Israel Medical Association Journal

Background: The correlation between epidural analgesia and successful Trial of Labor After Cesarean delivery (TOLAC) remains controversial.

Objectives: To explore this correlation considering the indication for previous cesarean section (CS).

Methods: We accessed an electronic database of an obstetrics department at a university tertiary medical center. All patients admitted for a TOLAC at term with a live singleton fetus with cephalic presentation between January 2015 and December 2021 were included. The primary outcome was the mode of delivery, based on the previous CS indication. Univariate and multivariate analyses were performed to identify the effect of epidural analgesia on TOLAC success.

Results: Overall, 1522 candidates for TOLAC were included, with previous CS due to arrest of descent in 261 cases (17.1%). Epidural analgesia was administered in 1098 deliveries (72.1%), and 282 women (18.5%) underwent a repeat CS. Women in the epidural group were younger, had higher body mass index, lower parity, and more frequent induction of labor. Prior vaginal birth after cesarean was more common in the non-epidural group. Univariate analysis showed a higher rate of epidural analgesia in repeat CS cases. However, in multivariable logistic regression, epidural analgesia was not significantly associated with the risk of repeat CS, both among women whose prior CS was for arrest of descent and among those with other indications.

Conclusions: The employment of epidural analgesia seems to have no observable influence on successful outcomes of TOLAC, regardless of the indication for the preceding CS. These findings imply that epidural anesthesia in TOLAC is safe.

Background: Fetal macrosomia is a risk factor for operative vaginal delivery (VD), shoulder dystocia, obstructed labor, and cesarean section (CS). Induction of labor (IOL) may decrease these risks but also leads to longer labor, increasing the risk of CS. No data exist regarding the optimal method of IOL in macrosomic fetuses, and most studies are limited to the efficacy of medical induction.

Objective: To compare medical and mechanical IOL in macrocosmic fetuses.

Methods: This retrospective case-control study included pregnant women who underwent IOL and delivered macrosomic neonates at a tertiary center between 2010 and 2020.

Women with non-cephalic presentation, prior CS, and multiple pregnancies were excluded. The primary outcome was the mode of delivery. Secondary outcomes included neonatal and maternal complications.

Results: A total of 247 women were included in the study, 188 underwent cervical ripening with prostaglandin E2 (PGE2) regimens and 59 with a double-balloon catheter. Higher rates of prior deliveries over 4000 grams and Oxytocin use during delivery were found in the mechanical induction group. No other clinically significant differences in demographic or clinical characteristics were identified. There were no statistically significant differences in the rates of VD or CS between the groups. The indications for CS were similar. Maternal and neonatal secondary outcomes were comparable.

Conclusion: PGE2 vaginal regimens and double catheter balloons are safe and effective methods for cervical ripening during IOL in term pregnancies with macrosomic neonates. The choice of cervical ripening method did not impact the mode of delivery or maternal and neonatal outcomes.

Late, preterm premature rupture of the membranes (PPROM) presents a major obstetrical challenge balancing between iatrogenic prematurity and risk of prolonged rupture of membranes. In recent years, the pendulum has been shifting toward expectant management until gestation week 37 + 0. We examined the latest guidelines and major trials and summarized optimal management. We addressed the major dilemmas of women with PPROM during gestation weeks 34 + 0 to 36 + 6.

Background: In recent years, the role of intrapartum sonography has expanded in childbirth management, in subjective clinical situations such as arrested deliveries, or prior to instrumental deliveries.

Objectives: To assess the current use of intrapartum ultrasound by obstetricians in Israel.

Methods: An anonymous questionnaire was completed by 79 obstetricians in second- and third level- hospitals in Israel. The results were analyzed according to main subspecialty (sonography, delivery), experience and gender.

Results: A questionnaire was completed by 56 senior obstetricians and 23 interns with an average experience of 14.3 and 2.4 years, respectively. All obstetricians performed ultrasound examinations in the delivery room for basic indications such as fetal presentation during twin delivery and to rule out placenta previa. Sonographers consistently reported advanced indications as compared to senior members of delivery teams and interns in the assessment of prolonged first (52% vs. 14% vs. 14%) and second stage of labor (88% vs. 52% vs. 62%) and in assessment of fetal head station (60% vs. 30% vs. 22%), head progression during descent (48% vs. 23% vs. 11%), diagnosis of head position (88% vs. 68% vs. 60%), spine direction (92% vs. 59% vs. 53%) and asynclytism (41% vs. 20% vs. 29%).

Conclusions: Ultrasound is currently used by all physicians in the delivery room for basic indications. However, obstetric teams report a low use of advanced intrapartum ultrasound and prefer to rely on their clinical experience. Advanced intrapartum sonographic imaging should be an integral part of obstetric qualifications. A steep learning curve, along with high reproducibility, suggests that ultrasound devices will become a common tool in labor and delivery management.

Background: Visual interpretation of fetal heart rare monitoring is subject to intra and inter observer variability.

Objective: To examine the effect of intrapartum administration of meperidine and promethazine on fetal heart activity measured by a computerized system.

Methods: Fourteen healthy women with normal pregnancies at term were studied during the active phase of labor. Fetal heart rate was recorded with the Oxford Sonicaid system 8000. Recordings were performed for 40 minutes prior to and after maternal intravenous administration of meperidine 50 mg with promethazine 25 mg.

Results: The combination of meperidine and promethazine caused a significant decrease in the number of accelerations of 10 beats per minute (9.7 versus 2.6, P = 0.002) and 15 beats per minute (5.2 vs. l.4, P = 0.003), time spent in episodes of high variation (14.8 vs. 2.0, P = 0.005) and short-term variation (7.8 vs. 5.0, P = 0.003). On the other hand there was an increase in the time spent in episodes of low variation (5.3 vs. 19.7, P = 0.009).

Conclusions: Maternal administration of meperidine with promethazine has a significant effect on FHR[1] indices during the active phase of normal labor.

Background: Patients who feel involved in their treatment have better outcomes than those who do not.

Objective: To identify determinants of perceived patient involvement in obstetric care.

Methods: A retrospective study was undertaken in 1,452 (83%) of 1,750 women sampled in November 1995 from maternity wards of 14 general hospitals in Israel. A postal and telephone survey using a self-administered questionnaire included the following variables: hospital (identity number), patients' age, self-reported complications, previous deliveries, education, ethnicity, and number of obstetric interventions performed and/or considered. The main outcome measured was the reported involvement in decisions for obstetric interventions.

Results: Reported full involvement varied from 72% for epidural analgesia to 13% for forceps/vacuum extraction. Factor analysis identified two dimensions of perceived involvement: one for routine” interventions (enema, monitor­ing, IV line and episiotomy), which are performed in Israel mostly by midwives, and another for "special" interventions (forceps/vacuum extraction, epidural or other analgesia, and cesarian section) performed by physicians. Logistic regression identified hospitals, younger age, number of interventions, and Arab ethnicity as correlates of a perceived non-involvement in decisions for "special" interventions.

Conclusions: Clinical setting, age and ethnicity affected patient perception of involvement in decisions for obstetric interventions.

Background: Obesity, a common condition in developed countries, is recognized as a threat to health.

Objectives: To describe the distribution of weight in pregnant women and evaluate the influence of obesity on pregnancy outcome in a high parity northern Israeli population.

Methods: The study included 887 women who gave birth in the Western Galilee Medical Center during the period August to November 1995. The patients were classified as underweight, normal weight, overweight, or obese according to body mass index. Maternal demographic, obstetric, and perinatal variables were compared. A control group of 167 normal weight women were matched with the obese group for maternal age, parity, and gestational age.

Results: Obese mothers had a higher incidence of gestational diabetes and pregnancy-induced hypertension compared to normal weight mothers (5.4% vs. 1.8%, and 7.2% vs. 0.6% respectively, P<0.01), a higher rate of labor induction (20.4% vs. 10.2%, P<0.01), and a higher cesarean section rate (19.6% vs.10.8%, P<0.05). There was also a significant difference in the prevalence of macrosomia in the offspring (16.8% vs. 8.4%, P<0.05).

Conclusion: Obese pregnant women are at high risk for complications during delivery and therefore need careful pre-conception and prenatal counseling, as well as perinatal management.