Duration and optimal management of prolonged second stage (P2S) in the primipara is still controversial and represents a source for primary cesarean deliveries. We assessed maternal and neonatal outcome when the second stage of labor was prolonged according to American College of Obstetricians and Gynecologists guidelines. Electronic medical record data from a retrospective cohort (2005–2022) at a tertiary medical center. All nulliparous births with term live singleton vertex fetus that reached full dilation were included. P2S was defined: with epidural > 3 hours, without > 2 hours. Statistics: Comparisons, adjusted multivariate model; Odds Ratio (OR 95%CI), p< 0.05 Study population included 55309 primiparous deliveries who reached full dilation. P2S occurred in 13.1% of nulliparas, with and without an epidural. Cesarean delivery rates with P2S compared to normal second stage (N2S) were 8.5% vs. 0.8% respectively. Vaginal delivery and assisted vaginal delivery rates were 48.4% vs. 85.6% and 43.1% vs. 13.6% for P2S compared to N2S, respectively. P2S was associated with higher maternal and neonatal morbidity when compared to N2S including PPH (1.1% vs 0.8%), and third-degree or fourth-degree perineal lacerations (1.8% vs 1.0%), Shoulder Dystocia (0.5% vs. 0.1%), NICU admissions >72 hours (3.6% vs. 2.4%), clavicular fracture (0.7% vs. 0.4%) and Apgar score at 5 minutes < 7 (1.3% vs. 0.7%), p< 0.0001 for all. Arrest of descent was the leading indication for CD. Multivariate analyses revealed independent association (OR 2.2 95% CI [2.1-2.4] between prolonged second stage and higher rates of composite maternal adverse outcome (27.9% vs. 13.6%), and composite neonatal adverse outcome 16.8% vs. 11%, p< 0.0001 for all. P2S for primiparous women at term, according to the traditional definition, is associated with adverse maternal and neonatal outcomes. Even with the benefits of increased rate of vaginal delivery, implementation of new relaxed guidelines for 2nd stage of labor might lead to additional health costs.

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.

Hemostatic agents were found to be associated with post-cesarean infections in general and endometritis specifically. We aim to evaluate the association between a hemostatic agent used at the time of cesarean delivery to uterine scar rupture or dehiscence at the subsequent trial of labor. A multicenter retrospective cohort study of women who underwent their first trial of labor after cesarean delivery between 2005 and 2021. Women with a singleton pregnancy in whom a hemostatic agent was placed at the time of the index cesarean were compared to women in whom no such agent was placed. The primary outcome of this study was the rate of uterine rupture or dehiscence. Secondary outcomes were adverse maternal and neonatal outcomes. Univariate analyses were followed by multivariate analysis (adjusted Odds Ratio (aORs); [95% Confidence Interval]). During the study period, 7204 women underwent a trial of labor and met inclusion and exclusion criteria, of whom 431 (6.0%) had prior use of a hemostatic agent and 6773 (94.0%) didn't. History of the use of hemostatic agent wasn't found to be significantly associated with uterine scar rupture (0.9% vs. 0.4%, p=0.15) or dehiscence (0.9% vs. 0.5%, p=0.21). Moreover, we found no differences between the study groups in any maternal or neonatal parameter examined (Table 1). This was confirmed on multivariate analysis as well [aOR 1.95 (0.67–5.69), p = 0.22] for uterine rupture (Table 2). Amongst women undergoing a trial of labor, a history of hemostatic agent use confers no additional risk than no use. Further prospective studies in other settings to strengthen these findings are needed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective: To investigate the impact of parity-customized versus population-based birth weight charts on the identification of neonatal risk for adverse outcomes in small (SGA) or large for gestational age (LGA) infants compared to appropriate for gestational age (AGA) infants. Study design: Observational, retrospective, cohort study based on electronic medical birth records at a single center between 2006 and 2017. Neonates were categorized by birth weight (BW) as SGA, LGA, or AGA, with the 10th and 90th centiles as boundaries for AGA in a standard population-based model adjusted for gestational age and gender only (POP) and a customized model adjusted for gestational age, gender, and parity (CUST). Neonates defined as SGA or LGA by one standard and not overlapping the other, are SGA/LGA CUST/POP ONLY. Analyses used a reference group of BW between the 25th and 75th centile for the population. Results: Overall 132,815 singleton, live, term neonates born to mothers with uncomplicated pregnancies were included. The customized model identified 53% more neonates as SGA-CUST ONLY who had significantly higher rates of morbidity and mortality compared to the reference group (OR = 1.33 95% CI [1.16–1.53]; p < 0.0001). Neonates defined as LGA by the customized model (LGA-CUST) and AGA by the population-based model LGA-CUST ONLY had a significantly higher risk for morbidity compared to the reference (OR = 1.36 95% CI [1.09–1.71]; p = 0.007) or the LGA POP group. Neonatal mortality only occurred in the SGA and AGA groups. Conclusions: The application of a parity-customized only birth weight chart in a population of singleton, term neonates is a simple platform to better identify birth weight related neonatal risk for morbidity and mortality.

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.

Duration of labor in primiparas is significantly longer in comparison to multiparas. We aimed to study if the first delivery birthweight is associated with the duration of subsequent spontaneous vaginal birth. A retrospective study (2005-2021). Women with singleton spontaneous second birth who had the first two consecutive deliveries in our medical center were included. Women with previous cesarean delivery and multifetal gestation in each birth were excluded. Multiparas in second delivery were sub-grouped based on first delivery birth weight (grams): < 1,000, 1000-1500, 1500-2000, 2000-2500, 2500-3000, 3000-3500 (reference group), 3500-4000, >4000. Duration of labor, the first stage of labor, and the second stage of labor were compared between the different sub-groups and the reference group, additional comparison was made to primiparas. Univariate analyses and Kaplan-Meier analyses were performed. A total of 33,885 first deliveries and 22,765 second deliveries were included in the study. Mean duration of labor, duration of the first and second stage were significantly longer in parturients at second delivery following a first delivery birthweight < 1000 grams compared to following a first delivery birthweight 3,000-3,500 grams (reference group), 5.4±3.8 versus 2.9±2.4 hours (duration of labor), 4.3±2.8 versus 2.5±2 hours (duration of 1st stage), 41.4±41.5 versus 16.2±18.9 minutes (duration 2nd stage), p< 0.001 for all, Table. In addition, mean duration of labor (5.4±3.8 versus 6±3.6 hours, p=0.29) and the duration of the first stage of labor (4.3±2.8 versus 4.4±2.9 hours, p=0.79) were similar between parturients at second delivery following a first delivery birthweight < 1000 grams and parturients at first delivery. Parturients at second delivery following a first delivery birthweight < 1000 grams have a similar duration of labor and especially the first stage of labor as primiparous and longer labor in comparison to other multiparous. Health care providers should expect that when managing labor in this subgroup of parturients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

To evaluate the maternal and neonatal outcomes of parturients attempting trial of labor (TOL) after two previous CD versus those who had an elective third repeat CD A retrospective computerized database cohort study was conducted at a single tertiary center between 2005-2019. Maternal and neonatal outcomes were compared between parturients attempting TOL after two CD versus parturients opting for elective third repeat CD. TOL after two CD was allowed only for those who met all the criteria of our departments' protocol; briefly, maternal request, previous 2 documented low segment CD, at 1 previous vaginal delivery, estimated fetal weight < 4000 gr and spontaneous onset and progress of labor. Parturients with identified contraindication to vaginal delivery were excluded from the analysis. A univariate analysis was conducted and was followed by a multivariate analysis. A total of 2719 eligible births following two CD were identified, of which 485 (17.8%) had attempted TOL. Successful vaginal delivery rate following two CDs was 86.2%. Uterine rupture/dehiscence rates were higher among those attempting TOL (0.6% vs 0.1% p=0.04). However, rates of hysterectomy, re-laparotomy, blood product infusion and intensive care unit admission did not differ significantly between the groups. Neonatal outcomes following elective repeat CD were less favorable (specifically, neonatal intensive care unit admission and composite adverse neonatal outcome). Nonetheless, when controlling for potential confounders (especially gestational age at delivery), an independent association between composite adverse neonatal outcome and an elective repeat CD was not demonstrated. In a subgroup analysis, diabetes mellitus and hypertensive disorders of pregnancy were found independently associated with failed TOLAC. TOL after two CD, under a strict protocol, is a safe alternative to elective repeated CD and associated with comparable maternal and neonatal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Introduction: Intraperitoneal closed suction drains are occasionally placed during cesarean delivery. This study aims to ascertain the prevalence, associated factors, outcome, and risks of intraperitoneal closed-suction drain placed during cesarean delivery. Material and methods: A retrospective cohort study of all women undergoing cesarean delivery in a single center from 2005 to 2015. We excluded cases of cesarean hysterectomy and women who had hollow viscus injury. Cesarean deliveries were categorized into two groups based on intraperitoneal drain use: drain?+?and drain?.The study aims were to describe: (1) drain use prevalence; (2) factors associated with drain use; (3) interval to relaparotomy due to intraperitoneal bleeding and outcome of drain use; and (4) unique drain-related adverse outcome. Statistics: univariate, multivariable, and inverse probability treatment weighting (IPTW) analysis. Results: After applying the inclusion and exclusion criteria, 16?581 (99.3%) cesareans were included. An intraperitoneal drain was used in 1264 (7.6%) cesareans, ranging from 4.4 to 18.8% in women with no and four or more cesareans, respectively. Comparing the drain?+?and drain- groups, multivariable analysis revealed that the factors associated with the use of a drain included (OR, 95%CI) uterine rupture (5.14, 3.15?8.38), intrapartum fever (2.65, 1.87?3.75), previous cesareans (2.29, 2.00?2.68), second-stage cesarean (2.21, 1.64?2.74), preterm delivery (1.89, 1.63?2.19), spontaneous onset of labor (1.42, 1.24?1.63), and maternal age greater than 35?years (1.35, 1.19?1.54); p?<?.001 for all. Of the forty-four women (0.27%) who underwent relaparotomy for intraperitoneal bleeding, there were fourteen in the intraperitoneal drain group. Inverse probability treatment weighting analysis demonstrated that median (interquartile range) times (hours) to relaparotomy were significantly shorter in the drain?+?group [3.5 (3.3?10.0) versus 12.5 (7.9?15.6), p?<?.001] and that puerperal fever incidence was higher in the drain?+?group (2.2 vs. 1.4%, p?<?.001). The incidence of relaparotomy to remove a retained drain or drain fragment was 0.48% (6/1264). Conclusions: Drain use in our study resulted in a shorter time to relaparotomy for intraperitoneal hemorrhage. However, it was associated with a higher risk for puerperal fever and a 0.5% risk for relaparotomy for removal of the drain.KEY MESSAGE Intraperitoneal drain placed during cesarean is used more often in complicated surgeries and is associated with a shorter interval to relaparotomy.

Objective Fetal growth restriction is suspected when the estimated fetal weight is <10th percentile for gestational age. Using a regional sonographic estimated fetal weight growth curve to diagnose fetal growth restriction has no known benefits; however, the traditional approach of using birthweight curves is misleading, since a large proportion of preterm births arise from pathological pregnancies. Our aim was to compare the diagnostic accuracies of sonographic versus birthweight curves in diagnosing fetal growth restriction. Our secondary aim was to compare maternal, fetal and neonatal outcome based on these two approaches. Methods Retrospective study based on computerized medical records. Included were women with a singleton pregnancy, that underwent fetal biometry between 24 and 36.6 weeks' gestation (January 2010-February 2016) and delivered in our center. Each pregnancy was assigned to one of three groups based on the earliest sonographic estimated fetal weight performed: G1-Appropriate for gestational age, G2-fetal growth restriction based on sonographic but not birthweight curves; or G3-fetal growth restriction based on birthweight growth curves. Demographics, obstetric characteristics, ultrasound data, and neonatal data were retrieved and compared between groups. Primary outcome: rate of small for gestational age neonates in each group. Secondary outcomes were various adverse maternal and neonatal outcomes. Results Six thousand and five pregnancies met inclusion criteria. Of these 5386 (89.6%) were categorized as G1, 300 (5%) as G2 and 319 (5.3%) as G3. The rate of small for gestational age neonates differed significantly between groups: G1 9.2%, G2 39.7% and G3 70%. Multivariable logistic regression modeling reiterated these rates: the odds ratios for small for gestational age were 6.47 [95% CI 4.99-8.40] and 23.99 [95% CI 18.26-31.51] for G2 and G3 respectively. Prediction of small for gestational age based on sonographic EFW curves increased the sensitivity for detection of SGA from 26% to 41% with a slight decrease in specificity from 98% to 95%, and a decrease of the positive likelihood ratio from 18.4 to 7.7, however there was no significant change in the overall test accurcy; 88.5% to 87.1%. Secondary outcomes also differed between groups: G2 and G3 had similar rates of maternal and neonatal morbidities and most parameters were higher than G1. G2 and G3 showed lower mean gestational age at delivery (36.2 weeks and 35.9 weeks vs.37.8; p < .0001), and higher rates of preterm delivery (40% and 51.7% vs. 21.5%; p < .001), as well as higher rates of intrauterine fetal demise 3% in G2, 6.9% in G3 and 0.9% in G1, p < .0001. Conclusion Pregnancies that are currently managed as appropriate for gestational age based on birthweight curves, but classified as growth restricted when prenatal sonographic curves are used, are associated with higher rates of small for gestational age and poor perinatal outcomes, at rates comparable to pregnancies that are classified as growth restricted based on birthweight curves. Furthermore, applying sonographic curves increases the sensitivity for detection of small for gestational age neonates. Consequently, consideration should be given to the use of sonographic biometry curves for defining fetal growth restriction.

Objective: Parturients in second delivery undergoing vaginal birth after cesarean (VBAC) are divided to those who had their cesarean delivery (CD) while in labor as opposed to those who had an elective CD. We aimed to study if the stage of labor that was present during the primary CD is associated with the duration of subsequent spontaneous VBAC. Methods: A retrospective study (2006-2014). Multiparas in second delivery with a history of a CD (P2-VBAC) were sub-grouped based on stage of labor at which the CD was performed in the first delivery; elective, latent, first or second stage of labor, Duration of labor was compared between P2-VBAC (as one group and further as the sub-groups) to primiparas (P1), multiparas in second (P2) and third (P3) vaginal delivery (VD). A Cox regression analysis was performed including maternal age, preterm-delivery, regional anesthesia, oxytocin augmentation, birthweight and neonatal gender. Results: A total of 58,028 parturients were included in the study. Mean duration of labor was significantly longer in parturients with a first VD (P1 and P2-VBAC) compared to repeat VD (P2 and P3), 6.0 versus 2.5 h, respectively, (P < 0.001). Analyzing duration of labor by the sub-groups of P2-VBAC revealed that spontaneous VD following a second-stage CD was associated with shorter duration of labor when compared with spontaneous VD following elective, latent and active first stage CD 4.2 versus 6.3, 7.0, 6.9 h respectively, p<0.001. Conclusion: Second stage CD shortens duration of the following VBAC compared to those who underwent cesarean in earlier stages of labor. (C) 2020 Elsevier B.V. All rights reserved.

Jaundice is the most common cause of readmission for term neonates. We aimed to evaluate the use of a novel combined technique to predict an early individualized probability score for term neonatal jaundice (NJ), in a large heterogeneous population. We used a machine learning algorithm (gradient boosting model - GBM), including multiple unselected clinical and laboratory data available prior and during birth to predict an individualized probability score for NJ in a single center; 2005-2018. Model accuracy was evaluated by ROC Curve (AUC) ;10-fold cross validation. Next, multivariable logistic models were applied to check for significance, magnitude and direction of the associations identified by the GBM algorithm. We identified 147,667 consecutive term live neonates delivered vaginally; 6,093 (4.12%) diagnosed with NJ. GBM AUC to predict NJ was 0.76±0.03 (Fig). The most important features used by the GBM (in order of importance/weight): maternal blood type, gestational age at delivery, duration of labor, BW, maternal age, maternal blood pressure and CBC at admission. Next, we fitted multivariable regression models. We identified within the "blood group", that maternal blood type O (- and +) was independently and significantly associated with an increased rate of NJ; OR=5.13 95% CI [4.77-5.52]; P< 0.0001. Markedly, an additional model based on the same algorithm and applied on a subgroup of very low risk population for NJ (excluded known risks factors for NJ; SGA, hypertensive disorders, previous cesarean, induction of labor; n=62,756) strengthened even more the association between maternal blood type O and NJ: OR=8.88 95% CI [7.7-10.2]; p< 0.0001. AUC=0.75 95% CI [0.74-0.76] (Table). We present a novel implementation of the GBM algorithm that achieved high accuracy in early prediction of term NJ. This model, using features routinely measured before and during labor, without need for neonatal blood bilirubin level, can identify neonates with high risk for NJ ; potentially alleviating the need for the routine bilirubin test while maintaining low readmission rates.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

OBJECTIVE:To evaluate success rates of vaginal birth after cesarean (VBAC) and maternal and neonatal outcomes associated with trial of labor after cesarean in grand multiparous women. STUDY DESIGN:A retrospective computerized data base study was conducted at a single tertiary center, between 2005 and 2019. The study compared the maternal and neonatal outcomes of trial of labor after cesarean delivery in grand multiparous women (parity ≥ 6) as compared to multiparous women (parity: 3-5). Comparison analysis was performed by univariate analysis and followed by adjusted multiple logistic regression models. RESULTS:During the study period we identified 2749 and 4294 cases of trial of labor after cesarean in grand multiparous and multiparas, respectively. VBAC was observed in 94.6% of the grand multiparous as compared to 96.5% in the multiparous group, p < .01. The grand multiparous group had a higher rate of postpartum hemorrhage (3 vs. 2.2%, p = .03) and prolonged postpartum hospitalization (1.4 vs. 0.7%, p < .01). The rates of uterine rupture (0.3 vs. 0.2%, p=.50), peripartum hysterectomy (0.1 vs. 0%, p = .33) and adverse neonatal outcomes were comparable between the groups. CONCLUSION:Trial of labor after cesarean in grand multiparous women is associated with favorable maternal and neonatal outcomes. Consideration and awareness should be given for the increased risk for postpartum hemorrhage, not associated with uterine rupture.

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.

Introduction: Disseminated intravascular coagulation following single fetal demise in a twin pregnancy is a rare event. As such, the diagnosis and management of such cases are complicated and require the assistance of various laboratory tests. Case: 26 years old patient, carrying dichorionic diamniotic twin pregnancy was complicated by single fetal demise at 21+6 weeks and preterm premature rupture of membranes (PPROM) at 24+5 weeks. Pregnancy was managed conservatively until 30+4 weeks gestation when abnormal laboratory tests including dysfibrinogenemia and pathological thromboelastogram (TEG) indicated the development of disseminated intravascular coagulopathy (DIC) while the patient remained asymptomatic. A multidisciplinary team decided on prompt delivery by cesarean section. Cesarean delivery (CD) was uneventful, yet post-operative course was complicated by worsening laboratory tests and post-partum hemorrhage that were treated by uterotonics and blood products resulting in clinical and laboratory normalization. Conclusion: DIC following single fetal demise in a twin pregnancy is rare. A new laboratory test, TEG, may aid in diagnosis and management of DIC.

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.

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). 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. 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). Absorbable adhesion barrier placement is associated with reduction in intraperitoneal adhesions and duration of surgery in subsequent CD.

To assess whether non-diabetic women who delivered a macrosomic infant are at higher risk for gestational diabetes mellitus (GDM) in their next pregnancy. Retrospective study based on computerized records in a single large university medical center. All women who had a singleton pregnancy with documented GDM status and subsequent delivery in our medical center between 2005 and 2017 were included. Women with pre-gestational diabetes or GDM were excluded. Unpaired student T-test was used to assess associations between newborn birthweights and maternal characteristics. Multivariable logistic model was conducted to assess the independent role of macrosomia on the risk of GDM at the next pregnancy. All tests are two-sided. P value below 0.05 was considered statistically significant. A total of 31,861 women met inclusion criteria. Overall rate of GDM in the next pregnancy was 2.1% (670 women). Parturients with GDM in the next pregnancy had significantly higher mean levels of birthweight in their index pregnancy in comparison to parturients without GDM in the next pregnancy (3343.7±539 vs. 3254.5±461 grams, respectively, p=0.024). Higher rates of GDM in next pregnancy were found among women who delivered neonates above 3620 grams (Figure 1). Univariate analysis revealed that GDM rates were significantly higher among women who previously delivered a macrosomic infant (> 4000 gram) in comparison with neonatal birthweight < 4000 gram (4% vs. 2%, respectively, p< 0.0001). Multivariate analysis controlling for known risk factors for GDM demonstrated that deliveries of macrosomic infants in index delivery were independently associated with higher rates of GDM in the next pregnancy (1.51, 95% CI 1.08-2.11, p=0.016). Delivery of a macrosomic infant among non-diabetic mothers is associated with increased risk of future GDM. Intervention efforts directed at this particular subgroup of women should be applied, with special attention to potentially modifiable risk factors in order to minimize the risk for future GDM.

Objective: Over the past few decades, the rate of repeat cesarean deliveries (CD) have taken on pandemic proportions. As part of the global effort to reduce the rate of CD, trail of labor (TOL) following one and even two previous CDs is encouraged. We aimed to evaluate maternal and neonatal outcomes of parturients attempting a TOL after two previous CDs, in which a strict departmental protocol was adopted. Study design: A retrospective cohort study of TOL following CD (TOLAC) at a single tertiary center, between 2005 and 2019. Various maternal and neonatal outcomes were assessed, in which parturients attempting TOL after two CD were compared to those after one previous CD. TOL after two CDs was permitted only to those parturients who fulfilled all the criteria of our department's protocol. A univariate analysis was initially conducted and was then followed by a multivariate analysis. Results: A total of 11,620 TOLAC were identified, of which 515 (4.4 %) were after two previous CDs. Overall, vaginal delivery rates were high, however, following two CDs the rate was lower than following one CD (83.1 % vs. 88.5 %, p < 0.01). Rates of uterine rupture, peripartum hysterectomy, and postpartum hemorrhage did not differ significantly between the groups. Neonatal results following two CDs were less favorable (specifically, one minute APGAR, neonatal care unit admissions and mechanical ventilation rates), yet, when controlling for potential confounders, an independent association between neonatal composite outcome and TOL following two CDs was not demonstrated. Conclusion: For parturients with a history of two CDs, when a strict protocol for selecting appropriate candidates is followed, TOL is a reasonable alternative to repeat CD and is associated with favorable maternal and neonatal outcomes. (C) 2020 Elsevier B.V. All rights reserved.