The adjusted relative risk (aRR) of delivery at 35 weeks of gestation was highest in women with four or more prior cesarean deliveries (aRR 2.79, 95% CI 2.74-2.82). Prior cesarean delivery also had a significant influence on neonatal morbidity. As the number of prior cesarean deliveries increased, the risk of composite neonatal morbidity increased, from 8.0% (aRR 1.5, 95% CI 1.48-1.51) with one prior cesarean delivery up to 21.0% (aRR 4.9, 95% CI 4.76-5.04) with four or more prior cesarean deliveries compared with a baseline risk of 5.5% in parous women without prior cesarean delivery. Conclusion Prior cesarean delivery is correlated with earlier delivery and increased neonatal morbidity. Advocating trial of labor after cesarean delivery may provide maternal and neonatal benefit.Maternal mortality is falling in most of the world’s countries, but, for 20 years, the United States has seen no reduction. Over this period, a dozen countries in various stages of development, all spending much less than the United States on health, achieved their United Nations’ Millennium Development Goal of 2015 (Millennium Development Goal 5 improve maternal health), with substantial reductions in maternal mortality rates. To consider whether interventions successful in reducing global maternal mortality rates could help the United States to lower its rate, the American College of Obstetricians and Gynecologists, at the 2018 International Federation of Gynecology and Obstetrics’ Rio de Janeiro World Congress, convened a panel of the presidents and representatives from five national societies with wide maternal mortality rate ranges and health expenditures and whose national societies had focused on reducing maternal mortality for Millennium Development Goal 5. They identified expanded access to reproductive health care, particularly contraception and safe abortion, as key interventions that had proven effective in decreasing maternal mortality rates worldwide.Objective To evaluate the difference in odds of cesarean delivery in term, singleton, vertex pregnancies between the midwife and obstetrician-led services at the same rural tertiary care center. Methods A retrospective cohort study of term, singleton, and vertex deliveries in patients without a history of cesarean delivery was performed. Patients self-selected a delivery service. The primary outcome was the odds of cesarean delivery between midwife and obstetrician-led services. After propensity score matching, logistic regression was performed on the matched sample to assess the adjusted odds of cesarean delivery. Results From January 2015 to December 2017, 1,787 (80.2% of total) deliveries were analyzed with management of 956 (53.5%) by the midwife service and 831 (46.5%) by the obstetrician-led service. The rate of cesarean delivery was 20.7% (n=172) in the obstetrician-led service and 13.1% (n=125) in the midwife service. In the matched sample, the odds of cesarean delivery were lower in the midwife service compared with the obstetrician-led service in unadjusted and adjusted analyses (odds ratio [OR] 0.62, 95% CI 0.47-0.81; adjusted odds ratio [aOR] 0.58, 95% CI 0.44-0.80). Older maternal age (OR 1.02, 95% CI 1.00-1.06; aOR 1.07, 95% CI 1.04-1.10) and higher delivery body mass index (OR 1.06, 95% CI 1.04-1.08; aOR 1.07, 95% CI 1.04-1.09) were associated with higher odds of cesarean delivery. Increased parity was associated with decreased odds of cesarean delivery (OR 0.41, 95% CI 0.31-0.55; aOR 0.35, 95% CI 0.26-0.48). There were no differences in neonatal outcomes. buy INCB084550 Conclusion At a single rural tertiary care center, patients on the midwife service have significantly lower adjusted odds of cesarean delivery than patients on the obstetrician-led service.Objective To assess the effect of a personalized repeated feedback approach using digital step counters (pedometers) on mobility after cesarean delivery in high-risk patients. Methods This was a randomized controlled trial at a tertiary university hospital. Patients who underwent cesarean delivery and were defined as high risk for thromboembolic events were asked to wear a pedometer around their wrists postpartum for 48 hours. Patients were randomized to the feedback group, which received personalized feedback by the research staff regarding their mobility at three set timepoints, or the control group, which received standard care. The number of steps taken by patients was compared between the groups and served as the primary outcome. Secondary outcomes included patient reported pain, physical and mental recovery, and overall satisfaction. Sample size was predetermined to detect a 25% between-group difference in the primary outcome. Results From December 2018 to July 2019, 215 patients were recruited, randomized and completed follow-up-108 in the feedback group and 107 in the control group. Patients’ demographics and intrapartum course were similar between the groups. The number of steps taken was significantly higher in the feedback group compared with the control group 5,918±3,116 vs 4,161±2,532 steps, P less then .001. Pain scores were similar between the groups, as was analgesic consumption. Patients in the feedback group reported a significantly easier physical and mental postpartum recovery and were significantly more satisfied with their delivery experience. Postpartum complications did not differ between the groups. Conclusion In high-risk patients after cesarean delivery, mobility was improved by using a personalized feedback approach. Enhanced mobility was not associated with a higher rate of complications or pain and was positively associated with patient satisfaction. Clinical trial registration ClinicalTrials.gov, NCT03724760.Objective To assess whether mild thrombocytopenia (platelet count 100-149 k/microliter) is associated with an increased risk of postpartum hemorrhage. Methods Nulliparous women with term, singleton, vertex pregnancies undergoing labor at our institution between August 2016 and September 2017 were included. The primary exposure was mild thrombocytopenia, defined as platelet count 100-149 k/microliter, and the comparator was normal platelet count (150 k/microliter or greater). Those with severe thrombocytopenia (platelet count less than 100 k/microliter) were excluded from analysis. The primary outcome was postpartum hemorrhage, determined by International Classification of Diseases, Tenth Revision codes and the hospital discharge problem list. Secondary outcomes included use of uterotonic agents (methylergonovine maleate or carboprost tromethamine), total blood loss 1,000 mL or greater, and blood transfusion. Data were analyzed by t test, χ or Fisher exact test, and multivariable logistic regression, with significance at α less then 0.