Risk factors for shoulder dystocia

The risk factors associated with the occurrence of shoulder dystocia were examined in the general obstetrical population of women delivering vaginally. An increasing incidence of shoulder dystocia was found as infant birth weight increased. Although one-third of shoulder dystocia occurred in pregnancies at 42 + weeks, except for those resulting in infants weighing 4500 + g, the vast majority was unaffected by shoulder dystocia. The incidence of shoulder dystocia in nondiabetic gravidas delivering an infant weighing 4000 to 4499 and 4500 + g vaginally was 10.0 and 22.6%, respectively. Within the 4000- to 4499-g group, no labor abnormality was clearly predictive; however, in the heaviest birth weight group, an arrest disorder heralded a shoulder dystocia in 55.0% of cases. Diabetics experienced more shoulder dystocia than nondiabetics. Among them, 31% of vaginally delivered neonates weighing 4000 + g experienced shoulder dystocia. Nevertheless, the risk factors of diabetes and large fetus (4000 + g) could predict 73% of shoulder dystocia among diabetics; large fetus along flagged 52% of shoulder dystocia in nondiabetics. Cesarean section is recommended as the delivery method for diabetic gravidas whose estimated fetal weight is 4000 + g. If others confirm the risk, the authors advise serious consideration of cesarean section for gravidas who are carrying fetuses estimated to be 4500 + g and who experience an abnormal labor.     

Amniotomy and oxytocin treatment of functional dystocia and route of delivery

The details of clinical management were examined in 101 nulliparous patients with functional dystocia who underwent amniotomy and were treated with oxytocin in the first stage of labor. It was our hypothesis that if the alleged "high" rate of cesarean sections was the result of mediocre or flawed practices, these should be most evident in patients delivered abdominally. A group of 68 patients delivered vaginally are compared with 33 patients delivered by cesarean section. The means of many variables were statistically similar. The cesarean group was characterized by less cervical dilatation at admission, greater birth weights, larger maximum doses of oxytocin, and longer durations of oxytocin therapy. We conclude from our analysis that the decision to perform cesarean section in nulliparous women with functional dystocia arises from disabilities of the patient and not from differences in the application of our management principles, services, or treatments.     

Prepregnancy body mass index in non-diabetic women with and without shoulder dystocia.

OBJECTIVE: To investigate the distribution of prepregnancy body mass index (BMI) in non-diabetic women with and without shoulder dystocia. STUDY DESIGN: Cases were 142 non-diabetic women experiencing shoulder dystocia during the period from 1 January 1993 to 31 December 1999. Shoulder dystocia was defined as the impossibility of delivering the fetal shoulders by standard procedures. Controls were 142 women vaginally delivering during the same period without experiencing shoulder dystocia. Cases and controls were matched for parity (primi-/multipara) and birthweight (+/-250 g). Women with diabetes mellitus, gestational diabetes or a history of shoulder dystocia in a previous birth were excluded. The BMI and selected obstetric data were extracted from an internal database in the department. RESULTS: Delivery was performed using McRoberts maneuvre (42%), Woods screw (50%) or by primary delivery of the posterior arm (8%). Women experiencing shoulder dystocia had significantly more labor augmentation and more instrumental deliveries. No differences were shown in the prevalence of low Apgarscores. The proportion of children with Erbs palsy and clavicular fracture was very close to be significantly different in cases or controls. However, these data does not allow any conclusion. The distribution of BMI was equal in cases and controls. CONCLUSION: Non-diabetic women experiencing shoulder dystocia do not have a higher BMI than non-diabetic women delivering without this experience, given a fixed fetal weight.     

Rupture and dehiscence of cesarean section scar during pregnancy and delivery

A prospective study was undertaken to evaluate the risk of uterine rupture or dehiscence after cesarean section. During the 10 years of the study, 24,644 patients were delivered of infants. Of these women, 2036 (8.3%) had previously undergone cesarean section. A trial of labor was allowed in 1008 of these patients, and 92.2% were delivered vaginally. The incidence of uterine rupture in this trial of labor group was 0.6%, compared with 0.4% in the total group. Cesarean section scar rupture caused no serious complications in either the mothers or the offspring in the trial of labor group. Uterine rupture in this group was not associated with use of oxytocin or epidural analgesia. Patients with lower-segment scar rupture had no history of puerperal pyrexia. The incidence of uterine dehiscence was 4%. In summary, the risk of uterine rupture in patients who have previously undergone cesarean section but are allowed a trial of labor is low and not associated with serious complications. Vaginal delivery is therefore considered the safest route of delivery in these patients.     

Active-phase labor arrest: oxytocin augmentation for at least 4 hours

OBJECTIVE: To assess a labor-management protocol that mandated at least 4 hours of oxytocin augmentation before cesarean delivery for active-phase labor arrest. METHODS: We prospectively evaluated term gravidas in spontaneous labor with active-phase labor arrest (cervix at least 4 cm dilated and 1 cm or less of cervical progress in 2 hours). Exclusion criteria included nonvertex presentation, previous cesarean, multiple gestation, and a nonreassuring fetal heart rate tracing or chorioamnionitis at the time of labor arrest. After the diagnosis of active-phase arrest, oxytocin was initiated with an intent to achieve a sustained uterine contraction pattern of greater than 200 Montevideo units. Cesarean delivery was not performed for labor arrest until at least 4 hours of a sustained uterine contraction pattern of greater than 200 Montevideo units, or a minimum of 6 hours of oxytocin augmentation if this contraction pattern could not be achieved. RESULTS: Five hundred forty-two women were managed by the protocol, and 92% delivered vaginally. The subsequent vaginal delivery rate for parous women who had not progressed (1 cm of cervical dilation or less) despite 2 hours of oxytocin augmentation was 91%, and it was 74% for nulliparas. With no labor progress after 4 hours of oxytocin augmentation, the subsequent vaginal delivery rates were 88% for parous women and 56% for nulliparas. There were no severe maternal complications. One neonate had persistent fetal circulation and one had a positive blood culture, but both did well. CONCLUSION: Extending the minimum period of oxytocin augmentation for active-phase labor arrest from 2 to at least 4 hours was effective and safe.     

Oxytocin and dystocia as risk factors for adverse birth outcomes: A cohort of low-risk nulliparous women

Objectivesaugmented and not augmented women without dystocia were compared to investigate associations between oxytocin and adverse birth outcomes. Augmented women with and without dystocia were compared, to investigate associations between dystocia and adverse birth outcomes.Designa cohort of low-risk nulliparous women originally included in a randomised controlled trial.Settingthe Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway.Participantsthe study population consists of 747 well defined low-risk women.Measurementsincidence of oxytocin augmentation, and associations between dystocia and augmentation, and mode of delivery, transfer of newborns to the intensive care unit, episiotomy and postpartum haemorrhage.Findingsof all participants 327 (43.8%) were augmented with oxytocin of which 139 (42.5%) did not fulfil the criteria for dystocia. Analyses adjusted for possible confounders found that women without dystocia had an increased risk of instrumental vaginal birth (OR 3.73, CI 1.93–7.21) and episiotomy (OR 2.47, CI 1.38–4.39) if augmented with oxytocin. Augmented women had longer active phase if vaginally delivered and longer labours if delivered by caesarean section if having dystocia. Among women without dystocia, those augmented had higher body mass index, gave birth to heavier babies, had longer labours if vaginally delivered and had epidural analgesia more often compared to women not augmented.Key conclusionin low-risk nulliparous without dystocia, we found an association between the use of oxytocin and an increased risk of instrumental vaginal birth and episiotomy.Implications for practicecareful attention should be paid to criteria for labour progression and guidelines for oxytocin augmentation to avoid unnecessary use.     

产程中改变产妇体位矫正胎方位的探讨

目的：探讨产程中改变产妇体位以矫正胎方位的临床效果。方法：选择先兆临产至潜伏期经Ｂ超检查判断为枕后位的初产妇２４０例，随机分为两组，各１２０例。研究组在产程中指导产妇取侧俯卧位，利用胎儿重力、羊水浮力、子宫间歇收缩的合力作用，使胎头在下降时逐渐从枕后位转至枕前位娩出，并与对照组比较。结果：研究组１０６例（８８．３％）胎儿从枕后位转到枕前位经阴道娩出。剖宫产１４例（１１．７％）。对照组经阴道娩出仅２０例（１６．７％），剖宫产１００例（８３．３％）。两组比较，差异有非常显著性（Ｐ＜０．００１）。研究组第一产程平均时间３０２．６分钟，第二产程平均５９．８分钟。对照组第一产程平均４８３．７分钟，第二产程平均１５６．７分钟。两组比较，差异有极显著性（Ｐ＜０．０１）。结论：在产程中指导产妇取侧俯卧位矫正胎头枕后位是降低难产发生率的有效方法。     

Labor course and delivery in epidural analgesia: a case-control study.

BACKGROUND: We aimed to establish if epidural analgesia is associated with a higher incidence of operative vaginal delivery, longer duration of labor and more frequent use of oxytocin than labor without analgesia. METHODS: We analyzed a cohort of 207 women with no risk factors who delivered with epidural analgesia in the labor unit of Spedali Civili, Brescia, Italy, during 2001. Length of the first and second stage of labor, mode of delivery, neonatal cord blood pH, neonatal Apgar score and neonatal outcomes were evaluated. RESULTS: Epidural analgesia was performed on request in 6%: in this group (group A) there were 141 (68%) nulliparae and 66 (32%) pluriparae; mean ( +/- standard deviation) gestational age at delivery was 39.4 +/- 1.3 weeks (range: 34.1-41.5 weeks). In this group, 184 (89%) had vaginal delivery and 23 (11%) delivered by Cesarean section. Among controls (group B), 368 (89%) had a vaginal delivery and 46 (11%) delivered by Cesarean section; vacuum extraction was used in 18 deliveries (9%) in group A and in 13 deliveries (3%) in group B. The duration of the second stage of spontaneous labor in the nulliparae of group A was significantly longer than in group B. No statistically significant differences were found between mean umbilical artery pH values of groups A and B. CONCLUSION: Our results confirm that epidural analgesia does not affect the rate of Cesarean delivery, while increasing the use of oxytocin augmentation, the duration of the second stage of labor and the rate of instrumental vaginal delivery.     

Triplet and quadruplet pregnancies--a forthcoming challenge also for the 'general' obstetrician

Data from 14 triplet and 2 quadruplet pregnancies (50 infants) during the period 1974-1988 were analysed. The perinatal mortality rate was only 6%, despite a preterm delivery rate of 88%. Preterm delivery was more common in young (less than or equal to 29 years) multiparous women. Perinatal complications were, as expected, strongly associated with immaturity. Respiratory problems of the infants occurred significantly more often among women delivered by elective Cesarean section than among those planned for vaginal delivery, but the mean gestational duration was 1 week longer in the latter group. Few problems arise in infants weighing 2000 g or more, or at delivery at 34 weeks or later, and under optimal conditions it would therefore seem safe to allow these women to give birth vaginally. Nor did birth order affect the outcome for infants born vaginally. It is recommended that quadruplets be delivered by Cesarean section because of the difficulty of ensuring satisfactory fetal surveillance in labor.     

Management of spontaneous rupture of the membranes in the absence of labor in primigravid women at term

One hundred and thirty-five healthy primigravid women at or near term with spontaneous rupture of the membranes without uterine contractions were submitted to a prospective trial of management. Rupture of the membranes was diagnosed by speculum examination. If labor did not commence, induction was performed by oxytocin infusion starting at 9 AM following admission. One hundred and five women went into labor spontaneously before induction became necessary. Sixty-three of these women required augmentation with oxytocin. Twenty-seven percent of the induced group required cesarean section delivery compared to 10% of those in spontaneous labor augmented by oxytocin and to none of those who did not require oxytocin (p less than 0.01). Ninety-four percent of those in spontaneous labor were delivered vaginally compared to 73% of the induced group (p less than 0.01). Forty-one percent of the augmented group were delivered by forceps. Awaiting the spontaneous onset of labor for 24 hours or less did not result in clinical maternal or neonatal infection. We would therefore advocate awaiting the spontaneous onset of labor after spontaneous rupture of membranes without contractions at or near term in healthy primigravid women for up to 24 hours because it seems to confer significant advantages without producing any additional hazard.     

The effect of continuous epidural analgesia on cesarean section for dystocia in nulliparous women

Epidural analgesia in labor is generally accepted as safe and effective and therefore has become increasingly popular. However, little is known regarding the effect of epidural analgesia on the incidence of cesarean section for dystocia in nulliparous women. During the first 6 months of 1987 we studied 711 consecutive nulliparous women at term, with cephalic fetal presentations and spontaneous onset of labor. Comparison of 447 patients who received epidural analgesia in labor with 264 patients who received either narcotics or no analgesia was performed. The incidence of cesarean section for dystocia was significantly greater (p less than 0.005) in the epidural group (10.3%) than in the nonepidural group (3.8%). There remained a significantly increased incidence (p less than 0.005) of cesarean section for dystocia in the epidural group after selection bias was corrected and the following confounding variables were controlled by multivariate analysis: maternal age, race, gestational age, cervical dilatation on admission, use of oxytocin, duration of oxytocin use, maximum infusion rate of oxytocin, duration of labor, presence of meconium, and birth weight. The incidence of cesarean section for fetal distress was similar (p greater than 0.20) in both groups. There were no clinically significant differences in frequency of low Apgar scores at 5 minutes or cord arterial and venous blood gas parameters between the two groups. This study suggests that epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparous women.     

Clinical significance of the floating fetal head in nulliparous women in labor

OBJECTIVE: To examine the course of labor in nulliparous women in active labor with a floating fetal head. STUDY DESIGN: A prospective, cohort study of nulliparous women presenting in active labor at term with a floating fetal head (station > or = -3, n = 108) or engaged fetal head (n = 241). All patients were examined by a senior physician. Assignment to the study or control group was noted in the investigator's records. However, management of labor was at the discretion of the labor ward team on duty. RESULTS: Cesarean section rates for failure to progress were significantly higher in the study group (17.1% versus 4.2%, P < .0001), and the second stage of labor was prolonged (65.3 +/- 27.1 versus 54.9 +/- 30.2 minutes, P < .03). None of the women who had a persistently floating fetal head at 7 cm of cervical dilation delivered vaginally. Birth weights were larger (P < .03) and Apgar scores lower (P < .0001) in the study group. The lengths of the active phase and instrumental delivery rates were similar in the two groups. CONCLUSION: Nulliparous women presenting in active labor at term with a floating head are at substantially increased risk of cesarean section for abnormal progress of labor. However, the majority of patients will still deliver vaginally. A persistently floating head with advanced cervical dilation (7 cm) should prompt consideration of cesarean section since little is to be gained by waiting.     

A prospective randomized study comparing misoprostol and oxytocin for premature rupture of membranes at term.

OBJECTIVE: The aim of this randomized trial was to compare the efficacy and safety of vaginal misoprostol and oxytocin for cervical ripening and labor induction in patients with premature rupture of membrane (PROM) at term. METHODS: Ninety-seven women with PROM at term were assigned randomly to receive intravaginal misoprostol or oxytocin. The primary outcome measure was the induction-delivery interval. Secondary outcomes included the number of women who delivered vaginally within 12 hours of the start of the induction in the two groups, the cesarean, hyperstimulation, and failed induction rates, the mode of delivery, and the neonatal outcome. RESULTS: Forty-eight women were assigned to intravaginal misoprostol and 49 to oxytocin administration. The mean interval from induction to delivery was 10.61 +/- 2.45 hours in the misoprostol group and 11.57 +/- 1.91 hours in the oxytocin group (p = 0.063). The rates of vaginal delivery were 83.3% and 87.7% and cesarean delivery were 16.7% and 8.2% in the misoprostol and oxytocin groups, respectively. Neonatal outcomes were not significantly different. Of the cases, 8.3% in the misoprostol group and 8.2% in the oxytocin group revealed uterine contraction abnormalities. CONCLUSION: Our study demonstrates that, intravaginally, misoprostol results in a similar interval from induction of labor to delivery when compared to oxytocin.     

Rates of successful vaginal delivery after cesarean for patients with private versus public insurance.

OBJECTIVE: To examine the effect of insurance status on method of delivery while controlling for clinical and sociodemographic characteristics of women delivering at a single medical center. STUDY DESIGN: Sociodemographic and clinical characteristics of 878 women, who delivered their infants between 1985 and 1991 at a university hospital, were analyzed. Women were included if their previous infant was delivered by cesarean section and if the current pregnancy was > or = 37 weeks' gestation at nonemergent delivery with insurance status clearly specified. The outcome of interest was the rate of successful vaginal births after cesarean (VBAC) delivery by insurance status. RESULTS: The trial of labor rate for the cohort, defined as the rate of VBAC or cesarean deliveries following labor, was 55%; 61% were vaginal deliveries. Significant differences with regard to insurance status and several maternal factors were noted between trial of labor and cesarean section--no labor groups. After controlling for potentially confounding variables, the Medicaid/indigent group was more likely than the privately insured group to undergo a trial of labor (odds ratio, 1.5; 95% confidence interval, 1.1 to 2.4). Of women who underwent a trial of labor, after controlling for other characteristics, the Medicaid/indigent group was more likely than the privately insured group to deliver vaginally (odds ratio, 1.9; 95% confidence interval, 1.1 to 3.2). CONCLUSION: After controlling for other covariables, women with a history of a prior cesarean section with Medicaid/indigent insurance were more likely than privately insured women to attempt a trial of labor, and subsequently, to deliver vaginally, given that a trial of labor was attempted.     

Spontaneous rupture of the membranes, functional dystocia, oxytocin treatment, and the route of delivery

The details of clinical management were examined in 96 nulliparous patients with functional dystocia who had spontaneous rupture of the membranes before admission and were treated with oxytocin in the first stage of labor. It was our hypothesis that if the allegedly "high" rate of cesarean sections was the result of mediocre or flawed practices, these should be most evident in patients delivered abdominally. A group of 59 patients delivered vaginally were compared with 37 patients delivered by cesarean section. The means of many variables were not statistically different. The cesarean section group was characterized by smaller stature, a lesser cervical dilatation rate both before and after oxytocin administration, a larger maximum oxytocin dose, a longer period of oxytocin administration, more frequent cessation of oxytocin administration or dose reduction because of hypercontractility or an abnormal fetal heart rate or both, and a higher incidence of intra-amniotic infection. We conclude that the decision to perform cesarean section in nulliparous women with functional dystocia arises from disabilities of the patient and not from differences in the application of our management principles, services, or treatments.     

The continuing effectiveness of active management of first labor, despite a doubling in overall nulliparous cesarean delivery

OBJECTIVE: The purpose of this study was to determine the continuing effectiveness of active management of labor, a protocol that involves early detection and correction of dystocia with oxytocin in spontaneous cephalic nulliparous labor, by analysis of the contribution of this cohort to a doubled overall nulliparous cesarean delivery rate. STUDY DESIGN: This was a retrospective analysis of annually collated institutional data on cesarean delivery and perinatal outcome. RESULTS: From 1989 to 2000, 81,855 women were delivered at the National Maternity Hospital, of whom 34,201 women (42%) were nulliparous; the annual proportion of nulliparous women in spontaneous labor decreased progressively from 83% to 60%; the overall nulliparous cesarean rate increased from 8.1% to 16.6%. Cesarean birth rate among nulliparous women in spontaneous labor, although showing a significant upward trend between 1989 and 2000 (2.4%-4.8%; P = .001), was stable, averaging 5% for the last 8 years (P = .705); the peripartum death rate in this group fell significantly (P = .024). Comparing results for 1989 with results for 2000, nulliparous women in spontaneous labor accounted for 14% of the overall increase in cesarean deliveries (dystocia, 5%), compared with 51% for nulliparous women with induced labor. The perinatal mortality rate in term infants was unchanged. CONCLUSION: Active management of spontaneous first labors remains an effective protocol for the promotion of vaginal delivery with low peripartum mortality rates; factors other than dystocia in spontaneous labor account for the progressive increase in the nulliparous cesarean delivery rate.     

Maternal serum levels of dehydroepiandrosterone sulfate and labor induction in postterm pregnancies.

OBJECTIVES: To study the relationship between maternal endogenous dehydroepiandrosterone sulfate (DHEAS) levels, success of labor induction, and Bishop scores in postterm pregnancies. METHODS: There were 65 postterm pregnancies. Group 1 consisted of women spontaneously in the active phase of labor, and group 2 of women with hypotonic uterine contractions whose labor was inducted by oxytocin. Levels of DHEAS were studied from venous blood samples. Demographic data and Bishop scores were recorded. RESULTS: The demographic characteristics of patients were similar, but DHEAS levels were higher in group 1 than in group 2 (P<0.001). Linear regression analysis showed a significant relationship between DHEAS and Bishop scores. DHEAS levels in women delivered vaginally were significantly higher than in women delivered by cesarean section. From the receiver operating characteristics (ROC) curve, DHEAS levels might determine the mode of delivery and success of labor induction; however, Bishop scores do not. CONCLUSIONS: DHEAS levels may be an important factor influencing the efficiency of labor and the success of labor induction in postterm pregnancies.     

Oral misoprostol (100 microg) versus vaginal misoprostol (25 microg) in term labor induction: a randomized comparison

OBJECTIVE: To compare the efficacy of vaginal misoprostol (25 microg) to oral misoprostol (100 microg) in labor induction at term. METHODS: One hundred and one women at term, with indications for labor induction and cervical Bishop's scores of less than 8, were randomly assigned to receive 100 microg of oral misoprostol or 25 microg vaginal misoprostol after random allocation. This could be repeated every 4 h to a maximum of five doses. The number delivering vaginally within 24 h of the induction was the main outcome measure. RESULTS: Of those who delivered vaginally (74.5% in the oral group vs. 72% in the vaginal group), significantly fewer women delivered within 24 h of induction in the oral group (42.1% vs. 72.2%, RR 0.6, 95% CI 0.4-0.9), with more women receiving more than one dose (45.7% vs. 16.7%, RR 2.7, 95% CI 1.2-6.0). More women in the oral group received oxytocin (68.6% vs. 44%, RR 1.6, 95% CI 1.1-2.2), and the induction to delivery interval was shorter in the vaginal group, although this was not statistically significant [28.9 h (SD 20.2) vs. 20.6 h (SD 16.1), mean difference - 8.3 h, 95% CI - 16.8 to 0.2]. There were no differences in the modes of delivery, uterine hyperstimulation rates or in the neonatal outcomes. CONCLUSION: Vaginal misoprostol in its currently recommended dose of 25 microg seems to be more efficacious than the 100 microg oral dose.     

Appropriateness of antibiotic use in the postpartum period

Objective: To determine the appropriateness of current postpartum antibiotic use in clinical practice. Methods: Medical records were reviewed for all patients delivering in a 3-month period who received postpartum antibiotics during the delivery hospitalization. Subjects were excluded if they received a single postpartum antibiotic dose as part of a mitral valve prolapse prophylaxis protocol, or if they received no more than one postpartum antibiotic dose for surgical prophylaxis. Characteristics of postpartum antibiotic use were abstracted. Results: Two hundred and eleven of 1537 (14%) delivering patients met the inclusion criteria. Seventy-four (35%) delivered vaginally and 137 (65%) delivered by Cesarean section. Postpartum fevers were found in 40 (54%) of vaginal delivery cases and 80 (58%) of women delivering by Cesarean section who received postpartum antibiotics ( p = 0.54). For vaginal deliveries there were no differences in the duration of antibiotic use or number of antibiotic doses based on fever status. For Cesarean deliveries, a fever was associated with more antibiotic doses and a longer duration of antibiotic use. Physician justification for antibiotic use was documented in only 116 cases (55%). Conclusions: The high proportion of women receiving postpartum antibiotics having no evidence for infection or documented indication for therapy suggests that antibiotics may not be appropriately used in the postpartum period.     

Maternal and neonatal outcomes after oxytocin augmentation in patients undergoing a trial of labor after prior cesarean delivery.

OBJECTIVE: To study the safety of oxytocin augmentation in patients having abnormal labors after a prior cesarean delivery. METHODS: We retrospectively analyzed a case series of women undergoing a trial of labor after a previous cesarean delivery from the University of California San Francisco perinatal data base. Women whose labors were augmented with oxytocin were compared to women with labor abnormalities managed without the use of oxytocin. A wide range of maternal and neonatal outcomes was compared. Only vertex singleton term deliveries were studied. RESULTS: From 1975-1990 there were 504 trials of labor, of which 185 (37%) had labor abnormalities; 62 of these 185 (34%) were augmented with oxytocin. Fifty-eight percent of the trials of labor ended in vaginal delivery. In patients since 1982, 73% delivered vaginally. Forty-six (74%) of augmented patients delivered vaginally. There were no maternal deaths, uterine ruptures, or hysterectomies. Estimated blood loss was slightly greater among augmented patients after controlling for mode of delivery (P < .05), but only by 50-100 mL on average. There was no difference in the need for maternal transfusion. Fetal trauma and fetal scalp blood sampling occurred more frequently (P < .05) in the augmented labors, but only in the subgroup delivered by cesarean. No increased risk was demonstrated by a comparison between patients receiving oxytocin and epidural anesthesia and patients with labor abnormalities receiving neither. CONCLUSION: Retrospective analysis supports the use of oxytocin and epidural anesthesia to augment abnormal trials of labor after prior cesarean.