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Uterine and abdominal muscle contractility are important in the control of labor and birth. The diagnosis of labor onset has been described as one of the most crucial and important judgments for effective management and successful outcome of pregnancy. Regular uterine contractions and cervical dilatation are the most common indicators of the onset and progress of labor. Better identification of onset of labor could contribute to the diagnosis of true labor. This could potentially improve the assessment of abnormalities, lead to enhanced quality of care, more accurate identification of risk groups, better counseling of patients, individualized management, and timely interventions. Electrical activity of uterine and abdominal muscles regulates contractility; therefore, measurement of electrical activity is key to understanding the stages of labor. Electrical activity of muscles can be measured by electromyography (EMG), which for recordings of uterine activity is also often referred to as electrohystography (EHG). In this brief review we summarize recent EMG studies of uterine and abdominal electrical activity, their relationship to cervical dilation and describe the importance of these events to the diagnosis for the onset and progress of labor.

BACKGROUND The coronavirus disease 2019 pandemic has exposed disproportionate health inequities among underserved populations, including refugees. Public safety net healthcare systems play a critical role in facilitating access to care for refugees and informing coordinated public health prevention and mitigation efforts during a pandemic. OBJECTIVE This study aimed to evaluate the prevalence ratios of severe acute respiratory syndrome coronavirus 2 infection between refugee women and nonrefugee parturient patients admitted to the hospital for delivery. Here, we suspected that the burden of infection was disproportionately distributed across refugee communities that may act as sentinels for community outbreaks. STUDY DESIGN A cross-sectional study was conducted examining parturient women admitted to the maternity unit between May 6, 2020, and July 22, 2020, when universal testing for severe acute respiratory syndrome coronavirus 2 was first employed. Risk factors for severe acute respiratory syndrome 2 positivity were ascertained, disaggregated by refugee status, and other clinical and sociodemographic variables examined. Prevalence ratios were calculated and comparisons made to county-level community prevalence over the same period. RESULTS The positive test percentage at the county-level during this study period was 21.6%. Of 350 women admitted to the hospital for delivery, 33 (9.4%) tested positive for severe acute respiratory syndrome 2. When refugee status was determined, 45 women (12.8%) were identified as refugees. Of the 45 refugee women, 8 (17.8%) tested positive for severe acute respiratory syndrome 2 compared with 25 nonrefugee patients (8.19%) who tested positive for severe acute respiratory syndrome 2 (prevalence ratio, 2.16; 95% confidence interval, 1.04–4.51). In addition, 7 of the refugee women who tested positive for severe acute respiratory syndrome coronavirus 2 were from Central Africa. CONCLUSION The severe acute respiratory syndrome coronavirus 2 outbreak has disproportionately affected refugee populations. This study highlighted the utility of universal screening in mounting a rapid response to an evolving pandemic and how we can better serve refugee communities. Focused response may help achieve more equitable care related to severe acute respiratory syndrome 2 among vulnerable communities. The identification of such populations may help mitigate the spread of the disease and facilitate a timely, culturally, and linguistically enhanced public health response.

Perinatal omphalocele rupture is a rare occurrence. We present a case of a baby delivered at 35 weeks with a known giant omphalocele, transverse lie, and the omphalocele downward in the birth canal who suffered rupture of the omphalocele and liver injury around the time of delivery. The pregnancy was complicated by one day of preterm labor, preterm premature rupture of the membranes, and the omphalocele was the presenting part. Despite pulmonary hypertension, rupture of the omphalocele, and a significant liver injury, individualized management with decompression of the liver hematoma allowed successful early closure with mesh followed by delayed reconstruction.

Pseudolabor has been reported in a handful of cases over the past 20 years and has been proposed as a subtype of conversion disorder. Pseudolabor is not well understood and remains a challenge for obstetrical providers to diagnose early enough so as to prevent unnecessary use of tocolytics and other unnecessary care for preterm labor. Contraction patterns observed in pseudolabor patients have classically been described with 2 different morphologies, both caused by prolonged abdominal skeletal muscle contraction. One morphology is described as “spiked,” abrupt in onset, and abrupt in descent. The second is described as an abrupt onset, plateau or flattop phase, followed by an abrupt descent. Here we describe a case of a 30-yearold woman who presented with signs suspicious for pseudolabor whose contraction patterns were convincing for uterine smooth muscle contractions. In this case, real-time ultrasound was used to demonstrate that the uterus was not contracting, thus confirming a diagnosis of pseudolabor.

Background: Management of rhinosinusitis during pregnancy requires special considerations. Objectives: 1. Conduct a systematic literature review for acute and chronic rhinosinusitis (CRS) management during pregnancy. 2. Make evidence-based recommendations. Methods: The systematic review was conducted using MEDLINE and EMBASE databases and relevant search terms. Title, abstract and full manuscript review were conducted by two authors independently. A multispecialty panel with expertise in management of Rhinological disorders, Allergy-Immunology, and Obstetrics-Gynecology was invited to review the systematic review. Recommendations were sought on use of following for CRS management during pregnancy: oral corticosteroids; antibiotics; leukotrienes; topical corticosteroid spray/irrigations/drops; aspirin desensitization; elective surgery for CRS with polyps prior to planned pregnancy; vaginal birth versus planned Caesarian for skull base erosions/ prior CSF rhinorrhea. Results: Eighty-eight manuscripts underwent full review after screening 3052 abstracts. No relevant level 1, 2, or 3 studies were found. Expert panel recommendations for rhinosinusitis management during pregnancy included continuing nasal corticosteroid sprays for CRS maintenance, using pregnancy-safe antibiotics for acute rhinosinusitis and CRS exacerbations, and discontinuing aspirin desensitization for aspirin exacerbated respiratory disease. The manuscript presents detailed recommendations. Conclusions: The lack of evidence pertinent to managing rhinosinusitis during pregnancy warrants future trials. Expert recommendations constitute the current best available evidence.

Progesterone (P4) and nitric oxide (NO) suppress uterine contractility (CTX). This study compares the effects of P4 to sodium nitroprusside (SNP, an NO donor) and their combination on human CTX of term/preterm and labor/nonlabor tissues. Uterine tissues (n = 128) from women (n = 28) undergoing Cesarean were suspended in organ baths. Tissues (n ≥ 6/group) were treated with vehicle, P4, SNP, or combinations. A subset of tissues (n ≥ 2/group) from term/preterm ± labor and nonpregnant patients was analyzed with P4 alone. Analysis of variance (ANOVA) was used for statistical differences (P < .05). The combination of P4 with SNP significantly suppresses CTX (% inhibition of −127.1 ± 14.5) to the levels lower than with either P4 (−20.1 ± 8.6) or SNP alone (−72.0 ± 11.2). Suppression of P4 is similar in term, preterm, and nonpregnant tissues, with increased sensitivity in laboring tissues. This indicates that P4 or SNP alone may be used for preterm labor and their combination may be more successful.

Progestin supplementation appears to be a promising approach to both preventing initiation of preterm labor and treating it once it is already established, given the role of progesterone in maintaining pregnancy, as well as support from basic and clinical research. Progesterone and 17α-hydroxyprogesterone acetate slow the process of cervical ripening, and this is the rationale for prophylactic long-term progestin supplementation mostly studied so far. However, progesterone (but not 17α-hydroxyprogesterone acetate) also inhibits myometrial activity even after the cervix has already ripened. Moreover, these effects depend greatly on the vehicle used and the route of administration. Understanding different mechanisms of action, as well as the importance of progestin formulation, vehicle and route of administration, is the key to finding the optimal progestin treatment for prevention of preterm birth.

Current methodologies to assess the process of labor, such as tocodynamometry or intrauterine pressure catheters, fetal fibronectin, cervical length measurement and digital cervical examination, have several major drawbacks. They only measure the onset of labor indirectly and do not detect cellular changes characteristic of true labor. Consequently, their predictive values for term or preterm delivery are poor. Uterine contractions are a result of the electrical activity within the myometrium. Measurement of uterine electromyography (EMG) has been shown to detect contractions as accurately as the currently used methods. In addition, changes in cell excitability and coupling required for effective contractions that lead to delivery are reflected in changes of several EMG parameters. Use of uterine EMG can help to identify patients in true labor better than any other method presently employed in the clinic.

Objective The purpose of this study was to determine if cesarean delivery is a risk factor for respiratory distress syndrome (RDS) and if this risk is modified by labor before cesarean. Study design This population-based case-control study compared 4778 cases of RDS to 5 times as many controls. Results Unadjusted, cesarean delivery was associated with RDS, odds ratio (OR) 3.5 (95% CI 3.2–3.8). After controlling for potential confounding variables, cesarean remained an independent risk factor, OR 2.3 (95% CI 2.1–2.6). Labor modified this risk significantly ( P =.02)—with labor, cesarean delivery had an OR of 1.9 (95% CI 2.2–2.9), without labor, the OR was 2.6 (95% CI 1.3–2.8). Conclusion Cesarean delivery was an independent risk factor for RDS. The risk was reduced with labor before cesarean, but still elevated. This supports the importance of being certain of fetal lung maturity before cesarean delivery, particularly when done before labor.

Objective Cervical length (CL) of 3 cm or greater has been shown to have a 97-99% negative predictive value for preterm delivery in women with threatened preterm labor. Consequently, hospitalization and treatment are not indicated in these patients. We analyzed how often patients with a CL of 3 cm or greater are still being admitted and treated for preterm labor and how much this contributes to the economic burden of preterm labor hospitalizations. Study Design Twelve month hospitalizations for preterm labor at less than 34 weeks at a single institution were reviewed and patients with a CL of 3 cm or greater were identified. We chose to use patients' hospital charges as a surrogate for health care costs, recognizing that charges are not synonymous with the final patient bill and also do not reflect additional costs such as the cost of treatment at the referring facility, transportation, physician fees, and other such costs as lost wages, need for additional child care, etc. Results Between July 2009 and June 2010, 139 patients were admitted and treated for preterm labor at our level III center. Fifty of these patients (36%) had a CL of 3 cm or greater. None of them delivered preterm. Total hospital charges for the management of these patients were $1,018 589 (mean, $20,372; median, $14,444). Conclusion Unnecessary admissions and treatments for threatened preterm labor are part of clinical practice and contribute to exploding health care costs. Using currently available diagnostics, these costs could be lowered significantly without jeopardizing outcome.

Domestic violence is the most common cause of injury to women. Obstetrician-gynecologists, who most women consider their primary care physicians, have a unique role in identifying battered women. This study was designed to assess the extent and nature of current training curricula regarding domestic violence education in obstetrics and gynecology residencies.A survey sent to all obstetrics and gynecology residencies requested demographic data, the curriculum in respect to domestic violence, availability of interested faculty, the prevalence of battering among patients, satisfaction with the current teaching, and knowledge of pending legislation. Respondents were also asked which of 10 common clinical presentations would prompt their faculty to discuss the possibility the patient was being battered.Eighty-three percent of programs responded. The "typical" program was urban, had five residents per year, and had faculties of full-time academicians and part-time private practitioners. Twenty-eight percent reported having at least one faculty member with expertise in domestic violence. One third reported a prevalence of battering ofor = 1% with 6% estimating fewer than 1 in 1000. Seventy-five percent did not recognize at least one clinical scenario as suggestive of battering. The majority were dissatisfied with their teaching and wanted help in curriculum development. Forty percent were unaware of pending legislation linking federal support of medical education to including domestic violence in curricula.The results of this survey highlight deficiencies in the education of obstetrics and gynecology residents about domestic violence. Programs report limited faculty interest, underestimate prevalence, fail to recognize common presentations, and are dissatisfied with their current curriculum. We are not preparing obstetrics and gynecology residents to care for patients with a common problem--domestic violence.In the US, domestic violence is the most common cause of injury to women, and, because they are women's primary care physicians, obstetrician-gynecologists (OB-GYNs) are in a position to identify battered women. With legislation pending that would require federally-funded medical education to include domestic violence in its curriculum, a survey was conducted of all OB-GYN residencies to determine their current status in the provision of domestic violence education. With 83% of the programs responding (n = 264), it was found that 28% had at least one faculty member with expertise in domestic violence, that the incidence of domestic violence among clients was underestimated, and that 75% of respondents did not recognize at least 1 of the 10 common clinical scenarios as suggestive of battering (at least 44% failed to recognize the risk factors of no prenatal care, preterm labor, emergency room visits, and psychiatric diagnoses). Only 28% of respondents reported that they teach residents to ask all or almost all patients about battering. Most respondents expressed dissatisfaction with their coverage of this topic and asked for help in curriculum development. In addition, 40% were unaware of the pending federal legislation. This study concluded that there is a strong need to develop an OB-GYN curriculum that deals with domestic violence but that further study is needed to determine the optimal teaching methods.

Progestin supplementation appears to be a promising approach to both preventing initiation of preterm labor and treating it once it is already established, given the role of progesterone in maintaining pregnancy, as well as support from basic and clinical research. Progesterone and 17α-hydroxyprogesterone acetate slow the process of cervical ripening, and this is the rationale for prophylactic long-term progestin supplementation mostly studied so far. However, progesterone (but not 17α-hydroxyprogesterone acetate) also inhibits myometrial activity even after the cervix has already ripened. Moreover, these effects depend greatly on the vehicle used and the route of administration. Understanding different mechanisms of action, as well as the importance of progestin formulation, vehicle and route of administration, is the key to finding the optimal progestin treatment for prevention of preterm birth.

Power spectrum (PS) of uterine electromyography (EMG) can identify true labor. EMG propagation velocity (PV) to diagnose labor has not been reported. The objective was to compare uterine EMG against current methods to predict preterm delivery.EMG was recorded in 116 patients (preterm labor, n = 20; preterm nonlabor, n = 68; term labor, n = 22; term nonlabor, n = 6). A Student t test was used to compare EMG values for labor vs nonlabor (P.05, significant). Predictive values of EMG, Bishop score, contractions on tocogram, and transvaginal cervical length were calculated using receiver-operator characteristics analysis.PV was higher in preterm and term labor compared with nonlabor (P.001). Combined PV and PS peak frequency predicted preterm delivery within 7 days with area under the curve (AUC) of 0.96. Bishop score, contractions, and cervical length had an AUC of 0.72, 0.67, and 0.54.Uterine EMG PV and PS peak frequency more accurately identify true preterm labor than clinical methods.

PURPOSE To test an educational intervention regarding domestic violence. METHOD Residents beginning their training in 1995 or 1996 were randomly assigned to attend, at their hospital orientation, either a 20-minute session emphasizing the importance of screening for domestic violence or a session on an unrelated topic. RESULTS Seventy-one percent of the residents in the experimental group diagnosed domestic violence; 52% in the control did so (RR, 1.35; 95% CI, 0.96-1.90; p = .07) in the nine to 12 months following the intervention. Rates of diagnosis differed by specialty (p < .01): 100% family practice, 90% emergency medicine, 80% obstetrics-gynecology, 63% pediatrics, 47% internal medicine, 0% surgery. Change in knowledge was assessed in 1996; significant improvement was noted (p = .002). CONCLUSION An intervention about domestic violence conducted at orientation for residents improved the rate of diagnosis of domestic violence. While the improvement was not statistically significant in this case, the intervention was brief and harmless. Other institutions should consider this kind of brief intervention.

Intimate partner violence (IPV) is a common occurrence in pregnancy and results in an increased risk of adverse outcomes. Homicide may be the most common cause of maternal death. Women who are pregnant and the victims of IPV have high rates of stress, are more likely to smoke or use other drugs, deliver a preterm or low birth weight infant, have an increase in infectious complications, and are less likely to obtain prenatal care. The IPV continues in the postpartum period. Adolescents may be at even higher risk than their adult counterparts. Children raised in violent homes have both immediate and life long adverse health outcomes as a result of their exposure to IPV. IPV adds substantially to healthcare costs both for direct services to treat the injuries and higher utilization of a wide range of healthcare services. Healthcare providers, particularly those who care for pregnant women, are in a unique position to identify these women and direct them and their families to the help they need to end the violence in their lives.

Progestin supplementation appears to be a promising approach to both preventing initiation of preterm labor and treating it once it is already established, given the role of progesterone in maintaining pregnancy, as well as support from basic and clinical research. Progesterone and 17α-hydroxyprogesterone acetate slow the process of cervical ripening, and this is the rationale for prophylactic long-term progestin supplementation mostly studied so far. However, progesterone (but not 17α-hydroxyprogesterone acetate) also inhibits myometrial activity even after the cervix has already ripened. Moreover, these effects depend greatly on the vehicle used and the route of administration. Understanding different mechanisms of action, as well as the importance of progestin formulation, vehicle and route of administration, is the key to finding the optimal progestin treatment for prevention of preterm birth.

Objective To compare the estimated date of confinement of paper gestational wheels to the estimated date of confinement of APPs wheels using a standard last menstrual period. Methods Obstetric providers were asked for their gestational wheels. The last menstrual period was set at Jan. 1, 2013, and the estimated date of confinement obtained was compared with the estimated date of confinement of Oct. 8th if the pregnancy completed 280 days. The process was performed on 20 electronic APPs downloadable to cell phones. The process was repeated for both for the leap year of 2012. Results Thirty-one paper wheels from a variety of sources were collected. Ten wheels (35%) were consistent with the standard pregnancy duration of 280 days. Among the wheels surveyed, the largest discrepancy was 4 days short of 280 days. Two wheels gave an estimated date of confinement that differed from each other by 7 days. Wheels from the same source did not agree with each other. Twenty electronic gestational age calculators were examined. All 20 gave an estimated date of confinement of Oct. 8 consistent with 280 days. None of the paper gestational wheels but all of the APPs corrected for a leap year. Conclusion In contrast to APPs gestational age calculators, the estimated date of confinement of the majority of paper wheels deviated from the standard pregnancy duration of 280 days. Precision in gestational age assessment is critical in a variety of clinical settings and heightened by the focus by payers and reporting agencies on elective deliveries before 39 weeks. The use of paper gestational age wheels should be abandoned.