Abstract Introduction Consensus is lacking regarding the upper limit for a safe contraction frequency during labor. We aimed to assess the association between different contraction frequencies and acidemia at birth, and whether an association was affected by oxytocin augmentation, concomitant cardiotocography (CTG) classification, and stage of labor. Material and Methods This is a case–control study based on CTG traces from births in southern Sweden during 2012–2017. Cases (N = 364) had umbilical artery pH <7.1 if born by first‐stage cesarean section and pH <7.05 if born vaginally or by second‐stage cesarean. Controls were included with a 1:2 ratio (N = 728) and had pH ≥7.15. CTG traces from the hour prior to birth were assessed blinded to the clinical outcome. Logistic regression was used to estimate odds ratios (OR) with 95% confidence intervals (CI). Results After excluding insufficient topography traces, 328 cases and 677 controls remained for analysis. Contraction frequencies 5, 5–6, and ≥6 per 10 min occurred in 15.2%, 19.5%, and 29.6% of cases and in 15.1%, 16.5%, and 11.1% of controls, respectively. The OR (95% CI) for acidemia were 1.6 (1.1–2.4), 1.9 (1.3–2.7), and 4.3 (3.0–6.2), respectively, compared with a reference group of <5. When comparing two separate binary cut‐offs of >5 and ≥5 contractions, similar strengths of association with acidemia were demonstrated with OR 2.7 (2.1–3.6) and 2.5 (1.9–3.3), respectively. The effect of contraction frequency >5 was similar in spontaneous (n = 586) and oxytocin‐augmented (n = 419) labor (OR 2.5, 1.7–3.8 vs. OR 2.4, 1.6–3.6), and whether the CTG was normal, suspicious, or pathological according to the Swedish CTG template (OR 2.1, 1.3–3.3; OR 3.5, 1.6–7.6; and OR 2.6, 1.4–4.7, respectively). The study lacked power to study any association during the first stage of labor. Conclusions Increasing contraction frequency is incrementally associated with fetal acidemia. Although an increased risk of acidosis is evident at contraction frequencies as low as five, such frequencies are common while acidemia is uncommon, implying a poor positive predictive value. A contraction frequency of more than five is associated with acidemia in both spontaneous and oxytocin‐augmented labor, and even when the fetal heart trace is normal.

Abstract Introduction Current international (FIGO) and Swedish cardiotocography (CTG) interpretation templates exhibit limited diagnostic accuracy for the detection of fetal acidemia. The objective of this study was to develop a novel intrapartum CTG classification template incorporating CTG parameters demonstrated to be strongly associated with acidemia, and to evaluate the diagnostic performance of the models by assessing their sensitivity and specificity in identifying CTG recordings from neonates with acidemia. Material and Methods A retrospective case–control study based on 1092 births in Region Skåne. The study material included 364 cases with umbilical cord blood pH <7.05, or <7.10 after 1st stage cesarean, and 728 controls with pH ≥7.15 and Apgar scores ≥9 at 5 and 10 min. CTG patterns were systematically evaluated across a set of predefined variables, and associations between specific patterns and fetal acidemia were quantified using ORs. Two models defining pathological patterns were created: Model 1 based on the presence of one of several listed criteria resulting in a positive test and Model 2 also including the presence of ≥2 B‐criteria resulting in a positive test. The main outcomes, sensitivity, and specificity to identify fetal acidemia at birth were calculated and compared with the current FIGO, NICE, and SWE guidelines. Results The sensitivity to identify fetal acidemia was 86.3%, 86.5%, 50.8%, 57.1%, and 87.4% for Model 1, Model 2, FIGO, SWE, and NICE, respectively. The corresponding specificity was 77.9%, 76.4%, 92.6%, 91.2%, and 70.6%. The sensitivity to identify severe acidemia (pH <7.0) was 90.4% for Model 1 and for NICE; 64.4% for SWE, and 56.7% for FIGO. A variable not included in current classification systems, “fetal heart rate below baseline for >50% of the time during 30 minutes” was the criterion contributing most to the sensitivity. Conclusions Our models show higher sensitivity but lower specificity for the defined outcome compared with SWE and FIGO, and similar sensitivity but higher specificity compared with NICE. Validating the model on a new material is essential before considering clinical use.

Objective: Classification of fetal heart rate (FHR) decelerations as suspicious or pathological differs between current interpretation templates for intrapartum cardiotocography. Decelerations are the most frequent FHR pattern irregularities during labour. The aim of this study was to assess the association between different types and characteristics of decelerations and acidemia at birth. Methods: This case-control study includes 365 cases with cord pH < 7.10 after 1st stage cesarean delivery or pH < 7.05 after vaginal delivery at > 34 + 0 weeks after induced or spontaneous labour, and 730 controls with pH ≥ 7.15. Cardiotocographic recordings from 60 min before birth were scrutinized and decelerations evaluated in detail. Odds ratios (OR) with 95 % confidence intervals for acidemia at birth were determined. Results: The following types of decelerations were associated with acidemia: Late decelerations; OR 9.0 (6.1–13) if > 5, and OR 19 (9.7–37) if repetitive > 20 min, combined decelerations; OR 4.2 (2.7–6.4) if > 5 and OR 6.4 (3.1–13) if repetitive > 20 min, one prolonged deceleration > 5 min; OR 12 (7.9–19), three prolonged decelerations for 3–5 min; OR 10 (4.3–25), and > 5 variable decelerations > 60 s; OR 2.2 (1.6–2.9). For variable decelerations > 60 s, absent variability within decelerations was the only additional characteristic significantly associated with acidemia; OR 5.8 (2.1–16). A strong association with acidemia was noted for a FHR below the baseline ≥ 50 % of the time > 30 min; OR 14 (10−19). Conclusion: Late and prolonged decelerations are strongly, and combined decelerations moderately associated with acidemia. The risk of acidemia is highly increased if FHR is below baseline ≥ 50 % of the time.

INTRODUCTION:Sweden, as many other high-income countries, has adopted guidelines to offer induction of labour at 41+0 gestational weeks to decrease the risk for perinatal death. As more than 20% of the pregnant population reach this gestational age, and along with other contributing factors, induction rates have increased up to 30% in many countries. Both women and care providers have raised the question if outpatient induction could be a convenient, safe and economic alternative, reducing the burden on inpatient care in maternity hospitals. Before introducing outpatient induction into clinical routine, studies need to assure safety for the child and woman as well as efficacy of the method. METHOD AND ANALYSIS:A register-based randomised controlled multicentre non-inferiority trial to study if outpatient induction in low-risk inductions is (1) as safe for the child (perinatal composite of mortality and morbidity) and (2) as effective (proportion of vaginal deliveries) as inpatient induction at the hospital. Secondary outcomes are further health outcomes, experiences of pregnant women, partners and care providers, health economics and future pregnancy outcome. Participating women with a singleton pregnancy and unripe cervix between 37+0 and 41+6 gestational weeks planned for low-risk induction will undergo induction of labour with either a balloon catheter or oral misoprostol according to clinical practice at the study site and the woman's informed choice. Randomisation will allocate women to either outpatient (home or patient hotel) or inpatient induction (standard care). Women undergoing outpatient induction can remain at home for up to 2 days, with an assessment after 24 hours including cardiotocography. Once active labour ensues, all women will receive standard care in the hospital.The assessment of non-inferiority will involve a two-sided 95% CI and 80% power, requiring randomisation of 8891 women to ensure a probability of at least 0.80 that the upper limit of a two-sided 95.7% CI for a difference in the primary safety outcome is below the non-inferiority margin of 1.5%. 31 of the 45 delivery units in Sweden are currently recruiting. Data will be collected from the electronic case report form and Swedish healthcare registers. Questionnaire and qualitative interview-based studies will be performed to explore experiences of pregnant women, partners and care providers. Additionally, a health economic evaluation will be performed. ETHICS AND DISSEMINATION:The Swedish Ethical Review Authority approved the study (3 June 2020; 2020-02675 with amendments 2021-03045, 2022-00865-02, 2023-01252-02, 2024-00560-02, 2024-2024-04597-02). The Swedish Medical Products Agency approved the study for the medication arm (25 August 2020, EudraCT number: 2020-000233-41; 5.1-2020-60240 with amendments 5.1-2022-73500, 5.1-2023-630). Due to changed regulation, in 2023, the study medication arm was transferred and approved by the European Medicines Agency (23 October 2023, EU CT Number: 2023-507164-39-00; CTIS 5.1.2-2023-099775 with amendments 5.1.2-2024-081916, 5.1.2-2025-036291). The Swedish Medical Products Agency approved the study for the medical device arm (6 April 2021, CIV-ID: CIV-20-09-034712; 5.1-2021-14812 with amendments 5.1-2022-14252, 5.1-2023-596, 5.1-2024-8886, 5.1-2024-55554). The medical device arm was transferred to Regulation (EU) 2017/745 (23 December 2024, 5.1-2025-24242 and amendment 5.1-2025-6050). The study will involve more than 80% of all delivery units in Sweden, which will allow for a smooth implementation of any new routine after the study's conclusion. Results will be published in relevant scientific journals, presented at national and international conferences, and communicated to participants and relevant institutions through the Outpatient Induction study homepage (www.optionstudien.se), the webinars of the Swedish Network for National Clinical Studies in Obstetrics and Gynecology (www.snaks.se) as well as social and public media. TRIAL REGISTRATION NUMBER:EudraCT No: 2020-000233-41, after transfer to the European Medicines Agency EU CT Number: 2023-507164-39-00; CIV-ID 20-09-034712.

Background: Healthcare workers in obstetric clinics may be exposed to airborne SARSCoV-2 when treating patients with COVID-19. Method: In this study, performed during the midst of the pandemic, air samples were collected in delivery rooms during childbirth and analysed for SARS-CoV-2 RNA content. Result: Six of 28 samples collected inside delivery rooms were positive for SARS-CoV-2, but none in anterooms or corridors. Five of the six positive samples were from the same occasion. Discussion: This indicates that some patients could be major sources of exhaled virus, although the individual variation is large, and it is thus difficult to predict the risk of infection. (c) 2024 The Authors. Published by Elsevier Ltd on behalf of The Healthcare Infection Society. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Objective: New guidelines for the interpretation of cardiotocography (CTG) have been presented by FIGO in 2015 (FIGO-15) and by NICE in 2017 (NICE-17) and 2022 (NICE-22) In Sweden, a previous template from 2009 (SWE-09) was replaced in 2017 (SWE-17). The objective of the study was to compare these five different templates for CTG classification regarding sensitivity, specificity, positive and negative predictive values in identifying neonates with acidemia at birth (cord artery pH <7.10). Methods This is a historical cohort study including singleton births in Lund November 2015-February 2016, after spontaneous or induced labor at >= 34 completed gestational weeks with validated umbilical cord acid-base samples. Characteristics of cardiotocographic traces during the last hour before birth were reviewed by two independent assessors blinded to outcome. Each template was then used to classify the CTG as normal, suspicious, or pathological. Traces for which classification differed between the two assessors for any of the templates were assessed by a third assessor. The classification by majority (at least 2 of 3) was used for analyses. Main outcome measures were the sensitivity, specificity, and positive and negative predictive values for each template to identify neonates with cord artery pH <7.10 by the classification pathological. In a secondary analysis, these outcome measures were calculated for the classifications suspicious + pathological together. Results SWE-09 and NICE-22 had significantly higher sensitivity (both 92%; 95% CI 79-98%) than NICE-17 (68%; 51-82%), FIGO-15 (42%; 26-59%) and SWE-17 (39%; 24-57%) to identify neonates with acidemia by the classification pathological. Specificity was significantly higher for SWE-17 (91%; 88-93%), FIGO-15 (90%; 88-93%) and NICE-17 (78%; 74-81%) than for NICE-22 (63%; 59-67%) and SWE-09 (62%; 58-66%). The positive predictive value of a pathological pattern ranged between 15% (SWE-09 and NICE-22) and 24% (FIGO-15), and negative predictive values between 95% (SWE-17) and 99% (SWE-09 and NICE-22). Combining suspicious and pathological patterns increased the sensitivity and decreased the specificity for all templates. Conclusions Current CTG interpretation templates either have low sensitivity to identify fetal acidemia or low specificity. Among current guidelines, NICE 2022 had the highest sensitivity to identify neonates with acidemia and is considered the safest current classification system. Efforts to further improve diagnostic precision are warranted.

Induction of labor is one of the most common obstetrical procedures today, with a successively rising rate. With a limited number of hospital beds, the option of starting induction at home has gained increasing attention. The primary aim of this study was to compare the proportion of women achieving vaginal delivery and the duration of hospital stay before delivery in induction of labor with oral misoprostol starting at home and induction with oral misoprostol at the hospital, in a low-risk population. Women with home induction ( n  = 282) were individually matched to controls induced at the hospital during the same time period regarding parity, age, body mass index, labor unit and indication for induction. The rates of vaginal birth were similar in outpatients and inpatients (84.8% vs 86.2%; p  = 0.5). Time from hospital admission to delivery in the outpatient group was significantly shorter than in the inpatient group (12.8 vs 20.6 h; p  < 0.001), as was total hospital stay (2 vs 3 days; p  < 0.001). There were no significant differences between the groups in neonatal or maternal outcomes. One patient undergoing outpatient induction had an unplanned home birth. Starting induction at home reduced the time spent in hospital without affecting the vaginal delivery rate. Although underpowered to assess safety, this study did not show any differences in adverse maternal and perinatal outcomes between inpatients and outpatients. Further research is needed to evaluate the safety of outpatient induction of labor with misoprostol.

Objective Determination of lactate in fetal scalp blood (FBS) during labor has been studied since the 1970s. The internationally accepted cut-off of >4.8mmol/L indicating fetal acidaemia is exclusive for the point-of-care device (POC) LactateProTM, which is no longer in production. The aim of this study was to present a new cut-off for scalp lactate based on neonatal outcomes with the use of StatstripLactate®/StatstripXpress® Lactate system, the only POC lactate meter designed for hospital use. Design Observational Study Setting January 2016 to March 2020 labouring women with an indication for FBS were prospectively included from seven Swedish and one Australian delivery unit. Population Inclusion criteria: singleton pregnancy, vertex presentation, ≥35+0 gestational weeks. Method Based on the optimal correlation between FBS lactate and cord pH/lactate, only cases with ≤25 minutes from FBS to delivery were included in the final calculations. Main outcome measures Metabolic acidosis in cord blood was defined as pH <7.05 plus BDecf >10 mmol/L and/or lactate >10 mmol/L. Results 3334 women were enrolled of which 799 were delivered within 25 minutes. The areas under the ROC curves (AUC) and corresponding optimal lactate cut-off values were as follows; metabolic acidosis AUC 0.87(95% CI:0.77-0.97), cut-off 5.7mmol/L; pH <7.0 AUC 0.83(95% CI:0.68-0.97), cut-off 4.6mmol/L; pH <7.05 plus BD ≥12mmol/L AUC 0.97(95% CI:0.92-1), cut-off 5.8mmol/L; Apgar score <7 at 5 minutes AUC 0.74(95% CI:0.63-0.86), cut-off 5.2mmol/L; and pH <7.10 plus composite neonatal outcome AUC 0.76(95% CI:0.67-0.85), cut-off 4.8mmol/L. Conclusions Suggested intervention threshold for fetal acidemia is scalp lactate of 5.2mmol/L using the StatstripLactate®/StatstripXpress®.

Introduction: The risk for brain injury manifested as cerebral palsy is higher in very preterm born children than in term. Prenatal administration of magnesium sulfate (MgSO4) has been shown to be neuroprotective and reduces the proportion of very preterm born children later diagnosed with cerebral palsy. A Swedish national clinical practice guideline was implemented in March 2020, stipulating the administration of a single intravenous dose of 6 g MgSO4 1-24 h prior to delivery before gestational age 32+ 0, aiming for 90% treatment coverage. The aim of this study was to evaluate the feasibility of this new clinical practice guideline in the first year of its implementation. Material and methods: Data on MgSO4 treatment were collected by reviewing the medical charts of women who gave birth to live born children in gestational age 22+ 0-31+ 6 during the period of March 1, 2020 to February 28, 2021, at five Swedish university hospitals. Women with pre-eclampsia, eclampsia, or high elevated liver enzymes low platelets (HELLP) were excluded. Results: A total of 388 women were eligible and 79% received treatment with MgSO4. Of the 21% not receiving treatment, 9% did not receive treatment due to lack of knowledge about the clinical practice guideline, 9% were not possible to treat and 3% had missing data. The proportion treated increased from 72% to 87% from the first to the last 3 months. Of those treated, 81% received the drug within the stipulated timeframe (mean 8.7 h, median 3.4 h). Conclusions: There was a positive trend over time in the proportion of women receiving MgSO4 treatment, but the a priori target of 90% was not reached during the first year of implementation. Our findings indicate that this target could be reached with additional information to clinicians.

Induction of labor is one of the most common obstetrical procedures today, with a successively rising rate. With a limited number of hospital beds, the option of starting induction at home has gained increasing attention. The primary aim of this study was to compare the proportion of women achieving vaginal delivery and the duration of hospital stay before delivery in induction of labor with oral misoprostol starting at home and induction with oral misoprostol at the hospital, in a low‐risk population.

Objective: To study whether a revision of CTG guidelines and educational program influenced the perceived need for intervention by residents in obstetrics and gynecology. A secondary aim was to study the sensitivity and specificity of the classification pathological after classification by residents using two different guidelines in identifying neonates with acidemia.Study design: Cardiotocograms, CTGs, from 223 neonates with acidemia at birth (cord blood pH < 7.05 at vaginal birth or second stage cesarean, or pH < 7.10 at first stage cesarean) were included, as well as 223 CTGs from neonates with cord blood pH >= 7.15. Two separate groups of residents, who each were educated in and had clinical experience only from either of the two different guidelines, SWE09 and SWE17, classified the patterns according to the at the time current template and judged whether the patterns indicated an intervention. Sensitivity, specificity, and agreement were calculated. Results: Residents using SWE09 found indication to intervene in a higher proportion of neonates with acidemia (84.8%) than residents using SWE17 (75.8%; p = 0.002), as well as in cases without acidemia (29.6% vs 22.4%; p = 0.038). Among residents using SWE09 the perceived need for intervention had a sensitivity of 85% and a specificity of 70% to identify acidemia. With SWE17 the corresponding rates were 76% and 78%. The sensitivity to identify neonates with acidemia by classification pathological was 91% with SWE09 and 72% with SWE17. The specificity was 53% and 76% respectively. The agreement rate between perception of indication to intervene and classification pathological using the SWE09 was lc 0.73, moderate, and with the SWE17 lc 0.77, moderate. The agreement on subjective perception of necessity to intervene between users of the two templates was weak to moderate, lc 0.60, and on classification pathological weak, lc 0.47.Conclusion: The perceived need for intervention by residents interpreting CTGs was significantly affected by the guidelines in use. The difference in decisions were less pronounced than the difference in classification. The sensitivity for both perceived need for intervention and for classification pathological to identify acidosis was higher with SWE09, and the specificity higher with SWE17, when assessed by the two comparable groups of residents.

Objective: To compare the rate of vaginal birth after cesarean section (VBAC), including the maternal and perinatal outcomes, in two historical cohorts before and after the implementation of specific changes in the clinical practice.Design: A retrospective cohort study.Setting: Skkne University Hospital in Malmo, Sweden.Participants: including all women with one previous cesarean section (CS), who delivered during two 4-year periods: 20 05-20 08 (Group I) and 2013-2016 (Group II).Methods: Medical records were retrieved from the hospital's computerized medical system. The surgical reports of all women delivered by repeat CS were reviewed and the appearance of the lower uterine segment at CS was assessed. The primary outcome was VBAC. Secondary maternal outcomes were uterine rupture/dehiscence, hysterectomy and blood loss. The secondary perinatal outcomes were cord blood pH < 7.05 and perinatal mortality rate. Differences for categorical data were studied using the chi-square test and Fisher's exact test. To assess differences for continuous data t-tests were used. To determine which factors predicted VBAC both univariate and multivariate logistic regression analysis with the likelihood ratio test were performed. A two-tailed P-value < 0.05 was considered statistically significantFindings: 2017 patients were included to the study: 792 patients in Group I and 1225 in Group II. The rate of trial of labor after cesarean (TOLAC) was 65.0% and 76.9% and the VBAC rate was 49.8% and 62.0% in Group I and II respectively ( p < 0.0 0 01). Maternal and perinatal adverse outcomes were not statistically different between the two groups.Key conclusions and implications for practice: Appropriate management of women with one previous CS might increase the VBAC rate without a negative impact on maternal or perinatal outcomes. The antenatal teamwork has the greatest contribution to VBAC rate by increasing the number of women undergoing TOLAC.(c) 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )

There is growing evidence that induction of labor at 41 completed weeks improves neonatal outcome, at least among primiparous women. This study was performed to investigate whether maternal body mass index (BMI) should be considered when deciding on timing of intervention in term pregnancies. The study design was a historical cohort study using data from the Swedish Medical Birth Register, singletons in cephalic presentation with births 39+0 to 41+6 weeks, with available information on maternal BMI 2005–2017 ( n  = 352 567). Modified Poisson regression analyses were used to investigate the association between gestational duration and stillbirth or death before 45 postmenstrual weeks (primary outcome) and Apgar score <7 at 5 minutes (secondary outcome) by BMI, respectively. Adjustments were made for maternal age, smoking, country of birth and educational level. The adjusted relative risk (ARR) of stillbirth or death before 45 weeks among infants born at 41+0 to 41+6 vs 40+0 to 40+6 weeks, was 1.26 with a 95% confidence interval (CI) of 1.07–1.48. Among women with BMI ≥30, the offspring mortality risk in pregnancies lasting 39+0 to 39+2 weeks was significantly above the corresponding risk among women of normal BMI who delivered at 41+0 to 41+2 weeks (ARR = 1.95; 95% CI 1.07–3.56) but no statistically significant heterogeneity was found regarding the magnitude of the association between gestational duration and offspring mortality. The ARR, for Apgar <7 at 5 minutes (41+0 to 41+6 vs 40+0 to 40+6 weeks, regardless of BMI), was 1.36 (95% CI 1.27–1.45). The risk for low Apgar score at 41+0 weeks was 1.5% among all children regardless of maternal BMI. Among children to women with BMI ≥30, this magnitude of risk was found already at 39+3 weeks. In primiparous women with obesity the risk of stillbirth or death before 45 postmenstrual weeks were increased throughout all full-term gestational age categories, compared with women with overweight or normal BMI. Children to obese women had the same risk for Apgar scores <7 at 5 minutes compared with women overall at earlier gestational age. The results suggest that maternal BMI needs to be considered when discussing timing of elective induction in term healthy pregnancies of primiparous women.

Cardiotocography (CTG) is the main method of intrapartum fetal surveillance. In 2015 a new guideline was introduced by the International Federation of Gynecology and Obstetrics (FIGO), FIGO-15. In Sweden it was adjusted to SWE-17, replacing the previous national template, SWE-09. This study, conducted at one university hospital and one regional hospital in southern Sweden, evaluated the diagnostic validity of these three templates to detect fetal acidosis during the first stage of labor.A total of 73 neonates with pH <7.1 in umbilical cord artery or vein at cesarean delivery during the first stage of labor were identified retrospectively. For each acidotic neonate, three non-acidemic neonates, with a pH ≥7.2 in cord artery and vein, and Apgar scores ≥9 at five and ten minutes, in all 219 neonates, were selected. The CTG tracings before birth in acidemic neonates, and tracings at the same cervical dilatation in the non-acidemic neonates, were independently assessed by three professionals from the obstetric staff, blinded to group and clinical data. Based on their categorizations of the included variables (baseline, variability, accelerations, decelerations and contraction rate), each CTG tracing was systematically classified according to the three templates. The sensitivity and specificity to identify acidemia by the classification pathological were determined for each template. Interobserver agreement in the assessments of tracings as pathological or not was analyzed, using free-marginal Kappa index.The sensitivity for patterns classified as pathological to identify acidemia was similar for FIGO-15 (71%) and SWE-17 (77%, p = .13), and the specificity was 97% for both. SWE-09 had a significantly higher sensitivity (95%, p < .001) albeit with a lower specificity (90%, p < .001) than the other two templates. Among acidemic neonates, the fraction of tracings classified as normal was higher with SWE-17 (9.6%) than with SWE-09 (0%; p = .01) and FIGO-15 (1.4%; p = .06). For tracings from neonates with acidemia, agreement for three independent assessors was strong (κ 0.85) with SWE-09, and weak for FIGO-15 (κ 0.47), and SWE-17 (κ 0.51). For tracings from neonates without acidemia, the agreement was almost perfect for FIGO-15 (κ 0.91), strong withSWE-17 (κ 0.90) and moderate with SWE-09 (κ 0.78).The ability of FIGO-15 and SWE-17 to identify fetal acidosis is considered insufficient. The combination of a high sensitivity and a high specificity makes SWE-09 the most discriminatory template during the first stage of labor.

PurposeTo determine the association between the occurrence of sporadic and periodic fetal heart rate accelerations during labor and acidemia at birth.Materials and methodsThis is a case-control study of fetal heart rate patterns from 364 neonates with acidemia at birth (cord blood pH <7.05 at vaginal birth, or pH <7.10 at birth after first stage cesarean delivery) and 731 controls with pH >= 7.15. The last 30-60 min of the cardiotocographic traces before birth from the neonates born with acidemia and from the corresponding stage in labor for the controls were scrutinized. Odds ratios (OR) with 95% confidence interval for acidemia at birth were determined.ResultsDuring the first stage, >= 2 sporadic accelerations were present in 16% of cases and 78% of controls; OR for acidemia (compared to 0-1 accelerations) 0.05 (0.02-0.10). In the second stage, the corresponding rates were 13% and 60%, OR 0.09 (0.06-0.14). Isolated periodic accelerations were infrequent. A weak negative association between >= 2 periodic accelerations and acidemia (compared with 0-1 accelerations) was found in the second stage, OR 0.51 (0.30-0.86), but was not significant in the first stage, OR 0.24 (0.04-1.4). Even among fetuses with normal fetal heart rate variability (5-25 beats per minute) the occurrence of less than two sporadic accelerations was associated with an increased risk of acidemia, OR 10.3 (7.2-14.8).ConclusionsSporadic accelerations indicate a very low probability of acidosis but are absent in 40% of fetuses with normal pH during a 30-60 min second-stage recording.

Abstract Objective: To determine the occurrence of sporadic and periodic accelerations during labour and odds ratio, OR, for acidaemia. Design: Case-control study. Setting: One regional and one university hospital. Sample: Cardiotocograms, CTGs, from 295 neonates with cord blood pH <7.05 born during the second stage of labour, 70 neonates with cord blood pH <7.10 born during the first stage and 731 controls with pH ≥7.15. Method: The last 30-60 minutes of CTG recordings before birth from 365 neonates born with acidaemia and from the corresponding stage in labour for 731 controls were scrutinized. Main outcome measures: Odds ratio with 95% confidence interval for acidaemia at birth. Results: During the first stage, sporadic accelerations were present in 16% of cases and 78% of controls; OR for acidaemia 0.05 (0.02-0.10). In the second stage the corresponding rates were 13% and 60%; OR 0.09 (0.06-0.14). Isolated periodic accelerations were infrequent. A weak negative association with acidaemia was found in the second stage; OR 0.51 (0.30-0.86), whereas it was not significant in the first stage; OR 0.24 (0.04-1.4). Less than two sporadic accelerations were associated with an increased risk of acidaemia despite normal fetal heart rate variability (5-25 beats per minute, OR 10.3 (7.2-14.8)). Conclusions: Sporadic accelerations indicate a very low probability of acidosis but are absent in 40% of fetuses with normal pH during a 30-60 minutes second stage recording. Tweetable abstract: Sporadic, but not periodic, accelerations indicate normal fetal pH. This should be a part of CTG guidelines.

Objective To investigate the risk of stillbirth or neonatal death before 45 post-menstrual weeks in relation to gestational duration, stratified by body mass index (BMI) and parity. Design Retrospective study. Setting Data from the Swedish Medical Birth Register. Population Singleton, cephalic births at between 39(+0) and 42(+2) weeks of gestation, 2005-2016 (n = 892 339). Methods Relative risk ratios for mortality in relation to gestational duration were stratified by parity and BMI, and were adjusted for maternal age, smoking, country of birth and educational level. Main outcome measures Primary outcome: stillbirth or neonatal death before 45 post-menstrual weeks. Secondary outcome: stillbirth. Results Among children of primiparous women, children born at 41(+3) weeks of gestation, or later, were at increased risk of stillbirth or neonatal death before 45 post-menstrual weeks compared with children born between 39(+0) and 40(+2) weeks of gestation (aRR 1.29, 95% CI 1.10-1.52). For primiparous women with BMIs of <25, 25-29.9 and >= 30 kg/m(2), the corresponding aRRs were: 1.04 (95% CI 0.81-1.34), 1.25 (95% CI 0.94-1.66) and 1.52 (95% CI 1.10-2.10), respectively. No significant increase in risk with gestational age was detected for multiparous women, regardless of BMI class. Among primipara, the risk of stillbirth increased with gestational duration in all BMI classes, with the highest risk increase for BMI >= 30 kg/m(2), from 0.8/1000 at 40(+3)-40(+6) weeks of gestation to 4.0/1000 at 42(+0)-42(+2) weeks of gestation. Conclusions At 41(+3)-42(+2) weeks of gestation, pregnancy duration was associated with an increased risk for stillbirth or neonatal death before 45 post-menstrual weeks among primiparous women, especially among women who were obese. For multiparous women, no significant association between gestational duration and mortality was found. Tweetable abstract In term pregnancies the risk for stillbirth and neonatal death is affected by gestational age, parity and BMI.

Introduction There is growing evidence that induction of labor at 41 completed weeks improves neonatal outcome, at least among primiparous women. This study was performed to investigate whether maternal body mass index (BMI) should be considered when deciding on timing of intervention in term pregnancies. Material and methods The study design was a historical cohort study using data from the Swedish Medical Birth Register, singletons in cephalic presentation with births 39+0 to 41+6 weeks, with available information on maternal BMI 2005-2017 (n = 352 567). Modified Poisson regression analyses were used to investigate the association between gestational duration and stillbirth or death before 45 postmenstrual weeks (primary outcome) and Apgar score <7 at 5 minutes (secondary outcome) by BMI, respectively. Adjustments were made for maternal age, smoking, country of birth and educational level. Results The adjusted relative risk (ARR) of stillbirth or death before 45 weeks among infants born at 41+0 to 41+6 vs 40+0 to 40+6 weeks, was 1.26 with a 95% confidence interval (CI) of 1.07-1.48. Among women with BMI >= 30, the offspring mortality risk in pregnancies lasting 39+0 to 39+2 weeks was significantly above the corresponding risk among women of normal BMI who delivered at 41+0 to 41+2 weeks (ARR = 1.95; 95% CI 1.07-3.56) but no statistically significant heterogeneity was found regarding the magnitude of the association between gestational duration and offspring mortality. The ARR, for Apgar <7 at 5 minutes (41+0 to 41+6 vs 40+0 to 40+6 weeks, regardless of BMI), was 1.36 (95% CI 1.27-1.45). The risk for low Apgar score at 41+0 weeks was 1.5% among all children regardless of maternal BMI. Among children to women with BMI >= 30, this magnitude of risk was found already at 39+3 weeks. Conclusions In primiparous women with obesity the risk of stillbirth or death before 45 postmenstrual weeks were increased throughout all full-term gestational age categories, compared with women with overweight or normal BMI. Children to obese women had the same risk for Apgar scores <7 at 5 minutes compared with women overall at earlier gestational age. The results suggest that maternal BMI needs to be considered when discussing timing of elective induction in term healthy pregnancies of primiparous women.

IntroductionInduction of labor (IOL) is one of the most common obstetrical procedures, with an increasing rate. The prostaglandin E1 analogue misoprostol is frequently used as a primary method of labor induction. The optimal dose and route of administration is yet to be ascertained.AimTo compare efficiacy and safety between a regimen of sublingually administered misoprostol and a regimen of orally administered misoprostol, with cesarean delivery as primary outcome.MethodsA retrospective study was conducted including women carrying a live, singleton fetus in a cephalic position with labor induced at >37 + 0 gestational weeks at Skåne University hospital, Lund, between January 1st 2013 to December 31st 2017. Data was obtained from computerized obstetrical charts.ResultsTotally 2,404 women were included; 974 induced with sublingual misoprostol and 1,430 with oral solution. In primiparous women the cesarean delivery rate was lower in primiparous women induced with oral compared to sublingual misoprostol (20.5% vs. 28.6%, p < 0.001), whereas in parous women the rates did not differ significantly 4.9% vs. 7.5%; NS). The increased risk of caesarean remained after controlling for potential confounding factors (adjusted odds ratio 1.49 (1.14–1.95). Women induced with sublingual misoprostol had a shorter time to vaginal delivery when compared to oral solution (primiparous median 16.7 h vs. 21.7 h; p < 0.001, parous median 9.9 h vs. 13.3 h; p = 0.01), and a higher rate of vaginal delivery within 24 h (primiparas 77.7% vs. 63.3%, p < 0.001, parous 93.2% vs. 84.2%; p = 0.01).ConclusionIOL with oral misoprostol solution was associated with a significantly higher vaginal delivery rate when compared to sublingual misoprostol, whereas sublingual misoprostol was associated with a significantly shorter time from induction to vaginal delivery. Oral administration is considered the most safe and efficient administration of misoprostol, although more studies are needed to find the optimal route and dosage of misoprostol for IOL.