Mildred M. Ramirez

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

Treatment of pregnant breast cancer patients and outcomes of children exposed to chemotherapy in utero

As women in the US delay childbearing, it has been hypothesized that the incidence of breast cancer diagnosed during pregnancy will increase. There are very little prospective data on the treatment of pregnant women with breast cancer with chemotherapy and even less data on the outcomes of their children who were exposed to chemotherapy in utero.

Use of Thrombolytics for the Treatment of Thromboembolic Disease During Pregnancy

The incidence of thromboembolic disease is increased during pregnancy. Prevention and treatment of thromboembolic disease can have a significant impact on the morbidity and mortality of pregnant women. Anticoagulation with heparin is the treatment of choice; however, in some instances this is inadequate or contraindicated. In the nonpregnant patient, alternative therapies have included surgical intervention or fibrinolytic agents. Traditionally, thrombolytic therapy has been considered a relative contraindication during pregnancy due to the maternal and fetal risk of hemorrhagic complications. Hence, no controlled trials of agents such as streptokinase, urokinase, or tissue plasminogen activator for the treatment of thromboembolic events during pregnancy, have been performed, or are currently feasible. Since 1961, 36 reports have been published describing the use of thrombolytic agents during pregnancy. In a review of the worlds literature, 172 pregnant women affected with thromboembolic conditions were treated with thrombolytic medications. A maternal mortality rate of 1.2 percent was observed. Approximately 10 pregnancy losses were noted (5.8 percent). Hemorrhagic complications were reported in 8.1 percent of patients. We summarize the published literature on the use of thrombolytic agents during pregnancy and discuss the treatment success and reported complications.

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

Oxytocin regimen for labor augmentation, labor progression, and perinatal outcomes.

OBJECTIVE: To examine the effects and safety of high-dose (compared with low-dose) oxytocin regimen for labor augmentation on perinatal outcomes. METHODS: Data from the Consortium on Safe Labor were used. A total of 15,054 women from six hospitals were eligible for the analysis. Women were grouped based on their oxytocin starting dose and incremental dosing of 1, 2, and 4 milliunits/min. Duration of labor and a number of maternal and neonatal outcomes were compared among these three groups stratified by parity. Multivariable logistic regression and generalized linear mixed model were used to adjust for potential confounders. RESULTS: Oxytocin regimen did not affect the rate of cesarean delivery or other perinatal outcomes. Compared with 1 milliunit/min, the regimens starting with 2 milliunits/min and 4 milliunits/min reduced the duration of first stage by 0.8 hours (95% confidence interval 0.5–1.1) and 1.3 hours (1.0–1.7), respectively, in nulliparous women. No effect was observed on the second stage of labor. Similar patterns were observed in multiparous women. High-dose regimen was associated with a reduced risk of meconium stain, chorioamnionitis, and newborn fever in multiparous women. CONCLUSION: High-dose oxytocin regimen (starting dose at 4 milliunits/min and increment of 4 millliunits/min) is associated with a shorter duration of first-stage of labor for all parities without increasing the cesarean delivery rate or adversely affecting perinatal outcomes. LEVEL OF EVIDENCE: II

Gastroinstestinal hemorrhage during pregnancy in a patient with a history of vertical-banded gastroplasty

Pregnancy after gastric bypass for morbid obesity is well reported; however, the only maternal complications described have involved nutritional deficiencies. We report a case of gastrointestinal hemorrhage during pregnancy resulting from erosion of a synthetic graft from a vertical-banded gastroplasty performed 4 years previously.

Wound complications from surgery in pregnancy-associated breast cancer (PABC)

BACKGROUND there are concerns that physiologic changes of the peripartum breast may result in complications in breast conservation therapy. We present the complications of breast conservation surgeries and mastectomies performed for pregnancy-associated breast cancer (PABC). MATERIALS AND METHODS from April 1989 through April 2008, sixty-seven breast cancer patients underwent surgical management for PABC, defined as surgery during pregnancy or within one year postpartum. Records of women who had surgery were examined for post-operative wound complications of milk fistula, cellulitis, abscess, or hematoma. RESULTS Forty-seven patients underwent mastectomy. Twenty were treated with conservative breast surgery. There were six complications, all treated in the outpatient setting. There were no documented milk fistulae. CONCLUSIONS in our series, we had few postoperative complications and no milk fistulae for those patients undergoing surgery for PABC. When compared to those who had mastectomy for PABC, women who underwent breast conserving therapy did not appear to have increased frequency of surgical complications.