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.