79: Expansion of uterine incision at cesarean delivery: A randomized comparison of two techniques

SMFM Abstracts 79

EXPANSION OF UTERINE INCISION AT CESAREAN DELIVERY: A RANDOMIZED COMPARISON OF TWO TECHNIQUES ANTONELLA CROMI1, EDOARDO DI NARO2, GABRIELE SIESTO1, STEFANO UCCELLA1, ANNAMARIA CARINGELLA2, VALERIA UBOLDI1, FABIO GHEZZI1, 1University of Insubria, Varese, Italy, 2University of Bari, Italy OBJECTIVE: Since anatomical studies suggest that oblique and circular running muscle fibers dominate the region toward the isthmus of the uterus, we speculated that blunt extension of the uterine incision in a cephalad-caudad direction would minimize uterine wall trauma at the time of cesarean delivery. We therefore designed a study to investigate whether this method of expanding the uterine incision was associated with lower risk of unintended extensions and associated complications than the conventional expansion from medial to lateral. STUDY DESIGN: Consecutive women undergoing low segment transverse cesarean delivery were randomly assigned to cephalad-caudad or transversal expansion groups. Cephalad-caudad expansion was accomplished by separating the forefingers in a cephalad-caudad direction after the fingers are inserted into the small, midline uterine incision. An extension was defined as any unintended defect observed outside the limits of the original incision. Extensions that involved the uterine vessels and cervical extensions were recorded. Power calculation was based on a previous study in which the unintended extension rate was 12.4%.With ␣⫽0.05 and ␤⫽0.20, 403 patients in each arm were required to demonstrate a difference of 6% between groups. RESULTS: The cephalad-caudad (n⫽405) and transversal (n⫽406) expansion groups were similar with regard to patients characteristics, indication to surgery, and proportion of emergency procedures. No difference in duration of surgery (40.4⫾11.8 vs. 38.9⫾11.9 minutes, P⫽0.15), type of anesthesia (regional anesthesia: 90.1% vs. 87.9%, P⫽ 0.27), need for transfusions (0.7% vs, 0.7%, P⫽1.0) or estimated blood loss (440⫾341 vs. 398⫾242 mL, P⫽ 0.09) was noted. The incidence of unintended extension was significantly higher in the transversal expansion group than in the cephalad-caudad group (7.4% vs. 3.7%, P⫽0.03). CONCLUSION: Since it is associated with less risk of unintended extension, cephalad-caudad expansion should be preferred to transversal expansion of the uterine incision when performing cesarean delivery

www.AJOG.org 81

IMPACT OF A COMPREHENSIVE STRATEGY TO REDUCE OBSTETRIC ADVERSE EVENTS EDMUND FUNAI1, CHRISTIAN PETTKER1, STEPHEN THUNG1, CHERYL RAAB2, ERROL NORWITZ1, CATALIN BUHIMSCHI1, JOSHUA COPEL1, CHARLES LOCKWOOD1, 1Yale University School of Medicine, New Haven, Connecticut, 2Yale-New Haven Hospital (YNHH), Obstetrics & Gynecology, New Haven, Connecticut OBJECTIVE: Little information is available regarding expected rates of adverse events that occur in a hospital-based obstetrics service. Further, while OB related malpractice claims are a minority of total claims nationally, they represent a disproportionate share of overall medical professional liability insurance (MPLI) premium costs. In partnership with our MPLI carrier, we undertook a comprehensive strategy to track and reduce adverse events. STUDY DESIGN: The primary components of this initiative included: 1) independent review of the service by outside experts; 2) the creation of the dedicated position of Patient Safety Nurse to support performance improvement full-time; 3) protocol-based standardization of common procedures such as administration of oxytocin; 4) mandatory crew resource management training (“team training”) for all staff; 5) adoption of NICHD terminology for interpretation of fetal heart rate monitoring, culminating in a national certification exam; and 6) multidisciplinary oversight of performance by a department-based Patient Safety Committee. 14 individual outcomes (such as 5 minute Apgar ⬍ 7, unexpected NICU admission and fetal birth injury) were tracked and analyzed for trend. RESULTS: At project inception, the composite rate of adverse events was approximately 3%, which was concordant with the limited published literature. After 2.5 years, the composite rate decreased significantly, to 1.25% (p⬍0.02) (figure). Staff perception of overall safety climate improved 30%, while overall MPLI costs decreased by nearly 40%. CONCLUSION: A comprehensive strategy to decrease adverse events, which includes enhancements in communication and oversight, can have a dramatic impact on patient safety and MPLI costs.

0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.089

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LONGITUDINAL STUDY OF THE RISK OF DELIVERY RELATED PERINATAL DEATH ASSOCIATED WITH BREECH PRESENTATION AT TERM. DHAMINTRA PASUPATHY1, ANGELA WOOD2, JILL PELL3, MICHAEL FLEMING4, GORDON SMITH5, 1University of Cambridge, Department of Obstetrics and Gynaecology, Cambridge, United Kingdom, 2 University of Cambridge, Department of Public Health and Primary Care, Cambridge, United Kingdom, 3BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom, 4Common Services Agency, Information and Statistics Division, Edinburgh, United Kingdom, 5University of Cambridge, Department of Obstetrics & Gynaecology, Cambridge, United Kingdom OBJECTIVE: We sought to characterize the factors associated with the risk of delivery-related perinatal death (PND) among term infants presenting by the breech and the effect of changes in the mode of delivery on overall rates of PND associated with breech presentation. STUDY DESIGN: We studied 32,776 singleton pregnancies with the baby presenting by the breech at term in Scotland using national registries of pregnancy outcome data (SMR2) and perinatal death data (SSBIDE) from 1985-2004. We excluded multiple pregnancy, preterm births, non-breech presentation, perinatal deaths due to congenital anomaly and intrauterine fetal deaths prior to the onset of labor. The event was delivery-related PND (i.e. intra-uterine fetal death during labor or death of infant in the first four weeks of life), sub-divided according to intrapartum anoxia. Analysis was by multivariate logistic regression. RESULTS: Over the period 1985 to 2004, there was a 72% decrease (95% CI ⫺2 to 92%) in the risk of perinatal death. This was wholly explained by a 90% (95% CI 31-99%) reduction in the risk of death due to anoxia or trauma. Compared with vaginal breech delivery, the risk of anoxic death was reduced both with intrapartum cesarean section (OR 0.16, 95% CI 0.02-0.75) and planned cesarean section (OR 0.01, one-sided 95% CI 0.09). The rate of vaginal breech delivery declined from approximately 20% to 5% over the period of study. However, the change in mode of delivery appeared to account for only 25% of the decline in the risk of anoxic death that occurred over the period of study. CONCLUSION: We confirm the finding that cesarean delivery is associated with a reduced risk of delivery-related perinatal death among infants presenting by the breech at term. However, factors other than mode of delivery appear to have contributed towards reduction in rates of perinatal death in this context over the last 20 years in Scotland. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.090

0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.091

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PLACENTAL REMOVAL AT CESAREAN DELIVERY SHAWANA SWANN1, NATALIE BERTOIA2, EVA PRESSMAN2, 1Medical University of South Carolina, Obstetrics and Gynecology, Charleston, South Carolina, 2University of Rochester, Obstetrics and Gynecology, Rochester, New York OBJECTIVE: Current research suggests that spontaneous placental expulsion (SP) at the time of cesarean delivery (CD) is associated with decreased blood loss and lower rates of endometritis compared to manual removal (MR). Despite this, MR continues to be common practice. This study assesses the effect of mode of placental removal in elective CD at an academic tertiary care setting with a low incidence of endometritis where MR was standard practice. STUDY DESIGN: A prospective, randomized controlled study was performed between 8/06 and 5/07 after obtaining IRB approval. Patients were randomized to SP or MR. The primary outcome was change in hematocrit (HCT). Data was also collected on maternal demographics, indication for CD, estimated blood loss (EBL), operative and placental removal times, blood transfusions, and endometritis. Power analysis based on retrospective pilot data with a mean drop in HCT of 6.8% and standard deviation of 2.8% indicated that 32 patients in each group would provide 80% power to detect a 2% difference in the change in HCT between groups. The same pilot data found an incidence of endometritis of 6%. Analysis was performed using the student t-test and Chi square as appropriate. RESULTS: 86 patients were randomized: 40 to MR and 46 to SP. There were no differences in maternal demographics or indications for CD between groups. Mean drop in HCT was 4.4⫾2.9% for MR and 4.9⫾2.3% for SP (p⫽0.44). No differences were found in mean EBL (792⫾135 vs. 810⫾134 ml, p⫽0.55) or operative time (44.5⫾15.3 vs. 42.0⫾27.0 minutes; p⫽0.46). Delivery of the placenta was faster with MR (49 sec vs. 71 sec, p⫽0.04) but this is not clinically significant. No patients developed endometritis or received blood transfusions. CONCLUSION: In a population with a low incidence of endometritis, there is no clinical benefit to SP over MR. Specifically, there is no reduction in blood loss as measured by drop in HCT. Therefore, method of placental delivery should be left to the discretion of the surgeon. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.092

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American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2007