340 FAILED OPERATIVE VAGINAL DELIVERY – CAN IT BE PREDICTED?NIR MELAMED1, AVI BEN HAROUSH1, BORIS KAPLAN1, YARIV YOGEV1, 1RabinMedical Center, Beilinson Hospital, Obstetrics and Gynecology, Petah-Tiqva,Israel

OBJECTIVE: To identify factors predicting failure of operative vaginaldelivery.

STUDY DESIGN: A retrospective cohort study of all women who underwenta trial of operative vaginal delivery between 1993 and 2006. Vacuum extractionor low forceps delivery were initially employed by physicians preference, and incases of failed vacuum extraction either a cesarean section or a trial of forcepsdelivery were performed.

RESULTS: 1) Out of 83,351 deliveries, the rate of operative vaginal deliverywas 6.1% (5,120/83,351), and vacuum extraction (n=4299, 84.0%) was morecommon as the initial procedure compared with forceps delivery (n=821,16.0%). 2) Failed operative delivery occurred in 8.6% (n=443) of these cases,and was significantly less common with forceps delivery than with vacuumextraction (10.0% vs. 1.3% p!0.001). 3) When vacuum extraction failed, atrial of forceps delivery was undertaken in 72.6% (n=314) of the cases with a3.5% failure rate. 4) Failure of operative delivery was significantly morecommon in the case of macrosomia (8.9% vs. 2.6%, p!0.0001), persistentoccipito-posterior (4.3% vs. 2.6%, p=0.03), and in the absence of analgesia(4.9% vs. 2.5%, p!0.001). 5) When analgesia was provided, the use ofintravenous opiates was associated with a lower failure rate compared withepidural (1.2% vs. 2.6%, p!0.05). 6) On multivariate logistic regressionanalysis, the choice of forceps delivery rather than vacuum extraction(OR=0.37, 95% �CI=0.19-0.72), use of analgesia (OR=0.40, 95%�CI=0.26-0.63), persistent occipito-posterior (OR=1.80, 95% �CI=1.09-2.96), and macrosomia (OR=2.16, 95% �CI=1.17-3.98) were significant andindependent predictors of failed operative delivery.

CONCLUSION: Our data suggest that fetal weight and fetal head positionshould be included in the evaluation that precedes operative vaginal delivery.The use of analgesia should be encouraged prior to operative delivery.

0002-9378/$ - see front matterdoi:10.1016/j.ajog.2006.10.370

341 IS THERAPEUTIC CERCLAGE MORE EFFICACIOUS IN WOMEN WHO DEVELOPCERVICAL INSUFFICIENCY AFTER A TERM DELIVERY? NISHA VYAS1,ALESSANDRO GHIDINI2, JOHN PEZZULLO3, KIMBERLY HICKEY1, HELAIN LANDY1,SARAH POGGI2, 1Georgetown University, Obstetrics and Gynecology, Washing-ton, District of Columbia, 2Inova Alexandria Hopsital, Obstetrics andGynecol-ogy, Alexandria, Virginia, 3Georgetown University, Pharmacology andBiostatistics, Washington, District of Columbia

OBJECTIVE: Data are conflicting regarding the efficacy of therapeuticcerclage. Our objective was to determine whether therapeutic cerclage is moreefficacious in women with cervical insufficiency following a term delivery whencompared to those without a prior term delivery.

STUDY DESIGN: Demographic and obstetrical data were gathered prospec-tively on patients receiving a therapeutic cerclage defined as midtrimesterpresentation with a cervical length !2.5 cm (ultrasound-indicated) and priorPTD or cervical dilatation with prolapsing membranes (physcial exam-indi-cated). Delivery outcomes based on cerclage type were compared betweenwomen with vs. without a prior term birth. Excluded were patients with uterineanomalies, connective tissue disease, higher order multiple gestation or thoseexperiencing an indicated preterm delivery.

RESULTS: Patients with a history of a term birth (N=29) were similiar tothose without (N=34) in regards to maternal age (P=0.1), BMI, (P=0.6),ethnicity (P=0.3), rate of twins P=0.8), and cerclage type (physical exam /ultrasound indicated (44.8 vs. 38.2%, P=0.2)). Women with a therapeuticcerclage and a history of a prior term delivery were significantly more likely todeliver after 35 weeks as opposed to women with no prior term delivery (86%vs 57%, OR=11.0 (95% CI=2.9, 40.3)). Consequently, multiparas alsodelivered significantly larger fetuses than women with no history of a termdelivery (2828 +/�981 vs 2402 +/�1071, P=0.08 and experienced fewerNICU admissions and/or perinatal deaths (19 vs 71%, OR=0.1 (95%CI=0.03-.38)), with over half of NICU admissions for sepsis evaluation.

CONCLUSION: Patients who develop CI after a term delivery and have atherapeutic cerclage have improved perinatal outcomes compared to patientswithout a history of term delivery before presentation with CI.

0002-9378/$ - see front matterdoi:10.1016/j.ajog.2006.10.371

342 DOES INCREASING BMI AFFECT CERCLAGE EFFICACY? NISHA VYAS1,ALESSANDRO GHIDINI2, STACEY ANDERSON1, JOHN PEZZULLO3,HELAIN LANDY1, SARAH POGGI2, 1Georgetown University, Obstetrics and Gyne-cology, Washington, District of Columbia, 2Inova Alexandria Hospital,Obstetrics and Gynecology, Alexandria, Virginia, 3Georgetown University,Pharmacology and Biostatistics, Washington, District of Columbia

OBJECTIVE: Obesity is associated with a lower rate of spontaneous pretermbirth (Hendler et al, 2005) but an effect of the disease on cervical insufficiency(CI) has not been described. Our objective was to study the relationshipbetween body mass index (BMI) and gestational age (GA) at delivery inpatients with CI undergoing cerclage.

STUDY DESIGN: We reviewed our comprehensive database of patientsundergoing cerclage (N=175) for a well-characterized history of cervicalinsufficiency (prophylactic), shortened cervix !2.5 cm with a history of priorpreterm delivery (PTD) (ultrasound-indicated) or prolapse of membranesthrough the external os (physical exam-indicated). Excluded were patientsexperiencing indicated preterm deliveries (N=22) and those with uterineanomalies (N=5). Stepwise multivariate linear regression analysis wasperformed to determine the relationship between prepregnancy BMI andGA at delivery and univariate analysis was used to compare obese (BMI O30)to normal weight (BMI!25) patients for outcomes of PTD!35 weeks andGA at delivery.

RESULTS: After controlling for GA and cervical length at cerclage place-ment, cerclage type and indication, race, parity, and vaginal infections, BMIremained significantly predictive of prematurity (coefficient:�0.14, standarderror: 0.07, adjusted R2 = 0.18), such that every additional 1 kg/m2 of BMIwas associated with a 1 day reduction in GA at delivery (P!0.001). Ratesof PTD !35 weeks in obese vs. normal weight patients were significantlyhigher (37.2 vs. 17.1%, OR=2.9 (95% CI: 1.2, 6.9) with lower mean GA atdelivery (33.0 C/�9.2 vs 37.9 C/�1.6 weeks, P=0.02).

CONCLUSION: There is an inverse correlation between BMI and GA atdelivery in patients with CI receiving cerclage that remains after controlling forconfounders. The findings are even more striking given the protective effect ofobesity on the risk of spontaneous prematurity.

0002-9378/$ - see front matterdoi:10.1016/j.ajog.2006.10.372

343 SHORT TERM EFFECTS OF PERITONEAL CLOSURE AT CESAREAN SECTION: RESULTSOF A RANDOMIZED CONTROLLED TRIAL OFER GEMER1, JENYA KRUCHKOVICH1,VIKI KAPUSTIAN1, MICHAEL GDALEVICH2, SIMON SHENHAV3, VANIA VOLACH1,EYAL ANTEBY4, 1Barzilai Medical Center, Obstetrics and gynecology, Ashkelon,Israel, 2Barzilai Medical Center, District health office, Ashekelon, Israel,3Barzilai Medical Center, Israel, Ashkelon, Israel, 4Ben Gurion Universityof the Negev, Ashkelon, Israel

OBJECTIVE: To compare the short term effects of peritoneal closure versusnon closure in patients undergoing primary Cesarean section (CS).

STUDY DESIGN: Prospective randomized double blind controlled trialof women undergoing primary CS. Main outcome measures include operatingtime, post operative febrile morbidity, wound infection and analgesicrequirements.

RESULTS: 389 women were enrolled in the study. 192 where allocated toclosure, and 187 to non-closure of the peritoneum. There were no significantdifferences between the closure and the non-closure groups in regard toduration of operation (42.4C/- 11.6 vs. 41.6C/�5.6 minutes, p=0.51), woundinfection rate (10.4% vs. 7.4%, p=0.31), narcotic (1.3C/�1.0 vs. 1.4, p=0.38)and non narcotic (4.6C/- 2.8 vs. 4.5C/- 2.5, p=0.81) administrations, as wellas hospitalization days (4.1C/�0.7 vs. 4.2C/�0.8, p=0.75). Febrile morbiditytended to occur less often in the closure versus the non-closure group (0.04%vs. 0.08%, p=0.07).

CONCLUSION: Non closure of the peritoneum during CS had no significanteffect on operative and short term post operative outcome.

0002-9378/$ - see front matterdoi:10.1016/j.ajog.2006.10.373

SMFM Abstracts S111