Astrid Nystedt

Cesarean Section without Medical Reason, 1997 to 2006: A Swedish Register Study

BACKGROUND Cesarean section performed in the absence of medical indication is of concern in many countries, but studies focusing on its prevalence are inconclusive. The objective of this study was, first, to describe the prevalence of cesarean section without medical reason in terms of the diagnostic code listed in the Swedish Medical Birth Register, and to assess its contribution to the general increase in the number of cesarean sections; and second, to study regional differences and differences in the maternal characteristics of women having a cesarean birth with this diagnostic code. METHODS Birth records of 6,796 full-term cesarean sections in two Swedish regions with the diagnostic code O828 were collected from the Swedish Medical Birth Register. Descriptive data, t test, and logistic regression analysis were used to analyze data. RESULTS The rate of cesarean sections without medical indication increased threefold during the 10-year period, but this finding represents a minor contribution to the general increase in the number of cesarean sections. The diagnostic code O828 was more common in the capital area (p<0.001). Secondary diagnoses were found, the most frequent of which were previous cesarean section and childbirth-related fear. Regional differences existed concerning prevalence, classification, maternal sociodemographic, obstetric, and health variables. CONCLUSIONS The rate of cesarean sections without medical reasons in terms of the diagnostic code O828 increased during the period. The prevalence and maternal characteristics differed between the regions. Medical code classification is not explicit when it comes to defining cesarean sections without medical reasons and secondary diagnoses are common.

A comparative study of the experience of childbirth between women who preferred and had a caesarean section and women who preferred and had a vaginal birth

OBJECTIVE The aim of this study was to compare experiences and feelings during pregnancy and childbirth in women who preferred caesarean section during pregnancy and were delivered by a planned caesarean section, and women who preferred to give birth vaginally and actually had a spontaneous vaginal birth. DESIGN Longitudinal cohort study where 693 women participated, 420 of whom were multiparas. METHODS Data were collected from questionnaires distributed to women during pregnancy and two months postpartum in a Mid Sweden county. RESULTS Women who preferred and actually were delivered by caesarean section experienced a fear of childbirth to a higher degree as compared to women with a vaginal birth. Despite a fulfilled request, women who had a caesarean section were not pleased with the decision making process. In addition, women who had a caesarean section on request were less satisfied with antenatal care and had a more negative birth experience, which made them doubt whether they would have more children. CONCLUSIONS This study shows that a fulfilled request on mode of birth does not guarantee a positive birth experience. Antenatal information of all aspects of a caesarean section is vital for women who consider caesarean section where no medical indication is present. More research is needed about the decision making process regarding caesarean section on maternal request. Childbirth related fear is a common reason to request a caesarean birth. More knowledge about how women reason about caesarean section is required, and treatment related to fear of birth needs to be developed.

Women’s experiences of induction of labour – Findings from a Swedish regional study

Background:  Induction of labour is common in modern obstetrics but its impact on women’s birth experiences is inconclusive.

Diverse definitions of prolonged labour and its consequences with sometimes subsequent inappropriate treatment

BackgroundProlonged labour very often causes suffering from difficulties that may have lifelong implications. This study aimed to explore the prevalence and treatment of prolonged labour and to compare birth outcome and women’s experiences of prolonged and normal labour.MethodWomen with spontaneous onset of labour, living in a Swedish county, were recruited two months after birth, to a cross-sectional study. Women (n = 829) completed a questionnaire that investigated socio-demographic and obstetric background, birth outcome and women’s feelings and experiences of birth. The prevalence of prolonged labour, as defined by a documented ICD-code and inspection of partogram was calculated. Four groups were identified; women with prolonged labour as identified by documented ICD-codes or by partogram inspection but no ICD-code; women with normal labour augmented with oxytocin or not.ResultsEvery fifth woman experienced a prolonged labour. The prevalence with the documented ICD-code was (13%) and without ICD-code but positive partogram was (8%). Seven percent of women with prolonged labour were not treated with oxytocin. Approximately one in three women (28%) received oxytocin augmentation despite having no evidence of prolonged labour. The length of labour differed between the four groups of women, from 7 to 23 hours.Women with a prolonged labour had a negative birth experience more often (13%) than did women who had a normal labour (3%) (P <0.00). The factors that contributed most strongly to a negative birth experience in women with prolonged labour were emergency Caesarean section (OR 9.0, 95% CI 1.2-3.0) and to strongly agree with the following statement ‘My birth experience made me decide not to have any more children’ (OR 41.3, 95% CI 4.9-349.6). The factors that contributed most strongly to a negative birth experience in women with normal labour were less agreement with the statement ‘It was exiting to give birth’ (OR 0.13, 95% CI 0.34-0.5).ConclusionsThere is need for increased clinical skill in identification and classification of prolonged labour, in order to improve care for all women and their experiences of birthing processes regardless whether they experience a prolonged labour or not.

Women’s postoperative experiences before and after the introduction of spinal opioids in anaesthesia for caesarean section

AIM The aim was to evaluate a new anaesthetic routine and to study the effect of spinal opioids for caesarean section on postoperative pain, expectations of pain, satisfaction with pain treatment, breastfeeding, infant care and length of hospital stay. BACKGROUND Inadequate postoperative pain relief is a problem among hospitalised patients. Women undergoing caesarean section have been shown to experience high levels of pain during the first days after operation. Women are expected to breastfeed and care for their newborn while recovering from major abdominal surgery and sufficient pain relief are of importance. DESIGN Comparative patient survey. METHODS Data were collected through a questionnaire distributed to two independent samples of women undergoing elective and emergency caesarean section before and after the introduction of an additive of opioids in obstetric spinal anaesthesia. Chi-square tests were performed, and risk ratios were used for bivariate analysis. Logistic regression modelling was used for multivariate analysis. RESULTS The group of women undergoing caesarean section with opioids added to the spinal anaesthesia reported significantly lower levels of experienced pain. High pain levels irrespective of mode of caesarean section affected breastfeeding and infant care. Length of hospital stay for caesarean women was shortened and the consumption of analgesics was reduced. CONCLUSIONS Women receiving an additive of opioids in spinal anaesthesia experienced lower levels of pain. Low pain levels facilitate breastfeeding and infant care and are of relevance for financial considerations. RELEVANCE TO CLINICAL PRACTICE The results of this study indicate that spinal opioids for women undergoing caesarean section have a positive effect on the postoperative pain experience. Women undergoing caesarean section and have high pain levels are in special need of attention and care because of a higher risk of a decreased ability to breastfeed and to take care of their newborn.

Presence and process of fear of birth during pregnancy—Findings from a longitudinal cohort study

BACKGROUND The prevalence of fear of birth has been estimated between 8-30%, but there is considerable heterogeneity in research design, definitions, measurement tools used and populations. There are some inconclusive findings about the stability of childbirth fear. AIM to assess the prevalence and characteristics of women presenting with scores ≥60 on FOBS-The Fear of Birth Scale, in mid and late pregnancy, and to study change in fear of birth and associated factors. METHODS A prospective longitudinal cohort study of a one-year cohort of 1212 pregnant women from a northern part of Sweden, recruited in mid pregnancy and followed up in late pregnancy. Fear of birth was assessed using FOBS-The fear of birth scale, with the cut off at ≥60. FINDINGS The prevalence of fear of birth was 22% in mid pregnancy and 19% in late pregnancy, a statistically significant decrease. Different patterns were found where some women presented with increased fear and some with decreased fear. The women who experienced more fear or less fear later in pregnancy could not be differentiated by background factors. CONCLUSIONS More research is needed to explore factors important to reduce fear of childbirth and the optimal time to measure it.