Objective: To investigate trends in low 5-minute Apgar scores in (near) term singletons. Design: Nationwide cohort study. Setting: The Netherlands. Population: A cohort of 1,583,188 singletons liveborn between 35 +0 and 42 +6 weeks of gestation in the period 2010-2019 from the Dutch Perinatal Registry. Methods: We studied trends using Cochrane-Armitage trend tests. Risk factors were studied by logistic regression analysis and Population Attributable Risk (PAR) calculation. Main outcome measures: Low 5-minute Apgar score (<7 and <4) as primary outcome. Results: The proportion of infants with low 5-minute Apgar score <7 and <4 increased significantly between 2010 and 2019 (1.04-1.42% (p<0.001), 0.17-0.19% (p=0.009), respectively). While neonatal mortality remained unchanged, NICU admissions and low umbilical artery pH’s increased significantly. Many perinatal characteristics showed a significant association with low Apgar scores. The highest risks were found for nulliparity, epidural analgesia, emergency caesarean section, instrumental vaginal delivery, prolonged second stage of labour, male sex and delivery in secondary care. The obstetric interventions induction of labour, epidural analgesia and planned caesarean section showed an increasing trend. Instrumental vaginal delivery and emergency caesarean section were performed less frequently over time, however within these obstetric intervention subgroups the highest increase in low Apgar scores was observed. Conclusions In the Netherlands, the risk of a low 5-minute Apgar score increased significantly over the last decade, with the highest increase being observed in the obstetric intervention subgroups of instrumental vaginal delivery and emergency caesarean section. Neonatal mortality remained stable over the study period.

Objective To gain insight into perinatal outcomes in women with chronic conditions, in order to contribute to the optimization of personalized perinatal care. Design Population-based study using data of the Dutch national perinatal registry between 2010-2019. Setting Nationwide. Population Pregnancies of women who were diagnosed with chronic medical conditions by a medical specialist before pregnancy (n=36,835), divided over seven subgroups and a reference group of pregnancies of women without known chronic medical conditions (n=1,084,623). Methods Descriptive and testing statistics. Main outcome measures The primary outcome was mode of birth. Secondary outcomes were onset of labor, preterm birth, asphyxia, NICU admission, and perinatal mortality. Results Spontaneous birth ranged from 45.0% (orthopedic conditions) to 71.3% (neurological conditions) to 82.6% in the reference group. Instrumental vaginal birth (p<0.001), planned Cesarean birth (p<0.001) and emergency Cesarean birth (p<0.001) differed significantly in all groups if compared to the reference group. Preterm birth was significantly more present in the studied groups (p<0.001) as well as perinatal asphyxia (p<0.001) and NICU admission (p<0.001). Adjusting for mode of birth, parity, age and ethnicity did not change the outcomes for the total group of women with chronic medical conditions. Perinatal mortality was seen in all groups but in none of the separate groups significantly more than in the reference group. Conclusions Women with chronic conditions more often are confronted with preterm birth, Cesarean deliveries, NICU admission of the newborn, and perinatal mortality

Objective Describe changes over time regarding mode of birth and perinatal outcomes in women with one previous caesarean section in the Netherlands over the past 20 years. Design Population-based study. Setting Nationwide. Population All women with one previous caesarean section and no previous vaginal birth, who gave birth to a term singleton in cephalic presentation between 2000 and 2019 (n=143,308). Methods Analysis of Dutch perinatal registry data. Main outcome measures Primary: mode of birth per year, intended vaginal birth versus planned caesarean section. Secondary: failed versus successful vaginal birth in case of intended vaginal birth after caesarean (VBAC), and adverse perinatal outcome (perinatal mortality up to 28 days, low Apgar score at 5 minutes, asphyxia, and NICU admission >24 hours). Results A decrease of 21.5% was seen in women with one previous caesarean section intending VBAC in a subsequent pregnancy, from 77.2% in 2000 to 55.7% in 2019, with a marked acceleration from 2009 onwards. The VBAC success rate dropped gradually, from 71.0% to 65.3%. Overall caesarean section rate (planned and unplanned) increased from 45.1% to 63.6%. Adverse perinatal outcomes were higher in women intending VBAC compared to planned caesarean section. However, after an initial decrease, perinatal mortality remained stable from 2009 onwards with only a minimal difference between both modes of birth. Conclusions In the Netherlands, the proportion of women intending VBAC after a previous caesarean section has decreased markedly, particularly from 2009 onwards. This decrease was not accompanied by a synchronous decrease in perinatal mortality after that year.

Objective: Description of characteristics, risk factors, management strategies and maternal, obstetric and neonatal outcomes of SARS-CoV-2 infected pregnant women in the Netherlands. Design: Multi-centre prospective nationwide population-based cohort study. Setting: Nationwide. Population: All pregnant women in the Netherlands with confirmed SARS-CoV-2 infection in home-isolation or admitted to hospital between March 1st, 2020 and August 31st, 2020. Methods: Pregnant women with positive PCR or antibody tests were registered using the Netherlands Obstetrics Surveillance System. Testing occurred according to national guidelines (selective testing). Data from the national birth registry (Perined) and Dutch National Institute for Public Health and the Environment (RIVM) were used as reference. Main Outcome Measures: Incidence of pregnant women with SARS-CoV-2 infection. Maternal, obstetric and neonatal outcomes including hospital and critical care admission, clinical management and mode of birth. Results: Of 312 registered women, 65 (20%) were admitted to hospital, of whom 5 (2%) to intensive care and 9 (14%) to obstetric high care units. Risk factors for admission were non-Caucasian background (n=28; OR 6.67, 95%CI 4.08-10.90) and being overweight or obese (n=38; OR 2.64, 95%CI1.51 to 4.61). Hospital and intensive care admission were higher compared to age-matched infected women (respectively, OR 14.57, 95%CI 10.99-19.03 and OR 5.02, 95%CI 2.04-12.34). One maternal death occurred. Caesarean section after labour onset was increased (OR 2.50; 95%CI 1.57-3.97). Conclusions: Pregnant women with SARS-CoV-2 infection are at increased risk of hospital admission, ICU admission and caesarean section. Funding: No funding was received. Keywords: Pregnancy, COVID-19, SARS-CoV-2, Pregnancy complications, Pregnancy outcome, Obstetric surveillance system.