Per E. Børdahl

Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement.

BackgroundWomen experiencing decreased fetal movements (DFM) are at increased risk of adverse outcomes, including stillbirth. Fourteen delivery units in Norway registered all cases of DFM in a population-based quality assessment. We found that information to women and management of DFM varied significantly between hospitals. We intended to examine two cohorts of women with DFM before and during two consensus-based interventions aiming to improve care through: 1) written information to women about fetal activity and DFM, including an invitation to monitor fetal movements, 2) guidelines for management of DFM for health-care professionals.MethodsAll singleton third trimester pregnancies presenting with a perception of DFM were registered, and outcomes collected independently at all 14 hospitals. The quality assessment period included April 2005 through October 2005, and the two interventions were implemented from November 2005 through March 2007. The baseline versus intervention cohorts included: 19,407 versus 46,143 births and 1215 versus 3038 women with DFM, respectively.ResultsReports of DFM did not increase during the intervention. The stillbirth rate among women with DFM fell during the intervention: 4.2% vs. 2.4%, (OR 0.51 95% CI 0.32–0.81), and 3.0/1000 versus 2.0/1000 in the overall study population (OR 0.67 95% CI 0.48–0.93). There was no increase in the rates of preterm births, fetal growth restriction, transfers to neonatal care or severe neonatal depression among women with DFM during the intervention. The use of ultrasound in management increased, while additional follow up visits and admissions for induction were reduced.ConclusionImproved management of DFM and uniform information to women is associated with fewer stillbirths.

Trends in Risk Factors for Obstetric Anal Sphincter Injuries in Norway

OBJECTIVE: To investigate risk factors for obstetric anal sphincter injuries in a large population-based data set, and to assess to what extent changes in these risk factors could account for trends in obstetric anal sphincter injuries. METHODS: This is a population-based cohort study on data from the Medical Birth Registry of Norway between 1967 and 2004, including all vaginal singleton deliveries of vertex-presenting fetuses weighing 500 g or more. Women with their first birth before 1967 and births with previous obstetric anal sphincter injuries were excluded, leaving 1,673,442 births for study. The outcome variable was third- and fourth-degree obstetric anal sphincter injuries. The associations of obstetric anal sphincter injuries with possible risk factors were estimated by odds ratios (ORs) obtained by logistic regression. RESULTS: The occurrence of obstetric anal sphincter injuries increased from 0.5% in 1967 to 4.1% in 2004. After adjusting for demographic and other risk factors, as well as possible confounders, the increase of obstetric anal sphincter injuries persisted, although reduced (unadjusted OR 7.1; 95% confidence interval [CI] 6.8–7.4; adjusted OR 5.6; 95% CI 5.3–5.9). Obstetric anal sphincter injuries were significantly associated with maternal age 30 years or older, vaginal birth order of one, previous cesarean delivery, instrumental delivery, episiotomy, type 1 diabetes, gestational diabetes, induction of labor by prostaglandin, size of maternity unit, birth weight 3,500 g or more, head circumference 35 cm or more, and African or Asian country of birth. CONCLUSION: Risk of obstetric anal sphincter injuries considerably increased in Norway in 1967 to 2004. Changes in the risk factors studied could only partially explain this increase. LEVEL OF EVIDENCE: II

Maternal characteristics and pregnancy outcomes in women presenting with decreased fetal movements in late pregnancy

Objective. ‘Normal’ fetal activity is recognized as a sign of fetal well‐being and concerns for decreased fetal movements is a frequent cause of non‐scheduled antenatal visits. The aim of this study was to identify maternal characteristics in women presenting decreased fetal movements in a total population, to identify the risk of adverse outcomes and assess the management provided. Design. Prospective population‐based cohort. Setting. Fourteen delivery units in Norway. Population. A total of 2,374 pregnancies presenting with a perception of decreased fetal movements and 614 control/referent cases. Methods. All singleton third trimester pregnancies presenting with a perception of decreased fetal movements were registered from June 2004 through October 2005. Pregnancies never examined for this condition were collected as a cross‐sectional sample from the same population. Main outcome measures. Fetal growth restriction, preterm birth and stillbirth. Results. Mothers with decreased fetal movements were more often smokers, overweight and primiparous. Of the women, 32% presented with perceived absence of fetal movements, of whom 25% waited for more than 24 hours without any movements. Abnormal findings were identified in 16% of examinations. Decreased fetal movements were associated with adverse pregnancy outcome in 26%, including preterm birth and fetal growth restriction. An intervention or repeated consultations were performed in 41% of cases, including 14% admissions to maternity ward. None of the included hospitals had written guidelines for management. Conclusions. A perception of decreased fetal movements is significantly associated with adverse pregnancy outcome such as preterm birth, fetal growth restriction and stillbirth. Guidelines for management and information to pregnant women are needed.

Management of Decreased Fetal Movements

Maternal perception of decreased fetal activity is a common complaint, and one of the most frequent causes of unplanned visits in pregnancy. No proposed definitions of decreased fetal movements have ever been proven to be superior to a subjective maternal perception in terms of identifying a population at risk. Women presenting with decreased fetal movements do have higher risk of stillbirth, fetal growth restriction, fetal distress, preterm birth, and other associated outcomes. Yet, little research has been conducted to identify optimal management, and no randomized controlled trials have been performed. The strong associations with adverse outcome suggest that adequate management should include the exclusion of both acute and chronic conditions associated with decreased fetal movements. We propose guidelines for management of decreased fetal movements that include both a nonstress test and an ultrasound scan and report findings in 3014 cases of decreased fetal movements.

Implementation of Uniform Information on Fetal Movement in a Norwegian Population Reduced Delayed Reporting of Decreased Fetal Movement and Stillbirths in Primiparous Women - A Clinical Quality Improvement

BackgroundDelayed maternal reporting of decreased fetal movement (DFM) is associated with adverse pregnancy outcomes. Inconsistent information on fetal activity to women during the antenatal period may result in delayed reporting of DFM. We aimed to evaluate an intervention of implementation of uniform information on fetal activity to women during the antenatal period.MethodsIn a prospective before-and-after study, singleton women presenting DFM in the third trimester across 14 hospitals in Norway were registered. Outcome measures were maternal behavior regarding reporting of DFM, concerns and stillbirth. In addition, cross-sectional studies of all women giving birth were undertaken to assess maternal concerns about fetal activity, and population-based data were obtained from the Medical Birth Registry Norway.ResultsPre- and post-intervention cohorts included 19 407 and 46 143 births with 1 215 and 3 038 women with DFM respectively. Among primiparous women with DFM, a reduction in delayed reporting of DFM (≥48 hrs) OR 0.61 (95% CI 0.47-0.81) and stillbirths OR 0.36 (95% CI 0.19-0.69) was shown in the post-intervention period. No difference was shown in rates of consultations for DFM or maternal concerns. Stillbirth rates and maternal behavior among women who were of non-Western origin, smokers, overweight or >34 years old were unchanged.ConclusionsUniform information on fetal activity provided to pregnant women was associated with a reduction in the number of primiparous women who delayed reporting of DFM and a reduction of the stillbirth rates for primiparous women reporting DFM. The information did not appear to increase maternal concerns or rate of consultation. Due to different imperfections in different clinical settings, further studies in other populations replicating these findings are required.

A validation of the diagnosis of obstetric sphincter tears in two Norwegian databases, the Medical Birth Registry and the Patient Administration System

Background. The purpose of the present study was to validate the registration of obstetric sphincter tears in 2 registers, the Medical Birth Registry of Norway [MBRN] and Patient Administration System [PAS]. Methods. A retrospective cohort study of all obstetric sphincter tears that occurred in our department in 1990–1992 and 2000–2002 was performed. The case records of all patients registered either in MBRN, PAS or the birth logs were compared with the information in the medical records, which constituted the ‘golden standard’. Results. The incidence of obstetric sphincter tears in 1990–1992 was 5.8% (774/13381), 5.6% (745/13381) had a perineal tear of third degree and 0.2% (29/13381) of fourth degree. In 2000–2002, the total incidence was 6.6% (813/12380), 5.9% (731/12380) was a third degree perineal tear and 0.7% (82/12380) fourth degree, respectively. The sensitivity and specificity of the MBRN database to detect obstetric sphincter tears was 85.3 and 99.5% in 1990–1992, and 91.8 and 99.7% in 2000–2002, respectively. The positive and negative predictive values of a MBRN‐registered diagnosis of obstetric sphincter tears in 1990–1992 were 91.4 and 99.1%, while the corresponding percentages in 2000–2002 were 95.4 and 99.4%, respectively. The sensitivity and specificity of the PAS database was correspondingly 52.1 and 99.0% in 1990–1992, and 84.6 and 98.5% in 2000–2002. The positive and negative predictive values of a PAS‐diagnosis of obstetric sphincter tears were 75.8 and 97.1% in 1990–1992. In 2000–2002, they were 92.7 and 98.9%, respectively. Conclusion. The validity of a diagnosis of obstetric sphincter tears, based on the MBRN, is sufficiently high to justify future large‐scale epidemiologic studies based on this database, while the validity of a PAS diagnosis is lower, but improves.

Increasing twinning rates in Norway, 1967–2004: the influence of maternal age and assisted reproductive technology (ART)

Background. The incidence of twin pregnancies is increasing in industrialized countries, including Norway. In the present nationwide study from Norway, we aimed at evaluating the effect of assisted reproductive technologies and delayed childbearing age on this epidemic rise. Material and method. Altogether 2.19 million pregnancies, including 27,849 twin pairs and higher‐order multiples, were included in this population‐based study with data from the Medical Birth Registry of Norway covering the years 1967–2004. The study period was divided into two, 1967–87 and 1988–2004, respectively. For the last time period, pregnancies from assisted reproductive technologies were available through a separate registration, and these data were linked with the Medical Birth Registry of Norway birth record. Additionally, we compared the twinning rates from natural conception in the two time periods in relation to maternal age. Logistic regression was used for adjusted odds ratio estimation. Results. During 1967–1987, the twinning rate remained constant at 1.0% of the total number of births in Norway. Thereafter, the total twinning rate increased from 1.1% in 1988 to 1.9% in 2004. After excluding pregnancies from assisted reproductive technologies, the increase was from 1.1% to 1.6% in this period. There was a significantly higher twinning rate in all age groups in the time period 1988–2004 compared with 1967–1987. In naturally conceived pregnancies, OR for twins were 1.11 (95% CI 1.05–1.17) in the age group 20–24 years, 1.25 (95% CI 1.19–1.31) in the age group 30–34, and 1.36 (95% CI 1.11–1.67) in the age group 40–44 comparing the two time periods. Conclusions. The multiple pregnancy rate increased by 50% in Norway during the time period 1988–2004, even when twin pregnancies from assisted reproduction were excluded. Maternal age and assisted reproductive technologies cannot alone satisfactorily explain the rise in the twinning rate.

The Nordic medical birth registers – a potential goldmine for clinical research

The Nordic medical birth registers have long been used for valuable clinical research. Their collection of data for more than four decades offers unusual possibilities for research across generations. At the same time, serum and blotting paper blood samples have been stored from most neonates. Two large cohorts (approximately 100 000 births) in Denmark and Norway have been described by questionnaires, interviews and collection of biological samples (blood, urine and milk teeth), as well as a systematic prospective follow‐up of the offspring. National patient registers provide information on preceding, underlying and present health problems of the parents and their offspring. Researchers may, with permission from the national authorities, obtain access to individualized or anonymized data from the registers and tissue‐banks. These data allow for multivariate analyses but their usefulness depends on knowledge of the specific registers and biological sample banks and on proper validation of the registers.

Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team

Whether planned cesarean section is better than planned vaginal delivery for breech presentation at term (37–42 weeks) has been the subject of debate for some time. Apart from two small randomized controlled trials (1,2) from the early 1980s, the evidence on breech delivery was based on patient series and register studies, which have been considered to be of low scientific value. However, in October 2000 the randomized multicenter Term Breech Trial (TBT) was published in The Lancet (3), with a 3-month follow-up in 2002 (4). The study included 2083 deliveries from 121 obstetric departments in 26 countries. One Danish and one Finnish, but no Norwegian, obstetric departments took part in the study. The TBT concluded that planned cesarean section led to a significantly better perinatal outcome than planned vaginal delivery. The occurrence of maternal complications was similar for the two groups. Not surprisingly, the TBT ignited intense discussion among doctors, midwives and the public. Data from the Medical Birth Registry of Norway show a slight increase in the incidence of breech presentation among infants with a birthweight greater than 2499 g in the period 1981–98, and the incidence is 2.9% in 1998 (Fig. 1). In Norway, 40% of approximately 1500 annual term breech infants are currently delivered vaginally (Fig. 2). A change to routine use of cesarean section would have an unprecedented impact on clinical practice in Norway. The use of external cephalic version on the Norwegian population has not been studied previously. A review team was therefore assigned to review (5,25) all current literature on term breech deliveries as well as on external cephalic version, using predetermined standard literature review methodology.

Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries.

The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.