248 HOW LONG IS TOO LONG: IS A PROLONGED SECOND STAGE OFLABOR ASSOCIATED WITH WORSE MATERNAL AND NEONATAL OUT-COMES? YVONNE CHENG1, LINDA M. HOPKINS1, AARON B. CAUGHEY1,1University of California, San Francisco, Obstetrics & Gynecology, SanFrancisco, CA

OBJECTIVE: To examine maternal and neonatal outcomes in relation tothe duration of the second stage of labor.

STUDY DESIGN: A retrospective cohort study of 34,497 term, cephalic,singleton births delivered at an academicmedical center from 1976 to 2001. Thesecond stage of labor was divided into 1-hour intervals. Maternal and neonataloutcomes were compared using the chi-square test. Possible confoundingvariables including maternal age, weight, parity, ethnicity, fetal position,birthweight, and use of episiotomy were controlled for using multivariatelogistic regression.

RESULTS: Increasing rates of operative deliveries and perineal trauma wereassociated with lengthening second stage of labor beyond the first hour (seeTable). While there were small changes in the rates of 5-minute Apgar < 7, nodifference was seen in the rates of umbilical artery pH <7.0. In the multivariateanalysis, compared to patients delivered in the 2- to 3-hour time interval, those inthe > 4 hour interval had higher rates of operative deliveries and perinealtrauma when controlling for confounders; there were no differences in neonataloutcomes.

CONCLUSION: Although the length of second stage of labor is notassociated with worse neonatal outcomes, a prolonged second stage is associatedwith increased maternal morbidity.

249

250 REEVALUATING THE ROLE OF THE MFM SPECIALIST: LEAD, FOLLOW,OR GET OUT OF THE WAY ROBERT D. EDEN1, ANN PENKA2, DAVID W.BRITT3, ELLEN J. LANDSBERGER4, MARK I. EVANS5, 1St. Luke’s RooseveltHospital Center, Obstetrics & Gynecology, New York, NY 2Desert PerinatalCenter, Palm Springs, CA 3Institute for Genetics & Fetal Medicine St. Luke’sRoosevelt Hospital Center, Obstetrics & Gynecology, New York, NY4Columbia University, Institute for Human Nutrition, New York, NY5Institute for Genetics & Fetal Medicine, St. Luke’s Roosevelt/Columbia,Obstetrics and Gynecology, New York, NY

OBJECTIVE: To assess the outcomes in high-risk pregnancies between casesmanaged only by MFM and those in which consultations from generalists weresought ‘‘as needed’’ and MFM assumed the primary patient care responsibility.

STUDY DESIGN: Demographics and outcomes were ascertained fromdeliveries by MFM at a community hospital over an 11-year period comparingthose exclusively managed by MFM to those with MFM care assumed midcourseor those transferred late in pregnancy.

RESULTS: Despite comparable demographics and risk factors (not shown),high-risk pregnancies managed exclusively by MFM had substantially lowerIUFDs, NNDs, c/section rates, and complications than those cases managedprimarily by generalists until consultation was requested.

CONCLUSION: Traditionally, the generalist has served as the ‘‘gatekeeper’’to subspecialty (MFM) consultation for high-risk patients. Our data suggest thatthe system is broken and that the reverse model may provide more optimaloutcomes for less cost in known high-risk patients.

251 THE IMPACT OF TOBACCO AND COCAINE USE ON PRETERM PRE-MATURE RUPTURE OF THE MEMBRANES (PPROM) ROBERT ANDRES1,1for the NICHD MFMU Network, Bethesda, MD

OBJECTIVE: To determine if tobacco and/or cocaine increase theincidence of preterm premature rupture of the membranes (pPROM) and/oralter perinatal outcomes after pPROM.

STUDY DESIGN: Secondary analysis of patients enrolled in themulticenterPreterm Prediction Study and the BV/TV Study. Patients were subdivided into 3groups: non-smokers (N), smokers (S), and cocaine users (C) all of whom weresmokers. The incidence of pPROM was noted for each group. Additionaloutcome measures (latency after pPROM, estimated gestational age [EGA] atdelivery, birth weight [BWT], neonatal sepsis, positive neonatal cultures, andneonatal stay [LOS]) were evaluated for the NS and S groups only, as the Cgroup had only 2 patients with pPROM. Categorical data were analyzed usingchi-square or Fisher’s exact test; ordinate data were analyzed with Wilcoxonrank-sum test

RESULTS: There were 4286 women analyzed; N: 3111 (73%), S: 1134(26%), C: 41 (1%). Among the 1175 smokers 267 (23%) reported quittingsmoking early in pregnancy, 716 (61%) smoked < 1 pack per day (ppd) and 192(16%) continued to smoke > 1 ppd. pPROM occurred in 179 (4.2%) of cohort;and was not more frequent with smoking (4.5%) or cocaine use (4.9%) ascompared with non-smokers (4.1%). The incidence of pPROM did not increasewith increasing tobacco use in smokers. There was no difference in latency afterpPROM between groups (NS: 72 ± 226, S: 47 ± 72 hrs), neonatal sepsis (NS:25.2%, S: 24.5%), or positive neonatal cultures (NS: 3.4%, S: 4.1%). The EGA atdelivery (NS: 33.6 ± 3.6, S: 33.2 ± 3.8 wk), BWT (S: 2259 ± 684, S: 2218 ± 687gm), and LOS (NS: 11.3 ± 16.9, S: 14.6 ± 27.4 days) were similar.

CONCLUSION:Our findings do not support the presence of an associationbetween tobacco or cocaine use and the occurrence of pPROM. We found noevident increase in morbidity after pPROM with maternal tobacco use.

Maternal and neonatal outcomes in the second stage of labor

0-1hour(%)

1-2hours(%)

2-3hours(%)

3-4hours(%)

> 4hours(%)

Pvalues

C/S 19.6 1.6 6.4 17.0 34.5 < 0.001Oper. vaginal

del.6.2 18.0 35.7 51.0 45.6 < 0.001

3rd/4thdegree lacs

5.8 13.3 19.2 24.9 31.9 < 0.001

uapH<7.0 0.6 0.8 0.8 0.9 1.1 0.1775-min.

Apgar < 72.0 2.4 2.8 3.5 2.7 < 0.001

MFM primary vs referral

Primary MFMCare

MFM ReferralCare P value

N 1857 757

First MFM Care (weeks) 19.9 ± 9.9 28.2 ± 6.4 < 0.001Delivery Weeks: 38.2 ± 2.7 35.1 ± 5.0 < 0.001Preterm Delivery

( < 37 wks)327 (17.6%) 392 (51.8%) < 0.001

Primary C/section: 293 (15.8%) 242 (32.0%) < 0.001C/Section Fetal Distress: 144 (7.7%) 122 (16.1%) < 0.0015-minute Apgar < 7 25 (1.3%) 42 (5.5%) < 0.001Perinatal Mortality Rate 8.0/1000 34.3/1000 <0.001

Volume 189, Number 6Am J Obstet Gynecol

SMFM Abstracts S131

THE ACTIVE MANAGEMENT OF RISK IN PREGNANCY AT TERM IN ANURBAN SETTING: THE ASSOCIATION BETWEEN HIGHER GROUPINDUCTION OF LABOR RATES AND LOWER GROUP CESAREANDELIVERY RATES JAMES NICHOLSON1, GEORGE MACONES2, 1Univer-sity of Pennsylvania, Family Practice and Community Medicine, Philadelphia,PA 2University of Pennsylvania, Obstetrics and Gynecology, Philadelphia, PA

OBJECTIVE: To explore the association between exposure to an alternativemethod of obstetric care, called the Active Management of Risk in Pregnancy at Term(AMOR-IPAT), and lower group cesarean delivery rates.

STUDY DESIGN:Two different studies, the first unmatched and the secondmatched for parity, used a retrospective cohort approach to compare the clinicaloutcomes of 100 exposed pregnant women to those of 300 non-exposedpregnant women. The studies were unique and did not share study subjects.AMOR-IPATused risk factors for cesarean delivery to estimate an upper limit ofthe optimal time of delivery (ULOTD) for each subject, and used induction oflabor, if necessary, to ensure that subjects entered labor on or before theirindividual ULOTD. Subjects in the exposed group that were scheduled forinduction and had a Bishop score #5, received PGE2 (dinoprostone).

RESULTS: When compared to the non-exposed groups, the AMOR-IPAT–exposed groups experienced higher induction of labor rates and lower cesareandelivery rates. When data from the two studies were combined, AMOR-IPATexposure was also associated with significantly improved rates of otherimportant birth outcomes (see Table).

CONCLUSION: Exposure to AMOR-IPAT, which included a greaterutilization of induction of labor and more frequent delivery before individualULOTD, was significantly associated in both studies with a lower group cesareandelivery rate.

InductionRate

CesareanRate

NICUAdmit

$3rdDegree Thick Mec

Study A 63% vs26.3%*

4% vs16.7%*

9% vs14.3%

2% vs12.3%*

5% vs11.7%

Study B 55% vs15.7%*

7% vs19.3%*

4% vs9.7%

2% vs3.7%

5% vs14%*

Joined 59% vs21%*

5.5% vs18%*

6.5% vs12%*

2% vs8%*

5% vs12.8%*

*P < 0.05.