outcome after adjusting for calendar time.

Results

No evidence for seasonal variation was found for any of the outcomes: acute cesarean delivery due to dystocia (p = 0.44); instrumental vaginal delivery due to dystocia (p = 0.69); oxytocin augmentation due to dystocia (p = 0.46); and overall dystocia (p = 0.91).

Conclusion

No seasonal variation in the incidence of dystocia was observed in a large cohort of Danish women. This may reflect no association between vitamin D and dystocia, or alternatively that other factors with seasonal variation and influence on the occurrence of dystocia attenuate such an association.

[Implementation of new guidelines for management of prelabour rupture of membranes did not have the desired effect]

Many resources are used in developing guidelines for the treatment and handling of different diseases and clinical situations. It is important to evaluate the effect of these guidelines; are they being followed and do they have the desired impact on patient care? This report describes a quality control evaluation of whether the implementation of a new PROM (prelabour rupture of membranes) management guideline at Department Y at the Aarhus University Hospital had the wanted effect on the length of labour, use of prophylactic antibiotics, frequency of neonatal admission and neonatal infection.

First-trimester Down syndrome screening: pregnant women's knowledge

OBJECTIVES

The primary aim of this study was to assess pregnant women's knowledge of first-trimester combined Down syndrome screening in a setting of required informed consent. As the secondary aim, we wanted to identify relevant differences in knowledge level among subgroups of pregnant women, including those informed in different ways about prenatal examinations.

METHODS

Data stem from a population-based cross-sectional questionnaire study including 15 multiple-choice questions assessing knowledge of different aspects of screening. Included were 6427 first-trimester pregnant women from three Danish obstetric departments offering prenatal screening free of charge. Both participants and non-participants in the screening program were included. The results are based on 4095 responders (64%). Differences between subgroups were examined using chi-squared tests and logistic regression analysis. Estimates are stated with 95% CI.

RESULTS

The majority of the participants (87.6 (86.6-88.6)% to 92.6 (91.7-93.3)%) correctly identified the test concept and the main condition being screened for. Fewer participants (16.4 (15.3-17.6)% to 43.3 (41.8-44.8)%) correctly recognized test accuracy and the potential risk of adverse findings other than Down syndrome. Knowledge level was positively associated with length of education (adjusted ORs 1.0 (0.8-1.4) to 3.9 (2.4-6.4)) and participation in the screening program (adjusted OR 0.9 (0.6-1.3) to 5.9 (3.9-8.8)). Participation in an individual information session was weakly associated with more knowledge.

CONCLUSION

The majority of the pregnant women correctly identified the test concept and the main condition being screened for. The pregnant women were found less knowledgeable on test accuracy and drawbacks.

Knowledge of prenatal screening and psychological management of test decisions

OBJECTIVES

To study associations between pregnant women's knowledge of prenatal screening and decisional conflict in deciding whether to participate in first-trimester screening for Down syndrome in a setting of required informed consent, and to study associations between knowledge and personal wellbeing, and worries in pregnancy.

METHODS

A population-based cross-sectional study with 6427 pregnant women consecutively included before the time of a nuchal translucency scan. Participants were recruited from three Danish obstetric departments offering prenatal screening free of charge. The results presented are based on 4111 pregnant women (64%). Knowledge was measured using 15 questions. The primary outcomes were measured using pre-existing validated scales, i.e. The Decisional Conflict Scale, the WHO Well-Being Index and the Cambridge Worry Scale. Associations were analyzed by multivariate logistic and linear regression analyses.

RESULTS

A higher level of knowledge was associated with less decisional conflict when deciding whether to participate in first-trimester Down syndrome screening (adjusted odds ratio 1.31 (95% CI, 1.26-1.37)). An increased level of knowledge was also associated with higher levels of wellbeing (adjusted linear coefficient 0.51 (95% CI, 0.26-0.75), P < 0.001). Knowledge was not associated with worries, either in general or specifically about something being wrong with the baby.

CONCLUSION

The results of this study indicate the importance of ensuring a high level of knowledge for pregnant women making choices about participation in prenatal screening for Down syndrome in order to improve the psychological management of test decisions.

Maternal deaths in Denmark 2002-2006

OBJECTIVE

To describe a method for identification, classification and assessment of maternal deaths in Denmark and to identify substandard care.

DESIGN

Register study and case audit based on data from the Registers of the Danish Medical Health Board, death certificates and hospital records.

SETTING

Denmark 2002-2006.

POPULATION

Women who died during a pregnancy or within 42 days after a pregnancy.

METHODS

Maternal deaths were identified by notification from maternity wards and data from the Danish National Board of Health. A national audit committee assessed hospital records of direct and indirect deaths.

MAIN OUTCOME MEASURES

Maternal mortality ratio, causes of death and suboptimal care.

RESULTS

In the study period, 26 women died during pregnancy or within 42 days from direct or indirect causes, leading to a maternal mortality ratio of 8.0/100,000 live births. Causes of death were cardiac disease, thromboembolism, hypertensive disorders of pregnancy, Streptococcus A infections, suicide, amniotic fluid embolism, cerebrovascular hemorrhage, asthma and diabetes.

CONCLUSION

Our method proved valid and can be used for future research. Causes of death could be identified and learning points from the assessments could form the basis of focused education and guidelines. Future complementary 'near miss' studies and cooperation with other countries with comparable health systems are expected to improve the benefits of the enquiries, contributing to improved management of life-threatening conditions in pregnancy and childbirth.

Acupuncture as pain relief during delivery: a randomized controlled trial

BACKGROUND

Many women need some kind of analgesic treatment to relieve pain during childbirth. The objective of our study was to compare the effect of acupuncture with transcutaneous electric nerve stimulation (TENS) and traditional analgesics for pain relief and relaxation during delivery with respect to pain intensity, birth experience, and obstetric outcome.

METHODS

A randomized controlled trial was conducted with 607 healthy women in labor at term who received acupuncture, TENS, or traditional analgesics. Primary outcomes were the need for pharmacological and invasive methods, level of pain assessed by a visual analogue scale, birth experience and satisfaction with delivery, and pain relief evaluated at 2 months postpartum. Secondary obstetric outcomes were duration of labor, use of oxytocin, mode of delivery, postpartum hemorrhage, Apgar score, and umbilical cord pH value. Analysis complied with the intention-to-treat principle.

RESULTS

Use of pharmacological and invasive methods was significantly lower in the acupuncture group (acupuncture vs traditional, p < 0.001; acupuncture vs TENS, p = 0.031). Pain scores were comparable. Acupuncture did not influence the duration of labor or the use of oxytocin. Mean Apgar score at 5 minutes and umbilical cord pH value were significantly higher among infants in the acupuncture group compared with infants in the other groups.

CONCLUSIONS

Acupuncture reduced the need for pharmacological and invasive methods during delivery. Acupuncture is a good supplement to existing pain relief methods.

Validity of a self-administered questionnaire, with reference to a clinical stress urinary incontinence test

OBJECTIVE

To estimate the criterion validity of a self-administered questionnaire on urinary incontinence (UI) using a clinical stress UI test as reference.

MATERIAL AND METHODS

A total of 4710 women aged 20-59 years randomly selected from the municipalities of Aarhus and Randers (Denmark) participated in a population survey on UI. A sub-sample of 96 women stratified by the duration and frequency of UI answered an assisted, self-administered questionnaire concerning UI during the preceding 6 months. Subsequently, a clinical stress UI test was performed with the researchers being blinded with regard to the questionnaire information.

RESULTS

Based on the clinical stress test and questionnaire, 22 (22.7%) and 21 women (21.6%) had stress UI, respectively. UI occurring in more than drops and UI lasting for > 4 weeks were found to be adequate predictors of UI (odds ratio 8.9 and 4.6; p < 0.001 and p < 0.05). Regarding all forms of UI, the agreement between the stress UI test result and the questionnaire data ranged from 51.0% to 77.1%. The probability of finding a positive stress UI test was 62% among women who answered that UI had lasted for > 4 weeks and occurred in more than drops, compared to 22.9% in the total study group. The sensitivity and specificity of the stress UI test among women in whom UI lasted for > 4 weeks and occurred in more than drops were 22.7% and 95.9%, respectively.

CONCLUSIONS

These findings suggest that there is a greater probability of finding severe UI if the women have experienced it in more than drops and it has lasted for > 4 weeks and it is therefore necessary to estimate the degree of incontinence further by means of a stress UI test. In contrast, women who experienced UI in less than drops and for a duration of < 4 weeks only suffered from a very mild degree of UI.

Postpartum perineal repair performed by midwives: a randomised trial comparing two suture techniques leaving the skin unsutured

OBJECTIVE

To compare a continuous suture technique with interrupted stitches using inverted knots for postpartum perineal repair of second-degree lacerations and episiotomies.

DESIGN

A double-blind randomised controlled trial.

SETTING

A Danish university hospital with more than 4800 deliveries annually.

POPULATION

A total of 400 healthy primiparous women with a vaginal delivery at term. METHOD Randomisation was computer-controlled. Structured interviews and systematic assessment of perineal healing were performed by research midwives blinded to treatment allocation at 24-48 hours, 10 days and 6 months postpartum. Pain was evaluated using a visual analogue scale and the McGill Pain Questionnaire. Wound healing was evaluated using the REEDA scale and by assessment of gaping wounds >0.5 cm. Analysis complied with the intention-to-treat principle.

MAIN OUTCOME MEASURES

The primary outcome was perineal pain 10 days after delivery. Secondary outcomes were wound healing, patient satisfaction, dyspareunia, need for resuturing, time elapsed during repair and amount of suture material used.

RESULTS

A total of 400 women were randomised; 5 women withdrew their consent, leaving 395 for follow up. The follow-up rate was 98% for all assessments after delivery. No difference was seen in perineal pain 10 days after delivery. No difference was seen in wound healing, patient satisfaction, dyspareunia or need for resuturing. The continuous suture technique was significantly faster (15 versus 17 minutes, P = 0.03) and less suture material was used (one versus two packets, P < 0.01).

CONCLUSION

Interrupted, inverted stitches for perineal repair leaving the skin unsutured appear to be equivalent to the continuous suture technique in relation to perineal pain, wound healing, patient satisfaction, dyspareunia and need for resuturing. The continuous technique, however, is faster and requires less suture material, thus leaving it the more cost-effective of the two techniques evaluated.