Spontaneous Vaginal Delivery Rate Research Articles

348 Prenatal care and the hispanic paradox

The aim of this study was to determine the effect of insufficient PNC on perinatal outcomes according to Hispanic ethnicity. This was a retrospective cohort study of 10,495 low-risk parturients delivering between April 2014-2017. Demographic, obstetric, and neonatal outcomes were recorded. PNC was considered sufficient if begun in the first-trimester with completion of ≥80% of visits. Data was compared between Hispanic and Non-Hispanic ethnicity and stratified by PNC received. Group variables were analyzed using chi-square/fisher exact. T-test was used for normally distributed data and Wilcoxon rank sum test for non-normal data. Data was collected on 19,665 women during the study period. Of those, 10,495 met inclusion criteria. There were 5,749 (55%) Hispanic women of which 62.5% received insufficient prenatal care. Vaginal delivery rates were significantly higher for Hispanic women with insufficient care (p=0.009), while the rate of operative vaginal delivery was lower (p=0.009) compared to non-Hispanics. There were no differences in maternal morbidities including chorioamnionitis or blood transfusion in either ethnic group with regards to PNC (p>0.05; Table 1). Results demonstrate an increased spontaneous vaginal delivery rate for low risk Hispanic women with insufficient PNC, supporting the epidemiologic phenomenon of the Hispanic Paradox.

Association of Persistent Breech Presentation With External Cephalic Version Success.

To evaluate a possible correlation between a new variable-persistent breech presentation-and the success rate of external cephalic version (ECV). This was a retrospective study of ECVs performed from January 2008 through January 2019 in an Israeli tertiary care hospital. The study group included all pregnant women who underwent an ECV at or beyond 37 weeks of gestation. Persistent breech presentation was defined as persistent breech presentation during all ultrasound examinations performed between the anatomy scan at mid-pregnancy and the gestational week when ECV was attempted. Women in whom cephalic presentation was documented at least once on these ultrasound examinations were defined as not having persistent breech presentation. The primary outcome was defined as the success rate of ECV, and the secondary outcome was defined as the mode of delivery after a successful ECV. We identified 1,271 women with breech presentation during the study period. They had undergone median of five (range 2-7) ultrasound examinations. External cephalic version was attempted in 684 women (53.8%), with a success rate of 61.5%. External cephalic version succeeded in 19.6% of those with persistent breech presentation (44/224) compared with 82.0% (377/460) of those without persistent breech presentation (P<.001). Ultimately, women with persistent breech presentation and successful ECV experienced a lower rate of vaginal delivery (27.3% vs 79%, P<.001), and a higher rate of instrumental (29% vs 13%, P<.001) and cesarean deliveries (43% vs 7%, P<.001) compared with the nonpersistent breech presentation group. The rate of noninstrumental vaginal delivery among women with persistent breech presentation, regardless of ECV, was 5.4%. Women with persistent breech presentation experienced a high rate of ECV failure and a low rate of spontaneous vaginal delivery.

Effects of Midwifery Care on Mode of Delivery, Duration of Labor and Postpartum Hemorrhage of Elderly Parturients.

Background:We aimed to explore the influence of midwifery care on the mode of delivery (MOD), duration of labor and postpartum hemorrhage (PPH) of elderly parturients.Methods:A total of 165 elderly parturients admitted to Tongde Hospital of Zhejiang Province, China from May 2018 to Aug 2019 were allocated into a study group (n=85, midwifery care) and a control group (n=80, conventional nursing care). Visual analogue scale (VAS) was employed to estimate the pain of parturients, and self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were employed to evaluate the anxiety and depression status. The satisfaction of patients on nursing care was scored by a self-made satisfaction questionnaire.Results:The parturients in the study group presented higher spontaneous vaginal delivery (SVD) rate (P < 0.05), and had shortened duration of first and second stages of labor and total duration of labor (P < 0.05). The incidence of both PPH and neonatal asphyxia in the study group was lower than that in the control group (both P < 0.05). The VAS, SAS and SDS scores in the study group were significantly lower than those in the control group (P < 0.05), and the patients’ satisfaction in the study group was significantly higher (P < 0.05).Conclusion:Midwifery care is effective for the delivery of elderly parturients, which significantly improves VSD rate, shortens duration of labor, reduces incidence of PPH and neonatal asphyxia, as well as relives labor pain, anxiety and depression, and increases satisfaction of parturients.

The effect of maternal body mass index on duration of induced labor.

Obese primiparous women with induction of labor are at high risk for a cesarean section. There are contradictory results regarding time in induced labor in relation to maternal body mass index (BMI). It is important to characterize the course of induced labor to prevent unnecessary cesarean section. We aimed to evaluate whether the duration of labor was associated with maternal BMI in primiparous women with induction of labor. A national retrospective cohort study, including 15259 primiparae with a single term pregnancy, admitted for induction of labor from January 2014 to August 2017. Data were obtained from the Swedish Pregnancy Registry. Cox regression analyses were used to illustrate the association between BMI and active labor and between BMI and time from admission until start of active labor. Duration of active labor was shorter in underweight women and prolonged in women with BMI ≥40kg/m2 compared with women in other BMI classes, illustrated by Cox regression graphs (P<.001). The median durations of active labor in underweight women were 6.1 and 7.4hours in women with BMI ≥40kg/m2 . The time from admission until start of active labor increased with maternal BMI, illustrated by Cox regression graphs (P<.001) and the median duration increased from 12.9hours in underweight women to 22.6hours in women with BMI ≥40kg/m2 . The cesarean section rate in active labor increased significantly with BMI (P<.001) from 7.4% in underweight women to 22.0% in women with BMI ≥40kg/m2 . Obese and normal weight women had similar rates of spontaneous vaginal delivery (69.9% in the total study population). The duration of active labor was associated with maternal BMI for underweight women and women with BMI ≥40kg/m2 . Although women with BMI ≥40kg/m2 who reached the active phase of labor had the same chance for a spontaneous vaginal delivery as normal weight women, the duration of active labor and the cesarean section rate were increased. The time from admission until start of active labor increased successively with maternal BMI.

Term spontaneous trial of labor in nulliparous women of short stature: A hospitals-based cohort study

ObjectivesTo study the mode of delivery in a well selected cohort of short nulliparous women. Study designHospitals-based cohort study between 2010-2018. The threshold (150 cm, i.e 2,3°p), for the short stature was chosen before the analysis by corresponding to – 2SD of the average population size distribution of all women who delivered over the same period: 2010–2018.Were included nulliparous women with a heigh ≤ 150 cm in term spontaneous labor with a single livung fetus in vertex presentation without malformation.Exclusion criteria were: multiparous, scarred uterus, twin pregnancy, induced labor, preterm delivery (< 37 W P), non-vertex pregnancy, medical termination of pregnancy, stillbirth, severe fetal malformations, pre-labor cesarean, and late dating ultrasound.The main outcome was the mode of delivery. Univariate and multivariate analysis adjusted on potential confounding variable were performed to investigate the risk of intrapartum CS. Results178 nulliparous women were included. The mean height was 148 cm. The rate of spontaneous vaginal delivery, operative vaginal delivery a nd intrapartum CS were :35,4 %, 35,4 % and 29,2 % respectively.Intrapartum CS was performed during the first stage labor in 15 (28, 8 %) women and during the second stage in 37 (71, 2 %) women. An arrest of labor was significantly more frequent in the active labor than the early labor stage: 62,1 % vs. 33.3 % (p = 0, 02).In univarate analysis were associated with intrapartum CS : Gestational diabetes, birthweight> 3,5 kg, individual adjusted birthweight >90°p, occiput posterior, oxytocin use, cephalic circumference.After adjustment on birthplace and overweight (BMI over 25), only a birthweight > 3,5 kg remains associated with the risk of intrapartum CS (aOR4.3 ;95 %CI 1.96–10.2). ConclusionAn attempt of vaginal birth is a reasonable option for short stature women. Maternal height could be included in the selection criteria for planned birth center or home birth.The customized gestational-related optimal weigh could be useful to identify large of gestational age fetus.

Cesarean Section and Maternal-fetal Mortality Rates in Nigeria: An Ecological Lens into the Last Decade.

Background or Objectives:Despite the global decline in maternal mortality within the last decade, women continue to die excessively from pregnancy-related complicationsin developing countries. We assessed the trends in maternal mortality, fetal mortality and cesarean section (C-Section) rates within 25 selected Nigerian hospitals over the last decade.Methods:Basic obstetric data on all deliveries were routinely collected by midwives using the maternity record book developed for the project in all the participating hospitals. Trends of C-Section Rates (CSR), Maternal Mortality Rates (MMR), Fetal Mortality Rates (FMR) and Spontaneous Vaginal Delivery rates (SVD) were calculated using joinpoint regression models.Results:The annual average percent change in CSR was 12.2%, which was statistically significant, indicating a rise in CSR over the decade of the study. There was a noticeable fall in MMR from a zenith of about 1,868 per 100,000 at baseline down to 1,315/100,000 by the end of the study period, representing a relative drop in MMR of about 30%. An average annual drop of 3.8% in FMR and 1.5% drop in SVD over time were noted over the course of the study period.Conclusion and Global Health Implications:We observed an overall CSR of 10.4% and a significant rise in CSR over the 9-year period (2008-2016) of about 108% across hospital facilities in Nigeria. Despite the decrease in MMR, it was still high compared to the global average of 546 maternal deaths per 100 000 livebirths. The FMR was also high compared with the global average. The MMR found in this study clearly indicates that Nigeria is far behind in making progress toward achieving the Sustainable Development Goal 3 (SGD 3) which aims to reduce the global MMR to less than 70 per 100 000 live births by 2030.

968: Extending the second stage of labor in nulliparous women with epidural analgesia: a cost-effectiveness analysis

In an effort to prevent primary cesarean deliveries, ACOG has recommended an increase of one hour in the time spent in the second stage before diagnosing a prolonged second stage of labor. In nulliparous women with epidural analgesia, this translates to an increase from 3 to 4 hours. A subsequent small randomized trial of nulliparous and multiparous women showed an increased rate of spontaneous vaginal delivery by extending the second stage by one hour. The purpose of this study is to examine the differences in outcomes with an extended second stage and determine if this new recommendation is cost effective. A cost-effectiveness analysis model was built using TreeAge Pro 2019 software with model inputs derived from the literature. We used a theoretical cohort of 152,000 women, approximately the number of nulliparous U.S. women reaching 3 hours of second stage with an epidural. We compared maternal outcomes and costs associated with expectant management of the second stage until 4 hours versus delivery at 3 hours. Perinatal outcomes included mode of delivery, chorioamnionitis, postpartum hemorrhage, third- and fourth-degree perineal lacerations and maternal deaths. Secondary outcomes included cost per quality-adjusted life years (QALY; willingness-to-pay threshold set to $100,000/QALY). Sensitivity analyses were performed to determine the robustness of baseline assumptions. In a cohort of 152,000 women, expectant management to 4 hours was the dominant strategy as it was cost saving and resulted in more overall QALYs (Table 1). Sensitivity analysis indicated that expectant management until 4 hours was cost-effective as long as the probability of cesarean delivery at 4 hours was below 41.8%, and was the dominant strategy below 38.2% (baseline input: 19.5%). Expectant management of the second stage of labor until 4 hours is a cost-effective strategy to prevent primary cesarean deliveries, decrease costs, and improve maternal outcomes.

Effect of Immediate Versus Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia: A Randomized Clinical Trial

(JAMA. 2018;320(14):1444–1454) Although &gt;3 million women give birth in the United States every year, there is a lack of evidence regarding optimal labor management. In an effort to optimize cesarean delivery rates, there has been extensive research examining the management of labor. There are conflicting data on whether the mother should push immediately or delay pushing, as prolonged labor is associated with adverse outcomes for both mother and infant. The objective of this study was to evaluate whether immediate or delayed pushing would impact rates of spontaneous vaginal delivery as well as be more effective to reduce maternal and neonatal morbidities.

Effect of delayed misoprostol dosing interval for induction of labor: a retrospective study

BackgroundInduction of labor occurs in greater than 22% of all pregnancies in the United States. Previous studies have shown that misoprostol is more effective for induction than oxytocin or dinoprostone alone. The World Health Organization recommends vaginal misoprostol 25mcg every 6 hours and the American Congress of Obstetricians and Gynecologists recommends 25mcg vaginal misoprostol every three to 6 hours. Although route of administration and dosage of misoprostol has been extensively studied, little is known about the optimal dosing interval of vaginal misoprostol.MethodsThe primary objective of this study is to determine the effect of delayed vaginal misoprostol dosing, defined as any interval longer than 4.5 h, on time to vaginal delivery. Our hypothesis is that the routine dosing interval of 4 hours shortens times to vaginal delivery compared to delayed dosing, even when adjusted for the time of delay. Secondary objectives include the effect of delayed vaginal misoprostol dosing on cesarean section rate, operative vaginal delivery rate, maternal outcomes, and neonatal outcomes.We conducted a retrospective chart review of 323 inductions of labor at one academic institution. The primary outcome was the proportion of patients who achieved a vaginal delivery within 24 h. The group who received all doses of misoprostol within a 4.5 h dosing window (Routine Dosing Interval Group) was compared with the group who had any dosing deviation (Delayed Dosing Interval Group).ResultsOf 133 included patients, 64 subjects received routine interval dosing and 69 subjects received delayed interval dosing. The vaginal delivery rates within 24 h were 56% (36/64) and 20% (14/69), respectively (P < 10− 4). Spontaneous vaginal delivery rates were 86% (55/64) vs. 75% (52/69), respectively (P = .13). Kaplan Meier curves demonstrated statistically significant difference in time to vaginal delivery between groups, with a Cox Proportional Hazard ratio for routine dosing interval of 1.73 (P < 10− 5) unadjusted and 1.34 (P = .01) when adjusted for dosing delay.ConclusionsThis retrospective study demonstrates a significant increase in delay-adjusted time to vaginal delivery when doses of vaginal misoprostol are delayed past 4.5 h.

Defining the upper limit of the second stage of labor in nulliparous patients

Increased duration of the second stage of labor provides clinical challenges in decision-making regarding the optimal mode of delivery that minimizes maternal and neonatal morbidity. In a large cohort of uncomplicated nulliparous singleton cephalic labors, we sought to examine the effect of increasing duration of second stage on delivery and perinatal outcome. The GENESIS Study recruited 2336 nulliparous patients with vertex presentation in a prospective double-blinded study to examine prenatal and intrapartum predictors of delivery. Metrics included maternal demographics, duration of second stage, mode of delivery, and associated maternal and neonatal outcomes. Indicators of morbidity included third- or fourth-degree tear, postpartum hemorrhage, neonatal intensive care unit admission, low Apgar scores, cord pH <7.20 and a composite of birth injury that included cephalohematoma, fetal laceration, brachial plexus palsy, facial nerve palsy, and fetal fracture. Of 2336 recruited nulliparous participants, 1872 reached the second stage of labor and had complete data for analysis. Increased maternal age (P=.02) and birthweight (P<.001) were found to be associated with a longer second stage. Increasing second stage duration was found to impact on mode of delivery, such that at <1 hour duration the spontaneous vaginal delivery rate was 63% vs 24% at >3 hours (P<.001). Operative vaginal delivery increased from 35% at <1 hour to 65% at >3 hours (P<.001). The rate of cesarean delivery increased with duration of the second stage from 1.2% at <1 hour to 11% at >3 hours (P<.001). The rates of third- or fourth-degree tear increased with second stage duration (P=.003), as did postpartum hemorrhage (P<.001). The composite neonatal birth injury rate increased from 1.8% at <1 hour to 3.4% at >3 hours. The maximum rate of birth injury was 6.5% at 2-3 hours (P<.001). Multiple logistic regression analysis that controlled for maternal age and birthweight confirmed that operative vaginal delivery, perineal trauma, postpartum hemorrhage, and neonatal birth injury remained significantly more likely with increasing second stage duration. In a prospective cohort of nulliparous pregnancies, increasing duration of second stage of labor was associated with increased rates of operative vaginal and cesarean delivery. Although almost 90% of term nulliparous women with a second stage of labor >3 hours will succeed in achieving a vaginal birth, this success comes at a maternal morbidity cost, with a 10% risk of severe perineal injury and an increasing rate of significant neonatal injury.

Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia: A Randomized Clinical Trial

(Abstracted from JAMA 2018;320(14):1444–1454) Despite the frequency of childbirth, many aspects of labor management lack an evidence-based approach. The second stage of labor, defined as the interval from complete cervical dilation through delivery of the fetus, is the most physiologically demanding period of labor for both the mother and the fetus.

Membrane sweeping in patients planning a trial of labor after cesarean: a systematic review and meta-analysis of randomized controlled trials

Background: Membrane sweeping has been shown to reduce time to the onset of labor in women at term but the effects of membrane sweeping in women with a prior cesarean delivery are largely unknown. Objective: To determine the effects of membrane sweeping on promoting labor in patients undergoing a trial of labor after cesarean. Study design: Searches were performed in Medline, Ovid, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials using a combination of keywords related to “membrane sweeping,” “membrane stripping,” “vaginal birth after cesarean,” and “trial of labor after cesarean” from inception of databases until April 2018. Study eligibility criteria: We included all randomized controlled trials (RCTs) of singleton or twin gestations at 36 weeks or greater that evaluated prophylactic or prelabor membrane sweeping in patients undergoing a trial of labor after cesarean. Exclusion criteria were trials that did not include patients with a prior uterine scar or cesarean delivery, or that were studies of membrane sweeping during initiation of induction of labor. Study appraisal and synthesis methods: the primary outcome was the rate of spontaneous labor. Meta-analysis was performed using the random-effects model of DerSimonian and Laird, to produce relative risk (RR) with 95% confidence interval (CI). Results: Two studies met inclusion criteria and were included in our meta-analysis (n = 361). Membrane sweeping did not have an effect on the onset of labor (RR 1.05, 95% CI 0.92–1.20). There was no significant difference for the rate of spontaneous vaginal delivery (RR 1.06, 95% CI 0.84–1.34), operative vaginal delivery (RR 0.97, 95% CI 0.25–3.78), or cesarean delivery (RR 1.00, 95% CI 0.87–1.14). Conclusion: Membrane sweeping in patients planning a trial of labor after cesarean was not found to be effective in promoting the onset of labor. This systematic review highlights the limited data addressing the utility of membrane sweeping for women with prior cesarean delivery.

Timing of Second Stage Pushing Doesn't Affect Spontaneous Vaginal Delivery Rate.

According to this study: Among nulliparous women receiving neuraxial anesthesia, the spontaneous vaginal delivery rate is similar in those who use immediate and delayed pushing approaches during the second stage of labor.

98: Second stage duration and labor outcomes in nulliparous women with neuraxial analgesia

Optimal duration of the second stage should maximize the chance of spontaneous vaginal delivery while minimizing morbidity. We tested the hypothesis that increasing second stage duration is associated with decreased rates of spontaneous vaginal delivery and increased rates of maternal and neonatal morbidity. Planned secondary analysis of data from the Optimizing Management of the Second Stage (OMSS) multicenter randomized trial in which nulliparous women with term pregnancies and neuraxial analgesia were randomly assigned at complete cervical dilation to immediate pushing or delay for 1 hour. The primary outcome was spontaneous vaginal delivery. Secondary outcomes were cesarean, operative vaginal delivery, composite neonatal morbidity, severe perineal lacerations (3rd or 4th degree) and postpartum hemorrhage. Composite neonatal morbidity was defined as occurrence of one or more of: neonatal death, serious birth injury (skull fracture, brachial plexus injury, cephalohematoma), umbilical cord arterial acidosis, respiratory distress, transient tachypnea, meconium aspiration with pulmonary hypertension, hypoxic-ischemic encephalopathy, hypoglycemia, hypothermia treatment, or suspected neonatal sepsis. Multivariable logistic regression was used to estimate adjusted odds ratios for outcomes with each additional hour compared to the first hour. A total of 2404 patients were included; 1200 immediate and 1204 delayed pushing. Rate of spontaneous vaginal delivery was significantly lower beyond 2 hours, with a corresponding increase in operative vaginal delivery and cesarean (Table). Rates of the composite neonatal morbidity and severe perineal lacerations increased nearly 2- fold with second stage duration beyond 3 hours. Rate of postpartum hemorrhage was not significantly different with increasing second stage duration. Among nulliparous women with neuraxial analgesia at term, increased second stage duration is associated with lower rate of spontaneous vaginal delivery and increased rate of maternal and neonatal morbidity especially beyond 3 hours. These findings should inform decisions on acceptable duration of the second stage.

973: Trial of labor after a previous single cesarean delivery in grand multiparous women

The risks and benefits of a trial of labor after previous cesarean delivery (TOLAC) have been studied extensively in past years. Grand-multiparous women (parity≥5) have an a priori increased risk for many of the complications associated with TOLAC, even in the absence of uterine scar, such as uterine rupture, placental abruption, postpartum hemorrhage (PPH), and neonatal morbidity. Yet, the synergetic risk of TOLAC among grand- multiparous women is not well studied as is reflected by lack of guidelines for this subpopulation. Therefore, we aimed to estimate the impact of one previous cesarean delivery on pregnancy and neonatal outcomes among grand-multiparous women attempting a vaginal birth. A retrospective cohort study of all grand-multiparous women with singleton pregnancy at term who delivered at a single, referral, university-affiliated medical center, between 2007 and 2014. Our primary outcome was mode of delivery. Secondary outcomes were uterine rupture. composite maternal morbidity (defined as ≥1 of the following: uterine rupture, postpartum hemorrhage, or postpartum transfusion) and composite neonatal morbidity (defined as ≥1 of the following: mechanical ventilation, respiratory distress syndrome, arterial cord pH<7.05, 5-minutes Apgar score <7, birth asphyxia, hypoxic-ischemic encephalopathy, or neonatal death). Grand-multiparous women with and without one previous cesarean delivery were compared (Figure). During the study period, 2,815 grand-multiparous women met the study criteria. Grand-multiparous women with (n=310, 11.0%) and without (n=2,505, 89.0%) previous cesarean delivery were compared. Baseline characteristic were similar between the groups. The rate of spontaneous vaginal delivery was over 95% in both groups, with no between-group differences, and the rate of cesarean delivery was 2.6% and 1.8% in women with and without previous cesarean delivery, respectively (p=0.31). No cases of uterine rupture were observed in either group. A history of one previous cesarean delivery was not found to affect any of the aforementioned outcomes significantly (Table). Grand-multiparous women with a history of a single previous cesarean delivery have delivery and neonatal outcomes comparable to their counterparts with no previous cesarean delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

175: Perinatal outcomes after implementing a hemorrhage risk assessment at admission

To evaluate the impact of a novel assessment of hemorrhage risk at admission on subsequent perinatal outcomes. This retrospective cohort analysis of a multicenter database included women admitted to labor and delivery from January 2015 to June 2018. A novel nursing assessment developed by Association of Women's Health, Obstetric and Neonatal Nurses was used to categorize patients as low, medium or high risk for hemorrhage. This was implemented 6/1/2016 across the centers. Perinatal outcomes related to blood transfusion, estimated blood loss (EBL) ≥ 1000cc, ICU admission, chorioamnionitis, general anesthesia, oxytocin use and cesarean delivery were evaluated before and after implementation. There were a total of 109,719 women included, with 38,751 women included prior to implementation of the hemorrhage risk assessment and 70,968 women after implementation. Rates of any blood transfusion (0.5 to 0.4%, p=0.02) and EBL ≥ 1000cc (6.3 to 6.0%, p=0.02) were significantly lower after implementation. Incidence of ICU admission, chorioamnionitis and general anesthesia did not change overall in the time period studied. There were higher rates of oxytocin use (83.4 to 85.2%, p<0.0001) and spontaneous vaginal delivery (58.8 to 59.9%, p=0.01). Details on perinatal outcomes are included (Table). After implementation of a hemorrhage risk assessment at admission, we found a 20% reduction in rates of blood transfusion and EBL ≥ 1000cc. Significantly increased oxytocin use was also observed. Further analysis must be done to assess if any other changes could account for these trends.

Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia

It is unclear whether the timing of second stage pushing efforts affects spontaneous vaginal delivery rates and reduces morbidities. To evaluate whether immediate or delayed pushing results in higher rates of spontaneous vaginal delivery and lower rates of maternal and neonatal morbidities. Pragmatic randomized clinical trial of nulliparous women at or beyond 37 weeks' gestation admitted for spontaneous or induced labor with neuraxial analgesia between May 2014 and December 2017 at 6 US medical centers. The interim analysis suggested futility for the primary outcome and recruitment was terminated with 2414 of 3184 planned participants. Follow-up ended January 4, 2018. Randomization occurred when participants reached complete cervical dilation. Immediate group participants (n = 1200) began pushing immediately. Delayed group participants (n = 1204) were instructed to wait 60 minutes. The primary outcome was spontaneous vaginal delivery. Secondary outcomes included total duration of the second stage, duration of active pushing, operative vaginal delivery, cesarean delivery, postpartum hemorrhage, chorioamnionitis, endometritis, perineal lacerations (≥second degree), and a composite outcome of neonatal morbidity that included neonatal death and 9 other adverse outcomes. Among 2414 women randomized (mean age, 26.5 years), 2404 (99.6%) completed the trial. The rate of spontaneous vaginal delivery was 85.9% in the immediate group vs 86.5% in the delayed group, and was not significantly different (absolute difference, -0.6% [95% CI, -3.4% to 2.1%]; relative risk, 0.99 [95% CI, 0.96 to 1.03]). There was no significant difference in 5 of the 9 prespecified secondary outcomes reported, including the composite outcome of neonatal morbidity (7.3% for the immediate group vs 8.9% for the delayed group; between-group difference, -1.6% [95% CI, -3.8% to 0.5%]) and perineal lacerations (45.9% vs 46.4%, respectively; between-group difference, -0.4% [95% CI, -4.4% to 3.6%]). The immediate group had significantly shorter mean duration of the second stage compared with the delayed group (102.4 vs 134.2 minutes, respectively; mean difference, -31.8 minutes [95% CI, -36.7 to -26.9], P < .001), despite a significantly longer mean duration of active pushing (83.7 vs 74.5 minutes; mean difference, 9.2 minutes [95% CI, 5.8 to 12.6], P < .001), lower rates of chorioamnionitis (6.7% vs 9.1%; between-group difference, -2.5% [95% CI, -4.6% to -0.3%], P = .005), and fewer postpartum hemorrhages (2.3% vs 4.0%; between-group difference, -1.7% [95% CI, -3.1% to -0.4%], P = .03). Among nulliparous women receiving neuraxial anesthesia, the timing of second stage pushing efforts did not affect the rate of spontaneous vaginal delivery. These findings may help inform decisions about the preferred timing of second stage pushing efforts, when considered with other maternal and neonatal outcomes. ClinicalTrials.gov Identifier: NCT02137200.

Associations between iron deficiency anemia and clinical features among pregnant women: a prospective cohort study

BackgroundIron deficiency anemia (IDA) during pregnancy is a common and preventable disorder. It remains a contributing factor to maternal morbidity and mortality and is associated with high perinatal mortality rates.ObjectiveTo determine the prevalence of IDA and its associated clinical features among pregnant women.MethodsThis analytical prospective cohort study included 1,579 pregnant women who attended an antenatal clinic, Women’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia, between January 2018 and April 2018. The type of anemia and its associated maternal and fetal outcomes were determined.ResultsAbout 702 women were confirmed to have IDA, with a prevalence of 44.5 %. Most women (79.8%) were younger than 35 years. A low hemoglobin concentration was reported in 45 % of participants. The major type of anemia was microcytic hypochromic anemia (98.7%). More than half of the participants (57.3%) reported use of iron supplementation during pregnancy. IDA anemia was highest in pregnant women with gravidity >8 in 40 (56.3%) compared to normal pregnant women 31 (43.7%), and lowest in those with gravidity ≤2 in 281 (41.4%) compared to normal pregnant women 397 (58.6%). The difference was statistically significant, P=0.024. Similarly, this type of anemia was highest in those with parity of >3 (53.3%) and lowest in nulliparous women (39.3%) compared to normal pregnant women (46.7%) and (60.7%), respectively. This was statistically significant P=0.002. IDA had significantly (P=0.012) lower spontaneous vaginal delivery rates compared with normal pregnant women (44.5% vs 55.5%, respectively). IDA had significantly (P=0.017) lower antenatal fetal distress rates compared with normal pregnant women (68.5% vs 31.5%, respectively).ConclusionAnemia in general and microcytic hypochromic anemia in particular were significantly associated with higher gravidity and parity. The significant outcome associated with IDA during pregnancy was a lower rate of spontaneous vaginal delivery and antenatal fetal distress. Compliance with iron supplementation in order to prevent maternal and fetal adverse outcomes was observed.

413. Comparing patients with inflammatory and non-inflammatory arthritic conditions in pregnancy. A retrospective analysis of a single centre in London. 2012–2015

Introduction Rheumatic conditions are either inflammatory (IA): rheumatoid arthritis (RA), psoriatic arthritis (PSA) and ankylosing spondylitis (AS) or non-inflammatory (NIA): ehlers-danlos (EDS), benign joint hypermobility syndromes (BJHS), fibromyalgia (FM), chronic lower back pain (LBP) and osteoarthritis (OA). Both cause pain but co-morbid IA in pregnancy is historically associated with a higher risk of adverse outcomes for mother and child. Objectives We evaluate our experience of managing women with IA and NIA to highlight differences and similarities. Methods In our unit, pregnant women with rheumatic conditions are reviewed in a joint obstetric-rheumatology clinic. We retrospectively analysed health-records of all patients from 2012–2015, focusing on disease activity, obstetric and neonatal outcomes. Results were analysed in excel. Results 53patients with IA (23:RA, 11:PSA, 10:AS) and 24patients with NIA (9:EDS, 6:BJHS, 6:FM, 1:LBP, 1:OA, 1:congenital hip dysplasia) were identified. 7patients were excluded (incorrect diagnosis or incomplete medical records). Mean age: 33 vs. 31 years and mean gestational age: 38 + 3 vs. 37 + 1 (IA vs. NIA). Despite babies of IA mothers born 1 week later, average birthweight was comparable (3,170 kg vs. 3,130 kg). Spontaneous vaginal delivery (SVDs) rates were significantly higher in IA patients: 75% v. 41.7% (p-value 0.009) and caesarean section rates (CS) higher in the NIA patients: 25% v. 58.8% (p-value 0.009); elective-CS: 10% vs. 38.8% and emergency-CS: 15% v. 20%. Disease activity was lower antenatally (48%:RA, 27%:PSA, 0:AS) compared with post-partum (65%:RA, 54%:PSA, 50%:AS) in IA patients. There were no documented flares in the NIA patients. Discussion Measured outcomes were favourable in both groups are a likely reflection of improvements in IA treatment. Babies of IA mothers were however smaller for dates as compared with NIA. Surprisingly, women with IA were more likely to undergo SVD. This may reflect higher perceptions/fears about pain in NIA patients. To understand these trends better, prospective multi-centre studies are welcome.

Synthetic osmotic dilators in the induction of labour—An international multicentre observational study

To evaluate the effects of synthetic osmotic dilators (Dilapan-S/ Dilasoft) in women who required induction of labour in a large prospective multicentre international observational study. Primary outcomes were duration of Dilapan-S/Dilasoft insertion (hours), total induction - delivery interval (hours) and the rate of vaginal deliveries within 24 h (%). Secondary outcomes were the number of dilators inserted, Bishop score increase after extraction of Dilapan-S/Dilasoft, complications during induction (uterine contractions, uterine tachysystole and hyperstimulation, effect on the fetus) and post induction (infections and neonatal outcomes), agents / procedures used for subsequent induction of labour, immediate rate of spontaneous labours following cervical ripening period, rate of spontaneous vaginal deliveries, rate of instrumental vaginal deliveries and caesarean sections. Total of 543 women were recruited across 11 study sites, of which, 444 women were eligible for analysis. With Dilapan-S/Dilasoft use of <12 h (n = 188) the overall vaginal delivery rate was 76.6% with 45.7% of these births occurring within 24 h, 66% within 36 h and 75.5% within 48 h from insertion of Dilapan-S/Dilasoft. The mean insertion-delivery interval for this group was 24.3(±10.4) hours. With Dilapan-S/Dilasoft use of >12 h (n = 256), the overall vaginal delivery rate was 64.8%, with 16% of these births occurring within 24 h, 48.4% within 36 h and 54.7% within 48 h from insertion of Dilapan-S/Dilasoft. The mean insertion-delivery interval for this group was 39.1(±29.2) hours. The mean gain in the Bishops score was +3.6(±2.3). The mean number of Dilapan-S/Dilasoft dilators used was 3.8 (±1.1). The overall rate of caesarean section was 30.1%. The overall complication rate was low including infection risk. No adverse neonatal outcome was attributable to the use of Dilapan-S/Dilasoft. Dilapan-S/Dilasoft are safe and effective methods for cervical ripening. Their use is associated with low maternal and neonatal complication rates. Future research should aim at level I clinical trials comparing Dilapan-S to other mechanical or pharmacological cervical ripening agents. https://clinicaltrials.gov/ct2/show/NCT02318173.