Fear of Childbirth Impairs Breastfeeding Success Independent of Mode of Birth.

Background: The good qualities of breastfeeding are well known. The aim of this study was to closely examine the impact of specific maternal, prenatal, obstetric, and early neonatal factors on the success of breastfeeding. Materials and Methods: We used data from the Kuopio Birth Cohort study and analyzed 2,521 online questionnaires, which were answered by women 1 year after giving birth. Breastfeeding variables were divided into successful breastfeeding (breastfeeding exclusively with one's own breast milk ≥4 months or breastfeeding with formula ≥6 months) and poor breastfeeding (breastfeeding exclusively with one's own milk <4 months and duration of all breastfeeding <6 months) for univariate and multivariable analyses. Results: In this study, 97.8% (N = 2,466) reported breastfeeding their newborns for ≥1 postnatal week, and 75.2% (N = 1,896) breastfed newborns for ≥6 months. The rate of breastfeeding for ≥6 months increased from 71.3% to 84.7% between 2013 and 2020. In the multivariable analysis, poor breastfeeding success was associated most significantly with smoking during pregnancy (adjusted odds ratio [aOR] 4.64; 95% confidence interval [CI] 2.75-7.81), twin pregnancy (aOR 4.13; 95% CI: 2.10-8.15), maternal obesity (body mass index > 35) (aOR 3.27; 95% CI: 2.15-4.99), fear of childbirth (aOR 2.80; 95% CI: 1.89-4.13), and birth during the period of 2013-2014 (aOR 2.94; 95% CI: 2.08-4.14) or 2015-2016 (aOR 2.62; 95% CI: 1.85-3.70). Other significant factors related to poor success were younger maternal age, nonmarried family relationships, passive or quitting smoking before or in the first trimester, any hypertensive disorder during pregnancy, birth by nonelective cesarean, and lowest or highest quartiles of birth weight. Conclusions: Mother's fear of childbirth is strongly associated with the poor breastfeeding success even after controlling for mode of birth.

Obstetric and neonatal outcomes in women with Ankylosing spondylitis - an evaluation of a population database.

BACKGROUND: Ankylosing Spondylitis (AS) is a systemic chronic rheumatic disease characterized by involvement of the axial skeletal and sacroiliac joints. Although this disease is not rare amongst women of reproductive age, data regarding pregnancy outcomes have demonstrated conflicting results. We therefore aimed to compare pregnancy and perinatal outcomes between women who suffered from AS to those who did not. METHODS: A retrospective cohort study using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS). Included in the study were all pregnant women who delivered or had a maternal death in the US between 2004 and 2014. Women with an ICD-9 diagnosis of AS before or during pregnancy were compared to those without. Pregnancy, delivery, and neonatal outcomes were compared between the two groups using multivariate logistic regression models adjusting for potential confounders. RESULTS: A total of 9,096,788 women were inclusion in the analysis. Amongst them, 383 women (3.8/100,000) had a diagnosis of AS and the rest were controls. Women with AS, compared to those without, were more likely to be older; Caucasian; from higher income quartiles; suffer from thyroid disorders, and have multiple pregnancies (p < 0.001, all). After adjusting for confounders, patients in the AS group, compared to those without, had a higher rate of cesarean delivery (CD) (aOR 1.47, 95% CI 1.14-1.91, p = 0.003); gestational diabetes (aOR 1.55, 95% CI 1.02-2.33, p = 0.038); and placenta previa (aOR 3.6, 95% CI 1.6-8.12, p = 0.002). Regarding neonatal outcomes, patients with AS, compared to those without, had a higher rate of small-for-gestational-age (SGA) neonates (aOR 2.19, 95% CI 1.22-3.93, p = 0.009); and intrauterine fetal death (IUFD) (aOR 3.46, 95% CI 1.11-10.83, p = 0.033). CONCLUSION: Women diagnosed with AS have an increased risk of obstetric complications, including CD, as well as an increased risk of SGA and IUFD.

Maternal and Neonatal Consequences of Early Augmentation of Labor Among Women With Spontaneous Onset of Labor: A National Population-Based Study.

BACKGROUND: While some labor interventions are essential in preventing maternal and neonatal morbidity, there is little evidence to support systematic early augmentation of labor (EAL). Our objective was to assess the association between EAL and cesarean delivery rate, postpartum hemorrhage and adverse neonatal outcomes. METHODS: Population-based study using data from the 2016 French Perinatal Survey. Women with a singleton cephalic fetus, delivering at term after a spontaneous labor were included. "EAL" was defined by artificial rupture of the membranes (AROM) and/or oxytocin within 1 h of admission and/or duration between interventions of less than 1 h. Women without EAL were women without labor augmentation or without EAL. The primary endpoint, cesarean delivery and the secondary endpoints were compared between women with and without EAL using univariate analysis. A multivariable logistic regression was adjusted on the suspected confounders and a propensity score approach was then performed. RESULTS: Among the 7196 women included, 1524 (21.2%) had EAL. Cesarean delivery rates were significantly higher in the EAL group compared with the no EAL group, 8.40% versus 6.15% (p < 0.01). EAL was associated with cesarean delivery in the multivariable analysis aOR 1.45 95% CI [1.15-1.82] and in the cohort matched on the propensity score, OR 1.56 [1.17-2.07]. EAL was not associated with severe postpartum hemorrhage, low 5-min Apgar score, low neonatal cord pH or transfer to NICU. CONCLUSION: EAL is frequent, involving one in five spontaneous laboring women in France. This practice is associated with an increased cesarean delivery risk.

The Impact of Indication for Cesarean on Blood Loss.

BACKGROUND: Postpartum hemorrhage is the leading cause of maternal mortality worldwide. Quantitative blood loss assessment at the time of cesarean delivery is a more accurate measure of blood loss than is simple estimation. Risk factors for postpartum hemorrhage are well described; however, contemporary, systematic investigations into the impact of the indication for cesarean delivery on quantitative blood loss are lacking. OBJECTIVE: To investigate whether there are clinically significant differences in quantitative blood loss and postpartum hemorrhage risk based on the indication for cesarean delivery. STUDY DESIGN: A cohort of 4,881 cesarean deliveries performed at a large academic hospital between 2020 and 2022 was identified. Primary and repeat cesarean deliveries were analyzed separately and further subdivided into seven indications: elective, labor arrest, fetal heart rate abnormalities, placenta previa, placenta accreta, malpresentation, and other. Quantitative blood loss and rates of postpartum hemorrhage ( > 1000 cc and >1500cc) were compared among the different indications. RESULTS: Mean quantitative blood loss for primary, repeat and total cesarean deliveries was 886 cc, 697 cc and 792 cc, respectively. Excluding cases of placenta accreta, the greatest blood loss in both primary and repeat groups was seen in cesareans performed for labor arrest, with blood loss exceeding 1500 cc in 18% and 13% of all cases. Blood loss exceeding 1500cc was seen in 1% and 2% of elective cesarean deliveries. The mean blood loss for planned repeat cesarean/hysterectomies for placenta accreta was < 400cc greater than primary cesareans performed for labor arrest (1442 cc vs. 1065 cc), despite the addition of an often-complex hysterectomy to the procedure. CONCLUSIONS: Clinically and statistically significant differences in blood loss exist based on the indication for cesarean delivery. Large differences in rates of serious postpartum hemorrhage (>1500cc) with negligible differences in mean quantitative blood loss suggests the presence of frequent, large clinical outliers not reflected in a statistical mean. The indication for cesarean and the possibility of such outliers, rather than the predicted "average blood loss for cesarean delivery" should be considered in determining risk and the degree of necessary pre-operative blood preparation. These data raise questions about whether current, traditional techniques of non-accreta related cesarean delivery can be justified in non-emergent cases when such procedures could be performed with significantly less blood loss using accreta-specific techniques.

Early oral feeding within two hours for parturients compared with delayed oral feeding after cesarean section: a systematic review and meta-analysis.

BACKGROUND: It is recommended that postpartum women undergo early oral feeding (EOF) after cesarean section (CS). However, the optimal early time for oral feeding after CS is unclear. We performed a meta-analysis to assess whether EOF within two hours is superior to delayed oral feeding (DOF) after CS. METHODS: The PubMed, Embase, Cochrane Library, and Google Scholar databases were searched from inception to February 2024 for randomized controlled trials comparing EOF versus DOF after CS. Primary outcomes included the time to normal bowel function. The secondary outcomes included postoperative complications, the time to ambulation after surgery, the time to removal of the catheter, the time to start of a regular diet, the length of hospital stay and patient satisfaction. RESULTS: Data from 8 studies involving a total of 2572 women were obtained. EOF within two hours was significantly associated with shorter durations of return bowel movement (WMD, - 2.41, 95% CI, - 3.80-- 1.02; p < 0.001; I2 = 96%), passage flatus after surgery (WMD, - 3.55, 95% CI, - 6.36-- 0.75; p = 0.01; I2 = 98%), ambulation after surgery (WMD, - 0.96, 95% CI, - 1.80-- 0.13; p = 0.02; I2 = 53%), removal of catheters (WMD, - 15.18, 95% CI, - 25.61-- 4.74; p = 0.004; I2 = 100%) and starting a regular diet (WMD, - 7.03, 95% CI, - 13.13-- 0.92; p = 0.02; I2 = 99%) compared with DOF. EOF was not related to increased vomiting (RR, 1.08; 95% CI, 0.74-1.57; p = 0.69; I2 = 0%), nausea (RR, 1.21; 95% CI, 0.83-1.77; p = 0.33; I2 = 37%), abdominal distension (RR, 0.76; 95% CI, 0.31-1.89; p = 0.55; I2 = 54%) or ileus (RR, 0.91; 95% CI, 0.40-2.06; p = 0.81; I2 = 12%). CONCLUSIONS: This meta-analysis provides evidence that EOF within two hours after CS has comparable safety with DOF, and can accelerate the recovery time for normal bowel function. TRIAL REGISTRATION: INPLASY202320055.

The effect of mode of delivery on postpartum comfort level and breastfeeding self-efficacy: a systematic review and meta-analysis.

OBJECTIVE: This study was conducted to determine the effect of the mode of delivery on maternal postpartum comfort level and breastfeeding self-efficacy. METHODS: The study was conducted as a systematic review and a meta-analysis. Searching was performed from March to July 2022, on PubMed, National Thesis Center, Dergi Park, Google Scholar, Web of Science, and EBSCO search engines and we included studies from the last 10 years. The Joanna Briggs Institute Critical Appraisal tools used in cross-sectional studies were employed to appraise the methodological quality and performed meta-analyses using a random-effects model for all outcomes. Study data consisted of continuous variables calculated by Mean Difference. RESULTS: From 3732 records received, 21 cross-sectional studies involving 5266 participants were determined to be eligible. Meta-analysis results showed that cesarean section reduced postpartum comfort, albeit not statistically significant (MD: -0.87 95%: -1.98-0.24, Z = 1.53, p = 0.44), whereas the combined results of breastfeeding self-efficacy showed that delivery type did not affect breastfeeding self-efficacy. CONCLUSION: The results of this review have clinical implications for postpartum caregivers, as the effects of mode of delivery on postpartum comfort and breastfeeding self-efficacy have been well documented in previous studies. The authors recommend caregivers plan maternal care to increase their comfort, taking into account the factors that may affect postpartum comfort in the light of evidence-based practices.

Development of the obstetric unanticipated difficult video-laryngoscopy algorithm through a quality improvement randomized open-label in situ simulation study.

BACKGROUND: Video-laryngoscopy is increasingly used during general anesthesia for emergency cesarean deliveries. Given the heightened risk of difficult tracheal intubation in obstetrics, addressing challenges in airway management is crucial. In this simulation study, we hypothesized that using a flexible bronchoscope would lead to securing the airway faster than the Eschmann introducer when either device is used in addition to video-laryngoscopy. METHODS: Twenty-eight anesthesia trainees (n=14/group) were randomized to use either one of the rescue devices and video-recorded in a simulated scenario of emergency cesarean delivery. The primary outcome was the time difference in establishing intubation; secondary outcomes were the differences in incidence of hypoxemia, need for bag and mask ventilation, and failed intubation between the two rescue devices. RESULTS: Mean (±SD) time to intubation using flexible bronchoscopy was shorter compared to using an Eschmann introducer (24 ±â€¯10 vs 86 ±â€¯35 s; P<0.0001; difference in mean 62 seconds, 95% CI 42 to 82 seconds). In the fiberoptic bronchoscopy group, there were no episodes of hypoxemia or need for bag and mask ventilation; in contrast both such events occurred frequently in the Eschmann introducer group (71%, 10/14); P=0.0002). All flexible bronchoscopy-aided intubations were established on the first attempt. The incidence of failed intubation was similar in both groups. CONCLUSIONS: Our data from simulated emergency tracheal intubation suggest that flexible bronchoscopy combined with video-laryngoscopy results in faster intubation time than using an Eschmann introducer combined with video-laryngoscopy.

Racial inequities in cesarean use among high- and low-risk deliveries: An analysis of childbirth hospitalizations in New Jersey from 2000 to 2015.

OBJECTIVE: To examine racial inequities in low-risk and high-risk (or "medically appropriate") cesarean delivery rates in New Jersey during the era surrounding the United States cesarean surge and peak. STUDY SETTING AND DESIGN: This retrospective repeated cross-sectional study examined the universe of childbirth hospitalizations in New Jersey from January 1, 2000 through September 30, 2015. We estimate the likelihood of cesarean delivery by maternal race and ethnicity, with mixed-level logistic regression models, stratified by cesarean risk level designated by the Society of Maternal Fetal Medicine (SMFM). DATA SOURCES AND ANALYTIC SAMPLE: We used all-payer hospital discharge data from the Healthcare Cost and Utilization Project's State Inpatient Discharge Database and linked this data to the American Hospital Association Annual Survey. ZIP-code Tabulation Area (ZCTA)-level racialized economic segregation index data were from the 2007-2011 American Community Survey. We identified 1,604,976 statewide childbirth hospitalizations using International Classification of Diseases-9-CM (ICD-9) diagnosis and procedure codes and Diagnosis-Related Group codes, and created an indicator of cesarean delivery using ICD-9 codes. PRINCIPAL FINDINGS: Among low-risk deliveries, Black patients, particularly those in the age group of 35-39 years, had higher predicted probabilities of giving birth via cesarean than White people in the same age categories (Black-adjusted predicted probability = 24.0%; vs. White-adjusted predicted probability = 17.3%). Among high-risk deliveries, Black patients aged 35 to 39 years had a lower predicted probability (by 2.7 percentage points) of giving birth via cesarean compared with their White counterparts. CONCLUSIONS: This study uncovered a lack of medically appropriate cesarean delivery for Black patients, with low-risk Black patients at higher odds of cesarean delivery and high-risk Black patients at lower odds of cesarean than their White counterparts. The significant Black-White inequities highlight the need to address misalignment of evidence-based cesarean delivery practice in the efforts to improve maternal health equity. Quality metrics that track whether cesareans are provided when medically needed may contribute to clinical and policy efforts to prevent disproportionate maternal morbidity and mortality among Black patients.

Maintenance infusion rate of oxytocin after initial 1-IU bolus for elective Cesarean delivery: a dose-finding study.

PURPOSE: The purpose of our study was to determine the minimum effective dose of oxytocin maintenance infusion required to maintain adequate uterine tone in 90% of patients (ED90) after administration of the initial bolus at elective Cesarean delivery (CD) under spinal anesthesia. METHODS: We conducted a prospective, double-blind dose-finding study with biased coin up-down design. Immediately after delivery, a 1-IU oxytocin bolus was administered, followed by a maintenance infusion. The obstetrician assessed the uterine tone by palpation as satisfactory or unsatisfactory. In case of unsatisfactory response, the dose for the next patient was increased by 2 IU·hr-1. For satisfactory response, the dose for the next patient was either decreased by 2 IU·hr-1 with a probability of 1/9, or remained unchanged. The primary outcome was a satisfactory uterine tone from five minutes after delivery until discharge from postanesthesia care unit. The secondary outcomes were blood loss, need for additional uterotonics, and side effects. RESULTS: We analyzed data for 40 patients. The ED90 of oxytocin maintenance infusion was 4.5 IU·hr-1 (95% confidence interval, 3.3 to 5.5) based on the isotonic regression estimator. The median [interquartile range] blood loss was 861 [553-1,181] mL; 18% received additional uterotonics, and 38% developed hypotension post delivery. CONCLUSION: Based on the results of this dose-finding study, we recommend a maintenance infusion rate of 4.5 IU·hr-1 following an oxytocin bolus of 1 IU for adequate uterine tone in pregnant patients undergoing elective CDs. This infusion rate is four-fold lower than that required without an initial bolus. STUDY REGISTRATION: ClinicalTrials.gov ( NCT04946006 ); first submitted 25 June 2021.

RéSUMé: OBJECTIF: L'objectif de notre étude était de déterminer la dose minimale efficace de perfusion d'entretien d'ocytocine nécessaire pour maintenir un tonus utérin adéquat chez 90 % des personnes parturientes (DE90) après l'administration du bolus initial lors d'une césarienne programmée sous rachianesthésie. MéTHODE: Nous avons réalisé une étude prospective et en double aveugle de détermination de la dose avec une méthodologie de conception biaisée type « up-and down ¼. Immédiatement après l'accouchement, un bolus d'ocytocine de 1 UI a été administré, suivi d'une perfusion d'entretien. L'obstétricien·ne a évalué le tonus utérin par palpation comme satisfaisant ou insatisfaisant. En cas de réponse insatisfaisante, la dose pour la personne suivante a été augmentée de 2 UI·h−1. Lors d'une réponse satisfaisante, la dose pour la personne suivante a été diminuée de 2 UI·h−1 avec une probabilité de 1/9, ou est restée inchangée. Le critère d'évaluation principal était un tonus utérin satisfaisant de cinq minutes après l'accouchement jusqu'à la sortie de la salle de réveil. Les critères d'évaluation secondaires étaient la perte de sang, la nécessité d'utérotoniques supplémentaires et les effets secondaires. RéSULTATS: Nous avons analysé les données de 40 patient·es. La DE90 de perfusion d'entretien d'ocytocine était de 4,5 UI·h−1 (intervalle de confiance à 95 %, 3,3 à 5,5) basé sur l'estimateur de régression isotonique. La perte de sang médiane [écart interquartile] était de 861 [553-1 181] mL; 18 % ont reçu des utérotoniques supplémentaires et 38 % ont développé une hypotension après l'accouchement. CONCLUSION: D'après les résultats de cette étude de détermination de la dose, nous recommandons un débit de perfusion d'entretien de 4,5 UI·h−1 après un bolus d'ocytocine de 1 UI pour un tonus utérin adéquat chez les personnes parturientes bénéficiant d'une césarienne programmée. Ce débit de perfusion est quatre fois inférieur à celui requis sans bolus initial. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov ( NCT04946006 ); première soumission le 25 juin 2021.

Prophylactic phenylephrine infusion versus treatment with vasopressor bolus as needed during non-urgent cesarean delivery and neonatal acidemia: a retrospective cohort study (2016-2021).

INTRODUCTION: Prophylactic vasopressor administration reduces spinal hypotension during cesarean delivery, however the effects of vasopressor administration on neonatal acidemia remain uncertain. We examined the occurrence of neonatal acidemia in the setting of non-urgent cesarean delivery and compared outcomes between cases receiving prophylactic phenylephrine infusion versus cases treated with boluses of phenylephrine. METHODS: Retrospective cohort study with ethical approval, comparing non-urgent cesarean delivery cases performed under spinal anesthesia (2016 to 2021), receiving either prophylactic phenylephrine infusion or boluses as needed. Data were collected from anesthesia and labor ward electronic medical records. Records with missing pH or missing blood pressure data were excluded. The independent variable was prophylactic phenylephrine administration, a strategy implemented following international recommendations in 2018. The main outcome was neonatal acidemia, defined as umbilical artery pH < 7.1. The secondary outcome was maternal hypotension, defined as at least one systolic blood pressure (SBP) measurement below 100 mmHg or below 80% baseline. RESULTS: A total of 4392 patients were included in the final analysis; 1318 (30.0%) received prophylactic phenylephrine infusion. Neonatal acidemia (umbilical artery pH < 7.1) occurred in 28 (2.1%) cases receiving prophylactic phenylephrine versus 50 (1.6%) treated with boluses as needed (p = 0.188). Prophylactic phenylephrine infusion was not associated with occurrence of neonatal acidemia (aOR 0.83; 95% CI 0.52 to 1.33, p = 0.435). Prophylactic phenylephrine infusion was associated with a reduced spinal hypotension rate when defined as SBP < 100 mmHg (OR 0.47; 95% CI 0.37 to 0.57; p < 0.001), with similar results when hypotension was defined as a drop below 80% or 90% of baseline SBP. CONCLUSION: In this pragmatic study, prophylactic phenylephrine infusion was associated with a reduction in maternal spinal hypotension, but not reduced neonatal acidemia.

Recovery quality of transversus abdominis plane block with liposomal bupivacaine after cesarean delivery: A randomized trial.

STUDY OBJECTIVE: This study aimed to investigate the effect of liposomal bupivacaine in transversus abdominis plane block (TAP) on recovery quality after cesarean delivery. DESIGN: A randomized trial. SETTING: An operating room, a post-anesthesia care unit, and a hospital ward. PATIENTS: A total of 147 women scheduled for cesarean delivery under spinal anesthesia were enrolled and randomized to receive a TAP block with plain bupivacaine (bupivacaine group), liposomal bupivacaine (liposomal group), or a mixture of plain bupivacaine and liposomal bupivacaine (mixture group). INTERVENTIONS: The bupivacaine group received bilateral TAP blocks with plain bupivacaine 50 mg alone. The liposomal group received bilateral TAP blocks with liposomal bupivacaine 266 mg alone. The mixture group received bilateral TAP blocks with plain bupivacaine 50 mg followed by liposomal bupivacaine 266 mg. MEASUREMENTS: The primary outcome was the Quality of Recovery-15 (QoR - 15) score assessed 24 h postoperatively. Secondary outcomes encompassed the QoR - 15 score at 48 h post-surgery, the VAS pain score at rest and with movement at 24, 48, and 72 h postoperatively, opioid consumption within the 0-24 h and 24-48 h periods following surgery, as well as patient's satisfaction with analgesic. MAIN RESULTS: The QoR - 15 score at 24 h postoperatively was significantly higher in both the liposomal group and the mixture group compared to the bupivacaine group. Specifically, the QoR - 15 score for the liposomal group versus the bupivacaine group (median [IQR]: 120 [107, 128] vs. 109 [104, 120]; median difference, 7; 95 % CI, 2 to 13; P = 0.011) and for the mixture group versus the bupivacaine group (median [IQR]: 122 [112, 128] vs. 109 [104, 120]; median difference, 9; 95 % CI, 4 to 14; P = 0.001). The QoR - 15 score in both the liposomal group and the mixture group were also higher than those in the bupivacaine group at 48 h postoperatively, though the difference was not clinically meaningful. Additionally, both the liposomal and mixture groups exhibited lower pain score at 24 h and 48 h postoperatively compared to the bupivacaine group, but no significant clinical differences were achieved in either pain scores or opioid consumption. Patients in both the liposomal and mixture groups reported higher satisfaction score with analgesia than those in the bupivacaine group. CONCLUSIONS: TAP block using either liposomal bupivacaine or a mixture of plain bupivacaine and liposomal bupivacaine provided superior quality of recovery at 24 h after cesarean delivery compared to using plain bupivacaine alone.

What is the best mode of delivery in nulliparous, singleton, term, vertex pregnancies of individuals ≥ 35 years old?: Short title: What is the best mode of delivery in nulliparous, singleton, term, vertex pregnancies?

With approximately 145 million births occurring worldwide each year - over 30 million by cesarean delivery, the need for evaluation of maternal and perinatal outcomes in different delivery scenarios is more pressing than ever. Recently, in a meta-analysis of the available randomized controlled trials (RCTs), planned cesarean delivery was associated with decreased rates of low umbilical artery pH, and neonatal complications such as birth trauma, tube feeding, and hypotonia when compared to planned vaginal delivery. Among singleton pregnancies, planned cesarean delivery was associated with a lower rate of perinatal death. For mothers, planned cesarean delivery was associated with significantly less chorioamnionitis, more wound infection, and less urinary incontinence at 1-2 years. Conversely, planned vaginal delivery has been associated with benefits such as a lower incidence of wound infection and quicker postpartum recovery compared to planned cesarean delivery. Nonetheless, several risk factors for cesarean delivery are increasing - such as older maternal age, obesity, diabetes, excessive gestational weight gain, and birth weight - while maternal pelvises are getting smaller. Concerns about the potential long-term risks of multiple cesarean deliveries, such as placenta accreta spectrum disorders, highlight the need for a balanced evaluation of both delivery modes. However, the total fertility rate is decreasing in the US and around the world, with many people wanting two or fewer babies, which decreases future risk of placenta accreta incurred by multiple cesarean deliveries in these individuals. Furthermore, one in four obstetricians-gynecologists has undergone a cesarean delivery on maternal request for their nulliparous, singleton, term, vertex (NSTV) pregnancy, and cesarean delivery rates less than about 19% have been associated with higher perinatal and maternal mortality. Thus, we propose that it is imperative that we prioritize conducting randomized trials to compare planned cesarean to planned vaginal delivery for NSTV pregnancies. Such trials would need to include 8,000 or more individuals; they would ideally follow each participant to the end of their reproductive life and study perinatal and maternal outcomes, including non-biologic outcomes such as patient satisfaction, postpartum depression, breastfeeding rates, mother-infant bonding, post-traumatic stress, and cost-effectiveness. The time for such a trial is now, as it holds the potential to inform and improve obstetrical care practices globally.

Trial of labor following cesarean among patients with polyhydramnios: a multicenter retrospective study.

PURPOSE: This study aimed to assess maternal and neonatal outcomes in patients with polyhydramnios attempting trial of labor after cesarean (TOLAC) compared to those undergoing planned repeat cesarean delivery (PRCD). METHODS: A multi-center retrospective cohort study was conducted and included women with term singleton viable pregnancies following a single low-segment transverse cesarean delivery (CD) with a polyhydramnios diagnosis (maximal vertical pocket > 8 cm and/or Amniotic Fluid Index > 24 cm) within 14 days before birth who delivered between the years 2017 and 2021. Maternal and neonatal outcomes were compared between those attempting TOLAC and those opting for PRCD. The primary outcome was composite adverse maternal. Univariate analysis was followed by multivariate analysis to control for potential confounders. RESULTS: Out of 358 included births with a previous CD, 208 (58.1%) attempted TOLAC, while 150 had PRCD (41.9%). The successful vaginal birth after cesarean (VBAC) rate was 82.2%, and no cases of uterine rupture, hysterectomy, or maternal intensive care unit admission occurred in either group. After controlling for potential confounders, no independent association between TOLAC and composite adverse maternal (adjusted odds ratio [aOR] 0.62, 95% confidence interval [CI] 0.32-1.20, p = 0.16) and neonatal (aOR 0.89, 95% CI 0.51-1.53, p = 0.67) adverse outcomes was demonstrated. CONCLUSION: In patients with a term diagnosed polyhydramnios, TOLAC appears to be a reasonable alternative associated with favorable outcomes. Larger prospective studies are needed to refine management strategies and enhance maternal and neonatal outcomes in this context.

External cephalic version: a retrospective chart review at a Canadian tertiary care centre.

OBJECTIVES: The primary objective is to identify our local external cephalic version (ECV) success rate, variables associated with increased likelihood of success, and complication rates. The secondary objective is to allow obstetrical care providers to accurately counsel patients undergoing trial of ECV. METHODS: We analyzed patient charts between January 2018 and December 2022 who underwent ECV. Variables included maternal age, parity, gestational age at time of ECV attempt, breech type, anesthetic, uterine relaxant, placental location, neonatal birthweight, and provider seniority. Outcomes were ECV success, mode of delivery, emergent cesarean delivery rate due to ECV, and NICU admission. Appropriate statistical analysis was performed. RESULTS: 258 patients were included. Overall success rate was 31%. Multiparity, transverse presentation, and neonatal birthweight > 3.3 kg were associated with significantly increased success rates. Uterine relaxant use was associated with a lower success rate than no relaxant use, which is potentially explained by significantly more frequent relaxant use in non-transverse presentations and non-significant trend in increased relaxant use in primiparous patients. Other factors including anesthetic use, maternal age, gestational age, placental location, and provider seniority did not significantly impact success. Emergency cesarean delivery rate was 10% and NICU admission rate was 8%, both of which were higher than anticipated. CONCLUSION: ECV remains an option for management of the term breech. Obstetrical providers at our centre and in others may use this study to more accurately counsel patients using local data and optimize likelihood of success based on patient and peri-procedural factors. OBJECTIFS: L'objectif principal est de déterminer le taux local de versions céphaliques externes (VCE) réussies, les variables associées à une grande probabilité de réussite et le taux de complications. L'objectif secondaire est d'outiller les prestataires de soins obstétricaux de sorte qu'ils puissent bien accompagner les patientes se soumettant à un essai de VCE. MÉTHODE: Nous avons analysé les dossiers des patientes s'étant soumises à une VCE dans la période de janvier 2018 à décembre 2022. Les variables analysées étaient l'âge maternel, la parité, l'âge gestationnel au moment de la tentative de VCE, le type de présentation du siège, l'anesthésie, le relaxant utérin, le positionnement du placenta, le poids à la naissance et les années d'expérience du prestataire. Les critères étaient la réussite de la VCE, le mode d'accouchement, le taux de césarienne d'urgence en raison de la VCE et l'admission aux soins intensifs néonataux. Une bonne analyse statistique a été réalisée. RÉSULTATS: Au total, 258 patientes ont été incluses. Le taux de réussite global a été de 31 %. La multiparité, la présentation transverse et le poids de naissance supérieur à 3,3 kg ont été associés à un taux de réussite significativement plus élevé. L'utilisation de relaxants utérins a été associée à un moins bon taux de réussite comparativement à l'absence de relaxant, ce qui peut s'expliquer par l'utilisation significativement plus fréquente de relaxants dans les présentations non transverses et une tendance non significative à l'augmentation du recours aux relaxants chez les primipares. D'autres facteurs, tels que l'utilisation d'anesthésiques, l'âge maternel, l'âge gestationnel, le positionnement du placenta et les années d'expérience du prestataire, n'ont pas eu d'effet significatif sur la réussite de l'intervention. Le taux de césarienne d'urgence était de 10 % et le taux d'admission aux soins intensifs néonataux était de 8 %, tous deux plus élevés que prévu. CONCLUSION: La VCE reste une option pour la prise en charge de la présentation du siège à terme. Les prestataires de soins obstétricaux de notre centre et d'autres centres peuvent utiliser cette étude pour bien accompagner les patientes en utilisant des données locales et optimiser les chances de réussite en fonction des facteurs liés à la patiente et à la période avant, pendant et après l'intervention.

Associations of primiparous pre-pregnancy body mass index and gestational weight gain with cesarean delivery after induction: a prospective cohort study.

Objective: The effects of Pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) in primiparas remain unclear. This study examines the associations of pre-pregnancy BMI and GWG with cesarean delivery after induction (CDaI) in primiparous women. Methods: This prospective cohort study included 3,054 primiparous women. We recorded pre-pregnancy BMI, first, second, and third trimester weight values, as well as instances of CDaI and other pregnancy outcomes. We analyzed the associations of pre-pregnancy BMI and GWG with CDaI by conducting a multivariate logistic regression analysis after adjusting for covariates, and adjusted risk ratios (aRR) and 95% confidence intervals were reported. Results: We recorded 969 CDaIs. In the vaginal delivery group, each increase of 1 standard deviation in the pre-pregnancy BMI was correlated with a 6% increase in the CDaI risk [aRR (95% CI), 1.06 (1.01-1.11)]. Each increase of 1 standard deviation in the rate of weight gain during the entire pregnancy was correlated with a 21% increase in the CDaI risk [aRR (95% CI), 1.21 (1.14-1.29)]. Compared to women with a normal weekly GWG in the second and third trimester, those with slow GWG had a 19% increased risk of CDaI [aRR (95% CI), 1.19 (1.01-1.37)]. The subgroup analysis results showed that increases in pre-pregnancy BMI could increase the CDaI risk regardless of the induction method. Conclusion: High pre-pregnancy BMI, excessive GWG, and rapid first trimester weight gain are risk factors for CDaI in primiparous women. Excessive first trimester weight gain, may associated with increased risks of CDaI in primiparous women.

Duration of double balloon catheter for patients with prior cesarean: a before and after study.

Background: Previous studies that suggest a shorter time from cervical ripening balloon placement to delivery with shorter total balloon placement time have excluded patients with prior cesarean deliveries. Objective: To evaluate, in patients with a prior history of cesarean delivery undergoing cervical ripening with a double-balloon catheter, whether planned removal of device after 6 vs 12 hours would result in shorter time to vaginal delivery. Study Design: A before-and-after study was performed after a practice change occurred November 2020, shortening the planned time of double-balloon catheter placement for cervical ripening from 12 to 6 hours. Data were collected via retrospective electronic chart review. Primary outcome was time from balloon placement to vaginal delivery. Secondary outcomes included rates of cesarean delivery, maternal intraamniotic infection, and uterine rupture. Kaplan-Meier curves compared median times to delivery between the groups. A Cox proportional-hazards model was used to adjust for time of balloon placement, number of previous vaginal deliveries, and co-medications used. Results: From November 2018 to November 2022, 189 analyzable patients with a prior history of cesarean delivery received a double-balloon catheter for cervical ripening during their trial of labor. Patients were separated into pre- and postpolicy change groups (n=91 and 98, respectively). The median time to vaginal delivery for the pregroup was 28 hours (95% CI: 26, 35) and 25 hours (95% CI: 23, 29) for those in the postgroup (P value .052). After adjusting for dilation at time of balloon placement, number of previous vaginal deliveries, and co-medication, the estimated hazard ratio for successful vaginal delivery postpolicy change was 1.89 (95% CI: 1.27, 2.81). There were no differences in rates of secondary outcomes. Conclusion: In patients with prior cesarean delivery undergoing mechanical cervical ripening with a double-balloon catheter, planned removal at 6 hours compared to 12 hours may result in higher chances of successful vaginal delivery and possibly a shorter time to delivery, without increasing rates of cesarean delivery and intraamniotic infection.

Prenatal identification of invasive placentation using ultrasound in women with placenta previa and prior cesarean delivery.

OBJECTIVE: To evaluate the performance of ultrasound for antenatal identification of invasive placentation in women with placenta previa in the setting of prior cesarean delivery. STUDY DESIGN: This was a multicenter, retrospective, cohort study. Singleton pregnancies at risk of placenta accreta because of persistent placenta previa in the setting of prior cesarean delivery who delivered at four centers, from January 2010 to May 2020, were included in the study. For this study, pregnancies with diagnosis of accreta, increta, or percreta were considered under the umbrella term of placenta accreta. All women with placenta previa identified in the second trimester had a follow-up ultrasound at 32-34 weeks. Only those with prior cesarean delivery were considered at risk of placenta accreta. Women were considered with suspected accreta in case of suspected prenatal ultrasound. Women with suspected placenta accreta had delivery planned via cesarean hysterectomy at 34+0 - 35+6 weeks, without any attempt to remove the placenta. The primary endpoint of the study was the performance of ultrasound for antenatal identification of invasive placentation. The following ultrasound signs were evaluated: placenta lacunae; loss of clear space; increased vascularity between myometrium and placenta; intracervical lake; rail sign; uterovesical hypervascularity; increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region; and disruption of bladder-myometrial interface. RESULTS: 180 singleton pregnancies with placenta previa in the setting of prior cesarean delivery were identified. Of them, 155 (86.1%) had antenatal suspected placenta accreta based on ultrasound, having at least one sign of invasive placentation. Of the 155 suspected cases, 99 had confirmed placenta accreta at the time of delivery. Among the 99 cases of confirmed placenta accreta, all of them had at least one sign of invasive placentation at ultrasound. Among the 81 cases with placenta previa, prior cesarean delivery, without placenta accreta, 25/81 (30.9%) had ultrasound scan negative for sign of invasive placentation, and 56/81 (69.1%) had at least one sign of invasive placentation). In particular, 12/81 (14.8%) had placenta lacunae, 16/81 (19.8%) had loss of clear space, 20/81 (24.7%) had increased vascularity between myometrium and placenta, 9/81 (11.1%) had intracervical lake, 14/81 (17.3%) had rail sign, 14 (17.3%) had uterovesical hypervascularity, 5/81 (6.2%) had increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region, 8/81 (9.9%) had disruption of bladder-myometrial interface. In the group of women with confirmed placenta accreta, the most common sign recorded was the disruption of bladder-myometrial interface, being recorded in 88/99 women. Disruption of bladder-myometrial interface had the highest sensitivity in detection placenta accreta. Women with disruption of bladder-myometrial interface at ultrasound had 73-fold increase in the risk of placenta accreta compared to those who did not. CONCLUSION: Prenatal ultrasound has an excellent diagnostic accuracy in identifying invasive placentation in women with placenta previa and prior cesarean delivery.

Prevention of postoperative nausea and vomiting after cesarean delivery under neuraxial anesthesia and postpartum analgesia in Japan: A cross-sectional study.

AIMS: This study aims to investigate the clinical practice of physicians working in obstetric setting toward postoperative nausea and vomiting (PONV) in parturients undergoing cesarean delivery (CD) with neuraxial anesthesia. METHODS: We conducted this online survey to all active members of the Japan Society of Obstetric Anesthesiology and Perinatology (JSOAP), where leads academic society in obstetric anesthesia in Japan. The questionnaire was developed using the Delphi method. The survey included questions about routine practices for PONV prevention, the use of neuraxial opioids, optimal practices, and perceived obstacles. The email sent three times every 2 weeks as a reminder. RESULTS: A total of 1046 e-mails were sent, and 307 JSOAP members responded to the survey (29.3%). More than half of responders (62.7%) used neuraxial opioids with intrathecal morphine being the most frequent. They had a higher rate of multimodal PONV prophylaxis compared with who did not use neuraxial opioids for postoperative analgesia (19.9% vs 6.7%). Metoclopramide was the commonest medication for PONV prevention, and there was a significant difference in the use of 5-hydroxytryptamine receptor antagonists (19.9% vs. 8.6%, p = 0.012). We observed that 80% of physicians reported the routine administration of prophylaxis for PONV for CD. Among these, 20% indicated the use of two or more agents. Conversely, in the cohort not administering neuraxial opioids, only 6.7% reported the use of two or more agents. CONCLUSION: The online survey showed that the physicians using neuraxial opioids for CD had a higher proportion of multimodal PONV management involving two or more agents.

Association of in vitro fertilization with severe maternal morbidity in low-risk patients without comorbidities.

OBJECTIVE: To determine whether an association exists between in vitro fertilization (IVF) and severe maternal morbidity among low-risk pregnant patients. DESIGN: Retrospective cohort study. SETTING: Academic healthcare system. PATIENT(S): Low-risk pregnant patients who delivered between January 2019 and December 2022. Low-risk was defined as having an obstetric comorbidity index score of 0. INTERVENTION(S): In vitro fertilization. MAIN OUTCOME MEASURE(S): The primary outcome (dependent variable) was any severe maternal morbidity. The secondary outcome was the need for a cesarean delivery. A modified Poisson regression with robust error variance was used to model the probability of severe maternal morbidity as a function of IVF. Risk ratios and their associated 95% confidence intervals (CIs) were computed. An α value of 0.05 was considered statistically significant. RESULT(S): A total of 39,668 pregnancies were included for analysis, and 454 (1.1%) were conceived by IVF. The overall severe maternal morbidity rate was 2.4% (n = 949), with the most common indicator being blood transfusion. The overall cesarean delivery rate was 18.8% (n = 7,459). On modified Poisson regression, IVF-conceived pregnancies were associated with 2.56 times the risk of severe maternal morbidity (95% CI, 1.73-3.79) and 1.54 times the risk of having a cesarean delivery (95% CI, 1.37-1.74) compared with non-IVF pregnancies. CONCLUSION(S): In vitro fertilization is associated with higher rates of severe maternal morbidity, primarily the need for a blood transfusion, and cesarean delivery in low-risk pregnancies without major comorbidities. Recognizing this association allows healthcare providers to implement proactive measures for better monitoring and tailored postpartum care.

Synchronous cesarean delivery and revision of infected ventral hernia repair mesh in a complex abdominal wall.

Ventral hernias are a common abdominal wall defect vulnerable to the gravid abdomen's physiological changes. This case report describes a 38-year-old gravida 3 para 2002 female with a complex abdominal surgical history and a chronic infection of the abdominal wall at the site of prior hernia repair with mesh. She was managed conservatively with antibiotics until delivery. Abdominal wall debridement and repair was coordinated with her 39-week cesarean, which allowed for a successful delivery of her infant paralleled with surgical management of the infected mesh.