An evidence-based oxytocin protocol for the third stage of labor to improve hemorrhage outcomes.

OBJECTIVE: To assess the use of an evidence-based oxytocin protocol for management of the third stage of labor to decrease non-beneficial clinical variation and improve clinical outcomes. DESIGN: This is a cohort study of pregnant patients delivering before implementation of an evidence-based oxytocin protocol compared to patients delivering after implementation of an evidence-based oxytocin protocol. SETTING: A level III maternal care referral hospital with an average delivery volume of approximately 3000 deliveries. PARTICIPANTS: Pregnant patients delivering over a 60-month period from January 2013 to December 2017. INTERVENTION: An evidence-based oxytocin protocol: 3 units of oxytocin administered over 3 minutes, with a second 3-unit bolus if inadequate tone, then oxytocin infusion at 18 units/hour × 1 hour and then 3.6 units/hour for 3 hours. MAIN OUTCOME MEASURES: Postpartum hemorrhage (PPH) rate (EBL ≥500 ml for vaginal and ≥1000 ml for cesarean). RESULTS: Data from 14 603 deliveries were analyzed, 8408 pre-protocol and 6195 post-protocol. We demonstrated a significant decrease in PPH from 5.2% to 2.9% (P < 0.001) and a small but non-significant increase in the transfusion rate from 1.8% to 2.3% (P = 0.11). CONCLUSION: A standardized oxytocin infusion protocol in the third stage of labor resulted in a significant decrease in PPH for both vaginal and cesarean deliveries.

Practice Variation in Regional Anesthesia Utilization by Current and Former U.S. Military Anesthesiology Residents.

INTRODUCTION: Per Joint Trauma System guidelines, military anesthesiologists are expected to be ready to lead an Acute Pain Service with regional anesthesia in combat casualty care. However, regional anesthesia practice volume has not been assessed in the military. The objective of this study was to assess regional anesthesia utilization among current residents and graduates of U.S. military anesthesiology residency programs. MATERIALS AND METHODS: All current and former active duty military anesthesiology program residents, trained at any of the four military anesthesiology residency programs between 2013 and 2019, were anonymously surveyed about their regional anesthesia practice. Bivariate statistics described the total single-injection and catheter block techniques utilized in the last month. Cluster analysis assessed for the presence of distinct practice groups within the sample. Follow-up analyses explored potential associations between cluster membership and other variables (e.g., residency training site, residency graduation year, overall confidence in performing regional anesthesia, etc.). This protocol received exemption determination separately from each site's institutional review board. RESULTS: Current and former residents reported broad variation in regional anesthesia practice and clustered into four distinct practice groups. Less than half of respondents utilized a moderate to high number of different single-injection and catheter blocks. CONCLUSIONS: These findings highlight the need for creative solutions to increase regional anesthesia training in military anesthesiology programs and continued ability to implement skills, such that all military anesthesiologists have adequate practice for deployed responsibilities.

Association of obstructive sleep apnea with adverse pregnancy-related outcomes in military hospitals.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with significant morbidity and mortality in non-obstetrical and obstetrical patients. OBJECTIVES: To estimate the prevalence of OSA and its relationship with pregnancy-related complications in a general obstetric population of Department of Defense beneficiaries receiving direct-care at military treatment facilities. STUDY DESIGN: A retrospective cohort study of all women (N=305,001) who gave birth at a military treatment facility from 2008 to 2014. OSA cases were randomly selected and matched on age (3:1 ratio) to non OSA cases. Multivariable logistic regression was used to examine the risks of adverse pregnancy outcomes (cesarean delivery, gestational diabetes, gestational hypertension, preeclampsia, postoperative wound complications, hospital stay greater than five days, acute renal failure, pulmonary edema, preterm delivery, poor fetal growth, and stillbirth) between pregnant women with and without a diagnosis of OSA. Cases were identified using ICD-9 codes, while controlling for demographics, obesity, and medical comorbidities associated with OSA and the outcomes of interest. RESULTS: We identified 266 cases of OSA (OSA rate=8.7 per 10,000; increased from 6.4 to 9.9 per 10,000 from 2009 to 2013). OSA was associated with a higher odds of cesarean delivery (AOR,1.60; 95% CI, 1.06-2.40), gestational hypertension, (AOR, 2.46; 95% CI, 1.30-4.68), preeclampsia (AOR, 2.42; 95% CI, 1.43-4.09), and preterm delivery (AOR, 1.90; 95% CI, 1.09-3.30). CONCLUSIONS: Obstructive sleep apnea is associated with adverse maternal and fetal outcomes.