Neonatal morbidity associated with shoulder dystocia maneuvers.

OBJECTIVE: We sought to examine neonatal morbidity associated with different maneuvers used among term patients who experience a shoulder dystocia. STUDY DESIGN: We conducted a retrospective cohort study of all women who experienced a clinically diagnosed shoulder dystocia at term requiring obstetric maneuvers at a single tertiary care hospital from 2005 through 2008. We excluded women with major fetal anomaly, intrauterine death, multiple gestation, and preterm. Women exposed to Rubin maneuver, Wood's screw maneuver, or delivery of the posterior arm were compared to women delivered by McRoberts/suprapubic pressure only, which served as the reference group. The primary outcome was a composite morbidity of neonatal injury (defined as clavicular or humeral fracture or brachial plexus injury) and neonatal depression (defined as Apgar <7 at 5 minutes, arterial cord pH <7.1, continuous positive airway pressure use, intubation, or respiratory distress). Logistic regression was used to adjust for nulliparity and duration of shoulder dystocia, defined as time from delivery of fetal head to delivery of shoulders. RESULTS: Among the 231 women who met inclusion criteria, 135 were delivered by McRoberts/suprapubic pressure alone (57.9%), 83 women were exposed to Rubin maneuver, 53 women were exposed to Wood's screw, and 36 women were exposed to delivery of posterior arm. Individual maneuvers were not associated with composite morbidity, neonatal injury, or neonatal depression after adjusting for nulliparity and duration of shoulder dystocia. CONCLUSION: We found no association between shoulder dystocia maneuvers and neonatal morbidity after adjusting for duration, a surrogate for severity. Our results demonstrate that clinicians should utilize the maneuver most likely to result in successful delivery.

Risk factors for serious morbidity in term nonanomalous neonates.

OBJECTIVE: The purpose of this study was to identify ante- and intrapartum risk factors for serious morbidity in term nonanomalous neonates. STUDY DESIGN: We analyzed the first 5000 subjects within an ongoing prospective cohort study of consecutive term births from 2010-2012. The primary outcome was a composite of serious neonatal morbidity defined as ≥1 cases of hypoxic ischemic encephalopathy, meconium aspiration with pulmonary hypertension, requirement of hypothermia therapy, respiratory distress syndrome, seizures, sepsis or suspected sepsis, or death. We calculated odds ratios for the composite morbidity that is associated with ante- and intrapartum factors. Multivariable logistic regression was used to estimate adjusted odds ratios. RESULTS: Of 5000 term nonanomalous births, 393 had the composite morbidity. Significant risk factors for morbidity were nulliparity, presence of meconium, first stage of labor >95th percentile, second stage of labor >95th percentile, pregestational diabetes mellitus, chronic hypertension, obesity, maternal intrapartum fever, and cesarean delivery. In contrast, induction of labor and gestational age ≥41 weeks were not associated with significant morbidity. CONCLUSION: We identified several significant risk factors for serious morbidity in term nonanomalous neonates. Clinicians may use these risk factors to help anticipate the potential need for additional neonatal support at delivery.

Time from uterine incision to delivery and hypoxic neonatal outcomes.

OBJECTIVE: The objective of this study was to estimate the association between time from uterine incision to delivery and hypoxic neonatal outcomes in nonanomalous term infants. METHODS: All women undergoing in-labor term cesarean deliveries (CDs) in the first 2 years of an ongoing prospective cohort study were included. The primary exposure was time in seconds from uterine incision to delivery. The primary outcome was a composite of hypoxia-associated neonatal outcomes, defined as at least one of: seizures, hypoxic ischemic encephalopathy, need for hypothermia treatment, and death within 7 days. RESULTS: Of 812 patients who underwent in-labor CD, the composite hypoxia outcome occurred in 18 (2.2%) neonates. There was no significant difference in the rate of hypoxic morbidity with increasing increments of 60 seconds from uterine incision to delivery (p = 0.35). There was a significantly increased risk of hypoxic morbidity in those delivered in the highest quintile (>240 seconds) compared with those in the lowest quintile (≤ 60 seconds) in cesareans performed for an indication other than nonreassuring fetal status (relative risk, 5.58; 95% confidence interval, 1.30-23.91). CONCLUSION: Overall, duration from uterine incision to delivery for in-labor cesareans of nonanomalous term infants was not associated with an increase in risk of hypoxia-associated morbidities.

Normal first stage of preterm labor.

OBJECTIVE: To compare first-stage labor patterns in women in preterm labor to those in labor at term. STUDY DESIGN: We performed a retrospective cohort study of consecutive women admitted from 2004 to 2008 with viable (≥ 24 weeks) vertex singleton gestations who reached the second stage of labor. Labor curves for preterm and term labor were created using a repeated-measures analysis with polynomial modeling. Interval-censored regression was used to estimate and compare median time of progression of labor. Multivariable analyses were performed to adjust for smoking, obesity (body mass index ≥ 30), induction, and nulliparity. The adjusted model was stratified by parity and induction of labor. RESULTS: Of 5,612 consecutive births, 224 were preterm (<37 weeks) and 5,388 were term (≥ 37 weeks). Preterm first-stage labor progressed significantly faster than term labor (median time 4 to 10 cm: 3.3 hours versus 4.5 hours, p < 0.01). When stratified by parity, preterm labor progressed significantly more rapidly than term labor in both nulliparous and multiparous women (median time 4 to 10 cm: 3.7 hours versus 4.9 hours [p = 0.04] in nulliparous women and 2.5 hours versus 4.3 hours [p = 0.01] in multiparous women). CONCLUSION: Women in preterm labor progress more rapidly through the first stage of labor than women at term.

The Contraceptive CHOICE Project: recruiting women at highest risk for unintended pregnancy and sexually transmitted infection.

BACKGROUND: Unintended pregnancy disproportionately affects younger, minority, and low-income women. The purpose of this analysis is to describe our recruitment strategies and to determine if targeted efforts to reach women at greatest risk for unintended pregnancy and sexually transmitted infection (STI) were successful. METHODS: The Contraceptive CHOICE Project is a prospective cohort study providing reversible contraception at no cost to 10,000 women aged 14-45 years in the St. Louis area in order to evaluate method satisfaction and continuation and to reduce unintended pregnancies in the region. We describe four strategies for effective outreach and recruitment of high-risk women, including forming strong community partnerships. We analyze the evolution of baseline demographic and behavioral characteristics over the three waves of enrollment of the first 2,500 participants in order to assess whether our outreach efforts were successful. RESULTS: Overall, >60% of participants were aged ≤25 years. There was a significant increase in the percentage of minority participants enrolled throughout the first 2,500 subjects (p < 0.001). The number of women who reported trouble paying for basic necessities significantly increased over the three waves (p = 0.025). Throughout the three waves of enrollment, there was a significant increase in the number of women who tested positive for an STI at baseline (p < 0.001). CONCLUSIONS: A multiple method approach with collaboration of key community partners led to successful recruitment of hard to reach populations at high risk for unintended pregnancy and STI.