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Objective:  Implementation of standardized protocols for antepartum anemia increases intravenous iron (IVFe) use and improves predelivery hemoglobin (Hb). However, this condition is often overlooked and inadequately treated in postpartum care settings. We aimed to determine if implementation of a standardized protocol for postpartum anemia increases postpartum IVFe use and affects clinical outcomes., Study Design:  We performed a prospective cohort study evaluating implementation of a standardized inpatient protocol for postpartum anemia. This protocol, implemented in December 2021, recommends (1) IVFe for postpartum Hb 7.0 to 8.9 g/dL and (2) oral iron for postpartum Hb 9.0 to 9.9 g/dL. We compared all postpartum inpatients at a single site from April 2021 (preimplementation period [PRE]) to April 2022 (postimplementation period [POST]). The primary outcome was any IVFe use. Secondary outcomes included number of IVFe doses, oral iron supplementation at discharge, postpartum complications, and length of stay., Results:  A total of 805 patients were included (PRE = 401; POST = 404). Patients in the PRE and POST groups differed in ethnicity (PRE: 8.2% Hispanic vs. POST: 14.9% Hispanic, p  = 0.003). IVFe use significantly increased from PRE to POST (PRE: 6.0% vs. POST: 11.1%, p  = 0.009) even when controlling for differences between groups (adjusted odds ratio: 2.48, 95% confidence interval: [1.08-5.67]). Patients receiving IVFe in the POST group were more likely to receive the recommended three doses of IVFe compared with patients receiving IVFe in the PRE group (POST: 29% vs. PRE: 4%, p  = 0.04). Patients in the POST group had shorter lengths of stay than in the PRE group (POST: 1.69 days vs. PRE: 1.81 days, p  < 0.001). There were no significant differences in blood transfusion, oral iron supplementation, or postpartum complications., Conclusion:  Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay., Key Points: · Postpartum anemia is associated with postpartum depression, fatigue, impaired cognition, and altered maternal-infant bonding.. · IVFe is more effective and better tolerated than oral iron.. · Implementation of standardized protocols for antepartum anemia has been shown to increase IVFe use.. · Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay.., Competing Interests: None declared., (Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA.)

Objective: We aimed to describe hemoglobin (Hb) change after transfusion in the nonacute postpartum anemic population in order to provide clinicians with appropriate expectations regarding Hb rise posttransfusion., Study Design: We performed a secondary analysis of a randomized controlled trial comparing initial transfusion with 1 unit of packed red blood cells (pRBCs) to 2 units pRBCs for postpartum women requiring nonacute transfusion ( n  = 66). Inclusion criteria were: age 18 years and older, Hb level either <7 g/dL or >7 g/dL with signs or symptoms of anemia, and > 6 hours postpartum without contraindication to transfusion. Hb assessment was performed 4 to 6 hours after initial transfusion. Hb change (ΔHb) was calculated as posttransfusion Hb minus randomization Hb. Our primary goal was to describe mean ΔHb per pRBC transfused at the 4- to 6-hour posttransfusion blood count. We also compared ΔHb per pRBC transfused by number of units transfused, body mass index (BMI), and symptoms (dizziness and/or fatigue) at time of posttransfusion assessment., Results: Participants were mean age 29, mean BMI of 27, and over 70% self-identified as black, 12% identified as white, and 9% as Asian race. Mean Hb prior to transfusion was 6.9 ± 0.6 g/dL. Mean ΔHb per pRBC transfused was 0.9 ± 0.4g/dL. There was no difference in ΔHb per pRBC by BMI category (normal weight < 25 kg/m 2 : 1.1 ± 0.2 g/dL; overweight 25-29.9 kg/m 2 : 0.9 ± 0.5 g/dL; obese ≥ 30 kg/m 2 : 0.9 ± 0.5 g/dL; p  = 0.12). Finally, there was also no significant difference in ΔHb per pRBC by whether or not symptoms of anemia persisted after initial transfusion (1.0 ± 0.7 vs. 0.9 ± 0.4 g/dL, p  = 0.39)., Conclusion: Our data supports the classically accepted rise in Hb after pRBC of approximately 1 g/dL, regardless of BMI category or anemia symptomatology. The study population includes patients at highest risk of postpartum anemia. The results of our study provide important information for clinicians caring for postpartum patients with nonacute anemia., Key Points: · Postpartum anemia is a significant public health issue.. · Providers use hemoglobin change to assess response to blood transfusion.. · The established 1 g/dL change in Hb after transfusion is based on historic surgical populations.. · Our data suggests the 1 g/dL Hb change is applicable to postpartum patients.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: The objective of this study is to examine risk factors and adverse outcomes related to preeclampsia with severe features complicated by pulmonary edema., Study Design: This is a nested case-control study of all patients with preeclampsia with severe features who delivered in a tertiary, urban, academic medical center over a 1-year period. The primary exposure was pulmonary edema and the primary outcome was a composite of severe maternal morbidity (SMM), defined according to the Centers for Disease Control and Prevention and based on International Classification of Diseases, 10th revision, Clinical Modification codes. Secondary outcomes included postpartum length of stay, maternal intensive care unit admission, 30-day readmission, and discharge on antihypertensive medication. A multivariable logistic regression model adjusting for clinical characteristics related to the primary outcome was used to determine adjusted odds ratios (aOR) as measures of effect., Results: Of 340 patients with severe preeclampsia, there were seven cases of pulmonary edema (2.1%). Pulmonary edema was associated with lower parity, autoimmune disease, earlier gestational age at diagnosis of preeclampsia and at delivery, and cesarean section. Patients with pulmonary edema demonstrated increased odds of SMM (aOR: 10.11, 95% confidence interval [CI]: 2.13-47.90), extended postpartum length of stay (aOR: 32.56, 95% CI: 3.95-268.45), and intensive care unit admission (aOR: 102.85, 95% CI: 7.43-1422.92) compared with those without pulmonary edema., Conclusion: Pulmonary edema is associated with adverse maternal outcomes among patients with severe preeclampsia, and is more likely to affect patients who are nulliparous, have an autoimmune disease, and are diagnosed preterm., Key Points: · Pulmonary edema increases odds of severe maternal morbidity in preeclamptics.. · Pulmonary edema prolongs postpartum and intensive care unit stay in preeclamptics.. · Risk factors for pulmonary edema include nulliparity and autoimmune disease.. · Earlier diagnosis of severe preeclampsia increases risk of pulmonary edema.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Our prior work demonstrated decreased birth satisfaction for Black women undergoing labor induction. We aimed to determine if implementation of standardized counseling around calculated cesarean risk during labor induction could reduce racial disparities in birth satisfaction., Study Design: We implemented use of a validated calculator that provides an individual cesarean risk score for women undergoing induction into routine care. This prospective cohort study compared satisfaction surveys for 6 months prior to implementation (preperiod: January 2018-June 2018) to 1 year after (postperiod: July 2018-June 2019). Women with full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix undergoing induction were included. In the postperiod, providers counseled patients on individual cesarean risk at the beginning of induction using standardized scripts. This information was incorporated into care at patient-provider discretion. The validated 10-question Birth Satisfaction Scale-Revised (BSS-R) subdivided into three domains was administered throughout the study. Patients were determined to be "satisfied" or "unsatisfied" if total BSS-R score was above or below the median, respectively. In multivariable analysis, interaction terms evaluated the differential impact of the calculator on birth satisfaction by race (Black vs. non-Black women)., Results: A total of 1,008 of 1,236 (81.6%) eligible women completed the BSS-R (preperiod: 330 [79.7%] versus postperiod: 678 [82.5%], p  = 0.23), 63.8% of whom self-identified as Black. In the preperiod, Black women were 50% less likely to be satisfied than non-Black women, even when controlling for differences in parity (Black: 39.0% satisfied vs. non-Black: 53.9%, adjusted odds ratio [aOR] = 0.49, 95% confidence interval [CI]: 0.30-0.79). In the postperiod, there was no difference in satisfaction by race (Black: 43.7% satisfied vs. non-Black: 44.0%, aOR = 0.97. 95% CI: 0.71-1.33). Therefore, disparities in birth satisfaction were no longer present at postimplementation (interaction p  = 0.03)., Conclusion: Implementation of standardized counseling with a validated calculator to predict cesarean risk after labor induction is associated with a decrease in racial disparities in birth satisfaction., Key Points: · Preintervention, Black women were less likely to have above-median birth satisfaction.. · We implemented standardized counseling around cesarean risk with labor induction.. · Implementation was associated with reduced racial disparities in birth satisfaction scores.., Competing Interests: None declared., (Thieme. All rights reserved.)

Hospital labor and delivery floors frequently operate like intensive care units (ICUs)-with continuous data feeds pouring into central monitoring stations against a background of blaring alarms. Yet the majority of obstetric patients are healthy and do not require ICU-level care. Despite limited organizational recommendations guiding the frequency of vital sign measurement, continuous pulse oximetry is used widely for laboring patients. There is also no evidence that morbidity prevention is linked to specific frequencies of vital sign monitoring in low-risk patients. In fact, studies examining the performance of maternal early warnings systems based on vital signs suggest that these may not reliably provide actionable information regarding maternal physiologic status. Furthermore, it is very possible that intrapartum maternal overmonitoring can impact care negatively by generating alarm fatigue, causing providers to miss actual abnormal vital signs that may precede morbidity. KEY POINTS: · Labor and delivery units may engage in maternal physiologic overmonitoring.. · Overmonitoring increases risk for alarm fatigue.. · Deimplementing low-value care may improve obstetric outcomes.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: This study aimed to evaluate maternal and neonatal outcomes by method of cervical ripening for labor induction among low-risk nulliparous individuals., Study Design: This is a secondary analysis of a multicenter randomized trial of labor induction at 39 weeks versus expectant management in low-risk nulliparous participants. Participants undergoing cervical ripening for labor induction in either group were included. Participants were excluded for preripening membrane rupture, abruption, chorioamnionitis, fetal demise, or cervical dilation ≥3.5 cm. Cervical ripening was defined by the initial method used: prostaglandin only (PGE; referent), Foley with concurrent prostaglandin (Foley-PGE), Foley only (Foley), and Foley with concurrent oxytocin (Foley-oxytocin). Coprimary outcomes were adverse maternal and neonatal composites. Secondary outcomes included cesarean delivery and length of labor and delivery (L&D) stay. Multivariable analysis was used to adjust for patient characteristics., Results: Of 6,106 participants included in the trial, 2,376 (38.9%) met criteria for this analysis. Of these, 1,247 (52.4%) had cervical ripening with PGE, 290 (12.2%) had Foley-PGE, 385 (16.2%) had Foley, and 454 (19.1%) had Foley-oxytocin. The maternal composite outcome was similar among participants who received Foley-PGE (24.1%, adjusted relative risk [aRR] = 1.21, 95% confidence interval [CI]: 0.96-1.52), Foley (21.3%, aRR = 1.16, 95% CI: 0.92-1.45), or Foley-oxytocin (19.4%, aRR = 1.04, 95% CI: 0.83-1.29), compared with PGE (19.7%). The neonatal composite outcome was less frequent in participants who received the Foley-PGE (2.4%, aRR = 0.35, 95% CI: 0.16-0.75) or Foley (3.6%, aRR = 0.51, 95% CI: 0.29-0.89) but did not reach statistical significance for participants who received Foley-oxytocin (4.6%, aRR = 0.63, 95% CI: 0.40-1.01) compared with PGE only (6.8%). Participants who received Foley-PGE or Foley-oxytocin had a shorter L&D stay (adjusted mean difference = -1.97 hours, 95% CI: -3.45 to -0.49 and -5.92 hours, 95% CI: -7.07 to -4.77, respectively), compared with PGE., Conclusion: In term low-risk nulliparous participants, Foley alone or concurrent with PGE is associated with a lower risk of adverse neonatal outcomes than with PGE alone. Length of L&D stay was the shortest with concurrent Foley-oxytocin., Key Points: · Adverse maternal outcomes are similar among different methods of cervical ripening in low-risk women.. · Adverse neonatal outcomes are less frequent with use of Foley alone or in combination with PGE.. · The use of Foley alone, or in combination with other agents, appears to be beneficial.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Health care providers and health systems confronted new challenges to deliver timely, high-quality prenatal care during the coronavirus disease 2019 (COVID-19) pandemic as the pandemic raised concerns that care would be delayed or substantively changed. This study describes trends in prenatal care delivery in 2020 compared with 2018 to 2019 in a large, commercially insured population and investigates changes in obstetric care processes and outcomes., Study Design: This retrospective cohort study uses de-identified administrative claims for commercially insured patients. Patients whose entire pregnancy took place from March 1 to December 31 in years 2018, 2019, and 2020 were included. Trends in prenatal care, including in-person, virtual, and emergency department visits, were evaluated, as were prenatal ultrasounds. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included preterm birth and stillbirth. To determine whether COVID-19 pandemic-related changes in prenatal care had an impact on maternal outcomes, we compared the outcome rates during the pandemic period in 2020 to equivalent periods in 2018 and 2019., Results: In total, 35,112 patients were included in the study. There was a significant increase in the prevalence of telehealth visits, from 1.1 to 1.2% prior to the pandemic to 17.2% in 2020, as well as a significant decrease in patients who had at least one emergency department visit during 2020. Overall prenatal care and ultrasound utilization were unchanged. The rate of SMM across this period was stable (2.3-2.8%) with a statistically significant decrease in the preterm birth rate in 2020 (7.4%) compared with previous years (8.2-8.6%; p  < 0.05) and an unchanged stillbirth rate was observed., Conclusion: At a time when many fields of health care were reshaped during the pandemic, these observations reveal considerable resiliency in both the processes and outcomes of obstetric care., Key Points: · Overall prenatal care and ultrasound were unchanged from 2018 to 2019 to 2020.. · There was a large increase in the prevalence of telehealth visits in 2020.. · There was no change in the rate of severe maternal morbidity or stillbirth in 2020 compared with 2018 to 2019.., Competing Interests: N.E.S. is an employee of Optum and owns stock in the parent company, UnitedHealth Group.A.R.K.-G. is supported by a National Institutes of Health T32 Training Grant in Perinatal Epidemiology at the University of Pennsylvania and a Society for Maternal Fetal Medicine-AMAG Health Policy Award.The other authors report no conflict of interest., (Thieme. All rights reserved.)

Objective: The aim of the study is to determine the relationship between a hospital's provision of subspecialty neonatal and maternal care. Specifically, we sought to understand where women with high-risk maternal conditions received intrapartum care and estimate the potential transfer burden for those with maternal high-risk conditions delivering at hospitals without subspecialty maternal care., Study Design: This is a descriptive study using data from 2015 State Inpatient Databases and the American Hospital Association Annual Survey. Characteristics were compared between hospitals based on the concordance of their maternal and neonatal care. The incidences of high-risk maternal conditions (pre-eclampsia with severe features, placenta previa with prior cesarean delivery, cardiac disease, pulmonary edema, and acute liver failure) were compared. To determine the potential referral burden, the percent of women with high-risk conditions delivering at a hospital without subspecialty maternal care but delivering in a county with a hospital with subspecialty maternal care was calculated., Results: The analysis included 486,398 women who delivered at 544 hospitals, of which 104 (19%) and 182 (33%) had subspecialty maternal and neonatal care, respectively. Ninety-eight hospitals provided both subspecialty maternal and neonatal care; however, 84 hospitals provided only subspecialty neonatal care but no subspecialty maternal care. Among high-risk maternal conditions examined, approximately 65% of women delivered at a hospital with subspecialty maternal care. Of the remainder who delivered at a hospital without subspecialty maternal care, one-third were in a county where subspecialty care was present. For women with high-risk conditions who delivered in a county without subspecialty maternal care, the median distance to the closest county with subspecialty care was 52.8 miles (IQR: 34.3-87.7 miles)., Conclusion: Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care. This discordance may present a challenge when both high-risk maternal and neonatal conditions are present., Key Points: · High-risk women who deliver at hospitals without subspecialty care are in more rural areas.. · Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care.. · This discordance may present a challenge when both high-risk maternal and neonatal conditions are present.., Competing Interests: M.A.C. reports grants from American College of Obstetricians and Gynecologists, during the conduct of the study. The other authors report no conflict of interest., (Thieme. All rights reserved.)

Objective: We aimed to determine the risk of cesarean among women with obesity undergoing labor induction within a prospective trial that utilized a standardized labor protocol., Study Design: This was a secondary analysis of a randomized trial of induction methods. Term (≥37 weeks) women with intact membranes undergoing induction with an unfavorable cervix (Bishop's score ≤6 and dilation ≤2 cm) were included. The trial utilized a labor protocol that standardized induction and active labor management, with recommendations for interventions at particular time points. Only women with a recorded body mass index (BMI) at prenatal care start were included in this analysis. The primary outcome was cesarean delivery compared between obese (≥30 kg/m 2 ) and nonobese (<30 kg/m 2 ) women. Indication for cesarean was also evaluated., Results: A total of 465 women were included: 207 (44.5%) obese and 258 (55.5%) nonobese. Women with obesity had a higher risk of cesarean compared with women without obesity (33.3 vs. 23.3%, p  = 0.02), even when adjusting for parity, weight change over pregnancy, and indication for induction (adjusted relative risk [aRR] = 1.79, 95% confidence interval [CI]: [1.34-2.39]). Compared with women without obesity, women with obesity had a higher risk of failed induction (47.8 vs. 26.7%, p  = 0.01) without a difference in arrest of active phase ( p  = 0.39), arrest of descent ( p  = 0.95) or fetal indication ( p  = 0.32), despite adherence to a standardized labor protocol., Conclusion: Compared with women without obesity, women with obesity undergoing an induction are at increased risk of cesarean, in particular a failed induction, even within the context of standardized induction management. As standardized practices limit provider variation in labor management, this study may support physiologic differences in labor processes secondary to obesity., Key Points: · Even with a standardized induction protocol, women with obesity are at higher risk of cesarean.. · In particular, women with obesity are at increased risk of cesarean for failed induction.. · These findings support a possible biologic relationship between obesity and failed induction.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Studies demonstrate shorter time to delivery with concurrent use of misoprostol and cervical Foley catheter. However, concurrent placement may not be feasible. If misoprostol is used to start an induction, little is known regarding the benefit of sequentially using Foley catheter. We examine obstetrical outcomes in women with Foley catheter placed after misoprostol compared with those only requiring misoprostol., Study Design: Retrospective cohort study of singleton pregnancies, intact membranes, and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) undergoing term induction May 2013 to June 2015. We compared obstetrical outcomes between women receiving misoprostol alone versus those that had a Foley catheter placed after misoprostol. Outcomes are mode of delivery, time to delivery, chorioamnionitis, admission to neonatal intensive care unit, and maternal morbidity. Chi-square and Fisher's exact tests were used for categorical variables, Mann-Whitney U -tests compared continuous variables., Results: Among 364 women, 281 began induction with misoprostol alone. A total of 135 (48%) subsequently had a Foley catheter placed. Characteristics were similar between the groups, although nulliparity and cervical dilation <1 cm at start of induction were more likely to have subsequent Foley catheter. Women with Foley catheter placement after misoprostol had a longer median time to delivery (15 vs. 11 hours, p  < 0.001), twofold higher rate of cesarean (42 vs. 26%, odds ratio: 2.1, 95% confidence interval: 1.26-3.44, p  = 0.004), and increased risk of neonatal intensive care unit (NICU) admission (21 vs. 11%, p  = 0.024). There was a nonsignificant increased risk of chorioamnionitis (12 vs. 7%, p  = 0.1) and maternal morbidity (15 vs. 8%, p  = 0.08) in the misoprostol followed by Foley catheter group., Conclusion: In women receiving misoprostol for induction, nulliparas and those with dilation <1 cm are more likely to have subsequent Foley catheter placement. Sequential use of cervical Foley catheter after misoprostol is associated with longer labor, higher cesarean rate, and increased NICU admission. Requirement of Foley catheter after misoprostol confers higher risk and may guide counseling., Key Points: · Little is known regarding efficacy of misoprostol followed by cervical Foley catheter.. · Nulliparas and dilation <1 cm increases need for Foley after misoprostol.. · Complications were more common in women requiring Foley after misoprostol.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use., Study Design: We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge., Results: Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90-195] PRE to 114 [range: 45-168] POST ( p  = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5-8] vs. POST 5 [range: 3-7], p  < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16-30] vs. POST 17.5 [range: 4-25], p  = 0.001). The number of pills consumed was significantly associated with number prescribed ( p  < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2-6] vs. POST 3[range: 1-5], p  = 0.03)., Conclusion: Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients., Key Points: · An ERAS-CD pathway was associated with decreased opioid use.. · Outpatient opioid consumption after cesarean warrants further study.. · Physician prescribing drives patients' opioid consumption.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: The aim of the study is to evaluate the association between amniotomy at various time points during labor induction and maternal and neonatal outcomes among term, nulliparous women., Study Design: Secondary analysis of a randomized trial of term labor induction versus expectant management in low-risk, nulliparous women (2014-2017) was conducted. Women met inclusion criteria if they underwent induction ≥38 weeks' gestation using oxytocin with documented time and type of membrane rupture. Women with antepartum stillbirth or fetal anomaly were excluded. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal complications. Maternal and neonatal outcomes were compared among women with amniotomy versus women with intact membranes and no amniotomy at six 2-hour time intervals: before oxytocin initiation, 0 to <2 hours after oxytocin, 2 to <4 hours after, 4 to <6 hours after, 6 to <8 hours after, and 8 to <10 hours after. Multivariable logistic regression adjusted for maternal age, body mass index, race/ethnicity, modified Bishop score on admission, treatment group, and hospital (as a random effect)., Results: Of 6,106 women in the parent trial, 2,854 (46.7%) women met inclusion criteria. Of these 2,340 (82.0%) underwent amniotomy, and majority of the women had amniotomy performed between 2 and <6 hours after oxytocin. Cesarean delivery was less frequent among women with amniotomy 6 to <8 hours after oxytocin compared with women without amniotomy (21.9 vs. 29.7%; adjusted odds ratio 0.61, 95% confidence interval 0.42-0.89). Amniotomy at time intervals ≥4 hours after oxytocin was associated with lower odds of labor duration >24 hours. Amniotomy at time intervals ≥2 hours and <8 hours after oxytocin was associated with lower odds of maternal hospitalization >3 days. Amniotomy was not associated with postpartum or neonatal complications., Conclusion: Among a contemporary cohort of nulliparous women undergoing term labor induction, amniotomy was associated with either lower or similar odds of cesarean delivery and other adverse outcomes, compared with no amniotomy., Competing Interests: None declared., (Thieme. All rights reserved.)

In an effort aimed at improving outcomes, obstetric teams have enacted comprehensive care bundles and other clinical tools. Yet, these practices have had limited degrees of success on a national scale. Implementation science aims to bridge the divide between the development of evidence-based interventions and their real-world utilization. This emerging field takes into account key stakeholders at the clinician, institution, and health policy levels. Implementation science evaluates how well an intervention is or can be delivered, to whom, in which context, and how it may be up-scaled and sustained. Other medical disciplines have embraced these concepts with success. The frameworks and theories of implementation science can and should be incorporated into both obstetric research and practice. By doing so, we can increase widespread and timely adoption of evidence and further our common goal of decreasing maternal morbidity and mortality. KEY POINTS: · Evidence-based practices have been implemented in obstetrics with variable success.. · Implementation science aims to bridge the divide between the development of evidence-based interventions and their real-world utilization.. · The methodologies of implementation science may be helpful to obstetric research and practice.., Competing Interests: None declared., (Thieme. All rights reserved.)

As new information about coronavirus disease 2019 (COVID-19) is rapidly discovered, clinicians are better equipped to make informed decisions for their patients. While current research suggests COVID-19 viral antigen is not found in vaginal secretions, its detectability in the female lower genital tract may have clinical implications for obstetric and gynecologic care for women. We present a case of a woman at 31 weeks' gestation with simultaneous upper respiratory symptoms and vulvovaginitis. She was found to have a vulvar lesion positive for severe acute respiratory syndrome-COVID by viral swab. This case shows that COVID-19 is detectable in the vulva. This may have implications for health care workers' exposure and personal protective equipment needs. While vertical transmission has largely not been reported, the presence of detectable virus in the female lower genital tract makes this a continued possibility and area of study. KEY POINTS: · COVID-19 is detectable in the female lower genital tract.. · The detection of COVID-19 in the vulva may have implications for personal protective equipment use.. · The detection of COVID-19 in vulvovaginal lesions makes vertical transmission a continued possibility.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: We sought to compare adverse maternal outcomes between women with and without a uterine extension at the time of cesarean., Study Design: We conducted a retrospective cohort study of women with and without a uterine extension during a primary low transverse cesarean of a full-term singleton gestation. The primary outcomes were (1) estimated blood loss (EBL) and (2) composite maternal morbidity (defined as ≥ 1 of the following: blood transfusion, endometritis, or readmission). Pearson's chi-square or Fisher's exact test was used to compare categorical data; Student's t -test or Mann-Whitney's U -tests was used for continuous data. Linear and logistic regressions were used to adjust for confounding factors., Results: There were 252 women included (126 with extension and 126 without an extension). Women with extensions had a higher EBL (1,038 vs. 832 mL, p  < 0.001) and higher rate of the composite maternal morbidity (19.1 vs. 5.6%, p  = 0.001). Additionally, women with extensions had an increased risk of postpartum hemorrhage ≥ 1 L (53.2 vs. 23.8%, p  < 0.001) and 1.5 L (12.7 vs. 0%, p  < 0.001) and were associated with prolonged length of hospital stay (29 vs. 17%, p  = 0.04)., Conclusion: Uterine extensions are associated with adverse maternal outcomes including higher EBL and increase in maternal morbidity., Competing Interests: L.D.L. reports consultant work on induction of labor from Sudler and Hennessey, outside the submitted work. All the other authors report no conflict of interest., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: To determine if increasing predicted risk of cesarean was associated with longer labor length and increased morbidity among women undergoing induction with an unfavorable cervix., Study Design: Using a publically available database, we evaluated whether a previously validated prediction model for cesarean delivery after induction was associated with labor length, maternal morbidity (third-/fourth-degree lacerations, endometritis, blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and death), and neonatal morbidity (blood transfusion, encephalopathy, intraventricular hemorrhage, severe respiratory distress syndrome, necrotizing enterocolitis, and sepsis). Full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix (Bishop score ≤6 and dilation ≤2 cm) undergoing induction of labor were included., Results: A total of 8,466 women met the inclusion criteria. Each category increase in cesarean probability (<20, 20-39.9, 40-59.9, ≥60%) was associated with an increase in labor length (9.6, 10.8, 11.7, and 11.9 hours, respectively; p  < 0.001). With increasing predicted probability of cesarean there, was also a significant increase in maternal morbidity with each category (2.6, 4.7, 5.1, 6.1%; p  = 0.001) and increase in neonatal morbidity (0.9, 1.5, 2, 2.2%; p  = 0.002)., Conclusion: Using a validated prediction model for cesarean delivery among women induced with an unfavorable cervix, increasing predicted probability of cesarean is associated with longer labor length and increased maternal and neonatal morbidity., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: A recent document by the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine introduced the concept of uniform levels of maternal care (LMCs)., Objective: We assessed LMC across hospitals and measured their association with maternal morbidity, focusing on women with high-risk conditions., Study Design: We collected data from hospitals from May to November 2015 and linked survey responses to Statewide Inpatient Databases (SID) hospital discharge data in a retrospective cross-sectional study of 247,383 births admitted to 236 hospitals. Generalized logistic regression models were used to examine the associations between hospitals' LMC and the risk of severe maternal morbidity. Stratified analyses were conducted among women with high-risk conditions., Results: High-risk pregnancies were more likely to be managed in hospitals with higher LMC ( p  < 0.001). Women with cardiac conditions had lower odds of maternal morbidity when delivered in level I compared with level IV units (adjusted odds ratio: 0.29; 95% confidence interval: 0.08-0.99; p  = 0.049). There were no other significant associations between the LMC and severe maternal morbidity., Conclusion: A higher proportion of high-risk pregnancies were managed within level IV units, although there was no overall evidence that these births had superior outcomes. Further prospective evaluation of LMC designation with patient outcomes is necessary to determine the impact of regionalization on maternal outcomes., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: This article evaluates the differences in adverse maternal outcomes related to severe preeclampsia in obese versus nonobese women., Study Design: Retrospective cohort study and planned secondary analysis of women with severe preeclampsia comparing a composite adverse maternal outcome related to preeclampsia among obese (body mass index [BMI] ≥ 30 kg/m 2 ) and nonobese (BMI < 30 kg/m 2 ) women. The composite outcome was defined as ≥ 1 of the following prior to discharge: renal failure, liver abnormality, thrombocytopenia, blood transfusion, pulmonary edema, disseminated intravascular coagulation, stroke, or eclampsia. Multivariable logistic regression was used to control for confounders., Results: Of the 152 women included, 37.5% were obese and 62.5% were nonobese. The prevalence of the primary outcome was 15.8% with obese women less likely to have the composite outcome compared with nonobese women (7% vs. 21.1%, p  = 0.02). This remained after adjusting for confounders including maternal age, race, and chronic hypertension (adjusted odds ratio, 0.33 [0.12-0.89], p  = 0.03). Obese women were, however, more likely to require intravenous antihypertensive medication peripartum compared with nonobese women (49.1% vs. 28.4%, p  = 0.01)., Conclusion: Obese women with severe preeclampsia may have a different phenotype of severe preeclampsia that is more associated with severe hypertension rather than end-organ damage., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: Obstetric hemorrhage is a leading cause of morbidity and mortality. We sought to assess whether institution of a postpartum hemorrhage (PPH) bundle could improve maternal morbidity in our population., Study Design: Preintervention data (PRE) was collected on all deliveries at Hospital of the University of Pennsylvania between October 15, 2013 and December 15, 2013. A two-pronged, multidisciplinary educational and procedural intervention related to PPH was instituted from March 2015 to June 2015. Postintervention data (POST) was collected on all deliveries from October 20, 2015 to December 20, 2015., Results: Note that 592 of 626 (95%) PRE and 583 of 613 (95%) POST deliveries were included. The rates of PPH by estimated blood loss (EBL) ≥ 1,000 mL and by 3 g hemoglobin drop were not significantly different from PRE to POST (9.0% versus 12.2%, p  = 0.07 and 10.5% versus 13.5%, p  = 0.10, respectively). There was no significant change in transfusion rate (3.4% versus 5.1%, p  = 0.13). Use of uterotonics was reduced from 9.8 to 6.3% from PRE to POST ( p  = 0.03)., Conclusion: While institution of a PPH bundle is designed to improve the morbidity of PPH, our data demonstrate that it cannot be expected to do so within 6 months of implementation. Further studies will need to assess the long-term effects of such a resource-intensive protocol, including perceptions of improved safety by all providers, nurses, and staff., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective:  The National Partnership for Maternal Safety released a postpartum hemorrhage bundle in 2015 recommending quantification of blood loss (QBL) for all deliveries. We sought to determine whether QBL more accurately predicts hemoglobin (Hb) drop than visually estimated blood loss (EBL)., Study Design:  This is a prospective observational study. Preintervention data (PRE) were collected on all deliveries between October 15, 2013 and December 15, 2013. Deliveries were included if EBL, admission Hb, and 12-hour postpartum Hb (12hrCBC) were available. QBL was implemented in July 2015. Postintervention data (POST) were collected between October 20, 2015 and December 20, 2015. A total of 500 mL EBL was predicted to result in 1 g/dL Hb drop at 12hrCBC. Student's t -test was used to compare the means., Results:  A total of 592 of 626 (95%) PRE and 583 of 613 (95%) POST deliveries were included. Overall, 278 (48%) POST deliveries had QBL recorded. In both PRE and POST, actual Hb drop differed from predicted by 0.6 g/dL in both groups of deliveries. When evaluating deliveries with EBL > 1,000 mL, QBL in POST was slightly better at predicting Hb drop versus EBL in PRE, although not statistically significant (0.2 vs. 0.5 g/dL, p  = 0.17)., Conclusion:  In all deliveries, QBL does not predict Hb drop more accurately than EBL. The decision to perform QBL needs to balance accuracy with a resource intense measurement process., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background  Obstetrical hemorrhage is a leading cause of morbidity and mortality, yet is inconsistently defined. In 2014, the American Congress of Obstetricians and Gynecologists (ACOG) reVITALize program redefined postpartum hemorrhage (PPH) as greater than 1,000 mL blood loss regardless of the mode of delivery (MOD). Objective  We sought to assess the reVITALize definition's validity by understanding whether the definition of PPH should, as proposed by ACOG, be one value regardless of MOD. Study Design  This is a retrospective study of all women who delivered at the hospital of the University of Pennsylvania from October 15, 2013 through December 15, 2013. Results  A total of 592 of the 626 (95%) women were included. The average reported estimated blood loss (EBL) for vaginal delivery (VD) was significantly lower than for cesarean delivery (CD) ([350 ±170 mL) and [880 ± 360 mL]; p  < 0.001). The average hemoglobin (Hb) drop was only slightly lower for VD compared with CD ([1.4 ± 1.0 g/dL {11.5% drop}] and [1.9 ± 1.2 g/dL {16.2% drop}], respectively, p  < 0.001). The association between EBL and observed Hb drop differed in accuracy by MOD. Conclusion  Likely based on historic perceptions, obstetric providers estimate blood loss for VD as less than half that of CD. However, using objective measures, blood loss is more similar than perceived between VD and CD, supporting the ACOG reVITALize single definition of PPH regardless of MOD., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Data evaluating the accuracy of ICD9-CM codes in identifying inductions are limited. Our objective was to examine the test characteristics of ICD9-CM coding for induction of labor and to identify differences between those captured by coding and those not., Methods: We performed a retrospective cohort study of ICD9-CM codes in identifying charts of induced women at our institution from 2005 to 2009. Review of the medical record was the gold standard. Characteristics of the charts were compared using Mann-Whitney U tests and chi-square tests where appropriate., Results: A total of 3,263 women were included, 708 with ICD9-CM coding for induction (screen positive). A total of 422 women were randomly sampled from those not coded as induction (screen negative). The sensitivity of ICD9-CM coding for induction was 51.4%, specificity 98.8%, positive predictive value 96.6%, negative predictive value 74.7%. False negative charts (25%) were more likely to be women induced for premature rupture of membranes (40% versus 8%, p < 0.001) or with oxytocin (51% versus 33%, p < 0.001) when compared with screen positive charts., Conclusions: It is reassuring that 97% of charts coded for induction by ICD9-CM codes are, in fact, patients that were induced. With this degree of accuracy, we can be confident that charts coded as induction are unlikely to be miscoded., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: Standardized oxytocin protocols have been used to improve the safety and quality of obstetric care. We examined rates of chorioamnionitis and labor dystocia requiring cesarean delivery as unintended consequences of the implementation of a low-dose, checklist-based oxytocin protocol., Study Design: We performed a retrospective cohort study of live singleton deliveries that underwent a trial of labor in two 15-month periods, comparing outcomes in those who delivered before to after protocol implementation. Patients and outcomes were identified using a combination of electronic medical records and International Classification of Diseases, 9th Revision, Clinical Modification codes. Time trend analysis was performed to evaluate for secular trends., Results: A total of 8,717 women were included; 5,077 received oxytocin. Despite an unchanged rate of cesarean deliveries from before to after initiation of the protocol (15.15 vs. 14.75%, p = 0.60), deliveries after protocol implementation were generally characterized by higher rates of chorioamnionitis (7.48 vs. 5.97%, p < 0.001), longer median time from admission to delivery (524 vs. 462 minutes, p < 0.001), more cesarean deliveries performed for labor dystocia (50.62 vs. 40.92%, p < 0.001), and fewer cesarean deliveries performed for fetal distress (32.52 vs. 38.67%, p = 0.02)., Conclusion: Low-dose oxytocin protocols are intended to increase safety, but they may have unintended consequences related to prolonged labor, and should be studied before widespread use., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: Antenatal testing has been implemented for advanced maternal age (AMA) women given their increased stillbirth risk. Our objective was to evaluate cesarean delivery and induction rates after the start of antenatal testing at our institution., Study Design: A retrospective cohort study of AMA women (≥ 40 years) who delivered at our institution was performed. Testing for AMA began in 2005. AMA women who delivered before (unexposed) and after (exposed) the implementation were compared. Our primary outcome was cesarean delivery and secondary outcome was induction. Chi-square compared categorical variables and multivariable logistic regression calculated odds ratio (OR) and controlled for confounders., Results: A total of 276 women were included (147 unexposed and 129 exposed). The cesarean rate was higher in the exposed group (53 vs. 39%, OR 1.76 [1.09-2.84]). The increased risk of cesarean remained after adjusting for race, previous cesarean, multiple gestations, and parity (adjusted OR 1.85 [1.05-3.28]). When excluding those with previous cesareans, the risk of primary cesarean was not significant (OR 1.57 [0.89-2.76]). The induction rate was not different (38 vs. 33%, p = 0.4)., Conclusions: While overall cesareans increased, there was no difference in primary cesarean and induction rates for AMA women after implementation of antenatal testing for AMA., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: Obesity is a demonstrated barrier to obtaining health care. Its impact on obtaining prenatal care (PNC) is unknown. Our objective was to determine if obesity is an independent barrier to accessing early and adequate PNC., Study Design: We performed a retrospective cohort study of women who initiated PNC and delivered at our institution in 2005. Body mass index (BMI) was categorized by World Health Organization guidelines: underweight (<18.5 kg/m(2)), normal weight (18.5 to 24.9 kg/m(2)), overweight (25.0 to 29.9 kg/m(2)), and obese (≥30 kg/m(2)). Maternal history and delivery information were obtained through chart abstraction. Differences in gestational age at first visit (GA-1) and adequate PNC were evaluated by BMI category. Data were compared using χ(2) and nonparametric analyses., Results: Overall, 410 women were evaluated. The median GA-1 was 11.1 weeks and 69% had adequate PNC. There was no difference in GA-1 or adequate PNC by BMI category (p = 0.17 and p = 0.66, respectively). When BMI groups were dichotomized into obese and nonobese women, there was no difference in GA-1 or adequate PNC (p = 0.41)., Conclusion: In our population, obesity is not an independent barrier to receiving early and adequate PNC. Future work is warranted in evaluating the association between obesity and PNC and the perceived barriers to obtaining care., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

We tested the hypothesis that the cardiac biomarker N-terminal pro-brain natriuretic peptide would be elevated in hypertensive disorders of pregnancy, with an increase in levels of this biomarker across increasing gradations of disease severity. We performed a case-controlled study of women admitted to labor and delivery at the Hospital of the University of Pennsylvania between 24 and 42 weeks of gestation. Cases had hypertension that developed after 20 weeks of gestation, and controls were normotensive women presenting for delivery. N-terminal pro-brain natriuretic peptide levels were compared between cases ( N = 83) and controls ( N = 290). Cases were subclassified into gestational hypertension ( N = 20) and mild ( N = 15) and severe preeclampsia ( N = 48), and N-terminal pro-brain natriuretic peptide levels were compared between these subgroups. N-terminal pro-brain natriuretic peptide levels were higher in cases than in controls (81 pg/mL versus 37 pg/mL, P < 0.001), with a graded increase in levels from gestational hypertension (64 pg/mL) to preeclampsia (89 pg/mL) to severe preeclampsia (157 pg/mL; P < 0.001). Each log increase in N-terminal pro-brain natriuretic peptide doubled the risk of preeclampsia (odds ratio = 2.10 P < 0.001). N-terminal pro-brain natriuretic peptide levels were increased in hypertensive disorders of pregnancy and discriminate between subcategories of disease., (Thieme Medical Publishers.)

Vaginal birth after cesarean delivery (VBAC) failure is associated with perinatal morbidity. The ability to predict VBAC failure in subgroups of high-risk women is important. Our objectives were: (1) to estimate if women with pregestational diabetes (PDM) who attempt VBAC are at increased risk of failure, and (2) to identify clinical characteristics of PDM women associated with failure. We performed a retrospective cohort study of women eligible for VBAC, delivered between 1995 and 1999 at 17 hospitals to study maternal history/outcomes and neonatal outcomes ascertained through chart abstraction. Women with gestational diabetes were excluded. Student T test was used to compare continuous characteristics. Chi-square/Fisher exact tests were used to compare categorical variables. Multivariable logistic regression analysis was used to control for confounders. Of all eligible women (23,601), 37% of diabetics ( N = 127) and 56% of nondiabetics ( N = 12968) attempted VBAC. The VBAC failure rate for PDM was 38% versus 24% for nondiabetic women ( P < 0.001). The risk of failure for PDM patients was increased after controlling for confounders (adjusted odds ratio 1.61, 95% confidence interval 1.06 to 2.51; P = 0.038). PDM is independently associated with VBAC failure. The success rate for women with PDM who attempted VBAC (62%) is at the lower end of the general published VBAC success rate range., (Thieme Medical Publishers.)

We compared short-term neonatal outcomes between premature infants with spontaneous preterm birth (s-PTB) and those delivered due to preeclampsia (PEC). Data were collected from women with singleton pregnancies admitted with spontaneous preterm labor (PTL) (2002 to 2005) and PEC (2005 to 2007). Patients delivering 24 to 36(6/7) weeks were analyzed. The incidence of adverse outcomes was compared. Chi-square and Fisher exact tests compared outcomes between neonates of varying gestational ages, and Poisson regression was used to control for confounders. Data describing 368 infants are included (PTL: n = 224; PEC: n = 144). Overall, s-PTB infants had less favorable outcomes at earlier gestational ages, and at later gestational ages those born preterm secondary to PEC (pec-PTB) had less favorable outcomes. s-PTB infants 24 to 27(6/7) weeks were 21% more likely to stay in the neonatal intensive care unit (NICU) > or = 8 days than pec-PTB infants (incident rate ratios [IRR] 0.79, P = 0.002, 95% confidence interval [CI] 0.68 to 0.92). Pec-PTB infants 32 to 33(6/7) weeks were 6 times more likely to stay in the NICU > or = 31 days than s-PTB infants (IRR 5.82, P = 0.03, 95% CI 1.20 to 28.31). Short-term neonatal outcomes differ by the etiology of preterm birth. These data can help facilitate proper patient counseling and allocation of resources. Future studies should address mechanisms by which the etiology of PTB leads to specific adverse outcomes, thus allowing for more direct interventional strategies., (Thieme Medical Publishers.)

The objective of this study was to determine if preeclampsia (PRE) or gestational hypertension (GH) affects the rate of success of vaginal birth after cesarean delivery (VBAC), VBAC-related complications, or patient election to attempt VBAC. We performed a retrospective cohort study of all women who were offered VBAC from 1996 to 2000 in 17 community and university hospitals. Demographic, medical, and obstetric history, complications, treatment, and index pregnancy outcome information was collected on all patients in the database. Bivariate analysis and multivariable logistic regression were used to assess the independent association between GH and PRE and the rate of success of VBAC, VBAC-related complications, or patient election to attempt VBAC. A total of 25,005 patients were registered in the database. 13,706 (54.81%) attempted VBAC and 11,299 (45.19%) elected repeat cesarean delivery. After adjusting for confounding variables using multivariable logistic regression, patients with PRE were more likely to fail VBAC (relative risk [RR], 1.56; 95% CI, 1.22 to 2.00). Patients with GH were less likely to attempt VBAC (RR, 0.39; 95% CI, 0.34 to 0.46). A total of 304 (1.46%) patients had a uterine rupture. The VBAC group had a rupture rate of 0.93% and the elective cesarean group had a rupture rate of 0.04%. There was no difference in uterine rupture rates between the cohorts. Patients with gestational hypertension were less likely to attempt a VBAC. Patients with PRE, if they attempted a VBAC trial, had a higher VBAC failure rate. Patients with PRE or GH do not have increased uterine rupture rates. These findings can be used to improve mode of delivery counseling for VBAC candidate patients with preeclampsia.