Assessing the Clinical Significance of Third-Trimester Post-Coital Bleeding.

INTRODUCTION: This study aimed to evaluate the impact of third-trimester post-coital bleeding (PCB) on pregnancy outcomes. METHODS: A retrospective cohort study was conducted at two tertiary medical centers, including all pregnant women between 24 and 34 weeks of gestation referred due to vaginal bleeding over an 11-year period. The study population includes all singleton deliveries; within this population, women were further classified into three groups: those admitted due to vaginal bleeding related to PCB, those admitted due to vaginal bleeding not related to PCB, and those who did not report vaginal bleeding. The primary outcome measure was delivery prior to 37 weeks of gestation, while secondary outcome measures included maternal and neonatal complications. Baseline characteristics of the two groups were compared. RESULTS: During the study period, there were a total of 51,698 deliveries. Among these, 230 cases involved bleeding between 24 and 34 weeks of gestation, 34 (14.8%) were identified as PCB, and 196 as bleeding unrelated to intercourse. In addition, 51,468 pregnancies without bleeding were analyzed as the general population for comparison. The incidence of preterm labor before 37 weeks of gestation was notably higher in both women with PCB (14.7%) and those with bleeding unrelated to coitus (20.9%) compared to the general population (5.6%); however, there was no statistically significant difference between the two bleeding groups (p = 0.403) while both were significantly different from the general population (p < 0.001). The odds ratio for preterm birth before 37 weeks of gestation after PCB was 3.29 (95% CI: 1.26-8.56, p = 0.0149). There were no significant differences between the PCB and bleeding unrelated to intercourse groups in terms of maternal and neonatal complications. CONCLUSION: This study found that third-trimester PCB is a risk factor for preterm delivery, with rates similar to other causes of third-trimester bleeding but significantly higher than the general population without bleeding. These findings challenge the assumption that PCB is benign.

Grandmultiparity, maternal age, and the risk for uterine rupture-A multicenter cohort study.

INTRODUCTION: Uterine rupture is a critical complication causing fetal and maternal morbidity and mortality. Data are conflicting regarding whether grandmultiparity (parity ≥ 6) is a risk factor. This multicenter cohort study aimed to determine whether grandmultiparity (parity ≥ 6) poses a risk for uterine rupture in women with no previous cesarean delivery. MATERIAL AND METHODS: A multicenter retrospective study of deliveries that occurred between the years 2003 and 2015 in three tertiary medical centers. Deliveries of grandmultiparous women were compared with those of multiparous women (parity 2-5). Women with previous cesarean deliveries were excluded. Multivariable regression modeling was applied to control for possible confounders. RESULTS: A total of 388 784 deliveries of multiparous women with unscarred uteri were recorded during the study period, including 53 965 deliveries of grandmultiparous women and 334 819 deliveries of multiparous women. Grandmultiparous women were significantly older (33.9 ± 5 vs 27.3 ± 5 years; P < 0.0001). Fourteen cases of uterine rupture were recorded in the grandmultiparae group (1 per 3855 labors) vs 41 in the multiparae group (1 per 8166 labors) (odds ratio [OR] 2.07, 95% confidence interval [95% CI] 1.13-3.81; P = 0.030). However, in a multivariable model controlling for maternal age, the association between grandmultiparity and uterine rupture lost its significance (adjusted OR 1.26, 95% CI 0.66-2.41; P = 0.491), and maternal age emerged as an independent predictor of uterine rupture (adjusted OR 1.08, 95% CI 1.04-1.13; P < 0.0001). Additionally, the risk for uterine rupture was elevated in a linear fashion, concomitant with age. CONCLUSIONS: Maternal age is a risk factor for uterine rupture. Grandmultiparity does not increase the risk beyond that associated with maternal age.

Neonatal subgaleal hemorrhage unrelated to assisted vaginal delivery: clinical course and outcomes.

PURPOSE: The purpose of the study was to evaluate the occurrence of subgaleal hemorrhage (SGH) following non-assisted vaginal delivery (normal vaginal delivery or cesarean delivery), and to characterize associated factors, clinical course, and outcomes, compared to attempted assisted vaginal delivery (AVD)-associated SGH METHODS: A retrospective cohort study was conducted. All cases of SGH encountered following delivery of a singleton neonate at Hadassah, Hebrew University Medical Center during 2011-2018 were included. Maternal, fetal, intrapartum, and neonatal characteristics and outcomes were compared between AVD-related and non-AVD-related SGH groups. RESULTS: The overall incidence of SGH was 4.5/1000 (369/82,256) singleton deliveries. The incidences of AVD- and non-AVD-related SGH were 44.6/1000 (350/7852) and 0.3/1000 (19/74,404) singleton deliveries, respectively. Ten (53%) of the 19 non-AVD-related SGH were diagnosed after vaginal delivery and 9 (47%) after an urgent cesarean section. SGH severity was mild, moderate, and severe in 68%, 16%, and 16% of the cases, respectively. SGH severity did not differ between the attempted AVD group and the non-AVD-related SGH group. A higher proportion of neonates with non-AVD SGH required phototherapy treatment than did those diagnosed with AVD-related SGH (56% vs. 24%, P = 0.003). Other neonatal outcomes, including Apgar scores, maximal bilirubin level, length of stay, and the rate of composite adverse outcomes, did not differ between the groups. CONCLUSIONS: SGH, although rare, may be diagnosed after unassisted vaginal or cesarean delivery in the absence of an AVD attempt. We advocate continuing education for all medical staff who participate in peripartum and neonatal care, regarding the possible occurrence of non-AVD-related SGH.

Trial of labor after cesarean delivery in twin gestations: systematic review and meta-analysis.

BACKGROUND: Trial of labor after cesarean is offered as a routine option for singleton gestations with previous cesarean delivery. However, adequate data are not available to determine whether the approach is equally valid in women with twin gestation. OBJECTIVE: This systematic review and meta-analysis aimed to assess maternal morbidities associated with trial of labor after cesarean delivery in twin gestations. STUDY DESIGN: Electronic databases were searched for cohort studies and randomized controlled trials evaluating the association between trial of labor after cesarean delivery in twin gestations and pregnancy outcomes. Maternal mortality and severe morbidities, such as uterine rupture and hysterectomy, were compared between women who had trial of labor and women who had a planned repeat cesarean delivery. Pooled odds ratios were calculated using a random-effects model. Additional analyses were performed to compare trial of labor after cesarean outcomes in singleton and twin gestations. RESULTS: Eleven cohort studies including a total of 8209 twin gestations with previous cesarean delivery were included in the present study. Of these gestations, 2484 were intended for planned vaginal birth and 5725 were intended for planned repeat cesarean delivery. The rate of uterine rupture in twin gestations was higher in the trial of labor after cesarean group than the elective cesarean group (odds ratio, 10.09, 95% confidence interval, 4.30-23.69, I2 = 68%). However, no statistically significant difference was found in the rate of uterine rupture between twin and single gestations attempting trial of labor after cesarean delivery (odds ratio, 1.34, 95% confidence interval, 0.54-3.31, I2 = 0%). Women who attempted a trial of labor after cesarean delivery with twins did not have an increased risk of uterine scar dehiscence, hemorrhage, blood transfusion, or neonatal morbidity and mortality compared with elective repeat cesarean delivery. Patients with twins had similar rates of successful vaginal delivery as patients with singletons (odds ratio, 0.85, 95% confidence interval, 0.61-1.18, I2 = 36%). CONCLUSION: This meta-analysis demonstrates that, although trial of labor with twins after previous cesarean delivery is associated with higher rates of uterine rupture compared with elective cesarean delivery, pregnancy outcomes and success rates are similar to a trial of labor after previous cesarean delivery in singleton gestations. Planned vaginal birth for women with twin gestation and previous cesarean delivery may be a safe alternative to a planned repeat cesarean.

Risk factors associated with subgaleal hemorrhage in neonates exposed to vacuum extraction.

INTRODUCTION: Subgaleal hemorrhage (SGH) is a life-threatening neonatal condition that is strongly associated with vacuum assisted delivery (VAD). The factors associated with the development of SGH following VAD are not well-established. We aimed to evaluate the factors associated with the development of SGH following attempted VAD. MATERIAL AND METHODS: A retrospective case-control study of women who delivered at a tertiary university-affiliated medical center in Jerusalem, Israel, during 2009-2018. Cases comprised all parturients with singleton pregnancies for whom attempted VAD resulted in neonatal SGH. A control group of VAD attempts was established by matching one-to-one according to gestational age at delivery, parity and year of delivery. Fetal, intrapartum and vacuum procedure characteristics were compared between the groups. RESULTS: In all, 313 (89.5%) of the 350 attempted VAD were nulliparous. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birthweight in the SGH group. In multivariate logistic regression analysis, only six independent risk factors were significantly associated with the development of SGH: second-stage duration (for each 30-minute increase, adjusted odds ratio [OR] 1.13; 95% confidence intervals [CI] 1.04-1.25; P = .006), presence of meconium-stained amniotic fluid (adjusted OR 2.61; 95% CI 1.52-4.48; P = .001), presence of caput succedaneum (adjusted OR 1.79; 95% CI 1.11-2.88; P = .01), duration of VAD (for each 3-minute increase, adjusted OR 2.04; 95% CI 1.72, 2.38; P < .001), number of dislodgments (adjusted OR 2.38; 95% CI 1.66-3.44; P < .001), and fetal head station (adjusted OR 3.57; 95% CI 1.42-8.33; P = .006). Receiver operating characteristic curves showed that VAD duration of ≥15 minutes had a 96.7% sensitivity and 75.0% specificity in predicting SGH formation, with an area under the curve equal to .849. CONCLUSIONS: Vacuum duration, the number of dislodgments, the duration of second stage of delivery, fetal head station, the presence of caput succedaneum and the presence of meconium were found to be independently associated with SGH formation.

A large head circumference is more strongly associated with unplanned cesarean or instrumental delivery and neonatal complications than high birthweight.

OBJECTIVE: Fetal size impacts on perinatal outcomes. We queried whether the fetal head, as the fetal part interfacing with the birth canal, might impact on obstetric outcomes more than birthweight (BW). We examined associations between neonatal head circumference (HC) and delivery mode and risk of perinatal complications as compared to high BW. STUDY DESIGN: This was an electronic medical records-based study of term singleton births (37-42 weeks' gestation) from January 2010 through December 2012 (N = 24,780, 6343 primiparae). We assessed risks of unplanned cesarean or instrumental delivery and maternal and fetal complications in cases with HC or BW ≥95th centile (large HC, high BW) vs those with parameters <95th centile (normal). Newborns were stratified into 4 subgroups: normal HC/normal BW (reference, n = 22,548, primiparae 5862); normal HC/high BW (n = 817, P = 213); large HC/normal BW (n = 878, P = 265); and large HC/high BW (n = 537, P = 103). Multinomial multivariable regression provided adjusted odds ratio (aOR) while controlling for potential confounders. RESULTS: Infants with HC ≥95th centile (n = 1415) were delivered vaginally in 62% of cases, unplanned cesarean delivery 16%, and instrumental delivery 11.2%; 78.4% of infants with HC <95th centile were delivered vaginally, 7.8% unplanned cesarean, and 6.7% instrumental delivery. Odds ratio (OR) for unplanned cesarean was 2.58 (95% confidence interval [CI], 2.22-3.01) and for instrumental delivery OR was 2.13 (95% CI, 1.78-2.54). In contrast, in those with BW ≥95th centile (n = 1354) 80.3% delivered vaginally, 10.2% by unplanned cesarean (OR, 1.2; 95% CI, 1.01-1.44), and 3.4% instrumental delivery (OR, 0.46; 95% CI, 0.34-0.62) compared to infants with BW <95th centile: spontaneous vaginal delivery, 77.3%, unplanned cesarean 8.2%, instrumental 7.1%. Multinomial regression with normal HC/normal BW as reference group showed large HC/normal BW infants were more likely to be delivered by unplanned cesarean (aOR, 3.08; 95% CI, 2.52-3.75) and instrumental delivery (aOR, 3.03; 95% CI, 2.46-3.75). Associations were strengthened in primiparae. Normal HC/high BW was not associated with unplanned cesarean (aOR, 1.18; 95% CI, 0.91-1.54), while large HC/high BW was (aOR, 1.93; 95% CI, 1.47-2.52). Analysis of unplanned cesarean indications showed large HC infants had more failure to progress (27.7% vs 14.1%, P < .001), while smaller HC infants had more fetal distress (23.4% vs 16.9%, P < .05). CONCLUSION: A large HC is more strongly associated with unplanned cesarean and instrumental delivery than high BW. Prospective studies are needed to test fetal HC as a predictive parameter for prelabor counseling of women with "big babies."

Induction of labor at term following external cephalic version in nulliparous women is associated with an increased risk of cesarean delivery.

PURPOSE: To determine whether induction of labor (IOL) after successful external cephalic version (ECV) is associated with an increased risk of cesarean delivery (CD) compared with IOL with spontaneous cephalic presentation. METHODS: Retrospective case-control study. All women having IOL after successful ECV were eligible. Each woman in the study group was matched for parity, age and indication for induction with two consecutive controls having IOL and spontaneous cephalic presentation. The primary outcome measure was CD. Secondary outcomes measures were operative vaginal delivery, perineal tear/episiotomy and post-partum hemorrhage. RESULTS: 79 women enrolled in the study group were matched with 158 controls. The overall incidence of CD was significantly higher in the study group compared with the control group (20.3 vs. 10.1 %; OR 2.25, 95 % CI 1.06-4.79, P = 0.03). After dividing the groups according to parity, the difference in the CD rate remained statistically significant for nulliparous women (36.7 vs. 15 %; OR 3.28, 95 % CI 1.17-9.16, P = 0.02), but not for multiparous women (10.2 vs. 7.1 %; OR 1.48, 95 % CI 0.44-4.92, P = 0.53). There was no significant difference in adjusted odds ratios for secondary outcomes. CONCLUSION: Induction of labor after successful ECV in nulliparous women increased the risk of CD compared with IOL with spontaneous cephalic presentation.

The association of maternal intrapartum subfebrile temperature and adverse obstetric and neonatal outcomes.

BACKGROUND: Subfebrile intrapartum maternal temperature is very common, yet there is sparse evidence regarding its causes or its effects on perinatal outcomes. We examined whether mild temperature elevation during labour is a risk marker for adverse obstetric and neonatal outcomes. METHODS: A retrospective cohort analysis including 42 601 term, singleton live-births in two medical centres between 2003 and 2010 was performed. This study compared women who experienced a maximal intrapartum temperature of ≤37°C with women who experienced subfebrile intrapartum temperature (37.1-37.9°C). Adjusted risks for adverse obstetric and neonatal outcomes were calculated by using multivariable logistic regression models. RESULTS: Compared with maternal temperature ≤ 37°C, subfebrile temperature was associated with higher rates of primary caesarean deliveries {adjusted odds ratios [aOR] = 1.36 [95% confidence interval (CI) 1.25, 1.49])} and assisted vaginal deliveries (aOR = 1.20 [95% CI 1.11, 1.30]), as well as with greater risks of early neonatal sepsis (aOR = 2.66 [95% CI 1.88, 3.77]), neonatal intensive care unit admissions (aOR = 1.40 [95% CI 1.08, 1.83]), and neonatal asphyxia or seizures (aOR = 3.18 [95% CI 1.51, 6.70]). Mildly elevated maternal intrapartum temperature (37.1-37.5°C) was also associated with adverse outcomes. CONCLUSIONS: Maternal intrapartum subfebrile temperature may be an indicator of operative delivery and neonatal morbidity. Further research is needed to confirm these findings and to reveal underlying mechanisms.

Membrane stripping in group B streptococcus carriers does not impede adequate intrapartum antibiotic prophylaxis: a retrospective study.

Objective: Membrane stripping in group B streptococcus (GBS) carriers poses an increased risk of inadequate antibiotic prophylaxis, potentially due to accelerated labor, thereby potentially impacting the management of GBS colonization during delivery. We compared the adequacy of intrapartum antibiotic prophylaxis between pregnant women colonized with GBS, who underwent membrane stripping and those who did not. The study aimed to determine whether the performance of membrane stripping, by potentially shortening labor duration, increases the risk of inadequate antibiotic prophylaxis dispensation. Study design: A retrospective cohort study was conducted on GBS screen-positive women with a full-term singleton pregnancy in cephalic presentation, who were eligible for vaginal delivery. The exposed group consisted of women who underwent membrane stripping, while the unexposed group consisted of women who did not undergo membrane stripping. The primary outcome was defined as inadequate duration of antibiotic prophylaxis during labor, wherein less than 4 h of beta-lactam antibiotics were administered prior to delivery. Neonatal outcome was compared between the groups. Results: This retrospective cohort study comprised 1,609 women, with 129 in the exposed group (stripping group) and 1,480 in the unexposed group (no stripping group). Adequate intrapartum antibiotic prophylaxis was received by 64.3% (83/129) of the exposed group, compared to 46.9% (694/1,480) of the unexposed group (p = 0.003). Membrane stripping was associated with increased odds of receiving adequate prophylaxis (OR 1.897, 95% CI 1.185-3.037, p = 0.008). After excluding women who presented to the labor ward in active labor and delivered in less than 4 h, both the exposed and unexposed groups had similarly high rates of adequate intrapartum antibiotic prophylaxis (87.5% vs. 85.8%, respectively). No significant difference was observed in adverse neonatal outcomes between the groups. Conclusion: The provision of membrane stripping did not impede adequate intrapartum antibiotic prophylaxis and was correlated with a higher rate of sufficient prophylaxis in comparison to non-swept patients. These observations suggest that membrane stripping can be considered a safe option for ensuring adequate antibiotic prophylaxis in women colonized with GBS.

Brillouin optical spectrum analyzer monitoring of subcarrier-multiplexed fiber-optic signals.

Optical spectral analysis of closely spaced, subcarrier multiplexed fiber-optic transmission is performed, based on stimulated Brillouin scattering (SBS). The Brillouin gain window of a single, continuous-wave pump is scanned across the spectral extent of the signal under test. The polarization pulling effect associated with SBS is employed to improve the rejection ratio of the analysis by an order of magnitude. Ten tones, spaced by only 10 MHz and each carrying random-sequence on-off keying data, are clearly resolved. The measurement identifies the absence of a single subcarrier, directly in the optical domain. The results are applicable to the monitoring of optical orthogonal frequency domain multiplexing and radio over fiber transmission.

Impact of full vs empty urinary bladder on external cephalic version success: a randomized controlled trial.

BACKGROUND: External cephalic version is a procedure used to turn a fetus from a breech position to a cephalic position before delivery. The success rate of the external cephalic version can be affected by various factors; however, the effect of bladder volume on the success rate of the external cephalic version remains controversial. OBJECTIVE: This study aimed to determine the effect of urinary bladder status (full or empty) on the success rate of the external cephalic version through a prospective randomized study. STUDY DESIGN: This was a prospective randomized controlled trial conducted at a tertiary care obstetrical center. Overall, 70 women with a singleton breech presentation at term undergoing external cephalic version were randomly allocated into 2 groups: external cephalic version with an empty bladder and external cephalic version with a full bladder. The external cephalic version procedure was performed by experienced obstetricians under ultrasound guidance. The primary outcome was the success rate of the external cephalic version. RESULTS: The success rate of the external cephalic version was 67.56% (25/37) in the full bladder group and 54.54% (18/33) in the empty bladder group, with no statistically significant difference between the groups (P=.26). In addition, the relative risk of successful external cephalic version was 1.23 (95% confidence interval, 0.84-1.81), indicating no significant difference. CONCLUSION: This randomized controlled trial demonstrated that the presence of a full or empty urinary bladder does not significantly affect the success rate of the external cephalic version in women with singleton breech presentation at term. Our findings suggest that women undergoing an external cephalic version do not need to have a full bladder to improve the success rate of the procedure.

The effectiveness of vaginal progesterone in reducing preterm birth in high-risk patients diagnosed with short cervical length after 24 weeks: A retrospective cohort study.

Objective: To assess the impact of progesterone treatment on maternal and neonatal outcomes in women with a history of preterm birth and short cervical length diagnosed after 24 weeks of gestation. Methods: A retrospective cohort study included women with a history of preterm birth and a transvaginal sonographic cervical length measurement of ≤ 25 mm, diagnosed between 24+0 and 33+6 weeks of gestation. Exclusion criteria included prior progesterone treatment, cervical cerclage, or pessary. The study population was divided into the progesterone treatment group and the non-treatment group. Results: The study included 104 women, with 46.2% (48/104) receiving progesterone treatment and 53.8% (56/104) not receiving treatment. The rate of spontaneous preterm birth before 37 weeks of gestation was 43% (24/56) in the non-treatment group and 31% (15/48) in the progesterone treatment group (P = 0.14); the rate of spontaneous preterm birth before 34 weeks was 7% (4/56) in the non-treatment group and 0% (0/48) in the progesterone treatment group (P = 0.05). Progesterone treatment was associated with a significant decrease in neonatal intensive care unit admissions (OR 0.20, 95% CI 0.05-0.74) and in the neonatal hospitalization period (mean difference in days 2.43, 95% CI 0.44-4.42). The risk of recurrent spontaneous preterm birth was highest (71%) among women with two or more previous preterm deliveries who did not receive progesterone treatment, and lowest (24%) among women with one previous preterm delivery who received progesterone treatment. Conclusion: Progesterone treatment was associated with a reduction in rates of spontaneous preterm birth before 34 weeks of gestation, neonatal intensive care unit admission, and neonatal length of stay in high-risk patients, even when initiated after 24 weeks of gestation.

The continuum of a prolonged labor and a second stage cesarean delivery.

OBJECTIVE: To investigate the association of the timing of primary cesarean delivery with the progress of labor and the operative delivery rate at the subsequent successful trial of labor. METHODS: A retrospective study of women with a primary cesarean and subsequent term cephalic vaginal delivery in two medical centers. Cesarean deliveries were classified as planned, intrapartum first stage or intrapartum second stage. The second stage duration and the operative delivery rate, adjusted to epidural analgesia and oxytocin use, were compared between the groups. χ2 and Kruskal-Wallis tests were used for analysis of categorical and continuous variables, respectively. RESULTS: The study population included 1166 women. The second stage of labor was longer when the previous cesarean delivery occurred during the second stage compared to planned or first stage (1.7 h vs 1.3 h vs 1.3 h, p = 0.005). The proportion of operative deliveries was greater among women with previous cesarean in the second stage of labor (39.6%), compared to planned (26.9%) or first stage (28.8%), p = 0.006. CONCLUSION: Cesarean delivery at the second stage of labor is associated with a longer second stage and an increased operative delivery rate at the subsequent vaginal birth. Our findings attest to the delicate passenger-passage relations that can exist in some parent-couples.

Long-term gynecological complications after conservative treatment of placenta accreta spectrum.

Objective: To examine the association between conservative treatment for PAS (placenta accreta spectrum) and subsequent gynecological and fertility complications. Methods: All women who underwent conservative treatment for PAS between January 1990 and December 2000 were included in this retrospective cohort study conducted in a tertiary teaching hospital. Gynecological and fertility complications experienced after the index delivery were collected from the medical records and telephone questionnaires. This data was compared to an age and parity-matched control group of women without PAS. Results: The study group included 134 women with PAS managed conservatively and 134 controls with normal deliveries matched by parity and age. Women in the PAS group required significantly more postpartum operative procedures such as hysteroscopy or D&C (OR = 6.6; 95%CI: 3.36-13.28; P = <0.001). Following the index delivery, there were 345 pregnancies among 107 women who attempted conception following conservative treatment for PAS vs. 339 pregnancies among 105 women who attempted conception in the control group. Among women who attempted conception following conservative treatment for PAS 99 (92.5%) delivered live newborns (a total of 280 deliveries) vs. 94 (89.5%) in the control group, (a total of 270 live newborns, p = 0.21). The need for fertility treatments was not different between the two groups (OR = 1.22; 95%CI: 0.51-2.93; P = 0.66). Conclusion: After conservative treatment for PAS, significantly more women required complementary procedures due to retained placenta and/or heavy vaginal bleeding. There was no evidence of fertility impairment in women post-conservative treatment for PAS.

Case report: An unusual presentation of puerperal sepsis.

Group A Streptococcus (GAS; Streptococcus pyogenes) is a facultative gram-positive coccus, uncommonly colonizing parturient genitalia, where its presence can potentially lead to a life-threatening invasive infection after delivery. GAS infection typically occurs within the first 4 days post-partum and is characterized by high fever, chills, flashing, abdominal pain, and uterine tenderness. Nonetheless, patients with GAS puerperal sepsis may have an unusual presentation, when fever is absent, and the symptoms and signs can be mild, non-specific, and not indicative of the severity of infection. This unusual presentation may lead to a delayed diagnosis and increase the risk for severe puerperal sepsis. Therefore, in these cases, a high index of suspicion and prompt early antibiotic and surgical treatment is crucial to saving the parturient's life.

Cesarean delivery on maternal request in Israel: Maternity department policies and obstetricians' perspectives.

OBJECTIVE: This study aimed to describe Israeli maternity departments' policies regarding cesarean delivery on maternal request, and factors associated with obstetricians' support for cesarean delivery on maternal request in specific scenarios. METHODS: This multicenter cross-sectional study included 22 maternity department directors and 222 obstetricians from the majority of Israeli hospitals. Directors were interviewed and completed a questionnaire about their department's cesarean delivery on maternal request policy, and obstetricians responded to a survey presenting case scenarios in which women requested cesarean delivery on maternal request. The scenarios represented profiles referring to the following factors: maternal age, poor obstetric history, pregnancy complications, and psychological problems. The survey also included the obstetricians' socio-demographic information and questions about other issues associated with cesarean delivery on maternal request. The main outcome measures were department policies regarding cesarean delivery on maternal request and obstetricians' support for cesarean delivery on maternal request in specific cases. RESULTS: Policies were divided between allowing and prohibiting cesarean delivery on maternal request (n = 10 and 12, respectively), and varied regarding issues such as informed consent and pre-surgery consultation. Most of the obstetricians (96.5%) did not support cesarean delivery on maternal request in the "reference scenario" describing a young woman with no obstetric complications. Additional factors increased the rate of support. Support was greater among obstetricians aged > 45 (odds ratio = 2.11; 95% confidence intervals 1.33-3.36) and lower among females (odds ratio = 0.58; 95% confidence intervals 0.39-0.86). Obstetricians whose department policy was less likely to allow cesarean delivery on maternal request reported lower rates of support for cesarean delivery on maternal request in most cases. CONCLUSION: Policies and obstetricians' support for cesarean delivery on maternal request vary broadly depending on clinical profiles and physician characteristics. Department policy has an impact on obstetricians' support for cesarean delivery on maternal request. Health policy will benefit from a framework in which the organizations, physicians, and patients are consulted.

Factors associated with postcesarean blood transfusion: a case control study.

OBJECTIVE: Cesarean delivery (CD) is a known risk factor for postpartum hemorrhage. However, the characteristics associated with post-CD transfusion are not well-established. We aimed to assess blood transfusion rates and associated factors following CD. METHODS: A retrospective case-control study of women who underwent CD at a university hospital. The study group comprised all women who received blood transfusion following surgery. A control group of women who did not receive postoperative blood transfusion was assigned in a two-to-one ratio. RESULTS: During study period, the overall post-CD blood transfusion rate was 4.7%. The study group comprised 170 women, and the control group 340. Maternal age (aOR [95% CI]: 1.07 (1.03, 1.11), p = .001), parity (aOR [95% CI]: 1.26 (1.09, 1.47), p = .002), gestational hypertensive disorders (aOR [95% CI]: 4.07 (1.52, 10.91), p = .005), maternal comorbidities (aOR [95% CI]: 4.16 (1.88, 9.1), p < .001), lower predelivery hemoglobin level (aOR [95% CI]: 0.43 (0.34, 0.54), p < .001), and major placental abnormalities (aOR [95% CI]: 2.74 (1.04, 7.18), p = .04) were independently associated with blood transfusion requirement. Intrapartum characteristics associated with blood transfusion requirement included nonelective procedure (aOR [95% CI]: 3.21 (1.72, 5.99), p < .001), prolonged second stage of labor (aOR [95% CI]: 5.50 (2.57, 11.78), p < .001), longer duration of surgery (aOR [95% CI]: 1.03 (1.02, 1.04), p < .001), general anesthesia (aOR [95% CI]: 2.11 (1.14, 3.91), p = .02), and greater estimated operative blood loss (aOR [95% CI]: 5.72 (3.15, 10.36), p < .001). CONCLUSIONS: Among women who underwent CD, we identified 11 factors associated with blood transfusion following surgery. Prospective studies are warranted to assess the implementations of prophylactic interventions to reduce transfusion rates among those deemed at high risk for CD-related bleeding.

[Trial of labor after two cesarean sections: the policy in Israel and four years experience].

INTRODUCTION: Trial of vaginal birth after caesarean is considered acceptable after one caesarean section. However, trial of vaginal birth after more than one caesarean section is still unaccepted by most clinicians. Birth rates in Israel are within the highest in the western world and many women are interested in a trial of labor after two previous caesarean sections. Therefore, it is crucial to establish evidence based guidelines for this issue. OBJECTIVE: To perform a systematic review of literature on success rate of vaginal birth after two caesarean sections and to present our experience in trial of labor after two caesarean sections. METHODS: We searched MEDLINE, using search terms "Caesarean section", "caesarian", "C*rean", "C*rian", "Vaginal birth after caesarean section", "Trial of labor". RESULTS: The literature revealed a success rate of 60-80%. The main complication is rupture of the uterus and its rate is 0-3%. During the years 2006-2009, 67 trials of labor after two caesarean sections were performed in our medical center. Our success rate is 88%. There were no cases of rupture of the uterus. CONCLUSION: A trial of labor after two caesarean sections is possible for carefully selected women and when appropriate medical resources are available.

Nifedipine versus ritodrine during external cephalic version procedure: a case control study.

OBJECTIVE: Published series regarding interventions for facilitating external cephalic version (ECV) have concluded that parenterally administered beta-stimulant tocolytics, increased ECV success rate and reduced the number of cesarean sections. However, there were insufficient data regarding calcium channel blockers to provide good evidence regarding its efficacy. Given the paucity of literature, we aimed to compare the efficacy of nifedipine to that of ritodrine on ECV success rates. METHODS: This is a retrospective case control study of prospectively collected data of patients who underwent ECV between January 2012 and December 2013 at Bikur Cholim Medical Center and Hadassah-Hebrew University Medical Center in Jerusalem, Israel. Patient undergoing ECV with tocolysis by ritodrine were compared with those using nifedipine as tocolysis. Patients were matched in a one-to-one ration by parity and placental location. RESULTS: Overall, 148 women received ritodrine and 148 women received nifedipine before ECV procedure. Overall success rate was higher among the ritodrine group (82.4 vs. 63.5%, p < .001). Among nulliparous and among parous, success rate was higher in the ritodrine group (78.9 vs. 57.9 and 88.6 vs. 73.5%, p = .001, p = .04, respectively). Vaginal delivery rate was higher among the ritodrine group (86.5 vs. 68.9%, p < .001). Cesarean delivery rate was 31.1% for the nifedipine group versus 13.5% in the ritodrine group (p < .001). Number needed to treat to benefit (NNTb) 5.7 (95% confidence interval 3.7-12.1). Overall, 216 of 296 (72.9%) of ECV were successful. Ritodrine was associated with higher success rates as compared with nifedipine (56.5 vs. 32.5%, p < .001). In a multivariate analysis, ritodrine tocolytic therapy was independently associated higher ECV success rates as compared to nifedipine (OR 4.54, 95% CI 2.38-9.09). Higher amniotic fluid index (OR 1.16, 95% CI 1.05-1.28) and nulliparity (OR 0.16, 95% CI 0.08-0.30) were additional independent predictors of ECV outcome. CONCLUSION: Ritodrine significantly improve the success of ECV compared with nifedipine. Both drugs are shown to be safe.

The association between low birth weight and outcomes of vacuum assisted vaginal delivery.

OBJECTIVE: It is often hypothesized that poor neonatal outcomes are more frequently observed in low birth weight (LBW) neonates following vacuum assisted vaginal delivery (VAVD). We sought to assess the association between low birth weight (< 2500 g) and neonatal outcomes, following vacuum extraction. STUDY DESIGN: This was a retrospective cohort study, including 1085 deliveries in a tertiary medical center between 2003 and 2015. Maternal and neonatal outcomes, including birth trauma related complications, were compared between women with singleton pregnancies beyond 34 weeks' gestation and fetal weight < 2500 g who were delivered by vacuum extraction (n=345) and a control group (n=740) with fetal weight ≥ 2500 g, matched in maternal age, parity and gestational week. RESULTS: During the study period, 370 women met the inclusion criteria for the study group, with 25 cases eventually excluded due to missing neonatal birth trauma related data. 740 patients were included in the matched control group. Induction of labor and non-reassuring fetal heart rate as an indication for VAVD were more prevalent in the LBW group. The composite birth trauma related adverse outcome was higher in the control group (9.1 % vs. 4.4 %, p = 0.008), mainly due to increased rate of cephalohematoma in this group (6.8 % vs. 2.9 %, p = 0.01). All other adverse neonatal outcomes rates did not differ between the groups. Women in the control group were more prone to post-partum hemorrhage (p < 0.001), had more episiotomies (p = 0.004) and a higher failed VAVD rate (11.4 % vs. 2.6 %, p < 0.001), leading to emergency cesarean delivery. A sub-group analysis of failed VAVD did not reveal a difference in neonatal complications between the LBW and the control group. CONCLUSION: Neonatal birth trauma and adverse outcomes following vacuum extraction are no more common in neonates weighing less than 2500 g than those with higher birth weights, even in failed vacuum cases.