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Objective: To examine trial of labor after cesarean delivery (TOLAC) success rates and its associated factors among women with a previous failed vacuum-assisted vaginal delivery., Methods: We conducted a retrospective cohort study. The study group comprised all women with a prior failed vacuum-assisted vaginal delivery who subsequently delivered from 2008 to 2017 at a university hospital., Results: Overall, 166 women with prior history of failed vacuum-assisted vaginal delivery delivered during the study period, with a median interdelivery interval of 28 (21-36) months. Of them, 53 (32%) had an elective repeat cesarean delivery, and 113 (68%) had a TOLAC. Although there were small statistical differences in the predelivery characteristics of the two groups, there were not clinically significant differences. Of the 113 women who underwent TOLAC in the subsequent pregnancy, the overall success rate was 67%. Neonatal 1- and 5-minute Apgar scores were lower among neonates born to women who experienced a failed TOLAC attempt compared with those who underwent successful TOLAC: 1-minute Apgar score less than 7 (6 [16%] vs 2 [3%], odds ratio [OR] 7.16, 95% CI 1.36-37.45, P=.01), 5-minute Apgar score less than 8 (3 [8%] vs 0 [0%], OR 15.5, 95% CI 1.78-308.7, P=.03). No events of obstetric anal sphincter injury, postpartum hemorrhage and uterine rupture were encountered among women who underwent TOLAC., Conclusion: Trial of labor after cesarean delivery in women with a previous failed vacuum-assisted vaginal delivery appears to be associated with an acceptable success rate. These data should improve patient counseling and provide reassurance for those who wish to deliver vaginally after a previous failed vacuum-assisted vaginal delivery.

Objective: To estimate the association between time of delivery after external cephalic version at term and the risk for cesarean delivery., Methods: This retrospective cohort study included all successful external cephalic versions performed in a tertiary center between January 1997 and January 2010. Stepwise logistic regression was used to calculate the odds ratio (OR) for cesarean delivery., Results: We included 483 external cephalic versions in this study, representing 53.1% of all external cephalic version attempts. The incidence of cesarean delivery for 139 women (29%) who gave birth less than 96 hours from external cephalic version was 16.5%; for 344 women (71%) who gave birth greater than 96 hours from external cephalic version, the incidence of cesarean delivery was 7.8% (P = .004). The adjusted OR for cesarean delivery was 2.541 (95% confidence interval 1.36-4.72). When stratified by parity, the risk for cesarean delivery when delivery occurred less than 96 hours after external cephalic version was 2.97 and 2.28 for nulliparous and multiparous women, respectively., Conclusion: Delivery at less than 96 hours after successful external cephalic version was associated with an increased risk for cesarean delivery., Level of Evidence: III.

Objective: To compare the success of external cephalic version using spinal analgesia with no analgesia among nulliparas., Methods: A prospective randomized controlled trial was performed in a tertiary referral center delivery suite. Nulliparous women at term requesting external cephalic version for breech presentation were randomized to receive spinal analgesia (7.5 mg bupivacaine) or no analgesia before the external cephalic version. An experienced obstetrician performed the external cephalic version. Primary outcome was successful conversion to vertex presentation., Results: Seventy-four women were enrolled, and 70 analyzed (36 spinal, 34 no analgesia). Successful external cephalic version occurred among 24 of 36 (66.7%) women randomized to receive spinal analgesia compared with 11 of 34 (32.4%) without, P=.004 (95% confidence interval [CI] of the difference: 0.0954-0.5513). External cephalic version with spinal analgesia resulted in a lower visual analog pain score, 1.76+/-2.74 compared with 6.84+/-3.08 without, P<.001. A secondary analysis logistic regression model demonstrated that the odds of external cephalic version success was 4.0-fold higher when performed with spinal analgesia P=.02 (95% CI, odds ratio [OR] 1.2-12.9). Complete breech presentation before attempting external cephalic version increased the odds of success 8.2-fold, P=.001 (95% CI, OR 2.2-30.3). Placental position, estimated fetal weight, and maternal weight did not contribute to the success rate when spinal analgesia was used. There were no cases of placental abruption or fetal distress., Conclusion: Administration of spinal analgesia significantly increases the success rate of external cephalic version among nulliparous women at term, which allows possible normal vaginal delivery., Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00119184, Level of Evidence: I.

Objective: The purpose of the study was to characterize the perinatal outcome of pregnancies complicated by placenta accreta., Methods: We conducted a case-control analysis of all deliveries between the years 1990 and 2000 that were complicated by placenta accreta. Perinatal variables included in the analysis were gestational age at delivery, birth weight, Apgar scores, and perinatal mortality. Statistical analysis was performed using both the unpaired and paired approach. P <.05 was considered significant., Results: The study encompassed 34,450 deliveries, from which 310 cases of placenta accreta were diagnosed (0.9%) and compared with 310 matched controls. In the pregnancies complicated by placenta accreta, we found a statistically significant increase in preterm deliveries (10.7% versus 1%, P <.001, odds ratio 12.1, 95% confidence interval 3.7-39.9) and small-for-gestational-age babies (27.3% versus 14%, P <.001, odds ratio 5.05, 95% confidence interval 1.46-3.28)., Conclusion: Pregnancies complicated by placenta accreta are at increased risk for perinatal adverse outcome. We speculate that these findings may arise from pathological implantation of the placenta, resulting in interference with normal fetal growth.

Objective: To compare the efficacy of intravaginal and intrarectal plus oral indomethacin for the treatment of preterm labor., Methods: Between December 1996 and November 1998, 46 eligible gravidas admitted with singleton pregnancies and idiopathic preterm labor before 33 gestational weeks were randomized to receive 200 mg of intravaginal or intrarectal plus oral indomethacin., Results: Twenty-three subjects were allocated to each study group. The interval from initiation of treatment to delivery was significantly longer in the intravaginal indomethacin group (26.5 +/- 5.7 versus 12.6 +/- 3.7 days; P =.007). Delivery was delayed by more than 7 days in 18 of 23 subjects (78%) in the intravaginal indomethacin group compared with ten (43%) in the intrarectal plus oral indomethacin group (P =.03). Birth weights were significantly higher (2306 +/- 436 versus 1862 +/- 232 g; P =.002) and hospitalization in a neonatal intensive care unit (NICU) (3.1 +/- 0.8 versus 9.3 +/- 3. 7 days; P =.001) and mechanical ventilation (1.4 +/- 0.2 versus 5.3 +/- 1.6 days; P =.001) were significantly shorter in the intravaginal indomethacin group., Conclusion: Intravaginal indomethacin is more effective than intrarectal plus oral application in delaying preterm labor and is associated with higher birth weights, shorter NICU stays, and shorter intervals of mechanical ventilation.

Obstetricians assume a dual role in the provision of health care for both mother and fetus during labor. Not only do they function as consultants for medical and surgical problems peculiar to labor, but they also assume a more broad-based role in the prevention of labor complications to achieve the best possible health maintenance for both patients. This includes the provision of continuous health care throughout pregnancy, delivery, and postpartum management. A summary of the common problems of management of labor and labor complications is provided, including fetal monitoring during labor, augmentation of labor, vaginal delivery after cesarean section, epidural analgesia and its effects on delivery, and fecal incontinence after delivery.

Fibromuscular dysplasia is an arteriopathy of unknown etiology that affects the intermediate-size branches of the aorta. Partial occlusion of these arteries may result in neurologic symptoms when carotid arteries are affected, and impaired liver or kidney function when their blood supply is compromised. Pregnancy and delivery in women who are diagnosed as having fibromuscular dysplasia may be associated with disease-related complications such as ischemic attacks. We report the course of a pregnancy and delivery in a patient with carotid artery fibromuscular dysplasia and suggest steps for general obstetric management and contraception in patients suffering from fibromuscular dysplasia.