Vacuum assisted delivery in Ecuador for prolonged second stage of labor: Maternal–neonatal outcome

Background. In South America, and particularly Ecuador, cesarean section rates have risen markedly over the past five years. The associated increases in maternal morbidity and healthcare costs indicate the need for alternative strategies. Operative vaginal delivery is minimally utilized in Ecuador, as neither vacuum nor forceps have been available.

Objective. As vacuum delivery was recently introduced to our clinical service, we sought to examine our initial experiences (i.e., maternal and neonatal outcome) with operative vaginal delivery for prolonged second stage of labor.

Methods. Following an initial educational program at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador, vacuum extraction cups (Mityvac®, Cooper Surgical) were offered to laboring women with term singleton gestations and cephalic presentations no higher than +3 station. Maternal and neonatal data were analyzed.

Results. During the study period, 100 vacuum applications were performed on laboring women complicated with prolonged second stage of labor. Mean maternal age was 23.8 ± 6.4 years (range14–41 years) with 57% of patients nulliparous. Left anterior and right posterior fetal positions were the most frequent (85% and 11%, respectively). Maternal complications included need for blood transfusion (1%), shoulder dystocia (1%) and perineal tears (first degree 6%, second degree 5%). Vaginal delivery was successful in 97% of cases. Among neonates, the average weight was 3149 ± 410 g, with 10% neonates small for gestational age and 5% large for gestational age. Only 1% of infants presented an Apgar score <7 at 5 min. There were no scalp lacerations, cephalohematomas, or subgaleal bleeds.

Conclusions. In this initial observational study, vacuum extraction for prolonged second stage was safe and effective. We propose that the introduction of operative vaginal delivery to developing countries will mitigate rising cesarean section rates.     

How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes?

OBJECTIVE: The purpose of this study was to examine maternal and neonatal outcomes in relation to lengthening intervals of the second stage of labor. STUDY DESIGN: This is a retrospective cohort study of 15,759 nulliparous, term, cephalic, singleton births at the University of California, San Francisco, between 1976 and 2001. The second stage of labor was divided into 1-hour intervals. Maternal and neonatal outcomes were compared with the use of chi-squared and Student t tests, and a probability value of < or =.05 was used to indicate statistical significance. Potential confounders were controlled for with multivariate logistic regression. RESULTS: Increasing rates of cesarean delivery, operative vaginal delivery, and perineal trauma were associated with the second stage beyond the first hour. In multivariate analysis, the >4-hour interval group had higher rates of cesarean delivery (odds ratio, 5.65; P < .001), operative vaginal deliveries (odds ratio, 2.83; P < .001), 3rd- or 4th-degree perineal lacerations (odds ratio, 1.33; P = .009), and chorioamnionitis (odds ratio, 1.79; P < .001). There were no differences in neonatal acid-base status associated with length of second stage. However, there were fewer neonates with a 5-minute Apgar score of <7 (odds ratio, 0.45; P = .01). CONCLUSION: Although the length of the second stage of labor is not associated with poor neonatal outcome, a prolonged second stage is associated with increased maternal morbidity and operative delivery rates.     

Labor and delivery following successful external cephalic version

The objective of this study is to determine if successful external cephalic version is followed by an increased likelihood of prolonged labor or operative delivery. Women having a successful external cephalic version of a normal singleton fetus > or =37 weeks' gestation between January 1, 1997 and December 31, 1998 were included. Each case was matched for gestational age at delivery (+/-1 week), labor onset (spontaneous or induced), prior vaginal delivery (yes or no), and cervical dilation on admission for delivery (+/-1 cm) to the next three patients delivering a spontaneously vertex term singleton. Maternal demographics, intrapartum variables, neonatal outcomes, and route of delivery were examined. Statistical comparisons were performed by the Student's t-test or Fisher's exact test. The 38 cases and 114 controls were similar by maternal age, race, gestational age at delivery, birth weight, and insurer. There were no differences in the frequency of epidural or oxytocin use, maternal genital tract lacerations, or blood loss at delivery. Neonatal outcomes, assessed by 1- and 5-min Apgar score <7, or neonatal intensive care unit (NICU) admission did not differ between cases and controls. The labor length of patients undergoing successful version was similar to that of women laboring with spontaneously vertex fetuses (10.8 +/- 8.9 vs. 10.1 +/- 10.1 hr, p = 0.4). The frequencies of operative vaginal and cesarean delivery in cases did not differ from those of controls (3/38 vs. 1/114, p = 0.56 and 4/38 vs. 8/114, p = 0.51, respectively.) Labor duration and delivery route following successful external cephalic version do not differ from women with spontaneously vertex fetuses.     

Choosing between bad,worse and worst: what is the preferred mode of delivery for failure of the second stage of labor?*

Objective: To determine the preferred mode of delivery (vacuum, forceps or cesarean delivery) for second-stage dystocia.

Methods: Retrospective cohort study of women delivered by forceps, vacuum or cesarean delivery due to abnormalities of the second stage of labor. Primary outcome included neonatal and maternal composite adverse effects.

Results: A total of 547 women were included: 150 (27.4%) had forceps delivery, 200 (36.5%) had vacuum extraction, and 197 (36.1%) had cesarean section. The rate of neonatal composite outcome was significantly increased in vacuum extraction (27%) compared to forceps delivery (14.7%) or cesarean section (9.7%) (p?p?=?0.004).

Conclusion: Operative vaginal delivery was associated with reduced postpartum infection compared to cesarean section. Forceps delivery was associated with reduced risk for adverse neonatal outcome compared to vacuum extraction, with no increase in the risk of composite maternal complications.     

Induction of labor or serial antenatal fetal monitoring in postterm pregnancy: a randomized controlled trial

OBJECTIVE: To compare induction of labor at gestational age 41 weeks with expectant management in regard to neonatal morbidity. Secondary aims were to assess the effect of these managements on mode of delivery and maternal complications. METHODS: Between September 2002 and July 2004, postterm women with singleton cephalic presentation and no prelabor rupture of membranes were randomly assigned to induction of labor at 289 days or antenatal fetal surveillance every third day until spontaneous labor. Main outcome measures were neonatal morbidity, operative delivery rates, and maternal complications. RESULTS: Five hundred eight women were randomly assigned, 254 in each group. No differences of clinical importance were observed in women in whom labor was induced compared with women who were expectantly managed with regard to the following outcomes: neonates whose 5-minute Apgar score was less than 7 (three neonates in the induction group compared with four in the monitoring group, P=.72); neonates whose umbilical cord pH was less than 7 (three compared with two, P=.69); prevalence of cesarean delivery (28 compared with 33, P=.50); or prevalence of operative vaginal delivery (32 compared with 27, P=.49). In the induction group more women had precipitate labors (33 compared with 12, P<.01; number needed to treat was 13), and the duration of second stage of labor was more often less than 15 minutes (94 compared with 56, P<.01; number needed to treat was 7). CONCLUSION: No differences were found between the induced and monitored groups regarding neonatal morbidity or mode of delivery, and the outcomes were generally good. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00385229. LEVEL OF EVIDENCE: I.     

中心电子监护系统的临床应用

目的 探讨使用中心电子监护系统对提高产科质量的作用。方法 对１９７９年１１月 １９９８年３月在我院分娩的孕周≥３７周的１２１６例孕妇进行ＣＥＭＳ监护,并与１９９６年１１月至１９９７年３月在我院分娩的孕周≥３７周、未行ＣＥＭＳ监护的１１３７例孕妇（对照组）进行比较,分析两组胎儿窘迫发生率,新生儿窒息发生率,剖宫痃和阴道手术率。结果 姐与则组胎儿窘迫发生率分别为９．８％、１２．８％;新生窒息发生率分别     

An Analysis of Second-Stage Labor beyond 3 Hours in Nulliparous Women

Objective?To analyze outcomes after second-stage labor beyond 3 hours and determine if prolonged second stages were intentional.Study Design?Retrospective cohort analysis of maternal and neonatal outcomes in nulliparous women based on second-stage duration. Medical records were reviewed for management decisions in women with second stages ≥4 hours; all other outcomes were accessed via computerized obstetric database.Results?Second stage exceeding 3 hours occurred in 1489 (7%) of 21,991 pregnancies analyzed. Of the 427 (2%) with second stages ≥4 hours, 315 (74%) reached 4 hours unintentionally, after a decision for operative delivery had been made. Only 34 (8%) women were intentionally allowed to continue second-stage labor beyond 4 hours, and half of these ultimately required cesarean. Indices of maternal and neonatal morbidity were significantly increased when second stages exceeded 3 hours.Conclusion?Most second stages reaching 4 hours are unintentional, occurring while awaiting an previously decided upon operative delivery. Maternal and neonatal morbidities are significantly increased with second stages beyond 3 hours.     

Immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries

OBJECTIVE: To estimate the differences in immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries. METHODS: We conducted a medical record review of all forceps and vacuum-assisted deliveries that occurred from January 1, 1998, to August 30, 1999, at Winthrop-University Hospital. Maternal demographics and delivery characteristics were recorded. Maternal outcomes, such as use of episiotomy and presence of lacerations, were studied. Neonatal outcomes evaluated were Apgar scores, neonatal intensive care unit admissions, cephalohematomas, instrument marks and bruising, and caput and molding. RESULTS: Of 508 operative vaginal deliveries, 200 were forceps and 308 were vacuum assisted. Forceps were used more often than vacuum for prolonged second stage of labor (P =.001). There was a higher rate of epidural (P =.02) and pudendal (P <.001) anesthesia, episiotomies (P =.01), maternal third- and fourth-degree perineal (P <.001) and vaginal lacerations (P =.004) with the use of forceps, whereas periurethral lacerations were more common in vacuum-assisted (P =.026) deliveries. More instrument marks and bruising (P <.001) were found in the neonates delivered by forceps, whereas there was a greater incidence of cephalohematomas (P =.03) and caput and molding (P <.001) in the neonates delivered with vacuum. Multivariable logistic regression analysis showed that forceps use was associated with an increase in major perineal and vaginal tears (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.27, 2.69; P =.001), an increase in instrument marks and bruising (OR 4.63; 95% CI 2.90, 7.41; P <.001) and a decrease in cephalohematomas (OR 0.49; 95% CI 0.29, 0.83; P =.007) compared with the vacuum. CONCLUSIONS: Maternal injuries are more common with the use of forceps. Neonates delivered with forceps have more facial injuries, whereas neonates delivered with vacuum have more cephalohematomas. LEVEL OF EVIDENCE: II-3     

Should we allow a trial of labor after a previous cesarean for dystocia in the second stage of labor?

OBJECTIVE: To estimate the rate of successful vaginal birth including operative vaginal delivery in patients with a previous cesarean for cephalopelvic disproportion in the second stage of labor. METHODS: Data from all patients who underwent trial of labor after a previous cesarean between 1990 and 2000 at our tertiary care institution were analyzed. Medical records were reviewed and data collected for the following variables: indication for the previous cesarean, birth weight and cervical dilatation at previous cesarean delivery, as well as the mode of delivery (spontaneous, vacuum, forceps, cesarean) and the birth weight for the subsequent pregnancy. Pearson's chi(2) test and one-way analysis of variance were used for statistical analyses. RESULTS: There were 2002 patients included in the study. Two hundred fourteen (11%) had their previous cesarean for dystocia in the second stage of labor, 654 (33%) for dystocia in the first stage of labor, and 1134 (57%) for other indications. The vaginal birth after cesarean success rate was 75.2% (P = .015 vs other indications), 65.6% (P < .001 vs other indications), and 82.5%, respectively. The rate of operative vaginal delivery was 15%, 12%, and 10% (P = .109). CONCLUSION: A trial of labor is reasonable in women whose previous cesarean was for dystocia in the second stage of labor. In this series, patients who underwent a trial of labor after a previous cesarean for dystocia in the second stage had 75.2% (95% confidence interval 69.5, 81.0) chance of achieving vaginal delivery.     

Isolated oligohydramnios in term pregnancy as an indication for induction of labor.

OBJECTIVE: To evaluate the outcome of active induction of labor for isolated oligohydramnios in low-risk term gestation. METHODS: This retrospective study analyzed the obstetric and perinatal outcome of 412 singleton term pregnancies with cephalic presentation and no maternal risk factors or fetal abnormalities. Two groups were compared: 206 deliveries after induced labor for isolated oligohydramnios, and 206 deliveries matched for gestational age following spontaneous labor with normal amniotic fluid index. RESULTS: The overall rate of cesarean deliveries and cesarean deliveries for nonreassuring fetal status, and operative vaginal delivery rates and those for nonreassuring fetal status were higher in the oligohydramnios group than in the control group. There were no differences between groups in neonatal outcome or perinatal morbidity or mortality. CONCLUSION: Active induction of labor in term low risk gestations with isolated oligohydramnios translated into higher labor induction, operative vaginal delivery and cesarean section rates. This led to increased maternal risk and an increase in costs with no differences in neonatal outcome.     

Risk factors for cesarean section and instrumental vaginal delivery after successful external cephalic version

Aim of this article is to examine if we could identify factors that predict cesarean section and instrumental vaginal delivery in women who had a successful external cephalic version. We used data from a previous randomized trial among 25 hospitals and their referring midwife practices in the Netherlands. With the data of this trial, we performed a cohort study among women attempting vaginal delivery after successful ECV. We evaluated whether maternal age, gestational age, parity, time interval between ECV and delivery, birth weight, neonatal gender, and induction of labor were predictive for a vaginal delivery on one hand or a CS or instrumental vaginal delivery on the other hand. Unadjusted and adjusted odds ratios were calculated with univariate and multivariate logistic regression analysis. Among 301 women who attempted vaginal delivery after a successful external cephalic version attempt, the cesarean section rate was 13% and the instrumental vaginal delivery rate 6%, resulting in a combined instrumental delivery rate of 19%. Nulliparity increased the risk of cesarean section (OR 2.7 (95% CI 1.2–6.1)) and instrumental delivery (OR 4.2 (95% CI 2.1–8.6)). Maternal age, gestational age at delivery, time interval between external cephalic version and delivery, birth weight and neonatal gender did not contribute to the prediction of failed spontaneous vaginal delivery. In our cohort of 301 women with a successful external cephalic version, nulliparity was the only one of seven factors that predicted the risk for cesarean section and instrumental vaginal delivery.     

Maternal and neonatal outcomes in patients with a prolonged second stage of labor

OBJECTIVE: To determine risk factors for a prolonged second stage of labor and evaluate the maternal and neonatal outcomes of such pregnancies. METHODS: We reviewed all 7818 patients who delivered at the University of Illinois at Chicago from 1996 to 1999. Excluding nonvertex and multiple gestations, 6791 reached the second stage. Group 1 (n = 6259) consisted of patients with a second stage of 120 minutes or less; group 2, greater than 120 minutes (n = 532 [7.8%]); group 2A, 121-240 minutes (n = 384 [5.7%]); and group 2B, greater than 240 minutes (n = 148 [2.2%]). We compared pregnancy outcomes for these groups with respect to maternal and neonatal morbidity factors using chi(2), Student t, and Wilcoxon rank-sum tests (significance, P <.05). RESULTS: Vaginal delivery rates were 98.7% (group 1), 84.0% (group 2), 90.2% (group 2A), and 65.5% (group 2B). Group 2 had higher rates of perineal trauma, episiotomy usage, chorioamnionitis, postpartum hemorrhage, and operative vaginal delivery than group 1 (P <.001, all comparisons). Group 2B had higher rates of episiotomy usage, operative vaginal deliveries, and perineal trauma than group 2A (P <.001, all comparisons). The neonatal morbidity rates were similar for the three groups. Diabetes, preeclampsia (P <.023), macrosomia, nulliparity, chorioamnionitis, oxytocin usage, and labor induction were each independently associated with an increased risk of a prolonged second stage (all but preeclampsia, P <.001). CONCLUSION: A prolonged second stage is associated with a high rate of vaginal delivery, but a high rate of maternal, though not neonatal, morbidity was observed. Certain antenatal and intrapartum conditions are associated with a prolonged second stage of labor.     

What to do after a failed attempt of vacuum delivery?

OBJECTIVES: To determine whether there is a difference in maternal and neonatal outcomes if a sequential operative vaginal or cesarean delivery follows failed vacuum delivery. STUDY DESIGN: A cross sectional study. We have analyzed maternal and neonatal outcomes of 215 vacuum extractions (group 1), 106 forceps assisted deliveries (group 2), 28 deliveries in which failed vacuum extraction were followed by forceps delivery (group 3) and 22 deliveries in which failed vacuum extraction were followed by cesarean delivery (group 4). RESULTS: Compared to other groups, patients in group 4 had significantly more post partum anemia, meconium stained amniotic fluid and hospital stay (both maternal and neonatal) as well as lower pH. Apgar scores were similar in groups 3 and 4. Incidence of respiratory distress syndrome, cephalhematoma and jaundice were similar in neonates of all groups. CONCLUSIONS: If an attempted vacuum delivery has failed, the risk of adverse neonatal outcome is increased with either subsequent forceps or cesarean delivery. It should remain in the judgment of the attending obstetrician to choose the method most suitable under the given circumstances.     

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.     

Shoulder dystocia and the next delivery: outcomes and management.

OBJECTIVE: To evaluate delivery mode management decisions and the rate of shoulder dystocia recurrence for women with a prior delivery complicated by shoulder dystocia. STUDY DESIGN: We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by shoulder dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of shoulder dystocia was calculated and the characteristics of these cases further described. RESULTS: Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 shoulder dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial shoulder dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subsequent delivery rate of 23% at our institution, significantly less than the overall population (42%, p < 0.001)). Complete data were available for 47 deliveries. Four women had elective CS without labor (one due to prior shoulder dystocia), 43 (91.5%) had a TOL, and 42 (88%) achieved vaginal delivery. Recurrent shoulder dystocia complicated 9.5% (4/42) of deliveries; one case included neonatal brachial plexus injury that resolved prior to hospital discharge. Of the four recurrent shoulder dystocia cases, none were complicated by maternal diabetes, macrosomia, prolonged second stage of labor, or underwent an operative vaginal delivery. No statistically significant univariate differences were seen between the recurrence group and the no-shoulder dystocia vaginal delivery group; however birth weight and nulliparity at initial shoulder dystocia pregnancy jointly demonstrated a relationship of recurrence (p = 0.048). CONCLUSION: In TOL cases that result in a vaginal delivery, the rate of recurrence of shoulder dystocia is high--approximately 10 times higher than the rate for the general population. Often the only identifiable risk factor is the prior history itself, which may influence delivery management in subsequent pregnancies. Birth weight and nulliparity at initial shoulder dystocia pregnancy may influence clinical decision-making in cases of prior shoulder dystocia.     

Neonatal acidemia with trial of labor among parturients with prior cesarean delivery: a case-control study

OBJECTIVE: To determine the risk factors for neonatal acidemia with trial of labor among parturients with a prior cesarean delivery. METHODS: From a prospectively collected database on all parturients attempting a trial of labor, newborns with umbilical arterial pH < 7.15 were selected as cases and the controls (1:4) were the next four patients who delivered nonacidotic (pH > or = 7.15) neonates. Exclusion criteria were no prior cesarean delivery, anomalous fetus, and nonavailability of umbilical arterial blood gas analysis. Student's t-test, chi2, and Fisher's exact tests were utilized and odds ratio (OR) and 95% confidence intervals (CI) were calculated. P < 0.05 was considered significant. RESULTS: The frequency of neonatal acidemia among patients undergoing trial of labor was 12% (28/234). The cases and controls (n = 112) were similar (P > 0.05) with regards to maternal age, frequency of more than one prior cesarean delivery (11% vs. 8%), gestational age, cervical exam on admission (3.0 +/- 1.5 vs. 3.4 +/- 1.7 cm), usage of oxytocin, and duration of first or second stage of labor. The mean birthweight was significantly higher among acidotic (3,758 +/- 670 g) than nonacidotic (3,470 +/- 545 g; P = 0.018) newborns. Compared to the controls, the cases had a significantly higher frequency of unsuccessful trial of labor (19% vs. 50%; OR: 4.09; 95% CI: 1.70, 9.82) and separation of the uterine scar (0.8% vs. 14%; OR: 18.50; 95% CI: 1.98, 173.05). CONCLUSIONS: Acidotic newborns with trial of labor tend to be heavier. Parturients have a failed attempt at vaginal birth after cesarean, and have separation of the uterine scar during labor.     

Prolonged Second Stage of Labor and Risk of Adverse Maternal and Perinatal Outcomes: A Systematic Review

ABSTRACT: Background: Safe and effective management of the second stage of labor presents a clinical challenge for laboring women and practitioners of obstetric care. This systematic review was conducted to evaluate evidence for the influence of prolonged second stage of labor on the risk of selected adverse maternal and neonatal outcomes. Methods: Articles were searched using PubMed, Cochrane Library, and CINAHL from 1980 until 2005. Studies were included according to 3 criteria: if they reported duration of the second stage of labor, if they reported maternal and/or neonatal outcomes in relation to prolonged second stage, and if they reported original research. Results: Our systematic review found evidence of a strong association between prolonged second stage and operative delivery. Although significant associations with maternal outcomes such as postpartum hemorrhage, infection, and severe obstetric lacerations were reported, inherent limitations in methodology were evident in the studies. Recurrent limitations included oversimplified categorization of second stage, inconsistency in study population characteristics, and lack of control of confounding factors. No associations between prolonged second stage and adverse neonatal outcomes were reported. Conclusions: The primary findings of our review indicated that most of the studies are flawed and do not answer the important questions for maternity caregivers to safely manage prolonged second stage. Meanwhile, approaches for promoting a normal second stage of labor are available to caregivers, such as maternal positioning and pain relief measures and also promoting effective pushing technique. (BIRTH 33:4 December 2006)     

The relationship between maternal age and uterine dysfunction: a continuous effect throughout reproductive life

OBJECTIVE: In a selected low-risk population with spontaneous term labor we sought to determine whether there was a continuous effect of maternal age on uterine function. STUDY DESIGN: With our comprehensive computerized database and medical record system, we identified 8496 patients who were nulliparous and in spontaneous labor at term (> or =37 weeks' gestation) with singleton fetuses in vertex presentation. This group was then analyzed according to maternal age for measures of labor dysfunction and rates of operative delivery. Analysis of variance and chi(2) statistics were used. RESULTS: Use of oxytocin, duration of second stage of labor, cesarean delivery, cesarean delivery for failure to progress, and operative vaginal delivery rates were significantly increased with advancing maternal age (P <.0001). These increases appeared to be continuous functions beginning during the early 20s rather than new phenomena beginning after age 35 years. CONCLUSION: Among nulliparous patients with uncomplicated labor there is a continuously increasing risk of uterine dysfunction related to maternal age.     

Route of breech delivery and maternal and neonatal outcomes.

OBJECTIVE: To compare maternal and neonatal outcomes in elective cesarean vs. attempted vaginal delivery for breech presentation at or near term. METHODS: We reviewed the maternal and neonatal charts of all singleton breech deliveries of at least 35 weeks' gestation or 2000 g delivered between 1986 and 1997 at our institution. Patients delivered by elective cesarean were compared to those attempting a vaginal delivery. The neonatal outcomes analyzed were: corrected mortality; Apgar scores less than 7 at 5 min; abnormal umbilical cord blood gases; birth trauma; and admissions to the intensive care nursery. Maternal morbidity was also assessed and compared. RESULTS: Of 848 women meeting criteria for evaluation, 576 were delivered by elective cesarean while 272 attempted a vaginal delivery. Of 272 women undergoing a trial of labor, 203 (74.6%) were delivered vaginally, while 69 (25.4%) failed an attempt at vaginal delivery and underwent a cesarean. When comparing patients delivered by elective cesarean with those attempting a vaginal delivery, no significant differences were noted in neonatal outcomes. However, maternal morbidity was higher among women delivered by cesarean, regardless of the indications for the procedure. Similar neonatal and maternal results were noted when nulliparous patients were analyzed separately. CONCLUSIONS: Cesarean delivery of selected near-term infants presenting as breech is associated with increased maternal morbidity without corresponding improvement in neonatal outcomes.     

Isolated oligohydramnios in term pregnancy as an indication for induction of labor

Objective. To evaluate the outcome of active induction of labor for isolated oligohydramnios in low-risk term gestation.

Methods. This retrospective study analyzed the obstetric and perinatal outcome of 412 singleton term pregnancies with cephalic presentation and no maternal risk factors or fetal abnormalities. Two groups were compared: 206 deliveries after induced labor for isolated oligohydramnios, and 206 deliveries matched for gestational age following spontaneous labor with normal amniotic fluid index.

Results. The overall rate of cesarean deliveries and cesarean deliveries for nonreassuring fetal status, and operative vaginal delivery rates and those for nonreassuring fetal status were higher in the oligohydramnios group than in the control group. There were no differences between groups in neonatal outcome or perinatal morbidity or mortality.

Conclusion. Active induction of labor in term low risk gestations with isolated oligohydramnios translated into higher labor induction, operative vaginal delivery and cesarean section rates. This led to increased maternal risk and an increase in costs with no differences in neonatal outcome.