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OBJECTIVES: To identify risk factors and complications associated with 3rd stage of labor removal of placental fragments (3rd SRPF) by manual uterine revision under a strict protocol. STUDY DESIGN: Ten years retrospective register-based cohort study of vaginal deliveries. Women with 3rd SRPF n = 3297 (exposed) and those without n = 97,888 (non exposed) were compared. MAIN OUTCOMES MEASURES: (1) risk factors for 3rd SRPF aOR (95%CI) (2) early (2a) and late (2b) maternal complications. RESULTS: (1) Risk factors for 3rd SRPF procedure were assisted reproductive technologies 2.20 (1.73-2.34), preterm delivery 2.53 (2.21-2.88), preeclampsia 1.66 (1.25-2.21) Multiple previous early pregnancy loss (>3) 1.40(1.19-1.66), VBAC 1.26(1.13-1.47) and epidural analgesia 1.56 (1.46-1.69). (2a) Early complications: puerperal fever 1.1% vs 0.3%, blood transfusion 9.0% vs. 0.5%, prolonged maternal hospitalization 21.0% vs. 11.4%, all P < 0.0001. Puerperal readmission was 0.819% in the 3rd SRPF vs. 0.315% the control group, P < 0.0001. (2b) Late complications: retained placenta and hysteroscopy / D&C rates were significantly higher among the 3rd SRPF vs. controls: 40.7% vs. 7.1%, 14.8% vs. 3.6% and 48.1% vs. 18.2%, respectively, all P < 0.0001. CONCLUSION: Uterine revision for 3rd SPRF is associated with significant early and late maternal morbidity; should be considered discriminative of a population at risk and postpartum health care planning, beyond being a therapeutic intervention.

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BACKGROUND: Unintended dural puncture (UDP) is one of the main risks of epidural analgesia, with a reported incidence of approximately 1.5% among the obstetric population. UDP is associated with maternal adverse outcomes, with the most frequent adverse outcome being postdural puncture headache (PDPH). Our retrospective cohort study objective was to identify demographic and obstetric risk factors that increase the risk of unintentional dural puncture as well as describing the obstetric outcome once a dural puncture has occurred. METHODS: We retrospectively reviewed all cases of UDPs during attempted vaginal delivery between the years 2004 and 2013 in a single Israeli hospital. Each UDP case was matched with the 2 parturients who received epidural analgesia before and 2 parturients after performed by the same anesthesiologist (control group). Demographic, anesthetic, and obstetric variables were compared between the UDP and control groups. RESULTS: Out of 46,668 epidural procedures, 177 cases of UDPs were documented (0.4%). One hundred seven women (60.5%) developed PDPH, and 38 (35.5%) required an epidural blood patch. In multivariate logistic regression, the degree of cervical dilation in centimeters at the time of epidural insertion was associated with an increased rate of UDP (P < .001). Multiparity was associated with PDPH after UDP (P = .004). Women with UDP had longer length of hospital stay than those without UDP (P < .001). CONCLUSIONS: UDP, an uncommon complication, is associated with obstetric factors. Nevertheless, it does not seem to be associated with adverse obstetric outcomes except for prolonged duration of hospital stay.

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PURPOSE: To revisit risk factors of major obstetric hemorrhage in a large obstetric center. STUDY DESIGN: A retrospective case control study was conducted based on institutional electronic database and blood bank registry of a single center, 2005-2014. The major obstetric hemorrhage event was defined as transfusion of ≥5 red blood cells units within 48 h of birth and compared to matched group (ratio 1:4) based on the time of birth. Multivariable stepwise backward logistic regression models were fitted to determine risk factors for major obstetric hemorrhage. Odds ratio (OR), further evaluated by standard measures of the predictive accuracy of the logistic regression models, C statistics, and associated neonatal adverse outcome are reported. RESULTS: 113,342 women delivered during the study; 122 (0.1 %) women experienced major obstetric hemorrhage. There was one major obstetric hemorrhage fatality (0.8 %). Compared to the controls, we identified historical as well as significant current modifiable risk factors for major obstetric hemorrhage: multifetal pregnancy (OR 3.92; 95 % CI 1.34-11.52; p = 0.013), induction of labor (OR 2.81; 95 % CI 1.22-7.05; p = 0.027), cesarean section (OR 25.56; 95 % CI 12.88-50.75; p < 0.001), and instrumental delivery (OR 6.58; 95 % CI 2.36-18.3; p < 0.001). C statistics of the model for major obstetric hemorrhage prediction was 0.919 (95 % CI 0.890-0.948, p < 0.001). CONCLUSION: Major obstetric hemorrhage is a rare event with potentially modifiable risk factors which represent a platform of interventions for lessening obstetric morbidity.

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OBJECTIVE: To evaluate anesthetic considerations in pregnancy for women at advanced maternal age (≥40 years). METHODS: A retrospective cohort study of laboring women aged 40 years or above comparing women aged 40-44 years old with those aged ≥45 years, in a single, tertiary, university affiliated medical center. RESULTS: Overall, 39,006 women delivered in our institution during the study period, of them 376 (1%) were eligible for analysis: 278 (74%) were 40-44 years old (control group) and 98 (26%) were 45 years old and above (study group). No differences were found between the groups with regards to analgesia or anesthesia management during labor. Differences were found in obstetrical characteristics such as higher rates of primiparity, preeclampsia, need for magnesium sulphate therapy and chronic hypertension among parturients aged ≥45 years. Of note, parturients aged ≥ 45 years had an approximately eight-fold risk for postpartum hemorrhage. CONCLUSION: Anesthesia management of parturients aged 45 years and above is comparable to the management of women aged 40-44 years. However, parturients≥45 are more susceptible to bleeding complications.

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BACKGROUND: Aseptic technique and handwashing have been shown to be important factors in perioperative bacterial transmission, however compliance often remains low despite guidelines and educational programs. Infectious complications of neuraxial (epidural and spinal) anesthesia are severe but fortunately rare. We conducted a survey to assess aseptic technique practices for neuraxial anesthesia in Israel before and after publication of international guidelines (which focused on handwashing, jewelry/watch removal and the wearing of a mask and cap). METHODS: The sampling frame was the general anesthesiology workforce in hospitals selected from each of the four medical faculties in Israel. Data was collected anonymously over one week in each hospital in two periods: April 2006 and September 2009. Most anesthesiologists received the questionnaires at departmental staff meetings and filled them out during these meetings; additionally, a local investigator approached anesthesiologists not present at these staff meetings individually. Primary endpoint questions were: handwashing, removal of wristwatch/jewelry, wearing mask, wearing hat/cap, wearing sterile gown; answering options were: "always", "usually", "rarely" or "never". Primary endpoint for analysis: respondents who both always wash their hands and always wear a mask ("handwash-mask composite") - "always" versus "any other response". We used logistic regression to perform the analysis. Time (2006, 2009) and hospital were included in the analysis as fixed effects. RESULTS: 135/160 (in 2006) and 127/164 (in 2009) anesthesiologists responded to the surveys; response rate 84% and 77% respectively. Respondents constituted 23% of the national anesthesiologist workforce. The main outcome "handwash-mask composite" was significantly increased after guideline publication (33% vs 58%; p = 0.0003). In addition, significant increases were seen for handwashing (37% vs 63%; p = 0.0004), wearing of mask (61% vs 78%; p < 0.0001), hat/cap (53% vs 76%; p = 0.0011) and wearing sterile gown (32% vs 51%; p < 0.0001). An apparent improvement in aseptic technique from 2006 to 2009 is noted across all hospitals and all physician groups. CONCLUSION: Self-reported aseptic technique by Israeli anesthesiologists improved in the survey conducted after the publication of international guidelines. Although the before-after study design cannot prove a cause-effect relationship, it does show an association between the publication of international guidelines and significant improvement in self-reported aseptic technique.

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BACKGROUND: Obstetric anesthesia workload demand in Israel has increased due to both an increase in the requests for labor analgesia and a marked increase in the cesarean delivery rate. We propose a new workload-driven performance indicator, the Obstetric Anesthesia Activity Index (OAAI), to serve as a single denominator of obstetric anesthesia activity to enable direct comparison of different hospitals despite dissimilar rates of epidural labor analgesia and cesarean delivery. METHODS: We performed a secondary analysis of two recent national surveys by the Israel Association of Obstetric Anesthesia. In 2005 and 2007 questionnaires were sent to all Israeli hospitals requesting information on the total numbers of deliveries, epidurals, and cesareans annually, together with the anesthesia workforce allocated for the provision of obstetric anesthesia services. The OAAI was calculated based on the premise that epidurals and cesareans are the predominant determinants of obstetric anesthesia workload and that a typical epidural takes about half the time of a typical cesarean. Accordingly, the OAAI for each hospital was calculated as ((0.75 * number of epidurals per year) + (1.5 * number of cesareans per year))/365. RESULTS: This secondary analysis assessed the 25 maternity units in Israel that participated in both the 2005 and 2007 surveys. As expected, there was a wide inter-hospital variability in epidural and cesarean rates. Hospital rankings based on annual delivery numbers were different from those based on the OAAI. The OAAI correlated closely both with the number of epidurals (2005: Pearson 0.97, p < 0.0001; 2007: Pearson 0.97, p < 0.0001) and cesareans (2005: Pearson 0.94, p < 0.0001; 2007: Pearson 0.92, p < 0.0001). These correlations were better for the OAAI than for the annual delivery numbers. CONCLUSIONS: As there was such a wide range of demand for different obstetric anesthesia services among different hospitals, the total number of deliveries is a poor summary indicator of obstetric anesthesia workload. The calculated OAAI better reflected the obstetric anesthesia workload as a single denominator of activity.

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