The use of the Cervilenz device to aid in the diagnosis of premature labor.

OBJECTIVE: A short cervix measured by transvaginal ultrasound has been correlated with increased risk for preterm delivery (PTD). Many patients presenting with a complaint of possible premature labor (PL); may not have access to cervical length (CL) screening by ultrasound. Cervilenz is an FDA cleared disposable device for obtaining vaginal CL measurements. This study was conducted to correlate Cervilenz measurements of CL with the occurrence of PTD. METHODS: Women presenting with regular uterine contractions at gestational age (GA) ≥22 and <34 weeks with intact membranes and cervical dilation <3 cm were recruited. A speculum examination was performed and Cervilenz measurement of CL was obtained. Patients were treated with tocolytics and/or corticosteroids based upon the attending physician's judgment. The occurrences of PTD as a result of PL or premature rupture of membranes within 7 days, <32 weeks, <34 weeks and <37 weeks, were determined. Patients who were delivered preterm for other maternal or fetal indications were excluded. Negative predictive value (NPV) was calculated. RESULTS: Of the 220 women recruited, 20 were subsequently excluded from analysis because they required PTD for unrelated indications. The mean GA at enrollment was 29.8 ± 2.8 (SD) weeks. One (0.5%), 2 (1.0%), 4 (2.0%) and 29 (14.5%) women delivered at ≤7 days from enrollment, ≤32 weeks, ≤34 weeks, and ≤37 weeks, inclusively. Seventy-seven (38.5%), 39 (19.5%) and 19 (9.5%) women had Cervilenz measurement of ≤30, ≤25 and ≤20 mm, respectively. The NPV for a Cervilenz measurement of >20 mm for delivery at, ≤32, ≤34 and ≤37 weeks were 99.2%, 98.3% and 86.7%, respectively. CONCLUSION: Cervilenz measurement >20 mm appears to have high NPV for PTD prior to 34 weeks.

Successful pregnancy following both endometrial ablation and uterine artery embolization.

OBJECTIVE: To present a description of the management of a pregnancy in a woman who had undergone endometrial ablation and uterine artery embolization for fibroids. DESIGN: Case report. SETTING: Division of Maternal Fetal Medicine within a tertiary community-based teaching hospital. PATIENT(S): A 43-year-old G2P1 woman who had undergone a hydrothermal ballon ablatation and a bilateral, nonselective embolization. INTERVENTION(S): Management of a high-risk pregnancy. MAIN OUTCOME MEASURE(S): Successful pregnancy. RESULT(S): The patient was prophylactically treated with 250 mg of 17 alpha-hydroxyprogesterone intramuscularly weekly, beginning at 16 weeks gestation, received a rescue McDonald cerclage at 22 weeks and 4 days, and remained on modified bed rest at home. Ultrasonically estimated fetal weights were in the 30th to 40th percentile. At 35 4/7th weeks she presented with uterine pain. Ultrasound revealed fundal elevation of the amniotic membranes, estimated fetal weight had decreased to the 20th percentile and a biophysical profile score of 4/10 was obtained. A cesarean resulted in the delivery of a vigorous infant weighing 2466 g. CONCLUSION(S): With aggressive therapy, successful pregnancy is possible in similar patients.

Evaluation and development of potentially better practices for perinatal and neonatal communication and collaboration.

OBJECTIVE: The obstetric and neonatal exploratory focus group of the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative 2002 set out to improve collaboration, communication, and coordination between maternal and neonatal caregivers in 3 areas: the pregnancy at 22 to 26 weeks, measurement of maternal outcomes that are linked with neonatal outcomes, and team performance during high-risk delivery. Antepartum and intrapartum maternal attributes and interventions also were considered important measurements to identify practice variations and their relationship to neonatal outcomes for ongoing obstetric and neonatal collaboration. METHODS: Potentially better practices were developed on the basis of evidence in the literature, expert opinion, and internal analysis at the participating perinatal centers. The potentially better practices include development of local guidelines at each center for the care and counseling of pregnant women who are at risk for delivering at the margin of viability; communication strategies for obstetric and neonatology providers relating to high-risk pregnancy treatment plans; team communication and performance at high-risk deliveries; design of organizational structures and processes that facilitate obstetric and neonatal collaboration; and development of perinatal data to evaluate effects of perinatal practices on maternal, fetal, and neonatal outcomes. RESULTS: As a result of the project, participating centers developed local guidelines for pregnancies between 22 and 26 weeks, created a cross-center maternal database that currently is being linked to neonatal outcomes, and completed a pilot study on video simulation of neonatal-perinatal team communication. CONCLUSIONS: Increased understanding of practice variation in the management of care for infants who are at the margins of viability, locally developed guidelines, and a focus on improved team communication during delivery can be accomplished with a multicenter collaborative approach.

Implementation and case-study results of potentially better practices for collaboration between obstetrics and neonatology to achieve improved perinatal outcomes.

OBJECTIVE: The objective of this study was to make improvements in communication and collaboration between neonatal and obstetric specialties. Five NICUs from the Vermont Oxford Network's Evidence-Based Quality Improvement Collaborative in Neonatal and Perinatal Medicine tested potentially better practices that overlap obstetric and NICU care. METHODS: One area of practice improvement was the management of the pregnancy at the margin of viability. Another included the use of team training and video simulation to improve team performance during high-risk deliveries using aviation-based communication techniques. Another focus of the collaborative was the creation of a multicenter database to measure combined perinatal and neonatal outcomes. RESULTS: The principle outcomes are increased patient satisfaction with teamwork between neonatology and obstetric services and improved team response times for emergent deliveries and the increased use of team communication skills during video simulations of high-risk deliveries. CONCLUSIONS: Implementing these potentially better practices can result in improved communication and collaboration related to perinatal and neonatal care.

Management of high-order multiple births: application of lessons learned because of participation in Vermont Oxford Network collaboratives.

OBJECTIVES: The delivery and care of sextuplets is complex. Potentially better practices that were developed as part of the Vermont Oxford Network improvement collaboratives were used to prepare for a sextuplet delivery at Akron Children's Hospital. METHODS: The team used potentially better practices that were learned from the Neonatal Intensive Care Quality Improvement Collaborative 2002 using multidisciplinary teams. There was extensive media coverage of the delivery. RESULTS: The goal was to use nearly all potentially better practices that focused on the goals of reducing nosocomial infection, reducing chronic lung disease, reducing radiograph use, reducing length of stay, reducing blood gas use, promoting nutrition, reducing intraventricular hemorrhage, and enriching family-centered care. The center aimed to use these 97 potentially better practices. Of the 97 possible potential better practices as set by the Neonatal Intensive Care Quality Improvement Collaborative 2002, 96 (99%) were used. CONCLUSIONS: This is a blueprint that any center that is faced with high-order multiple births could use as a reference point to begin planning. The team created a benchmark to achieve in every birth of very low birth weight infants and not just a special situation of high-order multiple births.

Attitudes of obstetric and pediatric health care providers toward resuscitation of infants who are born at the margins of viability.

OBJECTIVES: The objective of this study was to determine the attitudes of a variety of health care providers toward the recommendations that should be made to parents regarding the resuscitation of infants who are born at the margins of viability. METHODS: A written questionnaire was distributed to the medical and nursing staff at 4 tertiary perinatal centers. For each of 5 weekly gestational age intervals from 22 weeks to 26 weeks, 6 days, the health care providers were asked to describe on a scale from 1 to 5 whether they would strongly discourage through strongly encourage resuscitation. They also were queried regarding their comfort with counseling regarding these issues. The attitudes of various groups of providers were compared across weekly intervals. RESULTS: A total of 204 physicians and 539 nurses completed the survey. The majority would strongly discourage, either discourage or strongly discourage, be neutral or recommend, recommend or strongly recommend, and strongly recommend resuscitation during the 23rd, 24th, 25th, 26th, and 27th weeks of gestation, respectively. Obstetric caregivers were slightly less likely than pediatric caregivers to strongly discourage resuscitation from 22 weeks to 22 weeks, 6 days and 23 weeks to 23 weeks, 6 days. There were no significant differences in the recommendations of obstetricians and pediatricians. Pediatric nurses were more likely to strongly recommend resuscitation from 26 weeks to 26 weeks, 6 days and more likely either to discourage or to strongly discourage resuscitation from 23 weeks to 23 weeks, 6 days and to strongly discourage resuscitation from the 22 weeks to 22 weeks, 6 days than their obstetric counterparts. Obstetric nurses were slightly less likely than obstetricians to strongly recommend resuscitation at 26 weeks to 26 weeks, 6 days and less likely to strongly discourage resuscitation from 22 weeks to 22 weeks, 6 days. CONCLUSIONS: The caregivers' recommendations seem to be based logically on the current literature regarding survival and morbidity that is experienced by infants who are born at the threshold of viability. Although there are minor differences, there was a relatively consistent approach among professional groups.

A state-wide assessment of the obstetric, anesthesia, and operative team personnel who are available to manage the labors and deliveries and to treat the complications of women who attempt vaginal birth after cesarean delivery.

OBJECTIVE: The purpose of this study was to determine on a state-wide basis the range of obstetric, anesthesia, and surgical team personnel who were available immediately to manage the labors and deliveries of women who attempted vaginal birth after cesarean delivery. Additionally, we tried to determine whether hospitals had stopped performing vaginal births after cesarean delivery or made changes in their policies regarding vaginal birth after cesarean delivery as a result of recent American College of Obstetricians and Gynecologists recommendations. STUDY DESIGN: Available immediately was defined as "being present in the hospital." All hospitals that provided obstetric care in the State of Ohio were surveyed to determine whether an obstetrician with cesarean privileges, an anesthesiologist, or an anesthetist capable of independently administering anesthesia for a cesarean section, and a surgical team were available immediately when women attempted vaginal birth after cesarean delivery. The hospitals were also asked whether they had stopped allowing vaginal births after cesarean delivery or had made changes in their vaginal birth after cesarean delivery policies in response to the recent recommendations of the American College of Obstetricians and Gynecologists. Data were computerized and analyzed by the chi(2) test. RESULTS: Seventy-seven (93.9%), 35 (100%), and 13 (100%) of level I, II, and III hospitals performed vaginal births after cesarean delivery. An obstetrician was immediately available in 27.3%, 62.9%, and 100% of level I, II, and III institutions, respectively (P