Objective To evaluate the influence of mediolateral episiotomy on the perineal state after spontaneous, singleton vaginal deliveries with fetus in the occiput anterior position.
Design The study was a population based, observational study. Two approaches were used in the analyses. Initially, we considered the parturients as quasi-randomised to one of three equally sized groups of midwives with different attitudes towards episiotomy. Secondly, we studied the effect of episiotomy on the state of the anal sphincter, controlling for birthweight, parity, and duration of second stage of labour.
Subjects 2188 pregnant women delivering consecutively.
Main outcome measures Perineal lacerations and tear of the anal sphincter.
Results Women allocated to the group of midwives with the lowest rate of episiotomy were more likely to have intact perineum after delivery (OR = l.8 (l.4–2.2)), had a slight tendency towards more perineal lacerations (OR = 1.3 (1.0–1.5)), but no increase risk of having tear of the anal sphincter, compared with the women allocated to the two groups of midwives with higher frequencies of episiotomy. The second approach showed that episiotomy was related to an increased risk of tear of the anal sphincter (OR = 2.3 (1.2–4.6)). However, this relation was not found among the group of parturients delivered by the midwives with the lowest rate of episiotomy (22%).
Conclusions Our results encourage a conservative approach to the use of mediolateral episiotomy, and in the light of previous findings, it seems reasonable to suggest that episiotomy should ideally be used in about one in five spontaneous vaginal deliveries.
Abstract Background . One of the most feared complications in medicine is hypoxic brain damage to a newborn. The authors investigated the circumstances of registered peripartum hypoxic brain injuries in order to identify potential opportunities to improve patient safety and prevent injuries. Methods . The authors retrospectively investigated peripartum hypoxic brain injuries registered by the Danish Patient Insurance Association. Results . From 1992 to 2004, 127 approved claims concerning peripartum hypoxic brain injuries were registered and subsequently analysed. Thirty‐eight newborns died, and a majority of the 89 surviving children suffered from major handicaps, primarily cerebral palsy. In 69 of the cases, misinterpretation of or late action on an abnormal cardiotocography (CTG) were the reasons for the majority of the hypoxic brain injuries. Conclusions . All injuries could potentially have been avoided using established obstetric practice. CTGs are often misinterpreted. In the authors’ opinion, education and training in CTG interpretation is essential. The use of ST‐analysis of the fetus ECG (STAN) could probably reduce the number of these injuries.
Background. Fetal growth may be determined by genetic as well as environmental factors. Whether psychological distress during pregnancy influences fetal growth is a matter of debate. Material and methods. A prospective population‐based study with repeated measures of psychological distress (General Health Questionnaire) during pregnancy, based on the use of questionnaires. Danish speaking women with singleton pregnancies attending antenatal care between August 1, 1989 and September 30, 1991 were eligible to the study ( n = 8719). Of these women 5868 women (67%) completed all questionnaires. The main outcome measure was fetal growth (assessed as birth weight for gestational age (continuous)) and birth weight below the 10th percentile of birth weight for gestational age (light for gestational age (LGA) (dichotonmus). Gestational age was calculated primarily from an early ultrasound scan. Confounders were controlled using multivariate statistical methods. Results. Birth weight for gestational age and risk of delivering a LGA baby were not associated with psychological distress, neither distress in 16th week nor in 30th week of pregnancy. Conclusion. To the extent that fetal growth can be explored at birth, the results indicate that psychological distress does not influence fetal growth.
Abstract 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 aim of this cohort study was to evaluate the relationship between psychosocial job demands and job control during pregnancy and risk of small-for-gestational age (SGA) and preterm delivery.We studied 8711 Danish women with singleton pregnancies between 1989 and 1991. Information about medical and obstetric history, general psychosocial and lifestyle factors and occupational exposures were collected at 16 weeks gestation. The analyses were restricted to 3503 respondents who worked at least 30 hours per week during the first trimester. The women's scores on both the job demand and job control questionnaire were initially dichotomized at the median score, and combined into four exposure categories: relaxed jobs (low demands and high control), active jobs (high demands and high control), passive jobs (low demands and low control), and high-strain jobs (high demands and low control).After adjustment for confounders, women with relaxed jobs had the lowest risk of SGA and preterm delivery. Compared to this group the odds ratio (OR) for SGA delivery among women with passive jobs was 1.3 (95% confidence interval [CI]: 0.9-1.9), with high-strain jobs 1.1 (95% CI: 0.7-1.6), and with active jobs 1.1 (95% CI: 0.8-1.7). Compared to women with relaxed jobs, the OR for preterm delivery among women with passive jobs was 1.4 (95% CI: 0.8-2.3), high-strain jobs 1.3 (95% CI: 0.7-2.2) and active jobs 1.2 (95% CI: 0.7-2.2). All risks were consistently increased in women with low job control. The risks were higher for preterm than for SGA deliveries. However, none of the findings were statistically significant.The influence of work-related psychosocial strain on the risk of SGA and preterm delivery seems to be small in countries with highly developed social support systems and few other work-related hazards.
