Obstetric Outcomes Among Women With a History of Intimate Partner Violence in the United States.

OBJECTIVE: To evaluate the association between exposure to intimate partner violence (IPV) and delivery method in a U.S. obstetric cohort. METHODS: The study population included U.S. women with a history of recent live birth, drawn from the 2009-2018 PRAMS (Pregnancy Risk Assessment Monitoring System) cohort. The primary exposure was self-reported IPV. The primary outcome of interest was method of delivery (vaginal or cesarean). Secondary outcomes included preterm birth, small for gestational age (SGA), and admission to the neonatal intensive care unit (NICU). Bivariate associations between the primary exposure (ie, self-report of IPV vs no self-report of IPV) and each covariate of interest were assessed with weighted quasibinomial logistic regression. Weighted multivariable logistic regression was conducted to evaluate the association between IPV and delivery method controlling for confounders. RESULTS: A total of 130,000 women were included in this secondary analysis of a cross-sectional sample, representing 7,500,000 women nationwide based on PRAMS sampling design. Of these, 0.8% reported abuse in the 12 months before their current pregnancy and 1.3% reported abuse during pregnancy; 1.6% of the study population reported abuse both before and during pregnancy. After adjusting for maternal sociodemographic characteristics, IPV exposure at any time was not significantly associated with cesarean delivery, compared with no IPV exposure (odds ratio [OR] 0.98, 95% CI 0.86-1.11). Of secondary outcomes, 9.4% of women experienced preterm birth and 15.1% had neonates admitted to the NICU. Exposure to IPV was associated with a 21.0% increased risk of preterm birth, compared with women without exposure (OR 1.21, 95% CI 1.05-1.40), and a 33.3% increased risk of NICU admission (OR 1.33, 95% CI 1.17-1.52) after controlling for confounders. There was no difference in the risk of delivering a neonate who was SGA. CONCLUSION: Intimate partner violence was not associated with an increased risk of cesarean delivery. Intimate partner violence before or during pregnancy was associated with increased risk of adverse obstetric outcomes, such as preterm birth and NICU admission, corroborating previous research findings.

Mifepristone and misoprostol compared to osmotic dilators for cervical preparation prior to surgical abortion at 15-18 weeks' gestation: a randomised controlled non-inferiority trial.

OBJECTIVE: Cervical preparation is recommended prior to second-trimester surgical abortion. Osmotic dilators are an effective means to prepare the cervix, but require an additional procedure and may cause discomfort. We compared cervical preparation with mifepristone and misoprostol to preparation with osmotic dilators. STUDY DESIGN: A randomised, controlled, non-inferiority trial was performed to compare cervical preparation with mifepristone and misoprostol to preparation with osmotic dilators in women undergoing surgical abortion between 15 and 18 weeks gestation. The medication group (n=29) received mifepristone 200 mg orally 24 hours prior to uterine evacuation and misoprostol 400 µg buccally 2 hours before the procedure. The dilator group (n=20) underwent osmotic dilator insertion 24 hours prior to the procedure. The primary outcome was total procedure time, from insertion to removal of the speculum. Secondary outcomes included operative time (from intrauterine instrumentation to speculum removal), initial cervical dilation, nausea, pain, ease of procedure, and whether participants would choose the same modality in the future. RESULTS: For mean total procedure time, medication preparation (14.0 min, 95% CI 12.0-16.1) was not inferior to dilators (14.3 min, 95% CI 11.7 to 16.8, p<0.001). Mean operative time and ease of procedure were also similar between groups. More women in the medication group than the dilator group would prefer to use the same method in the future (86% vs 30%, p=0.003). CONCLUSION: Prior to surgical abortion at 15-18 weeks, use of mifepristone and misoprostol did not result in longer procedure times than overnight osmotic dilators. TRIAL REGISTRATION NUMBER: NCT01462.

Is an episiotomy necessary with a shoulder dystocia?

OBJECTIVE: The objective of the study was to determine whether a decrease in the use of episiotomy was associated with a change in the frequency of brachial plexus injury. STUDY DESIGN: All births at Brigham and Women's Hospital from Sept. 1, 1998, through Aug. 31, 2009, were reviewed. The total number of births, mode of delivery, shoulder dystocias, episiotomies with and without shoulder dystocias, and brachial plexus injuries were recorded. A nonparametric test of trend was performed. RESULTS: There were a total of 94,842 births, 953 shoulder dystocias, and 102 brachial plexus injuries. The rate of episiotomy with shoulder dystocia dropped from 40% in 1999 to 4% in 2009 (P = .005) with no change in the rate of brachial plexus injuries per 1000 vaginal births. CONCLUSION: Despite historical recommendations for an episiotomy to prevent brachial plexus injury when a shoulder dystocia is encountered, the trend we observed does not suggest benefit from this practice.