Effects of implementing a routine postpartum fasting blood glucose on the completion of the gold standard 2-hour oral glucose tolerance test in gestational diabetics.

OBJECTIVE: Rates of completion of the gold standard 2-hour oral glucose tolerance test (OGTT) for impaired glucose intolerance postpartum in patients with gestational diabetes mellitus (GDM) are consistently less than 50 percent. Screening tests performed prior to hospital discharge, including a fasting blood glucose (FBG) to detect persistent hyperglycemia, have been investigated. We lack evidence, however, on whether implementation of routine postpartum FBG impacts the likelihood of obtaining the routine 2-hour OGTT. We sought to retrospectively compare the rates of completion of the 2-hour OGTT pre- and post-implementation of a routine FBG screen. STUDY DESIGN: We performed a single-center retrospective cohort study comparing the completion of the 2-hour OGTT pre- and post-implementation of a routine FBG screen. Our primary outcome was completion of the postpartum OGTT. Bivariate analyses assessed associations of demographic and pre-induction clinical characteristics by pre- and post-implementation groups, as well as OGTT completion. Multivariable logistic regression was used to control for possible confounders. A sensitivity analysis was performed to account for the overlap with the COVID pandemic. RESULTS: 468 patients met inclusion and exclusion criteria. In our post-intervention group, 64% of patients completed a postpartum FBG. For our primary outcome, completion of the 2-hour OGTT significantly decreased in our post-intervention group from 37.1% to 25.9% (p=0.009), aOR 0.62 CI[0.41 - 0.92]. This difference was no longer statistically significant when excluding patients during the pandemic, from 40.3% to 33.1% (p=0.228), aOR 0.76 CI[0.455 - 1.27]. CONCLUSIONS: Implementation of a routine FBG was associated with a negative impact on patients completing a 2-hour OGTT. The difference was no longer significant when excluding patients who would have obtained the OGTT during the pandemic, which may have been due to the smaller cohort. Future work should investigate patient perceptions of the FBG and its impact on their decision-making around the OGTT.

Implementation and clinical impact of a guideline for standardized, evidence-based induction of labor.

OBJECTIVE: To assess the impact of implementation of an induction of labor (IOL) guideline on IOL length and utilization of evidence-based practices. STUDY DESIGN: We conducted a quality improvement project to increase utilization of three evidence-based IOL practices: combined agent ripening, vaginal misoprostol, and early amniotomy. Singletons with intact membranes and cervical dilation ≤2 cm admitted for IOL were included. Primary outcome was IOL length. Secondary outcomes included cesarean delivery and practice utilization. We compared pre-implementation (PRE; November 1, 2021 through January 31, 2022) to post-implementation (POST; March 1, 2022 through April 30, 2022) with sensitivity analyses by self-reported race and ethnicity. Cox proportional hazards models and logistic regression were used to test the association between period and outcomes. RESULTS: Among 495 birthing people (PRE, n=293, POST, n=202), IOL length was shorter POST (22.0 vs. 18.3 hours, P=.003), with faster time to delivery (aHR 1.38, 95% CI 1.15-1.66), more birthing people delivered within 24 hours (57% vs. 68.8%, aOR 1.90 [95% CI 1.25-2.89]), and no difference in cesarean. Utilization of combined agent ripening (31.1% vs. 42.6%, P=.009); vaginal misoprostol (34.5% vs. 68.3%, P<.001); and early amniotomy (19.1% vs. 31.7%, P=.001) increased POST. CONCLUSION: Implementation of an evidence-based IOL guideline is associated with shorter induction time. Additional implementation efforts to increase adoption of practices are needed to optimize outcomes after IOL.

Are Racial Disparities in Cesarean Due to Differences in Labor Induction Management?

OBJECTIVE: While there are known racial disparities in cesarean delivery (CD) rates, the exact etiologies for these disparities are multifaceted. We aimed to determine if differences in induction of labor (IOL) management contribute to these disparities. STUDY DESIGN: This retrospective cohort study evaluated all nulliparous patients with an unfavorable cervix and intact membranes who underwent IOL of a term, singleton gestation at a single institution from October 1, 2018, to September 30, 2020. IOL management was at clinician discretion. Patients were classified as Black, Indigenous, and People of Color (BIPOC) or White based on self-report. Overall rates of CD were compared for BIPOC versus White race. Chart review then evaluated various IOL management strategies as possible contributors to differences in CD by race. RESULTS: Of 1,261 eligible patients, 915 (72.6%) identified as BIPOC and 346 (27.4%) as White. BIPOC patients were more likely to be younger (26 years interquartile range (IQR) [22-30] vs. 32 years IQR [30-35], p < 0.001) and publicly insured (59.1 vs. 9.9%, p < 0.001). Indication for IOL and modified Bishop score also differed by race (p < 0.001; p = 0.006). There was 40% increased risk of CD for BIPOC patients, even when controlling for confounders (30.7 vs. 21.7%, p = 0.001; adjusted relative risk (aRR) 1.41, 95% confidence interval (CI) [1.06-1.86]). Despite this difference in CD, there were no identifiable differences in IOL management prior to decision for CD by race. Specifically, there were no differences in choice of cervical ripening agent, cervical dilation at or time to amniotomy, use and maximum dose of oxytocin, or dilation at CD. However, BIPOC patients were more likely to undergo CD for fetal indications and failed IOL. CONCLUSION: BIPOC nulliparas are 40% more likely to undergo CD during IOL than White patients within our institution. These data suggest that the disparity is not explained by differences in IOL management prior to cesarean, indicating that biases outside of induction management may be important to target to reduce CD disparities. KEY POINTS: · The etiologies for racial disparities in cesarean are likely multifaceted.. · In this work, there were no differences by race in measures of labor induction management.. · Biases outside of induction management during labor may be targeted to reduce CD disparities..

The Relationship between Gestational Weight Gain and Cesarean Delivery among Patients undergoing Induction of Labor.

OBJECTIVE: This study aimed to determine the impact of pregnancy weight gain above National Academy of Medicine (NAM) guidelines on cesarean delivery rates following induction. STUDY DESIGN: This is a secondary analysis of a prospective cohort study of patients who underwent induction at a single tertiary care center between July 2017 and July 2019. Included in the primary study were patients undergoing term (≥37 weeks) labor induction with a singleton gestation, intact membranes, and unfavorable cervical examination (Bishop score of ≤6 and cervical dilation ≤ 2 cm). Eligibility for this analysis was limited to patients with a documented prenatal body mass index (BMI) < 20 weeks' gestation. The primary exposure was gestational weight gain greater than NAM guidelines (WGGG) for a patient's initial BMI category. The primary outcome was cesarean delivery for any indication. RESULTS: Of 1,610 patients included in the original cohort, 1,174 (72.9%) met inclusion criteria for this analysis and 517 (44.0%) of these had weight gain above NAM guidelines. Of the entire cohort, 60.0% were Black and 52.7% had private insurance. In total, 160 patients (31%) with WGGG underwent cesarean compared with 127 patients (19.3%) without WGGG (p < 0.001), which equates to a 59% increased odds of cesarean when controlling for initial BMI category, parity, gestational diabetes, and indication for induction (Adjusted Odds Ratio [aOR] 1.58, 95% confidence interval [CI] 1.17-2.12). Among only nulliparous patients, WGGG was associated with an increased odds of cesarean (26.4 vs. 38.2%, aOR 1.50, 95% CI 1.07-2.10). In multiparous patients, however, there was no difference in cesarean between those with and without WGGG (8.8 vs. 14.1%, aOR 1.85, 95% CI 0.96-3.58). CONCLUSION: This study demonstrates that weight gain above NAM guidelines is associated with more than a 50% increased odds of cesarean. Patients should be informed of this association as gestational weight gain may be a modifiable risk factor for cesarean delivery. KEY POINTS: · Weight gain above NAM guidelines was associated with a 59% increased odds of cesarean delivery.. · Nulliparous patients with weight gain above NAM guidelines are at higher risk of cesarean delivery.. · No difference in cesarean delivery among multiparous patients regardless of gestational weight gain..

Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers.

BACKGROUND: Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA. METHODS: This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures. RESULTS: Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). 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 quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.

Contemporary Obstetric and Neonatal Outcomes in Sickle Cell Disease: A Retrospective Cohort Study.

OBJECTIVE: Sickle cell disease is associated with adverse perinatal outcomes. Aspects of sickle cell disease in pregnancy, such as health care utilization and neonatal abstinence syndrome, are understudied. We aimed to describe contemporary sickle cell disease outcomes in a U.S. hospital system to improve perinatal counseling. STUDY DESIGN: We conducted a retrospective cohort study of patients with sickle cell disease who delivered at >20 weeks' gestation at two sites within the University of Pennsylvania Health System from May 1, 2017 to August 30, 2020. Descriptive statistics were utilized. RESULTS: Over the study period, 48 patients with sickle cell disease had 52 deliveries of 53 neonates. Sickle cell disease-related morbidity was prevalent prior to pregnancy; 27% had a history of avascular necrosis, and 58% had experienced acute chest syndrome. In the year prior to pregnancy, 52% used daily opioids. During pregnancy, more than half of patients were admitted at least once for sickle cell disease-related complications, spending a median 3 days admitted interquartile range (0-23); >10% spent >70 days of pregnancy admitted. New daily opioids were prescribed during pregnancy for 10% to manage pain crises. Acute chest syndrome was experienced by 23% of patients during pregnancy, and 8% required placement of long-term intravenous access. Preterm delivery <37 weeks occurred in 48%. The primary cesarean rate in nulliparas was 43%. Additionally, 50% experienced a hypertensive disorder of pregnancy, 35% underwent transfusion during delivery admission, and 10% had a perinatal venous thromboembolism. Finally, 53% of neonates were admitted to the intensive care unit. Low birth weight was noted in 34%, severe respiratory distress in 15% of infants, and neonatal abstinence syndrome in 21%. CONCLUSION: Sickle cell disease remains associated with significant perinatal morbidity and need for hospitalization. These data provide contemporary outcomes to target improvements in the care of patients with sickle cell disease. KEY POINTS: · SCD was associated with significant perinatal morbidity and healthcare utilization.. · Most patients with SCD required hospitalization during pregnancy.. · Neonates of patients with SCD experienced preterm birth, NICU admission, and neonatal abstinence syndrome..

An interactive childbirth education platform to improve pregnancy-related anxiety: a randomized trial.

BACKGROUND: Perinatal anxiety is one of the most common conditions during pregnancy and is associated with adverse maternal and neonatal outcomes. Interventions that are focused on childbirth education and health literacy have been shown to help decrease pregnancy-related anxiety. These programs, however, have limitations. Transportation, childcare, and work conflicts pose barriers to patients. In addition, many of these programs have not been studied in high-risk patients, who are most at risk for pregnancy-related anxiety. Thus, it is uncertain whether an online childbirth education course can help to improve outcomes in a high-risk patient population. OBJECTIVE: This study aimed to compare an interactive online platform for childbirth education (Birthly) with usual prenatal education on anxiety, emergency healthcare utilization, and delivery outcomes for high-risk pregnancies. STUDY DESIGN: We performed a randomized trial comparing an interactive online childbirth education platform combined with usual prenatal education (intervention) with usual prenatal education alone (usual care). Nulliparous, English-speaking patients with internet access and a high-risk pregnancy (medical or mental health disorders) were included. Patients in 2 urban clinics that serve underresourced patients were enrolled at <20 weeks of gestation. The intervention included 3 interactive courses (prenatal bootcamp, breastfeeding, newborn care) and access to a clinician-moderated online community. Pregnancy-related Anxiety Scale questionnaires were administered at randomization and at 34 to 40 weeks. The primary outcome was third-trimester Pregnancy-related Anxiety Scale score. Secondary outcomes included change in Pregnancy-related Anxiety Scale score, unscheduled emergency visits, delivery, and postpartum outcomes. To demonstrate a 15% decrease in Pregnancy-related Anxiety Scale score, 37 patients would be needed per group. Accounting for a 20% loss to follow-up rate, we planned to recruit 90 total patients or 45 per group. RESULTS: A total of 90 patients were randomized with no differences in demographics or baseline Pregnancy-related Anxiety Scale scores. Most patients self-identified as Black and were publicly insured. More than 60% of patients (62.2%) in the intervention arm completed at least 1 Birthly course. Patients in the intervention arm had significantly lower third-trimester Pregnancy-related Anxiety Scale scores (indicating lower anxiety) compared with those receiving usual care (44.6±7.3 vs 53.9±13.8; P<.01), with a decrease in score of 8.3 points vs 0.7 for usual care (P<.01). Patients in the intervention arm also had fewer emergency visits (1 [0-2] vs 2 [1-3]; P=.003). There were no differences in delivery outcomes. Patients in the intervention arm were more likely to breastfeed at delivery, although this was not different by the postpartum visit. Finally, patients who received the intervention were more likely to be satisfied with their childbirth education (94.6% vs 64.9%; P<.01). CONCLUSION: An interactive online childbirth education platform can reduce pregnancy-related anxiety and emergency healthcare utilization while improving satisfaction in a high-risk patient population.

An evaluation of implementation climate in inpatient maternity care: a cross-sectional survey study.

OBJECTIVE: Researchers in obstetrics and gynecology are continuously generating new evidence to inform clinical care delivery. Yet, much of this newly emerging evidence fails to be rapidly and effectively integrated into routine clinical practice. Implementation climate refers to clinicians' perceptions of to what degree organizations support and reward use of an evidence-based practice (EBP) and is an important construct in the science of implementation in healthcare. Little is known about implementation climate for EBPs in maternity care. Thus, we aimed to (a) determine the reliability of the Implementation Climate Scale (ICS) for use in inpatient maternity care, (b) describe implementation climate in inpatient maternity care overall, and (c) compare individual perceptions of implementation climate between physician and nursing clinicians on these units. STUDY DESIGN: We performed a cross-sectional survey of clinicians in inpatient maternity units across 2 urban, academic hospitals in the northeastern United States in 2020. Clinicians completed the 18-question validated ICS [scored 0-4]. Scale reliability by role was evaluated using Cronbach's α. Subscale and total scores were described overall and compared by physician versus nursing role using independent t-tests, as well as linear regression to control for confounders. RESULTS: 111 clinicians completed the survey (physicians = 65; nursing = 46). Physicians were less likely to identify as female (75.4% vs. 100.0%, p < .001), but were of similar age and years of experience as nursing clinicians. Reliability of the ICS was excellent, with Cronbach's α of 0.91 and 0.86 among physicians and nursing clinicians, respectively. Scores were notably low for implementation climate in maternity care overall and for all subscales. ICS total scores were also higher among physicians as compared to nurses (2.18(±0.56) vs. 1.92(±0.50), p = .02), which remained significant in multivariable modeling (p = .02). Unadjusted subscale scores were higher among physicians in Recognition for EBP (2.68(±0.89) vs. 2.30(±0.86), p = .03) and Selection for EBP (2.24(±0.93) vs. 1.62(±1.04), p = .002). After adjustment for potential confounders, subscale scores for Focus on EBP (p = .04) and Selection for EBP (p = .002) were all higher among physicians. CONCLUSIONS: This study supports the ICS as a reliable scale for measuring implementation climate in the inpatient maternity care setting. Notably lower implementation climate scores across subscales and roles compared to other settings may underlie the vast evidence to practice gap in obstetrics. In order to successfully implement practices that reduce maternal morbidity, we may need to focus on building educational support and rewarding EBP utilization on labor and delivery units, with an emphasis on nursing clinicians.

Hemoglobin Change after Red Blood Cell Transfusion for Postpartum Anemia: Secondary Analysis of a Randomized, Controlled Trial.

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 or >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 < 25 kg/m2: 1.1 ± 0.2 g/dL; overweight 25-29.9 kg/m2: 0.9 ± 0.5 g/dL; obese ≥ 30 kg/m2: 0.9 ± 0.5 g/dL; p = 0.12). Finally, there was also no significant difference in ΔHb per pRBC by whether or not symptoms of anemia persisted after initial transfusion (1.0 ± 0.7 vs. 0.9 ± 0.4 g/dL, p = 0.39). 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: · Postpartum anemia is a significant public health issue.. · Providers use hemoglobin change to assess response to blood transfusion.. · The established 1 g/dL change in Hb after transfusion is based on historic surgical populations.. · Our data suggests the 1 g/dL Hb change is applicable to postpartum patients..

Reducing Alarm Fatigue in Maternal Monitoring on Labor and Delivery: A Commentary on Deimplementation in Obstetrics.

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..

Standardized Cesarean Risk Counseling with Induction: Impact on Racial Disparities in Birth Satisfaction.

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 preperiod, 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: · Preintervention, Black women were less likely to have above-median birth satisfaction.. · We implemented standardized counseling around cesarean risk with labor induction.. · Implementation was associated with reduced racial disparities in birth satisfaction scores..

A Resolved Placenta Previa is Still Associated with Postpartum Hemorrhage.

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: · Women with resolved previa or low-lying placenta were 2.5 times more likely to experience PPH.. · Women with resolved previa or low-lying placenta were more likely to be induced for bleeding.. · Resolved previa or low-lying placenta is still associated with adverse hemorrhage-related outcomes..

Racial Disparities in Sterilization Procedure Performed at Time of Cesarean Section.

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 < 0.01), bleeding disorders (3.9% vs. 1.3%, p < 0.01), preoperative anemia (hemoglobin < 11 g/dL; 36.9% vs. 21.3%, p < 0.01), and be of American Society of Anesthesiologist class 3 or higher (29.4% vs. 22.5%, p = 0.01) than non-Black patients. After adjusting for differences, Black patients were almost 50% less likely than non-Black patients to undergo bilateral salpingectomy compared with bilateral tubal ligation for sterilization at CD (adjusted odds ratio = 0.52, 95% confidence interval: 0.36-0.75). 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: · Opportunistic salpingectomy is recommended for primary prevention of ovarian cancer in patients undergoing pelvic surgery who have completed childbearing.. · Black patients were almost 50% less likely to undergo bilateral salpingectomy compared with bilateral tubal ligation than non-Black patients even after controlling for possible confounders.. · Further research is needed to determine root cause of the racial disparity in bilateral salpingectomy utilization rate..

FATE: The Effect of Fetal Antenatal Testing Education on Patient Knowledge and Satisfaction.

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: · A physician-created, readable, and patient-oriented education resource is feasible.. · Infographic patient-education materials do not change patient knowledge about antenatal testing.. · Infographic patient-education materials can improve patient attitude toward antenatal testing..

Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunities.

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.

From Research to Practice in OBGYN: How to Critically Interpret Studies in Implementation.

There is a growing body of research that addresses implementation-focused questions within obstetrics and gynecology. With this document, we provide clinicians with the necessary tools to critically read and interpret literature evaluating an implementation endeavor. We describe the process of implementation research, as well as common study designs and outcomes. Furthermore, we detail pitfalls in the design and analysis of implementation studies, using examples within obstetrics and gynecology. Armed with this knowledge, clinicians may better be able to translate a paper on implementation into improvement efforts in their own clinical practice setting.