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Objective To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings. Design Modified Delphi process. Setting Participants from 34 countries. Population Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group. Methods We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts. Main outcome measure Consensus on bundle items. Results Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’. Conclusion A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus. Tweetable abstract A maternal sepsis bundle for low resource settings has been developed by international consensus., Tweetable abstract A maternal sepsis bundle for low resource settings has been developed by international consensus.

Objective To evaluate enzymatic total serum bile acid quantification as a monitoring strategy for women with intrahepatic cholestasis of pregnancy (ICP) treated with ursodeoxycholic acid (UDCA). Design Cohort. Setting One UK university hospital. Population 29 ICP cases treated with UDCA. Methods Serial samples were collected prospectively throughout gestation. Total serum bile acids were measured enzymatically and individual bile acids by high‐performance liquid chromatography‐tandem mass spectrometry. Data were log‐transformed and analysed with random effects generalised least square regression. Main outcome measures The relationship between enzymatic total bile acid measurements and individual bile acid concentrations after UDCA treatment. Results In untreated women, cholic acid was the principal bile acid (51%) and UDCA concentrations were, Tweetable abstract Ursodeoxycholic acid constitutes approximately 60% of the bile acid measurement and reduces pathological cholic acid in treated women.

This is the peer reviewed version of the following article: Rossen, J., Klungsøyr, K., Albrechtsen, S., Løkkegård, E., Rasmussen, S., Bergholt, T. & Skjeldestad, F.E. (2018). Can oxytocin augmentation modify the risk of epidural analgesia by maternal age in cesarean sections? Acta Obstetricia et Gynecologica Scandinavica, 97(7), 872-879, which has been published in final form at https://doi.org/10.1111/aogs.13341. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. Introduction: Maternal age is an established risk factor for cesarean section; epidural analgesia and oxytocin augmentation may modify this association. We investigated the effects and interactions of oxytocin augmentation, epidural analgesia and maternal age on the risk of cesarean section. Material and methods: In all, 416 386 nulliparous women with spontaneous onset of labor, ≥37 weeks of gestation and singleton infants with a cephalic presentation during 2000–2011 from Norway and Denmark were included [Ten‐group classification system (Robson) group 1]. In this case‐control study the main exposure was maternal age; epidural analgesia, oxytocin augmentation, birthweight and time period were explanatory variables. Chi‐square test and logistic regression were used to estimate associations and interactions. Results: The cesarean section rate increased consistently with advancing maternal age, both overall and in strata of epidural analgesia and oxytocin augmentation. We observed strong interactions between maternal age, oxytocin augmentation and epidural analgesia for the risk of cesarean section. Women with epidural analgesia generally had a reduced adjusted odds ratio when oxytocin was used compared with when it was not used. In Norway, this applied to all maternal age groups but in Denmark only for women ≥30 years. Among women without epidural, oxytocin augmentation was associated with an increased odds ratio for cesarean section in Denmark, whereas no difference was observed in Norway. Conclusions: Oxytocin augmentation in nulliparous women with epidural analgesia is associated with a reduced risk of cesarean section in labor with spontaneous onset.

Objective To explore the healthcare experiences of parents whose baby died either before, during or shortly after birth between 20+0 and 23+6 weeks of gestation in order to identify practical ways to improve healthcare provision. Design Qualitative interview study. Setting England through two parent support organisations and four NHS Trusts. Sample A purposive sample of parents. Methods Thematic analysis of semi‐structured in‐depth narrative interviews. Main outcome measures Parents’ healthcare experiences. Results The key overarching theme to emerge from interviews with 38 parents was the importance of the terminology used to refer to the death of their baby. Parents who were told they were ‘losing a baby’ rather than ‘having a miscarriage’ were more prepared for the realities of labour, the birth experience and for making decisions around seeing and holding their baby. Appropriate terminology validated their loss, and impacted on parents’ health and wellbeing immediately following bereavement and in the longer term. Conclusion For parents experiencing the death of their baby at the margins between miscarriage, stillbirth and neonatal death, ensuring the use of appropriate terminology that reflects parents’ preferences is vital. This helps to validate their loss and prepare them for the experiences of labour and birth. Reflecting parents’ language preferences combined with compassionate bereavement care is likely to have a positive impact on parents’ experiences and improve longer‐term outcomes. Tweetable abstract Describing baby loss shortly before 24 weeks of gestation as a ‘miscarriage’ does not prepare parents for labour and birth, seeing their baby and making memories., Tweetable abstract Describing baby loss shortly before 24 weeks of gestation as a ‘miscarriage’ does not prepare parents for labour and birth, seeing their baby, and making memories.

Objectives To describe the characteristics, management and outcomes of women giving birth at advanced maternal age (≥48 years). Design Population‐based cohort study using the UK Obstetric Surveillance System (UKOSS). Setting All UK hospitals with obstetrician‐led maternity units. Population Women delivering at advanced maternal age (≥48 years) in the UK between July 2013 and June 2014 (n = 233) and 454 comparison women. Methods Cohort and comparison group identification through the UKOSS monthly mailing. Main outcome measures Pregnancy complications. Results Older women were more likely than comparison women to be overweight (33% versus 23%, P = 0.0011) or obese (23% versus 19%, P = 0.0318), nulliparous (53% versus 44%, P = 0.0299), have pre‐existing medical conditions (44% versus 28%, P, Tweetable abstract The pregnancy complications in women giving birth aged 48 or over are mostly explained by multiple pregnancy.

Please cite this paper as: Tajik P, van der Tuuk K, Koopmans C, Groen H, van Pampus M, van der Berg P, van der Post J, van Loon A, de Groot C, Kwee A, Huisjes A, van Beek E, Papatsonis D, Bloemenkamp K, van Unnik G, Porath M, Rijnders R, Stigter R, de Boer K, Scheepers H, Zwinderman A, Bossuyt P, Mol B. Should cervical favourability play a role in the decision for labour induction in gestational hypertension or mild pre-eclampsia at term? An exploratory analysis of the HYPITAT trial. BJOG 2012;119:11231130. Objective To examine whether cervical favourability (measured by cervical length and the Bishop score) should inform obstetricians decision regarding labour induction for women with gestational hypertension or mild pre-eclampsia at term. Design A post hoc analysis of the Hypertension and Pre-eclampsia Intervention Trial At Term (HYPITAT). Setting Obstetric departments of six university and 32 teaching and district hospitals in the Netherlands. Population A total of 756 women diagnosed with gestational hypertension or pre-eclampsia between 36 + 0 and 41 + 0 weeks of gestation randomly allocated to induction of labour or expectant management. Methods Data were analysed using logistic regression modelling. Main outcome measures The occurrence of a high-risk maternal situation defined as either maternal complications or progression to severe disease. Secondary outcomes were caesarean delivery and adverse neonatal outcomes. Results The superiority of labour induction in preventing high-risk situations in women with gestational hypertension or mild pre-eclampsia at term varied significantly according to cervical favourability. In women who were managed expectantly, the longer the cervix the higher the risk of developing maternal high-risk situations, whereas in women in whom labour was induced, cervical length was not associated with a higher probability of maternal high-risk situations (test of interaction P = 0.03). Similarly, the beneficial effect of labour induction on reducing the caesarean section rate was stronger in women with an unfavourable cervix. Conclusion Against widely held opinion, our exploratory analysis showed that women with gestational hypertension or mild pre-eclampsia at term who have an unfavourable cervix benefited more from labour induction than other women. Trial registration The trial has been registered in the clinical trial register as ISRCTN08132825.

Objective To develop a core metric set to monitor the quality of maternity care. Design Delphi process followed by a face‐to‐face consensus meeting. Setting English maternity units. Population Three representative expert panels: service designers, providers and users. Main outcome measures Maternity care metrics judged important by participants. Methods Participants were asked to complete a two‐phase Delphi process, scoring metrics from existing local maternity dashboards. A consensus meeting discussed the results and re‐scored the metrics. Results In all, 125 distinct metrics across six domains were identified from existing dashboards. Following the consensus meeting, 14 metrics met the inclusion criteria for the final core set: smoking rate at booking; rate of birth without intervention; caesarean section delivery rate in Robson group 1 women; caesarean section delivery rate in Robson group 2 women; caesarean section delivery rate in Robson group 5 women; third‐ and fourth‐degree tear rate among women delivering vaginally; rate of postpartum haemorrhage of ≥1500 ml; rate of successful vaginal birth after a single previous caesarean section; smoking rate at delivery; proportion of babies born at term with an Apgar score, Tweetable abstract Achieving consensus on core metrics for monitoring the quality of maternity care.