268 DELAYED INTERVAL DELIVERY IMPROVES INFANT SURVIVAL: A POP-ULATION-BASED STUDY JUN ZHANG1, BRADY HAMILTON2, JOYCEMARTIN2, ANN TRUMBLE3, 1National Institutes of Health, EpidemiologyBranch, Bethesda, MD 2National Center for Health Statistics, Hyattsville, MD3National Institutes of Health, Bethesda, MD

OBJECTIVE: The number of multifetal pregnancies has increaseddramatically. Cases such as premature rupture of the membranes of one fetus,single fetal demise, and premature labor in extreme preterm are encounteredmore often than before. Delaying delivery of the remaining fetus(es) is feasiblein some cases. However, benefits and risks of this procedure have yet to beestablished.

STUDY DESIGN: We used the U.S. 1995-98 Matched Multiple Birth File toexamine infant survival after delayed interval delivery. We identified 200 twinpregnancies in which the first twin was delivered between 17 and 29 weeks ofgestation and the second twin was delivered at least 24 hours later. Weindividually matched the delayed deliveries with 374 twin pregnancies in whichdelivery of second twin was not delayed. Perinatal outcomes and infant survivalwere compared between the delayed and non-delayed twins.

RESULTS: Among the 200 pregnancies with delayed delivery, the meangestational age at first delivery was 23 weeks and the median duration of delaywas 6 days (ranging from 2 to 107 calendar days). With every week of delay indelivery, the fetus gained 131 grams on average (95% CI: 115-147 g). 56% of thedelayed second twins survived to 1 year of age (95% CI: 50-64%) while only 24%of the non-delayed second twins did so (95% CI: 20-29%) (P < 0.001). Thedelayed twins also had significantly higher Apgar scores at 5 minutes. However,delayed delivery was also associated with 11% of risk (95% CI: 6-16%) for fetaldeath of the remaining twin before 24 weeks.

CONCLUSION: Delaying delivery of the remaining fetus(es) before 30weeks of gestation improves infant survival by more than twofold and, probably,reduces long-term child morbidity by increasing birthweight and Apgar score at5 minutes.

269 A POPULATION-BASED ANALYSIS OF RISK FACTORS FOR OBSTETRI-CAL BRACHIAL PLEXUS PALSY IN NEONATES DELIVERED BY VACUUMEXTRACTION: AN ANALYSIS BASED ON 13,716 DELIVERIES LARSLADFORS1, MARGARETA MOLLBERG1, HAKAN LILJA1, HENRIKHAGBERG1, 1Perinatal Center/Sahlgrenska University Hospital, Sweden,Gothenburg, Sweden

OBJECTIVE: To identify risk factors for obstetrical brachial plexus palsy(OBPP) in neonates delivered by vacuum extraction.

STUDY DESIGN: During 3 years (1995, 1996, and 1997), data wereprospectively collected in a national registry for operative vaginal deliveries.13,716 vacuum extractions and 140 forceps deliveries were registered, which was77.2%of all instrumental deliveries in Swedenduring the period. Univariate andstepwise logistic regression were used to analyze variables associated with OBPPin neonates delivered by vacuum extraction.

RESULTS: OBPP was diagnosed in 153 (1.12%) neonates. Variablesassociated with an increased risk for OBPP were: neonates in occiput posteriorpresentation of the head OR 2.01 (95% CI 1.01-3.93), the fetal head above or atthe level of the ischial spine at the time of extractionOR 1.94 (95%CI 1.10-3.13),if the indication for assisted delivery was delay of second stage (compared toextraction due to fetal distress) OR 2.20 (95% CI 1.54-3.15), applying fundalpressure OR 2.3 (1.65-3.14), multiple tractions (more then five tractions) OR2.82 (95% CI 1.85, 4.31). Compared to neonates with a birth weight below 4000grams, neonates with a birth weight of 4000-4499 grams had an increased risk forOBPP (OR 5.1, 95% CI 3.5, 7.3) and a birth weight$4500 grams (OR 14.5, 95%CI 9.5, 22.2). In the stepwise logistic analysis the most important factor was thebirth weight, a neonate over 5000 grams had an OR 12.64 (95% CI 8.18, 19.53)for OBPP, a birth weight 4500-4999 grams OR 4.58 (95% CI 3.13, 6.72),extraction time over 15 minutes OR 2.40 (95% CI 1.46, 3.94), fundal pressureOR 1.92, 95% CI 1.37, 2.69, inefficient uterine action OR 1.58 (95% CI 1.09,2.29), vacuum delivery OR 0.63 (95% CI 0.40, 0.98).

CONCLUSION: The combination of a high birth weight, extraction timeover 15 minutes, fundal pressure, and inefficient uterine contractions isassociated with a high risk for OBPP.

270 MATERNAL OUTCOMES AT 2 YEARS POST PARTUM IN THE TERMBREECH TRIAL MARY HANNAH1, HILARY WHYTE2, WALTER HANNAH1,Term Breech Trial Collaborative Group3, 1University of Toronto, Obstetricsand Gynaecology, Toronto, Ontario, Canada 2University of Toronto, Paedia-trics, Toronto, Ontario, Canada 3University of Toronto, MIRU, Toronto,Ontario, Canada

OBJECTIVE: The Term Breech Trial was a randomized controlled trial ofplanned caesarean section versus planned vaginal birth for breech presentationat term.We undertook a follow-up study ofmothers enrolled in the TermBreechTrial to assess maternal outcomes at 2 years post partum.

STUDY DESIGN: At 85 centers, in 18 countries, 917 of 1159 mothers werefollowed to 2 years post partum and asked to complete a questionnaire to reporton their health in the previous 3 to 6months, as well as on their views of the birthexperience and their participation in the Term Breech Trial.

RESULTS: Planned caesarean section, compared with planned vaginalbirth, was not associated with less breast-feeding; difficulties with relationshipswith the child or husband/partner; problems with sexual relations; pain;subsequent pregnancy; urinary, fecal, or flatal incontinence; depression;painful, irregular, or heavy menstrual periods; or most other health problems.Women in the planned caesarean section group had a higher risk ofconstipation, felt less worried about their baby’s health, and experienced lesspain than expected during labor and delivery than women in the plannedvaginal birth group.

CONCLUSION: Planned caesarean section is not associated with sub-stantially better or worse outcomes for women 2 years after the birth, comparedwith planned vaginal birth, if the fetus is in breech presentation at term.

271

December 2003Am J Obstet Gynecol

S136 SMFM Abstracts

THE CONTINUING EFFECTIVENESS OF ACTIVE MANAGEMENT INNULLIPARAS IN SPONTANEOUS LABOR, DESPITE A DOUBLING INOVERALL NULLIPAROUS CESAREAN DELIVERY MICHAEL FOLEY1, MAYALARAB2, DECLAN KEANE2, KATHRYN MCQUILLAN3, LESLIE DALY4,COLM O’HERLIHY1, 1University College Dublin, Obstetrics and Gynaecol-ogy, Dublin 2, Ireland 2National Maternity Hospital, Dublin 2, Ireland3National Maternity Hospital, Delivery Unit, Dublin 2, Ireland 4UniversityCollege Dublin, Public Health Medicine and Epidemiology, Dublin 2,Ireland

OBJECTIVE: To determine the effectiveness of active management of laborin correcting dystocia in nulliparas in spontaneous labor by analyzing thecontribution of this cohort to a greatly increased overall nulliparous cesareandelivery rate.

STUDY DESIGN: Annually collated institutional data were analyzedretrospectively, including cesarean rates for nulliparas in spontaneous laborfor whom an active management protocol was applied and the percentagecontribution of this category to the overall increase in nulliparous cesareansduring a 12-month period.

RESULTS: From 1989 to 2000, 81,855 women were delivered, of whom34,201 were nulliparas (42%); the proportion of nulliparas in spontaneous labordecreased progressively from 83% to 59%. The overall nulliparous cesarean rateincreased from 8.1% to 16.6%, but the cesarean rate for nulliparas inspontaneous labor was unchanged, averaging 3.3% per year (range 2.0-4.2).Comparing 1989 with 2000, nulliparas in spontaneous labor accounted for 14%of the overall increase in cesarean rate compared with 59.2% for nulliparas notin spontaneous labor. Cesareans for dystocia accounted for only 7% of theincrease among nulliparas.

CONCLUSION: Active management of spontaneous first labors remains aneffective protocol for promoting vaginal delivery; factors other than dystociaaccount for the progressive increase in the nulliparous cesarean delivery rate.