Pål Øian

A multicenter interventional program to reduce the incidence of anal sphincter tears.

OBJECTIVE: In Norway, we have experienced a gradual increase in the incidence of obstetric anal sphincter injuries from under 1% in the late 1960s to 4.3% in 2004. This study was aimed to assess whether an interventional program causes a decrease in the frequency of anal sphincter tears. METHODS: In all, 40,152 vaginal deliveries between 2003 and 2009 were enrolled in the interventional cohort study from four Norwegian obstetric departments. The focus of the intervention was on manual assistance during the final part of the second stage of labor. Data were analyzed in relation to occurrence of obstetric anal sphincter tears. RESULTS: The proportion of parturients with anal sphincter tears decreased from 4–5% to 1–2% during the study period in all four hospitals (P<.001). The tears associated with both noninstrumental and instrumental deliveries decreased dramatically. The number of patients with grades 3 and 4 anal sphincter ruptures decreased significantly, and the reduction was most pronounced in grade 4 tears (−63.5%) and least in 3c tears (−47.5%) (both P<.001). The number of episiotomies increased in two hospitals but remained unchanged in the other two. The lowest proportion of tears at the end of the intervention (1.2% and 1.3%, respectively) was found in the two hospitals with an unchanged episiotomy rate. CONCLUSION: The multicenter intervention caused a highly significant decrease in obstetric anal sphincter injuries. LEVEL OF EVIDENCE: II

Inter-observer variation in assessment of 845 labour admission tests: comparison between midwives and obstetricians in the clinical setting and two experts

Objective To assess the inter‐observer agreement in assessment of the labour admission test between midwives and obstetricians in the clinical setting and two experts in the non‐clinical setting, the inter‐observer agreement between two experts in the non‐clinical setting and to what degree fetal distress in labour could be predicted by the two experts.

Neonatal alloimmune thrombocytopenia due to anti‐HPA 1a antibodies; the level of maternal antibodies predicts the severity of thrombocytopenia in the newborn

Eleven thousand one hundred pregnant women were genotyped for human platelet antigen HPA 1, and 198 HPA 1bb women were followed in the pregnancy with quantitative assay for anti‐HPA 1a antibodies. Antibodies were detected in 24 women, and nine children were born with severe thrombocytopenia (< 50×109/L). All mothers with high levels of antibodies were delivered of children with severe thrombocytopenia. None of the newborn infants had clinical signs of intra‐cranial haemorrhage. The level of maternal anti‐HPA 1a antibodies is predictive for fetal thrombocytopenia and may be used in decisions related to time and mode of delivery.

Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case‐control study

Please cite this paper as: Stedenfeldt M, Pirhonen J, Blix E, Wilsgaard T, Vonen B, Øian P. Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case‐control study. BJOG 2012;119:724–730.

Eclampsia in Scandinavia: incidence, substandard care, and potentially preventable cases

Background. Description of incidence, clinical signs, symptoms, and consequences of eclampsia in Scandinavia, and assessment of substandard care and potential preventability. Methods. A descriptive cohort study including all women giving birth in a 2‐year period (mid‐1998–mid‐2000) in Scandinavia. Notifications of eclampsia cases were obtained from all obstetric units at 3‐monthly intervals. All patient files were reviewed, and systematic audit was performed to identify potentially preventable cases by using predefined criteria. Main outcome measures. Signs and symptoms preceding the eclamptic seizure, the standard of medical care, maternal and perinatal morbidity, and mortality were all recorded. Potentially preventable cases through improved care and cases eligible for primary prophylactic magnesium sulfate (MgSO4) were estimated. Results. The incidence of eclampsia was 5.0/10 000 maternities (CI = 4.3–5.7/10 000). Eighty‐six percent had a diagnosis of pre‐eclampsia before the seizure. Nine of 10 had at least one physical complaint before the first seizure, severe headache being the most common symptom, occurring in two‐thirds. Most seizures (90%) occurred after admission to hospital. By audit, 89 cases (42%) were classified as having received substandard care. Prophylactic use of magnesium sulfate might have reduced the number of eclampsia cases by 35 (17%). Conclusions. Eclampsia occurred mainly in hospital and the majority of women had symptoms heralding the seizure. In retrospect, nearly half of the cases were found potentially preventable by timely intervention, improved medical care, and systematic use of prophylactic treatment with MgSO4.

Why do some pregnant women prefer cesarean? The influence of parity, delivery experiences, and fear

OBJECTIVE We sought to identify predictors of preferences for cesarean among pregnant women, and estimate how different predictors influence preferences. STUDY DESIGN This was a cross-sectional study based on the Norwegian Mother and Child Cohort Study (n = 58,881). RESULTS Of the study population, 6% preferred cesarean over vaginal delivery. While 2.4% of nulliparous had a strong preference for cesarean, the proportion among multiparous was 5.1%. The probability that a woman, absent potential predictors, would have a cesarean preference was similar (<2%) for both nulliparous or multiparous. In the presence of concurrent predictors such as previous cesarean, negative delivery experience, and fear of birth, the predicted probability of a cesarean request ranged from 20-75%. CONCLUSION The proportion of women with a strong preference for cesarean was higher among multiparous than nulliparous women, but the difference was attributable to factors such as previous cesarean or fear of delivery and not to parity per se.

Prognostic value of the labour admission test and its effectiveness compared with auscultation only: a systematic review

Objective  To assess the effectiveness of the labour admission test in preventing adverse outcomes, compared with auscultation only, and to assess the tests prognostic value in predicting adverse outcomes.

Childhood abuse and fear of childbirth - a population-based study

BACKGROUND Childhood abuse affects adult health. The objective of this study was to examine the association between a self-reported history of childhood abuse and fear of childbirth. METHODS A population-based, cross-sectional study was conducted of 2,365 pregnant women at five obstetrical departments in Norway. We measured childhood abuse using the Norvold Abuse Questionnaire and fear of childbirth using the Wijma Delivery Expectancy Questionnaire. Severe fear of childbirth was defined as a Wijma Delivery Expectancy Questionnaire score of ≥ 85. RESULTS Of all women, 566 (23.9%) had experienced any childhood abuse, 257 (10.9%) had experienced emotional abuse, 260 (11%) physical abuse, and 290 (12.3%) sexual abuse. Women with a history of childhood abuse reported severe fear of childbirth significantly more often than those without a history of childhood abuse, 18 percent versus 10 percent (p = 0.001). The association between a history of childhood abuse and severe fear of childbirth remained significant after adjustment for confounding factors for primiparas (adjusted OR: 2.00; 95% CI: 1.30-3.08) but lost its significance for multiparas (adjusted OR: 1.17; 95% CI: 0.76-1.80). The factor with the strongest association with severe fear of childbirth among multiparas was a negative birth experience (adjusted OR: 5.50; 95% CI: 3.77-8.01). CONCLUSIONS A history of childhood abuse significantly increased the risk of experiencing severe fear of childbirth among primiparas. Fear of childbirth among multiparas was most strongly associated with a negative birth experience.

Placenta weight in pre‐eclampsia

Objective. Preterm and term pre‐eclampsia may differ in etiology. This could be reflected in differences in placenta weight. Therefore, we compared placenta weight in pregnancies with preterm or term pre‐eclampsia to placenta weight in pregnancies without pre‐eclampsia. Design. Population study. Setting. Medical Birth Registry of Norway. Population. All singleton pregnancies in Norway from 1999 through 2004 delivered at or after 21 weeks’ gestation (n = 317,688). Methods. Placenta weight in pregnancies without pre‐eclampsia (n = 304,875) was compared to placenta weight in pregnancies with preterm pre‐eclampsia (delivery before week 37 of pregnancy, n = 3,070) and term pre‐eclampsia (delivery on or after week 37 of pregnancy, n = 9,743). Placenta weight z‐scores were calculated to adjust for offspring sex and length of gestation, and grouped in tenths. Placenta weight according to pre‐eclampsia status is presented as proportions within each tenth. Main outcome measures. Pre‐eclampsia status. Results. In preterm pre‐eclampsia, placentas were over‐represented in the two lowest (33.8%; 95% CI 32.1–35.5) and under‐represented in the two highest (13.1%; 95% CI 11.9–14.3) tenths of placenta weight compared to pregnancies without pre‐eclampsia (20%). In term pre‐eclampsia, placentas were over‐represented in the two lowest (22.0%; 95% CI 21.2–22.8) and the two highest (22.7%; 95% CI 21.9–23.6) placenta weight groups. Mean placenta weight z‐score was higher in term pre‐eclampsia compared to pregnancies without pre‐eclampsia. Conclusions. Small placentas were associated with pre‐eclampsia, and more strongly with preterm than term pre‐eclampsia. In term pre‐eclampsia, the association with placenta weight was u‐shaped, yielding higher proportions of both low and high placenta weight compared to pregnancies without pre‐eclampsia.

Hormone replacement therapy reduces the reactivity of monocytes and platelets in whole blood — A beneficial effect on atherogenesis and thrombus formation?

OBJECTIVE Our purpose was to investigate the effects of hormone replacement therapy on the reactivity of monocytes and platelets in whole blood, measured by tissue factor activity, tumor necrosis factor-alpha, and thromboxane B2. STUDY DESIGN Thirty-two women were randomized into either transdermal or oral combined hormone replacement therapy and underwent blood sampling before and after 3 and 12 months of treatment. The tissue factor activity in monocytes was measured both in unstimulated whole blood and after a weak lipopolysaccharide stimulation. Tumor necrosis factor-alpha and thromboxane B2 formation in plasma were measured after a weak lipopolysaccharide stimulation of whole blood. RESULTS After 12 months of hormone replacement therapy there were significant reductions of tissue factor activity in both unstimulated and lipopolysaccharide-stimulated monocytes (p < 0.001) and significant reductions in the formation of tumor necrosis factor-alpha (p < 0.03) and thromboxane B2 (p < 0.02). There were no differences in these parameters between the transdermal and the oral groups. No changes were observed after 3 months of therapy. CONCLUSION Twelve months of hormone replacement therapy reduces cellular activation of blood monocytes and platelets; these changes may account for some of the beneficial effects in reducing the risk of cardiovascular disease.