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In this work, a very fast integrated transport model involving every region that interacts directly with the plasma of a tokamak, has been developed. The confined region is modeled in 1.5D, while the scrape-off layer has a 0D structure. For the core region, a physics-based analytical regression based on a set of simulations with the transport model TGLF [Staebler 2005 Phys. Plasmas 12 102508] has been produced. For the H-mode regime, an average edge-localized-modes model is applied in the pedestal region. In the scrape-off layer a two-point model for electron temperature (exhaust) and a particle balance for the species density at the separatrix have been implemented. All the models have first been validated individually in a standalone setting. Finally, six fully integrated simulations of an L-mode discharge, and five H-mode discharges, have been performed in the Fenix flight simulator [Janky et al 2019 Fusion Eng. Des. 146 1926, Fable et al 2022 Plasma Phys. Control. Fusion 64 044002], including transients, matching the experimental trajectories of an ASDEX upgrade discharge during flat-top and ramp-down. A broader validation including more discharges and the ramp-up phase is planned for the near future.

The most important knowledge gap in connection with obstetric management for time of delivery in term low-risk pregnancies relates to the absence of information on long-term neurodevelopmental outcomes.We examined risks of stillbirth, infant mortality, cerebral palsy (CP) and epilepsy among low-risk pregnancies.In this population-based Swedish study, we identified, from 1998 to 2019, 1,773,269 singleton infants born between 37 and 42 completed weeks in women with low-risk pregnancies. Poisson log-linear regression models were used to examine the association between gestational age at delivery and stillbirth, infant mortality, CP and epilepsy. Adjusted rate ratios (RR) and 95% confidence intervals expressing the effect of birth at a particular gestational week compared with birth at a later gestational week were estimated.Compared with those born at a later gestation, RRs for stillbirth and infant mortality were higher among births at 37 weeks' and 38 weeks' gestation. The RRs for infant mortality were approximately 20% and 25% lower among births at 40 or 41 weeks compared with those born at later gestation, respectively. Infants born at 37 and 38 weeks also had higher RRs for CP (vs infants born at ≥38 and ≥39 weeks, respectively), while those born at 39 gestation had similar RRs (vs infants born at ≥40 weeks); infants born at 40 and 41 weeks had lower RRs of CP (vs those born at ≥41 and 42 weeks, respectively). The RRs for epilepsy were higher in those born at 37 and 38 weeks compared with those born at later gestation.Among low-risk pregnancies, birth at 37 or 38 completed weeks' gestation is associated with increased risks of stillbirth, infant mortality and neurological morbidity, while birth at 39-40 completed weeks is associated with reduced risks compared with births at later gestation.

To investigate the effect of maternal stature on adverse birth outcomes and quantify perinatal risks associated with small- and large-for-gestational age infants (SGA and LGA, respectively) born to mothers of short, average, and tall stature.Retrospective cohort study.USA, 2016-2017.Women with a singleton live birth (N=7 325 741).Using data from the National Center for Health Statistics, short and tall stature were defined as10Preterm birth (37 weeks' gestation), neonatal intensive care unit (NICU) admission, and severe neonatal morbidity/mortality (SNMM).With increased maternal height, risk of adverse outcomes increased in SGA infants and decreased in LGA infants compared with appropriate-for-gestational age (AGA) infants (p0.001). SGA infants of tall women had the highest risk of NICU admission (ARR 1.98, CI: 1.91-2.05; p0.001), while LGA infants of tall women had the lowest risk (ARR 0.85, CI 0.82-0.88; p0.001) compared with AGA infants of average statured women. LGA infants of short statured women had an increased risk of NICU admission and SNMM compared with AGA infants of average statured women (ARR 1.32, CI 1.27-1.38; ARR 1.21, CI 1.13-1.29, respectively).Maternal height modifies the association between SGA and LGA status at birth and neonatal outcomes. This quantification of risk can assist healthcare providers in monitoring fetal growth, and optimizing neonatal care, and follow up.

BACKGROUND AND OBJECTIVES Although racial and ethnic disparities in adverse birth outcomes have been well documented, it is unknown whether such disparities diminish in women who use medically assisted reproduction (MAR). We examined differences in the association between maternal race and ethnicity and adverse birth outcomes among women who conceived spontaneously and those who used MAR, including assisted reproduction technology (ART), eg, in-vitro fertilization, and also non-ART MAR, eg, fertility drugs. METHODS We conducted a population-based retrospective cohort study using data on all singleton births (N = 7 545 805) in the United States from 2016 to 2017. The outcomes included neonatal and fetal death, preterm birth, and serious neonatal morbidity, among others. Modified Poisson regression was used to estimate adjusted rate ratios (aRR) and 95% confidence intervals (CI) and to assess the interactions between race and ethnicity and mode of conception. RESULTS Overall, 93 469 (1.3%) singletons were conceived by MAR. Neonatal mortality was twofold higher among infants of non-Hispanic Black versus non-Hispanic White women in the spontaneous-conception group (aRR = 1.9, 95% CI: 1.8–1.9), whereas in the ART-conception group, neonatal mortality was more than fourfold higher in infants of non-Hispanic Black women (aRR = 4.1, 95% CI: 2.9–5.9). Racial and ethnic disparities between Hispanic versus non-Hispanic White women were also significantly larger among women who conceived using MAR with regard to preterm birth ( CONCLUSIONS Compared to women who conceived spontaneously, racial and ethnic disparities in adverse perinatal outcomes were larger in women who used MAR. More research is needed to identify preventive measures for reducing risks among vulnerable women who use medically assisted reproduction.

The initial COVID-19 pandemic response-related effects on conceptions following the use of assisted reproductive technologies (ART), and on changes in the maternal characteristics of women who conceived during the early vs. pre-pandemic period, have been understudied.To examine the effects of ART clinic closures in the United States (US) in March 2020 on the frequency of ART-conceived live births, multiple births and stillbirths; and to describe changes in the characteristics of women who conceived in the early pandemic period.Population-based cohort study including all births in the US from January 2015 to December 2020 (22,907,688 live births; 134,537 stillbirths). Interrupted time series (ITS) methodology was used to estimate rate ratios (RR) of expected versus observed rates in December 2020 (i.e., among births conceived mainly in March 2020). Demographic and clinical characteristics were compared between mothers who conceived in March 2020 versus March 2015-2019.Overall, 1.1% of live births and 1.7% of stillbirths were conceived by ART. ART-conceived live births decreased by 57.0% in December 2020 (observed vs. expected RR 0.43, 95% confidence interval [CI] 0.40, 0.45), and these declines occurred in all subgroups of women. Multiple births also declined in December 2020. Stillbirth rates increased in December 2020 in ART-conceived births (RR 2.55, 95% CI 1.63, 3.92) but remained unchanged in the non-ART group. Maternal characteristics of women who conceived in the early pandemic versus pre-pandemic period differed and included an increased prevalence of pre-pregnancy obesity class 3 and chronic hypertension.The early pandemic closure of ART clinics resulted in a substantial decline in ART-conceived live births and multiple births in December 2020 and an increase in the proportion of stillbirths among ART-conceived births. Women who conceived in the early pandemic period also had an increased prevalence of obesity and chronic hypertension.

Introduction Postpartum hemorrhage (PPH) is recognized as a leading cause of obstetric morbidity and mortality. Population-wide studies have used International Classification of Diseases (ICD) diagnostic codes to track and report the prevalence of PPH. Although the tenth revision (ICD-10) was introduced in Sweden in 1997, the accuracy of ICD-10 codes for PPH is not known. Thus, the aim was to determine the accuracy of diagnostic coding for PPH in the Swedish Pregnancy Register. Material and methods We performed a retrospective cohort study of 609 807 deliveries in Sweden between 2014 and 2019. Information on ICD-10 codes for PPH and estimated blood loss were extracted from the Swedish Pregnancy Register. Using an estimated blood loss >1000 ml as the reference standard, we evaluated the diagnostic accuracy of ICD-10 codes for PPH by estimating sensitivity, specificity, positive predictive value and negative predictive value with exact binomial 95% confidence intervals (CIs). In our secondary analysis, we assessed the ICD-10 coding accuracy for severe PPH, defined as an estimated blood loss >1000 ml and transfusion of at least one unit of red blood cells registered in the Scandinavian Donations and Transfusion database. Results Of the 609 807 deliveries, 43 312 (7.1%) had an ICD-10 code for PPH and 45 071 (7.4%) had an estimated blood loss >1000 ml. The ICD-codes had a sensitivity of 88.5% (95% CI:88.2 - 88.7), specificity of 99.4% (95% CI:99.4 - 99.4), positive predictive value of 92.0% (95% CI:91.8 - 92.3) and negative predictive value of 99.1% (95% CI:99.1 - 99.1). In our secondary analysis, on deliveries with severe PPH, the sensitivity for an ICD-code was 91.3% (95% CI:90.7 - 91.9) whereas specificity was 83.5% (95% CI:82.3 - 84.6). Conclusions Our findings indicate that ICD-10 codes for PPH in Sweden have moderately high sensitivity and excellent specificity. These results suggest that PPH diagnostic codes in medical records and linked pregnancy and birth registers can be used for research, quality improvement and reporting PPH prevalence in Sweden.

An overview of recent results obtained at the tokamak ASDEX Upgrade (AUG) is given. A work flow for predictive profile modelling of AUG discharges was established which is able to reproduce experimental H-mode plasma profiles based on engineering parameters only. In the plasma center, theoretical predictions on plasma current redistribution by a dynamo effect were confirmed experimentally. For core transport, the stabilizing effect of fast ion distributions on turbulent transport is shown to be important to explain the core isotope effect and improves the description of hollow low-Z impurity profiles. The L–H power threshold of hydrogen plasmas is not affected by small helium admixtures and it increases continuously from the deuterium to the hydrogen level when the hydrogen concentration is raised from 0 to 100%. One focus of recent campaigns was the search for a fusion relevant integrated plasma scenario without large edge localised modes (ELMs). Results from six different ELM-free confinement regimes are compared with respect to reactor relevance: ELM suppression by magnetic perturbation coils could be attributed to toroidally asymmetric turbulent fluctuations in the vicinity of the separatrix. Stable improved confinement mode plasma phases with a detached inner divertor were obtained using a feedback control of the plasma β. The enhanced Dα H-mode regime was extended to higher heating power by feedback controlled radiative cooling with argon. The quasi-coherent exhaust regime was developed into an integrated scenario at high heating power and energy confinement, with a detached divertor and without large ELMs. Small ELMs close to the separatrix lead to peeling-ballooning stability and quasi continuous power exhaust. Helium beam density fluctuation measurements confirm that transport close to the separatrix is important to achieve the different ELM-free regimes. Based on separatrix plasma parameters and interchange-drift-Alfvén turbulence, an analytic model was derived that reproduces the experimentally found important operational boundaries of the density limit and between L- and H-mode confinement. Feedback control for the X-point radiator (XPR) position was established as an important element for divertor detachment control. Stable and detached ELM-free phases with H-mode confinement quality were obtained when the XPR was moved 10 cm above the X-point. Investigations of the plasma in the future flexible snow-flake divertor of AUG by means of first SOLPS-ITER simulations with drifts activated predict beneficial detachment properties and the activation of an additional strike point by the drifts. This work has been carried out within the framework of the EUROfusion Consortium and has received funding from the Euratom research and training programme 2014–2018 and 2019–2020 under Grant Agreement No. 633053. The views and opinions expressed herein do not necessarily reflect those of the European Commission. Peer Reviewed "Article signat per més de 50 autors/es: U. Stroth, D. Aguiam, E. Alessi, C. Angioni, N. Arden, R. Arredondo Parra, V. Artigues, O. Asunta, M. Balden, V. Bandaru, A. Banon-Navarro, K. Behler, A. Bergmann, M. Bergmann, J. Bernardo, M. Bernert, A. Biancalani, R. Bielajew, R. Bilato, G. Birkenmeier, T. Blanken, V. Bobkov, A. Bock, T. Body, T. Bolzonella, N. Bonanomi, A. Bortolon, B. Böswirth, C. Bottereau, A. Bottino, H. van den Brand, M. Brenzke, S. Brezinsek, D. Brida, F. Brochard, C. Bruhn, J. Buchanan, A. Buhler, A. Burckhart, Y. Camenen, B. Cannas, P. Cano Megias, D. Carlton, M. Carr, P. Carvalho, C. Castaldo, M. Cavedon, C. Cazzaniga, C. Challis, A. Chankin, C. Cianfarani, F. Clairet, S. Coda, R. Coelho, J.W. Coenen, L. Colas, G. Conway, S. Costea, D. Coster, T. Cote, A.J. Creely, G. Croci, D.J. Cruz Zabala, G. Cseh, A. Czarnecka, I. Cziegler, O. D'Arcangelo, A. Dal Molin, P. David, C. Day, M. de Baar, P. de Marné, R. Delogu, S. Denk, P. Denner, A. Di Siena, J.J. Dominguez Palacios Durán, D. Dunai, A. Drenik, M. Dreval, R. Drube, M. Dunne, B.P. Duval, R. Dux, T. Eich, S. Elgeti, A. Encheva, K. Engelhardt, B. Erdös, I. Erofeev, B. Esposito, E. Fable, M. Faitsch, U. Fantz, M. Farnik, H. Faugel, F. Felici, O. Ficker, S. Fietz, A. Figueredo, R. Fischer, O. Ford, L. Frassinetti, M. Fröschle, G. Fuchert, J.C. Fuchs, H. Fünfgelder, S. Futatani, K. Galazka, J. Galdon-Quiroga, D. Gallart Escolà, A. Gallo10, Y. Gao11, S. Garavaglia3, M. Garcia Muñoz16, B. Geiger21, L. Giannone1, S. Gibson32, L. Gil2, E. Giovannozzi18, S. Glöggler1, M. Gobbin8, J. Gonzalez Martin, T. Goodman, G. Gorini, T. Görler, D. Gradic, G. Granucci, A. Gräter, H. Greuner, M. Griener, M. Groth, A. Gude, L. Guimarais, S. Günter, G. Haas, A.H. Hakola, C. Ham, T. Happel, N. den Harder, G. Harrer, J. Harrison, V. Hauer, T. Hayward-Schneider, B. Heinemann, T. Hellsten, S. Henderson, P. Hennequin, A. Herrmann, E. Heyn, F. Hitzler, J. Hobirk, K. Höfler, J.H. Holm, M. Hölzl, C. Hopf, L. Horvath, T. Höschen, A. Houben, A. Hubbard, A. Huber, K. Hunger, V. Igochine, M. Iliasova, T. Ilkei, K. Insulander Björk, C. Ionita-Schrittwieser, I. Ivanova-Stanik, W. Jacob, N. Jaksic, F. Janky, A. Jansen van Vuuren, A. Jardin, F. Jaulmes, F. Jenko, T. Jensen, E. Joffrin, A. Kallenbach, S. Kálvin, M. Kantor, A. Kappatou, O. Kardaun, J. Karhunen4, C.-P. Käsemann, S. Kasilov, A. Kendl, W. Kernbichler, E. Khilkevitch, A. Kirk, S. Kjer Hansen, V. Klevarova, G. Kocsis, M. Koleva, M. Komm, M. Kong, A. Krämer-Flecken, K. Krieger, A. Krivska, O. Kudlacek, T. Kurki-Suonio, B. Kurzan, B. Labit, K. Lackner, F. Laggner, A. Lahtinen, P.T. Lang, P. Lauber, N. Leuthold, L. Li, J. Likonen, O. Linder, B. Lipschultz, Y. Liu, A. Lohs, Z. Lu, T. Luda di Cortemiglia, N.C. Luhmann, T. Lunt, A. Lyssoivan, T. Maceina, J. Madsen, A. Magnanimo, H. Maier, J. Mailloux, R. Maingi, O. Maj, E. Maljaars, P. Manas, A. Mancini, A. Manhard, P. Mantica, M. Mantsinen, P. Manz, M. Maraschek, C. Marchetto, L. Marrelli, P. Martin, A. Martitsch, F. Matos, M. Mayer, M.-L. Mayoral, D. Mazon, P.J. McCarthy, R. McDermott, R. Merkel, A. Merle, D. Meshcheriakov, H. Meyer, D. Milanesio, P. Molina Cabrera, F. Monaco, M. Muraca, F. Nabais, V. Naulin, R. Nazikian, R.D. Nem, A. Nemes-Czopf, G. Neu, R. Neu, A.H. Nielsen, S.K. Nielsen, T. Nishizawa, M. Nocente, J.-M. Noterdaeme, I. Novikau, S. Nowak, M. Oberkofler, R. Ochoukov, J. Olsen, F. Orain, F. Palermo, O. Pan, G. Papp, I. Paradela Perez, A. Pau, G. Pautasso, C. Paz-Soldan, P. Petersson, P. Piovesan, C. Piron, U. Plank, B. Plaum, B. Plöck, V. Plyusnin, G. Pokol, E. Poli, L. Porte, T. Pütterich, M. Ramisch, J. Rasmussen, G. Ratta, S. Ratynskaia, G. Raupp, D. Réfy, M. Reich1, F. Reimold, D. Reiser, M. Reisner, D. Reiter, T. Ribeiro, R. Riedl, J. Riesch, D. Rittich, J.F. Rivero Rodriguez, G. Rocchi, P. Rodriguez-Fernandez, M. Rodriguez-Ramos, V. Rohde, G. Ronchi, A. Ross, M. Rott, M. Rubel, D.A. Ryan, F. Ryter, S. Saarelma, M. Salewski, A. Salmi, O. Samoylov, L. Sanchis Sanchez, J. Santos, O. Sauter, G. Schall, K. Schlüter, K. Schmid, O. Schmitz, P.A. Schneider, R. Schrittwieser, M. Schubert, C. Schuster, T. Schwarz-Selinger, J. Schweinzer, E. Seliunin, A. Shabbir, A. Shalpegin, S. Sharapov, U. Sheikh, A. Shevelev, G. Sias, M. Siccinio, B. Sieglin, A. Sigalov, A. Silva, C. Silva, D. Silvagni, J. Simpson, S. Sipilä, E. Smigelskis, A. Snicker, E. Solano, C. Sommariva, C. Sozzi, G. Spizzo, M. Spolaore, A. Stegmeir, M. Stejner, J. Stober, E. Strumberge1, G. Suarez Lopez, H.-J. Sun, W. Suttrop, E. Sytova, T. Szepesi, B. Tál, T. Tala, G. Tardini, M. Tardocchi, D. Terranova, M. Teschke, E. Thorén, W. Tierens, D. Told, W. Treutterer, G. Trevisan, E. Trier, M. Tripský, M. Usoltceva, M. Valisa, M. Valovic, M. van Zeeland, F. Vannini, B. Vanovac, P. Varela, S. Varoutis, N. Vianello, J. Vicente, G. Verdoolaege, T. Vierle, E. Viezzer, I. Voitsekhovitch, U. von Toussaint, D. Wagner, X. Wang, M. Weiland, A.E. White, M. Willensdorfer, B. Wiringer, M. Wischmeier, R. Wolf, E. Wolfrum, Q. Yang, Q. Yu, R. Zagórski, I. Zammuto, T. Zehetbauer, W. Zhang, W. Zholobenko, M. Zilker, A. Zito, H. Zohm, S. Zoletnik and the EUROfusion MST1 Team "

ObjectivesTo investigate the association between paternal use of antiepileptic drugs (AEDs) and adverse neurodevelopmental outcomes and major congenital malformations (MCM) in the offspring.MethodsUsing nationwide Swedish registries, we included 1 144 795 births to 741 726 fathers without epilepsy and 4544 births to 2955 fathers with epilepsy. Of these, 2087 (45.9%) were born to fathers with epilepsy who had dispensed an AED during the conception period. Children who had both parents with epilepsy were excluded. The incidence rate of MCM, autism spectrum disorder, attention deficit hyperactivity disorder (ADHD) and intellectual disability in offspring was analysed.ResultsOffspring of fathers exposed to AEDs did not show an increased risk of MCM (adjusted OR 0.9, 95% CI 0.7 to 1.2), autism (adjusted HR (aHR) 0.9, 95% CI 0.5 to 1.7), ADHD (aHR 1.1, 95% CI 0.7 to 1.9) or intellectual disability (aHR 1.3, 95% CI 0.6 to 2.8) compared with offspring of fathers with epilepsy not exposed to AEDs. Among offspring of fathers with epilepsy who used valproate in monotherapy during conception, rates of autism (2.9/1000 child-years) and intellectual disability (1.4/1000 child-years) were slightly higher compared with the offspring of fathers with epilepsy who did not use AEDs during conception (2.1/1000 child-years autism, 0.9/1000 child-years intellectual disability), but in the propensity-score adjusted analyses, no statistically significant increased risk of adverse outcomes was found.ConclusionsPaternal AED use during conception is not associated with adverse outcomes in the offspring.

Background Maternal overweight and obesity might increase risks of adiposity and cardiovascular and metabolic diseases in offspring. We examined associations between maternal overweight and obesity severity and risk of cardiovascular diseases in young offspring. Methods In this population-based cohort study, we used data from live singleton births recorded in the Swedish Medical Birth Register. We calculated maternal BMI in early pregnancy from self-reported height and weight measurements at the first prenatal visit. We used multivariable Cox proportional hazards regression to estimate adjusted hazard ratios (HRs) and 95% CIs. We calculated the proportion of the associations mediated through known consequences of obesity that also predicted cardiovascular diseases and did family case-control analyses. Findings We identified 2 230 115 live singleton infants (without congenital malformations) in Sweden registered between Jan 1, 1992, and Dec 31, 2016. Overall, 1741 (0·08%) offspring were diagnosed with a cardiovascular disease between ages 1 and 25 years. Cardiovascular disease rates by maternal BMI categories were 0·57 per 10 000 child-years (BMI 18·5-24·9 kg/m2; normal weight), 0·61 per 10 000 child-years (25·0-29·9 kg/m2; overweight), 0·67 per 10 000 child-years (30·0-34·9 kg/m2; obesity grade I), 1·02 per 10 000 child-years (35·0-39·9 kg/m2; obesity grade II), and 1·38 per 10 000 child-years (≥40·0 kg/m2; obesity grade III). Compared with offspring of mothers with normal BMI, HRs of cardiovascular diseases were 1·10 (95% CI 0·97-1·25) for overweight, 1·16 (0·95-1·43) for obesity grade I, 1·84 (1·36-2·49) for obesity grade II, and 2·51 (1·60-3·92) for obesity grade III. Risks of cerebrovascular diseases increased with maternal obesity severity and were partly mediated through asphyxia-related neonatal complications. The sibling-cohort analysis also indicated a positive trend between maternal BMI and cardiovascular disease rates. Interpretations Our findings indicate that maternal obesity might be a risk factor for cardiovascular diseases in childhood and early adulthood. These results need to be replicated and possible underlying mechanisms identified. Funding Swedish Research Council for Health, Working Life and Welfare.

OBJECTIVES We assessed the incidence, risk factors and adverse birth outcomes associated with elevated liver enzymes and low platelets (HELLP) syndrome. DESIGN A retrospective population-based cohort study. SETTING Canada (excluding Quebec), 2012/2013-2015/2016. POPULATION Mothers with a singleton hospital live birth or stillbirth at ≥24 weeks' gestation (n = 1 078 323). METHODS HELLP syndrome was identified using ICD-10-CA diagnostic code from delivery hospitalisation data. We used logistic regression to identify independent risk factors for HELLP syndrome by obtaining adjusted odds ratios (AOR) and 95% confidence intervals (CI), and to assess the associations with adverse outcomes. MAIN OUTCOME MEASURES Adverse maternal (e.g. eclampsia) and fetal/neonatal outcomes (e.g. intraventricular haemorrhage, perinatal death). RESULTS The incidence of HELLP syndrome was 2.5 per 1000 singleton deliveries (n = 2663). Risk factors included: age ≥35 years, rural residence, nulliparity, parity ≥4, pre-pregnancy and gestational hypertension and diabetes, assisted reproduction, chronic cardiac conditions, systemic lupus erythematosus, obesity, chronic hepatic conditions, placental disorders (e.g. fetomaternal transfusion) and congenital anomalies. PROM and age

Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel. However, opportunities for training in OVD have declined and, given these shifts in practice, the safety of OVD is unknown. We estimated incidence rates of trauma following OVD in Canada, and quantified variation in trauma rates by instrument, region, level of obstetric care and institutional OVD volume.We conducted a cohort study of all singleton, term deliveries in Canada between April 2013 and March 2019, excluding Quebec. Our main outcome measures were maternal trauma (e.g., obstetric anal sphincter injury, high vaginal lacerations) and neonatal trauma (e.g., subgaleal hemorrhage, brachial plexus injury). We calculated adjusted and stabilized rates of trauma using mixed-effects logistic regression.Of 1 326 191 deliveries, 38 500 (2.9%) were attempted forceps deliveries and 110 987 (8.4%) were attempted vacuum deliveries. The maternal trauma rate following forceps delivery was 25.3% (95% confidence interval [CI] 24.8%-25.7%) and the neonatal trauma rate was 9.6 (95% CI 8.6-10.6) per 1000 live births. Maternal and neonatal trauma rates following vacuum delivery were 13.2% (95% CI 13.0%-13.4%) and 9.6 (95% CI 9.0-10.2) per 1000 live births, respectively. Maternal trauma rates remained higher with forceps than with vacuum after adjustment for confounders (adjusted rate ratio 1.70, 95% CI 1.65-1.75) and varied by region, but not by level of obstetric care.In Canada, rates of trauma following OVD are higher than previously reported, irrespective of region, level of obstetric care and volume of OVD among hospitals. These results support a reassessment of OVD safety in Canada.

Background Chronic hypertension is a strong risk factor for severe preeclampsia/eclampsia (SPE), and timely obstetric intervention can prevent SPE and reduce perinatal complications. We quantified gestational age-specific rates of SPE and estimated the benefits of preventive interventions among women with chronic hypertension at term gestation (≥37 weeks). Methods Women with chronic hypertension and a term, singleton, hospital delivery in Washington State, 2003-2013, were included in the study (N = 9697) with data obtained from birth certificates and hospital records. Adverse outcomes included SPE and composite severe neonatal morbidity (e.g., seizures, intracranial hemorrhage) and perinatal death (SNMM). Preventive interventions included labour induction and pre-labour cesarean delivery. Results There were 1026 cases of SPE (10.6 per 100 women with chronic hypertension). Gestational age-specific SPE rates ranged between 2.8 and 4.1 per 100 ongoing pregnancies; the frequency of preventive intervention at each gestational week ranged between 58% and 66%. Gestational age-specific SPE and SNMM rates were lower following preventive intervention: such intervention reduced the frequency of SPE/SNMM by 28 per 100 additional interventions at 37 weeks, 22 per 100 at 38 weeks, 17 per 100 at 39 weeks, 13 at 40 weeks and 6 per 100 additional interventions at 41 weeks’ gestation. Conclusions Labour induction and pre-labour cesarean delivery at term gestation can prevent a substantial proportion of severe preeclampsia/eclampsia and perinatal death/severe neonatal morbidity among women with chronic hypertension. Key messages SPE occurs in approximately 11% of women with chronic hypertension at term gestation. Obstetric interventions can prevent SPE and improve adverse pregnancy outcomes.

Objective To examine postpartum haemorrhage (PPH) trends in Sweden using the Robson classification system. Design Population-based cohort study. Setting Sweden. Population Deliveries in 2000-2016, classified as Robson groups 1-5 (singleton pregnancies in vertex presentation, from gestational weeks 37+0; n = 1 590 178). Methods We examined temporal trends in PPH between 2000 and 2016 overall, and within each Robson group, and performed logistic regression to examine the influence of changes in risk factors (maternal, comorbidity, obstetric practice and infant factors) over time. Main outcome measures Postpartum haemorrhage, defined as an estimated blood loss of >1000 ml. Results The overall PPH rate increased from 5.4 to 7.3%, corresponding to a 37% (OR 1.37, 95% CI 1.32-1.42) increase over time. Rates varied between Robson groups, ranging from 4.5% in group 3 to 14.3% in group 4b. Increasing trends in PPH were found in all Robson groups except for groups 2b and 4b (prelabour caesarean deliveries). In the unstratified analysis, adjusting for maternal, comorbidity and obstetric practice factors slightly attenuated the risk of PPH in the later period (2013-2016), compared with the reference period (2000-2004; crude OR 1.26, 95% CI 1.24-1.29, adjusted OR 1.22, 95% CI 1.20-1.25). Within individual Robson groups, changes in risk factors did not explain increasing rates of PPH. Conclusions Postpartum haemorrhage rates varied between Robson groups. Changes in risk factors could not explain the 37% increase in PPH for women in Robson groups 1-5 in Sweden, 2000-2016. Tweetable abstract Changes in risk factors could not explain the increasing trend of PPH in Sweden, and rates of PPH varied widely between Robson groups.

The majority of previous studies on severe preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome were hospital-based or included a relatively small number of women. Large, population-based studies examining gestational age-specific incidence patterns and risk factors for these severe pregnancy complications are lacking.This study aimed to assess the gestational age-specific incidence rates and risk factors for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia.We carried out a retrospective, population-based cohort study that included all women with a singleton hospital birth in Canada (excluding Quebec) from 2012 to 2016 (N=1,078,323). Data on the primary outcomes (ie, severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia) were obtained from delivery hospitalization records abstracted by the Canadian Institute for Health Information. A Cox regression was used to assess independent risk factors (eg, maternal age and chronic comorbidity) for each primary outcome and to assess differences in the effects at preterm vs term gestation (37 vs ≥37 weeks).The rates of severe preeclampsia (n=2533), hemolysis, elevated liver enzymes, and low platelet count syndrome (n=2663), and eclampsia (n=465) were 2.35, 2.47, and 0.43 per 1000 singleton pregnancies, respectively. The cumulative incidence of term-onset severe preeclampsia was lower than that of preterm-onset severe preeclampsia (0.87 vs 1.54 per 1000; rate ratio, 0.57; 95% confidence intervals, 0.53-0.62), the rates of hemolysis, elevated liver enzymes, and low platelet count syndrome were similar (1.32 vs 1.23 per 1000; rate ratio, 0.93; 95% confidence interval, 0.86-1.00), and the preterm-onset eclampsia rate was lower than the term-onset rate (0.12 vs 0.33 per 1000; rate ratio, 2.64; 95% confidence interval, 2.16-3.23). For each primary outcome, chronic comorbidity and congenital anomalies were stronger risk factors for preterm- vs term-onset disease. Younger mothers (aged25 years) were at higher risk for severe preeclampsia at term and for eclampsia at all gestational ages, whereas older mothers (aged ≥35 years) had elevated risks for severe preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome. Regardless of gestational age, nulliparity was a risk factor for all outcomes, whereas socioeconomic status was inversely associated with severe preeclampsia.The risk for severe preeclampsia declined at term, eclampsia risk increased at term, and hemolysis, elevated liver enzymes, and low platelet count syndrome risk was similar for preterm and term gestation. Young maternal age was associated with an increased risk for eclampsia and term-onset severe preeclampsia. Prepregnancy comorbidity and fetal congenital anomalies were more strongly associated with severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia at preterm gestation.

BACKGROUND: The rate of obstetric anal sphincter injury has increased in recent years, particularly among operative vaginal deliveries. We sought to characterize temporal trends in episiotomy use and to quantify the association between episiotomy and obstetric anal sphincter injury. METHODS: Using a population-based retrospective cohort study design of hospital data from 2004 to 2017, we studied all vaginal deliveries of singleton infants at term gestation in Canada (excluding Quebec). Rates of obstetric anal sphincter injury were contrasted between women who had an episiotomy and those who did not. Log-binomial regression was used to estimate the association between episiotomy and obstetric anal sphincter injury among women with spontaneous and operative vaginal deliveries after controlling for confounders. RESULTS: The study population included 2 570 847 deliveries. Episiotomy use declined significantly among operative vaginal deliveries (53.1% in 2004 to 43.2% in 2017, p < 0.0001) and spontaneous vaginal deliveries (13.5% in 2004 to 6.5% in 2017, p < 0.0001). Episiotomy was associated with higher rates of obstetric anal sphincter injury among spontaneous vaginal deliveries (4.8 with episiotomy v. 2.4% without; adjusted rate ratio [RR] 2.06, 95% confidence interval [CI] 2.00–2.11) and this association remained after stratification by parity and obstetric history. In contrast, episiotomy was associated with lower rates of obstetric anal sphincter injury among forceps deliveries in nulliparous women (adjusted RR 0.63, 95% CI 0.61–0.66), and women with vaginal birth after cesarean (adjusted RR 0.71, 95% CI 0.60–0.85), but not among parous women without a previous cesarean (adjusted RR 1.16, 95% CI 1.00–1.34). INTERPRETATION: Episiotomy use has declined in Canada for all vaginal deliveries. The protective association between episiotomy and obstetric anal sphincter injury among women who gave birth by operative vaginal delivery (especially forceps) warrants reconsideration of clinical practice among nulliparous women and those attempting vaginal birth after cesarean.

BACKGROUND: The mode of delivery for women with a previous cesarean delivery remains contentious. We conducted a study comparing maternal and infant outcomes after attempted vaginal birth after cesarean delivery versus elective repeat cesarean delivery. METHODS: We used data from the Discharge Abstract Database that includes all hospital deliveries in Canada (excluding Quebec). In our analysis, we included singleton deliveries to women between 37 and 43 weeks gestation who had a single prior cesarean delivery between April 2003 and March 2015. The primary outcomes were severe maternal morbidity and mortality, and serious neonatal morbidity and mortality. We used logistic regression to estimate adjusted rate ratios (RRs) and 95% confidence intervals (CIs). RESULTS: Absolute rates of severe maternal morbidity and mortality were low but significantly higher after attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery (10.7 v. 5.65 per 1000 deliveries, respectively; adjusted RR 1.96, 95% CI 1.76 to 2.19). Adjusted rate differences in severe maternal morbidity and mortality, and serious neonatal morbidity and mortality were small (5.42 and 7.09 per 1000 deliveries, respectively; number needed to treat 184 and 141, respectively). The association between vaginal birth after cesarean delivery, and serious neonatal morbidity and mortality showed a temporal worsening (adjusted RR 0.94, 95% CI 0.77 to 1.15 in 2003–2005; adjusted RR 2.07, 95% CI 1.83 to 2.35 in 2012–2014). INTERPRETATION: Although absolute rates of adverse outcomes are low, attempted vaginal birth after cesarean delivery continues to be associated with higher relative rates of severe morbidity and mortality in mothers and infants. Temporal worsening of infant outcomes after attempted vaginal birth after cesarean delivery highlights the need for greater care in selecting candidates, and more careful monitoring of labour and delivery.

Rigorous studies carried out by the National Center for Health Statistics show that previously reported increases in maternal mortality rates in the United States were an artifact of changes in surveillance. The pregnancy checkbox, introduced in the revised 2003 death certificate and implemented by the states in a staggered manner, resulted in increased identification of maternal deaths and in reported maternal mortality rates. This Commentary summarizes the findings of the National Center for Health Statistics reports, describes temporal trends and the current status of maternal mortality in the United States, and discusses future concerns. Although the National Center for Health Statistics studies, based on recoding of death certificate information (after excluding information from the pregnancy checkbox), showed that crude maternal mortality rates did not change significantly between 2002 and 2018, age-adjusted analyses show a temporal reduction in the maternal mortality rate (21% decline, 95% CI 13-28). Specific causes of maternal death, which were not affected by the pregnancy checkbox, such as preeclampsia, showed substantial temporal declines. However, large racial disparities continue to exist: Non-Hispanic Black women had a 2.5-fold higher maternal mortality rate compared with non-Hispanic White women in 2018. This overview of maternal mortality underscores the need for better surveillance and more accurate identification of maternal deaths, improved clinical care, and expanded public health initiatives to address social determinants of health. Challenges with ascertaining maternal deaths notwithstanding, several causes of maternal death (unaffected by surveillance artifacts) show significant temporal declines, even though there remains substantial scope for preventing avoidable maternal death and reducing disparities.

Background Several studies of prenatal determinants and neonatal morbidity and mortality among very preterm births have resulted in unexpected and paradoxical findings. We aimed to compare perinatal death rates among cohorts of very preterm births (24–31 weeks) with rates among all births in these groups (≥24 weeks), using births-based and fetuses-at-risk formulations. Methods We conducted a cohort study of singleton live births and stillbirths ≥24 weeks’ gestation using population-based data from the United States and Canada (2006–2015). We contrasted rates of perinatal death between women with or without hypertensive disorders, between maternal races, and between births in Canada vs the United States. Results Births-based perinatal death rates at 24–31 weeks were lower among hypertensive than among non-hypertensive women (rate ratio [RR] 0.67, 95% CI 0.65–0.68), among Black mothers compared with White mothers (RR 0.94, 95%CI 0.92–0.95) and among births in the United States compared with Canada (RR 0.74, 95%CI 0.71–0.75). However, overall (≥24 weeks) perinatal death rates were higher among births to hypertensive vs non-hypertensive women (RR 2.14, 95%CI 2.10–2.17), Black vs White mothers (RR 1.86, 95%CI 184–1.88;) and births in the United States vs Canada (RR 1.08, 95%CI 1.05–1.10), as were perinatal death rates based on fetuses-at-risk at 24–31 weeks (RR for hypertensive disorders: 2.58, 95%CI 2.53–2.63; RR for Black vs White ethnicity: 2.29, 95%CI 2.25–2.32; RR for United States vs Canada: 1.27, 95%CI 1.22–1.30). Conclusion Studies of prenatal risk factors and between-centre or between-country comparisons of perinatal mortality bias causal inferences when restricted to truncated cohorts of very preterm births.

The rate of obstetric anal sphincter injury has increased in recent years, particularly among operative vaginal deliveries. We sought to characterize temporal trends in episiotomy use and to quantify the association between episiotomy and obstetric anal sphincter injury.Using a population-based retrospective cohort study design of hospital data from 2004 to 2017, we studied all vaginal deliveries of singleton infants at term gestation in Canada (excluding Quebec). Rates of obstetric anal sphincter injury were contrasted between women who had an episiotomy and those who did not. Log-binomial regression was used to estimate the association between episiotomy and obstetric anal sphincter injury among women with spontaneous and operative vaginal deliveries after controlling for confounders.The study population included 2 570 847 deliveries. Episiotomy use declined significantly among operative vaginal deliveries (53.1% in 2004 to 43.2% in 2017,Episiotomy use has declined in Canada for all vaginal deliveries. The protective association between episiotomy and obstetric anal sphincter injury among women who gave birth by operative vaginal delivery (especially forceps) warrants reconsideration of clinical practice among nulliparous women and those attempting vaginal birth after cesarean.

OBJECTIVES: We examined demographic characteristics and birth outcomes of infants with neonatal abstinence syndrome (NAS) and their mothers in Canada. METHODS: This retrospective, population-based, descriptive cross-sectional study of mother-infant dyads included all singleton live births in Canada (excluding Quebec), from 2005–2006 to 2015–2016 (N = 2 881 789). Demographic characteristics, NAS, and neonatal and maternal morbidities were identified from delivery hospitalization data (including diagnostic codes). The main composite outcomes were maternal and neonatal mortality and/or severe morbidity, including death and potentially life-threatening conditions in the mother and the infant, respectively. Logistic regression yielded adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: The study included 10 027 mother-infant dyads with NAS. The incidence of NAS increased from 0.20% to 0.51%. Maternal mortality was 1.99 vs 0.31 per 10 000 women in the NAS group versus the comparison group (aOR = 6.53; 95% CI: 1.59 to 26.74), and maternal mortality and/or severe morbidity rates were 3.10% vs 1.35% (aOR = 2.21; 95% CI: 1.97 to 2.49). Neonatal mortality was 0.12% vs 0.19% (aOR = 0.28; 95% CI: 0.15 to 0.53), and neonatal mortality and/or severe morbidity rates were 6.36% vs 1.73% (aOR = 2.27; 95% CI: 2.06 to 2.50) among infants with NAS versus without NAS. CONCLUSIONS: NAS incidence increased notably in Canada between 2005–2006 and 2015–2016. Infants with NAS had elevated severe morbidity, and their mothers had elevated mortality and severe morbidity. These results highlight the importance of implementing integrated care services to support the mother-infant dyad during childbirth and in the postpartum period.

Background: Maternal overweight and obesity may increase offspring risks of adiposity, cardiovascular and metabolic diseases in childhood. We examined the associations between maternal overweight and obesity severity on risks of cardiovascular diseases (CVD) in offspring during childhood and early adulthood. Methods: In this population-based cohort study, we identified 2,412,100 non-malformed live singleton infants in the Swedish Medical Birth Register between 1992 and 2016. The diagnoses of CVD, pregnancy and neonatal complications were based on information from the nation-wide Medical Birth and Patient Registers. Multivariable Cox proportional hazards regression was used to estimate association between maternal body mass index (BMI) and CVD risk with adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). We further calculated the proportion of the association mediated through known consequences of obesity that also predicted CVD. To account for unmeasured genetic or environmental factors, we conducted sibling-controlled analyses. Findings: The overall incidence of CVD in offspring aged 1-25 years, was 0·75 per 10,000 child-years. Compared with offspring of normal weight mothers (BMI 18·5 to

The ARRIVE trial showed that adverse perinatal outcomes among low-risk nulliparous women at 39 weeks’ gestation were lower following labor induction (4.3%) compared with expectant management (5.4%; P value 0.049). Although this difference was deemed to be not statistically significant (since the significance threshold had been set at 0.046), there is a need to interpret trial results using a Bayesian approach and to review the conceptual significance of trial findings. The ARRIVE trial hypothesis represents a challenge to the central paradigm of modern obstetrics because it abandons maternal or fetal compromise as a pre-requisite for early delivery. The P value function based on the ARRIVE trial shows that study findings are not consistent with even a modest increase in adverse perinatal outcomes following labor induction for 39 weeks’ gestation, and instead, consistent with a substantial reduction in adverse perinatal outcomes. Physiologic evidence, epidemiologic evidence (on gestational age-specific rates of pregnancy complications, fetal growth-restriction and perinatal morbidity and mortality), and meta-analyses of related randomized trials show that pregnancies accrue small and progressively increasing risks of adverse outcomes at later gestation. Bayesian analysis, based on previous randomized trials updated with ARRIVE trial results, also shows that labor induction for 39 weeks’ gestation has a protective effect with regard to adverse perinatal outcomes. Obstetricians need to be cognizant of this balance of risks and benefits with regard to labor induction and expectant management at 39 weeks’ gestation and beyond, though as always, the ultimate valuation in decision-making has to be guided by principles of patient autonomy.

To describe temporal and regional variations in Canada in the use of operative vaginal delivery (OVD) at term for singleton pregnancies by pelvic station between 2004 and 2013.Rates of OVD among term singleton pregnancies in Canada (excluding Quebec) were estimated using information from the Discharge Abstract Database of the Canadian Institute for Health Information for the years 2004-2012 (n = 2 284 109). Deliveries were stratified by pelvic station. Temporal trends were assessed using the Cochran-Armitage test for linear trend in proportions by year. Geographic variation was assessed by calculating the rate and 95% confidence interval of each mode of delivery from 2010-2012 for each province and territory.Among singleton pregnancies at term, the OVD rate decreased from 12.0% in 2004 to 10.7% in 2012 (P0.001), whereas Caesarean section rates (excluding those following failed OVDs) increased from 24.9% to 26.7%. Forceps deliveries decreased from 3.1% to 2.5%, primarily due to decreases in midpelvic forceps delivery. Vacuum-assisted delivery increased significantly at outlet and low stations (by 26.0% and 15.1%, respectively) and remained stable at midpelvic station. The failed OVD rate was 0.3% and decreased by 23.7% (P0.001). There were large variations in OVD rates by province.Temporal trends in OVD rates varied by pelvic station, with rates of outlet and low OVD increasing and rates of midpelvic and failed OVD decreasing. Vacuum extraction is increasingly replacing forceps deliveries at outlet and low stations, whereas Caesarean sections are replacing forceps deliveries at midpelvic stations. Variations in OVD rates across provinces suggest differences in instrument preference and/or an evolution in standards of practice.

Clinician-initiated deliveries at 34 to 36 weeks gestation have increased in Canada since 2006, but the impacts of clinician-initiated deliveries on the overall preterm birth (PTB) rate and concomitant changes in neonatal outcomes are unknown. This study examined gestational age-specific trends in spontaneous and clinician-initiated PTB and associated neonatal mortality and morbidity.This population-based study included 1 880 444 singleton live births in Canada (excluding Québec) in 2009-2016, using hospitalization data from the Canadian Institute for Health Information. The primary outcomes were neonatal mortality and a composite outcome mortality and/or severe neonatal morbidity identified by International Statistical Classification of Diseases and Related Health Problems, 10th revision, Canada codes. Outcomes were stratified by spontaneous and clinician-initiated deliveries and gestational age categories. Logistic regression yielded adjusted odds ratios (aORs) per 1-year change and 95% confidence intervals (CIs) (Canadian Task Force Classification II-2).The PTB rate remained stable (6.2%) and the proportion of clinician-initiated PTBs increased from 31.0% to 37.9% (P 0.001). Although overall neonatal mortality remained stable (1.1%), mortality declined among infants born spontaneously at 28 to 33 weeks gestation (aOR 0.92; 95% CI 0.87-0.97). The composite mortality and/or severe morbidity declined from 12.7% to 12.2% (aOR 0.98; 95% CI 0.97-0.99). Declines were observed in the rates of sepsis (aOR 0.96; 95% CI 0.95-0.98) and respiratory distress syndrome requiring ventilation (aOR 0.97; 95% CI 0.96-0.98), whereas rates of intraventricular hemorrhage increased (aOR 1.03; 95% CI 1.01-1.05).With the increase in clinician-initiated deliveries, the stable rates of PTB and neonatal mortality and the decline in composite mortality and/or severe morbidity are encouraging findings. This study adds to clinical understanding of carefully timed and medically justified early interventions.

BACKGROUND: Increased use of operative vaginal delivery (use of forceps, vacuum or other device) has been recommended to address high rates of cesarean delivery. We sought to determine the association between rates of operative vaginal delivery and obstetric trauma and severe birth trauma. METHODS: We carried out an ecological analysis of term, singleton deliveries in 4 Canadian provinces (2004–2014) using data from the Canadian Institute for Health Information. The primary exposure was mode of delivery. The primary outcomes were obstetric trauma and severe birth trauma. RESULTS: Data on 1 938 913 deliveries were analyzed. The rate of obstetric trauma was 7.2% in nulliparous women, and 2.2% and 2.7% among parous women without and with a previous cesarean delivery, respectively, and rates of severe birth trauma were 2.1, 1.7 and 0.7 per 1000, respectively. Each 1% absolute increase in rates of operative vaginal delivery was associated with a higher frequency of obstetric trauma among nulliparous women (adjusted rate ratio [ARR] 1.06, 95% confidence interval [CI] 1.05–1.06), parous women without a previous cesarean delivery (ARR 1.10, 95% CI 1.08–1.13) and parous women with a previous cesarean delivery (ARR 1.11, 95% CI 1.07–1.16). Operative vaginal delivery was associated with more frequent severe birth trauma, but only in nulliparous women (ARR 1.05, 95% CI 1.03–1.07). In nulliparous women, sequential vacuum and forceps instrumentation was associated with the largest increase in obstetric trauma (ARR 1.44, 95% CI 1.35–1.55) and birth trauma (ARR 1.53, 95% CI 1.03–2.27). INTERPRETATION: Increases in population rates of operative vaginal delivery are associated with higher population rates of obstetric trauma, and in nulliparous women with severe birth trauma.

ObjectiveInstrumental vaginal delivery is associated with birth trauma to infant and obstetric trauma to mother. As caesarean delivery rates increased during the past decades, the rate of instrumental vaginal delivery declined. We examined concomitant temporal changes in the rates of severe birth trauma and maternal obstetric trauma.DesignA retrospective observational study.Settings and participantsAll hospital singleton live births in Washington State, USA, 2004–2013, excluding breech delivery. Severe birth trauma (brain, nerve injury, fractures and other severe birth trauma) and obstetric trauma (third/fourth degree perineal lacerations, cervical/high vaginal lacerations) were identified from hospitalisation data. Pregnancy and delivery characteristics were obtained from birth certificates. Temporal trends were assessed by the Cochran-Armitage test. Logistic regression was used to obtain adjusted ORs (AORs) and 95% CI.ResultsOverall, 732 818 live births were included. The rate of severe birth trauma declined from 5.3 in 2004 to 4.5 per 1000 live births in 2013 (PConclusionWhile the rates of fractures and other birth trauma declined among infants delivered by spontaneous vaginal delivery, the rate of birth trauma remained unchanged in instrumental vaginal delivery and caesarean delivery. Among mothers, the rates of severe perineal lacerations declined, except for women with forceps delivery.

Objectives To quantify, firstly, temporal trends in episiotomy use among spontaneous vaginal deliveries (SVDs) and operative vaginal deliveries (OVDs) in Canada, and secondly, the associations between episiotomy and obstetric anal sphincter injury (OASI) among SVDs and OVDs. Methods Population-based, retrospective, cohort study of all singleton, term deliveries in Canada (2004-2014) using hospitalization data. Temporal trends in episiotomy use by parity, previous cesarean delivery and mode of delivery were tested using the Cochran-Armitage test. Logistic regression was used to estimate the association between episiotomy and OASI among women with SVD and OVD after controlling for confounders. Results The study included 1,442,484 deliveries. Among nulliparous women, there was a smaller absolute decline in episiotomy use among SVDs (22.9% in 2004 to 14.1% in 2014; p Conclusions Episiotomy use has declined in Canada in recent years among SVDs and OVDs. There is a pressing need to consider episiotomy use in OVD (especially with forceps) given the protective association between episiotomy and OASI.

We thank Dr. Pairaudeau[1][1] and Dr. Barrett and colleagues[2][2] for their interest and expert commentary on our article.[3][3] The high rates of severe perinatal and maternal morbidity reported in our analyses may or may not be reflective of adverse outcome rates following midpelvic operative

Objective To quantify severe perinatal and maternal morbidity/mortality associated with midcavity operative vaginal delivery compared with caesarean delivery. Design Population‐based, retrospective cohort study. Setting British Columbia, Canada. Population Term, singleton deliveries (2004–2014) by attempted midcavity operative vaginal delivery or caesarean delivery in the second stage of labour, stratified by indication for operative delivery (n = 10 901 deliveries; 5057 indicated for dystocia, 5844 for fetal distress). Methods Multinomial propensity scores and mulitvariable log‐binomial regression models were used to estimate adjusted rate ratios (ARR) and 95% confidence intervals (95% CI). Main outcome measures Composite severe perinatal morbidity/mortality (e.g. convulsions, severe birth trauma and perinatal death) and severe maternal morbidity (e.g. severe postpartum haemorrhage, shock, sepsis and cardiac complications). Results Among deliveries with dystocia, attempted midcavity operative vaginal delivery was associated with higher rates of severe perinatal morbidity/mortality compared with caesarean delivery (forceps ARR 2.11, 95% CI 1.46–3.07; vacuum ARR 2.71, 95% CI 1.49–3.15; sequential ARR 4.68, 95% CI 3.33–6.58). Rates of severe maternal morbidity/mortality were also higher following midcavity operative vaginal delivery (forceps ARR 1.57, 95% CI 1.05–2.36; vacuum ARR 2.29, 95% CI 1.57–3.36). Among deliveries with fetal distress, there were significant increases in severe perinatal morbidity/mortality following attempted midcavity vacuum (ARR 1.28, 95% CI 1.04–1.61) and in severe maternal morbidity following attempted midcavity forceps delivery (ARR 2.34, 95% CI 1.54–3.56). Conclusion Attempted midcavity operative vaginal delivery is associated with higher rates of severe perinatal morbidity/mortality and severe maternal morbidity, though these effects differ by indication and instrument. Tweetable abstract Perinatal and maternal morbidity is increased following midcavity operative vaginal delivery., Tweetable abstract Perinatal and maternal morbidity is increased following midcavity operative vaginal delivery.

Purpose of Review Several prestigious agencies routinely rank countries based on crude perinatal and infant mortality rates, while more recently, international neonatal networks have begun comparing neonatal mortality and morbidity rates among very preterm and very low-birth-weight infants. We discuss the methodologic challenges that compromise such comparisons and potential remedies. Recent Findings Crude perinatal mortality rates are biased by international variations in birth registration, especially at the borderline of viability. Such bias is demonstrated by significant differences in crude versus birth weight- and gestational age-specific comparisons of perinatal mortality. Comparisons of neonatal mortality among very preterm and very low-birth-weight infants are plagued by incorrect denominators, and this leads to paradoxical findings. Summary A lack of standardization with regard to birth registration and inadequate appreciation of the methods for calculating gestational age-specific mortality rates are responsible for biasing international comparisons of perinatal mortality.

BACKGROUND: Increased use of operative vaginal delivery (i.e., forceps or vacuum application), of which 20% occurs at midpelvic station, has been advocated to reduce the rate of cesarean delivery. We aimed to quantify severe perinatal and maternal morbidity and mortality associated with attempted midpelvic operative vaginal delivery. METHODS: We studied all term singleton deliveries in Canada between 2003 and 2013, by attempted midpelvic operative vaginal or cesarean delivery with labour (with and without prolonged second stage). The primary outcomes were composite severe perinatal morbidity and mortality (e.g., convulsions, assisted ventilation, severe birth trauma and perinatal death), and composite severe maternal morbidity and mortality (e.g., severe postpartum hemorrhage, shock, sepsis, cardiac complications, acute renal failure and death). RESULTS: The study population included 187 234 deliveries. Among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was associated with higher rates of severe perinatal morbidity and mortality compared with cesarean delivery (forceps, adjusted odds ratio [AOR] 1.81, 95% confidence interval [CI] 1.24 to 2.64; vacuum, AOR 1.81, 95% CI 1.17 to 2.80; sequential instruments, AOR 3.19, 95% CI 1.73 to 5.88), especially with higher rates of severe birth trauma. Rates of severe maternal morbidity and mortality were not significantly different after operative vaginal delivery, although rates of obstetric trauma were higher (forceps, AOR 4.51, 95% CI 4.04 to 5.02; vacuum, AOR 2.70, 95% CI 2.35 to 3.09; sequential instruments, AOR 4.24, 95% CI 3.46 to 5.19). Among women with fetal distress, similar associations were seen for severe birth trauma and obstetric trauma, although vacuum was associated with lower rates of severe maternal morbidity and mortality (AOR 0.52, 95% CI 0.33 to 0.80). Associations tended to be stronger among women without a prolonged second stage. INTERPRETATION: Midpelvic operative vaginal delivery is associated with higher rates of severe birth trauma and obstetric trauma, whereas overall rates of severe perinatal and maternal morbidity and mortality vary by indication and operative instrument.