Helain J. Landy

Contemporary cesarean delivery practice in the United States

OBJECTIVE To describe contemporary cesarean delivery practice in the United States. STUDY DESIGN Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic medical records from 19 hospitals across the United States, 2002-2008. RESULTS The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation. CONCLUSION To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.

Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes

OBJECTIVE: To use contemporary labor data to examine the labor patterns in a large, modern obstetric population in the United States. METHODS: Data were from the Consortium on Safe Labor, a multicenter retrospective study that abstracted detailed labor and delivery information from electronic medical records in 19 hospitals across the United States. A total of 62,415 parturients were selected who had a singleton term gestation, spontaneous onset of labor, vertex presentation, vaginal delivery, and a normal perinatal outcome. A repeated-measures analysis was used to construct average labor curves by parity. An interval-censored regression was used to estimate duration of labor, stratified by cervical dilation at admission and centimeter by centimeter. RESULTS: Labor may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm of dilation. Nulliparous and multiparous women appeared to progress at a similar pace before 6 cm. However, after 6 cm, labor accelerated much faster in multiparous than in nulliparous women. The 95th percentiles of the second stage of labor in nulliparous women with and without epidural analgesia were 3.6 and 2.8 hours, respectively. A partogram for nulliparous women is proposed. CONCLUSION: In a large, contemporary population, the rate of cervical dilation accelerated after 6 cm, and progress from 4 cm to 6 cm was far slower than previously described. Allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the rate of intrapartum and subsequent repeat cesarean deliveries in the United States. LEVEL OF EVIDENCE: III

Maternal and neonatal outcomes by labor onset type and gestational age

OBJECTIVE We sought to determine maternal and neonatal outcomes by labor onset type and gestational age. STUDY DESIGN We used electronic medical records data from 10 US institutions in the Consortium on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age. RESULTS Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks (P < .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.28-0.53), sepsis (OR, 0.36; 95% CI, 0.26-0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48-0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08-9.54) with elective induction, 1.16 (95% CI, 0.24-5.58) with indicated induction, and 6.57 (95% CI, 1.78-24.30) with cesarean without labor compared to spontaneous labor. CONCLUSION Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk.

The maternal body mass index: a strong association with delivery route.

OBJECTIVE We sought to assess body mass index (BMI) effect on cesarean risk during labor. STUDY DESIGN The Consortium on Safe Labor collected electronic data from 228,668 deliveries. Women with singletons > or = 37 weeks and known BMI at labor admission were analyzed in this cohort study. Regression analysis generated relative risks for cesarean stratifying for parity and prior cesarean while controlling for covariates. RESULTS Of the 124,389 women, 14.0% had cesareans. Cesareans increased with increasing BMI for nulliparas and multiparas with and without a prior cesarean. Repeat cesareans were performed in > 50% of laboring women with a BMI > 40 kg/m(2). The risk for cesarean increased as BMI increased for all subgroups, P < .001. The risk for cesarean increased by 5%, 2%, and 5% for nulliparas and multiparas with and without a prior cesarean, respectively, for each 1-kg/m(2) increase in BMI. CONCLUSION Admission BMI is significantly associated with delivery route in term laboring women. Parity and prior cesarean are other important predictors.

Characteristics Associated With Severe Perineal and Cervical Lacerations During Vaginal Delivery

OBJECTIVE: To characterize potentially modifiable risk factors for third- or fourth-degree perineal lacerations and cervical lacerations in a contemporary U.S. obstetric practice. METHODS: The Consortium on Safe Labor collected electronic medical records from 19 hospitals within 12 institutions (228,668 deliveries from 2002 to 2008). Information on patient characteristics, prenatal complications, labor and delivery data, and maternal and neonatal outcomes were collected. Only women with successful vaginal deliveries of cephalic singletons at 34 weeks of gestation or later were included; we excluded data from sites lacking information about lacerations at delivery and deliveries complicated by shoulder dystocia; 87,267 and 71,170 women were analyzed for third- or fourth-degree and cervical lacerations, respectively. Multivariable logistic regressions were used to adjust for other factors. RESULTS: Third- or fourth-degree lacerations occurred in 2,516 women (2,223 nulliparous [5.8%], 293 [0.6%] multiparous) and cervical lacerations occurred in 536 women (324 nulliparous [1.1%], 212 multiparous [0.5%]). Risks for third- or fourth-degree lacerations included nulliparity (7.2-fold risk), being Asian or Pacific Islander, increasing birth weight, operative vaginal delivery, episiotomy, and longer second stage of labor. Increasing body mass index was associated with fewer lacerations. Risk factors for cervical lacerations included young maternal age, vacuum vaginal delivery, and oxytocin use among multiparous women, and cerclage regardless of parity. CONCLUSION: Our large cohort of women with severe obstetric lacerations reflects contemporary obstetric practices. Nulliparity and episiotomy use are important risk factors for third- or fourth-degree lacerations. Cerclage increases the risk for cervical lacerations. Many identified risk factors may not be modifiable. LEVEL OF EVIDENCE: II

Appendicitis and Cholecystitis in Pregnancy

Acute abdominal pain in pregnancy may be attributable to a broad range of nonobstetrical causes. The evaluation of an acute abdomen during pregnancy must include in the differential diagnosis appendicitis and cholecystitis, which are 2 of the most common reasons for nonobstetric surgical intervention in pregnancy. Both conditions may be associated with significant maternal and fetal morbidity and/or mortality. This study will provide a contemporary synopsis regarding the diagnosis and management of appendicitis and cholecystitis during pregnancy.

The fetus with gastroschisis: Impact of route of delivery and prenatal ultrasonography

OBJECTIVES Our purpose was (1) to assess the influence of delivery route on neonatal outcome in fetuses with gastroschisis and (2) to correlate ultrasonographic appearance of fetal bowel with immediate postnatal outcome. STUDY DESIGN Forty-seven cases (1986 to 1994) were reviewed; three abortions and two stillbirths were excluded. Ultrasonographic appearance of fetal bowel (small bowel dilatation > 10 mm) was evaluated in 27 cases. RESULTS Twenty-six infants (61.9%) were delivered vaginally and 16 (38.1%) by cesarean section (11 elective, 5 in labor). Delivery route was not significantly associated with indicators of neonatal outcome (rate of primary closure, postoperative complications, days of parenteral nutrition, days to oral feeding, hospital days, or mortality). When ultrasonographic appearance of fetal bowel was correlated with outcome, fetuses with prenatally dilated bowel had significantly more bowel edema at birth (p=0.038), longer operative time (p=0.013), and higher overall rate of postoperative complications (p=0.037). CONCLUSIONS (1) Elective cesarean delivery does not improve neonatal outcome in infants with gastroschisis. (2) Abnormal ultrasonographic appearance of fetal bowel is associated with a more difficult repair and a higher overall incidence of postoperative complications.

Obstetric Complications, Neonatal Morbidity, and Indications for Cesarean Delivery by Maternal Age

OBJECTIVE: To delineate adverse obstetric and neonatal outcomes as well as indications for cesarean delivery by maternal age in a contemporaneous large national cohort. METHODS: This was a retrospective analysis of electronic medical records from 12 centers and 203,517 (30,673 women aged 35 years or older) women with singleton gestations stratified by maternal age. Logistic regression was performed to investigate maternal and neonatal outcomes for each maternal age strata (referent group, age 25.0–29.9 years), adjusting for race, parity, body mass index, insurance, pre-existing medical conditions, substance and tobacco use, and site. Documented indications for cesarean delivery were analyzed. RESULTS: Neonates born to women aged 25.0–29.9 years had the lowest risk of birth weight less than 2,500 g (7.2%; P<.001), admission to neonatal intensive care unit (11.5%; P<.001), and perinatal mortality (0.7%; P<.001). Hypertensive disorders of pregnancy were higher in women aged 35 years or older (cumulative rate 8.5% compared with 7.8%; 25.0–29.9 years; P<.001). Previous uterine scar was the leading indication for cesarean delivery in women aged 25.0 years or older (36.9%; P<.001). For younger women, failure to progress or cephalopelvic disproportion (37.0% for those younger than age 20.0 years and 31.1% for those aged 20.0–24.9-years; P<.001) and nonreassuring fetal heart tracing (28.7% for those younger than 20.0 years and 21.2% for those aged 20.0–24.9-years; P<.001) predominated as indications. Truly elective cesarean delivery rate was 20.2% for women aged 45.0 years or older (adjusted odds ratio 1.85 [99% confidence interval 1.03–3.32] compared with the referent age group of 25.0–29.9 years). CONCLUSIONS: Maternal and obstetric complications differed by maternal age, as did rates of elective cesarean delivery. Women aged 25.0–29.9 years had the lowest rate of serious neonatal morbidity. LEVEL OF EVIDENCE: II

Adverse Maternal and Neonatal Outcomes in Adolescent Pregnancy.

STUDY OBJECTIVE To investigate the outcomes of adolescent pregnancy. DESIGN Retrospective cohort study from the Consortium on Safe Labor between 2002 and 2008. SETTING Twelve clinical centers with 19 hospitals in the United States. PARTICIPANTS Nulliparous women (n = 43,537) younger than 25 years of age, including 1189 younger adolescents (age ≤ 15.9 years), 14,703 older adolescents (age 16-19.9 years), and 27,645 young adults (age 20-24.9 years). INTERVENTIONS Adjusted odds ratio (aOR) with 95% confidence interval (CI) were calculated, controlling for maternal characteristics and pregnancy complications (young adults as a reference group). MAIN OUTCOME MEASURES Maternal, neonatal outcomes, cesarean indications, and length of labor. RESULTS Younger adolescents had an increased risk of maternal anemia (aOR = 1.25; 95% CI, 1.07-1.45), preterm delivery at less than 37 weeks of gestation (aOR = 1.36; 95% CI, 1.14-1.62), postpartum hemorrhage (aOR = 1.46; 95% CI, 1.10-1.95), preeclampsia or hemolysis, increased liver enzyme levels, and low platelet syndrome (aOR = 1.44; 95% CI, 1.17-1.77) but had a decreased risk of cesarean delivery (aOR = 0.49; 95% CI, 0.42-0.59), chorioamnionitis (aOR = 0.63; 95% CI, 0.47-0.84), and neonatal intensive care unit admission (aOR = 0.80; 95% CI, 0.65-0.98). Older adolescents had an increased risk of maternal anemia (aOR = 1.15; 95% CI, 1.09-1.22), preterm delivery at less than 37 weeks of gestation (aOR = 1.16; 95% CI, 1.08-1.25), and blood transfusion (aOR = 1.21; 95% CI, 1.02-1.43), but had a decreased risk of cesarean delivery (aOR = 0.75; 95% CI, 0.71-0.79), chorioamnionitis (aOR = 0.83; 95% CI, 0.75-0.91), major perineal laceration (aOR = 0.82; 95% CI, 0.71-0.95), and neonatal intensive care unit admission (aOR = 0.89; 95% CI, 0.83-0.96). Older adolescents were less likely to have a cesarean delivery for failure to progress or cephalopelvic disproportion (aOR = 0.89; 95% CI, 0.81-0.98). For adolescents who entered spontaneous labor, the second stage of labor was shorter (P < .01). CONCLUSION Adolescents were less likely to have a cesarean delivery. Failure to progress or cephalopelvic disproportion occurred less frequently in older adolescents. Adolescents who entered spontaneous labor had a shorter second stage of labor.

Predictive value of transvaginal cervical length in triplet pregnancies for spontaneous preterm delivery at ≤ 32 weeks

Objective: To establish whether cervical length is a predictor of spontaneous preterm delivery at ≤ 32 weeks in triplet pregnancies. Methods: This was a case-control study of all triplet pregnancies followed with more than three sonographic assessments of cervical length at 4-week intervals from 1995 to 2000. Cervical length in women delivered spontaneously at ≤ 32 weeks (cases) was compared with that of the remaining women (controls). Statistical analysis included Fishers exact test, χ2 test, one-way analysis of variance, logistic regression and receiver operating characteristic (ROC) curve to determine optimal cervical length thresholds for spontaneous preterm delivery at ≤ 32 weeks. Results: Of the 58 women included in the study, 17 (29%) delivered spontaneously at ≤ 32 weeks. The preterm delivery group had similar demographic and obstetric variables, but a higher rate of cerclage placement (65% vs 17%, p < 0.001) than controls. Mean ± standard deviation cervical length was significantly shorter among cases than controls at 16-20.0 weeks (3.0 ± 1.2 vs. 3.9 ± 0.8 cm, p = 0.01), but not at 20.1-24.0 weeks (3.5 ± 1.1 vs. 3.8 ± 1.0 cm, p = 0.76). Logistic regression analysis determined that cervical length at 16-20 weeks had an odds ratio of 0.43 (95% CI = 0.23, 0.80) for the prediction of spontaneous preterm delivery at ≤ 32 weeks. ROC curve analysis identified a cervical length of ≤ 2.6 cm as the optimal threshold for the prediction of spontaneous preterm delivery at ≤ 32 weeks (sensitivity 41%, specificity 92%). Conclusions: In a population of triplet gestations with a 29% rate of preterm delivery, cervical length at 16-20.0 weeks, but not at 20.1-24.0 weeks, was inversely correlated with the probability of preterm delivery at ≤ 32 weeks.