Rosie Genova is sharing with people the cover to her new book A Dish Best Served Cold!
A Jersey girl born and bred, national bestselling author Rosie Genova left her heart at the shore, which serves as the setting for much of her work. The atmosphere of the Jersey shore is present in the details, whether it's the smell of the sea, the sound of a Springsteen song, or the taste of Kohr's custard from the boardwalk. And no summer is complete unless she has sand in her shoes.
A bookworm from the time she could sound out words, Rosie spent many happy hours in her home town library where she hid behind the stacks reading the titles she was too young to check out. She earned two degrees in English from Rutgers University, where she discovered to her delight that reading Jane Austen was actually considered homework. Though she's always considered herself a writer, she didn't pen her first novel until ten years ago, and she hasn't stopped since.
Her series, the Italian Kitchen Mysteries, is informed by her deep appreciation for good food, her pride in her heritage, and her love of classic mysteries, from Nancy Drew to Miss Marple. Her debut novel, Murder and Marinara, was named a Best Cozy of 2013 by Suspense Magazine and was a finalist for a 2014 Daphne Du Maurier Award. An English teacher by day and novelist by night, Rosie also writes women's fiction as Rosemary DiBattista. She still lives in her home state with her husband and her youngest son.
Özgür is poor, hungry, and on the verge of a mental breakdown, with only one weapon against Rio: to write the city that has robbed her of everything. Reading the bits and pieces of Özgür's unfinished eponymous novel, with its autobiographical protagonist named Ö, Özgür's story begins to emerge. Meanwhile, the narrator limns a single day of Özgür's life, which is in fact her last. As Özgür follows Ö through the shanty towns, Condomble rituals, and the violence and sexuality of the streets to her own death, the narrator searches for a way to make peace with life, a route to catharsis. The two concentric novels, the borderline between the two Rio's — Özgür's Rio as a metaphor for death and Rio as life — begin to blur. Asli Erdogan's brilliantly evocative, experimental second novel was a major hit in Turkey and Europe. Now available in translation, the book does for Rio what Joyce did for Dublin.
As you can see, Rio is the main character of the book. In addition, there's Özgür, who's run away to Rio to try and write her book while she's trying to put together money for food and cigarettes. She doesn't like the city's asphyxiating heat, how it makes her shirt cling onto her chest, how her breath gets stuck to her throat. She doesn't like the sound of rifles that has become the regular soundtrack of her days. She doesn't like that she has to protect her money and her life with every step. Even though this may be the case, Özgür is also caught up in this crazy city's magic... We see a darker, suffocating and dangerous Rio in The City in Crimson Cloak; not the one we're used to seeing on TV with its colorful dances.
In the fall of 1978, on a 640-acre family ranch on Goat Mountain in Northern California, an eleven-year-old boy joins his grandfather, his father, and his father's best friend on the family's annual deer hunt.
Every fall they return to this dry, yellowed landscape dotted with oak, buck brush, and the occasional stand of pine trees. Goat Mountain is what this family owns and where they belong. It is where their history is kept, memories and stories that will be shared again by these men. And for the first time, the boy's story will be added if he can find a buck. Itching to shoot, he is ready.
When the men arrive at the gate to their land, the father discovers a poacher and sights him through the scope of his gun. He offers his son a look-a simple act that will explode in tragedy, transforming these men and this family, forcing them to question themselves and everything they thought they knew.
In prose devastating and beautiful in its precision, David Vann creates a haunting and provocative novel that explores our most primal urges and beliefs, the bonds of blood and religion that define and secure us, and the consequences of our actions-what we owe for what we've done.
When I read Dirt last year, one thought popped up in my head, and I found myself thinking the same thing while I was reading Goat Mountain: "If David Vann hadn't chosen writing, he might have been a serial killer or something." Of course, I don't know the guy. What I do know is he has a step grandmother who first shot her husband and then herself and a father who committed suicide. As far as I can tell from the two books of his that I've read, he's been through more trauma than is regular. I feel the blood boiling in my veins while I read Vann's work. Even though I'm safely tucked in bed with the book in my hand, my whole body hurts. As if that's not enough, my heart and brain hurt, too. On the one hand, I'm in awe of the guy... I go back and forth through that threshold that stands between pleasure and pain is how I can summarize reading David Vann.
Goat Mountain is the story of a boy, who's also the narrator, his father, grandfather and his father's friend Tom, who's the only character a name is given for. It starts off with them going deer hunting. The boy knows he has to hunt a deer to show he deserves to hold a gun, to prove he's become a man. Instead, he ends up shooting a poacher. Things start to go downhill very fast as the crowd of men try to decide what to do with the body. I must say that the boy, the narrator, is quite the psycho, who feels the same thing he feels while looking at a dead deer when he sees the lifeless body of a man.
This one event is Vann's starting point of making us question the bigger things in life. He does this in a way that sends strong chills through your entire body. His main question is, WHY DO WE HUNT? Is killing something people do because they have to or is it an instinct they can't rid themselves of? Is liking the kill a psychopathic emotion or is it instinctive and normal? Why is shooting animals okay while shooting another person isn't? Why do we live? Why do we die? Why does killing exist at all? What is it all about?! This book is definitely not for those with a faint heart.
Kelly pulled into the harbor parking lot next to the pier and noticed that Amber's car wasn't in its usual place and there was no sign of her. She was usually standing at the door of Kelly's Koffee Shop, waiting for Kelly to open up. Wonder what that's all about, she thought.
The local residents of Cedar Bay come to Kelly's Koffee Shop for breakfast, lunch, and lots of gossip. Kelly serves it all up as she works to solve the murder of the high school Homecoming Queen. The townspeople can't believe what has happened in their sleepy little Oregon seaside town. She identifies five prime suspects, but which one did it?
Follow Kelly, her boxer dog, Rebel, and her boyfriend, Mike, the county sheriff, as they try to determine who the killer is in a murder that's shocked the town.
Kelly's Coffee Shop is a mouth-watering cozy mystery with recipes!
This book follows Kelly whose a widower having lost her husband when he was in his thirties, she has raised two kids and is running her Koffee shop in town while dating Mike the local sheriff. Not long into this book a co-worker of Kelly's winds up missing and turns up at the bottom of the bay. Kelly and many other residents in town are distraught over the death of a girl loved by many in town.
Kelly and Mike are determined to find out what happened to Amber Cook, was it her boyfriend Brandon Black were they having relationship issues? Or was it the mysterious Doc in town or the coach at the high school? Or could it have been her enemy Madison?
With no shortage of suspects Kelly and her trusty sidekick dog Rebel are hot on the trail trying to figure out who killed Amber. While I enjoyed the story I found somethings that I haven't read in a cozy mystery yet, Mike being the cop divulging alot of information to Kelly that I don't normally see in a cozy mystery. That struck me as odd not in a bad way just never saw something like that.
This is a great book for cozy lovers who will fall in love with the town of Cedar Bay and will find themselves eager to see what comes next with this group of characters.
Sequel to The Sun, the Moon, and Maybe the TrainsWith her senior year looming, Tess McKinnon has two goals: hanging out with her best friend, Liz, and avoiding her judgmental, alcoholic mother. Then yummy John Bartley arrives—to tell Mrs. McKinnon that her daughter is dead. Distinctly still alive, Tess is baffled by John's tales of 1800s time travel, rewritten lives, and love. She knows she's never seen him before, but her feelings refuse to be denied.
When Tess and John discover an aged newspaper clipping that indicates John's uncle was hanged for Tess's murder in 1875, John decides to return to his time to save his uncle's life, but when Tess checks the article after John's departure, she is horrified to discover that John has been hanged instead.
Armed with determination and modern ingenuity, Tess must abandon her past and risk her future for a chance to catch her own killer and find her first love for the second time.
This book picked up where the previous book left off with John face to face with Tess, this one was written in two viewpoints John's and Tess's in this one John has to explain everthing that happened to Tess in 1875 and after finding out his uncle is in trouble decides to go back.
Tess keeps an eye on what is happening in 1875 but can't settle with what is happening and decides after doing a few things to settle some scores in 1875, but she knows when she goes she won't return.
This book was great with realizing that living in 2009 won't work with Tess and John they go about fixing the damage that was created in the first book. Tess realizes that the only way they can work is if Tess goes to 1875 and stays there.
It's a great story for those who love time travel stories or movies like The Butterfly Effect. It pulls you in and you find you can't put it down until you know how it plays out I enjoyed it especially the ending!!
Quiet Kismet, Pennsylvania, may look like any other small town, but as a home stager, Caprice De Luca can see behind closed doors--and it seems someone has designs on murder. . .Life is a full house for Caprice these days. She's dating, she's rescuing adorable cocker spaniels, and she's decorating the roomy interiors of Kismet's most well-heeled residents with fun fantasy themes. But she's worried about her pregnant sister. Bella's marriage is coming apart like a bad wallpaper job, and to make matters worse, she's decided to meet up with a former flame Bob Preston, a house painter Caprice frequently employs. When he's found dead in a pool of green paint swirling with blood, it's time for Caprice to stage an investigation. With all eyes trained on Bella's husband, Caprice shifts her attention from finding the perfect curtains to finding the perfect culprit. . .
This is the second book in the Caprice De Luca series in this one she is stagging houses again and her sister Bella soon finds a dead body and it is up to Caprice to clear both her sister Bella and her husband Joe. The two seems to be having a bad time lately and Caprice can't imagine either one of them committing the crime.
I enjoyed this book learning more about the residents in Kismet and delving more into Caprice's relationship with Dr. Seth. I also enjoyed learning more about Grant the lawyer that works with Vince Caprice's brother.
Which I will be doing a book tour with in February can't wait to share this book with everyone!
Gianna Mancini has chatted with ghosts most of her life. It's never affected her much. Until now.
The latest ghost in Gianna's family-centric, boy-complicated, job-depleted world is Emma Tinsdale, a woman Gianna despises. Wanting Emma out of her apartment and her orbit, Gianna chooses to help her move on, but she doesn't expect to come across poisonous jam, a vengeful cop, or a group of friendly clowns.
When a relative is framed for Emma's death, Gianna must dig deeper and faster to find out what really happened that fatal night on the beach. With help from her sister, her cop brother, and her ex-boyfriend, Julian, she gets close to figuring out the truth. But when the killer closes in, Gianna better watch her step unless she wants to become the latest member of the dearly departed.
This book follows the story of Gianna whose moving on with her life now that she has moved back to town leaving behind her boyfriend Jullian. Her sister Izzie's having her own issues with her husband and has moved out taking residency at her parents house. While Izzie and Gianna as having a night out they stumble into both ex's Gianna's at the first bar they stop at and Izzie's at the second bar being serviced by a clown.
It's not long into the book before two ghosts show up to Gianna whose trying to get her life in order and has to now deal with two ghosts one a college age man who seems to be waiiting for someone the other is the clown from the night at the bars and Gianna finds herself helping Emma aka Cupcake the Clown to find out what happened the night she died.
This book I was great I loved the family dynamics along with the ghost issues I was drawn in and didn't even notice i read it in one day it was that good. If you haven't checked this series out you really should it's totally worth reading!
I have one copy of this book to giveaway to a lucky follower. This contest is open to USA residents only. To enter just comment below with your email address and I will pick a winner at random!
Caprice DeLuca stages houses for high-end clients. When she discovers a body in the castle-mansion she staged to sell and starts asking questions, she finds herself in danger. On the way to solving the murder, Caprice's large Italian family helps and hinders. She also finds romance with Dr. Seth Randolph. But does her brother's partner, attorney Grant Weatherford, care about her, too? Or is he just worried she'll get herself killed and her family will blame him?
This is a new series where Caprice DeLuca does house staging for clients who want to sell their house. When her friend Roz's husband winds up dead it's up to Caprice to find out who really had an axe to grind with Roz's husband. Of course it doesn't help that Ted's Roz husband was having an affair and had an obsession with daggers. Who had the most to gain by his death? His wife? His mistress? Or someone through his company?
After leaving a decade ago, Angie has been called back to Harbor Haven by her grandmother, Charlotte, who raised her following her mother's disappearance when she was a child. Her mother has been found, and now the question of her whereabouts has sadly become the mystery of her murder.
This book begins with Angie Curtis being called back to Maine when her grandmother Charlotte tells her that her mother has been found. Angie heads back to Maine to help bury her mother, while there she finds herself helping her grandmother when she is being scammed by someone who offered to help with her business Mainely Needlepointers. Also while there Angie figures she will try to find the motive into her mothers murder. If nothing more than to satisfy the small child who lost a mother as a child.
This book was great new series that offers a different kind of relationship a daughter and Grandmother connected by Jenny the daughter/mother who disappeared so many years ago. This book shows that sometimes you can come home and that your fate is written in the stars. That going home isn't always as bad as you think it is.
I loved the characters and relationships they have that Angie was able to reconnect with some friends Chem and Cindy who she has grown up with and finds she can reconnect with them. I can't wait to see what Lea Wait comes up with next!
What would it take to convince you that the woods you just left is a hundred and forty-four years distant from the one you entered?
Ten years have passed since the Civil War broke up John Bartley's family. Living with his aunt and uncle in the tiny village of Greendale, Vermont, isn't filled with excitement for a seventeen-year-old.
John Bartley finds himself in 2009 when he passes a tree and winds up at Tess McKinnon's house unsure of how to get home or how he got there. Tess is not quick to believe John's story and tests his history to find out how much it is true. When she is unable to shake the feeling that John needs her help she does what she can to help him.
This book was great and reminds me like various other time traveling books, where characters need help to return to their time frame. I enjoyed the story and learning about Tess and John and the various details of their history.
The follow-up short story to Emerald Barnes' Entertaining Angels, Before We Say I Do, is now available! If you loved Chase and Mads in Entertaining Angels, you'll love this!
Chase Sanders and Madison Andrews are about to declare their love for one another in the most sacred of ways. Everything has been going perfectly, especially when an old friend returns to town to stand by Chase's side on their big day.
But is Zach there to see their union, or is he concealing the truth of why he's actually back in town? Chase has lived perfectly fine without his father around, but now that his father is divorcing again, he is seeking forgiveness. Chase can't look at his father, let alone forgive him.
The day had finally come. I was marrying my best friend. Tears of joy stung my eyes, but I tried to hold them in. I couldn't cry. Not now. Mom and Mandy would kill me if I messed up my makeup.
I stared in the mirror. I had come a long way in the two years since I'd met Zach. We graduated high school, and I was now working on a degree in counseling. I'd fallen head-over-heels in love with my best friend, and I learned to love myself for who I really was. I won't lie. It hasn't been easy for me. Sometimes I would look in the mirror, and I'd see the fat girl from high school. Other times, Chase would wrap his arms around my waist and reassure me that he loved every inch of me – whether I was big or small. It didn't matter to him. I was beautiful. When he'd say that, I'd remind myself that God had loved me enough to send his angel just to show me that I was important, loved, and beautiful.
Eventually, the way I saw myself began to change. I no longer compared myself to photo-shopped pictures of models in magazines or my friends who were smaller sizes than me, and I began to look at myself as a daughter of the King. God formed me. He knew exactly what I would look like, and as He'd told me before, He only makes beautiful things.
She wrapped her arms around me and pulled me close. I could hear her sniffle, but I fought the tears back again. I wasn't going to cry. Not now at least.
She pulled away and smiled at me before wiping away her own tears. I had always felt like Mrs. Cheryl was a second mom. And now, she would be!
I nodded, and Mom left the room.
"Can you help me sit?" I asked Mrs. Cheryl.
She walked over to me and helped lift my train, so I could sit comfortably without wrinkling the dress too much. The beaded bodice felt a little tight, but I wanted to look my best. I wasn't loosening it at all.
"You look gorgeous," Mrs. Cheryl said, pulling her phone out of her purse and snapping a picture of me.
"Thank you," I said, smiling at my future mother-in-law.
"Are you nervous?" she asked, taking a seat beside me.
I laughed, praying that what I'd just spoken wouldn't come true at all. I don't suppose it mattered. I was about to be joined with Chase forever in our very own happily ever after. I knew not all marriages were perfect, and I didn't expect ours to be any different. I did hope that we would have a beautiful marriage as close to perfect as possible. I knew that if we put God first, we could get through anything; however, the wedding night was what really made me nervous. I just didn't want to tell Cheryl that.
Chase and I had waited until marriage. It was what was right to do according to the Bible. We wanted to be each other's firsts and each other's lasts. At least we were both new at it. I wondered if that was why he was nervous, too. I mean, I certainly understood that.
"Is that all?" she asked, staring at me knowingly. I briefly wondered what all Chase might have told her. This might be awkward. I didn't even talk to my own mom about stuff like this.
I felt the blood rushing to my cheeks, and I was thankful for the pink blush already coloring them.
I shook my head, biting the inside of my cheek. I wasn't going to cry now. "No," I said, "I'll never forget what he's done. Zach's here too." I added on that last bit to distract her from the conversation she seemed wanted to have.
Her smile faded at the mention of him. She rarely brought him up, but I couldn't blame her for that. He'd left her for another woman and ignored them for the first seven years he'd been away. He'd only just started talking to Chase again two years ago. Even Chase didn't want to tell his dad about our union, so we kept it a secret from him. I didn't know if that would work or not, but Chase really didn't want him ruining the day. I wasn't going to force him to invite his father to our wedding, though. It was entirely his decision.
"We didn't invite him, you know," I said.
I didn't know what else to say. I hated that Chase had such a rocky relationship with his dad. I couldn't imagine not having Dad around, but then again, Dad didn't cheat on Mom and have a new family while ignoring me completely for the first few years of his new life.
I looked at Mrs. Cheryl and gave her a big smile. She stood and extended her hand out to me.
I wrapped my arms around her in a tight hug after she helped pull me off of the chair I sat in. She kissed my cheek, and we walked out of the room and into the sanctuary where we were about to take pictures. It was now a little over two hours before I officially became Mrs. Chase Sanders.
Enter to win one of five digital copies of Before We Say I Do!!
Where can you buy Before We Say I Do?
And, in honor of Before We Say I Do's release, Entertaining Angels, the first book in the series is $0.99!!
Emerald Barnes resides in a small town in Mississippi and has the accent to prove it. She tries her hardest to write novels that appeal not only to young adults but to those who are young at heart as well. She mainly writes suspense/thrillers in the YA genre, but she dabbles in other genres and her books are enjoyed by all ages! She's constantly working on new novels and has more ideas than she knows what to do with. She's also a volunteer at the World Literary Cafe which is amazing, and she is a crazy grammar nazi who proofreads novels!
When she isn't writing or proofreading novels, she's spending all of her time with her nieces and nephews. She's a self-proclaimed nerd, avid reader, and TV watcher. God is number One in her life, and she thanks Him continuously for His love and favor.
It's springtime in Savannah, the azaleas and magnolias are in bloom, and Reagan Summerside's consignment shop, the Prissy Fox, is bustling with customers out to enjoy the beautiful weather. On a day like today, what could go wrong?
As a mortician beautician and housekeeper, Mercedes is no stranger to corpses or messy bathrooms. But the last thing she expects to find in a client's bathtub is a dead body! Now she's a murder suspect and it seems like her life is going down the drain. She turns to local lawyer Walker Boone to get her out of hot water.
But Walker has his own surprising connections to the dead man in the tub, and now he needs Reagan's help to clear his own name—and keep him alive.
In this book it's told from Walker Boone's point of view anyone who is anyone knows that Walker Boone is the lawyer that helped Reagan's ex-husband when he divorced Reagan and again in the first book when Reagan's ex was on the chopping block for a crime he didn't commit.
This book starts off right away with a murder having been committed and Walker being at the scene of the crime along with Mercedes a mortician/housekeeper who seems to be on the hook for the murder mind you Reagan isn't far behind in this book she wants to consign some furniture she was suppose to consign prior to his death.
Somebody is determined to silence Walker and he has to have Reagan help keep him alive and figure out who killed the victim Conway Adkins. Will he find out before he meets his own demise?
Such a good book and I loved every bit of it and can't wait to see what happens next. Ms. Brown needs to get back at it so we can find out who the killer is and what happened with Boone!! I love visiting this southern community they are so great and I always find myself wanting to go back there more and more frequently!
Brandi Haas is no domestic goddess . . . but she'll tell you that motherhood is probably the hardest gig in the universe: "The pay is horrible, the wardrobe is pathetic, and your boss (although utterly adorable) is usually a tyrant."
Brandi brings her trademark wit from the popular blog to this new collection, sharing stories of birthday party mayhem, mommy martyrdom, and snow shoveling majesty.
The setting is Anytown, USA, among barking dogs, picket fences, and eclectic neighbors.
Tales from Suburbia: You Don't Have to Be Crazy to Live Here, but It Helps will make you laugh, warm your heart, and let you know you're not alone. Mothers (and fathers) will recognize themselves, their children, and the absurd situations that family life brings to us all.
Brandi Haas has really hit on something that I think every mom who use to work goes through how neurotic we can be as stay at home moms, and how silly we can be when dealing with things. This book is so funny at times.
This setting for this book is so true it could talk place any where it deals with different situations from being a Head Mom at school, There all also various discussions on mom groups, Target field trips, good old Chuck E. Cheese's, and also deals with things like fundraisers, Girl Scouts.
I loved this book it was great and refreshing to read about Brandi's antics. Definitely worth checking out and keeping on hand for many years to come. I think all Mom's and Dad's should get this book and read all about it and see how much of it they find themselves doing.
Can't wait to see what Brandi comes up next! So glad she was able to share her book with us!
Another murder in small town Cold Creek has tensions rising. Clive Johnson, the groundskeeper at Cold Creek College, is a convenient scapegoat for a police chief who seeks an easy solution. Convinced Chief Pfeiffe has it all wrong, professor and psychologist Sheridan Hendley sets out to help prove Clive's innocence. But not everyone is pleased by her enthusiastic search for the truth. Just as her life is looking up personally, it looks like she might be the next victim.
This is the second book in the Cold Creek series in this book a body is found dead and Sheridan is called over to help people who are suffering from shock and her boyfriend Brett is called in to investigate the crime. It's not long before the reader finds out murder is going on at the college. Who had the most to gain from this murder? Will Sheridan and Brett figure it out before the murderer strikes again?
This is a great mystery that kept me guessing as to who the murderer was and I really enjoyed that. I also enjoyed the aspect of Sheridan being a professor and psychologist which you don't see in many mystery books.
I also enjoyed the friendship between Sheridan and Kim. Their friendship works well together. As well as being friends and co-workers. I think many cozy readers will love this series can't wait to see what Ms. Nardi comes up with next in the Cold Creek series!
They met at the worst possible moment...or maybe it was just in time. David McClain was about to go to war and Lindsey Wood was there at his going-away party, capturing his heart when falling for a woman was the last thing on his mind. While David was serving his country, he stayed in close contact with Lindsey. But war changes a person, and when he came home very little had the same meaning that it had before – including the romance that had sustained him. Was love truly unconquerable, or would it prove to be just another battlefield casualty?
Gooseberry Island is the most nuanced, dramatic, and romantic novel yet from a writer whose ability to plumb the depths of human emotion knows few peers.
There was movement three hundred yards out on the street below. Unusual, David thought. It was a teenage boy, maybe fourteen, carrying a burlap bag and hurrying home before dark. Never seen him before, David thought.
It only took a few seconds, but the whole scene played out in sequence in his mind—both men yelling and slapping the boy as he screamed for help; the slaps turning to a vicious beating until finally the boy was dead. He could almost hear Command say "Negative" again after he asked if he could intervene. He felt the anguish in his soul threatening to overwhelm him, but it was quickly replaced by a burning rage.
His eyes filled with tears, David returned to the present and started for the man in a mad rush. He was three steps from the shocked stranger when reality clicked in. It's the boy's father, he realized. He's…he's okay.
David's body convulsed. He'd forgotten he was home, and the reality of it slapped him hard in the face.
The man pulled the teenage boy close to him; both of them were frightened by David's sudden charge toward them.
"Sorry," David said, though it sounded more like "Sigh." Trying unsuccessfully to smile at them, he turned on his heels and hurried back to the Mustang.
For the next hour, David sat alone in his car, trying to calm the physical effects of his anxiety. Once he'd reined that in, he spent another two hours beating back the depression that always followed in anxiety's wake.
His wasn't sure whether the abyss existed within his heart or mind, but he knew that he was now filled with a great void—nothingness. There was no light there, only darkness. There was no hope, only despair. In time, he'd learned to embrace the silence, as the screams and whimpers of faceless victims became echoes that returned again and again, pushing the line of madness. Yet, the solitude was relentless, enveloping, merciless. It would have been better had I never existed, he thought, fearing another moment more than cashing in and leaving it all behind. No love, he thought, no peace. His memories were slanted in such thick negativity that his entire past would have been better off erased. And no one knows I'm dying inside, he thought, inviting another wave of panic attacks to crash onto the shore of his weary mind.
He closed his eyes tightly and tried to calm the short labored gasps. Just ride the wave, he told himself. Just ride the wave.
But in another room in his mind, he knew that even if he rode that wave—and didn't crack his skull on all the rocks beneath him—he'd have to take the ride again and again. It didn't take long before the jagged rocks seemed like the more merciful option.
Enough time had passed for Lindsey to realize David was not coming after her. He's obviously in a lot of pain, she thought, and doesn't want to burden anyone with it. She shook her head. But I care way too much about him to let him go through this alone.
With Craig's permission, she slammed David's front door behind her and marched through the living room into the kitchen. "Don't you dare play the coward with me, David McClain," she shouted before even reaching the room.
He looked at her with tormented eyes but didn't say a word.
"But you can't, can you?" she said, her entire insides starting to tremble.
"Don't you dare feed me that tired line! I spent a year praying for you…writing letters and wishing for us to…" She stopped, trying in vain to contain her emotions.
His face looked panicked, as his mind obviously spiraled out of control to gather the right words. "I don't have the words," he said in less than a whisper.
"After the first time I came here, I thought for sure you'd chase after me," she said. "I'm not stupid, David. I realize something happened over there that has you all twisted up. But I also thought that once you saw my face, you'd…" She stopped again and began to cry.
"Okay," she said, her tears threatening to flood her face.
He took a few deep breaths. "I've given this a lot of thought, and I want you to know that I've never lied to you…and I don't plan to now." He shook his head. "I'm so messed up right now, Lindsey, I can't even explain it." He could barely hold eye contact with her. "I really hope we can be together someday…more than you can ever imagine. But I'm just not ready yet. I…I need to heal," he stuttered.
She took a deep breath and held it.
"You guess?" She returned his shrug to him, perturbed.
He nodded, tears streaming down his face.
Lindsey took a deep breath and surrendered. "David, I've told you the way that I feel for you and what I want for us. That's all I can do. The rest is in your hands." She peered into his dull eyes. "I can only hope that you'll think of me every day, as I will you. I hope a lot of things, David." She paused to collect herself. "Most of all, I hope the day will come when Afghanistan is behind you and we can fall in love all over again and catch up on all the things we've missed." Mimicking him, she shrugged. "Maybe you're right. I guess time will tell." She pulled her hand away from his and felt her heart rip clean out of her chest. "Until then, you'll be in my thoughts," she whispered.
"I'm so sorry, Lindsey," he sobbed, his shoulders rocking.
"I love you, David," she said and, with one final attempt, grabbed his chin and forced eye contact between them. "Now tell me you don't want to see me and I'll leave you alone," she whispered.
As he looked at her, Lindsey could clearly see the anguish in his eyes.
"You can't, can you?" she said, hopefully.
His tears continued to leak down his cheeks. "I don't want to see you…for now," he said, and turned his eyes away from hers.
It felt as though someone had just slugged her in the gut. "Okay," she gasped and ran out of the house crying harder than she'd ever cried before.
Day turned into dusk and, like most nights, just beyond the sobs and sniffles the world turned quiet and black.
After four or five weeks of self-imposed solitary confinement—a punishment filled with death-defying panic attacks and long, treacherous tunnels of depression—David decided to reach out to the men he had served with. They're the only ones who can relate, he thought. And I wonder how they're doing…really doing?


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Home > June 2009 - Volume 113 - Issue 6 > Maternal and Perinatal Outcomes With Increasing Duration of...
Thought you might appreciate this item(s) I saw at Obstetrics & Gynecology.
Maternal and Perinatal Outcomes With Increasing Duration of the Second Stage of Labor
Allen, Victoria M. MD, MSc1; Baskett, Thomas F. MB1; O'Connell, Colleen M. PhD2; McKeen, Dolores MD, MSc3; Allen, Alexander C. MD, CM1,2,4
Obstetrics & Gynecology: June 2009 - Volume 113 - Issue 6 - p 1248-1258
doi: 10.1097/AOG.0b013e3181a722d6
OBJECTIVE: To estimate maternal and perinatal outcomes among women with increasing duration of the second stage of labor.
METHODS: A population-based cohort study was conducted among women with low-risk, singleton, vertex, nonanomalous deliveries at or after 37 weeks of gestation between 1988 and 2006. Individual maternal (hemorrhagic, infectious, and traumatic), perinatal (birth depression, infectious, and traumatic), and composite outcomes were evaluated with increasing duration of the second stage. Logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals for all outcomes and to account for confounding variables, including maternal age, prelabor rupture of membranes, augmentation of labor, antibiotics in labor, regional analgesia, gestational age, birth weight, and year of birth. Effect modification caused by method of delivery was considered.
RESULTS: From a population of 193,823 women, 121,517 women met inclusion and exclusion criteria, of whom 63,404 (52%) were nulliparous. There was an increase in risk of maternal obstetric trauma, postpartum hemorrhage, puerperal febrile morbidity and composite maternal morbidity, and low 5-minute Apgar score, birth depression, admission to the neonatal intensive care unit, and composite perinatal morbidity among both nulliparous women and multiparous women, with increasing duration of the second stage of labor. Method of delivery only modified the effect of duration of second stage among nulliparous women.
CONCLUSION: Risks of both maternal and perinatal adverse outcomes rise with increased duration of the second stage, particularly for duration longer than 3 hours in nulliparous women and longer than 2 hours in multiparous women.
LEVEL OF EVIDENCE: II
Risks of maternal and perinatal adverse outcomes in both nulliparous and multiparous women rise with increased duration of the second stage of labor.
From the 1Department of Obstetrics and Gynaecology, the 2Perinatal Epidemiology Research Unit, and the 3Departments of Anaesthesia and 4Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada.
Dr. Allen is supported by a Clinical Research Scholar Award from Dalhousie University and by a New Investigator Award of the Canadian Institutes of Health Research.
The authors thank the Reproductive Care Program of Nova Scotia for providing access to the data.
Corresponding author: Victoria M. Allen, Department of Obstetrics and Gynaecology, IWK Health Centre, Room G2141, 5850/5980 University Avenue, Halifax, Nova Scotia, Canada B3K6R8; e-mail: victoria.allen@dal.ca.
Financial Disclosure The authors did not report any potential conflicts of interest.
Temporal increases in operative delivery worldwide1–3 may in part be attributed to changes in maternal characteristics and obstetric practice patterns.4 In particular, operative delivery in the second stage of labor has been associated with significant adverse maternal and perinatal outcomes,5–7 which may be related to the time from full cervical dilatation to delivery.8,9 Challenges to evaluating these outcomes associated with a specific duration of the second stage of labor include establishing a definition of prolonged second stage in contemporary practice6,9,10–13 and assessing studies that have small numbers, combined analyses with both nulliparous and multiparous women,6,12 heterogeneous study groups6 and selected outcomes,14–18 and that report variable use of regional anesthesia.19 Although some studies have attempted to evaluate outcomes with varying lengths of the second stage of labor,8 the influence of progressive duration of the second stage remains unclear. A recent systematic review on this topic9 determined that variable definitions of prolonged second stage of labor, diverse study population characteristics and lack of control of confounding variables increase the difficulty in addressing the effect of the duration of the second stage on obstetric outcomes. In addition, mode of delivery was included variably as an outcome measure in the eligible studies, whereas the systematic review identified effect modification caused by mode of delivery as an important analysis not previously performed.
The present study used data extracted from a population-based database to estimate the magnitude of the effect of progressively increasing durations of the second stage of labor on maternal and perinatal outcomes, in nulliparous women separate from multiparous women, after accounting for clinically relevant confounding factors and method of delivery as an effect modifier.
We conducted a population-based, cohort analysis using data from the Nova Scotia Atlee Perinatal Database for the years 1988 to 2006. This database collects provincial information on all pregnancy outcomes for residents of Nova Scotia, and was used to evaluate maternal, fetal, and neonatal morbidity associated with increasing durations of the second stage of labor. The low-risk population was defined by the inclusion and exclusion criteria. Pregnancies were included if there was a liveborn singleton at or after 37 weeks of gestational age reaching full cervical dilatation. Pregnancies were excluded if deliveries occurred before onset of labor, if there was a major congenital anomaly, if there was at least one previous cesarean delivery, if there were preexisting (including hypertension and diabetes) or severe pregnancy-related (including hypertension and diabetes requiring therapeutic intervention) medical disorders, or if there was missing outcome data. Information on medical conditions, lifestyle factors, labor and delivery events, and neonatal outcomes was available for analysis. Ongoing data quality assurance programs and validation studies have shown that the information in the database is reliable.20,21
Maternal and infant summary characteristics included maternal age, parity, maternal prepregnancy weight, neighborhood socioeconomic status, smoking in pregnancy, prelabor rupture of membranes, regional anesthesia, augmentation of labor, antibiotic use in labor, method of delivery, gestational age at delivery, and birth weight. Smoking was defined as any maternal smoking in pregnancy. Socioeconomic status was approximated using QAIPPE, a variable developed by Statistics Canada,22 to provide an adjusted annual income based on census data averaged over all households in a postal code. Low socioeconomic status was defined as QAIPPE 1–2, with higher incomes defined as QAIPPE 3–5. Prelabor rupture of membranes was defined as rupture longer than 24 hours before delivery. Regional anesthesia included spinal, epidural, or combined anesthesia. For the majority of the study duration, consideration for induction of labor or increased fetal surveillance in a postterm pregnancy in our center typically started at 41 completed weeks.
The length of the second stage of labor was defined, based on available data in the database, as the duration from full cervical dilatation to delivery. Current United States and Canadian national clinical practice guidelines state that the diagnosis of a prolonged second stage of labor should be considered in nulliparous women when the second stage exceeds 2–3 hours and in multiparous women when the second stage exceeds 1–2 hours,9,10 the upper limit modified by the need for regional anesthesia. In the present study, the length of the second stage of labor was grouped into five categories for nulliparous women (2 hours or less, more than 2 hours to 3 hours or less, more than 3 hours to 4 hours or less, more than 4 hours to 5 hours or less, and more than 5 hours), and into four categories for multiparous women (1 hour or less, more than 1 hour to 2 hours or less, more than 2 hours to 3 hours or less, and more than 3 hours). These groupings were based on the objective of the study, which was to estimate risks associated with increasing duration of the second stage of labor.
Maternal morbidity outcome variables included chorioamnionitis by placental pathology, uterine rupture or dehiscence, maternal obstetric trauma (laceration of the uterine artery, laceration of the bladder, bowel, or ureter, severe extension of the uterine incision, or third-degree or fourth-degree perineal lacerations), need for blood transfusions, hysterectomy, early and late postpartum hemorrhage (physician-diagnosed with an estimated blood loss greater than 500 mL for vaginal delivery or greater than 1,000 mL for cesarean delivery), wound complications (including abdominal or perineal wound infections or dehiscence), puerperal febrile morbidity (more than 38°C on two or more occasions in any 48- hour period, excluding the first 24 hours after delivery), peripartum venous thromboembolism, near-miss maternal mortality (transfer to intensive care) or a composite of any of the above.
Neonatal morbidity outcome variables included 5-minute Apgar score less than 7, birth depression (defined as delay in initiating and maintaining respirations after birth requiring resuscitation by mask or endotracheal tube for at least 3 minutes, a 5-minute Apgar score of 3 or less, or neonatal seizures due to hypoxic-ischemic encephalopathy [Sarnat Score higher than stage 1]),23 neonatal trauma (brachial plexus palsy, facial palsy, fractures, or intracranial hemorrhage), sepsis (positive blood culture, septicemia or systemic infection), and neonatal intensive care unit (NICU) admission with duration of stay longer than 24 hours, or a composite of any of the above. Neonatal traumas included in these analyses were intracranial hemorrhage (defined as tentorial tear, spinal cord hemorrhage, subgaleal hemorrhage, or other intracranial hemorrhage), cephalhematoma, brachial plexus palsy, facial palsy, skull fractures (depressed or linear), and other fractures (clavicle, ribs, humerus, or femur). Neonatal trauma was considered major if one or more of the following were present: depressed skull fracture, intracranial hemorrhage, or brachial plexus palsy, and was considered minor if one or more of the following were present: linear skull fracture, other fractures, facial palsy, or cephalhematoma.
To describe the study population with reference to duration of the second stage of labor consistent with national clinical practice guidelines, summary characteristics in nulliparous women with a second stage duration longer than 3 hours and in multiparous women with a second stage duration longer than 2 hours were compared with all other women in the second stage of labor (regardless of regional anesthesia). To remain consistent with national clinical practice guidelines, to estimate the effect of increasing duration of the second stage of labor, and to provide information on normal duration of the second stage, outcomes in nulliparous women with increasing duration of the second stage longer than 2 hours were compared with a duration of 2 hours or less, whereas outcomes in multiparous women with increasing duration of the second stage longer than 1 hour were compared with a duration of 1 hour or less.
Categorical data were compared using χ2. Multivariate logistic regression analysis was performed in a backward, stepwise fashion (factor retained if it changed the point estimate of the variable representing duration of second stage by 5% or more) to generate adjusted odds ratios for all outcomes by duration of the second stage of labor, accounting for potential confounding variables (maternal age, prelabor rupture of membranes, augmentation of labor, antibiotics in labor, regional anesthesia, gestational age, birth weight and year of birth). Effect modification caused by method of delivery on the outcomes of interest was determined with the most parsimonious model using the difference in –2 log likelihood, χ2. The general estimating equation procedure provided standard errors corrected for nonindependence of multiple pregnancies to the same woman. Odds ratios and 95% confidence intervals were determined. Statistical significance was P<.05. Statistical analyses were performed using the SAS 8.0 programming package for Windows (SAS Institute, Inc., Cary, NC), Egret 2.0.3 for Windows (Cytel Statistical Software & Services, Cambridge, MA), and EpiInfo (Centers for Disease Control and Prevention, Atlanta, GA). This study received approval from the Reproductive Care Program of Nova Scotia Data Access Committee and from the IWK Health Centre Research Ethics Board.
The potential study population of women delivering in Nova Scotia for the 19-year period (1988–2006) was 193,823. Of these, 80.0% met the inclusion criteria of having no previous cesarean delivery and delivering liveborn singletons at or after 37 weeks in cephalic presentation after reaching full cervical dilatation. Exclusion of major congenital anomalies (3.2%), serious preexisting or pregnancy-related medical disorders (3.0%), previous cesarean delivery (9.8%), cesarean deliveries without labor (5.8%), and missing outcome data (2.9%) resulted in the actual study population of 129,517, of whom 52% were nulliparous.
To determine expected duration of the second stage of labor in our population in a group representing normally laboring women, duration of the second stage was first examined in a selected group of nulliparous (n=31,065) and multiparous women (n=49,955) within the actual study population who entered labor spontaneously and progressed to spontaneous vaginal delivery. These median durations were found to be 1.0 hours (range 0–10.2 hours) for nulliparous women and 0.3 hours (range 0–7.8 hours) for multiparous women. Based on these findings, duration of the second stage of labor in our study longer than 3 hours for nulliparous women and longer than 2 hours for multiparous women represented duration of the second stage greater than the 75th percentile for each group.
In the actual study population, 9,314 (14.8%) of nulliparous women were identified as having a second stage of labor duration longer than 3 hours and 2,156 (3.2%) of multiparous women were identified as having a second stage of labor duration of longer than 2 hours. From 1988 to 2006 (Fig. 1), the rate of this longer second stage in nulliparous women increased from 10.2% to 16.6% (χ2 for trend P<.001), and the rate of this longer second stage in multiparous women increased from 2.5% to 3.2% (χ2 for trend P<.001). For nulliparous women having this longer second stage, the proportion having regional anesthesia increased from 89.20% in 1988 to 98.17% in 2006 (P<.001). For multiparous women with this longer second stage, the proportion having regional anesthesia increased from 78.76% in 1988 to 90.70% in 2006 (P<.001).
Table 1 summarizes maternal and perinatal characteristics of the study population with reference to the second stage of labor consistent with national clinical practice guidelines (and consistent with duration of the second stage greater than the 75th percentile for each group in the selected normally laboring population). Each variable in Table 1 was considered a clinically relevant characteristic and a potential confounder (except for method of delivery, which was tested as an effect modifier), and the groups were shown to be significantly different for each variable.
Tables 2–7 summarize the unadjusted and adjusted comparisons of selected maternal and perinatal outcomes separately among nulliparous and multiparous women with increasing duration of the second stage of labor. Smoking, prepregnancy weight, and socioeconomic status were not included as confounding variables in the regression analysis owing to the high percentage of missing values (greater than 10%). The outcome variables of uterine rupture or dehiscence, hysterectomy, venous thromboembolism, and transfer to an intensive care unit were not subjected to regression analysis owing to low occurrence (less than 0.1%). Further evaluation by duration longer than 4 hours for multiparous women was difficult owing to diminishing numbers of women in this group.
Examination of unadjusted analyses of maternal outcomes in nulliparous women (Table 2) demonstrated increased risks for chorioamnionitis, maternal obstetric trauma, postpartum hemorrhage, wound complications, puerperal febrile morbidity and composite maternal morbidity for all durations of the second stage longer than 2 hours. Regression analyses evaluating the effect of length of second stage of labor on maternal outcomes in nulliparous women (Table 2), where method of delivery was not a significant effect modifier, demonstrated progressive additional risks of obstetric trauma and postpartum hemorrhage (45–73%) for second stage of labor duration of 3 hours or longer. Evaluation of puerperal febrile morbidity demonstrated ongoing risks with increasing second-stage duration. There was a decreased risk for blood transfusion for durations longer than 4 hours but shorter than 5 hours. No difference in risk was observed for wound complications at any second stage duration longer than 2 hours.
The joint effects of duration of the second stage of labor and method of delivery (where method of delivery was found to be a significant effect modifier) were examined for the outcomes of chorioamnionitis and composite maternal morbidity (Table 3). There was no increase in risk for chorioamnionitis with spontaneous vaginal delivery regardless of the duration of second stage, and an increased risk for all durations with cesarean delivery. Risk for any maternal morbidity was increased with the joint effect of every duration of the second stage of labor and every method of delivery, with up to an additional 426% risk for nulliparous women delivering greater than 5 hours by operative vaginal delivery.
Unadjusted analyses of perinatal outcomes in nulliparous women (Table 4) demonstrated increased risks for a 5-minute Apgar score less than 7, birth depression, minor and major trauma, NICU admission, sepsis, and composite perinatal morbidity for most or all durations second stage longer than 2 hours. Adjusted analyses evaluating the effect of length of second stage of labor on perinatal outcomes in nulliparous women, where method of delivery was not a significant effect modifier (Table 4), demonstrated an increased risk of low 5-minute Apgar score for all second stage of labor durations, and for minor trauma with duration of the second stage greater than 2 to less than or equal to 3 hours. No differences in risk were observed for major trauma or neonatal sepsis.
The joint effects of duration of the second stage of labor and method of delivery (where method of delivery was found to be a significant effect modifier) were examined for the outcomes of birth depression, admission to NICU, and composite perinatal morbidity (Table 5). Increased risk for birth depression was shown for early durations of the second stage with operative deliveries (likely representing intervention for nonreassuring fetal status) but also for longer durations, regardless of method of delivery. Risk of admission to NICU was increased for longer durations with all methods of delivery. Risk for any perinatal morbidity was increased with the joint effect of every duration of the second stage of labor and every method of delivery.
Examination of unadjusted analyses of maternal outcomes in multiparous women (Table 6) demonstrated progressive increases in risk for maternal obstetric trauma, blood transfusion, postpartum hemorrhage, wound complications, puerperal febrile morbidity and composite maternal morbidity for second stage duration longer than 1 hour. Method of delivery was not found to be an effect modifier for any maternal or perinatal outcome among multiparous women. In multiparous women, regression analyses evaluating the effect of length of second stage of labor on maternal outcomes demonstrated a progressive increase in risk for obstetric trauma, postpartum hemorrhage, wound complications, puerperal febrile morbidity, and composite of maternal morbidity (Table 6), with the highest additional risks (7–144%) occurring longer than 3 hours. No differences in risk were observed for chorioamnionitis or need for blood transfusion for any second stage duration.
Unadjusted analyses of perinatal outcomes in multiparous women (Table 7) demonstrated increased risks of 5-minute Apgar scores less than 7, birth depression, minor neonatal trauma, NICU admission, and composite perinatal morbidity for durations of the second stage longer than 1 hour. In multiparous women, regression analyses evaluating the effect of length of second stage of labor on perinatal outcomes demonstrated an increase in risk for 5-minute Apgar score less than 7, birth depression, minor trauma, NICU admission, and any perinatal morbidity (Table 7), with the highest additional risks (15–57%) occurring longer than 2 hours. No differences in risk were observed for major neonatal trauma or sepsis in multiparous women for second stage duration longer than 2 hours.
Although studies have focused on adverse perinatal outcomes associated with a long duration of the second stage of labor, there are few studies that have considered adverse maternal outcomes or the effect of increasing duration of the second stage. Our large population-based study, designed to characterize the magnitude of effect of progressive increases in duration of the second stage of labor on maternal and perinatal morbidity, demonstrated important observations in maternal and perinatal risks for nulliparous and multiparous women delivering after 36 weeks of gestation, especially when durations of the second stage were longer than 3 hours in nulliparous women and longer than 2 hours in multiparous women.
A previous evaluation of outcomes with increasing duration of labor in a cohort of low- and high-risk nulliparous women at term has demonstrated that rates of chorioamnionitis, severe perineal lacerations, and postpartum hemorrhage increased significantly after controlling for potential confounding variables.8 Women were more likely to have adverse maternal outcomes when they had second stages longer than 3 hours and longer than 4 hours compared with durations shorter than 3 hours and shorter than 4 hours, respectively.8 Significant differences (adjusted analyses) also have been observed in rates of postpartum hemorrhage and chorioamnionitis among women who delivered after less than 2 hours compared with those who delivered after more than 2 hours, with no difference in these maternal outcomes when 2 to 4 hours was compared with more than 4 hours.6 An increase in unintentional hysterotomy extensions has been observed in a low-risk cohort of women at term requiring cesarean delivery, when the effect of duration of a second stage of less than 3 hours was compared with more than 4 hours. Differences in disseminated intravascular coagulation, postpartum fever, need for blood transfusion, or composite morbidity were not demonstrated.14 Our findings of increased risks of maternal morbidity with increased duration of the second stage of labor are consistent with other studies, demonstrating progressive increases in risk for the majority of the adverse outcomes evaluated in our study among nulliparous and multiparous, especially when including the joint effects of method of delivery and duration of the second stage. The risk of any maternal morbidity, which was increased with all durations of the second stage among nulliparous and multiparous women regardless of method of delivery, retained significant increased risk in both groups when postpartum hemorrhage and puerperal febrile morbidity was removed from the composite outcome analysis (data not shown). The need for blood transfusion was reduced significantly for second stage durations of more than 4 hours to 5 hours or less, even though the risk for postpartum hemorrhage was significantly increased for all durations, although it becomes difficult to interpret the clinical significance of this finding given the small number of women in this group and the dramatic reduction in transfusion of blood products in Canada because of infection-related concerns during the years of the study.
The majority of studies addressing the effect of duration of the second stage on perinatal or neonatal outcomes have not observed differences in serious morbidity,6,8,9,12–14,18 including low 5-minute Apgar score, admission to NICU, neonatal seizures, and fetal acid-base status. One study has demonstrated that prolonged second stage is not an independent predictor of neonatal Erb's palsy,17 and others have not demonstrated a relationship with duration of the second stage and related neonatal outcomes such as shoulder dystocia.6 Our study included Erb's palsy in the group of major trauma and demonstrated no increased risk for major trauma in nulliparous women or multiparous women. However, minor trauma was increased for both nulliparous women with a second stage of more than 2 hours to 3 hours or less and for all durations of the second stage among multiparous women, regardless of method of delivery. Admission to NICU was shown previously to be increased for infants born to women with a second stage longer than 2 hours,6 but this finding has not been supported by other studies.12,13,18 Our study showed increases in risk of admission to NICU with longer second stage durations and with all methods of delivery. The risk of any perinatal morbidity, which was increased with all durations of the second stage among nulliparous and multiparous women regardless of method of delivery, retained significant increased risk among multiparous, but not nulliparous, women when admission to NICU was removed from the composite outcome analysis (data not shown).
Several studies limited their analysis of outcomes to women with either vaginal12 or cesarean8,14 delivery. In a previous study by our group investigating maternal and neonatal outcomes in a group of low-risk women requiring cesarean delivery in labor, an evaluation of morbidity at full cervical dilatation including the effect of duration of the second stage demonstrated no difference in outcomes when the duration of the second stage was longer than four hours (n=204) compared with a duration of shorter than or equal to 4 hours (n=345),7 although these finding may have been a function of small study numbers. However, a meta-analysis of outcomes with prolonged second stage has identified the importance of accounting for method of delivery as a significant effect modifier in studies evaluating the influence of duration of second stage, given the causal nature of the relationship between prolonged second stage and operative delivery.9 Our study was able to consider modification of the effect of longer second stage duration on maternal and perinatal outcomes by method of delivery, because of the comprehensive collection of delivery data in the Nova Scotia Atlee Perinatal Database.
Although there are methodologic challenges to studying labor progression owing to multiple influencing factors,24 we employed a large data set from a validated electronic perinatal database that allowed separate analyses by parity and controlling for other relevant maternal and perinatal factors, including use of regional anesthesia and year of birth. This capability becomes particularly important in the setting of previous studies limited by lack of confounding variables and, in our study, the numerous statistically significant comparisons in the unadjusted analyses. An important limitation of the present study is that the duration of the second stage of labor was defined as the time from full dilatation to delivery based on the information available in the database, which would also include the time from decision to intervene with operative delivery (forceps/vacuum assisted vaginal delivery or cesarean delivery) to the intervention itself. Although the data in the Nova Scotia Atlee Perinatal Database have been shown, through data reabstraction (with a high level of agreement for most routine variables) and validation studies, to contain reliable information,20,21 retrospective studies are limited to available data and so there may be other variables relevant to the present study that are not routinely captured in the database, such as the intrapartum factors of maternal positioning in labor25 or delayed pushing techniques.19
In this population-based study evaluating maternal and perinatal outcomes associated with prolonged second stage of labor, increasing duration of the second stage of labor was associated with increasing risks for both maternal and perinatal adverse outcomes among both nulliparous and multiparous women. The increased risks for many of the outcomes with longer durations of the second stage of labor were independent of method of delivery. Maternal, fetal and intrapartum characteristics must be considered in the management of the second stage of labor. Most of the factors associated with a longer duration of the second stage of labor cannot be modified, other than to assure effective uterine action with oxytocin augmentation. However, knowledge that there is increasing maternal and perinatal morbidity with prolongation may help guide timely intervention when second stage dystocia is diagnosed.
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Obstetrics & Gynecology113(6):1248-1258, June 2009.
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Disseminated Intravascular Coagulation Syndromes in Obstetrics
Practice Bulletin No. 142: Cerclage for the Management of Cervical Insufficiency
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redpajama_set_name: RedPajamaCommonCrawl


Ryan Reed has competed at Indianapolis Motor Speedway (IMS) twice in the NASCAR XFINITY Series. In his 2014 rookie season, Reed finished 20th after starting 13th and suffering a mechanical issue near the end of the race. In this race last year, Reed finished 20th after starting 22nd.
American Diabetes Association® representative and diabetes advocate James H. (Andy) Anderson, Jr., MD will 'ride' along with Roush Fenway Racing driver Ryan Reed during this weekend's race. The Indianapolis, Ind. resident will have his name featured on a decal above the passenger-side window of the No. 16 Ford Mustang.
Anderson Jr.'s interest in diabetes began during his time at Louisiana State University's Medical School, where he did experiments on insulin secretion. He enjoyed it so much that he spent the next two summers in the lab, with support from the local American Diabetes Association. That work led to a fellowship in diabetes and endocrinology, and a career as a diabetologist in patient care, academic research and experiments in long-acting diabetes medicines. Later in life, he developed diabetes and sought out diabetes management programs associated with the local American Diabetes Association. Through these programs, Anderson Jr. found help with his weight loss, physical activity and a support structure to manage his health.
Reed and his Roush Fenway Racing teammates will sign autographs for fans at the Lilly Diabetes Brickyard Block Party on Thursday, July 21st from 6-7 p.m. in downtown Indianapolis on the West block of Georgia St. The free event runs from 4 p.m. – 8 p.m. and includes racing simulators, live music, food, pit stop demonstrations and a performance by fellow diabetes advocate and American Idol finalist Crystal Bowersox.
Reed is scored 10th in the NASCAR XFINITY Series Championship standings after 17 races. He has led eight laps for the season, has one top-10 finish and has recorded an average finish of 17.2.
Reed and the No. 16 team finished 14th at New Hampshire Motor Speedway on Saturday after starting 22nd and fighting the handling of the car for the majority of the 200-lap event.
Reed and the rest of the NASCAR XFINITY Series will take the green flag from IMS in the Lilly Diabetes 250 on Saturday, July 23rd at 3:30 p.m. ET on NBC Sports Network.


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"The purveyor of mostly forgettable plonk." This is how renowned wine critic Anthony Gismondi once described the British Columbia wine industry. Protected by legislation from international competition and cultivating mostly Vitis Lubrusca and hybrid grapes, wine produced in British Columbia were considered poor alternatives to European and American wines. However, after the implementation of NAFTA and GATT, Canadian wine producers where forced to improve their wine's quality in order to survive in this new environment. Today, British Columbia wines are considered world-class, particularly newly planted Vitis Vinifera varieties.
The first instances of wine-making in British Columbia occurred when Oblate missionaries, who settled in the Okanagan Valley in the mid 1800s, cultivated grapes for sacramental wine. These were Vitis Labrusca and Vitis Riparia grapes since Vitis Vinifera vines usually succumbing to diseases induced by hot, humid summers and severely low winter temperatures. For the next 100 years, the Canadian and British Columbian wine industry was focused around these grapes as well as any hybrids that good withstand the Canadian environment. Whereas the number of smaller wineries had increased through prohibition – because the law allowed producing wine for personal use – the number of wineries decreased sharply after Prohibition as the industry consolidated and provinces restricted the establishment of new wineries. In the mid 1970s, the provinces relented and began to issue new licenses to produce and sell wine. The number of new wineries increased dramatically, however, protected against foreign competition, the quality of the wine remained poor. After the passage of GATT and NAFTA treaties, the wine industry undertook a major program to replace native grape varieties with vinifera grapes. New investments in technology and updated wine techniques have allowed these wine makers to produce world class vinifera wines.
However one hybrid that survived the transition to vinifera grapes is Ortega, a cross between the German Muller Thurgau and Siegerrebe. It was originally developed to enhance the quality of Riesling in poor vintages in the Rheinhessen region in Germany. Since the grape possesses the ability to excel in cold-winter conditions, it has been successfully grown in British Columbia, and with limited success in a couple of eastern provinces. This grape produces rich, flowery, peachy wines, with high natural sugar levels.
One B.C. winery that cultivates Ortega is Recline Ridge Vineyard and Winery, a family-owned and operated winery which is located in the heart of the Shuswap Lake area of British Columbia. Mike Smith, the winery's owner-operator, lists several factors that persuaded him to vinify Ortega. First, the grape is extremely winter hardy and actually develops better character in the cooler zones. In warmer environments the grape ripens too early to develop proper character. Second, Ortega's parent grape, Siegerrebe, is very aromatic and flavorful and these characteristics are passed down to its "offspring". And finally, Ortega generally provides good yields per acre – so the grape is very cost affective. Recline Ridge's Ortega has been well received by the Canadian wine public – it is the winery's second best white wine seller. In addition, the 2002 vintage won a Bronze medal at the 2005 Northwest Wine Summit after the 2001 vintage wine "Peoples Choice" award and "Best White Wine" at the 2004 Kamloops Wine Festival. Mr. Smith attributes Ortega's success to the Shuswap Lake terrior, in which he believes provides the conditions necessary to yield the greatest flavor potential. In addition to having a great taste, Ortega wine is very versatile wine with regards to the food it complements. Mr. Smith notes that Ortega finds many friends on the patio in summer with sea foods and cheeses or a crisp fruit salad, the kitchens and dinning rooms presenting a spicy curry dish, Cajun chicken, and Chinese food or simply to quench the thirst of a group of friends around a beach fire and a pot of Dungeness crab.
One of the first wineries to emerge after the British Columbia province began to issue commercial license to produce wine was Domaine de Chaberton Estates. The winery is located very close to the Washington border in the Fraser Valley and was started by Claude Violet, a ninth generation French wine maker. Today, it is the 4th largest estate winery in B.C. The winery cultivates Ortega because of the favorable climate conditions and they enjoy favor. They produce two types of Ortega wine, a vintage wine that tastes similar to a Muscat flavor wine and a Botrytis affected dessert wine that resembles a Sauternes wine. Sometimes called Noble Rot, Botrytis is a mold that causes grapes to lose nearly all of their water content – but not the sugar. The result: an extremely concentrated and sweet grape juice with honeyed, aromatic characteristics. Both wines have been accepted by the general public and wine officials: they have won over 30 medals\awards throughout the years, most notably a Silver Medal at Vinandino '97, an O.I.V. competition held in Mendoza Argentina.
Finally, Zanatta Winery, cultivates Ortega not only because it is reliable, excels in their climate, and is resistant to disease, but more importantly, because they like the wine. They have found that translating their appreciation of the grape to the general public has been a long and slow process. People are reluctant to buy what they do not know and a common question they hear is "Is it like Chardonnay?" Over time, as wine drinkers become more daring, this question will no longer be raised.
In September, MissourWineCountry.com is hosting the first National Norton Wine Festival in St. Louis Missouri. The festival consists of a tasting competition held August 4th and a general tasting of 25 of the top Norton producers on September 8th. The results of the tasting competition will be announced the night before the general tasting and at the general tasting there will also be an opportunity to taste vertical Norton offerings for those who purchase a Norton VIP. The sponsors invited Norton producers from 12 states to the competition and currently there are 93 wines entered, representing 43 wineries from 10 states. Not a bad turnout. These wines will be judged by eight highly respected wine experts, such as Doug Frost (one of only three individuals who passed the Master Sommelier and Master of Wine examinations) and Bob Foster (Chief Judge of the Riverside International Wine Competition).
I am very interested to see how the east coast Norton fairs against the Midwestern wines. While traveling to the Midwest last year I became a huge fan of Kansas and Missouri Norton - such as Davenport Winery, Kugler's Vineyard, Holy-Field Winery, Stone Hill Winery, Röbller Vineyard Winery, Mount Pleasant Winery, St. James Winery, Stonehaus Farms, and Augusta Winery. There are dozens more Norton producers that I haven't tasted spread throughout Missouri, Illinois, Indiana, and Arkansas. Many of these wineries will be participating in the competition. From the east coast, New Jersey's Valenzano Winery is sending their Cynthiana which won the NJ Governors two years in a row. Most of Virginia's Norton producers have entered; the country's largest Norton grower Chrysalis Vineyards, Rappahannock Cellars, Cooper Vineyards, The Winery at La Grange, Veramar Vineyard, Keswick Vineyards, and Horton Vineyards. I've tasted the Norton from all these Virginia producers and believe they will be very competitive. Finally, several smaller Norton producers are also participating, including Jones Cabin Run Vineyards (West Virginia), Grove Winery (North Carolina), and Crane Creek Vineyards (Georgia).
We will post the results of the competition when they become available and look forward to trying several of these wines at the general tasting.
There is a good article called Ripe Time for Fruit Wine published in the San Francisco Chronicle. Author, Derrick Schneide, briefly describes the history of fruit wines in the United States, the difficulties producing quality fruit wine, and highlights a few wineries: Hawaii's Tedeschi Vineyards, Illinois' Lynfred Winery, and California's Bargetto Winery. It's nice to see a California publication printing an article that includes wineries in other states.
On Saturday, July 14th we attended the second day of Potomac Point Winery's three day Grand Opening event. The winery is located in Stafford County Virginia and currently offers a wide range of excellent wines from grapes grown mostly in Orange County Virginia. There are wines for everyone. Their Norton, Viognier (gold medal), Vidal Blanc dessert wine, and Cabernet Franc are great examples of how these grapes thrive in Virginia. They also offer excellent Bordeaux, Italian, and Portuguese styled red wines, as well as a gold winning Chardonnay. These wines are impressive and for an initial release, outstanding. The winery itself is also impressive with meticulously designed metalwork throughout the Mediterranean-style building. This building is worth a visit itself - let alone the desire to "hang out" for a few hours. You can red the full account of our visit at Compass Tours.
Here's a completely new concept. Wine in a can. Yes, that's right, wine in a can. Produced by a Dutch company, Horeca Europe International (HEI), IronWine is made from Argentinian grapes and there are currently two offerings: a Chenin Blanc and a Malbec\Cabernet Sauvignon blend. Worried about tasting the can that happens with some lite beers? The cans contain a liner that separates the can's interior and the wine. HEI markets the wine to those "on the go" - for picnics, hiking, or for those just interested in a single serving such as business travelers. Ironwine is currently being served in the Buenos Aires Hilton and Sheraton hotels. What do you think? Would you buy a can?
While browsing the Garden State Wine Growers Association website, I noticed that they had posted the winners of the 2007 Governor's Cup competition. Congratulations are in order to Unionville Vineyards and Alba Vineyard for winning the Governor's Cup for their Unionville's NV Port and Alba's Blueberry wine and Chambourcin wine. According to the winery, the Unionville Port "...was produced from Marechal Foch (92%) and Chambourcin (8%) grapes. Aged grape brandy was added to stop fermentation and to bring the alcohol level up to 18.5%. After pressing, the wine was left to age quietly for at least three years in old oak barriques. This traditional dessert wine tastes of ripe raisins with hints licorice and dark cherries.".
Last year we visited Alba Vineyard and posted a review here. In short we loved their wines and location; their Delaware Dolce was our favorite. The are now recipients of two Governors Cup medals, one for their Blueberry wine and one for their 2005 Chambourcin. The chambourcin "is a good example of this grape's potential in our New Jersey vineyards. It exhibits strawberry and Bing cherry nuances in the perfumed aroma and rich flavors. Aging in small oak barrels gives this wine attractive overtones of mocha, vanilla and roasted nuts. Serve with full flavored dishes; we especially like it with grilled beef or roasted lamb." The Blueberry wine "is produced from only the highest quality fresh berries and fermented in a way that maximizes color and flavor concentration. No grape juice, flavoring, or distilled spirits are used. It is delicious as a dessert wine or it can be served as an aperitif or a fruit wine cordial."
Finally, another of our favorite New Jersey wineries, Silver Decoy Winery, was named winery of the year. We hope to be able to taste these wines the weekend of August 11/12 at the Jersey Fresh Wine & Food Festival.
This past weekend, while wondering between concourses at the Charlotte Airport, I came upon the Yadkin Valley Wine Bar. The wine bar is sponsored by the Yadkin Valley Winegrowers Association and carries the wines of Hanover Park Vineyard, RagApple Lassie Vineyards, RayLen Vineyards, Round Peak Vineyards, Shelton Vineyards, Stony Knoll Vineyards, and Westbend Vineyards. I was relieved to seeing the wine bar, because I was treading spending an hour at the food court, or a crowded restaurant, or at the gate. There was a wide array of wines available from dry Cabs to Chardonnays to Blush wines. I decided on two chardonnay wines, Stony Knoll's 2003 Chardonnay and RayLen's Barrel Chardonnay. Stony Knoll's Chardonnay was aged 10 months in French oak which provides the buttery finish - but the chardonnay fruit is still prevalent. RayLen's Chardonnay was very similar with even a stronger buttery finish. I was tempted to purchase a few bottles, but was already loaded down with carry on items. The wine bar does make it easy to ship wine; they will pay the shipping for orders over a case. Not a bad idea. And I no longer tread extended layovers in Charlotte.
On a recent trip to southern California, I stumbled upon an awesome wine shop in the middle of San Diego's GasLight District: The Wine Bank. The retailer had a large selection of domestic wines, but an even more interesting collection of Mexican tequilas and wine. One of the largest selections of Mexican wines was from L.A. Cetto Vineyards. The winery is located in Col. Lomas de Chapultepec, but the grapes are harvested from vineyards located in the Guadalupe, San Vicente, and Redondo valleys - all in Baja California. L.A. Cetto produces a wide variety of vinifera wines, Cabernet Sauvignon, Chardonnay, Petite Sirah, Zinfandel, Chenin Blanc, and Nebbiolo. Interestingly, all of their wines had won awards in International Competitions and I decided to purchase a bottle of their Nebbiolo Private Reserve after seeing that in 2005 it had won Gold and the Best Red Wine Trophy at the Vinalies Internationales in Paris. The wine was made from 100% Nebbiolo grapes grown in the Guadalupe Valley. The wine was aged a year in French oak and then two additional years in the bottle. The result: an incredibly smooth wine with a vanilla nose, a strong cherry flavor, and a smooth balanced finish. At $15, this wine was also an amazing bargain. For those living on the east coast, I am searching for an east coast retailer that carries L.A. Cetto's wines. I will let you know when I find one.
Texas is a grape paradise? Yes, insist many Texas wine growers. And considering that the state currently produces over 50% of the known species of grape in the world, they may be right.
When Spanish missionaries arrived in Texas in the 1600's, wild grapes were flourishing in the Texas countryside. By 1650, Father Garcia de San Fancisco y Zuniga, the father of present day El Paso, had begun cultivating Spanish black grape (Lenoir) into sacramental wine. During the next hundred years, the wine industry surrounding El Paso expanded as a result of irrigation projects developed by the Franciscan's. However, the Texas wine industry deteriorated in the early 1800's because of the failure to increase the wine's quality and the outbreak of the war with Mexico. In the late 1800's the region received a large influx of European immigrants who brought with them wine making skills handed down by distant generations. These immigrants then started to vinify the local grapes that inhabited the region. One of these grapes still cultivated today is the Mustang grape.
The Mustang Grape belongs to the Vitis Mustangensis species of grape and grows wild throughout Texas and can also be found in northern Mexico, Oklahoma, Arkansas, Louisiana, Mississippi, and Alabama. Mustang grapes are very acidic, tart and according to Mustang expert Jack Keller, "almost impossible to eat with any degree of enjoyment." Because of these characteristics, making wine from Mustang grapes is extremely challenging. Many are surprised that it is even possible to produce quality wine from this grape.
As European immigrants entered Texas in larger numbers, wine making expanded throughout the state. At the same time, T.V. Munson, a horticulturist from Illinois arrived in Texas, an event which changed wine history. Mr. Munson was a renowned expert on grape species and he developed numerous grape hybrids suitable for the Texas environment. After phylloxera destroyed more than 6 million acres of vineyards, the French wine industry requested Munson to send rootstock developed during his studies, where it was grafted with European vinifera. Munson's work along with another horticulturist, Hermann Jaeger, helped to save the European wine industry.
As the end of the 19th century approached, wine making was succeeding in most Texas regions. In 1883, the Qualia family established Val Verde Winery, growing Spanish black grape. The winery is the oldest continuing operating winery in Texas today. At the same time the wine industry was slowly perishing in El Paso. Nature played a part with numerous extended wet and dry periods. Economics also had a part; it became more profitable to raise truck crop produce than viticulture. Finally, the great flood of 1897 washed away a majority of the vineyards in the El Paso area, forcing many to give up the struggle. Though grapes would continue as a crop into the 20th century, this area would never regain its viticulture prominence.
During the early 20th century the Texas wine industry rose and fell depending on economic and weather conditions. However, Prohibition sent Texas wineries into extinction. Val Verde Winery was the only winery to survive this period, subsisting by growing table grapes. From the end of Prohibition until the mid 1970's the wine industry never recovered with Val Verde Winery the sole commercial producer. In the late 1970's vineyards at A&M's Experimental Station in Lubbock began showing promising results for growing vinifera in Texas. This encouraged the emergence of a new generation of wineries, such as Guadalupe Valley Winery and Fall Creek Vineyards. In the 1980's the Texas Legislature supported this trend by easing the rules required to establish small wineries. During the next two decades, the law of "Creative Destruction" exerted itself on the Teas wine industry as some wineries failed at the same time that new wineries were succeeding. Currently there are over 80 bonded Texas wineries, making Texas the 5th largest wine producing state. With many wineries awaiting permits and the increased number of Texas wineries winning international quality awards, the Texas wine industry appears extremely healthy.
The Mustang grape was also able to survive prohibition. Currently two Texas wineries vinify the grape: Lehm Berg Winery and Poteet Country Winery. Lehm Berg Winery is located in the central Texan town of Giddings and originated after father and son, Carl and Ben Droemer, collected wild mustang grapes and made 42 gallons of mustang grape wine from an old family recipe. After sharing their wine with friends and neighbors they were persuaded to open a commercial winery, which they finally completed in 2001. Today the winery sells three types of Mustang wine - Weiss, Rosa, and Rot – still using wild Mustang grapes and the old family recipe. They hope to encourage more people to use wild mustang grapes, which is quite possible – since the general public has responded positively to their Mustang offerings. Poteet Country Winery is located 30 minutes south of San Antonio. The winery currently produces a Mustang blend and a vintage White Mustang wine.


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using CommonMark;
using coreDox.Core.CodeModel;
using coreDox.Core.CodeModel.Members;
using DotLiquid;
using System.Linq;

namespace coreDox.Core
{
    public sealed class DoxTemplateBuilder
    {
        public DoxTemplateBuilder()
        {
            // Register the DoxCodeModel as save types
            Template.RegisterSafeType(typeof(DoxAssembly), typeof(DoxAssembly).GetMembers().Select(m => m.Name).ToArray());
            Template.RegisterSafeType(typeof(DoxNamespace), typeof(DoxNamespace).GetMembers().Select(m => m.Name).ToArray());
            Template.RegisterSafeType(typeof(DoxType), typeof(DoxType).GetMembers().Select(m => m.Name).ToArray());
            Template.RegisterSafeType(typeof(DoxEvent), typeof(DoxEvent).GetMembers().Select(m => m.Name).ToArray());
            Template.RegisterSafeType(typeof(DoxField), typeof(DoxField).GetMembers().Select(m => m.Name).ToArray());
            Template.RegisterSafeType(typeof(DoxMethod), typeof(DoxMethod).GetMembers().Select(m => m.Name).ToArray());
            Template.RegisterSafeType(typeof(DoxProperty), typeof(DoxProperty).GetMembers().Select(m => m.Name).ToArray());

            // Register Models
            foreach(var modelType in PluginRegistry.Instance().GetAllModelTypes())
            {
                Template.RegisterSafeType(modelType, modelType.GetMembers().Select(m => m.Name).ToArray());
            }

            // Register Filters
            Template.RegisterFilter(typeof(DotLiquidFilters));
        }

        public string Render(string template, object data)
        {
            return Template.Parse(template).Render(Hash.FromAnonymousObject(new { data }));
        }
    }

    internal static class DotLiquidFilters
    {
        public static string Html(string input)
        {
            return CommonMarkConverter.Convert(input);
        }
    }
}

redpajama_set_name: RedPajamaGithub