Is Oxytocin Administration During Childbirth Associated With Increased Risk for Postpartum Posttraumatic Stress Symptoms?: A Preliminary Investigation.

INTRODUCTION: Synthetic oxytocin is one of the most regularly administered medications to facilitate labor induction and augmentation. The present study examined the associations between oxytocin administration during childbirth and postpartum posttraumatic stress symptoms (PTSS). MATERIALS AND METHODS: In a multicenter longitudinal study, women completed questionnaires during pregnancy and at 2 months postpartum (N = 386). PTSS were assessed with the Impact of Event Scale. Logistic regression was used to examine the difference in PTSS at Time 2 between women who received oxytocin and women who did not. RESULTS: In comparison with women who did not receive oxytocin, women who received oxytocin induction were 3.20 times as likely to report substantial PTSS (P = .036, 95% confidence interval: 1.08-9.52), and women who received oxytocin augmentation were 3.29 times as likely to report substantial PTSS (P = .036, 95% confidence interval: 1.08-10.03), after controlling for being primiparous, preeclampsia, prior mental health diagnosis, mode of birth, postpartum hemorrhage, and satisfaction with staff. DISCUSSION: Oxytocin administration was associated with a 3-fold increased risk of PTSS. The findings may reflect biological and psychological mechanisms related to postpartum mental health and call for future research to establish the causation of this relationship.

Extended fertility at highly advanced reproductive age is not related to anti-Müllerian hormone concentrations.

RESEARCH QUESTION: Is extended fertility at the advanced reproductive age of 43-47 years associated with high anti-Müllerian hormone (AMH) concentrations? DESIGN: Prospective cohort study including 98 women aged 43-47 years old with a spontaneous conception who were tested for AMH concentrations 1-4 days and 3-11 months post-partum. AMH concentrations at 3-11 months post-partum were further compared with AMH concentrations in healthy age-matched controls that last gave birth at ≤42 years old. Women with current use of combined hormonal contraceptives (CHC), ovarian insult or polycystic ovary syndrome were excluded. Power analysis supported the number of participating women. RESULTS: Median AMH concentrations did not differ between the extended fertility (n = 40) and control (n = 58) groups (0.50 versus 0.45 ng/ml, P = 0.51). This remained when analysing by age (≥ or <45 years old). AMH concentrations and women's age did not correlate within the extended fertility group (r = 0.017, P = 0.92); a weak negative correlation was found within the control group (r = -0.23, P = 0.08). AMH was significantly higher 3-11 months post-partum (0.50 ng/ml [0.21-1.23]) than 1-4 days post-partum (0.18 ng/ml [0.06-0.40]), P < 0.001. The two results for each participant were highly correlated (r = 0.82, P < 0.001). The extended fertility and control groups were similar regarding age, age at menarche, past CHC use and history of fertility concern. Parity differed but showed no significant correlation with AMH. CONCLUSIONS: Serum AMH concentrations that reflect ovarian reserve do not seem to predict reproductive potential at highly advanced age. Thus, additional factors such as oocyte quality should also be considered in evaluating reproductive potential. AMH suppression that is associated with pregnancy at 1-4 days post-partum recovers at 3-11 months post-partum in women of highly advanced reproductive age.

Secundiparas following a failed vacuum delivery-factors associated with a successful vaginal delivery: a historical prospective cohort.

BACKGROUND: Few studies have focused on the delivery subsequent to a failed vacuum delivery (failed-VD) in secundiparas. The objective of the current study was to examine the factors associated with a vaginal delivery following a failed-VD. METHODS: An historical prospective cohort. Obstetric characteristics of secundiparas who underwent a planned caesarean delivery (CD) were compared to those who elected a trial of labour (TOLAC) at single medical-centre, throughout 2006-2019. The latter were further analysed to study for factures associated with successful vaginal birth (VBAC). RESULTS: Among the 115 secundiparas included, 89 (77%) underwent TOLAC. Compared to women who underwent an elective CD, those who underwent TOLAC were younger by a mean of 4 years, were more likely to have conceived spontaneously, and had a more advanced gestation by a mean of 10 days. VBAC was achieved in 62 women (70%). New-borns of women with VBAC had in average a lower birth weight compared to those with failed TOLAC, (-)195 g ± 396 g versus ( +)197 g ± 454 g respectively, P < 0.01. Having a higher neonatal birthweight at P2 by increments of 500 g, 400 g or 300 g was associated with a failed TOLAC; OR of 9.7 (95%CI; 2.3, 40.0), 11.5 (95%CI; 2.8, 46.7) and 4.5 (95%CI; 1.4, 13.9), respectively. CONCLUSIONS: Among secundiparas with a previous CD due to a failed-VD, the absolute difference of neonatal BW was found to be significantly associated with achieving VBAC.

Induction of labor at second delivery subsequent to a primary cesarean: is stage of labor at previous cesarean a factor?

PURPOSE: Parturients with a history of a cesarean delivery (CD) in the first delivery (P1), undergoing induction of labor (IOL) in the subsequent delivery (P2) are at increased risk for obstetric complications. The primary aim was to study if "the stage of labor" at previous cesarean (elective/latent/first/second) is associated with a successful IOL. The secondary aim was to search for other obstetric characteristics associated with a successful IOL. METHODS: A retrospective longitudinal follow-up study in a large tertiary medical center. All parturients at term who underwent IOL at P2 with a singleton fetus in cephalic presentation, with a prior CD, between the years 2006 and 2014 were included. A univariate analysis was performed including the stage of labor at previous cesarean, birth weight of newborn at P1 and P2, gestational week of delivery at P2, time of interpregnancy interval, indication and mode of IOL, epidural analgesia and augmentation of labor at P2. Significant factors were incorporated in a multivariate logistic regression model. RESULTS: During the study period, 150 parturients underwent IOL (P2) subsequent to a previous CD (P1). VBAC was achieved in 78 (52%). We found no association between the stages of labor in which the previous CD was performed to a successful IOL. Applying the multivariate logistic regression revealed that augmentation of labor with oxytocin, OR 4.17, [1.73-10.05], epidural analgesia OR 3.30 [1.12-9.73] and birth weight (P2) < 4000 g, OR 5.88, [1.11-33.33] were associated with a successful IOL. CONCLUSION: The stage of labor at previous CD should not be incorporated among the variables found to be associated with a successful IOL. As a result of our findings, clinician's will be able to adjust a personalized consult prior to initiating IOL.

Fertility intentions and the way they change following birth- a prospective longitudinal study.

BACKGROUND: Women's fertility intentions, their desired number of children and desired inter-pregnancy interval (IPI) are related to micro (personal) and macro (socio-cultural) level factors. We investigated factors that contribute to changes in women's fertility intentions in Israel, a developed country with high birth rates. METHODS: Pregnant women (N = 1163), recruited from prenatal clinics and hospitals in two major metropolitan areas, completed self-report questionnaires prenatally (≥24 weeks gestation) and postpartum (2 months after childbirth). Women reported their socio-demographic background and obstetric history prenatally, their desired number of children and IPI at both time-points, and their objective and subjective birth experiences postpartum. RESULTS: The findings indicated that background characteristics were related to prenatal fertility intentions. The strongest contributor to prenatal fertility intentions was women's degree of religiosity- the more religious they were, the more children they desired and the shorter their intended IPI. Women's postpartum fertility intentions were mostly consistent with their prenatal reports. In regression models, women who were very-religious, more educated and had previously given birth were less likely to report a lower number of desired of children at postpartum, compared to their prenatal report. Women who reported greater birth satisfaction and gave birth for the first time were less likely to change desired IPI. CONCLUSION: Having a negative birth experience could adversely affect women's fertility intentions. Yet, in a pronatalist and medicalized birth culture, social pressures may decrease the effects of birth experiences on fertility intentions.

Women's preferences for mode of second birth-A prospective study of two Israeli birth cohorts.

INTRODUCTION: Various biopsychosocial factors affect women's preferences with respect to mode of birth, but they are usually not examined simultaneously and prospectively. In the current study, we assessed the contribution of personal characteristics of first-time mothers, their prior prenatal perceptions, events during birth, and subjective birth experiences, on their preference about mode of second birth. METHODS: This was a secondary analysis of two prospective birth cohort studies. Participants included 832 primiparous women recruited mostly from women's health centers in Israel, and through natural birth communities and cesarean birth websites. Women completed questionnaires prenatally and were followed up at 6-8 weeks postpartum to understand their preferences for a second birth. RESULTS: Regression models indicated that after vaginal first birth, being less religious, believing that birth is a medical process, and having a negative experience increased the odds of preferring primary cesarean for the second birth. After cesarean birth, being more religious, having higher education, conceiving spontaneously, having a more negative birth experience, and perceiving better treatment from the staff during birth contributed to preferring vaginal birth for the second birth. CONCLUSIONS: Religiosity is central to women's preferences, probably because of its association with the desire to have many children. Modifiable factors, such as women's beliefs about the nature of birth, their overall birth experience, and their perceived treatment from the staff, could influence the uptake of having vaginal births. Intrapartum care that is empathic and encouraging, along with education about modes of birth, could help decrease cesarean birth rates.

The use of absorbable adhesion barriers to reduce the incidence of intraperitoneal adhesions at repeat cesarean delivery.

PURPOSE: We aimed to evaluate the effect of an absorbable adhesion barrier (oxidized regenerated cellulose) for the prevention of peritoneal adhesions in women undergoing repeat cesarean delivery (CD). METHODS: This is a retrospective, single center study that included all women who underwent two consecutive CDs, 2011-2018. Women in whom an absorbable adhesion barrier (oxidized regenerated cellulose) was placed at the time of the initial CD (index CD) were compared to women in whom no such barrier was placed. The association between absorbable adhesion barrier placement at index CD and the presence of intraperitoneal adhesions at subsequent CD was assessed. Factors evaluated included intraperitoneal adhesion severity, time from skin incision to newborn delivery and total duration of surgery. RESULTS: We identified 2125 women that met the inclusion criteria. They were divided into two groups; those in whom an absorbable adhesion barrier was placed at index CD and those in whom no such absorbable barrier was placed. 161 (7.6%) had an absorbable adhesion barrier placed at index CD. At the time of index CD, the rate of intra-peritoneal adhesions was 34.8% in the absorbable adhesion barrier group vs 26.5% in the group without the absorbable adhesion barrier (p = 0.02). At the time of subsequent CD, the rate of intraperitoneal adhesions was 39.8% in the absorbable adhesion barrier group vs 46% in the group without the absorbable adhesion barrier (p = 0.13). Notably, the use of an absorbable adhesion barrier lowered the mean increase in adhesions rate 0.05 ± 0.55 vs 0.20 ± 0.55 (p < 0.01). Absorbable adhesion barrier placement at index CD was found to be independently associated with a lower rate of intraperitoneal adhesions at subsequent CD, aOR 0.67 (0.47-0.96). Overall, absorbable adhesion barrier placement at index CD was associated with a shorter mean duration of subsequent surgery (min), 37.7 ± 18.9 vs. 42.7 ± 27.1 (p = 0.02). CONCLUSION: Absorbable adhesion barrier placement is associated with reduction in intraperitoneal adhesions and duration of surgery in subsequent CD.

A decade's experience in primipara, term, singleton, vertex parturients with a sustained low rate of CD.

Background Cesarean delivery (CD) in primiparas with a term singleton vertex fetus (PTSV) is a sentinel event for the future mode of delivery and determinant of repeat CD risk. We aimed to evaluate the risk factors for primary CD in a population with a decade of sustained low rate of intrapartum CD. Methods This was a retrospective single-center cohort study between 2005 and 2014. The primary outcome of the study was the mode of delivery. PTSV who attempted vaginal delivery were identified and categorized according to the mode of delivery: vaginal delivery vs. CD. Risk factors for intrapartum CD adjusted odds ratio (aOR) [95% confidence interval (CI)] in multivariate analysis were reported. Results During the study, 121,483 deliveries were registered; 26,301 (21.6%) PTSV were admitted in labor, of which 1944 (7.4%) had an intrapartum CD. Significantly in multivariate analysis, this group had a unique risk profile as compared to those who delivered vaginally; non modifiable risks included advanced maternal age: 3.06 (2.16-4.33), P < 0.001; prior multiple (≥3) miscarriages: 1.94 (1.04-3.62), P = 0.04; low (<6) modified admission cervical score: 2.41 (2.07-2.82), P < 0.001; low birth weight (BW): 1.42 (1.00-2.01), P = 0.05 or macrosomia: 2.38 (1.77-3.21), P < 0.001; modifiable risks included induction of labor: 1.79 (1.51-2.13), P < 0.001 and oxytocin labor augmentation: 8.36 (6.84-10.22), P < 0.001. Conclusion In a population of PTSV with a sustained low risk for intrapartum cesarean maintained by a strict labor management, induction of labor remains a significant and sole potentially modifiable risk factor for CD.

Assessment of maternal GBS colonization and early-onset neonatal disease rate for term deliveries: a decade perspective.

Objective To assess the maternal group B streptococcal (GBS) colonization rate and neonatal early-onset GBS (EOGBS) disease in term deliveries, a decade apart. Methods This was a retrospective computerized study between 2005 and 2016. A universal GBS culture-based approach gradually replaced the GBS risk-oriented screening. A vaginal-rectal culture taken at 35-37 weeks was recorded at admission for delivery. Results We identified 149,910 term deliveries during the study period. GBS status was recorded in 53,879 (35.9%) cases. The GBS screening rate constantly increased from 20% in 2005 to 47.5% in 2016. GBS colonization rates significantly decreased, from 50.3% in 2005 to 31.7% in 2016, P<0.001. Overall, EOGBS disease was diagnosed in 37 term neonates (0.25 per 1000 live births.). The rate of EOGBS in neonates decreased dramatically from 0.361 per 1000 deliveries between 2005 and 2009 to 0.19 per 1000 deliveries between 2010 and 2016 (P<0.05). During the latter period, over 35% of the deliveries were screened for GBS. Remarkably, 64.9% of the EOGBS originated in the non-screened population. Conclusion The universal screening policy was associated with a significant decrease in neonatal EOGBS and therefore should be adopted. Further national surveillance studies should be performed in order to validate this approach.

Correction to: Antenatal Management for Women with Inflammatory Bowel Disease: Experience from Our 'IBD MOM' Clinic.

The original version of the article unfortunately contained tagging error in first and family name of authors Ariella Bar-Gil Shitrit and Ami Ben Ya'acov. This has been corrected with this erratum.

Antenatal Management for Women with Inflammatory Bowel Disease: Experience from Our 'IBD MOM' Clinic.

BACKGROUND: Inflammatory bowel disease affects women during their reproductive years and thus pregnancy outcomes. IBD MOM is a multidisciplinary, single-center clinic established to benefit women with IBD and their neonates. AIM: The aim of this study was to evaluate the perinatal outcomes of the IBD MOM clinic patients compared to patients who attended antenatal and gastrointestinal disease community clinics (IBD CC). METHODS: This single-center, prospective study was conducted from 2011 to 2015. The primary outcome was cesarean delivery; secondary was adverse perinatal outcomes. In parallel, a new pregnancy-oriented, disease severity score was evaluated for its association with perinatal risk (score low = 0 to severe = 5). RESULTS: We identified 90 women in the IBD MOM clinic and 206 in the IBD CC. Maternal age, smoking habits, pregnancy complications, and type of IBD (CD/UC) were similar between groups. Rates of labor induction and birth weight were also similar between IBD MOM and IBD GI. The IBD MOM overall preterm delivery (PTD) rate (< 37 weeks) was significantly higher 18.9 versus 9.7% (P = 0.028). The IBD MOM group had a significantly higher IBD MOM disease severity score that correlated with a higher rate of PTD. The overall IBD MOM score and scores > 3 were significantly associated with PTD risk in both groups (P = 0.013 and P = 0.004, respectively). CONCLUSION: Women with moderate and severe IBD who attended a multidisciplinary clinic may benefit from this unique center. Healthcare planning policies can assume that costly, multidisciplinary clinics for women with IBD should be reserved for those with moderate and severe disease.

Prolonged operative time of repeat cesarean is a risk marker for post-operative maternal complications.

BACKGROUND: Repeat cesarean delivery (CD) accounts for approximately 15% of all annual deliveries in the US with an estimated 656,250 operations per year. We aimed to study whether prolonged operative time (OT; skin incision to closure) is a risk marker for post-operative maternal complications among women undergoing repeat CD. METHODS: We conducted a cross-sectional retrospective study in a single tertiary center including all women who underwent repeat CD but excluding those with cesarean hysterectomy. Prolonged OT was defined as duration of CD longer than the 90th percentile duration on record for each specific surgeon in order to correct for technique differences between surgeons. Bi-variate analysis was used to study the association of prolonged OT with each one of the following maternal complications: post-operative blood transfusion, prolonged maternal hospitalization (defined as hospitalization duration longer than 1 week post-CD), infection necessitating antibiotics, re-laparotomy within 7 days post-CD, and re-admission within 42 days post-CD. A multivariate regression analysis was performed controlling for maternal age, ethnicity, parity, number of fetus, gestational age at delivery, trial of labor after cesarean, anesthesia, and number of previous CDs. The adjusted odd ratio was calculated for each complication independently and for a composite adverse maternal outcome defined as any one of the above. RESULTS: A total of 6507 repeat CDs were included; prolonged OT was highly associated (P value < 0.000) with: post-operative blood transfusion (4.4% vs. 1.5%), prolonged hospitalization (8.4% vs. 4.0%), infection necessitating antibiotics (2% vs. 1%), and readmission (1.8% vs. 0.8%) when compared to control. The composite adverse maternal outcome was also associated with prolonged OT (20.2% vs. 11.2%, p < 0.000). These correlations remained statistically significant in the multivariate regression analysis when controlling for confounders. CONCLUSIONS: Among women undergoing repeat CD, prolonged OT (reflecting CD duration greater than 90th percentile for the specific surgeon) is a risk marker for post-operative maternal complications.

Epidural analgesia at trial of labor after cesarean (TOLAC): a significant adjunct to successful vaginal birth after cesarean (VBAC).

INTRODUCTION: Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes. MATERIALS AND METHODS: A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural "users" were compared to "non-users". Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators. RESULTS: Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural "users" 8.7% vs. "non-users" 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural "users" were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes. CONCLUSION: Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC.

Fetal Urine Production Rate in Preterm Premature Rupture of Membranes Is Associated with Adverse Neonatal Outcome: A Pilot Study.

AIM: In this study, we evaluate the associations between fetal urinary production rate (FUPR), measured by ultrasound, and adverse neonatal outcome in women with preterm premature rupture of membranes (PPROM). METHODS: We conducted a prospective pilot cohort of singleton pregnancies complicated by PPROM occurring at gestational week 24 or later managed until spontaneous labor (after 48 h of admission), chorioamnionitis, or induction by protocol at 35 + 0 weeks. FUPR was evaluated by 2D sonography at admission (corrected for gestational age). The main neonatal outcome measures were chorioamnionitis, placental inflammatory grading, first neonatal creatinine value, first neonatal dextrose value, length of neonatal intensive care unit (NICU) stay, necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH) (grades I-IV), blood transfusions, reduced neonatal urine production rate (<4 mL/kg/h), and early neonatal sepsis. Samples of maternal (at admission) and umbilical cord blood were analyzed for interleukin-6 (IL-6) level. RESULTS: The study included 38 women. Low FUPR was associated with clinical chorioamnionitis, longer NICU hospitalization (p = 0.01), higher rates of NEC or IVH (p = 0.008), and blood transfusion (p = 0.004). CONCLUSIONS: A finding of FUPR on in utero ultrasound examination in pregnancies complicated by PPROM may be indicative of adverse neonatal outcome.

Amniotic Fluid Embolism: A Rare Complication of Second-Trimester Amniocentesis.

Amniotic fluid embolism occurring following diagnostic amniocentesis is extremely rare. Only 2 cases have been reported in the English literature over the past 55 years, the most recent one approximately 3 decades ago. We present a case of amniocentesis at 24 weeks' gestation that was performed as part of an evaluation of abnormal fetal ultrasound findings. Immediately following amniotic fluid aspiration, maternal hemodynamic collapse occurred, initially diagnosed and treated as anaphylactic shock. Shortly after initial therapy, coagulopathy was noted and amniotic fluid syndrome suspected. Rapid response restored maternal hemodynamic stability; however, the fetus had suffered fatal damage.

New Israeli Sonographic Estimated Fetal Weight Growth Curves as Compared to Current Birth Weight Growth Curves: On What Should Diagnosis of Intrauterine Growth Disorders Be Based?

BACKGROUND: Two types of growth curves are commonly used to diagnose fetal growth disorders: neonatal birth weight (BW) and sonographic estimated fetal weight (EFW). The debate as to which growth curve to use is universal. OBJECTIVES: To establish sonographic EFW growth curves for the Israeli population and to assess whether the use of the BW growth curves currently adapted in Israel leads to under-diagnosis of intrauterine growth disorders. METHODS: Biometric data collected during a 6 year period was analyzed to establish sonographic EFW growth curves between 15-42 weeks of gestation for the Israeli population. Growth curves were compared to previously published sonographic EFW growth curves. A comparison with the Israeli BW growth curves was performed to assess the possibility of under-diagnosis of intrauterine growth disorders. RESULTS: Out of 42,778 sonographic EFW studies, 31,559 met the inclusion criteria. The sonographic EFW growth curves from the current study resembled the EFW curves previously published. The comparison of the current sonographic EFW and BW growth curves revealed under-diagnosis of intrauterine growth disorders during the preterm period. Four percent of the fetuses assessed between 26-34 weeks would have been suspected of being growth restricted; 2.8 percent of the fetuses assessed between 30-36 weeks would have been suspected of having macrosomia, based on the BW growth curves. CONCLUSIONS: New Israeli sonographic EFW growth curves resemble previously published sonographic EFW curves. Using BW growth curves may lead to the under-diagnosis of growth disorders. We recommend adopting sonographic EFW growth to diagnose intrauterine growth disorders.

Impact of surgeon annual volume on short-term maternal outcome in cesarean delivery.

BACKGROUND: The annual procedure volume is an accepted marker for quality of care and has been documented in various medical fields. Surgeon volume has been shown to correlate with morbidity and mortality rates in surgical and high-risk medical procedures. Although cesarean delivery is 1 of the most common surgical procedures in the United States, the link between a surgeon's annual cesarean delivery volume and maternal outcome has never been tested. OBJECTIVE: The purpose of this study was to evaluate the impact of a surgeon's annual volume on short-term maternal outcome in cesarean deliveries. STUDY DESIGN: We performed a retrospective cohort study in a single tertiary center between 2006 and 2013. Cesarean deliveries were categorized into 2 groups based on the annual volume of cesarean delivery of the attending obstetrician. The "low" group included obstetricians with a low annual volume, whose annual volume of cesarean delivery was lower than median. The "high" group comprised obstetricians with a high annual volume whose annual volume was at median and above. Further analyses were done for quartiles and for 4 clinical relevant groups according to the annual number of cesarean deliveries that were performed/supervised by the attending obstetrician (≤20, 21-60, 61-120, and >120). The primary outcome was a composite adverse maternal outcome that included ≥1 of the following outcomes: urinary or gastrointestinal tract injuries, hemoglobin drop >3 g/dL, blood transfusion, relaparotomy, puerperal fever, prolonged maternal hospitalization, and readmission. Secondary outcomes were operative times (skin incision to delivery and overall). RESULTS: A total of 11,954 cesarean deliveries were included; the median annual number of cesarean deliveries that were performed/supervised by 1 obstetrician was 48. Unadjusted analysis suggested that the patients in the high group had fewer urinary and gastrointestinal injuries (18/9278 [0.2%] vs 16/2676 [0.6%] injuries; P < .001), less blood loss as measured by hemoglobin drop >3 g/dL (1053/9278 [11.5%] vs 366/2676 [13.8%]; P < .001), and fewer cases of prolonged maternal hospitalization (80/9278 [0.9%] vs 39/2676 [1.5%]; P = .006). The rate of blood transfusion, relaparotomy, puerperal febrile morbidity, and readmission to hospital did not differ between groups. Multivariable regression analysis showed that cesarean delivery performed/supervised by the high group resulted in a significantly lower composite adverse maternal outcome (15.8% vs 18.9%; odds ratio, 0.86; 95% confidence interval, 0.78-0.95; P = .004). This was related primarily to a decreased frequency of urinary and gastrointestinal injuries, lower likelihood of hemoglobin drop >3 g/dL, and lower incidence of prolonged maternal hospitalization. Operative times were significantly shorter for the high group. Composite adverse maternal outcome ranged from 21.8% in the lowest quartile to 17.9% in quartile 2, to 17.4% in quartile 3, and 15.6% in quartile 4. quartile 4 served as the reference; quartile 3 had an odds ratio of 1.14 (95% confidence interval, 1.01-1.29; P = .029); quartile 2 had an odds ratio of 1.18 (95% confidence interval, 1.02-1.36; P = .021, and quartile 1 had an odds ratio of 1.51 (95% confidence interval, 1.14-1.99; P = .004) for composite adverse maternal outcome. Composite adverse maternal outcome ranged from 21.5% in clinical group 1 to 17.5% in clinical group 2, to 17.9% in clinical group 3, and 15.2% in clinical group 4 (P = .001). Cesarean delivery performed/supervised by clinical groups 2, 3, and 4 in comparison with clinical group 1 were associated with a statistically significant risk reduction, (23%, 25%, and 34% respectively). CONCLUSION: Maternal composite morbidity is decreased as the volume of cesarean deliveries that are performed or supervised by obstetricians increases.

The association between ABO blood group and obstetric hemorrhage.

UNLABELLED: Whether intra- and early post-partum hemorrhage is influenced by ABO blood groups remains unknown. Therefore, we compared women with O to non-O blood groups with regard to maternal post-partum hemorrhage and transfusion need. This retrospective study was conducted in a single tertiary center between 2005 and 2014. For the purpose of the study, parturients were categorized as O and non-O blood groups. Data included all deliveries but excluded patients with missing blood grouping or hemoglobin values, and/or stillbirth. Drop in hemoglobin was defined as hemoglobin concentration at admission for delivery minus lowest hemoglobin concentration post-delivery. Study outcomes were postpartum hemorrhage, hemoglobin drop >2-7 g/dL inclusive, and packed red blood cells transfusion. STATISTICS: descriptive, χ(2) (p < 0.05 significant) and multivariable regression models [odds ratio (OR), 95 % confidence interval (CI), p value]. 125,768 deliveries were included. After multivariable analysis, women with O blood type relative to women with non-O blood type had significantly higher odds of postpartum hemorrhage (OR 1.14; 95 % CI 1.05-1.23, p < 0.001), higher odds of statistically significant hemoglobin decreases of >2, 3, or 4 g/dL (OR 1.07; 95 % CI 1.04-1.11, p < 0.001, OR 1.08; 95 % CI 1.03-1.14, p = 0.002, OR 1.14; 95 % CI 1.05-1.23, p = 0.001; respectively), and higher odds, albeit not statistically significant of 5, 6, or 7 g/dL decreases in hemoglobin (OR 1.13; 95 % CI 1.00-1.29, p = 0.055, OR 1.05; 95 % CI 0.84-1.32, p = 0.66, OR 1.15; 95 % CI 0.79-1.68, p = 0.46; respectively), but no difference in blood products transfusion (OR 1.03; 95 % CI 0.92-1.16, p = 0.58). In conclusion, women with blood type O may be at greater risk of obstetrical hemorrhage.

Grouping Parturients by Parity, Previous-Cesarean, and Mode of Delivery (P-C-MoD Classification) Better Identifies Groups at Risk for Postpartum Hemorrhage.

Objective We aimed to create a clinical classification to better identify parturients at risk for postpartum hemorrhage (PPH). Method A retrospective cohort, including all women who delivered at a single tertiary care medical center, between 2006 and 2014. Parturients were grouped by parity and history of cesarean delivery (CD): primiparas, multipara, and multipara with previous CD. Each were further subgrouped by mode of delivery (spontaneous vaginal delivery [SVD], operative vaginal delivery [OVD], emergency or elective CD). In all, 12 subgroups, based on parity, previous cesarean, and mode of delivery, formed the P-C-MoD classification. PPH was defined as a decrease of ≥3 gram% hemoglobin from admission and/or transfusion of blood products. Univariate analysis followed by multivariate analysis was performed to assess risk for PPH, controlling for confounders. Results The crude rate of PPH among 126,693 parturients was 7%. The prevalence differed significantly among independent risk factors: primiparity, 14%; multiparity, 4%; OVD, 22%; and CD, 15%. The P-C-MoD classification, segregated better between parturients at risk for PPH. The prevalence of PPH was highest for primiparous undergoing OVD (27%) compared with multiparous with SVD (3%), odds ratio [OR] = 12.8 (95% confidence interval [CI],11.9-13.9). These finding were consistent in the multivariate analysis OR = 13.1 (95% CI,12.1-14.3). Conclusion Employing the P-C-MoD classification more readily identifies parturients at risk for PPH and is superior to estimations based on single risk factors.

Delivering elsewhere between the first and second deliveries is a risk marker for obstetric complications in the second delivery.

PURPOSE: We speculate that parturients who deliver elsewhere between the first and second deliveries compose a unique clinical group, characterized by higher rates of cesarean section (CS) both in the first and second deliveries, compared with parturients who deliver both deliveries at the same hospital. METHODS: A retrospective study conducted at Shaare Zedek Medical Center in a tertiary university-affiliated hospital. The cohort included all women in the second delivery, aged ≤24 years with a singleton pregnancy who delivered their second child in our medical center during 2010-2012. Parturients who delivered both the first and second children in our medical center ("stayers") were compared with parturients who delivered their first child in a different hospital ("switchers"). Groups were compared in regard to history of CS in the first delivery and obstetric complications in the second delivery, including CS, instrumental vaginal delivery (IVD), preterm delivery (PTD), and postpartum hemorrhage (PPH). Logistic regressions were constructed to study if delivering elsewhere between the first and second deliveries was a risk for adverse pregnancy outcome, followed by multivariate analysis controlling for confounders. RESULTS: In all, 4166 parturients were included: "stayers" = 3163 and "switchers" = 1003. History of CS in the first delivery was approximately twice as prevalent in "switchers" (12 versus 6.3 %, p < 0.000). "Switchers" experienced higher rates of CS: OR = 1.8 (95 % CI 1.2-2.3); IVD: OR = 1.3 (95 % CI 0.8-2.1); and PTD (<37w): OR = 1.4 (95 % CI 1.0-1.9). CONCLUSIONS: Parturients who deliver elsewhere between the first and second childbirth are at increased risk for CS and PTD in the second delivery; hence, the decision to deliver elsewhere after the first delivery should be considered as a risk marker for obstetric complication.