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(J Clin Anesth. 2022;80:110795 | https://doi.org/10.1016/j.jclinane.2022.110795|)Labor involves significant pain for the mother, influenced by various factors. The ability to control this pain positively impacts the mother’s psychological and physiological well-being. Epidural analgesia is commonly chosen for pain relief during vaginal delivery. Mother-infant bonding, crucial for a child’s later attachment and self-perception, develops from pregnancy into early childhood. A strong bond correlates with positive parenting, cognitive development, and improved neurobehavioral outcomes. Impaired bonding, affecting 7% to 11.3% of mothers, can lead to long-term issues for both mother and child, including depression, anxiety, and socioemotional challenges. Several risk factors for impaired bonding include primiparity, negative feelings toward pregnancy, low birth weight, higher education, and postpartum depression. Pain during labor, a significant element, may impact the bonding process. Studies on epidural analgesia’s association with postpartum depression yield conflicting results, and no research examines its connection to mother-infant bonding. The primary study’s aim is to explore the link between epidural analgesia and mother-infant bonding, with a secondary focus on its association with postpartum depression immediately after childbirth.

AbstractOther than obesity, no definitive insights have been gained regarding the apparent association between mode of delivery and long-term endocrine and metabolic outcomes in the offspring. We aimed to determine whether elective cesarean delivery (CD) impacts on long-term endocrine and metabolic morbidity of the offspring. A population-based cohort analysis was performed including all singleton-term deliveries occurring between 1991 and 2014 at a single tertiary medical center. A comparison was performed between children delivered via a non-emergent CD and those delivered vaginally (VD). Hospitalizations of the offspring up to the age of 18 years involving endocrine morbidity were evaluated. A Kaplan–Meier survival curve was used to compare cumulative morbidity incidence. Cox and a Weibull regression models were used to control for confounders. During the study period 131,880 term deliveries met the inclusion criteria; 8.9% were elective non-urgent CDs (n=11,768) and 91.1% (n=120,112) were VDs. The survival curve demonstrated a significantly higher cumulative incidence of endo-metabolic morbidity in offspring born via CD (P=0.010). In the regression models, adjusted for maternal obesity, CD was not noted as an independent risk factor for long-term pediatric endocrine and metabolic morbidity of the offspring while maternal obesity emerged as a strong predictor. We therefore conclude that CD per-se does not appear to increase the risk for long-term pediatric endo-metabolic morbidity of the offspring.

AbstractThis study aims to examine the association between creatinine level during the first 20 weeks of pregnancy and the development of pre-eclampsia in the second half of the pregnancy. The study population included all registered births (n=9341) between 2001 and 2007 in a tertiary medical centre. Student’s t-test and receiver operating characteristic (ROC) curves were used to determine any association. Significant association was documented between creatinine level in the first 20 weeks and the prevalence of hypertensive disorders. The mean plasma creatinine value in women with mild pre-eclampsia versus healthy women was 0.59 mg/dL ± 0.14 versus 0.57 mg/dL ± 0.15, respectively (P=0.023). The mean plasma creatinine value in women with severe pre-eclampsia versus healthy women was 0.61 mg/dL ± 0.17 versus 0.58 mg/dL ± 0.15, respectively (P=0.040). The mean plasma creatinine value in women with hypertensive disorders versus healthy women was 0.60 mg/dL ± 0.15 versus 0.58 mg/dL ± 0.15, respectively (P=0.003). The ROC curve demonstrated a significant association between creatinine level in the first 20 weeks of pregnancy and the development of mild and severe pre-eclampsia in the second half of pregnancy (area under the curve: 0.54, 95% confidence interval [CI]: 0.51–0.57, P=0.02, and 0.56, 95% CI: 0.50–0.62, P=0.033, respectively). Higher creatinine levels during the first 20 weeks of pregnancy are associated with a higher risk of developing mild and severe pre-eclampsia.

(Acta Obstet Gynecol Scand. 2020;99:267–273)The rare complication of uterine rupture can potentially result in catastrophic consequences for both mother and fetus. The most common risk factor for uterine rupture is previous cesarean delivery (CD), but few published studies exist addressing uterine rupture in women without a history of previous CD. Conflicting conclusions have been reported regarding any association between grandmultiparity and uterine rupture. In this population, obstetricians have been cautious due to a fear of increased risk for uterine rupture. This approach might trigger the performance of unnecessary CDs. Therefore, this study was undertaken to determine if grandmultiparity is an independent risk factor for intrapartum uterine rupture in women without a history of previous uterine surgery.

Objective: To determine risk factors for maternal rehospitalization after term vaginal delivery. Study design: The study group consisted of all women who were rehospitalized following singleton vaginal deliveries during 1996-1998 (n = 194). The control group consisted of 427 women who were not rehospitalized during the same period. Results: The incidence of rehospitalization was 0.75% (194/25 885). Maternal chronic diseases, preterm contractions and pre-eclampsia rates were significantly higher among the study group as compared to the controls (25.3% vs. 8.4%, p < 0.001; 6.7% vs. 2.8%, p = 0.022; 9.3% vs. 4.9%, p = 0.037, respectively). Duration of labor was significantly longer in the study group as opposed to the controls (379 ± 406 min vs. 259 ± 276 min, p < 0.001). The rates of postpartum hemorrhage, blood transfusion and antibiotic treatment during delivery hospitalization were significantly higher among the study group (1.5% vs. 0.2%, p = 0.021; 4.6% vs. 0.7%, p < 0.001; 26.8% vs. 14.1%, p < 0.001, respectively). Using a forward logistic regression analysis, prolonged labor and blood transfusion during labor were found as independent risk factors associated with rehospitalization (OR 1.001, 95% CI 1.001-1.002, p = 0.001; OR 4.751, 95% CI 1.698-13.292, p = 0.003). In contrast, vertex presentation had a protective effect against rehospitalization (p = 0.027, OR 0.084, 95% CI 0.009-0.758). Conclusions: Blood transfusion and prolonged labor are independent risk factors for rehospitalization after term vaginal delivery. Special attention should be given during the early postpartum period to patients receiving blood transfusions and those with prolonged deliveries, in order to reduce rehospitalization rates.

Objective: To determine the incidence, obstetric risk factors and pregnancy outcome of placental abruption at term. Methods: A comparison of all singleton term deliveries (≥ 37 weeks' gestation) complicated with placental abruption to singleton term deliveries without placental abruption. Multivariate analysis was performed to investigate independent risk factors for placental abruption. Results: Placental abruption complicated 0.3% of all term deliveries (n = 72995). A multiple logistic regression model with backward elimination found the following factors to be independently associated with the occurrence of placental abruption in term pregnancies: pregnancy-induced hypertension (PIH), intrauterine growth restriction (IUGR), non-vertex presentation, hydramnios and advanced maternal age. Perinatal mortality was significantly higher in pregnancies complicated with placental abruption (OR = 30.0, 95% CI 19.7-45.6; p < 0.001). In order to assess whether the increased risk for perinatal mortality was due to the placental abruption or to its significant association with other risk factors, a multivariate analysis was constructed with perinatal mortality as the outcome variable. Placental abruption (OR = 50.5, 95% CI 32.2-79.1), cord prolapse, small for gestational age and congenital malformations were found to be independent risk factors for perinatal mortality. Conclusion: Abruption of the placenta at term was found to be significantly associated with PIH, non-vertex presentation, IUGR, hydramnios and advanced maternal age. Owing to the independent association found between placental abruption and perinatal mortality, these conditions should be carefully evaluated in order to reduce the occurrence of placental abruption.

Objective: To compare obstetric risk factors for failure of labor to progress in the first versus the second stage. Study design: A comparison was performed of all singleton, vertex and term deliveries with an unscarred uterus, complicated with non-progressive labor during the first and the second stages. Deliveries occurred between the years 1988 and 1999 in a tertiary university medical center. Results: Patients with non-progressive labor in the first stage (n = 1197) were significantly older, of higher birth order, and were more likely to have complications such as gestational diabetes, hypertensive disorders, premature rupture of membranes, meconium-stained amniotic fluid, hydramnios and oligohydramnios (p < 0.001 for all variables) as compared to patients with non-progressive labor in the second stage (n = 1545). In addition, pregnancies complicated with non-progressive labor in the first stage had a significantly higher rate of fetal macrosomia as compared to patients with non-progressive labor in the second stage (11.6% vs. 8.8%; p < 0.001). Conclusions: Higher rates of fetal macrosomia and high-risk pregnancies were noted among pregnancies complicated with non-progressive labor during the first vs. the second stage. The significant increase in Cesarean deliveries during the first stage of labor among high-risk pregnancies might reflect exaggerated concern of caregivers. This concern may influence an overall conservative attitude leading to the seemingly simpler mode of direct intervention by Cesarean delivery.

Objective: To determine obstetric risk factors for the occurrence of preterm placental abruption and to investigate its subsequent perinatal outcome. Study design: A retrospective comparison of all singleton preterm deliveries complicated with placental abruption, between the years 1990-1998, to all singleton preterm deliveries without placental abruption, in the Soroka University Medical Center. Results: Placental abruption complicated 300 (5.1%) of all preterm deliveries (n = 5934). A back-step multivariable analysis found the following factors to be independently correlated with the occurrence of preterm placental abruption: grandmultiparity (more than five deliveries), early gestational age, severe pregnancy-induced hypertension, previous second-trimester bleeding and non-vertex presentation. These pregnancies had a significantly lower rate of preterm premature rupture of membranes than preterm pregnancies without placental abruption. Pregnancies complicated with preterm placental abruption had significantly higher rates of cord prolapse, non-reassuring fetal heart rate patterns, congenital malformations, Cesarean deliveries, perinatal mortality, Apgar scores lower than 7 at 5 min, postpartum anemia and delayed discharge from the hospital than did preterm deliveries without placental abruption. In order to assess whether the increased risk for perinatal mortality was due to the placental abruption, or due to its significant association with other risk factors, a multivariable analysis was constructed with perinatal mortality as the outcome variable. Placental abruption (OR 3.0, 95% CI 2.1-4.1) as well as cord prolapse, previous perinatal death, low birth weight and congenital malformations were found to be independent risk factors for perinatal mortality. Conclusion: Preterm placental abruption is an unpredictable severe complication associated with significant perinatal morbidity and mortality. Factors found to be independently associated with placental abruption were grandmultiparity, severe pregnancy-induced hypertension, malpresentation, earlier gestational age and a history of second-trimester vaginal bleeding.

Objective: To evaluate the effect of meconium-stained amniotic fluid (AF) on perinatal outcome. Methods: A prospective observational study was performed, comparing perinatal outcome of parturients with thick and thin meconium-stained AF to those with clear AF. Results: The rate of meconium-stained AF was 18.1% (106/586). Of those, 78 (13.3%) patients had thin and 28 (4.8%) had thick meconium-stained AF. The rate of oligohydramnios was significantly higher among pregnancies complicated with thick meconium-stained AF (OR 7.2, 95% CI 2.1-24.1; p = 0.002). A significant linear association, using the Mantel-Haenszel test for linearity, was found between the thickness of the meconium and abnormal fetal heart rate patterns during the first and second stages of labor, low Apgar scores at 1 min and the risk for Cesarean section. A statistically significantly higher risk for neonatal intensive care unit admission was observed among patients with thick meconium as compared to those with clear AF (OR 11.4, 95% CI 2.0-59.3; p = 0.006), even after adjustment for oligohydramnios and abnormal fetal heart rate patterns. Conclusions: Thick, and not thin, meconium-stained AF, was associated with an increased risk for perinatal complications during labor and delivery. Therefore, thick meconium-stained AF should be considered a marker for possible fetal compromise, and lead to careful evaluation of fetal well-being.

Objective: To determine the incidence, obstetric risk factors and perinatal outcome of placenta previa. Study design: All singleton deliveries at our institution between 1990 and 1998 complicated with placenta previa were compared with those without placenta previa. Results: Placenta previa complicated 0.38% ( n = 298) of all singleton deliveries ( n = 78 524). A back-step multiple logistic regression model found the following factors to be independently correlated with the occurrence of placenta previa: maternal age above 40 years (OR 3.1, 95% CI 2.0-4.9), infertility treatments (OR 3.1, 95% CI 1.8-5.6), a previous Cesarean section (OR 1.8, 95% CI 1.4-2.4), a history of habitual abortions (OR 1.3, 95% CI 1.3-2.7) and Jewish ethnicity (OR 1.3, 95% CI 1.1-1.8). Pregnancies complicated with placenta previa had significantly higher rates of second-trimester bleeding (OR 156.0, 95% CI 87.2-277.5), pathological presentations (OR 7.6, 95% CI 5.7-10.1), abruptio placentae (OR 13.1, 95% CI 8.2-20.7), congenital malformations (OR 2.6, 95% CI 1.5-4.2), perinatal mortality (OR 2.6, 95% CI 1.1-5.6), Cesarean delivery (OR 57.4, 95% CI 40.7-81.4), Apgar scores at 5 min lower than 7 (OR 4.4, 95% CI 2.3-8.3), placenta accreta (OR 3.6, 95% CI 1.1-9.9) postpartum hemorrhage (OR 3.8, 95% CI 1.2-10.5), postpartum anemia (OR 5.5, 95% CI 4.4-6.9) and delayed maternal and infant discharge from the hospital (OR 10.9, 95% CI 7.3-16.1) as compared to pregnancies without placenta previa. In a multivariable analysis investigating risk factors for perinatal mortality, the following were found to be independent significant factors: congenital malformations, placental abruption, pathological presentations and preterm delivery. In contrast, placenta previa and Cesarean section were found to be protective factors against the occurrence of perinatal mortality while controlling for confounders. Conclusion: Although an abnormal implantation per se was not an independent risk factor for perinatal mortality, placenta previa should be considered as a marker for possible obstetric complications. Hence, the detection of placenta previa should encourage a careful evaluation with timely delivery in order to reduce the associated maternal and perinatal complications.

Objective: Idiopathic hydramnios is an independent risk factor for perinatal morbidity and mortality, although the precise mechanism is unknown. Hydramnios may alter oxygen delivery to the human fetus. The middle cerebral artery (MCA) pulsatility index (PI) is a sensitive parameter for detection of blood flow redistribution or centralization. The aim of this study was to determine whether idiopathic hydramnios is associated with changes in the PI of the MCA and the umbilical artery (UA). Design: The PI of the MCA and UA were determined prospectively in 113 consecutive pregnant women with singleton pregnancies and idiopathic hydramnios (study group) and in 113 matched control patients with normal amniotic fluid (AF) volume (control group). The control group was matched for maternal age, gravidity, parity and gestational age at examination. Hydramnios was defined as an AF index above 24 cm. Patients with fetal structural or chromosomal anomalies and with diabetes mellitus were excluded. A PI below the 5th centile for the MCA was considered abnormal. Results: The rate of abnormal MCA PI was significantly higher in the study group than in the control group (30.9% (35/113) vs. 5.3% (6/113), respectively, OR 8.0; p < 0.0001; 95% CI 3.3-22.1). A significant inverse correlation was found between MCA PI and increasing AF index among patients with hydramnios ( p = 0.008, r = 0.46). In contrast, there were no significant differences between the UA PI (0.93 (0.57-2.06) vs. 1.0 (0.49-1.48), ( p = 0.20)) and MCA/UA (1.86 (0.77-2.01) vs. 2.15 (0.86-4.11), ( p = 0.14)) in both groups. Conclusions: Our observations provide evidence of cerebral blood flow redistribution in fetuses with idiopathic hydramnios.

The purpose of the study was to characterize parturients who prefer to deliver without the use of analgesia. The study population consisted of 446 consecutive low risk laboring women in early active stage of labor. Data were collected prospectively by an obstetrician, using a structured questionnaire. The degree of pain was assessed by using a visual analog scale (VAS). An obstetrician and a midwife together estimated the degree of pain as was exhibited by the parturients, using the same scale. Univariate analysis found women who undertake labor without analgesia to be significantly older, with higher birth order, of Bedouin ethnicity and to be of lower educational level than those taking analgesics during labor. Women who refused analgesia had experienced and apparently expressed lower degrees of pain (mean VAS score = 7.4 and 6.7, respectively) than those who consented to analgesia (mean VAS score = 8.6 and 8.0, respectively; p < 0.001). A multiple logistic regression model found only the severity of pain (odds ratio (OR) = 0.67, 95% confidence interval (CI) 0.51-0.88; p = 0.004), as well as high maternal age (OR = 1.12, 95% CI 1.16-2.04; p = 0.038) to be independent factors affecting the decision not to accept analgesia during labor. In conclusion, parturients refusing analgesia were older and had experienced less pain during labor than women using analgesia.

Abstract.: Rupture of membranes before 37 completed weeks of gestation, and before the onset of contractions occurs among 2–3% of pregnancies, and in about 30%–40% of women who deliver preterm. It is known as preterm premature rupture of membranes (PPROM) and is associated with maternal and neonatal morbidity. It has been postulated that antibiotic therapy may significantly decrease the complications associated with infection. The aim of the present review is to summarize the available data about the value of antibiotic therapy in PPROM.

Polyhydramnios complicates 1 to 3 of all pregnancies, and approximately 50 to 60 of cases are idiopathic. Although many fetal and maternal causes of polyhydramnios are known, idiopathic polyhydramnios is defined as that with no identifiable etiology. Amniotic fluid is commonly assessed using the amniotic fluid index (AFI), with polyhydramnios defined as an AFI of 24 cm or greater or 25 cm or greater, which is in the 95th or 97.5th percentile in normal singleton pregnancies. Polyhydramnios is subdivided into mild (24–30), moderate (30.1–35), and severe (AFI > 35). This retrospective cohort study was performed to reevaluate the cutoff point for polyhydramnios and identify a specific value associated with an increased risk for adverse outcomes.