Second stage duration and delivery outcomes among women laboring after cesarean with no prior vaginal delivery.

BACKGROUND: We aimed to evaluate the association of the duration of the second stage with labor after cesarean (LAC) success and other outcomes among women with one prior cesarean delivery (CD) and no prior vaginal births. METHODS: All women undergoing LAC that reached the second stage of labor from March 2011 to March 2020 were included in this retrospective cohort study. The primary outcome was the mode of delivery by second stage duration. The secondary outcomes included adverse maternal and neonatal outcomes. We allocated the study cohort into five groups of second stage duration. Further analysis compared <3 to ≥3 h of second stage based on prior studies. LAC success rates were compared. Composite maternal outcome was defined as the presence of uterine rupture/dehiscence, postpartum hemorrhage, or intrapartum/postpartum fever. RESULTS: One thousand three hundred ninety seven deliveries were included. Vaginal birth after cesarean (VBAC) rates decreased as the second stage length time interval increased: 96.4% at <1 h, 94.9% at 1 to <2 h, 94.6% at 2 to <3 h, 92.1% at 3 to <4 h and 79.5% at ≥4 h (p < 0.001). Operative vaginal and CDs were significantly more likely as second stage duration time interval increased (p < 0.001). The composite maternal outcome was comparable among groups (p = 0.226). When comparing the outcomes of deliveries at <3 h versus ≥3 h, the composite maternal outcome and neonatal seizure rates were lower in the <3 h group (p = 0.041 and p = 0.047, respectively). CONCLUSION: Vaginal birth after cesarean rates decreased as second stage time interval length increased. Even with prolonged second stage, VBAC rates remained relatively high. Increased risk of composite adverse maternal outcomes and neonatal seizures were observed when the second stage lasted 3 h or more.

Perinatal Outcome following the Suspension of Intrapartum Oxygen Treatment.

OBJECTIVE: This study aimed to evaluate whether the suspension of intrapartum maternal oxygen supplementation for nonreassuring fetal heart rate is associated with adverse perinatal outcomes. STUDY DESIGN: A retrospective cohort study, including all individuals that underwent labor in a single tertiary medical center. On April 16, 2020, the routine use of intrapartum oxygen for category II and III fetal heart rate tracings was suspended. The study group included individuals with singleton pregnancies that underwent labor during the 7 months between April 16, 2020, and November 14, 2020. The control group included individuals that underwent labor during the 7 months before April 16, 2020. Exclusion criteria included elective cesarean section, multifetal pregnancy, fetal death, and maternal oxygen saturation <95% during delivery. The primary outcome was defined as the rate of composite neonatal outcome, consisting of arterial cord pH <7.1, mechanical ventilation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3/4, and neonatal death. The secondary outcome was the rate of cesarean and operative delivery. RESULTS: The study group included 4,932 individuals, compared with 4,906 individuals in the control group. The suspension of intrapartum oxygen treatment was associated with a significant increase in the rate of composite neonatal outcome (187 [3.8%] vs. 120 [2.4%], p < 0.001), including the rate of abnormal cord arterial pH <7.1 (119 [2.4%] vs. 56 [1.1%], p < 0.01). A higher rate of cesarean section due to nonreassuring fetal heart rate was noted in the study group (320 [6.5%] vs. 268 [5.5%], p = 0.03).A logistic regression analysis revealed that the suspension of intrapartum oxygen treatment was independently associated with the composite neonatal outcome (adjusted odds ratio = 1.55 [95% confidence interval, 1.23-1.96]) while adjusting for suspected chorioamnionitis, intrauterine growth restriction, and recent coronavirus disease 2019 exposure. CONCLUSION: Suspension of intrapartum oxygen treatment for nonreassuring fetal heart rate was associated with higher rates of adverse neonatal outcomes and urgent cesarean section due to fetal heart rate. KEY POINTS: · The available data on intrapartum maternal oxygen supplementation are equivocal.. · Suspension of maternal oxygen for nonreassuring fetal heart rate during labor was associated with adverse neonatal outcomes.. · Oxygen treatment might still be important and relevant during labor..

Vaginal Progesterone Is Associated with Intrahepatic Cholestasis of Pregnancy.

OBJECTIVE: The frequency of intrahepatic cholestasis of pregnancy (ICP) peaks during the third trimester of pregnancy when plasma progesterone levels are the highest. Furthermore, twin pregnancies are characterized by higher progesterone levels than singletons and have a higher frequency of cholestasis. Therefore, we hypothesized that exogenous progestogens administered for reducing the risk of spontaneous preterm birth may increase the risk of cholestasis. Utilizing the large IBM MarketScan Commercial Claims and Encounters Database, we investigated the frequency of cholestasis in patients treated with vaginal progesterone or intramuscular 17α-hydroxyprogesterone caproate for the prevention of preterm birth. STUDY DESIGN: We identified 1,776,092 live-born singleton pregnancies between 2010 and 2014. We confirmed second and third trimester administration of progestogens by cross-referencing the dates of progesterone prescriptions with the dates of scheduled pregnancy events such as nuchal translucency scan, fetal anatomy scan, glucose challenge test, and Tdap vaccination. We excluded pregnancies with missing data regarding timing of scheduled pregnancy events or progesterone treatment prescribed only during the first trimester. Cholestasis of pregnancy was identified based on prescriptions for ursodeoxycholic acid. We used multivariable logistic regression to estimate adjusted (for maternal age) odds ratios for cholestasis in patients treated with vaginal progesterone, and in patients treated with 17α-hydroxyprogesterone caproate compared with those not treated with any type of progestogen (the reference group). RESULTS: The final cohort consisted of 870,599 pregnancies. Among patients treated with vaginal progesterone during the second and third trimester, the frequency of cholestasis was significantly higher than the reference group (0.75 vs. 0.23%, adjusted odds ratio [aOR]: 3.16, 95% confidence interval [CI]: 2.23-4.49). In contrast, there was no significant association between 17α-hydroxyprogesterone caproate and cholestasis (0.27%, aOR: 1.12, 95% CI: 0.58-2.16) CONCLUSION: Using a robust dataset, we observed that vaginal progesterone but not intramuscular 17α-hydroxyprogesterone caproate was associated with an increased risk for ICP. KEY POINTS: · Previous studies have been underpowered to detect potential association between progesterone and ICP.. · Vaginal progesterone was significantly associated with ICP.. · Intramuscular 17α-hydroxyprogesterone was not associated with ICP..

Trial of labor after cesarean in women with hypertensive disorders and no prior vaginal delivery.

KEY MESSAGE: Trial of labor among women who never delivered vaginally with hypertensive disorder is associated with nearly half the success rate of the general population. PURPOSE: To study the trial of labor after cesarean (TOLAC) among women with hypertensive disorders and no prior vaginal delivery. METHODS: A retrospective cohort study was conducted including women with no prior vaginal delivery undergoing TOLAC during 2010-2020. Women with hypertensive disorder were compared to those without. RESULTS: A total of 54/2,144 (2.5%) TOLACs had a hypertensive disorder: 32 (59%) had gestational hypertension, 16 (30%) had chronic hypertension and 6 (11%) had preeclampsia. Women with hypertensive disorders had higher BMI and higher proportion of diabetic disorders. TOLAC success rate was lower among hypertensive mothers: 32 (59%) vs. 1,605 (76.8%), p=0.003 odds ratio (OR), 95% confidence interval (CI) 0.44 (0.25-0.76). The rate of uterine rupture was 23/2,144 (1.1%). In a multivariable logistic regression analysis, hypertensive disorder was independently negatively associated with TOLAC success, adjusted OR (95% CI) 0.47 (0.26-0.85). Other factors negatively independently associated with TOLAC failure were maternal age, predelivery body mass index, dystocia at primary CD, gestational age at TOLAC, induction of labor and birth weight. Epidural was independently positively associated with TOLAC success, adjusted OR (95% CI) 1.54 (1.18-1.99). CONCLUSION: TOLAC in hypertensive women with no prior vaginal delivery is safe. Success rate is impaired in comparison to non-hypertensive women.

Predictors of successful vaginal birth after cesarean without an epidural among women with no prior vaginal delivery.

BACKGROUND: Data are scarce on predictors for success of labor after cesarean (LAC) among women delivering without epidural anesthesia (EA). We aimed to study the predictors for success of LAC among women with no prior vaginal delivery that did not use EA. METHODS: A retrospective study including all women undergoing LAC between 3/2011 and 1/2021 with no prior vaginal delivery that did not use EA. Factors associated with successful vaginal birth after cesarean were examined using multivariable analysis. RESULTS: Of the 466 no EA LAC, 339 (72.7%) delivered vaginally. Women in the successful LAC group had lower pregestational and predelivery BMI as compared to those who had a repeat cesarean [odds ratio (OR) 95% confidence interval (CI) 0.90 (0.85-0.94), P < 0.001, and 0.89 (0.85-0.93), P < 0.001, respectively]. The rate of labor dystocia in previous cesarean was lower in the LAC success group [92 (27.1%) vs 50 (39.4%), OR 95% CI 0.57 (0.37-0.88)]. Mean gestational age at LAC was lower in the LAC success group (385/7  ± 25/7 vs 395/7  ± 15/7 , P = 0.014). In a multivariable logistic regression analysis, the following factors were negatively and independently associated with LAC success: higher predelivery BMI [adjusted odds ratio (aOR) 95% CI 0.90 (0.86-0.95)], higher gestational age at previous cesarean and at LAC [aOR 95% CI 0.81 (0.70-0.93) and 0.97 (0.94-0.98), respectively], induction of labor [aOR 95% CI 0.08 (0.03-0.25)], and duration of ruptured membranes [aOR 95% CI 0.97 (0.96-0.99)]. CONCLUSIONS: We have identified that lower BMI, lower gestational age, shorter ruptured membranes duration, and spontaneous labor are associated with successful LAC among nonusers of EA with no prior vaginal delivery at one tertiary care facility in Israel.

Transplantation of small ovarian tissue fragments using pipelle device is effective: method evaluation and reproductive outcomes.

PURPOSE: To assess the feasibility, effectiveness, and reproductive outcomes of transplantation of tiny cryopreserved ovarian pieces through a pipelle cannula during laparoscopic surgery. METHODS: A retrospective study of patients who underwent ovarian tissue transplantation for fertility restoration between 2004 and 2022. The "pipelle group" had their ovarian cortex cut into tiny pieces of ~ 1-2 mm3 before cryopreservation. The pieces were too small to be handled and transplanted via standard laparoscopic tools. Transplantation was performed using a pipelle cannula during laparoscopic surgery. The "control group" underwent transplants of ovarian cortex pieces 1-2 mm thick, measuring approximately 25-50 mm2 pieces, using standard procedures. RESULTS: The pipelle group consisted of 4 patients aged 19, 21, 27, and 28 years old at ovarian tissue cryopreservation (OTC). The control group consisted of 14 patients aged 21-30 years old. All pipelle patients restored their endocrine activity, and all of them conceived. FSH levels dropped during the first 3 months following the pipelle transplant. IVF cycle outcomes were similar for both groups. All patients from the pipelle group conceived, resulting in 5 pregnancies and 4 live births (one patient had 2 deliveries, and one additional pregnancy is ongoing), compared to the control group, where 8 patients achieved a total of 20 pregnancies and 18 live births. CONCLUSION: Pipelle transplantation for tiny cryopreserved ovarian pieces is feasible and effective. This study opens a door for patients who had their ovaries cut into small pieces and may even simplify the procedure in some instances, making ovarian transplant more accessible. TRIAL REGISTRATION: (#6531-19-SMC) [18/09/2019].

Sonographic fetal head circumference is associated with trial of labor after cesarean section success.

PURPOSE: The purpose is to study the association of the fetal sonographic head circumference (SHC) with trial of labor after cesarean (TOLAC) success rate, among women with no prior vaginal deliveries. METHODS: A retrospective case-control study including all women with no prior vaginal delivery undergoing TOLAC during 3/2011-6/2020 with a sonographic estimated fetal weight within one week from delivery. TOLAC success and failure groups were compared. RESULTS: Of 1232 included women, 948 (76.9%) delivered vaginally. The mean fetal SHC was smaller in the TOLAC success group (330 ± 10 vs. 333 ± 11 mm, p < 0.001). In a multivariate regression analysis, predelivery BMI, hypertensive disorders, gestational age at prior CD, SHC and epidural analgesia administration were independently associated with TOLAC success. A ROC analysis of the multivariable model composed of the factors found independently associated with TOLAC success, excluding SHC, yielded an area under curve of 0.659 (95% CI 0.622-0.697) compared with 0.668 (95% CI 0.630-0.705) with SHC included. CONCLUSION: Smaller SHC is independently associated with TOLAC success among women that did not deliver vaginally before, and has additive clinical value for the prediction of TOLAC success when combined with non-sonographic factors.

Prediction of successful trial of labor after cesarean among grand-multiparous women.

PURPOSE: To determine the factors associated with successful trial of labor after cesarean (TOLAC) among grand-multiparous (GMP) women. METHODS: A retrospective cohort study was conducted, including all GMP women (≥ 5 deliveries) undergoing TOLAC during 3/2011 and 6/2020, delivering a singleton cephalic newborn. Factors associated with successful vaginal delivery were examined by multivariable analysis. RESULTS: Overall, 381/413 (92.2%) GMP succeeded TOLAC. Maternal characteristics did not differ between TOLAC success and TOLAC failure groups. Previous cesarean delivery characteristics did not differ between study groups. The median number of previous vaginal births after cesarean was 2 [interquartile range 1-4]. Gestational age at TOLAC was lower in the success group (mean 371/7 ± 36/7 vs. 385/7 ± 31/7 weeks, p = 0.028). A lower rate of modified Bishop score < 4 was associated with TOLAC success [149 (39.1%) vs. 22 (69%), odds ratio (OR) 95% confidence interval (CI) 0.29 (0.13-0.64), p = 0.001]. The rate of induction of labor was higher in the TOLAC failure group [120 (31.5%) vs. 17 (53%), OR 95% CI 0.40 (0.19-0.83), p = 0.013]. The rate of oxytocin administration was higher in the TOLAC failure group [94 (24.7%) vs. 15 (47%) OR (95% CI) 0.37 (0.17-0.77), p = 0.006]. The duration of rupture of membranes was negatively associated with TOLAC success. Neonatal and maternal adverse outcomes did not differ between study groups. In multivariable logistic regression analysis, only the duration of rupture of membranes and modified Bishop score < 4 were independently associated with TOLAC success [adjusted OR (95% CI) 0.98 (0.96-0.99), p = 0.027 and 0.40 (0.16-0.97), p = 0.044]. CONCLUSION: TOLAC among GMP has a very-high success rate. Shortening the duration of ruptured membranes is a modifiable factor that may be associated with increased TOLAC success rates.

Dynamic esophageal patency assessment: an effective method for prenatally diagnosing esophageal atresia.

BACKGROUND: Esophageal atresia is a major anomaly with a low prenatal detection rate. We propose a sonographic method termed dynamic esophageal patency assessment. OBJECTIVE: This study aimed to assess the feasibility and performance of the dynamic esophageal patency assessment in a high-risk population. STUDY DESIGN: A prospective study was conducted in a single tertiary fetal ultrasound unit for 12 months. The study group included pregnant women referred for a targeted scan because of one or more of the following: (1) polyhydramnios; (2) small or absent stomach; (3) vertebral, anal atresia, cardiac, tracheoesophageal fistula, renal, and limb abnormalities; (4) first-degree relative with esophageal atresia; and (5) genetic mutation associated with esophageal atresia. In addition to dynamic esophageal patency assessment, a comprehensive anomaly scan was carried out. The fetal esophagus was observed during swallowing. Cases that demonstrated uninterrupted fluid propagation through the esophagus were classified as normal. Cases that demonstrated interrupted fluid propagation, with the formation of a pouch, were classified as abnormal. Cases with unclear visualization of the esophagus or cases that failed to demonstrate either fluid propagation or a pouch were classified as undetermined. Dynamic esophageal patency assessment results were compared with postnatal findings, considered "gold standard." Test performance indices and intra- and interobserver agreements were calculated. RESULTS: For 12 months, 130 patients were recruited, and 132 fetuses were scanned. The median gestational age (interquartile range) at the time of scan was 31.4 weeks (29.0-35.3). Of 132 fetuses enrolled, 123 (93.2%) were normal, 8 (6%) were abnormal, and 1 (0.8%) was undetermined. Excluded from test performance analysis were 3 cases that were terminated without postmortem autopsy (1 was abnormal and 2 were normal), and a fourth case was excluded as it was classified as undetermined. The detection rate of esophageal atresia was 100%, with no false-positive or false-negative case. Sensitivity, specificity, and positive and negative predictive values of the dynamic esophageal patency assessment were 100%. The Kappa coefficient was 1 for both inter- and intraobserver agreements (P<.0001). The median time (interquartile range) required to complete the dynamic esophageal patency assessment was 6.00 minutes (3.00-13.25). CONCLUSION: The dynamic esophageal patency assessment is a feasible and highly effective method of ascertaining an intact esophagus and detecting esophageal atresia in suspected cases.

Risk of anal sphincter injury in trial of labor post cesarean section.

INTRODUCTION: We wanted to evaluate whether secundiparas who achieved vaginal birth after cesarean (VBAC) were at an increased risk for obstetric anal sphincter injury (OASI) compared to primiparas who delivered vaginally, with a stratification by the mode of delivery-spontaneous or operative vaginal delivery. MATERIAL AND METHODS: We conducted a retrospective cohort study of primiparous women who delivered by vacuum-assisted delivery between March 2011 and June 2019. Primiparas delivering vaginally and secundiparas undergoing VBAC were compared. The cohort was further stratified into two categories: spontaneous vaginal delivery and operative vaginal delivery. RESULTS: Overall, 23 822 primiparas who delivered vaginally and 1596 secundiparas who underwent VBAC were analyzed. Operative vaginal delivery was performed in 4561 deliveries. OASI rate did not differ between the VBAC and primipara groups (1.3% vs 1.8%, P = .142). A total of 20 857 women delivered by spontaneous vaginal delivery, among them 1180 (5.7%) women were secundiparas and 19 677 (94.3%) were primiparas. OASI rate was comparable between the secundiparas undergoing VBAC and primiparas delivering vaginally (17 [1.4%] vs 338 [1.7%], P = .436). A total of 4561 women delivered by operative vaginal delivery, among them 416 (9.1%) were secundiparas and 4145 (90.9%) were primiparas. The rate of operative vaginal deliveries was higher among the VBAC group compared with the primipara group (6.1% vs 17.4%, P < .001). However, women undergoing successful VBAC had lower rates of OASI compared with primiparas (3 [0.7%] vs 96 [2.3%]; odds ratio [OR] 0.30, 95% CI 0.09-0.97, P = .032). After multivariate logistic regression including all statistically significant factors, OASI was not associated with VBAC in spontaneous or operative vaginal deliveries (adjusted OR 0.85, 95% CI 0.51-1.40 and 0.39, 95% CI 0.12-1.28, respectively). CONCLUSIONS: Secundiparas undergoing VBAC were not at a higher risk of OASI when compared with primiparas delivering vaginally, either in spontaneous or operative vaginal deliveries. This information might aid when counseling women contemplating a trial of labor after cesarean--to address their concerns regarding the risks and benefits of VBAC.

Pregnancy and neonatal outcomes of twin pregnancies - the role of maternal age.

OBJECTIVES: We aim to study the association of maternal age with maternal and neonatal complications in twin pregnancies. METHODS: A retrospective cohort study of dichorionic-diamniotic twin pregnancies stratified into three groups according to maternal age ("A" <25, "B" 25-34 and "C" 35-44 years old). Outcome measures included pregnancy, delivery and neonatal complications. A sub-analysis of in vitro fertilization pregnancies only was conducted. RESULTS: Compared with younger women (groups A [n=65] and B [n=783]), older women [group C (n=392)] demonstrated significantly higher rates of gestational diabetes mellitus (B 6.6% vs. A 0%, p =0.027, C 10.2% vs. B 6.6%, p =0.032), were more likely to undergo cesarean deliveries (C 66.6%, B 57.6%, A 52.3%, p =0.007), and were at increased risk of having more than 20% difference in weight between the twins (C 24.5%, B 17.4%, A 16.9%, p =0.013). Other outcomes, including preeclampsia, did not differ between the groups. A sub-analysis of the in vitro fertilization only pregnancies was performed. Compared with younger women (groups A [n=18] and B [n=388]), older women (group C [n=230]) underwent more cesarean deliveries (p=0.004), and had more than 20% difference in weight between the twins (p<0.004). Other outcomes, including gestational diabetes mellitus rates and preeclampsia, did not differ between the groups. CONCLUSIONS: Women at advanced maternal age with dichorionic twin pregnancies had significantly higher rates of gestational diabetes mellitus, cesarean deliveries and fetal weight discordancy as compared with younger women. In contrast, the incidence of preeclampsia was not affected by maternal age.

The association of vacuum-assisted delivery and shoulder dystocia among macrosomic newborns: a retrospective study.

PURPOSE: Although shoulder dystocia (ShD) is associated with fetal macrosomia and vacuum-assisted delivery (VAD), the independent role of the latter in the occurrence of ShD is yet to be completely elucidated, as it is difficult to study its true independent contribution to ShD formation in the presence of many confounding factors. Therefore, we aimed to study whether VAD is independently associated with an increased risk for ShD among macrosomic newborns. METHODS: A retrospective cohort study from a single tertiary medical center including all women who delivered vaginally a macrosomic infant during 2011-2020. We allocated the study cohort into two groups: (1) VAD (2) spontaneous vaginal deliverys, and analyzed risk factors for ShD. A multivariate regression analysis was performed to identify determinants independently associated with ShD occurrence. RESULTS: Of 2,664 deliveries who met the study inclusion criteria, 118 (4.4%) were VAD. The rate of ShD in the entire cohort was 108/2664 (4.1%). The following factors were more frequent among the VAD group: no previous vaginal delivery [odds ratio (OR) 2.4 (95% confidence interval (CI) 1.4-4.0, p < 0.001)], prolonged second stage (OR 11.9; 95% CI 8.1-17.6, p < 0.01), induction of labor (OR 2.4; 95% CI 1.5-3.8, p < 0.01) and ShD (OR 2.0; 95% CI 1.0-4.1, p = 0.04). ShD was associated with higher rates of maternal height < 160 cm (OR 2.0; 95% CI 1.3-3.1, p < 0.01), pregestational diabetes (OR 7.2; 95% CI 2.0-26.8, p = 0.01), hypertensive disorder (OR 2.6; 95% CI 1.1-6.2, p = 0.02) and higher birthweight (mean 4,124 vs. 4,167 g, p < 0.01). On multivariate regression analysis, the following factors remained independently associated with ShD occurrence: increased birthweight (aOR 1.0; 95% CI 1.0-1.0, p < 0.01), pregestational diabetes (aOR 5.3; 95% CI 1.1-25.0, p = 0.03), while maternal height was negatively associated with ShD (aOR 0.9; 95% CI 0.9-0.9, p < 0.01). CONCLUSION: In deliveries of neonates above 4000 g, VAD did not independently increase the risk of ShD occurrence. Therefore, when expeditious delivery of a macrosomic infant is required, VAD is a viable option.

Chorioamnionitis at latent phase more than doubles the risk for cesarean delivery compared to chorioamnionitis at active phase.

PURPOSE: Chorioamnionitis, or intraamniotic infection, is a common condition, carrying an increased risk of intrapartum cesarean delivery (CD). The morbidity related to chorioamnionitis is more common in those undergoing CD, as compared to those with successful vaginal delivery. We aimed to examine the risk factors associated with CD among women with chorioamnionitis. METHODS: A retrospective cohort study from a tertiary medical center. We included women at term carrying a singleton gestation with suspected chorioamnionitis undergoing a trial of labor between 2011 and 2019. The primary outcome was the mode of delivery. RESULTS: Data from 1436 women with chorioamnionitis were analyzed; 1288 (89.7%) were nulliparous. Overall, 1064 (74.1%) delivered vaginally, and 372 (25.9%) by CD. The rate of CD was significantly higher in nulliparous as compared to parous parturients (26.9% vs. 16.9%, P = 0.008), and in those with fever onset at latent phase as compared to those in whom fever appeared at active labor (≥ 6 cm) (47.0% vs. 18.1%, P < 0.001). In a multivariate analysis, CD was positively associated with: onset of fever at latent phase (aOR [95% CI] 4.75 (3.54, 6.32), P < 0.001), nulliparity (aOR [95% CI] 3.25 (1.98, 5.34), P < 0.001), maternal age (aOR [95% CI] 1.52 (1.10, 2.09), P = 0.01) and birth weight (aOR [95% CI] 1.23 (1.04, 1.44), P = 0.01). CONCLUSION: Women with chorioamnionitis had a high rate of CD. Nulliparity and onset of fever prior to active labor were the strongest independent predictors of CD. It remains to be determined whether those deemed at high risk for failed trial of labor, should undergo CD earlier in the course of labor to improve chorioamnionitis-related outcomes.

Risk factors for obstetric anal sphincter injury among parous women.

PURPOSE: Nulliparity and operative vaginal delivery are established risk factor for obstetric anal sphincter injury (OASI). However, risk factors for OASIS occurrence among parous women delivering vaginally are not well-established. We aimed to study the risk factors for OASI occurrence among parous women. METHODS: A retrospective study including all parous women who delivered vaginally at term during 2011-2019 at a university hospital. Deliveries of parous women with OASI were compared to deliveries without OASI. The risk factors associated with OASI were investigated. RESULTS: Overall, 35,397 women were included in the study with an OASI rate of 0.4% (n = 144). A higher rate of only one previous vaginal delivery was noted in the OASI group (78.5% vs. 46.4%, OR [95% CI] 4.20, 2.82-6.25, p < 0.001). The rate of vacuum-assisted deliveries was comparable between the study groups. The median birth weight was higher among the OASI group (3566 vs. 3300 g, p < 0.001), as was the rate of macrosomic neonates (19.4% vs. 5.5%, OR [95% CI] 4.15, 2.74-6.29, p < 0.001). On multivariate logistic regression analysis, only two factors were independently positively associated with the occurrence of OASI: a history of only one previous vaginal delivery (adjusted OR [95% CI] 4.34, 2.90-6.49, p = 0.001), and neonatal birth-weight (for each 500 g increment) (adjusted OR [95% CI] 2.51, 1.84-3.44, p < 0.001). CONCLUSIONS: Among parous women, the only factors found to be independently positively associated with OASI were the order of parity and neonatal birth-weight. Vacuum-assisted delivery was not associated with an increased risk of OASI among parous women.

Vaginal delivery in SARS-CoV-2-infected pregnant women in Israel: a multicenter prospective analysis.

KEY MESSAGE: Among SARS-CoV-2-infected mothers, vaginal delivery rates were high and associated with favorable outcomes with no cases of neonatal COVID-19. PURPOSE: To investigate the mode of delivery and its impact on immediate neonatal outcome in SARS-CoV-2-infected women. METHODS: A prospective study following pregnant women diagnosed with COVID-19 who delivered between March 15th and July 4th in seven university affiliated hospitals in Israel. RESULTS: A total of 52 women with a confirmed diagnosis of COVID-19 delivered in the participating centers during the study period. The median gestational age at the time of delivery was 38 weeks, with 16 (30.8%) cases complicated by spontaneous preterm birth. Forty-three women (82.7%) underwent a trial of labor. The remaining 9 women underwent pre-labor cesarean delivery mostly due to obstetric indications, whereas one woman with a critical COVID-19 course underwent urgent cesarean delivery due to maternal deterioration. Among those who underwent a trial of labor (n = 43), 39 (90.7%) delivered vaginally, whereas 4 (9.3%) cases resulted in cesarean delivery. Neonatal RT-PCR nasopharyngeal swabs tested negative in all cases, and none of the infants developed pneumonia. No maternal and neonatal deaths were encountered. CONCLUSIONS: In this prospective study among SARS-CoV-2-infected mothers, vaginal delivery rates were high and associated with favorable outcomes with no cases of neonatal COVID-19. Our findings underscore that delivery management among SARS-CoV-2-infected mothers should be based on obstetric indications and may potentially reduce the high rates of cesarean delivery previously reported in this setting.

Growth Velocity and Doppler Evaluation to Predict Nonreassuring Fetal Heart Rate at Birth in Low-Risk Women: A Prospective, Longitudinal Study.

INTRODUCTION: This study investigated whether fetal growth deceleration in term, appropriate-for-gestational-age (AGA) fetuses is associated with placental insufficiency and nonreassuring fetal heart rate (NRFHR) at birth. METHODS: In this prospective study, 246 low-risk, singleton pregnancies at term with AGA fetuses were recruited. Correlation between decreased growth velocity (decline in estimated fetal weight [EFW] percentile), low EFW (EFWQ1 = latest EFW between 11 and 25% percentiles), umbilical artery (UA) pulsatility index (PI), middle cerebral artery (MCA) PI, and cerebro-placental ratio (CPR) with cesarean and instrumental deliveries due to NRFHR were tested. RESULTS: The median change between fetal weight estimates (percentiles/week) was +0.49% (95% CI: -4 to +5%). Ten percent had decreased EFW percentile >3.5%/week. Fetal growth velocity/week was associated with MCA (r = 0.21, p < 0.001) and CPR (r = 0.24, p < 0.001) and inversely correlated with UA PI (r = -0.28, p < 0.001). NRFHR and cesarean section (CS) rates due to NRFHR were associated with decreased growth velocity, EFWQ1, and low CPR. The combination of abnormal CPR with decreased growth velocity occurred in 12 pregnancies, of which 5 (42%) had urgent CS due to NRFHR. The combination of abnormal CPR with EFWQ1 occurred in 9 pregnancies, of which 4 (44%) had urgent CS due to NRFHR. These combinations increased the likelihood ratio of CS due to NRFHR two-fold (8.41; 2.54-24.5) but did not significantly alter the number needed to treat by elective CS (3.78-4.68). CONCLUSION: Fetal growth velocity, EFW between 10 and 25th percentiles (EFWQ1), and abnormal CPR improves prediction of unplanned CS due to NRFHR among term AGA fetuses. This should be considered when counseling about the delivery method.

Factors Associated with More Than 500 Grams Inaccuracy in Sonographic Fetal Weight Estimation.

BACKGROUND: The sonographic assessment of estimated fetal weight (EFW) is essential for identification of fetuses in weight extremes and aids in peripartum management. However, there are inconsistent reports regarding EFW accuracy. OBJECTIVES: To examine maternal and fetal determinants associated with unreliable EFW. METHODS: A retrospective case-control study was conducted at a single, tertiary medical center between 2011 and 2019. All term, singleton deliveries with a sonographic EFW within 2 weeks of delivery were included. Unreliable EFW was defined as > 500 grams discordance between it and the actual birth weight. We allocated the study cohort into two groups: unreliable EFW (cases) and accurate EFW (controls). RESULTS: Overall, 41,261 deliveries met inclusion criteria. Of these, 1721 (4.17%) had unreliable EFW. The factors positively associated with unreliable EFW included body mass index > 30 kg/m2, weight gain > 20 kg, higher amniotic fluid index, pregestational diabetes, gestational age > 410/7, and birth weight ≥ 4000 grams. On multiple regression analysis, pregestational diabetes (odds ratio [OR] 2.22, 95% confidence interval [95%CI] 1.56-3.17, P < 0.001) and a higher birth weight (OR 1.91, 95%CI 1.79-2.04, P < 0.001) were independently associated with unreliable EFW. On analysis of different weight categories, pregestational diabetes was associated with unreliable EFW only among birth weights ≥ 3500 grams (OR 3.28, 95%CI 1.98-5.44, P< 0.001) and ≥ 4000 grams (OR 4.27, 95%CI 2.31-7.90, P < 0.001). CONCLUSIONS: Pregestational diabetes and increased birth weight are independent risk factors for unreliable EFW and should be considered when planning delivery management.

Factors associated with early phosphate levels in preterm infants.

To investigate perinatal factors and early morbidities associated with early serum phosphate (sPhos) levels in a cohort of preterm infants. Retrospective data were obtained from the medical records of a cohort of 454 infants born at < 32 weeks gestational age. Serum phosphate levels were directly associated with gestational age, body weight z-score, and Apgar scores and inversely associated with timing of enteral nutrition initiation and diet consisting of mostly breast milk. Maternal hypertension, lactate levels, early symptomatic hypotension, and total protein supplemented on days 1 to 3 were also inversely associated with sPhos. Morbidities that were found to be associated with sPhos did not persist after adjustment for confounding factors.Conclusions: We report a novel association between early sPhos and timing and content of enteral nutrition, as well as with the early neonatal hemodynamic condition of preterm infants. This information may help identify infants at risk for low sPhos and aid in the nutritional strategy utilized in these patients. This study did not identify early morbidities associated with sPhos. What is Known: • High initial amino acid intake is associated with increased risk of Refeeding like syndrome and hypophosphatemia, among preterm infants. What is New: • Early enteral nutrition, starting within the first 72 h of life, is associated with higher serum phosphate (sPhos) compared to nothing per os (NPO). • sPhos was not associated with early adverse neonatal outcomes.

Determinants of adverse neonatal outcome in vaginal deliveries complicated by suspected intraamniotic infection.

PURPOSE: Intraamniotic infection, categorized into isolated maternal fever, suspected intraamniotic infection (SII), and confirmed intraamniotic infection, is associated with neonatal morbidity. However, there is paucity of data regarding the association between intraamniotic infection duration and neonatal outcomes among term singleton vaginal deliveries. We aimed to study the risk factors for adverse neonatal outcome among vaginal deliveries complicated by SII. METHODS: A retrospective observational study conducted at a tertiary medical center. All consecutive singleton term deliveries with SII were included between 2011 and 2019. Maternal and obstetrical characteristics were evaluated to identify risk factors for adverse neonatal outcome. Correlation between SII duration and neonatal adverse outcome was analyzed. RESULTS: Overall, 882 were analyzed. Most women (85.4%) were primiparous. Median gestation age at delivery was 40 2/7 weeks. Median time from SII to delivery was 170 min. Adverse neonatal outcomes occurred in 113 (12.8%) of deliveries. Duration of SII was not associated with adverse neonatal outcome. Analysis for determinants of adverse neonatal outcome revealed that oligohydramnios was more common in pregnancies with adverse neonatal outcome (7/113 (6.2%) vs. 41 (5.4%) OR [95% CI] 2.47 (1.02-5.98), p = 0.03). Duration of second stage of labor was longer in the adverse outcome group (median 179 min vs. 126 min, p = 0.008). Prolonged second stage was more common in the adverse outcome group (60 (53.1%) vs. 273 (35.5%) OR [95% CI] 2.05 (1.38-3.06), p < 0.001). On logistic regression analysis, prolonged second stage was the only modifiable factor independently associated with adverse neonatal outcome [adjusted OR 2.09 (1.37-3.2), p = 0.001]. Other variables tested did not differ between groups. Only phototherapy and base excess ≥ 12 mmol/L were significantly associated with the duration of second stage of labor; for each additional hour of the second stage, the OR for the former increased by 0.34 (p = 0.008), and for the latter by 0.69 (p = 0.007). CONCLUSION: Duration of suspected intraamniotic infection was not associated with increased neonatal morbidity among women delivering vaginally at term. Prolonged second stage was a strong independent predictor of an adverse neonatal outcome among fetuses exposed to intraamniotic infection.

Does birthweight have a role in the effect of episiotomy on anal sphincter injury?

PURPOSE: Most professional guidelines advise against routine episiotomy during vaginal delivery, although mounting evidence supports its protective role regarding obstetric anal sphincter injury (OASI). We aimed to study the effect of lateral and mediolateral episiotomies on the rate of OASI in relation to birthweight among nulliparous women undergoing vaginal delivery. METHODS: A historical cohort study was conducted of all nulliparous women who delivered vaginally at term between 2011 and 2019 at a tertiary university hospital. Women were allocated into two groups: (1) with OASI and (2) without OASI. Episiotomy performance and birthweight groups were analyzed. RESULTS: Overall, 22,250 deliveries were analyzed for inclusion: 18,533 (83.3%) spontaneous vaginal deliveries (SVD), 3222 (14.5%) vacuum-assisted deliveries (VAD) and 495 (2.2%) forceps deliveries. Total episiotomy and OASI rate was 48.2% and 1.7%, respectively. Episiotomy rate was lower in the OASI group as compared to the no OASI group (158 (41.3%) vs. 10,568 (48.3%), OR 0.75, 0.61-0.92, p = 0.006). Median birthweight was higher for OASI group neonates (3355 vs. 3160, p < 0.001). In SVDs, episiotomy decreased the rate of OASI in neonatal birthweight groups of 3000-3499, 3500-3999 and > 4000 g (OR 0.56, 0.38-0.82, p = 0.003; 0.66, 0.45-0.99, p = 0.04 and 0.24, 0.07-0.78, p = 0.01, respectively). In VADs, episiotomy decreased the rate of OASI in the neonatal weight groups of 2500-2999 and 3000-3499 g (OR 0.36, 0.14-0.89, p = 0.02 and OR 0.38, 0.19-0.75, p = 0.004, respectively). CONCLUSIONS: Lateral and mediolateral episiotomies are independent modifiable predictors of OASI, protective against OASI in SVDs when neonates weigh > 3000 g and 2500-3499 g in VADs.