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To rank clinician-driven tests and treatments (CTTs) by their total cost during the birth hospitalization for preterm infants.Retrospective cohort of very low birth weight (1500 g) and/or very preterm (32 weeks) subjects admitted to US children's hospital Neonatal Intensive Care Units (2012-2018). CTTs were defined as pharmaceutical, laboratory and imaging services and ranked by total cost.24,099 infants from 51 hospitals were included. Parenteral nutrition ($85M, 32% of pharmacy costs), blood gas analysis ($34M, 29% of laboratory costs), and chest radiographs ($18M, 31% of imaging costs) were the costliest CTTs overall. More than half of CTT-related costs occurred during 10% of hospital days.The majority of CTT-related costs were from commonly used tests and treatments. Targeted efforts to improve value in neonatal care may benefit most from focusing on reducing unnecessary utilization of common tests and treatments, rather than infrequently used ones.

OBJECTIVES: To examine trends in survival without major morbidity and its individual components among very low birth weight infants across California and assess remaining gaps that may be opportune targets for improvement efforts. METHODS: The study population included infants born between 2008 and 2017 with birth weights of 401 to 1500 g or a gestational age of 22 to 29 weeks. Risk-adjusted trends of survival without major morbidity and its individual components were analyzed. Survival without major morbidity was defined as the absence of death during birth hospitalization, chronic lung disease, severe peri-intraventricular hemorrhage, nosocomial infection, necrotizing enterocolitis, severe retinopathy of prematurity or related surgery, and cystic periventricular leukomalacia. Variations in adjusted rates and/or interquartile ranges were examined. To assess opportunities for additional improvement, all hospitals were reassigned to perform as if in the top quartile, and recalculation of predicted numbers were used to estimate potential benefit. RESULTS: In this cohort of 49 333 infants across 142 hospitals, survival without major morbidity consistently increased from 62.2% to 66.9% from 2008 to 2017. Network variation decreased, with interquartile ranges decreasing from 21.1% to 19.2%. The largest improvements were seen for necrotizing enterocolitis and nosocomial infection. Bronchopulmonary dysplasia rates did not change significantly. Over the final 3 years, if all hospitals performed as well as the top quartile, an additional 621 infants per year would have survived without major morbidity, accounting for an additional 6.6% annual improvement. CONCLUSIONS: Although trends are promising, bronchopulmonary dysplasia remains a common and persistent major morbidity, remaining a target for continued quality-improvement efforts.

> First, do no harm. > Attributed to various sources To intubate or not to intubate an infant born through meconium-stained amniotic fluid (MSAF) has been a question that has challenged this often-quoted principle of first doing no harm, with the answer evolving significantly since the publication of the first Neonatal Resuscitation Program (NRP) guidelines >30 years ago.1 Those who trained and practiced in the 1980s and 1990s remember an era when all infants born through MSAF (both vigorous and nonvigorous) were routinely intubated after delivery or when decisions to intervene were perhaps based on the consistency and thickness of the meconium. NRP recommendations have since evolved, such that intubation was no longer recommended for vigorous infants born through MSAF after the fourth edition of the NRP guidelines was published in 2000.2 However, the recommendation for management of nonvigorous infants born through MSAF remained unchanged until the most recent seventh edition of the NRP guidelines (published in 2016), which no longer recommended routine intubation and tracheal suctioning for nonvigorous infants born through MSAF.3 These recommendations were made partly after a review of a few smaller single-center randomized controlled trials in which tracheal suctioning was compared with no suctioning in nonvigorous infants born through MSAF.4,5 On the basis of this review and the lack of evidence to support routine intubation and tracheal suctioning of nonvigorous infants born through MSAF, the most recent NRP recommendations were made in the context of avoiding the potential harm of intubation and the subsequent delay …

OBJECTIVES: Efforts to study potential overuse of NICU admissions and hospital variation in practice are often hindered by a lack of an appropriate data source. We examined the concordance of hospital-level NICU admission rates between birth certificate data and California Children’s Services (CCS) data to inform the utility of birth certificate data in studying hospital variation in NICU admissions. METHODS: We analyzed birth certificate data from California in 2012 and hospital-specific summary data from CCS regarding NICU admissions. NICU admission rates were calculated for both data sets while using CCS data as the gold standard. The difference between birth certificate–based and CCS-based NICU admission rates was assessed by using the Wilcoxon signed rank test, and concordance between the 2 rates was evaluated by using Lin’s concordance correlation coefficient and Kendall’s W concordance coefficient. RESULTS: Among a total of 103 hospitals that were linked between the 2 data sets, birth certificate data generally underreported NICU admission rates compared with CCS data (median = 7.72% vs 11.51%; P < .001). However, in a subset of 35 hospitals where the difference in NICU admission rates between the 2 data sets was small, the birth certificate–based NICU admission rate showed good concordance with the rate from CCS data (Lin’s concordance correlation coefficient = 0.91; 95% confidence interval: 0.84–0.95; Kendall’s W concordance coefficient = 0.99; P < .001). Hospitals with good-concordance data did not differ from other hospitals in the institutional characteristics assessed. CONCLUSIONS: For a selected subset of hospitals, birth certificate data may offer a reasonable means to investigate hospital variation in NICU admissions.

Background This study aims to examine hospital variation in both maternal and neonatal morbidities and identify institutional characteristics associated with hospital performance in a combined measure of maternal and neonatal outcomes. Methods Using the California Linked Birth File containing data from birth certificate and hospital discharge records, we identified 1 322 713 term births delivered at 248 hospitals during 2010-2012. For each hospital, a risk-standardized rate of severe maternal morbidities and a risk-standardized rate of severe newborn morbidities were calculated after adjusting for patient clinical risk factors. Hospitals were ranked based on combined information on their maternal and newborn morbidity rates. Results Risk-standardized severe maternal and severe newborn morbidity rates varied substantially across hospitals (10th to 90th percentile range = 67.5-148.2 and 141.8-508.0 per 10 000 term births, respectively), although there was no significant association between the two (P = 0.15). Government hospitals (non-Federal) were more likely than other hospitals to be in worse rank quartiles (P value for trend = 0.004), whereas larger volume was associated with better rank among hospitals in the first three quartiles (P = 0.004). The most prevalent morbidities that differed progressively across hospital rank quartiles were severe hemorrhage, disseminated intravascular coagulation, and heart failure during procedure/surgery for mothers, and severe infection, respiratory complication, and shock/resuscitation for neonates. Conclusions Hospitals with low maternal morbidity rates may not have low neonatal morbidity rates and vice versa, highlighting the importance of assessing joint maternal-newborn outcomes in order to fully characterize a hospital's obstetrical performance. Hospitals with smaller volume and government ownership tend to have less desirable outcomes and warrant additional attention in future quality improvement efforts.

Transcutaneous bilirubin measurements (TcBs) provide a noninvasive method for screening infants for hyperbilirubinemia and have been used extensively in term and late preterm newborns in well baby nurseries, offices, and outpatient clinics. Several studies have also demonstrated the utility of TcBs as a screening tool for infants 28 weeks' gestation and their ability to reduce the need for blood sampling. The objectives of this study are to identify how often TcBs are used among California Newborn Intensive Care Units (NICUs) in preterm, late preterm and term infants, and other aspects of jaundice management.We conducted a survey on TcB use and practices relating to jaundice management in 150 California NICUs between April and October 2016.TcB screening is routinely used in 28% (42/150) of NICUs. Only 7% (11/150) of NICUs use TcB in preterm infants 28 weeks. Practice varied similarly across NICU levels of care. Among the subset of NICUs that responded to questions related to phototherapy and screening practices, prophylactic phototherapy was used in 38% (23/59) and 90% (55/61) screened for glucose-6-phosphate dehydrogenase deficiency based on race, ethnicity, and/or family history.Despite studies validating the accuracy of TcB in preterm infants 28 weeks, only 28% of California NICUs routinely use TcB devices. TcB screening in infants 28 weeks gestation is not widely used and no recommendation can be made in this regard until there is more experience with its application using a standardized protocol in these infants and on a large scale.

This 2019 focused update to the American Heart Association neonatal resuscitation guidelines is based on 2 evidence reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. The International Liaison Committee on Resuscitation Expert Systematic Reviewer and content experts performed comprehensive reviews of the scientific literature on the appropriate initial oxygen concentration for use during neonatal resuscitation in 2 groups: term and late-preterm newborns (≥35 weeks of gestation) and preterm newborns (

NICU patients are disproportionately affected by any disaster due to their vulnerability and highly specialized care needs that require a multitude of resources. Research in disaster preparedness and its effect on NICU patients is limited.From March to May 2018, NICUs across California participated in a survey designed to assess their preparedness for a disaster.Of the 84 responding units, 99% were urban, 73% were nonprofit, and 65% were community NICUs. As for NICU participation in hospital training exercises for disaster preparedness, 10% did not participate in annual drills, 44% did once a year, 36% did twice a year, and 10% did more than two times per year.We showed that many NICUs had redundant systems in place and plans for various disasters; however, there is not consistent participation by NICUs in hospital training exercises for disaster preparedness.

A full-term female newborn is noted to have a perineal lesion a few hours after birth. ### Prenatal and Birth Histories ### Presentation (Day 0) On initial physical examination of the infant at 3 hours after birth, a wet erythematous sulcus was noted in the perineum extending from the posterior fourchette to the anterior edge of the anus (Fig 1). Bilateral preauricular ear tags were noted and the remainder of the physical examination was normal. Pediatric surgery was consulted because of a concern for a perineal tear. Figure 1. Neonate with perineal lesion. ### Vital Signs ### Physical Examination (Day 0)

Purpose Retinopathy of prematurity (ROP) may cause visual impairment in infants with very low birth weight. Lack of parent knowledge may contribute to gaps in screening and treatment. We studied parents' knowledge and education of ROP. Design Cross-sectional study. Methods Setting : Four high-acuity neonatal intensive care units in California (40-84 beds). Participants Total of 194 English- and Spanish-speaking parents of very low birth weight ( Main Outcome Measures We asked parents what they knew about ROP, how they were educated about ROP, and their experiences obtaining outpatient eye care. We used multivariate analysis to assess whether parent knowledge was associated with level of English proficiency and literacy, education modality (verbal, written, online, video), and hospital transfer status. Results Of the 194 participants, 131 (68%) completed surveys: 18% had both limited English proficiency and low literacy while overall 26% had limited English proficiency and 37% had low literacy; 17% did not know that ROP is an eye disease, and 38% did not know that very low birth weight and prematurity are both risk factors for ROP. Parents reported receiving verbal (62%) or written (56%) information; few used online resources (12%) or videos (3%). Half reported receiving information about infants' retinopathy status at discharge. No education modality was associated with higher knowledge. Limited English proficiency and low literacy were associated with lower knowledge (vs English-proficient, literate). Conclusions Parents of infants with very low birth weight, particularly those with limited English proficiency and low health literacy, lack knowledge about ROP.

BackgroundIntraventricular hemorrhage (IVH) and pre-pregnancy obesity and underweight have been linked to inflammatory states. We hypothesize that IVH in preterm infants is associated with pre-pregnancy obesity and underweight due to an inflammatory intrauterine environment.MethodsPopulation-based study of infants born between 22 and 32 weeks' gestation from 2007 to 2011. Data were extracted from vital statistics and the California Perinatal Quality Care Collaborative. Results were examined for all cases (any IVH) and for severe IVH.ResultsAmong 20,927 infants, 4,818 (23%) had any IVH and 1,514 (7%) had severe IVH. After adjustment for confounders, there was an increased risk of IVH associated with pre-pregnancy obesity, relative risk 1.14 (95% confidence interval (CI) 1.06, 1.32) for any IVH, and 1.25 (85% CI 1.10, 1.42) for severe IVH. The direct effect of pre-pregnancy obesity on any IVH was significant (P0.001) after controlling for antenatal inflammation-related conditions, but was not significant after controlling for gestational age (P=0.56).ConclusionPre-pregnancy obesity was found to be a risk factor for IVH in preterm infants; however, this relationship appeared to be largely mediated through the effect of BMI on gestational age at delivery. The etiology of IVH is complex and it is important to understand the contributing maternal factors.

Objective To explore women's birth experiences to develop an understanding of their perspectives on patient safety during hospital-based birth. Design Qualitative description using thematic analysis of interview data. Participants Seventeen women ages 29 to 47 years. Methods Women participated in individual or small group interviews about their birth experiences, the physical environment, interactions with clinicians, and what safety meant to them in the context of birth. An interdisciplinary group of five investigators from nursing, medicine, product design, and journalism analyzed transcripts thematically to examine how women experienced feeling safe or unsafe and identify opportunities for improvements in care. Results Participants experienced feelings of safety on a continuum. These feelings were affected by confidence in providers, the environment and organizational factors, interpersonal interactions, and actions people took during risk moments of rapid or confusing change. Well-organized teams and sensitive interpersonal interactions that demonstrated human connection supported feelings of safety, whereas some routine aspects of care threatened feelings of safety. Conclusion Physical and emotional safety are inextricably embedded in the patient experience, yet this connection may be overlooked in some inpatient birth settings. Clinicians should be mindful of how the birth environment and their behaviors in it can affect a woman's feelings of safety during birth. Human connection is especially important during risk moments, which represent a liminal space at the intersection of physical and emotional safety. At least one team member should focus on the provision of emotional support during rapidly changing situations to mitigate the potential for negative experiences that can result in emotional harm.

Despite significant technological advances and increasing survival of premature infants, bronchopulmonary dysplasia (BPD) continues to be the most prevalent major morbidity in surviving very low-birthweight infants. Infants with BPD are often sicker, require longer stays in the NICU, and accumulate greater hospital costs. However, care of the infant with BPD extends beyond the time spent in the NICU. This article reviews the costs of BPD in the health-care setting, during the initial hospitalization and beyond, and the long-term neurodevelopmental impact of BPD, as well as the impact on a family caring for a child with BPD.

Objective This article characterizes programmatic features of a population-based network of high-risk infant follow-up programs and identifies potential challenges associated with attendance from the providers' perspective. Study Design A web-based survey of high-risk infant follow-up program directors, coordinators, and providers of a statewide high-risk infant follow-up system. Frequencies and percentages were used to describe the survey responses. Results Of the 68 high-risk infant follow-up programs in California, 56 (82%) responded to the survey. The first visit no-show rate between 10 and 30% was estimated by 44% of programs with higher no-show rates for subsequent visits. Common strategies to remind families of appointments were phone calls and mailings. Most programs (54%) did not have a strategy to help families who lived distant to the high-risk infant follow-up clinic. Conclusion High-risk infant follow-up programs may lack resources and effective strategies to enhance follow-up, particularly for those living at a distance.

Objective To examine hospital variation in cost of childbirth hospitalizations and identify factors that contribute to the variation. Design Cross-sectional analysis of linked birth certificate and hospital discharge data. Setting 220 hospitals in California delivering ≥100 births per year. Population 405,908 nulliparous term singleton vertex births during 2010-2012. Methods Cost of childbirth hospitalizations was compared across hospitals after accounting for differences in patient clinical risk factors. Relative contribution of patient sociodemographic, obstetric intervention, birth attendant, and institutional characteristics to variation in cost was assessed by further adjusting for these factors in hierarchical generalized linear models. Main Outcome Measures Cost of childbirth hospitalization. Results Median risk-standardized cost of childbirth was $7,149 among the hospitals (10th-90th percentile range: $4,760-$10,644). Maternal sociodemographic characteristics and type of birth attendant did not explain hospital variation in cost. Adjustment for obstetric interventions overall reduced within-hospital variance by 15.8% (P

Alistair G.S. Philip, MD, has retired as editor-in-chief of NeoReviews . From my perspective, Alistair has retired twice, once in 2004 when he was awarded emeritus status at Stanford University, and recently in 2017, when he made the decision to leave his editorial role at the journal. However, I suspect that this time, his family and golf may have finally taken the Scot from us—although not his legacy. Nonetheless, I also trust that we will still see him occasionally at our professional gatherings or hear from him from time to time through an editorial or commentary, if he thinks we need some further tutoring in some manner of our practice, which I am sure he will decide is necessary. Alistair has never deviated from a career trajectory of continuing education. He was an early immigrant from the United Kingdom, more specifically Scotland, and has maintained a bit of the manner and brogue of the Scot to this day—besides being a decent golfer. He received his medical education at the University of Edinburgh Medical School, achieving his MB, Ch.B in 1961. His Doctor of Medicine degree (MD) was also awarded in Edinburgh, in 1983, after completion of a thesis based on original research. He was an intern at Belfast City Hospital in Northern Ireland, and he served as a resident between 1962 and 1963 at the American Hospital of Paris, Neuilly-sur-Siene, France. The latter experience was evidence of the first expression of his “gene for adventure,” which ultimately would lead him to us at Stanford. Indeed, he was allured by the West early in his career, beginning in 1963 to 1964 when he was a pediatric resident at the Kauikeolani Children’s Hospital in Honolulu, Hawaii. Between 1964 and 1969, he moved between various medical training experiences in Edinburgh, Boston, and Paris, …

TITLE: Barriers to optimal breast milk provision in the Neonatal Intensive Care Unit (NICU) Background: In the high risk NICU setting, breast milk use is associated with decreased morbidity and improved neurodevelopmental outcomes. Objective: This retrospective study aimed to identify patient and systems barriers to optimal breast milk use in infants admitted to a regional NICU in California. Design/Methods: 699 babies born at 23-41 weeks of gestation with no congenital anomalies admitted to the NICU within 3 days of birth from 9/2015 to 6/2018 were included. …

Objective To examine the hypothesis that increasing rates and differential uptake of antenatal steroids would bias estimation of impact of antenatal steroids on neonatal death and severe (grade III-IV) intraventricular hemorrhage (IVH). Study design The study population included infants born between 24 and 28 weeks of gestational age in the California Perinatal Quality Care Collaborative. Outcomes were in-hospital mortality and severe IVH. Mixed multivariable logistic regression models estimated the effect of antenatal steroid exposure, one model accounting for individual risk factors as fixed effects, and a second model incorporating a predicted probability factor estimating overall risk status for each time period. Results The study cohort included 28 252 infants. Antenatal steroid exposure increased from 80.1% in 2005 to 90.3% in 2016, severe IVH decreased from 14.5% to 9.0%, and mortality decreased from 12.8% to 9.1%. When stratified by group, 3-year observed outcomes improved significantly in infants exposed to antenatal steroids (12.5%-8.6% for IVH, 11.5%-8.8% for death) but not in those not exposed (20.7%-19.1% and 16.6%-15.5%, respectively). Women not receiving antenatal steroids had greater risk profile (such as no prenatal care) and greater predicted probability for severe IVH and mortality. Both outcomes exhibited little change (P > .05) over time for the group without antenatal steroids. In contrast, in women receiving antenatal steroids, observed and adjusted rates for both outcomes decreased (P Conclusions As the population's proportion of antenatal steroid use increased, the observed positive effect of antenatal steroids also increased. This apparent increase may be designated as the “population improvement bias.”

Delaying umbilical cord clamping (DCC) for 1 min or longer following a neonate’s birth has now been recommended for preterm and term newborns by multiple professional organizations. DCC has been shown to decrease rates of iron deficiency anemia, intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and blood transfusion. Despite these benefits, clinicians typically cut the umbilical cord without delay in neonates requiring resuscitation and move them to a radiant warmer for further care; this effectively prevents these patients from receiving any benefits from DCC. This study evaluated the feasibility of a delayed cord clamping cart (DCCC) in low-risk neonates born via Cesarean section (CS). The DCCC is a small, sterile cart designed to facilitate neonatal resuscitation while the umbilical cord remains intact. The cart is cantilevered over the operating room (OR) table during a CS, allowing the patient to be placed onto it immediately after birth. For this study, a sample of 20 low-risk CS cases were chosen from the non-emergency Labor and Delivery surgical case list. The DCCC was utilized for 1 min of DCC in all neonates. The data collected included direct observation by research team members, recorded debriefings and surveys of clinicians as well as surveys of patients. Forty-four care team members participated in written surveys; of these, 16 (36%) were very satisfied, 12 (27%) satisfied, 13 (30%) neutral, and 3 (7%) were somewhat dissatisfied with use of the DCCC in the OR. Feedback was collected from all 20 patients, with 18 (90%) reporting that they felt safe with the device in use. This study provides support that utilizing a DCCC can facilitate DCC with an intact umbilical cord.

Implementation of standardized practices in the delivery room fosters a safe environment to ensure that newborn infants are cared for optimally, whether or not they require extensive resuscitation. Quality improvement (QI) is an excellent methodology for implementation of standardized practices due to the multidisciplinary nature of the delivery room, the complexity of the tasks involved, and opportunities to track measurable processes and outcomes. In this article, we discuss the various ways that the delivery room is a unique environment and present specific examples on how to approach delivery room QI. Key areas of potential focus for teams pursuing delivery QI include thermal regulation, optimizing respiratory support, and facilitating team communication.

Background and Objective Teamwork may affect clinical care in the neonatal intensive care unit (NICU) setting. The objective of this study was to assess teamwork climate across NICUs and to test scale-level and item-level associations with health care–associated infection (HAI) rates in very low-birth-weight (VLBW) infants. Methods Cross-sectional study of the association between HAI rates, defined as any bacterial or fungal infection during the birth hospitalization, among 6,663 VLBW infants cared for in 44 NICUs between 2010 and 2012. NICU HAI rates were correlated with teamwork climate ratings obtained in 2011 from 2,073 of 3,294 eligible NICU health professionals (response rate 63%). The relation between HAI rates and NICU teamwork climate was assessed using logistic regression models including NICU as a random effect. Results Across NICUs, 36 to 100% (mean 66%) of respondents reported good teamwork. HAI rates were significantly and independently associated with teamwork climate (odds ratio, 0.82; 95% confidence interval, 0.73–0.92, p = 0.005), such that the odds of an infant contracting a HAI decreased by 18% with each 10% rise in NICU respondents reporting good teamwork. Conclusion Improving teamwork may be an important element in infection control efforts.

OBJECTIVE: The objectives of this study are to use network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions and to determine factors associated with transport outside the originating sub-network. STUDY DESIGN: This cross-sectional database study included 6546 infants

To assess the accuracy of different sonographic estimated fetal weight (EFW) cutoffs, and combinations of EFW and biometric measurements for predicting small for gestational age (SGA) in fetal gastroschisis.Gastroschisis cases from two centers were included. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated for different EFW cutoffs, as well as EFW and biometric measurement combinations.Seventy gastroschisis cases were analyzed. An EFW10% had 94% sensitivity, 43% specificity, 33% PPV and 96% NPV for SGA at delivery. Using an EFW cutoff of5% improved the specificity to 63% and PPV to 41%, but decreased the sensitivity to 88%. Combining an abdominal circumference (AC) or femur length (FL) z-score less than -2 with the total EFW improved the specificity and PPV but decreased the sensitivity.A combination of a small AC or FL along with EFW increases the specificity and PPV, but decreases the sensitivity of predicting SGA.

Introduction Communication errors are an important contributing factor in adverse outcomes in labor and delivery (L&D) units. The objective of this study was to identify common lapses in verbal communication using simulated obstetrical scenarios and propose alternative formats for communication. Methods Health care professionals in L&D participated in three simulated clinical scenarios. Scenarios were recorded and reviewed to identify questions repeated within and across scenarios. Questions that were repeated more than once due to ineffective communication were identified. The frequency with which the questions were asked across simulations was identified. Results Questions were commonly repeated both within and across 27 simulated scenarios. The median number of questions asked was 27 per simulated scenario. Commonly repeated questions focused on three general topics: (1) historical data/information (i.e., estimated gestational age), (2) maternal clinical status (i.e., estimated blood loss), and (3) personnel (i.e., “Has anesthesiologist been called?”). Conclusion Inefficient verbal communication exists in the process of transferring information during obstetric emergencies. These findings can inform improved training and development of information displays to improve teamwork and communication. A visual display that can report static historical information and specific dynamic clinical data may facilitate optimal human performance.

To examine hospital variation in intrapartum care and its relationship with cesarean rates.Cross-sectional survey.Connecticut and Massachusetts hospitals providing obstetric services.Nurse managers or other clinical staff knowledgeable about intrapartum care.We assessed labor and delivery unit capacity and staffing, fetal monitoring, labor management, intrapartum interventions, newborn care, quality assurance, and performance review practices. Association of hospital characteristics and intrapartum practices with cesarean rate was evaluated using Wilcoxon exact rank sum test and Kendall's tau-b correlation coefficient.Among 60 eligible hospitals, respondents from 39 hospitals (65%) completed the survey. Cesarean rates varied from 21% to 42% (median = 30%). Regular review of cesarean rates and indications (85%), regular provision of feedback on cesarean rates and indications to physicians (80%), and regular review of vaginal birth after cesarean rates (94%) were commonly performed at responding hospitals. These practices, however, were not associated with hospital cesarean rate. Hospitals that offered cesarean at the request of the woman (p .01) and had more liberal indications for labor induction (p .01) and cesarean birth (p .01) had significantly greater cesarean rates than institutions without these practices. Routinely placing an intravenous line (p .01) and drawing blood for complete blood count/type and antibody screen (p .01) in low-risk women were associated with greater cesarean rates; having a certified nurse-midwife in house at all times (p = .01) and permitting women to eat during labor (p = .02) were associated with lower cesarean rates.Intrapartum practices of hospitals varied markedly. These different patterns of care may suggest differing levels of intrapartum intervention.

A female infant is born at 37 weeks’ gestation via vaginal delivery to a gravida 4, para 3 woman. The woman’s pregnancy and delivery are uncomplicated. The infant’s birthweight is 2,680 g. She is discharged from the hospital in good condition; at home, she breastfeeds well and gains weight appropriately; on day 10, her weight is 2,778 g (4% above birthweight). On day 12, the mother notes that the infant has begun to breastfeed poorly. On day 14, formula feeding is attempted, but her intake remains poor, with an associated decrease in urine output. On day 16, she presents to an outpatient clinic, where she appears cachectic and severely dehydrated but responsive. Her weight is 1,760 g, a decrease of more than 1 kg (37%) from 6 days ago. She is transferred to the NICU for further evaluation and treatment. The infant’s newborn screening results from day 1 are normal; however, repeat newborn screening performed on day 10 shows an abnormality in the fatty acid oxidation profile, with malonyl carnitine levels of 0.68 μmol/L (normal ≤0.5 μmol/L). The patient’s initial laboratory tests were notable for the following results: sodium, 174 mEq/L (174 mmol/L); potassium, 7.2 mEq/L (7.2 mmol/L); chloride, 141 mEq/L (141 mmol/L); bicarbonate, 7 mEq/L (7 mmol/L); blood urea nitrogen, 273 mg/dL (97 mmol/L); creatinine, 5.61 mg/dL (428 μmol/L); glucose, 1,266 mg/dL (70.2 …

Objective Our primary objective was to identify risk factors for maternal readmission with sepsis. Our secondary objectives were to (1) assess diagnoses and infecting organisms at readmission and (2) compare early ( Study Design We identified our cohort using linked hospital discharge data and birth certificates for California deliveries from 2008 to 2011. Consistent with the 2016 sepsis classification, we defined sepsis as septicemia plus acute organ dysfunction. We compared women with early or late readmission with sepsis to women without readmission with sepsis. Results Among 1,880,264 women, 494 (0.03%) were readmitted with sepsis, 61% after 6 weeks. Risk factors for readmission with sepsis included preterm birth, hemorrhage, obesity, government-provided insurance, and primary cesarean. For both early and late sepsis readmissions, the most common diagnoses were urinary tract infection and pyelonephritis, and the most frequently identified infecting organism was gram-negative bacteria. Women with early compared with late readmission with sepsis shared similar obstetric characteristics. Conclusion Maternal risk factors for both early and late readmission with sepsis included demographic characteristics, cesarean, hemorrhage, and preterm birth. Risks for sepsis after delivery persist beyond the traditional postpartum period of 6 weeks.

OBJECTIVE: To determine the rate, maternal characteristics, timing, and indicators of severe maternal morbidity (SMM) that occurs at postpartum readmission. STUDY DESIGN: Women with a birth in California during 2008–2012 were included in the analysis. Readmissions up to 42 days after delivery were investigated. SMM was defined as presence of any of the 21 indicators defined by ICD-9 codes. RESULTS: Among 2,413,943 women with a birth, SMM at readmission occurred in 4229 women. Of all SMM, 12.1% occurred at readmission. Over half (53.5%) of the readmissions with SMM occurred within the first week after delivery hospitalization. The most common indicators of SMM were blood transfusion, sepsis, and pulmonary edema/acute heart failure. CONCLUSION: Twelve percent of SMM was identified at readmission with the majority occurring within 1 week after discharge from delivery hospitalization. Because early readmission may reflect lack of discharge readiness, there may be opportunities to improve care.

ObjectiveTo characterise the association between weekend (Saturday and Sunday) deliveries of very low birthweight (VLBW) infants and delivery room outcomes in the ‘golden hour’ after birth.Design and settingA retrospective cohort study using California Perinatal Quality Care Collaborative data from participating neonatal intensive care units.PatientsThe study population after exclusions was 26 515 VLBW infants born in California from 2010 to 2016.Main outcome measuresDelivery room outcomes assessed included: chest compressions, epinephrine, intubation prior to continuous positive airway pressure ventilation, 5 min Apgar ResultsInfants delivered on weekends were less likely to have been prenatally diagnosed with intrauterine growth restriction but were otherwise not significantly different in gestational age, ethnicity, sex or maternal risk factors than those born during weekdays. Caesarean deliveries were less common on weekends, while vaginal deliveries were consistent across all days. After adjusting for sex and race, weekend delivery was associated with delivery room chest compressions (OR: 1.12, 95% CI 1.02 to 1.24) and lower 5 min Apgar (OR: 1.11, 95% CI 1.01 to 1.21).ConclusionIn this population-based study of VLBW infants, there was an increase in chest compressions for infants born on the weekend. More research is needed on the differences between populations born on weekdays versus weekends, and how these may contribute to observed associations.

CONTEXT: Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear. OBJECTIVE: To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting. DATA SOURCES: Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: “neonatal intensive care units,” “racial or ethnic disparities,” and “quality of care.” STUDY SELECTION: English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected. DATA EXTRACTION: Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities. RESULTS: Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included. LIMITATIONS: Quantitative meta-analysis was not possible because of study heterogeneity. CONCLUSIONS: Overall, this systematic review revealed complex racial and/or ethnic disparities in structure, process, and outcome measures, most often disadvantaging infants of color, especially African American infants. There are some exceptions to this pattern and each area merits its own analysis and discussion.

OBJECTIVE: To evaluate potential differences and to show the risk associated with small for gestational age (SGA) at birth and discharge among infants born to mothers of various Asian/Pacific islander (PI) races. STUDY DESIGN: In this retrospective cohort study, infants with weight

OBJECTIVES: To estimate the percentage of hospital births receiving antibiotics before being discharged from the hospital and efficiency diagnosing proven bloodstream infection. METHODS: We conducted a cross-sectional study of 326 845 live births in 2017, with a 69% sample of all California births involving 121 California hospitals with a NICU, of which 116 routinely served inborn neonates. Exposure included intravenous or intramuscular antibiotic administered anywhere in the hospital during inpatient stay associated with maternal delivery. The main outcomes were the percent of newborns with antibiotic exposure and counts of exposed newborns per proven bloodstream infection. Units of observation and analysis were the individual hospitals. Correlation analyses included infection rates, surgical case volume, NICU inborn admission rates, and mortality rates. RESULTS: The percent of newborns with antibiotic exposure varied from 1.6% to 42.5% (mean 8.5%; SD 6.3%; median 7.3%). Across hospitals, 11.4 to 335.7 infants received antibiotics per proven early-onset sepsis case (mean 95.1; SD 71.1; median 69.5), and 2 to 164 infants received antibiotics per proven late-onset sepsis case (mean 19.6; SD 24.0; median 12.2). The percent of newborns with antibiotic exposure correlated neither with proven bloodstream infection nor with the percent of patient-days entailing antibiotic exposure. CONCLUSIONS: The percent of newborns with antibiotic exposure varies widely and is unexplained by proven bloodstream infection. Identification of sepsis, particularly early onset, often is extremely inefficient. Knowledge of the numbers of newborns receiving antibiotics complements evaluations anchored in days of exposure because these are uncorrelated measures.

Objective To determine costs of hospitalization associated with bronchopulmonary dysplasia (BPD) during the first year in very low birth weight infants. Study design Retrospective cohort study of California births from 2008 to 2011 linking birth certificate, discharge records, and clinical data from California Perinatal Quality Care Collaborative. Inclusion: birth weight 401–1500 g, gestational age

To understand arson and explosions, it is very helpful to know a bit of the basic chemistry and physics of fire. Arson fires are a criminal activity that is very difficult to effectively police. It is not easy to prove that someone committed arson. Solvent wash is the last of the common technique for recovering possible accelerant material form arson evidence. In processing the scene of a suspicious fire, identification of a possible accelerant is very important in making the determination of whether a particular suspicious fire was the result of arson. One thinks of explosives-related crimes as acts of terrorism or major destructive events that make the nightly news on television. There are many additional incidents involving explosives or explosions that are more localized, such as a pipe bomb placed under a car, injury of an individual transporting an explosive device or extortion attempts using a crudely constructed explosive device.

The nature of and the mechanism for generating physical evidence are critical concerns for forensic scientists. Finding or identifying physical evidence is important, but not sufficient to allow one to make the best possible use of it. Another way that physical evidence is generated is through the transfer of material between surfaces, which came into contact with the material. In addition to transfers resulting from direct contact, one can find useful evidence traces of many types that result from a deposit rather than a direct contact transfer. Physical evidence is also produced as a result of damage, tearing force, breakage, cuts, and many other processes. The role of physical evidence in helping to identify a victim or a suspect is central to forensic evidence. Utilization of physical evidence in the justice system requires that a series of steps be taken in the proper sequence: recognition, documentation, and collection, packaging, and preservation.

Crime scene investigation is one of the most important and most challenging area in forensic investigation. It consists of two aspects: processing and analysis. Classification of crime scenes may offer a guide to the investigator on how to proceed with crime scene processing, may suggest types of evidence more likely to be found in the type of case, and may provide a basis for an investigation logic tree. Sometimes, crime scene safety is a high priority to protect a victim, suspect, witness, ourselves, or our partner from a dangerous condition. The steps in crime scene processing are briefly described: scene survey and evidence recognition, documentation, scene searches, evidence collection and preservation, preliminary scene analysis and reconstruction, and release of the scene. Scene survey and evidence recognition is the most dependent on the experience and training of the crime scene investigator. The classical methods for crime scene documentation include notes, sketches, and photography.

A comparison of surface pressure coefficient measurements obtained using pressure-sensitive paint (PSP) measurements with predictions from the computational fluid dynamics (CFD) code FUN3D is presented for the NASA SLS Block 1B crew vehicle. Overall, the flow features over the SLS configuration were captured by both the PSP data and CFD data at freestream Mach numbers (M(sub ∞)) of 0.8 and 1.3. Overall, the flow features over the SLS are captured by the PSP data but the intensities of large pressure gradients are less intense than what was predicted by the CFD data. Several examples of this observation are given including the flow interaction at the booster nose cone edge, core body, and forward booster attachment hardware at M(sub ∞) = 0.8.