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Objective Nationwide, obstetric clinics modified prenatal care to include telehealth visits in response to the coronavirus disease 2019 (COVID-19) pandemic, enabling the opportunity to investigate its impact on patient outcomes. We hypothesized that use of prenatal telehealth visits would increase the number of prenatal visits, decrease the frequency of urgent triage/emergency department (ED) visits, and improve perinatal outcomes. This study aimed to determine the impact of telehealth on number of obstetric prenatal visits and urgent triage/ED visits amidst the COVID-19 pandemic. Study Design This is a retrospective cohort of patients from a federally qualified health center in central Texas. Patients with a singleton gestation who delivered after 32 weeks were included. Comparison groups were made between those patients who delivered between May 2020 and December 2020 (presumed modified prenatal visit schedule with in-person and telehealth) and those patients delivering between June 2019 and February 2020 (the traditional care model with in-person visits only). Multivariable linear and logistic regression models were used to estimate differences in the number of prenatal visits and unscheduled triage/ED visits. Results A total of 1,654 patients were identified with 801 (48.4%) patients undergoing modified prenatal care and 853 (51.6%) patients receiving traditional care during the study period. No significant differences were seen in overall prenatal attendance or triage/ED presentations. However, when stratified by parity, multiparous patients undergoing modified prenatal care were less likely to experience an urgent triage/ED presentation (8.7 vs. 12.7%; odds ratio, 1.69; 95% confidence interval, 1.10–2.61). Conclusion When compared with a traditional prenatal visitation cohort prepandemic, patients who received modified telehealth prenatal care during the COVID-19 pandemic had similar prenatal attendance and unscheduled emergency presentations. However, multiparous patients experienced a decreased rate of unscheduled emergency presentations. Supplementing prenatal care with telehealth may provide overall comparable prenatal care delivery. Key Points Use of telehealth has the potential to improve prenatal care. The COVID-19 pandemic allowed for comparison to traditional prenatal care. Multiparous patients had a decreased frequency of ED visits. Similar prenatal attendance was seen between both prenatal models. [ABSTRACT FROM AUTHOR]

Objective Following the release of A Randomized Trial of Induction versus Expectant Management (ARRIVE) trial, the induction of labor at 39 weeks has increased in the United States. The risk of uterine rupture and optimal timing of elective induction in those patients with a prior cesarean delivery is not well-described, and they were not included in the original trial. We aimed to determine the risk of uterine rupture in those patients undergoing elective induction of labor with prior cesarean delivery. Study Design This was a retrospective cohort of participants with prior cesarean delivery from 1996 to 2000. Participants were included if they had two or more prior cesareans. Participants were excluded if they had a history of an unknown prior incision, a classical incision, gestational age <39 weeks, any diabetes, chronic hypertension, twin gestation, collagen or vascular disease, or HIV. Those undergoing expectant management were compared with those undergoing elective induction with no medical or obstetrical indications for delivery. Analysis was performed at three gestational age groups: 39 weeks, 40 weeks, and 41 weeks. The primary outcomes were uterine rupture, rates of successful vaginal delivery, and a composite major morbidity risk. Multivariable logistic regression was performed. Results At 39 weeks, 618 (10.3%) elective inductions were compared with 5,365 (89.7%) undergoing expectant management; uterine rupture occurred more frequently (13 patients [2.1%] vs. 49 patients [0.9%]; adjusted odds ratio [aOR], 2.5; 95% confidence interval, 1.3–4.6) with fewer successful vaginal birth after cesarean [VBAC; 66.8 vs. 75%; aOR, 0.6; 95% confidence interval, 0.5–0.7]. The risk of uterine rupture was similar between groups at 40 weeks (5 patients [0.8%] vs. 21 patients [1.2%]; p = 0.387) and 41 weeks (7 patients [1.4%] vs. 2 patients (0.8%); p = 0.448). Conclusion Patients undergoing elective induction of labor with a prior cesarean scar had an increased risk of uterine rupture when compared with expectant management at 39 weeks, with fewer successful VBAC. Key Points TOLAC elective induction at 39 weeks has an increased risk of uterine rupture. TOLAC elective induction at 39 weeks has a less successful chance of vaginal delivery. Awaiting spontaneous labor in this cohort does not increase the risk of uterine rupture. [ABSTRACT FROM AUTHOR]

Objective Periviable premature rupture of membranes (PROM) counseling should describe maternal and neonatal outcomes associated with both immediate delivery and expectant management. Unfortunately, most published data focuses on neonatal outcomes and maternal risk estimates vary widely. We performed a meta-analysis to describe outcomes associated with expectant management compared with immediate delivery of periviable PROM. Study Design We performed a search on PubMed, MEDLINE, Web of Science, PROSPERO, Cochrane library, and ClinicalTrials.gov utilizing a combination of key terms. Published clinical trials and observational cohorts were included if published after 2000. Publications were selected if they included maternal and/or neonatal outcomes for both expectant management and immediate delivery. Gestational age range was limited from 14 to 25 weeks. The primary outcome was maternal sepsis. Secondary outcomes included chorioamnionitis, hemorrhage, laparotomy, and neonatal survival. Pooled risk differences (RDs) were calculated for each outcome using a random-effects model. Publication bias was assessed using funnel plots and Harbord test. Results A total of 2,550 studies were screened. After removal of duplicates and filtering by abstract, 44 manuscripts were reviewed. A total of five publications met inclusion for analysis: four retrospective and one prospective. Overall, 364 (68.0%) women underwent expectant management and 171 (32.0%) underwent immediate delivery. Maternal sepsis was significantly more frequent in the expectant group (RD, 4%; 95% confidence interval, 2–7%) as was chorioamnionitis (RD: 30%; p < 0.01) and any laparotomy (RD: 28%; p < 0.01). Neonatal survival in the expectant group was 39% compared with 0% in the immediate group (p < 0.01). Conclusion Women who undergo expectant management following periviable rupture of membranes experience significantly increased risks of sepsis, chorioamnionitis, and laparotomy. Overall, 39% of neonates survive to discharge. Knowledge of these risks is critical to counseling patients with this diagnosis. Key Points Expectant management associated with 4% increased risk of sepsis. Expectant management associated with 30% increased risk of chorioamnionitis. A total of 39% of neonates survived to discharge with expectant management. [ABSTRACT FROM AUTHOR]

Objective: To determine intrapartum factors associated with perineal laceration at delivery. Methods: This was a planned secondary analysis of a multicenter randomized clinical trial of delayed versus immediate pushing among term nulliparous women in labor with neuraxial analgesia conducted in the United States. Intrapartum characteristics were extracted from the medical charts. The primary outcome was perineal laceration, defined as second degree or above, characterized at delivery in women participating in longer term pelvic floor assessments post-delivery. Multivariable logistic regression was used to refine risk estimates while adjusting for randomization group, birth weight, and maternal age. Results: Among the 941 women participating in the pelvic floor follow-up, 40.6% experienced a perineal laceration. No first stage labor characteristics were associated with perineal laceration, including type of labor or length of first stage. Receiving an amnioinfusion appeared protective of perineal laceration (adjusted odds ratio, 0.48; 95% confidence interval 0.26–0.91; P = 0.01). Second stage labor characteristics associated with injury were length of stage (2.01 h vs. 1.50 h; adjusted odds ratio, 1.36; 95% confidence interval 1.18–1.57; P < 0.01) and a prolonged second stage (adjusted odds ratio, 1.64; 95% confidence interval 1.06–2.56; P < 0.01). Operative vaginal delivery was strongly associated with perineal laceration (adjusted odds ratio, 3.57; 95% confidence interval 1.85–6.90; P < 0.01). Conclusion: Operative vaginal delivery is a modifiable risk factor associated with an increased risk of perineal laceration. Amnioinfusion appeared protective against injury, which could reflect a spurious finding, but may also represent true risk reduction similar to the mechanism of warm perineal compress. Significance: The objective of this study was to examine intrapartum factors associated with an increased risk of perineal laceration at delivery among nulliparous women. Operative vaginal delivery and the length of second stage, particularly prolonged second stage, are modifiable risk factors associated with an increased risk of perineal laceration. Receiving an amnioinfusion appeared to be protective against perineal laceration. There are few intrapartum modifiable risk factors other than operative delivery for perineal laceration in nulliparous women. Length of the second stage is an important risk factor for perineal lacerations that is modifiable through active management. [ABSTRACT FROM AUTHOR]

To review the findings of the Optimizing Management of the Second Stage of Labor randomized controlled trial in the context of prior and subsequent obstetric literature. A multi-database search was performed in addition to a review of the parent trial and secondary studies. Nulliparous patients with neuraxial anesthesia randomized to either immediate or delayed pushing showed no difference in vaginal delivery rates. However, delayed pushing is associated with an increased duration of the second stage and perinatal morbidity. Patients should be appropriately counseled on the timing of second-stage pushing and the risks of prolonged second-stage labor. [ABSTRACT FROM AUTHOR]

Objective: To describe rates of postpartum sterilization and indications for unfulfilled requests when Medicaid policy is not a limiting factor.Study Design: We conducted a single-institution, retrospective review. Women who requested postpartum tubal ligation after vaginal delivery from August 2015 to March 2019 were studied. Select demographic characteristics were compared between those who did and did not undergo the procedure. Reasons for why the procedure was cancelled, alternate contraceptive plans, and subsequent pregnancies were collected. Statistical analysis included the t test and chi-squared test, with p < 0.05 considered significant.Results: A total of 4103 patients requested postpartum tubal ligation following vaginal delivery. About 3670 (89.4%) procedures were performed and 433 (10.6%) were canceled. Of the 433, 423 (98%) were not performed at patient request; 10 (2 %) were cancelled based on physician recommendation. Of these, 3 were due to significant maternal anemia in the setting of refusal of blood products, 1 due to anesthesia concerns, 1 for increased body mass index, and 1 due to delivery events. Alternative contraception methods were offered; 72 (28% of patients not receiving a tubal ligation) received Depo Provera prior to discharge. One-fourth (n = 110, 25.4%) did not keep the postpartum follow-up appointment. 83 (19.2%) of the 433 patients had at least one subsequent pregnancy. Although over half expressed interest at the time of discharge in long-acting reversible contraceptives, only 20% obtained this method at the postpartum visit.Conclusions: Postpartum sterilization was predominantly achieved, among women whose requests were unfulfilled, the majority (98%) were at patient request with a minority by physician recommendation.Implications: When the availability of postpartum tubal ligation is independent of Medicaid reimbursement and the hospital system and providers are organized to support timely access to permanent postpartum contraception, the majority of tubal ligations requests can be fulfilled following vaginal delivery. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the association of increasing body mass index (BMI) on postpartum tubal ligation safety and estimate the rates of procedure complication.Methods: We conducted a single-institution, retrospective review. Women undergoing postpartum permanent contraception after vaginal delivery from August 2015 to March 2019 were studied. Our primary outcome included a composite morbidity of intraoperative complications (bleeding requiring additional surgery, and extension of incision), blood transfusion, aborted procedure, anesthetic complication, readmission, wound infection, venous thromboembolism, ileus or small bowel obstruction, incomplete transection, and subsequent pregnancy. Statistical analysis included t test, χ test, and Wilcoxon rank-sum test, with P<0.05 considered significant.Results: During the study period, 3,670 women were studied: 263 were underweight or normal weight (BMI 24.9 or lower), 1,044 were overweight (25-29.9), 1,371 had class I obesity (30-34.9), 689 had class II obesity (35-39.9), and 303 had class III obesity (40 or higher) at the time of admission. Composite morbidity occurred in 49 cases (1.3%) and was not significantly different across the BMI categories (P=.07). Twelve cases of incomplete transection were noted on pathology reports; however, none of these accounted for the six subsequent pregnancies that were identified. There were no deaths or events leading to death noted in the study population. The length of time to complete the procedure increased across BMI categories (23 minutes in women with normal weight, and 31 in women with class III obesity) (P<.001).Conclusion: There was no association between increased BMI and morbidity with women undergoing postpartum tubal ligation. Postpartum tubal ligation should be considered a safe and reasonable option for women, regardless of BMI. [ABSTRACT FROM AUTHOR]