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OBJECTIVE: To compare the labor curve between individuals with induced labor and those undergoing spontaneous labor. METHODS: This was a secondary analysis of the Consortium on Safe Labor database, including nulliparous and multiparous individuals with singleton vertex pregnancy who delivered vaginally after spontaneous labor or induction of labor at term. Labor that resulted in uterine rupture and neonates with a 5-minute Apgar scores less than 7, birth injury, or neonatal intensive care unit admission was excluded. We modeled the course of cervical dilation using repeated-measures analysis with a polynomial function. We compared traverse time, defined as the elapsed time between two given dilation measures, between induced and spontaneous labor using interval-censored regression. RESULTS: Of 46,835 nulliparous individuals, 18,576 and 28,259 underwent induced and spontaneous labor, respectively. Of 77,503 multiparous individuals, 29,684 and 47,819 underwent induced and spontaneous labor, respectively. The start of the active phase on the labor curve was 6 cm in induced labor, regardless of parity. In nulliparous individuals, induced labor compared with spontaneous labor had a significantly shorter traverse time from 6 to 10 cm (median 1.8 hours [5th–95th percentile 0.4–8.6 hours] vs 2.3 hours [5th–95th percentile 0.6–9.4 hours]; P<.01). In multiparous individuals, induced labor compared with spontaneous labor had a significantly shorter traverse time from 6 to 10 cm (median 0.9 hours [5th–95th percentile 0.1–6.0 hours] vs 1.4 hours [5th–95th percentile 0.3–7.9 hours]; P<.01). CONCLUSION: Similar to spontaneous labor, the start of the active phase of induced labor was at 6 cm of dilation. Comparatively, induced labor had a shorter active phase than spontaneous labor. These findings suggest that the current criteria for active phase arrest provided by the American College of Obstetricians and Gynecologists do not need to be lengthened for individuals in induced labor. [ABSTRACT FROM AUTHOR]

In low-risk nulliparous people, lower socioeconomic status, minority race and ethnicity, operative delivery, and more labor pain were associated with lower perceived control during labor. OBJECTIVE: To evaluate the association between maternal and delivery characteristics and self-reported perceived control during childbirth. METHODS: A secondary analysis of a multicenter randomized trial was conducted to compare labor induction at 39 weeks of gestation with expectant management in low-risk nulliparous people. Six to 96 hours after delivery, participants who experienced labor completed the Labor Agentry Scale, a validated self-administered questionnaire to ascertain perceived control during childbirth. Scores range from 29 to 203, with higher scores indicating a sense of greater control. Multivariable linear regression was used to determine which maternal and delivery characteristics were associated with the Labor Agentry Scale score. Eligible characteristics included age, self-reported race and ethnicity, marital status, employment status, type of insurance, previous pregnancy loss before 20 weeks of gestation, body mass index (BMI), smoking, alcohol use, mode of delivery, labor pain (0–10 points), and a composite of perinatal death or severe neonatal complications. Significant variables (P <.05) were retained in the final multivariable model, and adjusted mean differences (95% CIs) between groups were estimated. RESULTS: Of 6,106 people enrolled in the trial, 6,038 experienced labor, of whom 5,750 (95.2%) completed the Labor Agentry Scale and were included in this analysis. Mean [95% CI] adjusted Labor Agentry Scale scores were significantly lower among those who identified as Asian (−6.4 [−10.5 to −2.3]) or Hispanic (−3.7 [−5.7 to −1.7]) compared with White, smoked compared with did not smoke (−2.8 [−5.5 to −0.1]), had BMIs of 35 or higher compared with less than 30 (−2.0 [−3.8 to −0.2]), were unemployed (−3.15 [−4.76 to −1.55]), did not have private health insurance (−2.61 [−4.47 to −0.76]), underwent operative vaginal (−5.1 [−7.7 to −2.6]) or cesarean (−14.4 [−16.1 to −12.6]) delivery compared with spontaneous vaginal delivery, and reported greater labor pain score of 8 or higher compared with less than 8 (−11.9 [−13.4 to −10.4]). Mean [95% CI] adjusted Labor Agentry Scale scores were significantly higher among people who were employed compared with unemployed (3.2 [1.6–4.8]) and had private compared with nonprivate insurance (2.6 [0.76–4.5]). CONCLUSION: In nulliparous people at low risk, unemployment, lack of private health insurance, Asian race, Hispanic ethnicity, smoking, operative delivery, and more labor pain were associated with lower perceived control during labor. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT01990612. [ABSTRACT FROM AUTHOR]

In this multisite, double-blind, placebo-controlled randomized trial, there was no difference in cesarean delivery rate between patients who received propranolol and those who received placebo for management of prolonged labor. OBJECTIVE: To evaluate the rates of cesarean delivery in patients with prolonged labor randomized to receive intravenous (IV) propranolol compared with placebo. METHODS: A double-blind, placebo-controlled, randomized trial was conducted at two hospitals within a large academic health system. Eligible patients were at 36 weeks or more with a singleton gestation and prolonged labor , defined as: 1) prolonged latent phase of labor (dilation less than 6 cm after 8 hours or more with ruptured membranes and receiving oxytocin infusion) or 2) prolonged active phase of labor (dilation 6 cm or greater and less than 1-cm cervical dilation change over 2 hours or more with ruptured membranes and receiving oxytocin infusion). Patients were excluded for severe preeclampsia, maternal heart rate less than 70 beats per minute, maternal blood pressure less than 90/50 mm Hg, asthma, diabetes requiring insulin during labor, or a cardiac contraindication to β-blockade. Patients were randomized to propranolol (2 mg IV) compared with placebo (2 mL normal saline IV), with one possible repeat dose. The primary outcome was cesarean delivery; secondary outcomes included labor duration, shoulder dystocia, and maternal and neonatal morbidity. With an estimated cesarean delivery rate of 45%, α 0.05, and 80% power, we required 163 patients per group to detect a 15% absolute reduction in cesarean delivery rate. A planned interim analysis was performed, and the trial was stopped for futility. RESULTS: From July 2020 to June 2022, 349 patients were eligible and approached; 164 were enrolled and randomized, with 84 in the propranolol group and 80 in the placebo group. The rate of cesarean delivery was not different between groups (57.1% propranolol vs 57.5% placebo, relative risk [RR] 0.99, 95% CI 0.76–1.29). Results were similar by subgroup of prolonged latent (n=123) and active (n=41) phases of labor and nulliparous (n=137) and multiparous (n=27) patients. Though not statistically significant, the frequency of postpartum hemorrhage was higher in the propranolol group (20% vs 10%, RR 2.02, 95% CI 0.93–4.43). CONCLUSION: In this multisite, double-blind, placebo-controlled randomized trial, there was no difference in cesarean delivery rate for patients who received propranolol compared with those who received placebo for management of prolonged labor. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04299438. [ABSTRACT FROM AUTHOR]

Nulliparous women have similar cesarean delivery rates in the second stage of labor when using the Zhang compared with the Friedman labor curve. OBJECTIVE: To estimate the cesarean delivery rate in the second stage of labor in nulliparous women when using the Zhang compared with the Friedman labor curve by performing a systematic review and meta-analysis. DATA SOURCES: We explored MEDLINE, EMBASE, Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials for studies comparing the cesarean delivery rate in the second stage of labor in nulliparous women when using the Zhang compared with the Friedman labor curve. METHODS OF STUDY SELECTION: Two reviewers separately ascertained studies, obtained data, and gauged study quality. The cesarean delivery rate was compared, and odds ratios (ORs) with 95% CIs were estimated. TABULATION, INTEGRATION, AND RESULTS: Five retrospective cohort studies and two randomized controlled trials were identified with 20,165 nulliparous women (10,861 with the Zhang labor curve vs 9,304 with the Freidman labor curve). Studies evaluated women with delivery from June 2010 to May 2017. Two studies were from the United States; two were from Israel; and one each was from China, France, and Norway. The median point prevalence of cesarean delivery in the second stage was 4.0% (95% CI 2.1–14.5%) in cases managed with the Zhang labor curve compared with 5.6% (95% CI 1.8–28.6%) in cases managed with the Friedman labor curves. The overall cesarean delivery rate in the second stage of labor was similar when the Zhang labor curve compared with the Friedman labor curve was used (pooled OR 0.86, 95% CI 0.47–1.57, I 2=93%). When the two randomized controlled trials were excluded, the results of the cohort studies continued to demonstrate that the overall cesarean delivery rate in the second stage of labor was similar (pooled OR 0.84, 95% CI 0.42–1.69, I 2=92%). CONCLUSION: Nulliparous women have similar cesarean delivery rates in the second stage of labor when either the Zhang or Friedman labor curve is used. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022346425. [ABSTRACT FROM AUTHOR]

Objective: To systematically review all studies that developed or validated a vaginal birth after cesarean (VBAC) prediction model.Data Sources: MEDLINE, EMBASE, CINAHL, Cochrane Library, and ClinicalTrials.gov were searched from inception until February 2022.Methods Of Study Selection: We included observational studies that developed or validated a multivariable VBAC prediction model in women with a singleton pregnancy and one previous lower segment cesarean delivery. A total of 3,758 articles were identified and screened.Tabulation, Integration, and Results: For 57 included studies, data were extracted in duplicate using a CHARMS (Critical Appraisal and Data Extraction for Systematic Review of Prediction Modelling Studies) checklist-based tool and included participants' characteristics, sample size, predictors, timing of application, and performance. PROBAST (Prediction model Risk of Bias Assessment Tool) and TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis) were used to assess risk of bias and transparency of reporting. Several studies developed or validated more than one model. There were 38 unique prediction models, 42 external validations of 10 existing prediction models, and six modifications of existing models. Of the 38 unique models, only 19 (19/38, 50%) were internally validated in the initial study. No studies externally validated their model in the initial study. Age, previous vaginal birth, and previous cesarean delivery for labor dystocia were the commonest predictors. The area under the curve in included studies ranged from 0.61 to 0.95. Models used close to delivery generally outperformed those used earlier in pregnancy. Most studies demonstrated a high risk of bias (45/57, 79%), the remainder were unclear (7/57, 12%) and low (5/57, 9%). Median TRIPOD checklist adherence was 70% (range 32-93%).Conclusion: Several prediction models for VBAC success exist, but many lack external validation and are at high risk of bias. Models used close to delivery outperformed those used earlier in pregnancy; however, their generalizability and applicability remain unclear. High-quality external validation and effect studies are required to guide clinical use.Systematic Review Registration: PROSPERO, CRD42020190930. [ABSTRACT FROM AUTHOR]

Objective: To assess whether outpatient cervical ripening with a synthetic osmotic dilator shortens the length of hospital stay in term pregnancies undergoing labor induction.Methods: Pregnant participants scheduled for labor induction at term with unfavorable cervix (less than 3-cm dilated and less than 60% effaced) and not requiring inpatient maternal or fetal monitoring were consented, and synthetic osmotic dilator rods were inserted on the day of scheduled induction. After reassuring fetal heart tracing, patients randomized to the outpatient group were asked to return 12 hours after insertion or sooner if needed. Those randomized to the inpatient group remained in the hospital. After the first round of ripening, additional ripening, oxytocin, and labor management were left up to the clinical health care professionals. The primary outcome was the proportion of participants with hospital stays longer than 48 hours. We estimated that a sample size of 338 would provide 85% power to detect a 30% difference between groups.Results: From November 2018 to November 2021, 339 participants were randomized (171 inpatient, 167 outpatient, one withdrawal). Four patients in the outpatient group were admitted before12 hours for suspected labor and rupture of membranes, and 19 in the inpatient group had the device removed before 12 hours. The proportion of participants with hospital stays longer than 48 hours was lower in the outpatient group compared with the inpatient group (89 [53%] vs 152 [89%], relative risk [RR] 0.60, 95% CI 0.52-0.70). Patients in the outpatient group had a shorter total length of stay and time from admission to active labor. They were more likely to have a vaginal delivery within 24 hours of admission and were less likely to receive analgesics during ripening. Route of delivery and other maternal and neonatal outcomes were not significantly different between groups.Conclusion: Outpatient cervical ripening with a cervical osmotic dilator decreased hospital stay compared with inpatient ripening, without significant adverse outcomes.Funding Source: Medicem Technology s.r.o., Czech Republic.Clinical Trial Registration: ClinicalTrials.gov, NCT03665688. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the use of cervical dilators concurrently with misoprostol to shorten labor in second-trimester medical termination of pregnancy.Methods: This multicenter randomized controlled trial compared the efficacy of cervical dilators inserted concurrently with misoprostol with that of misoprostol, alone, to shorten labor for women undergoing termination of pregnancy between 15 0/7 and 27 6/7 weeks of gestation. The primary outcome was the proportion of women with a duration of labor exceeding 12 hours. Secondary outcomes included median duration of labor, time to amniotomy, side effects, complications, NPRS (Numeric Pain Rating Scale) score, and women's distress as measured by the IES-R (Impact of Event Scale-Revised). These outcomes also were studied separately in the nulliparous subgroup. To demonstrate a reduction of 50% of the proportion of women with a duration of labor exceeding 12 hours in the dilator group, with a power of 80% and a 2-sided 0.05 significance level, a sample of 268 women (134 in each group) was required.Results: Between December 2017 and September 2019, this study enrolled and analyzed 347 women: 174 in the dilator group and 173 in the control group, including 87 and 93 nulliparous patients, respectively. Sociodemographic and obstetric characteristics were similar between groups. The proportion of women with labor exceeding 12 hours was not different between groups (49/174 [28.2%] in the dilator group vs 53/173 [30.6%] in the control group [ P =.61] for the whole population, and 37/87 [42.5%] vs 42/93 [45.2%] [ P =.72], respectively, among nulliparous patients). Median duration of labor was 8.5 hours in the dilator group compared with 9.2 hours in the control group ( P =.65) for the whole population, and 10.5 hours compared with 11.8 hours, respectively, among nulliparous patients ( P =.33). Median time to amniotomy was 3.6 hours in the dilator group compared with 5.0 hours in the control group ( P =.08) for the whole population, and 3.5 hours compared with 6.7 hours, respectively, among nulliparous patients ( P =.003). Side effects, complications, NPRS score, and IES-R score were similar between groups.Conclusion: Cervical dilators inserted concurrently with misoprostol did not reduce the proportion of women whose labor exceeded 12 hours compared with misoprostol alone.Clinical Trial Registration: ClinicalTrials.gov , NCT03194230. [ABSTRACT FROM AUTHOR]

Objective: To compare outcomes of women with low-lying placenta by planned mode of delivery and distance from the internal os distance.Methods: Six tertiary maternity hospitals in France participated in this retrospective multicenter study of births from 2007-2012. Women with low-lying placenta , defined as an internal os distance of 20 mm or less, who gave birth after 35 weeks of gestation were included and classified in the planned trial-of-labor or elective cesarean delivery groups. The primary endpoint was severe postpartum hemorrhage (PPH) defined as blood loss exceeding 1,000 mL. Secondary outcomes were composite variables of severe maternal and neonatal morbidity. We used multivariable logistic regression and propensity scores to compare outcomes by planned mode of delivery.Results: Among 128,233 births during the study period, 171 (0.13%) women had low-lying placenta: 70 (40.9%) in the trial-of-labor group and 101 (59.1%) who underwent elective cesarean delivery. The rate of severe PPH was 22.9% (16/70, 95% CI 13.7-34.4) for the trial-of-labor group and 23.0% (23/101, 95% CI 15.2-32.5) for the cesarean delivery group ( P =.9); severe maternal and neonatal morbidity rates were likewise similar (2.9% vs 2.0% [ P =.7] and 12.9% vs 9.9% [ P =.5], respectively). Trial-of-labor was not significantly associated with a higher rate of severe PPH after multivariable logistic regression and propensity score-weighted analysis (adjusted odds ratio [aOR] 1.42, 95% CI 0.62-3.24 [ P =.4]; and aOR 1.34, 95% CI 0.53-3.38 [ P =.5], respectively). The vaginal delivery rate in the trial-of-labor group was 50.0% (19/38) in those with an internal os distance of 11-20 mm and 18.5% (5/27) in those with a distance of 1-10 mm.Conclusion: Our results support a policy of offering a trial of labor to women with low-lying placenta after 35 weeks of gestation and an internal os distance of 11-20 mm. An internal os distance of 1-10 mm reduces the likelihood of vaginal birth considerably, compared with 11-20 mm, but without increasing the incidence of severe PPH or severe maternal morbidity. [ABSTRACT FROM AUTHOR]

A study published in Obstetrics & Gynecology examined the association between the use of nitrous oxide for labor pain relief and short-term neonatal outcomes. The study found that nitrous oxide was associated with a lower likelihood of neonatal intensive care unit admission but an increased risk of hyperbilirubinemia. The authors suggest that further research is needed to understand the potential effects of nitrous oxide on neonatal health. It is important for pregnant women considering the use of nitrous oxide to be informed about these findings. [Extracted from the article]

A study published in Obstetrics & Gynecology examined the association between the use of nitrous oxide for labor pain relief and short-term neonatal outcomes. The study found that nitrous oxide was associated with a lower likelihood of neonatal intensive care unit admission but an increased risk of hyperbilirubinemia. The authors suggest that further research is needed to understand the potential effects of nitrous oxide on neonatal health. It is important for pregnant women considering the use of nitrous oxide to be informed about these findings. [Extracted from the article]

Objective: To evaluate whether a synthetic osmotic cervical dilator is noninferior to oral misoprostol for cervical ripening.Methods: In an open-label, noninferiority randomized trial, pregnant women undergoing induction of labor at 37 weeks of gestation or more with Bishop scores less than 6 were randomized to either mechanical cervical dilation or oral misoprostol. Participants in the mechanical dilation group underwent insertion of synthetic osmotic cervical dilator rods, and those in the misoprostol group received up to six doses of 25 micrograms orally every 2 hours. After 12 hours of ripening, oxytocin was initiated, with artificial rupture of membranes. Management of labor was at the physician's discretion. The primary outcome was the proportion of women achieving vaginal delivery within 36 hours of initiation of study intervention. Secondary outcomes included increase in Bishop score, mode of delivery, induction-to-delivery interval, total length of hospital stay, and patient satisfaction. On the basis of a noninferiority margin of 10%, an expected primary outcome frequency of 65% for misoprostol and 71% for mechanical methods, and 85% power, a sample size of 306 participants was needed.Results: From November 2018 through January 2021, 307 women were randomized, with 151 evaluable participants in the synthetic osmotic cervical dilator group and 152 in the misoprostol group (there were four early withdrawals). The proportion of women achieving vaginal delivery within 36 hours was higher with mechanical cervical dilation compared with misoprostol (61.6% vs 59.2%), with an absolute difference of 2.4% (95% CI -9% to 13%), indicating noninferiority for the prespecified margin. No differences were noted in the mode of delivery. Tachysystole was more frequent in the misoprostol group (70 [46.4%] vs 35 [23.3%]; P=.01). Participants in the synthetic osmotic cervical dilator group reported better sleep, less unpleasant abdominal sensations, and lower pain scores (P<.05).Conclusion: Synthetic osmotic cervical dilator is noninferior to oral misoprostol for cervical ripening. Advantages of synthetic osmotic cervical dilator include a better safety profile and patient satisfaction, less tachysystole, lower pain scores, and U.S. Food and Drug Administration approval.Clinical Trial Registration: ClinicalTrials.gov, NCT03670836.Funding Source: Medicem Technology s.r.o., Czech Republic. [ABSTRACT FROM AUTHOR]

Objective: To compare health care medical resource utilization in low-risk nulliparous pregnancies according to body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) categories.Methods: This is a secondary analysis of a multicenter randomized controlled trial of induction of labor between 39 0/7 39 and 4/7 weeks of gestation compared with expectant management in low-risk nulliparous pregnant people, defined as those without standard obstetric indications for delivery at 39 weeks. Body mass index at randomization was categorized into four groups (lower than 25, 25-29, 30-39, and 40 or higher). The primary outcome of this analysis was time spent in the labor and delivery department from admission to delivery. Secondary outcomes included length of stay (LOS) postdelivery, total hospital LOS, and antepartum, intrapartum, and postpartum resource utilization, which were defined a priori. Multivariable generalized linear modeling and logistic regressions were performed, and 99% CIs were calculated.Results: A total of 6,058 pregnant people were included in the analysis; 640 (10.6%) had BMIs of lower than 25, 2,222 (36.7%) had BMIs between 25 and 29, 2,577 (42.5%) had BMIs of 30-39, and 619 (10.2%) had BMIs of 40 or higher. Time spent in the labor and delivery department increased from 15.1±9.2 hours for people with BMIs of lower than 25 to 23.5±13.6 hours for people with BMIs of 40 or higher, and every 5-unit increase in BMI was associated with an average 9.8% increase in time spent in the labor and delivery department (adjusted estimate per 5-unit increase in BMI 1.10, 99% CI 1.08-1.11). Increasing BMI was not associated with an increase in antepartum resource utilization, except for blood tests and urinalysis. However, increasing BMI was associated with higher odds of intrapartum resource utilization, longer total hospital LOS, and postpartum resource utilization. For example, every 5-unit increase in BMI was associated with an increase of 26.1% in the odds of antibiotic administration, 57.6% in placement of intrauterine pressure catheter, 5.1% in total inpatient LOS, 31.0 in postpartum emergency department visit, and 23.9% in postpartum hospital admission.Conclusion: Among low-risk nulliparous people, higher BMI was associated with longer time from admission to delivery, total hospital LOS, and more frequent utilization of intrapartum and postpartum resources.Clinical Trial Registration: ClinicalTrials.gov, NCT01990612. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether outpatient cervical ripening with a balloon catheter results in a shorter amount of time in the labor and delivery unit when compared with use in the inpatient setting.Data Sources: PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov were searched from their inception until December 2020. No restrictions for language or geographic location were applied.Methods Of Study Selection: Using a predefined protocol and search strategy, 1,152 titles were identified and screened. Randomized controlled trials that compared outpatient and inpatient cervical ripening with balloon catheters were included.Tabulation, Integration, and Results: Data extraction and risk of bias assessments were performed by two reviewers. Meta-analysis was performed to produce mean difference for continuous data and risk ratio (RR) for dichotomous data, both with a 95% CI. The primary outcome was the amount of time from admission to the labor ward until delivery. Additional secondary maternal and neonatal outcomes were evaluated. Eight trials (740 patients) were included; six studies (571 patients) reported on our primary outcome. Compared with the inpatient group, outpatient balloon cervical ripening was associated with significantly less time in the labor and delivery unit (outpatient 16.3±9.7 hours vs inpatient 23.8±14.0 hours; mean difference -7.24 hours, 95% CI -11.03 to -3.34). There were no differences in total induction time or total hospital admission. The outpatient group was significantly less likely than the inpatient group to undergo cesarean delivery (21% vs 27%), RR 0.76 (95% CI 0.59-0.98). There were no differences in other maternal or neonatal outcomes. There were no deliveries outside of the hospital and no stillbirths.Conclusion: Outpatient balloon cervical ripening in low-risk patients is associated with a decreased amount of time from admission to labor and delivery until delivery. Outpatient balloon cervical ripening is a safe alternative for low-risk patients and has the potential for significant benefits to patients, and labor and delivery units.Systematic Review Registration: PROSPERO, CRD42019140503. [ABSTRACT FROM AUTHOR]

Rates of attempted and successful trial of labor after cesarean delivery increased from 2010 to 2020 in the United States. The vaginal birth after cesarean (VBAC) delivery rate was last reported as 13.8% in 2019. However, contemporary trends in attempted and successful trial of labor after cesarean (TOLAC) delivery among individuals with prior cesarean delivery have not been evaluated. We performed a repeated cross-sectional analysis of singleton, cephalic, term deliveries in individuals with a history of one or two cesarean deliveries in the National Vital Statistics System from 2010 to 2020. Temporal trends in attempted and successful TOLAC, as well as VBAC, were characterized using joinpoint regression. Overall, 4,277,800 deliveries were included. Attempted TOLAC increased from 15.3% in 2010 to 21.7% in 2020, with an annual percent increase (relative) of 4.25% (95% CI 2.9–5.6%). Successful TOLAC increased from 69.8% to 74.7%, with an annual percent change (relative) of 0.91% (95% CI 0.7–1.2%). The VBAC rate similarly increased such that, by 2020, it was 16.2%. [ABSTRACT FROM AUTHOR]

Today, more than 70% of laboring women in the United States use neuraxial analgesia.[3] The ideal labor analgesia technique is safe for both mother and fetus or newborn and does not have adverse effects on the progress of labor or other harmful effects. Finally, for individual patients, we must always weigh the risks and benefits of different analgesia modalities and consider a patient's wishes and expectations for labor analgesia. Combined with patient-controlled epidural analgesia, this mode of analgesia is associated with reduced anesthetic requirements and a lower risk of operative vaginal delivery.[10] Labor neuraxial analgesia is not a generic procedure. [Extracted from the article]

Objective: To evaluate patient safety, resource utilization, and transfusion-related cost after a policy change from universal type and screen to selective type and screen on admission to labor and delivery.Methods: Between October 2017 and September 2019, we performed a single-center implementation study focusing on risk-based type and screen instead of universal type and screen. Implementation of our policy was October 2018 and compared 1 year preimplementation with 1 year postimplementation. Patients were risk-stratified in alignment with California Maternal Quality Care Collaborative recommendations. Under the new policy, the blood bank holds a blood sample for processing (hold clot) on patients at low- and medium-risk of hemorrhage. Type and screen and crossmatch are obtained on high-risk patients or with a prior positive antibody screen. We collected patient outcomes, safety and cost data, and compliance and resource utilization metrics. Cost included direct costs of transfusion-related testing in the labor and delivery unit during the study period, from a health system perspective.Results: In 1 year postimplementation, there were no differences in emergency-release transfusion events (4 vs 3, P>.99). There were fewer emergency-release red blood cell (RBC) units transfused (9 vs 24, P=.002) and O-negative RBC units transfused (8 vs 18, P=.016) postimplementation compared with preimplementation. Hysterectomies (0.05% vs 0.1%, P=.44) and intensive care unit admissions (0.45% vs 0.51%, P=.43) were not different postimplementation compared with preimplementation. Postimplementation, mean monthly type and screen-related costs (ABO typing, antibody screen, and antibody workup costs) were lower, $9,753 compared with $20,676 in the preimplementation year, P<.001.Conclusion: Implementation of selective type and screen policy in the labor and delivery unit was associated with projected annual savings of $181,000 in an institution with 4,000 deliveries per year, without evidence of increased maternal morbidity. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of single-dose azithromycin, with or without amoxicillin, with placebo to prevent peripartum infection in laboring women.Methods: We conducted a multicenter, three-group, double-blind randomized controlled trial of women with viable term nonanomalous pregnancies with either prolonged labor of 18 hours or longer or rupture of membranes for 8 hours or longer in Cameroon. Women with chorioamnionitis before randomization, study drug contraindications, or planned cesarean births were excluded. Women were randomized to oral azithromycin 1 g-placebo (group 1), oral azithromycin 1 g-oral amoxicillin 2 g (group 2), or placebo-placebo (group 3). All groups received usual care, including antibiotics given at the health care professional's discretion. The primary outcome was a composite of maternal peripartum infection or death from any cause up to 6 weeks postpartum. Two primary comparisons (group 1 vs group 3 and group 2 vs group 3) were planned. We estimated that 241 women per group (planning for 750 total) would provide 80% power at two-sided α=0.05 (0.025 per comparison) to detect a 50% effect size assuming 20% baseline composite infection rate.Results: From January 6, 2018, to May 15, 2020, 6,531 women were screened, and 756 (253 in group 1, 253 in group 2, and 250 in group 3) were randomized. Baseline characteristics (including body mass index, duration of rupture of membranes or labor, and parity) were balanced across groups, except for maternal age. More than 60% of women in each group received usual-care antibiotics: more than 90% penicillin and approximately 50% for prolonged rupture of membranes across all study groups. Composite outcome incidences were similar in antibiotic groups 1 (6%) and 2 (7%) compared with placebo group 3 (10%) (RR 0.6, 95% CI 0.3-1.2; 0.7, 95% CI 0.4-1.3, respectively). Chorioamnionitis and wound infection were significantly lower in group 2 (3.2% vs 0.4% and 4% vs 0.8% respectively, both P=.02) compared with group 3. There were no differences in other maternal or neonatal outcomes including neonatal infection.Conclusion: A single dose of oral azithromycin with or without amoxicillin for prolonged labor or rupture of membranes at term did not reduce maternal peripartum or neonatal infection. Observed lower than expected infection rates and frequent usual-care antibiotic use may have contributed to these findings.Clinical Trial Registration: ClinicalTrials.gov, NCT03248297.Funding Source: Merck for Mothers Investigator Studies Program grant. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To characterize respiratory emissions produced during labor and vaginal delivery vis-a-vis the potential for transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods: Observational study of three women who tested negative for SARS-CoV-2 and had uncomplicated vaginal deliveries. Using background-oriented schlieren imaging, we evaluated the propagation of respiratory emissions produced during the labor course and delivery. The primary outcome was the speed and propagation of breath over time, calculated through processed images collected throughout labor and delivery. Results: In early labor with regular breathing, the speed of the breath was 1.37 meters/s (range 1.20-1.55 meters/s). The breath appeared to propagate faster with a cough during early labor at a speed of 1.69 meters/s (range 1.22-2.27 meters/s). During the second stage of labor with Valsalva and forced expiration, the propagation speed was 1.79 meters/s (range 1.71-1.86 meters/s). Conclusion: Labor and vaginal delivery increase the propagation of respiratory emissions that may increase risk of respiratory transmission of SARS-CoV-2. [ABSTRACT FROM AUTHOR]

Health care systems have an opportunity to foster transparency and trust by implementing clear and open recording policies. [ABSTRACT FROM AUTHOR]

Strategies to safely reduce the rate of nulliparous, term, singleton, vertex (NTSV) cesarean deliveries have thus far largely ignored the contribution that labor and delivery nurses make to the delivery mode. We used a recently developed method to calculate nurse-specific cesarean delivery rates and provide these to labor and delivery nursing leadership, who shared the rates with labor and delivery nurses beginning in September 2020. We performed a 3-year interrupted time series analysis comparing our NTSV cesarean delivery rates before and after nurse-specific rates were released. On release of nurse-specific rates, our labor and delivery unit's NTSV cesarean delivery rate declined from 25.7% to 22.0%. Further work to find strategies to sustain nurse engagement is warranted. [ABSTRACT FROM AUTHOR]

Most studies of severe maternal morbidity (SMM) include only cases that occur during birth hospitalizations. We examined the increase in cases when including SMM during antenatal and postpartum (within 42 days of discharge) hospitalizations, using longitudinally linked data from 1,010,250 births in California from September 1, 2016, to December 31, 2018. For total SMM, expanding the definition resulted in 22.8% more cases; for nontransfusion SMM, 45.1% more cases were added. Sepsis accounted for 55.5% of the additional cases. The increase varied for specific indicators, for example, less than 2% for amniotic fluid embolism, 7.0% for transfusion, 112.9% for sepsis, and 155.6% for acute myocardial infarction. These findings reiterate the importance of considering SMM beyond just the birth hospitalization and facilitating access to longitudinally linked data to facilitate a more complete understanding of SMM. [ABSTRACT FROM AUTHOR]

Objective: To assess the comparative effectiveness and potential harms of cervical ripening in the outpatient compared with the inpatient setting, or different methods of ripening in the outpatient setting alone.Data Sources: Searches for articles in English included MEDLINE, EMBASE, CINAHL, Cochrane Library, ClinicalTrials.gov, and reference lists (up to August 2020).Methods Of Study Selection: Using predefined criteria and DistillerSR software, 10,853 citations were dual-reviewed for randomized controlled trials (RCTs) and cohort studies of outpatient cervical ripening using prostaglandins and mechanical methods in pregnant women at or beyond 37 weeks of gestation.Tabulation, Integration, and Results: Using prespecified criteria, study data abstraction and risk of bias assessment were conducted by two reviewers, random-effects meta-analyses were conducted and strength of evidence was assessed. We included 30 RCTs and 10 cohort studies (N=9,618) most generalizable to women aged 25-30 years with low-risk pregnancies. All findings were low or insufficient strength of evidence and not statistically significant. Incidence of cesarean delivery was not different for any comparison of inpatient and outpatient settings, or comparisons of different methods in the outpatient setting (most evidence available for single-balloon catheters and dinoprostone). Harms were inconsistently reported or inadequately defined. Differences were not found for neonatal infection (eg, sepsis) with outpatient compared with inpatient dinoprostone, birth trauma (eg, cephalohematoma) with outpatient compared with inpatient single-balloon catheter, shoulder dystocia with outpatient dinoprostone compared with placebo, maternal infection (eg, chorioamnionitis) with outpatient compared with inpatient single-balloon catheters or outpatient prostaglandins compared with placebo, and postpartum hemorrhage with outpatient catheter compared with inpatient dinoprostone. Evidence on misoprostol, hygroscopic dilators, and other outcomes (eg, perinatal mortality and time to vaginal birth) was insufficient.Conclusion: In women with low-risk pregnancies, outpatient cervical ripening with dinoprostone or single-balloon catheters did not increase cesarean deliveries. Although there were no clear differences in harms when comparing outpatient with inpatient cervical ripening, the certainty of evidence is low or insufficient to draw definitive conclusions.Systematic Review Registration: PROSPERO, CRD42020167406. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether manual rotation of fetuses in occiput posterior positions at full dilation increases the rate of spontaneous vaginal delivery.Methods: In an open, single-center, randomized controlled trial, patients with a term, singleton gestation, epidural analgesia, and ultrasonogram-confirmed occiput posterior position at the start of the second stage of labor were randomized to either manual rotation or expectant management. Our primary endpoint was the rate of spontaneous vaginal delivery. Secondary endpoints were operative vaginal delivery, cesarean delivery, and maternal and neonatal morbidity. Analyses were based on an intention-to-treat method. A sample size of 107 patients per group (n=214) was planned to detect a 20% increase in the percent of patients with a spontaneous vaginal delivery (assuming 60% without manual rotation vs 80% with manual rotation) with 90% power and alpha of 0.05.Results: Between February 2017 and January 2020, 236 patients were randomized to either manual rotation (n=117) or expectant management (n=119). The success rate of the manual rotation maneuver, defined by conversion to an anterior position as confirmed by ultrasonogram, was 68%. The rate of the primary endpoint did not differ between the groups (58.1% in manual rotation group vs 59.7% in expectant management group (risk difference -1.6; 95% CI -14.1 to 11.0). Manual rotation did not decrease the rate of operative vaginal delivery (29.9% in manual rotation group vs 33.6% in expectant management group (risk difference -3.7; 95% CI -16.6 to 8.2) nor the rate of cesarean delivery (12.0% in manual rotation group vs 6.7% in expectant management group (risk difference 5.3; 95% CI -2.2 to 12.6). Maternal and neonatal morbidity was also similar across the two groups.Conclusion: Manual rotation of occiput posterior positions at the start of second stage of labor does not increase the rate of vaginal delivery without instrumental assistance.Clinical Trial Registration: ClinicalTrials.gov, NCT03009435. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether a high-dose oxytocin regimen reduces the risk for primary cesarean birth and other obstetric morbidities when compared with standard dosing.Methods: In a double-blind randomized clinical trial of nulliparous women at or beyond 36 weeks of gestation who were undergoing augmentation of labor, participants were assigned to high-dose (initial and incremental rates of 6 milliunits/min) or standard-dose (initial and incremental rates of 2 milliunits/min) oxytocin regimens. The primary outcome was cesarean birth. Prespecified secondary outcomes included labor duration, clinical chorioamnionitis, endometritis, postpartum hemorrhage, Apgar score 3 or less at 5 minutes, umbilical artery acidemia, neonatal intensive care unit admission, perinatal death, and a severe perinatal morbidity composite. A sample size of 501 per group (n=1,002) was planned to detect a 6.6% absolute reduction in rate of the primary outcome, from 20% in the standard-dose group to 13.4% in the high-dose group with 80% power.Results: From September 2015 to September 2020, 1,003 participants were randomized-502 assigned to high-dose and 501 assigned to standard dosing. The majority of participants were of White race, were married or living as married, and had commercial insurance. Baseline characteristics between groups were similar. The primary outcome occurred in 14.5% of those receiving high-dose compared with 14.4% of those receiving standard-dose oxytocin (relative risk, 1.01; 95% CI 0.75-1.37). The high-dose group had a significantly shorter mean labor duration (9.1 vs 10.5 hours; P<.001), and a significantly lower chorioamnionitis incidence (10.4% vs 15.6%; relative risk, 0.67; 95% CI 0.48-0.92) compared with standard dosing. Umbilical artery acidemia was significantly less frequent in the high-dose group in complete case analysis, but this finding did not persist after multiple imputation (relative risk, 0.55; 95% CI 0.29-1.04). There were no significant differences in other secondary outcomes.Conclusion: Among nulliparous participants who were undergoing augmentation of labor, a high-dose oxytocin regimen, compared with standard dosing, did not affect the cesarean birth risk but significantly reduced labor duration and clinical chorioamnionitis frequency without adverse effects on perinatal outcomes.Clinical Trial Registration: ClinicalTrials.gov, NCT02487797. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the length of the second stage of labor in twin deliveries and to compare the length of the second stage in twin and singleton gestations.Methods: This is a retrospective cohort study from three large hospitals in Israel. Clinical data were collected from the electronic medical record. The primary outcome was the length of the second stage (the time from documented 10-cm dilation until spontaneous vaginal delivery of the first twin). Multivariable linear regression was used to examine the association of clinical factors with the length of the second stage. The length of the second stage in twin and singleton pregnancies was compared.Results: From 2011 to June, 2020, there were 2,009 twin deliveries and 135,217 singleton deliveries. Of the twin deliveries, 655 (32.6%) of the patients were nulliparous (95th percentile length of the second stage 3 hours and 51 minutes), 1,235 (61.5%) were parous (95th percentile 1 hour 56 minutes), and 119 (5.9%) were grand multiparous (five or more prior deliveries) (95th percentile 1 hour 24 minutes). In women delivering twins, epidural use was associated with a statistically significant increase in the length of the second stage of 40 minutes in nulliparous patients and 15 minutes in parous patients. In all groups, the length of the second stage was longer in patients delivering twins compared with singletons. Second-stage length longer than the 95th percentile in twins was associated with admission to the neonatal intensive care unit and need for phototherapy.Conclusion: Second-stage labor is longer in twins than singletons and is associated with obstetric history. Normal ranges for the second stage may be useful in guiding clinical practice. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether prophylactic administration of oxytocin plus ergonovine or oxytocin plus carboprost is more effective than oxytocin alone in reducing the need for additional uterotonics among women undergoing cesarean delivery for labor arrest.Methods: In this double-blind, three-arm randomized controlled trial, participants were assigned to receive either oxytocin 5 units intravenous alone, or with ergonovine 0.25 mg intravenous or carboprost 0.25 mg intramuscular immediately after delivery, followed with maintenance infusion of oxytocin 40 milliunits/minute in all groups. Uterine tone was assessed at 3, 5, and 10 minutes after delivery, and additional uterotonics were administered if deemed necessary. The primary outcome was intraoperative need for additional uterotonics. Secondary outcomes included uterine tone, calculated blood loss, and side effects. A sample size of 34 per group (n=102), based on the null hypothesis that there is no association between treatment assignment and the need for additional uterotonics, permitted independent post hoc pairwise comparisons between oxytocin plus ergonovine, oxytocin plus carboprost, and oxytocin alone using an adjusted P-value of .025. The association between the need for additional uterotonics and treatment group was assessed using the χ2 test.Results: From June 2013 through July 2019, 105 participants were randomized (35 per group) and data from 100 participants were analyzed: oxytocin (n=35), oxytocin plus ergonovine (n=33), and oxytocin plus carboprost (n=32). There was no difference in the requirement of additional intraoperative uterotonics across groups (oxytocin [37%] vs oxytocin plus ergonovine [33%] vs oxytocin plus carboprost [34%], P=.932). Uterine tone and calculated blood loss were similar across groups. Incidence of nausea or vomiting was higher in oxytocin plus ergonovine (85%; odds ratio [OR] 5.3, 95% CI 1.7-16.9, P=.003) and oxytocin plus carboprost (72%; OR 2.4, 95% CI 0.9-6.7, P=.086) compared with the oxytocin (51%) group.Conclusion: Compared with oxytocin alone, prophylactic use of a combination of uterotonic drugs did not reduce the need for additional uterotonics at cesarean delivery for labor arrest.Clinical Trial Registration: ClinicalTrials.gov, NCT01869556. [ABSTRACT FROM AUTHOR]

Objective: To estimate the incidence of failed induction of labor and the associated patient risk factors.Methods: We performed a case-control study from a cohort of nulliparous women who delivered between 39 and 41 weeks of gestation after an induction of labor in one of seven hospitals. Cases of failed induction were defined using the Obstetric Care Consensus criteria (ie, cesarean delivery performed in early labor [less than 6 cm dilatation] after at least 12 hours of oxytocin administration from membrane rupture). For each case of failed induction, the next four women who did not meet the criteria for failed induction of labor were selected for the control group, matched by hospital. We identified characteristics associated with failed induction of labor using a multivariable conditional logistic regression that was constructed with backward stepwise method for variable selection.Results: Across the hospitals, 4,123 of 10,175 nulliparous women were induced (40.5%), of whom 82 had a failed induction of labor (2.0%). A total of 328 women were selected for the matched control group. Baseline characteristics were similar between the groups. Compared with women in the control group, women with a failed induction were more likely to have a delivery body mass index (BMI) of 40 or higher (28.0 vs 8.2%, P<.001), shorter height (mean 63.9 vs 64.8 inches, P=.01), and closed cervix on admission (41.5 vs 24.1%, P=.002). Factors significantly associated with induction failure in the multivariable model included: 1) delivery BMI (adjusted odds ratio [aOR] 7.93, 95% CI 3.48-18.09, for BMI 40 or higher relative to BMI lower than 30, 2) height in inches (aOR 0.89, 95% CI 0.80-0.98), and 3) number of centimeters dilated on admission 2 or more (aOR 0.30, 95% CI 0.14-0.65).Conclusion: Failed induction of labor occurs infrequently. Risk factors include shorter height, BMI 40 or higher, and cervical dilatation of less than 2 cm on admission. Even so, most women with these risk factors will not experience failed labor induction. [ABSTRACT FROM AUTHOR]

Objective: To examine the relative contribution of changes in patient demographics and physician management to changes in the cesarean delivery rate in labor among nulliparous women.Methods: We conducted a retrospective cohort study of 485,451 births to nulliparous women who experienced labor at or beyond 35 weeks of gestation in Alberta, Canada, from 1992 to 2018. The data were from a province-wide perinatal database. The primary outcome was cesarean delivery. Multivariate logistic regression and calculation of population attributable risk for identified risk factors were performed.Results: The cesarean delivery rate increased from 12.5% in 1992 to 24% in 2018. The prevalence of maternal risk factors for cesarean delivery such as obesity, maternal age 35 years or older at delivery, and comorbidities increased over the study period. However, this did not account for the increase in cesarean delivery, because the frequency of cesarean delivery increased irrespective of risk status. Additionally, the population-attributable risk for each risk factor was stable across the study period. For example, for maternal age 35 years or older at delivery, the number of cesarean deliveries attributable to this factor (the population-attributable risk) was 0.9 per 100 deliveries in 1992-1998 and 1 per 100 in 2014-2018. The proportion of cesarean deliveries in which nonreassuring fetal status was the indication increased from 30.1% in 1992 to 51.1% in 2018. The absolute rate of cesarean delivery in the second stage of labor increased from 3.1% in 1992 to 5.9% in 2018. This was due to a significant increase, among those who entered the second stage, in cesarean delivery without a trial of forceps, from 2.5% in 1992 to 7.0% in 2018.Conclusion: The observed doubling of the rate of cesarean delivery in labor in first-time mothers was not driven by patient risk factors. Increases in the rate of cesarean delivery for nonreassuring fetal status and decreased operative vaginal deliveries were important factors. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether fetal head station at the index cesarean delivery is associated with a subsequent trial of labor success rate among primiparous women.Methods: A retrospective cohort study conducted at two tertiary medical centers included all primiparous women with subsequent delivery after cesarean delivery for second-stage dystocia during 2009-2019, identified from the electronic medical record databases. Univariate and multivariate analyses were performed to assess the factors associated with successful trial of labor after cesarean (TOLAC) (primary outcome). Additionally, all women with failed TOLAC were matched one-to-one to women with successful TOLAC, according to factors identified in the univariate analysis.Results: Of 481 primiparous women with prior cesarean delivery for second-stage dystocia, 64.4% (n=310) attempted TOLAC, and 222 (71.6%) successfully delivered vaginally. The rate of successful TOLAC was significantly higher in those with fetal head station below the ischial spines at the index cesarean delivery, as compared with those with higher head station (79.0% vs 60.5%, odds ratio [OR] 2.46, 95% CI 1.49-4.08). The proportion of neonates weighing more than 3,500 g in the subsequent delivery was lower in those with successful TOLAC compared with failed TOLAC (29.7% vs 43.2%, OR 0.56, 95% CI 0.33-0.93). In a multivariable analysis, lower fetal head station at the index cesarean delivery was the only independent factor associated with TOLAC success (adjusted OR 2.38, 95% CI 1.43-3.96). Matching all women with failed TOLAC one-to-one to women with successful TOLAC, according to birth weight and second-stage duration at the subsequent delivery, lower fetal head station at the index cesarean delivery remained the only factor associated with successful TOLAC.Conclusion: Lower fetal head station at the index cesarean delivery for second-stage dystocia was independently associated with a higher vaginal birth after cesarean rate, with an overall acceptable success rate. These findings should improve patient counseling and reassure those who wish to deliver vaginally after prior second-stage arrest. [ABSTRACT FROM AUTHOR]

Objective: To test the hypothesis that digital placement of a balloon catheter is not inferior to the speculum method in terms of rate of maternal infection.Methods: In an open-label noninferiority randomized trial, pregnant women who were undergoing induction of labor with unfavorable cervix (less than 3 cm dilated and less than 60% effaced) were randomly assigned to balloon catheter that was placed either digitally or using a sterile speculum. The primary outcome was a composite of maternal infection, defined by occurrence of fever (temperature 38°C or higher), chorioamnionitis, or endometritis (diagnoses were made by the managing obstetric physician or midwife). Prespecified secondary outcomes included outcomes in the primary composite, cesarean delivery rates, and maternal and neonatal outcomes. A patient satisfaction survey was also obtained. On the basis of a noninferiority margin of 10% and an expected primary outcome frequency of 10%, a sample size of 372 women was needed (90% power to confirm noninferiority with 90% protocol adherence).Results: From February 2018 through February 2019, 372 women were randomized (185 digital placement, 187 sterile speculum). Baseline characteristics were similar between groups. The composite maternal infection rate was not different between groups (digital placement arm: 15.7% vs speculum arm: 12.8%), with an absolute difference with respect to the sterile speculum arm of 2.8% (95% CI -4.3 to 9.9%), indicating noninferiority for the prespecified margin. Secondary outcomes were not different between groups, except for a higher need for a second balloon catheter in the sterile speculum arm. Maternal and neonatal adverse events were not different between groups. Irrespective of method of placement, women were equally satisfied with the explanation of the method before placement, anxiety regarding the procedure, and pain during placement. More women in the sterile speculum group would choose the digital placement method for the subsequent pregnancy (37.6% vs 25.7%; P=.02.).Conclusion: Digital placement of a balloon catheter for preinduction cervical ripening is noninferior to the sterile speculum method, in terms of maternal infection. Women in the sterile speculum group more frequently required a second round of the mechanical dilator. The blind digital approach is a reasonable option for balloon placement for cervical ripening.Clinical Trial Registration: ClinicalTrials.gov, NCT03450408. [ABSTRACT FROM AUTHOR]

Objective: To assess whether outpatient cervical ripening with a transcervical Foley catheter in nulliparous women undergoing elective labor induction shortens the time from admission to delivery.Methods: We performed a randomized controlled trial of patients with singleton pregnancies undergoing elective labor induction at 39 weeks of gestation or more with a modified Bishop score less than 5. Women were randomized 1:1 to outpatient or inpatient transcervical Foley. In the outpatient group, the Foley was inserted the day before admission for scheduled induction; insertion was performed at scheduled admission in the inpatient group. The primary outcome was duration of time from admission to the labor and delivery unit to delivery. With 80% power and a two-sided α of 0.05, a sample size of 126 was estimated to detect at least a 5-hour mean difference in time from admission to delivery between groups from a baseline duration of 19±10 hours.Results: From May 2018 to October 2019, 126 women were randomized, 63 in each group. Baseline characteristics were balanced between groups, except that body mass index (31±5.4 vs 34±7.5, P=.01) and group B streptococcus colonization (31% vs 54%, P=.01) were lower in the outpatient group. The time from admission to delivery was shorter in the outpatient group (17.4±7.4 vs 21.7±9.1 hours, P<.01, mean difference 4.3 hours, 95% CI 1.3-7.2). Admissions before scheduled induction were higher in the outpatient group (22% vs 5%, relative risk [RR] 4.7, 95% CI 1.4-15.4, P<.01), as was median modified Bishop score on admission (3 vs 1, P<.01). Cesarean delivery (24% vs 32%, RR 0.8, 95% CI 0.4-1.3, P=.32) and chorioamnionitis (22% vs 13%, RR 1.8, 95% CI 0.8-3.9, P=.16) were not significantly different between groups.Conclusion: In nulliparous patients undergoing elective labor induction at term, outpatient cervical ripening with a transcervical Foley catheter reduced the time from admission to delivery.Clincal Trial Registration: ClinicalTrials.gov, NCT03472937. [ABSTRACT FROM AUTHOR]

Objective: To identify characteristics associated with vaginal delivery compared with cesarean delivery after labor induction among women with hypertensive disorders of pregnancy and to develop and validate a prediction model to assist in clinical care.Methods: We studied a retrospective cohort of women with singleton pregnancies who had hypertensive disorders of pregnancy and who underwent induction of labor at 34 weeks of gestation or more from January 1, 2002, to March 31, 2013. Exclusion criteria included spontaneous labor, prelabor cesarean delivery, and known fetal anomalies. The study cohort was randomly divided into two groups; 70% of pregnancies were used to identify characteristics associated with vaginal delivery and develop a prediction model, and 30% were used to internally validate the model. Candidate predictors were limited to those associated with cesarean delivery and were available to a practitioner at time of induction. Stepwise backward logistic regression was used to build the most parsimonious model predicting cesarean delivery. Hosmer-Lemeshow test was used to assess goodness-of-fit. Model discrimination was evaluated using the concordance index and displayed through the area under the receiver operating characteristic curve (AUC).Results: Of the 1,357 women meeting study criteria, 974 (71.8%) had a vaginal delivery. The final model consisted of eight variables: maternal age, body mass index, gestational age, intrapartum magnesium sulfate for seizure prophylaxis, need for cervical ripening, prior cesarean delivery and cervical dilation, and effacement. Model calibration and discrimination were satisfactory with Hosmer-Lemeshow test P=.35 and with a 95% CI, an AUC of 0.76 (0.73-0.79). Among those with predicted probability of cesarean delivery of 20% or less, 89.5% had a vaginal delivery. Internal validation demonstrated similar discriminatory ability.Conclusion: Using information available before labor induction, and contingent on future external validation, our model can help women better understand their likelihood of vaginal delivery success when undergoing induction of labor for hypertensive disorders of pregnancy. [ABSTRACT FROM AUTHOR]

Objective: To examine whether an insulin protocol for intrapartum glucose control among parturients with diabetes was associated with improved outcomes.Methods: This is a retrospective cohort study of women with pregestational or gestational diabetes delivering a liveborn neonate at Northwestern Memorial Hospital. Before 2011, women with diabetes were given intravenous (IV) insulin or glucose during labor at the discretion of the on-call endocrinologist. In 2011, a standardized protocol was designed to titrate insulin and glucose infusions. Outcomes were compared between two time periods: January 2005-December 2010 (before implementation) and January 2012-December 2017 (after implementation) with 2011 excluded to account for a phase-in period. Maternal outcomes included intrapartum hyperglycemia (blood glucose greater than 125 mg/dL) and hypoglycemia (blood glucose less than 60 mg/dL). Neonatal outcomes included hypoglycemia (blood glucose less than 50 mg/dL), intensive care admission, and IV dextrose therapy. t tests, Wilcoxon rank sum tests, and χ tests were used for bivariable analyses. Linear and logistic multivariable regression were used to account for confounding factors.Results: Of 3,689 women, 928 (25.2%) delivered before 2011. After protocol implementation, frequencies of both maternal intrapartum hyperglycemia (51.3% vs 37.9%) and hypoglycemia decreased (6.1% vs 2.5%), both P<.001; respective adjusted odds ratio [aOR] 0.64, 95% CI 0.54-0.77 and 0.50, 95% CI 0.33-0.78. The frequency of neonatal hypoglycemia, however, increased (36.6% vs 49.2%, P<.001; aOR 1.73, 95% CI 1.45-2.07). Admission to the neonatal intensive care unit and need for IV dextrose therapy were similar across time periods.Conclusion: A formal protocol to manage insulin and glucose infusions for parturients with diabetes was associated with improved intrapartum maternal glucose control, but an increased frequency of neonatal hypoglycemia. [ABSTRACT FROM AUTHOR]

Objective: Trial of labor after cesarean delivery has been mostly studied in the setting of one prior cesarean delivery; controversy remains regarding the risks and benefits of trial of labor for women with two prior cesarean deliveries. This study aimed to examine utilization, success rate, and maternal and neonatal outcomes of trial of labor in this population.Methods: Using linked hospital discharge and birth certificate data, we retrospectively analyzed a cohort of mothers with nonanomalous, term, singleton live births in California between 2010-2012 and had two prior cesarean deliveries and no clear contraindications for trial of labor. We measured whether they attempted labor and, if so, whether they delivered vaginally. Association of patient and hospital characteristics with the likelihood of attempting labor and successful vaginal birth was examined using multivariable regressions. We compared composite severe maternal morbidities and composite severe newborn complications in those who underwent trial of labor as opposed to planned cesarean delivery using a propensity score-matching approach.Results: Among 42,771 women who met sample eligibility criteria, 1,228 (2.9%) attempted labor, of whom 484 (39.4%) delivered vaginally. There was no significant difference in the risk of composite severe maternal morbidities, but there was a modest increase in the risk of composite severe newborn complications among women who attempted labor compared with those who did not (2.0% vs 1.4%, P=.04). After accounting for differences in patient and hospital characteristics, propensity score-matched analysis showed no significant association between trial of labor and the risk of composite severe maternal morbidities (odds ratio [OR] 1.16, 95% CI 0.70-1.91), but trial of labor was associated with a higher risk for the composite of severe newborn complications (OR 1.78, 95% CI 1.04-3.04).Conclusion: Among women with two prior cesarean deliveries, trial of labor was rarely attempted and was successful in 39.4% of attempts. Trial of labor in this population was associated with a modest increase in severe neonatal morbidity. [ABSTRACT FROM AUTHOR]

Objective: To compare the actual health-system cost of elective labor induction at 39 weeks of gestation with expectant management.Methods: This was an economic analysis of patients enrolled in the five Utah hospitals participating in a multicenter randomized trial of elective labor induction at 39 weeks of gestation compared with expectant management in low-risk nulliparous women. The entire trial enrolled more than 6,000 patients. For this subset, 1,201 had cost data available. The primary outcome was relative direct health care costs of maternal and neonatal care from a health system perspective. Secondary outcomes included the costs of each phase of maternal and neonatal care. Direct health system costs of maternal and neonatal care were measured using advanced costing analytics from the time of randomization at 38 weeks of gestation until exit from the study up to 8 weeks postpartum. Costs in each randomization arm were compared using generalized linear models and reported as the relative cost of induction compared with expectant management. With a fixed sample size, we had adequate power to detect a 7.3% or greater difference in overall costs.Results: The total cost of elective induction was no different than expectant management (mean difference +4.7%; 95% CI -2.1% to +12.0%; P=.18). Maternal outpatient antenatal care costs were 47.0% lower in the induction arm (95% CI -58.3% to -32.6%; P<.001). Maternal inpatient intrapartum and delivery care costs, conversely, were 16.9% higher among women undergoing labor induction (95% CI +5.5% to +29.5%; P=.003). Maternal inpatient postpartum care, maternal outpatient care after discharge, neonatal hospital care, and neonatal care after discharge did not differ between arms.Conclusion: Total costs of elective labor induction and expectant management did not differ significantly. These results challenge the assumption that elective induction of labor leads to significant cost escalation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether removal of a double-balloon device for cervical ripening for 6 compared with 12 hours in women with an unfavorable cervix will result in a shorter time to delivery, similar cervical ripening, and without affecting cesarean delivery rate.Methods: In a prospective randomized trial, cervical ripening was performed using a double-balloon device. Women were randomized to removal of the device after 6 compared with 12 hours. Primary outcome was time to delivery. Secondary outcomes included mode of delivery, Bishop score, and maternal and neonatal adverse outcomes. A sample size of 100 nulliparous and 100 parous women was required assuming a 95% CI, power of 80%, and mean decrease of 6 hours to delivery between the groups.Results: From March 2017 through February 2019, 688 women were screened, 243 were found eligible, and 197 were randomized as follows: nulliparous cohort (n=101): removal after 6 hours (n=48) compared with removal after 12 hours (n=53); parous cohort (n=96): removal after 6 hours (n=49) compared with removal after 12 hours (n=47). Insertion-to-delivery interval was significantly shorter in the 6-hour group for both nulliparous (25.6±12.8 hours vs 31.4±15.2 hours, P<.04; mean difference 5.8, 95% CI 0.2-11.3), and parous cohorts (18.0±6.8 hours vs 22.6±8.2 hours, P=.003; mean difference 4.7, 95% CI 1.6-7.7). Bishop score change and cesarean delivery rate were similar between groups regardless of parity. The 12-hour group in the combined cohort was associated with higher rates of maternal intrapartum fever (2% vs 10%, P=.02; odds ratio 5.3, 95% CI 1.1-24.8).Conclusion: Insertion-to-delivery interval is shorter after 6 compared with 12 hours for both nulliparous and parous women. Cervical ripening with a double-balloon device may be achieved in 6 hours. The longer time was associated with a higher rate of intrapartum fever. Six hours should be considered as standard placement time for double-balloon catheters.Clinical Trial Registration: ClinicalTrials.gov, NCT03045939. [ABSTRACT FROM AUTHOR]

Objective: To predict a woman's risk of postpartum hemorrhage at labor admission using machine learning and statistical models.Methods: Predictive models were constructed and compared using data from 10 of 12 sites in the U.S. Consortium for Safe Labor Study (2002-2008) that consistently reported estimated blood loss at delivery. The outcome was postpartum hemorrhage, defined as an estimated blood loss at least 1,000 mL. Fifty-five candidate risk factors routinely available on labor admission were considered. We used logistic regression with and without lasso regularization (lasso regression) as the two statistical models, and random forest and extreme gradient boosting as the two machine learning models to predict postpartum hemorrhage. Model performance was measured by C statistics (ie, concordance index), calibration, and decision curves. Models were constructed from the first phase (2002-2006) and externally validated (ie, temporally) in the second phase (2007-2008). Further validation was performed combining both temporal and site-specific validation.Results: Of the 152,279 assessed births, 7,279 (4.8%, 95% CI 4.7-4.9) had postpartum hemorrhage. All models had good-to-excellent discrimination. The extreme gradient boosting model had the best discriminative ability to predict postpartum hemorrhage (C statistic: 0.93; 95% CI 0.92-0.93), followed by random forest (C statistic: 0.92; 95% CI 0.91-0.92). The lasso regression model (C statistic: 0.87; 95% CI 0.86-0.88) and logistic regression (C statistic: 0.87; 95% CI 0.86-0.87) had lower-but-good discriminative ability. The above results held with validation across both time and sites. Decision curve analysis demonstrated that, although all models provided superior net benefit when clinical decision thresholds were between 0% and 80% predicted risk, the extreme gradient boosting model provided the greatest net benefit.Conclusion: Postpartum hemorrhage on labor admission can be predicted with excellent discriminative ability using machine learning and statistical models. Further clinical application is needed, which may assist health care providers to be prepared and triage at-risk women. [ABSTRACT FROM AUTHOR]

Objective: To assess the association of fetal movement counting with perinatal mortality.Data Sources: Electronic databases (ie, MEDLINE, ClinicalTrials.gov, ScienceDirect, the Cochrane Library at the CENTRAL Register of Controlled Trials) were searched from inception until May 2019. Search terms used were: "fetal movement," "fetal movement counting," "fetal kick counting," "stillbirth," "fetal demise," "fetal mortality," and "perinatal death."Methods Of Study Selection: We included all randomized controlled trials comparing perinatal mortality in those women randomized to receive instructions for fetal movement counting compared with a control group of women without such instruction.Tabulation, Integration and Results: The primary outcome was perinatal mortality. Five of 1,290 identified articles were included, with 468,601 fetuses. Definitions of decreased fetal movement varied. In four of five studies, women in the intervention group were asked to contact their health care providers if they perceived decreased fetal movement; the fifth study did not provide details. Reported reduction in fetal movement usually resulted in electronic fetal monitoring and ultrasound assessment of fetal well-being. There was no difference in the incidence of perinatal outcome between groups. The incidence of perinatal death was 0.54% (1,252/229,943) in the fetal movement counting group and 0.59% (944/159,755) in the control group (relative risk [RR] 0.92, 95% CI 0.85-1.00). There were no statistical differences for other perinatal outcomes as stillbirths, neonatal deaths, birth weight less than 10th percentile, reported decreased fetal movement, 5-minute Apgar score less than 7, neonatal intensive care unit admission or perinatal morbidity. There were weak but significant increases in preterm delivery (7.6% vs 7.1%; RR 1.07, 95% CI 1.05-1.10), induction of labor (36.6% vs 31.6%; RR 1.15, 95% CI 1.09-1.22), and cesarean delivery (28.2% vs 25.3%; RR 1.11, 95% CI 1.10-1.12).Conclusion: Instructing pregnant women on fetal movement counting compared with no instruction is not associated with a clear improvement in pregnancy outcomes. There are weak associations with some secondary outcomes such as preterm delivery, induction of labor, and cesarean delivery.Systematic Review Registration: PROSPERO, CRD42019123264. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether women with protracted active phase labor longer than 6 hours have an increased risk of adverse maternal and neonatal outcomes after the implementation of new labor management guidelines.Methods: This was a retrospective study of nulliparous, term, singleton, vertex deliveries at Cedars Sinai Medical Center from August 2016 to September 2017. Women were included if they progressed to active phase labor, defined by cervical dilation of 6 cm or more. Women then were divided into three groups based on the time course of cervical change between 6 and 10 cm: 1) normal active phase: cervical change 1 cm or more within 4 hours throughout active labor; 2) mildly protracted active phase: cervical change 1 cm or less over 4-6 hours; and 3) very protracted active phase: cervical change 1 cm or less over 6 hours. Rate of change was assessed between cervical examinations. Primary outcome was a composite of maternal morbidity by study group. Secondary outcome was a composite of neonatal morbidity. We hypothesized that women with very protracted active phase had higher rates of adverse outcomes when compared with normal active phase. Regression analyses were performed to compare maternal and neonatal outcomes by study group.Results: There were 2,559 deliveries, of which 2,378 (90.8%) were vaginal deliveries. Composite maternal and neonatal morbidity was higher with longer labor. Maternal morbidity-very protracted active phase (42.0%) compared with normal active phase (22.6%) adjusted odds ratio (aOR) 2.15 (95% CI 1.62-2.86); mildly protracted active phase (39.5%) compared with normal active phase (22.6%) aOR 2.18 (95% CI 1.67-2.84). Neonatal morbidity: very protracted active phase (19.8%) compared with normal active phase (13.8%) aOR 1.38 (95% CI 0.98-1.96); mildly protracted active phase (19.4%) compared with normal active phase (13.8%) aOR 1.44; (95% CI 1.04-1.99). Composite maternal and neonatal morbidity was not different between mildly protracted and very protracted groups.Conclusion: Composite maternal morbidity was greater in women with cervical change consistent with mildly protracted (4-6 hours) and very protracted (more than 6 hours) labor compared with cervical change in the normal active phase (less than 4 hours) group. However, composite maternal and neonatal morbidity was not different between mildly protracted and very protracted groups. [ABSTRACT FROM AUTHOR]

Objective: To describe the status of implementation of the Alliance for Innovation in Maternal Health's primary cesarean birth patient safety bundle in Maryland after 1 year (2016-2017), and assess whether hospital characteristics and implementation strategies employed are associated with bundle implementation.Methods: The Alliance for Innovation in Maternal Health's bundle to decrease primary cesarean births includes 26 evidence-based practices that hospitals can adopt based on specific needs. One year after the start of a statewide implementation collaborative at 31 of 32 birthing hospitals in Maryland, we sent a computer-based survey to hospital collaborative leaders to assess progress. Respondents reported on hospital characteristics, adoption of bundle practices, and use of 15 selected implementation strategies. We conducted descriptive and bivariate analyses of their responses.Results: Among 26 hospitals with complete reporting, 23 fully implemented at least one bundle practice (range 1-7) during the collaborative's first year. Of 26 bundle practices, on average, hospitals had fully implemented a third (mean 8.6; SD 5.5; range 0-17) before the collaborative, and 3 new practices (SD 2.4; range 0-8) during the collaborative. Hospitals' use of six implementation strategies, all highly dependent on strong clinician involvement, was significantly associated with their fully implementing more practices during the collaborative's first year.Conclusion: Our assessment has promising results, with a majority of hospitals having implemented new cesarean birth bundle practices during the collaborative's first year. However, there are lessons from the wide variability in the number and type of practices adopted. Clinicians should be aware of this variability and become more involved in the implementation of cesarean birth bundle practices. We identified six strategies associated with full implementation of more bundle practices for which clinicians' support and commitment to practice changes are critical. Clinicians' understanding of available and effective implementation strategies can better assist with the implementation of this and other Alliance for Innovation in Maternal Health patient safety bundles. [ABSTRACT FROM AUTHOR]

On August 8, 2018, Grobman et al published the findings from the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial, a large randomized controlled trial of elective induction of labor in nulliparous women at 39 weeks of gestation compared with expectant management. Conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, the trial found there was no difference between the two groups in the primary outcome, a composite of neonatal morbidity. Also, there was a reduction in rates of cesarean delivery and hypertensive disorders of pregnancy in the elective induction group. The topic of elective induction has been of interest to clinicians for decades, and research has yielded inconsistent results in the past. This trial offers the best evidence thus far to address this complex issue. Our objective is to briefly review the history and literature regarding elective induction of labor, discuss the recently published ARRIVE trial, and consider its implications on clinical practice and health policy. [ABSTRACT FROM AUTHOR]

Obstetrician-gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction. Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. For women who are in latent labor and are not admitted to the labor unit, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. Admission during the latent phase of labor may be necessary for a variety of reasons, including pain management or maternal fatigue. Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Data suggest that for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring. The widespread use of continuous electronic fetal monitoring has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies. Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. For most women, no one position needs to be mandated or proscribed. Obstetrician-gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor. Birthing units should carefully consider adding family-centric interventions that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode. This Committee Opinion has been revised to incorporate new evidence for risks and benefits of several of these techniques and, given the growing interest on the topic, to incorporate information on a family-centered approach to cesarean birth. [ABSTRACT FROM AUTHOR]

Objective: To explore the pregnancy and childbirth experiences and preferences of women with a history of sexual trauma in order to identify trauma-informed care practices that health care providers may use to improve obstetric care.Methods: We conducted a qualitative study consisting of semistructured interviews with women who either self-identified as having a history of sexual trauma or did not. Participants were recruited from a tertiary care ambulatory clinic and had at least one birth experience within the past 3 years. Interviews were audio-recorded and transcribed verbatim. Grounded theory was used to derive themes using the participants' own words.Results: From 2015 to 2017, we interviewed 20 women with a history of sexual trauma and 10 without. Women with a history of sexual trauma desired clear communication about their history between prenatal care providers and the labor and delivery team. In the intrapartum period, they desired control over who was present in the labor room at the time of cervical examinations and for health care providers to avoid language that served as a stressing reminder of prior sexual trauma. They wanted control over the exposure of their bodies during labor and to be asked about their preference for a male health care provider. In the postpartum period, some women with a history of sexual trauma found breastfeeding healing and empowering.Conclusion: Women with a history of sexual trauma have clear needs, preferences, and recommendations for obstetric care providers regarding disclosure, cervical examinations, health care provider language, body exposure, and male health care providers. They offer insight into unique breastfeeding challenges and benefits. [ABSTRACT FROM AUTHOR]

The use of antibiotics to prevent infections during the antepartum, intrapartum, and postpartum periods is different than the use of antibiotics to treat established infections. For many years, the use of prophylactic antibiotics was thought to have few adverse consequences. Concerns about the emergence of resistant strains of common bacteria, in addition to the emergence of strains with increased virulence, have resulted in increased scrutiny of the use of antibiotics, particularly in the hospital setting. Awareness of the potential adverse effects of resistant bacterial infections on neonates has been growing. Attention has been focused on the effect of mode of delivery or early antibiotic exposure on the neonatal oral and gut microbiome, which is essential for immune development. Finally, cost is a consideration in the use and choice of prophylactic agents. The purpose of this Practice Bulletin is to present a review of clinical situations in which prophylactic antibiotics are frequently prescribed and to weigh the evidence that supports the use of antibiotics in these scenarios. This Practice Bulletin is updated to reflect a limited change to clarify and provide additional information on recommendations from recent consensus guidelines for antimicrobial prophylaxis in surgery and the prevention of surgical site infection. The following practices related to cesarean delivery include preoperative skin and vaginal cleansing, weight-based dosage for cefazolin antibiotic prophylaxis, the addition of adjunctive azithromycin antibiotic prophylaxis, and antibiotic selection and dosage for women with a penicillin allergy. [ABSTRACT FROM AUTHOR]

Objective: To assess whether outpatient cervical ripening with a transcervical Foley catheter in parous women undergoing elective induction of labor shortens the total duration of time from admission to the labor ward until delivery.Methods: We performed an open-label randomized controlled trial at a single academic center in parous women at 39 weeks of gestation or greater with a cervix 3 cm or less dilated, or, if 2-3 cm dilated, less than 80% effaced and reassuring fetal heart rate monitoring (defined as moderate variability with a normal baseline and absence of decelerations). Exclusions were obstetric and neonatal conditions deemed unsuitable for outpatient cervical ripening, contraindications to vaginal delivery, or conditions that required immediate hospitalization. Women were randomized in the ambulatory setting to either an outpatient transcervical catheter (with immediate placement) or inpatient transcervical catheter placement and concomitant oxytocin infusion on the labor ward. Women in the outpatient group were instructed to return to the hospital the next day or sooner if labor occurred. Induction of labor was managed per institutional protocol, and once participants were admitted, oxytocin was initiated. The primary outcome was the duration of time from labor ward admission until delivery. Based on a prior study in our institution, a total of 128 women were needed for 80% power to detect a 12-hour difference in total duration spent from labor ward admission until delivery with a two-sided α of 0.05.Results: Of 743 women screened, 129 provided consent and were randomized from May 2016 to October 2017. Baseline characteristics were balanced between groups. Outpatient cervical ripening did not significantly shorten the time from labor ward admission until delivery (12.4±7.4 vs 13.5±7.0 hours, P=.38).Conclusion: Outpatient cervical ripening in parous women does not shorten the time from labor ward admission until delivery if oxytocin is initiated simultaneously with inpatient transcervical catheter placement.Clinical Trial Registration: ClinicalTrials.gov, NCT02756689. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether there was an association between the systematic promotion of twin vaginal delivery and an increase in the rates of twin vaginal birth.Methods: We conducted a retrospective cohort study. We implemented a quality improvement initiative promoting twin vaginal delivery at an academic tertiary care center in 2013. The program included a needs assessment, simulation of vaginal twin delivery, online educational material, and the expansion of a dedicated twin clinic. We analyzed rates of twin vaginal birth in pregnancies at or beyond 24 weeks of gestation without a contraindication to labor, prior uterine surgery, or a demise or lethal anomaly of either twin. Using linear regression, we calculated annual adjusted rates of twin vaginal birth from 2010 to 2015 and in the 3 years before and after our intervention. We performed an interrupted time-series analysis estimating rates of change before and after the intervention to account for the influence of secular trend.Results: Of 1,574 patients delivering twins, 897 (57%) were included, with 479 in the 3 years before and 418 in the 3 years after the intervention. Adjusted rates of vaginal delivery increased from 32.1% (n=153) to 44.2% (n=185) before and after the intervention (P<.01), with a decrease in elective cesarean delivery from 54.6% (n=479) to 44.3% (n=185) (P<.01). Rates of breech extraction increased after the intervention (5.7% vs 9.3%, P=.04). However, there was no difference in the rate of change in twin vaginal birth in the time period before (1.35% annual increase, P=.76) or after (5.8% annual increase, P=.40) the intervention.Conclusions: Although we observed an increased rate of twin vaginal birth in the time period after our intervention, because the rates of increase before and after the intervention were not statistically different, the increase is not attributable to our intervention and is more properly attributed to secular trend. [ABSTRACT FROM AUTHOR]

Objective: To examine changes over time in surgeon and hospital procedural volume for hysterectomy for endometrial cancer and explore the association between changes in volume and perioperative outcomes.Methods: We used the Statewide Planning and Research Cooperative System database to analyze women who underwent abdominal or minimally invasive hysterectomy from 2000 to 2014. Annualized surgeon and hospital volume was estimated. The association between surgeon and hospital volume and perioperative morbidity, mortality, and resource utilization (transfusion, length of stay, hospital charges) was estimated by modeling procedural volume as a continuous and categorical variable.Results: A total of 44,558 women treated at 218 hospitals were identified. The number of surgeons performing cases each year decreased from 845 surgeons with 2,595 patients (mean cases=3) in 2000 to 317 surgeons who operated on 3,119 patients (mean cases=10) (P<.001) in 2014, whereas the mean hospital volume rose from 14 to 32 cases over the same time period (P=.29). When stratified by surgeon volume quartiles, the morbidity rate was 14.6% among the lowest volume surgeons, 20.8% for medium-low, 15.7% for medium-high, and 14.1% for high-volume surgeons (P<.001). In multivariable models in which volume was modeled as a continuous variable, there was no association between surgeon volume and the rate of complications, whereas excessive total charges were lowest and perioperative mortality highest for the high-volume surgeons (P<.001 for both).Conclusion: Care of women with endometrial cancer has been concentrated to a smaller number of surgeons and hospitals. The association between surgeon and hospital volume for endometrial cancer is complex with an increased risk of adverse outcomes among medium-volume hospitals and surgeons but the lowest complication rates for the highest volume surgeons and centers. [ABSTRACT FROM AUTHOR]

Objective: To estimate whether there are differences in obstetric interventions or outcomes by the gender of the delivering physician.Methods: We conducted a retrospective cohort study of all nulliparous women delivering singleton, vertex, live births at 37 weeks of gestation or greater at a tertiary care institution (2014-2015). Patient clinical characteristics were analyzed by delivering physician gender. The primary outcomes were delivery mode and episiotomy. Secondary outcomes included major perineal laceration, postpartum hemorrhage, 5-minute Apgar score less than 7, cord umbilical artery pH less than 7.0, and neonatal intensive care unit admission. Univariable and hierarchical multivariable analyses including physician as a random effect were utilized for analyses.Results: Of the 7,027 women who met inclusion criteria, 81.3% (n=5,716) were delivered by a female physician. Women delivered by female physicians were slightly younger than those delivered by male physicians and were more likely to be publicly insured (11.7% vs 7.1%, P<.001). Mode of delivery did not differ by physician gender; the cesarean delivery rate was 20.6% for male physicians and 20.5% for female physicians (P=.61). Although the episiotomy rate did differ by physician gender, with 5.9% of patients delivered by male physicians undergoing episiotomy compared with 3.6% of patients delivered by female physicians (P=.001), this finding did not persist in the multivariable model after accounting for potential confounders (adjusted odds ratio 0.87, 95% CI 0.49-1.56). There were no differences by physician gender regarding any of the examined secondary outcomes in univariable or multivariable analyses.Conclusion: Outcomes of nulliparous women undergoing a trial of labor did not differ by delivering physician gender. [ABSTRACT FROM AUTHOR]

Objective: To characterize probabilities of vaginal delivery based on second-stage duration along with maternal and neonatal risks for women undergoing labor after cesarean delivery.Methods: This unplanned secondary analysis of the Maternal-Fetal Medicine Units Cesarean Registry, a prospective observational cohort, assessed outcomes in women with a prior uterine scar and included women with a previous cesarean delivery without prior vaginal delivery who reached the second stage of labor. The primary outcome was mode of delivery by second-stage duration. Secondary outcomes included assessment of individual adverse maternal (chorioamnionitis, atony, endometritis, hysterectomy, uterine rupture or dehiscence, and red cell transfusion) and neonatal (cord pH less than 7.10, Apgar score less than 6 at 5 minutes, neonatal intensive care unit admission, and ventilatory support) outcomes.Results: Of 4,579 women with a previous cesarean delivery who reached the second stage of labor, 4,147 (90.6%) delivered vaginally. As second stage increased, successful vaginal delivery rates decreased: 97.3% at less than 1 hour (95% CI 96.6-97.9%), 91.5% at 1 to less than 2 hours (95% CI 89.8-93.1%), 78.5% at 2 to less than 3 hours (95% CI 74.5-82.1%), 62.3% at 3 to less than 4 hours (95% CI 55.2-69.1%), and 45.6% at 4 hours or greater (95% CI 37.7-53.7%). Risk of all adverse maternal outcomes increased with the length of the second stage. Specifically, risk of uterine rupture or dehiscence increased with second-stage length from less than 1 hour (0.7%), 1 to less than 2 hours (1.4%), 2 to less than 3 hours (1.5%), to 3 hours or greater (3.1%) (P<.001 for differential risk across the second stage). Risk of neonatal outcomes did not differ significantly by second-stage length.Conclusion: Although many women with a longer second stage (greater than 3 hours) will achieve successful vaginal delivery, these patients may be at increased risk for adverse maternal outcomes and should have close observation of fetal heart rate monitoring, maternal vital signs, and symptoms suggestive of uterine rupture or dehiscence. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the use of a transcervical Foley catheter plus oxytocin infusion compared with oxytocin infusion alone for labor induction and cervical ripening in women 34 weeks of gestation or greater with prelabor rupture of membranes.Methods: This is a randomized, multicenter trial of women with a live, singleton gestation at 34 weeks of gestation or greater with prelabor rupture of membranes, an unfavorable cervical examination (less than or equal to 2 cm dilated and less than or equal to 80% effaced), and no contraindication to labor. Participants were randomly allocated to a transcervical Foley catheter inflated to 30 cc with concurrent oxytocin infusion or oxytocin infusion alone. Oxytocin administration was standardized across sites. The primary study outcome was interval from induction to delivery. To detect a 2.5-hour difference in the interval from induction to delivery, we required outcome data on 194 women, assuming 80% power and a two-tailed α of 5%. Analysis was by intent to treat.Results: We enrolled 201 women: 93 were allocated to Foley and 108 to oxytocin. Demographics were similar between the groups. Time to delivery was not significantly different between groups: in the Foley group, it was 13.9 hours (±6.9 SD) compared with 14.4 hours (±7.9 SD) in the oxytocin group (P=.69). There were more cases of clinical chorioamnionitis (8% compared with 0%, P<.01) in the Foley group compared with the oxytocin group. There were no differences for other infectious morbidities or any other variable studied.Conclusion: In patients with prelabor rupture of membranes, the use of a transcervical Foley catheter in addition to oxytocin does not shorten the time to delivery compared with oxytocin alone, but may increase the incidence of intraamniotic infection.Clinical Trial Registration: ClinicalTrials.gov, NCT01973036. [ABSTRACT FROM AUTHOR]