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Objective In the era of group B Streptococcus (GBS) screening and intrapartum antibiotic prophylaxis (IAP), GBS colonization has been associated with a lower risk of chorioamnionitis, possibly due to a protective effect of IAP. We sought to confirm this finding and assess whether this association varies by gestational week at delivery. Study Design We performed a retrospective cohort study of term (37.0–42.6 weeks), singleton parturients with known GBS status who delivered from 2005 to 2021 at two academic medical centers in Israel. We excluded patients who underwent planned cesarean, out of hospital birth, or had a fetal demise. Patients received GBS screening and IAP for GBS positivity as routine clinical care. The primary outcome was a diagnosis of clinical chorioamnionitis as determined by the International Classification of Diseases 10th Revision code, compared between GBS-positive and -negative groups, and assessed by gestational week at delivery. Results Of 292,126 deliveries, 155,255 met inclusion criteria. In total, 30.1% were GBS positive and 69.9% were negative. GBS-positive patients were 21% less likely to be diagnosed with clinical chorioamnionitis than GBS-negative patients, even after controlling for confounders (1.5 vs. 2.2%, adjusted odds ratio: 0.79, 95% confidence interval: 0.68–0.92). When assessed by gestational week at delivery, there was a significantly greater difference in rates of clinical chorioamnionitis between GBS-positive versus GBS-negative groups with advancing gestational age: 1.5-fold difference at 38 to 40 weeks, but a twofold difference at 42 weeks. The risk of clinical chorioamnionitis remained stable in the GBS-positive group, but increased significantly in the GBS-negative group at 41- and 42-week gestation (2.0 vs. 2.9%, p < 0.01 at 41 weeks; up to 3.9% at 42 weeks, p < 0.01). Conclusion In a large multicenter cohort with universal GBS screening and IAP, GBS positivity was associated with a lower risk of chorioamnionitis, driven by an increasing rate of chorioamnionitis among GBS-negative patients after 40 weeks. Key Points GBS positivity and IAP may be associated with lower risk of chorioamnionitis. GBS-positive patients were less likely to be diagnosed with chorioamnionitis. This difference increased with advancing gestational age after 40 weeks. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the rates of vaginal birth after cesarean (VBAC) among parturients attempting preterm trial of labor following a cesarean delivery (TOLAC) vs. term TOLAC. Methods: A multicenter historic cohort study was conducted at two university-affiliated centers between August 2005 and March 2021. Parturients in their second delivery, attempting TOLAC after a single low segment transverse cesarean delivery were included. We retrospectively examined computerized medical records of all preterm (< 37 weeks) and term (37–42 weeks) births. Multifetal gestations and postterm deliveries (≥ 42 weeks) were excluded. A univariate analysis was conducted, followed by a multivariate analysis. Results: 4865 second deliveries following previous cesarean were identified: 212 (4.4%) preterm and 4653 (95.6%) term. Hypertensive disorders, diabetes and fertility treatments were significantly more prevalent in the preterm group. VBAC rate was significantly lower in preterm group (57.5 vs 79.7%., p < 0.01), including both spontaneous and vaginal-assisted deliveries. In multivariate analysis, preterm TOLAC was independently associated with TOLAC failure [adjusted odds ratio 2.24, [95% confidence interval 1.62–3.09]. Overall, maternal outcomes were favorable. Rates of uterine rupture, re-laparotomy and postpartum hemorrhage were comparable between groups. Neonatal outcomes were less favorable among the preterm group; however, preterm vs. term TOLAC was not associated with low 5 min Apgar score (aOR 1.76, 95% CI 0.92–3.40). Conclusion: In our study, VBAC rates were lower in preterm compared to term deliveries. Maternal outcomes were comparable. Neonatal outcomes were less favorable in the preterm group, more likely due to prematurity than delivery mode. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To examine whether mode of preterm delivery is associated with the risk of recurrent preterm delivery in subsequent pregnancy.Study Design: A multicenter retrospective study. Women with the first two consecutive singleton deliveries at two university-affiliated medical centers between August 2005-March 2021, with first delivery occurring spontaneously < 37 weeks of gestation were included. Excluded were women with multifetal pregnancies in either pregnancy and those with an indicated first preterm delivery. A univariate analysis was followed by a multivariate analysis.Results: A total of 1,019 women with spontaneous preterm first delivery were included. Of those, 141 (13.8 %) underwent cesarean delivery in their first preterm delivery, while 878 (86.2 %) had a vaginal delivery. Univariate analysis revealed that women who underwent cesarean delivery in their first delivery had, during the subsequent delivery: longer mean gestational age at delivery (37.8 ± 3.3 vs 36.8 ± 3.7 weeks; p < 0.01), but statistically similar rates of recurrent preterm delivery both < 37 weeks and < 34 weeks (23.4 % vs 27.2 % and 7.1 % vs 10.6 %; p = 0.34 and p = 0.20, respectively). Multivariate analysis revealed that mode of delivery- cesarean - in the preterm delivery was not associated with recurrent pre-term delivery (0.66 (0.41-1.04), p = 0.07).Conclusion: Mode of delivery in first preterm delivery is not associated with higher or lower rates of recurrent preterm delivery. [ABSTRACT FROM AUTHOR]

Objectives: To determine the risk of spontaneous preterm birth (sPTB) associated with the length of second stage of labour in the first term delivery. Design Retrospective cohort study. Setting: University hospital. Population Women with first two consecutive singleton births and the first birth at term. Those who did not reach the second stage of labour in the first delivery were excluded. Methods: Charts from 2007 to 2019 were reviewed. Main outcome measures: Rate of sPTB (<37 weeks of gestation) in the second delivery. Results: Of 13 958 women who met study inclusion criteria, 1464 (10.5%) parturients had a prolonged second stage (≥180 min) in their first term delivery. The rate of sPTB in the second delivery was similar in those with and without a prolonged second stage in first delivery (2.8% versus 2.8%; adjusted odds ratio [aOR] 1.35, 95% CI 0.96–1.90). After adjustment for mode of delivery, prolonged second stage was also not associated with subsequent sPTB in those who delivered by spontaneous and operative vaginal delivery. Those delivered by second‐stage caesarean section in the first delivery had a higher risk of sPTB in the second delivery (25/526, 4.8%; aOR 2.66, 95% CI 1.71–4.12; p < 0.001), with a more pronounced risk in those with second‐stage caesarean following a prolonged second stage of labour (15/259, 5.8%; aOR 3.40, 95% CI 1.94–5.94; p < 0.001). Conclusion: Second‐stage duration in a first term vaginal delivery is not associated with subsequent sPTB. The risk of sPTB is increased following second‐stage caesarean section, particularly if performed after a prolonged second stage. Second‐stage caesarean delivery, particularly after prolonged second stage, increases the risk of preterm birth. Second‐stage caesarean delivery, particularly after prolonged second stage, increases the risk of preterm birth. [ABSTRACT FROM AUTHOR]

Objective: Twin trial of labor after a cesarean section (TOLAC) is associated with a lower success rate of vaginal delivery than singleton TOLAC, and a higher rate of adverse outcomes in comparison to an elective repeat cesarean delivery. This study aims to investigate the factors associated with failed TOLAC, among women with twin gestation. Study design: A multicenter retrospective cohort study was undertaken. All women with twin pregnancies attempting a trial of labor after a previous cesarean in two university-affiliated obstetrical centers, between 2005 and 2021 were included. The study population included women with a twin gestation where twin A presented in the vertex position, a single previous low segment transverse section, and those who were eligible for a vaginal delivery. Labor, maternal, and neonatal characteristics were compared. A univariate analysis was undertaken, followed by multivariate analysis (aORs; [95% CI]). Results: A total of 160 women attempting a twin TOLAC were included. Vaginal birth after cesarean was achieved in 86.3% of these cases. Assisted reproductive technology (ART), the lack of oxytocin use 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. In the multivariate analysis, cervical dilation on admission (aOR 0.6 [0.40–0.82], p < 0.01), no use of oxytocin (aOR 5.2 [1.36–19.73], p = 0.02), gestational age at delivery (aOR 0.8 [0.65–1.00], p = 0.047) and lack of epidural analgesia (aOR 4.5 [1.01–20.16], p = 0.049), were all found to be significantly associated with failed TOLAC. Conclusion: In the investigated population of women with twins undergoing TOLAC, the use of epidural analgesia, the use of oxytocin and increased cervical dilation to the delivery room are associated with a higher rate of vaginal delivery, and may reduce the risk of repeat cesarean delivery. [ABSTRACT FROM AUTHOR]

Shoulder dystocia (SD) is a risk factor for neonatal clavicular fracture (CF). Previous SD is a known risk factor for subsequent SD. It is unknown whether an isolated neonatal CF (one that is not associated with SD) increases the risk of future SD. We aimed to investigate this question. A retrospective computerized database study conducted at Shaare Zedek Medical Center, a university-affiliated hospital, between 2005 and 2018. We included in the study all women that had a vaginal delivery without SD and had a subsequent vaginal delivery in our center between 2005 and 2018. Medical records of parturients who had a coded diagnosis of neonatal CF were retrieved. The first delivery with the neonatal diagnosis of an isolated CF was chosen as index delivery. Rates of SD at the subsequent delivery were assessed and compared between parturients with isolated neonatal CF (INCF) and parturients without neonatal CF or SD at the index delivery. To account for dependency between deliveries of the same individual parturient, we used generalized estimating equation (GEE) models. We identified 39,601 parturients that met the inclusion criteria. During the study period, 519 parturients with a diagnosis of INCF that had at least one subsequent delivery were identified (1.3%). Overall, 3.9% of parturients with isolated CF (20/519) had subsequent SD, as compared to 0.5% of parturients without CF or SD at the index delivery (190/39082; p <.01). Previous diagnosis of INCF was found to be independently associated with SD in a subsequent delivery after controlling for known risk factors for SD (aOR = 6.41, 95% CI = 3.92–10.61). Previous diagnosis of an INCF was also found to be independently associated with a subsequent event of SD in all subsequent deliveries of the same individual parturient (aOR = 3.42, 95% CI = 2.26–5.18). Women with previous INCF have an increased risk for SD in subsequent deliveries. Intervention efforts directed at this particular subgroup of women should be applied, with special attention to potentially modifiable risk factors to minimize the risk for future SD. [ABSTRACT FROM AUTHOR]

Background: Data about the risk of recurrence of vacuum extraction (VE) in multiple consecutive deliveries are scarce. We aimed to evaluate the pattern and individual cumulative risk of recurrence of VE in consecutive term deliveries. Study Design: A retrospective cohort study based on a validated electronic database at a single center between 2005 and 2019. For the purpose of the study, we focused on consecutive term deliveries of all primiparas (P1) that had a record of at least one additional delivery during the study period. We identified P1 VE deliveries (reference group) and calculated the individual cumulative risk of repeated VE for three consecutive deliveries. Multivariate analysis was conducted adjusting for potential confounders. Results: We identified 35 113 primiparas that met inclusion criteria. The overall VE rate for P1 was 17.9% (6969 parturient). The cumulative rates of repeated VEs at the 2nd, 3rd, and 4th deliveries were 8.6%, 26.8%, and 25.0%, respectively. The risk of recurrent VE for each of the consecutive deliveries was confirmed after adjustment for confounders (aOR [95% CI]: 5.8 [4.76‐7.04], 34.2 [18.59‐62.81], and 113.9 [9.77‐1328.69] for the 2nd, 3rd, and 4th consecutive deliveries, respectively). Conclusion: Women with VE at the first and second deliveries have a substantially increased risk of VE in their following deliveries; this finding may influence woman's preference when choosing future mode of delivery. [ABSTRACT FROM AUTHOR]

Objective: In recent years there has been growing interest in the relationship between the workload of an individual practitioner and its short- and long-term consequences on birth outcomes. In this respect, data is limited with regard to midwives' workload. We aimed to evaluate the association between midwives' annual birth workload and the short-term, adverse maternal and neonatal outcomes occurring at birth.Study Design: This retrospective cohort study was performed in a single tertiary academic center between 2006 and 2018. All single, live vertex term vaginal births were included and categorized into two groups based on the midwife's median annual volume of births during the study duration. The "high-volume" and "low-volume" groups included births above and below the median annual volume, respectively as a dichotomous variable. Further analyses were performed for the annual volume by deciles. Short term maternal and neonatal outcomes were compared between groups and between deciles.Results: During the study period 140,856 births met the study criteria. The median annual volume of births of a single midwife was 152 [114-195]. Maternal and labor characteristics were comparable between the groups. Maternal outcomes were not significantly associated with the midwifes' annual workload. However, neonates delivered by midwives with "low" annual volume had higher rate of neonatal jaundice (aOR 1.07, 95 % CI [1.00-1.14]) and mechanical ventilation (aOR 1.32, 95 % CI [1.05-1.66).Conclusion: Adverse perinatal outcomes are only mildly affected by midwives' annual volume after controlling for the midwife, parturient and neonate's characteristics. [ABSTRACT FROM AUTHOR]

Objective: To examine the association between vaginal delivery of a previous macrosomic neonate (birthweight (BW)≥ 4000) among non-diabetic women and the rate of shoulder dystocia (SD) in the subsequent pregnancy.Study Design: A historical prospective cohort study in a university affiliated medical center from 2005 to 2019. Women who had a singleton pregnancy and two consecutive deliveries in our medical center were included. Women with previous GDM, SD or cesarean delivery were excluded. Univariate analysis was followed by multivariate logistic regression.Results: A total of 38,942 women were included. SD incidence among the subsequent pregnancies was 0.44 % (172 women). In univariate analysis women with previous delivery of large neonates: BW≥90th percentile for gestational age and BW ≥ 4000 g had higher risk for subsequent SD (odds ratio 2.69 [95 % confidence interval 1.89-3.84], p < 0.01 and 2.71 [1.66-4.44], p < 0.01, respectively). However, a backward stepwise multivariate logistic regression model adjusted for significant confounders for SD in the univariate analysis, showed that women with a previous delivery of macrosomic neonate ≥4000 g were not found to have higher or lower risk for SD in the subsequent delivery.Conclusion: Previous uneventful delivery of a macrosomic neonate to a non-diabetic mother should not be regarded as a risk factor for SD in the subsequent delivery. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: Antibiotic treatment during surgical repair of obstetric anal sphincter injuries (OASIS) had been a matter of debate. We aimed to review the available literature regarding the efficacy of metronidazole administration in women undergoing perineal repair following obstetric OASIS.Study Design: To identify potentially eligible studies, we searched PubMed, Scopus, Embase and the Cochrane Library from inception to January 13th, 2019.Reference lists of identified studies were searched. No language restrictions were applied. We used a combination of keywords and text words represented by "Metronidazole", "obstetrics", "obstetric anal sphincter injury", "OASIS", "third degree tear", "fourth degree tear", "third degree laceration", "fourth degree laceration", "antibiotic therapy", "perineal damage" and "perineal trauma". Two reviewers independently screened the titles and abstracts of records retrieved from the database searches. Both reviewers recommended studies for the full-text review. Thescreen of full-text articles recommended by at least one reviewer was done independently by the same two reviewers and assessedfor inclusion in the systematic review. Disagreements between reviewers were resolved by consensus.Results: The electronic database search yielded a total of 54,356 results (Fig. 1). After duplicate exclusion 28,154 references remained. Of them, 26 were relevant to the review based on title and abstract screening. None of these articles dealt with the use of metronidazole for the prevention of infections complicating anal sphincter repair in women with OASIS. A Cochrane review addressing antibiotic prophylaxis for patients following OASIS, compared prophylactic antibiotics against placebo or no antibiotics, included only one randomized controlled trial of 147 participants. This study showed that prophylactic antibiotics (not metronidazole) may be helpful to prevent perineal wound complications following OASIS. Fig. 1 Study seection process CONCLUSION: Anaerobic infections potentially complicate wound repair after OASIS. Although scientific societies recommend the use of antibiotics for the prevention of infectious morbidity after OASIS, no study has specifically assessed the role of metronidazole. [ABSTRACT FROM AUTHOR]

Objective: We aimed to evaluate the impact of epidural analgesia on the mode of delivery of nulliparous women with a term single fetus in vertex presentation (NTSV) that attained the second stage of labor.Study design: A single-center retrospective study provided a strict and constant department protocol for epidural analgesia practice and obstetric interventions, between 2005 and 2014. Epidural users were compared to nonusers. The primary outcome was the mode of delivery. Secondary outcomes were diagnosis of prolonged second stage of labor and maternal and neonatal morbidities. The outcomes were evaluated by adjusted multivariate analyses (Adjusted Odds Ratios (aOR), 95% CI).Results: During the study period, 25,643 NTSV attained the second stage of labor; 18 676 (73%) epidural users and 6967 (27%) nonusers. Epidural users had an increased risk of instrumental delivery 2.48, [2.22-2.76], along with a lower risk of cesarean delivery 0.38, [0.29-0.50]. Notably, the diagnosis of prolonged second stage of labor was comparable among the study groups 0.99, [0.89-1.12]. The epidural users had a significantly higher risk of early postpartum hemorrhage 1.15, [1.04-1.27]. The risk for neonatal morbidity was comparable among the study groups 1.21 [0.90-1.63].Conclusion: Epidural analgesia in a population of NTSV that attains the second stage of labor is associated with a higher risk of instrumental delivery, nonetheless with a reduced risk of cesarean delivery; independent of the length of the second stage of labor is and safe for the neonate. [ABSTRACT FROM AUTHOR]

Background: Group B streptococcus (GBS) is a significant cause of neonatal morbidity and mortality. GBS maternal colonization status was found to be transient, intermittent, or chronic and screening during each subsequent pregnancy was advised. Recent studies showed that GBS colonization rate was higher among women with history of GBS positive in prior pregnancy.Objective: To establish the cumulative risk of group B streptococcus (GBS) colonization in consecutive subsequent term deliveries as referred to the first delivery GBS colonization status.Study design: A retrospective cohort study, based on a validated computerized database at a tertiary single center between the years 2005-2016. Pregnant women preform vaginal-rectal culture at 35-37 weeks of gestation. We analyzed records of term primiparas women that had records of up to three additional term consecutive deliveries and GBS colonization status.Results: 8641 primiparas met inclusion criteria; 3972 (46.0%), 993 (11.5%), and 243 (2.8%) had second, third, and fourth consecutive deliveries with recorded GBS status respectively. The overall colonization rate for primiparas was 28.4%. The cumulative rates and cumulative risks of repeated GBS positive colonization at the second, third and fourth term consecutive deliveries were 62.0%, 6.93 (95% CI 5.96-8.06), 68.0%, 5.05 (95% CI, 3.67-6.93), and 66.1%, 2.96 (95% CI, 1.54-5.68), respectively. Notably, after a negative GBS colonization in the first, second, and third repeated deliveries, the rate and cumulative risk of GBS positive in each consecutive delivery was significantly lower: 18.2%, 0.14, (95% CI 0.12-0.17), 19.4%, 0.21 (95% CI 0.15-0.28), and 21%, 0.26 (95% CI 0.13-0.51) for the second, third, and fourth consecutive deliveries, respectively.Conclusion: GBS colonization status at the time of first pregnancy is a milestone for the colonization risk in subsequent term deliveries. This risk evaluation may influence the decision-making process for future screening and intrapartum antibiotic prophylaxis for term consecutive deliveries. [ABSTRACT FROM AUTHOR]

This study aimed to quantify the association between mode of operative delivery in the second stage of labor (cesarean delivery vs operative vaginal delivery) and spontaneous preterm birth in a subsequent pregnancy. MEDLINE, Embase, EmCare, CINAHL, the Cochrane Library, Web of Science: Core Collection, and Scopus were searched from database inception to April 1, 2023. All retrospective cohort studies with participants who had a second-stage cesarean delivery (defined as intrapartum cesarean delivery at full cervical dilation) or operative vaginal delivery (including forceps- and/or vacuum-assisted delivery) and that reported the rate of preterm birth (either spontaneous or not specified) in subsequent pregnancy were included. Both a descriptive analysis and a meta-analysis were performed. A meta-analysis was performed for dichotomous data using the Mantel-Haenszel random-effects model and used the odds ratio as an effect measure with 95% confidence intervals. The risk of bias was assessed using Cochrane's 2022 Risk Of Bias In Non-randomized Studies of Exposure tool. After screening 2671 articles from 7 databases, a total of 18 retrospective cohort studies encompassing 605,138 patients were included. The pooled rates of spontaneous preterm birth in a subsequent pregnancy were 6.9% (12 studies) after second-stage cesarean delivery and 2.6% (8 studies) after operative vaginal delivery. A total of 7 studies encompassing 75,460 patients compared the primary outcome of spontaneous preterm birth after second-stage cesarean delivery vs operative vaginal delivery in an index pregnancy with an odds ratio of 2.01 (95% confidence interval, 1.57–2.58) in favor of operative vaginal delivery. However, most studies did not include important confounding factors, did not address exposure misclassification because of failed operative vaginal delivery, and considered operative vaginal delivery as a homogeneous category with no distinction between forceps- and vacuum-assisted deliveries. Although a synthesis of the existing literature suggests that the risk of spontaneous preterm birth is higher in those with a previous second-stage cesarean delivery than in those with operative vaginal delivery, the risk of bias in these studies is very high. Findings should be interpreted with caution. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the maternal and neonatal morbidity outcome associated with vacuum assisted (VA) vaginal delivery at first vaginal birth following a previous cesarean delivery (CD).Study Design: This is a retrospective computerized study conducted at a single tertiary center, between 2005 and 2018. The study compared the morbidity outcome of VA vaginal delivery between two groups of parturients at their first vaginal birth; primigravid and those in second delivery with a prior cesarean. The primary outcome was the maternal adverse outcome: postpartum hemorrhage (PPH), anal sphincter injuries, retained placenta, shoulder dystocia, uterine rupture, and intensive care unit (ICU) admissions. Secondary outcome was the neonatal adverse outcome: Apgar score, NICU admission, meconium aspiration, jaundice, sepsis, birth trauma, and death. Univariate analysis was followed by a multiple logistic regression model controlling for potential confounders, adjusted odds ratios (95% confidence interval).Results: During the study period, we identified 3695 parturients that engaged in Trial of labor after cesarean with no previous vaginal birth, among which 679 (18.4%) delivered by Vacuum (VA-VBAC). These were compared to 6544/43,083 (15.2%) primigravid delivered by Vacuum. The VA-VBAC group had higher risk of PPH (10.5% vs. 7.2%, p < 0.01), blood transfusions (5.6% vs. 3.5%, p < 0.01), retained placenta (10.2% vs. 4.7%, p < 0.01), and uterine rupture (0.4% vs. 0%, p < 0.01). The adverse neonatal outcomes were comparable among groups.Conclusion: The VA-VBAC has a higher risk of maternal postpartum hemorrhagic complications; preventive measures should be directed to this selected group of operative vaginal deliveries. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the association between unintended uterine extension in cesarean delivery and uterine scar disruption (rupture or dehiscence) at the subsequent trial of labor after cesarean delivery (TOLAC). Methods: This is a multicenter retrospective cohort study (2005–2021). Parturients with a singleton pregnancy who had unintended lower‐segment uterine extension during the primary cesarean delivery (excluding T and J vertical extensions) were compared with patients who did not have an unintended uterine extension. We assessed the subsequent uterine scar disruption rate following the subsequent TOLAC and the rate of adverse maternal outcome. Results: During the study period, 7199 patients underwent a trial of labor and were eligible for the study, of whom 1245 (17.3%) had a previous unintended uterine extension and 5954 (82.7%) did not. In univariate analysis, previous unintended uterine extension during the primary cesarean delivery was not significantly associated with uterine scar rupture in the following subsequent TOLAC. Nevertheless, it was associated with uterine scar dehiscence, higher rates of TOLAC failure, and a composite adverse maternal outcome. In multivariate analyses, only the association between previous unintended uterine extension and higher rates of TOLAC failure was confirmed. Conclusion: A history of unintended lower‐segment uterine extension is not associated with an increased risk for uterine scar disruption following subsequent TOLAC. Synopsis: Unintended extension at index cesarean delivery is not associated with higher rates of uterine rupture/dehiscence at subsequent vaginal delivery. [ABSTRACT FROM AUTHOR]

Objective: Obstetric anal sphincter injures (OASIS) have long‐term implications on women's health. Administration of antibiotic prophylaxis and treatment following OASIS repair is controversial. We conducted a national survey to provide data about practice routines regarding antibiotic prophylaxis and treatment following OASIS repair in Israeli labor and delivery units. Methods: A national survey was performed among obstetricians and gynecologists from 24 university‐affiliated delivery centers within the jurisdiction of the Israeli Ministry of Health during 2020. Representatives from each center completed the "Google form" electronic survey. For each questionnaire item, the most common answer was chosen to represent the center's answer. Results: The number of physicians who responded per center varied from 1 to 14 (median, 3.5). Preoperative and postoperative antibiotic treatment was given in 75% and 92% of the centers, respectively. While most centers (58.3%) recommend pelvic floor physical therapy on release, recommendations about functional radiologic tests vary. In all centers, there is a designated clinic for postpartum follow‐up of OASIS. Most centers (83%) allow trial of vaginal delivery in the subsequent pregnancy, on an individual basis. Conclusion: Heterogeneity exists in managing OASIS in Israel, particularly regarding administration of antibiotics. Further studies are needed to examine the consequences of different management protocols. Synopsis: Our national survey demonstrates that despite guidelines, management of obstetric anal sphincter injuries in Israel lacks consistency, specifically regarding administration of preoperative and postoperative antibiotics. [ABSTRACT FROM AUTHOR]

Objective: In singleton pregnancies, delivery of large for gestational age (LGA) newborn is associated with various adverse maternal and neonatal outcomes, yet data regarding LGA in twin pregnancies is scarce. We aimed at evaluating maternal and neonatal outcomes associated with LGA presenting twin.Study Design: A multicenter retrospective computerized database study in two university-affiliated obstetrical centers, between 2005 and 2021. Parturients with di-amniotic twin pregnancy who had a trial of vaginal delivery were included. Maternal and neonatal outcomes of parturients with LGA presenting twin were compared to parturients with non-LGA presenting twin.Results: During the study period, 2,491 parturients with twin pregnancies were found eligible, of those 287 (11.5%) had LGA presenting twin. Parturients with LGA presenting twin were of higher gravidity and parity, had higher rates of previous cesarean deliveries and diabetes (pre-gestational & gestational). Mode of delivery of both presenting and second twin did not differ between the study groups. Maternal outcomes were comparable, specifically, rates of shoulder dystocia, and postpartum hemorrhage did not differ. Neonatal outcomes did not differ significantly between the groups other than a single case of clavicular fracture and a single case of encephalopathy in the group of LGA presenting twin.Conclusion: In our study, delivery of LGA presenting twin was found safe to both, mother and neonate. Our findings provide reassurance regarding the safety of vaginal labor in this specific population and should be presented during counseling prior to twins' delivery. [ABSTRACT FROM AUTHOR]

Objective: To evaluate maternal and neonatal outcomes associated with recurrent short interpregnancy interval (IPI) in women in their third delivery.Methods: A retrospective computerized database study of all women who delivered their first three consecutive deliveries in a single tertiary medical center over 20 years (1999-2019). Maternal and neonatal outcomes of women with recurrent short IPI (<6 months between the 1st and 2nd pregnancy and the 2nd and 3rd pregnancy) were compared to women with recurrent optimal IPI (18-48 months), and to women with a single short IPI (<6 months between the 1st and 2nd pregnancy followed by an optimal IPI of 18-48 months between the 2nd and 3rd pregnancy). Additionally, in the recurrent short IPI groups, outcomes of the 2nd and 3rd pregnancies were compared in order to achieve an ideal adjustment to background characteristics. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.Results: During the study period 10,569 women had three consecutive deliveries at our medical center, of those 338 (3.2%) women had recurrent short IPIs, and 1,021 (9.7%) had recurrent optimal IPIs. Recurrent short IPI was associated with a significantly higher risk of maternal anemia (Hb < 10gr%) on admission to labor (aOR 3.4 [95% CI 1.09-10.65], p = 0.04) and higher risk of small for gestational age neonates (aOR 10.4 [95% CI 2.32-46.93], p < 0.01), as compared with women with recurrent optimal IPI and significantly higher rates of low neonatal birth weights (2500 gr) and anemia (Hb < 10gr%) alongside lower rates of operative vaginal deliveries as compared with women with single short IPI followed by an optimal IPI. In the recurrent short IPI groups, the 3rd deliveries had significantly higher rates of in-labor cesarean and anemia (Hb < 10gr%) on admission as compared to their 2nd deliveries.Conclusion: Recurrent short IPI is associated with maternal anemia and small for gestational age neonates. Guiding patients towards prolongation of the IPI should include explanatory comments on these outcomes. [ABSTRACT FROM AUTHOR]

Objective: To assess the frequency of puerperal perineal wound re-suturing, and to evaluate the indications, risk factors and outcomes of this procedure.Study Design: A retrospective series of all parturients that underwent puerperal perineal tear suturing between 2005 and 2019 was undertaken. All parturients who required re-suturing during the delivery hospitalization were identified and compared with those who had puerperal perineal wound repair and did not require re-suturing. General demographics, obstetrical history, current delivery characteristics, re-suturing indications, and outcome were obtained and analyzed.Results: During the study period, 54,934 parturients required puerperal perineal tear suturing, of which 47 (0.09%) required re-suturing within their postpartum hospitalization. Median time from delivery to perineal re-suturing was 5.38 h [IQR 4.07-7.14]. The most common indication was vulvovaginal hematoma (n = 37, 78.7%). The independent risk factors found to be associated with re-suturing were: cephalic malposition (aOR 9.3, 95% CI 1.26-67.74) and meconium stained amniotic fluid (aOR 2.1, 95% CI 1.10-3.85). Parturients who underwent re-suturing had significantly higher rates of postpartum hemorrhage (78.5% vs. 11.4%) blood transfusions (36.2% vs. 1.3%), puerperal fever, and longer hospitalizations (P < 0.01 for all).Conclusion: In our population, early re-suturing of puerperal perineal tears is rare, however, it is associated with increased short term maternal morbidity. [ABSTRACT FROM AUTHOR]