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Background Obstetrics–gynecology residents should graduate with competence in comprehensive contraceptive care, including long-acting reversible contraception. Lack of hands-on training and deficits in provider education are barriers to long-acting reversible contraception access. Identifying the number of long-acting reversible contraception insertions performed by obstetrics–gynecology residents could provide insight into the depth and breadth of long-acting reversible contraception training available to obstetrics–gynecology residents in Accreditation Council for Graduate Medical Education–accredited residency programs. Objective Our study investigates long-acting reversible contraception–specific training in obstetrics–gynecology residency programs across the United States, including the self-reported number of long-acting reversible contraception insertions per resident and the impact of resident demographic characteristics and residency program characteristics on training. Study Design Obstetrics–gynecology residents completed a voluntary electronic survey during the 2016 Council on Resident Education in Obstetrics and Gynecology examination. The survey included resident demographic characteristics and residency program characteristics as well as resident education and training in long-acting reversible contraception (number of intrauterine devices and implants inserted, training in immediate postpartum intrauterine device placement). A binary “long-acting reversible contraception insertion experience” variable dichotomized respondents as having a low level of long-acting reversible contraception insertions (0 implants and/or 10 or fewer intrauterine devices ) or a high level of long-acting reversible contraception insertions (1 or more implants and/or 11 or more intrauterine devices). χ2 tests were used to compare the presence of long-acting reversible contraception insertion experience by postgraduate year, resident demographic characteristics, and residency program characteristics. Adjusted logistic regression was performed to ascertain the independent effects of gender, race/ethnicity (non-Hispanic white vs other), residency program type (university vs community), and residency program geographic region on the likelihood of “low” overall long-acting reversible contraception insertion experience. Results In total, 5055 obstetrics–gynecology residents completed the survey (85%); analysis included only residents in United States obstetrics–gynecology programs (N=4322). Of the total analytic sample, 1777 (41.2%) had low long-acting reversible contraception insertion experience. As expected, the number of intrauterine device insertions, implant insertions, and overall long-acting reversible contraception experience increased as residents progressed through training. Long-acting reversible contraception insertion experience varied by residency program geographic region: 169 (27.1%) residents in programs in the West had low long-acting reversible contraception insertion experience compared with 498 (39.0%) in the South, 473 (45.3%) in the Midwest, and 615 (46.0%) in the Northeast. Only 152 (14.9%) of all postgraduate year 4 residents had low long-acting reversible contraception insertion experience. Among postgraduate year 4 residents, low long-acting reversible contraception insertion experience was significantly associated racial/ethnic minority status and community-based residency program type (compared with university-based). Postgraduate year 4 residents in programs located in the Northeast and Midwest had 4.25 (95% confidence interval, 2.04–8.85) and 2.75 (95% confidence interval, 1.27–5.97) times the odds of low long-acting reversible contraception experience compared with those in residency programs in the West, even after adjusting for other respondent characteristics and other residency program characteristics. Conclusion Obstetrics–gynecology residents experience a range of long-acting reversible contraception training and insertions, which differed according to resident race/ethnicity and residency program characteristics (program type and geographic region). Residency programs with low long-acting reversible contraception training experience should consider opportunities to improve competence in this fundamental obstetrics–gynecology skill.

We sought to determine the impact of the laborist staffing model on cesarean rates and maternal morbidity in California community hospitals.This is a cross-sectional study comparing cesarean rates, vaginal birth after cesarean rates, composite maternal morbidity, and severe maternal morbidity for laboring women in California community hospitals with and without laborists. We conducted interviews with nurse managers to obtain data regarding hospital policies, practices, and the presence of laborists, and linked this information with patient-level hospital discharge data for all deliveries in 2012.Of 248 childbirth hospitals, 239 (96.4%) participated; 182 community hospitals were studied, and these hospitals provided 221,247 deliveries for analysis. Hospitals with laborists (n = 43, 23.6%) were busier, had more clinical resources, and cared for higher-risk patients. There was no difference in the unadjusted primary cesarean rate for laborist vs nonlaborist hospitals (11.3% vs 11.7%; P = .382) but there was a higher maternal composite morbidity rate (14.4% vs 12.0%; P = .0006). After adjusting for patient and hospital characteristics, there were no differences in laborist vs nonlaborist hospitals for any of the specified outcomes. Hospitals with laborists had higher attempted trial of labor after cesarean rates, and lower repeat cesarean rates (90.9% vs 95.9%; P.0001). However, among women attempting trial of labor after cesarean, there was no difference in the vaginal birth after cesarean success rate.We were unable to demonstrate differences in cesarean and maternal childbirth complication rates in community hospitals with and without laborists. Further efforts are needed to understand how the laborist staffing model contributes to neonatal outcomes, cost and efficiency of care, and patient and physician satisfaction.

ObjectiveThe objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital.Study desginThis was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression.ResultsCompared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88).ConclusionIn this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.

Objective: We sought to evaluate the effectiveness and safety of promoting a trial of labor after prior cesarean birth in a community hospital. Study Design: A 4-year prospective cohort study was conducted of all patients who had prior cesarean births (N = 1481). A comparison of outcomes was performed between those who elected repeat cesarean delivery (n = 727) and those who attempted a trial of labor after previous cesarean(s) (n = 754). Results: We found that the vaginal birth after cesarean attempt rate was 50.9% and declined significantly during the last 2 years of the study. The elective repeat cesarean rate was 49.1% and increased significantly during the last 2 years of the study. In addition, we found that neonatal outcomes were similar, with the exception of 2 neonatal deaths caused by uterine rupture. Twelve uterine ruptures occurred (1.6%), and 11 of the 12 ruptures involved either induction or augmentation of labor, or both. Conclusions: A trial of vaginal birth after cesarean is safe provided that induction of labor is not used. The uterine rupture rate of 1.6% is higher than reported in the literature; this may reflect underreporting by community hospitals. (Am J Obstet Gynecol 2001;184:1478-87.)

Objective: My purpose was to describe the rationale behind the establishment of a hospital-based program instituted to enhance the health of the Jehovah's Witness community and to evaluate patient profiles and outcomes of gynecologic patients treated surgically at our institution, during the past 5 years, whose intake was through the Bloodless Surgery Program and who were not accepting of blood or most blood products. I further describe how a coordinated program dedicated to serving this particular population might improve outcomes and patient satisfaction. Study Design: A retrospective review of the charts of 89 patients, all Jehovah's Witnesses, who were enrolled through the Bloodless Surgery Program and underwent gynecologic surgery involving at least 1 night's hospitalization at our institution between January 1, 1993, and December 31, 1997, was performed. A comparison of patient length of stay, hospital charges, and surgical blood loss, in a subset of 41 patients who underwent abdominal hysterectomy, with a cohort of patients not affiliated with the Jehovah's Witnesses or the Bloodless Surgery Program was performed. Data regarding patient satisfaction were obtained through surveys and are presented. Results: Patients enrolled through the Bloodless Surgery Program and undergoing abdominal hysterectomy were significantly younger (average age 43.4 vs 47.7 years) and incurred significantly lower hospital charges (average cost $8754 vs $9539). No significant difference between the group studied and the control group could be found in average length of stay or the average change between preoperative and postoperative hemoglobin levels. Data from patient satisfaction surveys suggest a high level of satisfaction with the Bloodless Surgery Program. Conclusion: A program dedicated to the special needs of the Jehovah's Witness community can be instituted in a community-based hospital with no evidence of increased morbidity, as evidenced by length of stay, hospital charges, and surgical blood loss, in a gynecologic patient population. Development of such programs is associated with a high level of patient satisfaction and the potential for improved patient care. (Am J Obstet Gynecol 1999;180:1491-8.)

any reports have chronicled the large variation in US in performance and outcomes? The authors address this in a 6 M obstetric care with total cesarean rates ranging from 6.1% to 69.9%; hospital rates of early elective delivery rates varying from 0% to 83%; and thirdand fourth-degree laceration rates swinging from 0.5% to 9.5% among delivery services. In California, we also see significant variation within all levels of care, among university hospitals, among large urban facilities, and even among small rural facilities, for morbidity indicators as well as for process indicators such as failed labor induction. If we could only understand what drives such variation, we would be well on our way toward improving care for our entire birthing population and not just facility by facility, or so quality improvement science would suggest. There must be some objective criteria that establish a recipe for success. Would that it be so easy. In this issue, Korst et al present a series of well-designed and carefully executed studies to search for this elusive goal. They first describe a comprehensive survey with 185 questions that covered hospital staffing (eg, all types of direct and support providers), clinical resources (eg, pharmacy and blood bank 24 hours a day 7 days a week, resources for severe obese patients), and patient care activities (eg, protocols for emergencies, drills, and educational programs). The surveyors were persistent and they achieved a remarkable response rate of > 96%. Not surprisingly, they found that the 26 staff-model health maintenance organization facilities had 100% in-house obstetricians and 24 hours a day 7 days a week availability of specialists. The 26 teaching facilities were more varied, but the 187 community facilities with private practice providers showed great variation for most of the services. Clearly there is more opportunity for investigation among subdivisions of this population of hospitals that accounts for the large majority of maternity care in the United States. But the overarching question remains: does the variation in maternity services and capabilities help explain the variation

OBJECTIVE: With the use of a university- and community hospital-based faculty, we attempted to determine at what performance level remediation would be recommended. STUDY DESIGN: The Committee on In-Training Examinations for Residents in Obstetrics and Gynecology Task Force on Standard-Based Scoring sent the 1991 examination to 16 university- and 12 community hospital-based faculty members. Given a standardized definition of a "borderline third-year resident," each faculty scored each item on the examination on whether that hypothetic resident would or would not correctly answer the item. RESULTS: The mean expectation of correct responses on the 397-item test was 236 (59%). This was identical to the score obtained if 2 SDs were subtracted from the actual mean for all third-year residents taking the examination. University- and community hospital-based faculty members had generally similar expectations of this defined resident. CONCLUSION: Although poor examination results should not be recommended as the sole determinant for promotion, it appears that 2 SDs below the mean may be an appropriate score below which remediation could be recommended.

The purpose of this study was to compare labor induction and cesarean delivery rates at term in community vs university hospitals.A population-based retrospective cohort study of births was performed. Primary outcomes were term gestation at39 weeks, labor induction, and cesarean delivery. After we adjusted for comorbidities, malpresentation, and previous cesarean delivery, logistic regression assessed the association between hospital type and primary outcomes.Births occur less often in week 37 (n = 24390 [11%] vs 4006 [13%]; adjusted odds ratio [OR], 0.9; 95% confidence interval [CI], 0.8-0.9) and are similar in week 38 in community vs university hospitals. Inductions occur more commonly in community vs university settings at 37 weeks (n = 6440 [27%] vs 757 [19%]; adjusted OR, 1.7; 95% CI, 1.5-1.8) and at 38 weeks (n = 16586 [31%] vs 1530 [21%]; adjusted OR, 1.8; 95% CI, 1.7-1.9). Cesarean rates are no different between hospital types.Induction is 70-80% more likely at community vs university hospitals before the optimal gestational age of ≥ 39 weeks, but cesarean delivery rates do not differ at term.

Objective We sought to examine the difference in use of labor epidural analgesia among women from different neighborhood socioeconomic groups. Study Design Neighborhood socioeconomic variables from the 2001 Canadian Census were linked to singleton vaginal births from the Niday perinatal database (2004–2006) in Ontario, Canada. Births were divided into income and education groups by quintiles. Generalized estimating equations were employed to evaluate the association between labor epidural and neighborhood socioeconomic status. Supplementary analysis was conducted after stratifying data by hospital types. Results Compared with those from the richest neighborhood, women from the poorest quintile were the least likely to receive labor epidural analgesia (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.58–0.61). The differences were smallest in teaching hospitals (OR, 0.73; 95% CI, 0.67–0.79) and largest in small community hospitals (OR, 0.57; 95% CI, 0.50–0.64). Similar association was found in neighborhood education quintiles. Conclusion The use of labor epidural analgesia is decreased with decreasing neighborhood economic and education levels.

Objective Our goal was to lower unplanned primary cesarean deliveries by reducing elective inductions. Study Design To implement and sustain an induction management program, a committee of care providers reviewed induction rates. “Elective” and other categories were defined. An induction consent form was drafted. Consent compliance, induction rates, hours in labor and delivery and mode of delivery were evaluated. Outcomes were compared with historical data from 2 years earlier. Results A total of 10,166 nulliparas and 9869 multiparas attempted vaginal deliveries. Elective inductions decreased significantly, from 4.3% to 0.8% in nulliparas and from 13% to 9.5% in multiparas. A longer time to delivery was seen for both nulliparas (5.2 hours) and multiparas (4 hours) with elective inductions. Unplanned primary cesarean delivery rates are significantly lower in spontaneously laboring women, compared with those induced. Conclusion A program aimed at reducing elective inductions was successfully implemented and sustained.

The objective of the study was to describe the resources and activities associated with childbirth services.We adapted models for assessing the quality of healthcare to generate a conceptual framework hypothesizing that childbirth hospital resources and activities contributed to maternal and neonatal outcomes. We used this framework to guide development of a survey, which we administered by telephone to hospital labor and delivery nurse managers in California. We describe the findings by hospital type (ie, integrated delivery system [IDS], teaching, and other [community] hospitals).Of 248 nonmilitary childbirth hospitals in California, 239 (96%)responded; 187 community, 27 teaching, and 25 IDS hospitals reported. The context of services varied across hospital types, with community hospitals more likely to have for-profit ownership, be in a rural or isolated location, and have fewer annual deliveries per hospital. Results included the findings of the following: (1) 24 hour anesthesia availability in 50% of community vs 100% of IDS and teaching hospitals (P.001); (2) 24 hour in-house labor and delivery physician coverage in 5% of community vs 100% of IDS and 48% of teaching hospitals (P.001); (3) 24 hour blood bank availability in 88% of community vs 96% of IDS and 100% of teaching hospitals (P = .092); (4) adult subspecialty intensive care unit availability in 33% of community vs 36% of IDS and 82% of teaching hospitals (P.001); (5) ability to perform emergency cesarean delivery in 30 minutes 100% of the time in 56% of community vs 100% of IDS and 85% of teaching hospitals (P.001); (6) pediatric care available both day and night in 54% of community vs 63% of IDS vs 76% of teaching hospitals (P = .087); and (7) no neonatal intensive care unit in 44% of community vs 12% of IDS and 4% of teaching hospitals (P.001).Childbirth services varied widely across California hospitals. Cognizance of this variation and linkage of these data to childbirth outcomes should assist in the identification of key resources and activities that optimize the hospital environment for pregnant women and set the groundwork for identifying criteria for the provision of maternal risk-appropriate care.

Objective This study was undertaken to assess the safety of trial of labor after previous cesarean delivery. Study design Retrospective cohort study of 308,755 Canadian women with previous cesarean delivery between 1988 and 2000. Occurrences of in-hospital maternal death, uterine rupture, and other severe maternal morbidity were compared between women with a trial of labor and those with an elective cesarean section. Results Rates of uterine rupture (0.65%), transfusion (0.19%), and hysterectomy (0.10%) were significantly higher in the trial-of-labor group. Maternal in-hospital death rate, however, was lower in the trial-of-labor group (1.6 per 100,000) than in the elective cesarean section group (5.6 per 100,000). The association between trial of labor and uterine rupture was stronger in low volume ( Conclusion Trial of labor is associated with increased risk of uterine rupture, but elective cesarean section may increase the risk of maternal death.

Objective This study was undertaken to assess feasibility of magnetic resonance imaging (MRI) pelvimetry in conjunction with fetal ultrasonography as a technique in evaluating patients with previous cesarean sections for cephalopelvic disproportion (CPD). Study deisgn Pregnant patients with one previous cesarean section for CPD who planned a trial of labor after cesarean (TOLAC) were recruited to undergo MRI pelvimetry and fetal ultrasonography at 37 to 38 weeks. Entry criteria included no previous successful vaginal deliveries and no contraindications for vaginal delivery in the ongoing pregnancy. A fetal-pelvic index was calculated for each patient but not disclosed to patients or their physicians. The pregnancies were managed routinely. Analysis after delivery was used to ascertain whether this index would have predicted clinical outcome. Results There were no difficulties in performing the MRI or ultrasound. Sixteen patients completed their pregnancies. Three patients did not labor. The fetal-pelvic index was plotted on a scattergram and compared with the outcome. Three discriminatory zones were identified. Five of 6 patients in the most favorable zone delivered successfully. Two patients in the most unfavorable zone had failed vaginal birth after cesarean section (VBAC) attempts. In the 5 patients in the middle intermediate zone, TOLAC success appeared to depend on fetal presentation and gestational age. Conclusion The use of comparative MRI pelvimetry and fetal ultrasonography is feasible in a community hospital. In this pilot study, it appeared to have potential in enhancing the management of VBAC candidates. This technique may allow sorting of patients before labor into zones that would favor or preclude VBAC attempts.

Objective: The purpose of this study was to evaluate the effect of induction on the route of delivery in nulliparous women laboring at term in a community hospital system. Study Design: From April 1997 to October 1999, there were 7282 deliveries in nulliparous patients who met inclusion criteria. Cesarean delivery rates were calculated for patients in spontaneous labor and for patients who underwent induction. Results: Among 4635 women (63.7%) in spontaneous labor, the cesarean delivery rate was 11.5% versus 23.7% among the 2647 (36.3%) patients who underwent induction. An important variable that affected the delivery route was the Bishop score at the initiation of the induction. The cesarean delivery rate was 31.5% among patients whose Bishop score was P Conclusion: The induction of labor in nulliparous patients, especially those women with an unfavorable cervix as measured by Bishop score, is associated with a significantly increased risk of cesarean delivery. (Am J Obstet Gynecol 2003;188:1565-72.)

Objective: The purpose of this study was to estimate the cost differences between elective cesarean delivery and the alternative of attempted vaginal delivery and to assess the economic impact of cesarean delivery on demand. Study Design: Cost data were obtained over a 12-month period from a not-for-profit community hospital to calculate a per-patient cost for clinical alternatives. Results: The average cost of an attempted vaginal delivery without oxytocin (Pitocin) or epidural anesthesia was 15.1% lower in nulliparous women and 20% lower in multiparous women than with elective cesarean delivery. However, in nulliparous women, the addition of Pitocin nullified any cost differences; if epidural anesthesia was also used, total costs exceeded the cost of elective cesarean delivery by almost 10%. The cost of a failed attempt at vaginal delivery was much higher than elective cesarean delivery for both groups. The average cost for all women who attempted vaginal delivery was only 0.2% less than the per-patient cost of elective cesarean delivery. Conclusion: The adoption of a policy of cesarean delivery on demand should have little impact on the overall cost of obstetric care. (Am J Obstet Gynecol 2003;188:1418-23.)

Objective: The purpose of this study was to determine whether knowledge of the results of a rapid fetal fibronectin test affects treatment decisions during the evaluation and treatment of possible preterm labor. Previous observational studies have suggested that a negative test might help to avoid unnecessary intervention. Study Design: This was a randomized study of women who were between 24 weeks and 34 weeks 6 days of gestation with symptoms of preterm labor and who were seen in three community hospitals. A rapid fetal fibronectin test was performed on all subjects. Patients were assigned randomly to a group whose results were known to physician or to a group whose results were not known. Treatment decisions were at the discretion of the physician. Results: One hundred eight samples were collected between September 2000 and December 2001. There were 10 positive fetal fibronectin tests. The overall prevalence of delivery within 2 weeks for the study population was 2.8%. For women who had negative fetal fibronectin test results, the hospital stay was not significantly shorter when the result was known (6.8 hours) than when it was not known (8.1 hours, P =.35). However, when the physician knew the fetal fibronectin status of women with a negative test result who were observed for >6 hours, the hospital stay was shortened 40%, to 22.7 hours from 37.8 hours ( P =.04). Conclusion: Fetal fibronectin testing may be able to supplement clinical judgment in the evaluation of the condition of patients with symptoms of preterm labor. The greatest benefit of fetal fibronectin testing might be for the patient whom the physician judges to be at high risk for imminent delivery. In such patients, the knowledge of a negative fetal fibronectin may shorten the hospital stay.

Objective: The purpose of this study was to determine the pregnancy loss rate after genetic amniocentesis that was performed by general obstetrician-gynecologists in a community hospital. Study Design: Medical records and billing information were used to identify all genetic amniocenteses that had been performed by a group of general obstetricians-gynecologists from 1996 through 2000. Maternal charts were reviewed for data that were pertinent to the risk of fetal loss: maternal age, parity, ethnicity, procedure indication, gestational age at procedure, karyotype results, physician operator, gestational age at delivery, and live birth/stillbirth. Results: During this 5-year time period, 370 procedures were performed by this physician group. Completed delivery outcomes were available on 369 of 370 patients (99.7%). Three patients underwent pregnancy termination. Data were analyzed on the remaining 366 patients. There was 1 pregnancy loss (amniocentesis at 17 weeks with vaginal bleeding at 21 week and preterm delivery at 24 weeks). There was 1 other procedure-related complication: membrane rupture 7 days after the procedure, with spontaneous resealing of the membranes after prolonged bedrest. Conclusion: Over a 5-year period, pregnancy loss after midtrimester amniocentesis performed by general obstetrician-gynecologists was 1 in 366 procedures. (Am J Obstet Gynecol 2002;186:1130-2.)

Objective: The purpose of this study was to determine if the success and safety of vaginal birth after cesarean delivery in a small, isolated, rural hospital compare with those seen in larger centers. Study Design: As part of a continuing study, the prenatal and hospital records of all patients with previous cesarean delivered by the Rural Health Group between October 1988 and January 1991 were reviewed. Patients were allowed a trial of labor with one or more previous cesarean sections, unknown scar, and breech presentation but not for other malpresentation or a vertical scar. Results: A total of 67 patients were studied; 76.1% of these had a trial of labor, and 60.8% of them were delivered vaginally, whereas 39.2% underwent repeat cesarean delivery. Of the 67 patients 11.9% were not candidates for vaginal birth after cesarean delivery, and the same percentage refused. Forty-nine percent received oxytocin; of these, 56% were delivered vaginally. Overall, maternal complications were similar between the groups. Two uterine ruptures occurred; neither was associated with labor. The major maternal complications occurred in the vaginal birth after cesarean delivery group, but all were associated with antepartum conditions and not related to labor and delivery. There were no maternal deaths. The only neonatal death resulted from a congenital anomaly. Conclusion: We concluded that vaginal birth after cesarean delivery can be performed safely in an isolated small community hospital with success rates similar to those of larger centers and with no increased maternal or neonatal morbidity or mortality.

Our objective was to determine whether case mix model adjustment would help to explain differences in cesarean delivery rates between community and university hospitals. We also wished to define a patient population in which the cesarean delivery rate would be more reflective of individual practice patterns than of obstetric or medical risk.Established risk factors for cesarean delivery were identified by retrospective chart review at two community hospitals (designated A and B) and a university hospital. Each delivery was assigned exclusively to 1 of 6 risk categories: (1) multiple gestation, (2) fetal malpresentation, (3) delivery at36 weeks' gestation, (4) not suitable for trial of labor, and (5) term delivery (or =36 weeks' gestation) with medical complications, and (6) term delivery (or =36 weeks' gestation) without medical complications. Parity and history of cesarean delivery further subdivided these categories into a total of 18 unique subgroups. Case mix was defined as the distribution of patients into each subgroup. Patients assigned to the categories of multiple gestation, fetal malpresentation, delivery at36 weeks' gestation, and not eligible for trial of labor were considered to compose the group at high risk for cesarean delivery. The remaining patients composed the group at low risk for cesarean delivery. Observed cesarean delivery rates were calculated for each cell of the case mix grid within individual hospitals. Total, primary, and repeat cesarean delivery rates were determined for each hospital. The cesarean delivery rates for the low-risk populations were calculated. Data were evaluated both by chi(2) test and by direct standardization analysis with the university hospital case mix used as the standard population.A total of 5705 delivery reports were reviewed (university hospital, n = 4538; hospital A, n = 531; hospital B, n = 636). The cesarean delivery rates were significantly different between hospitals (university hospital, 16. 9%; hospital A, 13.6%; hospital B, 12.0%; P =.002). The distributions of patients in the high-risk group were also significantly different between hospitals (university hospital, 16. 8%; hospital A, 5.8%; hospital B, 8.8%; P = .001). The percentage of medically complicated cases in the low risk for cesarean group was significantly higher at the university hospital (university hospital, 16.9%; hospital A, 8.8%; hospital B, 9.8%; P =.001). However, no statistical differences were detected between hospitals in either the observed cesarean delivery rates or the standardized rates for the low-risk groups.The case mix model provides a more accurate method of comparing cesarean delivery rates between community and university hospitals. The low-risk group of patients discriminated in this model represents a population in which the cesarean delivery rate may be more reflective of individual practice patterns than of maternal or fetal risks.

Objective: The purpose of this study was to describe the outcome of peripartum cardiomyopathy in patients cared for in a community hospital. Study Design: The cases of peripartum cardiomyopathy treated at Central Baptist Hospital in Lexington, Kentucky, from January 1, 1992, to December 31, 1998, were reviewed. Results: Eleven patients with peripartum cardiomyopathy were identified. The patient population was 91% white and 9% African American. Seventy-two percent of patients were nulliparous, and the prevalence of chronic hypertension was 27%. All patients were examined with echocardiography and met diagnostic criteria for the disease when this modality was used. The mean ejection fraction was 32% ± 10%. Invasive techniques used to assist in diagnosis included left ventricular catheterization (63%), right ventricular catheterization (54%), and cardiac biopsy (54%). One patient required cardiac transplantation. This patient also had an embolic stroke from a confirmed mural thrombus. No study patient died of the disease, and no other major complications were observed. Conclusions: The patient profile of peripartum cardiomyopathy in this study differed remarkably from profiles in published reports. Nulliparous white women have better outcomes than indicated by previous reports, probably because of the low frequency of coexisting chronic disease and a younger age at diagnosis. (Am J Obstet Gynecol 2000;182:1036-8.)

Despite a decrease in the overall cesarean delivery rate at Ravenswood Hospital Medical Center in Chicago, a wide range of variation existed among individual obstetricians' rates. This study evaluated obstetricians' characteristics to determine whether they affected cesarean delivery rates.In 1994 members of my department adopted strategies to decrease the cesarean delivery rate. Data on women who were delivered at the obstetric unit from 1994-1997 and data on their neonates were studied. Certain characteristics of obstetricians were also analyzed. The data were grouped according to personal characteristics and obstetricians' cesarean delivery rates: group 1 had a low rate (/=15%) and group 2 had a high rate (15%). Pearson chi2 analysis was used to evaluate the differences between the proportions. P.05 was considered significant.The departmental cesarean delivery rate decreased from 20.5% in 1994 to 15.5% in 1997 (P.0001), whereas individual obstetricians' rates varied from 0% to 44.4%. Obstetricians in group 1 (average rate 12.2%) and group 2 (average rate 20.8%, P.0001) served similar populations with similar outcomes. Compared with obstetricians in group 2, those in group 1 (low rate) performed more vaginal deliveries after cesarean birth and used epidural analgesia and the vacuum extractor more frequently. Young age of physician, graduation from a domestic medical school, group practice, and smaller volume of births were all significantly linked to lower cesarean delivery rates.Cesarean delivery rates can safely be reduced. Certain individual obstetrician characteristics influence cesarean delivery rates. Obstetricians' commitment facilitates lowering of cesarean delivery rates.

This clinical trial evaluated the efficacy of intravaginal misoprostol (prostaglandin E1) and compared it with that of dinoprostone (prostaglandin E2) for cervical ripening and induction of labor in a community hospital.This study involved a retrospective analysis of 81 patients undergoing cervical ripening and induction of labor with prostaglandin E2 from May 1, 1996, to May 1, 1997. A comparison prospective analysis of 145 patients undergoing the same procedure with prostaglandin E1 from May 1, 1997 to May 1, 1998, was performed.The mean time to delivery was significantly shorter with misoprostol (19.8 +/- 10.4 hours) than with prostaglandin E2 (31.3 +/- 13.0 hours, P.001). Delivery within 24 hours of induction was significantly more frequent with misoprostol (71.9% of subjects vs 31.3%, P.001). There was no difference in the cesarean delivery rate with misoprostol (25.6% vs 22.2%, P.67). The incidence of uterine hyperstimulation was higher with prostaglandin E2 (7.4% vs 0.7%, P.007). There were no uterine ruptures with prostaglandin E2. There were 2 uterine ruptures and 1 dehiscence with prostaglandin E1 in 3 patients with previous cesarean deliveries and 1 rupture in a patient without a history of uterine scarring. There was no difference in neonatal outcome, with the exception of a fetal death related to uterine rupture in the misoprostol group.Compared with prostaglandin E2, misoprostol is more effective in cervical ripening and induction of labor, is as safe for patients who do not have a history of cesarean birth, may carry a higher incidence of uterine rupture, and should not be used for patients attempting vaginal birth after previous cesarean delivery.

Objective: The goal of this project was to study the increasing risk of induction of labor in a community hospital and to determine whether it had an adverse effect on the rate of cesarean delivery. Study Design: From January 1, 1990, through July 31, 1997, 18,055 consecutive singleton pregnancies in women who were candidates for labor were reviewed via a comprehensive perinatal database. The risk of and indication for induction were reviewed. Cesarean delivery rates were calculated for nulliparous and multiparous patients by indication for induction and were compared with rates for patients who had spontaneous labor. Overall trends in cesarean delivery were reviewed for the duration of the study period. Results: The annual induction rate significantly rose from 32% to 43% at the conclusion of the study period. Labor was induced in nearly 40% of nulliparous patients. Postdate pregnancy was the most common indication for induction, although few patients were at or beyond 42 weeks' gestation. The cesarean delivery rate remained at or below 20% for the years of the study. No increase was noted in spite of the increasing risk of induction. However, for nulliparous patients who had elective induction of labor, the risk of cesarean delivery was twice that of nulliparous patients who had spontaneous labor. Conclusion: The use of induction methods has significantly increased in this community hospital. More than 40% of patients are now candidates for induction. The cesarean delivery rate remains low in this facility in spite of a marked increase in risk of operative delivery for nulliparous patients who undergo induction. (Am J Obstet Gynecol 1999;180:628-33.)

Objective To determine whether clinics that serve indigent patients demonstrate equal compliance with sexually transmitted infection testing guidelines when compared with private clinics. Study Design One hundred eighty-three women were divided into cohorts based on whether they received prenatal care at a private or indigent clinic. Timing of required antenatal sexually transmitted infection screening was collected for 8 tests and compliance scores were calculated. Primary outcome was average compliance score compared between clinic types. Secondary outcomes included disease-specific compliance and percent of perfect compliance at different office types. Results Compliance was found to be different between clinic types ( P = .023). Indigent clinics had the same median with slightly higher inner-quartile range than private clinics (7 [7–8], 7 [7–7]). Indigent clinics had higher mean compliance scores (7.1 vs 6.9) and a greater percentage of patients demonstrating perfect compliance (42% vs 14%, P Conclusion Clinics serving indigent patient populations had a higher compliance with required testing compared to private clinics. HIV testing in the third trimester remains the greatest need for improvement for all practice types.

Our objective was to establish whether intrathecal narcotics for obstetric analgesia offer an adequate and cost-effective alternative to epidural analgesia with minimal side effects in our small, semirural community hospital with limited anesthesia coverage.Low-risk patients ator = 35 gestational weeks in active labor were offered intrathecal narcotics. A retroactive chart review of every patient receiving an intrathecal injection was compared with a chart review of the next consecutive low-risk patient who did not receive an intrathecal narcotic. Age, parity, and status of labor at the time of application were noted, as was the subsequent rate of labor and the type of delivery. Side effects such as changes in vital signs, headache, vomiting, pruritus, urinary retention, and/or respiratory depression were noted. All study patients received fentanyl, 25 to 35 micrograms, plus 0.25 to 0.3 mg of preservative-free morphine combined with 6 to 8 mg of lidocaine. Within 15 minutes of delivery intravenous nalbuphine (Nubain), 5 mg, and oral naltrexone, 12.5 mg, were administered. Pain relief was recorded as excellent, satisfactory, or unsatisfactory (requiring additional medication).During the 30-month review period, 90 patients (3% of total deliveries) received intrathecal narcotics. There were three sets of twins, for a total of 93 live births. Ten patients (11%) required primary cesarean section, and of the 83 vaginal births 35 (38%) were spontaneous, two (2%) required forceps deliveries, and 46 (49%) were delivered by vacuum extraction, which was significantly higher than the 28 (31%) for controls. The rate of labor was not affected, with both groups requiring a similar rate of oxytocin (Pitocin) augmentation. Significantly more patients receiving intrathecal narcotics experienced pruritus and urinary retention compared with controls. There was no incidence of respiratory depression. Eighty-four (93%) of the 90 patients reported excellent pain relief, five patients had satisfactory relief lasting 2.5 to 6 hours, and one was unsatisfactory.In our hospital with limited anesthesia services intrathecal narcotics offer excellent labor pain relief with manageable side effects and without adverse obstetric outcome.

Objective: The study was undertaken to evaluate the use of the loop electrosurgical excision procedure as an outpatient hospital or surgicenter procedure. Study Design: The records of 358 patients treated for cervical intraepithelial neoplasia at a large community hospital over a 1-year period were reviewed. Results: The specimens obtained by loop electrosurgical excision procedure and laser cone excision were comparable in size but smaller than those by means of cold-knife conization. Seventy-two percent of loop electrosurgical excision procedure specimens consisted of two to eight tissue fragments (mean 3.4). In addition, 48% of the loop electrosurgical excision procedure specimens and 38% of laser cones had moderate or severe thermal artifacts. Fragmentation and cautery damage precluded orientation of tissue and evaluation of margins in 19% of the cases. Conclusions: The advent of the loop electrosurgical excision procedure has shifted the management of cervical intraepithelial neoplasia from the office to the outpatient surgery centers. This negates and, in fact, reverses the advantage of loop electrosurgical excision procedure over other methods in regard to cost and convenience through evaluating and treating a patient with cervical intraepithelial neoplasia in one office visit. Loop electrosurgical excision procedures provide specimens that are inferior compared with cold-knife cones; therefore the role of loop electrosurgical excision procedure for the management of cervical intraepithelial neoplasia outside the office appears limited.

The purpose of this study was to determine prognostic factors that could be altered to increase survival of patients with advanced ovarian cancer treated at the community hospital.This study is a retrospective analysis of 101 patients with stage III and IV epithelial ovarian carcinoma who underwent primary surgery at two private hospitals from 1970 to 1990.Primary laparotomy was done by a general surgeon in 54 cases. The tumors in 23% of stage IIIC cases were debulked to less than or equal to 2 cm residuum. The survival rate decreased as stage or postoperative tumor residual increased. Patients with stage IIIA and IIIB disease had similar survival rates, significantly better than those with stage IIIC disease. Cytoreduction of stages IIIB and IIIC to microscopic disease resulted in a survival curve equal to the "natural optimal" stage IIIA. Patients with cytoreduction of stage IIIC disease to less than or equal to 2 cm did not obtain survival rates equal to those with stage IIIB disease with visible tumor remaining. Patients with stage IIIC disease achieved a significant increase in survival rate if their tumors were cytoreduced to microscopic disease. Platinum-based combination chemotherapy compared with alkylating agents improved survival in patients with stage IIIC disease who had greater than 2 cm tumor residual. Seven patients survived greater than 5 years, with three patients currently free of disease. Three prognostic categories predict decreasing survival: (1) stage IIIC if tumor is cytoreduced to no visible residual, stage IIIA or stage IIIB; (2) stage IIIC with visible tumor residual; (3) stage IV.Survival of community hospital-treated advanced ovarian carcinoma patients can be improved by early diagnosis, adjuvant platinum-based combination chemotherapy, and surgical cytoreduction to minimal disease. This treatment requires a team approach and education of the medical staff, including nongynecologists.

This prospective study assesses factors that contribute to perinatal mortality. The study population includes the 1362 perinatal deaths that occurred among 85,402 live births between 1983 and 1987 at hospitals of the University of Chicago Perinatal Network. After peer review of demographic, clinical, and pathologic data, each perinatal death was classified in one of the following categories: (1) the result of congenital malformation incompatible with life, (2) unavoidable, (3) potentially avoidable by patient, by health provider, or by both, or (4) of undetermined responsibility. Of 1362 deaths, 12.3% involved congenital malformations incompatible with life, 56.9% were classified as unavoidable, 28.1% were judged potentially avoidable, and 2.7% due to undetermined causes. Of potentially avoidable deaths, 36% were due to patient factors (primarily noncompliance), 59% to health provider factors, and 15% to combined patient and provider factors. There was a significant reduction in the potentially avoidable cases during the study period. The maximum attainable reduction in perinatal mortality under optimal conditions is calculated. Intervention plans to achieve this goal are discussed.This prospective study assesses factors that contribute to perinatal mortality. The study population includes the 1362 perinatal deaths that occurred among 85,402 live births between 1983 and 1987 at hospitals of the University of Chicago Perinatal Network. After peer review of demographic, clinical and pathologic data, each perinatal death was classified in one of the following categories: 1) the result of congenital malformation incompatible with life, 2) unavoidable, 3) potentially avoidable by patient, by health provider, or by both, or 4) of undetermined responsibility. Of 1362 deaths, 12.3% involved congenital malformations incompatible with life, 56.9% were classified as unavoidable. 28.1% were judged potentially avoidable, and 2.7% due to undetermined causes. Of potentially avoidable deaths, 36% were due to patient factors (primarily noncompliance), 59% to health provider factors, and 15% to combined patient and provider factors. There was a significant reduction in the potentially avoidable cases during the study period. The maximum attainable reduction in perinatal mortality under optimal conditions is calculated. Intervention plans to achieve this goal indicate that greater attention must be paid to the socioeconomic conditions that contribute to the "unavoidable" perinatal mortality in our society. These latter cases make up the vast majority of the unacceptably high overall perinatal mortality rate. The present study serves as a model for the ongoing surveillance of factors that contribute to avoidable perinatal mortality, as well as for the implementation of educational programs for the improvement of perinatal care within an organized perinatal network. (Author's).

Objective The purpose of this study was to examine complications of labor induction compared to spontaneous labor in multiparas. Study Design This was a retrospective cohort study of multiparous women with live, singleton pregnancies at term, who had no contraindications to labor or labor induction. Cesarean delivery was the primary outcome. Results Of the study subjects, 7208 experienced spontaneous labor, 2190 underwent labor induction with oxytocin, and 239 underwent labor induction requiring cervical ripening agents. Oxytocin-induced multiparas were 37% more likely to require cesarean compared to those with spontaneous labor (OR, 1.37; 95% CI, 1.10-1.71) and nearly 3 times more likely to undergo cesarean when cervical ripening agents were used (OR, 2.82; 95% CI, 1.84-4.53). Women requiring cervical ripening were also 10 times more likely to spend more than 12 hours in labor than those with spontaneous labor. Conclusion Multiparas undergoing labor induction are at increased risk for obstetric complications compared to spontaneous labor.

Unanticipated perinatal catastrophe in a rural community hospital is responsible for the deaths of many potentially salvageable infants. An intrapartum risk scoring system was designed to help anticipate infants needing skilled resuscitation at the rural community hospital. Thirty-three percent of infants whose mothers scored as high risk (greater than or equal to 10) required resuscitation while only 6% of infants whose mothers scored less than 10 required resuscitation. Sequential Apgar scores of infants in need of resuscitation attended by a skilled resuscitator showed significant improvement compared with Apgar scores of infants not attended by a skilled resuscitator, suggesting at least a short-term benefit for early identification of the infant at risk.

A total of 185 cases were reviewed of major gynecologic surgery performed upon women 65 years of age and older from 1970 to 1973 at a 350 bed community hospital. Each private staff physician operated upon his private patient. There were 112 vaginal operations performed, mostly for pelvic relaxation problems, and 73 abdominal operations. Forty-two patients had surgery for cancer. There were nine postoperative complications and only two deaths. It can be concluded from this study that the elderly female can tolerate major gynecologic surgery very well in a modern-day hospital setting.

A review of 300 cases of breast cancer in a community hospital was undertaken to document who made the initial discovery of the breast lesion. In this series, the woman discovered her own cancer in 75% of the cases. Obstetrician-gynecologists, who made up only 8% of the medical staff, discovered almost one third of the primary lesions that were first noticed by physicians. Obstetrician-gynecologists were the first physicians consulted by 20% of the women who discovered their own breast lesions. Preoperative xeromammography was performed on 58% of the patients with breast cancer, and there was a false negative report in 21% of these patients.

In August 1965, a long-standing affiliation between the Department of Obstetrics and Gynecology of the University of Michigan and the Departments of Obstetrics and Gynecology of several community hospitals with residency programs was strengthened. The program directors began to meet monthly to discuss mutual problems, the teaching programs for staff and residents were improved and expanded, and students were encouraged to elect rotations in clinical obstetrics-gynecology in the community hospitals. The effect of this program on the number of residents and their quality, as measured by changes in numbers of foreign graduates and performances on examinations, is described.

1. 1. A series of multivisceral pelvic resections for advanced pelvic cancer is presented from a community, nonuniversity hospital. 2. 2. A mortality rate of 9 per cent is recorded with a concomitantly low morbidity-complication rate. 3. 3. The evolution of this surgical technique with appropriate safeguards is described. 4. 4. Criteria of operability with anticipated palliation and potential cure and discussed.