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Poster Session IV Epidemiology, Global Maternal-Fetal Public Health, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics www.AJOG.org

668 Obese women have an increased risk of morbidity afteresarean delivery compared to operative vaginal delivery

Clara Ward1, Aaron B. Caughey2, Yvonne W. Cheng1

1University of California, San Francisco, San Francisco, CA,2Oregon Health & Science University, Portland, OROBJECTIVE: To examine the risk of cesarean delivery (CD) comparedo operative vaginal delivery (OVD) in obese women.

STUDY DESIGN: This is a retrospective cohort study of 3417 deliveries toverweight and obese women at a single institution. Primary maternalutcome variables included postpartum hemorrhage, blood transfusion,horioamnionitis, and endomyometritis. Primary neonatal outcomeariables included Apgar scores, meconium aspiration syndrome, birthrauma, neonatal tachypnea, neonatal intensive care (NICU) admission,nd neonatal death. Univariate analysis and multivariable logistic regres-ion were used to assess the risk of maternal and neonatal morbidity whileontrolling for possible confounding covariables.

RESULTS: Obese women undergoing cesarean delivery have an in-reased risk of postpartum hemorrhage, blood transfusion, and infec-ion compared to those who have an OVD. Neonates delivered tobese women via OVD had an increased risk of birth trauma, whilehose delivered via CD more frequently required NICU admission.

CONCLUSIONS: Overweight and obese women have a disproportionateisk of maternal morbidity from CD compared to OVD. OVD shoulde considered a safer alternative to CD for obese women.

Table 1. Risk of Maternal and Neonatal Morbidity with CD compared to OVD

OVD % CD % aOR 95% CI P-value

MATERNAL..........................................................................................................................................................................................

Postpartum Hemorrhage 16.8 21.4 1.72 1.36-2.17 �0.001..........................................................................................................................................................................................

Blood Transfusion 1.25 2.66 2.24 1.04-4.80 0.038..........................................................................................................................................................................................

Chorioamnionitis 18.9 21.3 1.64 1.31-2.05 �0.001..........................................................................................................................................................................................

Endomyometritis 1.31 7.22 9.59 5.65-16.3 �0.001..........................................................................................................................................................................................

NEONATAL..........................................................................................................................................................................................

5-minute Apgar �7 4.41 4.40 0.89 0.55-1.46 0.652..........................................................................................................................................................................................

Acidemia 1.46 3.13 1.10 0.46-2.66 0.827..........................................................................................................................................................................................

Meconium Aspiration Syndrome 0.83 1.31 1.97 0.68-5.68 0.211..........................................................................................................................................................................................

Birth Trauma 2.35 0.33 0.28 0.82-0.96 0.043..........................................................................................................................................................................................

Neonatal Tachypnea 1.48 1.99 1.03 0.47-2.27 0.943..........................................................................................................................................................................................

NICU Admission 8.39 12.76 1.40 1.02-1.93 0.039..........................................................................................................................................................................................

Neonatal Death 0.28 0.60 1.07 1.68-6.86 0.941..........................................................................................................................................................................................

669 Classical cesarean delivery between 23-27eeks gestation: immediate complicationsnd effects on subsequent pregnancy

Eleanor Murray1, Scott Sullivan1, Angela Savatiel1,harles Rittenberg1, Eugene Chang1

1Medical University of South Carolina, Charleston, SCOBJECTIVE: To compare the immediate maternal and subsequent peri-

atal complications after classical cesarean (CCD) versus vaginal de-ivery (VD) � 27 weeks gestation.

STUDY DESIGN: We performed a retrospective cohort study on patientsundergoing either CCD or VD between 23 - 27 weeks gestation with asubsequent pregnancy at our institution. Patients were identified us-ing a perinatal database. Demographics, immediate and subsequentmaternal and neonatal outcomes were abstracted from direct chartreview. Univariable analysis was performed using Fisher’s exact andMann Whitney U. Multivariable logistic regression analysis was per-formed to control for confounders identified on univariable analysis.Final adjusted odds ratios were reported with 95% confidence inter-vals.RESULTS: Patients in the CCD group were older (p�.004), heavier

p�.04) and more commonly African American (p�.03) than the VD

S264 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2

group. CCD in the index pregnancy was associated with longer ma-ternal length of stay (p�.02)and increased blood loss (P�.0001).CCD was associated with preeclampsia (p�0.001) and a decreasedrisk of neonatal death (adj OR 0.65 95 % CI 0.45-0.93) In the subse-quent pregnancy mean birth-weight was less in the prior CCD group(2327�126 vs. 2680�97 grams, p� 0.03), although rates of IUGRwere not significantly increased (8.9% vs. 4.0%, p�0.42). Fetal acido-sis was increased in women with prior CCD compared to VD (OR 9.9695% CI 2.3-78), median 5 minute APGAR score were lower(p�0.035), pre-eclampsia was increased (p�.03) and fetal death rateswere doubled (4.4% vs 2.7%),although this difference was not statis-tically significant (p�0.63). Composite obstetrical complicationswere increased in the CCD group. (adj OR 1.73 95 % CI 1.1-2.5)CONCLUSIONS: Classical cesarean delivery � 27 weeks is associated

ith increased immediate maternal complications and increased fetalurvival. It is also associated with subsequent fetal complications inhe following pregnancy. This may have implications for the counsel-ng and surveillance of pregnancies following CCD.

670 Contributing indications to thencreasing cesarean delivery rate

Emma Barber1, Lisbet Lundsberg1, Cheryl Raab2, Christianettker1, Edmund Funai1, Jessica L. Illuzzi1

1Yale University, New Haven, CT, 2YaleNew Haven Hospital, New Haven, CTOBJECTIVE: The cesarean delivery rate has been steadily increasingince 1996 and in 2007 was the highest ever recorded at 32%. Wexamined physician-documented indications for cesarean section inrder to investigate which specific indications have contributed to the

ncrease.STUDY DESIGN: We examined rates of cesarean section, including pri-

ary cesarean section and indications, repeat cesarean section, andaginal birth after cesarean at Yale New Haven Hospital for all birthsn�64,012) between July 1996-February 2010. Linear regression wassed to estimate time trends for each indication and slopes were com-ared to determine the relative contribution of each indication to theverall increase.

RESULTS: The overall cesarean section rate increased drastically be-ween 1997 and 2009 (19.6% to 36.5%) as did the primary cesareanate (13.4% to 21.7%) and the repeat cesarean rate (6.25% to 14.9%).

eanwhile, VBAC rates plummeted from 42.5% to 7.8%. The rate ofesarean section for private patients was higher and rose more quicklyhan the rate for hospital service patients. The number of cesareanserformed for all indications increased with the exception of malpre-entation. The relative contribution of each indication to the totalncrease in the primary cesarean rate are: Non-reassuring fetal status30%), arrest of labor disorders (20%), multiple gestation (16%),acrosomia (10%), pre-eclampsia (10%), elective per patient request

8%), maternal-fetal conditions (5%), and obstetric conditions (1%).CONCLUSIONS: Among primary cesarean births, all indications for the

rocedure contributed to the increasing rate, with more subjectivendications (labor arrest disorders, non-reassuring fetal heart rateracings, and macrosomia) contributing larger proportions than

ore objective indications with long-standing definitions (malpre-entation and other obstetric conditions, e.g. placenta previa, accreta,ord prolapse, chorioamnionitis). Efforts to address the rising cesar-an rate may benefit from attempts to convert subjective indicationsnto objective ones though stronger and clearer evidence-baseduidelines.

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