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1.  A retrospective cohort study of mode of delivery among public and private patients in an integrated maternity hospital setting 
BMJ Open  2013;3(11):e003865.
To examine the associations between mode of delivery and public versus privately funded obstetric care within the same hospital setting.
Retrospective cohort study.
Urban maternity hospital in Ireland.
A total of 30 053 women with singleton pregnancies who delivered between 2008 and 2011.
The study population was divided into those who booked for obstetric care within the public (n=24 574) or private clinics (n=5479). Logistic regression analyses were performed to examine the associations between operative delivery and type of care, adjusting for potential confounding factors.
Main outcome measures
Caesarean section (scheduled or emergency), operative vaginal delivery (vacuum or forceps), indication for caesarean section as classified by the operator.
Compared with public patients, private patients were more likely to be delivered by caesarean section (34.4% vs 22.5%, OR 1.81; 95% CI 1.70 to 1.93) or operative vaginal delivery (20.1% vs 16.5%, OR 1.28; 95% CI 1.19 to 1.38). The greatest disparity was for scheduled caesarean sections; differences persisted for nulliparous and parous women after controlling for medical and social differences between the groups (nulliparous 11.9% vs 4.6%, adjusted (adj) OR 1.82; 95% CI 1.49 to 2.24 and parous 26% vs 12.2%, adj OR 2.08; 95% CI 1.86 to 2.32). Scheduled repeat caesarean section accounted for most of the disparity among parous patients. Maternal request per se was an uncommonly reported indication for caesarean section (35 in each group, p<0.000).
Privately funded obstetric care is associated with higher rates of operative deliveries that are not fully accounted for by medical or obstetric risk differences.
PMCID: PMC3840346  PMID: 24277646
Cohort Study; Operative Delivery; Caesarean Section; Private Healthcare; Operative Vaginal Delivery
2.  A Prospective Cohort Study of Alcohol Exposure in Early and Late Pregnancy within an Urban Population in Ireland 
Most studies of alcohol consumption in pregnancy have looked at one time point only, often relying on recall. The aim of this longitudinal study was to determine whether alcohol consumption changes in early and late pregnancy and whether this affects perinatal outcomes. We performed a prospective cohort study, conducted from November 2010 to December 2011 at a teaching hospital in the Republic of Ireland. Of the 907 women with a singleton pregnancy who booked for antenatal care and delivered at the hospital, 185 (20%) abstained from alcohol in the first trimester but drank in the third trimester, 105 (12%) consumed alcohol in the first and third trimesters, and the remaining 617 (68%) consumed no alcohol in pregnancy. Factors associated with continuing to drink in pregnancy included older maternal age (30–39 years), Irish nationality, private healthcare, smoking, and a history of illicit drug use. Compared to pre-pregnancy, alcohol consumption in pregnancy was markedly reduced, with the majority of drinkers consuming ≤ 5 units per week (92% in first trimester, 72–75% in third trimester). Perhaps because of this, perinatal outcomes were similar for non-drinkers, women who abstained from alcohol in the first trimester, and women who drank in the first and third trimester of pregnancy. Most women moderate their alcohol consumption in pregnancy, especially in the first trimester, and have perinatal outcomes similar to those who abstain.
PMCID: PMC3945584  PMID: 24549147
alcohol exposure; prospective cohort study; pregnancy; perinatal outcomes
3.  Population-Based Study of Smoking Behaviour throughout Pregnancy and Adverse Perinatal Outcomes 
There has been limited research addressing whether behavioural change in relation to smoking is maintained throughout pregnancy and the effect on perinatal outcomes. A cohort study addressed lifestyle behaviours of 907 women who booked for antenatal care and delivered in a large urban teaching hospital in 2010–2011. Adverse perinatal outcomes were compared for “non-smokers”, “ex-smokers” and “current smokers”. Of the 907 women, 270 (30%) reported smoking in the six months prior to pregnancy, and of those 160 (59%) had stopped smoking and 110 (41%) continued to smoke at the time of the first antenatal visit. There was virtually no change in smoking behaviour between the first antenatal visit and the third trimester of pregnancy. Factors associated with continuing to smoke included unplanned pregnancy (OR 1.9; 95% CI 1.3, 2.9), alcohol use (OR 3.4; 95% CI 2.1, 6.0) and previous illicit drug use (OR 3.6; 95% CI 2.1, 6.0). Ex-smokers had similar perinatal outcomes to non-smokers. Current smoking was associated with an average reduction in birth weight of 191g (95% CI −294, −88) and an increased incidence of intrauterine growth restriction (24% versus 13%, adjusted OR 1.39 (95% CI 1.06, 1.84). Public Health campaigns emphasise the health benefits of quitting smoking in pregnancy. The greatest success appears to be pre-pregnancy and during the first trimester where women are largely self-motivated to quit.
PMCID: PMC3799498  PMID: 23985771
smoking cessation; prospective cohort study; pregnancy; perinatal outcomes
4.  Behavioural change in relation to alcohol exposure in early pregnancy and impact on perinatal outcomes - a prospective cohort study 
There has been limited research addressing whether behavioural change in relation to alcohol exposure in pregnancy results in better perinatal outcomes.
A cohort study of 6725 women who booked for antenatal care and delivered in a large urban teaching hospital in 2010–2011. A detailed history of alcohol consumption pre-pregnancy and during early pregnancy was recorded at the first antenatal visit with follow-up of the mother and infant until discharge following birth. Adverse perinatal outcomes were compared for ‘non-drinkers’, ‘ex-drinkers’ and ‘current drinkers’.
Of the 6017 (90%) women who reported alcohol consumption prior to pregnancy 3325 (55%) engaged in binge drinking and 266 (4.4%) consumed more than 14 units on average per week. At the time of booking 5649 (94%) women were ex-drinkers and of the 368 women who continued to drink 338 (92%) had a low intake (0–5 units per week), 30 (8%) an excess intake (6-20+ units per week) and 93 (25%) reported at least one episode of binge drinking. Factors associated with continuing to drink in early pregnancy included older maternal age (30–39 years), (OR 1.6; 95% CI 1.3 to 1.8), Irish nationality (OR 3.1; 95% CI 2.2 to 4.3) and smoking (OR 2.6; 95% CI 1.9 to 3.5). Ex-drinkers had similar perinatal outcomes to non-drinkers. Compared to non-drinkers current drinking was associated with an increased risk of intrauterine growth restriction (IUGR) (13% versus 19%, crude OR 1.6; 95% CI 1.1 to 2.2, adjusted OR 1.2; 95% CI 0.8 to 1.8). The greatest risk of IUGR was among women who continued to both drink and smoke, (9% versus 32%, crude OR 4.8; 95% CI 3.3 to 7.0, adjusted OR 4.5; 95% CI 3.1 to 6.7).
Public Health campaigns need to emphasise the potential health gains of abstaining from both alcohol and smoking in pregnancy.
PMCID: PMC3549282  PMID: 23324650
Alcohol exposure; Prospective cohort study; Pregnancy; Perinatal outcomes
5.  Weight and pregnancy 
BMJ : British Medical Journal  2007;335(7612):169.
Women who maintain a normal healthy weight, before, during, and after pregnancy have better outcomes
PMCID: PMC1934487  PMID: 17656509
6.  Study Protocol. ECSSIT – Elective Caesarean Section Syntocinon® Infusion Trial. A multi-centre randomised controlled trial of oxytocin (Syntocinon®) 5 IU bolus and placebo infusion versus oxytocin 5 IU bolus and 40 IU infusion for the control of blood loss at elective caesarean section 
Caesarean section is one of the most commonly performed major operations in women throughout the world. Rates are escalating, with studies from the United States of America, the United Kingdom, China and the Republic of Ireland reporting rates between 20% and 25%. Operative morbidity includes haemorrhage, anaemia, blood transfusion and in severe cases, maternal death.
The value of routine oxytocics in the third stage of vaginal birth has been well established and it has been assumed that these benefits apply to caesarean delivery as well. A slow bolus dose of oxytocin is recommended following delivery of the baby at caesarean section. Some clinicians use an additional infusion of oxytocin for a further period following the procedure. Intravenous oxytocin has a very short half-life (4–10 minutes) therefore the potential advantage of an oxytocin infusion is that it maintains uterine contractility throughout the surgical procedure and immediate postpartum period, when most primary haemorrhages occur. The few trials to date addressing the optimal approach to preventing haemorrhage at caesarean section have been under-powered to evaluate clinically important outcomes. There has been no trial to date comparing the use of an intravenous slow bolus of oxytocin versus an oxytocin bolus and infusion.
Methods and design
A multi-centre randomised controlled trial is proposed. The study will take place in five large maternity units in Ireland with collaboration between academics and clinicians in the disciplines of obstetrics and anaesthetics. It will involve 2000 women undergoing elective caesarean section after 36 weeks gestation. The main outcome measure will be major haemorrhage (blood loss >1000 ml). A study involving 2000 women will have 80% power to detect a 36% relative change in the risk of major haemorrhage with two-sided 5% alpha.
It is both important and timely that we evaluate the optimal approach to the management of the third stage at elective caesarean section. Safe operative delivery is now a priority and a reality for many pregnant women. Obstetricians, obstetric anaesthetists, midwives and pregnant women need high quality evidence on which to base management approaches. The overall aim is to reduce maternal haemorrhagic morbidity and its attendant risks at elective caesarean section.
Trial registration
number: ISRCTN17813715
PMCID: PMC2739153  PMID: 19703279
8.  Study Protocol. IDUS – Instrumental delivery & ultrasound. A multi-centre randomised controlled trial of ultrasound assessment of the fetal head position versus standard care as an approach to prevent morbidity at instrumental delivery 
Instrumental deliveries are commonly performed in the United Kingdom and Ireland, with rates of 12 – 17% in most centres. Knowing the exact position of the fetal head is a pre-requisite for safe instrumental delivery. Traditionally, diagnosis of the fetal head position is made on transvaginal digital examination by delineating the suture lines of the fetal skull and the fontanelles. However, the accuracy of transvaginal digital examination can be unreliable and varies between 20% and 75%. Failure to identify the correct fetal head position increases the likelihood of failed instrumental delivery with the additional morbidity of sequential use of instruments or second stage caesarean section. The use of ultrasound in determining the position of the fetal head has been explored but is not part of routine clinical practice.
A multi-centre randomised controlled trial is proposed. The study will take place in two large maternity units in Ireland with a combined annual birth rate of 13,500 deliveries. It will involve 450 nulliparous women undergoing instrumental delivery after 37 weeks gestation. The main outcome measure will be incorrect diagnosis of the fetal head position. A study involving 450 women will have 80% power to detect a 10% difference in the incidence of inaccurate diagnosis of the fetal head position with two-sided 5% alpha.
It is both important and timely to evaluate the use of ultrasound to diagnose the fetal head position prior to instrumental delivery before routine use can be advocated. The overall aim is to reduce the incidence of incorrect diagnosis of the fetal head position prior to instrumental delivery and improve the safety of instrumental deliveries.
Trial registration
Current Controlled Trials ISRCTN72230496
PMCID: PMC3490917  PMID: 22970933
Fetal head position; Second stage of labour; Intrapartum ultrasound; Randomised controlled trial
9.  Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial  
BMJ : British Medical Journal  2007;334(7607):1305.
Objectives To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section.
Design Randomised trial, conducted from May 2004 to August 2006.
Setting Four maternity units in south west England, and Scotland.
Participants 742 pregnant women with one previous lower segment caesarean section and delivery expected at ≥37 weeks. Non-English speakers were excluded.
Interventions Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher.
Main outcome measures Total score on decisional conflict scale, and mode of delivery.
Results Women in the information programme (adjusted difference −6.2, 95% confidence interval −8.7 to −3.7) and the decision analysis (−4.0, −6.5 to −1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups.
Conclusions Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section.
Trial Registration Current Controlled Trials ISRCTN84367722.
PMCID: PMC1895676  PMID: 17540908
10.  Poor glycated haemoglobin control and adverse pregnancy outcomes in type 1 and type 2 diabetes mellitus: Systematic review of observational studies 
Glycaemic control in women with diabetes is critical to satisfactory pregnancy outcome. A systematic review of two randomised trials concluded that there was no clear evidence of benefit from very tight versus tight glycaemic control for pregnant women with diabetes.
A systematic review of observational studies addressing miscarriage, congenital malformations and perinatal mortality among pregnant women with type 1 and type 2 diabetes was carried out. Literature searches were performed in MEDLINE, EMBASE, CINAHL and Cochrane Library. Observational studies with data on glycated haemoglobin (HbA1c) levels categorised into poor and optimal control (as defined by the study investigators) were selected. Relative risks and odds ratios were calculated for HbA1c and pregnancy outcomes. Adjusted relative risk estimates per 1-percent decrease in HbA1c were calculated for studies which contained information on mean and standard deviations of HbA1c.
The review identified thirteen studies which compared poor versus optimal glycaemic control in relation to maternal, fetal and neonatal outcomes. Twelve of these studies reported the outcome of congenital malformations and showed an increased risk with poor glycaemic control, pooled odds ratio 3.44 (95%CI, 2.30 to 5.15). For four of the twelve studies, it was also possible to calculate a relative risk reduction of congenital malformation for each 1-percent decrease in HbA1c, these varied from 0.39 to 0.59. The risk of miscarriage was reported in four studies and was associated with poor glycaemic control, pooled odds ratio 3.23 (95%CI, 1.64 to 6.36). Increased perinatal mortality was also associated with poor glycaemic control, pooled odds ratio 3.03 (95%CI, 1.87 to 4.92) from four studies.
This analysis quantifies the increase in adverse pregnancy outcomes in women with diabetes who have poor glycaemic control. Relating percentage risk reduction in HbA1c to relative risk of adverse pregnancy events may be useful in motivating women to achieve optimal control prior to conception.
PMCID: PMC1635059  PMID: 17074087
11.  Operative delivery and postnatal depression: a cohort study 
BMJ : British Medical Journal  2005;330(7496):879.
Objectives To assess the association between elective caesarean section and postnatal depression compared with planned vaginal delivery and whether emergency caesarean section or assisted vaginal delivery is associated with postnatal depression compared with spontaneous vaginal delivery.
Design Prospective population based cohort study.
Setting ALSPAC (the Avon longitudinal study of parents and children).
Participants 14 663 women recruited antenatally with a due date between 1 April 1991 and 31 December 1992.
Main outcome measure Edinburgh postnatal depression scale score ≥ 13 at eight weeks postnatal on self completed questionnaire.
Results Albeit with wide confidence intervals, there was no evidence that elective caesarean section altered the odds of postnatal depression compared with planned vaginal delivery (adjusted odds ratio 1.06, 95% confidence interval 0.66 to 1.70, P = 0.80). Among planned vaginal deliveries there was similarly little evidence of a difference between women who have emergency caesarean section or assisted vaginal delivery and those who have spontaneous vaginal delivery (1.17, 0.77 to 1.79, P = 0.46, and 0.89, 0.68 to 1.18, P = 0.42, respectively).
Conclusions There is no reason for women at risk of postnatal depression to be managed differently with regard to mode of delivery. Elective caesarean section does not protect against postnatal depression. Women who plan vaginal delivery and require emergency caesarean section or assisted vaginal delivery can be reassured that there is no reason to believe that they are at increased risk of postnatal depression.
PMCID: PMC556158  PMID: 15734748
12.  Forceps delivery in modern obstetric practice 
BMJ : British Medical Journal  2004;328(7451):1302-1305.
This review discusses the specific uses and potential advantages of forceps over other modes of delivery. To enable women to make an informed choice about mode of delivery, obstetricians need to be adequately trained and supervised in the use of forceps
PMCID: PMC420176  PMID: 15166069
13.  My Foetus 
BMJ : British Medical Journal  2004;328(7446):1021.
Channel 4, 20 April at 11 05 pm
Rating: ★
PMCID: PMC404517
14.  Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study 
BMJ : British Medical Journal  2004;328(7435):311.
Objective To evaluate the reproductive outcome and the mode of delivery in subsequent pregnancies after instrumental vaginal delivery in theatre or caesarean section at full dilatation.
Design Prospective cohort study.
Setting Two urban hospitals with a combined total of 10 000 deliveries a year.
Participants A cohort of 393 women with term, singleton, cephalic pregnancies who needed operative delivery in theatre during the second stage of labour from February 1999 to February 2000. Postal questionnaires were received from 283 women (72%) at three years after the initial delivery.
Main outcome measure Mode of delivery in the subsequent pregnancy.
Results 140 women (49%) achieved a further pregnancy at three years. 91/283 (32%) women wished to avoid a further pregnancy. Women were more likely to aim for vaginal delivery (87% (47/54) v 33% (18/54); adjusted odds ratio 15.55 (95% confidence interval 5.25 to 46.04)) and more likely to have a vaginal delivery (78% (42/54) v 31% (17/54); 9.50 (3.48 to 25.97)) if they had had a previous instrumental vaginal delivery rather than a caesarean section. There was a high rate of vaginal delivery after caesarean section among women who attempted vaginal delivery 17/18 (94%). In both groups, fear of childbirth was a frequently reported reason for avoiding a further pregnancy (51% after instrumental vaginal delivery, 42% after caesarean section; 1.75 (0.58 to 5.25)).
Conclusion Instrumental vaginal delivery offers advantages over caesarean section for future delivery outcomes. The psychological impact of operative delivery requires urgent attention.
PMCID: PMC338093  PMID: 14724128
15.  Women's views on the impact of operative delivery in the second stage of labour: qualitative interview study 
BMJ : British Medical Journal  2003;327(7424):1132.
Objective To obtain the views of women on the impact of operative delivery in the second stage of labour.
Design Qualitative interview study.
Setting Two urban teaching hospitals in the United Kingdom.
Participants Purposive sample of 27 women who had undergone operative delivery in the second stage of labour between January 2000 and January 2002.
Key themes Preparation for birth, understandings of the indications for operative delivery, and explanation or debriefing after birth.
Results The women felt unprepared for operative delivery and thought that their birth plan or antenatal classes had not catered adequately for this event. They emphasised the importance of maintaining an open mind about the management of labour. They had difficulty understanding the need for operative delivery despite a review by medical and midwifery staff before discharge. Operative delivery had a noticeable impact on women's views about future pregnancy and delivery.
Conclusions Women consider postnatal debriefing and medical review important deficiencies in current care. Those who experienced operative delivery in the second stage of labour would welcome the opportunity to have a later review of their intrapartum care, physical recovery, and management of future pregnancies.
PMCID: PMC261808  PMID: 14615336

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