Changing surgical antimicrobial prophylaxis practices through education targeted at senior department leaders.

Prescribing antibiotics for perioperative prophylaxis in common surgical procedures presents an ideal target for educational intervention. In this situation, antibiotics are often used inappropriately, with consequent excess expense and risk of morbidity. We developed an educational intervention aimed at the choice and appropriate dosing of antibiotics for the prophylaxis of cesarean sections. Person-to-person educational messages targeted at authoritative senior department members were supplemented by brief reminders on a structured antibiotic order form. Time-series analyses were conducted on 34 months of antibiotic use data for 2,783 cesarean sections to estimate the trend of magnitude and significance of discontinuities associated with the start of the program. Prior to the intervention, 95% of sections receiving prophylaxis were given cefoxitin and 3% were given cefazolin. After the intervention, these proportions were reversed, with the shift in use occurring immediately after the intervention (p less than .001). Two years after the intervention, virtually all patients undergoing cesarean sections who receive antibiotic prophylaxis are given cefazolin. Savings from this change alone accounted for over $26,000 each year, or $47.36 per patient-day of prophylaxis. Substantial changes in prescribing practices for routine procedures can be accomplished through the implementation of a coordinated educational program that enlists influential senior staff members in a department in which policy-making is highly centralized, coupled with a structured educational ordering system. Lasting improvements in clinical practices may be brought about by means that are noncoercive, inexpensive and well-accepted by medical staff.

Blood transfusion in contemporary obstetric practice.

Blood transfusion during or after delivery is a serious and sometimes predictable event. An analysis of 30,621 consecutive deliveries showed that previous abortion, bleeding during pregnancy, polyhydramnios, oligohydramnios, operative delivery, multiple pregnancy, abnormal placentation, and primary cesarean were each associated with unexpectedly high transfusion rates. Most women who were transfused received 2 U of blood or fewer. Only 0.09% of pregnant women received more than 8 U. There has been a temporal reduction in the rate of blood transfusion in obstetric practice over the past 10 years. Currently, it appears that approximately 2% of women may require blood transfusion during the peripartum period.

Artifactual fetal heart rate recording secondary to 60-Hz power-line interference.

The presence of excessive 60-Hz power-line interference may produce fetal heart rate (FHR) monitor records that do not reflect the true fetal condition. A case in presented where improper leg-plate grounding resulted in an artifactual tracing that could have easily been misinterpreted. Careful examination of the monitor oscillographic display is urged whenever a tracing appears to have no variability and/or a rigidly fixed baseline rate.

Systolic time intervals in the nonasphyxiated fetus.

The preejection period (PEP) of the cardiac cycle of nonasphyxiated fetuses was evaluated to determine the range of normal to be expected during labor. Standard techniques using the filtered Doppler cardiogram and internally obtained fetal electrocardiogram (ECG) were used. It was demonstrated that the PEP is correlated, although poorly, with heart rate. There is no correlation with fetal weight. The variance from fetus to fetus is quite large. It is concluded that a single measurement of PEP may not be helpful in the determination of fetal hypoxia, since the range of normal varies widely.

Autologous blood donation during pregnancy: analysis of safety and blood use.

Forty-eight women in the third trimester of pregnancy who requested autologous blood donations were enrolled in an experimental protocol to evaluate the safety of this procedure. Risk factors suggesting the possible need for postpartum transfusion were present in 17 women, including previous history of transfusion, scheduled cesarean section, placenta previa, and previous pregnancy-induced hypertension. Nine women were unable to meet donation criteria. Thirty-nine participants donated one to three units each. There was one vasovagal reaction among 61 donations. Fetal monitoring performed during each donation to assess cardiovascular and neurologic effects of maternal hypovolemia revealed no abnormalities. Three women with symptomatic postpartum anemias were transfused with autologous blood; two of these patients were identified antepartum as being at risk for possible transfusion. Autologous donation during pregnancy was safe for both mother and fetus. However, the likelihood of postpartum transfusion, while possibly predictable based on antepartum history, was low in this study.

The effect of maternal blood sugar levels on fetal activity.

Nonstress testing of the fetal heart rate is an antepartum test for fetal well-being utilizing the fetal heart rate response to fetal movement. Performing the test during times of maximum fetal movement should reduce the time required for the test. In this study, fetal activity was evaluated before and during a 3-hour glucose tolerance test to determine the effect of maternal blood glucose levels on fetal activity. Fetal activity was monitored by a nurse at the bedside throughout the study, utilizing both the patient's perception of fetal movement and the recording of fetal movement by the tokodynamometer. Fetal activity increased significantly during the first 30 minutes after maternal ingestion of 100 g glucose and was significantly greater during the last 10 minutes of this time interval. No correlation could be found between absolute levels of glucose at any measured level and fetal activity.

Electronic fetal monitoring and clinical practice. A survey of obstetric opinion.

Interviews with 12 obstetricians recognized for their scientific and clinical contributions in the use of electronic fetal monitoring (EFM) revealed notable areas of agreement and disagreement in the interpretation and use of these methods. In reviewing 14 abnormal fetal heart rate (FHR) patterns, the obstetricians displayed an average pairwise agreement of 68% in classifying the patterns as "innocuous," "nonreassuring," or "ominous." When these patterns persisted after corrective treatment, average pairwise agreement was 69% in deciding between continued monitoring and immediate delivery. With the additional option of scalp blood pH sampling, average agreement was 59%. For the set of FHR patterns studied, scalp blood pH sampling was recommended more often to confirm conservative management of labor than to verify the need to intervene. The obstetricians may be classified by their degrees of (1) alarm and (2) interventionism, and by their (3) frequency of and (4) motivation for scalp sampling. Associations among these four dimensions of behavior were limited.

Sonographic appearance of uterine scar dehiscence.

We describe the sonographic appearance of two cases of uterine scar separation in patients with prior cesarean deliveries. In the first case, the anteriorly located placenta appeared to be a placenta previa with accreta and in the second case the placenta was also located directly beneath the uterine scar thus masking a separation until the third stage of labor was complete. These two cases demonstrate an unusual sonographic and clinical presentation of uterine scar separation involving anteriorly located placentas.

Evaluation of the model 78100A adult telemetry unit for use in fetal heart rate monitoring.

A commercially available adult telemetry unit was adapted for use in fetal heart rate monitoring. Advantages included permitting the mother to ambulate during labor, monitoring the fetus while the mother was in transit from the labor to the delivery area and reducing electrical noise levels. Patient as well as physician acceptance has been uniformly excellent. Patients who normally would not have accepted monitoring acceded to the use of the telemetry system when informed that they could move about while in labor. The equipment is easy to adapt, widely available, relatively inexpensive and simple to use.

Perioperative use of cefoxitin in primary cesarean section.

We performed a randomized, double-blind trial on a relatively low-risk population comparing the use of three doses of cefoxitin vs. placebo in the prevention of infection following primary cesarean section. Major site-related morbidity (endometritis, wound infection and septicemia) was significantly reduced in the cefoxitin group (8.9% vs. 27.8%; p = 0.017). Febrile morbidity alone tended to occur in the cefoxitin group (15.6% vs. 3.7%; p = 0.091), and all five urinary tract infections occurred in the cefoxitin group as well. Total morbidity was therefore not significantly different (cefoxitin, 35.6%; placebo, 31.5% [not significant]). Duration of hospitalization (mean, 6.0 days) and need for further postoperative antibiotic therapy were similar in the two groups. Our study demonstrated a modest benefit from the perioperative use of antibiotics in relatively low-risk patients undergoing primary cesarean section. Issues that need further study include definition of the optimal prophylactic regimen and of high-risk populations for whom prophylaxis would be most helpful.

A computerized aid to Ball pelvimetry.

A computer program is presented that will generate a table of capacities and volumes for use with the Ball technique for cephalopelvimetry. The technique of Ball pelvimetry is reviewed and directions for use are described. This table may be produced on any medium or large-scale digital computer equipped with a FORTRAN compiler and a standard page printer. Its use eliminates many errors inherent in previous methods of volume computation. Physician acceptance has been excellent.

The incidence of intrapartum fetal distress with advancing gestational age.

A total of 679 fetal monitoring records were carefully reviewed in order to determine the incidence of occurrence of late and variable deceleration patterns with respect to advancing gestational age. No statistically significant increase in occurrence of these patterns could be detected in gestations that progressed beyond 42 weeks. The previously held concept that routine prophylactic intervention in gestations of 42 weeks or more must be challenged.

Variation in antenatal testing over time and between clinic settings.

Variation in the use of diagnostic procedures may be due to characteristics of patients, physicians, or their environment. Testing rates for 24-hour urinary estriol levels (EST), diagnostic ultrasound, and antepartum fetal heart rate testing (AFHRT) were examined in 8,527 deliveries from 1975 through 1978. Over the period, utilization of EST remained constant at about 7% of deliveries, while ultrasound increased from 20% to 35% and AFHRT, from 7% to 12%. This increase persisted after stratifying patients on a multivariate confounder score using 45 items of clinical information. Those receiving antenatal care in a hospital-based group practice or a resident-staffed community clinic were more likely to be tested than patients seen in private offices or a prepaid group practice.