| 1. |
- Bergendahl, Sandra, et al.
(författare)
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Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA) : multicentre, open label, randomised controlled trial
- 2024
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Ingår i: BMJ (Clinical research ed.). - : BMJ Publishing Group Ltd. - 1756-1833. ; 385
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To assess the effect of lateral episiotomy, compared with no episiotomy, on obstetric anal sphincter injury in nulliparous women requiring vacuum extraction.DESIGN: A multicentre, open label, randomised controlled trial.SETTING: Eight hospitals in Sweden, 2017-23.PARTICIPANTS: 717 nulliparous women with a single live fetus of 34 gestational weeks or more, requiring vacuum extraction were randomly assigned (1:1) to lateral episiotomy or no episiotomy using sealed opaque envelopes. Randomisation was stratified by study site.INTERVENTION: A standardised lateral episiotomy was performed during the vacuum extraction, at crowning of the fetal head, starting 1-3 cm from the posterior fourchette, at a 60° (45-80°) angle from the midline, and 4 cm (3-5 cm) long. The comparison was no episiotomy unless considered indispensable.MAIN OUTCOME MEASURES: The primary outcome of the episiotomy in vacuum assisted delivery (EVA) trial was obstetric anal sphincter injury, clinically diagnosed by combined visual inspection and digital rectal and vaginal examination. The primary analysis used a modified intention-to-treat population that included all consenting women with attempted or successful vacuum extraction. As a result of an interim analysis at significance level P<0.01, the primary endpoint was tested at 4% significance level with accompanying 96% confidence interval (CI).RESULTS: From 1 July 2017 to 15 February 2023, 717 women were randomly assigned: 354 (49%) to lateral episiotomy and 363 (51%) to no episiotomy. Before vacuum extraction attempt, one woman withdrew consent and 14 had a spontaneous birth, leaving 702 for the primary analysis. In the intervention group, 21 (6%) of 344 women sustained obstetric anal sphincter injury, compared with 47 (13%) of 358 women in the comparison group (P=0.002). The risk difference was -7.0% (96% CI -11.7% to -2.5%). The risk ratio adjusted for site was 0.47 (96% CI 0.23 to 0.97) and unadjusted risk ratio was 0.46 (0.28 to 0.78). No significant differences were noted between groups in postpartum pain, blood loss, neonatal outcomes, or total adverse events, but the intervention group had more wound infections and dehiscence.CONCLUSIONS: Lateral episiotomy can be recommended for nulliparous women requiring vacuum extraction to significantly reduce the risk of obstetric anal sphincter injury.TRIAL REGISTRATION: ClinicalTrials.gov NCT02643108.
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| 2. |
- Envall, Niklas, 1984-, et al.
(författare)
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Use of contraception and attitudes towards contraceptive use in Swedish women : an internet-based nationwide survey
- 2022
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Ingår i: European journal of contraception & reproductive health care. - : Informa UK Limited. - 1362-5187 .- 1473-0782. ; 27:5, s. 409-417
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: Explore contraceptive use, unmet need of and attitudes towards contraceptive use in Sweden. Secondly, to investigate knowledge of contraceptives, prevalence and outcomes of unintended pregnancies.MATERIALS AND METHODS: Internet based e-survey of Swedish women aged 16-49. The e-survey contained 49 questions with both spontaneous and multi-choice character on demographics, contraceptive use, knowledge of and attitudes towards contraception, importance of monthly bleeding, and experience of unintended pregnancy. The e-survey was closed when reaching the estimated sample size of 1000 respondents.RESULTS: A total of 1016 women participated, whereof 62.4% used contraception, 31.8% did not and 5.8% had stopped in the last 12 months. Unmet need for contraception was estimated at 17.2%. At least one unintended pregnancy was experienced by 19.9%. All women rated effectiveness as the most important characteristic of a contraceptive method.CONCLUSIONS: Use of contraception in Swedish women remains low, 62.4%, and the unmet need for contraception has increased to 17.2%. Method effectiveness and health benefits of hormonal contraception should be emphasised during contraceptive counselling, and actions are needed to target groups with low use of effective contraception as well as to reach those who never seek contraception.KEY MESSAGE Close to one third of Swedish women do not use contraception and one fifth have experienced at least one unintended pregnancy. Unmet need for contraception is high despite easy access and subsidies for young women.
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| 3. |
- Wallström, Tove
(författare)
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Factors of importance for labor induction
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: What initiates the onset of labor is still not clarified, and it is debated whether expectant or active management is the best for the woman and the fetus. Active management means induction of labor (IOL) which is a very common obstetric intervention and is used in several situations. During the last five years, 17 % of all singleton pregnancies in Sweden were induced. There are large variations worldwide from less than five percent in some African countries such as Kenya, to extreme cases like for example Iran where IOL is performed in up to 80% of the labors. Both maternal and fetal complications are related to IOL, for instance prolonged labor, postpartum haemorrhage (PPH) and instrumental interventions as vacuum extraction/forceps or Cesarean section (CS). The increasing rate of CS continues to cause global concerns. The ideal management of the subsequent labor for women who have undergone one previous CS has been intensely debated. The two available options are Trial of Labor after Cesarean section (TOLAC) or an elective CS. Previous CS is the most important risk factor for Uterine rupture (UR). UR is a wellknown but unusual complication in vaginal deliveries with a previous CS in the history. The risk of UR is at least two-fold when labor is induced. In Sweden, women are allowed to deliver vaginally after one previous CS, regardless if labor starts spontaneously or is induced. Aim: The overall aim of the thesis is to identify factors of importance for the decision of IOL, and to find out which method for IOL is the most effective and safe for women with or without a previous CS. Study I, a prospective observational study of 52 healthy women with mixed parity examined at their post-term control in gestational week 41+3. CTG, ultrasound assessment of amniotic fluid, a vaginal examination for cervical status and a five-minute skin conductance measurement, including a ‘cold pressor test’ was performed. The aim of the study was to evaluate if altered skin conductance activity could predict spontaneous onset of labor in post-term pregnancies. The probability of having a spontaneous onset of labor increased 4.0 times if the skin conductance score was negative and increased 6,8 times to start within 48 h if the cervix was open ≥2 cm. Study II, a retrospective cohort study of 4002 women induced to labor with mixed parity. Inclusion criteria were viable singleton fetus in cephalic presentation, gestational age of ≥34 weeks. The women were divided into six groups according to method of IOL; Cytotec®, Minprostin®, Propess®, balloon catheter, amniotomy, or oxytocin. Methods of induction, baseline data, and delivery outcomes were compared. The primary endpoint of the study was the frequency of CS in each method of IOL. The lowest rate of CS overall, for both primi- and multiparous women with an unfavorable cervix Bishop Score (BS) ≤5, was found in the group where Cytotec® was administrated as an oral solution. Study III, a retrospective cohort study for evaluating the proportion of UR in 208 women with IOL after one previous CS. The women were divided into two subgroups regarding the method of IOL. Group 1 (n=121) was the unexposed group, meaning that the women did not receive Cytotec® as the method of IOL. Group 2 (n=87) serves as the exposed group meaning that most of the women (89%) received Cytotec® as an oral solution. Method of induction, baseline data, and delivery outcomes were recorded. The primary outcome of the study was the frequency of UR in each group. There was no significant difference in the incidence of UR between group 1 and 2 (4.1 vs 4.6%, p=0.9) despite a more favorable cervix in group 1. Study IV, a retrospective cohort study of 910 women with one previous CS, unfavorable cervix, and IOL. The study was performed at the four largest hospitals in Stockholm, the women were divided into three subgroups according method of IOL (Cytotec®, balloon catheter and Minprostin). The aim of the study was to compare the difference in the proportion of UR between the three methods There was no significant difference in the proportion of UR between Cytotec® and balloon catheter (p=0.64) for IOL after one previous CS. Orally administrated Cytotec® and balloon catheter resulted in a high success rate of vaginal deliveries of almost 70% compared to Minprostin® with the proportion of vaginal deliveries of 57% and which also had more than doubled rate of UR (5%). Study V, an open label randomized controlled trial of 196 women induced to labor, BS ≤4 and no previous CS divided into two subgroups. Participating women were randomized to receive an oral solution of misoprostol (Cytotec®) or vaginal slow release misoprostol (Misodel®) for IOL. The primary outcome was the induction-to-vaginal-delivery time. Vaginal delivery after IOL with slow release misoprostol resulted in a shorter induction-to-vaginal-delivery time compared with oral misoprostol solution but was associated with a higher risk of hyperstimulation, and fetal distress. There were no differences in mode of delivery or neonatal outcome. Conclusion: Spontaneous onset of labor is usually preferred, because it generally means lower risk of complications compared to IOL. An oral solution of misoprostol for IOL in women with an unfavourable cervix is safe, cheap, easy to control and can be used in all settings as it gives a high success rate of vaginal deliveries without hyperstimulation. It is also a good method for IOL among women with one previous CS and is as safe as balloon catheter. Both methods give a high success rate of Vaginal Birth after Cesarean Section almost 70% despite an unfavorable cervix. These studies give further support to the feasibility of an oral solution of misoprostol for IOL which is in line with the recommendations from International Federation of Gynecology and Obstetrics.
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| 4. |
- Wallström, Tove, et al.
(författare)
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Labor Induction with Orally Administrated Misoprostol : A Retrospective Cohort Study
- 2017
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Ingår i: BioMed Research International. - : Hindawi Limited. - 2314-6133 .- 2314-6141.
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Tidskriftsartikel (refereegranskat)abstract
- Introduction. One great challenge in obstetric care is labor inductions. Misoprostol has advantages in being cheap and stable at room temperature and available in resource-poor settings.Material and Methods. Retrospective cohort study of 4002 singleton pregnancies with a gestational age >= 34w at Sodersjukhuset, Stockholm, during 2009-2010 and 2012-2013. Previously usedmethods of labor induction were compared with misoprostol given as a solution to drink, every second hour. Main outcome is as follows: Cesarean Section (CS) rate, acid-base status in cord blood, Apgar score < 7,5 ', active time of labor, and blood loss > 1500 ml (PPH).Results. The proportion of CS decreased from 26% to 17% when orally given solution of misoprostol was introduced at the clinic (p < 0.001). No significant difference in the frequency of low Apgar score (p = 0.3), low aPh in cord blood (p = 0.1), or PPH (p = 0.4) between the differentmethods of induction was studied. After adjustment for different risk factor for CS the only method of induction which was associated with CS was dinoproston** (Propess (R)) (aor = 2.9 (1.6-5.2)).Conclusion. Induction of labor with misoprostol, given as an oral solution to drink every second hour, gives a low rate of CS, without affecting maternal or fetal outcome.
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| 5. |
- Wallström, Tove, et al.
(författare)
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Skin conductance activity in post-term pregnancies
- 2015
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Ingår i: The Journal of Maternal-Fetal & Neonatal Medicine. - : Informa UK Limited. - 1476-7058 .- 1476-4954. ; 28:16, s. 1912-1916
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Tidskriftsartikel (refereegranskat)abstract
- Objective: The pain threshold in humans rises during late pregnancy, and the woman becomes less sensitive to stress. The aim of this study was to investigate whether monitoring the sympathetic nervous system response to stimuli by skin conductance activity might be a useful predictor of spontaneous onset of labour in post-term pregnancies. Study design: A prospective observational study. Fifty-two healthy pregnant women were consecutively asked for inclusion in the study at their post-term pregnancy examination. Initially, a Ctg (cardiotocography) registration was performed, followed by 5 min of skin conductance measurement including a ''cold pressor test''. Finally, a vaginal examination with a cervical assessment were performed according to clinical guidelines. Results: A statistically significant lower pain reaction during the period of provocation was seen in deliveries close to spontaneous onset of labour compared with induced deliveries with an non-spontaneous onset of labour before 294 days (p = 0.02). Sixty-three per cent (19/30) of the women with spontaneous onset had a negative value at provocation compared with 30% (6/20) in the induced group. Conclusions: Decreased response to pain stimuli, as an indication of decreased activity in the sympathetic nervous system, has a correlation to spontaneous onset of labour in post-term pregnancies.
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