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Delayed interval delivery improves infant survival: a population-based study
S136 SMFM Abstracts
December 2003 Am J Obstet Gynecol
268
DELAYED INTERVAL DELIVERY IMPROVES INFANT SURVIVAL: A POPULATION-BASED STUDY JUN ZHANG1, BRADY HAMILTON2, JOYCE MARTIN2, ANN TRUMBLE3, 1National Institutes of Health, Epidemiology Branch, Bethesda, MD 2National Center for Health Statistics, Hyattsville, MD 3 National Institutes of Health, Bethesda, MD OBJECTIVE: The number of multifetal pregnancies has increased dramatically. Cases such as premature rupture of the membranes of one fetus, single fetal demise, and premature labor in extreme preterm are encountered more often than before. Delaying delivery of the remaining fetus(es) is feasible in some cases. However, benefits and risks of this procedure have yet to be established. STUDY DESIGN: We used the U.S. 1995-98 Matched Multiple Birth File to examine infant survival after delayed interval delivery. We identified 200 twin pregnancies in which the first twin was delivered between 17 and 29 weeks of gestation and the second twin was delivered at least 24 hours later. We individually matched the delayed deliveries with 374 twin pregnancies in which delivery of second twin was not delayed. Perinatal outcomes and infant survival were compared between the delayed and non-delayed twins. RESULTS: Among the 200 pregnancies with delayed delivery, the mean gestational age at first delivery was 23 weeks and the median duration of delay was 6 days (ranging from 2 to 107 calendar days). With every week of delay in delivery, the fetus gained 131 grams on average (95% CI: 115-147 g). 56% of the delayed second twins survived to 1 year of age (95% CI: 50-64%) while only 24% of the non-delayed second twins did so (95% CI: 20-29%) (P < 0.001). The delayed twins also had significantly higher Apgar scores at 5 minutes. However, delayed delivery was also associated with 11% of risk (95% CI: 6-16%) for fetal death of the remaining twin before 24 weeks. CONCLUSION: Delaying delivery of the remaining fetus(es) before 30 weeks of gestation improves infant survival by more than twofold and, probably, reduces long-term child morbidity by increasing birthweight and Apgar score at 5 minutes.
270
MATERNAL OUTCOMES AT 2 YEARS POST PARTUM IN THE TERM BREECH TRIAL MARY HANNAH1, HILARY WHYTE2, WALTER HANNAH1, Term Breech Trial Collaborative Group3, 1University of Toronto, Obstetrics and Gynaecology, Toronto, Ontario, Canada 2University of Toronto, Paediatrics, Toronto, Ontario, Canada 3University of Toronto, MIRU, Toronto, Ontario, Canada OBJECTIVE: The Term Breech Trial was a randomized controlled trial of planned caesarean section versus planned vaginal birth for breech presentation at term. We undertook a follow-up study of mothers enrolled in the Term Breech Trial to assess maternal outcomes at 2 years post partum. STUDY DESIGN: At 85 centers, in 18 countries, 917 of 1159 mothers were followed to 2 years post partum and asked to complete a questionnaire to report on their health in the previous 3 to 6 months, as well as on their views of the birth experience and their participation in the Term Breech Trial. RESULTS: Planned caesarean section, compared with planned vaginal birth, was not associated with less breast-feeding; difficulties with relationships with the child or husband/partner; problems with sexual relations; pain; subsequent pregnancy; urinary, fecal, or flatal incontinence; depression; painful, irregular, or heavy menstrual periods; or most other health problems. Women in the planned caesarean section group had a higher risk of constipation, felt less worried about their baby’s health, and experienced less pain than expected during labor and delivery than women in the planned vaginal birth group. CONCLUSION: Planned caesarean section is not associated with substantially better or worse outcomes for women 2 years after the birth, compared with planned vaginal birth, if the fetus is in breech presentation at term.
269
A POPULATION-BASED ANALYSIS OF RISK FACTORS FOR OBSTETRICAL BRACHIAL PLEXUS PALSY IN NEONATES DELIVERED BY VACUUM EXTRACTION: AN ANALYSIS BASED ON 13,716 DELIVERIES LARS LADFORS1, MARGARETA MOLLBERG1, HA˚KAN LILJA1, HENRIK HAGBERG1, 1Perinatal Center/Sahlgrenska University Hospital, Sweden, Gothenburg, Sweden OBJECTIVE: To identify risk factors for obstetrical brachial plexus palsy (OBPP) in neonates delivered by vacuum extraction. STUDY DESIGN: During 3 years (1995, 1996, and 1997), data were prospectively collected in a national registry for operative vaginal deliveries. 13,716 vacuum extractions and 140 forceps deliveries were registered, which was 77.2% of all instrumental deliveries in Sweden during the period. Univariate and stepwise logistic regression were used to analyze variables associated with OBPP in neonates delivered by vacuum extraction. RESULTS: OBPP was diagnosed in 153 (1.12%) neonates. Variables associated with an increased risk for OBPP were: neonates in occiput posterior presentation of the head OR 2.01 (95% CI 1.01-3.93), the fetal head above or at the level of the ischial spine at the time of extraction OR 1.94 (95% CI 1.10-3.13), if the indication for assisted delivery was delay of second stage (compared to extraction due to fetal distress) OR 2.20 (95% CI 1.54-3.15), applying fundal pressure OR 2.3 (1.65-3.14), multiple tractions (more then five tractions) OR 2.82 (95% CI 1.85, 4.31). Compared to neonates with a birth weight below 4000 grams, neonates with a birth weight of 4000-4499 grams had an increased risk for OBPP (OR 5.1, 95% CI 3.5, 7.3) and a birth weight $4500 grams (OR 14.5, 95% CI 9.5, 22.2). In the stepwise logistic analysis the most important factor was the birth weight, a neonate over 5000 grams had an OR 12.64 (95% CI 8.18, 19.53) for OBPP, a birth weight 4500-4999 grams OR 4.58 (95% CI 3.13, 6.72), extraction time over 15 minutes OR 2.40 (95% CI 1.46, 3.94), fundal pressure OR 1.92, 95% CI 1.37, 2.69, inefficient uterine action OR 1.58 (95% CI 1.09, 2.29), vacuum delivery OR 0.63 (95% CI 0.40, 0.98). CONCLUSION: The combination of a high birth weight, extraction time over 15 minutes, fundal pressure, and inefficient uterine contractions is associated with a high risk for OBPP.
271
THE CONTINUING EFFECTIVENESS OF ACTIVE MANAGEMENT IN NULLIPARAS IN SPONTANEOUS LABOR, DESPITE A DOUBLING IN OVERALL NULLIPAROUS CESAREAN DELIVERY MICHAEL FOLEY1, MAY ALARAB2, DECLAN KEANE2, KATHRYN MCQUILLAN3, LESLIE DALY4, COLM O’HERLIHY1, 1University College Dublin, Obstetrics and Gynaecology, Dublin 2, Ireland 2National Maternity Hospital, Dublin 2, Ireland 3 National Maternity Hospital, Delivery Unit, Dublin 2, Ireland 4University College Dublin, Public Health Medicine and Epidemiology, Dublin 2, Ireland OBJECTIVE: To determine the effectiveness of active management of labor in correcting dystocia in nulliparas in spontaneous labor by analyzing the contribution of this cohort to a greatly increased overall nulliparous cesarean delivery rate. STUDY DESIGN: Annually collated institutional data were analyzed retrospectively, including cesarean rates for nulliparas in spontaneous labor for whom an active management protocol was applied and the percentage contribution of this category to the overall increase in nulliparous cesareans during a 12-month period. RESULTS: From 1989 to 2000, 81,855 women were delivered, of whom 34,201 were nulliparas (42%); the proportion of nulliparas in spontaneous labor decreased progressively from 83% to 59%. The overall nulliparous cesarean rate increased from 8.1% to 16.6%, but the cesarean rate for nulliparas in spontaneous labor was unchanged, averaging 3.3% per year (range 2.0-4.2). Comparing 1989 with 2000, nulliparas in spontaneous labor accounted for 14% of the overall increase in cesarean rate compared with 59.2% for nulliparas not in spontaneous labor. Cesareans for dystocia accounted for only 7% of the increase among nulliparas. CONCLUSION: Active management of spontaneous first labors remains an effective protocol for promoting vaginal delivery; factors other than dystocia account for the progressive increase in the nulliparous cesarean delivery rate.
December 2003 Am J Obstet Gynecol
268
DELAYED INTERVAL DELIVERY IMPROVES INFANT SURVIVAL: A POPULATION-BASED STUDY JUN ZHANG1, BRADY HAMILTON2, JOYCE MARTIN2, ANN TRUMBLE3, 1National Institutes of Health, Epidemiology Branch, Bethesda, MD 2National Center for Health Statistics, Hyattsville, MD 3 National Institutes of Health, Bethesda, MD OBJECTIVE: The number of multifetal pregnancies has increased dramatically. Cases such as premature rupture of the membranes of one fetus, single fetal demise, and premature labor in extreme preterm are encountered more often than before. Delaying delivery of the remaining fetus(es) is feasible in some cases. However, benefits and risks of this procedure have yet to be established. STUDY DESIGN: We used the U.S. 1995-98 Matched Multiple Birth File to examine infant survival after delayed interval delivery. We identified 200 twin pregnancies in which the first twin was delivered between 17 and 29 weeks of gestation and the second twin was delivered at least 24 hours later. We individually matched the delayed deliveries with 374 twin pregnancies in which delivery of second twin was not delayed. Perinatal outcomes and infant survival were compared between the delayed and non-delayed twins. RESULTS: Among the 200 pregnancies with delayed delivery, the mean gestational age at first delivery was 23 weeks and the median duration of delay was 6 days (ranging from 2 to 107 calendar days). With every week of delay in delivery, the fetus gained 131 grams on average (95% CI: 115-147 g). 56% of the delayed second twins survived to 1 year of age (95% CI: 50-64%) while only 24% of the non-delayed second twins did so (95% CI: 20-29%) (P < 0.001). The delayed twins also had significantly higher Apgar scores at 5 minutes. However, delayed delivery was also associated with 11% of risk (95% CI: 6-16%) for fetal death of the remaining twin before 24 weeks. CONCLUSION: Delaying delivery of the remaining fetus(es) before 30 weeks of gestation improves infant survival by more than twofold and, probably, reduces long-term child morbidity by increasing birthweight and Apgar score at 5 minutes.
270
MATERNAL OUTCOMES AT 2 YEARS POST PARTUM IN THE TERM BREECH TRIAL MARY HANNAH1, HILARY WHYTE2, WALTER HANNAH1, Term Breech Trial Collaborative Group3, 1University of Toronto, Obstetrics and Gynaecology, Toronto, Ontario, Canada 2University of Toronto, Paediatrics, Toronto, Ontario, Canada 3University of Toronto, MIRU, Toronto, Ontario, Canada OBJECTIVE: The Term Breech Trial was a randomized controlled trial of planned caesarean section versus planned vaginal birth for breech presentation at term. We undertook a follow-up study of mothers enrolled in the Term Breech Trial to assess maternal outcomes at 2 years post partum. STUDY DESIGN: At 85 centers, in 18 countries, 917 of 1159 mothers were followed to 2 years post partum and asked to complete a questionnaire to report on their health in the previous 3 to 6 months, as well as on their views of the birth experience and their participation in the Term Breech Trial. RESULTS: Planned caesarean section, compared with planned vaginal birth, was not associated with less breast-feeding; difficulties with relationships with the child or husband/partner; problems with sexual relations; pain; subsequent pregnancy; urinary, fecal, or flatal incontinence; depression; painful, irregular, or heavy menstrual periods; or most other health problems. Women in the planned caesarean section group had a higher risk of constipation, felt less worried about their baby’s health, and experienced less pain than expected during labor and delivery than women in the planned vaginal birth group. CONCLUSION: Planned caesarean section is not associated with substantially better or worse outcomes for women 2 years after the birth, compared with planned vaginal birth, if the fetus is in breech presentation at term.
269
A POPULATION-BASED ANALYSIS OF RISK FACTORS FOR OBSTETRICAL BRACHIAL PLEXUS PALSY IN NEONATES DELIVERED BY VACUUM EXTRACTION: AN ANALYSIS BASED ON 13,716 DELIVERIES LARS LADFORS1, MARGARETA MOLLBERG1, HA˚KAN LILJA1, HENRIK HAGBERG1, 1Perinatal Center/Sahlgrenska University Hospital, Sweden, Gothenburg, Sweden OBJECTIVE: To identify risk factors for obstetrical brachial plexus palsy (OBPP) in neonates delivered by vacuum extraction. STUDY DESIGN: During 3 years (1995, 1996, and 1997), data were prospectively collected in a national registry for operative vaginal deliveries. 13,716 vacuum extractions and 140 forceps deliveries were registered, which was 77.2% of all instrumental deliveries in Sweden during the period. Univariate and stepwise logistic regression were used to analyze variables associated with OBPP in neonates delivered by vacuum extraction. RESULTS: OBPP was diagnosed in 153 (1.12%) neonates. Variables associated with an increased risk for OBPP were: neonates in occiput posterior presentation of the head OR 2.01 (95% CI 1.01-3.93), the fetal head above or at the level of the ischial spine at the time of extraction OR 1.94 (95% CI 1.10-3.13), if the indication for assisted delivery was delay of second stage (compared to extraction due to fetal distress) OR 2.20 (95% CI 1.54-3.15), applying fundal pressure OR 2.3 (1.65-3.14), multiple tractions (more then five tractions) OR 2.82 (95% CI 1.85, 4.31). Compared to neonates with a birth weight below 4000 grams, neonates with a birth weight of 4000-4499 grams had an increased risk for OBPP (OR 5.1, 95% CI 3.5, 7.3) and a birth weight $4500 grams (OR 14.5, 95% CI 9.5, 22.2). In the stepwise logistic analysis the most important factor was the birth weight, a neonate over 5000 grams had an OR 12.64 (95% CI 8.18, 19.53) for OBPP, a birth weight 4500-4999 grams OR 4.58 (95% CI 3.13, 6.72), extraction time over 15 minutes OR 2.40 (95% CI 1.46, 3.94), fundal pressure OR 1.92, 95% CI 1.37, 2.69, inefficient uterine action OR 1.58 (95% CI 1.09, 2.29), vacuum delivery OR 0.63 (95% CI 0.40, 0.98). CONCLUSION: The combination of a high birth weight, extraction time over 15 minutes, fundal pressure, and inefficient uterine contractions is associated with a high risk for OBPP.
271
THE CONTINUING EFFECTIVENESS OF ACTIVE MANAGEMENT IN NULLIPARAS IN SPONTANEOUS LABOR, DESPITE A DOUBLING IN OVERALL NULLIPAROUS CESAREAN DELIVERY MICHAEL FOLEY1, MAY ALARAB2, DECLAN KEANE2, KATHRYN MCQUILLAN3, LESLIE DALY4, COLM O’HERLIHY1, 1University College Dublin, Obstetrics and Gynaecology, Dublin 2, Ireland 2National Maternity Hospital, Dublin 2, Ireland 3 National Maternity Hospital, Delivery Unit, Dublin 2, Ireland 4University College Dublin, Public Health Medicine and Epidemiology, Dublin 2, Ireland OBJECTIVE: To determine the effectiveness of active management of labor in correcting dystocia in nulliparas in spontaneous labor by analyzing the contribution of this cohort to a greatly increased overall nulliparous cesarean delivery rate. STUDY DESIGN: Annually collated institutional data were analyzed retrospectively, including cesarean rates for nulliparas in spontaneous labor for whom an active management protocol was applied and the percentage contribution of this category to the overall increase in nulliparous cesareans during a 12-month period. RESULTS: From 1989 to 2000, 81,855 women were delivered, of whom 34,201 were nulliparas (42%); the proportion of nulliparas in spontaneous labor decreased progressively from 83% to 59%. The overall nulliparous cesarean rate increased from 8.1% to 16.6%, but the cesarean rate for nulliparas in spontaneous labor was unchanged, averaging 3.3% per year (range 2.0-4.2). Comparing 1989 with 2000, nulliparas in spontaneous labor accounted for 14% of the overall increase in cesarean rate compared with 59.2% for nulliparas not in spontaneous labor. Cesareans for dystocia accounted for only 7% of the increase among nulliparas. CONCLUSION: Active management of spontaneous first labors remains an effective protocol for promoting vaginal delivery; factors other than dystocia account for the progressive increase in the nulliparous cesarean delivery rate.