Cecilia Ekéus

Introduction: The association between vacuum extraction and intracranial hemorrhage has been debated. We sought to investigate the impact of protracted vacuum extraction on the risk for neonatal intracranial hemorrhage in term infants.Material and methods: This nationwide case‐control study covered Swedish maternity wards from 1999 to 2013. All term, live‐born infants diagnosed with neonatal intracranial hemorrhage after vacuum‐assisted delivery were included as cases (n = 167). For each case, 3 vacuum‐delivered controls, without a diagnosis for intracranial hemorrhage, were selected (n = 546 controls). Conditional logistic regression analysis was used to study the association between protracted extraction (defined as vacuum duration > 15 min, > 6 pulls or > 2 cup detachments), and neonatal intracranial hemorrhage.Results: Extractions exceeded 15 min among 33% of the cases, vs 5% of the controls. More than six pulls were used in 25% of the cases and in 4% of the controls, and more than two cup detachments occurred in 3.6% of the cases and in 0.6% of the controls. Compared with extractions adhering to safety recommendations, the odds for intracranial hemorrhage were nine‐fold (OR 8.91, 95%, CI 5.22‐15.20) among infants exposed to a protracted extraction. After adjustments for potential confounders, the OR decreased to 8.04 (95% CI 4.49‐14.38).Conclusions: The strong association between protracted extraction and intracranial hemorrhage suggests that adherence to safety recommendations may reduce the risk for intracranial hemorrhage in infants delivered by vacuum extraction. However, safe limits for vacuum duration and number of pulls are still unknown and intracranial hemorrhage may occur even when performed in accordance with safety recommendations.

Introduction: The routine to deliver almost all term breech cases by elective cesarean section (CS) has continued to be debated due to the risk of maternal and neonatal complications. The aims of the study were (1) to investigate if mode of delivery impacts on the risk of morbidity and mortality among term infants in breech presentation and (2) to compare the rates of severe neonatal complications and mortality in relation to presentation and mode of delivery. Methods: This population-based cohort study used data from the Swedish Medical Birth Register. All women (and their newborn infants) with singleton pregnancies who gave birth at term to an infant in breech (n = 27,357) or cephalic presentation (n = 837,494) between 2001 and 2012 were included. Births with vacuum extraction and induced labors were excluded, as well as antepartum stillbirths, births with infants diagnosed with congenital malformations and multiple births. Results: On one hand, the rates of neonatal complications and mortality were higher among infants born in vaginal breech compared to the vaginal cephalic group. On the other hand, after CS, the rates of all neonatal complications under study and neonatal mortality were lower among infants in breech presentation than in those in cephalic presentation. After adjustment for confounders, infants delivered in vaginal breech had 23.8 times higher odds AOR (ratio) for brachial plexus injury, 13.3 times higher odds ratio for Apgar score <7 at 5 min, 6.7 times higher odds of intracranial hemorrhage (ICH), or convulsions and 7.6 higher odds ratio for perinatal mortality than those delivered by elective CS. Conclusions: Despite a probable selection of women who before-hand were considered at low risk and, therefore, could be recommended vaginal breech delivery, infants delivered in vaginal breech faced substantially increased risks of severe neonatal complications compared with infants in breech presentations delivered by elective CS.

Obstetric anal sphincter injury (OASI) is a rare but serious outcome of vaginal birth. Based on concerns about the increasing number of women who commence childbearing later than previous generation, this study aimed at investigating age-related risk of OASI in women of different parity. A population-based register study including 959,559 live singleton vaginal births recorded in the Swedish Medical Birth Register 1999 to 2011. In each parity group risks of OASI at age 25–29 years, 30–34 years, and ≥35 years compared with age < 25 years were investigated by logistic regression analyses, adjusted for year of birth, education, region of birth, smoking, Body Mass Index, infant birthweight and fetal presentation; and in parous women, history of OASI and cesarean section. Additional analyses also adjusted for mediating factors, such as epidural analgesia, episiotomy, and instrumental delivery, and maternal age-related morbidity. Rates of OASI were 6.6%, 2.3% and 0.9% in first, second and third births respectively. Age-related risk increased from 25-29 years in first births (Adjusted OR 1.66; 95% CI 1.59–1.72) and second births (Adjusted OR 1.78; 95% CI 1.58–2.01), and from 30-34 years in third births (Adjusted OR 1.60; 95% CI 1.00–2.56). In all parity groups the risk was doubled at age ≥ 35 years, compared with the respective reference group of women under 25 years. Adding mediating factors and maternal age-related morbidity only marginally reduced these risk estimates. Maternal age is an independent risk factor for OASI in first, second and third births. Although age-related risks by parity are relatively similar, more nulliparous than parous women will be exposed to OASI due to the higher baseline rate.

Objective: To investigate the association between complicated vacuum extraction (VE) deliveries and neonatal complications. Methods: Observational study including data on the management of 596 consecutive VE-deliveries at 6 different birth clinics in Sweden in 2013. We used logistic regression to examine the association between a complicated VE and: extracranial bleeding, severe neonatal complication (intracranial hemorrhage and/or asphyxia/low Apgar score and/or convulsions, and/or encephalopathy), and brachial plexus injury. VE was considered complicated if duration exceeded 15 min, and/or more than six pulls were used, and/or more than one cup detachment occurred. Uncomplicated VE served as the reference group. Results: Ten percent of the infants were diagnosed with at least one of the investigated complications. Cephalohematoma occurred in 5.2% of the infants and 1.5% had a subgaleal hematoma. Altogether 24 (4.0%) infants were diagnosed with a severe complication; low Apgar score, neonatal convulsions, encephalopathy or intracranial hemorrhages. Brachial plexus injury occurred in eight (1.3%) infants. The crude odds ratio for extracranial hemorrhages was 2.6 (95% CI 1.17–5.77), 4.07 (1.67–9.92) for severe neonatal complications, and 4.63 (1.08–19.76) for brachial plexus injury. Conclusions: Extraction time >15 min, >6 pulls and >1 cup detachment is associated with increased risk of neonatal complications. These results support compliance with guidelines and recommendations for VE deliveries.

Advanced maternal age is associated with labor dystocia (LD) in nulliparous women. This study investigates the age-related risk of LD in first, second and third births. All live singleton cephalic births at term (≥ 37 gestational weeks) recorded in the Swedish Medical Birth Register from 1999 to 2011, except elective cesarean sections and fourth births and more, in total 998 675 pregnancies, were included in the study. LD was defined by International Classification of Diseases, version 10 codes (O620, O621, O622, O629, O630, O631 and O639). In each parity group risks of LD at age 25–29 years, 30–34 years, 35–39 years and ≥ 40 years compared with age < 25 years were investigated by logistic regression analyses. Analyses were adjusted for year of delivery, education, country/region of birth, smoking in early pregnancy, maternal height, body mass index, week of gestation, fetal presentation and infant birthweight. Rates of LD were 22.5%, 6.1% and 4% in first, second and third births, respectively. Adjusted odd ratios (OR) for LD increased progressively from the youngest to the oldest age group, irrespective of parity. At age 35–39 years the adjusted OR (95% CI) was approximately doubled compared with age 25 and younger: 2.13 (2.06–2.20) in first birth; 2.05 (1.91–2.19) in second births; and 1.81 (1.49–2.21) in third births. Maternal age is an independent risk factor for LD in first, second and third births. Although age-related risks by parity are relatively similar, more nulliparous than parous women will be exposed to LD due to the higher rate.

Introduction: High birthweight is associated with complicated childbirth. The aim of the present study was to investigate the association between birthweight, mode of delivery, and neonatal complications among infants born at term with a birthweight ≥3000 g.Material and methods: This population‐based cohort study used data from the Swedish Medical Birth Register from 1999 to 2012, including 1 030 775 births at >36 completed weeks. Exposure was mode of delivery, categorized into non‐instrumental vaginal delivery (VD), emergency cesarean section (CS), vacuum extraction (VE) or cesarean section following attempted vacuum extraction (VE + CS), and birthweight was divided into five categories (3000–3999 g, 4000–4499 g, 4500–4999 g, and ≥5000 g). The following outcomes were assessed: 5‐min Apgar score <7, neonatal convulsions, intracranial hemorrhage, and brachial plexus injury. Infants born after VD with a birthweight of 3000–3999 g were used as reference in the logistic regression analysis.Results: The odds ratios for all complications increased at higher birthweights among infants born after VE/VE + CS and VD. The highest risks were seen after VE/VE + CS with an adjusted odds ratio for neonatal convulsions of 2.6 (95% CI 2.1–3.2) in the reference birthweight group and 6.3 (95% CI 4.3–9.2) among infants with a birthweight of ≥4500 g. The corresponding adjusted odds ratios for intracranial hemorrhage were 2.6 (95% CI 1.7–3.9) and 6.7 (95% CI 3.3–13.6) and for brachial plexus injury 4.0 (95% CI 3.3–4.9) and 88.4 (95% CI 71.9–108.4).Conclusion: Vacuum extraction is a risk factor for serious neonatal complications, in particular when used in macrosomic fetuses.

Background: Previous studies show contradictory results about the impact of induced labor on the cesarean delivery rate and few studies have investigated the risk of vacuum extraction subsequent to induced labor. The aims of the present study were to describe the rate of induced labor in Sweden from 1999 to 2012, and to assess the risk of unplanned cesarean delivery and vacuum extraction after induced labor in relation to medical complications and length of gestation.Methods: A register‐based cohort study was conducted, including 1,078,536 women with spontaneous or induced onset of labor who gave birth by noninstrumental vaginal delivery, unplanned cesarean delivery, or vacuum extraction in gestational week 37 + 0 to 41 + 6. Logistic regression was used to study the association between induced labor and instrumental delivery.Results: The rate of induced labor increased from 7.7 to 12.9 percent among primiparous and from 7.5 to 11.8 percent among multiparous women. Induced labor was associated with 2–3 times greater risk of unplanned cesarean delivery among all women, except multiparas in gestational week 37–38, and with a 20–50 percent higher risk of vacuum extraction after the adjustment for confounding factors. Among women without a recognized medical complication, induced labor was associated with a threefold increased risk of cesarean delivery in gestational week 39–41 and a 40 percent increase in gestational week 37–38 compared with women with spontaneous onset of labor.Conclusions: The proportion of induced labors increased substantially during the 14‐year study period and was associated with an increased risk of both cesarean delivery and vacuum extraction, even in women without a documented medical complication. The increased risk of instrumental delivery should be taken into account when counseling about the risks and benefits of induced labor.