Patient-perceived barriers to early initiation of prenatal care at a large, urban federally qualified health center: a mixed-methods study.

BACKGROUND: Early initiation of prenatal care is widely accepted to improve the health outcomes of pregnancy for both mothers and their infants. Identification of the various barriers to entry into care that patients experience may inform and improve health care provision and, in turn, improve the patient's ability to receive necessary care. AIM: This study implements a mixed-methods approach to establish methods and procedures for identifying barriers to early entry to prenatal care in a medically-vulnerable patient population and areas for future quality improvement initiatives. METHODS: An initial chart review was conducted on obstetrics patients that initiated prenatal care after their first trimester at a large federally qualified health center in Brooklyn, NY, to determine patient-specified reasons for delay. A thematic analysis of these data was implemented in combination with both parametric and non-parametric analyses to characterize the population of interest, and to identify the primary determinants of delayed entry. RESULTS: The age of patients in the population of interest (n = 169) was bimodal, with a range of 15 - 43 years and a mean of 28 years. The mean gestational age of entry into prenatal care was 19 weeks. The chart review revealed that 8% recently moved to Brooklyn from outside of NYC or the USA. Nine percent had difficulty scheduling an initial prenatal visit within their first trimester. Teenage pregnancy accounted for 7%. Provider challenges with documentation (21%) were noted. The most common themes identified (n = 155) were the patient being in transition (21%), the pregnancy being unplanned (17%), and issues with linkage to care (15%), including no shows or patient cancellations. Patients who were late to prenatal care also differed from their peers dramatically, as they were more likely to be Spanish-speaking, to be young, and to experience a relatively long delay between pregnancy confirmation and entry into care. Moreover, the greatest determinant of delayed entry into care was patient age. CONCLUSION: Our study provides a process for other like clinics to identify patients who are at risk for delayed entry to prenatal care and highlight common barriers to entry. Future initiatives include the introduction of a smart data element to document reasons for delay and use of community health workers for dedicated outreach after no show appointments or patient cancellations.

Impact of measuring quantification of blood loss versus estimation of blood loss during cesarean deliveries.

OBJECTIVE: Our objective was to determine whether there is a numerical difference between quantitative blood loss (QBL) versus visual estimation of blood loss (EBL) during cesarean delivery (CD), and whether initiation of QBL leads to increased recognition and intervention for postpartum hemorrhage. METHODS: A retrospective review was conducted of 250 patients undergoing CD with only EBL documented and 250 patients undergoing CD with both EBL and QBL documented at Montefiore Medical Center between October 2017 and November 2018. Since May 2018, the protocol for all CD included documentation of EBL and QBL. RESULTS: Average EBL when documented alone (897.0 ml ± 301.0 ml) trended lower than average EBL when documented with QBL (940.0 ml ± 371.0 ml, P = 0.161). For CD with both blood loss documented, average EBL (940.0 ml ± 371.0 ml) was significantly lower than average QBL (1065.3 ml ± 649.8 ml, P = 0.0001). CD with both blood loss documented had a greater number of blood transfusions (24 CD, 9.6%) versus only EBL documented (14 CD, 5.6%) (P = 0.125). CONCLUSION: The use of QBL may function in the algorithm to determine up-front resuscitative intervention to improve maternal outcomes and merits further study.

Respiratory outcomes after neonatal prone versus supine positioning following scheduled cesarean delivery: a randomized trial.

BACKGROUND: Prone positioning is a common practice after vaginal birth promoting skin to skin contact and has been associated with improved oxygenation in mechanically ventilated neonates in the recent analysis. Neonates of women not in labor delivered via C-section are at increased risk of respiratory distress; it is unclear whether vigorous neonates without a need of resuscitation would benefit from prone positioning immediately after birth. OBJECTIVE: To determine whether prone positioning of vigorous term neonates for the first 5 min after scheduled cesarean delivery will decrease the incidence of respiratory distress and therapeutic interventions, characterized by the frequency and duration of respiratory support (RS). DESIGN/METHODS: In a single center, randomized parallel clinical trial, vigorous term neonates delivered via scheduled cesarean delivery were positioned prone or supine and their heart rate, oxygen saturation and signs of respiratory distress were recorded at 1-min intervals for the first 5 min. Infants not reaching target oxygen saturations suggested by the neonatal resuscitation guidelines received RS via Neopuff in supine position; respiratory support was discontinued once oxygen saturation targets were met and infant was free of respiratory symptoms. Primary outcomes measured were frequency and duration of RS, secondary outcomes were admission to the NICU for respiratory distress, length of stay, heart rate and oxygen saturation during the initial 5 min of life. RESULTS: Two hundred twenty-five neonates in prone and 231 in supine position completed the study out of 500 randomized subjects. Frequency of RS (31 versus 30%, p = .93), mean RS duration (4.08 versus 4.39 min; p = .71), frequency of admission to the NICU (5% in both groups; p = .95) and mean length of stay (0.14 versus 0.28 days; p = .42) were similar between the prone and supine groups. The supine cohort had higher initial oxygen saturation (p = .02) as well as heart rate (p = .004). CONCLUSIONS: Prone or supine positioning of term neonates after scheduled cesarean delivery resulted in comparable respiratory outcomes including the need for resuscitation in the first minutes of life.

A Low-Cost Trainer for the Surgical Management of Postpartum Hemorrhage.

INTRODUCTION: Simulation-based training to manage surgical postpartum hemorrhage allows for improved preparation for these rarely needed life-saving procedures. Our objectives were to design a low-tech simulation model for use in training and evaluation of surgical techniques for the management of postpartum hemorrhage and to present evidence of its validity in assessment and training. METHODS: Fifty-two obstetrics and gynecology residents and 25 attending physicians from an academic hospital were video recorded while performing the O'Leary and B-Lynch techniques on the low-tech model. Performance was evaluated using a Technical Skills Checklist, for B-Lynch and O'Leary techniques, and the Reznick's Global Rating Scale. Interrater reliability was computed to assess the consistency of the ratings between 2 raters. Average scores were determined and compared between incoming residents, junior residents, senior residents, and attending physicians to show construct validity. RESULTS: For the B-Lynch, Technical Skills Checklist scores (maximum 17 points) of attendings (15.04) and senior residents (15.12) were higher than those of junior residents (5.63) and new residents (3.38). Global Rating Scale scores (maximum 25 points) on the B-Lynch reflected the same increase (22.38, 19.35 vs. 8.85, 6.75, respectively). For the O'Leary stitch, the scores of attendings, senior, junior, and incoming residents were as follows: 15.20, 13.65, 11.54, and 2.83, respectively (maximum 19 points). This supports the construct validity of the model. The model was considered realistic and useful for improving surgical skills in 71.4% of participants. CONCLUSIONS: This low-cost, easily constructed model is a useful tool for training these surgical skills.

Understanding Zika virus as an STI: findings from a qualitative study of pregnant women in the Bronx.

OBJECTIVES: Pregnant women in the Bronx were at risk for travel-related Zika exposure in the USA between 2016 and 2017. This qualitative study explored the experiences of 13 pregnant women to learn about their knowledge of Zika and prevention measures. METHODS: In the summer of 2017, pregnant women at risk of travel-related Zika exposure were interviewed in either Spanish or English to learn about their experiences and transcripts were analysed using a grounded theory approach. RESULTS: Most participants were Latinas living in the Bronx, median age of 29 years and median household income between $26 000 and $50 000. Participants displayed a strong understanding of Zika transmission via mosquito bites yet lacked knowledge about its sexual transmission. Interviews revealed three key themes: (1) Zika as a new disease, (2) denial as a coping mechanism and (3) the recommendation to treat Zika as an STI. Women observed Zika as a brand new disease with early messages emphasising mosquito-borne transmission. They lacked awareness of newer messaging about sexual transmission. Furthermore, if women did read about risk of sexual transmission, many stated being in denial and struggling with recommendations to prevent sexual transmission. Barriers included problems changing travel plans and rejection of condom use. Women unanimously suggested labelling Zika as an STI and adding it to existing lists of STIs for messaging and outreach in community-based and clinical prevention. CONCLUSION: Many pregnant women were unaware that Zika virus can be sexually transmitted due to: (1) novelty of Zika, (2) denial as a coping mechanism and (3) Zika not being listed along with well-known STIs. Overcoming these barriers via community-based as well as clinical education for pregnant women in the Bronx would be helpful in 2019 and beyond when the risk of travel-related Zika exposure remains a public health threat to optimal pregnancy outcomes.

Multidrug-Resistant Escherichia coli Resulting in Postpartum Necrotizing Endomyometritis.

BACKGROUND: Postpartum endometritis is a fairly common postoperative complication occurring in up to 11 percent of all cesarean deliveries. Multidrug-resistant pathogenic organism is increasingly a factor in postoperative source of infection. Postpartum endomyometritis from a multidrug-resistant Escherichia coli infection resulting in uterine is one such rare clinical circumstance where there is minimal information in the literature to guide its treatment and management. CASE: A 29-year-old G1P0 who underwent a primary cesarean delivery for a failed induction of labor developed endomyometritis on post-op day one and was treated with multiple broad-spectrum antibiotic regimens. The source of infection was found to be multidrug-resistant Escherichia coli with uterine involvement and pelvic abscesses, requiring hysterectomy and drainage of pelvic abscesses. Severe uterine necrosis from this multidrug-resistant Escherichia coli infection was noted intraoperatively. After three weeks of antibiotic therapy, she had resolution of her infection. CONCLUSION: Multidrug-resistant Escherichia coli is a highly pathogenic organism that can cause endomyometritis, persistent bacteremia, and uterine necrosis, which necessitates definitive surgical management with hysterectomy to achieve resolution of the infection.

Checklists, Huddles, and Debriefs: Critical Tools to Improve Team Performance in Obstetrics.

Checklists, huddles, and debriefs are tools being more commonly adopted in health care with the goal to achieve a safer health system. Details regarding what, how and when to implement these tools in different circumstances related to women's health are described in this review.

Stevens Johnson Syndrome with Vaginal Pain and Lesions as Initial Presentation.

BACKGROUND Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are causes of rare but life-threatening emergencies characterized by desquamation of the skin and mucosa. As SJS most commonly presents with skin rash followed by mucosal involvement, we present a case of vulvovaginal lesions as the initial presentation with progression to SJS after re-exposure to the culprit drug. CASE REPORT A 27-year-old female with acute cystitis was given trimethoprim-sulfamethoxazole. After 2 days, she reported vaginal pain. Three days later, she was hospitalized with vulvovaginal ulcerations and restarted on trimethoprim-sulfamethoxazole, leading to worsening vaginal lesions with rapid desquamation of conjunctival and oropharyngeal involvement. Biopsies of arm lesions revealed SJS. CONCLUSIONS It is important to recognize SJS as a rare but life-threatening cause of vulvovaginal ulceration, as early diagnosis is vital for successful treatment.

Selective Reduction of a Heterotopic Cesarean Scar Pregnancy Complicated by Septic Abortion.

BACKGROUND: Heterotopic pregnancy involving the implantation of an ectopic pregnancy into a prior cesarean scar with a concurrent intrauterine pregnancy is a rare and potentially life-threatening condition with minimal information in the literature to guide treatment and management options. CASE: A 40-year-old G5P3103 at 12 weeks and 3 days with a history of two cesarean deliveries was diagnosed with a live heterotopic pregnancy containing a cesarean scar ectopic and an intrauterine pregnancy. After selective reduction of the cesarean scar gestation with potassium chloride (KCl), the patient presented ten days later to the emergency department with septic abortion and sepsis. The patient underwent bilateral uterine artery embolization followed by ultrasound guided uterine evacuation with dilation and curettage, which was complicated by intraoperative hemorrhage and persistent bacteremia. The patient had resolution of her bacteremia after total abdominal hysterectomy. CONCLUSION: Conservative management of uterine infection resulting from selective reduction of a heterotopic pregnancy cesarean scar pregnancy may be considered; however, severe septicemia and persistent bacteremia may necessitate definitive surgical management.

Prolonged gonadotropin stimulation is associated with decreased ART success.

PURPOSE: to evaluate whether the duration of gonadotropin stimulation predicts the likelihood of live birth after ART. METHODS: all IVF or ICSI cycles using fresh autologous oocytes at our institution between January 2004 and December 2007 were analyzed. RESULTS: out of 699 cycles resulting in oocyte retrieval, 193 produced a live birth (27.6%). Women who achieved a live birth had a significantly shorter stimulation phase (11.1 vs. 11.5 days, respectively). Multivariable analysis suggested that 13 days or longer of stimulation decreased the likelihood of a live birth by 53% as compared to cycles that were 10-12 days long (odds ratio [OR] 0.47; 95% confidence interval [CI]: 0.30-0.75) after adjustment for female age, maximum historical FSH, total dose of gonadotropin received, oocytes retrieved, embryos transferred, antagonist suppression and PCOS diagnosis. CONCLUSIONS: prolonged duration of gonadotropin stimulation is an independent negative predictor of ART success in our cohort.