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Background Despite improving supplies, SARS-CoV-2 nucleic acid amplification tests remain limited during surges and more so given concerns around COVID-19/influenza co-occurrence. Matching clinical guidelines to available supplies ensures resources remain available to meet clinical needs. We report a change in clinician practice after an electronic health record (EHR) order redesign to impact emergency department (ED) testing patterns. Methods We included all ED visits between December 1, 2021 and January 18, 2022 across a hospital system to assess the impact of EHR order changes on provider behavior 3 weeks before and after the change. The EHR order redesign included embedded symptom-based order guidance. Primary outcomes were the proportion of COVID-19 + flu/respiratory syncytial virus (RSV) testing performed on symptomatic, admitted, and discharged patients, and the proportion of COVID-19 + flu testing on symptomatic, discharged patients. Results A total of 52 215 ED visits were included. For symptomatic, discharged patients, COVID-19 + flu/RSV testing decreased from 11.4 to 5.8 tests per 100 symptomatic visits, and the rate of COVID-19 + flu testing increased from 7.4 to 19.1 before and after the intervention, respectively. The rate of COVID-19 + flu/RSV testing increased from 5.7 to 13.1 tests per 100 symptomatic visits for symptomatic patients admitted to the hospital. All changes were significant (P < 0.0001). Conclusions A simple EHR order redesign was associated with increased adherence to institutional guidelines for SARS-CoV-2 and influenza testing amidst supply chain limitations necessitating optimal allocation of scarce testing resources. With continually shifting resource availability, clinician education is not sufficient. Rather, system-based interventions embedded within exiting workflows can better align resources and serve testing needs of the community.

ImportancePregnancy induces unique physiologic changes to the immune response and hormonal changes leading to plausible differences in the risk of developing post-acute sequelae of SARS-CoV-2 (PASC), or Long COVID. Exposure to SARS-CoV-2 during pregnancy may also have long-term ramifications for exposed offspring, and it is critical to evaluate the health outcomes of exposed children. The National Institutes of Health (NIH) Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC aims to evaluate the long-term sequelae of SARS-CoV-2 infection in various populations. RECOVER- Pregnancy was designed specifically to address long-term outcomes in maternal-child dyads.MethodsRECOVER-Pregnancy cohort is a combined prospective and retrospective cohort that proposes to enroll 2,300 individuals with a pregnancy during the COVID-19 pandemic and their offspring exposed and unexposed in utero, including single and multiple gestations. Enrollment will occur both in person at 27 sites through theEunice Kennedy ShriverNational Institutes of Health Maternal-Fetal Medicine Units Network and remotely through national recruitment by the study team at the University of California San Francisco (UCSF). Adults with and without SARS-CoV-2 infection during pregnancy are eligible for enrollment in the pregnancy cohort and will follow the protocol for RECOVER-Adult including validated screening tools, laboratory analyses and symptom questionnaires followed by more in-depth phenotyping of PASC on a subset of the overall cohort. Offspring exposed and unexposed in utero to SARS-CoV-2 maternal infection will undergo screening tests for neurodevelopment and other health outcomes at 12, 18, 24, 36 and 48 months of age. Blood specimens will be collected at 24 months of age for SARS-CoV-2 antibody testing, storage and anticipated later analyses proposed by RECOVER and other investigators.DiscussionRECOVER-Pregnancy will address whether having SARS-CoV-2 during pregnancy modifies the risk factors, prevalence, and phenotype of PASC. The pregnancy cohort will also establish whether there are increased risks of adverse long-term outcomes among children exposed in utero.RegistrationNCT05172024

Hospital readmission is considered a core measure of quality in healthcare. Readmission soon after hospital discharge can result from suboptimal care during the index hospitalization or from inadequate systems for postdischarge care. For many conditions, readmission is associated with a high rate of serious morbidity and potentially avoidable costs. In obstetrics, for postpartum care specifically, hospitals and payers can easily track the rate of maternal readmission after childbirth and may seek to incentivize obstetricians, maternal-fetal medicine specialists, or provider groups to reduce the rate of readmission. However, this practice has not been shown to improve outcomes or reduce harm. There are major concerns with incentivizing providers to reduce postpartum readmissions, including the lack of a standardized metric, a baseline rate of 1% to 2% that is too low to accurately discriminate between random variation and controllable factors, the need for risk adjustment that greatly complicates rate calculations, the potential for bias depending on the duration of the follow-up interval, the potential for the "gaming" of the metric, the lack of evidence that obstetrical providers can influence the rate, and the potential for unintended harm in the vulnerable postpartum population. Until these problems are adequately addressed, maternal readmission rate after a childbirth hospitalization currently has limited utility as a metric for quality or performance improvement or as a factor to adjust provider reimbursement.

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants continues to shape the coronavirus disease 2019 (Covid-19) pandemic. The detection and rapid spread of the SARS-CoV-2 ‘ Omicron’ variant (lineage B.1.1.529) in Botswana and South Africa became a global concern because it contained 15 mutations in the spike protein immunogenic receptor binding domain and was less neutralized by sera derived from vaccinees compared to the previously dominant Delta variant. To investigate if Omicron is more likely than Delta to cause infections in vaccinated persons, we analyzed 37,877 nasal swab PCR tests conducted from 12-26 December 2021 and calculated the test positivity rates for each variant by vaccination status. We found that the positivity rate among unvaccinated persons was higher for Delta (5.2%) than Omicron (4.5%). We found similar results in persons who received a single vaccine dose. Conversely, our results show that Omicron had higher positivity rates than Delta among those who received two doses within five months (Omicron = 4.7% vs. Delta = 2.6%), two doses more than five months ago (4.2% vs. 2.9%), and three vaccine doses (2.2% vs. 0.9%). Our estimates of Omicron positivity rates in persons receiving one or two vaccine doses were not significantly lower than unvaccinated persons but were 49.7% lower after three doses. In comparison, the reduction in Delta positivity rates from unvaccinated to 2 vaccine doses was 45.6-49.6% and to 3 vaccine doses was 83.2%. Despite the higher positivity rates for Omicron in vaccinated persons, we still found that 91.2% of the Omicron infections in our study occurred in persons who were eligible for 1 or more vaccine doses at the time of PCR testing. In conclusion, escape from vaccine-induced immunity likely contributed to the rapid rise in Omicron infections.

Objective The cesarean delivery rate in the United States is 31.9%. One of the leading indications for primary cesarean delivery is labor arrest. A modern understanding of the labor curve supports more time prior to the diagnosis of labor arrest. We conducted this study to examine the impact of adherence to the modern criteria for labor arrest and failed induction on rates of primary cesarean delivery and to identify predictors of meeting these criteria. Study Design We analyzed rates of primary cesarean deliveries overall and primary cesarean deliveries occurring due to arrest of dilation, arrest of descent, and failed induction among the 17,877 live births at a large academic center from 2010 through 2013. Multiple logistic regression modeling identified predictors of meeting the new criteria for these indications based on guidelines published by the 2012 National Institute of Child Health and Human Development. Results The primary cesarean delivery rate decreased from 23.5 to 21.1% (p = 0.026) from 2010 to 2013. Primary cesarean delivery rate for labor arrest and failed induction decreased from 8.5 to 6.7% (p = 0.005). The percentage of primary cesarean deliveries meeting the 2012 criteria for labor arrest increased from 18.8 to 34.9% (p = 0.002), and the rate of primary cesarean deliveries due to arrest of dilation decreased from 5.1 to 3.4% (p Conclusion A decrease in the primary cesarean rate was attributable to a decrease in cesarean for arrest of dilation in the setting of a significant increase in meeting the 2012 criteria for arrest of dilation. At the end of the study period, 65.2% of cesareans still did not meet the criteria for arrest of dilation. Greater rates of adherence to these guidelines may yield further reductions in the cesarean rate. Key Points

Antenatal corticosteroids, specifically betamethasone, administered to patients at risk for late preterm delivery have been associated with reduced rates of neonatal respiratory complications. However, whether these risks vary by delivery indication among betamethasone-exposed, late-preterm infants is not known.This study aimed to evaluate if spontaneous preterm labor or preterm prelabor rupture of membranes, compared with indicated late preterm delivery, is associated with better neonatal respiratory outcomes after accounting for betamethasone administration in the late preterm period.This was a secondary analysis of the Antenatal Late Preterm Steroids trial, a multicenter, placebo-controlled trial in which patients with singleton pregnancies at risk for delivery at 34 0/7 to 36 5/7 weeks of gestation were randomized to a single course of antenatal corticosteroids (betamethasone) or placebo. Patients were eligible if they had spontaneous preterm labor, preterm prelabor rupture of membranes, or if they were undergoing indicated late preterm delivery. The primary outcome was a composite of need for respiratory support, stillbirth, or neonatal death within 72 hours after delivery. Secondary outcomes included individual neonatal morbidities. Bivariate analyses were performed, and multivariable logistic regression models were used to control for potential confounders. Using the indicated preterm delivery group as the reference group, adjusted odds ratios and 95% confidence intervals were calculated for the outcomes by delivery indication. Subgroup analyses separately examined the treatment and placebo groups to determine the odds of the primary outcome by delivery indication.Of 2827 participants at high risk for late preterm delivery, 1427 (50.5%) received betamethasone. There were 790 (27.9%) infants born after preterm labor, 620 (21.9%) born after preterm prelabor rupture of membranes, and 1417 (50.1%) born after indicated preterm delivery. Compared with indicated preterm delivery, the odds of the primary outcome were lower among those born after preterm labor (7.3% vs 16.4%; adjusted odds ratio, 0.57; 95% confidence interval, 0.40-0.82) and among those born after preterm prelabor rupture of membranes (12.4% vs 16.4%; adjusted odds ratio, 0.49; 95% confidence interval, 0.35-0.69). Preterm labor had lower odds of all neonatal complications except feeding problems, and preterm prelabor rupture of membranes had lower odds of all neonatal complications except newborn intensive care unit admission for ≥3 days when compared with indicated preterm delivery. For the placebo group, the odds of the primary outcome were lower for the preterm labor group (8.2% vs 18.5%; adjusted odds ratio, 0.55; 95% confidence interval, 0.34-0.91) and the preterm prelabor rupture of membranes group (13.2% vs 18.5%; adjusted odds ratio, 0.46; 95% confidence interval, 0.29-0.73) than for the indicated preterm delivery group. For those exposed to betamethasone, the odds of the primary outcome remained lower for the preterm labor group (6.5% vs 14.3%; adjusted odds ratio, 0.58; 95% confidence interval, 0.34-0.99) and the preterm prelabor rupture of membranes group (11.7% vs 14.3%, adjusted odds ratio, 0.56; 95% confidence interval, 0.34-0.91) than for the indicated preterm delivery group.Compared with indicated preterm delivery, preterm labor and preterm prelabor rupture of membranes were associated with reduced odds of neonatal respiratory complications irrespective of betamethasone exposure in the late preterm period.

This quality improvement study describes the results of a mass preprocedure SARS-CoV-2 testing strategy during a period of high community transmission in Connecticut.

Background Hospitals across the country are investing millions of dollars to adopt new Health Insurance Portability and Accountability Act (HIPAA)-compliant secure text messaging systems. However, in nearly all cases, these implementations are occurring without evaluation of their impact on patient care. Objective To evaluate perceived impact on patient care and workflow of new text messaging system implemented in obstetrics at Yale-New Haven Hospital and to inform guidelines for future implementations in emergent settings. Methods A new HIPAA-compliant texting system was implemented in obstetrics in 2016. Before implementation of the new system, residents and nurses were surveyed on perceived effect of communication system (pagers with text receiving, service mobile phones, personal cell phones) on clinical workflow and patient care using 5-point Likert scale and open-ended questions. Following roll-out (1 and 6 months), both teams were surveyed with same questions. Results were compared using Wilcoxon–Mann–Whitney test (0–1 months and then 0–6 months). Open-ended question results were qualitatively compared for recurrent unifying themes. Results In both nursing and resident domains, 1 month after implementation, the new communication system was perceived to significantly improve efficiency and patient care across all metrics. After 6 months, this effect decayed in nearly all categories (including efficiency, real-time communication, and knowledge of covering provider). The exception was nurse's knowledge of which resident to contact and resident's timely evaluation of patient, for which we observed sustained improvements. System shortcomings identified included interrupted connection (i.e., dropped calls), dysfunctional and inaccurate alert system, and unclear identification of the covering provider. Conclusion A new text-messaging–based communication system may improve efficiency and patient care in emergent settings, but system shortcomings can substantially erode potential benefits over time. We recommend implementers evaluate new systems for a set of specific functional requirements to increase probability of sustained improvement and decrease risk of poor patient outcomes.

There is no single framework for a successful obstetric patient safety program. However, there are ample resources for the important components needed to create a patient safety program. All labor and delivery units should formulate their own quality and safety program that is individualized to the patients and staff that they serve. Here we will lay out the infrastructure as has been supported by the literature and reinforced in our experience.

Evaluating trends in indications may identify targets to safely reduce the primary cesarean delivery rate.The purpose of this study was to examine physician-documented indications for cesarean delivery to identify specific factors that contribute to a decreasing cesarean delivery rate.We analyzed rates of primary and repeat cesarean deliveries, which included indications for the procedure, among 22,265 live births at an academic tertiary center from 2009-2013. Time trends for each indication were modeled to estimate the absolute and cumulative annualized relative risk of cesarean delivery by indication over time and the relative contribution of each indication to the overall decrease in primary cesarean delivery rate.From 2009-2013, the cesarean delivery rate decreased from 36.5-31.4%; 74% of the decrease was attributable to a decrease in primary cesarean deliveries, which decreased from 21.7-17.6%. Among documented indications for primary cesarean delivery, labor arrest, abnormal or indeterminate fetal heart rate, and preeclampsia decreased significantly over time (P.001), whereas malpresentation, multiple gestation, maternal-fetal, macrosomia, and other obstetric and elective/maternal requests did not change (P.05). Labor arrest was responsible for the largest proportion of the decrease in the primary cesarean delivery rate (44%), followed by abnormal or indeterminate fetal heart rate (23%) and preeclampsia (13%).Primary cesarean births accounted for 74% of the decreasing cesarean delivery rate. Reductions in the diagnosis of labor arrest and abnormal fetal heart rate led to a decreased cesarean delivery rate at a major academic institution. Contemporaneous changes in definitions of labor arrest and approaches to fetal monitoring that were adopted at our institution may have considerable effect on the cesarean delivery rate.

To examine whether women who varied from recommended gestational weight gain guidelines by the Institute of Medicine (IOM, now known as the National Academy of Medicine) were at increased risk of severe maternal morbidity during delivery hospitalization compared with those whose weight gain remained within guidelines.We conducted a retrospective cohort study using linked 2008-2012 New York City discharge and birth certificate data sets. Cases of severe maternal morbidity were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes based on the Centers for Disease Control and Prevention criteria, which consists of 21 indicators of possible life-threatening diagnoses, life-saving procedures, or death. Multivariable logistic regression was used to evaluate the association between gestational weight gain categories based on prepregnancy body mass index (BMI) and severe maternal morbidity adjusting for maternal demographics and socioeconomic status. The analysis was stratified by prepregnancy BMI categories.During 2008-2012, there were 515,148 term singleton live births in New York City with prepregnancy weight and gestational weight gain information. In 24.8%, 35.1%, 32.1%, and 8.0% of these births, women gained below, within, 1-19 lbs above, and 20 lbs or more above the IOM guidelines, respectively. After adjusting for maternal demographic and socioeconomic characteristics, women who had gestational weight gain 1-19 lbs above (adjusted odds ratio [AOR] 1.08, 95% CI 1.02-1.13) or 20 lbs or more above the IOM recommendations (AOR 1.21, 95% CI 1.12-1.31) had higher odds of overall severe maternal morbidity compared with women who gained within guidelines. Although the increased odds ratios (ORs) were statistically significant, this only resulted in an absolute rate increase of 2.1 and 6 cases of severe maternal morbidity per 1,000 deliveries for those who gained 1-19 and 20 lbs or more above recommendations, respectively. Women with gestational weight gain 20 lbs or more above recommendations had significantly higher ORs of eclampsia, heart failure during a procedure, pulmonary edema or acute heart failure, transfusion, and ventilation.Women whose gestational weight gain is in excess of IOM guidelines are at increased risk of severe maternal morbidity, although their absolute risks remain low.

Mass asymptomatic SARS-CoV-2 nucleic acid amplified testing of healthcare personnel (HCP) was performed at a large tertiary health system. A low period-prevalence of positive HCP was observed. Of those who tested positive, half had mild symptoms in retrospect. HCP with even mild symptoms should be isolated and tested.

Antibiotics for preterm prelabor rupture of membranes (PPROM) have been shown to prolong the length of pregnancy as well as improve neonatal outcomes as demonstrated by the landmark article by Mercer et al. PPROM complicates 3% of all pregnancies, and approximately one-half of patients will deliver within 1 week of membrane rupture. Infection is thought to play a role in both the etiology of PPROM and subsequent maternal and neonatal complications. Premature birth further complicates neonatal outcomes, therefore prolongation of pregnancy after PPROM is essential for risk reduction. Administration of broad spectrum antibiotics have been associated with prolonged latency in women with PPROM at less than 32 weeks and 0 days of gestation as well as improved neonatal outcomes.

The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.

Objective To evaluate relationships between cycle threshold values and COVID-19 presentations and clinical courses in women presenting for childbirth. Cycle threshold values from polymerase chain reaction (PCR) testing are inversely proportional to viral burden and may be important predictors of disease state and infectivity risk. Design Retrospective cohort study Setting Three Yale-New Haven Health Hospitals between 4/2/2020-5/14/2020 Population Women presenting for childbirth who underwent SARS-CoV-2 PCR testing Methods Electronic health records were reviewed for socio-demographics, medical comorbidities, pregnancy and postpartum course, and COVID-19 symptoms and exposures. Records of SARS-CoV-2 positive women were reviewed for symptom onset, duration, and relation to test timing, disease course, and neonatal SARS-CoV-2 results. Main Outcome Measures SARS-CoV-2 real-time PCR cycle threshold values from positive tests were compared between asymptomatic and symptomatic women and in relation to disease severity. In women with symptomatic COVID-19, cycle threshold values were evaluated as a function of time since symptom onset. Results 1,210 women gave birth during the study period with 84 (6.9%) positive for SARS-CoV-2. Higher cycle threshold values were seen in asymptomatic SARS-CoV-2 positive patients (8/38 (21.1%) of asymptomatic women had cycle threshold

Intrahepatic cholestasis of pregnancy is a hepatic disorder characterized by pruritus and an elevation in serum bile acid levels. Although intrahepatic cholestasis of pregnancy poses little risk for women, this condition carries a significant risk for the fetus, including complications such as preterm delivery, meconium-stained amniotic fluid, and stillbirth. The purpose of this Consult is to review the current literature on intrahepatic cholestasis of pregnancy and provide recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend measurement of serum bile acid and liver transaminase levels in patients with suspected intrahepatic cholestasis of pregnancy (GRADE 1B); (2) we recommend that ursodeoxycholic acid be used as the first-line agent for the treatment of maternal symptoms of intrahepatic cholestasis of pregnancy (GRADE 1A); (3) we suggest that patients with a diagnosis of intrahepatic cholestasis of pregnancy begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal fetal testing results or at the time of diagnosis if the diagnosis is made later in gestation (GRADE 2C); (4) we recommend that patients with total bile acid levels of ≥100 μmol/L be offered delivery at 36 0/7 weeks of gestation, given that the risk of stillbirth increases substantially around this gestational age (GRADE 1B); (5) we recommend delivery between 36 0/7 and 39 0/7 weeks of gestation for patients with intrahepatic cholestasis of pregnancy and total bile acid levels of100 μmol/L (GRADE 1C); (6) we recommend administration of antenatal corticosteroids for fetal lung maturity for patients delivering before 37 0/7 weeks of gestation if not previously administered (GRADE 1A); (7) we recommend against preterm delivery at37 weeks of gestation in patients with a clinical diagnosis of intrahepatic cholestasis of pregnancy without laboratory confirmation of elevated bile acid levels (GRADE 1B).

Though much of routine healthcare pauses in a public health emergency, childbirth continues uninterrupted. Crises like COVID-19 put incredible strains on healthcare systems and require strategic planning, flexible adaptability, clear communication, and judicious resource allocation. Experiences from obstetric units affected by COVID-19 highlight the importance of developing new teams and workflows to ensure patient and healthcare worker safety. Additionally, adapting a strategy that combines units and staff from different areas and hospitals can allow for synergistic opportunities to provision care appropriately to manage a structure and workforce at maximum capacity.

Background Older age and medical comorbidities are identified risk factors for developing severe coronavirus disease 2019. However, there are limited data on risk stratification, clinical and laboratory course, and optimal management of coronavirus disease 2019 in pregnancy. Objective Our study aimed to describe the clinical course of coronavirus disease 2019, effect of comorbidities on disease severity, laboratory trends, and pregnancy outcomes of symptomatic and asymptomatic severe acute respiratory syndrome coronavirus 2–positive pregnant women. Study Design This is a case series of pregnant and postpartum women who received positive test results for severe acute respiratory syndrome coronavirus 2 between March 3, 2020, and May 11, 2020, within 3 hospitals of the Yale New Haven Health delivery network. Charts were reviewed for basic sociodemographic and prepregnancy characteristics, coronavirus disease 2019 course, laboratory values, and pregnancy outcomes. Results Of the 1567 tested pregnant and postpartum women between March 3, 2020, and May 11, 2020, 9% (n=141) had a positive severe acute respiratory syndrome coronavirus 2 result. Hispanic women were overrepresented in the severe acute respiratory syndrome coronavirus 2–positive group (n=61; 43.8%). In addition, Hispanic ethnicity was associated with a higher rate of moderate and severe diseases than non-Hispanic (18% [11/61] vs 3.8% [3/78], respectively; odds ratio, 5.5; 95% confidence interval, 1.46–20.7; P=.01). Of note, 44 women (31.2%) were asymptomatic, 37 of whom (26.2%) were diagnosed on universal screening upon admission for delivery. Moreover, 59% (n=83) were diagnosed before delivery, 36% (n=51) upon presentation for childbirth, and 5% (n=7) after delivery. Severe disease was diagnosed in 6 cases (4.3%), and there was 1 maternal death. Obese women were more likely to develop moderate and severe diseases than nonobese women (16.4% [9/55] vs 3.8% [3/79]; odds ratio, 4.96; 95% confidence interval, 1.28–19.25; P=.02). Hypertensive disorders of pregnancy were diagnosed in 22.3% of women (17/77) who delivered after 20 weeks’ gestation. Higher levels of C-reactive protein during antepartum coronavirus disease 2019–related admission were more common in women with worse clinical course; however, this association did not reach statistical significance. Conclusion Coronavirus disease 2019 in pregnancy may result in severe disease and death. Hispanic women were more likely to receive a positive test result for severe acute respiratory syndrome 2 than other ethnic groups. Obesity and Hispanic ethnicity represent risk factors for moderate and severe diseases.

This study describes the prevalence of positive SARS-CoV-2 test results among asymptomatic pregnant women presenting for labor and delivery at Yale New Haven health system hospitals.

BACKGROUND: The effects of the novel coronavirus disease 2019 (COVID-19) in pregnancy remain relatively unknown. We present a case of second trimester pregnancy with symptomatic COVID-19 complicated by severe preeclampsia and placental abruption. METHODS: We analyzed the placenta for the presence of severe acute respiratory syndrome coronavirus 2 (SARS–CoV-2) through molecular and immunohistochemical assays and by and electron microscopy and measured the maternal antibody response in the blood to this infection. RESULTS: SARS–CoV-2 localized predominantly to syncytiotrophoblast cells at the materno-fetal interface of the placenta. Histological examination of the placenta revealed a dense macrophage infiltrate, but no evidence for the vasculopathy typically associated with preeclampsia. CONCLUSION: This case demonstrates SARS–CoV-2 invasion of the placenta, highlighting the potential for severe morbidity among pregnant women with COVID-19. FUNDING: Beatrice Kleinberg Neuwirth Fund and Fast Grant Emergent Ventures funding from the Mercatus Center at George Mason University. The funding bodies did not have roles in the design of the study or data collection, analysis, and interpretation and played no role in writing the manuscript.

INTRODUCTION Decision aids are central to shared decision making and are recommended for value-sensitive pregnancy decisions, such as birth after cesarean. However, effective strategies for widespread decision aid implementation, with interactive web-based platforms, are lacking. This study tested the feasibility and acceptability of implementing a Health Insurance Portability and Accountability Act-secure, web-based decision aid to support shared decision making about birth choices after cesarean, within urban, ethnically diverse outpatient settings. METHODS A before-and-after design was used to assess feasibility and acceptability for decision aid implementation. Measures included women's knowledge, decisional conflict, birth preferences, birth outcomes, decision aid use, decision aid acceptability ratings (content, features, and functions), and views on how the decision aid supported shared decision making. RESULTS Of the 68 women who participated, most were black (46.2%) or Hispanic (35.4%). Their knowledge scores increased by 2.58 points out of 15 (P < .001; d = 0.87), and decisional conflict score reduced by 0.45 points out of 5 points (P < .001; d = 0.69). Forty-four women (65.9%) attempted a vaginal birth after cesarean, of whom 29 (65.7%) succeeded. Women rated decision aid content, features, and functions as good or excellent. Most indicated they would recommend it to others. Health care providers recommended additional strategies to simplify decision aid access and integration into routine care. DISCUSSION Implementing web-based decision aids within ethnically diverse practice settings is potentially feasible and worthwhile. However, strategies are needed to improve women's access and to encourage timely decision aid usage to prepare them for decision discussions with health care providers. Sustained implementation will require seamless integration into clinic workflow, which could include health care provider tools (counselling guides) embedded within the electronic health record, along with continuing education to support and engage health care providers in their use.

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.

OBJECTIVES: We sought to report the frequency of, circumstances surrounding, and outcomes of newborn falls in our hospital. We evaluated the impact of specific interventions on the frequency of newborn falls and the time between falls. METHODS: We performed a retrospective study of newborn falls reported on our postpartum unit over a 13-year period. Demographic information and circumstances of falls were collected via an electronic event reporting system and medical record review. RESULTS: There were 63 633 births and 29 newborn falls, yielding an average of 4.6 falls per 10 000 live births (median: 2 per year; range 0–5 per year). Newborns who sustained a fall were exclusively breastfeeding (75.9%), 24 to 48 hours of age at the time of the fall (58.6%), and had first-time parents (62.1%). At the time of the fall, most newborns were with the mother compared with being with the father or both parents (65.5% vs 34.5%); in the mother’s bed compared with being elsewhere, such as on a couch or chair, with a parent, or in the parent’s arms (62.1% vs 37.9%); and feeding at the time of the fall versus not (79.3% vs 20.7%). All newborns were monitored after the fall, with no adverse outcomes. Despite interventions, we continued to see cases of newborn falls, although the overall trend revealed decreasing falls per 10 000 patient-days and longer time between falls over the study period. CONCLUSIONS: Newborn falls in our hospital are infrequent but continue to occur despite preventive efforts, highlighting the importance of continuous awareness and education.

Preeclampsia is responsible for significant maternal and neonatal morbidity and is associated with a substantial economic burden. Aspirin has been shown to be effective in decreasing the risk of preterm preeclampsia; however, there is no consensus on the target population for aspirin prophylaxis. In May 2018, the Gottesfeld-Hohler Memorial Foundation organized a working group meeting with the goal of identifying the optimal preeclampsia risk-assessment strategy and consequent intervention in the United States. The meeting brought together experts from the leading professional societies. We discussed available literature and trends in preeclampsia risk assessment, current professional guidelines for identifying women at risk for preeclampsia, prophylactic use of aspirin in the United States and Europe, cost-effectiveness data, and feasibility of implementation of different assessment tools and preventive strategies in the United States. We identified specific knowledge gaps and future research directions in preeclampsia risk assessment and prevention that need to be addressed before practice change.

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

Despite our best intentions to improve health when a patient presents for care, adverse events are ubiquitous in medical practice today. Known complications related to the course of a patient's illness or condition or to the characteristics of the treatment have been an openly stated part of taking care of patients for centuries. However, it is only in the past decade that preventable adverse events, instances of harm related to error and deviations in accepted practice have become a primary part of these conversations. Human and system errors are an innate part of working in a complex environment like health care and we are now well aware of this burden in medicine. Now, we are building ways to react to adverse events from error in systematic ways. A systematic approach to identifying and classifying events is a critical part of any safety program, let alone an obstetric safety program. This article reviews the various systems that are used to identify adverse events, in particular sentinel events, state reportable events, and the significant local adverse "trigger" events in obstetrics. These events typically become identified through robust reporting systems where staff can report adverse, near-miss events, or precursor safety events. After events are reported, a system for classifying events, including a structured tracking and reporting system with built in accountability, is necessary. The concept of the "serious safety event," and how these differ from known complications or unpreventable events, and how this is classified are also reviewed.

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.

Background Larger volume Foley catheters are occasionally used for labor induction. In some instances the balloon is overinflated to obtain this volume. Neither the risk or rate of rupture are known for this practice. Objective The purpose of this study was to evaluate the use of overinflated Foley catheter balloons and the rate of rupture in prospective trials and to describe rupture events in our institutions. Study Design Clinical trials and prospective cohorts were identified through a search of MEDLINE from 2000 through May 1, 2017; prospective studies were examined for the use of overinflated Foley catheters. Reports of overinflated balloons were then reviewed in detail to determine if rupture occurred and to record any reported maternal, neonatal, or gynecologic outcomes. Internal reports to the Obstetric Safety Report System were used to describe the local cases at our institutions. Results We reviewed 296 abstracts. Seventeen prospective cohorts or randomized trials used larger balloon volumes (≥50 mL), of which 12 abstracts confirmed routine overinflation of the balloon. Within these studies, 19 patients who underwent cervical ripening with overinflated Foley catheters experienced balloon rupture during use. The incidence of rupture in these studies was 0.9%. No adverse maternal or fetal effects were noted. Internal safety reporting yielded an additional case. One gynecologic case was identified internally. The patient had an overinflated Foley catheter balloon used to tamponade excessive uterine bleeding after uterine evacuation. Balloon rupture was noted, and hysteroscopy was needed to remove fragments of the balloon. Conclusion Overinflation of Foley catheter balloons in obstetric and gynecologic applications may cause rupture. Because of possible underreporting, the extent of complications that may result from balloon rupture is unknown.

Mass asymptomatic SARS-CoV-2 nucleic acid amplified testing of healthcare personnel (HCP) was performed at a large tertiary health system. A low period-prevalence of positive HCP was observed. Of those who tested positive, half had mild symptoms in retrospect. HCP with even mild symptoms should be isolated and tested.

Objectives To determine (1) how often routine screening fetal anatomic sonography fails to completely visualize fetal anatomy; (2) the proportion of women with incomplete ultrasound examinations who are recommended for repeat screening and then undergo repeat sonography; and (3) how often abnormal fetal anatomy is detected on repeat sonography. Methods We conducted a retrospective cohort study at a high-volume academic obstetric ultrasound center. Participants were 16,300 women at 17 through 21 weeks' gestation with a singleton pregnancy presenting for screening anatomic sonography between January 2009 and December 2013. Main outcome measures were (1) incomplete visualization of anatomy at initial screening sonography; (2) among women with incomplete but otherwise normal initial screening ultrasound examinations, recommendation for and performance of repeat sonography; and (3) among women undergoing repeat sonography, discovery of abnormal fetal anatomy within anatomic components that were previously incompletely visualized. Results The mean maternal age ± SD was 30.8 ± 6.3 years, and the mean gestational age was 18.8 ± 1.0 weeks. Among 16,300 initial screening ultrasound examinations, 2157 (13.2%) had incomplete visualization of fetal anatomy. Of those women eligible for follow-up, 91.5% were recommended for repeat screening, of whom 92.8% had a subsequent examination. Of 1560 repeat screening ultrasound examinations, 8 (0.5%) showed an abnormality in the components of anatomy that were previously visualized incompletely. Conclusions In this large single-center study, incomplete visualization was common in screening fetal anatomic ultrasound examinations. Recommendations for repeat imaging were nearly universal, but abnormal fetal anatomy was infrequently discovered on repeat screening.

OBJECTIVES Complete and accurate documentation by the delivering provider in cases of shoulder dystocia is critical for providing clinical information and care to the patient and protecting providers from litigation risks. Standardized forms improve inclusion of certain data elements in the medical record, but the impact on subsequent narrative notes is unknown. We aimed to determine if implementation of a standardized shoulder dystocia documentation form improves obstetric provider written narrative delivery notes. METHODS In February 2005, our institution introduced a mandatory, standardized shoulder dystocia form containing 29 discrete data points relevant to shoulder dystocia documentation. We identified all deliveries complicated by shoulder dystocia from 1 year before and 4 years after implementation of this form and analyzed medical records for inclusion of delivery information in both the required form and the narrative delivery notes. RESULTS We identified 52 cases before and 100 cases after implementation of the standardized form. Inclusion of elements from the form in narrative delivery notes increased significantly after implementation (P = 0.01). Elements present at higher rates included prepregnancy maternal weight (13% before vs 28% after, P = 0.043), total maternal weight gain (19% vs 36%, P = 0.03), estimated fetal weight (60% vs 77%, P = 0.03), duration of active labor (40% vs 65%, P < 0.01), duration of second stage (27% vs 52%, P < 0.01), and time of delivery from head to body (4% vs 30%, P < 0.01). CONCLUSIONS Use of a mandatory shoulder dystocia documentation form is associated with significant improvement in the comprehensiveness of delivering provider narrative notes and may encourage more complete and accurate charting. Such improvements can allow for more complete and accurate explanation of events to patients and better demonstrate adherence to standards of care in the management of shoulder dystocia and may improve litigation defensibility.

Trial of labor after cesarean delivery is an effective and safe option for women without contraindications.The objective of the study was to examine hospital variation in utilization and success of trial of labor after cesarean delivery and identify associated institutional characteristics and patient outcomes.Using linked maternal and newborn hospital discharge records and birth certificate data in 2010-2012 from the state of California, we identified 146,185 term singleton mothers with 1 prior cesarean delivery and no congenital anomalies or clear contraindications for trial of labor at 249 hospitals. Risk-standardized utilization and success rates of trial of labor after cesarean delivery were estimated for each hospital after accounting for differences in patient case mix. Risk for severe maternal and newborn morbidities, as well as maternal and newborn length of stay, were compared between hospitals with high utilization and high success rates of trial of labor after cesarean delivery and other hospitals. Bivariate analysis was also conducted to examine the association of various institutional characteristics with hospitals' utilization and success rates of trial of labor after cesarean delivery.In the overall sample, 12.5% of women delivered vaginally. After adjusting for patient clinical risk factors, utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals, with a median of 35.2% (10th to 90th percentile range: 10.2-67.1%) and 40.5% (10th to 90th percentile range: 8.5-81.1%), respectively. Risk-standardized utilization and success rates of trial of labor after cesarean delivery demonstrated an inverted U-shaped relationship such that low or excessively high use of trial of labor after cesarean delivery was associated with lower success rate. Compared with other births, those delivered at hospitals with above-the-median utilization and success rates of trial of labor after cesarean delivery had a higher risk for uterine rupture (adjusted risk ratio, 2.74, P.001), severe newborn respiratory complications (adjusted risk ratio, 1.46, P.001), and severe newborn neurological complications/trauma (adjusted risk ratio, 2.48, P.001), but they had a lower risk for severe newborn infection (adjusted risk ratio, 0.80, P = .003) and overall severe unexpected newborn complications (adjusted risk ratio, 0.86, P.001) as well as shorter length of stays (adjusted mean ratio, 0.948 for mothers and 0.924 for newborns, P.001 for both). Teaching status, system affiliation, larger volume, higher neonatal care capacity, anesthesia availability, higher proportion of midwife-attended births, and lower proportion of Medicaid or uninsured patients were positively associated with both utilization and success of trial of labor after cesarean delivery. However, rural location and higher local malpractice insurance premium were negatively associated with the utilization of trial of labor after cesarean delivery, whereas for-profit ownership was associated with lower success rate.Utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals. Strategies to promote vaginal birth should be tailored to hospital needs and characteristics (eg, increase availability of trial of labor after cesarean delivery at hospitals with low utilization rates while being more selective at hospitals with high utilization rates, and targeted support for lower capacity hospitals).

OBJECTIVE: To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices. METHODS: Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. Association between institutional characteristics and adoption of evidence-supported practices (i.e., those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests. RESULTS: Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private non-profit hospitals were more likely to have written protocol for management of abnormal fetal heart rate (p=0.002). One in ten hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, while only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3% and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, and postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (p≤0.04 for all); while larger volume was associated with more frequent simulations for eclampsia (p=0.04). CONCLUSION: Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.