Independent Predictors Of Cesarean Delivery Research Articles

The Impact on Birth Outcomes of Sonographic Fetal Weight Estimation in Neonatal Macrosomia.

Our objective was to examine the association between sonographic estimated fetal weight (EFW) and obstetrical and neonatal outcomes in women with neonatal macrosomia. This study, conducted at a tertiary university-affiliated hospital from 2017 to 2021, compared obstetrical and neonatal outcomes between two groups of women who delivered macrosomic newborns (actual birthweight ≥ 4,000 g): (1) those with EFW ≥ 3,800 g (suspected impending macrosomia) and (2) those with EFW < 3,800 g (unsuspected impending macrosomia). During the study period, 854 women with neonatal macrosomia attempted vaginal delivery. Only 9.2% had a sonographic EFW ≥ 4,000 g. Among women with EFW ≥ 3,800 g (n = 317) compared with EFW < 3,800 g (n = 537), the cesarean delivery (CD) rate was higher (17.0 vs. 10.5%, p = 0.004) and the operative delivery rate was lower (3.2 vs. 0.6%, p = 0.015). Among primiparous women, the CD rate was higher among those with EFW ≥ 3,800 versus <3,800 g (37.3 vs. 23.2%, p = 0.033). EFW ≥3,800 g was associated with CD, regardless of predelivery body mass index, parity, diabetes mellitus, maximal fetal weight at previous deliveries, actual birthweight, and labor induction (p = 0.014). EFW ≥ 3,800 g and diabetes mellitus were independent predictors of CD. Among women with EFW ≥3,800 g and diabetes mellitus, the risk of CD was double that of those without diabetes and with EFW ≥ 3,800 g (31.4% vs. 15.2%, p = 0.02), although their actual birthweights were similar. Obstetrical and neonatal outcomes were similar between those with sonographic EFW ≥ 3,800 and < 3,800 g. Larger EFW increased CD risk among pregnancies with actual neonatal macrosomia. Antenatally suspected macrosomia might alter labor management due to concerns for potential complications, especially when associated with primiparity, diabetes mellitus, or maternal obesity. The increase in the CD rate did not show an association with improved maternal and neonatal outcomes. · Antenatally suspected macrosomia might alter labor management due to concerns about complications.. · Larger EFW increased cesarean delivery risk among pregnancies with actual neonatal macrosomia.. · The increase in the cesarean delivery rate was not associated with improved outcomes..

Secular trends in pregnancy rates, delivery outcomes, and related health care utilization among women with congenital heart disease

The number of women with congenital heart disease (CHD) of reproductive age is increasing, yet a description of trends in pregnancy and delivery outcomes in this population is lacking. To assess secular trends in pregnancy rates, delivery outcomes, and related health care utilization in the adult female CHD population in Quebec, Canada. The Quebec CHD database was used to construct a cohort with all women with CHD aged 18-45 years between 1992 and 2004. Pregnancy and delivery rates were determined yearly and compared to the general population. Secular trends in pregnancy and delivery rates were assessed with linear regression. The cesarean delivery rate in the CHD population was compared to the general population. Predictors of cesarean section were determined with multivariable logistic regression. Cox regression, adjusted for comorbidities, was used to analyze the impact of cesarean sections on 1-year health care use following delivery. About 14878 women were included. A total of 10809 pregnancies were identified in 5641 women, of whom 4551 (80%) and 2528 (45%) experienced at least one delivery and/or abortion, respectively. Absolute yearly numbers and rates of pregnancies and deliveries increased during the study period (P<.05). The increment in cesarean section rates was more pronounced among women with CHD than among the general population. Gestational diabetes (OR 1.50, 95% CI [1.13, 1.99]), gestational hypertension (OR 1.81, 95% CI [1.27, 2.57]), and preeclampsia (OR 1.59, 95% CI [1.11, 2.8]) were independent predictors of cesarean delivery. Cesarean sections were associated with postpartum cardiac-hospitalization within 1 year following delivery (HR = 2.35, 95% CI [1.05, 5.28]). Yearly numbers and rates of pregnancies and deliveries in adult females with CHD rose significantly during the study period. Cesarean sections led to increased health care utilization. Further research is required to determine causes of high cesarean section rates in this patient population.

Hospital volume and cesarean delivery among low-risk women in a nationwide sample.

We sought to determine if hospital delivery volume was associated with a patient's risk for cesarean delivery in low-risk women. This study retrospectively examines a cohort of 1 657 495 deliveries identified in the 2013 Nationwide Readmissions Database. Hospitals were stratified by delivery volume quartiles. Low-risk patients were identified using the Society for Maternal-Fetal Medicine definition (n=845 056). A multivariable logistic regression accounting for hospital-level clustering was constructed to assess the factors affecting a patient's odds for cesarean delivery. The range of cesarean delivery rates was 2.4-51.2% among low-risk patients, and the median was 16.5% (IQR 12.8-20.5%). The cesarean delivery rate was higher in the top two-volume-quartile hospitals (17.4 and 18.2%) compared to the bottom quartiles (16.4 and 16.3%) (P<0.001). Hospital volume was not associated with a patient's odds for cesarean delivery after adjusting for patient and other hospital characteristics (P=0.188). Hospital delivery volume is not an independent predictor of cesarean delivery in this population.

Prediction of the risk of cesarean delivery after labor induction in twin gestations based on clinical and ultrasound parameters.

To develop a model based on clinical and ultrasound parameters to predict the risk of cesarean delivery after labor induction in near-term twin gestations. This retrospective cohort study included 189 consecutive women with twin gestations at ≥ 36.0 weeks scheduled for labor induction. The Bishop score and transvaginal ultrasonographic measurements of cervical length were obtained immediately before labor induction. Parameters studied included maternal age, height, weight, parity, gestational age, Bishop score, cervical length, epidural analgesia, method of conception, chorionicity and birth weight. Prostaglandin E2 (dinoprostone) and oxytocin were used for labor induction. Logistic regression analysis and receiver operating characteristic curve were used to generate a predictive model for cesarean delivery. Fifty (26.5%) of the 189 women had cesarean deliveries. According to logistic regression analysis, maternal height (P = 0.004), parity (P = 0.005) and cervical length (P = 0.016), but not Bishop score (P = 0.920), were identified as independent predictors of cesarean delivery. A risk score based on a model of these three parameters was calculated for each patient. The model was shown to have an adequate goodness of fit (P = 0.201) and the area under the curve was 0.722, indicating fairly good discrimination. Maternal height, parity and cervical length were independent parameters for predicting the risk of cesarean delivery after labor induction in twin gestations. A predictive model using these parameters may provide useful information for deciding whether or not to induce labor.

Cesarean delivery among women with prolonged labor induction.

The objective of this study was to determine characteristics associated with cesarean delivery among women with labor induction lasting over 24 h. Women with live singleton pregnancies without prior cesarean delivery undergoing a labor induction lasting >24 h between September 2006 and March 2009 at Duke University Hospital were identified. Collected variables were compared between subjects by mode of delivery. A multivariate logistic regression model for the outcome cesarean delivery was constructed separately for nulliparous and parous women. There were 303 women who met inclusion criteria. The overall cesarean delivery rate was 57% (n=172) and remained constant with time (P=0.15, test-for-trend). Nulliparous women having a cesarean delivery were more likely to be obese [adjusted OR (aOR) 2.00; 95% CI 1.05, 3.80] and have a larger fetus [aOR 1.11 (aOR for every 100 g increase in birthweight), 95% CI 1.03, 1.20] compared to those having a vaginal delivery. Increasing BMI and birthweight were independent predictors of cesarean delivery among nulliparous women with prolonged labor induction. Despite this, after 24 h of labor induction, the overall mean cesarean delivery rate remained constant at 57%, and did not change with time. Among women having a vaginal delivery following a prolonged labor induction, we saw high rates of shoulder dystocia, operative vaginal delivery and severe perineal laceration.

Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in nulliparous women at term

We sought to assess amniotic fluid lactate (AFL) at diagnosis of spontaneous labor at term (≥37 weeks) as a predictor of labor disorders (dystocia) and cesarean delivery (CD). This was a single-institution, prospective cohort study of 905 singleton, cephalic, term (≥37 weeks) nulliparous women in spontaneous labor. A standard management of labor (active management of labor) including a standard oxytocin regimen up to a maximum dose of 30 mU/min was applied. AFL was measured using a point-of-care device (LMU061; ObsteCare, Stockholm, Sweden). Labor arrest in the first stage of labor was defined as the need for oxytocin when cervical dilatation was <1 cm/h over 2 hours and in the second stage of labor by poor descent and rotation over 1 hour. Standard statistical analysis included analysis of variance, Pearson correlations, and binary logistic regression. Unsupervised decision tree analysis with 10-fold cross-validation was used to identify AFL thresholds. AFL was normally distributed and did not correlate with age, body mass index, or gestation. Unsupervised decision tree analysis demonstrated that AFL could be divided into 3 groups: 0-4.9 mmol/L (n = 118), 5.0-9.9 mmol/L (n = 707), and ≥10.0 mmol/L (n = 80). Increasing AFL was associated with higher total oxytocin dose (P = .001), labor disorders (P = .005), and CD (P ≤ .001). Multivariable regression analysis demonstrated that women with AFL ≥5.0-9.9 mmol/L (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.06-2.39) and AFL ≥10.0 mmol/L (OR, 1.72; 95% CI, 1.01-2.93) were independent predictors of a labor disorder. AFL ≥5.0-9.9 mmol/L did not predict CD but multivariable analysis confirmed that AFL ≥10.0 mmol/L was an independent predictor of CD (OR, 3.35; 95% CI, 1.73-6.46). AFL ≥5.0-9.9 mmol/L had a sensitivity of 89% in predicting a labor disorder and a sensitivity of 93% in predicting CD with a 97% negative predictive value. AFL ≥10.0 mmol/L was highly specific but lacked sensitivity for CD. There was no difference in birthweight of infants according to labor disorder and delivery method. AFL at diagnosis of labor in spontaneously laboring single cephalic nulliparous term women is an independent predictor of a labor disorder and CD. These data suggest that women with AFL between 5.0-9.9 mmol/L with a labor disorder may be amenable to correction using the active management of labor protocol.

Predictors of Failed Trial of Labor Among Women With an Extremely Obese Body Mass Index

Objective The purpose of this study was to examine predictors associated with cesarean delivery (CD) among extremely obese women undergoing a trial of labor (TOL). Study design Using a delivery database, we identified all pregnant women delivering at our institution from Jan. 1, 2008, through July 31, 2010, weighing >275 lb at the time of delivery who attempted a TOL with a singleton gestation >34 weeks' gestation. Demographic and obstetrical factors were compared for those having a successful vaginal delivery to those having a CD. Results During the study period, there were 357 pregnant women who weighed >275 lb (all with body mass index [BMI] >40 kg/m 2 ), and among these, 248 (69.5%) attempted a TOL. Women having a CD had a greater BMI (51.6 vs 49.9 kg/m 2 , P = .038), were less likely to be parous (32.2% vs 65.8%, P 2 was associated with a 3.5 increased odds ( P = .002) for CD. Conclusion Among nulliparous extremely obese women attempting a TOL, BMI was an independent predictor of CD, with the rate of CD increasing further with increasing BMI. The underlying mechanisms for failed TOL in the setting of maternal obesity remain largely unknown.

Predictors of failed trial of labor among women with an extremely obese body mass index

The purpose of this study was to examine predictors associated with cesarean delivery (CD) among extremely obese women undergoing a trial of labor (TOL). Using a delivery database, we identified all pregnant women delivering at our institution from Jan. 1, 2008, through July 31, 2010, weighing >275 lb at the time of delivery who attempted a TOL with a singleton gestation >34 weeks' gestation. Demographic and obstetrical factors were compared for those having a successful vaginal delivery to those having a CD. During the study period, there were 357 pregnant women who weighed >275 lb (all with body mass index [BMI] >40 kg/m(2)), and among these, 248 (69.5%) attempted a TOL. Women having a CD had a greater BMI (51.6 vs 49.9 kg/m(2), P = .038), were less likely to be parous (32.2% vs 65.8%, P < .0001), and were more likely to be induced (80.5% vs 57.8%) compared to those having a vaginal delivery. Using a multivariable logistic regression model, among nulliparous women, maternal age, parity, and cervical dilation at time of admission were independent predictors for CD. Furthermore, an increase in BMI of 10 kg/m(2) was associated with a 3.5 increased odds (P = .002) for CD. Among nulliparous extremely obese women attempting a TOL, BMI was an independent predictor of CD, with the rate of CD increasing further with increasing BMI. The underlying mechanisms for failed TOL in the setting of maternal obesity remain largely unknown.

Estimated Fetal Weight by Ultrasound

Use of prenatal ultrasonography (US) has risen concomitantly with the increase in cesarean delivery (CD) rates. Sonographic overestimation of fetal macrosomia may be associated with a lower threshold for CD for labor arrest. If obtaining the US estimated fetal weight (US-EFW) near term increases the risk of CD, this could be a modifiable risk factor. This retrospective cohort study was undertaken to determine whether women with a US-EFW within 1 month of delivery are more likely to undergo CD compared with women without a US-EFW. The women had singleton live births; their demographic and delivery data were obtained from medical records, and the date, indication, and EFW were recorded. Patients were divided into those with a US-EFW within 1 month of delivery and women with no US-EFW. Logistic regression was used to analyze whether US-EFW was an independent risk factor for CD. The mode of delivery was the outcome variable. The statistical software package SPSS version 12.0 was used for all data analyses. Subsets created were groups at low risk, those with EFWs of less than 3000 g, those with EFWs greater than 3500 g, and those with actual birth weights of greater than 4000 g. This cohort included 2329 women with term pregnancies who met the inclusion and exclusion criteria, of whom 1168 (50.2%) had a US-EFW within 1 month of delivery. Of those with a US-EFW, 540 (46%), 276 (24%), 179 (15%), and 173 women (15%) had the US within 1 week of delivery and 1 to 2 weeks, 2 to 3 weeks, and 3 weeks to 1 month before delivery, respectively. The most common indications were “postdates” (19%), uterine size less than dates (17%), uterine size greater than dates (14%), and older maternal age (16%). Women with a US-EFW within 1 month of delivery were significantly older and more likely to be white, be cared for by a physician rather than a midwife, be obese, undergo labor induction, and deliver at slightly later gestational ages. No differences in parity, previous CD, or actual birth weight were found between the 2 groups. The unadjusted CD rates showed that women with a US-EFW were 55% more likely to have a CD (15.7% vs 10.2%; P < 0.01). The timing of US within the 1-month period before delivery had little impact. The CD rates were 16% with a US within 1 month of delivery and 16%, 15.5%, and 12% for a US within 3, 2, and 1 week(s) of delivery, respectively. The main indications for CD were failure to progress and nonreassuring fetal heart tracings in both groups. Of 17 CDs performed for presumed macrosomia, all in the US-EFW group, only 3 deliveries had an EFW of greater than 5000 g. When controlling for birth weight, maternal age, race, body mass index, previous CD, parity, gestational age, induction versus spontaneous labor, and provider group, US-EFW was a statistically significant independent risk factor for CD. Women with a US-EFW within 1 month of delivery were 44% more likely to have a CD. Other independent predictors of CD were birth weight, advanced maternal age, black or Hispanic race, nulliparity, obesity, previous CD, and faculty provider group. In the entire cohort, US-EFW was associated with increased odds of CD (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.1–1.9). For those with fetuses of less than 3000 g, US-EFW was not associated with an increased risk of CD (OR, 0.97; 95% CI, 0.45–2.1). With EFW greater than 3500 g, the OR was greater and statistically significant (OR, 1.8; 95% CI, 1.3–2.7) and was stronger still for the population with an actual birth weight greater than 4000 g (OR, 3.1; 95% CI, 1.2–8.3). For women with a US-EFW within 1 month of delivery, the association between the US and CD seems to be due to provider concern over larger US-EFWs because the risk of CD was not increased if the US-EFW was less than 3000 g. However, for women with a US-EFW of greater than 3500 g, an 85% increased risk of CD was apparent with US-EFW determination. The rising CD rate is a great concern, but many of the known reasons contributing to the rise are not readily modifiable. These results indicate that provider knowledge of larger US-EFW may be associated with a higher rate of CD. Limiting the use of US to determine fetal weight near term may help to reduce the CD rate in the United States.

Transvaginal sonographic measurement of cervical length vs. Bishop score in labor induction at term: tolerability and prediction of Cesarean delivery

To compare transvaginal sonography for cervical length measurement and digital examination for Bishop score assessment in women undergoing labor induction at term, to assess their tolerability (in terms of pain) and ability to predict need for Cesarean delivery. A prospective study was performed on 249 women admitted for labor induction. Cervical length was measured using transvaginal ultrasound examination. A 10-point visual analog scale (VAS) for procedure-related pain was obtained. Bishop score was determined just before labor induction and another pain score was obtained. Delivery outcome was recorded. Analyses were by t-test, Fisher's exact test, receiver-operating characteristics (ROC) curves and multivariate logistic regression. Transvaginal sonography was significantly less painful than digital examination for Bishop score assessment (mean difference in VAS score 3.46; P<0.001). Analyses of the ROC curves for cervical length and Bishop score indicated that both were predictors of Cesarean delivery (area under the curve 0.611 vs. 0.607; P=0.012 vs. P=0.015, respectively) with optimal cut-offs for predicting Cesarean delivery of >20 mm for cervical length and Bishop score<or=5. Cervical length had superior sensitivity (80% vs. 64%) and marginally better positive (30% vs. 27%) and negative (89% vs. 83%) predictive values. Multivariate logistic regression analysis revealed that only nulliparity (adjusted odds ratio (AOR) 4.1; 95% CI, 2.1-8.1; P<0.001) and transvaginal sonographic cervical length>20 mm (AOR 3.4; 95% CI, 1.4-8.1; P=0.006) were independent predictors of Cesarean delivery. Transvaginal sonography for cervical length measurement is better tolerated than digital examination for Bishop score assessment. Both cervical length and Bishop score are useful predictors of the need for Cesarean delivery following labor induction. A cervical length>20 mm at labor induction at term is an independent predictor of Cesarean delivery.

Impact on Delivery Outcome of Ultrasonographic Fetal Head Position Prior to Induction of Labor

To assess clinical and sonographic fetal head position before induction of labor, position at delivery, and whether occiput posterior (OP) position is associated with adverse delivery outcome. Abdominal palpation and ultrasonographic fetal head and spine position were determined at 36 weeks or more of gestation in 289 women immediately before induction of labor and the head position at delivery noted. Chi-square, Mann-Whitney U tests, and logistic regression were used to assess whether OP position was associated with cesarean delivery. Ninety-seven (36%) of 270 women with full outcome data had an OP position on ultrasonography before induction of labor. Of these 97 women, eight (8%) were OP at delivery. Sixty-eight percent of the 25 OP positions at delivery occurred due to a mal-rotation from a non-OP position during labor. Logistic regression showed that OP position before induction of labor was not an independent predictor of cesarean delivery (odds ratio 1.75, 95% confidence interval 0.97-3.15, P=.06). Two thirds of OP positions at delivery after induction of labor occur due to a mal-rotation in labor from a non-OP position. Ultrasonography is an easy method of assessing fetal head position before induction of labor. In clinical practice, its usefulness is limited by the fact that, contrary to conventional teaching, OP position before induction of labor does not appear to be associated with an increased risk of cesarean delivery. II.

Gestational weight gain, macrosomia, and risk of cesarean birth in nondiabetic nulliparas.

To examine how the association between excessive weight gain and cesarean birth is modified by infant birth weight in nondiabetic women. We designed a retrospective cohort study of singleton, term, nulliparous women with cephalic presentations delivering at a single university hospital. Subjects with diabetes were excluded. Bivariate and multivariate analyses were performed. Regression models controlled for maternal age, maternal prepregnancy body mass index, gestational age, ethnicity, smoking, birth weight, and date of delivery. Women gaining above Institute of Medicine guidelines were more likely to have a cesarean birth, even if birth weight was less than 4,000 g. In the multivariate analysis, women with excessive weight gain had an odds ratio of 1.40 (95% confidence interval 1.22-1.59) for cesarean birth. When absolute weight gain (total pregnancy weight gain minus birth weight and placental weight) was used in the multivariate analysis, excessive weight gain was still an independent predictor of cesarean delivery. Although macrosomia was a stronger predictor of cesarean than weight gain alone, excessive weight gain was much more common than macrosomia in our cohort. Excessive weight gain during pregnancy is an independent risk factor for cesarean birth, even when birth weight is not excessive. Other mechanisms besides macrosomia may be involved in the association between high weight gain and cesarean birth. We estimate that of the approximately 288,000 primary cesarean deliveries performed in nulliparas annually in the United States, 64,000 would be prevented if no women gained above Institute of Medicine recommendations. II-2

Independent predictors of Cesarean delivery in women with diabetes

Objectives: To identify independent risk factors for Cesarean delivery in women with pregnancy complicated by diabetes.Methods: Retrospective analysis of pregnancies from 5735 diabetic women delivering liveborn infants. Maternal demographic, medical, obstetric historical factors and index pregnancy obstetric, glycemic and neonatal outcome parameters were evaluated for association with Cesarean delivery after a trial of labor. Individual risk factors were analyzed for association by χ2and ANOVA. Independent predictors of Cesarean delivery and adjusted relative risk (RR) were identified by stepwise logistic regression.Results: Trial of labor waspermitted in 90.8% and 59.4% of women without (n=4643) and with prior Cesarean delivery (n=1092) and was successful in 85.2% and 56.9%, respectively. Eleven independent predictors were found. Five were related to obstetric history and maternal age: prior Cesarean delivery (RR 5.34, 95% CI 3.94–7.25), no prior live birth (RR 3.17, 95% CI 1.98–5.07), no prior vaginal delivery (RR 2.28, 95% CI 1.50–3.44), prior stillbirth (RR 1.71, 95% CI 1.09–2.68%) and maternal age ≥35 years(RR 1.53, 95% CI 1.20–1.93). Two were related to the severity of diabetes at entry to diabetes care: requiring insulin (RR 1.53, 95% CI 1.20–1.93) and highest fasting plasma glucose level (RR 1.04, 95% CI 1.01–1.07). Two were related to obstetric factors: pre-eclampsia/hypertension (RR 2.56, 95% CI 2.00–3.27) and labor induction (RR 3.32, 95% CI 2.70–4.10). The remaining two were birth weight (per 250 g, RR 1.12, 95% CI 1.09–1.17) and pre-delivery body mass index (RR, 1.03, 95% CI 1.00–1.05).Conclusion: The majority of predictors were not modifiable, relating to obstetric history, maternal age and diabetes severity. Possible modifiable interventions to avoid/improve labor induction, and decrease birth weight and maternal weight gain might decrease risk of Cesarean delivery. Future studies must address these multiple predictors.

Predictors of Cesarean Delivery After Prelabor Rupture of Membranes at Term

In Brief Objective To identify the significant predictors of cesarean delivery after prelabor rupture of membranes (PROM) at term. Methods In a multicenter study involving 72 institutions in six countries, 5041 women were randomized to induction of labor with oxytocin or prostaglandins or to expectant management. We did univariate and multivariate logistic regression analyses to determine the statistically significant independent predictors of cesarean delivery (P < .05). Results The following variables were found to be significantly associated with cesarean delivery: delivery in Israel, versus Canada (odds ratio [OR] 0.34); delivery in Australia, versus Canada (OR 1.93); nulliparity (OR 2.81); labor lasting more than 12 hours, versus less than 6 hours (OR 2.78); labor lasting 6–12 hours, versus less than 6 hours (OR 1.66); previous cesarean delivery (OR 2.75); epidural anesthesia (OR 2.66); clinical chorioamnionitis (OR 2.42); internal fetal heart rate monitoring (OR 2.19); birth weight of at least 4000 g (OR 2.07); use of oxytocin (OR 1.97); maternal age of at least 35 years (OR 1.44); latent period of at least 12 hours (OR 1.41); and meconium staining (OR 1.41). Conclusion Strong predictors of cesarean delivery after PROM at term were country of birth, nulliparity, long labor, previous cesarean delivery, and epidural anesthesia. Strong predictors of cesarean delivery in women with prelabor rupture of membranes at term are country of birth, nulliparity, long labor, previous cesarean delivery, and epidural anesthesia.

Predictors of cesarean delivery after prelabor rupture of membranes at term

Objective: To identify the significant predictors of cesarean delivery after prelabor rupture of membranes (PROM) at term. Methods: In a multicenter study involving 72 institutions in six countries, 5041 women were randomized to induction of labor with oxytocin or prostaglandins or to expectant management. We did univariate and multivariate logistic regression analyses to determine the statistically significant independent predictors of cesarean delivery ( P < .05). Results: The following variables were found to be significantly associated with cesarean delivery: delivery in Israel, versus Canada (odds ratio [OR] 0.34); delivery in Australia, versus Canada (OR 1.93); nulliparity (OR 2.81); labor lasting more than 12 hours, versus less than 6 hours (OR 2.78); labor lasting 6–12 hours, versus less than 6 hours (OR 1.66); previous cesarean delivery (OR 2.75); epidural anesthesia (OR 2.66); clinical chorioamnionitis (OR 2.42); internal fetal heart rate monitoring (OR 2.19); birth weight of at least 4000 g (OR 2.07); use of oxytocin (OR 1.97); maternal age of at least 35 years (OR 1.44); latent period of at least 12 hours (OR 1.41); and meconium staining (OR 1.41). Conclusion: Strong predictors of cesarean delivery after PROM at term were country of birth, nulliparity, long labor, previous cesarean delivery, and epidural anesthesia.