Quality improvement efforts directed at optimal umbilical cord management in delivery room.

Delayed or deferred cord clamping (DCC) and umbilical cord milking (UCM) benefit all infants by optimizing fetal-neonatal transition and placental transfusion. Even though DCC is recommended by almost all maternal and neonatal organizations, it has not been universally implemented. There is considerable variation in umbilical cord management practices across institutions. In this article, we provide examples of successful quality improvement (QI) initiatives to implement optimal cord management in the delivery room. We discuss a number of key elements that should be considering among those undertaking QI efforts to implement DCC and UCM including, multidisciplinary team collaboration, development of theory for change, mapping of the current and ideal process and workflow for cord management, and creation of a unit-specific evidence-based protocol for cord management. We also examine important strategies for implementation and provide suggestions for developing a system for measurement and benchmarking.

Cord management strategies in multifetal gestational births.

Multifetal gestations are associated with high risks of neonatal mortality and morbidities primarily due to prematurity. Delayed cord clamping and cord milking facilitate the postnatal transition and improve outcomes. Limited evidence shows that delayed cord clamping for 30-60 s and cord milking are feasible without causing harm and potentially beneficial in uncomplicated multifetal deliveries. However, data on maternal bleeding from the limited studies are inconsistent. Based on current knowledge of the risk vs. benefits, it is reasonable to perform delayed cord clamping or cord milking (>28 weeks of gestation) in uncomplicated monochorionic and dichorionic multiples. Clearly defined criteria for suitable candidates, indications for clamping or milking the cord during delivery, and improved obstetric techniques in Cesarean deliveries are critical to minimize risks and optimize neonatal transition. Research is needed to identify safe and optimal cord-management strategies for improving survival and long-term outcomes in this high-risk population.

Impacts of embracing 39-week elective induction across an entire labor and delivery unit.

BACKGROUND: Induction of labor among low-risk, 39-week nulliparas increased significantly in the United States following publication of the outcomes of A Randomized Trial of Induction Versus Expectant Management trial. However, the rates of labor induction and outcomes in non-nulliparous patients and the wider impacts on the labor unit have not been reported widely. OBJECTIVE: This study aimed to compare the induction of labor rates and outcomes before and after liberal implementation of 39-week elective induction at a single center. STUDY DESIGN: This was a retrospective cohort study comparing the delivery characteristics of pregnancies 1 year before and 1 year after adoption of a new 39-week elective induction policy at a single, tertiary-care center. Notably, elective induction was not restricted to nulliparas. We examined all live, singleton, in-born deliveries ≥36 weeks gestation, excluding those with fetal anomalies and prolonged antenatal admission. Deliveries at ≥39 weeks gestation were further subcategorized as being high risk (diabetes mellitus, chronic hypertension, intrauterine growth restriction, history of fetal demise or cholestasis) or low risk, nulliparas vs multiparas, and with or without a previous cesarean delivery. Elective deliveries were those without a maternal, fetal, or obstetrical indication. Primary outcomes included gestational age and indications for delivery, rates of labor induction and elective induction, and time from admission to delivery. Secondary outcomes included the rate of cesarean deliveries, indications for cesarean deliveries, and maternal and newborn morbidities. The outcomes were compared using Wilcoxon rank-sum tests or chi-square tests as appropriate. The odds of cesarean delivery were analyzed using multivariate logistic regression and controlling for relevant confounders. RESULTS: A total of 2672 pre-implementation and 2526 post-implementation deliveries were studied. Among patients at ≥39 weeks gestation, elective delivery increased (pre-implementation, 344/1788 [19.2%] vs post-implementation, 684/1710 [40.0%]; P<.01) and admission for labor or ruptured membranes decreased (pre-implementation, 920/1788 [51.5%] vs post-implementation, 579/1710 [33.9%]; P<.01). Labor induction in the 39th week of gestation increased among low-risk and high-risk nulliparas, multiparas, and those with a previous cesarean delivery (P<.05 for each pairwise comparison), and the rate of 39-week elective inductions increased in all low-risk subgroups. Deliveries at 36 to 38 weeks gestation were similar in the proportion, timing, indications for delivery, and rate of labor induction. The odds of cesarean delivery was unchanged overall (adjusted odds ratio, 0.97; 95% confidence interval, 0.83-1.14) and for low-risk, ≥39-week nulliparas (adjusted odds ratio, 0.90; 95% confidence interval, 0.66-1.23) and low-risk, ≥39-week multiparas (adjusted odds ratio, 1.18; 95% confidence interval, 0.71-1.98). Among all deliveries, the median (interquartile range) time from admission to delivery increased significantly (pre-implementation, 12.8 [6.0-21.6] hours vs post-implementation, 15.6 [7.1-25.1] hours; P<.01) and the total cumulative patient care time from admission to delivery increased by 15% (pre-implementation, 41,578 hours vs post-implementation, 47,605 hours) when normalized by delivery volume. Chorioamnionitis incidence increased, whereas other maternal and neonatal morbidities were unchanged. CONCLUSION: Following adoption of a nonrestrictive, 39-week elective induction policy at a single, tertiary-care center, the rates of 39-week induction of labor and elective inductions increased among nulliparas, multiparas, and those with a previous cesarean delivery. The rate of cesarean delivery was unchanged, and the median time from admission to delivery and the cumulative admission to delivery hours increased significantly. Future studies are needed to further explore the full scope of the impacts on labor unit operations, costs, and patient experiences and outcomes.

Limitations of Gravimetric Quantitative Blood Loss during Cesarean Delivery.

Objective This study examined the accuracy, sources of error, and limitations of gravimetric quantification of blood loss (QBL) during cesarean delivery. Study Design Blood loss determined by assays of the hemoglobin content on surgical sponges and in suction canisters was compared with QBL in 50 parturients. Results QBL was moderately correlated to the actual blood loss ( r = 0.564; p < 0.001). Compared with the reference assay, QBL overestimated blood loss for 44 patients (88%). QBL deviated from the assayed blood loss by more than 250 mL in 34 patients (68%) and by more than 500 mL in 16 cases (32%). Assayed blood loss was more than 1,000 mL in four patients. For three of these patients, QBL was more than 1,000 mL (sensitivity = 75%). QBL was more than 1,000 mL in 12 patients. While three of these had an assayed blood loss of more than 1,000 mL, 9 of the 46 patients with blood losses of less than 1,000 mL by the assay (20%) were incorrectly identified as having postpartum hemorrhage by QBL (false positives). The specificity of quantitative QBL for detection of blood loss more than or equal to 1,000 mL was 80.4%. Conclusion QBL was only moderately correlated with the reference assay. While overestimation was more common than underestimation, both occurred. Moreover, QBL was particularly inaccurate when substantial bleeding occurred. Key Points QBL is inaccurate in cesarean delivery.QBL deviated from the assay result by more than 500 mL in 32% of cases.QBL sensitivity and specificity for hemorrhage is 75.0% (95% confidence interval [CI]: 0.19-0.93) and 80.4% (95% CI: 0.69-0.92), respectively.

Nonmydriatic Photographic Screening for Diabetic Retinopathy in Pregnant Patients with Pre-Existing Diabetes in a Safety Net Population: 1 Year Results from the Diabetic Retinopathy in Pregnant Patients Study.

Background: Pregnant patients with pre-existing diabetes mellitus (DM) are at increased risk for development or progression of existing diabetic retinopathy (DR). A quality improvement project was initiated to improve DR screening during pregnancy at a safety net hospital. This article highlights the utility and generalizability of our telemedicine-based screening model. Materials and Methods: In April 2018, we implemented a photographic retinal screening system in the Maternal Fetal Medicine (MFM) clinic at Santa Clara Valley Medical Center in San Jose, CA. The system is intended to screen all pregnant patients with pre-existing diabetes (type 1 and 2). Retinal images are automatically uploaded to a secure server and interpreted by a retina specialist (C.K.P.). Results: A total of 71 pregnant patients with pre-existing DM were seen in the MFM clinic during the study period. Sixty-six of 71 patients (93.0%) were screened compared with 69.1% in the year prior. Of the 64 patients screened with readable images 11 (17.2%) had DR, whereas 53 did not. Forty-nine of the 64 (74.2%) patients screened underwent screening using the new nonmydriatic system in the MFM clinic. Only 7 out of 47 (14.9%) patients with readable images in the MFM clinic required referral to the ophthalmology clinic. Conclusion: Our model for DR screening in pregnant patients in safety net hospitals is effective in improving screening rates and expediting evaluation and treatment for those in need. This system can prevent irreversible vision loss in pregnant patients and provides an effective framework for ophthalmic care in a safety net hospital system.

Accuracy of Blood Loss Measurement during Cesarean Delivery.

Objective This study aims to compare the accuracy of visual, quantitative gravimetric, and colorimetric methods used to determine blood loss during cesarean delivery procedures employing a hemoglobin extraction assay as the reference standard. Study Design In 50 patients having cesarean deliveries blood loss determined by assays of hemoglobin content on surgical sponges and in suction canisters was compared with obstetricians' visual estimates, a quantitative gravimetric method, and the blood loss determined by a novel colorimetric system. Agreement between the reference assay and other measures was evaluated by the Bland-Altman method. Results Compared with the blood loss measured by the reference assay (470 ± 296 mL), the colorimetric system (572 ± 334 mL) was more accurate than either visual estimation (928 ± 261 mL) or gravimetric measurement (822 ± 489 mL). The correlation between the assay method and the colorimetric system was more predictive (standardized coefficient = 0.951, adjusted R2 = 0.902) than either visual estimation (standardized coefficient = 0.700, adjusted R2 = 00.479) or the gravimetric determination (standardized coefficient = 0.564, adjusted R2 = 0.304). Conclusion During cesarean delivery, measuring blood loss using colorimetric image analysis is superior to visual estimation and a gravimetric method. Implementation of colorimetric analysis may enhance the ability of management protocols to improve clinical outcomes.

Nonpneumatic antishock garment combined with bakri balloon as a nonoperative "uterine sandwich" for temporization of massive postpartum hemorrhage from disseminated intravascular coagulation.

Disseminated intravascular coagulation (DIC) is an uncommon but potentially catastrophic complication of postpartum hemorrhage. We describe two cases of massive postpartum hemorrhage complicated by DIC that were successfully temporized with combined use of the Bakri balloon and nonpneumatic antishock garment (NASG) during massive transfusion. In the first case, a healthy, term gravida underwent emergent cesarean for fetal bradycardia during labor induction. 10 minutes after completion of surgery, brisk vaginal hemorrhage of nonclotting blood from fulminant DIC resulted in maternal shock. A Bakri balloon and NASG were placed during massive transfusion, resulting in rapid maternal stabilization. In the second case, a healthy, term gravida suffered an amniotic fluid embolism during labor requiring emergent cesarean delivery and complicated by cardiac arrest with successful resuscitation. Postoperative rapid uterine bleeding from DIC was treated with a Bakri balloon and NASG, stabilizing the patient during massive transfusion. Neither patient required further surgical procedures. NASG combined with Bakri balloon may serve as a valuable nonoperative treatment or temporization option in cases of massive postpartum hemorrhage complicated by coagulopathy such as these. Further study of the utility of NASG in high-resource settings is warranted.

A new model for providing cell-free DNA and risk assessment for chromosome abnormalities in a public hospital setting.

OBJECTIVE: Cell-free DNA (cfDNA) offers highly accurate noninvasive screening for Down syndrome. Incorporating it into routine care is complicated. We present our experience implementing a novel program for cfDNA screening, emphasizing patient education, genetic counseling, and resource management. STUDY DESIGN: Beginning in January 2013, we initiated a new patient care model in which high-risk patients for aneuploidy received genetic counseling at 12 weeks of gestation. Patients were presented with four pathways for aneuploidy risk assessment and diagnosis: (1) cfDNA; (2) integrated screening; (3) direct-to-invasive testing (chorionic villus sampling or amniocentesis); or (4) no first trimester diagnostic testing/screening. Patients underwent follow-up genetic counseling and detailed ultrasound at 18-20 weeks to review first trimester testing and finalize decision for amniocentesis. RESULTS: Counseling and second trimester detailed ultrasound were provided to 163 women. Most selected cfDNA screening (69%) over integrated screening (0.6%), direct-to-invasive testing (14.1%), or no screening (16.6%). Amniocentesis rates decreased following implementation of cfDNA screening (19.0% versus 13.0%, P < 0.05). CONCLUSION: When counseled about screening options, women often chose cfDNA over integrated screening. This program is a model for patient-directed, efficient delivery of a newly available high-level technology in a public health setting. Genetic counseling is an integral part of patient education and determination of plan of care.

Altered placental development in undernourished rats: role of maternal glucocorticoids.

Maternal undernutrition (MUN) during pregnancy may lead to fetal intrauterine growth restriction (IUGR), which itself predisposes to adult risk of obesity, hypertension, and diabetes. IUGR may stem from insufficient maternal nutrient supply or reduced placental nutrient transfer. In addition, a critical role for maternal stress-induced glucocorticoids (GCs) has been suggested to contribute to both IUGR and the ensuing risk of adult metabolic syndrome. While GC-induced fetal organ defects have been examined, there have been few studies on placental responses to MUN-induced maternal stress. Therefore, we hypothesize that 50% MUN associates with increased maternal GC levels and decreased placental HSD11B. This in turn leads to decreased placental and fetal growth, hence the need to investigate nutrient transporters. We measured maternal serum levels of corticosterone, and the placental basal and labyrinth zone expression of glucocorticoid receptor (NR3C1), 11-hydroxysteroid dehydrogenase B 1 (HSD11B-1) predominantly activates cortisone to cortisol and 11-dehydrocorticosterone (11-DHC) to corticosterone, although can sometimes drive the opposing (inactivating reaction), and HSD11B-2 (only inactivates and converts corticosterone to 11-DHC in rodents) in control and MUN rats at embryonic day 20 (E20). Moreover, we evaluated the expression of nutrient transporters for glucose (SLC2A1, SLC2A3) and amino acids (SLC38A1, 2, and 4). Our results show that MUN dams displayed significantly increased plasma corticosterone levels compared to control dams. Further, a reduction in fetal and placental weights was observed in both the mid-horn and proximal-horn positions. Notably, the placental labyrinth zone, the site of feto-maternal exchange, showed decreased expression of HSD11B1-2 in both horns, and increased HSD11B-1 in proximal-horn placentas, but no change in NR3C1. The reduced placental GCs catabolic capacity was accompanied by downregulation of SLC2A3, SLC38A1, and SLC38A2 expression, and by increased SLC38A4 expression, in labyrinth zones from the mid- and proximal-horns. In marked contrast to the labyrinth zone, the basal zone, which is the site of hormone production, did not show significant changes in any of these enzymes or transporters. These results suggest that dysregulation of the labyrinth zone GC "barrier", and more importantly decreased nutrient supply resulting from downregulation of some of the amino acid system A transporters, may contribute to suboptimal fetal growth under MUN.

Paradoxical increase in maternal plasma leptin levels in food-restricted gestation: contribution by placental and adipose tissue.

Maternal food restriction (FR) during pregnancy results in decreased body weight with increased plasma leptin. To address this paradox, we investigated the effects of FR during pregnancy on growth and leptin levels in maternal, placental, and fetal sites. From embryonic day E10, control pregnant rats received ad libitum (AdLib) food, whereas study rats were 50% FR. At gestational ages, E16 and E20, the alterations in maternal body composition, retroperitoneal versus subcutaneous adipose leptin expression, and plasma leptin levels were studied. Furthermore, these changes were related to non-pregnant (NP) status and placental/fetal growth and leptin levels. As compared to NP, both FR and AdLib dams showed a progressive increase in body and lean body mass. However, total body fat was reduced in FR dams but remained unchanged in AdLib dams. Furthermore, plasma leptin levels in FR dams were markedly increased at E20 unlike AdLib dams, which showed moderate increments at E16 and E20. Additionally, FR dams showed significantly decreased leptin expression in subcutaneous and notably unaltered levels in retroperitoneal adipose tissue, suggesting an alternate source of elevated maternal plasma leptin. More importantly, the FR dams had reduced placental weights with paradoxical increased leptin expression at both gestations. Thus, increased plasma leptin levels at E20 in maternal FR pregnancies may be explained, in part, by upregulation of placental leptin. Despite maternal and placental hyperleptinemia during FR pregnancies, the growth-restricted FR fetus had reduced leptin levels. These findings have important implications for pregnancy outcome and fetal growth.

Clinician bias in fundal height measurement.

OBJECTIVE: To establish whether the degree of clinician bias in fundal height measurement is affected by patient body mass index (BMI) or provider experience. METHODS: Singleton, ultrasound-dated pregnancies between 24 weeks and 40 weeks underwent fundal height measurements (n=103) by two providers, each using one blank and one marked measuring tape. Outcomes were the differences between the blank and marked measurements (bias) and between fundal height and gestational age for blank and marked tapes. Mixed models for repeated measures (provider and tape type) were used to estimate outcomes and compare them according to provider experience level and for patient background and anthropometric characteristics. RESULTS: Bias increased with patient BMI, although only among providers with less than 2 years of experience (juniors, P=.004) and not for those with more experience (seniors, P=.38). Similarly, bias decreased over the study enrollment period among junior, but not senior providers. Providers of all levels were more likely to measure a fundal height within 3 cm of gestational age using a marked tape than a blank tape (odds ratio 1.83, 95% confidence interval 1.41-2.38). CONCLUSION: Clinicians are biased in their fundal height measurements by knowledge of gestational age and use of a marked measuring tape. This tendency increases with higher patient BMI and with less provider experience.