Labor Admission Research Articles

Blood Microbial Communities During Pregnancy Are Associated With Preterm Birth.

Microbial infection of the placenta, amniotic fluid, vaginal canal, and oral cavity is known to significantly contribute to preterm birth (PTB). Although microbes can be translocated into the blood, little is known regarding the blood microbiota during pregnancy. To assess changes in the microbiome during pregnancy, blood samples were obtained 2 or 3 times during pregnancy from a cohort of 45 pregnant women enrolled between 2008 and 2010. To analyze the association with PTB, we conducted a case-control study involving 41 pregnant women upon admission for preterm labor and rupture of membrane (20 with term delivery; 21 with PTB). Bacterial diversity was assessed in number and composition between the first, second, and third trimesters in term delivered women according to 16S rRNA gene amplicon sequencing, and data were analyzed using Quantitative Insight Into Microbial Ecology (QIIME). Taxonomy was assigned using the GreenGenes 8.15.13 database. Dominant microorganisms at the phylum level in all pregnant women were identified as Firmicutes, Proteobacteria, Bacteroidetes, and Actinobacteria. However, the number and composition of bacteria in women with PTB differed from that in women with term delivery. Firmicutes and Bacteroidetes were more abundant in women with PTB than in women with term delivery, while Proteobacteria was less prevalent in women with PTB. At the genus level, Bacteroides, Lactobacillus, Sphingomonas, Fastidiosipila, Weissella, and Butyricicoccus were enriched in PTB samples. These observational results suggest that several taxa in the maternal blood microbiome are associated with PTB. Further studies are needed to confirm the composition of the blood microbiota in women with PTB. Additionally, the mechanism by which pathogenic microbes in maternal blood cause infection and PTB requires further analysis.

Role of admission test by Cardiotocography (CTG) as a predictor of perinatal outcome: A prospective study

Background: Routine and continuous electronic monitoring of foetal heart rate (FHR) in labour has become an established obstetric practice. In this study we aim to evaluate if the admission Cardiotocography (CTG) can be used as a predictor in detecting foetal hypoxia at the time of admission in labour and to correlate the results of the admission CTG with the perinatal outcome. Material & Method: Total of 100 patients admitted in the labour room with singleton live pregnancy after 37 weeks of gestation were included in this prospective observational study. Foetal heart tracing was recorded at the time of admission to labor room, for a period of 20 minutes and evaluated using standard procedure. Result: One hundred patients were recruited. The admission CTG were ‘reactive’ in 67, equivocal in 21, and ‘ominous’ in 12 women. Occurrence of foetal distress, meconium stained liquor and neonatal intensive care unit (NICU) admission was significantly more frequent among patients with ominous test results compared with equivocal or reactive test results on admission. Incidence of vaginal delivery was more common when the test was reactive. Conclusion: It is simple and easy test and an effective screening test to identify group of women with greater risk of Intrapartum foetal hypoxia and prevents unnecessary delay in intervention.

Does Implementation of Universal Cervical Length Screening Increase Antepartum Resource Utilization? [15E

INTRODUCTION: Concern has been raised regarding “intention creep” and increased resource utilization with implementation of universal cervical length (CL) screening. We compared the incidence of antepartum interventions before and after implementation of screening. METHODS: Retrospective cohort study of singleton gestations who underwent anatomic ultrasound between 16w0d and 20w6d for two years pre and post implementation of screening. Excluded multiples, fetal anomalies, aneuploidy, and missing records. Interventions included ≥2 repeat CL measurements, vaginal progesterone, 17-OHP, cerclage, pessary, admission for preterm labor, betamethasone administration, and NICU consultation. Multivariable logistic regression was used. RESULTS: There were 8309 patients- 4350 before (unexposed) vs. 3959 after (exposed). In the unexposed group 94 (0.87%) patients had a CL of ≤3 cm vs. 56 (1.41%) in the exposed group (p=0.02). There were no differences in demographics between groups. Of those with short cervix, the median CL was 2.4 cm (unexposed) vs. 2.5 cm (exposed). The exposed were less likely to undergo ≥1 antepartum intervention (58.9% vs. 80.0%, aRR 0.68, 95% CI 0.34, 0.99). There were no differences in the rates of individual interventions (cerclage placement, vaginal progesterone, 17-OHP, PTL admission, NICU consultation or administration of steroids). Chorioamnionitis was less frequent in the exposed (8.9 vs. 26.3%, p=0.02). There were no differences in neonatal outcomes or the rate of preterm birth. CONCLUSION: Implementation of universal CL screening identified more people with a short cervix with no difference in the rate of individual interventions. The exposed were less likely to undergo ≥one intervention. Universal CL screening does not unduly increase antepartum resource utilization.

Effectiveness of a Labor-Admission Education Program on Anxiety, Uncertainty, Locus of Labor Control, and Labor Outcomes in Pregnant Women

The process of hospital admission undergone by expectant mothers readily induces feelings of loss of control, anxiousness, and uncertainty. Thus, education to promote the proper response of women to their impending hospital admission may be beneficial in terms of minimizing the number of labor-related hospital trips and the wastage of medical resources. To explore the effects a labor-admission education program on perceived anxiousness, uncertainty, locus of control, and labor outcomes in expectant mothers. A quasi-experimental research design was used to recruit participants. Eligible participants were primipara women who were expected to experience a complications-free pregnancy with a single fetus. A total of 151 participants were enrolled, with 76 assigned to the experimental group and 75 assigned to the control group. The experimental group received the labor and delivery education program intervention while the control group received standard nursing guidance. Participants received the education program in their regular prenatal checkup after the 35th gestational week. The intervention (education program) lasted an hour and included three parts: normal labor signs and appropriate timing of labor admission, self-care strategies at home, and indicators of the onset of labor. A structured questionnaire, including a basic OB/GYN datasheet, the Visual Analogue Scale (VAS) of uncertainty and anxiety, the Labor Agentry Scale (LAS), and birth-outcome information, was used to collect data. Participants completed the three scales at two time points: 1) prior to admission and after the education program and 2) at 3-days postpartum. The findings support the effectiveness of providing a pre-admission education program in terms of lowering perceived uncertainty and anxiousness (p < .001), enhancing the locus of control during birth (p = .001), increasing awareness of the proper time for admission after the onset of labor (p = .001), and reducing the numbers of repeat trips to the hospital (p = .007) and consultations (p < .001). Further, the education program may improve the rate of 3cm-or-greater cervical dilation at admission (p < .001) and reduce the need for induced deliveries (p = .002). In the absence of contraindications, this education program should be provided to expectant mothers as an effective method to maximize the duration of the at-home, latent phase of labor in order to increase locus of control over delivery, reduce uncertainty and anxiousness, and attain optimal birth outcomes.

Cerebroplacental ratio assessment in early labor in uncomplicated term pregnancy and prediction of adverse perinatal outcome: prospective multicenter study.

It has been suggested that the use of Doppler ultrasound in term pregnancies with normal-sized fetuses is able to identify those at high risk of subclinical placental function impairment. The objective of this study was to evaluate the relationship between cerebroplacental ratio (CPR) measured in early labor and perinatal and delivery outcomes in a cohort of uncomplicated singleton term pregnancies. This was a prospective multicenter observational study conducted at three tertiary centers between January 2016 and July 2017. Low-risk term pregnancies, defined by the absence of maternal morbidity or pregnancy complication, accompanied by normal ultrasound and clinical screening of fetal growth in the third trimester, with spontaneous onset of labor were included. Umbilical artery (UA) and fetal middle cerebral artery (MCA) Doppler was assessed on admission for early labor. All measurements were performed in between uterine contractions and according to international standards. CPR was computed by dividing MCA pulsatility index by UA pulsatility index and converted into multiples of the median (MoM) in order to adjust for gestational age. Doctors and midwives involved in the clinical management of the women were blinded to the results of the Doppler evaluation. Mode of delivery and perinatal outcome were compared between pregnancies with reduced CPR MoM, defined as CPR MoM within the lowest decile of the study population, and those with normal CPR MoM. Receiver-operating characteristics curve analysis was used to assess the predictive performance of CPR for obstetric intervention due to fetal distress and composite adverse perinatal outcome. Overall, 562 women were included. The rate of obstetric intervention for suspected fetal distress in labor was more than three times higher among cases with reduced CPR MoM compared to those with normal CPR MoM (9/54 (16.7%) vs 28/508 (5.5%); P= 0.004). Furthermore, a significantly higher rate of composite adverse perinatal outcome was found in fetuses with CPR MoM < 10th percentile compared to those with CPR MoM ≥ 10th percentile (6/54 (11.1%) vs 19/508 (3.7%); P= 0.012). CPR had low sensitivity and low positive predictive value for prediction of obstetric intervention due to fetal distress (24.3% and 18.0%, respectively) and composite adverse perinatal outcome (24.0% and 11.1%, respectively). Data on a wide cohort of low-risk term pregnancies in early labor showed that, while reduced CPR is associated with a higher risk of obstetric intervention due to fetal distress and composite adverse perinatal outcome, it is a poor predictor of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Associations among cervical dilatation at admission, intrapartum care, and birth mode in low‐risk, nulliparous women

Admission in early labor is associated with increased likelihood of cesarean birth, but the context in which this occurs is unclear. Previous research has explored the relationship between dilatation at admission and the use of single intrapartum interventions; however, the majority of women in the United States receive multiple intrapartum interventions. The objective of this study was to examine the associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women with spontaneous onset of labor. This was a cross-sectional, observational study of 21858 nulliparous, singleton, term vertex births that occurred from 2002 to 2007 across nine hospitals in the Consortium on Safe Labor. Outcome measures included the individual and combined use of intrapartum interventions (amniotomy, epidural anesthesia, oxytocin augmentation) and birth mode. In this sample, 92.0% of women received at least one intrapartum intervention and 22.7% received all three interventions. After propensity score adjustment, women were more than twice as likely to receive the combination of amniotomy-epidural-oxytocin when admitted at 0-3cm (RR 2.83 [95% CI 2.45-3.27]) and 4-5cm (2.49 [2.15-2.89]) compared to 6-10cm. Adjusted likelihood of cesarean birth was five times greater for women admitted at 0-3cm (5.26 [4.36-6.34]) and two times greater for women admitted at 4-5cm (2.27 [1.86-2.77]) compared to 6-10cm. To promote normal physiologic birth, low-risk, nulliparous women should be engaged in shared decision-making about timing of admission after spontaneous onset of labor.

52: Evaluation of an external fetal ECG monitoring system: a randomized controlled trial

To compare interpretability of two intrapartum abdominal fetal heart rate (FHR) monitoring strategies. We hypothesized that an external fetal electrocardiogram (fECG) monitoring system, a new technology using cable-free abdominal pads, would produce more interpretable FHR data compared to standard of care (SOC) external Doppler FHR monitoring. Randomized trial conducted at 4 Utah hospitals. Patients were enrolled at labor admission and randomized in blocks based on body mass index (BMI) to SOC or fECG. Primary outcome was the percentage of interpretable minutes of FHR tracing. An interpretable minute was defined as >25% FHR data present and no more than 25% continuous missing FHR data or artifact present. FHR tracings were read in blinded fashion by two reviewers. We also considered the rate of successful device set up, defined as the ability to obtain any interpretable FHR tracing, as well as the number of interpretable 10 minute FHR segments, device adjustments, clinical outcomes, and patient/provider device satisfaction as determined by Likert scale survey. We calculated that 100 patients per arm (200 total) would be needed to detect a 5% difference in interpretability with 95% power. 218 women were randomized, 108 to fECG and 110 to SOC (Figure). Device set up failure occurred more often in the fECG group (7.4% vs 0% for SOC). There were no differences in the primary outcome or 10 minute FHR segment analyses, but fECG produced more interpretable FHR tracing in BMI≥30 (Table). Maternal demographics and clinical outcomes were similar between arms. More device changes occurred in the fECG group, however fECG use required fewer nursing adjustments compared to SOC. There was no difference in physician device satisfaction between groups, but fECG generated higher patient device satisfaction scores. Although the primary outcome did not differ between groups, patients preferred the fECG system. Significant differences were noted with BMI stratification, where fECG outperformed SOC in women with BMI≥30. To our knowledge, this is the first randomized clinical comparison of an external fECG device and SOC. Further investigation should focus on predictors of fECG device failure and determining settings in which fECG may be the preferred and more cost-effective FHR monitoring strategy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

430: The American College of Cardiology/American Heart Association new blood pressure criteria and associated neonatal outcomes

The blood pressure cut off for diagnosis of preeclampsia has historically been based on hypertension criteria defined by the American College of Cardiology (ACC) and American Heart Association (AHA). Recently, they decreased their criteria, defining stage 1 hypertension as a blood pressure greater than 130/80, raising the question as to whether the new definition should be adopted in pregnancy. We aimed to evaluate whether women meeting this new blood pressure threshold at the time of admission for labor had an increased risk for adverse neonatal outcomes. This is a retrospective cohort study of all women with singleton pregnancies admitted for delivery at a tertiary care center from 2004-2014. Using blood pressure on admission, women were classified into three groups: 1) normotensive if their blood pressure was <130/80, 2) stage 1 hypertension if their blood pressure was 130-139/80-89, or 3) overt hypertension if their blood pressure was >140/90. Patients with preexisting chronic hypertension were excluded. The risk of small for gestational age (SGA), 5-minute Apgar score <7, and higher level nursery admission were examined across groups. Baseline characteristics were compared using chi square and ANOVA. Neonatal outcomes were compared with the normotensive group as the reference using logistic regression to control for confounders. 28,993 women met inclusion criteria, 14,685 (51%) were classified as normotensive, 7,828 (27%) were classified as stage 1 hypertension, and 6,480 (22%) were classified as having overt hypertension. Women with hypertensive disorders were more likely to be older, nulliparous, African American, obese, and have pre-gestational diabetes. Incidence of SGA increased across the three groups (12.5%, 13.1%, 15.7%) but was only statistically significant for women with overt hypertension (aOR 1.56, 95% CI 1.02-1.31). The risk of Apgar <7 at 5 minutes and higher order nursery admission was significantly increased in the overt hypertension group only (Table). The impact of lowering the diagnostic criteria for hypertension in pregnancy according to the new ACC/AHA criteria has unknown impact for obstetric patients. These results suggest that rates of SGA and immediate neonatal outcomes may be similar among normotensive patients and those with blood pressure elevations of 130- 139/80-89. Further research is required before diagnostic criteria for hypertension are lowered in pregnancy.

548: 10-year trend in preterm labor admissions and outcomes in the united states

548: 10-year trend in preterm labor admissions and outcomes in the united states

Admission cardiotocography versus intermittent auscultation of the fetal heart in low-risk pregnancy during evaluation for possible labour admission - a multicentre randomised trial: the ADCAR trial.

To assess the effect of admission cardiotocography (ACTG) versus intermittent auscultation (IA) of the fetal heart (FH) in low-risk pregnancy during assessment for possible labour on caesarean section rates. A parallel multicentre randomised trial. Three maternity units in the Republic of Ireland. Healthy, low-risk pregnant women, at term and ≥ 18 years old, who provided written informed consent. Women were randomised to receive IA of the FH or 20 minutes ACTG on admission for possible labour onset, using remote telephone randomisation. Both groups received IA during labour, with conversion to continuous CTG as clinically indicated. Caesarean section (primary outcome), obstetric interventions (e.g. continuous CTG during labour, fetal blood sampling, augmentation of labour) and neonatal morbidity (e.g. metabolic acidosis, admission to the neonatal intensive care unit, neonatal death). Based on 3034 women (1513 and 1521 randomised to IA and ACTG, respectively), there was no statistical difference between the groups in caesarean section [130 (8.6%) and 105 (6.9%) for IA and ACTG groups, respectively; relative risk (RR) 1.24; 95% CI 0.97-1.58], or in any other outcome except for use of continuous CTG during labour, which was lower in the IA group (RR 0.90, 95% CI 0.86-0.93). Our study demonstrates no differences in obstetric or neonatal outcomes between IA and ACTG for women with possible labour onset, other than an increased risk for continuous CTG in women receiving ACTG. No differences in outcomes between intermittent auscultation and admission cardiotocography for women with possible labour onset.

Clinical efficacy and reliability of amniotic fluid index (AFI) as labour admission test in correlation to perinatal outcome

Clinical efficacy and reliability of amniotic fluid index (AFI) as labour admission test in correlation to perinatal outcome

ERegQual\u2014an electronic health registry with interactive checklists and clinical decision support for improving quality of antenatal care: study protocol for a cluster randomized trial

BackgroundHealth worker compliance with established best-practice clinical and public health guidelines may be enhanced by customized checklists of care and clinical decision support driven by point-of-care data entry into an electronic health registry. The public health system of Palestine is currently implementing a national electronic registry (eRegistry) for maternal and child health. This trial is embedded in the national implementation and aims to assess the effectiveness of the eRegistry’s interactive checklists and clinical decision support, compared with the existing paper based records, on improving the quality of care for pregnant women.MethodsThis two-arm cluster randomized controlled trial is conducted in the West Bank, Palestine, and includes 120 clusters (primary healthcare clinics) with an average annual enrollment of 60 pregnancies. The intervention tool is the eRegistry’s interactive checklists and clinical decision support implemented within the District Health Information System 2 (DHIS2) Tracker software, developed and customized for the Palestinian context. The primary outcomes reflect the processes of essential interventions, namely timely and appropriate screening and management of: 1) anemia in pregnancy; 2) hypertension in pregnancy; 3) abnormal fetal growth; 4) and diabetes mellitus in pregnancy. The composite primary health outcome encompasses five conditions representing risk for the mother or baby that could have been detected or prevented by high-quality antenatal care: moderate or severe anemia at admission for labor; severe hypertension at admission for labor; malpresentation at delivery undetected during pregnancy; small for gestational age baby at delivery undetected during pregnancy; and large for gestational age baby at delivery. Primary analysis at the individual level taking the design effect of the clustering into account will be performed as intention-to-treat.DiscussionThis trial, embedded in the national implementation of the eRegistry in Palestine, allows the assessment of process and health outcomes in a large-scale pragmatic setting. Findings will inform the use of interactive checklists and clinical decision support driven by point-of-care data entry into an eRegistry as a health systems-strengthening approach.Trial registrationISRCTN trial registration number, ISRCTN18008445. Registered on 6 April 2017.

Per-Partum Anaemia and Missed Post-Partum Haemorrhage in Low Resources Settings

Background: Post-partum haemorrhage is the leading cause of maternal death throughout the world, and anaemia is one of its indirect causes. Anaemia during labour increases the risk of PPH and may lead to maternal mortality even after moderate PPH. Undiagnosed PPH and post-partum anaemia increases the risk of late maternal death in the community. The aim of this study was to assess the prevalence of anaemia on admission for labour, the occult early post-partum haemorrhage and the magnitude of post-partum anaemia in a low resource setting. Methods: This was a longitudinal study. We included pregnant women in labour. Haemoglobin concentration was measured on admission (H0), then 24 hours (H24) and 48 (H48) hours later. The post-partum blood loss was estimated by delta haemoglobin, using the criteria of M. Driessen et al. Results: We recruited 245 pregnant women. The mean age was 27.0 ± 6.0 years. The mean hemoglobin concentration was 11.7 ± 1.9 g/dl, the frequency of anaemia was 30.6% and was related to ethnicity (P = 0.042) gestational age (p < 0.001) marital status (p = 0.014) and the inter pregnancy time space (p = 0.001). Twenty-two-point two percent had post-partum haemorrhage among which 40% were undiagnosed. The mean blood loss was 375 ml and post-partum anaemia rate was 44.5%. Conclusion: Anaemia on admission was related to socio-demographic characteristics. The frequencies of anaemia during labour, missed PPH and undiagnosed post-partum anaemia were high. Haemoglobin concentration on admission for labour and after delivery, reliable method to assess PPH should be mandatory, to better identify per and post-partum anemia, and the management of PPH, in low income environments.

933: Comparing potential risk factors for perinatal death in singleton and twin pregnancies at a rural hospital in Uganda

Perinatal deaths, defined as stillbirths (fetal deaths before delivery, at or after 22 weeks gestation) and neonatal deaths within 7 days of birth, occur more frequently in twin gestations than singleton gestations. Given the limited data on this phenomenon in low resource areas, our study aims to compare risk factors associated with perinatal death in singleton and twin pregnancies in rural Uganda. We conducted a retrospective case-control study using data from birth registers at Tororo District Hospital, a regional hospital in rural Uganda. All cases of perinatal deaths from January to December 2014 were collected. Controls were derived from the labor admissions immediately preceding and following the cases of perinatal death. Each pregnancy was the unit of analysis. Statistical comparisons were performed using Fisher’s exact test, chi-square and t-test. During the study period, there were 185 cases of perinatal death, including 19 twin pregnancies. There were 354 control pregnancies, including 5 twin pregnancies. Twin gestation was associated with an odds ratio (OR) of 8.0 for perinatal death compared to singleton gestation (95% confidence interval (CI) 2.8 - 27.7, p = 0.0000). Perinatal deaths among twins were more likely to be fresh stillbirths (e.g. without findings suggestive of death prior to labor) (68.4% vs 35.8%, OR 3.9, CI 1.28 - 13.1, p = 0.0057) and more likely to be affected by low birth weight than singleton gestations (93.3% vs 33.1%, OR 28.3, CI 4.0 - 1209.6, p = 0.0000). There were no statistically significant associations between twin gestation and maternal age or gravidity, premature delivery, or mode of delivery. Our results confirm a higher frequency of perinatal deaths in twin gestations compared to singleton gestations in Tororo and identity an association with low birth weight. The greater proportion of fresh stillbirths among twins compared to singletons implies more deaths shortly before delivery for the former. Prenatal identification of twin pregnancies may reduce the perinatal loss rate in similar settings.

Timing of hospital admission in labour: latent versus active phase, mode of birth and intrapartum interventions. A correlational study.

Hospitalization of women in latent labour often leads to a cascade of unnecessary intrapartum interventions, to avoid potential disadvantages the recommendation should be to stay at home to improve women's experience and perinatal outcomes. The primary aim of this study was to investigate the association between hospital admission diagnosis (latent vs active phase) and mode of birth. The secondary aim was to explore the relationship between hospital admission diagnosis, intrapartum intervention rates and maternal/neonatal outcomes. A correlational study was conducted in a large Italian maternity hospital. Data from January 2013 to December 2014 were collected from the hospital electronic records. 1.446 records of low risk women were selected. These were dichotomized into two groups based on admission diagnosis: 'latent phase' or 'active phase' of labour. 52.7% of women were admitted in active labour and 47.3% in the latent phase. Women in the latent phase group were more likely to experience a caesarean section or an instrumental birth, artificial rupture of membranes, oxytocin augmentation and epidural analgesia. Admission in the latent phase was associated with higher intrapartum interventions, which were statistically correlated to the mode of birth. Women admitted in the latent phase were more likely to experience intrapartum interventions, which increase the probability of caesarean section. Maternity services should be organized around women and families needs, providing early labour support, to enable women to feel reassured facilitating their admission in labour to avoid the cascade of intrapartum interventions which increases the risk of caesarean section.

Outcomes of childbearing Medicaid beneficiaries engaged in care at Strong Start birth center sites between 2012 and 2014.

BackgroundVariations in care for pregnant women have been reported to affect pregnancy outcomes.MethodsThis study examined data for all 3136 Medicaid beneficiaries enrolled at American Association of Birth Centers (AABC) Center for Medicare and Medicaid Innovation Strong Start sites who gave birth between 2012 and 2014. Using the AABC Perinatal Data Registry, descriptive statistics were used to evaluate socio‐behavioral and medical risks, and core perinatal quality outcomes. Next, the 2082 patients coded as low medical risk on admission in labor were analyzed for effective care and preference sensitive care variations. Finally, using binary logistic regression, the associations between selected care processes and cesarean delivery were explored.ResultsMedicaid beneficiaries enrolled at AABC sites had diverse socio‐behavioral and medical risk profiles and exceeded quality benchmarks for induction, episiotomy, cesarean, and breastfeeding. Among medically low‐risk women, the model demonstrated effective care variations including 82% attendance at prenatal education classes, 99% receiving midwifery‐led prenatal care, and 84% with midwifery‐ attended birth. Patient preferences were adhered to with 83% of women achieving birth at their preferred site of birth, and 95% of women using their preferred infant feeding method. Elective hospitalization in labor was associated with a 4‐times greater risk of cesarean birth among medically low‐risk childbearing Medicaid beneficiaries.ConclusionsThe birth center model demonstrates the capability to achieve the triple aims of improved population health, patient experience, and value.

Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India

BackgroundIn 2008, the Indian government introduced financial assistance to encourage health facility deliveries. Facility births have increased, but maternal and neonatal morbidity and mortality have not decreased raising questions about the quality of care provided in facilities and access to a quality referral system. We evaluated the potential role of inter-institutional transfers of women admitted for labor and delivery on adverse maternal and neonatal outcomes in an ongoing prospective, population-based Maternal and Newborn Health Registry in Central India.MethodsPregnant women from 20 rural Primary Health Centers near Nagpur, Maharashtra were followed throughout pregnancy and to day 42 post-partum. Inter- institutional referral was defined as transfer of a woman from a first or second level facility where she was admitted for labor and delivery to facility providing higher level of care, after admission to the day of delivery. Maternal mortality, stillbirth, early and late neonatal mortality were compared in mothers who were and were not referred. Factors associated with inter-institutional referral were analyzed using multivariable models with generalized estimating equations, adjusted for clustering at the level of the Primary Health Center.ResultsBetween June 2009 and June 2013, 3236 (9.4%) of 34,319 women had inter-institutional referral. Factors associated with referrals were maternal age (adjusted Relative Risk or aRR 1.1; 1.0–1.2); moderate or severe anemia (aRR 1.2; 1.2–1.4), gestational age <37 weeks (aRR 1.16; 1.05–1.27), multiple gestation (aRR 1.6; 1.2–2.1), absent fetal heart rate (aRR 1.7; 1.3–2.2), primigravida (aRR 1.4; 1.3, 1.6), primigravida with any pregnancy related maternal condition such as obstructed or prolonged labor; major antepartum or post-partum hemorrhage, hypertension or preeclampsia and breech, transverse or oblique lie (aRR 4.7; 3.8, 5.8), multigravida with any pregnancy related conditions (aRR 4.2; 3.4–5.2). Stillbirths, early neonatal,late neonatal and early infant deaths occurred in 7.3% referred mothers vs. 3.7% of not referred.ConclusionsAlmost 10% of the women had an inter-institutional referral and still birth or neonatal deaths were doubled in referred women. Conditions associated with referral were often known before onset of labor and delivery. Improvements in maternal and neonatal outcomes will likely require pregnant women with conditions associated with referral to be directly admitted at facilities equipped to care for complicated pregnancies and at risk neonates, as well as prompt detection and transfer those who develop “at risk” conditions during labor and delivery.Trial registrationClinicalTrials.gov NCT01073475.

Titration of Intravenous Oxytocin Infusion for Postdates Induction of Labor Across Body Mass Index Groups

ObjectiveTo evaluate whether oxytocin titration for postdates labor induction differs among women who are normal weight, overweight, and obese and whether length of labor and birth method differ by oxytocin titration and body mass index (BMI). DesignRetrospective cohort study. SettingU.S. university-affiliated hospital. ParticipantsOf 280 eligible women, 21 were normal weight, 134 were overweight, and 125 were obese at labor admission. MethodsData on women who received oxytocin for postdates induction between January 1, 2013 and June 30, 2013 were extracted from medical records. Oxytocin administration and labor outcomes were compared across BMI groups, controlling for potential confounders. Data were analyzed using χ2, analysis of variance, analysis of covariance, and multiple linear and logistic regression models. ResultsWomen who were obese received more oxytocin than women who were overweight in the unadjusted analysis of variance (7.50 units compared with 5.92 units, p = .031). Women who were overweight had more minutes between rate changes from initiation to maximum than women who were obese (98.19 minutes compared with 83.39 minutes, p = .038). Length of labor increased with BMI (p = .018), with a mean length of labor for the normal weight group of 13.96 hours (standard deviation = 8.10); for the overweight group, 16.00 hours (standard deviation = 7.54); and for the obese group, 18.30 hours (standard deviation = 8.65). Cesarean rate increased with BMI (p = .001), with 4.8% of normal weight, 33.6% of overweight, and 42.4% of obese women having cesarean births. ConclusionWomen who were obese and experienced postdates labor induction received more oxytocin than women who were non-obese and had longer length of labor and greater cesarean rates.

Does Intramuscular Progesterone Help Women With Prior Preterm Birth Screened for Ultrasound-Indicated Cerclage? [25K

INTRODUCTION: Weekly intramuscular 17α-hydroxyprogesterone caproate (17P) is endorsed by the American College of Obstetricians and Gynecologists for recurrent preterm birth (PTB) prevention. Cerclage is indicated in patients with prior PTB and a midtrimester cervical length (CL) less than 25 mm. We aimed to assess if these two preventive strategies, when combined, confer additive benefit in prolonging gestation. METHODS: Retrospective cohort of all singletons delivered at a single center that underwent CL screening from 2011 to 2016 for prior PTB. Exposure was any 17P use. Primary outcome was gestational age (GA) at delivery. Secondary outcomes included cerclage, preterm labor (PTL) admission, and preterm premature rupture of membranes (PPROM). ANCOVA was used to assess the relationship between 17P and delivery GA, controlling for cerclage, initial CL, number of prior PTB, and GA of earliest prior PTB. RESULTS: Of 409 patients who underwent CL screening, 293 received 17P (group 17P), and 116 did not. Groups did not differ by age, race, BMI, payer, number of prior PTB, or initial CL. GA of earliest prior PTB was lower in group 17P (27.4 vs 29.9 weeks; P &lt; .001). Delivery GA occurred earlier in group 17P (35.7 vs 37.2 weeks; P=.002). Group 17P also had higher rates of PPROM (22.2% vs 11.2%; P=.011), PTL admission (42% vs 25%; P=.001), and cerclage (18.1% vs 5.2%; P &lt; .001). After controlling for confounders, delivery GA remained significantly lower in group 17P (34.9 vs 35.9 weeks; P=.027). CONCLUSION: In a population with prior PTB followed with CL screening and ultrasound-indicated cerclage, 17P did not prolong gestation.

The Effect of Surges in Patient Volume on Resource Management of an Academic Labor and Delivery Unit [5D

INTRODUCTION: Clinical managers in charge of labor and delivery units are challenged by the need to allocate scarce resources, such as beds and nursing staff, when there are surges in patient volume. When particularly busy, managers may resort to a variety of strategies, such as calling in additional staff or delaying new admissions. The thresholds for applying strategies that preserve labor floor resources have not been previously well defined and may have significant implications for patient safety. METHODS: We developed a virtual labor floor environment in JAVA to simulate dynamic labor floor conditions, including the expected waxing and waning of patient acuity and volume over the course of a nursing shift. We recorded an inter-professional cohort of clinicians making resource allocation decisions over multiple simulated shifts. Using logistic regression, we determined the odds of delaying admission for patients in early labor when labor floor occupancy varied. RESULTS: Eight nurses played the game for 20 minutes on average, which translates to 64 simulated hours of decision-making. In a logistic regression model, we found there is an increased odds of delaying admissions for early labor as the percent of labor and delivery bed occupancy increases (unadjusted odds ratio 1.11, 95% confidence interval 1.03, 1.19). CONCLUSION: Early labor admissions were more often delayed with increasing bed occupancy, indicating that the care of patients on labor and delivery units may be sensitive to the total occupancy of the unit. Additional research is needed to understand the impact of resource management on patient safety.