Does a large infant head or a short perineal body increase the risk of obstetrical perineal trauma?

BACKGROUND: Perineal trauma after vaginal delivery can have significant long-term consequences. It is unknown if a larger infant head circumference or smaller maternal perineal anatomy are risk factors for perineal trauma after vaginal delivery. METHODS: We conducted a prospective cohort study of low-risk nulliparous women. Data collected included maternal characteristics, antepartum Pelvic Organ Prolapse Quantification measurements of the perineal body and genital hiatus, labor characteristics, perineal trauma, and infant head circumference. Perineal trauma was defined as trauma that extended into the muscles of the perineum (second-degree or deeper). Univariate and multivariate logistic models were created to calculate odds ratios (OR) and 95 percent confidence intervals (CI). RESULTS: We observed 448 vaginal births. Multivariate analysis demonstrated a significant association between infant head circumference at birth and perineal trauma: OR 1.22 for each increase of 1 cm in head circumference (95% CI 1.05-1.43). There was no association between perineal body or genital hiatus length and perineal trauma. CONCLUSIONS: In nulliparous low-risk women a larger infant head circumference at birth increases the likelihood of perineal trauma, although the effect is modest. Antenatal perineal body and genital hiatus measurements do not predict perineal trauma. These results do not support alteration in mode of delivery or other obstetric practices.

Promotion rates for assistant and associate professors in obstetrics and gynecology.

OBJECTIVE: To estimate promotion rates of physician faculty members in obstetrics and gynecology during the past 30 years METHODS: Data were collected annually by the Association of American Medical Colleges from every school between 1980 and 2009 for first-time assistant and associate professors to determine whether and when they were promoted. Data for full-time physician faculty were aggregated by decade (1980-1989, 1990-1999, 2000-2009). Faculty were included if they remained in academia for 10 years after beginning in rank. Data were analyzed by constructing estimated promotion curves and extracting 6-year and 10-year promotion rates. RESULTS: The 10-year promotion rates (adjusted for attrition) declined significantly for assistant professors from 35% in 1980-1989 to 32% in 1990-1999 to 26% in 2000-2009 (P<.001), and for associate professors from 37% to 32% to 26%, respectively (P<.005). These declines most likely resulted from changes in faculty composition. The most recent 15 years saw a steady increase in the proportion of entry-level faculty who were women (now 2:1) and primarily on the nontenure track. The increasing number of faculty in general obstetrics and gynecology had lower promotion probabilities than those in the subspecialties (odds ratio 0.16; P<.001). Female faculty on the nontenure track had lower promotion rates than males on the nontenure track, males on the tenure track, and females on the tenure track (odds ratio 0.8 or less; P<.01). CONCLUSION: A decline in promotion rates during the past 30 years may be attributable to changes in faculty composition. LEVEL OF EVIDENCE: II.

Retention of entry-level faculty members in obstetrics and gynecology.

OBJECTIVE: The purpose of this study was to examine retention rates of entry-level physician faculty members in obstetrics and gynecology. STUDY DESIGN: Ongoing data were collected by the Association of American Medical Colleges between 1981 and 2009 for full-time, entry-level assistant professors to determine whether they remained at their original departments, switched to another school, or left academia. Retention curves and 5- and 10-year retention rates at their original department and for academia were determined. RESULTS: The number of entry-level faculty members per year increased significantly for women and those faculty members in general obstetrics and gynecology. Retention rates at the original departments improved for all disciplines in recent years (2000-09), regardless of sex. Among those faculty members who left their original department, faculty members in general obstetrics/gynecology were more likely than subspecialists to leave academia. CONCLUSION: Growth in the number of entry-level physician faculty members was accompanied by higher retention rates at their original departments only in recent years.

Trends in salaries of obstetrics-gynecology faculty, 2000-01 to 2008-09.

OBJECTIVE: We sought to determine whether downward trends in inflation-adjusted salaries (1989-99) continued for obstetrics and gynecology faculty. STUDY DESIGN: Data were gathered from the Faculty Salary Survey from the Association of American Medical Colleges for academic years 2001 through 2009. We compared median physician salaries adjusted for inflation according to rank and specialty. RESULTS: While faculty compensation increased by 24.8% (2.5% annually), change in salaries was comparable to the cumulative inflation rate (21.3%). Salaries were consistently highest among faculty in gynecologic oncology (P < .001), next highest among maternal-fetal medicine specialists (P < .001), and were not significantly different between general obstetrics-gynecology and reproductive-endocrinology-infertility. Inflation-adjusted growth of salaries in general obstetrics-gynecology was not significantly different from that in general internal medicine and pediatrics. CONCLUSION: Growth in salaries of physician faculty in obstetrics and gynecology increased from 2000-01 through 2008-09 with real purchasing power keeping pace with inflation.

Postpartum perineal pain in a low episiotomy setting: association with severity of genital trauma, labor care, and birth variables.

BACKGROUND: Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative vaginal delivery. METHODS: A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the present pain intensity (PPI) and visual analog scale (VAS) components of the validated short-form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. RESULTS: At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 +/- 1.61 vs 1.48 +/- 1.40; p < 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, p = 0.002) than women with minor or no trauma. By 3 months, average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non-Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model, only trauma group and length of active pushing predicted the pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on the level of pain at discharge beyond its effect on the incidence of major trauma. CONCLUSIONS: Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain.

Retention of chairs in obstetrics and gynecology: a comparison with other clinical departments.

OBJECTIVE: To compare the retention of chairs in academic obstetrics and gynecology with other core clinical departments. METHODS: Ongoing data were collected from each medical school for the Association of American Medical Colleges Faculty Roster between 1979 and 2007. Primary outcome measures included 5-year and 10-year retention rates and survival curves of first-time chairs. Comparisons were made between first-time chairs in obstetrics and gynecology and other core clinical departments: internal medicine, family medicine, pediatrics, psychiatry, and surgery. RESULTS: Five-year retention rates of obstetrics and gynecology chairs declined from 80% for those who began in 1979-1982 to 53% for those who began in 1998-2002. Ten-year retention in obstetrics and gynecology declined from 54% for those beginning in 1979-1982 to 26% for those beginning in 1993-1997. Other clinical departments experienced more stable 5-year and 10-year retention rates. Although substantially longer than other clinical departments in the 1979-1982 cohort, the median tenure of obstetrics and gynecology chairs who began in 1993-1997 was comparable with or less than that of other clinical departments. Discrete-time survival analysis revealed this decline in obstetrics and gynecology chair retention to be significant (P<.001) and more consistent than in other departments. CONCLUSION: Compared with other core clinical departments, retention of first-time chairs in obstetrics and gynecology declined more consistently from the highest to among the lowest. Chairs were inclined to not remain in office for a prolonged period. LEVEL OF EVIDENCE: II.

Medical students' awareness of traditional Southwest Native American values during pregnancy: a randomized, controlled trial.

OBJECTIVE: To determine if medical students' attendance at specialized prenatal clinics for Southwest Native American women would impact their awareness of and comfort in discussing traditional and unique values during pregnancy. STUDY DESIGN: In this unblinded, randomized trial, all 154 third-year students rotating consecutively on our obstetrics-gynecology clerkship consented to enrolling in this study. Participants were randomly assigned either to attend a high-risk prenatal clinic (rural or urban locations) for Native American women or to not attend (control group). Each anonymously answered a 20-question survey at the beginning and end of the clerkship about their comfort level and their awareness of patients' beliefs. A mixed model ANOVA was used to compare differences in scores between the groups while accounting for cluster effects in the study design. RESULTS: Regardless of whether the clinic was rural or urban, students became much more comfortable than controls in talking with Native American women about their pregnancy (p < 0.005). This applied especially to discussions about patients' spiritual beliefs, taboos that may affect pregnancy, participation in tribal ceremonies and belief in traditional medicine. As compared with the control group, students assigned to either clinic became more aware of how spirituality played an integral role in pregnancy (p < 0.05). CONCLUSION: Attendance at these specialized prenatal clinics enhanced medical students' comfort in talking with pregnant Native American women about the integrative roles of spiritual beliefs, tribal ceremonies and complementary medicine in their pregnancy outcome.

Minimum cord length that allows spontaneous vaginal delivery.

OBJECTIVE: To determine the shortest umbilical cord length that will permit spontaneous vaginal delivery. METHODS: This prospective, observational study included 166 randomly chosen women with no apparent antepartum complications who delivered spontaneously at or beyond 37 weeks. The cord was clamped at the maternal introitus immediately after delivery. The cord segment was measured from introitus to placental insertion. We reviewed a recent fetal scan to identify the placental implantation site (fundal or lateral). RESULTS: The mean cord segment from placental insertion to maternal introitus measured 22.4 cm (95% CI 11-32). The segment was 2.1 cm longer (95% CI 0.4-3.7) when the placenta was implanted at the uterine fundus rather than laterally (p < 0.01, 1-sided t test). An excessively short cord segment (<13 cm) was present in 2 cases (1.2%) with lateral placental implantation. There were no cases of fundal implantation with an excessively short cord. CONCLUSION: The uterine axis and birth canal are not long enough to prevent spontaneous vaginal delivery .in the presence of a short umbilical cord. Placental location does not impede delivery except perhaps when fundal in the presence of an excessively short cord.