Jørg Kessler

Objectives: The primary aim was to assess the prevalence of levator ani muscle (LAM) avulsion after forceps‐ and vacuum‐assisted deliveries, adjusting for indication for assisted vaginal delivery (AVD) and including spontaneous vaginal deliveries for comparison. The secondary aim was to compare neonatal injury between forceps and vacuum deliveries. Methods: This prospective observational cohort study was conducted at Haukeland University Hospital, Bergen, Norway. Primiparous women were recruited shortly after delivery, between June 2021 and April 2023, and LAM avulsion was assessed using transperineal ultrasound 9–12 months later. Delivery and neonatal data were collected from patient electronic health records. The risk of LAM avulsion was compared between forceps, vacuum and spontaneous vaginal deliveries using multivariable logistic regression analysis. Assisted deliveries were stratified by indication (fetal distress or protracted second stage of labor) and subgroup analyses were conducted for each indication, comparing forceps with vacuum delivery. Results: A total of 736 women were examined using transperineal ultrasound at a median of 307 (interquartile range, 279–332) days after delivery. The 252 women who delivered by forceps had a higher prevalence of LAM avulsion (29.8%) compared with the 252 women who delivered by vacuum (17.5%) and the 232 women who underwent spontaneous vaginal delivery (11.2%). The adjusted odds ratio (aOR) of LAM avulsion after forceps vs vacuum delivery was 1.99 (95% CI, 1.26–3.18). After a protracted second stage of labor, the odds of LAM avulsion after forceps vs vacuum delivery were even greater (aOR, 3.09 (95% CI, 1.53–6.46)). Among those who underwent AVD for fetal distress, no significant difference in the odds of LAM avulsion was observed between forceps and vacuum deliveries (aOR, 1.63 (95% CI, 0.83–3.23)). The odds of neonatal trauma were lower after forceps compared with vacuum delivery (aOR, 0.49 (95% CI, 0.25–0.92)). Conclusions: There was no significant difference in the prevalence of LAM avulsion between forceps and vacuum deliveries when the indication for AVD was fetal distress, but the odds of LAM avulsion were 3‐fold higher for forceps delivery when the indication was protracted second stage of labor. Forceps delivery was associated with a 51% reduction in the odds of neonatal injury compared with vacuum delivery, independent of indication for AVD. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To compare childbirth satisfaction and obstetrical outcomes with outpatient versus inpatient induction of labour (IOL). Design: Multicentre, randomised‐controlled trial. Setting: Eight hospitals in Norway. Population: Women scheduled for IOL, single cephalic presentation, ≥ 37 weeks, no previous uterine scar, and low risk of complications by predefined criteria. Methods: Included women received oral misoprostol (25 μg) for up to 48 h as the primary induction agent. The Childbirth Experience Questionnaire (CEQ) and the Experience with Induction Tool (EXIT) were used to assess childbirth satisfaction. Main Outcome Measures: CEQ‐score. Secondary Outcome Measures: EXIT questionnaire and obstetrical outcomes. Results: Of 283 women randomised, 152 women were allocated to outpatient and 131 to inpatient settings. Outpatient IOL resulted in a more positive childbirth experience (mean CEQ‐score 3.1 [0.44] vs. 3.0 [0.45]), mean difference 0.14, 95% CI (0.02–0.25), p = 0.02. In the outpatient group, women were admitted to the hospital 21 h shorter before delivery (15 vs. 36 h, mean difference −21, 95% CI −25 to −17, p < 0.01). Obstetrical outcomes were similar, and there were no cases of hyperstimulation before labour or serious adverse events. Conclusion: Outpatient IOL using oral misoprostol was associated with high maternal satisfaction, with 89% of women expressing a preference for this method in future pregnancies. Labour outcomes appear comparable to those of inpatient induction, while outpatient management also provides potential cost benefits due to shorter hospital admission. We advocate for this method as a feasible option for appropriately selected women; however, the occurrence of rare adverse events necessitates further investigation through larger studies. Trial Registration: ID NCT05144048. https://clinicaltrials.gov/study/NCT05144048?locStr=Norway&country=Norway&cond=Induction%20of%20Labor&rank=1

Introduction: A recent study recommended 5.2 mmol/L as a cutoff for fetal blood sample (FBS) lactate in labor for the StatStrip Lactate®/Lactate Xpress® lactate meter. In the present study, we validated FBS lactate cutoffs in a larger population‐based setting, with different CTG guidelines, testing external validity.Material and Methods: We conducted a prospective population‐based study at Oslo University Hospital, Ullevål, Norway, a tertiary referral obstetric department with 7000 annual deliveries. Women with a singleton fetus in cephalic presentation in gestational week ≥36 + 0 were included in the analyses. We used ROC curves to calculate the area under the curve (AUC) and estimate the optimal cutoff for the following adverse neonatal outcomes: Umbilical cord pH ≤7.10, umbilical cord pH ≤7.05, metabolic acidosis (pH 12 mmol/L), 1‐minute Apgar score <4, 5‐min Apgar score <7, hypoxic ischemic encephalopathy, and transfer to the neonatal intensive care unit. Analyses were restricted to women with a FBS lactate within 25 min prior to delivery. The study is registered in clinicaltrials.gov (ClinicalTrials.gov Identifier: NCT04779294).Results: Of 7816 included women, 1466 (19%) had a FBS lactate measurement within 25 min prior to delivery. The calculated optimal cutoff for FBS lactate varied by outcomes: 5‐min Apgar score <7: AUC 0.69 (0.57–0.80), cutoff 4.0 mmol/L; metabolic acidosis: AUC 0.92 (0.78–1.00), cutoff 7.0 mmol/L; hypoxic ischemic encephalopathy: AUC 0.95 (0.86–1.00), cutoff 4.7 mmol/L. Sensitivity increased for some of the outcomes with a decreasing cutoff. Specificity increased for all outcomes with an increasing cutoff.Conclusions: We consider an FBS lactate cutoff of ≥5.2 mmol/L a good balance between high sensitivity for adverse neonatal outcomes and an acceptable number of needed interventions.

Introduction: Assisted vaginal delivery has been associated with a negative childbirth experience and the development of secondary fear of childbirth, although it is less consistent than emergency Cesarean delivery. Whether the choice of instrument influences this, and the woman's preference for delivery mode in a potential subsequent pregnancy, is unknown. Our objective was to assess the association between the choice of instrument during assisted vaginal delivery, secondary fear of childbirth, and preference for an elective Cesarean delivery in a potential subsequent pregnancy.Material and Methods: Study design: Secondary analysis of Bergen birth study, a prospective observational study assessing maternal and neonatal outcomes after assisted vaginal delivery in primiparas at term, inclusion period: June 2021–April 2023. Wijma Delivery Expectancy/Experience Questionnaire version B was completed within a week after delivery. This validated instrument has 33 questions, a total score range from 0 to 165, and a score of ≥85 was used as a cutoff to define fear of childbirth. Preferred mode of delivery in a potential subsequent pregnancy, pain, and overall birth experience was also measured. Main outcome measures: Secondary fear of childbirth and request for Cesarean delivery in the next pregnancy.Results: 132 women after forceps, 160 after vacuum, and 139 after spontaneous delivery answered the questionnaires. Overall prevalence of secondary fear of childbirth was 12.2% after spontaneous and 14.4% after both forceps and vacuum deliveries. Compared with spontaneous delivery, the adjusted odds ratio of developing fear of childbirth was aOR 1.63 (95% CI 0.45–5.17, p = 0.4) after vacuum and aOR 1.71 (95% CI 0.43–6.14, p = 0.4) after forceps delivery. Secondary fear of childbirth (aOR: 11.3 (95% CI 5.30–24.6), p < 0.001) and maternal age ≥35 (aOR: 3.66 (95% CI: 1.49–8.81), p = 0.004) were associated with a preference for cesarean delivery in a potential subsequent pregnancy. Severe pain was reported just as often in the spontaneous delivery cohort (33.8%) as in the vacuum (25.6%) and forceps (24.2%) cohorts. Less than 5% in each cohort indicated that they were very unsatisfied with their birth experience.Conclusions: The choice of instrument during assisted vaginal delivery was not associated with secondary fear of childbirth or preference for cesarean delivery in a potential subsequent pregnancy.

Introduction: Detection and surveillance of fetal growth restriction (FGR) is well established, but there is still room for improvement. Animal studies indicate that compromised fetuses increase adrenal blood flow. Modern ultrasound equipment allows us to measure vascular impedance in the fetal adrenal arteries despite their modest size. However, extensive anatomical variance is a challenge to standardizing measurements. We set out to improve this.Material and Methods: We included 75 low‐risk pregnant women in a prospective cross‐sectional study aiming to develop a reliable technique to visualize and measure flow velocity in human fetal adrenal arteries. We used commercially available ultrasound equipment: a GE Voluson 10 2019 with a C2‐9 probe (GE Healthcare, Zipf, Austria), and a Philips Epiq Elite with a V9‐2 probe (Philips Medical Systems International B.V., Best, The Netherlands), exploiting the modern sensitive power Doppler modes in both scanners to visualize small vessels.Results: Among 72 fetuses, the inferior adrenal artery was the most consistently visualized and measured artery to the gland. Doppler velocimetry was achieved in 66 (92%) participants. We found the anatomical variation described previously but were able to develop visualization strategies to identify the common arteries and use a consistent Doppler technique for the second half of pregnancy.Conclusions: It is possible to visualize and measure flow velocity in the adrenal arteries of human fetuses. The success rate was highest for the inferior adrenal artery making this vessel a candidate for clinical studies.

Introduction: In clinical experience, occiput posterior (OP) position is associated with longer labor duration than occiput anterior (OA) position, but few studies have investigated the association between labor duration and fetal position. We aimed to compare duration of the active phase of labor in OP deliveries with OA deliveries in a contemporary population using survival methods. Secondary aims were to compare the frequencies of operative interventions, obstetric anal sphincter injuries (OASIS), postpartum hemorrhage, and newborn outcomes in OP with OA deliveries.Material and Methods: We did a historical cohort study in three university hospitals in Norway from 2012 to 2022. Women with a single fetus in cephalic presentation, no previous cesarean section and gestational age ≥37 weeks were eligible and stratified into the first four groups of the Robson ten‐group classification system (TGCS). We estimated the mean duration and calculated the hazard ratio (HR) for delivery using survival analyses. Cesarean sections and instrumental vaginal deliveries were censored.Results: The study population comprised 112 019 women, 105 571 (94.2%) were delivered in OA and 6448 (5.8%) in OP position. The estimated mean duration of the active phase of labor was longer in women with the fetus in OP position in all four TGCS groups. The estimated duration was longer in the OP groups in analyses stratified with respect to epidural analgesia and oxytocin augmentation. The graphical abstract illustrates the probability of delivery in OP compared with OA position in merged TGCS groups 1 and 2a, as a function of time. The unadjusted HR was 0.33 (95% CI 0.31–0.36) for fetuses delivered in OP position compared with OA position in TGCS group 1, 0.25 (95% CI 0.21–0.27) in group 2a, 0.70 (95% CI 0.67–0.73) in group 3, and 0.61 (95% CI 0.55–0.67) in group 4a, respectively. Neither maternal age, gestational age, BMI nor birthweight had confounding effect. Operative delivery rates and OASIS rates were higher in OP position in all four groups.Conclusions: We found longer duration of the active phase of labor in women with the fetus delivered in OP position in all four TGCS groups.

Objective: To validate an intrapartum Cesarean Section Classification System (ICSCS). Design: Nationwide prospective observational study. Setting: Twenty-five Norwegian maternity units Population or Sample: Singleton cephalic pregnancies with spontaneous or induced labour at ≥ 37 weeks gestation delivering February-August 2017. Methods: . After training of all collaborators, Cesarean section (CS) after spontaneous or induced labour were classified based on fetal status, dynamic progress in labour, use of oxytocin, frequency of contractions and linked to denominator data collected and centralized by the Norwegian Medical Birth Registry. Main Outcome Measures: Cohens kappa as measure of agreement for correct application of the classification. Prevalence of the different groups using the ICSCS within the Ten Group Classification System (Robson groups). Results: Of 49 trained experts, 40 (82%) had a κ >0.6 indicating good or very good level of agreement when the classification was applied. A total of 1425 CS were classified: CS classified as fetal indication (no oxytocin) was more common in induced (Group 2a, 4a, 5b) compared to spontaneous labours (Group 1, 3, 5a). CS classified as dystocia related to inefficient uterine action and poor response to oxytocin occurred more often in induced as compared to spontaneous labours. The prevalence of CS classified as dystocia with efficient uterine action (malposition or cephalopelvic disproportion) was low in all Robson groups. Conclusions: The ICSCS was successfully validated in a national study. It may become a valuable objective tool for analyzing the management of labour and explaining differences in the prevalence of CS between different groups of women.