Mothers’ Level of Education and Childbirth Interventions: A Population‐based Study in Flanders,Northern Belgium

Abstract: Background: Interventions to influence the time and way to be born have been a global concern for decades. Yet, limited information is available on what drives these interventions and their variation in frequency among countries, institutions, and practitioners. The objective of this study was to examine to what extent first‐time mothers’ educational achievement contributes to the frequency of childbirth interventions. Methods: Childbirth interventions, including induction of labor, cesarean section, instrumental delivery, and epidural analgesia, registered by the Flemish Study Center for Perinatal Epidemiology for Belgian‐born nulliparous women from 1999 to 2006, were linked to the level of maternal education, recorded by the Belgian civil birth registration. Education was divided into four levels based on the highest diploma attained and adjusted for marital and occupational status. Results: Frequencies of all interventions were inversely related to the level of maternal education. The effect remained after adjustment for birth year, maternal age, marital status, occupation, infant birthweight, gestational age, assisted conception, and type of hospital. Effect sizes between highest and lowest levels of education were relatively small for operative (31% vs 36%) and instrumental vaginal birth (20.7% vs 22.3%) compared with “initiated delivery” (defined as labor induction and prelabor cesarean section; 30.2% vs 40.3%) and epidural analgesia (66.8% vs 78.0%). The educational gradient in initiated delivery occurred at all gestational ages, contributing to lower gestational age and lower birthweight of term infants with decreasing levels of education. Conclusions: In an affluent society with universal and equitable access to maternity care, the more educated women are, the more likely they are to have a spontaneous labor and spontaneous birth without intervention. (BIRTH 38:3 September 2011)     

Qualitative analysis by interviews and video recordings to establish the components of a skilled low-cavity non-rotational vacuum delivery

Objectives  The objectives of this study were to define the components of a skilled low-cavity non-rotational vacuum delivery (occiput anterior, vertex at station +2 or below and less than 45-degree rotation from midline) and to facilitate the transfer of skills from expert to trainee obstetricians.
Design  Qualitative study using interviews and video recordings.
Setting  Two university teaching hospitals (St Michael's Hospital, Bristol, and Ninewell's Hospital, Dundee).
Participants  Ten obstetricians and eight midwives identified as experts in conducting or supporting operative vaginal deliveries.
Methods  Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low-cavity vacuum deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and compared for consistency of interpretation. The experts reviewed the coded interviews and video data for respondent validation and clarification. The themes that emerged following the final coding were used to formulate a list of skills.
Main outcome measures  Key technical skills of a low-cavity non-rotational delivery.
Results  The final list included detailed technical skills required for conducting a low-cavity vacuum delivery. The combination of semi-structured interviews and simulation videos allowed the formulation of a comprehensive skills tool for future evaluation.
Conclusion  This explicitly defined skills list could aid trainees understanding of the technique of low-cavity vacuum delivery. This is an important first step in evaluating clinical competence in intrapartum procedures.     

A case of laparoscopy-assisted vaginal cuff suturing for vaginal cuff dehiscence after total laparoscopic hysterectomy

IntroductionVaginal cuff dehiscence after hysterectomy is a rare complication and occurs in less than 1% of patients. It can present with serious complications, such as bowel evisceration and peritonitis.Presentation of caseA 51-year-old multigravida Korean woman underwent total laparoscopic hysterectomy for leiomyoma. Six months later, she reported lower abdominal pain and vaginal bleeding. Physical examination revealed rebound tenderness in the lower abdomen, and pelvic examination showed a small amount of vaginal bleeding with an evisceration of the small intestine through the vagina that exhibited healthy peristalsis. The eviscerated bowel, which seemed to be a part of the ileum, was carefully manually reduced transvaginally into the abdominal cavity. Laparoscopic observation revealed adhesions between the omentum, small intestine, and the peritoneum. Specifically, the small intestine was adhered around the vaginal cuff. An abdominal abscess was found in the left lower abdominal cavity. An adhesiotomy was performed and the abdominal abscess was removed and irrigated. Complete separation of the anterior and posterior vaginal cuff edges was obtained. The vaginal cuff was closed with interrupted 0-polydioxanone absorbable sutures without bowel injury. A 6-month follow-up examination revealed complete healing of the vaginal cuff.DiscussionIn this case, we were able to make use of both laparoscopic and transvaginal methods to perform a successful repair with a minimally invasive and safe technique.ConclusionLaparoscopically assisted vaginal cuff suturing for vaginal cuff dehiscence after total laparoscopic hysterectomy was found to be effective, safe, and minimally invasive.     

Are Asian American women at higher risk of severe perineal lacerations?

Objective: To evaluate whether Asian race is an independent risk factor for severe perineal lacerations.

Methods: We performed a nationwide population-based retrospective cohort study examining the relationship between Asian race and severe perineal lacerations (third and fourth degree). The data were collected from the 2012 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). Characteristics of Asian American women were compared with those of non-Asian women. The primary outcome of interest was severe perineal lacerations. Multivariable logistic regression was used to refine the associations between Asian race and severe perineal lacerations while adjusting for confounding effects. Results were compared with previously published data using a pooled odds ratio.

Results: 2,270,044 Women with singleton vaginal deliveries were identified, and 120,452 (5.3%) were Asian. After adjusting for confounders, Asian women were more likely to experience severe perineal lacerations than any other racial group (3.5% versus 6.3%, adjusted odds ratio [aOR] 1.50, 99% CI 1.29–1.74, p?p?Conclusion: Asian race is an independent risk factor for severe perineal lacerations in the United States.     

自由体位对阴道分娩的影响分析

目的:研究阴道分娩过程中采取自由体位对促进自然分娩、降低剖宫产手术率的作用。方法:选择本院2015年4至7月706例产妇为观察组,在产妇入产房分娩过程中采取自由体位(即卧、走、立、坐、跪、趴、蹲,任孕妇自由选择)分娩。601例产妇为对照组,采用常规体位分娩。观察两组产妇各产程时间、产程中用药、分娩方式、新生儿出生Apgar评分、产后出血、产伤等指标,并对其进行对比分析。结果:自由体位分娩组较常规体位分娩组第一、第二产程时间缩短,产程中干预明显减少,剖宫产率明显下降,差异有统计学意义。产后出血及产伤、新生儿窒息率无统计学差异。结论:自由体位阴道分娩可提高阴道分娩率,降低剖宫产率,同时不增高对胎儿及产妇的不良预后。     

The association between nitroglycerin use and adverse outcomes in women undergoing cesarean delivery in the second stage of labor

Objective: To identify predictors of hysterotomy extension in women undergoing cesarean delivery (CD) in the second stage of labor, and whether use of nitroglycerin (NTG) during CD has a protective effect.

Methods: We conducted a retrospective cohort study of women undergoing CD in the second stage of labor from 2012 to 2015. Some women received NTG at the obstetrician’s request. Logistic regression was used to examine the relationship between second stage duration and NTG administration on maternal and neonatal outcomes.

Results: Of the 391 women in the sample, 27% had an extension and 12% received NTG. Second stage?≥4?h was associated with a 2.14-fold higher risk of extension (95% CI 1.22–3.75), a 2.00-fold higher risk of hemorrhage (95% CI: 1.20–3.33) and 2.42-fold higher risk of blood transfusion during delivery hospitalization (95% CI: 0.99–5.91). Intravenous (IV) and sublingual-spray (SL-spray) NTG administration were not associated with an increased risk of hemorrhage or extension. SL-NTG was associated with 4.68-fold increased odds of 5-min Apgar?<7 (95% CI 1.42–15.41) and 3.36-fold greater odds of NICU admission (95% CI 1.20–9.41).

Conclusion: We found no evidence that NTG protects against extension, and SL-NTG use was associated with adverse neonatal outcomes. Clinical trials should be conducted to evaluate risk and benefits of NTG use.     

Effect of daytime,weekday and year of admission on outcome in acute ischaemic stroke patients treated with thrombolytic therapy

Background: Since doubts were raised, if a challenging medical procedure such as acute stroke treatment including thrombolysis with recombinant tissue plasminogen activator (rTPA) is available with identical standard and outcome 24 h and 7 days a week our aim was to examine if acute stroke patients defined by onset‐admission time (OAT) of ≤ 3 h were treated differently or had distinct outcome when admitted during off duty hours (day versus night and weekend versus weekdays) and if any differences in treatment or outcome were apparent when comparing patients admitted in the year 2003 with patients admitted in the year 2006. Methods: We analyzed 2003–2006 data of a prospective registry and grouped patients by time, day, and year of admission. The evaluation was limited to patients that were diagnosed with ischaemic stroke and with OAT of ≤ 3 h. Medical and sociodemographic items, use of thrombolytic treatment, complications during clinical course and place of discharge were obtained. Clinical state on admission and discharge was assessed using the modified Rankin scale. Comparison with chi‐square test, t‐test and logistic regression was performed. Results: Patient’s characteristics, rate of thrombolysis, and outcome were independent from time or day of admission. Proportion of patients with good clinical state at discharge increased significantly from 2003 to 2006 together with a higher rate of rTPA treatment without increase of intracranial hemorrhage. Proportion of patients discharged in good clinical condition after rTPA treatment increased from 34% to 44%. Conclusions: Stroke treatment in potential candidates for thrombolytic therapy revealed no impairment on weekend or at night already in 2003. During 4 years, it was possible to increase rate of rTPA treatment from 8.9% to 21.8% without increment of complications or death, confirming that rTPA is safe and can be implemented with full daily and weekly coverage.     

Developmental toxicity of nicotine: A transdisciplinary synthesis and implications for emerging tobacco products

While the health risks associated with adult cigarette smoking have been well described, effects of nicotine exposure during periods of developmental vulnerability are often overlooked. Using MEDLINE and PubMed literature searches, books, reports and expert opinion, a transdisciplinary group of scientists reviewed human and animal research on the health effects of exposure to nicotine during pregnancy and adolescence. A synthesis of this research supports that nicotine contributes critically to adverse effects of gestational tobacco exposure, including reduced pulmonary function, auditory processing defects, impaired infant cardiorespiratory function, and may contribute to cognitive and behavioral deficits in later life. Nicotine exposure during adolescence is associated with deficits in working memory, attention, and auditory processing, as well as increased impulsivity and anxiety. Finally, recent animal studies suggest that nicotine has a priming effect that increases addiction liability for other drugs. The evidence that nicotine adversely affects fetal and adolescent development is sufficient to warrant public health measures to protect pregnant women, children, and adolescents from nicotine exposure.