Post partum maternal readmission is a significant burden for mother, neonate and family as well as health system. The post-partum readmission rate is used to evaluate quality of care and to guide beneficial interventions. Thus, identifying women at risk for readmission is of high value. The WHO established the internationally used Robson group (RG) classification as an optimal measure of caesarean section (CS) rates. Although intended for evaluation of CS rates, in recent years the utilization of the RG classification has been expanded to evaluate other obstetrical outcomes. We aim to describe the rates of postpartum maternal readmission across RG classification and to identify risk groups. Retrospective register-based cohort study of women who delivered at a tertiary medical center. All women were classified into 1 of the 10 RGs. Rates of post-partum readmission within 42 days of delivery were calculated for each group. A total of 295,215 deliveries were classified to the 10 Robson classification groups. The 42-day readmission rate for the whole database was 0.52%. Maternal readmission rate varied significantly between RGs. Groups identified with a significant rate of maternal readmission were RG 9 (transverse lie) 2.14%, RG 8(multifetal pregnancies )1.37%, RG 7 (multiparous breech pregnancies)1.23% and RG2 (nulliparous pregnancies ≥ 37 w, labor induction' or prelabor cesarean) 1.21%. Post partum readmission rates varies among the RGs. Interventions aimed to lower the number of women in RG 2,7,8 and 9; such as use of external cephalic version, vaginal delivery of breech and multifetal pregnancies may be beneficial. The neonatal impact of such policy remains to be considered for each center.

Oligohydramnios is considered a determinant of adverse perinatal outcomes. However, information on trial of labor after cesarean (TOLAC) for parturients with oligohydramnios is limited. This study aims to evaluate the maternal and neonatal outcomes of parturients with oligohydramnios attempting TOLAC versus those who underwent planned repeat cesarean delivery (PRCD). We conducted a retrospective cohort study of women with a term singleton pregnancy and a live fetus following a single low-segment transverse cesarean delivery (CD) and a diagnosis of oligohydramnios (maximal vertical pocket < 2 cm and/or Amniotic Fluid Index < 5 cm) within 14 days from birth between 2017 and 2021. Maternal and neonatal outcomes were compared between parturients attempting TOLAC and those opting for PRCD. Univariate analysis was conducted, followed by a multivariate analysis. A total of 409 eligible births were included, of which 321 (78.4%) attempted TOLAC. The successful vaginal delivery rate for women who attempted TOLAC was 85%. There were no cases of hysterectomy in either group. Uterine rupture and dehiscence of uterine scar rates did not significantly differ between those who had TOLAC vs. PRCD (0.9% vs. 0%, p=0.36 vs. 0.3% vs. 1.3%, p=0.06, respectively). However, the rate of hypoglycemia (2.5% vs. 6.8%, p=0.049) and composite adverse neonatal outcome was higher among women with PRCD (11.5% vs. 21.6%, p=0.01). Nevertheless, after controlling for potential confounders, including hypertensive disorders of pregnancy, diabetes, and SGA, no independent association between composite adverse neonatal outcome and PRCD was demonstrated (adjusted odds ratio 0.50, 95% CI 0.17-1.41, p=0.19). TOLAC for parturients with oligohydramnios appears to be a reasonable alternative and is associated with favorable outcomes. Further large and prospective research in this area may lead to improved management strategies and better maternal and neonatal outcomes.

Background: Studies have found an association between second-stage cesarean sections (SSCSs) and subsequent preterm birth (PTB). We aimed to evaluate if secundiparas with previous second-stage cesarean sections due to a failed vacuum delivery (SSCS-F-VD) are associated with PTB in the subsequent delivery compared with secundiparas with previous spontaneous vaginal birth (SVB) at term. A secondary aim was to compare this association with secundiparas with a previous SSCS at term. Methods: A historical, prospective, longitudinal cohort study was conducted in a large tertiary university hospital between 2006 and 2019. Matched mothers who experienced first and second births at the indexed hospital, excluding those with a previous miscarriage or multiple pregnancy in either the first or second birth were grouped based on the mode of delivery and gestational week of the first birth. Results: Parturients with term SVB and term SSCSs were less likely to experience PTB in the following delivery compared with those who underwent an SSCS-F-VD, with 496/14,551 (3.4%) versus 6/160 (3.8%) versus 5/61 (8.2%), respectively, at p < 0.001. A logistic regression model revealed that secundiparas with previous SSCS-F-VD had an association with PTB in the following delivery compared with term SVB, with an OR of 2.756 (1.097; 6.922, p = 0.031). Conclusion: Previous SSCS-F-VD is associated with PTB in the following delivery, offering valuable insights for pregnancy management and patient counseling.

One-third of cesarean deliveries (CDs) are repeat operations, of which the majority are low-order, second (CD2) and third (CD3). The study objectives were to identify risk factors for a complicated maternal CD among women undergoing a repeat low-order CD and to develop a predictive model for at-risk women. A retrospective longitudinal follow-up study was conducted in a single medical center, during 2005–2016. Women who underwent both CD2 and CD3 at the site were included. Those with placenta accreta or a caesarean hysterectomy were excluded. A composite complicated maternal CD was defined by either uterine rupture/dehiscence, blood transfusion, relaparotomy, admission to the intensive care unit or prolonged operative time >90th percentile. Data was analyzed comparing between CD2 to CD3, each woman served as her own control. Univariate analysis followed by a multivariate logistic regression modeling were performed with an OR of 95% CI defining significance. The study group comprised of 1,331 women. A complicated CD occurred in 159 (12%) vs. 226 (17%) of CD2 vs. CD3 respectively, (p<0.001). Women with a complicated CD2 were at higher risk for complications in CD3, aOR 2.3 (95% CI 1.5, 3.3). Sub-Saharan African origin and preterm delivery at CD3 were both risk factors for a complicated CD3, aOR 3.7 (95% CI 1.9, 7.3) and aOR 1.7 (95% CI 1.1, 2.7), respectively. The multivariate regression model included 1328 cases, was statistically significant, χ2(7) = 50.760, p <0.001, explained 6.3% of the variance of composite complicated maternal CD3 and correctly classified 82.9% of cases. Although a complicated CD2, Sub-Saharan African origin and preterm delivery are risk factors for maternal complications in CD3, it is hard to predict which specific women will experience complications. Sensitivity, specificity, positive and negative predictive value of a complicated CD2 for detecting complications in CD3 were 21%, 90%, 30% and 85% respectively.

Intrapartum fever (IF) accompanied by either maternal or foetal tachycardia, elevated WBC, or purulent discharge is classified as "suspected triple 1", the hallmark of intraamniotic infection (IAI). Poor specificity of the clinical diagnosis of IAI results, in retrospect, in the unnecessary treatment of most parturients and neonates. We studied the yield of specific acute phase reactants (APRs): procalcitonin, CRP, IL-6, in detecting bacterial IAI among parturients classified as "suspected triple 1" (cases) compared to afebrile parturients (controls). Procalcitonin, CRP, and IL-6 were all significantly elevated in the cases compared to the controls, yet this by itself was not sufficient for an additive effect in detecting a bacterial infection among parturients clinically diagnosed with "suspected triple 1", as demonstrated by the poor area under the receiver operating characteristic curve of all three APRs.

Laparoscopy is now the gold standard approach to many surgical procedures thanks to its many advantages. Minimizing distractions is essential to a safe and successful surgery and an undisrupted surgical workflow. The SurroundScope, a wide angle (270°) laparoscopic camera system has the potential to decrease surgical distractions and increase workflow. Forty-two laparoscopic cholecystectomies were performed by a single surgeon, 21 with the SurroundScope and 21 with standard angle laparoscope. Video recordings of surgeries were reviewed for calculating the number of entries of surgical tools into the field of view, relative time of tools and ports viewed in surgical field and number of times camera was removed due to fog or smoke. The usage of the SurroundScope resulted in a significantly lower number of entries to the field of view compared to the standard scope (58.50 versus 102; P < 0.0001). Usage of SurroundScope resulted in a significantly higher appearance ratio of tools, with a value of 1.87 compared to 1.63 for standard scope (P-value < 0.0001), and the appearance ratio of ports was also significantly higher, measuring 1.84 compared to 0.27 for the standard scope (P-value < 0.0001). In addition, the SurroundScope had to be removed and reinserted due to smoke or fog in only 2 cases (9.5

The limited 70° field of view (FoV) used in standard laparoscopy necessitates maneuvering the laparoscope to view the ports, follow the surgical tools, and search for a target region. Complications related to events that take place outside the FoV are underreported. Recently, a novel laparoscopic system (SurroundScope, 270Surgical) was reported to dramatically expand the FoV from 70 to 270°. This study focuses on differences in performing laparoscopic cholecystectomy using the SurroundScope compared to the standard laparoscope. Forty-four laparoscopic surgeries were performed and video recorded. A subanalysis of 21 Cholecystectomies was performed and compared to 21 Cholecystectomies, performed with the standard laparoscope during the study period by the same surgeon. No accidental or intraoperative adverse events occurred when using the SurroundScope. Subanalysis of 21 Cholecystectomies revealed shorter fog/smoke cleaning times using the SurroundScope compared to the standard scope (1.45 ± 5.08 sec vs. 54.95 ± 137.77 sec, p = 0.0454). Furthermore, operations performed with the SurroundScope had a shorter trocar placement duration (85.0 ± 40.9 sec vs. 111.3 ± 70.5 sec; p = 0.077), shorter time to achieve critical view of safety (9.5 ± 4.14 min vs. 15.8 ± 11.87 min; p = 0.015), and shorter procedure duration (31.9 ± 10.4 min vs. 42.9 ± 22 min; p = 0.025). In post-operative evaluations, the surgeon noted that tools could be continuously followed and ports were visible without camera manipulation. Also, the surgeon agreed that the procedure could be better planned due to the wide FoV and that surgical workflow was improved. Furthermore, the surgeon agreed that the procedure was safer using the SurroundScope. Initial results demonstrate the advantages of the SurroundScope over standard laparoscopy. By expanding the FoV, visualization is improved, the procedure is more efficient, significantly shorter and most important, patient safety, per surgeons’ testimonials is improved. Further investigation to quantify these benefits in a larger group of patients and among various surgical procedures should be considered.

Objective This study aimed to evaluate whether a trial of labor after cesarean delivery (TOLAC) in women with a bicornuate uterus is associated with increased maternal and neonatal morbidity compared to women with a non-malformed uterus. Methods A multicenter retrospective cohort study was conducted at two university-affiliated centers between 2005 and 2021. Parturients with a bicornuate uterus who attempted TOLAC following a single low-segment transverse cesarean delivery (CD) were included and compared to those with a non-malformed uterus. Failed TOLAC rates and the rate of adverse maternal and neonatal outcomes were compared using both univariate and multivariate analyses. Results Among 20,844 eligible births following CD, 125 (0.6%) were identified as having a bicornuate uterus. The overall successful vaginal delivery rate following CD in the bicornuate uterus group was 77.4%. Failed TOLAC rates were significantly higher in the bicornuate group (22.4% vs. 10.5%, p < 0.01). Uterine rupture rates did not differ between the groups, but rates of placental abruption and retained placenta were significantly higher among parturients with a bicornuate uterus (9.8% vs. 4.4%, p < 0.01, and 9.8% vs. 4.4%, p < 0.01, respectively). Neonatal outcomes following TOLAC were less favorable in the bicornuate group, particularly in terms of neonatal intensive care unit admission and neonatal sepsis. Multivariate analysis revealed an independent association between the bicornuate uterus and failed TOLAC. Conclusions This study found that parturients with a bicornuate uterus who attempted TOLAC have a relatively high overall rate of vaginal birth after cesarean (VBAC). However, their chances of achieving VBAC are significantly lower compared to those with a non-malformed uterus. Obstetricians should be aware of these findings when providing consultation to patients.

Twin trial of vaginal birth after a previous cesarean (TOLAC) is associated with a lower rate of successful vaginal delivery than singleton deliveries and a higher rate of adverse outcomes compared to elective repeat cesarean delivery. We aimed to investigate the factors associated with failed TOLAC among women with twin gestation. A retrospective cohort study of all women with twin pregnancies attempted a labor trial after a previous cesarean in a single tertiary center (2005-2021). The study population included: women with twin gestation, single previous low segment transverse section, first fetus in vertex presentation who were eligible for vaginal delivery. Labor, maternal and neonatal characteristics were compared. Univariate analysis was followed by multivariate analysis (aORs ; [95% CI]). We identified 181 cases of a trial of labor during the study period after cesarean in women with twin gestation. Vaginal birth after cesarean was observed in 72.9% of the cases. Lower parity, fertility treatments, use of Oxytocin for augmentation during labor, the lack of epidural analgesia, and preterm birth before 34, 32, and 28 gestational weeks were all found to be associated with failed TOLAC (table 1). On multivariate analysis, lack of epidural analgesia (aOR 241.6 [11.93-4895.819]), use of Oxytocin (27.1 [3.32-220.52] and Low Bishop score ( < 6) (19.2 [1.42-259.29] were found to be significantly associated with failed TOLAC (table 2). In a population of TOLAC twins, the establishment of epidural analgesia, avoidance of Oxytocin use, and early admission to the delivery room are associated with a higher risk of vaginal delivery and may reduce the risk of repeat cesarean delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

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.

Objective: History of prior preterm birth (PTB) represents one of the strongest risk factors for recurrent PTB. Nevertheless, whether the occurrence of PTB in multifetal gestation is associated with increased risk of PTB in subsequent pregnancies remains unclear. We aimed to determine the recurrence risk of PTB in a subsequent singleton pregnancy after a previous spontaneous preterm triplet delivery. Study design: A retrospective matched case-control study. The study group comprised all women with spontaneous preterm trichorionic triplet delivery who had a subsequent singleton pregnancy during 2006-2017 at two university hospitals. A control group of women with spontaneous preterm dichorionic twin delivery and a subsequent singleton pregnancy, was established by matching, four-to-one, according to maternal age, parity, gestational age at delivery, and delivery year. Results: Data from 170 women were analyzed, 34 with preterm triplet delivery and 136 matched control women with preterm twin delivery. Gestational age at the subsequent singleton delivery was higher in those with preterm triplet delivery than in those with preterm twin delivery (median 39 vs 38 weeks, P=0.02). Women with prior triplet PTB had a significantly lower rate of recurrent PTB as compared with women with prior twin PTB (5.9 % vs. 25.0 %; OR [95 % CI]: 0.19 (0.04, 0.82), P = 0.02) with lower proportions of low-birth weight infants (<2500 g) (0 % vs. 11.8 %, P = 0.04). Conclusions: The risk of recurrent PTB following spontaneous PTB in triplet pregnancy was low compared to preterm twin delivery. These data provide reassurance for those who experienced preterm triplet delivery and suggest the need for further studies to understand the mechanisms contributing to PTB in multifetal pregnancies. (C) 2020 Elsevier B.V. All rights reserved.

Purpose To establish the frequency of vacuum extraction among parturients with twin pregnancies, identify the risk factors and perinatal outcomes. Methods A retrospective cohort database study was conducted between 2005-2018. Twin fetuses with vertex presentation >34 weeks gestation who achieved vaginal delivery were included. Outcomes were compared between neonates who were delivered by vacuum extraction and neonates delivered by spontaneous vaginal delivery (aORs; [95% CI]). Results A total of 1751 neonates of 905 parturients with twin pregnancies met inclusion criteria, of which 163 (18%) parturients had vacuum extraction and 225 (12.8%) neonates were delivered by vacuum extraction. The most significant risk factors for vacuum extraction were primiparity (6.79 [4.77-9.66]), previous cesarean delivery (5.59 [3.13-9.97]), and epidural analgesia (4.34 [1.83-10.31]). Vacuum extractions were associated with a spectrum of adverse maternal outcomes (2.60 [1.61-4.19]), particularly postpartum hemorrhage and its associated morbidities. From the neonatal aspect, vacuum extraction deliveries were associated with a composite of birth trauma injuries (21.81 [6.43-73.91]). Conclusion Vacuum extractions among twin pregnancies were found to be associated with significantly higher rates of postpartum hemorrhage, blood transfusion, and perinatal birth trauma. These findings should be presented to women when counseling on mode of delivery and considered individually against cesarean delivery disadvantages.

History of prior preterm birth (PTB) represented one of the strongest risk factors for recurrent PTB. Nevertheless, whether the occurrence of PTB in multifetal gestation is associated with increased risk of PTB in subsequent pregnancies remains unclear. We aimed to determine the recurrence risk of PTB in a subsequent singleton pregnancy after a previous spontaneous preterm triplet delivery. A retrospective matched case-control study. The study group comprised all women with spontaneous preterm trichorionic triplet delivery who had a subsequent singleton pregnancy during 2006-2017 at two university hospitals. A control group of women with spontaneous preterm dichorionic twin delivery and a subsequent singleton pregnancy, was established by matching, four-to-one, according to maternal age, parity, gestational age at delivery, and delivery year. Data from 170 women were analyzed, 34 with preterm triplet delivery and 136 matched control women with preterm twin delivery. Gestational age at the subsequent singleton delivery was higher in those with preterm triplet delivery than in those with preterm twin delivery (median 39 vs 38 weeks, P=0.02). Women with prior triplet PTB had a significantly lower rate of recurrent PTB as compared with women with prior twin PTB (5.9% vs. 25.0%; OR [95% CI]: 0.19 (0.04, 0.82), P=0.02) with lower proportions of low-birth weight infants (< 2,500 grams) (0% vs. 11.8%, P=0.04). The risk of recurrent PTB following spontaneous PTB in triplet pregnancy was low compared to preterm twin delivery. These data provide reassurance for those who experienced preterm triplet delivery and suggest the need for further studies to understand the mechanisms contributing to PTB in multifetal pregnancies.

A 26-year-old healthy gravida 5 para 2 woman at 36 weeks’ gestation presented to the emergency department with a 5-days history of abdominal pain followed by constipation, obstipation and urine retention. Despite the use of antispasmodics and laxatives, her pain worsened, and she had become unable to pass stool, flatus or urine. The vital signs were normal. The physical examination revealed a gravid woman with a distended and tender abdomen. Abdominal plain X-ray demonstrated a distended sigmoid loop with an inverted U shape, also known as ‘coffee bean sign’ with no free intraperitoneal gas. Computed tomography (CT) showed a dilated colon with a transitional zone and swirling of the mesentery, the “whirl sign’’. The presence of gas was not observed in the distal obstructed region, corresponding to a diagnosis of sigmoid volvulus (Fig. 1).