Perinatal Outcomes of Late Preterm Rupture of Membranes with or without Latency Antibiotics.

OBJECTIVE: This study aimed to examine whether the addition of latency antibiotics in late preterm rupture of membranes (ROM) decreases neonatal infection and increases latency. STUDY DESIGN: This retrospective two-center study was conducted at Holy Family Hospital (HFH) in Nazareth and Emek Medical Center (EMC) in Afula, on data collected between January 2017 and April 2023. HFH is the smaller institution. EMC and HFH implement similar policies regarding ROM at 340/7 to 366/7 weeks' gestation; the only difference is that a 10-day course of latency antibiotics is implemented at EMC. All women with ROM between 340/7 and 366/7 weeks' gestation who were admitted to one of the centers during the study period, and had a live fetus without major malformations, were included. The primary outcome was neonatal sepsis rate. Secondary outcomes included a composite of neonatal sepsis, mechanical ventilation ≥24 hours, and perinatal death. Additionally, gestational age at delivery and delivery mode were examined. RESULTS: Overall, 721 neonates were delivered during the study period: 534 at EMC (where latency antibiotics were administered) and 187 at HFH. The gestational age at ROM was similar (35.8 and 35.9 weeks, respectively, p = 0.14). Neonatal sepsis occurred in six (1.1%) neonates at EMC and one (0.5%) neonate at HFH (adjusted p = 0.71; OR: 1.69; 95% Confidence Interval [CI]: 0.11-27.14). The composite secondary outcome occurred in nine (1.7%) and three (1.6%) neonates at EMC and HFH, respectively (adjusted p = 0.71; OR: 0.73; 95% CI: 0.14-3.83). The gestational age at delivery was 36.1 and 36.2 weeks at EMC and HFH, respectively (mean difference: 5 h; adjusted p = 0.02). The cesarean delivery rate was 24.7% and 19.3% at EMC and HFH, respectively (adjusted p = 0.96). CONCLUSION: Latency antibiotics administered to women admitted with ROM between 340/7 and 366/7 weeks' gestation did not decrease the rate of neonatal sepsis. KEY POINTS: · Latency antibiotics in late preterm ROM does not decrease neonatal sepsis.. · Latency antibiotics in late preterm ROM does not prolong gestational age at delivery.. · Latency antibiotics in late preterm ROM does not affect the mode of delivery..

Pharmacologic and nonpharmacologic options for pain relief during labor: an expert review.

Labor pain is among the most severe types of physical pain that women may experience during their lifetime. Thus, pain relief is an essential part of medical care during childbirth. Epidural analgesia is considered to be the most efficient method of pain relief during labor. Nevertheless, patient preferences, contraindications, limited availability, and technical failure may require the use of alternative pain reliving methods during labor including systemic pharmacologic agents, and nonpharmacologic methods. Nonpharmacologic methods for pain alleviation during vaginal birth have become popular over the years, either as a complement to pharmacologic agents or at times as the principal therapy. Methods such as relaxation techniques (ie, yoga, hypnosis, and music), manual techniques (ie, massage, reflexology, and shiatsu), acupuncture, birthing ball, and transcutaneous electrical nerve stimulation are considered safe, although the evidence supporting their effectiveness for pain relief is not as robust as it is for pharmacologic agents. Systemic pharmacologic agents are mostly administered by inhalation (nitrous oxide) or through the parenteral route. These agents include opioids such as meperidine, nalbuphine, tramadol, butorphanol, morphine, and remifentanil, and non-opioid agents such as parenteral acetaminophen and nonsteroidal anti-inflammatory drugs. Systemic pharmacologic agents suggest a diverse armamentarium of medication for pain management during labor. Their efficacy in treating pain associated with labor varies, and some continue to be used even though they have not been proven effective for pain relief. In addition, the maternal and perinatal side effects differ markedly among these agents. There is a relative abundance of data regarding the effectiveness of analgesic drugs compared with epidural, but the data regarding comparisons among the different types of alternative analgesic agents are scarce, and there is no consistency regarding the drug of choice for women who do not receive epidural pain management. This review aims to present the available data regarding the effectiveness of the different methods of relieving pain during labor other than epidural. The data presented are mainly based on recent level I evidence regarding pharmacologic and nonpharmacologic methods for pain relief during labor.

Double-vs single-balloon catheter for induction of labor: Systematic review and individual participant data meta-analysis.

INTRODUCTION: Evidence comparing double-balloon vs single-balloon catheter for induction of labor is divided. We aim to compare the efficacy and safety of double-vs single-balloon catheters using individual participant data. MATERIAL AND METHODS: A search of Ovid MEDLINE, Embase, Ovid Emcare, CINAHL Plus, Scopus, and clinicaltrials.gov was conducted for randomized controlled trials published from March 2019 until April 13, 2021. Earlier trials were identified from the Cochrane Review on Mechanical Methods for Induction of Labour. Randomized controlled trials that compared double-balloon with single-balloon catheters for induction of labor in singleton gestations were eligible. Participant-level data were sought from trial investigators and an individual participant data meta-analysis was performed. The primary outcomes were rates of vaginal birth achieved, a composite measure of adverse maternal outcomes and a composite measure of adverse perinatal outcomes. We used a two-stage random-effects model. Data were analyzed from the intention-to-treat perspective. RESULTS: Of the eight eligible randomized controlled trials, three shared individual-level data with a total of 689 participants, 344 women in the double-balloon catheter group and 345 women in the single-balloon catheter group. The difference in the rate of vaginal birth between double-balloon catheter and single-balloon catheter was not statistically significant (relative risk [RR] 0.93, 95% confidence interval [CI] 0.86-1.00, p = 0.050; I2 0%; moderate-certainty evidence). Both perinatal outcomes (RR 0.81, 95% CI 0.54-1.21, p = 0.691; I2 0%; moderate-certainty evidence) and maternal composite outcomes (RR 0.65, 95% CI 0.15-2.87, p = 0.571; I2 55.46%; low-certainty evidence) were not significantly different between the two groups. CONCLUSIONS: Single-balloon catheter is at least comparable to double-balloon catheter in terms of vaginal birth rate and maternal and perinatal safety outcomes.

Oral analgesia in fixed-time interval administration versus spinal morphine for post-Cesarean pain: a randomised controlled trial.

PURPOSE: To compare the efficacy of fixed-time-interval oral analgesia and spinal-morphine for management of post-Cesarean pain. METHODS: In this open-label, parallel-group, randomized, controlled trial, 200 women due to undergo elective Caesarean section with spinal anaesthesia were enrolled between July 2015 and April 2016. Patients were randomly assigned to receive either spinal fentanyl followed by oral doses of tramadol, paracetamol, and diclofenac at predetermined regular intervals of 6 h for the first 48 h, and rescue treatment with percocet (oxycodone and paracetamol; oral analgesia group), or spinal morphine and rescue treatment with oral tramadol, paracetamol, and diclofenac (spinal-morphine group). The primary outcomes were pain intensity during the postoperative 48 h, measured on a 10-point numeric rating scale (NRS) and expressed as area under the curve (AUC), and the number of breakthrough events of moderate to severe pain (defined as NRS score ≥ 4). RESULTS: The oral analgesia group compared to the spinal-morphine group had similar mean pain intensity (AUC (120 ± 35 versus 121 ± 31, respectively; p = 0.8) but more events of moderate-to-severe breakthrough pain (4.8 ± 2 versus 3.8 ± 1.7, respectively; p = 0.0002). Higher rates and longer durations of pruritus, nausea, and vomiting were reported among patients receiving spinal morphine, as compared with oral analgesia. Satisfaction scores were high in both groups (8.2 ± 2.4 versus 8.7 ± 1.8 in the oral analgesia and spinal morphine, respectively; p = 0.23). CONCLUSIONS: Both oral analgesia at fixed time intervals and spinal morphine are satisfactory methods for treating post-Caesarean pain. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02440399, date of registration: 07/05/ 2015. URL: https://clinicaltrials.gov/ct2/show/NCT02440399?term=enav+yefet&rank=7 .

Double-blind randomized trial of progesterone to prevent preterm birth in second-trimester bleeding.

INTRODUCTION: Second-trimester vaginal bleeding increases the risk of spontaneous preterm birth. We aimed to examine the efficacy of vaginal progesterone to reduce preterm birth rate in women with second-trimester vaginal bleeding. MATERIAL AND METHODS: Two-center, double-blind, placebo-controlled trial involving pregnant women with second-trimester vaginal bleeding. Women with documented uterine bleeding were randomly assigned in a 1:1 ratio to receive 200 mg of micronized vaginal progesterone or placebo once daily at 16-26 weeks until 36 weeks of gestation. Women who had prior preterm birth or short cervix diagnosed before recruitment were not eligible. The primary outcome was spontaneous delivery <37 weeks. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01269450. RESULTS: Between March 2011 and January 2017, 128 women gave consent and were randomized; 16 withdrew consent and 3 had a second-trimester termination of pregnancy. The final analysis included 109 women: 60 in the progesterone group and 49 in the placebo group. Demographic and obstetric characteristics did not differ between the groups. Primary outcome occurred in 19 (31.7%) and 12 (24.5%) in the progesterone and placebo groups, respectively (odds ratio [OR] 1.32; 95% confidence interval [CI] 0.55-3.16; P = 0.53). The proportion of births <34 weeks was similar between the groups (OR 1.19; 95% CI 0.47-3.02; P = 0.72), as were the survival curves from randomization to delivery (hazard ratio, 1.24; 95% CI, 0.60-2.56; P = 0.57). There were no significant differences in neonatal morbidities between the groups. The study was ended prematurely because of slow recruitment. CONCLUSIONS: Antepartum vaginal progesterone does not seem to reduce the incidence of preterm birth in women with second-trimester bleeding.

Effect of inter-twin delivery interval on umbilical artery pH and Apgar score in the second twin.

BACKGROUND: To examine the effect of inter-twin delivery interval on umbilical artery pH and Apgar score of the second twin after vaginal delivery of the first twin. METHODS: Retrospective study conducted at a single teaching hospital. All pregnant women with twin gestation who delivered the first twin vaginally at more than 24 weeks between 1995 and 2015 were included. Major malformations and intrauterine deaths of one or both twins were excluded. Women were divided into those who had an inter-twin delivery interval of less than 30 minutes (group 1) or 30 minutes or more (group 2). Primary outcome was umbilical artery pH less than 7.1 and/or Apgar score less than 7 at 5 minutes of the second twin. Generalized linear regression with log was performed to evaluate the association with delivery interval. RESULTS: Of 88 145 deliveries during this period, 1955 (2.2%) were twins. Overall, 713 twin pregnancies, 596 (83.6%) in group 1 and 117 (16.4%) in group 2, were eligible and included. Mean inter-delivery interval was 11.0 ± 6.5 and 52.5 ± 31.5 minutes in groups 1 and 2, respectively. After adjusting for variables found significantly different between the groups in univariate analysis, inter-delivery interval of less than 30 minutes or 30 minutes or more was not a significant risk factor for pH less than 7.1 and/or Apgar less than 7 (P = .91). The cesarean rate for delivery of the second twin after vaginal delivery of the first twin was 4.3% overall, with a higher rate among group 2 compared with group 1 (18.2% and 3.2%, respectively; P = .001). CONCLUSIONS: The second twin's Apgar score and cord artery pH are probably not affected when the inter-twin delivery interval exceeds 30 minutes.

Peripartum events associated with severe neurologic morbidity and mortality among acidemic neonates.

PURPOSE: To identify peripartum events that may predict the development of short-term neurologic morbidity and mortality among acidemic neonates. METHODS: Retrospective case-control study conducted at a single-teaching hospital on data from January 2010 to December 2015. The study cohort group included all acidemic neonates (cord artery pH ≤ 7.1) born at ≥ 34 weeks. Primary outcome was a composite including any of the following: neonatal encephalopathy, convulsions, intra-ventricular hemorrhage, or neonatal death. The study cohort was divided to the cases group, i.e., acidemic neonates who had any component of the primary outcome, and a control group, i.e., acidemic neonates who did not experience any component of the primary outcome. RESULTS: Of all 24,311 neonates born ≥ 34 weeks during the study period, 568 (2.3%) had a cord artery pH ≤ 7.1 and composed the cohort study group. Twenty-one (3.7%) neonates composed the cases group. Multivariate logistic regression analysis revealed that cases were significantly more likely to have experienced placental abruption (OR 18.78; 95% CI 5.57-63.26), born ≤ 2500 g (OR 13.58; 95% CI 3.70-49.90), have meconium (OR 3.80; 95% CI 1.20-11.98) and cord entanglement (OR 5.99; 95% CI 1.79-20.06). The probability for developing the composite outcome rose from 3.7% with isolated acidemia to 97% among neonates who had all these peripartum events combined with intrapartum fetal heart rate tracing category 2 or 3. CONCLUSION: Neonatal acidemia carries a favorable outcome in the vast majority of cases. In association with particular antenatal and intrapartum events, the short-term outcome may be unfavorable.

The impact of postpartum cervical tear on the occurrence of preterm birth in subsequent pregnancy.

PURPOSE: To examine the occurrence of subsequent preterm birth (PTB) among women who experienced a cervical tear during prior delivery. METHODS: A retrospective study conducted at a single teaching hospital on data from January 1994 to March 2014. The study group included all women who had a cervical tear detected at uterine and cervical examination, performed due to early postpartum hemorrhage. The control group consisted of women who delivered vaginally, experienced an early postpartum hemorrhage, and had an intact cervix at uterine and cervical examination. The control group was matched for maternal age and ethnicity at a ratio of 1:2. Women who had a cervical tear but then did not have a subsequent delivery, or had multiple fetal gestations or cervical cerclage at subsequent pregnancies were excluded. Primary outcome was spontaneous PTB rate (<37 weeks) in the subsequent pregnancy. Secondary outcomes included any PTBs in other subsequent pregnancies. RESULTS: Overall, 389 women were included. Of all cases of cervical tear, 129 were identified eligible and included in the final analysis. The control group included 260 women with an intact cervix. No significant differences were found between the study and control groups in the incidence of spontaneous PTB in the immediate subsequent pregnancy [1.6% (2/129) vs. 3.8% (10/260), respectively, p = 0.35]. The incidence of any spontaneous PTBs in all subsequent pregnancies did not differ also [4.7% (6/129) vs. 7.3% (19/260), respectively, p = 0.31]. CONCLUSION: Cervical tear detected after delivery does not increase the risk of spontaneous PTB in subsequent pregnancies.

The effect of type and volume of fluid hydration on labor duration of nulliparous women: a randomized controlled trial.

PURPOSE: Type and volume of fluid administered for intrapartum maintenance had been reported to differently affect labor length, delivery mode, and cord artery pH and glucose level. We aimed to compare the effect of three different fluid regimens on labor duration. METHODS: In a randomized trial, healthy nulliparous in labor were randomized into one of three intravenous fluid regimens: group 1, the reference group, lactated Ringer's solution infused at a rate of 125 mL/h; group 2, lactated Ringer's solution infused at a rate of 250 mL/h; group 3, 0.9% saline solution boosted with 5% glucose, infused at a rate of 125 mL/h. The primary outcome was labor length from enrollment until delivery. RESULTS: Between December 2010 and July 2015, 300 women were randomized to one of the three groups. Demographic and baseline obstetric characteristics were comparable between the groups. There was no significant difference in the time from enrollment to delivery (p = 0.62). Furthermore, there were no significant differences in second stage duration (p = 0.73), mode of delivery (p = 0.21), cord artery pH and glucose level between the groups. CONCLUSIONS: Increasing the intravenous volume of lactated Ringer's solution or substituting to fluid containing 5% glucose solution does not affect labor length. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, http://www.clinicaltrials.gov , NCT01242293.

Risk of preterm birth and low birthweight following consecutive surgical and medical abortions.

PURPOSE: To examine the effect of consecutive surgical compared to medical uterine evacuations on spontaneous preterm birth (SPTB) and low birthweight (LBW) rates in the immediate subsequent delivery. METHODS: Retrospective study, conducted at a teaching hospital on data from January 2000 to March 2016. First study group consisted of all women who had ≥2 consecutive medical evacuations (ME-Group); second study group consisted of women who had ≥2 consecutive surgical evacuations (SE-Group). Both had a subsequent singleton delivery. Control group consisted of women without previous evacuations (unexposed group). The groups were matched for year of birth and ethnicity. The primary outcome was a composite that included SPTB (<37 weeks) and LBW (<2500 g). RESULTS: All 70 women found eligible in the ME-Group during the study period were included. SE-Group and the unexposed group consisted of 140 and 210 women, respectively. Primary outcome occurred in 4.3, 11.4, and 2.4% in the ME-Group, SE-Group, and the unexposed group, respectively (p = 0.002). After adjusting for variables that differed between the groups in univariate analysis, the primary outcome incidence was significantly higher among the SE-Group compared to the unexposed group (adjusted OR 6.8, 95% CI 1.7-26.3, p = 0.006). The difference was insignificant between the ME-Group and the unexposed group (adjusted p = 0.31). In the SE-Group, 7.1% women required fertility treatments to achieve a desired pregnancy compared to 1.4% in the ME-Group (p = 0.04). CONCLUSION: Two or more consecutive surgical evacuations were associated with an increased risk of both SPTB and LBW compared to unexposed group.

Risk factors and peripartum outcomes of failed epidural: a prospective cohort study.

PURPOSE: Awareness to rate, risk factors, and the associated peripartum outcomes of failed epidural analgesia (FEA) may improve expectations and labor management. We aimed to identify risk factors for FEA and to examine peripartum outcomes associated with failure. METHODS: A prospective cohort study conducted between March 2015 and August 2015, at a single university medical center. Laboring women at ≥34 weeks, receiving epidural analgesia, were eligible. Pain was evaluated using a 0-10 cm visual analogue scale (VAS). FEA was defined as VAS score ≥5, 30 min after the loading dose. The primary outcome was to identify risk factors for FEA. In addition, second-stage duration and operative vaginal delivery rate were also examined. Univariate logistic regression and stepwise multivariate logistic regression were performed to estimate the predictors for FEA. RESULTS: Of all 414 women included, 35 (8.5%) had FEA. Multivariate stepwise logistic regression revealed that fetal head station 1 cm above the ischial spines (p = 0.002, adjusted OR 5.4, 95% CI 1.9-16.0), oxytocin use (p = 0.026, adjusted OR 2.8, 95% CI 1.1-6.8), and seniority of the anesthesiologist (p = 0.046, adjusted OR 0.97, 95% CI 0.93-0.99) at epidural insertion were found as significant variables associated with FEA. Second-stage duration and operative vaginal delivery rate did not differ significantly between women with failed and successful epidural. CONCLUSION: Higher fetal head station and oxytocin use may be associated with higher failure rate. Labor outcomes related to epidural use, occurred at comparable rates, among women with failed and successful epidural.

Correlation between Clinical, Placental Histology and Microbiological Findings in Spontaneous Preterm Births.

AIMS: To examine the occurrence of chorioamnionitis and abruption among women who had a spontaneous preterm birth (SPTB), the correlation between clinical and placental findings, and the impact of these complications on neonatal outcome after delivery. METHODS: This was a retrospective case-control study conducted between 2008 and 2012 at a single teaching hospital. The study group included all women who had an SPTB (23-36 weeks). Placentas were cultured and underwent histological examination. RESULTS: A total of 478 women were included. The mean gestational age at delivery was 32.6 ± 3.1 weeks. Overall, 260 (54.4%) women had either clinical and/or histological abruption or chorioamnionitis. Clinical chorioamnionitis was diagnosed before birth in 14 (2.9%) women, while histological chorioamnionitis (HCA) in 84 (17.4%). Overall, 38 neonates had infection. Placental cultures were negative in 65.8% (25/38) of these neonates, and in 77.1% (27/38), HCA was ruled out. Logistic regression analysis revealed that neonatal morbidity and mortality were correlated with gestational age at delivery (p = 0.02), not with placental pathology (p = 0.08). CONCLUSIONS: Half of the women with PTB had clinical or histological abruption, chorioamnionitis or both. A partial correlation was found between clinical and placental findings. The main determinant of neonatal outcome was gestational age at delivery and not placental findings.

Meperidine Compared With Nitrous Oxide for Intrapartum Pain Relief in Multiparous Patients: A Randomized Controlled Trial.

OBJECTIVE: To compare the efficacy and adverse effects of intravenous meperidine and inhaled nitrous oxide for intrapartum analgesia in multiparous patients. METHODS: This randomized controlled trial was conducted in the delivery ward of a university teaching medical center in Afula, Israel. Multiparous patients with term, singleton pregnancies who were in labor were randomized in a 1:1 ratio to 50 mg intravenous meperidine or inhaled nitrous oxide. The primary outcome was pain intensity 20-30 minutes after analgesic administration, measured on a visual analog scale (VAS) from 0 to 10 cm. Secondary outcomes included the need for additional analgesia, labor length, delivery mode, patient satisfaction, and maternal and neonatal adverse effects. To detect a 1-cm (±2.6) difference in VAS score between the groups, 214 total participants were needed to achieve 80% power with an alpha of 0.05. RESULTS: From August 2016 through May 2019, 214 participants were enrolled. Fourteen were excluded after randomization. Of the 200 analyzed, 102 received nitrous oxide, and 98 received intravenous meperidine. Demographic and obstetric variables were comparable between the two groups. The VAS score 20-30 minutes after analgesic administration did not differ between the groups (7.7±2.3 cm and 7.6±2.7 cm in the nitrous oxide and meperidine groups, respectively, P=.89). There were no significant differences between the groups in the rate of additional analgesic use, labor length, delivery mode, Apgar scores, rate of breastfeeding, patient satisfaction, or maternal and neonatal adverse effects. CONCLUSION: Pain intensity was comparable in multiparous patients 20-30 minutes after administration of meperidine and nitrous oxide. Adverse effects were also comparable. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02783508.

Neonatal condition at birth of twins conceived by medically assisted reproductive technology compared to those conceived spontaneously: A retrospective study.

OBJECTIVE: To examine neonatal outcomes at birth among twins conceived spontaneously or by medically assisted reproduction (MAR). METHODS: A retrospective study was conducted at a single university teaching hospital on data collected between January 1995 and September 2019. Live twin deliveries at more than 24 weeks of pregnancy were included. The study group consisted of women who conceived by MAR and the controls were spontaneously conceived twins. The study group was further divided into two groups: in vitro fertilization (IVF) and ovulation induction (OI) groups. The primary outcomes were umbilical artery pH less than 7.1 and/or Apgar score less than 7 of any twin 5 min after birth. RESULTS: Overall, 2235 eligible twin gestations were included, corresponding to a total of 4470 live neonates; 1009 (45.1%) conceived by MAR (762 [75.5%] IVF and 247 [24.5%] OI) and 1226 (54.9%) conceived spontaneously. Incidence of the primary outcome was 5.3% and 5.1% in the study and control groups, respectively (P = 0.71). The primary outcome was comparable among the IVF (5%), OI (6.2%), and control (5.1%) groups. The results did not change even after adjusting for demographic and obstetric variables, including mode of delivery, which differed between the groups. CONCLUSION: Neonatal condition of twin pregnancies at birth among MAR subgroups is similar to spontaneously conceived twins.

Postpartum hemorrhage among twin pregnancies - Medically assisted versus spontaneously conceived.

INTRODUCTION: In singleton pregnancies, an increased risk of Postpartum hemorrhage (PPH) have been linked with assisted reproductive technology (ART) and abnormal placentation. It is unknown wheather such association exists in twin pregnancies conceived by Medically assisted reproduction (MAR). The aim of the current study was to compare maternal blood loss among twin pregnancies conceived by different types of MAR treatments to spontaneously conceived twins and to identify the cycle characteristics if an association exits. METHODS: Retrospective study conducted on data collected between 2011 and 2020. The study cohort included all twin pregnancies conceived by MAR and born at our institution. Controls were spontaneously conceived twins matched for maternal age on a 1:2 (study: controls) ratio. RESULTS: Overall 113 MAR twin births categorized into three groups; 25 ovulation induction, 59 fresh ART, 29 frozen-thawed ART cycles, and 226 controls were included. The incidence of PPH was higher among MAR twin pregnancies (5.3%) compared to the controls (4%). The highest incidence was observed among women in the frozen-thawed group (13.8%) which differed significantly compared with the controls (p = 0.024). A significant difference was also observed in the mean decrease of postpartum hemoglobin levels between these two groups (2.13 g/dL versus 1.3 g/dL respectively, p = 0.002). Blood transfusion was nearly 2.5 times more common in the frozen-thawed group (3.4%) compared to the control group (1.3%). DISCUSSION: The present study demonstrates that frozen embryo transfer (FET) ART-conceived twin pregnancies are associated with a markedly increased rate of PPH compared to spontaneously conceived twins.

Impact of liberal use of mediolateral episiotomy on the incidence of obstetric anal sphincter tear.

PURPOSE: To assess the impact of liberal compared with restrictive use of mediolateral episiotomy on the incidence of obstetric anal sphincter tear (OAST). METHODS: Data between the years 1999-2001 (era 1) when liberal mediolateral episiotomy was applied were compared with the years 2004-2008 (era 2) when restricted mediolateral episiotomy was implemented. Liberal mediolateral episiotomy was done for fetal or maternal indications, while restrictive mediolateral episiotomy was done when a tear was imminent. Primary outcome was the incidence of OAST. RESULTS: A total of 25,170 women who delivered vaginally were included. After adjusting for potential confounders, the incidence of OAST was found to be significantly higher in era 2 (0.4 %) compared to era 1 (0.1 %), (p = 0.02; adjusted OR 2.23; 95 % CI, 1.16-4.29). Among primiparous women, the incidence of mediolateral episiotomy was 71.8 and 27.1 % in eras 1 and 2, respectively (p < 0.001), and the incidence of OAST was 0.2 and 1 % in eras 1 and 2, respectively (p = 0.009; adjusted OR 4.15; 95 % CI, 1.42-12.10). Among multiparous women, the incidence of OAST did not differ significantly (p = 0.52). Returning to the liberal policy among primiparous women only, 124 deliveries are needed to prevent one OAST. CONCLUSION: Liberal compared to restrictive use of mediolateral episiotomy may be a sphincter-saving procedure among primiparous women.

Impact of "natural" cesarean delivery on peripartum blood loss: a randomized controlled trial.

BACKGROUND: Early skin-to-skin contact after vaginal delivery increases milk production and may increase oxytocin release, leading to a reduction in the rate of postpartum hemorrhage. OBJECTIVE: This study aimed to examine the effect of "natural" cesarean deliveries on perioperative maternal blood loss. STUDY DESIGN: This was a randomized controlled trial conducted at a single university-affiliated medical center, between August 2016 and February 2018. Term singleton pregnancies scheduled for a planned cesarean delivery under spinal anesthesia were included. Women were randomized at a ratio of 1:1 to natural cesarean delivery (study group) or traditional cesarean delivery (control group) during the routine preoperative assessment. Women in the study group watched fetal extraction, had early skin-to-skin contact, and breastfed until the end of surgery. Neonates in the control group were presented to the mother for a few minutes. Blood samples were drawn from all women, during fascia closure, to determine oxytocin levels using an enzyme-linked immunosorbent assay kit. The laboratory component was performed after recruitment completion and was accomplished in February 2019. The primary outcome was postpartum hemoglobin levels. To detect a difference of 0.5 g/dL between the groups with α=0.05 and ß=80%, 214 women were needed. RESULTS: Of 214 randomized women, 23 were excluded. There was no difference in demographic and obstetrical variables between the groups. Postpartum hemoglobin levels were 10.1±1.1 and 10.3±1.3 g/dL in the study and control groups, respectively (P=.19). There was no difference in the rates of postpartum hemorrhage and blood transfusion. Maternal pain scores, satisfaction, and exclusive breastfeeding were comparable. Maternal oxytocin blood levels were 389.5±183.7 and 408.5±233.6 pg/mL in the study and control groups, respectively (P=.96). The incidence of neonatal hypothermia was comparable between the groups (P=.13). CONCLUSION: Natural cesarean delivery did not affect perioperative hemoglobin level or maternal oxytocin blood concentration.

Efficacy of Single Wound Infiltration With Bupivacaine and Adrenaline During Cesarean Delivery for Reduction of Postoperative Pain: A Randomized Clinical Trial.

Importance: Most women report moderate to severe pain after cesarean delivery. The extent of the ability of surgical wound infiltration with local anesthetic agents during cesarean delivery for the reduction of postoperative pain is uncertain. Objective: To examine the efficacy of single wound infiltration with bupivacaine and adrenaline during cesarean delivery for the reduction of postoperative pain. Design, Setting, and Participants: This randomized clinical trial was conducted between January 25, 2018, and May 30, 2020, at a university teaching hospital in Afula, Israel. A total of 288 women with singleton pregnancy who were scheduled for a planned cesarean delivery at term were randomized to receive single wound infiltration with bupivacaine and adrenaline during cesarean delivery (intervention group) or no single wound infiltration (control group) at a 1:1 ratio. Interventions: In the intervention group, the subcutaneous layer was infiltrated on both sides of the wound by a mixture of bupivacaine and adrenaline before wound closure. Other perioperative techniques were similar between the groups. Main Outcomes and Measures: The primary outcome was mean pain intensity over the course of 24 hours after the operation, as measured by a visual analog scale (VAS) score ranging from 0 to 10 (with higher scores indicating greater pain intensity). To detect a mean (SD) reduction of 1 (3) points in the VAS score in the intervention group, 286 women were needed in total. Secondary outcomes included VAS score greater than 4 (indicating moderate pain) at 2 hours after the operation, use of rescue opioids, maternal satisfaction with the pain management procedure (using a scale of 1-5, with higher scores indicating greater satisfaction), duration of the operation, scar complications (hematoma, infection, and separation), and length of stay. Results: Among 288 women (mean [SD] age, 32.5 [5.1] years; all of Arab or Jewish ethnicity), 143 were randomized to the intervention group, and 145 were randomized to the control group. Demographic and obstetric variables were similar between groups. The primary outcome (VAS pain score) was significantly lower in the intervention group (mean [SD], 2.21 [0.56]) compared with the control group (mean [SD], 2.41 [0.73]; P = .02). In the intervention group, 11 women (7.7%) had a VAS score greater than 4 at 2 hours compared with 22 women (15.2%) in the control group (odds ratio, 0.47; 95% CI, 0.22-1.00; P = .05). In addition, compared with the control group, the intervention group had significantly lower postpartum use of rescue opioid analgesics (19 women [13.3%] vs 37 women [25.5%]; P = .009) and greater satisfaction with pain management (mean [SD] score, 4.65 [0.68] vs 4.44 [0.76]; P = .007). In the intervention vs control groups, duration of the operation, scar complications (hematoma, infection, or separation), and length of stay were comparable. Conclusions and Relevance: In this study, wound infiltration with a single administration of bupivacaine and adrenaline during cesarean delivery reduced postoperative pain and opioid use and may have improved maternal satisfaction with pain management. These findings suggest the technique is efficacious, safe, and easy to perform. Trial Registration: ClinicalTrials.gov Identifier: NCT03395912.