Volume 164 Kurnber 1. Pan 2

296 DIFFERENTIAL LITIGIOUSNESS AMONG OBSTETRIC PATIENTS BY PAYOR SOURCE. Thomas R. Moore and

Robert T. Andrewsx. Department of Reproductive Medicine, University of California San Diego, CA.

The rising incidence of malpractice suits has prompted a growing number of practitioners to refuse care to MediCme­insured patients because of a perception of increased risk of obstetrical complications and subsequent legal action. We reviewed the hospital and legal records of all obstetrical patients who initiated law suits (Notice of Intent or actual suit) at our hospital from July 1982 through June 1988. These patients were compared to all other 22,385 obstetrical admissions after stratifying by insurance carrier: private indemnified insurance (PI=24% of total), public funding (PF=51%) and health maintenance organization (HMO = 25%). Twenty patients (0.9 per 1000) initiated legal action: 10 PI (=50% of suits), 4 HMO (20%) and 6 PF (30%). HMO patients sued in proportion to their numbers admitted, but PI were twice as likely and PF one­third less likely to sue than expected (Chi sq = 5.5, p< .05). There was no correlation between payor source and time interval from alleged injury to time of filing (40 ± 19 wks PI, 25 ± 21 wks PF, 27 ± 23 wks HMO, p=NS), success in receiving payment or amount paid. These results suggest that pregnant women utilizing private insurance file law suits more frequently than women dependent on public funding sources.

297 VACUUM ASSISTED DELIVERY IN PATIENTS WITH A PRIOR CESAREAN SECTION Dayjd Schrjmmer M.D. Sheryl Ross, M.D:, Dena Ross', Richard H. Paul, M.D. , Jeffrey Greenspoon, M.D. University of Southern California

At the present time cesarean section (CIS) may account for as much as 30% of all deliveries. As this number continues to Increase, so will the inCidence of attempted vaginal birth after cesarean section (VBAC). The need to evaluate the role of operative vaginal techniques in a previously scarred uterus is therefore appropriate. Since contemporary obstetrics has discouraged the use of forceps for midpelvic procedures, the vacuum extractor has been proposed as an alternate method. In order to evaluate our experience a retrospective review for the five year penod starting July I, 1985 to July I, 1990 was done. A total of 181 patients With a prior CIG were identified who had a vacuum placed in an attempt to achieve a vaginal delivery. Of these 181 patients, 84 % ultimately delivered vaginally, and 16% required a repeat CIS. Of those who reqUired a repeat CIS, 93% were a result of failure of fetal descent. CharacteristiCS of labor in thiS study group Include a 92% rate of oxytocin use (mean time = 8 hours), a mean labor time of 12 hours and a mean time of 2.6 hours of pushing prior to vacuum placement. Reasons for the trial of vacuum extraction Included fetal distress (23%), maternal exhaustion (51 %), and persistent OCCiPUt transverse presentation (26%). Average fetal weight was 3502 gms with an EBL of only 444cc's. Of the vaginal deliveries, 85% of patients had a second degree episiotomy or less, and 30% of these extended to a third or fourth degree. Seven patients (4%) had sulcus tears requiring repair. Uterine dehiscence occurred in five patients (2.8%), and uterine rupture in two (1.1%). Hysterectomy was required in two patients, one for dehiscence, and the other for rupture. Neonatal complications included cephalohematoma In 14 (8%), one of whom required NICU admission for this problem.

SPO Abstracts 327

298 RAISING THE CLINICAL INDEX OF SUSPICION FOR RISK-DRINKING SS MartierX , RJ Sokol, JW AgerX, and SF Bottoms Wayne State Univ/Hutzel Hosp, Detroit, Michigan

Detecting the antepartum risk- drinker is difficult. To identify any clues that might be available in routine prenatal history taking, factors from the Michigan Alcoholism Screening Test (MAST) were substituted for difficult-to­obtain alcohol intake data in 2 previously reported multivariate analyses; in drinking women, maternal characteristics and other prenatal risks were related to the occurrence of fetal alcohol syndrome (FAS; N=869) and alcohol- related birth defects (ARBD; N=853). Factor analysis of the MAST yielded 2 factors-Fl, psychosocial disruption and F2, help seeking. In a 3-item discriminant model, F2 contributed significantly to the classification of FAS (F(3,865)=13.4, R Sq=4.5%). In a 4-item regression model, F2 was also significant (F(4.825)=13.0, R Sq=5.9%). These findings suggest that help-seeking behavior, e. g., seeing a psychiatrist for an alcohol-related problem, may be a marker for severe and prolonged alcohol abuse/dependence and high probability for persistent risk­drinking in pregnancy. Including a question in the past medical history concerning seeing a health care professional or hospitalization for any problem to which alcohol may have contributed may be of value. A pos i ti ve response should raise the index of suspicion for increased alcohol-related pregnancy risk.

299 UMBILICAL AND UTERINE ARTERY VELOCIMETRY IS UNALTERED BY ARTIFICIAL RUPTURE OF MEMBRANES. XByron Elliott, Edward Newton, Oded Langer, Dept of OB/GYN, University of Texas Health Science Center at San Antonio, Texas.

It is axiomatic that artificial rupture of membranes increases uterine tonicity and can initiate fetal heart rate decelerations and bradycardia A paucity of data eXIsts concerning the effect of artificial rupture of membranes (AROM) on umbilical and uterine velocimetry. The purpose of this study was to determine whether the acute changes in amniotic fluid volume during AROM significantly alters the uterine or umbilical artery velocimetry Twenty-five term pregnancies without complications underwent amniotomy in the active phase of labor Prior to amniotomy, umbilical and uterine artery velocimetry was obtained using continuous wave doppler, and an amniotic fluid index was obtained by ultrasound These measurements were repeated immediately following amnlotomy, and all measurements were obtained between uterine contractions. There was a significant difference in the amniotic fluid Index after amnlotomy (paired t­test: t=5.3677, p<.OOOI) The velocimetries are summarized below: SID ratio Umbilical Uterine

BeforeAROM 2.36 (.47) 2.70 (84)

After AROM 2.35 (.45) 254 (.70)

Change e .05 (52) NS

-.37 (1 44) NS expressed as Mean (St. Dev ) (paired t-test)

Our data suggests that changes in amniotic fluid volume during artificial rupture of membranes as measured by amniotic fluid index do not significantly effect umbilical or uterine artery SID ratios