S46 SMFM Abstracts

119 COMPARISON OF OBSTETRIC OUTCOME FOLLOWING THE INTRODUCTION OF

PATIENT-CONTROLLED EPIDURAL ANALGESIA WITH BACKGROUND INFUSION
COMPARED WITH CONTINUOUS EPIDURAL INFUSION TECHNIQUE AOIFE ONEILL1,
NIAMH HAYES1, EVE GAUGHAN1, JOHN LOUGHREY1, MICHAEL GEARY1, 1Rotunda
Hospital, Dublin, Ireland
OBJECTIVE: Patient controlled epidural analgesia (PCEA) with low-dose
background infusion has been shown in one study to result in fewer epidural
rescue interventions, but this has not been a universal nding.PCEA techniques have been associated with reduced analgesic requirements, which may
decrease instrumental delivery rates. We compared the eect of PCEA (5 ml
bolus every 15 min/as required) with background infusion (6 ml/hour), versus
continuous infusion epidural analgesia (CIEA) at 10 mls/hr with the same
solution (bupivacaine 0.1% and fentanyl 2 mcg/ml) for nulliparous women.
Our outcome measures were instrumental delivery rates, analgesic consumption and the frequency of rescue epidural reinforcement.
STUDY DESIGN: A retrospective review of the hospital database prior to and
after the introduction of PCEA with background infusion was conducted to
assess major obstetric outcomes. A chart review for a sample of parturients in
each group was also conducted to examine analgesic consumption and rates of
rescue intervention between PCEA with background infusion and CIEA.
RESULTS: The groups were demographically similar. There was no statistically signicant dierence in obstetric outcome between PCEA and CIEA
(table). There was a reduction in the frequency of rescue reinforcement by
anaesthetic and midwifery sta and a trend towards reduction in the average
hourly dose of bupivacaine.
CONCLUSION: Decreasing the number of rescue interventions reduces
anaesthetic and midwifery workload in maintaining acceptable epidural
analgesia on a busy labour ward. However, this technique has not reduced
instrumental delivery rates in nulliparous women at our hospital. We conclude
that PCEA with background infusion is an acceptable method of epidural
analgesia maintenance.

Nulliparas with epidural (n)

Maternal age (years)
Induction rate %
Instrumental delivery rate %
Caesarean section rate %

CIEA

PCEA

P value

1268
26.9
29.6
35.8
23.1

1177
26.9
27.3
37.0
23.3

ns
ns
ns
ns

120 VBAC OUTCOME ASSOCIATED WITH STANDARDIZED INTRAPARTUM PROTOCOL

AFTER ONE PREVIOUS CESAREAN COLM OHERLIHY1, 1University College Dublin,
Obstetrics and Gynaecology, Dublin 2, Ireland
OBJECTIVE: Although vaginal delivery rates of up to 80% have been
reported following labor after one previous lower segment cesarean section
(VBAC), there has been increasing recent controversy concerning the relative
safety of this management, compared with elective repeat cesarean delivery.
The aim of this study was to assess the obstetric outcome of a consecutive
series of women, managed according to an intrapartum protocol including
selective oxytocin augmentation.
STUDY DESIGN: The trial of labor protocol involved a constant intrapartum
attendant, continuous electronic monitoring, oxytocin augmentation only
after 3 hrs following senior obstetric assessment and rapid (15-30 mins) resort
to cesarean if sudden clinical deterioration occurred.
RESULTS: During the decade 1991-2000 at the National Maternity Hospital, 3349 of 39597 total multiparous women presented following previous
cesarean delivery; 1481 underwent repeat cesarean, leaving 1868 (4.7%) with
one previous cesarean who underwent trial of labor. 669 (36%) of this cohort
received oxytocin augmentation, 1347 (72%) delivered vaginally and 521 by
intrapartum cesarean. There were 15 (0.8%) cases of scar dehiscence/rupture, 5
following oxytocin and 1 requiring hysterectomy. Of 24 perinatal deaths, 12
were due to congenital anomalies, 6 occurred antepartum and 2 were related to
scar rupture. Of 6 infants with neonatal encaphalopathy, none followd scar
rupture.
CONCLUSION: When a standardized intrapartum management protocol is
employed involving clearly-dened intervention criteria combined with
prompt emergency delivery where indicated, satisfactory maternal and perinatal outcomes can be achieved in attempted VBAC. Selected oxytocin
augmentation in these circumstances does not increase risk of scar dehiscence.

121 RELATIONSHIP BETWEEN THE ROUTE OF DELIVERY AND PERINATAL OUTCOMES

IN PRETERM INTRAUTERINE GROWTH RESTRICTION (IUGR) ANTHONY ODIBO1,
LINDA ODIBO1,
GEORGE MACONES3, 1University of
DAVID STAMILIO2,
Pennsylvania, Obstetrics and Gynecology, Philadelphia, Pennsylvania,
2
University of Pennsylvania Medical Center, Philadelphia, Pennsylvania,
3
University of Pennsylvania Medical Center, Obstetrics and Gynecology,
Philadelphia, Pennsylvania
OBJECTIVE: To determine if the route of delivery aects perinatal outcomes
in cases of preterm IUGR.
STUDY DESIGN: Retrospective cohort study of singletons with preterm
(gestational age (GA) !33 weeks) IUGR (birthweight ! 5th percentile for
gestation) over a 6 year period. Deliveries by cesarean section (CS) were
compared with vaginal delivery for adverse perinatal outcomes. We excluded
all stillborn or fetuses with aneuploidy or congenital malformations.The
outcomes compared include: umbilical artery pH !7.0; respiratory distress
syndrome (RDS); periventricular leukomalacia (PVL); grades 3-4 intraventricular hemorrhage (IVH); neonatal death and a composite of at least one
adverse outcome. Statistical analysis included bivariate and multivariable
techniques.
RESULTS: We identied 149 singleton pregnancies with preterm IUGR, 93
(62%) delivered by CS and 56 (38%) vaginally. Demographic characteristics
were similar between the two groups. After adjusting for confounding
variables (including oligohydramnios, reason for CS, steroid administration
and GA at delivery) using logistic regression, no signicant dierence in
neonatal outcomes was detected between delivery by CS or by vaginal
route.The study had 80% power to detect a relative risk of 2.0 in the
composite outcome between the two groups.
CONCLUSION: In the setting of preterm IUGR, the route of delivery did not
aect perinatal outcomes. Cesarean deliveries should be reserved for obstetrical indications.

Outcome

CS
n = 93 (%)

Vaginal delivery
n = 56 (%)

Adjusted OR
(95% CI)

Arterial cord ph!7.0

PVL
NEC
IVH(III-IV)
RDS
NND
Composite

4
2
5
12
54
12
66

0
0
2
4
20
6
23

2.3
2.7
2.2
0.9
2.5

(4)
(2)
(5)
(13)
(58)
(13)
(71)

(0)
(0)
(4)
(8)
(38)
(11)
(41)

(0.3-16.7)
(0.7-10)
(0.9-5.1)
(0.1-5.5)
(0.9-6.5)

122 CORD AROUND THE NECK-SHOULD IT BE SEVERED AT LABOR? OSCAR SADAN1,

SAMUEL LURIE1, SHMUEL EVRON1, ABRAHAM GOLAN1, 1Department of Obstet.
and gynecol., Wolfson Medical Center. Sackler Medical School, Tel-Aviv
University, Holon, Israel
OBJECTIVE: Umbilical cord frequently becomes coiled around portions of
the fetus, usually the neck. Incidence of nuchal cord at birth rises with
advancing gestation reaching an incidence of 25-30% at term. In our present
study we assessed the practice of severing the cord, which was wrapped once
around the neck of the fetus, after delivery of the anterior shoulder and prior
to extraction of the body.
STUDY DESIGN: A prospective, randomized controlled study. The study and
the control groups included, each one, 30 consecutive women. Cord around the
neck was diagnosed during labor by ultrasound. It was cut intentionally in the
study group and left intact in the control group. Demographic data was
obtained. The course of labor was assessed by the need of induction or
augmentation and spontaneous or articial rupture of membranes (SROM or
AROM). Duration of the active phase of labor, 2nd stage of labor and the use of
epidural analgesia were compared between the groups. Oxytocin usage was
determined by Montevideo Units (MU). Fetal heart rate tracing was assessed
and the rate of normal pattern was reported. The frequency of the occurrence
of meconium stained amniotic uid (MSAF) was recorded. Neonatal outcomes
measured were cord pH, Apgar scores at 5 minutes and need for resuscitation.
Length of maternal and neonatal hospitalization was determined.
RESULTS: No dierences were found between the study and the control
group, before and during labor, regarding perinatal variables. pH 7.29+0.07
in the study group and 7.32+ 0.06, in the control group did not dier
signicantly, p=0.1.
CONCLUSION: Single nuchal encirclement by the umbilical cord during
labor, after delivery of the anterior shoulder, can be severed or left intact. Our
study did not detect any adverse perinatal outcomes in both groups. However,
it is suggested that a tight nuchal cord should be severed.