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Objective The aim of the study is to evaluate the use of a bipolar electrocautery device for complete salpingectomy at cesarean to improve procedure completion rates, operative time, and surgeon reported satisfaction as compared with standard bilateral tubal ligation (BTL) and suture-cut-tie salpingectomy. Study Design This is a prospective cohort study of women undergoing planned, non-emergent cesarean with desired sterilization with complete salpingectomy utilizing a bipolar electrocautery device. Study patients were compared with historic controls from a randomized controlled trial (RCT) of complete salpingectomy via suture-cut-tie method versus BTL conducted at our institution (SCORE trial, NCT02374827). Outcomes were compared with groups from the original RCT. Results Thirty-nine women were consecutively enrolled (12/2018–11/2019) into the device arm of the study and compared with the original SCORE cohort (n = 40 BTL, n = 40 salpingectomy without a device). Salpingectomy performance with the bipolar electrocautery device was successfully completed in 100% (39/39) of enrolled women, with one device failure requiring the use of a second device, as compared with 95% (38/40) in the BTL (p = 0.49) and 67.5% (27/40) in salpingectomies without a device (p < 0.001). Mean operative time of sterilization procedure alone demonstrated device use as having the shortest operative time of all (device salpingectomy 5.0 ± 3.6 vs. no device 18.5 ± 8.3 minutes, p < 0.001; and vs. BTL 6.9 ± 5.0, p = 0.032). Mean sterilization procedure endoscopic band ligation (EBL) was demonstrated to be significantly different between each group, least amongst BTL followed by device (6.3 ± 4.8 vs. 8.4 ± 24.8, p < 0.001), and most by suture-cut-tie method (17.7 ± 14.3, p < 0.001 compared with device). Surgeon reported attitudes of complete salpingectomy performance in general practice outside an academic setting was greater with a device than without (79.5 vs. 35.3%; p < 0.001). Conclusion Use of a bipolar electrocautery device improved operative times and surgeon satisfaction for salpingectomy at cesarean over standard suture ligation. Device use improved surgeon reported outcomes and may improve incorporation of complete salpingectomy at cesarean. Key Points Electrocautery bipolar device use was safe at the time of salpingectomy during cesarean. Greater surgeon satisfaction occurs using a device than without. Decreased surgical time with device use is seen making the procedure equal to BTL. [ABSTRACT FROM AUTHOR]

Objectives The aim of the study was to identify the characteristics associated with spontaneous labor onset in pregnant patients undergoing expectant management at greater than 39 weeks' gestation and delineate perinatal outcomes associated with spontaneous labor compared with labor induction. Study Design This was a retrospective cohort study of singleton pregnancies at ≥39 0/7 weeks' gestation delivered at a single center in 2013. The exclusion criteria were elective induction, cesarean delivery or presence of a medical indication for delivery at 39 weeks, more than one prior cesarean delivery, and fetal anomaly or demise. We evaluated prenatally available maternal characteristics as potential predictors of the primary outcome-spontaneous labor onset. Multivariable logistic regression was used to generate two parsimonious models: one with and one without third trimester cervical dilation. We also performed sensitivity analysis by parity and timing of cervical examination, and compared the mode of delivery and other secondary outcomes between patients who went into spontaneous labor and those who did not. Results Of 707 eligible patients, 536 (75.8%) attained spontaneous labor and 171 (24.2%) did not. In the first model, maternal body mass index (BMI), parity, and substance use were identified as the most predictive factors. Overall, the model did not predict spontaneous labor (area under the curve [AUC]: 0.65; 95% confidence interval [CI]: 0.61–0.70) with high accuracy. The addition of third trimester cervical dilation in the second model did not significantly improve labor prediction (AUC: 0.66; 95% CI: 0.61–0.70; p = 0.76). These results did not differ by timing of cervical examination or parity. Patients admitted in spontaneous labor had lower odds of cesarean delivery (odds ratio [OR]: 0.33; 95% CI: 0.21–0.53) and neonatal intensive care unit (NICU) admission (OR: 0.38; 95% CI: 0.15–0.94). Other perinatal outcomes were similar between the groups. Conclusion Maternal characteristics did not predict spontaneous labor onset at ≥39 weeks' gestation with high accuracy. Patients should be counseled on the challenges of labor prediction regardless of parity and cervical examination, outcomes if spontaneous labor does not occur, and benefits of labor induction. Key Points Majority of patients will attain spontaneous labor at ≥39 weeks. Maternal characteristics do not predict labor at ≥39 weeks. Spontaneous labor has associated lower perinatal risks. A shared decision model should be utilized in counseling patients who may choose expectant management. [ABSTRACT FROM AUTHOR]

Objective  The percentage of operative vaginal deliveries (OVDs) in the United States has sharply declined. In May 2016, our institution's obstetrics and gynecology (OB/GYN) residency program implemented a twice-yearly OVD curriculum consisting of didactics and simulation. We sought to evaluate the impact of this curriculum. Study Design  We performed a retrospective cohort study of all deliveries at our institution from July 2011 to May 2018. Deliveries were evaluated quarterly for the pre- (July 2011–April 2016) and postcurriculum (July 2016–May 2018) periods. Forceps-assisted vaginal delivery (FAVD), vacuum-assisted vaginal delivery (VAVD), and total OVD percentages, and the ratio of forceps to vacuums were calculated. Pre- and postcurriculum percentages were compared using Wilcoxon's rank-sum test. Cubic regression curves were fit to quarterly percentages to illustrate trends over time. Results  The quarterly OVD percentage was unchanged following curriculum implementation (mean 3.2% [Q 1 –Q 3 : 2.6–3.5%] pre- vs. 3.1% [2.5–3.8%] post-, p  > 0.99). The FAVD percentage was increased (1.2% [0.8–1.5%] vs. 2.0% [1.4–2.6%], p  = 0.027) and the VAVD percentage was decreased (2.0% [1.6–2.2%] vs. 1.2% [0.9–1.3%], p  < 0.001). This was accompanied by an increase in the ratio of FAVD to VAVD (0.6 [0.4–0.8] vs. 1.7 [1.3–2.2], p  < 0.001). FAVD percentage (3.1%) was higher in the last quarter than any other quarter in the 7-year study period, and total OVD percentage (3.9%) was higher in 2018 than any other calendar year. Conclusion  The implementation of an OVD curriculum in our OB/GYN residency program resulted in an increase in the percentage of FAVD and the ratio of FAVD to VAVD. Key Points OVD utilization in the United States continues to decline. We demonstrate real-world impact of an OVD curriculum. OVD curriculum implementation increases usage of FAVD. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to evaluate if maternal serum hormones along the maternal–fetal hypothalamic–pituitary–adrenal (HPA) axis, when drawn prior to labor induction, differed between women who delivered vaginally and those who underwent cesarean. Study Design  This was a prospective observational study at a single perinatal center performed from August 2017 to May 2018. Nulliparous women with uncomplicated singleton pregnancies ≥39 weeks had maternal serum collected prior to induction. Corticotrophin-releasing hormone (CRH) was measured by ELISA; dehydroepiandrosterone sulfate (DHEA-S), cortisol, estriol (E 3) estradiol (E 2), and progesterone (P 4) were measured by chemiluminescent reaction. Mean analyte concentrations as well as three ratios (E 2 /P 4 , E 3 /P 4, and E 2 /E 3) were compared between women who had a vaginal versus cesarean delivery. Logistic regression was used to model the relationship between CRH and the odds of vaginal birth. We estimated that a sample size of 66 would have 90% power to detect a 25% difference in mean CRH levels assuming a vaginal:cesarean ratio of 2:1 with a baseline CRH concentration of 140 (standard deviation = 36) pg/mL. Results  Of the 88 women who had their serum analyzed, 27 (31%) underwent cesarean. Mean maternal serum CRH levels were similar between the vaginal delivery and cesarean groups (122.6 ± 95.2 vs. 112.3 ± 142.4, p  = 0.73). Similarly, there were no significant differences in any other maternal serum analytes or ratios. Logistic regression showed a nonsignificant odds ratio for successful vaginal birth (p  = 0.69) even when evaluating only the 16 women who had a cesarean for an arrest disorder (p  = 0.08). Conclusion  In low-risk nulliparous women undergoing full-term labor induction, there were no differences noted in a broad array of other maternal-fetal HPA-axis hormones between women who had a vaginal or cesarean delivery. [ABSTRACT FROM AUTHOR]

Objective  To evaluate if fundal (F) dominance of the electrohysterogram is associated with vaginal delivery and lack of F dominance is associated with cesarean for labor dystocia. Study Design  We conducted a prospective cohort study of nulliparous women in spontaneous labor at ≥36 weeks. Clinicians were blinded to electrohysterography data which were in addition to standard cardiotocography. All contractions in the hour preceding diagnosis of complete cervical dilation (for women delivering vaginally) or the hour preceding the decision for cesarean were analyzed. Results  Of 224 patients, 167 had evaluable data. The proportion of F dominant contractions was not different for women undergoing cesarean for labor dystocia (n  = 11) compared with all others (n  = 156)—88.7 ± 10.2 versus 86.0 ± 11.4%; p  = 0.44. Results were similar when comparing the cesarean for labor dystocia group to those undergoing cesarean for other indications (n  = 10) and vaginal deliveries (n  = 146)—88.7 ± 10.2 versus 86.5 ± 10.0 versus 85.9 ± 11.5%; p  = 0.74. Conclusion  We were unable to confirm our earlier finding that F dominance of the electrohysterogram is associated with vaginal delivery and lack of F dominance is associated with cesarean for dystocia. [ABSTRACT FROM AUTHOR]

Objective: We sought to compare the skin microbiota above and below the panniculus of third-trimester pregnant women with class III obesity.Methods: We collected swabs from the anterior panniculus and from the intertriginous area under the panniculus of women with class III obesity (body mass index ≥40 kg/m(2)) carrying a live singleton at ≥28 weeks. DNA was extracted. PCR with primers targeting the 16S rDNA V4 region were used to prepare an amplicon library. PCR products were sequenced (Illumina MiSeq platform). The 16S rDNA sequences were processed, integrated, analyzed and reported using QIIME and in-house developed scripts. Taxonomy was assigned using RDP Classifier (threshold 0.8) against the Greengenes 16S rDNA database.Results: Twenty women were enrolled. One sample pair was excluded for low sequence depth. Using permutation testing, there was significantly less bacterial diversity in the samples above compared to below the panniculus (beta diversity using weighted UniFrac metrics; p < 0.001).Conclusion: In pregnant women with class III obesity, the skin microbiota in the subpannicular fold differs from and is more diverse than that on the anterior panniculus. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to compare maternal and neonatal outcomes in patients with preterm premature rupture of membranes (PPROM) delivered prior to 34(°/7) weeks upon confirmation of fetal lung maturity (FLM) to those managed expectantly until 34(°/7) weeks.Methods: We performed a retrospective cohort study of non-anomalous singleton gestations with PPROM occurring after 24 weeks delivered between 32(°/7) and 34(°/7) weeks from 2004 to 2012. Patients delivered upon documented FLM (+FLM)--defined as the presence of phosphatidylglycerol (PG) at 32(°/7)-33(6/7) weeks if amniotic fluid was obtainable vaginally--were compared with patients delivered without documented FLM between 32(°/7) and 34(°/7) weeks (expectant). Primary outcomes included maternal infection (clinically diagnosed endometritis or chorioamnionitis), placental abruption and a composite of neonatal morbidities (including but not limited to mechanical ventilation, intraventricular hemorrhage, necrotizing enterocolitis, sepsis and respiratory distress syndrome). Statistical analysis was performed using Student's t-test for continuous variables and Chi-square or Fisher's exact test for categorical data. Covariates were analyzed via multivariate logistic regression and adjusted odds ratios were calculated.Results: Of 237 PPROMs delivered at 32(°/7)-34(°/7) weeks, 74 were intentionally delivered for +FLM and 163 were expectantly managed. No cord prolapse or stillbirth was observed. Maternal infection (chorioamnionitis or endometritis) was lower in the +FLM group (aOR 0.33 95% CI 0.12-0.88). Overall, there was no difference in composite neonatal morbidity did not differ between the two groups (aOR 1.36 95% CI 0.53-3.54).Conclusions: In patients with PPROM, delivery after confirmation of FLM at 32(°/7)-33(6/7) weeks compared with expectant management until 34(°/7) weeks may prevent maternal infection without increasing neonatal morbidity. [ABSTRACT FROM AUTHOR]

Objective Postpartum higher-dose oxytocin (80 U) compared with lower dose (10 U) given in 500 mL over 1 hour does not decrease postpartum hemorrhage (PPH) requiring treatment, but reduces the risk of hematocrit decline ≥ 6% among women delivering vaginally. Our objective was to evaluate whether the duration of administration of oxytocin influences outcomes. Study Design We compared a cohort receiving a postpartum oxytocin infusion of 80 U/500 mL over 1 hour to a concurrent cohort of women receiving 80 U/500 mL over 8 hours. The primary outcome was any treatment of PPH (uterotonics, blood transfusion, tamponade, and surgery). Secondary outcomes included pre- to postdelivery median hematocrit change and hematocrit decline ≥ 6%. Results There were 653 and 676 women identified in the 1- and 8-hour cohorts, respectively. There was no difference in PPH requiring any treatment between the 1- and 8-hour cohorts (6 vs. 6%, p = 0.70). There were no differences in individual treatment components including blood transfusion (p = 0.75). Median hematocrit decline (p = 0.02) was lower in the 8-hour cohort, but there was no difference in frequency of hematocrit decline ≥ 6% (p = 0.15). Results were unchanged by multivariable adjustments. Conclusions Postpartum higher-dose oxytocin administered over 1 hour compared with 8 hours was not associated with an increased treatment of PPH or frequency of hematocrit decline ≥ 6%. [ABSTRACT FROM AUTHOR]

Objective To compare maternal and neonatal outcomes between planned cesarean delivery and induction of labor in women with class III obesity (body mass index ≥40 kg/m 2 ). Study Design In this retrospective cohort study, we identified all women with a body mass index ≥40 kg/m 2 who delivered a singleton at our institution from January 2007 to February 2013 via planned cesarean or induction of labor (regardless of eventual delivery route) at 37-41 weeks. Patients in spontaneous labor were excluded. The primary outcome was a composite of maternal morbidity including death as well as operative, infection, and thromboembolic complications. The secondary outcome was a neonatal morbidity composite. Additional outcomes included individual components of the composites. Student t , χ 2 , and Fisher exact tests were used for statistical analysis. To calculate adjusted odds ratios, covariates were analyzed via multivariable logistic regression. Results There are 661 mother-infant pairs that met enrollment criteria—399 inductions and 262 cesareans. Groups were similar in terms of prepregnancy weight, pregnancy weight gain, and delivery body mass index. Of the 399 inductions, 258 had cervical ripening (64.7%) and 163 (40.9%) had a cesarean delivery. After multivariable adjustments, there was no significant difference in the maternal morbidity composite (adjusted odds ratio, 0.98; 95% confidence interval, 0.55–1.77) or in the neonatal morbidity composite (adjusted odds ratio, 0.81; 95% confidence interval, 0.37–1.77) between the induction and cesarean groups. Conclusion In term pregnant women with class III obesity, planned cesarean does not appear to reduce maternal and neonatal morbidity compared with induction of labor. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to evaluate whether the time interval from corticosteroid administration to delivery is associated with variations in inflammatory/infectious markers in women with spontaneous preterm birth (SPTB). Study Design: We conducted a secondary analysis of a prospectively collected cohort of women experiencing SPTB from 230/7 to 316/7 weeks. Patients were categorized by corticosteroid receipt and time interval until delivery. Prevalence of markers of inflammation and colonization/infection (cord blood interleukin [IL]-6 levels; Ureaplasma urealyticum [UU], Mycoplasma hominis [MH], and other anaerobic/aerobic cultures; histology of the placental disc, membranes and cord) were compared between groups using χ2 and Mantel-Haenszel tests. Results: Two hundred seventy-three patients had SPTB. Prevalence of elevated IL-6 (P = .028) and positive UU/MH cultures (P = .019) were highest in women not receiving corticosteroids and those delivering more than 7 days from receipt. The prevalence of both decreased in groups with delivery delayed at least 12 hours but increased as the interval lengthened to more than 48 hours. Overall positive placental cultures also nadired among those delivering at 12-24 hours after corticosteroids (P = .049). As the interval increased, prevalence of acute inflammation at the rupture site increased (P = .017). There were similar, but nonsignificant, increases in chorionic plate inflammation and funisitis. Conclusion: The relationship between time interval from corticosteroids and evidence of inflammation in women experiencing SPTB is U shaped, suggesting earlier stages of inflammation in women with delayed delivery or transient decreases of inflammation in response to corticosteroids. This warrants further investigation to elucidate the natural history of SPTB and its modulation by corticosteroids. [Copyright &y& Elsevier]

Objective: To evaluate outcomes before and after implementation of a risk-stratified heparin-based obstetric thromboprophylaxis protocol.Methods: We performed a retrospective cohort study of all patients who delivered at our tertiary care center from 2013 to 2018. Deliveries were categorized as preprotocol (2013-2015; no standardized heparin-based thromboprophylaxis) and postprotocol (2016-2018). Patients receiving outpatient anticoagulation for active venous thromboembolism (VTE) or high VTE risk were excluded. Coprimary effectiveness and safety outcomes were postpartum VTEs and wound hematomas, respectively, newly diagnosed after delivery and up to 6 weeks postpartum. Secondary outcomes were other wound or bleeding complications, including unplanned surgical procedures (eg, hysterectomies, wound explorations) and blood transfusions. Outcomes were compared between groups, and adjusted odds ratios (aORs) and 95% CIs were calculated using the preprotocol group as reference.Results: Of 24,229 deliveries, 11,799 (49%) occurred preprotocol. Although patients were more likely to receive heparin-based prophylaxis postprotocol (15.6% vs 1.2%, P<.001), there was no difference in VTE frequency between groups (0.1% vs 0.1%, odds ratio 1.0, 95% CI 0.5-2.1). However, patients postprotocol experienced significantly more wound hematomas (0.7% vs 0.4%, aOR 2.34, 95% CI 1.54-3.57), unplanned surgical procedures (aOR 1.29, 95% CI 1.06-1.57), and blood transfusions (aOR 1.34, 95% CI 1.16-1.55).Conclusion: Risk-stratified heparin-based thromboprophylaxis in a general obstetric population was associated with increased wound and bleeding complications without a complementary decrease in postpartum VTE. Guidelines recommending this strategy should be reconsidered. [ABSTRACT FROM AUTHOR]

INTRODUCTION: We aimed to pragmatically analyze the effect of offering elective induction of labor (eIOL) in low-risk patients on perinatal outcomes. METHODS: This was a retrospective cohort study of low-risk nulliparous or multiparous patients delivering live, nonanomalous singletons at a single center at greater than or equal to 39 0/7 weeks' gestational age (GA). Those with prior or planned cesarean delivery (CD), ruptured membranes, medical comorbidities, or contraindications to vaginal delivery were excluded. Patients were categorized as before (pre-eIOL; January 2012 to March 2014) or after (post-eIOL; March 2019 to December 2021) an institution-wide policy offering eIOL at 39 0/7 weeks. Births from April 2014 to December 2018 were considered to be during-eIOL given increased exposure to eIOL during the period of the ARRIVE trial at our center. The primary outcome was CD. Characteristics and outcomes were compared between the pre- and during-eIOL, and pre- and post-eIOL groups, and adjusted OR (aOR) (95% CI) was calculated using multivariable regression. Subgroup analysis by parity was planned. RESULTS: Of 10,966 patients analyzed, 2,611 (23.8%) were pre-eIOL, 5,486 (50.0%) during-eIOL, and 2,869 (26.2%) post-eIOL. Groups differed with respect to labor type, age, race and ethnicity, marital and payor status, and GA at care entry. Post-eIOL was associated with lower odds of CD compared to pre-eIOL (aOR 0.75 [95% CI 0.66–0.87]), which was consistent for both nulliparas (aOR 0.71 [0.59–0.85]) and multiparas (aOR 0.64 [0.52–0.79]). During-eIOL was also associated with lower odds of CD compared to pre-eIOL (aOR 0.73 [0.65–0.82]). Both during- and post-eIOL groups were associated with higher odds of chorioamnionitis, operative delivery, and hemorrhage compared to pre-eIOL. However, only among post-eIOL were there fewer neonatal birth weights greater than 4,000 g, large-for-GA infants, and hypoglycemia compared to pre-IOL. CONCLUSION: Institutional policy offering eIOL at 39 0/7 to low-risk patients was associated with a lower CD rate and lower birth weights, and an increased risk of chorioamnionitis and hemorrhage. [ABSTRACT FROM AUTHOR]