Implementation of a laborist program and evaluation of the effect upon cesarean delivery.

OBJECTIVE: Laborist programs have expanded throughout the United States in the last decade. Meanwhile, there has been no published research examining their effect on patient outcomes. Cesarean delivery is a key performance metric with maternal health implications and significant financial impact. Our hypothesis is that the initiation of a full-time dedicated laborist staff decreases cesarean delivery. STUDY DESIGN: In a tertiary hospital staffed with private practice physicians, data were retrospectively reviewed for 3 time periods from 2006 through 2011. The first period (16 months) there were no laborists (traditional model), followed by 14 months of continuous in-hospital laborist coverage provided by community staff (community laborist), and finally a 24-month period with full-time laborists providing continuous in-hospital coverage. The primary hypothesis was that full-time laborists would decrease cesarean delivery rates. RESULTS: Data from 6206 term nulliparous patients were retrospectively reviewed. The cesarean delivery rate for no laborist care was 39.2%, for community physician laborist care was 38.7%, and for full-time laborists was 33.2%. With adjustment via logistic regression, full-time laborist presence was associated with a significant reduction in cesarean delivery when contrasted with no laborist (odds ratio, 0.73; 95% confidence interval, 0.64-0.83; P < .0001) or community laborist care (odds ratio, 0.77; 95% confidence interval, 0.67-0.87; P < .001). The community laborist model was not associated with an effect upon cesarean delivery. CONCLUSION: A dedicated full-time laborist staff model is associated with lower rates of cesarean delivery. These findings may be used as part of a strategy to reduce cesarean delivery, lower maternal morbidity and mortality, and decrease health care costs.

A prospective randomized controlled trial that compared misoprostol, Foley catheter, and combination misoprostol-Foley catheter for labor induction.

OBJECTIVE: The purpose of this study was to determine the efficacy of combination intravaginal misoprostol and intracervical Foley catheter for prelabor cervical ripening. STUDY DESIGN: A prospective, randomized controlled trial was conducted. Women who were undergoing labor induction, with a singleton gestation >or=28 weeks and an unfavorable cervix (Bishop score

Abnormal first-trimester fetal nuchal translucency and Cornelia De Lange syndrome.

BACKGROUND: Cornelia de Lange syndrome is a genetic disorder associated with delayed growth and characteristic facial features. There is no definitive biochemical or chromosomal marker for the prenatal diagnosis of this syndrome. We describe a case of Cornelia de Lange syndrome associated with an increased nuchal translucency in the first trimester. CASE: A large nuchal translucency was identified in a fetus during a first trimester ultrasound. Subsequent second- and third-trimester sonograms demonstrated severe fetal growth restriction, limb shortening, and abnormal facial features, despite normal fetal karyotype per chorionic villus sampling. Neonatal evaluation confirmed the diagnosis of Cornelia de Lange syndrome. CONCLUSION: Sonographic finding of an increased nuchal translucency in early pregnancy is associated with fetal aneuploidy and various structural and genetic abnormalities. Increased nuchal translucency may identify fetuses that require vigilant assessment, especially when found in association with other abnormalities.

Interdelivery interval and the success of vaginal birth after cesarean delivery.

OBJECTIVE: To determine whether a short interdelivery interval is associated with decreased rate of successful vaginal birth after cesarean (VBAC). METHODS: A retrospective cohort study from January 1, 1997, to December 31, 2000, was conducted. Patients with previous cesarean delivery who attempted VBAC were identified. The analysis was limited to patients at term with one prior cesarean. The interdelivery interval was calculated in months between the index pregnancy and prior cesarean delivery. RESULTS: A total of 1516 subjects who attempted VBAC were identified among 24,162 deliveries, with complete data available in 1185 cases. The VBAC success rate was 79.0% for patients with an interdelivery interval less than 19 months compared with 85.5% for patients with an interval delivery greater than or equal to 19 months (P =.12). For patients whose labors were induced, interdelivery intervals of less than 19 months were associated with a decreased rate of VBAC success when compared with longer intervals (P <.01). Sufficient power (beta =.95) existed to detect a 64% difference between the groups (alpha =.05). No significant difference was detected in women who underwent spontaneous labor (P =.98). There was no difference in the rate of symptomatic uterine rupture (P = 1.00). CONCLUSION: Interdelivery intervals of less than 19 months were associated with a decreased rate of VBAC success in patients who underwent induction, a difference not found in those with spontaneous labor.