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Objective: Studies on the optimal mode of delivery in women with a twin pregnancy

Objective: To compare, in women with twin pregnancy with the first twin in cephalic position, neonatal morbidity and mortality rates after actual 1) Vaginal delivery (VD) both twins versus 2) unplanned Cesarean Delivery (CD) of both twins and 3) after VD of twin A and CD of twin B (combined delivery).Study Design: We describe a nationwide cohort study of women pregnant with twins who planned to deliver vaginally between 32(+0) - 41(+6 )weeks with the first twin in cephalic position, between 2000-2012 in the Netherlands.We used multivariate logistic regression analysis to compare neonatal morbidity and mortality according to actual mode of delivery, overall, and for preterm and term groups separately.Results: We included 19,723 women of whom 15,785 women (80.0 %) delivered both twins by VD, 2926 (14.6 %) delivered both twins by unplanned CD, and 1012 (5.1 %) women delivered by combined delivery. After unplanned CD of both twins compared to VD more perinatal mortality (1 or more twins affected) was seen (adjusted Odds Ratio (aOR) 2.23 (95 % CI 1.26-4.129)), as was 'Asphyxia related morbidity' (aOR 2.44 (95 % CI 1.80-3.31), 'other morbidity' (aOR 1.34 (95 %Cl 1.17-1.54), and 'any morbidity or mortality' (a0R1.39 (95 % CI 1.22-1.58)). Less Trauma- related morbidity' after unplanned CD vs. VD (aOR 0.11 (95 % 0.02-0.79)) was seen.After combined delivery vs. VD, more perinatal mortality (aOR 7.75 (95 % CI 4.51-13.34)), more Asphyxia-related morbidity (aOR 6.67 (95 % C14.91-9.06), 'prematurity related morbidity' (aOR 2.11 (95 % CI 1.59-2.79) 'other morbidity' (aOR 2.01 (95 % CI 1.65-2.46), and 'any morbidity or mortality' (aOR 2.44 (95 % CI 2.04-2.91)) were noted. All outcomes expect 'trauma-associated morbidity' were more increased for twin B as compared to twin A.Conclusion: After unplanned CD of both twins vs. VD of both twins, a twofold increase in neonatal mortality is noted. Combined delivery vs. VD of both twins is associated with a sevenfold increase in perinatal mortality and a five-fold increase in asphyxia-related outcomes. Twin A is more affected after unplanned CD of both twins, while twin B is more affected after combined delivery. (C) 2020 Elsevier B.V. All rights reserved.

Objective: To assess intrapartum/neonatal mortality and morbidity risk in infants born at 37 weeks of gestation compared with infants born at 39–41 weeks of gestation. Design: Nationwide cohort study. Setting: The Netherlands. Population: A total of 755 198 women delivering at term of a singleton without congenital malformations during 2010–14. Methods: We used data from the national perinatal registry (PERINED). Analysis was performed with logistic regression and stratification for the way labour started and type of care. Main outcome measures: Intrapartum or neonatal mortality up to 28 days and adverse neonatal outcome (neonatal mortality, 5-minute Apgar

OBJECTIVE: In women with a triplet pregnancy, there is debate on the preferred mode of delivery. We performed a nationwide cohort study to assess the impact of mode of delivery on perinatal outcome in women with a triplet pregnancy.METHODS: Nationwide cohort study on women with a triplet pregnancy who delivered between 26 + 0 and 40 + 0 weeks of gestation in the years 1999-2008. We compared perinatal outcomes according to the intended mode of delivery and the actual mode of delivery. Outcome measures were perinatal mortality and neonatal morbidity. Perinatal outcomes were analyzed taking into account the dependency between the children of the same triplet pregnancy ("any mortality" and "any morbidity") and were also analyzed separately per child.RESULTS: We identified 386 women with a triplet pregnancy in the study period. Mean gestational age at delivery was 33.1 weeks (SD 2.5 weeks; range 26.0-40.0 weeks). Perinatal mortality was 2.3% for women with a planned caesarean section and 2.4% in women with a planned vaginal delivery (aOR 0.37; 95% confidence interval (CI) 0.09-1.5) and neonatal morbidity was 26.0% versus 36.0%, (aOR 0.88; 95% CI 0.51-1.4) respectively. In the subgroup analyses according to gestational age and in the analysis of perinatal outcomes per child separately, there were also no large differences in perinatal outcomes. The same applied for perinatal outcomes according to the actual mode of delivery.CONCLUSION: In this large cohort study among women with a triplet pregnancy, caesarean delivery is not associated with reduced perinatal mortality and morbidity.

Objective: Electronic foetal monitoring (EFM) together with non-invasive ST-analysis (STAN) has been suggested as a superior technique to EFM alone for foetal surveillance to prevent metabolic acidosis. This study aims to compare the cost-effectiveness of these two techniques from both maternal (short term) as neonatal (long term) perspective to guide clinical decision-making. Methods: We created two models: a maternal model, focused on the difference in mode of delivery as most important outcome, and a neonatal Markov model focused on the differences in metabolic acidosis – and its relationship to cerebral palsy (CP) – as the most relevant outcome to estimate the long-term cost-effectiveness. The cost to prevent one instrumental delivery was estimated in the maternal model. The costs to prevent one metabolic acidosis and the costs per quality adjusted life years were calculated in the neonatal model. Results: The average costs of STAN are only €34 higher when compared to EFM alone. From maternal perspective the cost of preventing one instrumental delivery was estimated at €2602. From neonatal perspective the cost to prevent one case of metabolic acidosis was €14 509. Over the long term, STAN becomes a dominant (cost saving) strategy if >1% of the patients exposed to metabolic acidosis acquire CP. Conclusions: Our study suggests that STAN, when compared to EFM alone, can be a cost-effective strategy from both a maternal and neonatal perspective.

Objective: To compare, in women with twin pregnancy with the first twin in cephalic position, neonatal morbidity and mortality rates after planned caesarean delivery (CD) versus planned vaginal delivery (VD). Study Design: A nationwide cohort study on women pregnant with twins and the first child in cephalic position, who delivered between 32 + 0-41 + 0 weeks between 2000 and 2012 in the Netherlands, using multivariate logistic regression analysis to compare neonatal morbidity and mortality according to planned delivery mode, and looking at subgroups 32 + 0-36 + 6 and 37 + 0-41 +0 weeks. Results: We included 21,107 women, of whom 1384 (6.6%) had a planned CD. Of the 19,723 women (93.4%) who had a planned VD, 19.7% delivered by intrapartum CD. We found no significant differences in 'any mortality' (aOR planned CD vs. planned VD 1.34 (95% CI 0.63-2.60)), the outcome 'Apgar score (AS) < 4 or death within 28 days' (aOR 1.28 (95% CI 0.77-2.11) or asphyxia-related morbidity (aOR 0.57 (95% CI 0.32-1.03)). After planned CD more prematurity -related morbidity (aOR 1.55 (95% CI 1.21-1.98)), other morbidity (aOR 1.50 (95% CI 1.26-1.78)) and 'any morbidity or mortality' (aOR 1.41 (95% CI 1.20-1.66) was noted. Trauma-associated morbidity was absent after planned CD and occurred 45 times (0.2%) after planned VD. Before 36 + 6 weeks, planned CD resulted in more perinatal mortality (aOR 2.10 (95% CI 0.92-4.76)), while asphyxia -related morbidity did not differ (aOR 0.80 (95% CI 0.41-1.54). Planned CD resulted in more 'any morbidity or mortality' (aOR 1.52 (95% CI 1.25-1.84)), 'AS < 4 or death within 28 days' (aOR 1.77 (95% CI 1.02-3.09)), prematurity -related morbidity (aOR 1.73 (95% CI 1.34-2.23)), and 'other morbidity' (aOR 1.56 (95% CI 1.28-1.90)). After 37 weeks, no significance differences in mortality, 'any morbidity or mortality

Objective To study the association of the intended mode of delivery and perinatal morbidity and mortality among breech fetuses who are delivered preterm. Methods We conducted a nationwide cohort study of women with a singleton pregnancy in breech presentation who delivered preterm (26 0/7-36 6/7 weeks of gestation) in the years 2000-2011. We compared perinatal outcomes according to the intended and actual mode of delivery using multivariate logistic regression analysis. We performed subgroup analyses of gestational age and parity. Results We studied 8,356 women with a preterm singleton breech delivery. Intended cesarean delivery (n=1,935) was not associated with a significant reduction in perinatal mortality compared with intended vaginal delivery (n=6,421) (1.3% compared with 1.5%; adjusted odds ratio [OR] 0.97, 95% confidence interval [CI] 0.60-1.57). However, the composite of perinatal mortality and morbidity was significantly reduced in the intended cesarean delivery group (8.7% compared with 10.4%; adjusted OR 0.77, 95% CI 0.63-0.93). In the subgroup of women delivering at 28-32 weeks of gestation, intended cesarean delivery was associated with a 1.7% risk of perinatal mortality compared with 4.1% with intended vaginal delivery (adjusted OR 0.27, 95% CI 0.10-0.77) and significantly reduced composite mortality and severe morbidity, 5.9% compared with 10.1% (adjusted OR 0.37, 95% CI 0.20-0.68). Conclusion In women delivering a preterm breech fetus, cesarean delivery is associated with reduced perinatal mortality and morbidity. Level of evidence II.

The objective of the present study is to investigate trends in birth asphyxia and perinatal mortality in the Netherlands over the last decade. A nationwide cohort study among women with a term singleton pregnancy. We assessed trends in birth asphyxia in relation to obstetric interventions for fetal distress. Birth asphyxia was defined as a 5-minute Apgar score

Objective To investigate trends in prenatal diagnosis and termination of pregnancy rates in cases of fetal cleft lip with or without cleft palate (CL +/- P), before and after the introduction in The Netherlands of the 20-week anomaly scan in 2007, and to assess the accuracy of this scan for the diagnosis of facial clefts.Methods This was a retrospective cohort study of consecutive cases of CL +/- P diagnosed in 2001-2010 in the referral region of the Academic Medical Centre. Cases diagnosed prenatally were identified from the hospital's database. These data, grouped according to the periods before and after the introduction of the routine 20-week anomaly scan, were compared with data of all cases managed by the multidisciplinary cleft team, which services the same region, to identify cases of CL +/- P that were not seen prenatally.Results We identified 123 cases of CL +/- P diagnosed prenatally, of which 76% (93/123) were diagnosed before 24 weeks. In one case, the CL +/- P was not confirmed after birth. There were 46 cases with associated structural anomalies and 76 isolated cases. The median gestational age at diagnosis decreased by 2 weeks after 2007 (P = 0.02). The proportion of isolated clefts detected prenatally increased significantly after 2007 (P Conclusion Introduction of the routine fetal anomaly scan has decreased the gestational age at diagnosis of CL +/- P and has increased the proportion diagnosed prenatally, without a significant change in the number of terminations of pregnancy. Copyright (C) 2013 ISUOG. Published by John Wiley & Sons Ltd.

The objective of this study is to investigate the effect of the mode of delivery in women with preterm breech presentation on neonatal and maternal outcome in the subsequent pregnancy. Nationwide population-based cohort study in the Netherlands of women with a preterm breech delivery and a subsequent delivery in the years 1999-2007. We compared planned caesarean section versus planned vaginal delivery for perinatal outcomes in both pregnancies. We identified 1543 women in the study period, of whom 259 (17%) women had a planned caesarean section and 1284 (83%) women had a planned vaginal delivery in the first pregnancy. In the subsequent pregnancy, perinatal mortality was 1.1% (3/259) for women with a planned caesarean section in the first pregnancy and 0.5% (6/1284) for women with a planned vaginal delivery in the first pregnancy (aOR 1.8; 95% CI 0.31-10.1). Composite adverse neonatal outcome was 2.3% (6/259) versus 1.5% (19/1284), (aOR 1.5; 95% CI 0.55-4.2). The average risk of perinatal mortality over two pregnancies was 1.9% (10/518) for planned caesarean section and 2.0% (51/2568) for planned vaginal delivery, (OR 0.98; 95% CI 0.49-1.9). In women with a preterm breech delivery, planned caesarean section does not reduce perinatal mortality, perinatal morbidity, or maternal morbidity rate over the course of two pregnancies

Objective: To study birthweight in consecutively born sibling singletons conceived with and without in vitro fertilization (IVF) to disentangle the effects of maternal characteristics from those of the IVF treatment itself.Design: Population-based study.Setting: Not applicable.Patient(s): Firstborn and secondborn children from a 9-year birth cohort (1999-2007) comprising of 272,551 women who conceived two siblings.Intervention(s): No intervention; children were conceived naturally or through IVF.Main Outcome Measure(s): Birthweight.Result(s): The study included 545,102 children born by natural conception (NC) or IVF with the data set obtained from the population-based Netherlands Perinatal Registry (PRN) containing information on pregnancies, deliveries, and neonatal outcomes. We used two approaches: [1] the intersibling approach and [2] the sibling-ship approach. In the first approach we included children born to four groups of mothers who conceived in the following order (numbers indicate birth order): NC1-NC2 (reference, n = 254,721), IVF1-NC2 (n = 1342), NC1-IVF2 (n = 471), and IVF1-IVF2 (n = 687). Several comparisons were made to interpret the effects of IVF and maternal characteristics separately. In the second approach, perinatal outcomes of IVF children (n = 1,813) were compared with those of their NC siblings (n = 1,813). The intersibling analyses suggested an association between maternal characteristics and a lower birthweight, with estimates of the maternal effect ranging from -7 g (95% CI, -40; 26) to -101 g (95% CI, -170; -32). Neither the intersibling analyses nor the sibling-ship analyses indicated an additional adverse effect of IVF treatment itself.Conclusion(s): Maternal characteristics of subfertile women are associated with a lower birthweight. In vitro fertilization treatment itself does not additionally contribute to a lower birthweight in the offspring. (C) 2016 by American Society for Reproductive Medicine.

Objectives We designed a computer-based decision aid (CDA) for use by pregnant women at home to investigate and participate in solving their pregnancy problems related to pregnancy-induced hypertension (PIH) and gestational diabetes (GD). The system cannot and is not intended to replace visits to physicians; rather it can help women focus on the most important symptoms and provides guidance on when to see a doctor. Methods The study is a randomized controlled trial, which is performed among Iranian pregnant women. For subjects, 420 healthy pregnant women have been recruited from two private and two public prenatal centers. The intervention group will receive the CDA for use at home, and the control group will receive care as usual. The CDA relies on knowledge extracted from the national guidelines on PIH and GD. Results The two primary outcomes for the study are self-efficacy and knowledge. Self-efficacy will be measured by the Stanford self-efficacy scale and knowledge will be evaluated by 15 binary (true/false) questions provided by the researchers. Secondary outcomes include type and frequency of doctor and/or medical center visits; blood pressure and blood sugar changes based on the national guidelines and according to pregnancy records, and anxiety will be assessed by the state component of the short Spielberger anxiety scale. Conclusions This paper describes the design of a CDA and a protocol for a randomized controlled trial to study the effects of the CDA on self-efficacy and knowledge of pregnant women pertaining to PIH and GD. Differences in the primary outcomes will be analyzed using 'intention-to-treat' principles.

Objective To examine the risk of recurrence of low Apgar score in a subsequent term singleton pregnancy. Design Population-based cohort study. Setting The Netherlands. Population A total of 190 725 women with two subsequent singleton term live births between 1999 and 2007. Methods We calculated the recurrence risk of low Apgar score after adjustment for possible confounders. Women with an elective cesarean delivery, fetus in breech presentation or a fetus with congenital anomalies were excluded. Results were reported separately for women with a vaginal delivery or a cesarean delivery at first pregnancy. Main outcome measures Prevalence of birth asphyxia, a 5-min Apgar score

Objective.The aim of this study was to evaluate the effect of the increased cesarean rate for term breech presentation on neonatal outcome. We also investigated whether the clinical case selection for vaginal delivery applied by Dutch obstetricians led to an optimization of neonatal outcome, or whether there is still room for improvement in terms of perinatal outcome.Design.Retrospective cohort.Setting.The Netherlands.Population.Singleton term breech deliveries from 37 +0 to 41 +6 weeks, excluding fetuses with congenital malformations or antenatal death.Method.We used data from the Dutch national perinatal registry from 1999 up to 2007.Main outcome measures.Perinatal mortality and morbidity.Results.We studied 58 320 women with a term breech delivery. There was an increase in the elective cesarean rate (from 24 to 60%). As a consequence, overall perinatal mortality decreased [1.3v odds ratio 0.51 (95% confidence interval 0.28‐0.93)], whereas it remained stable in the planned vaginal birth group [1.7v odds ratio 0.96 (95% confidence interval 0.52‐1.76)]. The number of cesareans done to prevent one perinatal death was 338.Conclusions.Adjustment of the national guidelines after publication of the Term Breech Trial resulted in a shift towards elective cesarean and a decrease of perinatal mortality and morbidity among women delivering a child in breech at term. Still, 40% of these women attempt vaginal birth. The relative safety of an elective cesarean should be weighed against the consequences of a scarred uterus in future pregnancies. Abbreviations:CI, confidence interval; OR, odds ratio; PRN, Netherlands Perinatal Registry; RR, relative risk.

Objective: to assess the mode of childbirth and adverse neonatal outcomes in women with a breech presentation with or without an external cephalic version attempt, and to compare the mode of childbirth among women with successful ECV to women with a spontaneous cephalic presentation. Design: prospective matched cohort study. Setting: 25 clusters (hospitals and its referring midwifery practices) in the Netherlands. Data of the Netherlands perinatal registry for the matched cohort. Participants: singleton pregnancies from January 2011 to August 2012 with a fetus in breech presentation and a childbirth from 36 weeks gestation onwards. Spontaneous cephalic presentations (selected from national registry 2009 and 2010) were matched in a 2:1 ratio to cephalic presentations after a successful version attempt. Matching criteria were maternal age, parity, gestational age at childbirth and fetal gender. Main outcomes were mode of childbirth and neonatal outcomes. Measurements and findings: of 1613 women eligible for external cephalic version, 1169 (72.5%) received an ECV attempt. The overall caesarean childbirth rate was significantly lower compared to women who did not receive a version attempt (57% versus 87%; RR 0.66 (0.62-0.70)). Women with a cephalic presentation after ECV compared to women with a spontaneous cephalic presentation had a decreased risk for instrumental vaginal childbirth (RR 0.52 (95% CI 0.29-0.94)) and an increased risk of overall caesarean childbirth (RR 1.7 (95%Cl 1.2-2.5)). Key conclusions: women who had a successful ECV are at increased risk for a caesarean childbirth but overall, ECV is an important tool to reduce the caesarean rate. Implication for practice: ECV is an important tool to reduce the caesarean section rates. (C) 2016 Published by Elsevier Ltd.