bluuebunny/crossref_metadata_2025 huggingface dataset:
Reducing Primary Cesarean Births via a Multidisciplinary Learning Collaborative Using Targeted Bundles [32P]
Authors: Low Lisa Kane , Chenok Kate , Dalgado Ana , Breman Rachel , Page Katie , Emeisc Cathy
Published: April 2020

INTRODUCTION:

The American College of Nurse Midwives Healthy Birth Initiative: Reducing Primary Cesareans is now entering its third year of operation. The initiative focuses on reduction of nulliparous, term, singleton vertex (NTSV) cesareans by engaging multidisciplinary teams from participating hospitals across the United States (U.S.) in a quality collaborative. The multidisciplinary teams participate in quality focused monthly educational webinars augmented by coaching sessions, that include faculty and peer coaches. Each hospital team initiates quality improvement efforts using one of three change bundles; labor progress, comfort and coping or intermittent auscultation which align with the National AIM Reducing Cesareans bundle.

METHODS:

Teams collect patient level data, and submit aggregated data on key variables to a central registry which produces individual hospital outcomes and process measures and benchmarks for the collaborative.

RESULTS:

Midwives, obstetricians, nurses and administrators from 25 hospitals around the US have engaged in the project. The hospitals represent public, community and academic medical centers in both urban and rural settings. The majority of the hospitals receive over 40% of their payments from public insurance, with at least one participant having 95% of its payments from public insurance. The decrease from baseline for participating hospitals overall was 7% with a range of 0 to 18% NTSV cesarean rate with no change in the balancing measures.

CONCLUSION:

A learning collaborative with data registry support for key outcomes and process measures is an effective way to promote reduction of NTSV cesareans and engage all maternity care team members in quality improvement.
Prior Cesarean Section Surgical Characteristics and Subsequent Uterine Rupture [30P]
Authors: Wilkie Gianna , Shipp Thomas , Little Sarah E. , Carusi Daniela A.
Published: April 2020

INTRODUCTION:

To determine if prior Cesarean surgical characteristics that may compromise healing are associated with an increased risk of subsequent uterine rupture.

METHODS:

Retrospective case-control study matching women with uterine rupture to randomly selected controls (1:3) based on number of prior Cesarean deliveries (CD) and labor at the time of current CD. A multivariable logistic regression was performed focusing on hemorrhage and surgical procedures at prior CD, including all factors that differentiated the groups plus maternal age.

RESULTS:

60 women with uterine rupture were matched to 180 controls. Case patients were more often white (P=.005) and had a higher rate of prior pelvic surgeries (P=.002). With regards to the prior CD, case patients had increased rates of classical incisions (P=.0006), labor (P=.001), and endometritis (P=.01). Case subjects had higher rates of prior postpartum hemorrhage (PPH) (9% vs. 3%, P=.04), and more prior hysterotomy extension (23% vs 6%, P=.0009), but did not differ in the rates of prior compression suture, arterial ligation, or uterine artery embolization (5% composite rate for each group). In multivariable regression analysis, prior uterine extension remained significantly associated with rupture (aOR 2.05, 95% CI 1.48–5.69), while PPH (aOR 1.31, 95% CI 0.15–4.20) was not.

CONCLUSION:

A prior history of hysterotomy extension is associated with an increased risk of subsequent uterine rupture. This may reflect vascular disruption or diminished integrity of the lower uterine segment. Prior surgical details should be reviewed in counseling patients in future pregnancies.
Predicting Post-Cesarean Surgical Site Infections: A Secondary Analysis of the Consortium on Safe Labor [27P]
Authors: Liao Caiyun , Aziz Michael , Chiu Chi-Yang , Mari Giancarlo , Tate Danielle L.
Published: April 2020

INTRODUCTION:

Surgical site infections (SSI) have been estimated to complicate 2–18% of cesarean deliveries (CD). We sought to establish prediction models for post-CD SSIs, using the Consortium on Safe Labor (CSL), a study involving 12 institutes in all the nine districts in the American College of Obstetricians and Gynecologists (ACOG).

METHODS:

All the CDs in CSL were included. The primary outcomes were endometritis and wound infections. Covariates were selected from clinical and demographic variables that might alter post-CD SSI risks, using backward stepwise selection. Multi-level modeling was used to account for data arising from the same patients. Model discrimination was assessed by area under a receiver-operator characteristic curve (C-statistics), while model calibration was assessed by comparing the predicted vs empirical probabilities. The study was approved by the Institutional Review Board.

RESULTS:

In CSL, 208,695 women delivered 228,438 pregnancies between July 2002 and July 2008. There were 65,979 CDs (28.9%), all of which were included in this study. The overall incidences of post-CD endometritis (n=490) and wound infections (n=547) were 0.74% and 0.83%, respectively. The C-statistics for the endometritis and wound infection models were 0.89 and 0.80, respectively, demonstrating good discrimination capacity. The endometritis model demonstrated good calibration, mainly when the estimated risks were low (<2%). The wound infection model was less accurate.

CONCLUSION:

Methodological challenges remain in predicting relatively rare yet morbid events, such as post-CD SSIs. However, statistical modeling based on national data, such as CSL, and the Birth Registry led by ACOG, may provide opportunities to better predict and prevent post-CD SSIs.
Predicted and Actual VBAC Success Rates in a Diverse Patient Population [26P]
Authors: Faulkner Shakeela , Brown Rochele , Palani Arthi , Walker Catherine , Chinkam Somphit
Published: April 2020

INTRODUCTION:

The Vaginal Birth After Cesarean (VBAC) success prenatal calculator predicts that black and Hispanic women will have lower success rates than white women. However, non-white women are diverse and it is not known if VBAC success varies among these women based on factors not included in the calculator. This study explored the differences between predicted and actual VBAC success rates of a diverse patient population.

METHODS:

We performed an IRB approved retrospective chart review of 143 women who attempted a trial of labor after cesarean delivery and delivered at term at a tertiary academic medical center between 2017 and 2018. We performed analyses using Excel.

RESULTS:

Patients' mean age was 31.9 (SD 5.3) years and mean prenatal BMI 29.7 (SD 6.2). Of the 143 patients, 17.4% had vaginal births before their cesarean and 8.4% had a prior VBAC. Patients were primarily non-Hispanic black (44.4%) and Hispanic white (34.7%); 75.9% were non-US born. non-Hispanic black women (55.4%) were as successful in comparison to the predictive model including race (57.9%, P=.58), but less successful than the model excluding race (71.8%, P=.003). Hispanic white women were as successful (65.2%) in comparison to the predictive model with (59.1%, P=.34) and without race (73.0%, P=.23). Non-Hispanic white women were as successful (87.5%) as the predictive model (73.2%, P=.095). There was no difference between VBAC success of US-born and non-US born (71.4% vs 61.2%, P=.31).

CONCLUSION:

Race significantly impacted the model's predictive accuracy for black patients, but the inclusion of ethnicity was not significant in predicting outcomes of Hispanic patients.
Outpatient Foley Catheter for Pre-induction Cervical Ripening in Low Risk Women: A Systematic Review [25P]
Authors: Christensen Alicia A , Hersh Alyssa R. , Caughey Aaron B. , Hermesch Amy , Sciscione Anthony C.
Published: April 2020

INTRODUCTION:

Multiple studies have been conducted comparing inpatient versus outpatient pre-induction cervical ripening with the Foley catheter in low risk women. We performed a metanalysis and systematic review of all existing data.

METHODS:

This systematic review was completed via PubMed search. Articles published prior to July 31, 2019 were included for review. We included two randomized control trials, one pilot randomized control trial, a clinical cohort study, and a retrospective cohort study in our review which met the following criteria: 1) compared outpatient versus inpatient use of Foley catheter for pre-induction cervical ripening in low-risk women at term (>37 weeks), Bishop score <5, cephalic presentation with an unfavorable cervix 2) detailed maternal and neonatal outcomes 3) full article text was available 4) article published in English. Five maternal and two neonatal primary outcomes were captured for analysis. Meta-analysis was completed via Stata v15.1 software.

RESULTS:

Five studies were included with 1,346 subjects. The final Bishop score, oxytocin infusion time, and induction-to-delivery time were greater in the outpatient group (Table 1, P<.05). However, there was no difference in cesarean delivery, vaginal delivery, initial Bishop score, NICU admission, and Apgar score <7 at 5 minutes between the outpatient and inpatient groups.

CONCLUSION:

In this large cohort, outcomes between low risk women who received the Foley catheter for pre-induction cervical ripening in the outpatient and inpatient setting were similar.
Outpatient Foley Catheter for Cervical Ripening in Low-Risk Women: A Cost-Effectiveness Analysis [24P]
Authors: Christensen Alicia A. , Hersh Alyssa R. , Hermesch Amy , Sciscione Anthony C. , Caughey Aaron B.
Published: April 2020

INTRODUCTION:

Based on research literature there appears to be a significant benefit to induction of labor (IOL) in nulliparous patients. A recent meta-analysis of the Foley catheter for pre-induction of labor cervical ripening in the outpatient setting concluded that the risk of adverse events is low (0.0–0.26%). We sought to investigate the cost effectiveness of Foley catheter use for pre-induction cervical ripening in an outpatient versus inpatient setting in low-risk women.

METHODS:

We created a decision-analytic model using TreeAge Pro software assessing the cost-effectiveness and outcomes associated with pre-induction cervical ripening using Foley catheter in an outpatient versus inpatient setting. We estimated a theoretical cohort of 760,000 low-risk nulliparous women with an unfavorable cervix at term. Outcomes included cesarean delivery, postpartum hemorrhage, maternal death, infant death and stillbirth, in addition to cost and quality-adjusted life years (QALYs) for both the woman and the neonate. A willingness-to-pay threshold was set at $100,000/QALY.

RESULTS:

In a theoretical cohort of 760,000 women undergoing pre-induction cervical ripening by Foley catheter, we found that outpatient Foley was the dominant strategy, meaning it was lower in cost and higher in effectiveness. There were fewer cesareans in the outpatient group primarily due to a lower rate of failed induction. However, there were 16 stillbirths in the outpatient cohort. Our results were robust over a wide range of assumptions.

CONCLUSION:

We found outpatient Foley catheter to be a cost-effective option for pre-induction cervical ripening in low-risk women at term and should be considered for such women undergoing scheduled induction of labor.
Inter-delivery Time Interval and the Likelihood of Successful Vaginal Birth After Cesarean Delivery [21P]
Authors: Gulersen Moti , Grunebaum Amos , Bornstein Eran , Chervenak Frank
Published: April 2020

INTRODUCTION:

The most commonly utilized prediction models to assist in the prediction of vaginal birth after cesarean delivery (VBAC) have not included inter-delivery time interval as a contributing variable. Therefore, we sought to determine the association of inter-delivery time interval and rate of successful VBAC.

METHODS:

This retrospective cohort study utilized the United States Natality Live Births database from the Center for Disease Control and Prevention for the years 2016–2017. Singleton patients at term with their second pregnancy and live birth undergoing a trial of labor after one prior cesarean delivery (TOLAC) were eligible for inclusion. The inter-delivery time interval, defined as the time elapsed between live births, was divided into 7 groups by months: 12–17, 18–23, 24–35, 36–47, 48–59, 60–71, 72 and beyond. Pearson's Chi-Squared test was used to compare rates of successful VBAC across the different inter-delivery time interval groups. Statistical significance was determined as P<.05.

RESULTS:

Of the 60,526 women who underwent TOLAC, 39,948 (66%) had a VBAC. The highest rate of VBAC success was seen with an inter-delivery time interval of 24 to 35 months (12,368/17,760; 69.6%). The differences in rates of VBAC between the different time intervals were statistically significant (P<.0001).

CONCLUSION:

Overall, the rate of successful VBAC in the United States among cases from 2016–2017 was 66%. Our data indicate that the rate of successful VBAC is affected by the inter-delivery time interval, with the optimal time for VBAC being 24–35 months after cesarean delivery. The clinical implication of this statistical finding requires further study.
Induction of Labor at 39 Weeks and the Risk of Perinatal Death [19P]
Authors: Diaz Maria , Rossi Jordan , Burn Sabrina , Contag Stephen , Yao Ruofan
Published: April 2020

INTRODUCTION:

To investigate the risk of perinatal death associated with induction of labor (IOL) at 39 weeks versus expectant management (EM).

METHODS:

This was a retrospective cohort analysis of singleton non-anomalous liveborn pregnancies in the United States between January 2015 and December 2017. Data was abstracted from the CDC National Center for Health Statistics from the Division of Vital Statistics. Analyses compared IOL at 39 weeks of gestation to EM with delivery between 40 and 42 weeks of gestation. Year over year rates of IOL and perinatal death were calculated and tested for trend over time. The risk of perinatal death associated with IOL compared to EM was estimated using logistic-binomial regression analysis, adjusting for potential confounders.

RESULTS:

There were 1,987,757 pregnancies included for analysis. 499,290 (25.1%) pregnancies were induced at 39 weeks. The year over year risk of IOL was 1.04 (95% CI 1.03–1.04). Conversely, the year over year risk of perinatal death was 0.96 (95% CI 0.94–0.99). There was a year over year decrease in risk of neonatal death, aRR: 0.91 (95% CI 0.85–0.96). In the IOL group there were 184 (0.04%) perinatal deaths compared to 2,421 (0.16%) in the EM group, (P<.001; aRR: 0.22, 95% CI 0.19–0.26).

CONCLUSION:

There was a year over year increase in IOL. Additionally, there was a year over year decrease in perinatal death, primarily due to a decrease in neonatal deaths. IOL at 39 weeks was associated with a decreased risk of perinatal death compared EM.
Efficacy of an Alternative Oxytocin Dosing Regimen for Postpartum Hemorrhage Prevention at Cesarean Delivery [13P]
Authors: Chouinard Sujata , Bronner Baillie , Mulekar Madhuri , Andrews Nicholas L. , Rivera Gabrielle
Published: April 2020

INTRODUCTION:

In 2013, the University of New Mexico Hospital transitioned from a 20IU oxytocin infusion to a “rule of threes” algorithm (3 IU of oxytocin titrated to uterine tone) for prevention of postpartum hemorrhage (PPH) at time of cesarean delivery. This study seeks to identify whether PPH rates have been affected by this change in oxytocin dosing.

METHODS:

This is a retrospective cohort study comparing PPH rates before and after an institutional shift in oxytocin administration at the time of cesarean delivery. IRB exemption was obtained for this study. Medical records were reviewed for scheduled and unscheduled cesarean section patients before and after the protocol change. 225 patients in each group were randomly selected for the analysis. Our primary outcome was the rate of PPH, determined by estimated blood loss reported by the surgeon. Secondary outcomes included administration of additional uterotonic agents, transfusion, hysterectomy, vasopressor administration, and mortality.

RESULTS:

There were no significant differences in age, gravidity, parity, prior number of cesarean sections, gestational age, BMI, fetal weight, or induction of labor. Women who received the 20IU oxytocin infusion had a significantly lower rate of PPH (22.2%) compared to “rule of threes” dosing (32.4%, Fishers test P=.0198).

CONCLUSION:

Our data show an increased rate of PPH with a rule of threes oxytocin dosing at the time of cesarean section compared with infusion dosing of oxytocin. These data indicate that rule of threes dosing may not be applicable to a wider patient population.
Correlation of Morbidly Adherent Placentas and Location of Hysterotomy in Cesarean Sections [10P]
Authors: Fox Courtney , Varlamov Anna , Lance Teresa , Feustel Paul
Published: April 2020

INTRODUCTION:

We evaluated the incidence of classical c-sections associated with morbidly adherent placenta (MAP). Better medical counsel can be provided if there was an association of classical c-section and MAP. We compared other clinical risk factors and outcomes; number of previous c-sections, uterine surgery (D and C), medical co-morbidities (smoking, hypertension, diabetes, advanced age) and other findings encountered.

METHODS:

This study was a case control during 1/1/2014 to 9/15/2018 to review patients' history of hysterotomy location during previous uterine surgery. Case definition and control group were women with MAP and women without MAP with a prior c-section in a 1:4 ratio. Fifty cases and 198 controls reviewed.

RESULTS:

The percent of patients who had MAP had a higher incidence of uterine surgery (32%). The odds of classical c-section with MAP compared to low-transverse with MAP was less than 1 (OR 0.8077, 95% CI 0.28–2.31) and was not statistically significant. We found each increase in prior c-sections by 1, odds of MAP increased by a factor of 2.18 (95% CI 1.59–2.99). D and C increased odds of having MAP (OR 4.05, 95% CI 1.88–8.69). Hypertension appeared to be a protective factor for MAP (OR 0.23, 95% CI 0.07–0.76). Other medical co-morbidities had no correlation.

CONCLUSION:

Findings concluded that there is no statistical significance in the location of hysterotomy and MAP. There is a greater incidence of MAP associated with prior uterine surgery. We can counsel our patients to promote vaginal delivery to decrease uterine surgery and the odds of having a morbidly adherent placenta.
Comparison of Delivery Outcomes in Early Versus Late Amniotomy During Induction of Labor [09P]
Authors: Irvey Teinesha M. , Prieto Jose
Published: April 2020

INTRODUCTION:

Despite the growing incidence of induction of labor, controversy continues to exist regarding optimal timing of membrane rupture during the induction process. We aim to determine whether early vs late amniotomy contributes to differences in delivery outcomes.

METHODS:

We performed a retrospective cohort study comparing early vs. late amniotomy delivery outcomes in nulliparous, term, singleton, vertex gestations undergoing induction of labor. We defined early amniotomy as rupture of membranes at less than 5 centimeters dilation, and late amniotomy at 5 or more centimeters cervical dilation.

RESULTS:

We reviewed 2,776 charts, 323 were analyzed. Early amniotomy was performed in 228 (70.6%) of patients vs late amniotomy in 95 (29.4%). We found no statistically significant difference in rate of vaginal, operative or cesarean delivery, nor induction method, maternal age, gestational age, maternal comorbidities or neonatal characteristics between groups. The late group had statistically more Caucasian women (P=.008) while the early group had more Hispanic women (P=.038). Lack of descent as an indication for cesarean delivery was higher in patients with late amniotomy (P=.008). Late amniotomy was strongly associated with shorter amniotomy to delivery time, without increasing hospital stay (P=.0001). 71.3% of all patients in the late group were delivered within 6 hours of rupture compared to 32% in the early group (P=.0001).

CONCLUSION:

In our study population, late amniotomy was associated with a statistically significant increase rate of delivery within 6 hours after amniotomy without an increase in the hospital stay. Contrary to many published reports, early amniotomy did not offer any benefit.
Characterizing Relationships Between Prenatal Care and TOLAC Outcomes in an Urban Population [07P]
Authors: Keerthy Madhurima , Smith Jeffery A.
Published: April 2020

INTRODUCTION:

Several studies have been published on factors predicting success rates of Trial of Labor after Cesarean section (TOLAC). Limited data exists on the relationship between prenatal care provider type and sufficiency of prenatal care. The purpose of this study is to evaluate the relationship between prenatal care provider and TOLAC outcomes.

METHODS:

Retrospective comparative analysis was performed on 289 charts. IRB approval was obtained. Criteria included patients delivered between 2013–16 with Singleton gestation, vertex presentation and at least 1 prior cesarean section attempting TOLAC at our institution. Exclusion criteria included multiple gestations, still birth and contraindications to vaginal delivery. ANOVA tests were used for the continuous variables and Chi-square test or Fisher's exact test were used for categorical variables. P-value <.05 considered for statistical significance.

RESULTS:

A total of 289 charts were reviewed. 176 patients achieved Vaginal Birth After Cesarean section (VBAC). Patients who received prenatal care from Physicians had higher VBAC rates when compared to patients who received care from CNMs at our institution (P<.0002). No statistically significance between TOLAC success and sufficiency of prenatal care was noted. There were no statistical differences between the two groups regarding Age, BMI, Race, Co-morbidities, IUGR, Calculated success scores.

CONCLUSION:

This study sheds light on relationship between providers, type of prenatal care and VBAC rates, a rarely explored area in TOLAC research. The results are from a single institution that functions as a staff model. Larger multi institutional prospective trials are necessary to prove or disprove results.
The Patient's Perspective and Patient Satisfaction in Labor and Delivery [35N]
Authors: Day Marilyn , Varghese Elizabeth , Valdes Hannah , Garry David , Garretto Diana
Published: April 2020

INTRODUCTION:

Clinical and subjective factors affect the patient's perception of labor and delivery, but little is known about how much each factor contributes to patient satisfaction. This study evaluates the correlation between clinical and subjective patient parameters during the intrapartum course and patient satisfaction.

METHODS:

This is a cross-sectional observational study. Participants completed surveys in the immediate postpartum period. Surveys assessed the patient's perception of intrapartum events and patient satisfaction. Survey responses were compared to patient charts. Logistic regressions determined predictors of patient satisfaction.

RESULTS:

332 women completed surveys. Positive subjective factors which predicted patient satisfaction included feeling the provider explained the intrapartum course well (OR 3.47, 95% CI 1.17–10.31, P=.025), patient input into managing labor (OR 2.96, 95% CI 1.46–5.98, P=.002), and increased support during labor (OR 2.45, 95% CI 0.99–6.04, P=.05). Having a birth plan led to less satisfaction (OR 0.49, 95% CI 0.24–0.96, P=.04). Birth classes and feeling pressured by providers in labor were not significant predictors of patient satisfaction. Positive clinical predictors of patient satisfaction included a vaginal delivery (OR 1.97, 95% CI 1.07–3.27, P=.02), but multiparity, advanced maternal age, regional anesthesia, episiotomy, or a postpartum hemorrhage were not significant predictors of satisfaction. Understanding the labor and delivery events predicted high satisfaction (P=.02).

CONCLUSION:

Patient satisfaction is dependent on patient input into labor, adequate explanations of the labor course, increased support in labor, high patient understanding, and achieving a vaginal delivery.
An Enhanced Recovery After Surgery Pathway for Cesarean Delivery May Improve Perioperative Euglycemia [04P]
Authors: Savitsky Leah M. , Hitti Jane , Bollag Laurent A. , Delgado Carlos M. , Mills Elizabeth B. , Fay Emily E.
Published: April 2020

INTRODUCTION:

Enhanced recovery after surgery (ERAS) pathways are standardized, evidence-based approaches to the care of surgical patients. One component of ERAS pathways is maintaining euglycemia pre- and post-operatively.

METHODS:

We conducted an IRB approved retrospective cohort study evaluating capillary blood glucose (CBG) values among women on the ERAS cesarean delivery pathway (ERAS CD) during the first year of implementation (4/1/2017–3/31/2018, n=531), compared to historical controls (3/1/2016–2/28/2017, n=661) in the year prior. Pregestational diabetics on insulin prior to pregnancy were excluded. ERAS CD pathway patients received preoperative carbohydrate loading as well as a pre-op, 1-hour post-op, and post-op day 1 and 2 CBG. We compared average CBG and percentage of time in-range, defined as any CBG between 70–140 mg/dL for both pre- and post-operative periods between the baseline and implementation groups using chi-square tests and Student t-tests.

RESULTS:

The women on the ERAS CD pathway had a significantly higher percentage of in-range CBGs both in the pre- and post-operative time period (pre-op: 84.9% vs. 95.4%, P<.001; post-op: 77.2% vs. 94.3%, P<.001) compared to historical controls. The average pre- and post-operative CBGs were also significantly lower among women on the ERAS CD pathway (pre-op: 93.3±19.3 mg/dL vs. 87.5±15.7, P=.0033; post-op: 109.5±29.2 mg/dL vs. 90.9±17.8 mg/dL, P<.001).

CONCLUSION:

Women on the ERAS CD pathway had significantly improved CBGs both pre- and post-operatively, as demonstrated by higher percentage of in-range CBGs and lower average CBGs during both time periods. This suggests that ERAS CD pathways may improve perioperative euglycemia, but further studies are needed to evaluate this.
A Randomized Controlled Trial: Do Family-Centered Cesarean Deliveries Improve Patient Satisfaction? [01P]
Authors: Montgomery Michelle O. , Kram Jessica J. , Forgie Marie M. , Perez Moreno Ana C. , Romdenne Taylor
Published: April 2020

INTRODUCTION:

In comparison to women who deliver vaginally, women who deliver via cesarean section report they are less satisfied with their birthing experience, have later skin-to-skin contact, and delayed mother-newborn interactions. Our study aimed to determine if maternal experiences, as well as maternal and neonatal outcomes, differ between family-centered and traditional cesarean delivery methods.

METHODS:

Pregnant women with singleton pregnancy ≥ 38 weeks' gestation who underwent planned cesarean delivery at one of two delivery units were enrolled June 2016–July 2018. Women were randomized to either family-centered (Method 1; can view birth, baby placed on chest) or traditional cesarean (Method 2; unable to view birth, baby taken to warmer). Satisfaction was recorded using modified Likert scale, ranging from 1 (lowest) to 5 (highest). Baseline characteristics, as well as maternal and neonatal outcomes, were compared using ANOVA and Pearson's chi-squared. This study was approved by local Institutional Review Board.

RESULTS:

Women in Method 1 (n=68) and Method 2 (n=61) did not significantly differ by baseline characteristics, nor maternal and neonatal outcomes. Patients in Method 1 established skin-to-skin contact on average 11 minutes earlier than those in Method 2 (P<.001). Additionally, patients in Method 1 were more satisfied, although not statistically significant (4.6 vs. 4.4 Method 2; P=.27).

CONCLUSION:

Our study found no statistical differences in maternal satisfaction or maternal/newborn outcomes, between methods. Even so, the family-centered cesarean was significantly associated with earlier skin-to-skin initiation, which has proven benefits. Given our findings, women should be allowed to choose either method of cesarean delivery based on personal preference.
The Job of the Obstetrician Does Not End by the Delivery of the Fetus With Non-reassuring Status [38O]
Authors: Ogunyemi Dotun , Farr Carly , Wharton Kurt , Karabon Patrick , Bahado-Singh Ray , Alhousseini Ali
Published: April 2020

INTRODUCTION:

Research generally focuses on neonatal outcomes when pregnancy is complicated by non-reassuring fetal status. Little attention has been directed to maternal outcomes after such deliveries.

METHODS:

A retrospective cohort study of 27,886 pregnancies at a single health system evaluated fetal status and postpartum maternal characteristics. Fetal heart tracing, arterial cord pH, maternal blood transfusion, and maternal ICU admission were among the evaluated characteristics. Multivariate logistic regression analyses were performed to assess correlation with markers of fetal well-being and maternal outcomes and adjusted odds ratios (AOR) were derived.

RESULTS:

Umbilical artery pH less than 7.0 was associated with transfusion (AOR 6.83 [95% CI 2.22–21.0, P<.001]), cesarean delivery (AOR 5.76 [95% CI 3.63–9.15, P<.0001]), and maternal readmission (AOR 12.6 [95% CI 2.26–69.8, P=.0039]). Fetal bradycardia events were associated with increased maternal ICU admission (AOR 3.22 [95% CI 1.23–8.46, P<.017]), transfusion (AOR 2.13 [95% CI 1.26–3.59, P<.005]) and readmission (AOR 4.17 [95% CI 1.16–15.0, P<.029]). Late decelerations were associated with cesarean delivery (AOR 1.65 [95% CI 1.55–1.76, P<.0001]), maternal readmission (AOR 1.24 [95% CI 1.01–1.53, P=.04]), chorioamnionitis (AOR 2.88 [95% CI 2.46–3.37, P<.0001]), and maternal need for antibiotics (AOR 1.89 [95% CI 1.66–2.15, P<.0001]).

CONCLUSION:

Non-reassuring fetal status is associated with significant risks to the mother as evidenced by significant increases in transfusions, ICU admissions, and readmissions. Obstetricians should remain vigilant after delivery for non-reassuring fetal status and focus on monitoring and optimization of maternal status.
Gabapentin's Effects on Hyperemesis Gravidarum: A Randomized Controlled Trial [17N]
Authors: Guttuso Thomas , Messing Susan , Mullin Patrick , Strittmatter Chad , Saha Sumona , Thornburg Loralei Lacina
Published: April 2020

INTRODUCTION:

Hyperemesis gravidarum (HG) is a disabling disease of early pregnancy for which there are no effective outpatient therapies. Because of the severe and persistent physical and psychological distress caused by HG, about 15% of HG pregnancies are terminated in the first trimester.

METHODS:

A randomized, double-blind, multi-center trial was conducted among patients with medically-refractory HG. Subjects were randomized (1:1) to either oral gabapentin (1,800–2,400 mg a day) or an active comparator arm of either oral ondansetron (24–32 mg a day) or oral metoclopramide (45–60 mg a day) for 7 days. Change in Motherisk-PUQE scores from baseline to Days 5–7 served as the primary endpoint.

RESULTS:

Thirty-one patients were enrolled from 10/2014–5/2019. Among the 21 subjects providing any primary outcome data (12 assigned to gabapentin, 9 to the active comparator arm), 18 were enrolled as outpatients and all 21 were outpatients on Days 5–7. Intention-to-treat analysis showed the gabapentin treatment arm to have greater reductions in Motherisk-PUQE scores (P=.005) and increases in oral nutrition (P=.007) from baseline as well as higher global satisfaction (P=.02), relief (P<.05) and desire to continue therapy (P=.04) compared to the active comparator arm. Adverse events and number of subject withdrawals were equivalent between the groups.

CONCLUSION:

Despite the small sample size of this trial and high rate of subject attrition, gabapentin therapy was more effective than standard-of-care therapy for HG symptoms in the outpatient setting. Considering the favorable safety profile of gabapentin use during early pregnancy, gabapentin therapy may be able to provide HG patients and their infants with improved long-term prognoses.
Mother-Baby Errors: A Potential Unintended Consequence of Distinct Newborn Naming Conventions [24O]
Authors: Goffman Dena , Kern-Goldberger Adina , Fernandes Yelstin , Salmasian Hojjat , Applebaum Jo R. , Adelman Jason S.
Published: April 2020

INTRODUCTION:

To prevent wrong-patient errors, The Joint Commission issued a requirement in 2019 that hospitals use distinct methods of newborn identification, such as incorporating the mother's first name into the newborn' name (eg, Jackson, Wendysgirl). However, since the requirement went into effect, there have been reports of wrong-patient errors between mother-baby dyads as an unintended consequence of having similar names.

METHODS:

The purpose of this study was to quantify the rate of mother-baby errors, using a validated measure of near-miss, wrong-patient orders. The Wrong-Patient Retract-and-Reorder measure identifies orders placed for a patient that are canceled and reordered by the same clinician for a different patient shortly thereafter. We examined all orders placed for women and newborns who were inpatients at the same time after delivery from 1/1/2015–12/31/2018 at a large academic medical center that used the required newborn naming convention over the entire study period.

RESULTS:

The analysis included a total of 5,953,738 orders placed for 59,737 mother-baby dyads. Overall, there were 311 wrong-patient orders (mean 77.8 per year), for a rate of 5.2 per 100,000 orders. Order errors occurred in 84 mother-baby dyads; in 77 dyads, orders placed for the mother were intended for the newborn, most commonly vaccines and newborn screens. Orders placed for the newborn intended for the mother included antihypertensives, anticoagulants, and opioids.

CONCLUSION:

These results provide further evidence of mother-baby errors related to newborn naming conventions. Although these were near-miss errors, the outcome of such errors reaching the patient could be catastrophic in this setting.
Maternal Sleep Quality in Month Prior to Delivery as It Relates to Breastfeeding [23O]
Authors: Herrine Gail , Fuhrman Sara , Washio Yukiko
Published: April 2020

INTRODUCTION:

The World Health Organization and the American College of Obstetrics and Gynecology encourage exclusive breastfeeding as the best nutritional intake for newborns for the first six months of life. Little evidence exists on how maternal sleep quality may relate to breastfeeding, particularly in underserved populations. Our study investigates correlations between maternal sleep quality, breastfeeding intention, and breastfeeding experience during hospital stay after delivery.

METHODS:

After obtaining institutional review board approval, we interviewed 122 mothers who recently delivered in an urban hospital setting regarding breastfeeding history, breastfeeding intention, and maternal sleep quality in the last month of pregnancy (assessed via Pittsburgh Sleep Quality Index [PSQI] questionnaire). Interviews were completed via surveys on the postpartum floors of maternity units in the mid-Atlantic region.

RESULTS:

Mothers were on average 26.0 years old, had 12.3 years of schooling, 42.1% identified as Hispanic, 30.3% identified as black/African American, and 78.5% were receiving Medicaid. We found that previous breastfeeding experience and intention to breastfeed positively correlated with PSQI scores during the last month of pregnancy (P=.095 P=.067, respectively). Specifically, Component 5 measuring sleep disturbances correlated with both previous breastfeeding experience and the intention to breastfeed (P=.027 P=.038, respectively).

CONCLUSION:

Our work indicates an association between breastfeeding and poor sleep quality during the last month of pregnancy, suggesting sleep disturbance is not a barrier for new mothers to breastfeeding. Further research will be needed to clarify and expand on the relationship between breastfeeding and sleep, particularly with regard to sleep environment and sleep hygiene.
Patients With Low Socioeconomic Status More Likely to Present for Non-Elective Ovarian Cancer Surgery [34H]
Authors: Rudasill Sarah E. , Budker Rachel , Mardock Alexandra L. , Bellamkonda Nikhil , Cohen Joshua G.
Published: April 2020

INTRODUCTION:

Non-elective surgery, performed less than 24 hours after presentation, is not well described in patients with gynecologic malignancy. Using the National Readmissions Database (NRD), we characterized non-elective hospital admissions for patients undergoing ovarian cancer surgery.

METHODS:

We evaluated the NRD for patients undergoing ovarian cancer surgery between 2010 and September 2015. Primary outcome was characterizing demographics and comorbidities of patients presenting non-electively. Secondary outcomes were mortality, length of stay (LOS), and adjusted costs at index hospitalization, as well as 30-day readmission rates. Multivariable analysis identified predictors and outcomes of non-elective presentation.

RESULTS:

Of 45,572 patients undergoing ovarian cancer surgery, 9,136 (20.1%) were classified as non-elective. Non-elective patients had a higher average Elixhauser comorbidity index (3.6 vs. 3.2, P<.001), greater Medicaid coverage (14.0 vs. 6.5%, P<.001), and reduced private insurance coverage (37.5 vs. 47.3%, P<.001) relative to elective patients. Multivariable analysis revealed that patients presenting non-electively had higher mortality (OR 3.00 [95% Confidence Interval (CI) 2.37-3.81]) and 30-day readmission rates (OR 1.30 [1.20-1.41]) than elective patients. After adjustment, non-elective patients spent 3.3 more days in the hospital [95% CI 3.1-3.6]) with $6,396 more in adjusted costs [95% CI $5,667-7,125]. Significant predictors of non-elective admission included lowest income quartile relative to highest (OR 1.43 [1.28-1.61]) and age less than 50 relative to age 50-69 (OR 1.52 [1.41-1.64]).

CONCLUSION:

The rate of non-elective ovarian cancer surgery remains high, with increased patient mortality and resource utilization. An independent association between lower income and higher rates of non-elective surgery was observed, highlighting the need to address low socioeconomic populations to prevent emergent hospitalization.
Preoperative and Perioperative Analgesia/Anesthesia in Ovarian Cancer Patients: Correlation With Recurrence [36H]
Authors: Podwika Sarah , Bosch Allison , Gammon Elizabeth , Modesitt Susan
Published: April 2020

INTRODUCTION:

Prior breast cancer studies demonstrated an association between beta blockers and nonsteroidal medication in disease-free survival, possibly due to immune interactions. This hypothesis-generating retrospective study evaluated the association between ovarian cancer recurrence and baseline medication use (aspirin, acetaminophen, nonsteroidals, beta blockers, or antidepressants) and the perioperative medication (Tylenol, NSAIDs and regional analgesia) administration.

METHODS:

After IRB approval, a retrospective chart review of an academic medical center’s pathology database and ovarian cancer registry was performed to evaluate medication administration and recurrence.

RESULTS:

284 women with ovarian cancer were included (mean age 62 years). At point of last contact, 34.2% were alive without recurrence, 15.7% were alive with disease, 43.1% had died of disease, and 7% unknown. 61.2% had cancer recurrence. Mean time from surgery to recurrence was 23.7 months (4.4-132.5 +/- 20). There was no statistically significant difference in baseline use of beta blockers (P=.076), aspirin (P=.29), acetaminophen (P=.67), NSAIDs (P=.78) or anti-depressants (P=.96). There was no statistically significant difference between perioperative medication use and recurrence, regional anesthesia (P=.12), beta-blocker (P=.93), acetaminophen (P=.68), and nonsteroidals (P=.12). Women who recurred were older (59.5 vs 63.7 years, P<.01) and had higher CA-125 (93.6% vs 6.4%, P<.01) at diagnosis. Of the medications evaluated, antidepressants showed the only statistically significant difference in progression free survival (PFS), (70 vs 77 months, P=.008).

CONCLUSION:

Outside of the association of antidepressant use with worse PFS, there was no statistically significant difference in disease recurrence based on baseline or perioperative analgesic medication use.
Prevalence on Synchronic Ovarian and Endometrial Cancer in the San Borja Arriaran Hospital From 2016 to 2019 [38H]
Authors: Cervantes Pedro , Altamirano-Assad Roberto , Nazzal Omar
Published: April 2020

INTRODUCTION:

Synchronous endometrial and ovarian cancer are relatively rare in the general population. It ranges from 3.1% –10.0% of patients with endometrial cancer and 10% of patients with ovarian cancer.

METHODS:

Retrospective review with statistical database analysis using: clinical records, protocols, biopsies and gynecologic-oncological committee records of patients diagnosed with ovarian and endometrial cancer between December 2014 and June 2019. Only patients with synchronous endometrial cancer were included and ovary regardless of histological type.

RESULTS:

A total of 317 patients were selected, 177 with endometrial cancer and 140 with ovarian cancer. 12 patients diagnosed with synchronous endometrial and ovarian cancer, with a median age of 58.1 years. Endometrial carcinomas were found in FIGO stage IA 75%, IB 8.3%, IIIA 16.6%. Histological type 83.3% endometrioid and 16.6% mixed. As for ovarian carcinomas, 83.3% were of epithelial and 16.6% were granulosa cells tumors. Stage FIGO IA 50%, IC 8.3%, IIA 41.6%. A prevalence of synchronous tumors was found in 6.7% of endometrial cancer 8.5% of ovarian cancer.

CONCLUSION:

Synchronous endometrial and ovarian cancers included in this study were presented in early stages, well differentiated and their prevalence was similar to international literature. Although they are rare, it is necessary to consider their existence.
The Impact of Patient Frailty on Readmission Morbidity and Mortality in Women Undergoing Ovarian Cancer Surgery [39H]
Authors: Sia Tiffany , Wen Timothy , Cham Stephanie , Friedman Alexander , Wright Jason
Published: April 2020

INTRODUCTION:

Frailty, defined as loss of reserve and vulnerability to changes in health, affects many elderly patients. We investigated the effect of frailty on readmission and mortality rates in patients undergoing laparotomy for ovarian cancer.

METHODS:

Patients underwent laparotomy between 2010-2014 were identified using the Nationwide Readmissions Database. Frailty was identified using the Johns Hopkins Adjusted Clinical Groups Frailty Indicator, which requires 1 of 10 frailty defining diagnoses. Univariable and multivariable log linear regression analyses were conducted to analyze the association between frailty and 30-day and 90-day all cause readmission and mortality. Models were adjusted by patient, hospital, and clinical factors.

RESULTS:

We identified 78,821 cases. Frailty affected 5.8% of patients. 30-day and 90-day readmission rates were 14.6% and 24.2%, respectively, with readmission mortality rates of 3.4% and 3.3% for 30- and 90-day readmissions. Frailty was independently associated with an 11% increased risk for both 30-day and 90-day readmission. Frailty was also associated with a 34% increased risk of mortality when readmitted at 90-days (RR 1.34, 95% CI 1.04-1.72, P=.02). Having two or more comorbid conditions, discharge to nursing facility, intermediate care facility or home health care, leaving against medical advice, receiving a postoperative blood transfusion, and having a medical or surgical complication increased the risk of 30- and 90-day readmissions and mortality at the time of readmission.

CONCLUSION:

Frailty is associated with an increased risk of readmission and a higher rate of mortality and should be considered when planning for ovarian cancer surgery.
Upstream Gynecology: Identifying Social Determinants of Health in a Gynecologic Oncology Population [40H]
Authors: Nora Anne , Haugsdal Michael L.
Published: April 2020

INTRODUCTION:

Social determinants of health (SDoH) are factors that affect a patient’s health quality and outcomes. Evidence suggests that clinical care contributes only 20% to patient outcomes, while the remainder is under the influence of upstream factors. The upstream approach to healthcare aims to address SDoH before they contribute to less ideal outcomes downstream. Several social determinants of health may contribute to outcomes for cancer patients. This Upstream Gynecologic Oncology Initiative seeks to identify which SDoH affect patients with gynecologic malignancies.

METHODS:

This needs assessment is the first step in a quality improvement project assessing the SDoH affecting women with gynecologic cancers. Female patients receiving care for gynecologic malignancies were invited to complete an anonymous needs assessment survey. Validated survey questions regarding housing, food, transportation, finances, health literacy and social support were used to identify needs. Data collected is being used to further develop a routine screening tool and to organize resources specific to the identified needs.

RESULTS:

Results demonstrate the relative prevalence of existing SDoH needs upstream of clinical care within this unique gynecologic oncology patient population. Results from the study population are also compared to prevalence among the general population of this institution's state.

CONCLUSION:

Upstream SDoH are identified to be present and likely contributing to health quality and outcomes within this gynecologic oncology patient population. Appreciation and assessment of their potential to impact care and management can be used to design a routine screening tool for the study population and organize resources to address or mitigate the identified needs.
“Is the Pre-cum Myth True?” An Analysis of Queries on Using Withdrawal for Contraception on Reddit [02I]
Authors: Latack Kyle , Patel Jasmine , Moog Dominic , Spencer Donovan , Nguyen Brian T.
Published: April 2020

INTRODUCTION:

Limited research and the lack of guidelines on “withdrawal” or coitus interruptus lead to inconsistent provider-patient recommendations regarding its use. Patients consequently rely on peers or online communities to learn about this neglected contraceptive method. To better understand knowledge gaps and concerns, we examined posts about withdrawal on the popular, anonymous internet discussion forum, Reddit.

METHODS:

Posts containing the search terms: “coitus interruptus,” “withdrawal,” “pull out,” “pre-ejaculate,” or “pre-cum” were extracted and filtered for relevant content. Data extraction was limited to gendered forums/subreddits from 2010-2019: “TwoXChromosomes,” “Askwomen,” “Askmen,” “OneY.” We developed an initial codebook with expected themes, augmented with salient themes emerging from a random sampling of 10% of posts, and revised iteratively until adequate inter-rater agreement was reached; remaining posts were coded independently.

RESULTS:

Of 271 withdrawal-related queries, 19% were submitted by men; 81% referenced the contributor’s own use of withdrawal. Salient themes included: concerns about pregnancy risk (52%), using withdrawal with additional contraception (49%), impact on personal life/relationship (27%), benefits/pleasure from using withdrawal (12%), when or how to effectively use withdrawal (7%), and problems encountered (3%). Posts to female-focused forums more frequently inquired about pregnancy risk, while those on men’s forums inquired about when/how to use withdrawal (P<.01); themes were not associated with contributor gender.

CONCLUSION:

Withdrawal-related queries on Reddit are more frequently posted by women, the majority of whom want to better understand their risk of pregnancy with withdrawal. Research on operationalizing withdrawal and withdrawal-related pregnancy risk may help providers counsel patients and decrease their reliance on online forums.