Comparative Effectiveness of labor management in obese, nulliparous women

描述（由申请人提供）：美国正处于肥胖的流行之中，近一半的美国育龄妇女超重（BMI 25-29.9）或肥胖（BMI¿30）。这个国家的肥胖反映了种族差异，非西班牙裔黑人和西班牙裔妇女受到的影响不成比例。肥胖妇女特别容易因意外剖宫产而终止足月妊娠，这在很大程度上是由于她们的分娩异常缓慢。怀孕第一胎的肥胖妇女（未分娩妇女）发生意外剖宫产的风险最高。当肥胖妇女剖宫产时，她们比正常体重的妇女更有可能经历剖宫产后的显著发病率和死亡率。研究子宫肌收缩力的体外研究表明，肥胖的细胞代谢环境可能是分娩时收缩效率下降、分娩持续时间延长以及对肥胖人群临床观察到的常用加速分娩干预措施反应下降的原因。我们对肥胖妇女分娩时技术干预的正确时机和使用的理解存在差距。本研究将调查肥胖、未产妇女的分娩管理，以发现与降低剖宫产风险相关的做法。比较有效性方法将用于描述和比较两种不同的分娩管理模式（产科医生模式与护士-助产士模式）对肥胖，未产妇女剖宫产的结果。将对在科罗拉多大学医院分娩的肥胖、未分娩妇女的医院记录进行回顾性数据库分析和详细的图表审查，该医院约有40%的分娩由护士助产士管理。将使用Logistic回归和风险分析来检验在护理助产士和产科医生模式的分娩护理中，肥胖、无产妇女样本在干预使用、干预时间和分娩结果方面的差异。通过倾向评分分析，将生成肥胖女性的匹配样本。肥胖对分娩时女性对外源性催产素反应的生物学效应也将被研究。本研究和培训计划符合申请人的长期研究目标，即了解肥胖无产妇女的生物行为决定因素和有效的产时护理管理策略，以减少无产妇女剖宫产的发生率、其短期和长期不良后果以及医疗保健费用。本研究获得的结果将为未来的研究提供信息，并促进对护士、护士助产士和医生有效护理实践的新理解，因为他们支持肥胖、未分娩妇女的弱势群体通过分娩获得安全的分娩结果。

DESCRIPTION (provided by applicant): The United States is in the midst of an obesity epidemic, with nearly half of U.S. women of childbearing age being either overweight (BMI 25-29.9) or obese (BMI¿30). Obesity in this country reflects an ethnic disparity, with non- Hispanic black and Hispanic women disproportionately affected. Obese women are at particular risk to end their full-term pregnancies with unplanned cesarean delivery, in large part due to their abnormally slow labors. Obese women pregnant with their first babies (nulliparous women) are at the highest risk for unplanned cesarean delivery. When obese women have cesarean delivery, they are more likely than normal-weight women to experience significant post-cesarean morbidity and mortality. In vitro research investigating myometrial contractility suggests that the cellular metabolic milieu of obesity may account for the decreased contractile efficiency in labor, longer labor duration, and decreased response to commonly-used interventions to hasten labor that are clinically observed in obese populations. Gaps exist in our understanding of the correct timing and use of technological interventions in the labors of obese women. The proposed study will investigate the labor management of obese, nulliparous women to discover the practices associated with decreased risk of cesarean delivery. A Comparative Effectiveness approach will be used to describe and compare two different labor management models (obstetrician model vs. nurse-midwife model) against the outcome of cesarean delivery in a sample of obese, nulliparous women. Retrospective database analysis and detailed chart-review will be performed on the hospital records of obese, nulliparous women delivering at the University of Colorado Hospital, where approximately 40% of births are managed by nurse-midwives. Logistic regression and hazard analysis will be used to examine the differences in intervention use, intervention timing, and delivery outcomes between samples of obese, nulliparous women in the nurse-midwife vs. obstetrician models of labor care. Matched samples of obese women will be created via propensity score analysis. Biologic effect of obesity on women's response to exogenous oxytocin in labor will also be examined. The proposed research study and training plan are congruent with the applicant's long-term research goals to understand the biobehavioral determinants and effective intrapartum care management strategies for obese nulliparous women in order to decrease the incidence of cesarean delivery, its short and long-term adverse consequences, and the cost of healthcare for nulliparous childbearing women. Results obtained from this study will inform future research and promote new understanding of effective care practices for nurses, nurse- midwives, and physicians as they support the vulnerable population of obese, nulliparous women through labor to a safe birth outcome.