Cohort Study Of Primiparous Women Research Articles

Re-evaluation of modifiable risk factors for obstetric anal sphincter injury in a real-world setting.

The objective was to identify modifiable risk factors for obstetric anal sphincter injury (OASI) in primiparous women. This was a retrospective cohort study of primiparous women with a singleton vaginal delivery. Main outcome measures were incidence of OASI and odds ratios for possible risk factors: maternal age, body mass index and height, fetal birthweight and head circumference, gestational age, epidural analgesia, mediolateral episiotomy, and instrumental deliveries. Univariate and multivariate logistic regressions were performed using forward methods for variable selection. Of 19,786 primiparous women with a singleton vaginal delivery, 369 sustained an OASI (1.9%). Risk factors were identified: vacuum extraction (adjusted OR 2.06, 95% CI, 1.59-2.65, p < 0.001), increased fetal weight (aOR 1.06, 95% CI, 1.02-1.11, p = 0.002, per 100-g increments); head circumference (aOR 1.24, 95% CI, 1.13-1.35, p < 0.001, per 1-cm increments); gestational week (aOR 1.11, 95% CI, 1.02-1.2, p = 0.012, per week). Protective factors: mediolateral episiotomy (aOR 0.75, 95% CI, 0.59-0.94, p = 0.013) particularly in vacuum deliveries (aOR 0.50, 95% CI, 0.29-0.97, p = 0.040); epidural analgesia (aOR 0.64, 95% CI, 0.48-0.84, p = 0.001); maternal height ≥157 cm (aOR 0.97, 95% CI, 0.96-0.98, p = 0.006, risk decreases by 2.6% per 1 cm increase in height). Mediolateral episiotomy was protective against OASI in both spontaneous and instrumental deliveries of primiparae. Increased fetal weight and large fetal head circumference, particularly in short women, were significant risk factors. These findings support the performance of ultrasound to acquire updated fetal measures before admission to the labor ward.

Impact of household income and Special Supplemental Nutritional Program for Women, Infants, and Children on feeding decisions for infants in the United States

Despite the known benefits of breastfeeding to infants and mothers, previous studies have demonstrated that underserved women are less likely to exclusively breastfeed. Existing studies on the impact of Special Supplemental Nutritional Program for Women, Infants, and Children enrollment on feeding decisions for infants have conflicting results with low-quality data and metrics. This study aimed to examine infant feeding trends nationally in the first week postpartum over a 10-year period, comparing breastfeeding rates for primiparous women with low income who used Special Supplemental Nutritional Program for Women, Infants, and Children resources with those women who did not enroll. We hypothesized that although the Special Supplemental Nutritional Program for Women, Infants, and Children is an important resource for new mothers, free formula associated with enrollment in the Special Supplemental Nutritional Program for Women, Infants, and Children may disincentivize women to exclusively breastfeed. This was a retrospective cohort study of primiparous women with singleton gestations who gave birth at term and who responded to the Centers for Disease Control and Prevention Pregnancy Risk Assessment Monitoring System between 2009 and 2018. Data were extracted from phases 6, 7, and 8 of the survey. Women with low income were defined as those with a reported annual household income of $35,000 or less. The primary outcome was exclusive breastfeeding after 1 week postpartum. Secondary outcomes included ever breastfeeding, any breastfeeding after 1 week postpartum, and introduction of other liquids within 1 week postpartum. Multivariable logistic regression was used to refine risk estimates with adjustment for mode of delivery, household size, education level, insurance status, diabetes, hypertension, race, age, and BMI. Among the 42,778 women with low income who were identified, 29,289 (68%) of these women reported receiving Special Supplemental Nutritional Program for Women, Infants, and Children resources. There was no significant difference in the rates of exclusive breastfeeding after 1 week postpartum between those enrolled in the Special Supplemental Nutritional Program for Women, Infants, and Children and those not enrolled (adjusted risk ratio, 1.04; 95% confidence interval, 1.00-1.07; P=.10). However, those enrolled were less likely to ever breastfeed (adjusted risk ratio, 0.95; 95% confidence interval, 0.94-0.95; P<.01) and were more likely to introduce other liquids within 1 week postpartum (adjusted risk ratio, 1.16; 95% confidence interval, 1.11-1.21; P<.01). Although exclusive breastfeeding rates after 1 week postpartum were similar, women enrolled in the Special Supplemental Nutritional Program for Women, Infants, and Children were significantly less likely to ever breastfeed and more likely to introduce formula within the first week postpartum. This suggests that Special Supplemental Nutritional Program for Women, Infants, and Children enrollment may impact the decision to initiate breastfeeding and may represent an important window to test future interventions.

Choice of scheduled cesarean delivery versus trial of labor for advanced maternal age primiparous women

Objective: We aimed to evaluate perinatal outcomes of advanced maternal age (AMA) primiparous women seeking scheduled cesarean delivery (CD) versus a trial of labor (TOL).Materials and methods: This was a retrospective cohort study of primiparous women ≥40 years of age carrying a single fetus, who delivered at a tertiary, university-affiliated medical center (2007–2014). We compared perinatal outcomes of women who chose a scheduled CD with those who chose TOL. Subsequently, we compared women who had successful TOL (sTOL) with those who had a failed TOL (fTOL).Results: Out of 62 102 deliveries during the study period, inclusion criteria were met by 374 women. Of them, 83 (22.2%) women had a scheduled CD, and 291 (77.8%) had TOL. Of the TOL group, 118 women (40.5%) had fTOL and 173 (59.5%) had sTOL. Women in the fTOL had higher rates of 1-min Apgar score <7, neonatal asphyxia and adverse neonatal composite outcome compared with women in the sTOL group (p < .05). After adjusting for potential confounders, compared with sTOL, fTOL was not associated with adverse neonatal composite outcome. Compared with scheduled CD, fTOL was associated with an increased risk for adverse neonatal composite outcome (aOR 2.65, 95% CI 1.13–6.19, p = .03).Conclusion: AMA primiparous women attempting TOL have comparable outcome to those seeking scheduled CD, however, women with fTOL have higher rates of adverse neonatal outcome.

Maternal depressive symptoms at three months postpartum and breastfeeding rates at six months postpartum: Implications for primary care in a prospective cohort study of primiparous women in Australia.

The World Health Organisation recommends exclusive breastfeeding to six months postpartum, but most women in developed countries do not breastfeed this long. Prior studies exploring the relationship between breastfeeding duration and maternal depression show ambiguous findings. To explore associations between maternal depressive symptoms at three months postpartum, and breastfeeding status over the first six months postpartum. Prospective pregnancy cohort study of nulliparous women. 1507 women were recruited from six public hospitals in early pregnancy, completing baseline data in early pregnancy (mean gestation 15 weeks). Follow-up questionnaires were completed at three and six months postpartum. Women reported how many months they breastfed for (breastfeeding refers to 'any' breastfeeding, including expressed breastmilk). Depressive symptoms were measured at three months postpartum with the Edinburgh Postnatal Depression Scale (scores ≥13 indicated probable major depression). Of the almost 95% of women who initiated breastfeeding, 76% were still breastfeeding at three months postpartum, and by six months postpartum this dropped to 61%. Women who reported depressive symptoms at three months had significantly lower rates of breastfeeding at six months postpartum compared to women without depressive symptoms (49% vs. 61%; adjusted OR=0.55, 95% CI 0.34-0.90). Maternal social characteristics associated with not breastfeeding at six months postpartum were: young maternal age; lower education; and smoking in pregnancy. Women's decisions around infant-feeding are influenced by a range of psycho-social factors, and early postnatal depressive symptoms appear to be a significant part of this picture, as either a cause or consequence of decisions to cease breastfeeding.

Perineal body stretch during labor does not predict perineal laceration, postpartum incontinence, or postpartum sexual function: a cohort study.

The perineum stretches naturally during obstetrical labor, but it is unknown whether this stretch has a negative impact on pelvic floor outcomes after a vaginal birth (VB). We aimed to evaluate whether perineal stretch was associated with postpartum pelvic floor dysfunction, and we hypothesized that greater perineal stretch would correlate with worsened outcomes. This was a prospective cohort study of primiparous women who had a VB. Perineal body (PB) length was measured antepartum, during labor, and 6months postpartum. We determined the maximum PB (PBmax) measurements during the second stage of labor and PB change (ΔPB) between time points. Women completed functional questionnaires and had a Pelvic Organ Prolapse Quantification (POP-Q) system exam 6months postpartum. We analyzed the relationship of PB measurements to perineal lacerations and postpartum outcomes, including urinary, anal, and fecal incontinence, sexual activity and function, and POP-Q measurements. Four hundred and forty-eight women with VB and a mean age of 24 ± 5.0years with rare (5%) third- or fourth-degree lacerations were assessed. During the second stage of labor, 270/448 (60%) had perineal measurements. Mean antepartum PB length was 3.7 ± 0.8cm, with a maximum mean PB length (PBmax) during the second stage of 6.1 ± 1.5cm, an increase of 65%. The change in PB length (ΔPB) from antepartum to 6months postpartum was a net decrease (-0.39 ± 1.02cm). PB change and PBmax were not associated with perineal lacerations or outcomes postpartum (all p > 0.05). PB stretch during labor is unrelated to perineal laceration, postpartum incontinence, sexual activity, or sexual function.

Pre-pregnancy maternal obesity and the risk of preterm preeclampsia in the American primigravida.

To estimate the risk of preterm preeclampsia in primiparous women by pre-pregnancy obesity class. A retrospective cohort study of primiparous women with singleton gestations was performed for deliveries from January 2003 to April 2014. Cases were stratified by delivery occurring either at ≥ 37 weeks or < 37 weeks. Pre-pregnancy maternal obesity was defined as a body mass index (BMI) ≥ 30 kg/m(2) . World Health Organization criteria were used to define BMI class of obesity. Multinomial logistic regression modeling estimated the association between term and preterm preeclampsia and pre-pregnancy obesity. Of 28,361 women with complete pre-pregnancy BMI data, 2,588 women (9.1%) had a diagnosis of preeclampsia. Women who developed preeclampsia prior to 37 weeks (n = 784) were more likely to be women with obesity compared to women who developed preeclampsia after 37 weeks (33.1% vs. 25.3%, P = 0.0001). Compared to normal-weight women without preeclampsia, the risk of preterm preeclampsia increased proportionally with pre-pregnancy obesity class, with women with a BMI ≥ 40 kg/m(2) having the greatest risk (RR 5.23, 95% CI: 3.86-7.09, P <0.001). The risk of preterm preeclampsia increased significantly as the severity of maternal pre-pregnancy obesity increased. Reduction in maternal pre-pregnancy BMI may be protective in mitigating such risk.

Predisposing and Precipitating Factors for Dissociation During Labor in a Cohort Study of Posttraumatic Stress Disorder and Childbearing Outcomes.

Peritraumatic dissociation is an important predictor of posttraumatic stress disorder (PTSD), depression, and impaired bonding following childbirth. The purpose of this study was to follow up on an earlier finding that peritraumatic dissociation in labor was associated with adverse postpartum outcomes by identifying predictors of dissociation in labor. This analysis used data from a prospective cohort study of primiparous women from southeast Michigan. There were 564 women included in the analysis; the primary outcome measure was the Peritraumatic Dissociative Experiences Questionnaire (PDEQ) score measuring dissociation during labor. The prevalence of dissociation in labor for this sample was 7.4%. Important predictors of dissociation in labor included both predisposing (eg, childhood maltreatment trauma, preexisting psychopathology) and precipitating (eg, perception of care, negative appraisal of labor) factors. Overall, these predictors explained 14.7% of variance in PDEQ score. In 3 separate, simple linear regression models, the PDEQ score explained 20% of variance in postpartum PTSD, 13% of variance in postpartum depression, and 9% of variance in impaired bonding. Women with maltreatment history and PTSD are at risk to be retraumatized or overwhelmed by birth and to dissociate. Although it would be optimal to assess for dissociative coping prenatally, assessing with the PDEQ following birth could contribute to evaluation of risk for postpartum psychopathology.

Perineal outcome and the risk of pelvic floor dysfunction: a cohort study of primiparous women.

Pelvic floor dysfunction (PFD) is the most common complication of childbirth. Assumptions have been made that perineal trauma increases the risk of PFD compared to an intact perineum, however the evidence for this is lacking. The aim of this study was to explore the relationship between perineal outcome and postpartum PFD. Prospective cohort study design, with a self-reported quality of life (QOL) questionnaire mailed to all primiparous women with a non-instrumental delivery at The Townsville Hospital between 2011 and 2012 (n=766). ANOVA was used to compare how the symptoms of PFD affect QOL in women with an intact perineum, episiotomy or spontaneous tear. Seventy-nine percent of the population had perineal injury; 60% had a spontaneous tear and 19% had an episiotomy. Ninety-seven percent of women who completed the questionnaire (n=196) complained of PFD symptoms. Women with episiotomy had the best QOL, reporting the lowest levels of urinary dysfunction (statistically significant). No differences between the groups were found for symptoms of bowel, prolapse or sexual dysfunction. This study shows a relationship between perineal outcome and PFD and suggests that an episiotomy is associated with the least morbidity due to symptoms of urinary incontinence. Additional large-scale prospective research is required to further investigate and delineate the impact of childbirth on PFD.

Postpartum sexual functioning and its relationship to perineal trauma: A retrospective cohort study of primiparous women

Objective: Our goal was to evaluate the relationship between obstetric perineal trauma and postpartum sexual functioning. Study Design: Our study was carried out with a retrospective cohort design in 3 groups of primiparous women after vaginal birth: Group 1 (n = 211) had an intact perineum or first-degree perineal tear; group 2 (n = 336) had second-degree perineal trauma; group 3 (n = 68) had third- or fourth-degree perineal trauma. These sample sizes reflect a 70% response rate. Outcomes were time to resuming sexual intercourse, dyspareunia, sexual satisfaction, sexual sensation, and likelihood of achieving orgasm. Results: At 6 months post partum about one quarter of all primiparous women reported lessened sexual sensation, worsened sexual satisfaction, and less ability to achieve orgasm, as compared with these parameters before they gave birth. At 3 and 6 months post partum 41% and 22%, respectively, reported dyspareunia. Relative to women with an intact perineum, women with second-degree perineal trauma were 80% more likely (95% confidence interval, 1.2-2.8) and those with third- or fourth-degree perineal trauma were 270% more likely (95% confidence interval, 1.7-7.7) to report dyspareunia at 3 months post partum. At 6 months post partum, the use of vacuum extraction or forceps was significantly associated with dyspareunia (odds ratio, 2.5; 95% confidence interval, 1.3-4.8), and women who breast-fed were ≥4 times as likely to report dyspareunia as those who did not breast-feed (odds ratio, 4.4; 95% confidence interval, 2.7-7.0). Episiotomy conferred the same profile of sexual outcomes as did spontaneous perineal lacerations. Conclusions: Women whose infants were delivered over an intact perineum reported the best outcomes overall, whereas perineal trauma and the use of obstetric instrumentation were factors related to the frequency or severity of postpartum dyspareunia, indicating that it is important to minimize the extent of perineal damage incurred during childbirth. (Am J Obstet Gynecol 2001;184:881-90.)

Obstetric events leading to anal sphincter damage

Objective: To identify the obstetric factors relating to anal sphincter injury at first vaginal delivery by prospective cohort study of primiparous women. Methods: We compared the results of a bowel function questionnaire and anal vector manometry before and 6 weeks after delivery in 184 primiparous women. Postpartum, pudendal nerve conduction latency was measured in all women, and anal endosonography was performed in 81 with altered fecal continence or abnormal physiology. Results: Sixteen (9%) women, none of whom had altered fecal continence, were delivered by cesarean. After vaginal delivery, 42 of 168 (25%) women had impairment of fecal continence and 76 of 168 (45%) women had abnormal anal physiology. Instrumental vaginal delivery was associated with an 8.1-fold (95% confidence interval [CI] 2.7, 24.0; P < .001) risk of anal sphincter injury and a 7.2-fold (95% CI 2.8, 18.6; P < .001) risk of symptoms. Duration of the second stage of labor beyond 60 minutes led to a 1.7-fold (95% CI 1.14, 2.48; P; < .01) risk of anal sphincter injury and a 1.6-fold (95% CI 1.03, 2.6, P = .01) risk of symptoms. Epidural analgesia, used in 58% of vaginal deliveries, prolonged the second stage of labor ( P = .004; odds ratio [OR] 7.7; 95% CI 4.0, 14.7) and was associated with increased risk of sphincter injury ( P = .02; OR 2.1; 95% CI 1.1, 4.0) and of symptoms ( P = .02; OR 2.0; 95% CI 1.1, 3.7). Conclusion: Instrumental delivery and a second stage of labor prolonged by epidural analgesia are the obstetric factors that pose the greatest risk of injury to the anal sphincter mechanism in primiparous vaginal delivery.