Patients' perspectives regarding induction of labor in the absence of maternal and fetal indications: are our patients ready for the ARRIVE trial?

BACKGROUND: After careful review of the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) data, induction of labor prior to one's due date in the absence of maternal and fetal indications (which the American College of Obstetricians and Gynecologists currently refers to as "elective") is now endorsed as a "reasonable" option by the American College of Obstetricians and Gynecologists (ACOG). As a result, there has been much discussion among providers regarding how best to operationalize this ACOG recommendation into shared decision making regarding delivery planning. However, we lack a formal understanding of the perspectives of patients themselves on this topic. OBJECTIVE: To assess patient understanding and preference for induction of labor prior to one's due date. MATERIALS AND METHODS: We conducted an anonymous, cross-sectional survey of women in their third trimester of pregnancy presenting for routine obstetric care in August 2018. The survey included a series of questions designed to assess basic demographics, obstetric history, and patient understanding and opinions about the practice of induction of labor, with a focus on induction of labor prior to one's due date in the absence of maternal and fetal indications. RESULTS: A total of 108 women were approached for participation, and 100 women participated in this survey (93% participation). Of the participants, 99% were supportive of induction of labor for fetal indications, and 96% were supportive for maternal indications prior to one's due date. In contrast, 54% of participants were not interested in induction of labor in the absence of maternal and fetal indications prior to one's due date. Women opposed to induction of labor in the absence of maternal and fetal indications were almost 4 times more likely to be concerned about the possibility that induction of labor in the absence of maternal and fetal indications could cause fetal harm (odds ratio, 3.9; confidence interval, 1.2-13.2). CONCLUSION: Nearly all women surveyed in our pilot study were interested in induction of labor prior to one's due date for maternal or fetal indications. 46% of those surveyed were interested in induction of labor in the absence of maternal and fetal indications prior to their due date. Concern about potential fetal harm was more likely among women opposed to induction of labor in the absence of maternal and fetal indications. As providers discuss delivery planning with their patients, these results may provide a useful context for operationalizing and individualizing the results of the ARRIVE trial for their patients.

Instagram Users' Experiences of Miscarriage.

OBJECTIVE: To explore the shared experiences of miscarriage using a qualitative analysis of social media posts on Instagram. METHODS: We performed this qualitative study by collecting text, photos, hashtags, and emoji from 200 Instagram posts on five arbitrarily selected days in 2019. Key eligibility criteria included posts that described a personal experience of miscarriage and that used the hashtag #ihadamiscarriage. Through directed content analysis, our multidisciplinary team conducted open coding to identify common topics in the data, developed a code book, and coded all posts. Twenty-five percent of posts were double-coded by two team members and analyzed for agreement. The codes were organized into overarching themes. RESULTS: Intercoder reliability was excellent (kappa 0.95). Themes included medical and physical experiences of miscarriage, social experiences of miscarriage, the emotional spectrum of experiencing a miscarriage, family identity and the effects of miscarriage, and mechanisms of processing and coping through a miscarriage. We observed complex and often conflicted emotional states and noted that the effects of miscarriage were felt for months and years by many Instagram users. Use of social media and disclosure of miscarriage was a source of coping for many users. CONCLUSION: Women post about their miscarriages on social media for a variety of reasons, especially to find support and community and to help break the silence around miscarriage. Health care providers may consider discussing use of this platform as a support and coping mechanism in the setting of pregnancy loss.

Expedited Scheduling of Interval Tubal Ligation: A Randomized Controlled Trial.

OBJECTIVE: To assess whether expedited scheduling for permanent contraception increases the proportion of patients completing interval tubal ligation within 6 months of delivery. METHODS: We randomly assigned patients with unfulfilled immediate postpartum tubal ligation requests to standard scheduling after a postpartum office visit or an expedited process in which we scheduled the interval tubal ligation surgery before discharge from the hospital. The primary outcome was proportion of participants undergoing tubal contraceptive procedures within 6 months of delivery. Secondary outcomes included patient satisfaction with the scheduling process, repeat pregnancy rates, and surgical outcomes. We estimated that 122 patients (61 per group) would provide greater than 80% power to identify a 25% difference favoring expedited scheduling in the primary outcome (one-sided α of 0.05). RESULTS: Between September 2016 and June 2018, 239 patients requested tubal ligation at the time of delivery; 155 were not completed. Of these, 126 patients were eligible for the study. We stopped the study at the prespecified 50% enrollment point after 67 patients enrolled, with 34 and 33 assigned to the standard and expedited arms, respectively. Fifteen participants in the expedited group, and two in the standard group completed tubal ligation within 6 months (50% vs 9%; odds ratio 10.0, CI 2.0-50.2). Delivery-to-surgery interval was 49 days in the expedited group, compared with 121 days in the standard group (P=.05). Seventeen participants in the expedited group and three in the standard group reported being very satisfied with the scheduling process (57% vs 13%, P=.03). The only two interim pregnancies both occurred in the standard group (P=.09). There were no surgical complications in any of the 17 completed tubal procedures. CONCLUSION: Expedited scheduling significantly improves tubal contraceptive surgery completion and patient satisfaction. Laparoscopic or hysteroscopic tubal ligation or salpingectomy can be performed 4-6 weeks after delivery with minimal interval outpatient follow-up. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02875483.

Potentially avoidable inter-hospital transfer for gynaecology consultation at a tertiary care centre: a retrospective study.

Inter-hospital transfers for consultation are common and costly in the USA. Our objective was to evaluate the inter-hospital transfers between the emergency departments (ED) for a gynaecology consultation and to identify markers for potentially avoidable transfers. We performed a retrospective chart review of all transfers accepted by a tertiary care hospital gynaecology service via the ED over two years. Our primary outcome was the designation of the transfer as 'potentially avoidable', defined as a patient discharged home directly from the ED, with no workup or treatment prior to their discharge. The Chi-square tests were used to assess what patient characteristics and medical diagnoses are associated with potentially avoidable transfers. Of 156 patients meeting the inclusion criteria, a total of 38 (24.4%) were potentially avoidable transfers. Women with potentially avoidable transfers were more likely to be pregnant than those whose transfers were necessary (63.2% vs. 40.7% p = .02), and more likely to specifically have a pregnancy of unknown location (PUL) or a complete abortion (p < .01).

Identifying Risk Factors for Not Breastfeeding: The Interaction of Race and Economic Factors: A Case for Seeking a Local Perspective.

Breastfeeding rates in the United States continue to rise, but still fall short of goals for both initiation and continuation. Many different maternal demographic characteristics have been identified as risk factors for not breastfeeding, but the literature remains inconsistent. National and even state-level data may not reflect patterns seen at the local level. Clinicians and breastfeeding advocates should be aware of the general trends, but should more importantly become familiar with the predominant risk patterns in their local area and populations. This presentation for the Breastfeeding Summit reports on our findings regarding the influence of race and economic status on breastfeeding behavior among women in inner city Philadelphia, and makes a case for advocates and clinicians to explore these trends in their own, local populations.

Utilizing V-Y fasciocutaneous advancement flaps for vulvar reconstruction.

OBJECTIVES: We aimed to analyze the outcomes of patients who underwent vulvectomy with subsequent V-Y fasciocutaneous flap reconstruction. METHODS: All medical records of all patients who underwent vulvectomies with V-Y fasciocutaneous flap reconstruction from January 2007 to June 2016 were retrospectively reviewed. Patient clinical and surgical data, demographics, and outcomes were abstracted. RESULTS: Of the 27 patients, 42 flaps were transferred. A simple vulvectomy was performed in 8 (30%) patients, partial radical vulvectomy in 15 (56%), and radical vulvectomy in 4 (15%). The median area of defect was 30 cm2. Minor wound separations occurred in 9 patients (33%). Infectious complications occurred in 4 patients (15%); this included urinary tract infections in 2 (50%), postoperative fevers in 2 (50%), and sepsis in 1 (25%) patient with a UTI. There were no instances of flap necrosis, wound dehiscence, or wound infections. Black race was more likely to be associated with an infectious complication with 3 (75%) patients, compared to white race with 1 (4%) patient (p < .01). The presence of diabetes was more likely to be associated with an infectious complication in 2 (67%) patients, compared to 1 (4%) in non-diabetic patients (p < .01). No other significant association was found during analysis of demographics, medical comorbidities, vulvar pathology, or surgical factors affecting V-Y fasciocutaneous flap infectious complications or minor wound separations. CONCLUSIONS: The use of a V-Y fasciocutaneous advancement flap for vulvar reconstruction is safe and associated with mostly minor complications. Infectious complications were more frequently associated with diabetes, black race, and HIV.

Differences in Breastfeeding Among Medicaid and Commercially Insured Patients: A Retrospective Cohort Study.

BACKGROUND: While breastfeeding rates have been increasing in the United States, they remain below targets set by multiple public health organizations. Lower rates are associated with certain demographic groups. We performed a retrospective chart review to examine rates of breastfeeding at the time of postpartum follow-up in a mixed-race urban cohort. OBJECTIVE: This study was conducted to examine the proportion of women who were breastfeeding at 6-8 weeks postpartum and to determine if these proportions differed by race and insurance status. MATERIALS AND METHODS: We identified women who delivered singleton term infants at an urban university hospital between July and December 2013. Self-reported breastfeeding status at 6-8 weeks postpartum was abstracted for all women who completed postpartum follow-up visits. Data were analyzed with logistic regression to compare rates of any or exclusive breastfeeding between women with Medicaid and private insurance. RESULTS: Charts of 656 women were reviewed; 405 women completed postpartum follow-up within 8 weeks. The Medicaid population had significantly lower rates of breastfeeding even after accounting for interaction and confounding by demographic factors (any breastfeeding odd ratio [OR] 0.53, confidence interval [CI] 0.04-0.31; exclusive breastfeeding OR 0.48, CI 0.33-0.85). When stratified by race, white women on Medicaid had the lowest probability of breastfeeding of all groups (p < 0.01). CONCLUSIONS: Among patients delivering at an urban academic hospital, women on Medicaid were significantly less likely to breastfeed than those with private insurance. The greatest differential by insurance was seen among white women. Efforts to improve breastfeeding should focus on low-income women of all races.

Impact of Peanut Ball Device on the Duration of Active Labor: A Randomized Control Trial.

OBJECTIVE: To evaluate whether the use of a peanut ball device shortens the duration of active labor in nulliparas. STUDY DESIGN: Single-site, nonblinded randomized trial in nulliparous women admitted for labor or labor induction. English-speaking women > 18 years of age with singleton pregnancies were enrolled. Participants were randomized to the use of peanut ball or usual care upon reaching the active phase of labor (≥ 6 cm cervical dilation) with an epidural. Primary outcome was rate of cervical dilation. Secondary outcomes were rates of cesarean delivery and fetal presentation at time of full dilation or delivery. RESULTS: Ninety-six patients enrolled; 63 reached full cervical dilation. There was no statistically significant difference in rates of cervical dilation (0.98cm/h vs. 0.79cm/h, p = 0.27) or length of labor (315 minutes vs. 387 minutes, p = 0.14) between the groups. There was no difference in the rates of cesarean delivery (33% vs. 35%, p = 0.8) or occiput posterior presentation. (28% vs. 9%, p = 0.09). Among the subgroup who had labor arrest, fewer patients using the peanut ball experienced arrest of dilation; this approached but did not reach statistical significance (30% vs. 73% p = 0.05). CONCLUSION: Use of the peanut ball does not significantly increase rates of cervical dilation or decrease time in active labor.

Physician and Nurse Perceptions of Gentle Cesarean Birth.

BACKGROUND: Protocols for neonatal care and mother-baby interaction at cesarean birth frequently differ from those at vaginal birth. There is increasing interest in adopting family-friendly or gentle protocols for women having cesarean birth. Current evidence suggests challenges in achieving interdepartmental cooperation and consensus are potential barriers to implementing gentle cesarean protocols. PURPOSE: To describe how care providers' professional role and characteristics may affect perception about gentle cesarean birth techniques and inform specific concerns about protocol changes. STUDY DESIGN AND METHODS: A cross-sectional survey with mixed-methods analysis incorporating quantitative and qualitative conventional content analysis was used. A structured survey was distributed via email to all care providers on the labor and birth unit, including attending physicians, resident physicians in training, fellows, labor nurses, respiratory therapists, and operating room technicians. Quantitative responses were analyzed with bivariable tests and logistic regression to describe associations between provider attitudes and provider characteristics. Open-ended responses were analyzed with conventional content analysis to develop a model describing influences on overall provider attitudes. RESULTS: Physicians and nurses generally have positive attitudes on benefits of gentle cesarean techniques. Their perceptions overall are informed by the balance of concerns about patient safety and logistical challenges versus perceived benefits of the techniques. On an individual level, care provider demographic and professional characteristics of gender and prior experience affected attitudes more than their specific role in patient care. CLINICAL IMPLICATIONS: Most labor and birth care providers have positive attitudes about gentle cesarean birth. Implementation of such programs should prioritize patient safety, educate physician and nurses about potential benefits for patients, and use experienced physicians and nurses as ambassadors to increase acceptance.

The activity of the Drosophila Vestigial protein is modified by Scalloped-dependent phosphorylation.

The Drosophila vestigial gene is required for proliferation and differentiation of the adult wing and for differentiation of larval and adult muscle identity. Vestigial is part of a multi-protein transcription factor complex, which includes Scalloped, a TEAD-class DNA binding protein. Binding Scalloped is necessary for translocation of Vestigial into the nucleus. We show that Vestigial is extensively post-translationally modified and at least one of these modifications is required for proper function during development. We have shown that there is p38-dependent phosphorylation of Serine 215 in the carboxyl-terminal region of Vestigial. Phosphorylation of Serine 215 occurs in the nucleus and requires the presence of Scalloped. Comparison of a phosphomimetic and non-phosphorylatable mutant forms of Vestigial shows differences in the ability to rescue the wing and muscle phenotypes associated with a null vestigial allele.

Abortion providers, professional identity, and restrictive laws: A qualitative study.

Most studies on the impact of restrictive abortion laws have focused on patient-level outcomes. To better understand how such laws affect providers, we conducted a qualitative study of 27 abortion providers working under a restrictive law in North Carolina. Providers derived professional identity from their motivations, values, and experiences of pride related to abortion provision. The law affected their professional identities by perpetuating negative characterizations of their profession, requiring changes to patient care and communication, and creating conflicts between professional values and legal obligations. We conclude that a holistic understanding of the impact of abortion laws should include providers' perspectives.

TRAP laws and the invisible labor of US abortion providers.

Targeted Regulations of Abortion Providers (TRAP laws) are proliferating in the United States and have increased barriers to abortion access. In order to comply with these laws, abortion providers make significant changes to facilities and clinical practices. In this article, we draw attention to an often unacknowledged area of public health threat: how providers adapt to increasing regulation, and the resultant strains on the abortion provider workforce. Current US legal standards for abortion regulations have led to an increase in laws that target abortion providers. We describe recent research with abortion providers in North Carolina to illustrate how providers adapt to new regulations, and how compliance with regulation leads to increased workload and increased financial and emotional burdens on providers. We use the concept of invisible labor to highlight the critical work undertaken by abortion providers not only to comply with regulations, but also to minimize the burden that new laws impose on patients. This labor provides a crucial bridge in the preservation of abortion access. The impact of TRAP laws on abortion providers should be included in the consideration of the public health impact of abortion laws.

The experiences and adaptations of abortion providers practicing under a new TRAP law: a qualitative study.

OBJECTIVE: Abortion laws are proliferating in the United States, but little is known about their impact on abortion providers. In 2011, North Carolina instituted the Woman's Right to Know (WRTK) Act, which mandates a 24-h waiting period and counseling with state-prescribed information prior to abortion. We performed a qualitative study to explore the experiences of abortion providers practicing under this law. STUDY DESIGN: We conducted semistructured interviews with 31 abortion providers (17 physicians, 9 nurses, 1 physician assistant, 1 counselor and 3 clinic administrators) in North Carolina. Interviews were audio-recorded and transcribed. Interview transcripts were analyzed using a grounded theory approach. We identified emergent themes, coded all transcripts and developed a thematic framework. RESULTS: Two major themes define provider experiences with the WRTK law: provider objections/challenges and provider adaptations. Most providers described the law in negative terms, though providers varied in the extent to which they were affected. Many providers described extensive alterations in clinic practices to balance compliance with minimization of burdens for patients. Providers indicated that biased language and inappropriate content in counseling can negatively impact the patient-physician relationship by interfering with trust and rapport. Most providers developed verbal strategies to mitigate the emotional impacts for patients. CONCLUSIONS: Abortion providers in North Carolina perceive WRTK to have a negative impact on their clinical practice. Compliance is burdensome, and providers perceive potential harm to patients. The overall impact of WRTK is shaped by interaction between the requirements of the law and the adaptations providers make in order to comply with the law while continuing to provide comprehensive abortion care. IMPLICATIONS: Laws like WRTK are burdensome for providers. Providers adapt their clinical practices not only to comply with laws but also to minimize the emotional and practical impacts on patients. The effects on providers, frequently not a central consideration, should be considered in ongoing debates regarding abortion regulation.

Intrauterine lidocaine for pain control during laminaria insertion: a randomized controlled trial.

OBJECTIVE: To determine if intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block reduces pain during laminaria insertion, when compared with paracervical block and saline placebo. STUDY DESIGN: This was a randomized, double blind placebo-controlled trial. Women presenting for abortion by dilation and evacuation (D&E) at 14-24 weeks gestational age were randomized to receive an intrauterine instillation of either 5 mL of 2% lidocaine or 5 mL of normal saline, in addition to standard paracervical block with 20 cc of 0.25% bupivacaine. Our primary outcome was self-reported pain scores on a 100mm Visual Analogue Scale (VAS) immediately following laminaria insertion. Secondary outcome was self-reported VAS pain score indicating the maximum level of pain experienced during the 24-48-h interval between laminaria insertion and D&E procedure. RESULTS: Seventy-two women were enrolled, and data for 67 women were analyzed, only two of whom were more than 21 weeks on gestation. The range of pain scores at both time points was large (1-90 mm at laminaria insertion; 0-100mm in laminaria-D&E interval). Mean pain scores were not different between treatment groups at laminaria insertion, (33 vs. 32, p=.8) or in the laminaria - D&E interval (43 vs. 44, p=.9). CONCLUSION: Intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block did not reduce pain with laminaria insertion when compared to paracervical block with saline placebo. IMPLICATIONS: Intrauterine lidocaine combined with paracervical block does not improve pain control at laminaria insertion when compared with paracervical block and saline placebo. Wide variation in pain scores and persistent pain after laminaria insertion suggests patient would benefit from more effective methods of pain control at laminaria insertion and during the post-laminaria interval.

Intrauterine anesthesia for gynecologic procedures: a systematic review.

OBJECTIVE: To assess the effectiveness of intrauterine local anesthesia in reducing pain associated with outpatient gynecologic procedures. DATA SOURCES: We searched online databases PubMed or MEDLINE, Embase, Google Scholar, and Clinicaltrials.gov and hand-searched reference lists from reviews evaluating pain-control methods for gynecologic office procedures. We identified randomized controlled trials using intrauterine local anesthetic in gynecologic procedures. METHODS: Titles and abstracts were screened for 1,236 articles. We identified 45 potential articles for inclusion. We excluded 22 of these studies because: 1) they were not randomized controlled trials; 2) they did not describe a quantifiable dose of medication used in the study; 3) they did not investigate an intrauterine anesthetic; 4) they did not study a potentially awake, outpatient procedure; and 5) they did not clearly report results or represented duplicate publication. Twenty-three articles were ultimately included for review. TABULATION, INTEGRATION, AND RESULTS: Two authors independently reviewed full search results and assessed eligibility for inclusion and independently abstracted data from all articles that met criteria for inclusion. Disagreements regarding eligibility or abstraction data were adjudicated by a third independent person. Our primary end point was the reported effect of intrauterine local anesthesia on patient-reported pain scores. As a result of heterogeneity in study methods, outcome measures, and reporting of outcomes, results could not be combined in a meta-analysis. Good evidence supports use of intrauterine anesthesia in endometrial biopsy and curettage, because five good-quality studies reported reduced pain scores, whereas only one good-quality study reported negative results. We found moderate evidence to support intrauterine anesthesia in hysteroscopy, because one good-quality study and two fair or poor quality studies reported reduced pain scores, whereas two good-quality studies had negative results. Good evidence suggests that intrauterine anesthesia is not effective in hysterosalpingography; three good-quality studies reported that pain scores were not reduced, and no good quality studies showed a beneficial effect in that procedure. Evidence was insufficient concerning first-trimester abortion, saline-infusion ultrasonogram, tubal sterilization, and intrauterine device insertion. CONCLUSION: Intrauterine local anesthesia can reduce pain in several gynecologic procedures including endometrial biopsy, curettage, and hysteroscopy and may be effective in other procedures as well.