Effect of previous wedge resection for interstitial pregnancy on pregnancy and neonatal outcomes following frozen-thawed embryo transfer (FET) cycles of IVF/ICSI: a retrospective study.

OBJECTIVE: The present study aimed to evaluate pregnancy and neonatal outcomes in women, with a previous history of wedge resection for interstitial pregnancy, in frozen-thawed embryo transfer (FET) cycles of IVF/ICSI. METHODS: The present study involved a retrospective case-control assessment of 75 cases and 375 control subjects over 6 years in a single center. To compare pregnancy and neonatal outcomes between cases, treated using wedge resection, and controls without any previous history of ectopic pregnancy, propensity score matching (1:5) was utilized. The study also compared subgroups in the case group. RESULTS: Women with previous wedge resection exhibited higher rates of ectopic pregnancy and uterine rupture rate as compared to control subjects (9.1% vs 1.3%, P = 0.025 and 4.5% vs 0%, P = 0.035, respectively). No statistically significant differences were recorded between the two cohorts with regard to clinical pregnancy rate, live birth rate, and neonatal outcomes. For pregnancy type subgroup analysis, Z-score and rates of large for gestational age were recorded to be significantly lower in twin pregnancy subgroup when compared with singleton pregnancy subgroup (0.10 (- 0.59, 0.25) vs 0.50 (- 0.97, 1.39), P = 0.005; 4.5% vs 26.1%, P = 0.047, respectively). CONCLUSION: The results of the present study indicated that previous wedge resection correlated to a higher risk of ectopic pregnancy and uterine rupture. However, it might not be related to an increased risk of adverse neonatal outcomes. The study recommended cesarean section in these patients. Further studies are required to verify the validity of current recommendations.

Effectiveness of emergency obstetric care training at the regional level in Ukraine: a non-randomized controlled trial.

BACKGROUND: Emergency obstetric care training, using Advances in Labour and Risk Management (ALARM) International Program (AIP) was implemented in Ukraine, a country with universal access to skilled perinatal and obstetric care but restricted resources. A total of 577 providers (65.5% of total) from 28 maternal clinics attended a 5-day training session focused on the five main causes of maternal mortality, with hands-on skill workshops, pre- and post- tests, and an objective structured clinical examination. The effects of this emergency obstetric care training on maternal outcomes is the subject of this paper. METHODS: A non-randomized controlled trial was conducted. The pilot areas where the training was implemented consisted of 64 maternity clinics of which 28 were considered as cases and 36 non-participating clinics were the referents. Data on maternal outcomes were collected for a 2-year span (2004-2005) prior to the trainings, which took place 2006-2007 and again after implementation of the trainings, from 2008 to 2009. Information was collected from 189,852 deliveries. Outcomes for the study were incidences of operative delivery and postpartum hemorrhage. Non-parametric statistics, meta-analyses, and difference in difference (DID) estimation were used to assess the effect of the AIP on maternal indices. RESULTS: DID analysis showed that after the training, compared to the referents, the cases had significant reduction of blood transfusions (OR: 0.56; 95%CI: 0.48-0.65), plasma transfusions (OR: 0.70; 95%CI: 0.63-0.78), and uterus explorations (OR: 0.64; 95%CI: 0.59-0.69). We observed a non-significant reduction of postpartum hemorrhage ≥1000 ml (OR: 0.92; 95%CI: 0.81-1.04; P = 0.103). Utilization of vacuum extraction for vaginal delivery increased (OR: 2.86; 95%CI: 1.80-4.57), as well as forceps assisted delivery (OR: 1.80; 95%CI: 1.00-3.25) and cesarean section (OR: 1.11; 95%CI: 1.06-1.17). There was no change in the occurrence of postpartum hysterectomy and maternal mortality. CONCLUSIONS: After one week of Emergency Obstetrics Care training of the obstetric staff in a setting with universal access to perinatal and obstetric care but restricted resources, an association with the reduction of postpartum hemorrhage related interventions was observed. The effects on the use of vacuum extraction and cesarean section were minimal. TRIAL REGISTRATION: Retrospectively registered 071212007807 from 07/12/2012.

Where Have All the Emergencies Gone? The Impact of the COVID-19 Pandemic on Obstetric and Gynecologic Procedures and Consults at a New York City Hospital.

STUDY OBJECTIVE: The purpose of this study was to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical volume and emergency department (ED) consults across obstetrics-gynecology (OB-GYN) services at a New York City hospital. DESIGN: Retrospective cohort study. SETTING: Tertiary care academic medical center in New York City. PATIENTS: Women undergoing OB-GYN ED consults or surgeries between February 1, 2020 and April 15, 2020. INTERVENTIONS: March 16 institutional moratorium on elective surgeries. MEASUREMENTS AND MAIN RESULTS: The volume and types of surgeries and ED consults were compared before and after the COVID-19 moratorium. During the pandemic, the average weekly volume of ED consults and gynecology (GYN) surgeries decreased, whereas obstetric (OB) surgeries remained stable. The proportions of OB-GYN ED consults, GYN surgeries, and OB surgeries relative to all ED consults, all surgeries, and all labor and delivery patients were 1.87%, 13.8%, 54.6% in the pre-COVID-19 time frame (February 1-March 15) vs 1.53%, 21.3%, 79.7% in the COVID-19 time frame (March 16-April 15), representing no significant difference in proportions of OB-GYN ED consults (p = .464) and GYN surgeries (p = .310) before and during COVID-19, with a proportionate increase in OB surgeries (p <.002). The distribution of GYN surgical case types changed significantly during the pandemic with higher proportions of emergent surgeries for ectopic pregnancies, miscarriages, and concern for cancer (p <.001). Alternatively, the OB surgery distribution of case types remained relatively constant. CONCLUSION: This study highlights how the pandemic has affected the ways that patients in OB-GYN access and receive care. Institutional policies suspending elective surgeries during the pandemic decreased GYN surgical volume and affected the types of cases performed. This decrease was not appreciated for OB surgical volume, reflecting the nonelective and time-sensitive nature of obstetric care. A decrease in ED consults was noted during the pandemic begging the question "Where have all the emergencies gone?" Although the moratorium on elective procedures was necessary, "elective" GYN surgeries remain medically indicated to address symptoms such as pain and bleeding and to prevent serious medical sequelae such as severe anemia requiring transfusion. As we continue to battle COVID-19, we must not lose sight of those patients whose care has been deferred.

Bimanual examination for clot evacuation: a retrospective cohort study of women with postpartum haemorrhage after vaginal delivery.

BACKGROUND: Bimanual clot evacuation (BCE) is a simple clinical manoeuvre that may reduce need for surgical intervention in the management of severe postpartum haemorrhage (PPH). We sought to determine whether performing BCE in cases of severe PPH after vaginal birth reduces the need for surgical intervention. METHODS: A retrospective chart review of women who delivered vaginally with a severe PPH between January 1, 2011 and December 31, 2014 in a single tertiary women's hospital in Sydney, Australia was conducted. Severe PPH was classified as a blood loss ≥1000mls. The need for surgical management (including operating theatre uterine exploration or evacuation, intrauterine balloon tamponade, repair of significant trauma, uterine or internal iliac artery ligation, B-Lynch suture insertion or hysterectomy) was the primary outcome measure, as expressed by need for operating theatre utilisation. RESULTS: From a cohort of 438, 149 women (34.0%) had BCE, of whom 29 (19.5%) required surgical management compared to 103 of 289 women with no BCE (35.6%); an odds ratio (OR) of 0.38 for BCE (confidence interval 0.20-0.72; p = 0.003). Early BCE (< 1 h of delivery) was associated with a further reduction in surgery (OR 0.24; confidence interval 0.08-0.70; p = 0.009) compared to late BCE (> 1 h of delivery). There was no reduction in estimated blood loss (p = 0.86) or blood transfusion (p = 0.71) with BCE. CONCLUSION: Our study suggests BCE reduces theatre utilisation in the context of severe PPH following vaginal delivery. Prospective trials are needed to determine whether BCE should be endorsed as a treatment modality for PPH post-vaginal delivery.

[Epidemiological, clinical and therapeutic features of acute pelvic pain in female patients hospitalized in the Yaoundé Gynaecology-Obstetrics and Pediatrics Hospital]. / Aspects épidémiologiques, cliniques et thérapeutiques des algies pelviennes aiguës de la femme à l'Hôpital Gynéco-Obstétrique et Pédiatrique de Yaoundé (HGOPY).

INTRODUCTION: Acute pelvic pain is an important cause of morbi-mortality. The purpose of this study was to describe the epidemiological, clinical and therapeutic features of acute pelvic pain in Yaoundé. METHODS: We conducted a cross-sectional, descriptive study with collection of prospective data in the Department of Gynecology and Obstetrics at the Yaoundé Gynaecology-Obstetrics and Pediatrics Hospital over the period 1st April-31st July 2015. We included all female subjects admitted for pelvic pain whose course was less than one month and who agreed to participate in the study. All women who were in the third trimester of pregnancy or in the post-partum period were excluded. Epi info software, version 3.5.4 was used to analyze data. Data were shown as frequency and percentage. RESULTS: During the study period, a total of 5915 women presented to the Yaoundé Gynaecology-Obstetrics and Pediatrics Hospital, of whom 125 (2.11%) had acute pelvic pain. The average age of patients was 29.5 ± 6.9 years. Pain was caused by upper genital tract infections (36.8%) and ectopic pregnancy (18.4%). Most patients received medical treatment (92.8%), associated with antibiotics in 65.5% of cases, anti-inflammatory drugs in 56.9% of cases and analgesics in 39.7% of cases. Surgery was performed in 25 (20%) patients via laparotomy (80%) and coelioscopy (20%). Surgery was indicated in patients with ectopic pregnancy (76% of cases). Regression of pain was obtained in 99% of cases. CONCLUSION: Acute pelvic pain mainly affected young women with upper genital tract infections and ectopic pregnancy. In the case of ectopic pregnancy surgical treatment via laparotomy was the gold standard treatment.

Risk factors for musculoskeletal disorders in an obstetrician-gynecologist and orthopedic surgeon.

BACKGROUND: Orthopedic and obstetrician-gynecologist (OB/GYN) surgeons have risks for musculoskeletal disorders (MSD) during work in the operating room (OR). Risks for MSD have not been identified as a result of work outside the OR or during non-work tasks. OBJECTIVE: The purpose of the study was to determine risk factors for MSD in an orthopedic and OB/GYN surgeon. METHODS: A case study format and mixed method design were used to gather data by using the Rapid Upper Limb Assessment (RULA) to measure MSD risks in the OR; the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) to measure surgeons' upper extremity disability; observation of surgeon office hours; and semi-structured interviews to gather qualitative data. RESULTS: Both surgeons had risks for MSD during occupational performance outside of work, with some risks similar to those experienced at work. Both surgeons had MSD risks during work inside and outside the OR. Both surgeons experienced MSD symptoms exacerbated by work and non-work tasks. CONCLUSIONS: Identifying and reducing MSD risk should include a comprehensive analysis of occupational performance for orthopedic and OB/GYN surgeons.

Core outcome set for studies investigating management of selective fetal growth restriction in twins.

OBJECTIVE: Selective fetal growth restriction (sFGR) occurs in monochorionic twin pregnancies when unequal placental sharing leads to restriction in the growth of just one twin. Management options include laser separation of the fetal circulations, selective reduction or expectant management, but what constitutes the best treatment is not yet known. New trials in this area are urgently needed but, in this rare and complex group, maximizing the relevance and utility of clinical research design and outputs is paramount. A core outcome set ensures standardized outcome collection and reporting in future research. The objective of this study was to develop a core outcome set for studies evaluating treatments for sFGR in monochorionic twins. METHODS: An international steering group of clinicians, researchers and patients with experience of sFGR was established to oversee the process of development of a core outcome set for studies investigating the management of sFGR. Outcomes reported in the literature were identified through a systematic review and informed the design of a three-round Delphi survey. Clinicians, researchers, and patients and family representatives participated in the survey. Outcomes were scored on a Likert scale from 1 (limited importance for making a decision) to 9 (critical for making a decision). Consensus was defined a priori as a Likert score of ≥ 8 in the third round of the Delphi survey. Participants were then invited to take part in an international meeting of stakeholders in which the modified nominal group technique was used to consider the consensus outcomes and agree on a final core outcome set. RESULTS: Ninety-six outcomes were identified from 39 studies in the systematic review. One hundred and three participants from 23 countries completed the first round of the Delphi survey, of whom 88 completed all three rounds. Twenty-nine outcomes met the a priori criteria for consensus and, along with six additional outcomes, were prioritized in a consensus development meeting, using the modified nominal group technique. Twenty-five stakeholders participated in this meeting, including researchers (n = 3), fetal medicine specialists (n = 3), obstetricians (n = 2), neonatologists (n = 3), midwives (n = 4), parents and family members (n = 6), patient group representatives (n = 3), and a sonographer. Eleven core outcomes were agreed upon. These were live birth, gestational age at birth, birth weight, intertwin birth-weight discordance, death of surviving twin after death of cotwin, loss during pregnancy or before final hospital discharge, parental stress, procedure-related adverse maternal outcome, length of neonatal stay in hospital, neurological abnormality on postnatal imaging and childhood disability. CONCLUSIONS: This core outcome set for studies investigating the management of sFGR represents the consensus of a large and diverse group of international collaborators. Use of these outcomes in future trials should help to increase the clinical relevance of research on this condition. Consensus agreement on core outcome definitions and measures is now required. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Bilateral cervix apex clamping procedure can be used as a new noninvasive second line therapy for postpartum hemorrhage.

In this study, we present a noninvasive procedure of bilateral cervix apex clamping (BCAC) procedure to control refractory postpartum hemorrhage (PPH) in vaginal delivery as a new second line therapy for refractory PPH. The procedure clamps the anterior and posterior walls of the cervical apex using toothless ovum forceps to arrest bleedingafter the failure of the first line therapy for PPH. 44 women were performed BCAC to control persistent bleeding in 13,359 vaginal deliveries from 1 January 2016 to 31 May 2018. In all of the BCAC, it can reduce bleeding significantly. The bleeding speed after BCAC was far less than that before it (2.64 ± 4.99 ml/min vs 20.23 ± 9.40 ml/min P < 0.001). The blood loss after BCAC was less than that before it (146.57 ± 170.83 vs 797.84 ± 200.73 ml P < 0.001). 41 (93.2%) BCACsucceeded and 3(6.8%) failed turned to intrauterine balloon tamponade, 2 succeeded and 1 failed turned to hysterectomy. In the successful group the bleeding speed after the BCAC was 1.38 ± 0.99 ml/min less than that 19.84 ± 6.27 ml/min in the failure group. (p < 0.001). The blood loss in the success group is also less than that in the failure ones after BCAC (107.29 ± 78.36mL vs 683.33 ± 202.07 ml P < 0.001) Even in the failure group, the bleeding speed also reduced after BCAC compared with that before BCAC (19.84 ± 6.27 vs 29.17 ± 7.12 ml/min p = 0.02). But the blood loss had no statistical difference (683.33 ± 202.07 vs 950 ± 132.29 ml p = 0.27) In all of the 13,359 vaginal deliveries, the incidence of PPH was 1.21% while the severe PPH was only 0.27%. The BCAC may reduce the incidence of severe PPH (0.27%) and also can reduce the necessity of IUBT (3/13,359 0.22‰), uterine artery embolization (UAE) (0/13,359) and even the exploratory laparotomy hysterectomy (1/13,359). Because it is effective, convenient, cheap and noninvasive, so we think it can be used as a new second line noninvasive treatment for PPH.

Obstetric and non-obstetric surgery during pregnancy: A 20-year Danish population-based prevalence study.

OBJECTIVES: Population-based studies on use of non-obstetric and obstetric surgical procedures during pregnancy are sparse. Therefore, our objective was to estimate the prevalence of surgery during pregnancy, including potential time trends, overall and by trimester and describe the characteristics of pregnant women undergoing surgery. DESIGN: This study is a large nationwide cohort study. SETTING: From administrative and medical databases, we obtained information about all pregnancies ending in a live birth, a stillbirth or an abortion (spontaneous and induced) in Denmark during 1996-2015. Procedures (excluding caesarean sections) conducted during pregnancy were categorised as a non-obstetric or obstetric surgery and further divided into laparoscopic or non-laparoscopic procedures. MAIN OUTCOME MEASURE: Main outcome measure is prevalence of surgery during pregnancy. RESULTS: We included 1 687 176 pregnancies of which 108 502 (6.4%) received 117 424 surgical procedures. The prevalence of non-obstetric surgery was almost stable (1.5% in 1996-1999 to 1.6% in 2012-2015), whereas non-obstetric abdominal or gynaecological laparoscopic procedures increased from 0.5% to 0.8%. For appendectomies, the proportion of laparoscopic surgery increased from 4.2% to 79.2% during the study period. In 49 pregnancies, surgery for internal herniation was conducted in 2012-2015 versus none in 1996-1999. The prevalence of obstetric surgery, excluding invasive diagnostic tests, increased from 0.2% to 0.8%. High multiplicity, smoking, increasing age, body mass index (BMI) and parity were factors associated with a high prevalence of surgery during pregnancy. CONCLUSIONS: The increase in the prevalence of laparoscopic surgery during pregnancy may reflect a decreased restraint concerning conductance of these surgical procedures during pregnancy. The increasing proportion of laparoscopic procedures complies with clinical recommendations, and the prevalence of surgery during pregnancy varied by multiplicity, smoking status, parity, age and BMI.

The surgical burden of disease and perioperative mortality in patients admitted to hospitals in Victoria, Australia: a population-level observational study.

OBJECTIVES: Comprehensive reporting of surgical disease burden and outcomes are vital components of resilient health systems but remain under-reported. The primary objective was to identify the Victorian surgical burden of disease necessitating treatment in a hospital or day centre, including a thorough epidemiology of surgical procedures and their respective perioperative mortality rates (POMR). DESIGN: Retrospective population-level observational study. SETTING: The study was conducted in Victoria, Australia. Access to data from the Victorian Admitted Episodes Dataset was obtained using the Dr Foster Quality Investigator tool. The study included public and private facilities, including day-case facilities. PARTICIPANTS: From January 2014 to December 2016, all admissions with an International Statistical Classification of Diseases-10 code matched to the Global Health Estimates (GHE) disease categories were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Admissions were assigned a primary disease category according to the 23 GHE disease categories. Surgical procedures during hospitalisations were identified using the Australian Refined Diagnosis Related Groups (AR-DRG). POMR were calculated for GHE disease categories and AR-DRG procedures. RESULTS: A total of 4 865 226 admitted episodes were identified over the 3-year period. 1 715 862 (35.3%) of these required a surgical procedure. The mortality rate for those undergoing a procedure was 0.42%, and 1.47% for those without. The top five procedures performed per GHE category were lens procedures (162 835 cases, POMR 0.001%), caesarean delivery (76 032 cases, POMR 0.01%), abortion with operating room procedure (65 451 cases, POMR 0%), hernia procedures (52 499 cases, POMR 0.05%) and other knee procedures (47 181 cases, POMR 0.004%). CONCLUSIONS: Conditions requiring surgery were responsible for 35.3% of the hospital admitted disease burden in Victoria, a rate higher than previously published from Sweden, New Zealand and the USA. POMR is comparable to other studies reporting individual procedures and conditions, but has been reported comprehensively across all GHE disease categories for the first time.

A Prediction Model for Severe Maternal Morbidity in Laboring Patients at Term.

OBJECTIVE: To determine the factors associated with severe maternal morbidity in a modern cohort of women laboring at term and to create a prediction model. STUDY DESIGN: This is a retrospective cohort study of all term, laboring patients with live births at a single tertiary care center from 2004 to 2014. The primary outcome was composite maternal morbidity including organ failure, amniotic fluid embolism, anesthesia complications, sepsis, shock, thrombotic events, transfusion, or hysterectomy. Multivariable logistic regression was used to identify independent risk factors. Antepartum, intrapartum, and combined risk scores were created and test characteristics were analyzed. RESULTS: Among 19,249 women delivering during the study period, 323 (1.68%) patients experienced severe morbidity, with blood transfusion the most common complication (286, 1.49%). Factors in the antepartum model included advanced maternal age, race, hypertension, nulliparity, history of cesarean delivery, smoking, and unfavorable Bishop score. Intrapartum factors included mode of delivery, use of cervical ripening agents or oxytocin, prolonged second stage, and macrosomia. The combined model had an area under the curve of 0.76 (95% confidence interval [CI], 0.73, 0.79). CONCLUSION: This three-part risk scoring system can help clinicians counsel patients and guide clinical decision making for anticipating severe maternal morbidity and necessary resources.

Influence of Resident Involvement in Obstetrics and Gynaecology Surgery on Surgical Outcomes: Systematic Review and Meta-Analysis.

OBJECTIVE: The effect of resident involvement during obstetrics and gynaecology (OB/GYN) surgery on surgical outcomes is unclear. This study sought to review the evidence systematically for the influence of resident participation in OB/GYN surgery on (1) operative time, (2) estimated blood loss, and (3) perioperative complications. METHOD: Published studies were identified via searches of PubMed, Embase, Cochrane Central Register, Web of Science, and ClinicalTrials.gov databases. The study included randomized or observational studies that compared outcomes for OB/GYN surgery performed by attending surgeons alone or with residents. Risk ratios or mean differences were extracted from the studies. A random effect model was performed for each outcome, with subgroup analysis by type of surgery and study quality. RESULTS: A total of 13 studies were included in the meta-analysis, comprising 40 968 patients in seven countries. Surgical procedures performed only by attending surgeons had shorter operative times (mean difference 18.20 minutes; 95% CI 13.58-22.82), whereas surgical procedures with resident involvement were associated with an increased risk of blood transfusion (risk ratio 1.23; 95% CI 1.08-1.41). There were no observable differences in risk of estimated blood loss, wound infection, urologic injury, viscus injury, or return to the operating room. Significant heterogeneity (I2 >50%) was present in one of seven outcomes. CONCLUSION: Resident participation in OB/GYN surgery is associated with longer operative times and increased risk of blood transfusion; however, other perioperative complications are not increased.

Pay-for-performance reduces healthcare spending and improves quality of care: Analysis of target and non-target obstetrics and gynecology surgeries.

OBJECTIVE: In Korea, the Value Incentive Program (VIP) was first applied to selected clinical conditions in 2007 to evaluate the performance of medical institutes. We examined whether the condition-specific performance of the VIP resulted in measurable improvement in quality of care and in reduced medical costs. DESIGN: Population-based retrospective observational study. SETTING: We used two data set including the results of quality assessment and hospitalization data from National Health Claim data from 2011 to 2014. PARTICIPANTS: Participants who were admitted to the hospital for obstetrics and gynecology were included. A total of 535 289 hospitalizations were included in our analysis. METHODS: We used a generalized estimating equation (GEE) model to identify associations between the quality assessment and length of stay (LOS). A GEE model based on a gamma distribution was used to evaluate medical cost. The Poisson regression analysis was used to evaluate readmission. MAIN OUTCOME MEASURES: The outcome variables included LOS, medical costs and readmission within 30 days. RESULTS: Higher condition-specific performance by VIP participants was associated with shorter LOSs, decreases in medical cost, and lower within 30-day readmission rates for target and non-target surgeries. LOS and readmission within 30 days were different by change in quality assessment at each medical institute. CONCLUSIONS: Our findings contribute to the body of evidence used by policy-makers for expansion and development of the VIP. The study revealed the positive effects of quality assessment on quality of care. To reduce the between-institute quality gap, alternative strategies are needed for medical institutes that had low performance.

Effect of Delayed Cord Clamping on Hematocrit, and Thermal and Hemodynamic Stability in Preterm Neonates: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the short term clinical effects of delayed cord clamping in preterm neonates. DESIGN: Randomized controlled trial. SETTING: A tertiary care neonatal unit from October 2013 to September 2014. PARTICIPANTS: 78 mothers with preterm labor between 27 to 316/7 weeks gestation. INTERVENTION: Early cord clamping (10 s), delayed cord clamping (60 s) or delayed cord clamping (60 s) along with intramuscular ergometrine (500 µg) administered to the mother. MAIN OUTCOME MEASURES: Primary: hematocrit at 4 h after birth; Secondary: temperature on admission in neonatal intensive care unit, blood pressure (non-invasive) at 12 h, and urinary output for initial 72 h. RESULTS: Mean (SD) hematocrit at 4 h of birth was 58.9 (2.4)% in delayed cord clamping group, and 58.7 (2.1) % in delayed cord clamping with ergometrine group as compared to 47.6 (1.3) % in early cord clamping group. Mean (SD) temperature on admission in NICU was 35.8 (0.2)ºC, 35.8 (0.3)ºC, and 35.5 (0.3)ºC, respectively in these three groups. The mean (SD) non-invasive blood pressure at 12 h of birth was 45.8 (7.0) mmHg, 45.8 (9.0) mmHg, and 35.5 (8.6) mmHg, respectively in these three groups. Mean (SD) urinary output on day 1 of life was 1.1 (0.2) mL/kg/h, 1.1 (0.2) mL/kg/hr and 0.9 (0.2) ml/kg/h, respectively. CONCLUSION: In preterm neonates delayed cord clamping along with lowering the infant below perineum or incision site and administration of ergometrine to mother has significant benefits in terms of increase in hematocrit, higher temperature on admission, and higher blood pressure and urinary output during perinatal transition.

A Practice Improvement Project to Reduce Cesarean Surgical Site Infection Rates.

We implemented an evidence-based practice improvement project at a health care facility in the Midwestern United States to address the increasing rate of cesarean surgical site infections. Women who experienced cesarean birth were cared for using a standardized evidence-based protocol including preoperative and postoperative care and education. In addition, a team-created educational video was used by both women and their families during the postoperative period and at home after discharge. This new protocol resulted in a decrease in the rate of cesarean surgical site infections from 1.35% in 2013 to 0.7% in 2014 and 0.36% in 2015. Our interdisciplinary approach to integrate best-practice strategies resulted in decreased infection rates and improved patient satisfaction scores.

Pre-pregnancy and Early Prenatal Care are Associated with Lower Risk of Ectopic Pregnancy Complications in the Medicaid Population: 2004-08.

BACKGROUND: Ectopic pregnancy causes significant maternal morbidity and mortality. Complications are more common among women with Medicaid or no insurance compared to those with private insurance. It is unknown whether preventive care prior to pregnancy and prenatal care, which are covered by Medicaid, would decrease complications if they were more fully utilised. METHODS: Medicaid claims were used to identify a clinical cohort of women who experienced an ectopic pregnancy during 2004-08 among all female Medicaid enrolees from a large 14-state population, ages 15-44. Diagnosis and procedure codes were used to identify ectopic pregnancies and associated complications. The primary outcomes were complications associated with ectopic pregnancy: blood transfusion, sterilisation, or hospitalisation with length of stay greater than 2 days. Independent variables were documentation of preventive care within 1 year prior to the ectopic pregnancy and prenatal care within 4 months prior. RESULTS: Controlling for race, age, and state of residence, women's risks of any ectopic pregnancy complication were independently higher among those who did not receive any Medicaid-covered preventive care within 1 year before the ectopic pregnancy compared to those who did (RR 1.12, 95% confidence interval (CI) 1.09, 1.16), and among those who did not receive any Medicaid-covered prenatal care within 4 months prior, compared to those who did (RR 1.89, 95% CI 1.83, 1.96). CONCLUSIONS: Pre-pregnancy and prenatal care are independently associated with decreased risk of ectopic pregnancy complications among Medicaid beneficiaries.

Surgical management of postpartum haemorrhage: survey of French obstetricians.

The aim of our study was to assess the theoretical and practical knowledge of French obstetricians about the surgical management of postpartum haemorrhage (PPH). Our study is a national anonymous self-administered survey. A total of 363 obstetricians responded to this questionnaire between December 2013 and April 2014. Questionnaire sent through email to all French obstetricians who are members of either of two federations of hospital-based obstetricians. Answers were collected until the end of June 2014. The main outcome measure was obstetricians' level of mastery of each surgical technique. The results were analysed descriptively (proportions). Only the 286 questionnaires fully completed were analysed; the complete response rate was 23% (286/1246). In all, 33% (95/286) of the responding obstetricians reported that they had not mastered sufficiently or even at all the technique for bilateral ligation of the uterine arteries, 37% (105/286) for uterine compression suture, 62% (178/286) for ligation of the internal iliac arteries, and 47% (134/286) for emergency peripartum hysterectomy. In all, 18% (52/286) of respondents stated that they had not mastered any of these techniques. Our study shows that a worrisome number of French obstetricians reported insufficient mastery of the surgical techniques for PPH management.

Global Estimation of Surgical Procedures Needed for Forcibly Displaced Persons.

INTRODUCTION: Sixty million people were displaced from their homes due to conflict, persecution, or human rights violations at the end of 2014. This vulnerable population bears a disproportionate burden of disease, much of which is surgically treatable. We sought to estimate the surgical needs for forcibly displaced persons globally to inform humanitarian assistance initiatives. METHODS: Data regarding forcibly displaced persons, including refugees, internally displaced persons (IDPs), and asylum seekers were extracted from United Nations databases. Using the minimum proposed surgical rate of 4669 procedures per 100,000 persons annually, global, regional, and country-specific estimates were calculated. The prevalence of pregnancy and obstetric complications were used to estimate obstetric surgical needs. RESULTS: At least 2.78 million surgical procedures (IQR 2.58-3.15 million) were needed for 59.5 million displaced persons. Of these, 1.06 million procedures were required in North Africa and the Middle East, representing an increase of 50 % from current unmet surgical need in the region. Host countries with the highest surgical burden for the displaced included Syria (388,000 procedures), Colombia (282,000 procedures), and Iraq (187,000). Between 4 and 10 % of required procedures were obstetric surgical procedures. Children aged <18 years made up 52 % of the displaced, portending a substantial demand for pediatric surgical care. CONCLUSION: Approximately three million procedures annually are required to meet the surgical needs of refugees, IDPs, and asylum seekers. Most displaced persons are hosted in countries with inadequate surgical care capacity. These figures should be considered when planning humanitarian assistance and targeted surgical capacity improvements.

The Changing Scenario of Obstetrics and Gynecology Residency Training.

BACKGROUND: Significant changes have been noted in aspects of obstetrics-gynecology (ob-gyn) training over the last decade, which is reflected in Accreditation Council for Graduate Medical Education (ACGME) operative case logs for graduating ob-gyn residents. OBJECTIVE: We sought to understand the changing trends of ob-gyn residents' experience in obstetric procedures over the past 11 years. METHODS: We analyzed national ACGME procedure logs for all obstetric procedures recorded by 12 728 ob-gyn residents who graduated between academic years 2002-2003 and 2012-2013. RESULTS: The average number of cesarean sections per resident increased from 191.8 in 2002-2003 to 233.4 in 2012-2013 (17%; P < .001; 95% CI -47.769 to -35.431), the number of vaginal deliveries declined from 320.8 to 261 (18.6%; P < .001; 95% CI 38.842-56.35), the number of forceps deliveries declined from 23.8 to 8.4 (64.7%; P < .001; 95% CI 14.061-16.739), and the number of vacuum deliveries declined from 23.8 to 17.6 (26%; P < .001; 95% CI 5.043-7.357). Between 2002-2003 and 2007-2008, amniocentesis decreased from 18.5 to 11 (P < .001, 95% CI 6.298-8.702), and multifetal vaginal deliveries increased from 10.8 to 14 (P < .001, 95% CI -3.895 to -2.505). Both were not included in ACGME reporting after 2008. CONCLUSIONS: Ob-gyn residents' training experience changed substantially over the past decade. ACGME obstetric logs demonstrated decreases in volume of vaginal, forceps, and vacuum deliveries, and increases in cesarean and multifetal deliveries. Change in experience may require use of innovative strategies to help improve residents' basic obstetric skills.

[Unmet obstetrical needs for major obstetric interventions in Dakar]. / Besoins obstétricaux non couverts pour les interventions obstétricales majeures à Dakar (Sénégal).

OBJECTIVES: To determine unmet needs formajor obstetric interventions and evaluatematernal and perinatal outcome in the region of Dakar in 2010. MATERIALS AND METHODS: This retrospective, descriptive, and analytic study of major obstetric interventions (MOI) for absolute maternal indications (AMI) in Dakar examined records in the reference health centers and public hospitals in Dakar for 2010. RESULTS: During the study period, we recorded 5 383 MOI. The epidemiological profile of patients was a woman with a mean age of 28 years, primiparous (41.1%), married (99.7%), and living more than 10 km from the clinic (51%). AMI accounted for 3 449 of the MOI. Cesarean deliveries were by far the predominant intervention (98.74%). Fetal-pelvic disproportion was the most frequent AMI in our study (75.85%). Because the expected number of MOI for AMI in Dakar was 2123, we estimated an unmet obstetric need (UON) of 1326 IOMs, that is, -62.45%of the excess number of IOMs, with disparities between districts. Of 22,349 deliveries, 47 mothers died (0.21%), mainly from antepartumand postpartum hemorrhages (59.6%) and preeclampsia/eclampsia (23.4%). In all, in 22,349 births, there were 442 deaths (2%). CONCLUSION: Obstetric needs are generally well supported in Dakar. However, this negative deficit recorded may mask a real obstetric need.