283 Two center RCT of outpatient versus inpatientcervical ripening for induction of labour with PGE2Chris Wilkinson1, Robert Bryce2, Pamela Adelson3,Judy Coffey4, John Coomblas5, Philip Ryan6,Georgina Stamp7, Deborah Turnbull31Women’s and Children’s Hospital, Maternal Fetal Medicine, North AdelaideSouth Australia, Australia, 2Flinders Medical Centre, Perinatal Medicine,South Australia, Australia, 3University of Adelaide, Psychology, SouthAustralia, Australia, 4Women’s and Children’s Hospital, Midwifery, NorthAdelaide South Australia, Australia, 5Flinders Medical Centre, Midwifery,South Australia, Australia, 6University of Adelaide, Public Health,South Australia, Australia, 7University of South Australia, Nursingand Midwifery, Adelaide, South Australia, AustraliaOBJECTIVE: To compare inpatient to outpatient cervical ripening forinduction of labour with PGE2.STUDY DESIGN: Two centre RCT. Women were low risk, induced forpost dates or social reasons. Consent and randomisation (stratified forparity) was performed when decision for induction of labour wasmade.RESULTS: 827 eligible consenting women from 2 tertiary centres wererandomised to an experimental (411) and a control (416) arm. 215experimental group and 210 control group received PGE2 cervicalripening, with the rest labouring spontaneously or not needing PGE2by the induction date. There were no significant differences in oxyto-cin use (60% v 57%, p � 0.28), spontaneous birth (53% v 51%,p�0.34), instrumental birth (23% v 22%, p�0.41) or cesarean section(24% v 27% p�0.24). Patient preference and patient satisfaction werealso assessed, and will be reported. There were 11 serious outcomes/incidents in the control group, of which 3 resulted in HIE (hypoxemicischemic encephalopathy). 2 of these cases were plausibly related toPGE2 administration. Of 16 serious outcomes/incidents in the exper-imental group, 3 cases of HIE occurred. One of these cases was plau-sibly related to PGE2 administration. When this case was reported tothe data monitoring committee, the trial was temporarily suspended,and further restrictions were imposed on recruitment eligibility re-garding glucose intolerance and maternal BMI. 27 women (13%) inthe experimental group receiving the outpatient intervention experi-enced hyperstimulation or non reassuring CTG monitoring withinthe 1 hour surveillance period and were not discharged. Another 13(6%) in this group changed their minds and decided not to go home,despite being eligible. 7 (3%) remained in hospital for other reasons.Overall, 22% of women receiving PGE2 as an intended outpatientprocedure did not go home.CONCLUSION: There were similar clinical outcomes in each group, in-cluding adverse outcomes. Strict adherence to clinical protocols iden-tified almost all cases of hyperstimulation prior to discharge, but re-sulted in 1 in 5 women in the outpatient group not being discharged.

284 Is the recent trend in elective induction of labormodified by race/ethnicity and gestational age at delivery?Darios Getahun1, Michael J. Fassett2, Sascha Dublin3, Deborah A.Wing4, Aaron B. Caughey5, Vicki Y. Chiu1, Steven J. Jacobsen1

1Kaiser Permanente Southern California, Department of Research andEvaluation, Pasadena, CA, 2Kaiser Permanente West Los Angeles MedicalCenter, Department of Obstetrics and Gynecology, Los Angeles, CA, 3GroupHealth, Group Health Research Institute, Seattle, WA, 4UC Irvine MedicalCenter, Obstetrics and Gynecology, Orange, CA, 5Oregon Health & ScienceUniversity, Department of Obstertics and Gynecology, Portland, OROBJECTIVE: Elective induction of labor (IOL) is common and contro-versial. Some studies suggest it may lead to worse outcomes. We aimto characterize recent trends in elective IOL by maternal race/ethnic-ity and gestational age.STUDY DESIGN: A trend analysis was performed using the 1997-2008Kaiser Permanente Southern Californias (KPSC) Perinatal ServiceSystem, Hospital Inpatient and Outpatient encounter records ofwomen delivering in KPSC hospitals and linked infant birth certificaterecords (n�330,000). Elective IOL was defined as present if IOL was

performed with no documented medical or obstetric reason accord-ing to ICD-9-CM code or birth certificate data. We calculated theproportion of births initiated by elective IOL in the earliest (1997-98)versus most recent (2007-08) biennial periods for subgroups stratifiedby race/ethnicity and gestational age. Adjusted relative risks (RR) and95% confidence intervals (CI) were used to estimate the magnitude ofthe change.RESULTS: The proportion of births initiated by elective IOL increasedfrom 9.9% in 1997-98 to 18.7% in 2003-04 (a relative increase of 90%,p �.001) and have leveled off since then. Race and gestational age-specific analysis revealed a higher rate of elective IOL among whitesthan nonwhites. From 1997-98 to 2007-08, elective IOL increasedamong whites, from 13.4% to 21.2% (RR 1.6 [95% CI 1.5-1.7]);among Hispanics, from 8.5% to 15.6% (RR 1.8 [95% CI 1.7-1.9]); andamong Asian/Pacific Islanders, from 8.3% to 13.7% (RR 1.6 [95% CI1.4-1.9]). Black women had the largest relative increase (8.0% to20.3%; RR 2.5 [95% CI 2.2-2.9]), and this was largely driven by elec-tive IOL performed at 37-38 weeks of gestation. For all racial groupsexcept Blacks, the increase was much greater in induction at 39-40weeks than at 37-38 weeks.CONCLUSION: The proportion of births initiated by elective IOL hasincreased between 1997 and 2004, but remained stable since then. Thesubstantially increased prevalence of elective IOL in Blacks at early-term gestation is disconcerting; largely because of the known in-creased risk this patient population has for adverse outcomes.

285 High contraction rates: incidence and associationwith decelerations in births with metabolic acidemiaEmily Hamilton1, Philip Warrick2, Eric Knox3,Daniel O’Keeffe4, Thomas Garite5

1PeriGen, Obstetrics and Gynecology, McGill University, Montreal,QC, Canada, 2PeriGen, Perinatal Research, Montreal, QC, Canada,3PeriGen, Perinatal Research, Minneapolis, MN, 4PeriGen,Perinatal Research, Princeton, NJ, 5Obstetrix Medical Group,Center for Research & Education, Denver, COOBJECTIVE: Although iatrogenic uterine tachysystole is often alleged inmedicolegal actions, a review of 10 RCTs of high-dose versus low-doseOyxtocin, concluded that despite nearly doubled rates of hyperstimu-lation, high-dose oxytocin was not associated with increased neonatalmorbidity. The study objective was to compare contraction and de-celeration patterns in births with normal UA gases (N) and those withmetabolic acidemia (MA).STUDY DESIGN: Tracings from the last 4 hrs from N-3,320 babies withbase deficit levels under 8 mmol/L, and MA-316 babies with basedeficits over 12, were analyzed by a computer (PeriCALM Patterns,Princeton, NJ) to measure contractions and decelerations in 10-minsegments. High contraction rates (HC) were defined as more than 5contractions/10 min. Since decelerations are often provoked by con-tractions, the absolute numbers of deceleration were expected to begreater when contractions are frequent. Thus we examined the ratio ofdecelerations to contractions to assess response to contractions.RESULTS: The incidence and duration of HC was similar in bothgroups. The % of segments exhibiting HC was the same in MA (5.7%)Vs. N (5.3%) P�0.20, as was the average time in HCMA�28.4min(22.9) Vs. N�29.1(28.9) P� 0.78. The % of motherswith 3 episodes of HC was also similar- MA�16.8% and N�13.5%P�0.13. HC rates increased over time and was higher in MA in onlytwo segments. Fig 1. Decelerations were markedly different. At almostall levels of contraction frequency, the babies in MA responded withmore decelerations. MA had more decelerations per contractions dur-ing the last 140 minutes before birth. Fig 2.CONCLUSION: HC was common in both groups. Higher ratios of de-celerations to contractions, not the incidence or duration of HC, dis-tinguished the MA group from the normal. Although contractionscontribute to decreased placental perfusion, they may be well toler-ated in some babies or may unmask poor function of the maternal-

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fetal-placenta unit in others. This analysis confirms that decelerationsare critical for evaluating the clinical significance of contractions.

286 Unexpected effects of reducing electiveinductions under 39 weeks gestationEmily Hamilton1, Ken Welch2, Yoni Barnhard3,Samuel Smith4, Eric Knox5, Daniel O’Keeffe6

1PeriGen, Obstetrics and Gynecology, McGill University, Montreal, QC,Canada, 2Banner Health, Banner Estrella Medical Center, Phoenix,AZ, 3Norwalk Hospital, Obstetrics and Gynecology, Norwalk, CT,4Franklin Square Hospital, Obstetrics and Gynecology, Baltimore,MD, 5PeriGen, Perinatal Research, Minneapolis, MN,6PeriGen, Perinatal Research, Princeton, NJOBJECTIVE: Reducing elective inductions below 39 wks is consistentwith best practice recommendations. Simply changing the recordedindication from elective to an acceptable term can result in fewerelective inductions. A clinically meaningful reduction should be mir-rored by a reduction in all inductions under 39 wks, as well as in alldeliveries under 39 wks and show no rise in complications. The studyobjective was to measure these related parameters in a group of hos-pitals participating in a quality improvement program with two com-mon aspects; 1. An intelligent EMR (PeriBirth, Princeton,NJ) thatrecognizes the intention to deliver or induce electively under 39 wksand requests written justification 2. Structured quarterly performancereviews with related measures. In addition, some institutions had for-mal objectives to reduce elective delivery under 39 wks, others did not.STUDY DESIGN: We examined an aggregate of 157,283 birth data be-tween 2007 and 2011 from settings ranging from small rural commu-nity to large urban teaching hospitals.RESULTS: Rates fell overall for; 1. Elective induction under 39 wks*0.98%-0.53%, 2. All elective births under 39 wks* 2.6%-1.4% (electiveinduction and elective CS) 3. Inductions under 39 wks for any reason*11.7%-9.5% and 4. All births under 39 wks* 43.9% -38.0%. The ratesof both primary CS and 5-min Apgar scores of 0-6 showed no changeduring the study period. Overall induction rates* rose from 32.6%-35.9%.(*P �0.0001).CONCLUSION: The intervention was highly successful in reducing elec-tive inductions under 39 wks without an increase in the rate of pri-mary CS or low 5-min Apgar scores. In addition, clinical behaviourchanged beyond the strict confines of elective induction, as we ob-served an unexpected decrease in induction rates under 39 wks for anyindication. This translated to a large reduction in the rate of all birthsunder 39 wks, which carries the greatest clinical significance. Further-more, these hospitals have greatly exceeded a recommended benchmark of �5% for elective delivery under 39 wks with their aggregaterate of 1.4% in 2011.

287 Breech deliveries in the Netherlands: effect of increasedcaesarean section rate on perinatal outcomeFloortje Vlemmix1, Jelle Schaaf2, Ageeth Rosman1,Anita Ravelli3, Arno Verhoeven4, Gerard Visser5,Ben Willem Mol1, Marjolein Kok1

1AMC, Obstetrics and Gynecology, Amsterdam, Netherlands, 2AMCAmsterdam, Medical Informatics, Amsterdam, Netherlands, 3AMC, MedicalInformatics, Amsterdam, Netherlands, 4not practicing, formerly RijnstateArnhem, Obstetrics and gynecology, Arnhem, Netherlands, 5UniversityMedical Center Utrecht, Obstetrics and Gynecology, Utrecht, NetherlandsOBJECTIVE: Publication of the results of the term breech trial (TBT)had a major impact on clinical practice in case of breech delivery allover the world. In the Netherlands, the planned CS rate increasedfrom 27 to 60% within three months. This resulted in a decreasedperinatal mortality rate from 0.35 to 0.18% (OR 0.53; 95%CI 0.33-0.83) and birth trauma from 0.29 to 0.08% (OR 0.26; 95%CI 0.14-0.50) between 1999 and 2003. In the present study, we analyzed themode of delivery for term breech birth and its effect on the neonataloutcome in the Netherlands up to 2007.STUDY DESIGN: We used data from the nationwide perinatal registryfrom 1999 to 2007. All singleton term breech deliveries from 37 weekswere selected, excluding pregnancies complicated by major congeni-tal malformations or antenatal death. We assessed the effect of modeof delivery on neonatal outcome (perinatal mortality, five minute Ap-gar score �7, and neonatal trauma), distinguishing the period beforeand after the publication of the TBT results.RESULTS: After the immediate shift in medical intervention behav-iour, the rate of planned CS, vaginal deliveries and emergency CS inwomen with a term breech delivery remained stable over a period ofseven years at 60%, 22% and 18%, respectively. The perinatal mortal-ity rate among planned CS and planned vaginal deliveries was 0.03%vs. 0.29% (OR 0.11, 95%CI 0.05 to 0.23), perinatal trauma rate was0.10% vs 0.41% (OR 0.24, 95%CI 0.15 -0.37), low apgar score rate was0.25% vs 2.15% (OR 0.11, 95% CI 0.09-0.15). The perinatal mortalitywithin the planned vaginal delivery group did not change after pub-lication the TBT (29% vs. 28%, OR 1.06, 95% CI 0.67 1.70).CONCLUSION: Ten years after publication of the TBT, still 40% of termbreech deliveries in the Netherlands are planned vaginal deliveries,with a tenfold mortality rate compared to the planned CS. Despite theclaim that selection for vaginal deliveries would improve neonataloutcome, there is no improvement since the TBT.

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