www.AJOG.
org Operative Obstetrics, Clinical Obstetrics, Intrapartum, Medical-Surgical
Antepartum obstetrical and medical complications
in subjects with VAMA compared to those without
*Adjusted for race/ethnicity, insurance type, year of delivery, pre-gestational
diabetes, cardiac disease, asthma, obesity, thyroid disease, chronic hyper-
tension, and multiple gestations.
591 Baseline variability in normal term births and in births
complicated by neonatal depression
Emily Hamilton1, Warrick Philip2, Judy Zacharias3, Samuel Smith3
1
McGill University, Obstetrics and Gynecology, Montreal, QC, Canada,
2
PeriGen, Perinatal Research, Montreal, QC, Canada, 3MedStar Franklin
Square Medical Center, Obstetrics and Gynecology, Baltimore, MD
OBJECTIVE: Clinical assessment of electronic fetal monitoring (EFM)
relies heavily upon visual estimates of baseline variability. Agreement
between observers at low levels of variability is poor. With validated
FHR pattern recognition software it is now possible to precisely and
consistently quantify baseline variability.
The objective of this study was to characterize baseline variability
during the last 5 hours before birth in a large sample of healthy term
babies and in a group with evidence of neonatal depression. De-
liveries occurred at an acute care, academic community teaching
hospital and regional referral center where umbilical artery gases
were performed on a selectively.
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
Poster Session IV
STUDY DESIGN: The study comprised all 6664 singleton presenting
babies at term. The reference group included 6496 babies dened by
a 5-min Apgar over 6, and if blood gases were available, a base decit
value under 8mmol/L. The neonatal depression group (DEP)
included 11 babies with 5 min Apgar scores between 0 and 4.
Each fetal heart record was analyzed electronically by PeriCALM
Patterns V2.01 (PeriGen, Princeton, NJ), an independently validated
pattern recognition software, to determine baseline segments and
their variability. The mathematical baseline variability algorithm was
based on the NICHD denition in which the entire FHR complex in
baseline segments is measured as a unit and summarized
periodically.
RESULTS: In the reference group the median baseline variability was
11.5bpm and rose shortly before delivery as is shown in Figure 1.
The 2nd percentile was 5bpm.
In DEP the median variability hovered around the 25th percentile
of the reference during the last 90 minutes. None of the DEP group
had baseline variability of 0, and 6/11 (54.5%) did not experience
any period of minimal variability.
CONCLUSION: Absent variability was exceedingly rare in our study.
Even in the DEP group most babies did not exhibit minimal vari-
ability. The presence of moderate baseline variability does not pre-
clude development of neonatal depression.
Baseline variability trends
592 6cm is the new 4cm: evaluating the definition of active
phase of labor and its potential effect on cesarean rates and
mortality
Nancy Nguyen1, Alison Cahill2, Emily Griffin1, Allison Allen1,
Aaron Caughey1
1
Oregon Health and Science University, Obstetrics and Gynecology, Portland,
OR, 2Washington University, Obstetrics and Gynecology, St. Louis, MO
OBJECTIVE: Friedmans labor curve denes active phase of labor
starting at 4cm cervical dilation. Recent work by Zhang and others
suggests that active phase may begin as late as 6cm cervical dilation.
Thus, we sought to evaluate the effect on cesarean rates when 6cm as
oppose to 4cm cervical dilation is used to dene the active phase of
labor, given that labor phase sets the standard for arrest diagnoses.
STUDY DESIGN: A decision-analytic model was built using TreeAge
software and probabilities were derived from the literature. The
model compared maternal outcomes when active phase of labor was
dened at 4cm as opposed to 6cm cervical dilation. Active phase
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Poster Session IV Operative Obstetrics, Clinical Obstetrics, Intrapartum, Medical-Surgical www.AJOG.org

arrest was strictly dened as no cervical change over two hours of
active labor. It was assumed that women with active phase arrest
were delivered via cesarean. Primary outcomes investigated were
cesarean rates and maternal mortality. Because of heterogeneous
labor experiences, the model was stratied by parity and obesity.
RESULTS: Cesarean rates among nulliparous, multiparous, and obese
women were higher when active phase was dened at 4cm as
compared to 6cm (Table 1). Similar outcomes were seen in maternal
mortality rates amongst the subgroups of women investigated.
CONCLUSION: Redening the initiation of active phase of labor from
4cm to 6cm substantially decreases rates of cesarean for arrest and
subsequent maternal mortality.
vaginal delivery within 24 h occurred in 29% vs. 23% (p0.27), and
the cesarean delivery rate was 40% vs. 45% (p0.42). See the gure.
Tests of interactions indicated no differences in the treatment effects
by parity (p0.26 for all outcomes), though the study was not
powered to detect these interactions.
CONCLUSION: As compared to the PGE2 vaginal insert, starting labor
inductions with a Foley catheter results in shorter times from agent
placement to delivery regardless of parity.
Cumulative incidence curves, showing the time in
hours on the x-axis and the proportion of women
delivered on the y-axis

593 Effect of parity on duration and outcome of labor

inductions with either Foley catheter or the prostaglandin E2
vaginal insert
Rodney Edwards1, Jeff Szychowski1, Jessica Berger2,
Megan Petersen3, Melissa Ingersoll4, Ana Bodea Braescu4,
Monique Lin4
1
University of Alabama at Birmingham, Obstetrics and Gynecology,
Birmingham, AL, 2Magee Womens Hospital of UPMC, Obstetrics,
Gynecology and Reproductive Sciences, Pittsburg, PA, 3University of
California Davis, Obstetrics and Gynecology, Sacramento, CA, 4Obstetrix/
Mednax, Phoenix Perinatal Associates, Phoenix, AZ
OBJECTIVE: To estimate the effect of parity on progress and outcomes
of labor induction starting with the Foley catheter (Foley) or the
prostaglandin E2 vaginal insert (PGE2).
STUDY DESIGN: We performed a multicenter randomized controlled
trial enrolling women with an unfavorable cervix undergoing labor Parous women are shown in the upper panel (log-rank p0.03), and
inductions. The primary analysis, presented in another abstract at nulliparous women are shown in the lower panel (log-rank p0.054).
this meeting, showed that Foley was associated with shorter times
from agent placement to delivery (median 21.6 vs. 26.6 h; p0.003) 594 The effect of BMI on maternal morbidity following
and vaginal delivery (20.1 vs. 24.3 h; p0.005). This secondary emergent peripartum hysterectomy
analysis was conducted to evaluate the effect of parity on outcomes. Alison Wortman1, Jennifer Hernandez1, Denisse Holcomb1,
RESULTS: We enrolled 376 women of whom 143 were parous (79 Karen Wilson1, Donald McIntire1, Jeanne Sheffield1
1
Foley, 64 PGE2) and 233 were nulliparous (106 Foley, 127 PGE2) University of Texas Southwestern Medical Center, Obstetrics and
(pNS). For parous women in the Foley and PGE2 groups, Gynecology, Dallas, TX
respectively, median time from agent placement to delivery was 17.2 OBJECTIVE: To determine the impact of maternal body mass index (BMI)
vs. 22.9 h (p0.01), delivery within 24 h occurred in 73% vs. 55% on maternal morbidity following emergent peripartum hysterectomy.
(p0.02), vaginal delivery within 24 h occurred in 65% vs. 44% STUDY DESIGN: We performed a retrospective cohort study of all
(p0.01), and the cesarean delivery rate was 18% vs. 25% (p0.29). consecutive peripartum hysterectomies at our institution from 1988 to
For nulliparous women in the Foley and PGE2 groups, respectively, 2012; scheduled hysterectomies were excluded. Medical records were
differences were in the same direction but not statistically signicant: reviewed and maternal, fetal, and surgical data collected for each sub-
median time from agent placement to delivery was 25.9 vs. 28.3 h ject. Maternal BMI was categorized by the NIH classications for
(p0.18), delivery within 24 h occurred in 42% vs. 33% (p0.14), overweight and obese. Statistical analyses included evaluation for trend.

S292 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014