Morbidity associated with the use of Foley balloon for cervical ripening in women with prior cesarean delivery.

OBJECTIVE: We evaluated the morbidity of Foley balloon for cervical ripening in comparison to oxytocin alone in women with a prior cesarean delivery. STUDY DESIGN: A four-hospital retrospective review of all women with viable singleton pregnancies and history of a single prior cesarean delivery presenting for cervical ripening between 1994 and 2015. Exposure groups were either Foley balloon or oxytocin, at the treating physician's discretion. The primary outcome was defined as maternal morbidity, evaluated by a composite that included hemorrhage, and/or uterine infection, and/or uterine rupture. We defined two secondary outcomes: neonatal morbidity, and vaginal delivery rate. Neonatal morbidity was evaluated by a composite that included five-minute APGAR score <7 and/or NICU admission. We adjusted results for potential confounding variables, including hospital site, maternal age and race, initial cervical dilation, and gestational age at delivery. RESULTS: We identified 688 patients who received ripening, 276 by Foley balloon and 412 by oxytocin. There was no significant difference in the primary outcome of maternal morbidity between groups: 38 (13.8%) in the Foley balloon group and 79 (19.2%) in the oxytocin group (aOR 1.43; 95% CI, 0.90-2.27). There was no significant difference in the secondary outcome of neonatal morbidity: 31 (11.3%) in the Foley balloon group and 51 (12.4%) in the oxytocin group (aOR 1.02; 95% CI, 0.57-1.80). The rate of vaginal delivery was significantly less in the Foley balloon group compared to the oxytocin group: 56.2% vs 64.1%, p = .037. CONCLUSION: When cervical ripening with either Foley balloon or oxytocin was utilized at the physician's discretion in women with prior cesarean, there was no identified difference in maternal and neonatal morbidity, but the rate of successful vaginal delivery was lower.

Comparison of staples vs subcuticular suture in class III obese women undergoing cesarean: a randomized controlled trial.

BACKGROUND: Obesity is a risk factor for infectious morbidity and wound complications after cesarean delivery. There are currently insufficient data to determine optimal skin closure technique for cesarean delivery, specifically for those women with class III obesity, defined as a body mass index ≥40 kg/m2. OBJECTIVE: We sought to compare stainless steel staples vs subcuticular suture for skin closure for cesarean delivery in class III obese women with body mass index ≥40 kg/m2. STUDY DESIGN: We conducted a randomized controlled trial at 2 teaching hospitals from 2015 through 2016 in which women with body mass index ≥40 kg/m2 undergoing cesarean delivery were randomly assigned to stainless steel staples or subcuticular suture skin closure. The primary outcome was composite wound complication defined as superficial or deep separation and infection occurring up to 6 weeks following delivery. Secondary outcomes included operative time, and patient pain and satisfaction scores. RESULTS: A total of 242 women were enrolled. In all, 119 in the staples group and 119 in the subcuticular suture group were analyzed. Maternal demographics and characteristics were similar in both groups. The composite wound complication frequency was 19.3% in the staples group and 17.6% in the subcuticular suture group (P = .74) with an overall wound complication incidence of 18.5% in the entire study cohort. There were also no differences in the frequencies of infection, or in superficial or deep wound separation between the 2 study groups. In a univariate analysis of predictors of wound complications, only current tobacco use was a significant predictor of wound complications (relative risk, 4.97; 95% confidence interval, 1.37-18.03; P = .02). Fewer women with staple closure would choose the same method with a future delivery (P = .01), however, self-reported pain and concern about wound healing were equal between the 2 groups. CONCLUSION: In class III obese women undergoing cesarean delivery, there was no difference in composite wound outcome up to 6 weeks postpartum between those who had staples and those who had subcuticular suture skin closure.

Contemporary labor patterns and maternal age.

OBJECTIVE: To evaluate labor progress and length according to maternal age. METHODS: Data were abstracted from the Consortium on Safe Labor, a multicenter retrospective study from 19 hospitals in the U.S. We studied 120,442 laboring gravid women with singleton, term, cephalic fetuses with normal outcomes and without a prior cesarean delivery from 2002 to 2008. Maternal age categories were younger than 20 years of age, 20-29 years of age, 30-39 years of age, and 40 years of age or older with the reference being younger than 20 years of age. Interval-censored regression analysis was used to determine median traverse times (progression centimeter by centimeter) with 95th percentiles adjusting for covariates (race, admission body mass index, diabetes, gestational age, induction, augmentation, epidural use, and birth weight). A repeated-measures analysis with an eighth-degree polynomial model was used to construct mean labor curves for each maternal age category stratified by parity. RESULTS: Traverse times for nulliparous women demonstrated the time to progress from 4 to 10 cm decreased as age increased up to age 40 years (median 8.5 hours compared with 7.8 hours in those 20-29 years of age group and 7.4 hours in the 30-39 years of age group, P<.001); the length of the second stage with and without epidural increased with age (P<.001). For multiparous women, time to progress from 4 to 10 cm decreased as age increased (median 8.8 hours, 7.5, 6.7, and 6.5 from the youngest to oldest maternal age groups, P<.001). Labor progressed faster with increasing maternal age in both nulliparous and multiparous women in the labor curves analysis. CONCLUSION: The first stage of labor progressed more quickly with increasing age for nulliparous women up to age 40 years and all multiparous women. Contemporary labor management should account for maternal age. LEVEL OF EVIDENCE: II.

Labor patterns in twin gestations.

OBJECTIVE: To compare labor progression in twin vs singleton gestations. STUDY DESIGN: Retrospective review of electronic database created by Consortium on Safe Labor, reflecting labor and delivery information from 12 clinical centers 2002-2008. Women with twin gestations, cephalic presentation of presenting twin, gestational age ≥34 weeks, with ≥2 cervical examinations were included. Exclusion criteria were fetal anomalies or demise. Singleton controls were selected by the same criteria. Categorical variables were analyzed by χ(2); continuous by Student t test. Interval censored regression was used to determine distribution for time of cervical dilation in centimeters, or "traverse times," and controlled for confounding factors. Repeated-measures analysis constructed mean labor curves by parity and number of fetuses. RESULTS: A total of 891 twin gestations were compared with 100,513 singleton controls. Twin gestations were more often older, white or African American, earlier gestational age, increased prepregnancy body mass index, and with lower birthweight. There was no difference in number of prior cesarean deliveries, induction, or augmentation, or epidural use. Median traverse times increased at every centimeter interval in nulliparous twins, in both unadjusted and adjusted analysis (P < .01). A similar pattern was noted for multiparas in both analyses. Labor curves demonstrated a delayed inflection point in the labor pattern for nulliparous and multiparous twin gestations. CONCLUSION: Both nulliparous and multiparous women have slower progression of active phase labor with twins even when controlling for confounding factors.