bluuebunny/crossref_metadata_2025_split huggingface dataset:
Preventing the Primary Cesarean Delivery—Adherence to Labor Arrest Guidelines [28P]
Authors: Cate Jennifer , Haynes Meagan Campol , Arkfeld Christopher , Lee Illuzzi Jessica , Campbell Katherine Harper , Raab Cheryl 
Published: April 2020

INTRODUCTION:
The ACOG/SMFM Safe Prevention of Primary Cesarean Delivery guidelines suggest minimum criteria at which cesarean should be performed for labor arrest with the goal of reducing primary cesarean delivery rates. This study evaluates current adherence to these criteria at an academic medical center with two different campuses in order to quantify variation in the modifiable proportion of the cesarean rate and to target quality improvement initiatives.

METHODS:
We analyzed cesareans deliveries performed for arrest of dilation, arrest of descent and failed induction among singleton, term, cephalic live births at a large academic center with two campuses from September 2018 to August 2019. Using the ACOG/SMFM guidelines, the labor course for each cesarean was examined to determine if minimum criteria were met.

RESULTS:
During the study period, there were 1716 cesarean deliveries with 286 performed for labor arrest disorders: 94 for arrest of dilation, 120 for arrest of descent, and 72 for failed induction of labor. At campus A, 27% met criteria for arrest of dilation, 46% for arrest of descent, and 45% for failed induction; at campus B, 95% met criteria for arrest of dilation, 61% for arrest of descent, and 60% for failed induction. Over the study period, the primary cesarean rates at campus A and B were 19.4% and 13.4%, respectively.

CONCLUSION:
The adherence to criteria for arrest disorders was suboptimal and varied significantly across campuses. Quality improvement initiatives targeted to improve adherence to criteria for labor arrest disorders have the potential to impact primary cesarean delivery rates.
Maternal Outcomes of Trial of Labor After Cesarean Delivery Compared With Elective Repeat Cesarean Delivery [23P]
Authors: Gold Stacey L. , Downs Sarah , Kawakita Tetsuya , Ghofranian Atoosa 
Published: April 2020

INTRODUCTION:
The vaginal birth after cesarean (VBAC) calculator developed by the MFMU Network helps to identify the likelihood of VBAC. It is not clear if undergoing a trial of labor after cesarean section (TOLAC) is associated with adverse maternal outcomes if the VBAC success rate is low. We compared maternal outcomes of TOLAC to those of elective repeat cesarean delivery after stratifying by the VBAC likelihood.

METHODS:
This was a retrospective cohort study of all women whose primary cesarean delivery and subsequent singleton delivery occurred at our academic center. Data from the second pregnancy were analyzed. The likelihood of VBAC success was categorized using the MFMU VBAC calculator, (less than 60% and 60–100%). The primary outcome was a composite of maternal complications (uterine rupture, postpartum hemorrhage). Multivariable logistic regression was used to calculate adjusted odds ratio (OR) and 95% confidence interval (CI).

RESULTS:
Of 626 women, 469 (75%) and 157 (25%) had VBAC likelihood of 60–100% and less than 60%, respectively. Women with VBAC likelihood less than 60% and likelihood of 60–100% who had underwent TOLAC were compared with those who had an elective repeat cesarean. Both groups had similar rates of the primary outcomes; likelihood less than 60% (25% vs. 16.5%; adjusted OR 1.51 [95% CI 0.60–3.78]) and likelihood 60–100% (14.3% vs 13.8%; adjusted OR 1.04 [95% CI 0.60–1.79]).

CONCLUSION:
Women with a history of a primary cesarean delivery, who underwent TOLAC compared to those who had an elective repeat cesarean had similar odds of maternal adverse outcomes regardless of the VBAC likelihood.
Labor Induction at 39 Weeks Versus Expectant Management in Women With Prior Cesarean Delivery [22P]
Authors: Shepherd Megan C. , Lee Alan , Olson Gayle , Saad Antonio , Saade George R. 
Published: April 2020

INTRODUCTION:
To compare maternal and neonatal outcomes between elective induction (EIOL) and expectant management (EM) in low risk women with a prior cesarean delivery.

METHODS:
Records of women with a prior cesarean and whose plan of delivery was a trial of labor (TOLAC) were reviewed. Patients who reached 39 weeks and were low risk were included and divided into 2 groups. Those who were induced electively between 39 weeks 0 days and 39 weeks 6 days (EIOL) versus those who were not (EM). Low risk was defined as absence of a maternal or fetal indication for delivery prior to 41 weeks 6 days. The primary outcome was a composite of adverse neonatal outcomes. Secondary outcomes included repeat cesarean delivery (CD) and maternal morbidities.

RESULTS:
From July 2014–July 2019, 552 low risk women underwent TOLAC: 317 women in the EM and 235 in the EIOL group. The primary outcome occurred in 5.38% in the EM group and 3.40% in the EIOL group (OR 0.62, 95% CI 0.23–1.55). The frequency of CD was 31.86% in the EM group and 26.38% in the EIOL group (OR 0.766, 95% CI 0.52–1.13).

CONCLUSION:
Elective induction of labor at 39 weeks among low risk women with a history of prior cesarean section was not associated with an increase in perinatal morbidity, and was associated with lower rates of hysterotomy-associated complications and medically-indicated delivery. It is reasonable to offer elective induction of labor at 39 weeks to women who are candidate for TOLAC.
Induction of Labor at 39 Weeks Versus Expectant Management With One Previous Cesarean Delivery [20P]
Authors: Yao Ruofan , Cryer Alicia , Davis-Nelson Shareece 
Published: April 2020

INTRODUCTION:
This study aims to determine the risks and benefits of induction of labor (IOL) at 39 weeks compared with expectant management (EM) until 42 weeks in pregnancies complicated by one previous cesarean delivery.

METHODS:
Retrospective cohort analysis of singleton non-anomalous pregnancies in the US between January 2015 and December 2017. Analyses included only pregnancies with a history of one previous cesarean delivery. Perinatal outcomes of pregnancies induced at 39 weeks were compared to pregnancies that were induced, augmented or otherwise had vaginal delivery between 40–42 weeks. Unlabored cesarean deliveries were excluded. Outcomes of interest included: cesarean delivery, blood transfusion, chorioamnionitis, adult ICU admission, uterine rupture, hysterectomy, Apgar score <3, prolonged neonatal ventilation, NICU admission, neonatal seizure and neonatal death. Logistic-binomial regression analysis was performed to calculate the relative risk (RR) for the outcomes of interest, adjusting for confounding variables.

RESULTS:
There were 53,924 pregnancies included for analysis with 11,052 women in the IOL group. Compared with EM, IOL at 39 weeks decreased the risk of chorioamnionitis (1.9% vs 3.1%, P<.001; aRR: 0.61 (95% CI 0.53, 0.71). Conversely, IOL increased the risk of cesarean delivery (45.5% vs 27.9%, P<.001; aRR: 1.69, 95% CI 1.64, 1.73). Furthermore, there were 1,102 (2.4%) additional cases of preeclampsia, and 47 (0.1%) additional cases of eclampsia in the EM group. There were no differences in other perinatal outcomes.

CONCLUSION:
In pregnancies complicated by one previous cesarean delivery, induction of labor at 39 weeks reduced the risk of chorioamnionitis while increasing the risk of cesarean delivery.
Induction of Labor and Risk of Third- and Fourth-Degree Perineal Tears [18P]
Authors: Al-Wahaibi Suhaila , Czuzoj-Shulman Nicholas , Abenhaim Haim A. 
Published: April 2020

INTRODUCTION:
The rate of induction of labor (IOL) at term has been increasing over the years. Our objective was to evaluate the risk of third- and fourth-degree perineal tears associated with term induction of labor.

METHODS:
We conducted a population-based, retrospective cohort study using the United States' Nationwide Inpatient Sample to evaluate the risk of third- and fourth-degree perineal tears in women who underwent IOL at term between 2005 and 2014. We included all term livebirths and excluded, preterm births, previous cesarean deliveries, multifetal gestations, and non-cephalic presentation. Women who underwent an IOL at term were identified using ICD-9 coding. Patient characteristics were compared between those women being induced at term with those who weren't, and logistic regression analysis were carried out to estimate the adjusted effect of IOL at term with risk of 3rd and 4th perineal tears

RESULTS:
Among 5,982,945 eligible live births, 1,035,003 (17.3%) underwent an IOL at term, increasing from 15.7% to 18.5%. Women with an IOL were more likely to be older, Caucasian, and with comorbid illnesses. Compared with women who did not undergo an IOL, women in the IOL group had lower risk of cesarean deliveries, 0.89 (0.88–0.89), 2nd degree tears, 0.89 (0.89–0.90), 3rd degree tears, OR 0.81 (95% CI 0.79–0.82) and 4th degree tears, OR 0.84 (95% CI 0.82–0.87).

CONCLUSION:
Induction of labor at term results in significantly lower risk of third- and fourth-degree perineal tears among all deliveries as well as among women with vaginal deliveries.
Implementation of Pre-cesarean Checklist for Labor Arrest and Failed Induction [16P]
Authors: Greenberg Jessica , Pardanani Setul , Bowman Donna 
Published: April 2020

INTRODUCTION:
National and Stamford Hospital cesarean delivery (CD) rates, at 32% and 40.4% respectively, remain high. A large contributor to the primary CD rate is labor arrest, including failed induction of labor (IOL). Use of new guidelines for diagnosing these conditions have been shown to decrease the CD rate. This study aims to assess adherence to new definitions and the impact of a pre-cesarean checklist at our institution.

METHODS:
A retrospective chart review for primary CD in nulliparous, singleton, term, vertex (NSTV) pregnancies performed for labor arrest, including failed IOL, from January 2018 to August 2019. In January 2019 a paper pre-cesarean checklist, adapted from a previously published checklist was introduced to labor and delivery to allow physicians to review labor arrest criteria. Calculated primary CD rates for labor arrest pre and post implementation were compared using chi square analysis.

RESULTS:
The primary cesarean delivery (pCD) rate in NSTV pregnancies for labor arrest was 14.1% in 2018 and 12.5% in 2019 (P=.5). Of the 55 pCD for labor arrest in 2019, 17 (30.9%) filled out the pre-cesarean checklist. Only 18 (32.79%) met criteria for labor arrest/failed IOL.

CONCLUSION:
At our institution, CD in NSTV pregnancies for labor arrest or failed IOL do not meet contemporary definitions. Introduction of a paper pre-cesarean checklist to evaluate labor arrest has not affected the CD rate. However, use of the checklist was limited, thus there remains significant room for a decrease in the cesarean rate if adherence can be improved.
Implementation of an Abdominal Closure Bundle in Patients Undergoing Cesarean Section—A Randomized Control Trial [15P]
Authors: Bruce Shaina , Rajendran Preethi , Mumford Brigid , Heidorn Elise , Smith Stephen 
Published: April 2020

INTRODUCTION:
Surgical site infections (SSI) are associated with increased morbidity, mortality, and healthcare costs. Literature in Colorectal Surgery and Gynecologic Oncology have suggested lower SSI rates among patients who receive closure bundles. This study investigated whether implementation of an abdominal closure bundle reduces SSI rates in patients undergoing cesarean section.

METHODS:
We conducted a prospective randomized controlled trial of patients who underwent a scheduled cesarean section. Enrolled patients were randomized to either standard operative procedure or the abdominal closure bundle. The bundle included changing of the surgical gown and gloves, repeat scrub, and usage of new instruments for closure of fascia, subcutaneous tissue, and skin. SSI rates were assessed and predictors of SSI were determined.

RESULTS:
241 patients were included in this interim analysis. No difference in SSI was found between the control (3/130, 2.3%) and closure bundle (2/111, 1.8%) groups (P=1.00). Logistic regression indicated that smoking status and number of prior cesarean sections were statistically reliable predictors of SSI (P=.009). Former or active smokers were 8.3 times more likely to have an infection (CI 1.61 – 43.3, P=.012). Those with prior cesarean sections were 2.5 times more likely to have an infection (CI 1.0 – 6.1, P=.045).

CONCLUSION:
Implementation of an abdominal closure bundle for patients undergoing scheduled cesarean sections did not significantly reduce SSI rate. We plan to investigate the impact of the abdominal closure bundle in a higher risk population as completion of this study as designed is unlikely to reach statistical significance.
Impact of a Quality Improvement Initiative on Prescribed Opioids for Cesarean Delivery [14P]
Authors: Wang Katherine Y. , Sood Shelly , Liveright Elizabeth 
Published: April 2020

INTRODUCTION:
Cesarean deliveries (CD) are one of the most common procedures performed in the United States, with patients being routinely discharged with prescriptions for opioids. Previous studies show that the amount prescribed is significantly greater than what patients require. Our objective is to decrease the number prescribed at discharge through education and monitoring of prescription practices.

METHODS:
The quality improvement initiative was introduced in May 2018 through a departmental Grand Rounds presentation. Data on post-operative prescription practices were collected by performing a retrospective chart review of all patients undergoing CD at our hospital in the month of January 2018 and in January 2019, 6 months after introduction of the initiative. IRB approval was obtained for this review.

RESULTS:
A total of 89 records of patients who underwent CD was reviewed: 42 records from January 2018 and 47 records from January 2019. A significant decrease (P<.001) in the number of pills prescribed at discharge was found, with a median of 30 (IQR 28–30) in January 2018 compared to a median of 20 (IQR 20–30) in January 2019. There was a significant difference (P<.001) in the type of opioid prescribed, shifting from oxycodone with acetaminophen (78% in January 2018 and 10% in January 2019) to oxycodone alone (7% in January 2018 compared to 74% in January 2019). There was no significant difference in refill attempts (P=.7) between January 2018 and January 2019.

CONCLUSION:
Low-cost interventions such as a department Grand Rounds and ongoing educational initiatives may be an effective strategy to decrease post-operative opioid prescription numbers.
Validation of an Algorithm to Identify Ectopic Pregnancy in a Large Integrated Health Care Delivery System Database [40N]
Authors: Getahun Darios , Alexeeff Stacey , Fassett Michael J. , Shi Jiaxiao M. , Asiimwe Alex , Raine-Bennett Tina 
Published: April 2020

INTRODUCTION:
Surveillance of ectopic pregnancy (EP) using electronic databases is important. We aimed to assess the validity of an enhanced version of a previously published algorithm, which used a combination of encounters with EP related diagnostic/procedure codes and methotrexate injections. The enhanced algorithm further included ICD-10 diagnostic/procedure codes along with telephone encounters and excluded cases with only abdominal EP codes.

METHODS:
Medical records of 681 women, aged 15–44 years with membership at Kaiser Permanente Southern and Northern California between 2009–2018 with a potential EP were reviewed and true cases were identified. The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and the overall performance (Youden's index and F-score) of the algorithm were evaluated and compared to the published algorithm.

RESULTS:
There were 418 true positive, 240 false positive, and 10 uncertain EP cases with available records. True positive and true negative EP cases did not differ significantly according to maternal age, race/ethnicity and smoking status. EP cases with only one encounter and non-tubal EP were more likely to be misclassified. The sensitivity, specificity, PPV, and NPV of the enhanced algorithm for EP were 96.4%, 80.8%, 89.8%, and 92.8%, respectively. The Youden index and F-score were 77.2% and 93.0%. The sensitivity and NPV were lower at 86.8% and 79.0%, respectively, for the published algorithm.

CONCLUSION:
The specificity of the algorithm for EP in the integrated healthcare databases is adequate to allow for use in future epidemiological studies. Use of the enhanced algorithm will likely result in better capture of true EP cases.
Effect of Hysterotomy Closure With Polyglactin 910 Versus Chromic Gut Suture on Secondary Cesarean Deliveries [12P]
Authors: Mersch Michelle , Ulfers Alexander , Hood Keren , Cuadra German , Stevenson Robert , Martingano Daniel 
Published: April 2020

INTRODUCTION:
The objective of this was study was to determine if hysterotomy closure with polyglactin 910 (PG) versus chromic gut (CG) suture material is associated with differences in development of adhesions and surgical complications in secondary cesarean deliveries (CD).

METHODS:
We conducted a 3 year retrospective cohort study and reviewed charts on all women who received a secondary CD. Operative notes were reviewed and charts were separated depending if closure of the hysterotomy was performed with PG or CG. Charts were excluded if at time of primary CD, a double layer closure of hysterotomy, closure of peritoneum and rectus muscle were not performed, or additional procedure was performed. Appropriate IRB approval was obtained. Primary outcomes included operating time, surgical blood loss, and report of “dense” or “extensive” adhesions (DEA) requiring lysis of adhesions and/or enterolysis as a separate procedure.

RESULTS:
The study included 313 patients, where 181 patients had hysterotomy closures with PG and 132 had closures with CG. Baseline characteristics were not significantly different between groups including previous abdominal surgery. The CG group was associated with lower rates of DEA (19% versus 21%, P=.031) and shorter total operative time (1.1 hours versus 1.9 hours, P=.024). No difference was noted in surgical blood loss or rates of postpartum hemorrhage. After controlling for perceived confounding factors, these differences remained significant.

CONCLUSION:
In this retrospective study, hysterotomy closures with CG suture were associated with lower rates of reported adhesions and decreased total operative time when compared with PG closures.
Doula Programs Improve Cesarean Section Rate, Breastfeeding Initiation, Maternal and Perinatal Outcomes [11P]
Authors: Font Guillermo , Testani Erica 
Published: April 2020

INTRODUCTION:
Doula support for socially disadvantaged women during pregnancy, childbirth and postpartum period is associated with improved outcomes, including lower rates of cesarean section, higher rates of breastfeeding initiation, and decreased maternal and perinatal complications. The purpose of our study is to report rates of primary cesarean section rate, breastfeeding initiation, and maternal and perinatal complications among socially or economically disadvantaged pregnant patients enrolled in a doula program in a large inner city setting.

METHODS:
Retrospective chart review of birth outcomes included primary cesarean section rate, breast feeding initiations, maternal and perinatal complications of patients enrolled in a certified doula support program in a large inner city setting. Outcomes were compared to local states percentages.

RESULTS:
Three hundred twenty two patients enrolled in the doula support program, 248 delivered vaginally and 74 required a cesarean section (cesarean section rate 22%), breast feeding initiation was reported in 269 patient (83% rate breast feeding initiations) and no maternal or perinatal loss was reported.

CONCLUSION:
Patients enrolled in a certified doula support programs in an inner city setting have improved cesarean section rates (22% vs 27%), breast feeding initiation rate (83% vs 80%) and improved maternal and perinatal outcomes compared to local state percentages. Our study confirms that pregnancy support by doulas are associated with improved outcomes in socially disadvantaged mothers because of racial disparities and psychosocial factors. Given these benefits certified doula support programs should be an available option during prenatal and postpartum care.
Communication, Respect, and Autonomy: Exploring Elements of a Meaningful Birth Partnership [08P]
Authors: Akpovi Eloho , Freeburg Taylor , Bocage Anne , Howard Elisabeth 
Published: April 2020

INTRODUCTION:
A health system focused on person-centered maternity care should place high value on women's sense of autonomy and perception of the decision-making process. We aim to triangulate quantitative findings to better understand the role of communication in improving maternal care delivery, in order to inform development of processes that facilitate a patient-centered birth partnership.

METHODS:
A paper questionnaire was self-administered to women receiving postpartum care at a hospital in the northeast United States. The questionnaire employed the Mothers Autonomy in Decision Making (MADM) scale, the Mothers on Respect (MOR) index, and questions from the Listening to Mothers III survey in asking about communication experiences and preferences during maternity care. One-way analysis of variance (ANOVA) was used to determine which communication preferences correlated with MADM and MOR scores.

RESULTS:
155 participants consented and enrolled into the study, with a mean age of 27.1 (SD 5.5). The mean MADM and MOR scores were 36.06 (SD 6.55) and 73.76 (SD 8.78), respectively. Use of overly medicalized terminology by maternity care providers negatively correlated with perceived respect. Satisfaction with time spent with maternity care providers and encouragement of participation in care positively correlated with perceived autonomy. Websites and “Apps” with pregnancy and childbirth information were considered twice as valuable as childbirth education classes.

CONCLUSION:
Data obtained from this study will significantly add to understanding of the patient experience and will inform future interventions that encourage a patient partnership in the provision of childbirth care.
Characterizing Perioperative Blood Glucose on an Enhanced Recovery After Surgery Pathway for Cesarean Delivery [06P]
Authors: Savitsky Leah M. , Hitti Jane , Delgado Carlos M. , Bollag Laurent A. , 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). Pregestational diabetics on insulin prior to pregnancy were excluded. ERAS CD pathway patients received a pre-op, 1-hour post-op, and post-op day 1 and 2 CBG. We calculated average CBG and percentage of time in-range, defined as any CBG between 70–140 mg/dL for all patients on the ERAS CD pathway, and stratified for type 2 diabetics (T2DM), gestational diabetics (GDM), and non-diabetics.

RESULTS:
Most patients had CBGs in-range preoperatively (n=268, 95.4%): 89.6% for T2DM, 89.8% for GDM, and 97.1% for non-diabetics. The average pre-op CBG was 87.5±15.7 mg/dL overall, 96.2±30.4 mg/dL for T2DM, 90.4±17.0 mg/dL for GDM, and 86.4±14.8 mg/dL for non-diabetics. Post-operatively, 94.3% (n=502) of patients had CBGs in-range: 66.8% for T2DM, 87.1% for GDM, and 95.5% for non-diabetics. The average post-op CBG was 90.9±17.8 mg/dL overall, 99.2±26.6 mg/dL for T2DM, 94.9±20.6 mg/dL for GDM, and 90.2±17.2 mg/dL for non-diabetics.

CONCLUSION:
Preoperatively most patients had in-range CBGs. Postoperatively, CBGs for non-diabetics and GDM remained primarily in-range, while CBGs for T2DM were more variable. For non-diabetic women it may not be useful to check pre- or post-operative CBGs as most will be within range. Further studies are needed to evaluate this aspect of care.