Fetal acidemia and electronic fetal heart rate patterns: is there evidence of an association?

OBJECTIVE: Despite the ubiquity of electronic fetal monitoring, the validity of the relationship between various fetal heart rate (FHR) patterns and fetal acidemia has not yet been established in a large unselected series of consecutive pregnancies. The aim of this study was to examine the published literature for evidence of such a relationship. METHODS: Four hypotheses based on assumptions in common clinical use were examined. The literature was searched for relationships between certain aspects of FHR patterns (e.g., degree of FHR variability, depth of decelerations), and fetal acidemia, or fetal vigor (5-minute Apgar score >or=7). We also attempted to relate duration of these patterns to the degree of acidemia. Using standardized FHR nomenclature we defined patterns based on baseline FHR variability, baseline rate, decelerations, and accelerations. RESULTS: The following relationships were observed: (1) Moderate FHR variability was strongly associated (98%) with an umbilical pH >7.15 or newborn vigor (5-minute Apgar score >or=7). (2) Undetectable or minimal FHR variability in the presence of late or variable decelerations was the most consistent predictor of newborn acidemia, though the association was only 23%. (3) There was a positive relationship between the degree of acidemia and the depth of decelerations or bradycardia. (4) Except for sudden profound bradycardia, newborn acidemia with decreasing FHR variability in combination with decelerations develops over a period of time approximating one hour. Most studies identified were observational and uncontrolled (grade III evidence of US Preventive Services Task Force); however, there was general agreement amongst the various studies, strengthening the validity of the observations. CONCLUSIONS: The validity of the relationship between certain FHR patterns and fetal acidemia and/or vigor, is supported by observations from the literature. In addition four assumptions commonly used in clinical management are supported. These conclusions need to be confirmed by a prospective examination of a large number of consecutive, unselected FHR patterns, and their relationship to newborn acidemia. Pending the completion of such studies, these observations can be used to justify certain aspects of current clinical management, and may assist in standardizing the diversity of opinions regarding FHR pattern management.

A descriptive model of preventability in maternal morbidity and mortality.

OBJECTIVE: To develop a descriptive model of preventability for maternal morbidity and mortality that can be used in quality assurance and morbidity and mortality review processes. STUDY DESIGN: This descriptive study was part of a larger case-control study conducted at the University of Illinois at Chicago in which maternal deaths were cases and women with severe maternal morbidity served as controls. Morbidities and mortalities were classified by a team of clinicians as preventable or not preventable. Qualitative analysis of data was conducted to identify and categorize different types of preventable events. RESULTS: Of 237 women, there were 79 women with preventable events attributable to provider or system factors. The most common types of preventable events were inadequate diagnosis/recognition of high-risk (54.4%), treatment (38.0%), and documentation (30.7%). CONCLUSIONS: A descriptive model was illustrated that can be used to categorize preventable events in maternal morbidity and mortality and can be incorporated into quality assurance and clinical case review to enhance the monitoring of hospital-based obstetric care and to decrease medical error.

Effect of chondrocalcinosis on the MR imaging of knee menisci.

OBJECTIVE: Our goal was to determine the influence of chondrocalcinosis on MR imaging in the detection of meniscal tears. MATERIALS AND METHODS: A retrospective review was performed of knee MR imaging and arthroscopy records from two university hospitals between 1996 and 1998. Seventy individuals had radiographic evidence of chondrocalcinosis and underwent knee MR imaging. Thirty-seven of these individuals had undergone arthroscopy for further evaluation of their symptoms. MR imaging sensitivity and specificity in the detection of medial and lateral meniscal tears were calculated in these 37 patients who had radiographic evidence of chondrocalcinosis and in a control group of 34 patients who underwent MR imaging and arthroscopy but did not have knee chondrocalcinosis. RESULTS: In the chondrocalcinosis group, MR imaging sensitivity, specificity, and accuracy for meniscal tear were 78%, 71%, and 78%, respectively, for the lateral meniscus, and 89%, 72%, and 81% for the medial meniscus. The control group showed sensitivity, specificity, and accuracy of 93%, 100%, and 97%, respectively, for the lateral meniscus and 100% in all cases for the medial meniscus. The MR imaging detection of meniscal tears in both the lateral and medial compartments combined is significantly poorer in the presence of chondrocalcinosis (p < 0.005). CONCLUSION: MR imaging sensitivity and specificity for detection of meniscal tear is decreased in the presence of meniscal chondrocalcinosis. Chondrocalcinosis appeared as a high-signal-intensity region on T1-weighted, intermediate-weighted, and inversion recovery sequences. The high signal of chondrocalcinosis on inversion recovery sequence is an interesting observation that to our knowledge has not been previously reported. Radiographic correlation with the MR imaging examination can help prevent overdiagnosing meniscal tears.

When parents reject interventions to reduce postnatal human immunodeficiency virus transmission.

In a recent Oregon case, the state successfully sued for custody of an infant to prevent his human immunodeficiency virus (HIV)-infected mother from breastfeeding him and to require antiretroviral prophylaxis. As more HIV-infected women give birth, pediatricians may increasingly face dilemmas when parents reject medical recommendations to forego breastfeeding and to administer antiretroviral prophylaxis to the infant. Such disagreements create ethical dilemmas because pediatricians have an obligation to both protect the infant and respect parental decision making. Pediatricians need to balance these obligations in deciding whether to ask the courts to intervene on the infant's behalf. To that end, we analyze the legal and ethical issues that arise when an HIV-infected mother refuses interventions to reduce neonatal transmission of HIV to her infant, provide an approach for addressing these disagreements, and present illustrative scenarios in which pediatricians should, may, and should not seek a court order to intervene.

Chorioamnionitis and uterine function.

OBJECTIVE: To clarify the relationships between intrapartum chorioamnionitis and abnormalities of uterine function, including labor abnormalities, cesarean delivery, and hemorrhage during parturition. METHODS: We did a retrospective cohort study on 16,226 deliveries between 1986 and 1996 that were identified from the University of California, San Francisco Perinatal Database. Variables included maternal age, parity, birth weight, gestational age, epidural usage, oxytocin usage, cesarean delivery, labor abnormalities, length of labor stages, estimated blood loss, and chorioamnionitis status. Analyses included chi(2), Student t test, and logistic regression. RESULTS: In the chorioamnionitis group, there was a statistically significantly higher proportion of women with labor abnormalities (relative risks [RRs] 2.6-4.1), cesarean delivery (RR 3.3; 95% confidence interval [CI] 3.0, 3.5), hemorrhage after cesarean (RR 1.2; 95% CI 1.1, 1.3), and hemorrhage after vaginal delivery (RR 2.1; 95% CI 1.9, 2.4) compared with the nonchorioamnionitis group. Those findings stayed significant after multivariate analysis for various labor abnormalities (adjusted odds ratios [ORs] ranged 1.3-2.1), cesarean delivery (adjusted OR 1.8; 95% CI 1.5, 2.1), hemorrhage after cesarean (adjusted OR 1.5; 95% CI 1.2, 1.8), and hemorrhage after vaginal delivery (adjusted OR 1.8; 95% CI 1.5, 2.1). CONCLUSION: Adverse associations between chorioamnionitis and labor abnormalities, cesarean rate, and hemorrhage during parturition appear to be significant, suggesting a deleterious effect of chorioamnionitis on uterine function.

Effect of magnesium prophylaxis and preeclampsia on the duration of labor.

OBJECTIVE: Our goals were to compare duration of labor at term for (1) women with preeclampsia versus normotensive nulliparous women and (2) nulliparous women with preeclampsia who received magnesium for seizure prophylaxis versus those who did not. STUDY DESIGN: We performed a retrospective cohort study of all nulliparous, term vaginal deliveries from 1989 through 1995 at University of California, San Francisco. The perinatal database and medical records were reviewed for information on duration of labor, maternal and labor characteristics, and neonatal outcomes. The chi2 odds ratio, and Student t tests were used to compare categoric and continuous variables between women with preeclampsia and control women and between women with preeclampsia who did and those who did not receive magnesium. Logistic regression was used to evaluate variables predictive of labor duration. RESULTS: Our study subjects were 4083 normotensive nulliparous women and 154 women with preeclampsia. A sample size calculation revealed that 1764 normotensive control subjects were needed to show a 10% difference in labor duration with 80% power and alpha of 0.05. Among women with preeclampsia, 93 (60%) were treated with magnesium and 61 (40%) were not. More women with preeclampsia than normotensive women had induction of labor and received epidural anesthesia, prostaglandin gel, and oxytocin (P <.003). Total labor duration did not differ between women with preeclampsia and normotensive women (P =.15) or between women with preeclampsia who received magnesium and those who did not (P =.09). In comparison with normotensive women, those with preeclampsia had a higher rate of postpartum hemorrhage (31% vs 22%, P =.005), and the rate was even higher among preeclamptic women treated with magnesium versus those who received no magnesium (34% vs 26%, P =.002). Logistic regression, with prolonged first stage of labor (>12 hours) used as the outcome variable, indicated that epidural anesthesia (odds ratio 2.3, 95% confidence interval 1.9-2. 6), oxytocin (odds ratio 1.8, 95% confidence interval 1.6-2.2), and persistent occipitoposterior presentation (odds ratio 1.6, 95% confidence interval 1.1-2.4) were associated with prolonged labor, whereas preeclampsia (odds ratio 0.9, 95% confidence interval 0.7-1. 1) and treatment with magnesium were not (odds ratio 1.1, 95% confidence interval 0.9-1.4). Induction (odds ratio 0.5, 95% confidence interval 0.4-0.6) and birth weight <2500 g (odds ratio 0. 5, 95% confidence interval 0.4-0.8) were associated with faster labor. CONCLUSIONS: In term nulliparous women, neither preeclampsia nor magnesium prophylaxis affected labor duration.

Misoprostol is more efficacious for labor induction than prostaglandin E2, but is it associated with more risk?

OBJECTIVE: Our purpose was to compare the efficacy and safety of misoprostol with dinoprostone (Prepidil) for labor induction. STUDY DESIGN: In a randomized, controlled trial of labor induction, patients were randomly assigned to receive either 50 microgram of intravaginal misoprostol every 4 hours or 0.5 mg of intracervical prostaglandin E2 every 6 hours. Eligibility criteria included gestation of >/=31 weeks, Bishop score <6, and fewer than 12 contractions per hour. Primary outcomes were cesarean section, induction to delivery time, oxytocin use, and fetal distress requiring delivery. RESULTS: One hundred fifty-nine women were randomly assigned to receive misoprostol (n = 81) or Prepidil (n = 78). There were no differences in the indication for induction, preinduction Bishop score, epidural use, or cesarean section rate. Mean time to delivery was significantly shorter in the misoprostol group (19 hours 50 minutes) than in the Prepidil group (28 hours 52 minutes) (P =.005). Only 58% of women in the misoprostol group required oxytocin augmentation, in comparison with 88% of women receiving Prepidil (P =.00002). However, 41% of women receiving misoprostol and 17% receiving Prepidil had late decelerations or bradycardias (P =.001), and 20% of the misoprostol group and 5% of the Prepidil group had deliveries for fetal distress (P =.05). CONCLUSIONS: Misoprostol is more efficacious than Prepidil for labor induction. However, the significantly increased incidence of abnormal fetal heart rate tracings and the trend in increased deliveries for fetal distress with misoprostol dosing of 50 microgram every 4 hours are of concern. These data suggest that either a lower dose of misoprostol or less frequent dosing of misoprostol should be considered.

Maternal fertility is not affected by fetal surgery.

The purpose of this report is to assess the impact of fetal surgery on future maternal fertility, subsequent pregnancy outcome, and the incidence of pregnancy complications. Retrospective data were collected on 70 mothers who underwent fetal surgery between April 1981 and June 1996. Indications for open hysterotomy fetal surgery included congenital diaphragmatic hernia (n = 44), congenital cystic adenomatoid malformation of the lung (n = 11), urinary obstruction (n = 9), sacrococcygeal teratoma (n = 4), heart block (n = 1), and acardiac-acephalic twin reduction (n = 1). The following data were obtained: number of pregnancy attempts, number of successful pregnancies, pregnancy outcome including obstetrical and neonatal complications, and infertility after fetal surgery. There were 45 respondents, of whom 35 attempted subsequent pregnancies. Thirty-two were successful, resulting in 31 livebirths. Two women had a strong prefetal surgery history of infertility, 1 has only attempted to conceive for 3 months. We report this experience because the effect of open fetal surgery on futrue fertility is such an important question for our patients and referring physicians. This analysis suggests that hysterotomy and open fetal surgery has a negligible impact on maternal fertility.

Pulmonary edema in obstetric patients is rapidly resolved except in the presence of infection or of nitroglycerin tocolysis after open fetal surgery.

OBJECTIVES: This study was designed to determine the etiology, course, and severity of pulmonary edema in obstetric patients in a tertiary care center. STUDY DESIGN: A retrospective study was carried out on 16,810 deliveries from University of California, San Francisco, 1985-1995. Diagnosis and severity of lung injury were defined by a 4-point system that was based on the chest radiograph, oxygenation, positive end-expiratory pressure, and lung compliance. Resolution of pulmonary edema was defined by improvement in the chest radiograph and hypoxemia (ratio of arterial oxygen tension to inspired oxygen concentration) scores or by extubation. RESULTS: Pulmonary edema developed in 86 patients, or 0.5% of all obstetric cases. It usually showed extensive air space consolidation on the chest radiograph and arterial hypoxemia. Although 43% of the patients had severe pulmonary dysfunction, the average time to resolution of pulmonary edema was 2.4 days. Only 45% of patients required admission to the intensive care unit and only 15% required intubation and positive-pressure ventilation. Patients with infection (mean of 7.2 days) or fetal surgery (mean of 3.8 days) had the most severe, protracted course. CONCLUSION: Although obstetric pulmonary edema is associated with extensive radiographic infiltrates and severe hypoxemia, resolution occurs rapidly in most patients, limiting the need for intensive care support.

Is there an association between water baths during labor and the development of chorioamnionitis or endometritis?

OBJECTIVE: Our purpose was to determine whether water baths during labor are associated with the development of chorioamnionitis or endometritis. STUDY DESIGN: One hundred ten cases of chorioamnionitis or endometritis and 97 controls were identified among singleton term gestations from the University of California at San Francisco perinatal database. Medical record review and patient interviews provided information on membrane rupture, history of bathing during labor, and relaxation and pain relief perceived by patients who experienced water bathing during labor. RESULTS: There was no statistically significant association between water baths during labor and the occurrence of chorioamnionitis or endometritis (odds ratio 0.93 [95% confidence interval 0.53 to 1.63]). CONCLUSIONS: Water baths during labor are not associated with chorioamnionitis or endometritis.

The clinical utility of serum uric acid measurements in hypertensive diseases of pregnancy.

OBJECTIVE: Our purpose was to evaluate the clinical utility of serum uric acid measurements in the hypertensive diseases of pregnancy. STUDY DESIGN: We performed a nested case-control study to assess the clinical utility of serum uric acid measurements in women with hypertensive diseases of pregnancy. We identified 344 women who had serum uric acid measurements at term and categorized them into five diagnostic groups according to definitions of hypertensive diseases in pregnancy published by the National Working Group on Hypertension in Pregnancy: transient hypertension of pregnancy (n = 69), preeclampsia (n = 130), chronic hypertension (n = 23), chronic hypertension with superimposed preeclampsia (n = 29), and normal (n = 93). We compared the mean uric acid concentration for each group with use of a one-way analysis of variance and Scheffe's post hoc test and calculated the sensitivities and specificities in diagnosing preeclampsia as well as the likelihood ratios for serum uric acid values of 5.5, 6.0, and 6.5 mg/dl. We also examined the correlation between serum uric acid levels and several clinical outcome measures in women with hypertensive diseases of pregnancy. RESULTS: The mean serum uric acid values for women with preeclampsia (6.2 +/- 1.4 mg/dl) and transient hypertension (5.6 +/- 1.7 mg/dl) were significantly higher than those of controls (4.3 +/- 0.8 mg/dl, p < 0.05). The difference in mean serum uric acid values between women with chronic hypertension (4.9 +/- 1.0 mg/dl) and superimposed preeclampsia (5.8 +/- 1.4 mg/dl) were not statistically significant. The likelihood ratio of having preeclampsia with a serum uric acid value of 5.5 mg/dl was 1.41 in gestational hypertension of pregnancy and 2.5 in chronic hypertension. With use of a receiver-operator characteristic curve, we were unable to identify a serum uric acid value that could be used to differentiate various hypertensive diseases of pregnancy. There was a weak correlation between serum uric acid values and several clinical outcome measures of preeclampsia (r = 0.06 to 0.26). CONCLUSION: Although mean serum uric acid values are elevated in women with preeclampsia, the clinical utility of serum uric acid values in differentiating various hypertensive diseases of pregnancy appears to be limited. In the setting of chronic hypertension, however, a serum uric acid level of > or = 5.5 mg/dl could identify women with an increased likelihood of having superimposed preeclampsia.

Changing management of gallstone disease during pregnancy.

BACKGROUND: Symptomatic gallstones may be problematic during pregnancy. The advisability of laparoscopic cholecystectomy (LC) is uncertain. The objective of this study is to define the natural history of gallstone disease during pregnancy and evaluate the safety of LC during pregnancy. METHODS: Review of medical records of all pregnant patients with gallstone disease at the University of California, San Francisco, from 1980 to 1996. RESULTS: Of approximately 29,750 deliveries, 47 (0.16%) patients were treated for gallstone disease, including biliary colic in 33, acute cholecystitis in 12, and pancreatitis in two. Conservative treatment was attempted in all patients but failed in 17 (36%) cases. Two patients required combined preterm Cesarean-section cholecystectomy and 10 required surgery in the early postpartum period for persistent symptoms. Seventeen patients required cholecystectomy during pregnancy for biliary colic (10), acute cholecystitis (six), and pancreatitis (one). Three patients were treated with open cholecystectomy. Fourteen patients underwent LC at a mean gestational age of 18.6 weeks, mean OR time of 74 min, and mean length of stay of 1.2 days. Hasson cannulation was utilized in 11 patients. Reduced-pressure pneumoperitoneum (6-10 mmHg) was used in seven patients. Prophylactic tocolytics were used in seven patients, with transient postoperative preterm labor observed in one. There were no open conversions, preterm deliveries, fetal loss, teratogenicity, or maternal morbidity. CONCLUSIONS: In past years, symptomatic gallstones during pregnancy were managed conservatively or with open cholecystectomy. LC is a feasible and safe method for treating severely symptomatic patients.

Outcome of infants born at 24-26 weeks' gestation: II. Neurodevelopmental outcome.

OBJECTIVE: To assess the neurodevelopmental outcome of infants born at 24-26 weeks' gestation. METHODS: One hundred thirty-eight nonanomalous infants were born at our hospital after pregnancies of 24-26 weeks' gestation between 1990 and 1994. Ninety-four infants survived to discharge and 86 were followed in a nursery follow-up program for outcome. Associations between gestational age and neurodevelopmental outcome and risk factors and outcome were analyzed. Mean age at follow-up was 32 months. RESULTS: The frequency of cerebral palsy did not differ significantly in the three groups (11, 20, and 11% at 24, 25, and 26 weeks, respectively). The incidence of normal cognitive outcome was associated significantly with gestational age at birth (28, 47, and 71% normal at 24, 25, and 26 weeks, respectively). Poor neurologic outcome was associated with the medical risk factor of intracranial hemorrhage grade 3 or 4 or periventricular leukomalacia. Poor cognitive outcome was correlated with both medical and social risk factors; however, there was an association between poor cognitive outcome and lower gestational age (P < .05), regardless of the relationships of any other risk factors to cognitive outcome. CONCLUSION: Although the incidence of cerebral palsy was low in these three groups, the high percentage of infants born at 24 and 25 weeks' gestation with cognitive deficits is concerning.

Outcome of infants born at 24-26 weeks' gestation: I. Survival and cost.

OBJECTIVE: To determine neonatal survival, short-term morbidities, and cost per survivor in pregnancies delivered at 24-26 weeks' gestation in a center in which antenatal steroids and exogenous surfactant are standard care. METHODS: A retrospective cohort study compared survival, short-term outcome, and initial hospital charges for pregnancies delivered at 24-26 weeks during 1990-1994. We calculated hospital costs for each year by using the corresponding institutional cost-charge ratio. RESULTS: There were 138 infants after excluding those with severe anomalies. Survival was 43%, 74%, and 83% at 24, 25, and 26 weeks, respectively (P = .006). The majority of women received antenatal steroids, and the majority of surviving neonates received exogenous surfactant. Severe retinopathy of prematurity and chronic lung disease decreased significantly from 24 to 26 weeks (P < or = .026). The likelihood of having a surviving infant without chronic lung disease or severe retinopathy of prematurity was 35% at 24 weeks and 78% at 26 weeks. Hospital costs for the 29 nonsurvivors were $1.46 million and for the 94 surviving infants were $16.9 million. The cost per day was similar at each gestational age, whereas the cost to produce a survivor was $294,749, $181,062, and $166,215 at 24, 25, and 26 weeks, respectively. CONCLUSION: Survival at 24 weeks was only 43% despite treatment with antenatal steroids and exogenous surfactant. The cost per survivor for infants born at 24 weeks was higher than the cost for those born after 1 more week in utero. Outcome improved markedly between 24 and 26 weeks, and small differences in gestational age lead to large economic differences. All efforts should be attempted to prolong pregnancy, and if prolongation is unsuccessful, treatment options including nonintervention should be available to parents of 24-week gestations.

Lack of value of routine postpartum hematocrit determination after vaginal delivery.

OBJECTIVE: To identify risk factors associated with low postpartum hematocrits after vaginal delivery and to define lower risk categories of patients for whom routine determination of hematocrit may not be necessary. METHODS: This case-control study was designed to identify risk factors for discharge hematocrit below 27% in nonanemic patients after a vaginal delivery using the University of California, San Francisco, Perinatal Database. Multivariate statistics were used to determine the most significant risk factors. Lower risk subpopulations were analyzed to determine their rate of low discharge hematocrits. RESULTS: Risk factors associated with odds ratios greater than 1.5 for discharge hematocrit less than 27% included estimated blood loss greater than 500 mL, placenta previa, abruption, prolonged third stage, preeclampsia, prior postpartum hemorrhage, and prior cesarean delivery. Estimated blood loss > 500 mL was the most significant risk factor for discharge hematocrit less than 27% (odds ratio 4.5, 95% confidence interval 3.8, 5.4). A population without statistically significant risk factors was identified; this group had a 1.4% risk of discharge hematocrit less than 27%. CONCLUSION: Routine postpartum hematocrits are unnecessary in clinically stable patients with an estimated blood loss of less than 500 mL.

Is there a benefit to episiotomy at operative vaginal delivery? Observations over ten years in a stable population.

OBJECTIVE: Our purpose was to examine the association between maternal vaginal and perineal morbidity and episiotomy performed at operative vaginal delivery. STUDY DESIGN: We obtained data from 2041 consecutive operative vaginal deliveries and compared yearly rates of episiotomy, lacerations, and potential confounders with linear regression and stratified analyses. RESULTS: Between 1984 and 1994 the use of episiotomy for operative vaginal deliveries fell significantly (93.4% to 35.7%, R2 = 0.85, p = 0.0001). This change was associated with a rise in the rate of vaginal lacerations (16.1% to 40.0%, R2 = 0.80, p = 0.0002), a decrease in the rate of fourth-degree lacerations (12.2% to 5.4%, R2 = 0.62, p = 0.004), but no significant change in the rate of third-degree lacerations. These associations held in separate analyses stratified by parity and type of instrument used for delivery. The prevalence of other previously reported risks for perineal morbidity did not change during the study period. CONCLUSION: At our institution a statistically and clinically significant reduction in the use of episiotomy for operative vaginal deliveries was not associated with a change in the rate of third-degree lacerations but was associated with an increase in the rate of vaginal lacerations and a decrease in the rate of fourth-degree lacerations.

Is there a benefit to episiotomy at spontaneous vaginal delivery? A natural experiment.

OBJECTIVE: Our purpose was to examine the association between maternal vaginal and perineal morbidity and episiotomy performed at spontaneous vaginal delivery. STUDY DESIGN: We obtained data from 17,483 consecutive spontaneous vaginal deliveries and compared the yearly rates of episiotomy, lacerations, and potential confounders with linear regression and stratified analyses. RESULTS: Between 1976 and 1994 the use of episiotomy fell significantly (86.8% to 10.4%, R2 = 0.92, p = 0.0001). This change was associated with a fall in the rate of third- and fourth-degree lacerations (9.0% to 4.2%, R2 = 0.59, p = 0.0001) and a rise in the rate of intact perinea (10.3% to 26.5%, R2 = 0.68, p = 0.0001) and vaginal lacerations (5.4% to 19.3%, R2 = 0.77, p = 0.0001). These associations held in separate analyses stratified by parity and birth weight, except for the subgroup of nulliparous women with macrosomic infants. CONCLUSION: At our institution a large reduction in the use of episiotomy in spontaneous vaginal deliveries was associated with a significant reduction in perineal trauma in all groups of women except for nulliparous women with macrosomic infants.

Head entrapment and neonatal outcome by mode of delivery in breech deliveries from 28 to 36 weeks of gestation.

OBJECTIVES: We attempted to determine whether there are differences in the incidence of head entrapment and adverse neonatal outcome by mode of delivery in breech deliveries from 28 to 36 weeks of gestation. STUDY DESIGN: Computerized data and charts of 321 viable consecutive singleton breech deliveries from 28 to 36 weeks' gestation were reviewed. Statistical methods used included chi2, logistic regression, and analysis of variance. RESULTS: Head entrapment occurred in 4 of 52 (7.7%) neonates delivered vaginally and 14 of 269 (5.2%) neonates delivered by cesarean section (p = 0.48). There were no statistically significant associations between head entrapment and adverse neonatal outcomes. CONCLUSIONS: There was no significant difference in the incidence of head entrapment by mode of delivery for breech infants at 28 to 36 weeks' gestation, nor was there an association with adverse neonatal outcomes after entrapment.