826: To push or not to push: managing the second stage in morbidly obese parturients

Abstract

826 To push or not to push: managing the second stage in morbidly obese parturients Jennifer McNamara, Anthony Odibo, Anthony Shanks, Methodius Tuuli, Kimberly Roehl, Alison Cahill Washington University in St. Louis, Department of Obstetrics and Gynecology, St. Louis, MO OBJECTIVE: Labor management of morbidly obese women presents a unique challenge, yet almost no published data exists regarding the potential advantage of passive descent in the 2nd stage for women with a body mass index(BMI) 40. We aimed to estimate the effect of passive descent on time spent pushing and birth outcomes in a morbidly obese cohort. STUDY DESIGN: A retrospective cohort study of all consecutive women with BMI 40 with term labor that reached the 2nd stage of labor from 2004-2008 at our institution. Detailed information was collected on maternal demographics, labor progress, and maternal and neonatal outcomes. Women allowed to labor down for at least 30min (passive descent) were compared to those who pushed immediately for length of pushing, length of 2nd stage, and maternal and neonatal outcomes using univariable and multivariable analysis. Active pushing time was also analyzed with Kaplan-Meier survival function. Subgroup analysis was performed by parity. RESULTS: Of 558 women with BMI 40, 97(17.4%) labored down and 461(82.6%) pushed immediately. The overall time (min) spent pushing was significantly longer,(19[7-39] vs 7[3-17], p 0.001), for morbidly obese women as was their length of 2nd stage (81[57-127] vs 15[8-27], p 0.001). Morbidly obese women in the passive descent group were significantly more likely to push for at least 60 min compared to those who pushed immediately,(16.5% vs. 7.2%, aOR 2.56[1.35-4.87]). They were also significantly more likely to push for 90min. The groups had similar rates of operative delivery, but significantly increased maternal febrile morbidity(14.4% vs 7.6%, aOR 2.14[1.09-4.18]) was seen in the labored down cohort. Subgroup analysis of nulliparous patients yielded similar results with no evidence for benefit for those obese women who labored down. CONCLUSION: Morbidly obese parturients who labored down spent greater time pushing, and had higher rates of febrile morbidity compared with morbidly obese women who pushed immediately. Passive descent is not an effective strategy for the management of the 2nd stage at term in morbidly obese patients. 827 Does advancing gestation affect patientreported sleep quality and daytime sleepiness? John Owen, Tamula Patterson, Susan Harding, Suzanne Cliver, John Hauth Univ of Alabama at Birmingham, Obstetrics and Gynecology, Birmingham, AL, Univ of Alabama at Birmingham, Pulmonary and Critical Care Medicine, Birmingham, AL OBJECTIVE: To evaluate sleep quality and daytime sleepiness in pregnancy using the validated Pittsburg Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). STUDY DESIGN: Prospective observational study of healthy women with normal gestations initiating care Jan, 2010 Jan, 2011. Sleep quality and daytime sleepiness were assessed in the early 2nd and 3rd trimesters (TM). The PSQI is a 10-question survey that assesses sleep hygiene, impediments to sleep, hypnotic use, daytime dysfunction, sleep partner and subjective sleep quality. Scores range from 0 to a maximum of 21, and scores 5 indicate poor sleep quality. The ESS grades the likelihood of dozing in 8 daily scenarios; scores range from 0 to 24, and 10 indicates significant daytime sleepiness. RESULTS: Of 495 consenting women, the mean age was 23 y, 53% were multiparous, and 81% were African American. They underwent initial evaluation at a mean (SD) gestational age (GA) of 15.7 (4.3) wks, and 458 (93%) had follow-up at a mean GA of 30.0 (1.0) wks. At the 2nd TM PSQI assessment, 201/495 (41%) of women had poor sleep quality, increasing to 216/458 (47%) in the 3rd TM. The mean PSQI also showed a small, but statistically significant, 0.5 unit increase (5.5 to 6.0) from the 2nd to the 3rd TM (p 0.01). Although the ESS score was not significantly different between the 2nd and 3rd TM (p 0.1), significant daytime sleepiness was observed in 27% at both assessments. Overall, 14% of women reported hypnotic use during either evaluation. Use of hypnotics was associated with a significantly worse sleep quality score ( 2 points on PSQI; p 0.0001) but had no effect on daytime sleepiness (p 0.6). CONCLUSION: Poor sleep quality and excessive daytime sleepiness are common in the 2nd and 3rd TM in an unselected obstetric population. Hypnotic use, reported in 14%, was associated with worsened sleep quality, but did not affect daytime sleepiness. Poster Session V Academic Issues, Antepartum Fetal Assessment, Genetics, Hypertension, Medical-Surgical-Disease www.AJOG.org