OBSTETRICS Volume 63, Number 4

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2008 by Lippincott Williams & Wilkins

Postpartum Urinary Retention After

Cesarean Delivery
C. C. Liang, S. D. Chang, Y. L. Chang, S. H. Chen, H. Y. Chueh,
and P. J. Cheng
Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of
Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; and Chang Gung University, Taoyuan, Taiwan
Int J Gynecol Obstet 2007;99:229–232

ABSTRACT
Reported rates of postpartum urinary retention (PUR) following vaginal delivery range as high as 18%, but the risk
of PUR associated with cesarean delivery is difficult to determine because of the effects of surgery and anesthesia on
postpartum bladder function and also because there is no consensus on what constitutes PUR. In this study, PUR was
diagnosed when ultrasonography demonstrated a postvoid residual bladder volume (PVRBV) of 150 mL or greater.
Participating in this prospective study were 605 pregnant women having cesarean section. The PVRBV was estimated
ultrasonically after first micturition.
The overall incidence of PUR following cesarean delivery was 24.1%. The incidence of overt PUR, when no spontaneous
micturition took place 6 hours after removal of the catheter and patients developed symptoms of obstructed voiding such as
incomplete emptying, straining, and difficulty voiding, was 7.4%. Covert PR, with no associated urinary symptoms despite
an elevated PVRBV, was more than twice as frequent (16.7%). Factors significantly associated with PUR included
postoperative epidural morphine administration, multiple pregnancy, and a low body mass index at the time of delivery. After
3 months of follow-up, 5% of patients had obstructive voiding symptoms and 9.1% had irritative voiding symptoms.
Differences in the frequency of voiding problems between the PUR and normal groups were not statistically significant.
Nearly one-fourth of these patients developed PUR following cesarean delivery. The chief contributing factor was the
use of morphine for postoperative analgesia. When transient and diagnosed at an early stage, PUR did not compromise
urinary function and was not associated with subsequent voiding problems.

EDITORIAL COMMENT
(In the immediate puerperium, most women
are predisposed to incomplete bladder empty-
ing and some are unable to void spontaneously.
This difficulty may rapidly lead to bladder over-
distension, as many women will have received a
large volume of intravenous fluid during labor or
in preparation for cesarean, and almost all will
have received oxytocin for labor stimulation or
to prevent postpartum hemorrhage. When the
oxytocin is discontinued and its antidiuretic ef-
fects abate, the bladder quickly fills.
Yip et al (Acta Obstet Gynecol Scand 1997;
76:667) reported a 4.9% rate of overt postpar-
tum urinary retention among 691 women who
were delivered vaginally, and a 9.7% rate of
202
covert urinary retention. All covert cases had
resolved by the fourth postpartum day (long-
term follow-up on the overt cases was not pro-
vided). The duration of both the first and second
stage of labor were positively correlated with the
risk of urinary retention. Ching-Chung et al (Aust
N Z J Obstet Gynaecol 2002;42:365) reported
immediate postpartum urinary retention in 4%
of 2866 term women delivered vaginally. In uni-
variable analyses, they found that nulliparity,
longer labor course, instrumental delivery, ex-
tensive vaginal and perineal lacerations, and
epidural analgesia were associated with urinary
retention. They did not perform multivariable
analysis. On long-term follow-up, 3 of 114 women
 Physiology & Pathophysiology of Pregnancy, Labor, & Puerperium
had persistent urinary symptoms. Based on ob-
stetric database review, Carley et al (Am J Obstet
Gynecol 2002;187:430) reported a much lower
(0.5%) rate of overt postpartum urinary retention in
over 11,000 women who underwent vaginal deliv-
ery at the Mayo Clinic. In their study, only 2 factors
were independently associated with urinary reten-
tion: regional anesthesia (odds ratio, 15) and op-
erative delivery (odds ratio, 3). In 80% of cases, the
voiding dysfunction had resolved by hospital
discharge.
How and when postpartum urinary retention is
defined will obviously influence the frequency
with which it will be diagnosed, particularly in
the setting of regional anesthesia, and espe-
cially after cesarean delivery, where the density
of the anesthetic block is typically more pro-
found than after vaginal delivery. The deeper or
more long-lasting the regional block, the greater
the risk of urinary retention. Likewise, if the in-
dwelling Foley catheter is removed before the
effect of the block has abated, urinary retention
is more likely, because the bladder can become
distended before sensation has returned. When
ultrasound is used to diagnose urinary retention,
rates are higher than when the diagnosis is
made on clinical grounds.
In the abstracted Liang study (which utilized
ultrasound), the rate of overt postpartum urinary
203
retention was 7.4% and the rate of covert reten-
tion was 16.7% among 605 women who under-
went cesarean delivery for a broad variety of
indications. Ten percent of women required
catheterization to resolve their voiding dysfunc-
tion. Women who received epidural morphine
for postpartum pain control had a more than
doubled risk of urinary retention. Almost cer-
tainly the effect of the morphine persisted
beyond Foley removal in these women. Unfor-
tunately, we are not provided with rates of uri-
nary retention by specific cesarean indication or
by other labor and delivery characteristics.
Regardless of the precise rates, to varying
degrees all women are at risk of postpartum
urinary retention and bladder over-distention
and should be observed accordingly, because
in extreme cases, lasting damage to the bladder
may occur. A markedly over-distended bladder
may be palpable above the symphysis pubis
and may displace the uterine fundus into the
upper abdomen. Inability to void 4 to 6 hours
after delivery or Foley catheter removal is ab-
normal and likely indicates a problem. If bladder
over-distension is diagnosed, intermittent cath-
eterization may resolve it, but often, placing an
indwelling catheter for 24 hours is the best
course of action as this will allow tone and sen-
sation to return to the bladder.—DJR)
204 Obstetrical and Gynecological Survey

Cognitive Function and Army Rejection

Rate in Young Adult Male Offspring of
Women With Diabetes: A Danish
Population-Based Cohort Study
Gunnar Lauge Nielsen, Claus Dethlefsen, Henrik Toft Sørensen,
Jan Fog Pedersen, and Lars Molsted-Pedersen
Department of Clinical Epidemiology, Aalborg University Hospital, Aalborg, Denmark; Center for
Cardiovascular Research, Aalborg Hospital, Aalborg, Denmark; Department of Radiology, Glostrup
University Hospital, Glostrup, Denmark; and Diabetes Centre, Department of Obstetrics, Rigshospitalet,
Copenhagen University Hospital, Copenhagen, Denmark
Diabetes Care 2007;30:2827–2831

ABSTRACT
Perinatal complications are more frequent in cases of maternal diabetes, but little is known about the long-term
intellectual outcome of offspring born to diabetic mothers. This study followed a cohort of Danish males born in the
years 1976–1984 whose mothers were diabetic. These 282 subjects were followed up to the time of military conscription
along with 870 population-based control subjects. The instrument used to gauge intelligence was the Boerge-Prien test,
a 45-minute validated measure whose results correlate closely with those obtained using the Wechsler Adult Intelligence
Scale.
The rejection rate was 52.5% for diabetes-exposed subjects and 45.4% for control subjects. The risk difference was
7.3%, with a 95% confidence interval (CI) of 0.6 to 14.01. Analysis of the medical reasons for rejection failed to disclose
diagnoses that could be related to cognitive performance. Among those who were not rejected, mean cognitive scores
were 41.4 units (95% CI, 40.2–42.6) in diabetes-exposed individuals and 42.7 units (95% CI, 42.0–43.4) in control
subjects. The findings were not altered when stratifying subjects by gestational age at birth or Apgar score. In a subgroup
of 39 pregnancies with available data, a 1% point increase in maternal AIC (glycosylated hemoglobin) was associated
with a 2.6% point decrease in cognitive score (95% CI, 1.8–4.8). Men whose maternal AIC was less than 7% had
cognitive scores identical to those of control subjects.
These findings point to a real, if minor, reduction in intelligence in young adult males whose mothers are diabetic.
The negative association between AIC and cognitive scores stresses the need to strive for optimal metabolic control in
diabetic women who are—or are planning to become—pregnant.

EDITORIAL COMMENT
(Especially at the beginning and at the end of
pregnancy, poorly controlled diabetes can have
dire fetal consequences. During embryogenesis,
hyperglycemia can cause severe anomalies of the
fetal heart, central nervous system, and the geni-
tourinary tract, and during the first trimester, hy-
perglycemia raises the risk of miscarriage. Later in
pregnancy, hyperglycemia promotes excessive
fetal growth and increases the risk of stillbirth.
These effects alone provide a compelling rationale
for the avoidance of hyperglycemia during preg-
nancy. A somewhat broader question, however, is
whether diabetes per se, or diabetes when it is
poorly controlled, exerts more subtle neurodevel-
opmental effects on the fetus and, if so, whether
these effects are persistent.
In attempt to shed light on these questions,
Ornoy et al (Arch Dis Child Fetal Neonatal Ed
1998;79:F94) assessed 57 children born to
pregestational diabetic mothers and 57 con-
trol children born to mothers without diabetes.
On average, children in both groups were 8
years old. Those born to diabetic mothers had
lower gross and fine motor functioning (although
the differences were not dramatic) but equal cog-
nitive functioning to the control children. The dif-
ferences in motor function were more pronounced
at ages 5–6 than at ages 9–12.
 Preconception and Prenatal Care
Rizzo and Silverman et al performed a series
of studies in which they assessed the relation-
ship of metabolic control during pregnancy in 94
pregestational diabetic women and the psy-
chomotor functioning of their offspring at ages 6
to 9. They found that the fasting plasma glucose
concentration and the degree of ketonemia
were positively associated with impaired intel-
lectual and motor functioning (Am J Obstet Gy-
necol 1995;173:1753; Diabetes Care 1998;21:
B142). This impairment, however, was mild, and
metabolic control accounted for only a small
proportion of it. Moreover, as a group, the mea-
sured intelligence of the 94 children was normal,
and their educational achievement and behav-
ioral adjustment were unrelated to indices of
maternal metabolic control during pregnancy.
The abstracted study of Nielsen et al de-
scribes the largest cohort of offspring who have
been assessed for the potential neurodevelop-
mental consequences of in utero exposure to
diabetes. Moreover, the period of follow-up of
this cohort is the longest, and ascertainment is
the most complete. Compared to controls, the
overall army rejection rate among the young
205
adult male offspring of diabetics was higher,
53% versus 45%. Most of this difference, how-
ever, was due to nonneurological chronic health
problems. Cognitive scores were not statisti-
cally significantly different between the 2 groups.
Among the offspring of diabetics, a maternal
hemoglobin A1C value greater than 7% was as-
sociated with the equivalent of an 8.4 point IQ
decrement, whereas values less than or equal to
7% were associated with equivalent IQ scores to
controls. However, these associations may be bi-
ased, as hemoglobin A1C values were available
for only 39 of 227 mothers; these 39 mothers might
not be representative, and we are not told when in
gestation the hemoglobin A1C was measured.
In summary, if poorly controlled, maternal
diabetes may have negative long-term neurode-
velopmental consequences for the fetus, al-
though the available literature is not entirely
consistent on whether cognition or coordination
is affected and what, precisely, is the degree of
risk. Striving to achieve good glucose control
during pregnancy already has ample rationale,
and perhaps the abstracted study of Nielsen
adds to it.—DJR)
206 Obstetrical and Gynecological Survey

Single-Dose Tenofovir and Emtricitabine

for Reduction of Viral Resistance to
Non-nucleoside Reverse Transcriptase
Inhibitory Drugs in Women Given
Intrapartum Nevirapine for Perinatal
HIV Prevention: An Open-Label
Randomized Trial
Benjamin H. Chi, Moses Sinkala, Felistas Mbewe, Ronald A. Cantrell,
Gina Kruse, Namwinga Chintu, Grace M. Aldrovandi, Elizabeth M. Stringer,
Chipepo Kankasa, Jeffrey T. Safrit, and Jeffrey S. A. Stringer
Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Schools of Medicine and Public Health,
University of Alabama, Birmingham; Missions Board, Lusaka, Zambia; Saban Research Institute, Keck
School of Medicine, University of Southern California, Los Angeles; University Teaching Hospital, Lusaka,
Zambia; and Elizabeth Glaser Pediatric AICS Foundation, Santa Monica, California
Lancet 2007;370:1698–1705

ABSTRACT
Administration of single-dose nevirapine intrapartum and neonatally is essential for preventing perinatal HIV in
settings where resources are limited. But after a single dose, a substantial proportion of women become resistant to
nonnucleoside reverse transcriptase inhibitors. The present randomized study was an attempt to learn whether adding
a combination of the antiretroviral drugs tenofovir disoproxil fumarate and emtricitabine would lessen the emergence
of resistance in the weeks following treatment. Of 400 HIV-infected pregnant women cared for at 2 primary health
facilities in Zambia, one was excluded. Two hundred were randomly assigned to receive a single oral dose of 300 mg
tenofovir with 200 mg emtricitabine under direct observation. The remaining 199 women received neither of these
drugs. All the women were offered a brief course of zidovudine as well as intrapartum nevirapine. The major outcome
was resistance to nonnucleoside reverse transcriptase inhibitors 6 weeks after delivery.
Women who received the intervention were 53% less likely than control women to have a mutation conferring
resistance to nonnucleoside reverse transcriptase inhibitors 6 weeks after delivery. The risk ratio was 0.47, with a 95%
confidence interval of 0.29–0.76. The overall rate of perinatal HIV transmission was similar in the intervention and
control groups (5.6% and 8.0%, respectively). This held true for both intrauterine transmission and intrapartum or early
postpartum transmission. Four women in each group were anemic in the postpartum period. Serious adverse events were
recorded for 10% of infants in the intervention group and 12% of control infants. Septicemia and pneumonia were the
most common problems. None of these events was thought to have resulted from the intervention.
A single dose combining tenofovir and emtricitabine, given at the time of delivery to HIV-infected women,
substantially reduced the frequency of resistance to nonnucleoside reverse transcriptase inhibitors 6 weeks postpartum
in this study. The investigators believe that this can be an important adjunct to intrapartum nevirapine in circumstances
where several days of combination drug treatment may not be feasible.

EDITORIAL COMMENT

(In a fairly recent SURVEY, I discussed that a HIV by almost half, from 25% to 13% at 14–16
single maternal dose of oral intrapartum nevi- weeks of age (2007;62:361). The distinct advan-
rapine, followed by single infant dose, reduces tage of this intervention is its low price and
the rate of mother to child transmission of simplicity; it is feasible in even the most impov-
 Management of Labor, Delivery, and the Puerperium
erished and underdeveloped settings. The dis-
advantage, however, is that 20%–75% of
women who receive single-dose NVP therapy
develop transient genotypic resistance to the
nonnucleoside reverse transcriptase inhibitor
(NNRTI) class of antiretroviral drugs. This resis-
tance is most consequential for women who go
on to initiate NNRTI-containing antiretroviral
therapy within 6–12 months of the initial nevi-
rapine exposure (Lockman S et al. N Engl J Med
2007;356:135).
The question then becomes how to derive the
benefits of perinatal HIV prevention that nevi-
rapine provides without compromising the sub-
sequent treatment and health of the mother? In
the abstracted study, Chi et al have addressed
this question. Their study also provides insight
into the continuing evolution of perinatal HIV
prevention in the developing world. In Lusaka,
Zambia, where Chi et al’s study was conducted,
1 in 5 pregnant women are HIV seropositive,
and in the absence of preventive efforts, 40%
would transmit the infection to their offspring.
Before 2001, perinatal HIV prevention inter-
ventions were not available in the public
sector. Since then, however, a city-wide and
progressively robust program has been imple-
mented. As of October 2007, it had tested
over 280,000 women for HIV and provided
perinatal prophylaxis to 57,000. More recently, as
additional resources have become available
through the US President’s Emergency Plan for
AIDS Relief and the Global Fund to Fight AIDS,
TB, and Malaria, the capacity of the health care
system to provide more complex and efficacious
regimens has expanded. The Lusaka District now
207
offers a 2-drug intervention of short course oral
zidovudine (300 mg BID from 32 weeks’ gestation)
“boosted” with intrapartum and neonatal single-
dose nevirapine. In clinical trials, this combination
regimen reduced the rate of perinatal HIV trans-
mission to 2% (Lallemant M et al. N Engl J Med
2004;351:217).
The appeal of Chi et al’s approach to the
prevent NNRTI resistance is its simplicity. Like
nevirapine, the tenofovir and the emtricitabine
are administered orally and in fact, are co-
formulated as a single tablet (Truvada) by Gilead
Sciences, USA. The single dose used in the
study, given at presentation for labor, was with-
out demonstrable side effects. Most impor-
tantly, it was fairly effective: in the control group,
25% of women had NNRTI resistance at 6
weeks, versus 12% of women in the tenofovir/
emtricitabine group. The goal, of course, would
be no resistance, and approaching this goal is
likely feasible, but will require further studies of
alternate strategies, e.g., administration of an
additional postpartum dose.
In the face of a disease pandemic that al-
most demands pessimism, legitimate progress is
being made in preventing perinatal transmission
and, more recently, in effectively treating adult and
pediatric HIV infection in low-resource settings
(Stringer JSA et al. JAMA 2006;296:782; Bolton-
Moore et al. JAMA 2007;298:1888). The intersec-
tion of the 2, as illustrated by the study of Chi, will
require creative strategies that balance effective-
ness, capacity for intervention and sustainability,
ease of implementation, and cost. I am proud of
my colleagues and of their colleagues for tak-
ing on these daunting challenges.—DJR)
208 Obstetrical and Gynecological Survey

Change in Knowledge of Midwives and

Obstetricians Following Obstetric
Emergency Training: A Randomized
Controlled Trial of Local Hospital,
Simulation Centre and Teamwork
Training
J. F. Crofts, D. Ellis, T. J. Draycott, C. Winter, L. P. Hunt,
and V. A. Akande
SaFE Study, Department of Obstetrics and Gynaecology, Southmead Hospital, North Bristol NHS Trust,
Bristol, United Kingdom; and University Department of Clinical Sciences at South Bristol, Institute of Child
Life and Health, UBHT Education Centre, Bristol, United Kingdom
BJOG 2007;114:1534–1541

ABSTRACT
Surveys in the United Kingdom have repeatedly discovered substandard care in significant proportions of maternal,
fetal, and neonatal deaths. In the United Kingdom, training in obstetrical emergencies is carried out both nationally and
locally in maternity units. This prospective, randomized controlled trial evaluated training in 6 hospitals in the United
Kingdom. The 140 participants included 22 junior and 23 senior doctors as well as 47 junior and 48 senior midwives.
They were randomized to one of 4 obstetrical emergency training interventions: a 1-day course at a local hospital, a
1-day course at a simulation center, a 2-day course with teamwork training at a local hospital, and a 2-day course with
teamwork training at a simulation center. A 183-question multiple choice questionnaire (MCQ) was completed up to 3
weeks before the training intervention and again 3 weeks after the intervention.
All but 7 of the 140 participants completed training and the posttraining assessment. Knowledge of obstetrical
emergency management increased following training. The increase in the mean MCQ score was significant at the P ⬍
0.001 level. All but 10 of 133 participants who completed both assessments had increased MCQ scores. Neither the
location of training nor the inclusion of teamwork training significantly influenced posttraining scores. Changes in MCQ
scores after training correlated negatively with pretraining scores. There were, however, no significant differences
between staff groups in their relative responses to the 4 training interventions. With one exception—management of
breech presentation—scores for individual components of the MCQ improved significantly.
This is the first study demonstrating objective improvement in what doctors and midwives know following training
in obstetrical emergency management. It remains to be determined whether this translates into lower maternal and
neonatal morbidity and mortality rates. The investigators believe that all relevant staff should take part in this type of
training on an annual basis.

EDITORIAL COMMENT
(In 3 prior SURVEY commentaries, I have dis-
cussed various aspects of focused training and
its relationship to obstetric outcomes. Initially, I
reviewed the study of Draycott et al, which was
the first to provide a description of a training
program for the management of acute obstetric
emergencies and an assessment of the possible
impact of the program on actual health outcomes
(BJOG 2006;113:201; SURVEY 2006;6:365). The
training was associated with improved Apgar
scores and a lowered incidence of hypoxic isch-
emic encephalopathy, but the before/after non-
randomized study design was less than optimal.
In another commentary, I reviewed the study
of Maslovitz et al, wherein obstetric emergen-
cies including eclampsia, postpartum hemorrhage,
shoulder dystocia, and breech presentation
were simulated with the use of high-tech man-
 Management of Labor, Delivery, and the Puerperium 209

nequins, the management of these emergencies
by trainees videotaped, and then the videotapes
reviewed by senior clinicians who provided graded
feedback (Obstet Gynecol 2007;109:1295; SURVEY
2007;10:636). When reassessed 6 months or
more after training, the scores of the trainees
were higher than they were before. Whether the
training was associated with improved actual
care or outcomes was not addressed in this
study.
In a third commentary, I reviewed the team-
work training trial of Neilsen et al (Obstet Gy-
necol 2007;109:48; SURVEY 2007;5:294). This
was a large and well-done cluster randomized
study that included 15 hospitals and 28,536 de-
liveries. Teamwork training was not effective, that
is, it did not lower the rate of a wide variety of
adverse maternal or neonatal outcomes that were
aggregated into an “Adverse Outcome Index.”
The abstracted trial of Crofts et al is another
recent attempt to assess the effect of obstetric
emergency training and, additionally, compare
the relative effectiveness of 4 means of deliver-
ing it. Training did improve the performance of
the trainees on a multiple choice test of knowl-
edge, but no one method of training was supe-
rior in this regard to any of the others. The main
strength of this study is its randomized design.
Its main weaknesses are its small size and the
fact that the primary outcome was not very
ambitious—improved written test performance.
Actual improvements in clinical care delivery or,
even better, improved clinical outcomes were
well beyond the scope of this study.
It is my sense that the momentum for focused
training in obstetric care and in the management
of obstetric emergencies is building. Teamwork
training has an intuitive, feel-good appeal, and
simulation training a modern, technological al-
lure. Both have financial backers. These traits,
however, are not sufficient justification for the
widespread adoption of these training modali-
ties. A properly designed, conducted, and ana-
lyzed randomized clinical trial would be. The
focus of such a trial should be actual clinical
outcomes, for example, a reduction in the rate
of brachial plexus injury or hypoxic ischemic
encephalopathy, not simply improved test scores,
or process measures such as the performance of
proper shoulder dystocia maneuvers. Somehow,
the trial would have to reconcile maternal and
perinatal outcomes and find a way to balance
them. For example, prelabor cesarean would re-
sult in fewer brachial plexus injuries and presum-
ably fewer asphyxiated neonates, but in many
cases would not be in the best interests of the
mother. Clearly, the trial would be a very difficult
undertaking, but now is the time for it.—DJR)

The Effect of Hyoscine Butylbromide on the

First Stage of Labor in Term Pregnancies
L. A. Samuels, L. Christie, B. Roberts-Gittens, H. Fletcher,
and J. Frederick
Department of Obstetrics, Gynecology and Child Health, University of the West Indies, Kingston,
Jamaica, West Indies
BJOG 2007;114:1542–1546

ABSTRACT
An example of actively managing labor is intravenous administration of hyoscine (scopolamine) butylbromide, which
has spasmolytic effects on smooth muscle of the genitourinary and gastrointestinal tracts. How this substance shortens
the duration of labor is not understood. This randomized, double-blinded, controlled trial, undertaken in Jamaica, West
210 Obstetrical and Gynecological Survey

Indies, compared IV hyoscine with a placebo, administered once active labor began. Sixty hyoscine-treated women were
compared with 69 placebo recipients. All participants were 18 years of age or older, were at term, and had no chronic
or pregnancy-induced disorders. The dose of hyoscine was 20 mg.
The duration of the first stage of labor declined from 228 minutes in control women to 156 minutes in hyoscine-
injected women, a reduction of 31.7%. There was no significant change in duration of either the second or third stage
of labor. The treatment and control groups did not differ with regard to blood loss or Apgar scores. Cesarean deliveries
were slightly but not significantly more frequent in women taking hyoscine (6.7% vs. 4.3%).
The investigators conclude that hyoscine butylbromide (Buscopan) significantly shortens the first stage of labor
without apparent adverse effects on either the mother or newborn infant.

EDITORIAL COMMENT
(Hyoscine-N-butylbromide (HBB) is a semi-
synthetic derivative of scopolamine, but, un-
like its parent compound, it does not cross the
blood brain barrier. Peripherally, because of
its anticholinergic effects, it inhibits smooth
muscle contractions in the genitourinary, bili-
ary, and gastrointestinal tracts. Apparently, it
is employed on a fairly widespread basis in
some regions of the world to hasten the pro-
gression of labor by overcoming cervical
“spasm.”
High-quality evidence that HBB does in fact
hasten labor or that it is safe is limited. In a
recent study, Sirohiwal et al (Aust N Z J Obstet
Gynecol 2005;45:128) allocated 200 alternate
women in spontaneous labor at term with sin-
gleton fetuses and intact membranes to two 10
mg HBB rectal suppositories or to standard
care. The first stage of labor in the 50 nulliparas
in the HBB group lasted 142 minutes, versus
434 minutes in the 50 nulliparas in the control
group—a statistically significant and whopping
difference of almost 5 hours! The respective
durations of the first stage of labor among
parous women were 106 and 302 minutes—a
31⁄4-hour difference. The durations of the sec-
ond and third stages did not differ between
groups, and neonatal outcomes were excel-
lent and equivalent between groups. Limita-
tions of this study include the nonrandomized
and nonblinded treatment allocation and lack
of data on the clinical comparability of the 2
study groups.
The abstracted study of Samuels et al appears
to be the best evaluation of HBB to date. It is
randomized, placebo-controlled, and double-
blinded. The sample size was prespecified, and,
importantly, labor was managed consistently for
all study participants according to clear guide-
lines. All women were in spontaneous labor at
term. Women in the experimental group re-
ceived 20 mg of intravenous HBB at a cervical
dilation of 4 to 5 cm. The first stage of labor in
the 29 nulliparas in the HBB group lasted 176
minutes, versus 257 minutes in the 34 nulliparas in
the control group—a difference of approximately
1 hour and 20 minutes. The respective durations
of the first stage of labor among parous women
were 137 and 200 minutes—a difference of ap-
proximately 1 hour. As in the Sirohiwal study, the
duration of the second and third stages did not
differ between groups, and other assessed mater-
nal and neonatal outcomes were equivalent.
Of 142 randomized women, 13 were subse-
quently excluded due to “inappropriate selec-
tion.” I am not sure what this means, but,
according to the intention to treat principle, they
should have been included and analyzed as al-
located. Nor are we told when they were ex-
cluded. If it was after the data were unblinded,
the potential that bias was introduced by their
exclusion is greater. Another limitation of the
study is its small size. Because the rate of ad-
verse outcome for infants delivered at term to
healthy mothers is low, hundreds, if not thou-
sands, must be studied to confidently exclude
harmful effects from an intervention.
Before seeing the abstracted article of Samuels,
I had never heard of hyoscine-N-butylbromide.
The available literature suggests that HBB is effi-
cacious and safe. That literature, however, is not
overwhelming, and the utility of HBB seems to be
premised on its ability to prevent or alleviate “cer-
vical spasm,” specifically smooth muscle spasm.
Yet smooth muscle is a minority component of
the cervical stroma. Thus, I would like to see
additional studies of HBB that are larger and
rigorous.—DJR)
 Home Birth; Obstetric Care by Midwife; Low Risk Deliveries 211

Evaluation of 280,000 Cases in Dutch

Midwifery Practices: A Descriptive Study
M. P. Amelink-Verburg, S. P. Verloove-Vanhorick, R. M. A. Hakkenberg,
I. M. E. Veldhuijzen, J. Bennebroek Gravenhorst, and S. E. Buitendijk
TNO Quality of Life, Netherlands Organization for Applied Scientific Research TNO, Leiden, Netherlands;
Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands; and Independently
Practicing Midwife
BJOG 2007

ABSTRACT
Over the past decade, an estimated 30% of Dutch infants have been born at home. Care in early pregnancy is delivered
primarily by independently practicing midwives, and in the absence of complications, this continues into the postpartum
period. This descriptive study, based on a database covering 95% of midwifery care and 80% of all Dutch pregnancies
in the years 2001–2003, was an attempt to determine the frequency and outcome of pregnancies referred intrapartum
from primary to secondary care. The study population consisted of 280,097 low-risk women who, at the outset of labor,
were solely cared for by a primary-level midwife with the intent to deliver either at home (62% of evaluable cases) or
in hospital (29%).
More than two-thirds of women in this study (68.1%) completed childbirth under the exclusive care of a midwife.
Another 28.3% were referred to secondary care without urgency, and 3.6% were referred urgently. The chief indications
for urgent referral were fetal distress and postpartum hemorrhage. Neonatal factors were implicated in 0.4% of cases.
Nearly three-fourths of nonurgent referrals were made during the first stage of labor. Women who had planned home
delivery were referred to secondary care less often than those planning hospital delivery (29.3% vs. 37.2%). In the
overall study population, the mean 5-minute Apgar score was 9.7 and the peripartum neonatal mortality rate was 0.05%.
No maternal deaths were recorded. Adverse neonatal outcomes were most prevalent in urgently referred cases and next
most frequent in nonurgent referrals.
These findings suggest than a system of obstetrical care based on risk assignment by midwives can work well. Further
study will be needed to learn whether outcomes would improve with earlier referrals, or whether some referrals in the
present series were unnecessary.

EDITORIAL COMMENT

(The authors of this study evaluated the Dutch
obstetric system, in which midwives determine
which low-risk pregnancies can be safely deliv-
ered at home and which require referral to a
hospital for care by a physician, and concluded
that the system is a good one, resulting in home
delivery of approximately 30% of all pregnan-
cies with a peripartum mortality rate of 0.05%.
These data support the concept that delivery in
a medical facility may be unnecessary for some
low-risk women.
Home delivery is currently a hot topic in many
states in the United States (ACOG State Legis-
lative Update—Year in Review, August 2007). In
2005, Virginia legalized home births attended by
“certified professional midwives,” and Missouri
passed a similar law this year. Although this
legislative action implies that the United States
is moving toward a system similar to that in the
Netherlands, there is at least one major difference
between the 2 countries; the midwives who pro-
vided the care examined in the Amelink-Verburg
study were trained and licensed professionals,
participating in a countrywide perinatal database.
The midwives who successfully campaigned for
home delivery in Virginia and Missouri are lay mid-
wives, despite their professional-sounding name.
Certified professional midwives (CPMs) are
“direct entry” midwives, meaning that they do
not go to nursing or midwifery school or take
any kind of formal certification exam, but di-
rectly become midwives through self-study and
apprenticeship with another CPM. These mid-
wives should not be confused with certified nurse
212 Obstetrical and Gynecological Survey
midwives, who train as nurses and then go to
midwifery school, or with “certified midwives”
(CMs), who undergo 3 years of university-affiliated
midwifery training; both nurse midwives and CMs
must take a formal science curriculum and have a
specified amount of clinical experience, and then
sit for a formal certification exam. Surprisingly, the
21 states that currently offer midwifery licensure to
attend home births require the CPM rather than
the CM or nurse midwife credential (ibid), even
though CPMs have no formal training and usually
have no collaborative relationship with an obste-
trician gynecologist. Although ACOG actively sup-
ports collegial relationships—based on mutual
trust, respect, and adherence to appropriate prac-
tice guidelines—between practicing obstetricians
and both CMs and certified nurse midwives,
ACOG does not support relationships with CPMs
(ACOG Joint Statements of Practice Relationships
Between Obstetrician Gynecologists and Certified
Nurse Midwives, Oct 1, 2002).
What will be the result of an increased number
of home deliveries in the United States attended
by lay midwives? Many leaders in our specialty
fear that these practitioners will not be able to
correctly classify pregnancies as low risk, and
will not recognize when more specialized care is
needed. Importantly, even if they do correctly
determine that urgent transfer to a hospital for
care by an obstetrician is necessary, the fact
that CPMs usually do not have collaborative
relationships with obstetricians means that they
won’t have a designated provider to refer their
patients to; in most cases, women who experi-
ence fetal stress, bleeding, or any of a number
of life-threatening intrapartum complications will
simply be sent to the local emergency room. It
seems likely that the perinatal mortality rate for
such women will be high. In a recent US study of
5418 low-risk home births attended by CPMs,
the intrapartum and neonatal mortality rate was
0.17%, more than 3 times higher than that re-
ported in the Amelink-Verburg study, and similar
to the prenatal mortality rate of all pregnancies
(both high risk and low risk) at term in the United
States (National Vital Statistics Reports, Vol 55,
No 6, Feb 21, 2007).
Amelink-Verburg and colleagues concluded
that risk selection is a crucial element of the
Dutch obstetric system. Being able to correctly
identify risk and determine the best therapy for
high-risk patients requires training, experience,
and continued lifelong education—all of which
are included only in certified nurse midwife and
CM training in the United States. The investiga-
tors also stressed that a major factor making
home delivery safe for certain patients is close
proximity to a hospital; they point out that the
Netherlands is a densely populated country,
where the distance between most patient’s
homes and the nearest hospital is short and the
average time from the phone call asking for
transport until arrival in the hospital is only 45
minutes. Many of the states in the United States
that have legalized home births by CPMs in-
clude large rural areas where the nearest hos-
pital may be hours away.
The Amelink-Verburg study endorses home
delivery of low-risk women by trained and li-
censed midwives in a country where transport
to a hospital is usually swift. These data cannot
be extrapolated to the United States, where
home births may be attended by midwives with
no formal training, and in locations hours from
the nearest hospital. Obstetricians who are con-
cerned about the current evolution of home birth
in the United States should consider getting
involved in local legislation.—KDW)
 Preterm Birth; Macrosomia; Cardiovascular Disease 213

Inflammation and Dyslipidemia Related

to Risk of Spontaneous Preterm Birth
Janet M. Catov, Lisa M. Bodnar, Roberta B. Ness, Stacy J. Barron,
and James M. Roberts
Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania; Magee Women Research
Institute, Pittsburgh; Department of Obstetrics, Gynecology, and Reproductive Sciences, University of
Pittsburgh; and Department of Biology, Emory University, Atlanta, Georgia
Am J Epidemiol 2007;166:1312–1319

ABSTRACT
There is epidemiological evidence suggesting that women who deliver preterm infants are at a 2- to 3-fold increased
risk of cardiovascular disease later in life. Excessive inflammation in both early and late gestation is one possible
explanation, and may be associated with dyslipidemia early in the course of gestation in women who subsequently have
spontaneous preterm birth (sPTB).
These associations were tested in a nested case-control study which utilized data from the Pregnancy Exposures and
Preeclampsia Prevention Study, carried out in the years 1997–2001. Case women had sPTB at 34 to 37 weeks’ gestation
(n ⫽ 76) or before 34 weeks (n ⫽ 33). The control group included 228 randomly chosen women having term births.
Early pregnancy inflammation was reflected by a C-reactive protein (CRP) level of 8 ␮g/mL or higher, and dyslipidemia
by a cholesterol level exceeding 230 mg/dL or a triglyceride level greater than 140 mg/dL. All these measurements were
made on serum drawn before 21 weeks’ gestation.
On logistic regression analysis adjusting for race, body mass index, periconceptional vitamin use, and gestational age
at the time of sampling, the 2 factors independently associated with sPTB at 34 to 37 weeks’ gestation were
inflammation early in pregnancy (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.1–7.2) and dyslipidemia (OR,
2.0; 95% CI, 1.0–4.2). The presence of both these conditions together increased the risk of sPTB before 34 weeks’
gestation by 6.4 fold (95% CI, 1.7–24.1). Half of all women with inflammation in early pregnancy had elevated CRP
levels late in gestation. Each of these factors was independently associated with the risk of sPTB before 34 weeks’
gestation.
These findings support the view that inflammation and dyslipidemia early in pregnancy are independently associated
with the risk of sPTB. The risk appears to be especially high if inflammation is present both early and late in the course
of pregnancy.

EDITORIAL COMMENT
EDITOR’S NOTE: See the combined discussion after the following abstract.
214 Obstetrical and Gynecological Survey

Associations of Prepregnancy
Cardiovascular Risk Factors With the
Offspring’s Birth Weight
Pål R. Romundstad, George Davey Smith, Tom I. L. Nilsen, and Lars J. Vatten
Department of Public Health, Norwegian University of Science and Technology, Trondheim, Norway;
and Department of Social Medicine, University of Bristol, Bristol, United Kingdom
Am J Epidemiol 2007;166:1359–1364

ABSTRACT
Previous studies have related cardiovascular risk factors—estimated before pregnancy—to birth weight, and also have
found an association between low birth weight and an increased risk of maternal cardiovascular death. This study used
linear regression analysis to prospectively examine associations between blood pressure and blood lipid levels measured
before conception, and birth weight adjusted for gestational age of the offspring. The study population included 3461
women whose deliveries were listed in the Medical Birth Registry of Norway up to the year 2005. Participants had a
mean age of 30.2 years at the time of delivery.
After adjusting for age, smoking status, height, parity, socioeconomic status, and prepregnancy body mass index, high
maternal systolic blood pressure was associated with low birth weight for gestational age. A similar but less marked
association was found between low birth weight and prepregnancy diastolic blood pressure. Unfavorable levels of total serum
cholesterol, high-density lipoprotein cholesterol, triglycerides, and blood glucose were positively associated with birth weight
for gestational age. The association between blood lipid levels and birth weight persisted after excluding pregnancies
complicated by preeclampsia.
The findings in this prospective study suggest that low birth weight, as well as high birth weight, may be an indicator
of increased maternal cardiovascular risk. Women with relatively high blood pressure tended to deliver small infants.
At the same time, those with unfavorable lipid levels tended to have large babies, suggesting reduced glucose tolerance.

EDITORIAL COMMENT
(A variety of data suggest that pregnancy is a kind
of stress test that identifies women who are at in-
creased risk of developing certain medical prob-
lems. Some of the earliest reports concerned the link
between gestational diabetes and type II diabetes.
JB O’Sullivan was one of the first to study gesta-
tional diabetes, and reported that 50% of affected
women developed full-blown diabetes within a few
years of their delivery (In: Sutherland HK, Stowers
JM, eds. Carbohydrate Metabolism in Pregnancy
and the Newborn. New York: Churchill Livingstone,
1984:174–180). Since then, there have been other
reports of associations between adverse pregnancy
outcomes and the later development of maternal
disease. Only recently, however, have investigators
attempted to determine the reverse: how the precur-
sors of future maternal diseases affect fetal life.
These 2 studies, by Catov et al and Romunds-
tad and colleagues, were each prompted by an ob-
served association between an adverse pregnancy
outcome and the later development of maternal
cardiovascular disease, and both investigators
asked if a precursor of the maternal disease could
be affecting fetal health. Catov et al studied pre-
term birth, while Romundstad and colleagues
focused on low birth weight, but both teams the-
orized that dyslipidemia might be the culprit. Ca-
tov showed that dyslipidemia alone significantly
increased the risk of preterm birth (odds ratio ⫽
2.0, 95% CI, 1.0–4.2), and that both dyslipidemia
and inflammation together resulted in even higher
risk (for birth at 34 to 37 weeks: OR ⫽ 4.0; 95% CI,
1.4–11.8; for birth before 34 weeks: OR ⫽ 6.4;
95% CI, 1.7–24.1). Romundstad and coworkers
found that women with dyslipidemia have larger
babies than those with normal lipid levels, possi-
bly through the relationship between an unfavor-
able lipid profile and glucose intolerance, unless
they have already developed hypertension, in
which case their infants are smaller.
 Down Syndrome Screening; Intrauterine Growth Restriction 215

The association between early inflammation and
preterm birth has been demonstrated in a variety
of studies (Goldenberg R et al. N Engl J Med
2000;342:1500). Although one obvious cause of
inflammation is infection, studies in which women
at increased risk of preterm birth received early
antibiotic treatment have been disappointing.
More recent studies have considered the possibil-
ity that some women may be genetically predis-
posed to have an over abundant inflammatory
response, and that this may be the source of their
increased risk (Romero R et al. Am J Reprod
Immunol 1992;27:117; Macones G et al. Am J
Obstet Gynecol 2004;190:1504). This over pro-
duction of certain inflammatory mediators may
also explain the observed link between a history of
preterm birth and cardiovascular disease later in
life—chronic low-level inflammation is damaging
to the vasculature and heart. Is there a similar
logical explanation for the observed link be-
tween dyslipidemia and both preterm birth
and cardiovascular disease? It has been
shown that inflammation and elevated levels
of inflammatory proteins lead to elevations in
cholesterol and triglycerides (Engstrom G et al.
Am J Epidemiol 2006;17:57). Conversely, drugs that
lower lipid levels have anti-inflammatory effects
(Albert MA et al. JAMA 2001;286;64; Ridker PM et al.
Circulation 1999;100:230). Thus dyslipidemia could
be present at the time of preterm birth as the result of
inflammation, or may somehow prompt inflamma-
tion. In either case, it appears that dyslipidemia and
inflammation are interrelated, and may work syner-
gistically to cause both preterm birth and cardiovas-
cular disease.
If confirmed, the relationship between inflamma-
tion, dyslipidemia, preterm birth, and heart dis-
ease is an interesting one. Although data from
both studies makes us wonder if treating dyslipi-
demia would reduce either the risk of preterm birth
or the risk of macrosomia, appropriate clinical tri-
als have not yet been done. Unfortunately, even if
such treatment is developed and tested, it would
probably have to be used preconceptionally only,
since none of the lipid-lowering drugs currently on
the market is considered safe during pregnancy.
The data should, however, prompt us to consider
screening women who have had a preterm birth or
a macrosomic infant for dyslipidemia, just as we
screen women with PCO for dyslipidemia and
those with gestational diabetes for diabetes. Since
many reproductive age women see their obstetri-
cian gynecologist more than any other doctor, it is
up to us to be sure that they undergo appropriate
screening tests and receive therapy if necessary
between pregnancies.—KDW)

First-Trimester Markers of
Aneuploidy and the Prediction of
Small-for-Gestational Age Fetuses
K. Spencer, N. J. Cowans, K. Avgidou, F. Molina, and K. H. Nicolaides
Prenatal Screening Unit, Clinical Biochemistry Department, Harold Wood Hospital, Romford, Essex; and
Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, United Kingdom
Ultrasound Obstet Gynecol 2008;31:15–19

ABSTRACT
First-trimester estimates of 2 biomarkers of placental origin, pregnancy-associated plasma protein-A (PAPP-A)
and free ␤-human chorionic gonadotropin (␤-hCG), are increasingly used along with ultrasound measurement of
nuchal translucency thickness to screen for trisomy 21 and other aneuploidies. There are preliminary indications
216 Obstetrical and Gynecological Survey

that reduced levels of these markers—especially PAPP-A—may help to identify at-risk pregnancies including
those resulting in delivery of a small-for-gestational age (SGA) infant. The study population included singleton
pregnancies with chromosomally normal fetuses that were screened at 11 to 14 weeks’ gestation. Biochemical
marker levels were converted to multiples of the expected normal median (MoM) for a pregnancy of the same
gestational age. Associations between levels of free ␤-hCG and PAPP-A and the incidence of SGA were assessed
by comparing relative incidence rates at MoM cutoffs and birth weight centile cutoffs.
A total of 46,262 pregnancies resulted in live births of infants weighing at or above the 10th centile, whereas
3539 others produced SGA infants weighing less than the 10th centile for gestation. The risk of an SGA infant was
significantly and inversely associated with maternal serum PAPP-A MoM, but not with free ␤-hCG MoM. In
pregnancies with PAPP-A levels below the 10th, 5th, and 3rd percentile, the incidence of SGA was 12%, 14%, and
16%, respectively, and the odds ratios for SGA were 2.70, 3.21, and 3.66, respectively. Free ␤-hCG levels did not
predict SGA.
The investigators believe that, in the presence of a normal fetal karyotype, low maternal serum levels of PAPP-A
are associated with an elevated risk of subsequently delivering a SGA infant. Low levels presumably indicate
impaired placentation. Present evidence warrants using low PAPP-A to help identify SGA pregnancies.

EDITORIAL
(Ever since maternal serum screening for fetal
neural tube defects (NTDs) and Down syndrome
was introduced in the early 1980s, investigators
have been trying to figure out the etiology and
the significance of abnormal maternal serum
analyte levels in pregnancies in which the fetus
is euploid and does not have a NTD. Since
maternal serum AFP was the first analyte used
for screening, the initial flurry of papers con-
cerned the association between unexplained
(not related to a fetal defect) elevated second-
trimester MSAFP levels and various pregnancy
complications, including growth restriction, pre-
eclampsia, abruption, preterm birth, and intra-
uterine fetal demise (Chandra S et al. Am J
Obstet Gynecol 2003;189:775). These associa-
tions have been confirmed by many research
groups, and it is now recognized that the
higher the AFP level, the more likely a poor
outcome. It is theorized that unexplained ele-
vated AFP reflects some kind of early placen-
tal damage or insufficiency; the damage causes
more AFP than usual to leak across the pla-
centa and into the maternal vascular system,
and also causes or contributes to a variety
of obstetric complications. Unfortunately, it is
not possible to reverse placental dysfunction,
and most of the complications associated
with elevated AFP—with the exception of still-
birth, which can be prevented by fetal moni-
toring and early delivery—cannot be avoided.
Thus, using AFP to identify pregnancies at risk
for such complications usually does not
change outcome.
COMMENT
This paper by Spencer et al presents similar
data. These investigators found that unex-
plained low levels of PAPP-A in the first tri-
mester were associated with insufficient fetal
growth; the lower the PAPP-A, the more likely
the fetus was to have a birth weight below the
10th, 5th, or 3rd percentiles. One difference
between AFP and PAPP-A, however, is that
AFP is produced by the fetal liver, while
PAPP-A is produced by the placenta. Thus
PAPP-A, like hCG, reflects placental metabo-
lism rather than placental damage. And unlike
AFP, which is probably a fetal form of albu-
men, PAPP-A has an important function—it
is a protease that cleaves insulin-like growth
factor (IGF) from binding proteins 4 and 5.
Thus, insufficient PAPP-A leads to more bound
(inactive) IGF and less free (functional) IGF.
Since IGF stimulates cell proliferation and differ-
entiation, increases insulin sensitivity, and im-
proves endothelial and microvascular function
(Kaski JC, Holt DW. Eur Heart J 2006;27:1637),
it is easy to hypothesize why decreased IGF—as
a result of decreased PAPP-A—leads to de-
creased fetal growth.
Are these data clinically relevant? Although
identifying high-risk women using elevated
MSAFP levels has not resulted in significant im-
provements in outcome, MSAFP is a second-
trimester marker, reflecting placental damage
that has already occurred and probably can’t be
reversed. Because PAPP-A is a first-trimester
marker which reflects placental enzyme produc-
tion and not necessarily placental damage, are
 Elective Cesarean; Elective Delivery; NICU Admission 217

low PAPP-A levels amenable to change? They should note the association between PAPP-A
might be, and perhaps one day a therapy which and SGA, but aside from keeping a close eye on
increases placental production of PAPP-A will such pregnancies, there is probably not much
be discovered. In the meantime, clinicians more we can do.—KDW)

Admission of Term Infants to Neonatal

Intensive Care: A Population-Based
Study
Sally K. Tracy, Mark B. Tracy, and Elizabeth Sullivan
Royal Hospital for Women, Sydney; Neonatal Intensive Care Unit, Nepean Hospital; and Australian Institute
of Health and Welfare, University of New South Wales, Sydney, New South Wales, Australia
Birth 2007;34:301–307

ABSTRACT
Infants admitted to neonatal intensive care units and special-care nurseries are thought of as being so small or ill that
their survival is unlikely unless they receive the special care provided in these facilities. Recent surveys in the United
Kingdom, however, suggest that it is not at all rare for term infants to be admitted to intensive care. The goal of this
study was to estimate rates of admission of term infants to neonatal intensive care and relate them to parity and type
of delivery. The study population consisted of 1,001,249 low-risk women who gave birth in Australia in the years
1999–2002. Rates of admission were compared in primiparous and multiparous women having cesarean section before
or after the onset of labor, vacuum or instrumental birth, or unassisted vaginal birth at 40 weeks’ gestation.
Overall rates of admission of term infants to neonatal intensive care were 8.9% for infants of primiparas and 6.3%
for infants of multiparas. Adjusted odds ratios for admission of low-risk primiparas to intensive care when operative
delivery was carried out before the onset of labor were 12.08 at 37 weeks’ gestation, 7.49 at 38 weeks, and 2.80 at 39
weeks. The adjusted odds ratio at 41 weeks was not significantly greater than at 40 weeks’ gestation. For low-risk
multiparas who had cesarean delivery before labor began, the adjusted odds ratios for admission to intensive care at 37,
38, and 39 weeks’ gestation were 15.40, 12.13, and 5.09, respectively. The odds ratio at 41 weeks’ gestation was
significantly lower than at 40 weeks. Compared with unassisted vaginal birth at 40 weeks’ gestation, infants born after
any form of operative delivery were more likely to be admitted to neonatal intensive care.
Although elective birth at 37 weeks’ gestation is considered to be a term birth, 37 weeks is not always a safe time
to be born with minimal risk to the infant. More attention should be given to what women are told about elective
cesarean section before 40 weeks’ gestation, and about the best birth site for appropriate neonatal care when an elective
procedure is planned.

EDITORIAL COMMENT
(Obstetricians have always done elective
deliveries—meaning deliveries scheduled more for
patient or physician convenience than for medical
indications. Until recently, however, most of these
deliveries have been by labor induction and vaginal
delivery or by repeat cesarean. The current twist
on elective delivery—elective primary cesarean—
although gaining in popularity, is still considered
controversial. In addition to concerns about the
maternal consequences of elective surgery—
and the consequences of multiple repeat elective
surgeries—many clinicians worry about the fetal
outcome. Concern for the fetus seems justified
when elective cesarean is done before 39 weeks,
given the rapidly accumulating data about the
neonatal complications associated with “near
218 Obstetrical and Gynecological Survey
term” birth. An example of such data is provided
by Young et al (Pediatrics 2007;119:e659), who
reviewed the outcomes of 283,975 births from
1999 to 2004 and, after excluding anomalous in-
fants, found that infants delivered at 37 or 38
weeks’ gestation had a significantly higher risk of
neonatal death than those delivered at 40 weeks
(for 37 weeks, RR ⫽ 1.90; 95% CI ⫽ 1.2–3.1; for
38 weeks, RR ⫽ 1.95; 95% CI ⫽ 1.3–2.9). Even
elective delivery at term is associated with in-
creased risk, when it is by prelabor cesarean. A
Norwegian study of planned cesarean versus
planned vaginal deliveries found that 9.1% of in-
fants delivered at term by elective cesarean re-
quired admission to the NICU, compared to 5.2%
of infants delivered vaginally. Very few studies,
however, have evaluated the effects of both near
term delivery and elective prelabor cesarean.
Such data is desperately needed because a pro-
portion of elective prelabor cesareans will inevita-
bly be performed before 39 weeks.
The data presented by Tracy et al is therefore
very timely. These investigators evaluated the
effects of both gestational age and elective pre-
labor cesarean on the need for admission to the
neonatal intensive care unit (NICU) in low-risk
women, meaning those between 20 and 34
years of age, without hypertension or diabetes
of any kind, who had an AGA singleton fetus in
vertex presentation. They found that 23% of
low-risk infants delivered by prelabor cesarean
at 37 weeks and 9.4% of those delivered at 38
weeks required NICU admission, compared to
only 5.7% of low-risk infants delivered by unas-
sisted vaginal delivery at 39 or 40 weeks. These
rates translated into significantly increased odds
of NICU admission for infants delivered electively
by prelabor cesarean, especially if the woman was
multiparous (for low-risk nulliparas with prelabor
cesarean at 37 weeks, OR ⫽ 12.08; 95% CI ⫽
8.64–16.89, and at 38 weeks OR ⫽ 7.49; 95%
CI ⫽ 5.54–10.11; for low risk multiparas at 37
weeks, OR ⫽ 15.40; 95% CI ⫽ 12.87–18.43, and
at 38 weeks OR ⫽ 12.13; 95% CI ⫽ 10.37–14.19).
Interestingly, even infants delivered by prelabor
cesarean at 39 weeks were at increased risk of
requiring NICU admission (7.7% admitted; OR ⫽
2.80; 95% CI ⫽ 2.02–3.88).
Data from this study and others should be
presented to patients who request prelabor ce-
sarean delivery. At the least, it again illustrates
why delivery before 39 weeks should be avoided
and why we should strictly adhere to the ACOG
criteria for elective delivery (listed below). Impor-
tantly, it demonstrates that prelabor cesarean fur-
ther increases the odds of a suboptimal outcome
for the infants of mothers requesting elective de-
livery. Considering this, elective cesareans should
ideally not be scheduled before 39 or, preferably,
40 weeks’ gestation. If we adopt this policy, some
women who desire cesarean delivery may go into
labor before their scheduled delivery, but that
would actually be good—the women in Tracy’s
study who had their elective cesarean after the
onset on labor actually had lower rates of NICU
admission at 39 and even 38 weeks’ gestation
(OR ⫽ 0.86; 95% CI ⫽ 0.76–0.99; OR ⫽ 0.77;
95% CI ⫽ 0.65–0.99, respectively)!
CONFIRMATION OF A TERM GESTATION
(ACOG PRACTICE BULLETIN NUMBER
10, NOVEMBER 1999)
• Fetal heart tones have been documented for
20 weeks by nonelectronic fetoscope or 30
weeks by Doppler.
• It has been 36 weeks since a positive serum or
urine hCG pregnancy test was performed by
a reliable laboratory.
• An ultrasound measurement of the crown
rum length, obtained at 6 to 12 weeks, sup-
ports a gestational age of at least 39 weeks.
• An ultrasound obtained at 13 to 20 weeks
confirms the gestational age of at least 39
weeks determined by clinical history and
physical examination.
ACOG Practice bulletin number 10, November
1999.—KDW)