Hanne Kjærgaard

Association between maternal weight gain and birth weight

OBJECTIVE: To investigate the association between maternal weight gain and birth weight less than 3,000 g and greater than or equal to 4,000 g in underweight (body mass index [BMI] less than 19.8 kg/m2), normal weight (BMI 19.8–26.0 kg/m2), overweight (BMI 26.1–29.0 kg/m2), and obese (BMI greater than 29.0 kg/m2) women, with emphasis on the use of the American Institute of Medicine (IOM) recommendations in Denmark. METHODS: We analyzed data from 2,248 women with singleton, term pregnancies. The relationship between weight gain and risk of birth weight less than 3,000 g and greater than or equal to 4,000 g was examined in the four BMI groups, and use of IOM recommendations was tested by logistic regression analyses. RESULTS: We found an inverse relationship between maternal weight gain and the proportion of infants with a birth weight less than 3,000 g. Birth weight greater than or equal to 4,000 g increased with an increasing weight gain in underweight and normal-weight women, but the association was less apparent in overweight and obese women. Underweight women seemed to benefit from gaining more weight than recommended by the IOM, because the odds ratio (OR) of birth weight less than 3,000 g was 0.3 (95% confidence interval [CI] 0.1–0.9) and the OR was 1.7 for birthweight greater than or equal to 4,000 g (95% CI 0.8–3.6). The normal-weight women had an increased risk of birth weight less than 3,000 g (OR 2.4, 95% CI 1.5–3.7) if weight gain was below the recommended range, and the OR of birth weight greater than or equal to 4,000 g was 1.9 (95% CI 1.5–2.5) when the women gained more than recommended. CONCLUSION: The IOM recommendations may provide a basis for Danish recommendations to pregnant women, although the upper recommended limit for underweight women may have to be increased. LEVEL OF EVIDENCE: II

Multimodal intervention raises smoking cessation rate during pregnancy.

Background.  The aim was to study the effect of a multimodal smoking cessation intervention regimen on a number of pregnant smokers.

Incidence and outcomes of dystocia in the active phase of labor in term nulliparous women with spontaneous labor onset

Objective. To estimate the incidence of dystocia among nulliparous women without apparent co‐morbidity and to examine maternal and fetal short‐term outcomes after dystocia. Design. A multi‐center cohort study with prospectively collected data. Setting. Nine obstetric departments with annual birth rates between 850 and 5,400. Population. Low‐risk nulliparous women in term spontaneous labor with a singleton fetus in cephalic presentation. Methods. Follow‐up of 2,810 nulliparas using self‐administered questionnaires supplemented with clinical records. Criteria for dystocia. Cervical dilatation ≤2 cm over four hours during the first stage of labor or no descent during two hours (three hours with epidural analgesia) in the descending phase of second stage or no progress for one hour during the expulsive phase of the second stage. Inclusion took place between May 2004 and July 2005. Main outcome measures. Incidences of dystocia, maternal, and fetal outcomes. Results. The cumulative incidence of dystocia was 37% and of the diagnoses 61% were given in the second stage of labor. Women with dystocia treated by augmentation had more cesarean and ventouse deliveries, more often non‐clear amniotic fluid, more post‐partum hemorrhage and their children were more often given low one‐minute neonatal Apgar scores as compared to women delivered without a diagnosis of dystocia. Conclusions. A dystocia incidence of 37% was found in healthy term nulliparas with no indication for induction or elective cesarean delivery. The adverse maternal and neonatal birth outcomes may be related to the cause of dystocia or to augmentation of labor and this question calls for further studies.

The effect of environmental tobacco smoke during pregnancy on birth weight.

Background. This study explores whether pregnant nonsmokers’ exposure to environmental tobacco smoke (ETS) affects the average birth weight at term.

Obstetric risk indicators for labour dystocia in nulliparous women: A multi-centre cohort study

BackgroundIn nulliparous women dystocia is the most common obstetric problem and its etiology is largely unknown. The frequency of augmentation and cesarean delivery related to dystocia is high although it is not clear if a slow progress justifies the interventions. Studies of risk factors for dystocia often do not provide diagnostic criteria for the diagnosis. The aim of the present study was to identify obstetric and clinical risk indicators of dystocia defined by strict and explicit criteria.MethodsA multi-centre population based cohort study with prospectively collected data from 2810 nulliparous women in term spontaneous labour with a singleton infant in cephalic presentation. Data were collected by self-administered questionnaires and clinical data-records. Logistic regression analyses were used to estimate adjusted Odds Ratios (OR) and 95% confidence intervals (CI) are given.ResultsThe following characteristics, present at admission to hospital, were associated with dystocia during labour (OR, 95% CI): dilatation of cervix < 4 cm (1.63, 1.38–1.92), tense cervix (1.31, 1.04–1.65), thick lower segment (1.32, 1.09–1.61), fetal head above the inter-spinal diameter (2.29, 1.80–2.92) and poor fetal head-to-cervix contact (1.83, 1.31–2.56). The use of epidural analgesia (5.65, 4.33–7.38) was also associated with dystocia.ConclusionVaginal examinations at admission provide useful information on risk indicators for dystocia. The strongest risk indicator was use of epidural analgesia and if part of that is causal, it is of concern.

Fear of childbirth in obstetrically low‐risk nulliparous women in Sweden and Denmark

The prevalence of troublesome fear of childbirth (FOC) in Western countries is about 20%, of which approximately 6–10% suffer from severe FOC that impacts daily life. The countries of Sweden and Denmark are quite alike as far as childbirth culture is concerned. However, to some extent they differ in the organisation of midwifery care during the antenatal and labour period, respectively, and this may influence womens FOC. The aims of this study were to compare FOC among Danish and Swedish nulliparous women and to investigate a possible difference in FOC between women who, during pregnancy, had met the midwife who they were subsequently coincidentally allocated to receive labour care from and women who had not previously met the midwife. In total 165 women participated, comprising 55 Swedes and 110 Danes, of whom 55 among the latter group had met the midwife during pregnancy. Severe FOC was found in 10%. There were no differences between the Swedish women and the Danish women who had or had not met the midwife. Fear of childbirth measured in gestational week 37 correlated positively with fear at admission to the labour ward.

Sports and Leisure Time Physical Activity During Pregnancy in Nulliparous Women.

To describe patterns of leisure time physical activity during pregnancy in relation to pre-pregnancy leisure time physical activity, socio-demographic characteristics, fertility history, and lifestyle factors. 4,718 nulliparous with singleton pregnancy and intended spontaneous vaginal delivery were included in the study at gestational week 33 from May 2004 to July 2005. Information was provided by self-administered questionnaires. Leisure time physical activity was categorised into four categories: competitive sport, moderate-to-heavy, light or sedentary. In this population of nulliparous women, 4% participated in competitive sport, 25% in moderate-to-heavy activities, 66% in light activities, and 5% in sedentary activities in the year prior to pregnancy. Physical activity before pregnancy was statistically significantly associated with age, pre-pregnancy BMI, chronic diseases, number of years at school, and smoking habits. The proportion of women who took part in competitive sports, and moderate-to-heavy activities decreased over the three trimesters of pregnancy. The proportion of women with light physical activity was stable during pregnancy while the proportion of women with sedentary activity increased from 6% to 29%. During the third trimester women performing competitive sports or moderate-to-heavy activities before pregnancy continued to have a higher level of physical activity than women with light activities or sedentary activities before pregnancy. In general the intensity and time spent on exercise decreased during pregnancy. Women with the highest level of exercise prior to pregnancy continued to be the most active during pregnancy. Among women with sedentary activities before pregnancy one-fourth changed to light activity during pregnancy.

Experiences of physical activity during pregnancy in Danish nulliparous women with a physically active life before pregnancy. A qualitative study

BackgroundNational guidelines recommend that healthy pregnant women take 30 minutes or more of moderate exercise a day. Most women reduce the level of physical activity during pregnancy but only a few studies of womens experiences of physical activity during pregnancy exist. The aim of the present study was to elucidate experiences and views of leisure time physical activity during pregnancy in nulliparous women who were physically active prior to their pregnancy.MethodsA qualitative study was conducted by means of personal interviews. Nineteen women, all with a moderate pre-pregnancy level of physical activity but with different levels of physical activity during pregnancy, participated in the study. Content analysis was applied.ResultsIn the analyses of experiences and views of physical activities during pregnancy, four categories and nine sub-categories were developed: Physical activity as a lifestyle (Habit and Desire to continue), Body awareness (Pregnancy-related discomfort, Having a complicated pregnancy and A growing body), Carefulness (Feelings of worry and Balancing worry and sense of security) and Sense of benefit (Feelings of happiness and Physical well-being).ConclusionAs other studies have also shown, women find that the discomfort and complications associated with pregnancy, the growing body, and a sense of insecurity with physical activity are barriers to maintaining former levels of physical activity. This study adds a new perspective by describing womens perceptions of these barriers and of overcoming them - thus, when pregnant, the majority of the women do not cease to be physically active but continue to be so. Barriers are overcome by applying ones own experience, looking to role models, mirroring the activities of other pregnant women and following the advice of experts (midwives/physiotherapists). Women then continue to be physically active during pregnancy, most often to a lesser extent or in alternative activities, and derive considerable enjoyment and physical well-being from this.

Mode of Delivery after Epidural Analgesia in a Cohort of Low-Risk Nulliparas

BACKGROUND   Although epidural analgesia is widespread and very effective for alleviating labor pain, its use is still controversial, as the literature is inconsistent about the risk of adverse birth outcome after administration of epidural analgesia. The aim of this study was to explore associations between epidural analgesia and mode of delivery. METHODS   Data were obtained from a prospective cohort from nine Danish labor wards and comprised 2,721 term nulliparous women with spontaneous onset of labor and a singleton fetus in cephalic presentation. Information about epidural analgesia, mode of delivery, and birth complications was obtained by the staff attending labor. Additional information was provided from self-administered questionnaires in gestational week 37. Multiple logistic regression analyses were used to estimate the association between epidural analgesia and birth outcomes. Results are presented as crude and adjusted odds ratios (OR [95% CI]). RESULTS   Of the total cohort, 21.6 percent required epidural analgesia, 8.7 percent had emergency cesarean section, and 14.9 percent had vacuum extraction. Women with epidural analgesia had a higher risk of emergency cesarean section (adjusted OR: 5.8; 95% CI: 4.1-8.1), and vacuum extraction (adjusted OR: 1.7; 95% CI: 1.3-2.2). In a subgroup of the cohort with a very low overall risk of cesarean section, 3.4 percent had emergency cesarean section and an increased risk of emergency cesarean section was also found in this group (adjusted OR: 3.5; 95% CI: 1.5-8.2). CONCLUSIONS   In nulliparous women of a very low-risk population, use of epidural analgesia for labor pain was associated with higher risks of emergency cesarean section and vacuum extraction.

Determination of a saliva cotinine cut‐off to distinguish pregnant smokers from pregnant non‐smokers

Background. Objective validation of smoking status is necessary. Earlier studies have used saliva cotinine concentrations between 14.2 and 30 ng/ml as cut‐off values to distinguish pregnant smokers from non‐smokers. However, these cut‐offs derive from studies including men and non‐pregnant women. This constitutes a problem, as recent studies have reported an accelerated metabolism in pregnant smokers. The aim of this study was to determine the optimum cut‐off cotinine level distinguishing pregnant smokers from pregnant non‐smokers. Methods. An observational study of 620 pregnant women, 359 self‐reported smokers and 261 self‐reported non‐smokers, with complete data on smoking status and saliva cotinine. The study was conducted at a large university hospital in Copenhagen, Denmark. Saliva was sampled at the first antenatal visit to the midwife and analyzed for cotinine level by gas chromatography. Participants completed a questionnaire immediately after the first visit. Results. A saliva cotinine cut‐off level of 13 ng/ml, corresponding to a sensitivity of 0.99 and specificity 0.98, was found to be the optimum cut‐off value separating pregnant smokers from non‐smokers. The sum of the sensitivity and specificity was at its maximum, 1.981. A 95% bootstrap confidence interval for the optimum cut‐off was (8–14 ng/ml). Conclusion. From the present data we recommend that in future studies on smoking cessation and pregnancy a cut‐off level of 13 ng/ml should be applied to distinguish between pregnant smokers and non‐smokers.