bluuebunny/crossref_metadata_2025_split huggingface dataset:
Use of Ropivacaine Wound Infusion Device for Cesarean Deliveries: Effect on Narcotic Use and Length of Stay [38P]
Authors: Khangura Raminder , Nkemeh Christine , Cooper Shontreal , Campbell Winston , Hammer Erica 
Published: April 2020

INTRODUCTION:
Women who use peripartum opioids for cesarean delivery have a 2.2% rate of new persistent opioid use. Opioids have consequences for breastfeeding women, and may contribute to CNS depression in the mother and her breastfed infant. Suboptimal perioperative pain management is associated with chronic pain, delayed functional recovery, impaired maternal-fetal bonding greater opioid use and postpartum depression. Women undergoing cesarean delivery may benefit from local anesthetics delivered by wound infiltration or transversus abdominis plane block. The ropivacaine continuous wound infusion device used in non-obstetrical surgery has shown clinically meaningful reductions in opioid use yet still good pain control. We hypothesize that mothers who use a continuous wound infiltration device for postpartum pain management use less narcotic pain medication compared to mothers who do not use the device.

METHODS:
This is a retrospective case-control study of 18 patients who received a wound infiltration device matched to 18 controls. Charts were abstracted for patient characteristics, length of stay (LOS) and morphine milligram milliequivalents (MME) of opioids used postpartum.

RESULTS:
The primary outcome of total MME and other demographic and clinical variables were not statistically associated with the use of the infiltration device (P>.05). The Spearman correlation coefficient between total MME and LOS (in days) was 0.38, which was not statistically different from zero (no association) with the p-value of 0.12.

CONCLUSION:
While non opioid adjuncts may be useful in reducing narcotic use postpartum, the wound infusion device did not appear to be more beneficial.
Validity of the Emergency Severity Index (Version 4) in Postpartum Women After Cesarean Delivery [40P]
Authors: Kawakita Tetsuya , Thomas Alexandra , Landy Helain J. 
Published: April 2020

INTRODUCTION:
To examine the validity of the Emergency Severity Index version 4 (ESI v.4) in women who presented to an Emergency Department within 6 weeks after cesarean delivery.

METHODS:
This was a retrospective cohort study of all women who presented to MedStar Washington Hospital Center Emergency Department from July 2013 to June 2018 within 6 weeks after cesarean delivery. Acuity level was assigned by triage nurses using the ESI v.4 algorithm (1 being the highest acuity and 5 being the lowest acuity). To analyze the validity of ESI v.4, women were divided into 3 groups: high-acuity (ESI levels 1 and 2), medium-acuity (ESI level 3), and low-acuity (ESI levels 4 and 5). We examined the rates of readmission, specialty consultations such as gynecologists, and high resource use (2 or more).

RESULTS:
Of 439 women who presented to the Emergency Department, the distribution of acuity levels was as follows: low-acuity 20.1%; medium-acuity 56.0%; and high-acuity 23.9%. High-acuity and medium-acuity groups had higher rates of hospital admission compared to low-acuity group (2.3% vs. 19.1% vs. 47.6%; P<.001). High-acuity and medium-acuity groups had higher rates of specialty consultation compared to low-acuity group (12.5% vs. 47.2% vs. 69.5%; P<.001). High-acuity and medium-acuity groups had higher rates of high resource use compared to low-acuity group (15.5% vs. 70.8% vs. 86.0%; P<.001).

CONCLUSION:
The ESI v.4 was predictive of readmission, specialty consultation, and high resource use in women who presented to the Emergency Department within 6 weeks after cesarean delivery.
Validation of a Cesarean Delivery Risk Calculator in Women Undergoing Induction of Labor [39P]
Authors: Gammon Betsy L , Melanson Nicole , Chronister Briana , Urban Amanda , Dudley Donald 
Published: April 2020

INTRODUCTION:
Prior studies of risk factors for unsuccessful inductions are largely limited to nulliparous women with favorable cervices. Our objective is to validate a recent risk model for cesarean delivery (CD) after induction with an unfavorable cervix (Levine et al., AJOG 2018;218:254).

METHODS:
We performed an IRB-approved retrospective chart review of deliveries between March 2011–2019. Of 2,392 inductions, we analyzed a convenience sample of 1,050, identifying 582 full-term, singleton pregnancies with unfavorable cervices (modified Bishop score ≤6; ≤2 cm dilation). Using the Labor Induction Calculator, participants were grouped by predicted CD probability (Group 1: 0–19.9%; Group 2: 20–39.9%; Group 3: 40–59.9%; Group 4: ≥60%). Grouped analysis was performed to determine whether actual CD rates within risk groups matched the expected probability. Logistic regression was performed to determine whether higher predicted CD probability was associated with increased CD rates (STATA16.0, College Station, Texas).

RESULTS:
The rate of actual CD was less than predicted for our population overall (actual 19.1% v. predicted 28.3%) and for each group. In higher predicted risk groups, actual CD rates were less than predicted (Group 3: actual 36.7% vs. predicted 49.3%*; Group 4: actual 41.2% vs. predicted 66.6%*; *P<.001). Logistic regression using CD probability as an independent risk factor for CD identified an Odds Ratio of 1.05 (95% CI 1.03–1.06, P<.001).

CONCLUSION:
Our CD rates were lower than predicted by the model in all groups, with a particularly pronounced difference among higher risk groups. Prior to adopting risk prediction calculators, validation studies should be performed in specific populations where they will be employed.
The Use of Silver in Cesarean Wound Bandages: A New Way to Decrease Infection and Healthcare Costs [36P]
Authors: Grossman Tracy , Fields Jessica , Chan-Akeley Rosalyn , Dayal Ashlesha 
Published: April 2020

INTRODUCTION:
Post-cesarean surgical site infection (SSI) occurs after 3.7–9.8% of cesarean deliveries and is associated with significant morbidity and healthcare costs. Silver has antimicrobial properties and bandages impregnated with it are associated with decreased rates of SSI in non-obstetric surgery. Our objective was to compare the rates of deep and superficial cesarean SSI before and after the institution of silver-impregnated bandages and to analyze related healthcare costs.

METHODS:
This was a retrospective cohort study comparing the rates of cesarean-related SSI five months before and after the institution of silver-impregnated bandages and associated healthcare costs. Data was analyzed using chi-square and Fisher's exact test.

RESULTS:
There were 1,044 cesarean deliveries and 33 wound-related emergency department (ED) presentations during the study period. The demographics of the standard-of-care (n=538) and silver-bandage (n=506) groups were similar. The overall rates of deep and superficial SSI were 0.8% (n=8) and 0.6% (n=6) respectively. The use of silver-bandages was associated with a decrease in the rate of deep SSI (0.6% (n=3) vs 0.9% (n=5), P=.2) and superficial SSI (0.4% (n=2) vs 0.7% (n=4), P=.3). There were 24% fewer ED presentations in the silver-bandage group (13 vs 17) and one wound dehiscence requiring re-operation and negative-pressure wound-therapy, which was in the standard-of-care group. Healthcare costs related to SSI, ED presentations and long-term wound care were 29% less in the silver-bandage group.

CONCLUSION:
The use of silver-impregnated bandages was associated with a decreased rate of cesarean SSI and decreased healthcare costs. Longer-term studies will likely yield statistically significant decreases in SSI and healthcare costs, as post-cesarean SSI is a rare outcome.
The Effect of an Oxytocin Rest Period on Cesarean Delivery Blood Loss [35P]
Authors: Cochrane Elizabeth , Huber Ashley , Jou Christopher , Chappelle Joseph 
Published: April 2020

INTRODUCTION:
Studies have demonstrated that two hours of oxytocin exposure can desensitize uterine oxytocin receptors; which may increase blood loss during delivery. Oxytocin's half-life is 10–15 minutes, previous work suggests that it takes approximately 60 minutes to be eliminated. Our objective was to determine if a greater than 60-minute oxytocin rest period prior to cesarean delivery had an impact on blood loss.

METHODS:
An IRB-approved retrospective cohort study of 272 women who underwent primary cesarean delivery after oxytocin augmentation between January 2013 and December 2017 at Stony Brook University Hospital was conducted. Women with a prior cesarean delivery, a cesarean hysterectomy, multiple gestation, and a greater than 240 minute oxytocin rest period were excluded. The primary outcome was percentage change between pre- and post-operative hematocrit (Hct) in women with less than 60-minute oxytocin rest period (60 min).

RESULTS:
There was no difference in demographic or obstetric characteristics between the groups. Women in the >60 min group had a higher cumulative dose (5112+4765 mU vs. 77017325 mU, P=.003), longer duration of oxytocin administration (671±458 min vs. 892±558 min, P=.001), and were more likely to receive uterotonics (6.7% vs. 15.2%, P=.047). No significant difference in percent change in HCT (-17.3±8.6 vs. -17.8±8.7, P=.635) was identified. Linear regression demonstrated a weak relationship between cervical dilation and percent change in Hct. (R2=0.048, P<.001).

CONCLUSION:
No significant correlation between duration of oxytocin rest period and blood loss was found. Women receiving oxytocin augmentation do not appear to benefit from oxytocin rest periods before proceeding to cesarean delivery.
Simultaneous Use of Oxytocin With Foley Balloon in Nulliparous Women Undergoing Induction of Labor [33P]
Authors: Eid Joe , Moutos Christopher , Jacobs Sara , Saade George R. , Saad Antonio 
Published: April 2020

INTRODUCTION:
Simultaneous use of oxytocin with Foley Balloon (FB) in induction of labor (IOL) is thought to shorten the interval to delivery. Our objective was to evaluate the effect of such approach on time to delivery and mode of delivery in nulliparous women.

METHODS:
This secondary analysis included nulliparous women who participated in a randomized controlled trial comparing methods of FB placement for cervical ripening. These patients received either oxytocin after FB removal (FB group) or oxytocin simultaneously with FB (FB-Pit group). Our primary outcome was time from FB placement to delivery in hours. Secondary outcomes included mode of delivery, and total time FB was in place. Wilcoxon rank sum test, Student's t-test and Chi Square test were used as appropriate. P<.05 was considered significant.

RESULTS:
The original trial involved 372 patients, 172 were nulliparous and were included in this study. Patients' characteristics were similar in both groups. No difference was noted between FB and FB-Pit groups respectively in terms of time from FB placement to delivery (23.1 vs 21.3 hours; P=.2) or total time FB was in place (8.5 vs 9.1 hours; P=.3). Rate of vaginal delivery was also not significantly different between the two groups (63% in FB group vs 67% in FB-Pit group, P=.5).

CONCLUSION:
Simultaneous use of oxytocin with FB in nulliparous women undergoing IOL did not significantly shorten the time to delivery or improve rate of vaginal delivery. These findings suggest the use of oxytocin in early stages of cervical ripening in such population may have no benefit.
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.