Examining the validity of a predictive model for vaginal birth after cesarean.

Background The Maternal-Fetal Medicine Units (MFMU) vaginal birth after cesarean (VBAC) calculator, while accurate for candidates with high predicted success rates, is not as accurate for poor candidates. This study examines the calculator's validity in an understudied multiracial cohort with a high proportion of poor candidates. Methods This retrospective study examined women with one or two prior cesarean deliveries who attempted VBAC at a single institution. Subjects were placed into quartiles based on MFMU-predicted success rates. For each quartile, actual and predicted success rates were compared. The calculated area under the receiver operating characteristic curve (AUC) was compared to the original AUC. Results The study included 1604 women. Actual and predicted VBAC rates were similar in the lowest and highest quartile groups, 18.2% vs. 21.2% (n = 11, P > 0.99) and 87.1% vs. 88.5% (n = 1090, P = 0.14), respectively. In the 51-75% predicted success rate group, the actual VBAC rate was higher than the predicted rate, 69.9% vs. 65.5% (n = 394) but not statistically significant (P = 0.07). In the 25-50% predicted success rate group, the actual VBAC rate was significantly higher than the predicted rate 55.1% vs. 39.6% (n = 109, P = 0.002). The actual AUC was lower than the MFMU model, 0.72 [95% confidence interval (CI) 0.69-0.75] vs. 0.77 (95% CI 0.76-0.78) (P < 0.001). Conclusion The MFMU VBAC calculator's predicted success rates were comparable to actual success rates for candidates with predicted success rates >75%. As predicted success rates declined, the calculator was increasingly inaccurate and underestimated the success rate. Caution should be taken when using the MFMU VBAC calculator for poor candidates.

Cesarean delivery complications in women with morbid obesity.

OBJECTIVE: To compare cesarean complication rates between women with body mass index (BMI) 40-49.9 kg/m(2) and BMI ≥ 50 kg/m(2) and associations with surgical techniques. METHODS: This retrospective cohort study from 2009 to 2014 included women who underwent cesarean with delivery BMI ≥ 50 and an equal number with BMI 40-49.9. Wound infections and/or separations were compared. We also examined wound complication rates between skin closure techniques and self-retaining retractor use. RESULTS: Among 498 patients (249 with BMI ≥ 50 and 249 with BMI 40-49.9) there were no differences in estimated blood loss >1000 mL, blood transfusion, deep vein thrombosis or endometritis. Among those with outpatient follow-up (144 with BMI ≥ 50 and 162 with BMI 40-49.9), those with BMI ≥ 50 had a significantly higher rate of wound separations (p = 0.01) but not infections. There were no differences in wound complication rates between skin closure techniques or self-retaining retractor use, though the study was not powered for these comparisons. CONCLUSION: Wound complications, particularly separations, increase with BMI ≥ 50 compared to a lesser degree of morbid obesity. Skin closure techniques and self-retaining retractor use were not associated with cesarean wound complications in patients with morbid obesity.

Comparison of Primary Cesarean Delivery Rates Among Low-Risk Women in Urban and Rural Hospitals in Hawaii.

Objective The purpose of this study was to examine primary cesarean delivery rates among women with low risk pregnancies in urban and rural hospitals in Hawaii. Methods This is a retrospective study of all low-risk women (term, vertex, singleton) who had a primary cesarean delivery in any Hawaii hospital from 2010 to 2011 using a statewide health information database. Hospitals were divided into two categories: rural and urban. Results Of the 27,096 women who met criteria for this study, 7105 (26.2 %) delivered in a rural hospital. Low-risk women who delivered in a rural hospital had a primary cesarean delivery rate of 18.5 % compared to 11.8 % in the urban hospitals, p < .0001. Low-risk women who delivered at rural hospitals had significantly higher unadjusted and adjusted odds ratios for cesarean delivery. The association with rural hospital was stronger after adjusting for confounders, aOR 2.47 (95 % CI 2.23-2.73) compared to unadjusted OR 1.70 (95 % CI 1.58-1.83) for primary cesarean delivery. Conclusions on practice In a geographically isolated population, rates of primary cesarean delivery among low-risk women are significantly higher in rural hospitals. This disparity should be investigated further.

Improving the Utilization of Human Papillomavirus and Cervical Cytology Co-testing for Cervical Cancer Screening in an Obstetrics and Gynecology Resident Clinic.

Human Papillomavirus (HPV) testing in combination with cervical cytology (HPV co-testing) has been recommended for cervical cancer screening for women 30 to 65 years of age. In several studies, HPV co-testing increased sensitivity for detecting high grade dysplasia and resulted in cost-savings. This retrospective cohort study assessed the prevalence of HPV co-testing in an obstetrics and gynecology resident clinic before and after a brief educational intervention which was designed to reinforce current cervical cancer screening recommendations. The intervention consisted of a short presentation that was given to all residents and medical assistants in October 2011. The proportion of women age 30-65 years of age who had cervical cancer screening with HPV co-testing as compared to cervical cytology alone was compared before and after the intervention using chi-square tests. The goal of the intervention was to increase the percentage of patients receiving co-testing from 0.5% to 7.8%. Each arm (pre- and post-intervention) required 130 subjects to achieve 80% power with a significance of P = .05. No significant differences in demographics including age, insurance type, and cytology were noted. HPV co-testing increased from 0% to 55% (P < .001). Of the 72 subjects who had co-testing, 58 (80%) will not need cervical cancer screening for another 5 years. HPV co-testing represents an underutilized cervical cancer screening modality for women 30 years and older. This brief educational intervention, adaptable to any clinical setting, significatnly increased co-testing at the clinical site.