US term stillbirth rates and the 39-week rule: a cause for concern?

BACKGROUND: More than a decade ago an obstetric directive called "the 39-week rule" sought to limit "elective" delivery, via labor induction or cesarean delivery, before 39 weeks 0 days of gestation. In 2010 the 39-week rule became a formal quality measure in the United States. The progressive adherence to the 39-week rule throughout the United States has caused a well-documented, progressive reduction in the proportion of term deliveries occurring during the early-term period. Because of the known association between increasing gestational age during the term period and increasing cumulative risk of stillbirth, however, there have been published concerns that the 39-week rule-by increasing the gestational age of delivery for a substantial number of pregnancies-might increase the rate of term stillbirth within the United States. Although adherence to the 39-week rule is assumed to be beneficial, its actual impact on the US rate of term stillbirth in the years since 2010 is unknown. OBJECTIVE: To determine whether the adoption of the 39-week rule was associated with an increased rate of term stillbirth in the United States. STUDY DESIGN: Sequential ecological study, based on state data, of US term deliveries that occurred during a 7-year period bounded by 2007 and 2013. The patterns of the timing of both term childbirth and term stillbirth were determined for each state and for the United States as a whole. RESULTS: A total of 46 usable datasets were obtained (45 states and the District of Columbia). During the 7-year period, there was a continuous reduction in all geographic entities in the proportion of term deliveries that occurred before 39 weeks of gestation. The overall rate of term stillbirth, when we compared 2007-2009 with 2011-2013, increased significantly (1.103/1000 vs 1.177/1000, RR 1.067, 95% confidence interval 1.038-1.096). Furthermore, during the 7-year period, the increase in the rate of US term stillbirth appeared to be continuous (estimated slope: 0.0186/1000/year, 95% confidence interval 0.002-0.035). Assuming 3.5 million term US births per year, and given 6 yearly "intervals" with this rate increase, it is possible that more than 335 additional term stillbirths occurred in the United States in 2013 as compared with 2007. In addition, during the 7-year period, there was a progressive shift in the timing of delivery from the 40th week to the 39th week. Absent this confounding factor, the magnitude of association between the adoption of the 39-week rule and the increase in rate of term stillbirth might have been greater. CONCLUSIONS: Between 2007 and 2013 in the United States, the adoption of the 39-week rule caused a progressive reduction in the proportion of term births occurring before the 39th week of gestation. During the same interval the United States experienced a significant increase in its rate of term stillbirth. This study raises the possibility that the 39-week rule may be causing unintended harm. Additional studies of the actual impact of the adoption of the 39-week rule on major childbirth outcomes are urgently needed. Pressures to enforce the 39-week rule should be reconsidered pending the findings of such studies.

Extraction of a Central Incisor From the Plica Fimbriata in the Outpatient Family Medicine Office: What's That Rattle?

All-terrain vehicle (ATV) accidents are all too common in the United States and can result in long-term injuries. Therefore, proper after-care is essential for the recovery of an injured person. Here, we present a case where an embedded tooth was overlooked for almost an entire year after an ATV accident. No imaging was performed despite multiple clinic and emergency department visits. The tooth was not discovered to be embedded within the tongue until it later started migrating and protruding. Therefore, extraction was performed in the office.

Mite and Bed Bug Infections.

Patients with suspected bites or skin rashes regularly present to their primary care physician. Common mite infections encountered in the primary care office include scabies, chiggers, grain itch, and allergic responses from dust mites. In fact, scabies is one of the 50 most prevalent diseases worldwide. Bed bugs are also becoming increasingly common, living in dark crevices, such as mattresses, feeding at night, and causing a maculopapular immune mediated allergic skin response in humans. Proper identification of the mite or bed bug is essential to guide treatment and eradication.

Surveying Applicants to Improve the Family Medicine Residency Interview Day.

INTRODUCTION: The diversity of family medicine residency programs across the country makes a generalized assessment of applicant preferences and experiences regarding the interview experience difficult. As such, there have been few publications in recent years relating to interview trail trends and modification of the interview day process to meet the needs of applicants. The purpose of this project was to identify applicant preferences and trends among applicants interviewing at Penn State Health's Milton S. Hershey Medical Center during the 2014-2015 and 2015-2016 application cycles. METHODS: Applicants completed a voluntary, anonymous, 16-question multiple-choice survey during the interview day. Questions explored the preinterview dinner, interview day, and postinterview day communication methods. RESULTS: In total, 67 surveys were collected from 68 eligible candidates (98.5%) in 2014-2015, and 65 surveys from 65 eligible candidates in 2015-2016 (100%) for a total of 132 participants. Applicant preferences focused on use of electronic communication and the importance of interviewing with both the program director and a current resident. Interview day trends experienced by those surveyed emphasized the inclusion of spouses/significant others, program support of hotel costs, frequency of applicant preinterview dinners, and the lack of emphasis on second-look visits. CONCLUSION: This study highlights how the utilization of applicant surveys during the interview day may allow family medicine programs to identify trends occurring on the interview trail, while developing an interview day agenda that meets the desires of the applicants the program attracts.