Evaluation of the Emergency Severity Index (Version 4) in Postpartum Women after Cesarean Delivery.

OBJECTIVE: The Emergency Severity Index (ESI) version 4 is a 5-level triage system (1 being the highest acuity and 5 being the lowest acuity) used in the emergency department (ED). Our goal of the study was to compare rates of readmission according to ESI in postpartum women. STUDY DESIGN: This was a secondary analysis of a retrospective cohort study of all women who presented to the ED within 6 weeks after cesarean delivery. The acuity level was assigned by triage nurses at the time of triage presentation. Our primary outcome was postpartum readmission. To examine if the addition of blood pressure to vital sign abnormalities would improve the prediction for readmission, we created a modified ESI. We identified women who had an ESI of level 3 and reassigned to a modified ESI of level 2 if blood pressure was in the severe range. Receiver operating characteristic curves with area under the curve (AUC) were created and compared between ESI and modified ESI. RESULTS: Of 439 women, ESI distribution was 0.2% ESI 1, 23.7% ESI 2, 56.0% ESI 3, 19.4% ESI 4, and 0.7% ESI 5. Readmission rates by ESI level were 100% ESI 1, 47% ESI 2, 18% ESI 3, 2% ESI 4, and 0% ESI 5 (p < 0.001). Of 246 women who were assigned an ESI of 3, total 25 had severe range blood pressures and were reassigned to a modified ESI of 2. Of these 25 women, 14 were readmitted. The AUC of the modified ESI was statistically higher than that of the standard ESI (AUC: 0.77 and 95% confidence interval: 0.72-0.82 vs. AUC: 0.73 and 95% confidence interval: 0.68-0.78; p < 0.01). CONCLUSION: The ESI was a useful tool to identify women who required postpartum readmission. Incorporation of severe range blood pressure as a parameter of acuity improved the prediction of readmission. KEY POINTS: · ESI does not consider blood pressure.. · The ESI version 4 was predictive of postpartum readmission.. · Consideration of a severe range blood pressure significantly improved the prediction of readmission..

Association between surgical complications and early academic period in women undergoing cesarean delivery.

OBJECTIVE: To compare rates of operative complications between the earlier and later academic periods. STUDY DESIGN: This was a retrospective cohort study of women undergoing cesarean delivery at 23 weeks' gestation or greater during the academic calendar between 2012 and 2017. Our primary outcome was a composite of surgical complications including hemorrhage (4 or more red blood cell transfusion), bladder injury, bowel injury, neonatal injury, cellulitis, wound complications, intensive care unit admission, and readmission. Outcomes were compared between two periods - the earlier academic period (July and August) and the later academic period (April and May). Multivariable logistic regression or linear regression was performed, controlling for predefined covariates. RESULTS: There were 1251 and 1111 cesarean delivery in the earlier and later academic periods, respectively. The earlier academic period compared to the late academic period was associated with a minute longer incision to delivery time (9 versus 8 min, adjusted p < .01) and a 2.5-min longer surgical duration (49 versus 46.5 min, adjusted p < .01). There was no difference in the primary outcome (10.5 versus 9.6%; adjusted odds ratio 1.11 [0.84-1.46]). CONCLUSIONS: Cesarean deliveries performed in the early months of the academic period was not associated with increased odds of surgical complications.

The Rate of Intrapartum Cesarean Delivery Based on Estimated Fetal Weight in Comparison to Previous Child's Birth Weight.

OBJECTIVE: The aim of the study is to examine whether an estimated fetal weight of the current pregnancy greater than previous birth weight is associated with increased odds of intrapartum cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study of all women who had more than one singleton pregnancy at 23 weeks' gestation or greater at a single labor and delivery unit. We only analyzed the second pregnancy in the dataset. We excluded women who had preterm birth in the second pregnancy. Women were categorized according to the difference between estimated fetal weight and previous birth weight-estimated fetal weight close to previous birth weight within 500 g (similar weight group); estimated fetal weight significantly (more than 500 g) greater than previous birth weight (larger weight group); and estimated fetal weight significantly (more than 500 g) lower than previous birth weight (smaller weight group). The primary outcome was intrapartum cesarean delivery. Multivariable logistic regression was performed to calculate adjusted odds ratios (aORs) with 95% confidence interval (95% confidence interval [CI]) after adjusting for predefined covariates. RESULTS: Of 1,887 women, there were 1,415 (75%) in the similar weight group, 384 (20%) in the greater weight group, and 88 (5%) in the smaller weight group. Individuals in the larger weight group compared with those in the similar weight group had higher odds of undergoing intrapartum cesarean delivery (11.2 vs. 4.5%; aOR 2.91; 95% CI 1.91-4.45). The odds of intrapartum cesarean delivery in the smaller weight group compared with those in the similar weight group were not increased (3.4 vs. 4.5%; crude OR 0.75; 95%CI 0.23-2.42). CONCLUSION: The difference between current estimated fetal weight and previous birth weight plays an important role in assessing the risk of intrapartum cesarean delivery. KEY POINTS: · Estimated fetal weight compared with previous birth weight is an important factor.. · Cesarean delivery is infrequent if estimated fetal weight is similar to previous birth weight.. · Larger estimated fetal weight greater than the previous birth weight is associated with cesarean delivery..

Expectant Management of Severe COVID-19 Pneumonia in Late Preterm Pregnancy and Subsequent Cholecystitis: Lessons Learned.

Introduction Since the emergence of coronavirus disease 2019 (COVID-19) as a pandemic in March 2020, research and guidance have been published with regard to the management of infection and considerations in pregnancy, but much is still unknown. Pregnant women with COVID-19 infection are more likely to be hospitalized and are at increased risk for intensive care unit admissions and intubation than nonpregnant women with COVID-19 infection. The optimal timing of delivery among pregnant women with COVID-19 infection has not been established at this time, especially when the infection arises in late preterm and early term gestation. It is suggested that COVID-19 infection should not be considered a sole indication for delivery. The risks and benefits of prolonging pregnancy versus delivery should be taken into consideration at any given gestational age in a patient with COVID-19 infection. Case Report We report a case of a patient in the late third trimester of pregnancy that presented with severe COVID-19 infection and was managed expectantly through her disease course with improvement of respiratory status without necessitating delivery. We also discuss the unique development of cholecystitis in her hospitalization that may represent another clinical association to COVID-19 infection. Conclusion This case illustrates that delaying delivery is an option even in later gestational ages for maternal stabilization. A multidisciplinary approach and teamwork is needed to manage pregnant women with COVID-19 infection for optimal outcomes for both mother and fetus. Key Points Delaying delivery in severe coronavirus disease 2019 (COVID-19) infection is a reasonable option even in late gestation.A multidisciplinary team is of utmost importance when managing a pregnant woman with COVID-19.Other clinical sequalae such as cholecystitis may arise in the setting of COVID-19 infection.

Maternal morbidity by attempted route of delivery in periviable birth.

OBJECTIVE: Much of the literature on clinical decision-making regarding the optimal route of delivery for periviable birth, 23 0/7-25 6/7 weeks gestation, has focused on neonatal risks. In fact, routine cesarean delivery at these early gestational ages has not been shown to improve neonatal mortality or neurological outcomes. Neonatal risks associated with the route of delivery are well known. Conversely, there is a paucity of data on maternal morbidity associated with the route of delivery. We examined maternal morbidity according to the attempted route of delivery in women undergoing periviable birth. STUDY DESIGN: In a secondary analysis of the Consortium on Safe Labor, a retrospective cohort study, maternal outcomes were compared between attempted vaginal delivery and planned cesarean delivery in women undergoing periviable birth. Analyses were repeated to compare maternal outcomes among actual mode of delivery (vaginal delivery versus cesarean delivery). Multivariable Poisson regression was used to estimate adjusted relative risks (aRR) with 95% confidence intervals (95% CI), controlling for predefined covariates. RESULTS: Of 678 women who underwent periviable birth, 558 (82.3%) and 120 (17.7%) attempted vaginal delivery and planned cesarean delivery, respectively. Of 558 women who attempted a vaginal delivery, 411 (73.7%) achieved a vaginal delivery. Women who attempted a vaginal delivery compared to those who had a planned cesarean delivery were less likely to have endometritis (3.1 versus 15.0%; aRR 0.18, 95% CI 0.09-0.35). Women who attempted a vaginal delivery compared to those who had a planned cesarean delivery had 7-day shorter total length of hospital stay (p < .001). Comparison of actual mode of delivery showed that women with vaginal had decreased risks of fever (2.9 versus 7.9%; aRR 0.42, 95% CI 0.20-0.90), endometritis (0.5 versus 12.4%; aRR 0.03, 95% CI 0.01-0.13), and maternal thrombosis (0.2 versus 3.0%; aRR 0.08, 95% CI 0.01-0.93) compared to cesarean delivery. Women with vaginal delivery had 3-day shorter total length of hospital stay (p < .001) compared to cesarean delivery. CONCLUSION: The majority of women (73.7%) who attempted a vaginal delivery achieved a vaginal delivery. Attempting a vaginal delivery between 23 0/7 and 25 6/7 weeks gestation compared to a planned cesarean delivery was associated with decreased risks of maternal infectious morbidity. Deciding the route of delivery is challenging in women undergoing periviable delivery. Our analysis provides important information on short-term maternal risks when considering the risks and benefits during these discussions.

Interpregnancy Body Mass Index Change and Risk of Intrapartum Cesarean Delivery.

OBJECTIVE: This study aimed to examine the association between interpregnancy body mass index (BMI, kg/m2) change and intrapartum cesarean delivery in multiparous women without a history of cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study of all women who had more than one singleton pregnancy at 23 weeks' gestation or greater at MedStar Washington Hospital Center from January 2009 to June 2018. We excluded women who had a history of cesarean delivery, prelabor cesarean delivery, and contraindications for vaginal delivery. Interpregnancy BMI change was calculated by the change of early pregnancy BMI measured in the office. Women were categorized according to the interpregnancy BMI change (BMI loss more than 2 kg/m2, BMI change ± 2 kg/m2, and BMI gain more than 2 kg/m2). The primary outcome was an intrapartum cesarean delivery. Multivariable logistic regression was performed to calculate adjusted odds ratio (aOR) with 95% confidence interval (CI) after adjusting for predefined covariates. RESULTS: Of 2,168 women who were analyzed, 258 (12%), 1,192 (55%), and 718 (33%) had interpregnancy BMI loss more than 2 kg/m2, BMI change ± 2 kg/m2, and BMI gain more than 2 kg/m2, respectively. Women with BMI gain more than 2 kg/m2 compared with those with BMI change ± 2 kg/m2 had increased odds of intrapartum cesarean delivery (7.4 vs. 4.5%; aOR: 1.78; 95% CI: 1.10-2.86) and cesarean delivery for arrest disorders (3.1 vs. 1.1%; aOR: 3.06; 95% CI: 1.30-7.15). Women with BMI loss more than 2 kg/m2 compared with those with BMI change ± 2 kg/m2 had similar rates of cesarean delivery. CONCLUSION: Compared with interpregnancy BMI change ± 2 kg/m2, interpregnancy BMI gain 2 kg/m2 was associated with increased odds of intrapartum cesarean delivery. KEY POINTS: · BMI gain between pregnancies was associated with intrapartum cesarean delivery.. · BMI loss between pregnancies was not associated with intrapartum cesarean delivery.. · Our study suggests that at least maintaining weight between pregnancies is beneficial..

Association between long interpregnancy intervals and cesarean delivery due to arrest disorders.

BACKGROUND: It is hypothesized that pregnancy causes time-limited physiologic adaptations of the reproductive system, such as increased blood flow to the uterus. With long interpregnancy intervals, those adaptations may regress, and maternal physiologic characteristics may revert to those of primigravid women. Therefore, it is plausible that long interpregnancy interval is associated with cesarean delivery, especially due to arrest disorders (failed induction of labor, arrest of dilation, or arrest of descent). OBJECTIVE: To examine the association between interpregnancy interval and cesarean delivery due to arrest disorders in multiparous women without a history of cesarean delivery. MATERIALS AND METHODS: This was a retrospective cohort study of all women who had more than 1 singleton pregnancy at 23 weeks' gestation or greater at MedStar Washington Hospital Center from January 2009 to June 2018. We defined the interpregnancy interval as the duration from the birth of the preceding offspring to the date of conception of the index offspring. We a priori decided to categorize women based on the interpregnancy interval (less than 18 months, 18-59 months, and 60 months or greater). Our primary outcome was cesarean delivery due to arrest disorders. We also examined overall cesarean delivery and cesarean delivery due to nonreassuring fetal heart tracing. Multivariable logistic regression was performed to calculate adjusted odds ratios and 95% confidence intervals, controlling for predefined covariates. RESULTS: Of 2741 women, 1143 (41.7%), 1369 (49.9%), and 229 (8.4%) had an interpregnancy interval of less than 18 months, 18-59 months, and 60 months or more, respectively. After adjusting for confounders, an interpregnancy interval of 60 months or more compared to an interpregnancy interval of 18-59 months was associated with increased odds of cesarean delivery due to arrest disorders (4.8% vs 1.3%; adjusted odds ratio, 3.06; 95% confidence interval, 1.34-6.97) and cesarean delivery due to arrest of dilation (3.1% vs 0.7%; adjusted odds ratio, 3.24; 95% confidence interval, 1.10-9.59). An interpregnancy interval of less than 18 months compared to an interpregnancy interval of 18-59 months was associated with decreased odds of cesarean delivery due to nonreassuring fetal heart tracing (2.4% vs 4.1%; adjusted odds ratio, 0.55; 95% confidence interval, 0.32-0.92). CONCLUSION: An interpregnancy interval of 60 months or greater compared to an interpregnancy interval of 18-59 months was associated with increased odds of cesarean delivery due to arrest disorders. Beneficial effects on postpartum adaptations in the reproductive system may regress as interpregnancy interval increases.

Evaluation of Risk-Assessment Tools for Severe Postpartum Hemorrhage in Women Undergoing Cesarean Delivery.

OBJECTIVE: To examine and compare the validity of three known risk-assessment tools (CMQCC [California Maternal Quality Care Collaborative], AWHONN [Association of Women's Health, Obstetric and Neonatal Nurses], and NYSBOH [New York Safety Bundle for Obstetric Hemorrhage]) in women undergoing cesarean delivery. METHODS: We conducted a retrospective cohort study that evaluated all women undergoing cesarean delivery at 23 weeks of gestation or longer from 2012 to 2017 at an urban hospital with average of 1,200 cesarean deliveries per year. Data were obtained by chart review. Severe postpartum hemorrhage was defined as transfusion of at least four units of packed red blood cells during the intrapartum or postpartum period. For each risk-assessment tool, women were stratified into low-risk, medium-risk, and high-risk groups. Risk factors were examined using multivariable logistic regression. RESULTS: Of 6,301 women who underwent cesarean delivery, a total of 76 (1.2%) had severe postpartum hemorrhage. Women classified as low- or medium-risk had lower rates of severe postpartum hemorrhage (0.4-0.6%) compared with women classified as high-risk (1.8-5.1%) (P<.001). Risk factors that were included in all three tools that were associated with severe postpartum hemorrhage included placenta accreta, placenta previa or low-lying placenta, placental abruption, hematocrit less than 30%, and prior uterine scar. Factors included in only one or two tools that were associated with severe postpartum hemorrhage included having more than four previous vaginal deliveries (CMQCC and AWHONN), stillbirth (AWHONN), and more than four prior births (NYSBOH). Area under the curve and 95% CI for CMQCC, AWHONN, and NYSBOH were all moderate-CMQCC 0.77 (0.71-0.84), AWHONN 0.69 (0.65-0.74), and NYSBOH 0.73 (0.67-0.79), respectively (AWHONN being most sensitive [88% with high-risk as cut-off] and CMQCC being most specific [87% with high-risk as cut-off]). CONCLUSIONS: Risk-assessment tools had moderate prediction to identify high-risk groups at risk for severe postpartum hemorrhage after cesarean delivery.

Reducing Cesarean Delivery Surgical Site Infections: A Resident-Driven Quality Initiative.

OBJECTIVE: To examine the association of a resident-driven quality initiative with cesarean delivery surgical site infections. METHODS: This was a quasi-experimental, preintervention and postintervention study of women undergoing cesarean delivery at 23 weeks of gestation or greater between January 2015 and June 2018 at a single tertiary care center. We implemented a resident-driven, evidence-based surgical bundle, excluding women who underwent emergency cesarean or had chorioamnionitis. The bundle included routine prophylactic antibiotics (both cefazolin and azithromycin), chlorhexidine alcohol skin preparation, use of clippers instead of a razor, vaginal cleansing with povidone iodine, placental removal by umbilical cord traction, subcutaneous tissue closure if wound thickness greater than 2 cm, suture skin closure, dressing removal between 24 and 48 hours, and use of postoperative chlorhexidine soap. Our primary outcome was surgical site infections (superficial incisional, deep incisional, and organ or space surgical site infections) occurring up to 6 weeks postpartum. Outcomes were compared between the preimplementation period (January 2015-August 2016) and postimplementation period (December 2016-June 2018). Coarsened Exact Matching with k-to-k solution was performed using age, race-ethnicity, body mass index, rupture of membranes, and labor. RESULTS: In total, 1,624 underwent cesarean delivery in the preimplementation and 1,523 postimplementation periods, respectively; 1,100 women in the postimplementation period were matched to 1,100 women in the preimplementation period. The rate of surgical site infections in the unmatched cohort was significantly lower in the postimplementation period compared to those in the preimplementation period (2.2% [33/1,523] vs 4.5% [73/1,624]; odds ratio [OR] 0.47 [95% CI 0.31-0.71]; P<.001). This decrease in the rate of surgical site infections remained statistically significant after matching (1.9% [21/1,100] vs 4.1% [45/1,100]; OR 0.46 [0.27-0.77]; P<.001). CONCLUSION: After implementation of a resident-driven quality initiative using a surgical bundle, we observed a significant decrease in cesarean surgical site infections.

Outcomes after periviable ultrasound-indicated cerclage.

BACKGROUND: Cerclage placed for a sonographically short cervix has been shown to reduce the risk of preterm delivery in women with a history of prior preterm birth. While short cervix is traditionally placed before viability, the threshold gestational age at which viability is achieved continues to decrease, and, as a result, a larger subset of women may be ineligible to receive this potentially beneficial procedure. OBJECTIVE: To evaluate the association between obstetric outcomes and perioperative complications after placement of an ultrasound-indicated cerclage at periviability compared to placement in the previable period. METHODS: This retrospective cohort study of patients who underwent ultrasound-indicated cerclage evaluated obstetric outcomes and perioperative complications based on gestational age at cerclage placement. Ultrasound-indicated cerclage was considered to have been placed at periviability if placed at 22 to <24 weeks (exposed) and at previability if placed at 16 to <22 weeks gestational age (unexposed). The primary outcome was preterm delivery <36 weeks. Secondary outcomes included mean gestational age at delivery, preterm delivery <32 weeks, <28, and <24 weeks, preterm premature rupture of membranes (PPROM), chorioamnionitis, and perioperative complications. Adjusted analyses were performed to account for demographic and obstetric factors. RESULTS: Of the 426 patients included in the analysis, 94 (22%) had cerclage placed between ≥22 weeks to <24 weeks, while 332 (78%) had cerclage placed at <22 weeks. On univariate analysis, women who had a periviable cerclage placed were less likely to have a recurrent preterm delivery <36 weeks compared to women with previable cerclage placement (26.6 versus 38.3%, respectively, p = .04). The adjusted model did not demonstrate a significant difference in risk for preterm delivery <36 weeks associated with periviable versus previable cerclage (odds ratio 0.66, 95%CI 0.37-1.17). Secondary outcomes were similar between the previable and periviable groups, including mean gestational age at delivery (35.1 versus 36.2 weeks, respectively, p = .08) and preterm delivery before 32-week gestation (20.7 versus 13.8%, respectively, p = .17). Intraoperative and postoperative complications were rare and rates were similar between groups. CONCLUSIONS: Obstetric outcomes between patients receiving periviable and previable cerclage are similar. Ultrasound-indicated cerclage placement is associated with a relatively low rate of complications. Given the evidence supporting benefit of cerclage for women with short ultrasound cervical length and prior preterm birth, our findings demonstrate that benefits of placement at ≥22 weeks to <24 weeks may outweigh risks.

Early preterm preeclampsia outcomes by intended mode of delivery.

BACKGROUND: The optimal route of delivery in early-onset preeclampsia before 34 weeks is debated because many clinicians are reluctant to proceed with induction for perceived high risk of failure. OBJECTIVE: Our objective was to investigate labor induction success rates and compare maternal and neonatal outcomes by intended mode of delivery in women with early preterm preeclampsia. STUDY DESIGN: We identified 914 singleton pregnancies with preeclampsia in the Consortium on Safe Labor study for analysis who delivered between 24 0/7 and 33 6/7 weeks. We excluded fetal anomalies, antepartum stillbirth, or spontaneous preterm labor. Maternal and neonatal outcomes were compared between women undergoing induction of labor (n = 460) and planned cesarean delivery (n = 454) and women with successful induction of labor (n = 214) and unsuccessful induction of labor (n = 246). We calculated relative risks and 95% confidence intervals to determine outcomes by Poisson regression model with propensity score adjustment. The calculation of propensity scores considered covariates such as maternal age, gestational age, parity, body mass index, tobacco use, diabetes mellitus, chronic hypertension, hospital type and site, birthweight, history of cesarean delivery, malpresentation/breech, simplified Bishop score, insurance, marital status, and steroid use. RESULTS: Among the 460 women with induction (50%), 47% of deliveries were vaginal. By gestational age, 24 to 27 6/7, 28 to 31 6/7, and 32 to 33 6/7, the induction of labor success rates were 38% (12 of 32), 39% (70 of 180), and 54% (132 of 248), respectively. Induction of labor compared with planned cesarean delivery was less likely to be associated with placental abruption (adjusted relative risk, 0.33; 95% confidence interval, 0.16-0.67), wound infection or separation (adjusted relative risk, 0.23; 95% confidence interval, 0.06-0.85), and neonatal asphyxia (0.12; 95% confidence interval, 0.02-0.78). Women with vaginal delivery compared with those with failed induction of labor had decreased maternal morbidity (adjusted relative risk, 0.27; 95% confidence interval, 0.09-0.82) and no difference in neonatal outcomes. CONCLUSION: About half of women with preterm preeclampsia who attempted an induction had a successful vaginal delivery. The rate of successful vaginal delivery increases with gestational age. Successful induction has the benefit of preventing maternal and fetal comorbidities associated with previous cesarean deliveries in subsequent pregnancies. While overall rates of a composite of serious maternal and neonatal morbidity/mortality did not differ between induction of labor and planned cesarean delivery groups, women with failed induction of labor had increased maternal morbidity highlighting the complex route of delivery counseling required in this high-risk population of women.

Prevalence and Location of Obstetric Lacerations in Adolescent Mothers.

STUDY OBJECTIVE: The objective of this study was to describe prevalence and location of obstetric lacerations in adolescents. DESIGN: Retrospective cohort study. SETTING: We performed an analysis of the Consortium on Safe Labor database including tertiary care university-affiliated urban hospitals. PARTICIPANTS: All primiparous women who delivered vaginally were included. INTERVENTIONS: Vaginal and perineal lacerations were compared between age groups 15 or younger, 16-21, 22-34, 35-39, and older than 40 years. MAIN OUTCOME MEASURES: Outcome measures included vaginal, perineal, labial, and periurethral lacerations. χ2 and Fisher exact tests were used as appropriate, with P < .05 considered significant. RESULTS: A total of 9777 patients were included in the analysis. Young adolescents and adolescents had significantly higher rates of labial and periurethral lacerations compared with individuals aged 22-34 years. The prevalence of third- and fourth-degree perineal tears increased with age. CONCLUSION: Adolescent primiparous women are less likely to have severe perineal obstetric tears, but have higher rates of labial and periurethral tears.

Choice of Prophylactic Antibiotics and Surgical Site Infections After Cesarean Delivery.

OBJECTIVE: To examine the rate of surgical site infection according to the choice of antibiotics in women undergoing cesarean delivery. METHODS: We conducted a retrospective cohort study of women undergoing cesarean delivery (labored, unlabored, and scheduled) from 2012 to 2017. Women with chorioamnionitis and those who did not receive any antibiotics were excluded. Our primary outcome was defined a priori as a composite of cellulitis, endometritis, deep wound infection, abdominopelvic abscess, and sepsis. Outcomes were examined according to the choice of antibiotics: cefazolin, a standard alternative (both clindamycin and gentamicin), and inappropriate alternatives (such as clindamycin only). A multivariable logistic regression model was used to calculate the propensity score for each observation, which was the probability of receiving a particular antibiotic regimen. The propensity score-adjusted logistic regression models were conducted to calculate adjusted odds ratios (ORs) and 95% CIs. Firth's penalized likelihood approach was applied to address issues of rare events. RESULTS: Among 6,584 selected women, 6,163 (93.6%), 274 (4.2%), and 147 (2.2%) received cefazolin, a standard alternative, and inappropriate alternatives, respectively. Use of standard alternative antibiotics compared with cefazolin was not associated with increased odds of the primary outcome (crude OR 1.50 [0.92-2.46]; adjusted OR 1.63 [0.97-2.60]) but was associated with increased odds of cellulitis (crude OR 2.07 [1.16-3.70]; adjusted OR 1.93 [1.03-3.31]). Use of inappropriate alternative antibiotics compared with cefazolin was associated with increased odds of the primary outcome (crude OR 4.37 [2.80-6.83]; adjusted OR 4.13 [2.59-6.36]) as well as some components of the composite outcome such as endometritis before discharge (crude OR 6.85 [3.94-11.90]; adjusted OR 6.68 [3.69-11.44]) and cellulitis (crude OR 3.36 [1.78-6.34]; adjusted OR 3.23 [1.63-5.81]). CONCLUSION: Both standard alternative and inappropriate alternatives were associated with increased odds of surgical site infections compared with cefazolin.

Risk Factors for Umbilical Cord Prolapse at the Time of Artificial Rupture of Membranes.

Objective The aim of the study was to examine the association between cervical exam at the time of artificial rupture of membranes (AROM) and cord prolapse. Study Design We conducted a retrospective cohort study using the data from the Consortium on Safe Labor. We included women with cephalic presentation and singleton pregnancies at ≥ 23 weeks' gestation who underwent AROM during the course of labor. Multivariable logistic regression was used to calculate the adjusted odds ratio (aOR) with 95% confidence interval (95% CI), controlling for prespecified covariates. Results Of 57,204 women who underwent AROM, cord prolapse occurred in 113 (0.2%). Compared with dilation 6 to 10 cm + station ≥ 0 at the time of AROM, <6 cm + any station and 6-10 cm + station ≤ -3 were associated with increased risks of cord prolapse (<6 cm + station ≤ -3 [aOR, 2.29; 95% CI, 1.02-5.40]; <6 cm + station -2.5 to -0.5 [aOR, 2.34; 95% CI, 1.23-4.97]; <6 cm + station ≥ 0 [aOR, 3.31; 95% CI, 1.39-8.09]; and 6-10 cm + station ≤ -3 [aOR, 5.47; 95% CI, 1.35-17.48]). Conclusion Cervical dilation < 6 cm with any station and 6 to 10 cm with station ≤ -3 were associated with a higher risk of cord prolapse.

Racial/Ethnic Differences in Labor Induction in a Contemporary US Cohort: A Retrospective Cohort Study.

OBJECTIVE: To examine labor induction by race/ethnicity and factors associated with disparity in induction. STUDY DESIGN: This is a retrospective cohort study of 143,634 women eligible for induction ≥24 weeks' gestation from 12 clinical centers (2002-2008). Rates of labor induction for each racial/ethnic group were calculated and stratified by gestational age intervals: early preterm (240/7-336/7), late preterm (340/7-366/7), and term (370/7-416/7 weeks). Multivariable logistic regression examined the association between maternal race/ethnicity and induction controlling for maternal characteristics and pregnancy complications. The primary outcome was rate of induction by race/ethnicity. Inductions that were indicated, non-medically indicated, or without recorded indication were also compared. RESULTS: Non-Hispanic black (NHB) women had the highest percentage rate of induction, 44.6% (p < 0.001). After adjustment, all racial/ethnic groups had lower odds of induction compared with non-Hispanic white (NHW) women. At term, NHW women had the highest percentage rate (45.4%) of non-medically indicated or induction with no indication (p < 0.001). CONCLUSION: Compared with other racial/ethnic groups, NHW women were more likely to undergo non-medically indicated induction at term. As labor induction may avoid the occurrence of stillbirth, whether this finding explains part of the increased risk of stillbirth for NHB women at term merits further research.

Surgical site infections after cesarean delivery: epidemiology, prevention and treatment.

Cesarean delivery (CD) is one of the most common procedures performed in the United States, accounting for 32% of all deliveries. Postpartum surgical site infection (SSI), wound infection and endometritis is a major cause of prolonged hospital stay and poses a burden to the health care system. SSIs complicate a significant number of patients who undergo CD - 2-7% will experience sound infections and 2-16% will develop endometritis. Many risk factors for SSI have been described. These include maternal factors (such as tobacco use; limited prenatal care; obesity; corticosteroid use; nulliparity; twin gestations; and previous CD), intrapartum and operative factors (such as chorioamnionitis; premature rupture of membranes; prolonged rupture of membranes; prolonged labor, particularly prolonged second stage; large incision length; subcutaneous tissue thickness > 3 cm; subcutaneous hematoma; lack of antibiotic prophylaxis; emergency delivery; and excessive blood loss), and obstetrical care on the teaching service of an academic institution. Effective interventions to decrease surgical site infection include prophylactic antibiotic use (preoperative first generation cephalosporin and intravenous azithromycin), chlorhexidine skin preparation instead of iodine, hair removal using clippers instead of razors, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples. Implementation of surgical bundles in non-obstetric patients has been promising., Creating a similar patient care bundle comprised evidence-based elements in patients who undergo CD may decrease the incidence of this major complication. Each hospital has the opportunity to create its own CD surgical bundle to decrease surgical site infection.

Neonatal outcomes in fetuses with cardiac anomalies and the impact of delivery route.

BACKGROUND: Congenital fetal cardiac anomalies compromise the most common group of fetal structural anomalies. Several previous reports analyzed all types of fetal cardiac anomalies together without individualized neonatal morbidity outcomes based on cardiac defect. Mode of delivery in cases of fetal cardiac anomalies varies greatly as optimal mode of delivery in these complex cases is unknown. OBJECTIVE: We sought to determine rates of neonatal outcomes for fetal cardiac anomalies and examine the role of attempted route of delivery on neonatal morbidity. STUDY DESIGN: Gravidas with fetal cardiac anomalies and delivery >34 weeks, excluding stillbirths and aneuploidies (n = 2166 neonates, n = 2701 cardiac anomalies), were analyzed from the Consortium on Safe Labor, a retrospective cohort study of electronic medical records. Cardiac anomalies were determined using International Classification of Diseases, Ninth Revision codes and organized based on morphology. Neonates were assigned to each cardiac anomaly classification based on the most severe cardiac defect present. Neonatal outcomes were determined for each fetal cardiac anomaly. Composite neonatal morbidity (serious respiratory morbidity, sepsis, birth trauma, hypoxic ischemic encephalopathy, and neonatal death) was compared between attempted vaginal delivery and planned cesarean delivery for prenatal and postnatal diagnosis. We used multivariate logistic regression to calculate adjusted odds ratio for composite neonatal morbidity controlling for race, parity, body mass index, insurance, gestational age, maternal disease, single or multiple anomalies, and maternal drug use. RESULTS: Most cardiac anomalies were diagnosed postnatally except hypoplastic left heart syndrome, which had a higher prenatal than postnatal detection rate. Neonatal death occurred in 8.4% of 107 neonates with conotruncal defects. Serious respiratory morbidity occurred in 54.2% of 83 neonates with left ventricular outflow tract defects. Overall, 76.3% of pregnancies with fetal cardiac anomalies underwent attempted vaginal delivery. Among patients who underwent attempted vaginal delivery, 66.1% had a successful vaginal delivery. Women with a fetal cardiac anomaly diagnosed prenatally were more likely to have a planned cesarean delivery than women with a postnatal diagnosis (31.7 vs 22.8%; P < .001). Planned cesarean delivery compared to attempted vaginal delivery was not associated with decreased composite neonatal morbidity for all prenatally diagnosed (adjusted odds ratio, 1.67; 95% confidence interval, 0.85-3.30) or postnatally diagnosed (adjusted odds ratio, 0.99; 95% confidence interval, 0.77-1.27) cardiac anomalies. CONCLUSION: Most fetal cardiac anomalies were diagnosed postnatally and associated with increased rates of neonatal morbidity. Planned cesarean delivery for prenatally diagnosed cardiac anomalies was not associated with less neonatal morbidity.

Maternal outcomes associated with early preterm cesarean delivery.

BACKGROUND: Data on complications associated with classic cesarean delivery are conflicting. In extremely preterm cesarean delivery (22 0/7-27 6/7 weeks' gestation), the lower uterine segment is thicker. It is plausible that the rates of maternal complications may not differ between classic and low transverse cesarean. OBJECTIVE: We sought to compare maternal outcomes associated with classic versus low transverse cesarean after stratifying by gestation (23 0/7-27 6/7 and 28 0/7-31 6/7 weeks' gestation). STUDY DESIGN: We conducted a multihospital retrospective cohort study of women undergoing cesarean delivery at 23 0/7 to 31 6/7 weeks' gestation from 2005 through 2014. Composite maternal outcome (postpartum hemorrhage, transfusion, endometritis, sepsis, wound infection, deep venous thrombosis/pulmonary embolism, hysterectomy, respiratory complications, and intensive care unit admission) was compared between classic and low transverse cesarean. Outcomes were calculated using multivariable logistic regression models yielding adjusted odds ratios with 95% confidence intervals and adjusted P values controlling for maternal characteristics, emergency cesarean delivery, and comorbidities. Analyses were stratified by gestational age categories (23 0/7-27 6/7 and 28 0/7-31 6/7 weeks' gestation). RESULTS: Of 902 women, 221 (64%) and 91 (16%) underwent classic cesarean between 23 0/7 and 27 6/7 and between 28 0/7 and 31 6/7 weeks' gestation, respectively. There was no increase in maternal complications for classic cesarean versus low transverse cesarean between 23 0/7 and 27 6/7 weeks' gestation. However, between 28 0/7 and 31 6/7 weeks' gestation, classic cesarean was associated with increased risks of the composite maternal outcome (adjusted odds ratio, 1.95; 95% confidence interval, 1.10-3.45), transfusion (adjusted odds ratio, 2.42; 95% confidence interval, 1.06-5.52), endometritis (adjusted odds ratio, 3.23; 95% confidence interval, 1.02-10.21), and intensive care unit admission (adjusted odds ratio, 5.05; 95% confidence interval, 1.37-18.52) compared to low transverse cesarean. CONCLUSION: Classic cesarean delivery compared with low transverse was associated with higher maternal complication rates between 28 0/7 and 31 6/7 weeks, but not between 23 0/7 and 27 6/7 weeks' gestation.

Induction of Labor in Women with Oligohydramnios: Misoprostol Compared with Prostaglandin E2.

Objective To compare perinatal outcomes in women with oligohydramnios and an unfavorable cervix undergoing labor induction with misoprostol to prostaglandin E2. Study Design We conducted a secondary analysis of women with oligohydramnios undergoing labor induction in the Consortium on Safe Labor study (2002-2008). Oligohydramnios was recorded in the medical chart. We evaluated perinatal outcomes. We limited the analysis to women with an unfavorable cervix defined by simplified Bishop score ≤ 4. Misoprostol was compared with prostaglandin E2. Women could have received oxytocin, underwent mechanical dilation, or had artificial rupture of membranes, but women who underwent induction with both misoprostol and prostaglandin E2 were excluded. We calculated adjusted odds ratios with 95% confidence intervals, controlling for maternal age, maternal body mass index (kg/m2), parity, and mechanical dilation. Results Among women with oligohydramnios and an unfavorable cervix who underwent induction of labor, 141 (39.4%) received misoprostol and 217 (60.6%) received prostaglandin E2. There were no significant differences in cesarean delivery, chorioamnionitis, postpartum hemorrhage, transfusion, neonatal intensive care unit (NICU) admission, NICU stay > 72 hours, mechanical ventilation, and neonatal sepsis. Conclusion In women with oligohydramnios and an unfavorable cervix, induction of labor with misoprostol was comparable to prostaglandin E2.

Duration of Oxytocin and Rupture of the Membranes Before Diagnosing a Failed Induction of Labor.

OBJECTIVE: To compare maternal and neonatal outcomes based on length of the latent phase during induction with rupture of membranes before 6 cm dilation. METHODS: This is a retrospective cohort study using data from the Consortium of Safe Labor study, including 9,763 nulliparous and 8,379 multiparous women with singleton, term pregnancies undergoing induction at 2 cm dilation or less with rupture of membranes before 6 cm dilation after which the latent phase ended. Outcomes were evaluated according to duration of oxytocin and rupture of membranes. RESULTS: At time points from 6 to 18 hours of oxytocin and rupture of membranes, the rates of nulliparous women remaining in the latent phase declined (35.9-1.4%) and the rates of vaginal delivery for those remaining in the latent phase at these time periods decreased (54.1-29.9%) Nulliparous women remaining in the latent phase for 12 hours compared with women who had exited the latent phase had significantly increased rates of chorioamnionitis (12.1% compared with 4.1%) and endometritis (3.6% compared with 1.3%) and increased rates of neonatal intensive care unit admission (8.7% compared with 6.3%). Similar patterns were present for multiparous women at 15 hours. CONCLUSION: Based on when neonatal morbidity increased, in an otherwise uncomplicated induction of labor with rupture of membranes, a latent phase after initiation of oxytocin of at least 12 hours for nulliparous women and 15 hours in multiparous women is a reasonable criterion for diagnosing a failed induction.