Objective: To investigate whether an association exists between deceleration and acceleration areas on continuous fetal cardiotocography (CTG) and neonatal encephalopathy (NE). Design: A retrospective case-control study. Setting: A single tertiary medical center with over 15,000 births a year. Population: All deliveries complicated by neonatal encephalopathy in our center during the study period, with two controls for every case, matched by gestational age and cord blood pH. Methods: We compared CTG characteristics of low-risk pregnancies (35 weeks gestation or more), complicated by moderate to severe NE with matched controls. We analyzed the intrapartum CTG recordings by calculation of the deceleration and acceleration areas. Main outcome measure: Deceleration and acceleration areas and the ratio between the two. Results: During the period between 2013 and 2019, we identified 95 cases of low-risk pregnancies that were complicated by moderate to severe NE in our center. Thirty-three (34.7%) deliveries were excluded, mostly due to an insufficient duration of the CTG recordings. The remaining 62 cases were matched with 123 controls. We found that NE was significantly associated with an increased total deceleration area, a decreased total acceleration area and a lower acceleration-to-deceleration ratio. Conclusions: In our population, NE was significantly associated with increased total deceleration area, decreased total acceleration area and a lower acceleration-to-deceleration ratio, irrespective of cord blood pH. Development of a computerized real-time analysis of fetal heart rate tracings may contribute to making these measurements a more valid clinical tool.

ABSTRACT Background: Obstetrical complications involving uteroplacental insufficiency associated disorders, such as preeclampsia, intrauterine growth restriction, and obstetric antiphospholipid syndrome, share pathophysiology and risk factors with cardiovascular diseases treated with statins. Objective: To evaluate associations of statin treatment with pregnancy prolongation, and neonatal and maternal morbidity, among women with uteroplacental insufficiency disorders. Search Strategy: Electronic databases including PubMed, Medline, Embase, Clinical Trials Registry Clinicaltrials.gov, and The Cochrane Library were searched from inception to January 2022. Selection Criteria: Cohort studies and randomized controlled trials (RCTs) Data collection and analysis: Pooled odds ratios were calculated using a random-effects model; meta-regression was utilized when applicable. Main Results: The analysis included ten studies describing 1391 women with uteroplacental insufficiency-associated disorders: 703 treated with pravastatin and 688 not treated with statins. Women who received pravastatin showed significant prolongation of pregnancy (mean difference 0.44 weeks, 95%CI:0.01-0.87, p=0.04, I2=96%) and less neonatal critical care unit admission (OR=0.42, 95%CI: 0.23-0.75, p=0.004, I2=25%). Trends were observed toward a decrease in preeclampsia diagnoses (OR=0.51, 95%CI:0.25–105, p=0.07, I=44%), and perinatal death (OR=0.32, 95%CI:0.09-1.13, p=0.08, I2=54%) and an increase in birth weight (mean difference=102 grams, 95%CI: -14–212, p=0.08, I2=96%). A meta-regression analysis revealed associations between earlier gestational age at initiation of pravastatin treatment to lower risk for development of preeclampsia (R2=1) and between longer duration of pravastatin treatment to lower rate of NICU admission (R2=0.33). No dose-response effect was demonstrated. Conclusions: Pravastatin treatment in pregnancies with high risk for developing uteroplacental insufficiency disorders may prolong pregnancy duration and improve neonatal outcomes.

Objective: To evaluate the maternal and neonatal outcomes of parturients attempting trial of labor (TOL) after two previous cesarean deliveries (CD) Design: A retrospective computerized database cohort study. Setting: A single tertiary center between 2005 and 2019. Population: Parturients attempting TOL after two CD were compared to parturients opting for elective third repeat CD. TOL after two CD was allowed only for those who met all the criteria of our departments’ protocol. Methods: A univariate analysis was conducted and was followed by a multivariate analysis. Main outcome measures: A composite of adverse maternal and neonatal outcomes. Results: A total of 2719 eligible births following two CD were identified, of which 485 (17.8%) had attempted TOL. Overall, successful vaginal delivery rate following two CDs was 86.2%. Uterine rupture rates were higher among those attempting TOL (0.6% vs 0.1% p=0.04). However, rates of hysterectomy, re-laparotomy, blood product infusion and intensive care unit admission did not differ significantly between the groups. Neonatal outcomes following elective repeat CD were less favorable (specifically, neonatal intensive care unit admission and composite adverse neonatal outcome). Nonetheless, when controlling for potential confounders, an independent association between composite adverse neonatal outcome and an elective repeat CD was not demonstrated. In a subgroup analysis, diabetes mellitus and hypertensive disorders of pregnancy were found independently associated with failed TOLAC. Conclusion: When following a strict protocol, TOL after two CD is a reasonable alternative and associated with favorable maternal and neonatal outcomes

Objective: To evaluate the association between certified nurse midwife (CNM) annual delivery workload and short-term, adverse maternal and neonatal outcomes occurring in vaginal deliveries. Design: A retrospective cohort study Setting: A single tertiary academic center. Population: All single, live vertex term vaginal deliveries between 2006 and 2018 were included Methods: deliveries were categorized into two groups based on the CNM median annual volume of deliveries during the study duration. The “high-volume” and “low-volume” groups included deliveries above and below the median annual delivery volume, respectively as a dichotomous variable. Further analyses were performed for the annual volume by deciles. Main outcomes measures: Short term maternal and neonatal outcomes were compared between “high-volume” and “low-volume” groups and between deciles. Results: During the study period 140,856 deliveries met the study criteria. The median annual deliveries of a single CNM was 152 [114-195]. Maternal and labor characteristics were comparable between the groups. Maternal outcomes were not significantly associated with the CNM’s annual workload. However, neonates delivered by CNMs with “low” annual volume had higher a 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 CNM’s annual volume after controlling for the CNM, parturient and neonate’s characteristics. Funding: This study was not funded by any organization.