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OBSTETRICS Volume 63, Number 4


Copyright © 2008 by Lippincott Williams & Wilkins

Postpartum Urinary Retention After

Cesarean Delivery
C. C. Liang, S. D. Chang, Y. L. Chang, S. H. Chen, H. Y. Chueh,
and P. J. Cheng
Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of
Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; and Chang Gung University, Taoyuan, Taiwan
Int J Gynecol Obstet 2007;99:229–232

Reported rates of postpartum urinary retention (PUR) following vaginal delivery range as high as 18%, but the risk
of PUR associated with cesarean delivery is difficult to determine because of the effects of surgery and anesthesia on
postpartum bladder function and also because there is no consensus on what constitutes PUR. In this study, PUR was
diagnosed when ultrasonography demonstrated a postvoid residual bladder volume (PVRBV) of 150 mL or greater.
Participating in this prospective study were 605 pregnant women having cesarean section. The PVRBV was estimated
ultrasonically after first micturition.
The overall incidence of PUR following cesarean delivery was 24.1%. The incidence of overt PUR, when no spontaneous
micturition took place 6 hours after removal of the catheter and patients developed symptoms of obstructed voiding such as
incomplete emptying, straining, and difficulty voiding, was 7.4%. Covert PR, with no associated urinary symptoms despite
an elevated PVRBV, was more than twice as frequent (16.7%). Factors significantly associated with PUR included
postoperative epidural morphine administration, multiple pregnancy, and a low body mass index at the time of delivery. After
3 months of follow-up, 5% of patients had obstructive voiding symptoms and 9.1% had irritative voiding symptoms.
Differences in the frequency of voiding problems between the PUR and normal groups were not statistically significant.
Nearly one-fourth of these patients developed PUR following cesarean delivery. The chief contributing factor was the
use of morphine for postoperative analgesia. When transient and diagnosed at an early stage, PUR did not compromise
urinary function and was not associated with subsequent voiding problems.

(In the immediate puerperium, most women covert urinary retention. All covert cases had
are predisposed to incomplete bladder empty- resolved by the fourth postpartum day (long-
ing and some are unable to void spontaneously. term follow-up on the overt cases was not pro-
This difficulty may rapidly lead to bladder over- vided). The duration of both the first and second
distension, as many women will have received a stage of labor were positively correlated with the
large volume of intravenous fluid during labor or risk of urinary retention. Ching-Chung et al (Aust
in preparation for cesarean, and almost all will N Z J Obstet Gynaecol 2002;42:365) reported
have received oxytocin for labor stimulation or immediate postpartum urinary retention in 4%
to prevent postpartum hemorrhage. When the of 2866 term women delivered vaginally. In uni-
oxytocin is discontinued and its antidiuretic ef- variable analyses, they found that nulliparity,
fects abate, the bladder quickly fills. longer labor course, instrumental delivery, ex-
Yip et al (Acta Obstet Gynecol Scand 1997; tensive vaginal and perineal lacerations, and
76:667) reported a 4.9% rate of overt postpar- epidural analgesia were associated with urinary
tum urinary retention among 691 women who retention. They did not perform multivariable
were delivered vaginally, and a 9.7% rate of analysis. On long-term follow-up, 3 of 114 women
Physiology & Pathophysiology of Pregnancy, Labor, & Puerperium 203

had persistent urinary symptoms. Based on ob- retention was 7.4% and the rate of covert reten-
stetric database review, Carley et al (Am J Obstet tion was 16.7% among 605 women who under-
Gynecol 2002;187:430) reported a much lower went cesarean delivery for a broad variety of
(0.5%) rate of overt postpartum urinary retention in indications. Ten percent of women required
over 11,000 women who underwent vaginal deliv- catheterization to resolve their voiding dysfunc-
ery at the Mayo Clinic. In their study, only 2 factors tion. Women who received epidural morphine
were independently associated with urinary reten- for postpartum pain control had a more than
tion: regional anesthesia (odds ratio, 15) and op- doubled risk of urinary retention. Almost cer-
erative delivery (odds ratio, 3). In 80% of cases, the tainly the effect of the morphine persisted
voiding dysfunction had resolved by hospital beyond Foley removal in these women. Unfor-
discharge. tunately, we are not provided with rates of uri-
How and when postpartum urinary retention is nary retention by specific cesarean indication or
defined will obviously influence the frequency by other labor and delivery characteristics.
with which it will be diagnosed, particularly in Regardless of the precise rates, to varying
the setting of regional anesthesia, and espe- degrees all women are at risk of postpartum
cially after cesarean delivery, where the density urinary retention and bladder over-distention
of the anesthetic block is typically more pro- and should be observed accordingly, because
found than after vaginal delivery. The deeper or in extreme cases, lasting damage to the bladder
more long-lasting the regional block, the greater may occur. A markedly over-distended bladder
the risk of urinary retention. Likewise, if the in- may be palpable above the symphysis pubis
dwelling Foley catheter is removed before the and may displace the uterine fundus into the
effect of the block has abated, urinary retention upper abdomen. Inability to void 4 to 6 hours
is more likely, because the bladder can become after delivery or Foley catheter removal is ab-
distended before sensation has returned. When normal and likely indicates a problem. If bladder
ultrasound is used to diagnose urinary retention, over-distension is diagnosed, intermittent cath-
rates are higher than when the diagnosis is eterization may resolve it, but often, placing an
made on clinical grounds. indwelling catheter for 24 hours is the best
In the abstracted Liang study (which utilized course of action as this will allow tone and sen-
ultrasound), the rate of overt postpartum urinary sation to return to the bladder.—DJR)
204 Obstetrical and Gynecological Survey

Cognitive Function and Army Rejection

Rate in Young Adult Male Offspring of
Women With Diabetes: A Danish
Population-Based Cohort Study
Gunnar Lauge Nielsen, Claus Dethlefsen, Henrik Toft Sørensen,
Jan Fog Pedersen, and Lars Molsted-Pedersen
Department of Clinical Epidemiology, Aalborg University Hospital, Aalborg, Denmark; Center for
Cardiovascular Research, Aalborg Hospital, Aalborg, Denmark; Department of Radiology, Glostrup
University Hospital, Glostrup, Denmark; and Diabetes Centre, Department of Obstetrics, Rigshospitalet,
Copenhagen University Hospital, Copenhagen, Denmark
Diabetes Care 2007;30:2827–2831

Perinatal complications are more frequent in cases of maternal diabetes, but little is known about the long-term
intellectual outcome of offspring born to diabetic mothers. This study followed a cohort of Danish males born in the
years 1976–1984 whose mothers were diabetic. These 282 subjects were followed up to the time of military conscription
along with 870 population-based control subjects. The instrument used to gauge intelligence was the Boerge-Prien test,
a 45-minute validated measure whose results correlate closely with those obtained using the Wechsler Adult Intelligence
The rejection rate was 52.5% for diabetes-exposed subjects and 45.4% for control subjects. The risk difference was
7.3%, with a 95% confidence interval (CI) of 0.6 to 14.01. Analysis of the medical reasons for rejection failed to disclose
diagnoses that could be related to cognitive performance. Among those who were not rejected, mean cognitive scores
were 41.4 units (95% CI, 40.2–42.6) in diabetes-exposed individuals and 42.7 units (95% CI, 42.0–43.4) in control
subjects. The findings were not altered when stratifying subjects by gestational age at birth or Apgar score. In a subgroup
of 39 pregnancies with available data, a 1% point increase in maternal AIC (glycosylated hemoglobin) was associated
with a 2.6% point decrease in cognitive score (95% CI, 1.8–4.8). Men whose maternal AIC was less than 7% had
cognitive scores identical to those of control subjects.
These findings point to a real, if minor, reduction in intelligence in young adult males whose mothers are diabetic.
The negative association between AIC and cognitive scores stresses the need to strive for optimal metabolic control in
diabetic women who are—or are planning to become—pregnant.

(Especially at the beginning and at the end of opmental effects on the fetus and, if so, whether
pregnancy, poorly controlled diabetes can have these effects are persistent.
dire fetal consequences. During embryogenesis, In attempt to shed light on these questions,
hyperglycemia can cause severe anomalies of the Ornoy et al (Arch Dis Child Fetal Neonatal Ed
fetal heart, central nervous system, and the geni- 1998;79:F94) assessed 57 children born to
tourinary tract, and during the first trimester, hy- pregestational diabetic mothers and 57 con-
perglycemia raises the risk of miscarriage. Later in trol children born to mothers without diabetes.
pregnancy, hyperglycemia promotes excessive On average, children in both groups were 8
fetal growth and increases the risk of stillbirth. years old. Those born to diabetic mothers had
These effects alone provide a compelling rationale lower gross and fine motor functioning (although
for the avoidance of hyperglycemia during preg- the differences were not dramatic) but equal cog-
nancy. A somewhat broader question, however, is nitive functioning to the control children. The dif-
whether diabetes per se, or diabetes when it is ferences in motor function were more pronounced
poorly controlled, exerts more subtle neurodevel- at ages 5–6 than at ages 9–12.
Preconception and Prenatal Care 205

Rizzo and Silverman et al performed a series adult male offspring of diabetics was higher,
of studies in which they assessed the relation- 53% versus 45%. Most of this difference, how-
ship of metabolic control during pregnancy in 94 ever, was due to nonneurological chronic health
pregestational diabetic women and the psy- problems. Cognitive scores were not statisti-
chomotor functioning of their offspring at ages 6 cally significantly different between the 2 groups.
to 9. They found that the fasting plasma glucose Among the offspring of diabetics, a maternal
concentration and the degree of ketonemia hemoglobin A1C value greater than 7% was as-
were positively associated with impaired intel- sociated with the equivalent of an 8.4 point IQ
lectual and motor functioning (Am J Obstet Gy- decrement, whereas values less than or equal to
necol 1995;173:1753; Diabetes Care 1998;21: 7% were associated with equivalent IQ scores to
B142). This impairment, however, was mild, and controls. However, these associations may be bi-
metabolic control accounted for only a small ased, as hemoglobin A1C values were available
proportion of it. Moreover, as a group, the mea- for only 39 of 227 mothers; these 39 mothers might
sured intelligence of the 94 children was normal, not be representative, and we are not told when in
and their educational achievement and behav- gestation the hemoglobin A1C was measured.
ioral adjustment were unrelated to indices of In summary, if poorly controlled, maternal
maternal metabolic control during pregnancy. diabetes may have negative long-term neurode-
The abstracted study of Nielsen et al de- velopmental consequences for the fetus, al-
scribes the largest cohort of offspring who have though the available literature is not entirely
been assessed for the potential neurodevelop- consistent on whether cognition or coordination
mental consequences of in utero exposure to is affected and what, precisely, is the degree of
diabetes. Moreover, the period of follow-up of risk. Striving to achieve good glucose control
this cohort is the longest, and ascertainment is during pregnancy already has ample rationale,
the most complete. Compared to controls, the and perhaps the abstracted study of Nielsen
overall army rejection rate among the young adds to it.—DJR)
206 Obstetrical and Gynecological Survey

Single-Dose Tenofovir and Emtricitabine

for Reduction of Viral Resistance to
Non-nucleoside Reverse Transcriptase
Inhibitory Drugs in Women Given
Intrapartum Nevirapine for Perinatal
HIV Prevention: An Open-Label
Randomized Trial
Benjamin H. Chi, Moses Sinkala, Felistas Mbewe, Ronald A. Cantrell,
Gina Kruse, Namwinga Chintu, Grace M. Aldrovandi, Elizabeth M. Stringer,
Chipepo Kankasa, Jeffrey T. Safrit, and Jeffrey S. A. Stringer
Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Schools of Medicine and Public Health,
University of Alabama, Birmingham; Missions Board, Lusaka, Zambia; Saban Research Institute, Keck
School of Medicine, University of Southern California, Los Angeles; University Teaching Hospital, Lusaka,
Zambia; and Elizabeth Glaser Pediatric AICS Foundation, Santa Monica, California
Lancet 2007;370:1698–1705

Administration of single-dose nevirapine intrapartum and neonatally is essential for preventing perinatal HIV in
settings where resources are limited. But after a single dose, a substantial proportion of women become resistant to
nonnucleoside reverse transcriptase inhibitors. The present randomized study was an attempt to learn whether adding
a combination of the antiretroviral drugs tenofovir disoproxil fumarate and emtricitabine would lessen the emergence
of resistance in the weeks following treatment. Of 400 HIV-infected pregnant women cared for at 2 primary health
facilities in Zambia, one was excluded. Two hundred were randomly assigned to receive a single oral dose of 300 mg
tenofovir with 200 mg emtricitabine under direct observation. The remaining 199 women received neither of these
drugs. All the women were offered a brief course of zidovudine as well as intrapartum nevirapine. The major outcome
was resistance to nonnucleoside reverse transcriptase inhibitors 6 weeks after delivery.
Women who received the intervention were 53% less likely than control women to have a mutation conferring
resistance to nonnucleoside reverse transcriptase inhibitors 6 weeks after delivery. The risk ratio was 0.47, with a 95%
confidence interval of 0.29–0.76. The overall rate of perinatal HIV transmission was similar in the intervention and
control groups (5.6% and 8.0%, respectively). This held true for both intrauterine transmission and intrapartum or early
postpartum transmission. Four women in each group were anemic in the postpartum period. Serious adverse events were
recorded for 10% of infants in the intervention group and 12% of control infants. Septicemia and pneumonia were the
most common problems. None of these events was thought to have resulted from the intervention.
A single dose combining tenofovir and emtricitabine, given at the time of delivery to HIV-infected women,
substantially reduced the frequency of resistance to nonnucleoside reverse transcriptase inhibitors 6 weeks postpartum
in this study. The investigators believe that this can be an important adjunct to intrapartum nevirapine in circumstances
where several days of combination drug treatment may not be feasible.


(In a fairly recent SURVEY, I discussed that a HIV by almost half, from 25% to 13% at 14–16
single maternal dose of oral intrapartum nevi- weeks of age (2007;62:361). The distinct advan-
rapine, followed by single infant dose, reduces tage of this intervention is its low price and
the rate of mother to child transmission of simplicity; it is feasible in even the most impov-
Management of Labor, Delivery, and the Puerperium 207

erished and underdeveloped settings. The dis- offers a 2-drug intervention of short course oral
advantage, however, is that 20%–75% of zidovudine (300 mg BID from 32 weeks’ gestation)
women who receive single-dose NVP therapy “boosted” with intrapartum and neonatal single-
develop transient genotypic resistance to the dose nevirapine. In clinical trials, this combination
nonnucleoside reverse transcriptase inhibitor regimen reduced the rate of perinatal HIV trans-
(NNRTI) class of antiretroviral drugs. This resis- mission to 2% (Lallemant M et al. N Engl J Med
tance is most consequential for women who go 2004;351:217).
on to initiate NNRTI-containing antiretroviral The appeal of Chi et al’s approach to the
therapy within 6–12 months of the initial nevi- prevent NNRTI resistance is its simplicity. Like
rapine exposure (Lockman S et al. N Engl J Med nevirapine, the tenofovir and the emtricitabine
2007;356:135). are administered orally and in fact, are co-
The question then becomes how to derive the formulated as a single tablet (Truvada) by Gilead
benefits of perinatal HIV prevention that nevi- Sciences, USA. The single dose used in the
rapine provides without compromising the sub- study, given at presentation for labor, was with-
sequent treatment and health of the mother? In out demonstrable side effects. Most impor-
the abstracted study, Chi et al have addressed tantly, it was fairly effective: in the control group,
this question. Their study also provides insight 25% of women had NNRTI resistance at 6
into the continuing evolution of perinatal HIV weeks, versus 12% of women in the tenofovir/
prevention in the developing world. In Lusaka, emtricitabine group. The goal, of course, would
Zambia, where Chi et al’s study was conducted, be no resistance, and approaching this goal is
1 in 5 pregnant women are HIV seropositive, likely feasible, but will require further studies of
and in the absence of preventive efforts, 40% alternate strategies, e.g., administration of an
would transmit the infection to their offspring. additional postpartum dose.
Before 2001, perinatal HIV prevention inter- In the face of a disease pandemic that al-
ventions were not available in the public most demands pessimism, legitimate progress is
sector. Since then, however, a city-wide and being made in preventing perinatal transmission
progressively robust program has been imple- and, more recently, in effectively treating adult and
mented. As of October 2007, it had tested pediatric HIV infection in low-resource settings
over 280,000 women for HIV and provided (Stringer JSA et al. JAMA 2006;296:782; Bolton-
perinatal prophylaxis to 57,000. More recently, as Moore et al. JAMA 2007;298:1888). The intersec-
additional resources have become available tion of the 2, as illustrated by the study of Chi, will
through the US President’s Emergency Plan for require creative strategies that balance effective-
AIDS Relief and the Global Fund to Fight AIDS, ness, capacity for intervention and sustainability,
TB, and Malaria, the capacity of the health care ease of implementation, and cost. I am proud of
system to provide more complex and efficacious my colleagues and of their colleagues for tak-
regimens has expanded. The Lusaka District now ing on these daunting challenges.—DJR)
208 Obstetrical and Gynecological Survey

Change in Knowledge of Midwives and

Obstetricians Following Obstetric
Emergency Training: A Randomized
Controlled Trial of Local Hospital,
Simulation Centre and Teamwork
J. F. Crofts, D. Ellis, T. J. Draycott, C. Winter, L. P. Hunt,
and V. A. Akande
SaFE Study, Department of Obstetrics and Gynaecology, Southmead Hospital, North Bristol NHS Trust,
Bristol, United Kingdom; and University Department of Clinical Sciences at South Bristol, Institute of Child
Life and Health, UBHT Education Centre, Bristol, United Kingdom
BJOG 2007;114:1534–1541

Surveys in the United Kingdom have repeatedly discovered substandard care in significant proportions of maternal,
fetal, and neonatal deaths. In the United Kingdom, training in obstetrical emergencies is carried out both nationally and
locally in maternity units. This prospective, randomized controlled trial evaluated training in 6 hospitals in the United
Kingdom. The 140 participants included 22 junior and 23 senior doctors as well as 47 junior and 48 senior midwives.
They were randomized to one of 4 obstetrical emergency training interventions: a 1-day course at a local hospital, a
1-day course at a simulation center, a 2-day course with teamwork training at a local hospital, and a 2-day course with
teamwork training at a simulation center. A 183-question multiple choice questionnaire (MCQ) was completed up to 3
weeks before the training intervention and again 3 weeks after the intervention.
All but 7 of the 140 participants completed training and the posttraining assessment. Knowledge of obstetrical
emergency management increased following training. The increase in the mean MCQ score was significant at the P ⬍
0.001 level. All but 10 of 133 participants who completed both assessments had increased MCQ scores. Neither the
location of training nor the inclusion of teamwork training significantly influenced posttraining scores. Changes in MCQ
scores after training correlated negatively with pretraining scores. There were, however, no significant differences
between staff groups in their relative responses to the 4 training interventions. With one exception—management of
breech presentation—scores for individual components of the MCQ improved significantly.
This is the first study demonstrating objective improvement in what doctors and midwives know following training
in obstetrical emergency management. It remains to be determined whether this translates into lower maternal and
neonatal morbidity and mortality rates. The investigators believe that all relevant staff should take part in this type of
training on an annual basis.

(In 3 prior SURVEY commentaries, I have dis- training was associated with improved Apgar
cussed various aspects of focused training and scores and a lowered incidence of hypoxic isch-
its relationship to obstetric outcomes. Initially, I emic encephalopathy, but the before/after non-
reviewed the study of Draycott et al, which was randomized study design was less than optimal.
the first to provide a description of a training In another commentary, I reviewed the study
program for the management of acute obstetric of Maslovitz et al, wherein obstetric emergen-
emergencies and an assessment of the possible cies including eclampsia, postpartum hemorrhage,
impact of the program on actual health outcomes shoulder dystocia, and breech presentation
(BJOG 2006;113:201; SURVEY 2006;6:365). The were simulated with the use of high-tech man-
Management of Labor, Delivery, and the Puerperium 209

nequins, the management of these emergencies fact that the primary outcome was not very
by trainees videotaped, and then the videotapes ambitious—improved written test performance.
reviewed by senior clinicians who provided graded Actual improvements in clinical care delivery or,
feedback (Obstet Gynecol 2007;109:1295; SURVEY even better, improved clinical outcomes were
2007;10:636). When reassessed 6 months or well beyond the scope of this study.
more after training, the scores of the trainees It is my sense that the momentum for focused
were higher than they were before. Whether the training in obstetric care and in the management
training was associated with improved actual of obstetric emergencies is building. Teamwork
care or outcomes was not addressed in this training has an intuitive, feel-good appeal, and
study. simulation training a modern, technological al-
In a third commentary, I reviewed the team- lure. Both have financial backers. These traits,
work training trial of Neilsen et al (Obstet Gy- however, are not sufficient justification for the
necol 2007;109:48; SURVEY 2007;5:294). This widespread adoption of these training modali-
was a large and well-done cluster randomized ties. A properly designed, conducted, and ana-
study that included 15 hospitals and 28,536 de- lyzed randomized clinical trial would be. The
liveries. Teamwork training was not effective, that focus of such a trial should be actual clinical
is, it did not lower the rate of a wide variety of outcomes, for example, a reduction in the rate
adverse maternal or neonatal outcomes that were of brachial plexus injury or hypoxic ischemic
aggregated into an “Adverse Outcome Index.” encephalopathy, not simply improved test scores,
The abstracted trial of Crofts et al is another or process measures such as the performance of
recent attempt to assess the effect of obstetric proper shoulder dystocia maneuvers. Somehow,
emergency training and, additionally, compare the trial would have to reconcile maternal and
the relative effectiveness of 4 means of deliver- perinatal outcomes and find a way to balance
ing it. Training did improve the performance of them. For example, prelabor cesarean would re-
the trainees on a multiple choice test of knowl- sult in fewer brachial plexus injuries and presum-
edge, but no one method of training was supe- ably fewer asphyxiated neonates, but in many
rior in this regard to any of the others. The main cases would not be in the best interests of the
strength of this study is its randomized design. mother. Clearly, the trial would be a very difficult
Its main weaknesses are its small size and the undertaking, but now is the time for it.—DJR)

The Effect of Hyoscine Butylbromide on the

First Stage of Labor in Term Pregnancies
L. A. Samuels, L. Christie, B. Roberts-Gittens, H. Fletcher,
and J. Frederick
Department of Obstetrics, Gynecology and Child Health, University of the West Indies, Kingston,
Jamaica, West Indies
BJOG 2007;114:1542–1546

An example of actively managing labor is intravenous administration of hyoscine (scopolamine) butylbromide, which
has spasmolytic effects on smooth muscle of the genitourinary and gastrointestinal tracts. How this substance shortens
the duration of labor is not understood. This randomized, double-blinded, controlled trial, undertaken in Jamaica, West
210 Obstetrical and Gynecological Survey

Indies, compared IV hyoscine with a placebo, administered once active labor began. Sixty hyoscine-treated women were
compared with 69 placebo recipients. All participants were 18 years of age or older, were at term, and had no chronic
or pregnancy-induced disorders. The dose of hyoscine was 20 mg.
The duration of the first stage of labor declined from 228 minutes in control women to 156 minutes in hyoscine-
injected women, a reduction of 31.7%. There was no significant change in duration of either the second or third stage
of labor. The treatment and control groups did not differ with regard to blood loss or Apgar scores. Cesarean deliveries
were slightly but not significantly more frequent in women taking hyoscine (6.7% vs. 4.3%).
The investigators conclude that hyoscine butylbromide (Buscopan) significantly shortens the first stage of labor
without apparent adverse effects on either the mother or newborn infant.

(Hyoscine-N-butylbromide (HBB) is a semi- lines. All women were in spontaneous labor at
synthetic derivative of scopolamine, but, un- term. Women in the experimental group re-
like its parent compound, it does not cross the ceived 20 mg of intravenous HBB at a cervical
blood brain barrier. Peripherally, because of dilation of 4 to 5 cm. The first stage of labor in
its anticholinergic effects, it inhibits smooth the 29 nulliparas in the HBB group lasted 176
muscle contractions in the genitourinary, bili- minutes, versus 257 minutes in the 34 nulliparas in
ary, and gastrointestinal tracts. Apparently, it the control group—a difference of approximately
is employed on a fairly widespread basis in 1 hour and 20 minutes. The respective durations
some regions of the world to hasten the pro- of the first stage of labor among parous women
gression of labor by overcoming cervical were 137 and 200 minutes—a difference of ap-
“spasm.” proximately 1 hour. As in the Sirohiwal study, the
High-quality evidence that HBB does in fact duration of the second and third stages did not
hasten labor or that it is safe is limited. In a differ between groups, and other assessed mater-
recent study, Sirohiwal et al (Aust N Z J Obstet nal and neonatal outcomes were equivalent.
Gynecol 2005;45:128) allocated 200 alternate Of 142 randomized women, 13 were subse-
women in spontaneous labor at term with sin- quently excluded due to “inappropriate selec-
gleton fetuses and intact membranes to two 10 tion.” I am not sure what this means, but,
mg HBB rectal suppositories or to standard according to the intention to treat principle, they
care. The first stage of labor in the 50 nulliparas should have been included and analyzed as al-
in the HBB group lasted 142 minutes, versus located. Nor are we told when they were ex-
434 minutes in the 50 nulliparas in the control cluded. If it was after the data were unblinded,
group—a statistically significant and whopping the potential that bias was introduced by their
difference of almost 5 hours! The respective exclusion is greater. Another limitation of the
durations of the first stage of labor among study is its small size. Because the rate of ad-
parous women were 106 and 302 minutes—a verse outcome for infants delivered at term to
31⁄4-hour difference. The durations of the sec- healthy mothers is low, hundreds, if not thou-
ond and third stages did not differ between sands, must be studied to confidently exclude
groups, and neonatal outcomes were excel- harmful effects from an intervention.
lent and equivalent between groups. Limita- Before seeing the abstracted article of Samuels,
tions of this study include the nonrandomized I had never heard of hyoscine-N-butylbromide.
and nonblinded treatment allocation and lack The available literature suggests that HBB is effi-
of data on the clinical comparability of the 2 cacious and safe. That literature, however, is not
study groups. overwhelming, and the utility of HBB seems to be
The abstracted study of Samuels et al appears premised on its ability to prevent or alleviate “cer-
to be the best evaluation of HBB to date. It is vical spasm,” specifically smooth muscle spasm.
randomized, placebo-controlled, and double- Yet smooth muscle is a minority component of
blinded. The sample size was prespecified, and, the cervical stroma. Thus, I would like to see
importantly, labor was managed consistently for additional studies of HBB that are larger and
all study participants according to clear guide- rigorous.—DJR)
Home Birth; Obstetric Care by Midwife; Low Risk Deliveries 211

Evaluation of 280,000 Cases in Dutch

Midwifery Practices: A Descriptive Study
M. P. Amelink-Verburg, S. P. Verloove-Vanhorick, R. M. A. Hakkenberg,
I. M. E. Veldhuijzen, J. Bennebroek Gravenhorst, and S. E. Buitendijk
TNO Quality of Life, Netherlands Organization for Applied Scientific Research TNO, Leiden, Netherlands;
Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands; and Independently
Practicing Midwife
BJOG 2007

Over the past decade, an estimated 30% of Dutch infants have been born at home. Care in early pregnancy is delivered
primarily by independently practicing midwives, and in the absence of complications, this continues into the postpartum
period. This descriptive study, based on a database covering 95% of midwifery care and 80% of all Dutch pregnancies
in the years 2001–2003, was an attempt to determine the frequency and outcome of pregnancies referred intrapartum
from primary to secondary care. The study population consisted of 280,097 low-risk women who, at the outset of labor,
were solely cared for by a primary-level midwife with the intent to deliver either at home (62% of evaluable cases) or
in hospital (29%).
More than two-thirds of women in this study (68.1%) completed childbirth under the exclusive care of a midwife.
Another 28.3% were referred to secondary care without urgency, and 3.6% were referred urgently. The chief indications
for urgent referral were fetal distress and postpartum hemorrhage. Neonatal factors were implicated in 0.4% of cases.
Nearly three-fourths of nonurgent referrals were made during the first stage of labor. Women who had planned home
delivery were referred to secondary care less often than those planning hospital delivery (29.3% vs. 37.2%). In the
overall study population, the mean 5-minute Apgar score was 9.7 and the peripartum neonatal mortality rate was 0.05%.
No maternal deaths were recorded. Adverse neonatal outcomes were most prevalent in urgently referred cases and next
most frequent in nonurgent referrals.
These findings suggest than a system of obstetrical care based on risk assignment by midwives can work well. Further
study will be needed to learn whether outcomes would improve with earlier referrals, or whether some referrals in the
present series were unnecessary.


(The authors of this study evaluated the Dutch legislative action implies that the United States
obstetric system, in which midwives determine is moving toward a system similar to that in the
which low-risk pregnancies can be safely deliv- Netherlands, there is at least one major difference
ered at home and which require referral to a between the 2 countries; the midwives who pro-
hospital for care by a physician, and concluded vided the care examined in the Amelink-Verburg
that the system is a good one, resulting in home study were trained and licensed professionals,
delivery of approximately 30% of all pregnan- participating in a countrywide perinatal database.
cies with a peripartum mortality rate of 0.05%. The midwives who successfully campaigned for
These data support the concept that delivery in home delivery in Virginia and Missouri are lay mid-
a medical facility may be unnecessary for some wives, despite their professional-sounding name.
low-risk women. Certified professional midwives (CPMs) are
Home delivery is currently a hot topic in many “direct entry” midwives, meaning that they do
states in the United States (ACOG State Legis- not go to nursing or midwifery school or take
lative Update—Year in Review, August 2007). In any kind of formal certification exam, but di-
2005, Virginia legalized home births attended by rectly become midwives through self-study and
“certified professional midwives,” and Missouri apprenticeship with another CPM. These mid-
passed a similar law this year. Although this wives should not be confused with certified nurse
212 Obstetrical and Gynecological Survey

midwives, who train as nurses and then go to 5418 low-risk home births attended by CPMs,
midwifery school, or with “certified midwives” the intrapartum and neonatal mortality rate was
(CMs), who undergo 3 years of university-affiliated 0.17%, more than 3 times higher than that re-
midwifery training; both nurse midwives and CMs ported in the Amelink-Verburg study, and similar
must take a formal science curriculum and have a to the prenatal mortality rate of all pregnancies
specified amount of clinical experience, and then (both high risk and low risk) at term in the United
sit for a formal certification exam. Surprisingly, the States (National Vital Statistics Reports, Vol 55,
21 states that currently offer midwifery licensure to No 6, Feb 21, 2007).
attend home births require the CPM rather than Amelink-Verburg and colleagues concluded
the CM or nurse midwife credential (ibid), even that risk selection is a crucial element of the
though CPMs have no formal training and usually Dutch obstetric system. Being able to correctly
have no collaborative relationship with an obste- identify risk and determine the best therapy for
trician gynecologist. Although ACOG actively sup- high-risk patients requires training, experience,
ports collegial relationships—based on mutual and continued lifelong education—all of which
trust, respect, and adherence to appropriate prac- are included only in certified nurse midwife and
tice guidelines—between practicing obstetricians CM training in the United States. The investiga-
and both CMs and certified nurse midwives, tors also stressed that a major factor making
ACOG does not support relationships with CPMs home delivery safe for certain patients is close
(ACOG Joint Statements of Practice Relationships proximity to a hospital; they point out that the
Between Obstetrician Gynecologists and Certified Netherlands is a densely populated country,
Nurse Midwives, Oct 1, 2002). where the distance between most patient’s
What will be the result of an increased number homes and the nearest hospital is short and the
of home deliveries in the United States attended average time from the phone call asking for
by lay midwives? Many leaders in our specialty transport until arrival in the hospital is only 45
fear that these practitioners will not be able to minutes. Many of the states in the United States
correctly classify pregnancies as low risk, and that have legalized home births by CPMs in-
will not recognize when more specialized care is clude large rural areas where the nearest hos-
needed. Importantly, even if they do correctly pital may be hours away.
determine that urgent transfer to a hospital for The Amelink-Verburg study endorses home
care by an obstetrician is necessary, the fact delivery of low-risk women by trained and li-
that CPMs usually do not have collaborative censed midwives in a country where transport
relationships with obstetricians means that they to a hospital is usually swift. These data cannot
won’t have a designated provider to refer their be extrapolated to the United States, where
patients to; in most cases, women who experi- home births may be attended by midwives with
ence fetal stress, bleeding, or any of a number no formal training, and in locations hours from
of life-threatening intrapartum complications will the nearest hospital. Obstetricians who are con-
simply be sent to the local emergency room. It cerned about the current evolution of home birth
seems likely that the perinatal mortality rate for in the United States should consider getting
such women will be high. In a recent US study of involved in local legislation.—KDW)
Preterm Birth; Macrosomia; Cardiovascular Disease 213

Inflammation and Dyslipidemia Related

to Risk of Spontaneous Preterm Birth
Janet M. Catov, Lisa M. Bodnar, Roberta B. Ness, Stacy J. Barron,
and James M. Roberts
Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania; Magee Women Research
Institute, Pittsburgh; Department of Obstetrics, Gynecology, and Reproductive Sciences, University of
Pittsburgh; and Department of Biology, Emory University, Atlanta, Georgia
Am J Epidemiol 2007;166:1312–1319

There is epidemiological evidence suggesting that women who deliver preterm infants are at a 2- to 3-fold increased
risk of cardiovascular disease later in life. Excessive inflammation in both early and late gestation is one possible
explanation, and may be associated with dyslipidemia early in the course of gestation in women who subsequently have
spontaneous preterm birth (sPTB).
These associations were tested in a nested case-control study which utilized data from the Pregnancy Exposures and
Preeclampsia Prevention Study, carried out in the years 1997–2001. Case women had sPTB at 34 to 37 weeks’ gestation
(n ⫽ 76) or before 34 weeks (n ⫽ 33). The control group included 228 randomly chosen women having term births.
Early pregnancy inflammation was reflected by a C-reactive protein (CRP) level of 8 ␮g/mL or higher, and dyslipidemia
by a cholesterol level exceeding 230 mg/dL or a triglyceride level greater than 140 mg/dL. All these measurements were
made on serum drawn before 21 weeks’ gestation.
On logistic regression analysis adjusting for race, body mass index, periconceptional vitamin use, and gestational age
at the time of sampling, the 2 factors independently associated with sPTB at 34 to 37 weeks’ gestation were
inflammation early in pregnancy (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.1–7.2) and dyslipidemia (OR,
2.0; 95% CI, 1.0–4.2). The presence of both these conditions together increased the risk of sPTB before 34 weeks’
gestation by 6.4 fold (95% CI, 1.7–24.1). Half of all women with inflammation in early pregnancy had elevated CRP
levels late in gestation. Each of these factors was independently associated with the risk of sPTB before 34 weeks’
These findings support the view that inflammation and dyslipidemia early in pregnancy are independently associated
with the risk of sPTB. The risk appears to be especially high if inflammation is present both early and late in the course
of pregnancy.

EDITOR’S NOTE: See the combined discussion after the following abstract.
214 Obstetrical and Gynecological Survey

Associations of Prepregnancy
Cardiovascular Risk Factors With the
Offspring’s Birth Weight
Pål R. Romundstad, George Davey Smith, Tom I. L. Nilsen, and Lars J. Vatten
Department of Public Health, Norwegian University of Science and Technology, Trondheim, Norway;
and Department of Social Medicine, University of Bristol, Bristol, United Kingdom
Am J Epidemiol 2007;166:1359–1364

Previous studies have related cardiovascular risk factors—estimated before pregnancy—to birth weight, and also have
found an association between low birth weight and an increased risk of maternal cardiovascular death. This study used
linear regression analysis to prospectively examine associations between blood pressure and blood lipid levels measured
before conception, and birth weight adjusted for gestational age of the offspring. The study population included 3461
women whose deliveries were listed in the Medical Birth Registry of Norway up to the year 2005. Participants had a
mean age of 30.2 years at the time of delivery.
After adjusting for age, smoking status, height, parity, socioeconomic status, and prepregnancy body mass index, high
maternal systolic blood pressure was associated with low birth weight for gestational age. A similar but less marked
association was found between low birth weight and prepregnancy diastolic blood pressure. Unfavorable levels of total serum
cholesterol, high-density lipoprotein cholesterol, triglycerides, and blood glucose were positively associated with birth weight
for gestational age. The association between blood lipid levels and birth weight persisted after excluding pregnancies
complicated by preeclampsia.
The findings in this prospective study suggest that low birth weight, as well as high birth weight, may be an indicator
of increased maternal cardiovascular risk. Women with relatively high blood pressure tended to deliver small infants.
At the same time, those with unfavorable lipid levels tended to have large babies, suggesting reduced glucose tolerance.

(A variety of data suggest that pregnancy is a kind outcome and the later development of maternal
of stress test that identifies women who are at in- cardiovascular disease, and both investigators
creased risk of developing certain medical prob- asked if a precursor of the maternal disease could
lems. Some of the earliest reports concerned the link be affecting fetal health. Catov et al studied pre-
between gestational diabetes and type II diabetes. term birth, while Romundstad and colleagues
JB O’Sullivan was one of the first to study gesta- focused on low birth weight, but both teams the-
tional diabetes, and reported that 50% of affected orized that dyslipidemia might be the culprit. Ca-
women developed full-blown diabetes within a few tov showed that dyslipidemia alone significantly
years of their delivery (In: Sutherland HK, Stowers increased the risk of preterm birth (odds ratio ⫽
JM, eds. Carbohydrate Metabolism in Pregnancy 2.0, 95% CI, 1.0–4.2), and that both dyslipidemia
and the Newborn. New York: Churchill Livingstone, and inflammation together resulted in even higher
1984:174–180). Since then, there have been other risk (for birth at 34 to 37 weeks: OR ⫽ 4.0; 95% CI,
reports of associations between adverse pregnancy 1.4–11.8; for birth before 34 weeks: OR ⫽ 6.4;
outcomes and the later development of maternal 95% CI, 1.7–24.1). Romundstad and coworkers
disease. Only recently, however, have investigators found that women with dyslipidemia have larger
attempted to determine the reverse: how the precur- babies than those with normal lipid levels, possi-
sors of future maternal diseases affect fetal life. bly through the relationship between an unfavor-
These 2 studies, by Catov et al and Romunds- able lipid profile and glucose intolerance, unless
tad and colleagues, were each prompted by an ob- they have already developed hypertension, in
served association between an adverse pregnancy which case their infants are smaller.
Down Syndrome Screening; Intrauterine Growth Restriction 215

The association between early inflammation and Circulation 1999;100:230). Thus dyslipidemia could
preterm birth has been demonstrated in a variety be present at the time of preterm birth as the result of
of studies (Goldenberg R et al. N Engl J Med inflammation, or may somehow prompt inflamma-
2000;342:1500). Although one obvious cause of tion. In either case, it appears that dyslipidemia and
inflammation is infection, studies in which women inflammation are interrelated, and may work syner-
at increased risk of preterm birth received early gistically to cause both preterm birth and cardiovas-
antibiotic treatment have been disappointing. cular disease.
More recent studies have considered the possibil- If confirmed, the relationship between inflamma-
ity that some women may be genetically predis- tion, dyslipidemia, preterm birth, and heart dis-
posed to have an over abundant inflammatory ease is an interesting one. Although data from
response, and that this may be the source of their both studies makes us wonder if treating dyslipi-
increased risk (Romero R et al. Am J Reprod demia would reduce either the risk of preterm birth
Immunol 1992;27:117; Macones G et al. Am J or the risk of macrosomia, appropriate clinical tri-
Obstet Gynecol 2004;190:1504). This over pro- als have not yet been done. Unfortunately, even if
duction of certain inflammatory mediators may such treatment is developed and tested, it would
also explain the observed link between a history of probably have to be used preconceptionally only,
preterm birth and cardiovascular disease later in since none of the lipid-lowering drugs currently on
life—chronic low-level inflammation is damaging the market is considered safe during pregnancy.
to the vasculature and heart. Is there a similar The data should, however, prompt us to consider
logical explanation for the observed link be- screening women who have had a preterm birth or
tween dyslipidemia and both preterm birth a macrosomic infant for dyslipidemia, just as we
and cardiovascular disease? It has been screen women with PCO for dyslipidemia and
shown that inflammation and elevated levels those with gestational diabetes for diabetes. Since
of inflammatory proteins lead to elevations in many reproductive age women see their obstetri-
cholesterol and triglycerides (Engstrom G et al. cian gynecologist more than any other doctor, it is
Am J Epidemiol 2006;17:57). Conversely, drugs that up to us to be sure that they undergo appropriate
lower lipid levels have anti-inflammatory effects screening tests and receive therapy if necessary
(Albert MA et al. JAMA 2001;286;64; Ridker PM et al. between pregnancies.—KDW)

First-Trimester Markers of
Aneuploidy and the Prediction of
Small-for-Gestational Age Fetuses
K. Spencer, N. J. Cowans, K. Avgidou, F. Molina, and K. H. Nicolaides
Prenatal Screening Unit, Clinical Biochemistry Department, Harold Wood Hospital, Romford, Essex; and
Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, United Kingdom
Ultrasound Obstet Gynecol 2008;31:15–19

First-trimester estimates of 2 biomarkers of placental origin, pregnancy-associated plasma protein-A (PAPP-A)
and free ␤-human chorionic gonadotropin (␤-hCG), are increasingly used along with ultrasound measurement of
nuchal translucency thickness to screen for trisomy 21 and other aneuploidies. There are preliminary indications
216 Obstetrical and Gynecological Survey

that reduced levels of these markers—especially PAPP-A—may help to identify at-risk pregnancies including
those resulting in delivery of a small-for-gestational age (SGA) infant. The study population included singleton
pregnancies with chromosomally normal fetuses that were screened at 11 to 14 weeks’ gestation. Biochemical
marker levels were converted to multiples of the expected normal median (MoM) for a pregnancy of the same
gestational age. Associations between levels of free ␤-hCG and PAPP-A and the incidence of SGA were assessed
by comparing relative incidence rates at MoM cutoffs and birth weight centile cutoffs.
A total of 46,262 pregnancies resulted in live births of infants weighing at or above the 10th centile, whereas
3539 others produced SGA infants weighing less than the 10th centile for gestation. The risk of an SGA infant was
significantly and inversely associated with maternal serum PAPP-A MoM, but not with free ␤-hCG MoM. In
pregnancies with PAPP-A levels below the 10th, 5th, and 3rd percentile, the incidence of SGA was 12%, 14%, and
16%, respectively, and the odds ratios for SGA were 2.70, 3.21, and 3.66, respectively. Free ␤-hCG levels did not
predict SGA.
The investigators believe that, in the presence of a normal fetal karyotype, low maternal serum levels of PAPP-A
are associated with an elevated risk of subsequently delivering a SGA infant. Low levels presumably indicate
impaired placentation. Present evidence warrants using low PAPP-A to help identify SGA pregnancies.

(Ever since maternal serum screening for fetal This paper by Spencer et al presents similar
neural tube defects (NTDs) and Down syndrome data. These investigators found that unex-
was introduced in the early 1980s, investigators plained low levels of PAPP-A in the first tri-
have been trying to figure out the etiology and mester were associated with insufficient fetal
the significance of abnormal maternal serum growth; the lower the PAPP-A, the more likely
analyte levels in pregnancies in which the fetus the fetus was to have a birth weight below the
is euploid and does not have a NTD. Since 10th, 5th, or 3rd percentiles. One difference
maternal serum AFP was the first analyte used between AFP and PAPP-A, however, is that
for screening, the initial flurry of papers con- AFP is produced by the fetal liver, while
cerned the association between unexplained PAPP-A is produced by the placenta. Thus
(not related to a fetal defect) elevated second- PAPP-A, like hCG, reflects placental metabo-
trimester MSAFP levels and various pregnancy lism rather than placental damage. And unlike
complications, including growth restriction, pre- AFP, which is probably a fetal form of albu-
eclampsia, abruption, preterm birth, and intra- men, PAPP-A has an important function—it
uterine fetal demise (Chandra S et al. Am J is a protease that cleaves insulin-like growth
Obstet Gynecol 2003;189:775). These associa- factor (IGF) from binding proteins 4 and 5.
tions have been confirmed by many research Thus, insufficient PAPP-A leads to more bound
groups, and it is now recognized that the (inactive) IGF and less free (functional) IGF.
higher the AFP level, the more likely a poor Since IGF stimulates cell proliferation and differ-
outcome. It is theorized that unexplained ele- entiation, increases insulin sensitivity, and im-
vated AFP reflects some kind of early placen- proves endothelial and microvascular function
tal damage or insufficiency; the damage causes (Kaski JC, Holt DW. Eur Heart J 2006;27:1637),
more AFP than usual to leak across the pla- it is easy to hypothesize why decreased IGF—as
centa and into the maternal vascular system, a result of decreased PAPP-A—leads to de-
and also causes or contributes to a variety creased fetal growth.
of obstetric complications. Unfortunately, it is Are these data clinically relevant? Although
not possible to reverse placental dysfunction, identifying high-risk women using elevated
and most of the complications associated MSAFP levels has not resulted in significant im-
with elevated AFP—with the exception of still- provements in outcome, MSAFP is a second-
birth, which can be prevented by fetal moni- trimester marker, reflecting placental damage
toring and early delivery—cannot be avoided. that has already occurred and probably can’t be
Thus, using AFP to identify pregnancies at risk reversed. Because PAPP-A is a first-trimester
for such complications usually does not marker which reflects placental enzyme produc-
change outcome. tion and not necessarily placental damage, are
Elective Cesarean; Elective Delivery; NICU Admission 217

low PAPP-A levels amenable to change? They should note the association between PAPP-A
might be, and perhaps one day a therapy which and SGA, but aside from keeping a close eye on
increases placental production of PAPP-A will such pregnancies, there is probably not much
be discovered. In the meantime, clinicians more we can do.—KDW)

Admission of Term Infants to Neonatal

Intensive Care: A Population-Based
Sally K. Tracy, Mark B. Tracy, and Elizabeth Sullivan
Royal Hospital for Women, Sydney; Neonatal Intensive Care Unit, Nepean Hospital; and Australian Institute
of Health and Welfare, University of New South Wales, Sydney, New South Wales, Australia
Birth 2007;34:301–307

Infants admitted to neonatal intensive care units and special-care nurseries are thought of as being so small or ill that
their survival is unlikely unless they receive the special care provided in these facilities. Recent surveys in the United
Kingdom, however, suggest that it is not at all rare for term infants to be admitted to intensive care. The goal of this
study was to estimate rates of admission of term infants to neonatal intensive care and relate them to parity and type
of delivery. The study population consisted of 1,001,249 low-risk women who gave birth in Australia in the years
1999–2002. Rates of admission were compared in primiparous and multiparous women having cesarean section before
or after the onset of labor, vacuum or instrumental birth, or unassisted vaginal birth at 40 weeks’ gestation.
Overall rates of admission of term infants to neonatal intensive care were 8.9% for infants of primiparas and 6.3%
for infants of multiparas. Adjusted odds ratios for admission of low-risk primiparas to intensive care when operative
delivery was carried out before the onset of labor were 12.08 at 37 weeks’ gestation, 7.49 at 38 weeks, and 2.80 at 39
weeks. The adjusted odds ratio at 41 weeks was not significantly greater than at 40 weeks’ gestation. For low-risk
multiparas who had cesarean delivery before labor began, the adjusted odds ratios for admission to intensive care at 37,
38, and 39 weeks’ gestation were 15.40, 12.13, and 5.09, respectively. The odds ratio at 41 weeks’ gestation was
significantly lower than at 40 weeks. Compared with unassisted vaginal birth at 40 weeks’ gestation, infants born after
any form of operative delivery were more likely to be admitted to neonatal intensive care.
Although elective birth at 37 weeks’ gestation is considered to be a term birth, 37 weeks is not always a safe time
to be born with minimal risk to the infant. More attention should be given to what women are told about elective
cesarean section before 40 weeks’ gestation, and about the best birth site for appropriate neonatal care when an elective
procedure is planned.

(Obstetricians have always done elective controversial. In addition to concerns about the
deliveries—meaning deliveries scheduled more for maternal consequences of elective surgery—
patient or physician convenience than for medical and the consequences of multiple repeat elective
indications. Until recently, however, most of these surgeries—many clinicians worry about the fetal
deliveries have been by labor induction and vaginal outcome. Concern for the fetus seems justified
delivery or by repeat cesarean. The current twist when elective cesarean is done before 39 weeks,
on elective delivery—elective primary cesarean— given the rapidly accumulating data about the
although gaining in popularity, is still considered neonatal complications associated with “near
218 Obstetrical and Gynecological Survey

term” birth. An example of such data is provided Interestingly, even infants delivered by prelabor
by Young et al (Pediatrics 2007;119:e659), who cesarean at 39 weeks were at increased risk of
reviewed the outcomes of 283,975 births from requiring NICU admission (7.7% admitted; OR ⫽
1999 to 2004 and, after excluding anomalous in- 2.80; 95% CI ⫽ 2.02–3.88).
fants, found that infants delivered at 37 or 38 Data from this study and others should be
weeks’ gestation had a significantly higher risk of presented to patients who request prelabor ce-
neonatal death than those delivered at 40 weeks sarean delivery. At the least, it again illustrates
(for 37 weeks, RR ⫽ 1.90; 95% CI ⫽ 1.2–3.1; for why delivery before 39 weeks should be avoided
38 weeks, RR ⫽ 1.95; 95% CI ⫽ 1.3–2.9). Even and why we should strictly adhere to the ACOG
elective delivery at term is associated with in- criteria for elective delivery (listed below). Impor-
creased risk, when it is by prelabor cesarean. A tantly, it demonstrates that prelabor cesarean fur-
Norwegian study of planned cesarean versus ther increases the odds of a suboptimal outcome
planned vaginal deliveries found that 9.1% of in- for the infants of mothers requesting elective de-
fants delivered at term by elective cesarean re- livery. Considering this, elective cesareans should
quired admission to the NICU, compared to 5.2% ideally not be scheduled before 39 or, preferably,
of infants delivered vaginally. Very few studies, 40 weeks’ gestation. If we adopt this policy, some
however, have evaluated the effects of both near women who desire cesarean delivery may go into
term delivery and elective prelabor cesarean. labor before their scheduled delivery, but that
Such data is desperately needed because a pro- would actually be good—the women in Tracy’s
portion of elective prelabor cesareans will inevita- study who had their elective cesarean after the
bly be performed before 39 weeks. onset on labor actually had lower rates of NICU
The data presented by Tracy et al is therefore admission at 39 and even 38 weeks’ gestation
very timely. These investigators evaluated the (OR ⫽ 0.86; 95% CI ⫽ 0.76–0.99; OR ⫽ 0.77;
effects of both gestational age and elective pre- 95% CI ⫽ 0.65–0.99, respectively)!
labor cesarean on the need for admission to the
neonatal intensive care unit (NICU) in low-risk
women, meaning those between 20 and 34 CONFIRMATION OF A TERM GESTATION
years of age, without hypertension or diabetes (ACOG PRACTICE BULLETIN NUMBER
of any kind, who had an AGA singleton fetus in 10, NOVEMBER 1999)
vertex presentation. They found that 23% of
low-risk infants delivered by prelabor cesarean • Fetal heart tones have been documented for
at 37 weeks and 9.4% of those delivered at 38 20 weeks by nonelectronic fetoscope or 30
weeks by Doppler.
weeks required NICU admission, compared to
• It has been 36 weeks since a positive serum or
only 5.7% of low-risk infants delivered by unas- urine hCG pregnancy test was performed by
sisted vaginal delivery at 39 or 40 weeks. These a reliable laboratory.
rates translated into significantly increased odds • An ultrasound measurement of the crown
of NICU admission for infants delivered electively rum length, obtained at 6 to 12 weeks, sup-
by prelabor cesarean, especially if the woman was ports a gestational age of at least 39 weeks.
multiparous (for low-risk nulliparas with prelabor • An ultrasound obtained at 13 to 20 weeks
cesarean at 37 weeks, OR ⫽ 12.08; 95% CI ⫽ confirms the gestational age of at least 39
8.64–16.89, and at 38 weeks OR ⫽ 7.49; 95% weeks determined by clinical history and
CI ⫽ 5.54–10.11; for low risk multiparas at 37 physical examination.
weeks, OR ⫽ 15.40; 95% CI ⫽ 12.87–18.43, and ACOG Practice bulletin number 10, November
at 38 weeks OR ⫽ 12.13; 95% CI ⫽ 10.37–14.19). 1999.—KDW)