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Fetal heart rate (FHR) tracings are classified into 3 categories per the National Institute of Child Health and Human Development guidelines. There exists broad consensus on the recognition and management of categories I and III. However, a category II FHR tracing is considered “indeterminate” and cannot be classified as either reassuring or non-reassuring. Absence of variability and high frequency and increased depth of decelerations are the key determining factors that make a category II tracing non-reassuring and are associated with fetal metabolic acidosis. Periodic category II tracing is present in the majority of normal laboring patients. In the setting of a category II tracing, an initial attempt should be made for in utero resuscitation of the fetus. If the tracing fails to improve over a period of 1 to 2 hours, or the fetal tracing gradually deteriorates, a decision should be made for operative vaginal or cesarean delivery. Category II tracing management algorithms can aid in decision-making in this uncertain clinical scenario. Team training and simulation may improve team performance and have a positive impact on neonatal outcomes.

Background: Current guidelines recommend regional anesthesia versus general as a method of choice for women undergoing cesarean deliveries (CS). However, little is known about the surgical times in the operating room and a choice of anesthesia for cesarean deliveries. Objective: This study was designed to compare times from the arrival to the OR to the delivery of the fetus between regional and general anesthesia along with maternal and fetal outcomes, for patients undergoing cesarean sections for non-reassuring fetal tracing. Study Design: Records were reviewed for patients who underwent cesarean delivery for non-reassuring fetal heart rate tracing from February 2012 to May 2018. A total of 190 charts were selected. Seven patients who received epidural or spinal anesthesia and then converted to general anesthesia (GA) were excluded. The primary outcomes were: 1) entering the operating room to skin incision (min); 2) the time from entering the operating room to delivery of the fetus (min). These times were compared among the patients who underwent epidural, spinal and general anesthesia. The secondary criteria included time from skin incision to delivery of the fetus (min), estimated blood loss (ml), Apgars scores, Arterial/venous cord pH, NICU admissions and fetal complications. ANOVA or Kruskal-Wallis Test was used for the continuous variable and Fisher’s exact test was used for the categorical variable to test the differences between groups. Logistic regression model was used for the binary outcomes after adjusting for age, BMI and number of prior laparotomies. Results: Infants in the GA group were delivered significantly faster when compared to epidural and spinal group separately with a P-value of 0.001. The mean time from arrival to OR to delivery of the newborn in GA group was 12.7 minutes, compared to 27 minutes in epidural group and 32.7 minutes in the spinal group. Time intervals from time in the OR to incision and time from incision to delivery of the fetus were also calculated and were significantly shorter in the GA group when compared to spinal and epidural groups, P < 0.001. The estimated blood loss (EBL) was similar between these three groups. Both arterial and venous umbilical cord mean PH were comparable in GA, spinal and epidural groups. Potential complications of GA include 36% of newborns had an Apgar score of less than 7 at 1 minute in GA group when compared to 15% of newborns in the epidural group, and 22% of newborns in the spinal group, which was not statistically significant. When comparing the NICU admission between the groups: 77% of newborns delivered under GA required NICU admission, 54% of the newborns delivered via epidural anesthesia were admitted versus 50% of newborns delivered via spinal anesthesia. Conclusion: The induction of general anesthesia for emergency cesarean section resulted in shorter times to delivery compared to spinal and epidural. General anesthesia was associated with lower, albeit not statistically significant Apgar scores and higher NICU admissions, and had similar cord gases compared to neuraxial anesthesia group.

Objectives: Spontaneous preterm birth is a leading cause of neonatal death. Fetal fibronectin (fFN) testing in cervical secretions between 22-34.6 weeks of gestation is used to predict non-delivery within the next 7 days in patients with symptoms of preterm labor. The objective of this study is to analyze fFN test performance in a group of patients with low risk for preterm delivery that presented with preterm labor symptoms, and to evaluate how the results of fFN testing influenced management decisions. Materials and Methods: Patients after preterm delivery (gestational age 24.0-36.6 weeks) and patients who underwent fFN testing in Metropolitan Hospital, NYC Health+Hospitals, New York, NY, from January 1, 2015 to December 31, 2015 were identified and reviewed. Patients with positive fFN test results (fFN+; >50 ng/dL) were compared to patients with negative fFN test results (fFN-). Results: Among 77 patients identified, 66 (86%) were fFN- and 11 (14%) fFN+; 15 patients (78%) who delivered preterm were not tested with fFN. Preterm birth rate during the study period was 1.9%. There was no difference in maternal or neonatal characteristics between the two groups. Among fFN-, 4 patients (6%) delivered preterm, while among fFN+, none delivered preterm. In both groups, none delivered within 7 days of testing. Compared to fFN-, fFN+ had higher rates of admissions (36% vs 0%; PPConclusions: In this retrospective analysis, use of fFN testing as an initial screening test for patients with symptoms of preterm labor in this low risk population did not result in improved clinical outcomes and was associated with a higher rates of hospital admissions and steroid administration.

Objective We sought to explore how racial/ethnic minority-serving hospitals perform on 15 delivery-related indicators, and examine whether indicators vary by race/ethnicity within the same type of hospitals. Study Design We used 2008 through 2011 linked State Inpatient Database and American Hospital Association data from 7 states, and designated hospitals with >50% of deliveries to non-Hispanic white, non-Hispanic black, and Hispanic women as white-, black-, and Hispanic-serving, respectively. We calculated indicator rates per 1000 deliveries by hospital type and, separately, for non-Hispanic white, non-Hispanic black, and Hispanic women within each hospital type. We fitted multivariate Poisson regression models to examine associations between delivery-related indicators and patient and hospital characteristics by hospital type. Results White-serving hospitals offer obstetric care to an older and wealthier population than black- or Hispanic-serving hospitals. Rates of the most prevalent indicators examined (complicated vaginal delivery, complicated cesarean delivery, obstetric trauma) were lowest in Hispanic-serving hospitals. Generally, indicator rates were similar in Hispanic- and white-serving hospitals. Black-serving hospitals performed worse than other hospitals on 12 of 15 indicators. Indicator rates varied greatly by race/ethnicity in white- and Hispanic-serving hospitals, with non-Hispanic blacks having 1.19-3.27 and 1.15-2.68 times higher rates than non-Hispanic whites, respectively, for 11 of 15 indicators. Conversely, there were few indicator rate differences by race/ethnicity in black-serving hospitals, suggesting an overall lower performance of these hospitals compared to white- and Hispanic-serving hospitals. Conclusion We found considerable differences in delivery-related indicators by hospital type and patients’ race/ethnicity. Obstetric care quality measures are needed to track racial/ethnic disparities at the facility and population levels.

Objective To define the frequency, risk factors, and outcomes of massive transfusion in obstetrics. Methods The State Inpatient Dataset for New York (1998-2007) was used to identify all delivery hospitalizations for hospitals that reported at least one delivery-related transfusion per year. Multivariable logistic regression analysis was performed to examine the relationship between maternal age, race, and relevant clinical variables and the risk of massive blood transfusion defined as 10 or more units of blood recorded. Results Massive blood transfusion complicated 6 of every 10,000 deliveries with cases observed even in the smallest facilities. Risk factors with the strongest independent associations with massive blood transfusion included abnormal placentation (1.6/10,000 deliveries, adjusted odds ratio [OR] 18.5, 95% confidence interval [CI] 14.7-23.3), placental abruption (1.0/10,000, adjusted OR 14.6, 95% CI 11.2-19.0), severe preeclampsia (0.8/10,000, adjusted OR 10.4, 95% CI 7.7-14.2), and intrauterine fetal demise (0.7/10,000, adjusted OR 5.5, 95% CI 3.9-7.8). The most common etiologies of massive blood transfusion were abnormal placentation (26.6% of cases), uterine atony (21.2%), placental abruption (16.7%), and postpartum hemorrhage associated with coagulopathy (15.0%). A disproportionate number of women who received a massive blood transfusion experienced severe morbidity including renal failure, acute respiratory distress syndrome, sepsis, and in-hospital death. Conclusion Massive blood transfusion was infrequent, regardless of facility size. In the presence of known risk for receipt of massive blood transfusion, women should be informed of this possibility, should deliver in a well-resourced facility if possible, and should receive appropriate blood product preparation and venous access in advance of delivery. Level of evidence : II.

Currently four pregnancy complications, gestational diabetes, hypertensive disorders in pregnancy, preterm delivery, and delivery of a small for gestational age (SGA) infant, are recognized as cardiovascular disease (CVD) risk factors.1 Incorporating a history of gestational diabetes or hypertensive disorders in pregnancy has been shown to improve CVD risk prediction in women.2 The relationship between gestational diabetes or hypertensive disorders in pregnancy and CVD is believed to be explained, at least in part, by the atherogenic inflammation and oxidative stress that often accompany obesity.3 Indeed, overweight/obese women are 2–6 times more likely to develop gestational diabetes and 2–3 times more likely to develop hypertensive disorders in pregnancy in comparison to normal weight women.5 Women with a history of these complications are more likely to develop hypertension or type 2 diabetes.6 Despite substantial evidence linking these risk factors to CVD, a lack of modifying treatments for these risk factors may limit their use in CVD risk assessment and management.