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To review management strategies associated with lower risk for cesarean delivery. Targeted literature review for labor interventions during the first stage of labor. There is evidence that policies regarding labor admission criteria, standardized policies regarding labor management including judicious use of oxytocin, standardized terminology and treatment for electronic fetal monitoring, standardized criteria for dystocia, and systematic implementation of policies that incorporate continuous supportive care during labor are associated with lower risk for cesarean. Evidence regarding use of amniotomy is conflicting. Management of the first stage of labor can affect the risk for cesarean delivery. [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]

A letter to the editor and a response about the article "The New Mammographic Screening Guidelines: What Were They Thinking?" published in a 2010 issue are presented.

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]

The Well-Woman Chart summarizes current recommendations for preventive health services for women from adolescence and continuing across the lifespan. It was developed by the Women's Preventive Services Initiative, a national collaborative of women's health professional organizations and patient representatives. The Well-Woman Chart includes current clinical guidelines from the U.S. Preventive Services Task Force, Bright Futures from the American Academy of Pediatrics, and the Women's Preventive Services Initiative that are covered with no cost-sharing for public and most private insurance plans under the prevention service mandate of the Affordable Care Act. The structure of the Well-Woman Chart is based on age intervals and pregnancy status categories that align with existing recommendations. The target audience for the Well-Woman Chart is all clinicians providing preventive health care for women, particularly in primary care settings, and patients affected by the recommendations. The preventive services recommendations apply to females 13 years of age and older and pregnant females of any age. The Well-Woman Chart provides clinical guidance for screening, counseling, and other recommended preventive services for women during health care visits based on age, pregnancy status, and risk factors. [ABSTRACT FROM AUTHOR]

Racial and ethnic disparities exist in both perinatal outcomes and health care quality. For example, black women are three to four times more likely to die from pregnancy-related causes and have more than a twofold greater risk of severe maternal morbidity than white women. In an effort to achieve health equity in maternal morbidity and mortality, a multidisciplinary workgroup of the National Partnership for Maternal Safety, within the Council on Patient Safety in Women's Health Care, developed a concept article for the bundle on reduction of peripartum disparities. We aimed to provide health care providers and health systems with insight into racial and ethnic disparities in maternal outcomes, the etiologies that are modifiable within a health care system, and resources that can be used to address these etiologies and achieve the desired end of safe and equitable health care for all childbearing women. [ABSTRACT FROM AUTHOR]

Objective: To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices.Methods: Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests.Results: Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P≤.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04).Conclusion: Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices. [ABSTRACT FROM AUTHOR]

Objective: To use population data to identify patient characteristics associated with a postpartum maternal emergency department visit within 90 days of discharge after birth.Methods: This retrospective cross-sectional study analyzed linked maternal discharge and emergency department data for all live California births from 2009 to 2011. The primary outcome was at least one emergency department visit within 90 days of hospital discharge after birth. Secondary outcomes included three or more visits within 90 days ("high utilization") and inpatient readmission. Independent variables included demographics (age, race or ethnicity, payer, income) and clinical characteristics (length of stay, antepartum complications, mode of delivery, and severe maternal morbidity at delivery). Multilevel logistic regression identified variables associated study outcomes; we validated the predictive model with a split-sample approach and receiver operating characteristic curve analysis.Results: Of 1,071,232 deliveries included, 88,674 women (8.3%) visited the emergency department at least once in the 90 days after delivery discharge. Emergency department use was significantly associated with Medicaid insurance (adjusted odds ratio [OR] 2.15, 95% CI 2.08-2.21), age younger than 20 years (adjusted OR 2.08, 95% CI 1.98-2.19), severe maternal morbidity at delivery (adjusted OR 1.58, 95% CI 1.49-1.71), antepartum complications (adjusted OR 1.46, 95% CI 1.42-1.50), and cesarean delivery (adjusted OR 1.40, 95% CI 1.37-1.44). Approximately one fifth of visits occurred within 4 days of discharge, and more than half were within 3 weeks. High utilizers comprised 0.5% of the entire sample (5,171 women) and only 1.2% of women presenting for emergency department care were readmitted. Receiver operating curve model analysis using the validation sample supported predictive accuracy for postpartum emergency department use (area under the curve=0.95).Conclusion: One in 12 California women visited the emergency department in the first 90 days after postpartum discharge. Women at increased risk for postpartum emergency department use per our validated model (eg, low income, birth complications) may benefit from earlier scheduled postpartum visits. [ABSTRACT FROM AUTHOR]

The article presents a case study of a young woman with heart failure, occurred due to familial nondialated cardiomyopathy. She was tested for stress and shows good tolerance with premature atrial and ventricular contractions. She was using an estradiol vaginal ring for contraception. The article discusses the risks of pregnancy and efficacy of the available contraceptive methods in patients with heart failure.

The article presents research which analyzed the efficacy of obstetric maneuvers for the acute management of shoulder dystocia. The researchers used an electronic database to identify women who suffered from a vertex fetus beyond 34 0/7 weeks of gestation and who incurred the medical condition during delivery. They found that the highest rate of delivery is associated with the occurrence of posterior shoulder.

The article presents information about a study on perineal lacerations and cervical lacerations in a contemporary U.S. obstetric practice. Researchers looked at the electronic medical records collected by the Consortium on Safe Labor from 19 hospitals within 12 institutions, including information on patient characteristics, prenatal complications, labor and delivery data, and maternal and neonatal outcomes. It was found that nulliparity and episiotomy are important risk factors for their- or fourth-degree lacerations.

This article presents a study which examined the labor patterns in a modern obstetric population in the U.S. using contemporary labor data. A review of related literature on normal and abnormal labor progression is provided. The methods and key findings of the study are detailed. The research concludes that the rate of cervical dilation in a contemporary population accelerated after six centimeters (cm.) and progress from four cm. to six cm.

The study determines whether hospital-specific rates of gestational pyelonephritis may serve as a measure of the quality of ambulatory maternal care services in California. The rates of preterm birth and congenital neonatal infection were higher among pregnant women with pyelonephritis. Pregnant women on MediCal as payer have a higher risk because poverty may indirectly make them more physiologically vulnerable or because they receive suboptimal care.

Background: The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes., Purpose: Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers., Methods: We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated., Results: Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions., Conclusions: Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The Agency for Healthcare Research and Quality (AHRQ) has established multiple sets of indicators for quality monitoring and improvement. One such set is the patient safety indicators (PSIs), which focuses on potentially preventable hospital complications after surgeries, procedures, and childbirth. Our objective in this study was to determine the prevalence of childbirth-related anesthesia complications by method of delivery and to evaluate the variation in complication rates across hospitals using the AHRQ PSI methodology and a modification specific to childbirth with the goal of determining the relevance of tracking anesthesia complications as a potential PSI for childbirth., Methods: The technical specifications of the experimental Anesthesia Complication Quality Indicator, one of the PSI defined by AHRQ, were modified to create a childbirth-specific indicator that included all childbirth admissions (vaginal and cesarean deliveries) and complications from general and neuraxial anesthesia/analgesia. Using California hospital discharge data, we calculated hospital-specific rates, adjusting for age, race/ethnicity, and pregnancy complications., Results: A total of 508,842 deliveries occurred in 254 hospitals in California in 2009. Hospitals with <200 annual deliveries (N = 12) were excluded from analyses. Among 242 hospitals, the rate of anesthesia complications was 0.13% for the standard AHRQ study population (adult surgical admissions, which included cesarean deliveries). The childbirth-specific rate of anesthesia complications was 0.31%. When stratified by method of delivery, complication rates were 0.49% for cesarean delivery and 0.22% for vaginal delivery (P < 0.0001). The unadjusted mean (SD) was 0.34% (0.34%), with range (0%-2.46%). The rates of 13 hospitals (including their 95% confidence limits) remained in the upper quartile as outliers, with adjusted rates from 0.52% to 2.13%., Conclusions: Rates of childbirth-related anesthesia complications may provide an opportunity to identify hospitals with extreme rates that may provide insights into systematic ways to improve patient safety.

Purpose of Review: In July 2011, in response to language in the Affordable Care Act (ACA) the Office of the Assistant Secretary for Planning and Evaluation of the US Department of Health and Human Services (HHS) tasked the Institute of Medicine (IOM) to develop a report on the clinical preventive services necessary for women. The committee proposed eight new clinical preventive service recommendations aimed at closing significant gaps in preventive healthcare. This article reviews the process, findings, and the implications for obstetrician gynecologists and other primary care clinicians. Obstetricians and gynecologists play a major role in delivering primary care to women and many of the services recommended by the Committee are part of the core set of obstetrics and gynecology services., Recent Findings: The women's health amendment to the ACA (Federal Register, 2010) requires that new private health plans cover - with no cost-sharing requirements - preventive healthcare services for women. Congress requested that a review be conducted to ascertain whether there were any additional needed preventive services specific to women's health that should be included., Summary: The IOM Committee on Preventive Services for Women recommended eight clinical measures specific to women's health that should be considered for coverage without co-payment. The US Department of HHS reviewed and adopted these recommendations, and, as a result, new health plans will need to include these services as part of insurance policies with plan years beginning on or after 1 August 2012. The authors discuss the implications of the IOM recommendations on practicing clinicians and on their potential impact on women's health and well being.

Purpose of Review: To describe the rationale behind the new recommendations for breast cancer screening issued by the U.S. Preventive Services Task Force (USPSTF)., Recent Findings: The USPSTF reviewed new summary evidence provided by the Oregon Evidence-based Practice Center and the Cancer Intervention Surveillance and Modeling Network about benefits and harms including radiation exposure and the likelihood of false-positive testing, unnecessary biopsies and treatments that may not impact overall breast cancer mortality., Summary: The USPSTF concluded maximal benefit in breast cancer mortality with least harms can be achieved with biennial mammography screening commenced at age 50 and continuing until age 74 years. A small additional benefit could be realized if screening starts at age 40 years. The USPSTF concluded that the decision to start biennial screening before age 50 years should be a personal one and take into account individual patient context, including an individual's values regarding specific benefits and harms. Evidence from large-scale randomized trials led the USPSTF to recommend against the teaching of breast self-examination. The USPSTF found insufficient evidence to recommend for or against performing clinical breast examination.

Objective: To use contemporary labor data to examine the labor patterns in a large, modern obstetric population in the United States., Methods: Data were from the Consortium on Safe Labor, a multicenter retrospective study that abstracted detailed labor and delivery information from electronic medical records in 19 hospitals across the United States. A total of 62,415 parturients were selected who had a singleton term gestation, spontaneous onset of labor, vertex presentation, vaginal delivery, and a normal perinatal outcome. A repeated-measures analysis was used to construct average labor curves by parity. An interval-censored regression was used to estimate duration of labor, stratified by cervical dilation at admission and centimeter by centimeter., Results: Labor may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm of dilation. Nulliparous and multiparous women appeared to progress at a similar pace before 6 cm. However, after 6 cm, labor accelerated much faster in multiparous than in nulliparous women. The 95 percentiles of the second stage of labor in nulliparous women with and without epidural analgesia were 3.6 and 2.8 hours, respectively. A partogram for nulliparous women is proposed., Conclusion: In a large, contemporary population, the rate of cervical dilation accelerated after 6 cm, and progress from 4 cm to 6 cm was far slower than previously described. Allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the rate of intrapartum and subsequent repeat cesarean deliveries in the United States.

Objective: To describe effective methods to engage nurse leaders in structured interview research., Background: The American Organization of Nurse Executives has identified the support of nurse leader participation in research as a key strategy to achieving its education and research objectives, particularly with regard to identifying and documenting nursing sensitive outcomes. Previous studies have delineated several methods to increase participation., Methods: Nurse leaders of California labor and delivery units reporting more than 50 deliveries during 2002 were asked to participate in a structured interview about staffing and clinical policies on their unit. Recruitment methodology involved 3 levels of intervention, including introductory letters, follow-up contacts, and personal encouragement from senior regional leaders and nurse executives., Results: Of the 268 eligible hospitals, 225 (84%) participated in the study. Fifty-four percent (n = 114) of the structured interviews were scheduled upon initial and second contacts by the research coordinator, and 73% (n = 161) were completed at the first scheduled appointment. Unit managers or directors personally completed 91% (n = 205) of the interviews, with only 20 (8.9%) designated to a staff nurse., Conclusions: Nurse leader participation is essential to the success of research dependent on collecting information regarding nurse practices and clinical processes. Using a multilevel approach to engage nurse leaders in research, such as endorsements and "detailing" by opinion leaders, phone calls, electronic mail, and incentives, is an effective strategy.

Background: The cesarean rate has served an integral role in the monitoring of obstetrical care, and in 2002, the national rate reached 26.1%, the highest ever reported., Objective: We sought to describe the effect of clinical complications on hospital cesarean rates., Research Design: This was a population-based cohort study., Subjects: All laboring women without a previous cesarean who delivered in California in 1995 as reported through public-use hospital discharge data were included., Measures: Women with and without maternal, fetal, or placental complications were compared with respect to cesarean use. Using recursive partitioning algorithms, women with complications were stratified into clinically homogeneous categories, which were analyzed separately with respect to cesarean use., Results: The 443,532 women delivered at 288 hospitals and included 116,170 women (26.2%) in the complicated group (cesarean rate 22.6%); and 327,362 women (73.8%) in the uncomplicated group (cesarean rate 6.7%). At the hospital level, the cesarean rates among the complicated and uncomplicated patients respectively were: median 23.5% (range, 2.2-9.9%); and median 6.5% (range, 1.8-18.2%). Recursive partitioning algorithms suggested 16 distinct clinical categories, with cesarean rates varying from 8.9% for women with asthma to 84.5% for women with an unengaged fetal head., Conclusions: Cesarean rates varied widely across complication types, and complication-specific rates varied widely among hospitals. Although the presence of pregnancy complications upon hospital admission comprised the strongest factor affecting first-time cesarean use among laboring women, the importance and interdependence of these clinical conditions has yet to be incorporated into commonly used models for cesarean rate comparisons.

Objective: To determine, within the context of all nursing duties, the amount of time nurses spend on documentation during the implementation of an electronic medical record (EMR) on an intrapartum unit., Background: Increased documentation needs during EMR implementation may necessitate increased staffing requirements in an already labor-intensive and demanding environment., Methods: A work-sampling study was conducted over a 14-day study period, and 18 of 84 (21%) potential 4-hour observation periods were selected. During each period, a single observer made 120 observations and, on locating a specific nurse, immediately recorded that nurse's activity on a standardized and validated instrument. Categories of nursing activities included documentation, bedside care, bedside supportive care, nonbedside care, and nonpatient care., Results: A total of 2160 observations were made. The total percentage of nursing time spent for documentation was 15.8%, 10.6% on paper and 5.2% on the computer. The percentage of time spent on documentation was independently associated with day versus night shifts (19.2% vs 12.4%, respectively)., Conclusions: Despite charting concurrently on both paper and computer, the amount of time spent on documentation was not excessive, and was consistent with previous studies in which neither electronic nor "double charting" occurred.