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Early maternal feeding following cesarean delivery: A prospective randomized study
SMFM Abstracts S123 415 EARLY MATERNAL FEEDING FOLLOWING CESAREAN DELIVERY: A PROSPECTIVE RANDOMIZED STUDY GUY BAR1, EYAL SHEINER1, ADI LEZEROVIZT1, TAL LAZER1, MORDECHAI HALLAK1, 1Soroka University Medical Center, Ben Gurion University of the Negev, Departments of Obstetrics and Gynecology, Beer-Sheva, Israel OBJECTIVE: To evaluate the effect of early maternal feeding (i.e. eating and drinking) on gastrointestinal function and maternal satisfaction in patients following simple and complicated cesarean delivery (CD). STUDY DESIGN: A prospective, randomized study was designed including 179 women undergoing first or repeated cesarean delivery. Patients were assigned randomly by picking one opaque sealed envelope in order to receive the assignment. Women who were assigned to the early feeding group received clear fluids and solid food immediately after the operation, and up to 8 hours following the procedure, according to their request. The traditionally fed women have received clear fluids 8-12 hour after the surgery subsequent to physician examination confirming bowel sounds. RESULTS: Eighty-two women were assigned to the traditionally feeding group, and 97 to the early feeding group. From the patients undergoing randomization, 58.7% had a repeated CD, and 27.9% had abdominal adhesions necessitating adhesiolysis. No significant differences were noted between the groups regarding post-operative complications, such as ileus and wound infection (3.1% in the early feeding vs. 8.5% in the traditional feeding group; P=0.114). Maternal satisfaction, however, was significantly higher among the early fed women (94.4% vs. 78.4% in the traditional feeding group; P=0.008). Most patients from the early feeding group tended to recommend such policy (95.8%), as compared to only 56.0% in the traditional feeding group (P=0.001). Using a multivariable analysis with post-operative complications as the outcome variable, controlling for operation number, no association was found between early feeding and post operative complications at the ward (OR=0.9; 95%CI 0.1-7.9; P=0.949). CONCLUSION: Early maternal feeding following cesarean delivery is not associated with higher rates of post-operative complications. Yet, it is associated with higher maternal satisfaction.
417 IS VAGINAL BIRTH AFTER CESAREAN (VBAC) OR ELECTIVE REPEAT CESAREAN SAFER IN WOMAN WITH A PRIOR VAGINAL DELIVERY? ALISON CAHILL1, DAVID M. STAMILIO2, ANTHONY O. ODIBO1, JEFFREY PEIPERT3, ERIKA J. STEVENS4, GEORGE A. MACONES3, 1University of Pennsylvania, Obstetrics/Gynecology, Philadelphia, Pennsylvania, 2University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, 3Brown University, Obstetrics & Gynecology, Providence, Rhode Island, 4University of Pennsylvania, Philadelphia, Pennsylvania OBJECTIVE: To determine if VBAC or elective repeat cesarean is safer overall for a woman with a prior vaginal delivery STUDY DESIGN: This retrospective cohort study of pregnant woman from 1996 to 2000 who had a prior cesarean, was conducted in 17 centers. Trained nurses extracted historical & maternal outcome data on subjects using standardized tools. This planned secondary analysis examined the sub-cohort that had also previously undergone a vaginal delivery, comparing those who underwent a VBAC trial to those who elected to have a repeat cesarean. Outcomes included uterine rupture, bladder injury, fever, transfusion and a composite (uterine rupture, bladder injury, and artery laceration). We performed bivariate and multivariable analyses. RESULTS: Of 6,619 patients with a prior cesarean who had also had a prior vaginal delivery, 5041 patients attempted a VBAC and 1578 had an elective cesarean. Although there was no significant difference in uterine rupture or bladder injury between the two groups, woman who underwent a VBAC attempt were less likely to experience the composite adverse maternal outcome, have a fever, or require a transfusion Risk of maternal morbidities associated with a VBAC attempt vs. elective repeat cesarean section in woman who have had a prior vaginal delivery Outcome Uterine rupture Bladder injury Composite* Fever Transfusion
VBAC attempt
Elective cesarean
0.40%
0.06%
0.32% 1.07% 6.52% 0.44%
0.25% 1.33% 18.63% 2.09%
Unadjusted RR (95% CI)
Adjusted OR (95% CI)
6.26 (0.84-46.6) 0.70 (0.08-6.18) 1.25 0.80 0.35 0.21
(0.42-3.74) (0.49-1.33) (0.30-0.40) (0.12-0.36)
1.22 0.32 0.21 0.17
(0.52-2.85) (0.14-0.72) (0.15-0.28) (0.06-0.47)
* Includes uterine rupture, uterine artery laceration and bladder injury. 416 UTERINE RUPTURE IN WOMAN ATTEMPTING VAGINAL BIRTH AFTER CESAREAN SECTION: CAN IT BE PREDICTED? ALISON CAHILL1, DAVID M. STAMILIO2, ANTHONY O. ODIBO1, JEFFREY PEIPERT3, SARAH J. RATCLIFFE4, ERIKA J. STEVENS5, MARY D. SAMMEL4, GEORGE A. MACONES2, 1University of Pennsylvania, Obstetrics/Gynecology, Philadelphia, Pennsylvania, 2University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, 3Brown University, Obstetrics & Gynecology, Providence, Rhode Island, 4University of Pennsylvania, Biostatistics, Philadelphia, Pennsylvania, 5University of Pennsylvania, Philadelphia, Pennsylvania OBJECTIVE: To determine if a single or group of antepartum and intrapartum factors could be used to predict uterine rupture in patients undergoing a VBAC trial, and therefore aid clinicians in avoiding this morbid event STUDY DESIGN: This is a planned secondary analysis of a retrospective cohort study of pregnant women from 1996 to 2000 who had at least one prior cesarean. Historical and maternal outcome data were collected on participants delivered in one of 17 tertiary or community hospitals. A case was defined as any patient that had a uterine rupture in the current pregnancy. Uterine rupture was strictly defined by surgical and clinical criteria. Control subjects were randomly selected from VBAC candidates who did not experience a uterine rupture. Sensitivity, specificity, and accuracy of each individual or group of risk factors were determined to assess predictive ability for uterine rupture. Bivariate and multivariable methods were used to create predictive models & models were compared using areas under the ROC curves RESULTS: Among 24, 842 patients, 134 cases of uterine rupture and 670 controls were identified. No single risk factor was sufficiently sensitive and specific for clinical prediction. Multivariable models that included antepartum factors did not yield an accurate predictive model for uterine rupture (AUC=0.68). When intrapartum factors were added, accuracy was improved (Figure 1 – AUC=0.71), but the model´s ability to discriminate between cases and controls was not sufficient for uterine rupture prediction
Multivariable predictive model with antepartum and intrapartum predictors CONCLUSION: Antepartum and intrapartum factors, individually or in combination, cannot reliably predict uterine rupture for clinical use. The proven inability to predict uterine rupture should be conveyed to patients during VBAC counseling, and has important medico-legal implications.
CONCLUSION: Among VBAC candidates who have had a prior vaginal delivery, those that attempt a VBAC trial have decreased risk for overall major maternal morbidities, as well as maternal fever and transfusion requirement compared to woman that elect repeat cesarean. Physicians should make this more favorable benefit-risk ratio explicit when counseling this patient subpopulation on a trial of labor
418 OUTCOMES FOR BREECH PRESENTATION BY METHOD OF DELIVERY: UNITED STATES 1990-2002 NORA DOYLE (F)1, MICHAEL MALLOY2, MICHAEL GARDNER1, 1 Emory University, Gynecology & Obstetrics, Atlanta, Georgia, 2University of Texas Medical Branch at Galveston, Neonatology, Galveston, Texas OBJECTIVE: In 2001 ACOG recommended that term singleton breech presentation should undergo a planned cesarean delivery (CD). Advocates of vaginal breech delivery (VB) considered this statement premature. Our objective was to evaluate changes in the prevalence of VB in the United States (US) since 1990 and to determine any changes in adverse outcomes. STUDY DESIGN: US Vital Statistics Natality files were used for the years 1990, 1995, and 2000-2003. Infant outcome measures included 5 minute Apgar scores, asphyxia (5 minute Apgar !3), meconium aspiration syndrome, oxygen requirement for ! 30 minutes, 30 minutes or more of intermittent mandatory ventilation, and presence of neonatal seizures. Linear and logistic regression modeling were used to examine the relationship between outcomes and mode of delivery. Adjusted models included race, maternal age, multiple birth, sex, and birth weight. RESULTS: There were 754,703 breech presentations for the years examined. There were 109,377 VB (14.5%) that included 4,175 vaginal births after cesarean. There was a significant drop in the prevalence of VB from 15.6% in 1990 to 13.1% in 2002. The mean 5 minute Apgar score for CD was higher (8.75 G 1.0) than that of VB (8.05 G 2.2), p!0.001. The adjusted odds ratio (OR) for asphyxia VB vs CD was 6.38 (6.05, 6.72). OR for the other adverse outcomes, except for O 30 minutes mechanical ventilation, were increased for VB compared to CD. Although there was a significant interaction between year of occurrence and method of delivery for 4 of the 5 outcomes examined, there were no trends for worsening outcomes for VB over time. CONCLUSION: There has been a reduction in VB in the US. Despite the reduction, and thus less experience in delivering breech presentations vaginally, the risk of adverse outcome for VB presentaions does not appear to be increasing. Nevertheless, the risk of an adverse outcome remains higher for VB.
417 IS VAGINAL BIRTH AFTER CESAREAN (VBAC) OR ELECTIVE REPEAT CESAREAN SAFER IN WOMAN WITH A PRIOR VAGINAL DELIVERY? ALISON CAHILL1, DAVID M. STAMILIO2, ANTHONY O. ODIBO1, JEFFREY PEIPERT3, ERIKA J. STEVENS4, GEORGE A. MACONES3, 1University of Pennsylvania, Obstetrics/Gynecology, Philadelphia, Pennsylvania, 2University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, 3Brown University, Obstetrics & Gynecology, Providence, Rhode Island, 4University of Pennsylvania, Philadelphia, Pennsylvania OBJECTIVE: To determine if VBAC or elective repeat cesarean is safer overall for a woman with a prior vaginal delivery STUDY DESIGN: This retrospective cohort study of pregnant woman from 1996 to 2000 who had a prior cesarean, was conducted in 17 centers. Trained nurses extracted historical & maternal outcome data on subjects using standardized tools. This planned secondary analysis examined the sub-cohort that had also previously undergone a vaginal delivery, comparing those who underwent a VBAC trial to those who elected to have a repeat cesarean. Outcomes included uterine rupture, bladder injury, fever, transfusion and a composite (uterine rupture, bladder injury, and artery laceration). We performed bivariate and multivariable analyses. RESULTS: Of 6,619 patients with a prior cesarean who had also had a prior vaginal delivery, 5041 patients attempted a VBAC and 1578 had an elective cesarean. Although there was no significant difference in uterine rupture or bladder injury between the two groups, woman who underwent a VBAC attempt were less likely to experience the composite adverse maternal outcome, have a fever, or require a transfusion Risk of maternal morbidities associated with a VBAC attempt vs. elective repeat cesarean section in woman who have had a prior vaginal delivery Outcome Uterine rupture Bladder injury Composite* Fever Transfusion
VBAC attempt
Elective cesarean
0.40%
0.06%
0.32% 1.07% 6.52% 0.44%
0.25% 1.33% 18.63% 2.09%
Unadjusted RR (95% CI)
Adjusted OR (95% CI)
6.26 (0.84-46.6) 0.70 (0.08-6.18) 1.25 0.80 0.35 0.21
(0.42-3.74) (0.49-1.33) (0.30-0.40) (0.12-0.36)
1.22 0.32 0.21 0.17
(0.52-2.85) (0.14-0.72) (0.15-0.28) (0.06-0.47)
* Includes uterine rupture, uterine artery laceration and bladder injury. 416 UTERINE RUPTURE IN WOMAN ATTEMPTING VAGINAL BIRTH AFTER CESAREAN SECTION: CAN IT BE PREDICTED? ALISON CAHILL1, DAVID M. STAMILIO2, ANTHONY O. ODIBO1, JEFFREY PEIPERT3, SARAH J. RATCLIFFE4, ERIKA J. STEVENS5, MARY D. SAMMEL4, GEORGE A. MACONES2, 1University of Pennsylvania, Obstetrics/Gynecology, Philadelphia, Pennsylvania, 2University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, 3Brown University, Obstetrics & Gynecology, Providence, Rhode Island, 4University of Pennsylvania, Biostatistics, Philadelphia, Pennsylvania, 5University of Pennsylvania, Philadelphia, Pennsylvania OBJECTIVE: To determine if a single or group of antepartum and intrapartum factors could be used to predict uterine rupture in patients undergoing a VBAC trial, and therefore aid clinicians in avoiding this morbid event STUDY DESIGN: This is a planned secondary analysis of a retrospective cohort study of pregnant women from 1996 to 2000 who had at least one prior cesarean. Historical and maternal outcome data were collected on participants delivered in one of 17 tertiary or community hospitals. A case was defined as any patient that had a uterine rupture in the current pregnancy. Uterine rupture was strictly defined by surgical and clinical criteria. Control subjects were randomly selected from VBAC candidates who did not experience a uterine rupture. Sensitivity, specificity, and accuracy of each individual or group of risk factors were determined to assess predictive ability for uterine rupture. Bivariate and multivariable methods were used to create predictive models & models were compared using areas under the ROC curves RESULTS: Among 24, 842 patients, 134 cases of uterine rupture and 670 controls were identified. No single risk factor was sufficiently sensitive and specific for clinical prediction. Multivariable models that included antepartum factors did not yield an accurate predictive model for uterine rupture (AUC=0.68). When intrapartum factors were added, accuracy was improved (Figure 1 – AUC=0.71), but the model´s ability to discriminate between cases and controls was not sufficient for uterine rupture prediction
Multivariable predictive model with antepartum and intrapartum predictors CONCLUSION: Antepartum and intrapartum factors, individually or in combination, cannot reliably predict uterine rupture for clinical use. The proven inability to predict uterine rupture should be conveyed to patients during VBAC counseling, and has important medico-legal implications.
CONCLUSION: Among VBAC candidates who have had a prior vaginal delivery, those that attempt a VBAC trial have decreased risk for overall major maternal morbidities, as well as maternal fever and transfusion requirement compared to woman that elect repeat cesarean. Physicians should make this more favorable benefit-risk ratio explicit when counseling this patient subpopulation on a trial of labor
418 OUTCOMES FOR BREECH PRESENTATION BY METHOD OF DELIVERY: UNITED STATES 1990-2002 NORA DOYLE (F)1, MICHAEL MALLOY2, MICHAEL GARDNER1, 1 Emory University, Gynecology & Obstetrics, Atlanta, Georgia, 2University of Texas Medical Branch at Galveston, Neonatology, Galveston, Texas OBJECTIVE: In 2001 ACOG recommended that term singleton breech presentation should undergo a planned cesarean delivery (CD). Advocates of vaginal breech delivery (VB) considered this statement premature. Our objective was to evaluate changes in the prevalence of VB in the United States (US) since 1990 and to determine any changes in adverse outcomes. STUDY DESIGN: US Vital Statistics Natality files were used for the years 1990, 1995, and 2000-2003. Infant outcome measures included 5 minute Apgar scores, asphyxia (5 minute Apgar !3), meconium aspiration syndrome, oxygen requirement for ! 30 minutes, 30 minutes or more of intermittent mandatory ventilation, and presence of neonatal seizures. Linear and logistic regression modeling were used to examine the relationship between outcomes and mode of delivery. Adjusted models included race, maternal age, multiple birth, sex, and birth weight. RESULTS: There were 754,703 breech presentations for the years examined. There were 109,377 VB (14.5%) that included 4,175 vaginal births after cesarean. There was a significant drop in the prevalence of VB from 15.6% in 1990 to 13.1% in 2002. The mean 5 minute Apgar score for CD was higher (8.75 G 1.0) than that of VB (8.05 G 2.2), p!0.001. The adjusted odds ratio (OR) for asphyxia VB vs CD was 6.38 (6.05, 6.72). OR for the other adverse outcomes, except for O 30 minutes mechanical ventilation, were increased for VB compared to CD. Although there was a significant interaction between year of occurrence and method of delivery for 4 of the 5 outcomes examined, there were no trends for worsening outcomes for VB over time. CONCLUSION: There has been a reduction in VB in the US. Despite the reduction, and thus less experience in delivering breech presentations vaginally, the risk of adverse outcome for VB presentaions does not appear to be increasing. Nevertheless, the risk of an adverse outcome remains higher for VB.