Fetal bradycardia in open versus fetoscopic prenatal repair of spina bifida.

OBJECTIVE: To compare the occurrence of fetal bradycardia in open versus fetoscopic fetal spina bifida surgery. METHODS: This is a single-institution retrospective cohort study of patients undergoing open (n = 25) or fetoscopic (n = 26) spina bifida repair between 2017 and 2022. From October 2017 to June 2020, spina bifida repairs were performed via an open classical hysterotomy, and from November 2020 to June 2022 fetoscopic repairs were performed following transition to this technique. Fetal heart rate (FHR) in beats per minute (bpm) was recorded via echocardiography every 15 min during the procedure. Cohort characteristics, fetal bradycardia and maternal physiologic parameters were compared between the groups. RESULTS: Fetuses undergoing an open repair more frequently developed bradycardia defined as <110 bpm (32% vs. 3.8%, p = 0.008), and a trend was observed for FHR decreases more than 25 bpm from baseline (20% vs. 3.8%, p = 0.073). Profound bradycardia less than 80 bpm was rare, occurring in only three operations (two in open, one in fetoscopic repair) with two fetuses (one in each group) requiring emergency cesarean delivery. CONCLUSION: When compared to open fetal surgery, fetal bradycardia occurred less frequently in fetoscopic surgery despite a significantly greater anesthetic exposure and the use of the intraamniotic carbon dioxide insufflation.

Society for Maternal-Fetal Medicine Special Statement: Checklist for pregnancies resulting from in vitro fertilization.

The management of pregnancies resulting from in vitro fertilization includes several recommended interventions at various times by various providers. To minimize the chance of errors of omission, the Society for Maternal-Fetal Medicine presents a patient-oriented checklist summarizing the recommended management of such pregnancies.

Bridging the postpartum gap: best practices for training of obstetrical patient navigators.

The postpartum period represents a critical window of opportunity to improve maternal short- and long-term health, including optimizing postpartum recovery, providing effective contraception, caring for mood disorders, managing weight, supporting lactation, initiating preventive care, and promoting cardiometabolic health. However, inadequate postpartum care, especially for individuals facing social and structural barriers, is common in the United States and contributes to suboptimal health outcomes with lasting consequences. Patient navigation is a patient-centered intervention that uses trained personnel to identify financial, cultural, logistical, and educational obstacles to effective healthcare and to mitigate these barriers to facilitate comprehensive and timely access to needed health services. Given the emerging evidence suggesting that patient navigation may be a promising method to improve health among postpartum individuals, our team developed a postpartum patient navigator training guide to be used in the Navigating New Motherhood 2 and other obstetrical navigation programs. Navigating New Motherhood 2 is a randomized trial exploring whether patient navigation by a trained, lay postpartum navigator for individuals with a low income can improve health and patient-reported outcomes during and after the postpartum period. Hiring and training patient navigators without health professional degrees are integral components of initiating a navigation program. However, patient navigator training is highly variable, and no guideline regarding key elements in such a training program exists for obstetrics specifically. Thus, this paper aimed to describe the core principles, content, and rationale for each element in a comprehensive postpartum patient navigator training program. Training should be centered around the following 6 core elements: (1) principles of patient navigation; (2) knowledge of pregnancy and postpartum care; (3) health education and health promotion principles; (4) cultural sensitivity and health equity; (5) care coordination and community resources; and (6) electronic medical record systems. These core elements can serve as a basis for the development of adaptable curricula for several institutions and contexts. In addition, we offer recommendations for the implementation of a navigator training program. A curriculum with built-in flexibility to meet community and institutional needs may promote the effective and sustainable use of patient navigation in the postpartum context.

Pre-pregnancy Health Behaviors and Gestational Weight Gain Among Hispanic/Latino Women: Hispanic Community Health Study/Study of Latinos.

OBJECTIVE: To examine the association between preconception diet quality, sedentary behavior, and physical activity with gestational weight gain (GWG) among Hispanic/Latina women. METHODS: This was a retrospective cohort study of participants from visits 1 and 2 of the Hispanic Community Health Study/Study of Latinos and singleton pregnancies between the 2 visits. Diet quality (alternative healthy eating index/AHEI-2010), sedentary behaviors, and physical activity (global physical activity questionnaire) were measured at visit 1 and accounted for preconception health behaviors. GWG was evaluated as a continuous and categorical variable according to the 2009 Institute of Medicine guidelines (inadequate, adequate, excessive). Linear and generalized logit survey regressions were used to study the association between health behaviors and GWG, using adequate GWG as the reference. RESULTS: Of the 457 women included, deliveries occurred at 3.2 years (mean) from visit 1; 48.7% of women had excessive GWG. Mean AHEI-2010 scores were < 45% for women of all Hispanic/Latina backgrounds. There was no association between each 10-unit increase in AHEI-2010 or a 500 kcal/day increase in energy intake for mean and categorical GWG. There was no association between 30 min/day higher sedentary behavior, 30 min/day higher physical activity, or meeting the 2008 US physical activity guidelines for mean and categorical GWG. CONCLUSIONS: We did not find any association between diet quality, sedentary behavior, and physical activity at visit 1 with GWG in pregnancies occurring between visits 1 and 2. We noted widespread poor diet quality as measured by the AHEI-2010 and low levels of physical activity among Hispanic/Latina women.

Gestational Weight Gain and Pregnancy Outcomes among Nulliparous Women.

OBJECTIVE: To determine the association between total gestational weight gain and perinatal outcomes. STUDY DESIGN: Data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be (NuMoM2b) study were used. Total gestational weight gain was categorized as inadequate, adequate, or excessive based on the 2009 Institute of Medicine guidelines. Outcomes examined included hypertensive disorders of pregnancy, mode of delivery, shoulder dystocia, large for gestational age or small for-gestational age birth weight, and neonatal intensive care unit admission. RESULTS: Among 8,628 women, 1,666 (19.3%) had inadequate, 2,945 (34.1%) had adequate, and 4,017 (46.6%) had excessive gestational weight gain. Excessive gestational weight gain was associated with higher odds of hypertensive disorders (adjusted odds ratio [aOR] = 2.05, 95% confidence interval [CI]: 1.78-2.36) Cesarean delivery (aOR = 1.24, 95% CI: 1.09-1.41), and large for gestational age birth weight (aOR = 1.49, 95% CI: 1.23-1.80), but lower odds of small for gestational age birth weight (aOR = 0.59, 95% CI: 0.50-0.71). Conversely, inadequate gestational weight gain was associated with lower odds of hypertensive disorders (aOR = 0.75, 95% CI: 0.62-0.92), Cesarean delivery (aOR = 0.77, 95% CI: 0.65-0.92), and a large for gestational age birth weight (aOR = 0.72, 95% CI: 0.55-0.94), but higher odds of having a small for gestational age birth weight (aOR = 1.64, 95% CI: 1.37-1.96). CONCLUSION: Both excessive and inadequate gestational weight gain are associated with adverse maternal and neonatal outcomes.

Outcomes of Elective Induction of Labor versus Expectant Management among Obese Women at ≥39 Weeks.

OBJECTIVE: Maternal obesity is associated with many adverse obstetric outcomes including cesarean delivery. It is unclear whether induction of labor can reduce these risks. Previous studies report conflicting results on the outcomes of elective induction of labor among obese women. This study aimed to compare maternal and neonatal outcomes between obese women undergoing elective induction of labor and those undergoing expectant management at ≥39 weeks. STUDY DESIGN: This was a retrospective cohort study from the Consortium on Safe Labor of obese women (defined by prepregnancy body mass index≥ 30kg/m2) with singleton gestations at ≥39 weeks without medical comorbidities from 2002 through 2008. Women scheduled for medically indicated induction of labor were excluded. The primary outcome of cesarean delivery was compared between obese women undergoing elective induction of labor and expectant management during 39th, 40th, and 41st weeks using univariable and multivariable analyses, stratifying by parity. RESULTS: In all, 7,298 nulliparous and 9,789 parous women were eligible for analysis. After controlling for potential confounders, elective induction of labor during 39th week in nulliparous and parous women was associated with lower odds of cesarean delivery (39.1 vs. 41.6%, adjusted odds ratio [OR]: 0.47, 95% confidence interval [CI]: 0.30-0.74 for nulliparous and 5.5 vs. 10.1%, adjusted OR: 0.34, 95% CI: 0.20-0.61 for parous women) compared with expectant management. Elective induction of labor during 40th and 41st weeks was not associated with lower odds of cesarean delivery. In addition, macrosomia was reduced in nulliparous women undergoing elective induction of labor during the 40th week (12.1 vs. 18.5%, adjusted OR: 0.56, 95% CI: 0.35-0.87) and in parous women undergoing elective induction of labor during 39th (11.6 vs. 17.6%, adjusted OR: 0.50, 95% CI: 0.38-0.66) and 40th weeks (16.4 vs. 22.2%, adjusted OR: 0.53, 95% CI: 0.36-0.78). CONCLUSION: Elective induction of labor at 39 weeks, when compared with expectant management, was associated with lower cesarean deliveries in obese nulliparous and parous women.

Gestational weight gain and group prenatal care: a systematic review and meta-analysis.

BACKGROUND: Group visits for chronic medical conditions in non-pregnant populations have demonstrated successful outcomes including greater weight loss compared to individual visits for weight management. It is plausible that group prenatal care can similarly assist women in meeting gestational weight gain goals. The purpose of this study was to evaluate the effect of group vs. traditional prenatal care on gestational weight gain. METHODS: A keyword search of Medline, Embase, Scopus, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, clinicaltrials.gov, and Google Scholar was performed up to April 2017. Studies were included if they compared gestational weight gain in a group prenatal care setting to traditional prenatal care in either randomized controlled trials, cohort, or case-control studies. The primary and secondary outcomes were excessive and adequate gestational weight gain according to the Institute of Medicine guidelines. Heterogeneity was assessed with the Q test and I2 statistic. Pooled relative risks (RRs) and confidence intervals (CI) were reported with random-effects models from the randomized controlled trials (RCT) and cohort studies. RESULTS: One RCT, one secondary analysis of an RCT, one study with "random assignment", and twelve cohort studies met the inclusion criteria for a total of 13,779 subjects. Thirteen studies used the CenteringPregnancy model, defined by 10 sessions that emphasize goal setting and self-monitoring. Studies targeted specific populations such as adolescents, African-Americans, Hispanics, active-duty military or their spouses, and women with obesity or gestational diabetes. There were no significant differences in excessive [7 studies: pooled rates 47% (1806/3582) vs. 43% (3839/8521), RR 1.09, 95% CI 0.97-1.23] or adequate gestational weight gain [6 studies: pooled rates 31% (798/2875) vs. 30% (1410/5187), RR 0.92, 95% CI 0.79-1.08] in group and traditional prenatal care among the nine studies that reported categorical gestational weight gain outcomes in the meta-analysis. CONCLUSIONS: Group prenatal care was not associated with excessive or adequate gestational weight gain in the meta-analysis. Since outcomes were overall inconsistent, we propose that prenatal care models (e.g., group vs. traditional) should be evaluated in a more rigorous fashion with respect to gestational weight gain.

A feasibility study of activity tracking devices in pregnancy.

BACKGROUND: We aimed to evaluate the feasibility of using an activity-tracking device (ATD) during pregnancy and compare self-reported to ATD-calculated energy expenditure in a 2-phase study. METHODS: (Phase 1) Twenty-five pregnant women were asked about exercise, computer use, smartphone ownership, and ATD attitudes. Descriptive statistics were reported. (Phase 2) Women ≥18 years, smartphone owners, < 16-weeks gestation, and without exercise restrictions were approached to participate in 2016-2017. Women received instructions to wear and sync the ATD daily. We assessed protocol adherence and satisfaction via surveys at 36-weeks and used mixed models to assess the relationship between gestational age and ATD data. Energy expenditure from the Pregnancy Physical Activity Questionnaire (PPAQ) was compared to ATD-calculated energy expenditure. RESULTS: (Phase 1) Walking was the most common exercise; 8% did not perform any activity during pregnancy. All women had internet access and owned a smartphone. Women stated they would wear the ATD all the time during a pregnancy (88%), with the intent to improve their health (80%). (Phase 2) The characteristics of the 48 women were: pre-pregnancy BMI 28, 62% non-Hispanic black, 62% multiparas. Of the 18 women who completed the 36-week survey, only 56% wore the ATD daily, 33% had a lost or broken ATD, and 17% had technical problems; however, 94% enjoyed wearing it, 94% would recommend it to a pregnant friend, and 78% thought it helped them reach activity goals. According to ATD data, the median number of active days was 41 (IQR 20-73) and the median proportion of active days out of potential days was 22% (IQR 11-40). As gestational age increased, mean log steps decreased, active minutes decreased, and sedentary hours increased in unadjusted and adjusted models (P < 0.05 all comparisons). There were no differences in mean energy expenditure (MET-h/week) estimated by PPAQ or ATD data at 28 weeks gestation [212 (22-992 range) vs. 234 (200-281 range), P = 0.66] and at 36 weeks [233 (86-907 range) vs. 218 (151-273 range), P = 0.68]). CONCLUSIONS: Women reported high motivation to wear an ATD and high satisfaction with actually using an ATD during pregnancy; however adherence to the study protocol was lower than expected and ATD technical problems were frequent.

Sexual Orientation Disparities in Pregnancy and Infant Outcomes.

Objectives Little is known about maternal and infant health among sexual minority women (SMW), despite the large body of research documenting their multiple preconception risk factors. This study used data from the 2006-2015 National Survey of Family Growth (NSFG) to investigate sexual orientation inequities in pregnancy and birth outcomes, including miscarriage, stillbirth, preterm birth, and birth weight. Methods Women reported 19,955 study eligible pregnancies and 15,996 singleton live births. Sexual orientation was measured using self-reported identity and histories of same-sex sexual experiences (heterosexual-WSM [women who only report sex with men]; heterosexual-WSW [women who report sex with women]; bisexual, and lesbian). Logistic regression models were used that adjusted for several maternal characteristics. Results Compared to heterosexual-WSM, heterosexual-WSW (OR 1.25, 95% CI 1.00-1.58) and bisexual and lesbian women (OR 1.77, 95% CI 1.34-2.35) were more likely to report miscarriage, and bisexual and lesbian women were more likely to report a pregnancy ending in stillbirth (OR 2.85, 95% CI 1.40-5.83). Lesbian women were more likely to report low birth weight infants (OR 2.64, 95% CI 1.38-5.07) and bisexual and lesbian women were more likely to report very preterm births (OR 1.84, 95% CI 1.11-3.04) compared to heterosexual-WSM. Conclusions for Practice This study documents significant sexual orientation inequities in pregnancy and birth outcomes. More research is needed to understand the mechanisms that underlie disparate outcomes and to develop interventions to improve sexual minority women's maternal and infant health.

Pregnancy After Bariatric Surgery.

This JAMA Insights Clinical Update discusses general adaptations for pregnancy after bariatric surgery, including recommendations regarding nutrition, maternal health, and fetal and neonatal risks.

Gestational weight gain.

Prenatal care providers are advised to evaluate maternal weight at each regularly scheduled prenatal visit, monitor progress toward meeting weight gain goals, and provide individualized counseling if significant deviations from a woman's goals occur. Today, nearly 50% of women exceed their weight gain goals with overweight and obese women having the highest prevalence of excessive weight gain. Risks of inadequate weight gain include low birthweight and failure to initiate breast-feeding whereas the risks of excessive weight gain include cesarean deliveries and postpartum weight retention for the mother and large-for-gestational-age infants, macrosomia, and childhood overweight or obesity for the offspring. Prenatal care providers have many resources and tools to incorporate weight and other health behavior counseling into routine prenatal practices. Because many women are motivated to improve health behaviors, pregnancy is often considered the optimal time to intervene for issues related to eating habits and physical activity to prevent excessive weight gain. Gestational weight gain is a potentially modifiable risk factor for a number of adverse maternal and neonatal outcomes and meta-analyses of randomized controlled trials report that diet or exercise interventions during pregnancy can help reduce excessive weight gain. However, health behavior interventions for gestational weight gain have not significantly improved other maternal and neonatal outcomes and have limited effectiveness in overweight and obese women.

Association among Maternal Obesity, Cervical Length, and Preterm Birth.

Objective The objective of this study was to determine if mid-trimester cervical length is associated with the inverse relationship between maternal body mass index (BMI) at delivery and spontaneous preterm birth (SPTB). Materials and Methods This was a retrospective cohort of women with a singleton pregnancy without prior SPTB who underwent routine transvaginal cervical length assessment between 18 and 24 weeks. Women were categorized into four BMI groups: (1) 18.5 to 24.9, (2) 25 to 29.9, (3) 30 to 34.9, and (4) ≥ 35 kg/m2. Univariable and multivariable analyses were conducted to determine whether BMI group was associated with SPTB at < 37, 34, or 32 weeks independent of the cervical length. Results Of the 18,100 women in this analysis, 43.5% had a BMI ≥ 30. In univariable analysis, increasing BMI group was associated with longer cervical length but not with cervical length < 10th percentile. SPTB at < 37, 35, and 32 weeks was less common among women with higher BMI. In multivariable regression, a higher BMI group was associated with a lower frequency of SPTB at 37 weeks (adjusted odds ratios [aORs] of 0.64, 0.68, and 0.51), at 34 weeks (aORs of 0.53, 0.54, and 0.31) and at 32 weeks (aORs of 0.47, 0.60, and 0.27) for BMI groups 2 to 4, respectively. This association persisted even when cervical length was entered into the model as a covariate. Conclusion Women with a higher BMI group had longer mid-trimester cervical length, and correspondingly reduced SPTB. However, the decreased risk of SPTB was not associated with cervical length. The reason for the potential protective effect from prematurity is unknown and its mechanisms require further investigation.

Induction of Labor in Women with Oligohydramnios: Misoprostol Compared with Prostaglandin E2.

Objective To compare perinatal outcomes in women with oligohydramnios and an unfavorable cervix undergoing labor induction with misoprostol to prostaglandin E2. Study Design We conducted a secondary analysis of women with oligohydramnios undergoing labor induction in the Consortium on Safe Labor study (2002-2008). Oligohydramnios was recorded in the medical chart. We evaluated perinatal outcomes. We limited the analysis to women with an unfavorable cervix defined by simplified Bishop score ≤ 4. Misoprostol was compared with prostaglandin E2. Women could have received oxytocin, underwent mechanical dilation, or had artificial rupture of membranes, but women who underwent induction with both misoprostol and prostaglandin E2 were excluded. We calculated adjusted odds ratios with 95% confidence intervals, controlling for maternal age, maternal body mass index (kg/m2), parity, and mechanical dilation. Results Among women with oligohydramnios and an unfavorable cervix who underwent induction of labor, 141 (39.4%) received misoprostol and 217 (60.6%) received prostaglandin E2. There were no significant differences in cesarean delivery, chorioamnionitis, postpartum hemorrhage, transfusion, neonatal intensive care unit (NICU) admission, NICU stay > 72 hours, mechanical ventilation, and neonatal sepsis. Conclusion In women with oligohydramnios and an unfavorable cervix, induction of labor with misoprostol was comparable to prostaglandin E2.

Preventing Maternal Morbidity from Obstetric Hemorrhage: Implications of a Provider Training Initiative.

Objective The objective of this study was to compare severe morbidity due to obstetrical hemorrhage and its potential preventability before and after a mandated provider training initiative on obstetric hemorrhage. Study Design Cases of severe morbidity due to obstetric hemorrhage during 2006 (n = 64 before training initiative) and 2010 (n = 71 after training initiative) were identified by a two-factor scoring system of intensive care unit admission and/or transfusion of ≥ 3 units of blood products and reviewed by an expert panel. Preventable factors were categorized as provider, system, and/or patient related. Results Potential preventability did not differ between 2006 and 2010, p = 0.19. Provider factors remained the most common preventable factor (88.2% in 2006 vs. 97.4% in 2010, p = 0.18), but the distribution in types of preventable factors improved over time for delay or failure in assessment (20.6 vs. 0%, p < 0.01) and delay or inappropriate treatment (76.5 vs. 39.5%, p < 0.01). System factors also differed (32.4 vs. 7.9%, p = 0.015) with a notable decline in factors related to policies and procedures (26.5 vs. 2.6%, p < 0.01) between 2006 and 2010. Conclusion We found significant improvement in provider assessment and treatment of obstetric hemorrhage and a significant reduction in preventable factors related to policies and procedures after the training initiative.

Adipokinins in pregnancies at risk of preterm delivery.

OBJECTIVE: To compare adipokinins between women experiencing preterm labor (PTL) and prior preterm deliveries (PTD). STUDY DESIGN: In this prospective observational cohort, 110 women with a singleton <35 weeks at increased risk of PTD were studied. Serum leptin, adiponectin, and resistin were obtained at three times (23-34 weeks, 35-36 weeks, at delivery) and analyzed via enzyme-linked immunosorbent assay. The adipokinins were compared across time and between PTL (n = 59) and prior PTD (n = 51) groups using generalized estimated equation models. RESULTS: There were no differences in leptin, adiponectin, or resistin levels over the three times between the PTL and PTD groups. There was a trend toward higher leptin levels (p = 0.06 unadjusted analysis, p = 0.09 adjusted analysis) at 23-34 weeks. When stratified by body mass index (BMI), there were differences in leptin (p < 0.001 for BMI < 30; p = 0.77 for BMI ≥ 30) and adiponectin (p = 0.04 for BMI < 30; p = 0.09 for BMI ≥ 30), but not in resistin over the three times between the PTL and prior PTD groups. CONCLUSION: There were no significant differences in adipokinins in women with PTL and a prior PTD. The trends toward higher leptin levels at 23-34 weeks in women with PTL may represent a compensatory response and require further evaluation in the study of treatments for PTL.

Diabetes Screening in US Women With a History of Gestational Diabetes, National Health and Nutrition Examination Survey, 2007-2012.

INTRODUCTION: Women with a history of gestational diabetes mellitus (GDM) are at increased risk for developing type 2 diabetes mellitus. We examined individual, socioeconomic, and health care use characteristics of women with a history of GDM and the association of those characteristics with diabetes screening, and we estimated their rates of undiagnosed prediabetes and diabetes. METHODS: Using 3 cycles of the National Health and Nutrition Examination Survey (2007-2008, 2009-2010, and 2011-2012), we identified 284 women with a history of GDM who were eligible for diabetes screening. Screening status was defined by self-report of having had a blood test for diabetes within the prior 3 years. Undiagnosed prediabetes and diabetes were assessed by hemoglobin A1c measurement. RESULTS: Among women with a history of GDM, 67% reported diabetes screening within the prior 3 years. Weighted bivariate analyses showed screened women differed from unscreened women in measured body mass index (BMI) category (P = .01) and number of health visits in the prior year (P = .001). In multivariable analysis, screening was associated with a greater number of health visits in the prior year (1 visit vs 0 visits, adjusted odds ratio [AOR], 1.91; 95% confidence interval [CI], 0.71-5.18; 2 or 3 visits, AOR, 7.05; and ≥4 visits, AOR, 5.83). Overall, 24.4% (95% CI, 18.3%-31.7%) of women had undiagnosed prediabetes and 6.5% (95% CI, 3.7%-11.3%) had undiagnosed diabetes. CONCLUSION: More health visits in the prior year was associated with receiving diabetes screening. Fewer opportunities for screening may delay early detection, clinical management, and prevention of diabetes. Prediabetes in women with a history of GDM may be underrecognized and inadequately treated.

Obesity Before, During, and After Pregnancy: A Review and Comparison of Five National Guidelines.

OBJECTIVE: This study aims to compare how national guidelines approach the management of obesity in reproductive age women. STUDY DESIGN: We conducted a search for national guidelines in the English language on the topic of obesity surrounding the time of a pregnancy. We identified six primary source documents and several secondary source documents from five countries. Each document was then reviewed to identify: (1) statements acknowledging increased health risks related to obesity and reproductive outcomes, (2) recommendations for the management of obesity before, during, or after pregnancy. RESULTS: All guidelines cited an increased risk for miscarriage, birth defects, gestational diabetes, hypertension, fetal growth abnormalities, cesarean sections, difficulty with anesthesia, postpartum hemorrhage, and obesity in offspring. Counseling on the risks of obesity and weight loss before pregnancy were universal recommendations. There were substantial differences in the recommendations pertaining to gestational weight gain goals, nutrient and vitamin supplements, screening for gestational diabetes, and thromboprophylaxis among the guidelines. CONCLUSION: Stronger evidence from randomized trials is needed to devise consistent recommendations for obese reproductive age women. This research may also assist clinicians in overcoming one of the many obstacles they encounter when providing care to obese women.

Labor patterns in women attempting vaginal birth after cesarean with normal neonatal outcomes.

OBJECTIVE: We sought to describe labor patterns in women with a trial of labor after cesarean (TOLAC) with normal neonatal outcomes. STUDY DESIGN: In a retrospective observational study at 12 US centers (2002 through 2008), we examined time interval for each centimeter of cervical dilation and compared labor progression stratified by spontaneous or induced labor in 2892 multiparous women with TOLAC (second delivery) and 56,301 nulliparous women at 37 0/7 to 41 6/7 weeks of gestation. Analyses were performed including women with intrapartum cesarean delivery, and also limiting only to women who delivered vaginally. RESULTS: Labor was induced in 23.4% of TOLAC and 44.1% of nulliparous women (P < .001). Cesarean delivery rates were 57.7% in TOLAC vs 19.0% in nulliparous women (P < .001). Oxytocin was used in 52.4% of TOLAC vs 64.3% of nulliparous women with spontaneous labor (P < .001) and 89.8% of TOLAC vs 91.6% of nulliparous women with induced labor (P = .099); however, TOLAC had lower maximum doses of oxytocin compared to nulliparous women: median (90th percentile): 6 (18) mU/min vs 12 (28) mU/min, respectively (P < .001). Median (95th percentile) labor duration for TOLAC vs nulliparous women with spontaneous labor from 4-10 cm was 0.9 (2.2) hours longer (P = .007). For women who entered labor spontaneously and achieved vaginal delivery, labor patterns for TOLAC were similar to nulliparous women. For induced labor, labor duration for TOLAC vs nulliparous women from 4-10 cm was 1.5 (4.6) hours longer (P < .001). For women who achieved vaginal delivery, labor patterns were slower for induced TOLAC compared to nulliparous women. CONCLUSION: Labor duration for TOLAC was slower compared to nulliparous labor, particularly for induced labor. By improved understanding of the rates of progress at different points in labor, this new information on labor curves in women undergoing TOLAC, particularly for induction, should help physicians when managing labor.

Obesity in Pregnancy: A Qualitative Approach to Inform an Intervention for Patients and Providers.

To investigate perceptions of minority pregnant women and providers about obesity and gestational weight gain (GWG), and to explore strategies to improve management of obesity in pregnancy with an emphasis on group prenatal care. Sixteen primarily non-Hispanic black pregnant women with a body mass index ≥ 30 kg/m(2) and 19 prenatal care providers participated in focus groups. Discussion topics included GWG goals, body image, health behaviors, and group prenatal care with additional emphasis on provider training needs. Women frequently stated a GWG goal >20 lbs. Women described a body image not in line with clinical recommendations ("200 pounds is not that big."). They avoided the term "obese". They were interested in learning about nutrition and culturally-acceptable healthy cooking. Women would enjoy massage and exercise in group settings, though definitions of "exercise" varied. Family members could help, but generational differences posed challenges. Most had to "encourage myself" and "do this for me and the baby". Providers expressed discomfort discussing GWG and difficulty finding the right words for obesity, which was partially attributed to their own weight. They noted the challenges they faced during prenatal care including time constraints, cultural myths, and system issues. Providers considered a group setting with social support an ideal environment to address health behaviors in obese women. Culturally-tailored programs that use acceptable terms for obesity, provide education regarding healthy eating and safe exercise, and encourage support from social networks may be effective in addressing GWG in obese minority women. Provider training in communication skills is necessary to address obesity in pregnancy.

Does Induction with Misoprostol Impact the Small for Gestational Age Neonate?

OBJECTIVE: To compare outcomes in small for gestational age neonates induced with misoprostol to other cervical ripening agents. We hypothesized that misoprostol use will demonstrate no significant difference in outcomes compared with alternative agents. STUDY DESIGN: Small for gestational age neonates (<10th percentile for gestational age) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) sponsored Consortium on Safe Labor database were analyzed. Neonates induced with misoprostol ± oxytocin (n = 451) were compared with neonates induced with prostaglandin E2 ± oxytocin and/or mechanical dilation ± oxytocin (n = 663). Primary outcomes included intrapartum fetal distress, cesarean section for fetal distress, cesarean section for any reason, neonatal intensive care unit admission, low 5-minute Apgar, and composite neonatal morbidity. Multiple logistic regression was used to calculate adjusted odds ratios (aORs). Data were analyzed using SAS. RESULTS: Small for gestational age neonates induced with misoprostol ± oxytocin compared with alternative agents had decreased low 5-minute Apgar scores (aOR 0.27 [0.10-0.71]). No significant differences were demonstrated among very small for gestational age neonates (<5th percentile for gestational age). CONCLUSION: Our results suggest that misoprostol does not increase risk of adverse outcomes in small for gestational age neonates; however, prospective studies are warranted to further assess optimal cervical ripening agents in this population.