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BackgroundThe rate of induction of labor in the U.S. has risen from 9.6% in 1990 to 25.7% in 2018, including 31.7% of first-time births. Recent studies that have examined inductions have been small qualitative studies or relied on either medical records or administrative data. This study examines induction from the perspective of those women who experienced it, with a particular focus on the prevalence and predictors of inductions for nonmedical indications, women’s experience of pressure to induce labor and the relationship between the attempt to medically initiate labor and cesarean section.MethodsStudy data are drawn from the 2119 respondents to theListening to Mothers in Californiasurvey who were planning to have a vaginal birth in 2016. Mothers were asked if there had been an attempt to medically initiate labor, if it actually started labor, if they felt pressured to have the induction, if they had a cesarean and the reason for the induction. Reasons for induction were classified as either medically indicated or elective.ResultsAlmost half (47%) of our respondents indicated an attempt was made to medically induce their labor, and 71% of those attempts initiated labor. More than a third of the attempts (37%) were elective. Attempted induction overall was most strongly associated with giving birth at 41+ weeks (aOR 3.28; 95% C.I. 2.21–4.87). Elective inductions were more likely among multiparous mothers and in pregnancies at 39 or 40 weeks. The perception of being pressured to have labor induced was related to higher levels of education, maternal preference for less medical intervention in birth, having an obstetrician compared to a midwife and gestational ages of 41+ weeks. Cesarean birth was more likely in the case of overall induction (aOR 1.51; 95% C.I. 1.11–2.07) and especially following a failed attempt at labor induction (aOR 4.50; 95% C.I. 2.93–6.90).ConclusionClinicians counselling mothers concerning the need for labor induction should be aware of mothers’ perceptions about birth and engage in true shared decision making in order to avoid the maternal perception of being pressured into labor induction.

BackgroundMost women who have had previous caesareans are eligible to have labour after caesarean (LAC), but only 11.9% do so. Studies show the majority of women have already decided about future mode of birth (FMOB) before a subsequent pregnancy. Hence, providing women with LAC counselling soon after birth may help women plan for future pregnancies. Prior to our intervention, our hospital had no method of ensuring that women received LAC counselling after caesarean section. The purpose of this QI initiative was to assess whether formal LAC documentation on labour and delivery (L&D) improves rates of LAC counselling post partum.MethodsOur three-part intervention included: (1) surgeon’s assessment of LAC feasibility in the operative note, (2) written LAC education for women in discharge paperwork and (3) documentation of LAC counselling in the discharge summary. We implemented these changes on L&D in January 2019. We conducted phone surveys of 40 women after caesarean preintervention and postintervention. Surveys included questions regarding three primary outcomes: whether or not they had received LAC counselling either in the hospital or at a postpartum visit, and whether or not they would pursue LAC as FMOB. Surveys also assessed two secondary outcomes: (1) women’s understanding of the indications for surgery and (2) their involvement in the decision process. We used a χ2 analysis to assess primary outcomes and a Fisher’s exact test to assess secondary outcomes. We also surveyed providers about the culture of LAC counselling at our hospital.ResultsAfter our intervention, there was a significant difference between the number of women reporting LAC postpartum counselling (30.77% vs 53.8%, p=0.04). There was also a significant difference in the number of women feeling involved in the decision-making process (68% vs 95%, p=0.03). Providers reported improved knowledge/confidence around LAC counselling (58%–100%). Providers universally stated that LAC counselling has become more ingrained in the culture on L&D.ConclusionsDocumentation of LAC counselling improved the consistency with which providers incorporated LAC counselling into postpartum care. Addressing FMOB at the time of pLTCS and documenting that counselling may be an effective first step in empowering women to pursue LAC in future pregnancies.

Objectives. To examine the extent to which differences in medication for opioid use disorder (MOUD) in pregnancy and infant neonatal opioid withdrawal syndrome (NOWS) outcomes are associated with maternal race/ethnicity. Methods. We performed a secondary analysis of a statewide quality improvement database of opioid-exposed deliveries from January 2017 to April 2019 from 24 hospitals in Massachusetts. We used multivariable mixed-effects logistic regression to model the association between maternal race/ethnicity (non-Hispanic White, non-Hispanic Black, or Hispanic) and prenatal receipt of MOUD, NOWS severity, early intervention referral, and biological parental custody at discharge. Results. Among 1710 deliveries to women with opioid use disorder, 89.3% (n = 1527) were non-Hispanic White. In adjusted models, non-Hispanic Black women (AOR = 0.34; 95% confidence interval [CI] = 0.18, 0.66) and Hispanic women (AOR = 0.43; 95% CI = 0.27, 0.68) were less likely to receive MOUD during pregnancy compared with non-Hispanic White women. We found no statistically significant associations between maternal race/ethnicity and infant outcomes. Conclusions. We identified significant racial/ethnic differences in MOUD prenatal receipt that persisted in adjusted models. Research should focus on the perspectives and treatment experiences of non-Hispanic Black and Hispanic women to ensure equitable care for all mother–infant dyads.

Objective Gestational diabetes mellitus (GDM) is a known harbinger of future type 2 diabetes mellitus (T2DM), hypertension, and cardiac disease. This population-based study was designed to identify gaps in follow-up care relevant to prevention of T2DM in a continuously insured sample of women diagnosed with GDM. Research design and methods We analyzed data spanning 2005–2015 from OptumLabs Data Warehouse, a comprehensive, longitudinal, real-world data asset with deidentified lives across claims and clinical information, to describe patterns of preventive care after GDM. Women with GDM were followed, from 1 year preconception through 3 years postdelivery to identify individual and healthcare systems characteristics, and report on GDM-related outcomes: postpartum glucose testing, transition to primary care for monitoring, GDM recurrence, and T2DM onset. Results Among 12 622 women with GDM, we found low rates of glucose monitoring in the recommended postpartum period (5.8%), at 1 year (21.8%), and at 3 years (51%). A minority had contact with primary care postdelivery (5.7% at 6 months, 13.2% at 1 year, 40.5% at 3 years). Despite increased population risk (GDM recurrence in 52.2% of repeat pregnancies, T2DM onset within 3 years in 7.6% of the sample), 70.1% of GDM-diagnosed women had neither glucose testing nor a primary care visit at 1 year and 32.7% had neither at 3 years. Conclusions We found low rates of glucose testing and transition to primary care in this group of continuously insured women with GDM. Despite continuous insurance coverage, many women with a pregnancy complication that portends risk for future chronic illness fail to obtain follow-up testing and may have difficulty navigating between clinician specialties. Results point to a need for action to close the gap between obstetrics and primary care to ensure receipt of preventive monitoring as recommended by both the American Diabetes Association and the American Congress of Obstetricians and Gynecologists.

Background The United States has recently experienced increases in both its rate of obesity and its cesarean rate. Our objective was to use a new item measuring prepregnancy body mass index (BMI) on the U.S. Standard Certificate of Live Birth to examine at a population level the relationship between maternal obesity and primary cesarean delivery for women at otherwise low risk for cesarean delivery. Methods By 2012, 38 states with 86 percent of United States births had adopted the U.S. Standard Certificate. The sample was limited to the 2,233,144 women who had a singleton, vertex, term (37–41 weeks) birth in 2012 and no prior cesarean. We modeled the likelihood of a primary cesarean by BMI category, controlling for maternal socio-demographic and medical characteristics. Results Overall, 46.4 percent of otherwise low-risk mothers had a prepregnancy BMI in the overweight (25.1%) or obese (21.3%) categories, with the obese category distributed as follows: obese I (BMI 30.0–34.9, 12.4%); obese II (BMI 35.0–39.9, 5.5%); and obese III (BMI 40+, 3.5%). Obesity rates were highest among American Indian and Alaska Native (32.5%) and non-Hispanic black mothers (30.5%). After adjustment for demographic and medical risks, the adjusted risk ratios (95% confidence intervals) of cesarean for low-risk primiparas were: 1.61 (1.60–1.63) for obese I, 1.86 (1.83–1.88) for obese II, and 2.21 (2.18–2.25) for obese III mothers compared with mothers in the normal weight category. Discussion A relationship between prepregnancy obesity and primary cesarean delivery among relatively low-risk mothers remained even after controlling for social and medical risk factors.

Maintaining patient safety in the operating room is a major concern of surgeons, hospitals, and surgical facilities. Circumventing preventable complications is essential, and the pressure to avoid these complications during elective cosmetic surgery is especially important. Traditionally, nursing and anesthesia staff have managed patient positioning and most safety issues in the operating room. As the number of office-based procedures in the plastic surgeon's practice increases, understanding and implementation of patient safety guidelines by the plastic surgeon is of increasing importance. Key aspects of patient safety in the operating room include thoughtful patient positioning, ocular protection, proper handling of electrocautery, and airway management. If performed correctly with attention to certain anatomic landmarks, preoperative positioning of the patient can prevent nerve injury and postoperative joint or muscle pain. In this article we discuss proper patient positioning with attention to protection against nerve palsy. Further, we discuss common patient positions on the operative table and highlight special concerns associated with each position. Other safety issues including prevention of ocular injury and proper management of electrocautery are discussed. Responsibility of postoperative complications ultimately lies with the surgeon. Careful attention to patient safety guidelines is of paramount importance to surgeons, especially during elective cosmetic procedures. Attention to detail in patient positioning, eye protection, and bovie use can help avoid unnecessary perioperative complications and significantly improve the patient's cosmetic surgery experience.

Surgery Facilities Resources, Inc. (SFR) is a subsidiary organization to the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), the “gold standard” for surgery facility accreditation in the United States. Organized in 2005, SFR was created to offer a program of accreditation internationally. In 2009, the SFR international accreditation program was renamed AAAASFI (AAAASF International) by the SFR board of directors. The AAAASFI name best represents who SFR is in international accreditation. Latin America countries have a significant interest in accreditation, especially Costa Rica. Currently, 40 AAAASFI accredited surgery facilities exist worldwide, as represented by Belgium, Serbia, South Africa, Australia, Finland, and Costa Rica. For a complete list of AAAASFI-accredited facilities, visit http://www.surgeryfacility.com. Past SFR President Michael McGuire and current SFR President Ronald Iverson, MD have championed this program of international accreditation for the past 5 years by speaking at many prestigious global conferences on health care and medical tourism and inspecting surgery facilities around the world. Recently, Jeff Pearcy, Executive Vice President, attended the Latin America Congress on Medical Tourism in Costa Rica and spoke on a panel discussing accreditation and patient safety. Dr. Geoffrey Keyes, AAAASF Secretary/Treasurer, was a keynote presenter on the second day of the Congress, presenting the latest study derived from the AAAASF peer review system data. It was the only data-driven presentation in the Congress. The President of Pro-Med, an international medical group and a leader in the movement to create a safe environment for medical tourism in Costa Rica, praised Dr. Keyes’ presentation. Representatives from Guatemala are in the process of working with Mr. Oscar Molina, the AAAASFI Latin American representative working for SFR, to discuss the development of an accreditation program that mirrors the successful program in Costa Rica. Many major Guatemalan dental facilities have received our application materials in anticipation of accreditation. A special set of dental standards has been developed by AAAASFI that more closely relate to surgical practices performed in dental clinics. Representatives from the Dominican Republic, El Salvador, and Columbia government agencies have received our accreditation program materials and have requested that we contact them for future development. A key contact for AAAASFI is Carlos Enrique Cardenas Rendon, director of a cluster of services for surgery and dentistry in Columbia. The benefits of global accreditation for plastic surgeons include the following: International practice of medicine: Aesthetic surgery has no true borders. It is becoming common practice for people to seek their aesthetic surgery in many different countries. Regardless of the motivation for this trend, one thing is constant: People want to be certain that they are receiving care in a safe facility. International accreditation gives them that assurance. Market advantage: Every country has individuals from a variety of surgical disciplines who currently offer aesthetic surgery. These people often qualify for their national or provincial license but may have only limited training and education in plastic surgery. The SFR/AAAASFI accreditation for aesthetic surgery is an effective tool for separating your practice from those of lesser quality. Assurance to patients: The certificate of accreditation is a symbol to patients that the accredited facility has taken the additional step of opening its practice to the scrutiny of an international organization dedicated to patient safety. This could be a deciding factor for patients seeking the highest-quality results in the safest environments. Dr. Ronald Iverson, President of SFR, has said, “This is truly a golden opportunity for any plastic surgeon to be recognized as a leader in his/her profession and to demonstrate to potential patients that he/she has taken every possible precaution for their safety. With the increased activity in medical tourism, now is the time to get involved in this international patient safety program of inspection and accreditation to help improve patient safety and quality care globally.”