The preliminary estimate of total births in the USA for 2005 was 4,138,349. Intrapartum fetal heart-rate (FHR) monitoring was used in more than 85% of the deliveries. Fetal heart-rate monitoring was introduced into clinical practice in the 1970s. At that time, obstetric providers and researchers in fetal physiology believed electronic fetal monitoring (EFM) would identify changes in the FHR and/or rhythm that reflect fetal acidosis. It was presumed that detection would be early enough to allow clinical intervention that would prevent perinatal asphyxia. Despite 30 years of widespread use and multiple randomized clinical trials, FHR monitoring has not yet been shown to decrease perinatal mortality other than by decreasing intrapartum fetal deaths. Moreover, some experts believe that the use of EFM leads to over-detection of non-reassuring FHR patterns, thereby directly contributing to the escalating rate of cesarean-section deliveries in the USA, which by 2005 increased to 30.3%. We will review the physiology underlying FHR patterns, and the possible reasons why randomized trials of EFM have so far failed to demonstrate efficacy. The current knowledge that guides interpretation of EFM in the intrapartum period will be discussed, with special emphasis on newer methods for intrapartum fetal surveillance.

AIM:To compare the safety and efficacy of ultrasound- and physical examination-indicated cervical cerclage in twin versus singleton gestations. METHODS:A retrospective cohort study of all ultrasound-indicated (cervical length ≤ 25 mm) and physical examination-indicated cerclage cases performed over a 9-year period. The primary outcome was the time interval from cerclage placement to delivery. RESULTS:The study cohort included 94 singleton and 16 twin pregnancies. The time interval from cerclage placement to delivery was comparable in singleton and twin gestations (14.77 vs. 12.07 weeks, p = 0.11), as were the rates of preterm births before 28 and 32 weeks. The rate of alive newborns >24 weeks was lower in the twin group (71.9% vs. 88.3%, p = 0.028). Regression analysis identified that cervical dilation, but not twin gestation, was the only factor independently associated with an increased risk for birth before 32 weeks. CONCLUSION:Ultrasound-indicated and physical examination-indicated cerclage had comparable efficacy in prolonging pregnancy in twin and singleton gestations, though live birth rates were lower in twins.

OBJECTIVES:The French AmbUlatory Extraperitoneal Cesarean Section (FAUCS) is aimed at improving patients' birth experience and recovery. However, data are scarce regarding its maternal and neonatal safety. This study seeks to compare maternal and neonatal outcomes between FAUCS and conventional cesarean deliveries at term. METHODS:This was a retrospective cohort study involving women who underwent scheduled cesarean deliveries at term. We compared a total of 810 cases using the FAUCS technique with 217 cases using conventional cesarean deliveries. Surgical complications, adverse neonatal events, and maternal recovery parameters were compared. RESULTS:The incidence of overall surgical complications was comparable between the 2 groups, with rates of 1.97% for FAUCS and 1.85% for the conventional cesarean deliveries. The rates of specific complications such as bladder injury (0.1%), bowel injury (0.1%), blood transfusion (1.35%), and postpartum hemorrhage (1%) were consistent with existing literature. Neonatal outcomes, including neonatal acidemia and admission rates to the neonatal intensive care unit, were comparable between the groups and demonstrated favourable comparisons with previously reported data. Notably, women in the FAUCS group required less analgesia, with only 0.8% receiving morphine, as opposed to 38% in the control group. Furthermore, the FAUCS group demonstrated significantly quicker recovery, with 86% achieving autonomy and early discharge at their discretion within 48 hours after operation, in contrast to only 17% in the control group. CONCLUSIONS:When performed by experienced practitioners, FAUCS proves to be a safe procedure, with no increased risk for maternal or neonatal complications. Its significant benefits in terms of enhancing maternal recovery are noteworthy.

BackgroundPelvic floor fascial mobilization (PFFM) is an innovative intravaginal and/or intrarectal manual therapy technique developed to treat pelvic distress by improving fascial gliding and muscle function.AimThe effect of PFFM on pelvic floor distress during pregnancy was compared to conventional pelvic floor muscle training.MethodsA pilot prospective randomized clinical trial. The primary outcome was the strength and function of the pelvic floor muscles measured via the Oxford grading scale, perineometry, and hip range of motion. Each subject was treated twice, one week apart.ResultsForty multiparous pregnant women at 24-30 weeks gestation, with pelvic distress, were allocated to PFFM (study group (n=20)) vs. pelvic floor muscle training (control group (n=20)). There was no difference in the severity of pelvic distress between the study and control groups before the interventions (PFDI-20: 27.1±12.2 vs. 26.0±13.5, respectively, p=0.7). Twenty-six subjects completed the study protocol. PFDI-20 showed significant improvement: 42% improvement in the study group vs. 12% improvement in the controls (p=0.001 for both groups). Group-by-time interaction (Cohen's d) was significant after the first treatment session for Oxford score, right hip internal rotation range of motion, and cervical length in the PFFM group and for perineometry and right hip internal rotation at the end of the study.ConclusionsBased on this pilot randomized trial, PFFM may potentially and partially 1. alleviate symptoms, 2. improve pelvic floor function and strength, and 3. elongate the cervix after one or two treatment sessions. Further, a more extensive study is needed to confirm these results.

Objective: Retained placenta is a serious complication of vaginal birth. The ability to predict retained placenta may have positive effect on timely management. We aimed to evaluate the maternal and obstetric risk factors associated with retained placenta after singleton live vaginal birth Methods: A retrospective cohort of women who had retained placenta after singleton live vaginal birth ≥ 24 weeks, compared in 1:2 ratio with women who had normal vaginal delivery without complications. Study and control group were matched for maternal age, gestational age and parity. Multivariate regression analysis was performed to evaluate the potential risk factors for retained placenta including maternal and obstetrical characteristics Results: Fifteen thousand two hundred sixty women underwent vaginal delivery at our medical center between 2015-2022. One hundred seventy women (1.1%) were diagnosed with retained placenta. Ninety-nine women (0.65%) who met the inclusion criteria, were matched with 198 women (1.3%) as controls. Multivariate logistic regression revealed various potential risk factors not previously described as associated with retained placenta including: IVF pregnancy (OR 3.8, 95% CI [1.3- 11.7], P 0.018), preeclampsia (OR 4.5, 95% CI[1.1- 17.5 ],P 0.0315), women with large for gestational age fetus (OR 28.2, 95% CI [5.4- 148.5], P 0.0298),labor Induction (OR 21.8, 95%CI [5.5- 86.8],P <0.001), vacuum assisted vaginal delivery (OR 2.3 .95% CI [1.2- 4.5], P 0.011), and Duration of second stage > 3 hours (OR 3.9,95%CI [1- 15.1], P <0.001) Conclusion: Our study highlights unreported risk factors associated with retained placenta such as macrosomia , in vitro fertilization and endometriosis. This emphasis on early risk identification and the exploration of possible preventive measures holds promise for enhancing antenatal care practices, ultimately improving outcomes for both mothers and infants .

(Abstracted from Birth 2022;49:805–811 Meconium-stained amniotic fluid (MSAF) occurs in up to 52% of postterm pregnancies, 25% of term pregnancies, and 5% of pregnancies <37 weeks of gestation. As a sign of fetal maturity, MFAS may also help signal fetal distress.

Reducing failed labor and emergency cesarean section (CS) rates is an important goal. A childbirth simulation tool (PREDIBIRTH software and SIM37 platform) that evaluates a 5-min magnetic resonance imaging (MRI) assessment performed at 37 weeks of gestation was developed to enhance the consulting obstetrician's ability to predict the optimal delivery mode. We aimed to determine the potential value of this childbirth simulation tool in facilitating the selection of an optimal delivery mode for both mother and infant. A retrospective cohort study was performed on all patients referred by their obstetricians to our level 2 maternity radiology department between December 15, 2015 and November 15, 2016, to undergo MRI pelvimetry at approximately 37 weeks of gestation. The childbirth simulation software was employed to predict the optimal delivery mode based on the assessment of cephalopelvic disproportion. The prediction was compared with the actual outcome for each case. Including childbirth simulations in the decision-making process had the potential to reduce emergency CSs, inappropriately scheduled CSs, and instrumental vaginal deliveries by up to 30.1%, 20.7%, and 20.0%, respectively. Although the use of the simulation tool might not have affected the overall CS rate, consideration of predicted birthing outcomes has the potential to improve the allocation between scheduled CS and trial of labor. The routine use of childbirth simulation software as a clinical support tool when choosing the optimal delivery mode for singleton pregnancies with a cephalic presentation could reduce the number of emergency CSs, insufficiently justified CSs, and instrumental deliveries.

Abstract Background: The use of cervical cerclage in singleton gestations is a well-established method to prevent preterm birth. Although cervical cerclage is becoming more frequently used among twin pregnancies, it is still a matter of great controversy. The purpose of this study was to compare the safety and efficacy of physical examination- and ultrasound-indicated cervical cerclage in twin versus singleton gestations.Methods: A retrospective cohort study of all ultrasound (cervical length ≤25 mm) and physical examination indicated cerclage cases performed over a 9-year period. The primary outcome was the time interval from cerclage placement to delivery. Results: The study cohort included 100 singleton and 16 twin pregnancies. Time interval from cerclage placement to delivery was comparable in twin and singleton gestations (14.1 versus 16.3 weeks, p=0.11), as well as the rates of preterm births <28 and <32 weeks. The rate of alive newborns >24 weeks was lower in the twin group (62% versus 89%, p=0.045). Regression analysis identified that cervical dilation, but not twin gestation, was the only factor independently associated with increased risk for birth before 32 weeks.Conclusion: Ultrasound-indicated and physical examination-indicated cerclage in twin and singleton gestations have comparable efficacy.

OBJECTIVE Although ultrasonographic estimation of fetal weight ≥90th percentile is not associated with a greater risk for uterine rupture, trial of labor after cesarean delivery (TOLAC) is considered relatively contraindicated for macrosomic fetuses. Hence, when an estimated fetal weight of 4000g is detected, TOLAC is usually avoided.Our aim was to evaluate the obstetrical outcome and safety of TOLAC in women with estimated large for gestational age fetuses (eLGA) (≥90th percentile). STUDY DESIGN Our retrospective cohort study encompassed all pregnant women with an estimated fetal weight ≥90th percentile for gestational age, admitted to a single tertiary care center between January 2012-July 2017 for TOLAC. RESULTS 1949 women met the inclusion criteria; 78 (4%) eLGA and 1871 (96%) controls. Fifty-five (70.5%) women in the study group had experienced a successful vaginal delivery compared to 1506 (80.5%) of the controls (p= 0.03). The rate of obstetrical complications, including scar dehiscence, uterine rupture, a 3rd/4th degree perineal tear or shoulder dystocia were comparable. The rate of post-partum hemorrhage (PPH) increased in the study group compared to the controls (7.7% vs.1.7%; p=0.001). CONCLUSION TOLAC for eLGA fetuses can be considered safe, however, lower successful rates of vaginal births after a cesarean delivery and an increased PPH rate, may be expected.

Maternal docosahexaenoic acid (DHA) is required during pregnancy to supply for normal fetal growth and development. This pilot study aimed to assess the unknown fatty acid (FA) composition in a cohort of non-pregnant and pregnant Israeli women at term and their offspring on a normal diet without n-3 FA supplementation. The fatty acid profile, analyzed using gas chromatography, showed significantly higher plasma monounsaturated (MUFA) and lower n-6 FA percent distribution with similar n-3 index, in pregnant compared to non-pregnant women. RBC exhibited significantly higher MUFA with similar n-3 index, in pregnant compared to non-pregnant women. N-3 FA significantly correlated between neonates' plasma, with higher n-3 index, and pregnant women's DHA. Conclusion: DHA levels in non-pregnant and pregnant Israeli women at term were comparable and the DHA in pregnant women's plasma positively correlated with their neonate's level, suggesting an efficient mother-fetus FA transfer and/or fetal fatty acid metabolism to longer FA products.

Objectives: Reducing the rate of failed labor and emergency caesarean section is of vital significance. A childbirth simulation software tool based on 5 minutes’ magnetic resonance imaging (MRI) performed at 37 weeks’ gestation, used to enhance the consulting obstetrician’s ability to predict the optimal delivery mode. Here, we aimed to analyze the predictive ability of this childbirth simulation software tool for choosing the optimal delivery mode compared with not using it. Methods: A retrospective cohort study was performed on 401 patients referred by their obstetrician for MRI pelvimetry at approximately 37 weeks of gestation between December 15, 2015 and December 15, 2016. We employed a childbirth simulation software to predict the optimal delivery mode. Those results were compared with results from the actual delivery mode. Results: The rate of emergency caesarean sections, inappropriately scheduled caesarean sections, and instrumental vaginal deliveries would have been reduced by 30·1%, 20·7%, and 20%, respectively, had the predictions from the childbirth simulation software been considered. The use of the childbirth simulation software did not significantly affect the overall caesarean section rate, but it improved the allocation between scheduled and emergency caesarean sections. Conclusions: The routine use of the childbirth simulation software as a clinical support tool for choosing the optimal delivery mode of singleton pregnancies with a cephalic presentation could reduce the number of emergency caesarean sections, insufficiently justified Caesarean sections, and instrumental deliveries.

Introduction The aim of this study is to compare immediate and long-term obstetrical outcomes of patients who underwent cesarean delivery with and without uterine artery embolization (UAE) for the management of placenta accreta spectrum disorder. Material and methods A retrospective case control study including all pregnant women admitted to a single tertiary medical center between December 2001 and May 2018 with a diagnosis of placenta accreta spectrum disorder, who underwent cesarean delivery with and without UAE. Groups were compared for maternal characteristics, operative management, postoperative complication rate and long-term outcomes. Follow up on future obstetrical outcomes was conducted via telephone questionnaire. Non-parametric statistics were used. Results During the study period, 272 women met the inclusion criteria: 64 (23.53%) and 208 (76.47%) underwent preservative cesarean section with and without UAE, respectively. UAE procedure was associated with a longer operative time (82.5 [68-110] vs 50.5 [39-77] minutes; P = .001), and higher blood loss (2000 (1500-3000) vs 1000 (600-2000) mL; P = .001). Hysterectomy rate was comparable between the groups (9 [14%] vs 35 [16.82%]; P = .88); however, multivariate logistic regression analysis found UAE to be an independent factor associated with lower hysterectomy rate (P = .02). Postoperative complications were more frequent in the UAE group. Follow up was achieved in 29 (59.18%) and 72 (51.79%) of the women with and without UAE, respectively (P = .36). No differences were found in rate of abortions, pregnancy and deliveries between the groups. Conclusions Cesarean delivery using UAE in placenta accreta spectrum disorder is associated with a higher rate of operative and postoperative complications. Nevertheless, in cases of severe adherence of the placenta, embolization reduces the need for hysterectomy, allowing future fertility.

The aim of this study is to compare immediate and long-term obstetrical outcomes of patients who underwent cesarean delivery with and without uterine artery embolization (UAE) for the management of placenta accreta spectrum disorder. A retrospective case control study including all pregnant women admitted to a single tertiary medical center between December 2001 and May 2018 with a diagnosis of placenta accreta spectrum disorder, who underwent cesarean delivery with and without UAE. Groups were compared for maternal characteristics, operative management, postoperative complication rate and long-term outcomes. Follow up on future obstetrical outcomes was conducted via telephone questionnaire. Non-parametric statistics were used. During the study period, 272 women met the inclusion criteria: 64 (23.53%) and 208 (76.47%) underwent preservative cesarean section with and without UAE, respectively. UAE procedure was associated with a longer operative time (82.5 [68-110] vs 50.5 [39-77] minutes; P  = .001), and higher blood loss (2000 (1500-3000) vs 1000 (600-2000) mL; P  = .001). Hysterectomy rate was comparable between the groups (9 [14%] vs 35 [16.82%]; P  = .88); however, multivariate logistic regression analysis found UAE to be an independent factor associated with lower hysterectomy rate ( P  = .02). Postoperative complications were more frequent in the UAE group. Follow up was achieved in 29 (59.18%) and 72 (51.79%) of the women with and without UAE, respectively ( P  = .36). No differences were found in rate of abortions, pregnancy and deliveries between the groups. Cesarean delivery using UAE in placenta accreta spectrum disorder is associated with a higher rate of operative and postoperative complications. Nevertheless, in cases of severe adherence of the placenta, embolization reduces the need for hysterectomy, allowing future fertility.

Objective Pelvic Floor Fascial Mobilization (PFFM) is an innovative intervention to improve pelvic floor dysfunction. Design Pregnant women at 24-30 weeks gestation, complaining of pelvic pain, and or stress urinary incontinence, were prospectively randomized to PFFM (study group) vs. pelvic floor muscle training (PFMT). Strength and function of the pelvic floor muscles was compared before and after interventions. Setting- Outpatient pregnancy clinic at a tertiary medical center Sample- 40 women randomly allocated to PFFM or PFMT Methods Each patient was treated twice, one week apart and was assessed immediately before and after each intervention, and one week after the second treatment. Main Outcome Measures PFDI 20 questionnaire , Oxford grading scale, perineometry to measure pelvic floor symptoms function and strength, transvaginal ultrasound cervical length Results PFFM group Oxford scale improved from 2.65±1.18 to 3.45±1.28 after the first session (p<0.001) with no difference in the PFMT group 3.40±1.05 vs 3.40±1.05 (p=1). Cervical Length elongated in the PFFM group after one treatment (39.8±6.5 vs 43.4±10.2 mm, p<0.05, but not in the PFMT group 40.9±6.7 vs 40.0±8.6 respectively (p=n.s). Among 26 participants who lasted the entire study – PFMT was associated with more than 40% improvement in both Oxford as well as PFDI-20 and Perineometry was improved by 23% (23.13±15.15 vs 28.58±16.07 cmH2O (p<0.05) while no such difference was found with PFMT; 30.03±12.73 vs 30.25±9.61 cmH2O respectively (p=n.s). Conclusions PFFM may improve pelvic floor function and strength, alleviate symptoms and elongate the cervix. Further bigger study is needed to better evaluate this method.

Extra peritoneal French Ambulatory Cesarean Section (FAUCS) has evolved in order to improve maternal well-being. Modified FAUCS (mFAUCS) technique includes a paramedian vertical incision of the fascia, paramedian separation of the rectus muscle with sparing of linea alba and intraperitoneal low segment transverse uterine incision. The objective of our trial was to compare maternal recovery after mFAUCS vs. standard cesarean section (CS). In this double-blind randomized controlled trial, women undergoing an elective CS at term were allocated into mFAUCS vs. standard CS. The protocol for all patients included decreased fluid load and avoidance of urinary catheter, spinal anesthesia with no use of morphine, continuous phenylephrine to avoid anesthesia-related hypotension, active participation of the mother in "abdominal birth" by the use of a blowing mouth piece, immediate skin to skin contact and skin closure using intradermal sutures and glue. Postoperative protocol included early eating, mobilization after 3-4h, and Paracetamol q8h and Ibuprofen q6h for the first 24h. The primary outcome was the composite of VAS > 6 at 3-4h, inability to walk at 3-4h, and Quality of Recovery score of < 90 at 24h. Secondary maternal and neonatal outcomes were recorded up to 6 weeks. 116 women were included (58 in each group). A trend in composite maternal outcome was noted in favor of mFAUCS group vs. standard CS: 21/54 (38.9%) vs. 28/52 (53.8%), respectively (p=0.1724). In both groups over 90% of the women were able to get up and walk 3-4h after the CS. Secondary outcomes did not differ between the two groups, except for longer operation duration in mFAUCS group (54.4±11.3 vs. 43.7±11.2 minutes in the standard CS group, p< 0.0001). mFAUCS may benefit maternal recovery. Active participation of the mother in the labor process, altered anesthesia, modified fluids and pain management protocols, as well as lack of bladder catheter and early mobilization, may explain early maternal recovery in standard CS group.

Introduction: Computed tomography (CT) imaging should be employed judiciously, given its cost, use of intravenous contrast, and ionizing radiation. The aim of this study was to determine the clinical benefit of a CT scan in the evaluation of refractory puerperal fever and to identify the appropriate candidates for its use. Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2007 to April 2017. Indications for CT scan were refractory postpartum fever of >= 3 days and/or ultrasound findings suggesting complex abdominal fluid collection. Primary outcome was defined as a change in the mode of treatment due to the CT findings. In addition, a multivariate analysis of risk factors for puerperal fever was performed to identify patients who would benefit from the CT scan evaluation. Results: There were 520 women that underwent an abdominal and pelvic CT scan during the study period, 238 (45.7%) met inclusion criteria, 94 (39.5%) had a normal CT scan, and 144 (60.5%) had abnormal findings including 32 (13.4%) cases with pelvic thrombophlebitis and 112 (47%) cases with pelvic fluid collections. Results of the CT changed clinical management in 93 (39.0%) patients, including: switching antibiotics in 24 (10%) patients, adding low molecular weight heparin for 28 (11.8%) patients, and surgical intervention (laparotomy or drainage insertion) in 41 (17.2%) patients. In the regression model, we didn't find any significant risk factors associated with treatment change following the CT scan. Conclusions: Abdominal and pelvic CT scan in women with refractory puerperal fever has a high clinical yield and lead to a change in management in a substantial number of patients.

Objective: Prediction of success of trial of labor after cesarean delivery (TOLAC) is of major importance. We investigated the impact of polyhydramnios on the success rate of TOLAC. Study design: A retrospective cohort study of all women with singleton pregnancies >= 34th weeks of gestation who underwent TOLAC after one previous cesarean delivery, between 2011 and 2016 in a single tertiary care center. Polyhydramnios was defined as amniotic fluid index >= 240 mm. Primary outcome was defined as the rate of successful TOLAC. Results: 31,245 women gave birth during the study period, of them 1637 (5.3 %) women underwent TOLAC and met inclusion criteria. 39 (2.4 %) women with polyhydramnios were compared to a control group of 1598 (97.6 %) women with amniotic fluid index < 240 mm. Polyhydramnios significantly reduced the rate of successful TOLAC: 69.2 % (27/39) in the study group compared to 85.8 % (1371/1598) in the control group (P = 0.009). In a subgroup analysis based on amniotic fluid index, women with AFI > 270 mm had substantially lower TOLAC success rate [9/19 (47.4 %) vs 18/20 (90 %); P = 0.006]. There was no difference in the rate of uterine rupture between the groups (0/39 (o%) vs 9/1598 (0.56 %); P = 0.64). Logistic regression analysis revealed that polyhydramnios remained significantly associated with higher rates of cesarean delivery [OR 3.09 (95 % CI, 1.37-6.98)] after adjustment for confounding factors. Conclusion: Polyhydramnios was associated with significantly reduced TOLAC success rate with no statistical difference in the rate of uterine rupture. This information should be considered in physician counseling. (C) 2020 Elsevier B.V. All rights reserved.

Objective Pelvic Floor Fascial Mobilization (PFFM) is an innovative intervention to improve pelvic floor dysfunction. Design Pregnant women at 24-30 weeks gestation, complaining of pelvic pain, and or stress urinary incontinence, were prospectively randomized to PFFM (study group) vs. pelvic floor muscle training (PFMT). Strength and function of the pelvic floor muscles was compared before and after interventions. Setting- Outpatient pregnancy clinic at a tertiary medical center Sample- 40 women randomly allocated to PFFM or PFMT Methods Each patient was treated twice, one week apart and was assessed immediately before and after each intervention, and one week after the second treatment. Main Outcome Measures PFDI 20 questionnaire , Oxford grading scale, perineometry to measure pelvic floor symptoms function and strength, transvaginal ultrasound cervical length Results PFFM group Oxford scale improved from 2.65±1.18 to 3.45±1.28 after the first session (p<0.001) with no difference in the PFMT group 3.40±1.05 vs 3.40±1.05 (p=1). Cervical Length elongated in the PFFM group after one treatment (39.8±6.5 vs 43.4±10.2 mm, p<0.05, but not in the PFMT group 40.9±6.7 vs 40.0±8.6 respectively (p=n.s). Among 26 participants who lasted the entire study – PFMT was associated with more than 40% improvement in both Oxford as well as PFDI-20 and Perineometry was improved by 23% (23.13±15.15 vs 28.58±16.07 cmH2O (p<0.05) while no such difference was found with PFMT; 30.03±12.73 vs 30.25±9.61 cmH2O respectively (p=n.s). Conclusions PFFM may improve pelvic floor function and strength, alleviate symptoms and elongate the cervix. Further bigger study is needed to better evaluate this method.