542 MATERNAL MORBIDITY WITH ELECTIVE REPEAT CESAREAN SECTION: THEINFLUENCE OF THE NUMBER OF PREVIOUS CESAREAN SECTIONSEMMANUELLE PARE1, DAVID STAMILIO1, ALISON CAHILL1, ERIKA STEVENS2,JEFFREY PEIPERT3, GEORGE MACONES1, 1University of Pennsylvania, Obstetricsand Gynecology, Philadelphia, Pennsylvania, 2University of Pennsylvania*,Philadelphia, Pennsylvania, 3Brown University, Obstetrics & Gynecology,Providence, Rhode Island

OBJECTIVE: To test the hypothesis that, in women having elective repeatcesarean section (C/S), the risk for adverse maternal outcomes increases with thenumber of previous C/S.

STUDY DESIGN: Retrospective cohort study of women having elective repeatC/S at 17 community and teaching hospitals from 1995 to 1999. Medical recordswere abstracted by trained nurses. Information collected included demographics,medical and obstetrical history, antenatal complications and pregnancy out-comes. Patients were stratified by their number of previous C/S (1, 2, 3, and 4 ormore). Adverse maternal outcomes included bladder injury, blood transfusion,post-operative fever and a composite adverse outcome (uterine rupture, bladderinjury, other major morbidity). Logistic regression was used to adjust forpotential confounders.

RESULTS: 11 297 women had an elective repeat C/S. After adjusting forconfounders, there was no increase in adverse outcomes in women with 2previous C/S. In women with 3 previous C/S, the risk was increased for alladverse outcomes except fever. In women with 4 previous C/S, the risk wasincreased for all adverse outcomes except blood transfusion. (table)

CONCLUSION: The risk of adverse maternal outcomes with elective repeat C/Sis significantly higher in women with three or more previous C/S. Thisinformation is useful in counseling women prior to an elective repeat C/S; it isalso useful to women deciding between a VBAC attempt and a repeat C/S whoare considering more than one future pregnancy.

Risk of adverse outcome by number of previous C/S

Outcome(OR; 95%CI)

1 prior C/S(7640 pts)

2 prior C/S(2888 pts)

3 prior C/S(673 pts)

4+ prior C/S(96 pts)

SMFM Abstracts S153

540 THE IMPACT OF MEDICAL LEGAL RISK ON OBSTETRICIAN-GYNECOLOGIST SUPPLYPAMELA ROBINSON1, XIAO XU2, KRISTIE KEETON3, SCOTT RANSOM1, 1Universityof Michigan, Obstetrics, Gynecology, Health Management and Policy, AnnArbor, Michigan, 2University of Michigan, Obstetrics and Gynecology, AnnArbor,Michigan, 3University ofMichigan, Obstetrics &Gynecology, AnnArbor,Michigan

OBJECTIVE: The objective of this study is to evaluate the effects of medicallegal risk on the supply of obstetrician-gynecologists.

STUDY DESIGN: We used the American College of Obstetricians andGynecologists (ACOG) Membership Record to determine the number ofFellows and Junior Fellows in practice in each state. We obtained liabilityinsurance premiums from the Medical Liability Monitor and state birth ratesfrom the National Center for Health Statistics. We used American MedicalAssociation (AMA) ‘Crisis’ and ACOG ‘Red Alert’ designations and statemalpractice premiums as a proxy to malpractice risk. We examined the changesin state births to obstetrician-gynecologist from 1995 to 2003 using student t andMann-Whitney U tests.

RESULTS: We found no significant difference in the decrease in births perFellow between AMA ‘Crisis’ and remaining states (mean: 13.3% vs. 13.9%;P = .77), nor ACOG ‘Red Alert’ and remaining states (mean: 12.3% vs. 14.7%;P = .29). No significant difference was observed in the increase in births perJunior Fellow between AMA ‘Crisis’ and remaining states (median: 9.8% vs.15.5%; P = .95), nor ACOG ‘Red Alert’ and remaining states (median: 16.4%vs. 12.2%; P = .54). We then analyzed states with the ten highest and ten lowestaverage 2002 malpractice premiums. We found no significant difference in thedecrease in births per Fellow in the highest premium states compared to thelowest premium states (mean: 15.1% vs. 16.4%: P = .67). The increase in birthsper Junior Fellow in the highest premium states was significantly greater than thelowest premium states (median: 28.5% vs. 5.0%; P = .03).

CONCLUSION: Malpractice premiums seem to influence practice location ofnew obstetricians. Neither the AMA designation of ‘Crisis’ nor the ACOGdesignation of ‘Red Alert’ had supply implications in the analysis. More researchon the interaction of malpractice rates and obstetrician supply is needed forinformed decisions regarding malpractice premium management.

541 DOWNWARD TREND IN PUBS AT A SINGLE TERTIARY CARE CENTERBORIS PETRIKOVSKY1, ANDREI REBARBER2, ASHLEY ROMAN2, DANIEL SALTZMAN2,SAMUEL BENDER2, DANIEL ROSHAN2, 1NYU School of Medicine, East Meadow,New York, 2New York University, Obstetrics and Gynecology, New York, NewYork

OBJECTIVE: Following the introduction of percutaneous umbilical bloodsampling (PUBS), it was enthusiastically incorporated as a useful procedure intothe field of maternal-fetal medicine. It appears that a downward trend hasevolved secondary to improved technology and increased regional MFMpresence in nonacademic training centers. The objective of this study is to seewhether there has been a significant decline in the total number of PUBS.

STUDY DESIGN: We reviewed our database to identify all patients whounderwent PUBS during 1992 to 1999. The number and indication for eachprocedure were recorded. We further divided this 8-year span into two, four-yearperiods. Statistical analysis was performed using Fisher exact test and c2;significance at P ! .05.

RESULTS: Trends in indications for PUBS performed are shown in the table.CONCLUSION: There was a significant decline in the number of PUBS

performed in this center. If this decline is sustained on a nationwide basis thelevel of fellow training and proficiency in this procedure is likely to decrease. Wespeculate that the number of procedures will decrease further due to the utility ofMCA Dopplers and preimplantation genetic diagnosis that has developed overthe past 5 years. Regional MFM training centers should have enhancedcooperation to optimize teaching this procedure and to create computersimulated models to enhance manual dexterity with the technique. Werecommend that SMFM establish a nationwide registry to examine trends andproficiency.

Trends in number of PUBS performed over time

Indication 1992-1995 1996-1999 P value

Fetal hematologic complication 117 89 ! .001Fetal infection 69 3 ! .001Rapid karyotyping 67 41 NSFetal acid-base status 11 1 !.05Total number 264 134

Compositeoutcome

Baselinegroup

1.27; 0.83-1.94 1.92; 1.02-3.60 5.02; 1.92-13.11

Bloodtransfusion

Baselinegroup

1.14; 0.76-1.72 1.80; 1.00-3.23 2.57; 0.78-8.47

Fever Baselinegroup

1.03; 0.89-1.18 1.0; 0.78-1.28 2.10; 1.28-3.46

Bladderinjury

Baselinegroup

1.52; 0.76-3.03 4.18; 1.84-9.49 14.48; 4.75-44.15

543 THE MFMU UNITS CESAREAN REGISTRY: FETAL INJURY ASSOCIATED WITHCESAREAN DELIVERY JAMES ALEXANDER1, 1for the NICHD MFMU Network,Bethesda, Maryland

OBJECTIVE: To describe the incidence of risk factors associated with fetalinjury in women undergoing cesarean delivery.

STUDY DESIGN: Between 1 January 1999 and 30 December 2000, a prospectiveobservational study of all cesarean deliveries was conducted at 19 universitycenters. Detailed information regarding maternal and infant outcomes wereabstracted directly from hospital charts by specially trained and certifiedresearch nurses.

RESULTS: 37,110 cesarean deliveries were included in the registry and 441(1.2%) had an identified fetal injury. The most common injury was skinlaceration n = 267 (0.7%). Other injuries included cephalohematoma n = 95(0.3%), clavicular fracture n = 11 (!0.1%), brachial plexus n = 9 (!0.1%),skull fracture n = 5 (!0.1%) and facial nerve palsy n = 10 (!0.1%). Thefrequency of fetal injury varied with the indication for cesarean. The strongestassociation was a failed forceps or vacuum attempt (6.8%) followed by cesareanfor abnormal presentation (1.6%), for fetal distress (1.5%), for dystocia (1.4%),for failed VBAC (1.4%), and for elective repeat cesarean (0.6%) P ! .001. Thetype of uterine incision was also associated with fetal injury, 3.4% T or Jincision, 1.4% for vertical incision and 1.2% for a low transverse P = .006. Fetalinjury was not associated with the type of skin incision, medical complications(diabetes, hypertension), gestational age at delivery, maternal BMI or infantbirthweight. Both a cord pH of !7.0 and 1-minute Apgar score !4 were morecommon in the fetal injury group compared to the no fetal injury group (4 vs2.6% P = .0006 and 10 vs 6.4% P = .03). Other outcomes including an Apgar!4 at 5 minutes, seizures, sepsis and infant death were similar between the twogroups.

CONCLUSION: Fetal injuries complicate 1.2% of cesarean deliveries. Thefrequency of fetal injury at cesarean delivery varies with the indication forsurgery and the type of uterine incision.