risk of death was 2.9 and 4.5, respec- tively. The etiologic factors identified were asphyxia, infection, sudden in- fant death syndrome, and external causes. The only difference in these etiologic factors between the two pe- riods was a reduction in the mortality rate due to infection. The authors, thus, conclude that mild and mod- erate preterm births are important contributors to neonatal death rates. They further caution obstetricians to be aware of these risks when pre- term delivery is contemplated. (Lev- el 11-2) . . . zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Commentary: This report is summa- rized in greater detail than usual be- cause of the extremely large cohort of patients and the focus on gestations of 32 to 37 weeks. Infants born in this gestational period are more com- mon but less likely to be studied than infants of 32 weeks’ gestation or less. An interesting aspect of this re- port is lack of significant improve- ment between the mid- 1980s and the mid-1990s in the relative risks with the exception of infection. Unfortu- nately, this report gives us little actual information on the four major causes of neonatal death other than complex tables. It would have been more valu- able to further delineate these causes if the data were available. Broad catego- ries such as “external causes” are not helpful to the reader. Likewise, broad categories such as “infection” or “as- phyxia related” do not shed any light upon a complex problem. This editor would caution the reader about use of the term asphyxia, although it is often used to describe infant death, especially among pedia- tricians. A much better term is hyp- zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA oxia. The reader is referred to ACOG Technical Bulletin No. 207, July 1995, entitled Fetal Heart Rate Pat- terns: Monitoring, Interpretation and Management. This bulletin carefully defines hypoxemia, hyp- oxia, and asphyxia. Asphyxia is not just any case of hypoxia or hypox- emia. Asphyxia is hypoxia with met- abolic acidosis. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Vertical Transmission of HCV in Pregnancy Hillemanns P, Dannecker C, Kimmig R, Hasbargen U. Obstetric risks and vertical transmission of hepatitis C virus infection in pregnancy. Acta Obstet Gynecol Stand 2000;79:543-7. Synopsis: These authors studied the course and outcome of Hepatitis C virus infection (HIV) in 35 pregnant women between October 1992 and December 1996. Three of the women had a spontaneous abortion and one an intentional abortion. The other 3 1 were followed to delivery. Children born to these women were followed at 6-, 12-, and 18-month intervals. They found that 13 (42%) of the 31 HCV- infected women had a cesarean deliv- ery and in 6 of the 13 the presurgery diagnosis was an abnormal fetal heart rate pattern. Preterm delivery oc- curred in 9 (29%) of the 31 patients. In patients without HCV infection the preterm delivery rate was 19%; ac- cording to the authors, the difference between the two groups was not sta- tistically significant. All of the 29 in- fants who were tested after delivery were found to be seropositive for HCV. Between 12 and 18 months, 10% of the infants were still anti- HCV positive and the one infant who was HCV-RNA positive 2 days after birth remained so beyond 12 months. They concluded the vertical transmis- sion rate is low but the risk of cesarean delivery is high. (Level 11-3) Commentary: Hepatitis C virus in- fection has had limited evaluation in pregnant women. This article of rela- tively few patients is one of a few be- ginning to be reported in this litera- ture. This study reports only a timed sequence of events in seropositive women without any attempt to make causal relationships, so we are left with only the observations. They imply an increased risk of cesarean delivery but with so few cases, this observation is not statistically significant. The Cen- ters for Disease Control reports an in- creasing incidence of HCV infection so future studies will help us under- stand its impact on pregnancy. ACOG Educational Bulletin No. 248, July 1998, entitled Viral Hepatitis in Preg- nancy, contains a two-paragraph de- scription of the infection along with hepatitis virus D, E, and G. All of these are less frequent than A or B but ultimately may be found to have as much or more importance. Risk Factors for Episiotomy Robinson JN, Norwitz ER, Cohen Al’, Lieberman E. Predictors of episiotomy use at first spontaneous vaginal delivery. Obstet Gynecol2000;96:214-8. Synopsis: These investigators studied 1576 consecutive term, singleton, spontaneous vaginal deliveries in nul- liparous patients from December 1994 through July 1995. Their objec- tive was to identify what, if any, fac- tors could be identified that were cor- related with use of an episiotomy at the time of delivery of the infant. The overall rate of episiotomy during this observation period was 40.6%. Most (99%) were midline episiotomies; only 6 were mediolateral. They com- pared the demographics of those with and those without episiotomies and found that midwives performed them at a lower rate (21.4%) than faculty (33.3%) or private providers (55.6%). Prolonged second stage of labor, labor induction or augmenta- tion, fetal macrosomia, and epidural anesthesia were also found to be fac- tors. The rate of third or fourth degree extension was 5.3% for midwives, 11.5% for faculty, and 10.1% for pri- vate practitioners. They concluded that the strongest factor associated with episiotomy is the provider cate- gory. (Level 11-3) . . . Commentary: Episiotomy has come under repeated challenge over the last 20 years. Before then, episiotomy was the rule rather than the exception. There have been many reasons for this change. First and foremost, the ratio- nale for episiotomy has become better understood; as studies have ques- tioned its value and, most impor- tantly, its sequelae, the procedure is not performed automatically. Studies describing long-term perineal prob- zyxwvutsrqponm 02001 by the American College of Obstetricians and Gynecaloglsts Pubbshed by Elsevier Wence Inc 1065-6862/01/$6 00 January/February 2001 l ACOG CLINICAL REVIEW l 3