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The processes of diagnosis and management involve clinical decision-making. However, decision-making is often affected by cognitive biases that can lead to medical errors. This statement presents a framework of clinical thinking and decision-making and shows how these processes can be bias-prone. We review examples of cognitive bias in obstetrics and introduce debiasing tools and strategies. When an adverse event or near miss is reviewed, the concept of a cognitive autopsy-a root cause analysis of medical decision-making and the potential influence of cognitive biases-is promoted as part of the review process. Finally, areas for future research on cognitive bias in obstetrics are suggested.

Objective We aimed to describe hemoglobin (Hb) change after transfusion in the nonacute postpartum anemic population in order to provide clinicians with appropriate expectations regarding Hb rise posttransfusion. Study Design We performed a secondary analysis of a randomized controlled trial comparing initial transfusion with 1 unit of packed red blood cells (pRBCs) to 2 units pRBCs for postpartum women requiring nonacute transfusion (n = 66). Inclusion criteria were: age 18 years and older, Hb level either 7 g/dL with signs or symptoms of anemia, and > 6 hours postpartum without contraindication to transfusion. Hb assessment was performed 4 to 6 hours after initial transfusion. Hb change (ΔHb) was calculated as posttransfusion Hb minus randomization Hb. Our primary goal was to describe mean ΔHb per pRBC transfused at the 4- to 6-hour posttransfusion blood count. We also compared ΔHb per pRBC transfused by number of units transfused, body mass index (BMI), and symptoms (dizziness and/or fatigue) at time of posttransfusion assessment. Results Participants were mean age 29, mean BMI of 27, and over 70% self-identified as black, 12% identified as white, and 9% as Asian race. Mean Hb prior to transfusion was 6.9 ± 0.6 g/dL. Mean ΔHb per pRBC transfused was 0.9 ± 0.4g/dL. There was no difference in ΔHb per pRBC by BMI category (normal weight Conclusion Our data supports the classically accepted rise in Hb after pRBC of approximately 1 g/dL, regardless of BMI category or anemia symptomatology. The study population includes patients at highest risk of postpartum anemia. The results of our study provide important information for clinicians caring for postpartum patients with nonacute anemia. Key Points

Background: Maternal health outcomes in the United States are far worse than peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted care variations. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the United States. Methods:This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. Through two sequential web-based surveys, participants submitted and ranked implementation research topics with five areas specific to implementation research: practices to prioritize for (1) broader implementation or (2) de-implementation, and research questions about (3) determinants of implementation, (4) implementation strategies, and (5) research methods/measures. Results:Eighty-two researchers, predominantly female (90%) and white (75%), volunteered to participate. Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research. Conclusions: Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the maternity care quality in the United States. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.

Objective Our objective was to determine whether resolution of a low-lying placenta or placenta previa is associated with postpartum hemorrhage (PPH). Study Design This is a retrospective, matched-control cohort study of women who underwent transvaginal sonography during fetal anatomic survey between 18 and 24 weeks of gestation at the University of Pennsylvania from January 2017 to May 2019. Exposure was defined as low-lying placenta (≤1 cm from the internal cervical os) or placenta previa (covering the os) at anatomic survey that was found to be resolved by transvaginal ultrasound in the third trimester. For each exposure, we identified a control patient whose placenta was > 1 cm from internal os at anatomic survey performed on the same day. The primary outcome was PPH at delivery, defined as estimated blood loss ≥ 1,000 mL. Results A total of 450 women were included (225/group). The exposed group of resolved placental previa included 85.0% with resolved low-lying placenta and 15.0% with resolved previa. The rate of PPH was significantly higher in the exposed group versus controls (9.8% vs. 4.4%, p = 0.03). Women with resolved previa were 2.5 times more likely to experience PPH than controls (adjusted odds ratio = 2.58, 95% confidence interval: 1.17–5.69), even when controlling for parity, prior cesarean, and delivery mode. Women with resolved previa were also more likely to present to triage with bleeding (16.4% vs. 8.0%, p = 0.006), receive antenatal corticosteroids, (9.3% vs. 3.1%, p = 0.006), and receive intravenous iron postpartum (7.6% vs. 3.1%, p = 0.04). Conclusion Our data demonstrate that women with a resolved low-lying placenta or placenta previa remain at significantly increased risk of bleeding-related complications in pregnancy and during delivery when compared with those who never had a previa. Clinicians should consider this association when counseling patients and performing hemorrhage risk stratification. Key Points

Objectives While bilateral tubal ligation has historically been performed for sterilization at cesarean delivery (CD), recent data supports the use and safety of opportunistic bilateral salpingectomy during CD to decrease lifetime ovarian cancer risk. Prior studies have described racial disparities in sterilization rates, but there is a paucity of data regarding racial disparities in type of sterilization procedure. Our objective was to determine differences in sterilization procedure type performed at CD by race (Black vs. non-Black) to evaluate for equity in bilateral salpingectomy utilization. Study Design We performed a retrospective cohort study of patients included in the American College of Surgeons National Surgical Quality Improvement Program database who underwent sterilization at time of CD from January 2019, to December 2020, identified using Current Procedural Terminology codes. Patients without documented race were excluded. Multivariable logistic regression was used to determine odds of undergoing bilateral salpingectomy compared with bilateral tubal ligation by race while controlling for confounders. Results Of 28,147 patients who underwent CD, 3,087 underwent concurrent sterilization procedure, and 2,161 met inclusion criteria (Black: n = 279; non-Black: n = 1,882). Black patients were significantly more likely to have hypertension (10.8% vs. 5.3%, p Conclusion Despite evidence that bilateral salpingectomy decreases ovarian cancer risk and is safe at CD, there is a racial disparity in bilateral salpingectomy utilization. While the cause of this disparity is unclear, further research is warranted to determine root causes and equitable solutions. Key Points

Objective We aimed to determine the risk of cesarean among women with obesity undergoing labor induction within a prospective trial that utilized a standardized labor protocol. Study Design This was a secondary analysis of a randomized trial of induction methods. Term (≥37 weeks) women with intact membranes undergoing induction with an unfavorable cervix (Bishop's score ≤6 and dilation ≤2 cm) were included. The trial utilized a labor protocol that standardized induction and active labor management, with recommendations for interventions at particular time points. Only women with a recorded body mass index (BMI) at prenatal care start were included in this analysis. The primary outcome was cesarean delivery compared between obese (≥30 kg/m2) and nonobese ( Results A total of 465 women were included: 207 (44.5%) obese and 258 (55.5%) nonobese. Women with obesity had a higher risk of cesarean compared with women without obesity (33.3 vs. 23.3%, p = 0.02), even when adjusting for parity, weight change over pregnancy, and indication for induction (adjusted relative risk [aRR] = 1.79, 95% confidence interval [CI]: [1.34–2.39]). Compared with women without obesity, women with obesity had a higher risk of failed induction (47.8 vs. 26.7%, p = 0.01) without a difference in arrest of active phase (p = 0.39), arrest of descent (p = 0.95) or fetal indication (p = 0.32), despite adherence to a standardized labor protocol. Conclusion Compared with women without obesity, women with obesity undergoing an induction are at increased risk of cesarean, in particular a failed induction, even within the context of standardized induction management. As standardized practices limit provider variation in labor management, this study may support physiologic differences in labor processes secondary to obesity. Key Points

Objective This study aimed to evaluate the effect of a physician-created educational infographic on the knowledge and attitudes of patients undergoing antenatal fetal surveillance. Study Design This single-center prospective cohort study evaluated the impact of implementing an electronic educational infographic about antenatal fetal surveillance. English-speaking women receiving antenatal surveillance between the ages of 18 to 50 years were approached for inclusion. The preimplementation group enrolled women receiving antenatal surveillance between March 8, 2021, and April 2, 2021, who received usual care. Postimplementation, from April 5 to May 6, 2021, patients at our site received the infographic about antenatal fetal surveillance at their first antenatal testing appointment. Both pre- and postimplementation groups received a 5-question multiple-choice knowledge and 12-question attitude survey between 320/7 to 336/7 weeks at baseline (prior to receipt of infographic in postimplementation group) and again between 350/7 to 366/7 weeks. Patients were included in the analysis only if they completed both surveys. Differences from initial to final survey were compared between groups. Results Of 106 patients who completed the initial survey, 74 (69.8%) participants finished both surveys (preimplementation = 39 and postimplementation = 35). There were no significant differences in demographics between the two groups, including in baseline knowledge (p = 0.58) or attitude tests (p = 0.57). There was no significant difference in knowledge on final surveys between groups (p = 0.79). However, utilization of the infographic was associated with a significant increase in attitude survey score from initial to final survey in the postimplementation group as compared with usual care (median difference: pre = 0, interquartile rang [IQR]: [−1 to +4] vs. post = +3, IQR: [+1 to +6], p = 0.016). Conclusion A physician-created infographic on antepartum fetal testing was associated with overall improved patient attitude toward fetal testing, showing that small education interventions can increase patient satisfaction with care. Key Points

OBJECTIVE: Standardized labor induction protocols utilizing evidence-based active management practices are associated with improved obstetric outcomes. However, these protocols are complex and include multiple components. We aimed to identify which of the individual components of an evidence-based labor induction protocol are most associated with reduced rates of cesarean delivery, maternal morbidity, and neonatal morbidity. STUDY DESIGN: This is a secondary analysis of a randomized trial comparing time to delivery among four labor induction methods. All patients enrolled in the trial had their labor managed with a multidisciplinary-developed, evidence-based standardized labor induction protocol. For each patient’s induction, we assessed adherence to seven components of the protocol. Primary outcomes included cesarean delivery, maternal morbidity, and neonatal morbidity. Bivariate analyses assessed the association of each protocol component with each outcome. Multivariable logistic regression determined independent predictors of each outcome. RESULTS: The 491 patients enrolled in the randomized trial were included in this analysis. For cesarean delivery, while adherence to four of the seven protocol components was associated with the outcome in bivariate analyses, only adherence to “cervical exams should be performed every 1–2 h in active labor” was associated with reduced cesarean rates when controlling for age, body mass index, and parity. For maternal morbidity, while adherence to “if misoprostol is utilized, it should not be continued beyond 6 doses or 24 h of use” was associated in bivariate analysis, it was no longer associated with the outcome in multivariable analysis. Finally, “cervical exams should be performed every 1–2 h in active labor” and “cervical exams should be performed every 2–4 h in latent labor” were associated with reduced neonatal morbidity both in bivariate analyses as well as when controlling for age, body mass index, and parity. CONCLUSIONS: Within a standardized labor induction protocol, adherence to cervical exams every 1–2 h in active labor was associated with reduced cesarean rate, and adherence to cervical exams every 2–4 h in latent labor, as well as every 1–2 h in active labor is associated with reduced neonatal morbidity. Regular cervical examination during labor induction likely allows for intervention when cervical change is not made. This data warrants further investigation into the optimal frequency of cervical exams during labor induction. Furthermore, an understanding of which components of a complex, evidence-based labor induction protocol are most effective may be helpful for streamlining and education around this protocol as implementation occurs across diverse sites.

Hospital labor and delivery floors frequently operate like intensive care units (ICUs)-with continuous data feeds pouring into central monitoring stations against a background of blaring alarms. Yet the majority of obstetric patients are healthy and do not require ICU-level care. Despite limited organizational recommendations guiding the frequency of vital sign measurement, continuous pulse oximetry is used widely for laboring patients. There is also no evidence that morbidity prevention is linked to specific frequencies of vital sign monitoring in low-risk patients. In fact, studies examining the performance of maternal early warnings systems based on vital signs suggest that these may not reliably provide actionable information regarding maternal physiologic status. Furthermore, it is very possible that intrapartum maternal overmonitoring can impact care negatively by generating alarm fatigue, causing providers to miss actual abnormal vital signs that may precede morbidity. KEY POINTS: · Labor and delivery units may engage in maternal physiologic overmonitoring.. · Overmonitoring increases risk for alarm fatigue.. · Deimplementing low-value care may improve obstetric outcomes..

Objective Our prior work demonstrated decreased birth satisfaction for Black women undergoing labor induction. We aimed to determine if implementation of standardized counseling around calculated cesarean risk during labor induction could reduce racial disparities in birth satisfaction. Study Design We implemented use of a validated calculator that provides an individual cesarean risk score for women undergoing induction into routine care. This prospective cohort study compared satisfaction surveys for 6 months prior to implementation (preperiod: January 2018–June 2018) to 1 year after (postperiod: July 2018–June 2019). Women with full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix undergoing induction were included. In the postperiod, providers counseled patients on individual cesarean risk at the beginning of induction using standardized scripts. This information was incorporated into care at patient–provider discretion. The validated 10-question Birth Satisfaction Scale-Revised (BSS-R) subdivided into three domains was administered throughout the study. Patients were determined to be “satisfied” or “unsatisfied” if total BSS-R score was above or below the median, respectively. In multivariable analysis, interaction terms evaluated the differential impact of the calculator on birth satisfaction by race (Black vs. non-Black women). Results A total of 1,008 of 1,236 (81.6%) eligible women completed the BSS-R (preperiod: 330 [79.7%] versus postperiod: 678 [82.5%], p = 0.23), 63.8% of whom self-identified as Black. In the pre-period, Black women were 50% less likely to be satisfied than non-Black women, even when controlling for differences in parity (Black: 39.0% satisfied vs. non-Black: 53.9%, adjusted odds ratio [aOR] = 0.49, 95% confidence interval [CI]: 0.30–0.79). In the postperiod, there was no difference in satisfaction by race (Black: 43.7% satisfied vs. non-Black: 44.0%, aOR = 0.97. 95% CI: 0.71–1.33). Therefore, disparities in birth satisfaction were no longer present at postimplementation (interaction p = 0.03). Conclusion Implementation of standardized counseling with a validated calculator to predict cesarean risk after labor induction is associated with a decrease in racial disparities in birth satisfaction. Key Points

BACKGROUND: In randomized trials, antepartum intravenous iron sucrose is effective at improving predelivery hemoglobin in iron deficiency anemia. Yet, there is a gap between this knowledge and its implementation into care. OBJECTIVE: We aimed to determine if the implementation of a standardized protocol for the management of antepartum anemia outside of a clinical trial improves intravenous iron sucrose utilization and clinical outcomes. STUDY DESIGN: We performed a prospective cohort study evaluating the incorporation of an anemia protocol into routine clinical care for women with antepartum hemoglobin

Background Audit and feedback as an implementation strategy leads to small, but potentially important improvements in practice. Yet, audit and feedback is time and personnel intensive. Many interventions designed for inpatient care are meant to be utilized by care teams all days of the week, including weekends when research staff are at a minimum. We aimed to determine if audit and feedback regarding use of an evidence-based inpatient obstetric intervention performed only on weekdays could have a sustained impact over the weekend. Methods This study was performed as a secondary analysis of a prospective cohort study examining the impact of implementation of a validated calculator that predicts the likelihood of cesarean delivery during labor induction. During the 1 year postimplementation period, Monday through Friday, a member of the study team contacted clinicians daily to provide verbal feedback. While the same clinician pool worked weekend shifts, audit and feedback did not occur on Saturdays or Sundays. The primary outcome was intervention use, defined as documentation of counseling around the cesarean risk calculator result, in the electronic health record. Intervention use was compared between those with (weekdays) and without (weekends) audit and feedback. Results Of the 822 women meeting eligibility criteria during the postimplementation period (July 1, 2018–June 30, 2019), 651 (79.2%) were admitted on weekdays when audit and feedback was occurring and 171 (20.8%) on weekends without audit and feedback. The use of the cesarean risk calculator was recorded in 676 of 822 (82.2%) of eligible patient charts. There was no significant difference in cesarean risk calculator use overall by days when audit and feedback occurred versus days without audit and feedback (weekday admissions 82.0% vs. weekend admissions 83.0%, aOR 0.90 95% CI [0.57–1.40], p = 0.76). There was no significant trend in the relationship between calculator use and weekday versus weekend admission by month across the study period (p = 0.21). Conclusions Daily weekday audit and feedback for implementation of an evidence-based inpatient obstetric intervention had sustained impact over the weekends. This finding may have implications for both research staffing, as well as sustainability efforts. Further research should determine the lowest effective frequency of audit and feedback to produce implementation success.

Objective This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use. Study Design We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge. Results Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90–195] PRE to 114 [range: 45–168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5–8] vs. POST 5 [range: 3–7], p Conclusion Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients. Key Points

Studies have demonstrated that antepartum intravenous iron sucrose infusion (IVFe) is safe and improves predelivery hemoglobin (Hb). Yet, there is little data guiding timing of administration or number of doses required to be impactful. We sought to determine if timing of antepartum IVFe and number of doses provided impacts efficacy.We performed a retrospective cohort study of women who obtained prenatal care and delivered at our institution 10/1/2015-10/30/2017. Women with a third-trimester hemoglobin (Hb)9.5 g/dL were included. Women with hemoglobinopathies and those who received an antepartum blood transfusion were excluded. Women receiving ≥1 antepartum 300 mg IVFe dose were considered in the IVFe group.Five-hundred-twenty-three (6.1%) of 8563 delivering women were included. Sixty-five (12.4%) of included women received IVFe. By timing of IVFe, the earlier IVFe was received before delivery, the greater the median Hb increase (No IVFe: Δ0.8g/dL, IVFe 0-1 weeks predelivery: Δ0.05 g/dL, 1-2 weeks: Δ0.9 g/dL, 2-4 weeks: Δ1.5 g/dL, 4-6 weeks: Δ1.8 g/dL, 6-8 weeks: Δ1.8 g/dL, 8-12 weeks: Δ2.75 g/dL,Antepartum IVFe effectively increases Hb from the third trimester to delivery admission when administered 2-12 weeks predelivery. There is increasing benefit the further out the IVFe is administered and with an increasing number of doses. Initiatives to combat antepartum anemia should focus on early detection and treatment to best optimize outcomes.

BACKGROUND: During the COVID-19 pandemic, our institution turned to telehealth as the primary method of postpartum care delivery. OBJECTIVE: We aimed to determine the impact of telehealth on completion of postpartum care goals. STUDY DESIGN: In a single-center retrospective cohort study, we compared a 14-week period, March to June 2019, before implementation of telehealth, with the same calendar months after implementation during 2020. Patients with a postpartum visit scheduled at our institution during the study period were included. To demonstrate a 10% difference in attendance to the postpartum visit in the postimplementation compared with the preimplementation group, a power analysis calculation resulted in a requirement of at least 356 subjects per group. Our primary outcome was attendance to the postpartum visit. Secondary outcomes included completion of postpartum depression screening, contraception selection, breastfeeding status at postpartum visit, completion of 2-hour glucose tolerance test postpartum for those with gestational diabetes mellitus, and cardiology follow-up when recommended. Multivariable logistic regression with backward elimination was used to control for confounders. RESULTS: Of the 1579 patients meeting inclusion criteria, 780 were in the preimplementation group and 799 in the postimplementation group. Subjects in the postimplementation group were at 90% increased odds of attending a postpartum visit compared with those in the preimplementation group, even when controlling for race, prenatal care provider, parity, gestational age at delivery, and insurance status (82.9% vs 72.4%; P

Objective To determine if increasing predicted risk of cesarean was associated with longer labor length and increased morbidity among women undergoing induction with an unfavorable cervix. Study Design Using a publically available database, we evaluated whether a previously validated prediction model for cesarean delivery after induction was associated with labor length, maternal morbidity (third-/fourth-degree lacerations, endometritis, blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and death), and neonatal morbidity (blood transfusion, encephalopathy, intraventricular hemorrhage, severe respiratory distress syndrome, necrotizing enterocolitis, and sepsis). Full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix (Bishop score ≤6 and dilation ≤2 cm) undergoing induction of labor were included. Results A total of 8,466 women met the inclusion criteria. Each category increase in cesarean probability ( Conclusion Using a validated prediction model for cesarean delivery among women induced with an unfavorable cervix, increasing predicted probability of cesarean is associated with longer labor length and increased maternal and neonatal morbidity.

With race-based definitions of antepartum anemia, Black women are at significant increased odds of delivery admission hemoglobin

BACKGROUND We previously conducted a prospective cohort study (n=1610) demonstrating that the implementation of a validated calculator to predict likelihood of cesarean delivery during labor induction was associated with reduced maternal morbidity, reduced cesarean delivery rate, and improved birth satisfaction. OBJECTIVE To optimize future implementation, we used qualitative interviews to understand the clinician perspective on: (1) the cesarean delivery risk calculator implementation and (2) the mechanisms by which the use of the calculator resulted in the observed improved outcomes. STUDY DESIGN After completion of the prospective study (June 30, 2019), 20 trainees and attending clinicians (including nurse-midwives, obstetrical physicians, and family medicine physicians) at the study site participated in a single, brief semistructured interview from March 1, 2020, to June 30, 2020. Transcriptions were coded using a systematic approach. RESULTS Overall, clinicians had favorable perspectives regarding the cesarean delivery risk calculator. Clinicians described the calculator as offering “objective data” and a “standardized snapshot of the labor trajectory.” Concerns were raised regarding “overreliance” on calculator output. Barriers to use included time for patient counseling and “awkwardness” around the interactions and perceived patient misunderstanding of the calculator result. Although most senior clinicians (n=8) reported that the calculator did not impact patient management, trainee clinicians (n=12) more often felt that the calculator influenced care at the extremes of cesarean delivery risk. Furthermore, more senior clinicians felt “neutral” regarding any impact of counseling patients on cesarean delivery risk compared with trainee clinicians, who felt that the counseling “built [patient-clinician] trust.” CONCLUSION This qualitative evaluation characterized the generally positive clinician perspective around the cesarean delivery risk calculator, while identifying specific facilitators and barriers to implementation. In addition, we elucidated potential mechanisms by which the calculator may have been related to clinician decision making and patient-clinician interactions, leading to reduced maternal morbidity and improved patient birth satisfaction. This information is important as widespread implementation of the cesarean delivery risk calculator begins.

This cohort study assesses whether implementation of a validated calculator for likelihood of cesarean delivery at the time of labor induction is associated with maternal morbidity and birth satisfaction., Key Points Question Is implementation of a validated calculator to predict cesarean delivery after labor induction associated with maternal morbidity and birth satisfaction? Findings In this cohort study of 1610 women admitted for labor induction, use of a cesarean delivery risk calculator was associated with a 6% absolute risk reduction in maternal morbidity, as well as an 8% absolute risk reduction in cesarean delivery. Calculator implementation was associated with improvements in women’s perception of quality of care received. Meaning These findings suggest that implementation of a validated calculator to predict risk of cesarean delivery in clinical care is associated with reduced obstetric morbidity and improved the patient birth experience., Importance A previously created and validated calculator provides an individualized cesarean delivery risk score for women undergoing labor induction. A higher predicted risk of cesarean delivery on the calculator has been associated with increased maternal and neonatal morbidity regardless of ultimate delivery mode. The effect of this calculator when implemented in clinical care has yet to be evaluated. Objective To determine whether implementation of a validated calculator that predicts the likelihood of cesarean delivery at the time of labor induction is associated with maternal morbidity and birth satisfaction. Design, Setting, and Participants This prospective cohort study used medical record review to compare the 1 year before calculator implementation (July 1, 2017, to June 30, 2018) with the 1 year after implementation (July 1, 2018, to June 30, 2019) at a US urban, university labor unit. Women admitted for labor induction with singleton gestation in cephalic presentation, intact membranes, and an unfavorable cervix were included. Data were analyzed from August 1, 2019, to September 13, 2020. Exposures Patient and clinician knowledge of the calculated cesarean delivery risk score based on the validated calculator. Main Outcomes and Measures The primary outcomes were (1) composite maternal morbidity defined by at least 1 of the following within 30 days of delivery: endometritis, postpartum hemorrhage (estimated or quantitative blood loss >1000 mL), blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and readmission and (2) patient satisfaction assessed via Birth Satisfaction Scale–Revised (BSS-R) scores. Secondary outcomes included rate of cesarean delivery and neonatal morbidity. Results A total of 1610 women were included in the analysis (788 in the preimplementation and 822 in the postimplementation periods) with a median age of 29 (interquartile range [IQR], 24-34) years. There were no significant baseline differences between groups except fewer inductions at a gestational age of 40 weeks or later in the postimplementation period (256 [31.1%] vs 298 [37.8%]). Calculator implementation was associated with decreased maternal morbidity overall, even when adjusting for confounders (141 [17.9%] vs 95 [11.6%]; adjusted absolute risk difference [aARD], −6.3%; 95% CI, −9.7% to −2.8%). Although there was no difference in birth satisfaction overall, calculator implementation was associated with improvements on items pertaining to quality of care provision (median BSS-R score, 19 [IQR, 16-20] vs 19 [IQR, 17-20]; P = .006). Calculator implementation was also associated with a decrease in cesarean delivery rate (228 [28.9%] vs 167 [20.3%]; aARD, −8.5% [95% CI, −12.6% to −4.5%]). There were no significant differences in neonatal morbidity. Conclusions and Relevance These findings suggest that implementation of a validated calculator to predict risk of cesarean delivery in clinical care is associated with reduced maternal morbidity. Implementation should occur broadly to determine whether calculator use improves national maternal outcomes.

Objective Studies demonstrate shorter time to delivery with concurrent use of misoprostol and cervical Foley catheter. However, concurrent placement may not be feasible. If misoprostol is used to start an induction, little is known regarding the benefit of sequentially using Foley catheter. We examine obstetrical outcomes in women with Foley catheter placed after misoprostol compared with those only requiring misoprostol. Study Design Retrospective cohort study of singleton pregnancies, intact membranes, and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) undergoing term induction May 2013 to June 2015. We compared obstetrical outcomes between women receiving misoprostol alone versus those that had a Foley catheter placed after misoprostol. Outcomes are mode of delivery, time to delivery, chorioamnionitis, admission to neonatal intensive care unit, and maternal morbidity. Chi-square and Fisher's exact tests were used for categorical variables, Mann–Whitney U-tests compared continuous variables. Results Among 364 women, 281 began induction with misoprostol alone. A total of 135 (48%) subsequently had a Foley catheter placed. Characteristics were similar between the groups, although nulliparity and cervical dilation Conclusion In women receiving misoprostol for induction, nulliparas and those with dilation Key Points

Recent surveys have shown widespread lapses in the procedures used to reduce the risk of transmitting infection via medical devices. Transvaginal ultrasound examination has the potential to transmit vaginal infections, including human papillomavirus. Areas of particular concern are the use of probe covers with high rates of leakage, disinfectants that are not effective against human papillomavirus, and coupling gel from multiple-use containers. We reviewed these issues, and we recommend 4 steps to reduce the risk of transmitting infection. First, during every transvaginal ultrasound exam, the probe should be covered with a sterile, single-use "viral barrier" cover or a condom. Second, sterile, single-use ultrasound gel packets should be used. Third, after every examination, the probe should be cleaned to remove any visible gel or debris. Finally, after cleaning, the probe should undergo high-level disinfection using an agent with proven efficacy against the human papillomavirus, including hydrogen peroxide, hypochlorite, or peracetic acid. Glutaraldehyde, orthophthalaldehyde, phenols, and isopropyl alcohol have virtually no efficacy against the human papillomavirus.

Background Standardized labor induction protocols improve obstetric outcomes. However, these protocols are complex. The Consolidated Framework for Implementation Research describes intervention components as “core” and “adaptable periphery.” We aimed to identify core components by investigating the individual components of an evidence-based protocol most associated with effectiveness. We planned to utilize this information to simplify our protocol prior to multi-site implementation. Methods This is a secondary analysis of an RCT comparing time to delivery among four labor induction methods. All patients enrolled in the trial had their labor managed with a multidisciplinary-developed, evidence-based labor induction protocol. For each patient’s induction, we assessed fidelity to 7 components of the protocol. Primary effectiveness outcomes included cesarean delivery, maternal morbidity, and neonatal morbidity. Bivariate analyses assessed association of each component with each primary effectiveness outcome. Multivariable logistic regression determined independent predictors of each outcome while controlling for demographic and clinical factors known to be related to our outcomes. Results The 491 patients enrolled in the RCT were included in this analysis. While multiple components were associated with each outcome in bivariate analysis, few were found to be independent predictors of effectiveness in multivariable analysis. For cesarean delivery, only one component “for women in active labor, all cervical exams were performed ≤2.5 hours apart” was an independent predictor. For maternal morbidity, only one “if an intracervical Foley catheter was utilized for cervical ripening, it was removed within 12 hours of placement” remained significant. For neonatal morbidity, two components “all cervical exams performed in latent labor were performed ≤4.5 hours apart” and “for women in active labor, all cervical exams were performed ≤2.5 hours apart” remained independent predictors. Of the independent predictors of effectiveness, most reflected the overarching concept of “frequent exams in labor will allow for more frequent intervention when no change is made”.Conclusions This study demonstrates a novel strategy to identify which components of an evidence-based intervention should be “core” and which are “adaptable periphery”; this provides valuable information when designing for dissemination and implementation. With an understanding of the relationship between fidelity to individual protocol components and effectiveness, we can systematically simplify interventions prior to large-scale implementation, a potential strategy to increase implementation success. These data will be used to streamline our protocol to best target cesarean rate and maternal/neonatal morbidity prior to a planned type I hybrid effectiveness-implementation trial.

Objective Obstetric hemorrhage is a leading cause of morbidity and mortality. We sought to assess whether institution of a postpartum hemorrhage (PPH) bundle could improve maternal morbidity in our population. Study Design Preintervention data (PRE) was collected on all deliveries at Hospital of the University of Pennsylvania between October 15, 2013 and December 15, 2013. A two-pronged, multidisciplinary educational and procedural intervention related to PPH was instituted from March 2015 to June 2015. Postintervention data (POST) was collected on all deliveries from October 20, 2015 to December 20, 2015. Results Note that 592 of 626 (95%) PRE and 583 of 613 (95%) POST deliveries were included. The rates of PPH by estimated blood loss (EBL) ≥ 1,000 mL and by 3 g hemoglobin drop were not significantly different from PRE to POST (9.0% versus 12.2%, p = 0.07 and 10.5% versus 13.5%, p = 0.10, respectively). There was no significant change in transfusion rate (3.4% versus 5.1%, p = 0.13). Use of uterotonics was reduced from 9.8 to 6.3% from PRE to POST (p = 0.03). Conclusion While institution of a PPH bundle is designed to improve the morbidity of PPH, our data demonstrate that it cannot be expected to do so within 6 months of implementation. Further studies will need to assess the long-term effects of such a resource-intensive protocol, including perceptions of improved safety by all providers, nurses, and staff.

To investigate perceptions of surgical participants and their caregivers regarding novel nerve transfer surgery to restore upper extremity function in cervical level spinal cord injury.A qualitative study design was used. A multidisciplinary team developed semi-structured interview guides. Interviews were recorded, transcribed and analyzed using basic text analysis.Participants had limited information about procedures to improve function after spinal cord injury. When discussing their choice to undergo nerve (as compared to traditional tendon) transfer surgery, they describe a desire to avoid post-operative immobilization. Barriers included the pre-operative testing, cost and inconvenience of travel for surgery, and understanding complex health information related to the procedure. While expectations matched descriptions of outcomes among participants and were generally positive, caregivers expressed disappointment. The long time interval for gains in function to be realized and relatively incremental gains achieved were frustrating to all.People with cervical spinal cord injury and their caregivers need more information about options to restore function and about realistic range of improvements with treatment. Further work to mitigate barriers and develop health information materials around nerve transfer surgery may improve medical decision making around and appropriate use of this newer treatment option.IMPLICATIONS FOR REHABILITATIONNerve transfer surgery is a novel and acceptable means of improving upper extremity function in the setting of cervical spinal cord injury.People with cervical spinal cord injury and their caregivers need information about options to restore hand and arm function and mitigation of barriers around these treatment options.

Background: Decreased birth satisfaction has been associated with labor induction. Yet, there is a paucity of data evaluating risk factors for decreased satisfaction associated with labor induction. We aimed to determine what factors impact low birth satisfaction in labor induction and evaluate racial disparities in birth satisfaction.Methods: We performed a prospective cohort study of women with term, singleton gestations undergoing labor induction at our institution from 1/2018-6/2018. Women completed the validated Birth Satisfaction Scale-Revised postpartum, which is subdivided into 3 domains. A total satisfaction score above the mean was classified as “satisfied”, and below as “unsatisfied.” Domain and item scores were compared by race. Results: 330 of 414 (79.7%) eligible women were included. There was no significant difference in birth satisfaction by age, body mass index, Bishop score, or induction agent. Black women were more 75% likely to be unsatisfied than non-Black women (54.0% vs. 37.2%, OR 1.75 [95%CI 1.11-2.76], p=0.037), nulliparas were more 71% likely to be unsatisfied than multiparas (54.2% vs. 40.9%, OR 1.71 [95%CI 1.09-2.67], p=0.019), and women whose labor resulted in cesarean birth were more almost 3 times more likely to be unsatisfied than women with a vaginal birth (67.4% vs. 42.3%, OR 2.82 [95%CI 1.69-4.70], p

OBJECTIVE: Understanding the importance of standardized care and utilizing the concepts of active management of labor, we developed a standardized induction of labor protocol at our institution. The objective of this study was to evaluate the impact of this induction of labor protocol on reducing maternal and neonatal morbidity in women undergoing an induction of labor with an unfavorable cervix. STUDY DESIGN: We performed a prospective cohort study of women undergoing an induction at our institution from May 2013 to June 2015. Women who were ≥18 years, ≥37 weeks, carrying a singleton gestation in cephalic presentation with intact membranes and an unfavorable cervix (Bishop score of ≤6 and cervical dilation ≤2 cm) were included. Women with a prior cesarean were excluded. We compared outcomes between women managed with the labor protocol versus women in an observation group, managed at the discretion of the provider. Outcomes evaluated were: Labor length, cesarean delivery, maternal and neonatal morbidity, and neonatal intensive care unit admission for >48 hours. Multivariable models incorporated confounders that were specific to each outcome. RESULTS: 855 women were included in this study (491 in labor protocol group; 364 in observational group). Women in the labor protocol group had a shorter time to delivery (15.7 hours vs. 18.0 hours, p48 hours (3.5% vs 8%, p=0.005), and a lower neonatal morbidity (3.0% vs. 7.7%, p=0.003) compared to women in the observational group. There was no difference in the rate of cesarean delivery between the labor protocol group and the observational group (27.7% vs. 32.7%, p=0.13). When adjusting for confounders specific to each outcome, women in the labor protocol group had a 60% reduction in NICU admission >48 hours (RR: 0.41, 95% CI: 0.22–0.76) and a 70% reduction in neonatal morbidity (RR: 0.31, 95% CI: 0.13–0.70). Time to delivery and maternal morbidity were not significantly different between the groups in adjusted models. CONCLUSION: Utilization of a standardized induction protocol was associated with a significant reduction in neonatal morbidity without increasing the risk of cesarean delivery or maternal morbidity.