Improving Rates of Early Entry Prenatal Care in an Underserved Population.

Introduction Early prenatal care can improve pregnancy outcomes, reduce complications, and ensure a healthier pregnancy. Unfortunately, many pregnant women do not seek early care. This research provides a framework for improving prenatal care in a low income community-based obstetrics clinic. Methods A multi-disciplinary quality improvement initiative was implemented at a large federally qualified health clinic in Houston, Texas to improve the rate of early entry into prenatal care by identifying barriers through patient surveys, focus groups, stakeholder feedback, and improving processes to reduce these barriers. Results A significant increase in early prenatal care was achieved by redesigning operational and clinical processes to improve access to care, expand patient education and outreach, increase resources, extend hours of operation, and increase presumptive insurance eligibility. Three months post implementation, an increase of 44.5% (p < 0.001) occurred in patients who had a prenatal visit in the first trimester. Patients with early prenatal care had better obstetrical and neonatal outcomes; however, the results were not statistically significant likely due to the small sample size. Discussion This quality improvement project provides various strategies and resources for other community-based clinics to consider when seeking improvement in their rates of early prenatal care.

The effect of monthly resident reflection on achieving rotation goals.

BACKGROUND: Reflection is a learning tool increasingly being used in medical education. It has not been well studied as a method of communicating resident rotation goals and objectives. PURPOSE: The purpose was to study the effect of monthly resident reflection on achieving curriculum goals. METHODS: During the first half of the 2005-06 academic year, obstetrics/gynecology residents at a community hospital received curriculum goals in a traditional written manner. During the second 6 months, the same trainees underwent 1-hr monthly structured reflection sessions on the rotation goals and objectives. RESULTS: Sixteen residents were studied. Compared to control, residents reported the rotation goals as better defined during reflection months. More trainees rated reflection as more valuable than the didactic time it replaced. All 16 residents documented more cumulative procedures in the Accreditation Council for Graduate Medical Education operative log Web site during reflection months for each of the three major categories; there was a mean increased number of procedures logged in Obstetrics (23.1 +/- 14.0, p < .001), Gynecology (18.3 +/- 10.9, p < .001), and Primary Care (21.1 +/- 23.5, p = .003). Overall, there was a mean of 62.6 +/- 32.1 (p < .001) more procedures entered during the reflection period, which translated to an 18% increase. CONCLUSIONS: Structured monthly reflection may lead to a higher success of achieving rotation goals.

Is fetal anatomic assessment on follow-up antepartum sonograms clinically useful?

OBJECTIVE: The purpose of this study was to evaluate the clinical usefulness of a fetal anatomic survey on follow-up antepartum sonograms. METHODS: A retrospective follow-up study was conducted at a low-risk maternity clinic from July 1, 2005, to June 30, 2006. Eligible women had at least 1 prior sonographic examination beyond 18 weeks' gestation with a complete and normal fetal anatomic assessment and at least 1 follow-up sonogram. Full fetal anatomic surveys were performed on all follow-up sonograms regardless of the indication. Neonatal charts were reviewed for those patients whose follow-up sonograms revealed unanticipated fetal anomalies. Neonatal intervention was defined as surgical or medical therapy or arranged subspecialty follow-up specifically for the suspected fetal anomaly. RESULTS: Of a total of 4269 sonographic examinations performed, 437 (10.2%) were follow-up studies. Of these, 101 (23.1%) were excluded because the initial sonogram revealed a suspected fetal anomaly, and 42 (9.8%) were excluded for other reasons. Of the remaining 294 women, 21 (7.1%) had an unanticipated fetal anomaly, most often renal pyelectasis. Compared with follow-up sonography for other reasons, repeated sonography for fetal growth evaluation yielded a higher incidence of unexpected fetal anomalies: 15 (12.3%) of 122 versus 6 (3.5%) of 172 (P = .01). When compared with the neonates in the nongrowth indications group, those neonates whose mothers had sonographic examinations for fetal growth had a higher rate of neonatal interventions: 6 (40.0%) of 15 versus 0 (0%) of 6 (P = .04). CONCLUSIONS: A fetal anatomic survey on follow-up sonograms may identify unanticipated fetal anomalies, especially when the indication is for fetal growth.

Genitourinary infections and their association with preterm labor.

Genitourinary tract infections are one cause of preterm delivery. Prematurity is one of the leading causes of perinatal mortality in the United States. Uterine contractions may be induced by cytokines and prostaglandins, which are released by microorganisms. Asymptomatic bacteriuria, gonococcal cervicitis and bacterial vaginosis are strongly associated with preterm delivery. The role of Chlamydia trachomatis, Trichomonas vaginalis and Ureaplasma urealyticum is less clear. By adopting a rational approach to the diagnosis and treatment of genitourinary infections, family physicians can substantially decrease a patient's risk of preterm delivery.