The relative impact of labor induction versus improved labor management: Before and after the ARRIVE (a randomized trial of induction vs. expectant management) trial.

OBJECTIVE: To evaluate the association of labor induction on cesarean delivery and other maternal and neonatal outcomes in low-risk, full-term patients in community hospitals during a period of concerted effort to safely prevent cesarean delivery. METHODS: We performed a retrospective cohort study using the California Maternal Data Center comprised linked discharge diagnoses and birth certificate data for all low-risk, nulliparous, term, singleton, vertex (NTSV) individuals between 39 and 41 weeks from three Sacramento Valley community hospitals from 2016 to 2022 (N = 10,821) during a period of state-wide efforts to safely reduce cesarean rates. Logistic regression was used to calculate odds ratios (ORs) and adjusted odds ratios (aORs) after labor induction in two time periods before and after the ARRIVE trial. RESULTS: During the study period, labor induction increased from 14.7% to 23.1%. Controlling for maternal age, pre-pregnancy BMI, birthweight, maternal race and ethnicity, birthplace, English language, gestational age, Medicaid status, delivery year, and labor induction was associated with an increased aOR of 1.67 (95% CI 1.48-1.89) for cesarean delivery. We found a trend toward increased aOR of chorioamnionitis but no differences in blood transfusion, severe maternal morbidity, unexpected newborn complications, chorioamnionitis, operative vaginal delivery, maternal lacerations, and shoulder dystocia with labor induction. A decrease aOR of cesarean delivery was observed comparing all births in 2019-2021 to 2016-2018. CONCLUSION: Labor induction was associated with an increased aOR for cesarean delivery both before and after the ARRIVE trial. A decreased aOR for cesarean delivery was observed during the period of statewide efforts to safely reduce cesarean delivery both with and without labor induction.

Safety and tolerability of Bifidobacterium longum subspecies infantis EVC001 supplementation in healthy term breastfed infants: a phase I clinical trial.

BACKGROUND: Historically, bifidobacteria were the dominant intestinal bacteria in breastfed infants. Still abundant in infants in developing nations, levels of intestinal bifidobacteria are low among infants in developed nations. Recent studies have described an intimate relationship between human milk and a specific subspecies of Bifidobacterium, B. longum subsp. infantis (B. infantis), yet supplementation of breastfed, healthy, term infants with this organism, has not been reported. The IMPRINT Study, a Phase I clinical trial, was initiated to determine the safety and tolerability of supplementing breastfed infants with B. infantis (EVC001). METHODS: Eighty mother-infant dyads were enrolled in either lactation support plus B. infantis supplementation (BiLS) or lactation support alone (LS). Starting with Day 7 postnatal, BiLS infants were fed 1.8-2.8 × 1010 CFU B. infantis EVC001 daily in breast milk for 21 days. Mothers collected fecal samples, filled out health questionnaires, and kept daily logs about their infants' feeding and gastrointestinal symptoms from birth until Day 61 postnatal. Safety and tolerability were determined from maternal reports. RESULTS: There were no differences in the mean gestational age at birth, weight 1 and 2 months postnatal, and breast milk intake between groups. The mean Log10 change in fecal Bifidobacterium from Day 6 to Day 28 was higher (p = 0.0002) for BiLS (6.6 ± 2.8 SD) than for LS infants (3.5 ± 3.5 SD). Daily stool number was higher (p < 0.005) for LS and lower (p < 0.05) for BiLS infants during supplementation than at Baseline. During supplementation, watery stools decreased and soft stools increased by 36% over baseline in BiLS infants (p < 0.05) with no significant changes in stool consistency for the LS infants. None of the safety and tolerability endpoints, including flatulence, bloody stool, body temperature, ratings of gastrointestinal symptoms, use of antibiotics or gas-relieving medications, infant colic, jaundice, number of illnesses, sick doctor visits, or diagnoses of eczema were different for the groups at any point. CONCLUSIONS: The B. infantis EVC001 supplement was safely consumed and well-tolerated. Stools were fewer and better formed in infants in the BiLS group compared with LS group. Adverse events were those expected in healthy infants and not different between groups. TRIAL REGISTRATION: ClinicalTrials.gov NCT02457338 . Registered May 27, 2015.

One obstetrician's look at a polarizing birth arena.

Birth, whether at home or in the hospital, should involve shared decision making that empowers women to choose or decline the interventions that are best for the woman and her baby. Obstetricians and home birth midwives must share important information with their patients.

VBAC in the trenches: a community perspective.

Is vaginal birth after cesarean in the community a disappearing practice? Since 1996 the rate of trial of labor after cesarean for low-risk women has dropped precipitously. This paper reviews the current literature and summarizes opinions of community obstetricians and midwives. Descriptive data are presented to document the scope of the problem and identify barriers: liability concerns, provider biases, and institutional restrictions. Our perspective draws on experience in our community hospital with a previously high vaginal birth after cesarean rate and a subsequent ban. Strategies to reduce the skyrocketing cesarean rate and encourage trial of labor after cesarean for low-risk women are outlined.

Obstetrician and nurse-midwife collaboration: successful public health and private practice partnership.

OBJECTIVE: To evaluate maternal and neonatal outcomes of collaborative maternity care for a socioeconomically diverse patient population in a California community hospital. METHODS: Collaborative practice structure and clinical guidelines were analyzed, as were de-identified electronic medical records for all primiparous women who delivered term singletons between 2000 and 2010 (N=4,426). Demographics, care processes, and perinatal outcomes were compared among women seen prenatally in a private collaborative practice compared with a Federally Qualified Health Center prenatal clinic run by nurse-midwives. RESULTS: Evidence-based practices were used to achieve excellent perinatal outcomes. Three quarters of women received intrapartum nurse-midwifery care (74.4%). Few differences were seen in management or outcomes among women from different prenatal clinics despite significant variation in demographic and clinical characteristics. Private practice patients were older, less likely to be obese, and more likely to speak English compared with counterparts from public health clinics. They were also more likely to use hydrotherapy or epidural analgesia, or experience severe perineal laceration and repair. Overall, pharmacologic pain relief methods were limited: less than a quarter of primiparous women used narcotics (21.2%), epidural analgesia (23.7%), or warm water immersion (23.2%). Labor induction and augmentation, and cesarean delivery rates (12.5%), were similar among groups and low overall. CONCLUSION: A collaborative practice of low-tech, high-touch care results in high-quality maternity services. The care model holds promise for replication to address health disparities by limiting obstetric interventions and warrants further investigation with regard to associated costs and resultant outcomes. LEVEL OF EVIDENCE: III.