Trends in Cesarean Delivery in Puerto Rico, 2018-2022.

Cesarean delivery is major surgery associated with higher costs and adverse outcomes, such as surgical complications, compared with vaginal delivery (1-3). The cesarean delivery rate in Puerto Rico rose from just over 30% in the early to mid-1990s to over 40% by the early 2000s (4,5). During this time, cesarean delivery rates in Puerto Rico were 40%-70% higher than rates in the U.S. mainland and up to 78% higher than rates for Hispanic women in the U.S. mainland (4,5). This report describes trends in Puerto Rico's cesarean delivery rate from 2010 to 2022 and explores changes by maternal age, gestational age, and municipality from 2018 to 2022.

Hospitalizations up to 8 years following delivery in assisted reproductive technology-treated and subfertile women.

OBJECTIVE: To investigate hospitalizations up to 8 years after live birth among women who used assisted reproductive technology (ART) or who were subfertile compared with women who conceived naturally. DESIGN: Retrospective cohort. SETTING: Deliveries among privately insured women aged ≥18 years between 2004 and 2017 from Massachusetts state vital records were linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System and hospital observational/inpatient stays. PATIENT(S): We compared patients with ART, medically assisted reproduction (MAR), and unassisted subfertile (USF) delivery with those with fertile delivery. INTERVENTION(S): NA. MAIN OUTCOME MEASURE(S): Postdelivery hospitalization information was derived from the International Classification of Diseases codes for discharges and combined by type. The relative risks and 95% confidence intervals (CIs) of hospitalization for up to the first 8 years postdelivery were modeled. RESULT(S): Among 492,515 deliveries, 5.6% used ART, 1.6% used MAR, and 1.8% were USF. Compared with fertile deliveries, deliveries that used ART or MAR or were USF were more likely to have hospital utilization (inpatient or observational stay) for any reason for up to 8 years of follow-up (USF, adjusted relative risk [aRR], 1.18 [95% CI, 1.12-1.25]; MAR, aRR, 1.20 [1.13-1.27]; and ART, aRR, 1.29 [1.25-1.34]). Assisted reproductive technology deliveries had an increased risk of hospitalization for conditions of the cardiovascular system (aRR, 1.31 [95% CI, 1.20-1.41]), overweight/obesity (aRR, 1.30 [1.17-1.44]), diabetes (aRR, 1.25 [1.05-1.49]), reproductive tract (aRR, 1.62 [1.47-1.79]), digestive tract (aRR, 1.39 [1.30-1.49]), thyroid (aRR, 2.02 [1.80-2.26]), respiratory system (aRR, 1.13 [1.03-1.24]), and cancer (aRR, 1.40 [1.18-1.65]) up to 8 years after delivery. Deliveries with MAR and subfertility had similar patterns of hospitalization as ART deliveries. CONCLUSION(S): Women who conceived through fertility treatment or experienced subfertility were at increased risk of subsequent hospitalization resulting from a variety of chronic and acute conditions.

The rates and medical necessity of cesarean delivery in China, 2012-2019: an inspiration from Jiangsu.

BACKGROUND: The World Health Organization (WHO) in 2015 stated that every effort should be made to provide cesarean delivery (CD) for women in need. In China, the two-child policy largely prompts the number of advanced age childbirth, which raises the possibility of an increasing number of women who need a c-section. The aim of this study was to assess the trends in the overall and medical indication-classified CD rates in the era of the two-child policy in Jiangsu, China. METHODS: A retrospective cross-sectional study of 291,448 women who delivered in 11 hospitals in Jiangsu province between 2012 and 2019 was conducted. Medical cesarean indication for each woman was ascertained by manually reviewing the medical records. The 291,448 women were divided into two subgroups according to the presence of the indications: the indicated group (7.80%) and the non-indicated group (92.20%). We then fitted joinpoint regression and log-binomial regression models to estimate trends in the CD rates across the study period. RESULTS: The overall CD rate was observed with a declining trend from 52.51% in 2012-2015 to 49.76% in 2016-2019 (adjusted RR, 0.92; 95% CI, 0.91-0.93; P < 0.001), along with an annual percentage change (APC) to be - 1.0 (95% CI, - 2.1 to 0.0) across the period. The participants were then divided into two subgroups according to the presence of medical CD indications: the indicated group (7.80%) and the non-indicated group (92.20%).We found the declining trend was most pronounced in the non-indicated group, with the CD rates decreased from 50.02% in 2012-2015 to 46.27% in 2016-2019 (adjusted RR, 0.90; 95% CI, 0.89-0.90; P < 0.001). By contrast, we observed a steady trend in the CD rate of the indicated group, which maintained from 87.47% in 2012-2015 to 86.57% in 2016-2019 (P = 0.448). In the indicated group, a higher risk of adverse pregnancy outcomes was revealed for those women who delivered vaginally as compared with those who received c-section. We further investigated that women with following specific indications had a higher proportion of vaginal delivery, i.e., pregnancy complications, fetal macrosomia, and pregnancy complicated with tumor (34.70%, 10.84%, and 16.34%, respectively). Women with the above 3 indications were observed with a higher risk of adverse pregnancy outcomes if delivered vaginally. The incidence rates of the medical indications among the general population increased considerably over the 8-year period (P < 0.001). CONCLUSIONS: Although the overall CD rate apparently decreased in the recent years, along with the decline of the unnecessary CD rate, a considerable proportion of indicated women were not provided with CD service in Jiangsu, China. Instead of targeting the overall CD rate, we need to take actions to reduce unnecessary CD rate and provide adequate c-section service for women with indications, particularly for those with underlying diseases and suspected fetal macrosomia.

Possibilidades para a mudança do modelo obstétrico hegemônico pelas enfermeiras obstétricas / Opportunities for nurse midwives to bring change to the hegemonic model of obstetrics / Posibilidades para el cambio del modelo obstétrico hegemónico por las enfermeras obstétricas

Objetivo: descrever o uso das tecnologias de cuidado da enfermeira obstétrica qualificada na modalidade de residência e sua relação com a práxis profissional. Método: estudo qualitativo com 13 enfermeiras obstétricas atuantes em duas maternidades públicas do Rio de Janeiro, Brasil. Dados coletados por entrevista individual, semiestruturada e análise hermenêutica-dialética. Resultados: a transição do modelo intervencionista estrutura-se no cuidado humanizado com a incorporação de um modelo centrado nas boas práticas e nas tecnologias não invasivas de cuidado da enfermeira obstétrica. A práxis da enfermeira obstétrica contribui para a transformação qualitativa deste cenário, com resgate sobre a fisiologia, o fortalecimento de vínculo e empoderamento da mulher, ressignificando o momento do parto. Conclusão: a prática da enfermeira e o uso das tecnologias não invasivas constituem possibilidades para ruptura do modelo hegemônico culturalmente instituído no Brasil, sendo necessária ainda a constituição de um consenso que supere o senso comum(AU)

Objective: to describe the use of care technologies by residency-qualified nurse midwives and their relationship with professional praxis. Method: in this qualitative study with 13 nurse midwives at two public maternity hospitals in Rio de Janeiro, Brazil, data were collected by individual, semi-structured interview and hermeneutic-dialectic analysis. Results: the transition from the interventionist model builds on humanized care by incorporating a model centered on nurse midwives' use of best practices and noninvasive care technologies. Their praxis contributes to qualitative change in this scenario by reinstating physiology, fostering stronger bonding, and empowering women, so as to re-signify the moment of childbirth. Conclusion: nurse midwives' praxis and use of noninvasive technologies constitute opportunities to break with the culturally established model hegemonic in Brazil, while a consensus still needs to be built to surmount common sense(AU)

Objetivo: describir el uso de tecnologías asistenciales por parte de enfermeras parteras tituladas en residencia y su relación con la praxis profesional. Método: en este estudio cualitativo con 13 enfermeras parteras de dos maternidades públicas de Río de Janeiro, Brasil, los datos fueron recolectados mediante entrevista individual, semiestructurada y análisis hermenéuticodialéctico. Resultados: la transición del modelo intervencionista se basa en la atención humanizada al incorporar un modelo centrado en el uso de las mejores prácticas y tecnologías de atención no invasiva por parte de las enfermeras parteras. Su praxis contribuye al cambio cualitativo en este escenario al reinstaurar la fisiología, fomentar vínculos más fuertes y empoderar a las mujeres, para resignificar el momento del parto. Conclusión: la praxis de las enfermeras parteras y el uso de tecnologías no invasivas constituyen oportunidades para romper con el modelo hegemónico culturalmente establecido en Brasil, mientras que aún debe construirse un consenso para superar el sentido común(AU)

Maternal safety: recent advances and implications for the obstetric anesthesiologist.

PURPOSE OF REVIEW: Recognition of the increasing maternal mortality rate in the United States has been accompanied by intense efforts to improve maternal safety. This article reviews recent advances in maternal safety, highlighting those of particular relevance to anesthesiologists. RECENT FINDINGS: Cardiovascular and other chronic medical conditions contribute to an increasing number of maternal deaths. Anesthetic complications associated with general anesthesia are decreasing, but complications associated with neuraxial techniques persist. Obstetric early warning systems are evolving and hold promise in identifying women at risk for adverse intrapartum events. Postpartum hemorrhage rates are rising, and rigorous evaluation of existing protocols may reveal unrecognized deficiencies. Development of regionalized centers for high-risk maternity care is a promising strategy to match women at risk for adverse events with appropriate resources. Opioids are a growing threat to maternal safety. There is growing evidence for racial inequities and health disparities in maternal morbidity and mortality. SUMMARY: Anesthesiologists play an essential role in ensuring maternal safety. While continued intrapartum vigilance is appropriate, addressing the full spectrum of contributors to maternal mortality, including those with larger roles beyond the immediate peripartum time period, will be essential to ongoing efforts to improve maternal safety.

Cesarean section rates in Brazil: Trend analysis using the Robson classification system.

Cesarean section (CS) is a surgical procedure used to deliver babies that is medically indicated to prevent maternal and neonatal mortality. However, it is associated with short- and long-term risks. CS rates have increased, and efforts are being made to ensure that CS is performed only when necessary. The Robson classification system is considered useful for studying, evaluating, monitoring, and comparing CS rates within and between healthcare facilities. In Brazil, there are few studies on this subject, and no large epidemiological studies on this topic utilizing the Robson classification have been reported. This study aimed to report and analyze CS rates in Brazil using the Robson classification system, and subsequently suggest possible measures to address it.Data were collected from the Brazilian Live Birth Information System (Sistema de Informações sobre Nascidos Vivos) that contains data of the entire obstetric population, from 2014 to 2017. All births in the country during this period were analyzed according to the Robson classification.A total of 11,774,665 live births were reported in Brazil during 2014 to 2017, most of which were mostly via CS (55.8%). Regions with high human development indexes had significantly higher CS rates than those with low human development indexes. The Robson group (RG) 1 to 4 accounts for 60.2% of live births and 47.1% of all CSs. RG5 was larger than all the other groups and contributed to the highest global rate of CS (31.3%), in addition to being the group who presented the largest growth.Although RG 1 to 4 present favorable initial conditions for vaginal delivery, CS accounted for almost half of births in these groups. The size of RG1 and RG2 in Brazil was comparable to that in countries with low CS rates; however, CS rates in these groups were 3 times higher in Brazil. Nulliparous women in RG1 and RG2 who undergo CS are subsequently categorized into RG5, increasing the global CS rate by 1% annually.We suggest the implementation of health policies to avoid the unnecessary performance of CS in RG1 and RG2 to decrease the CS rates in Brazil.

Amniotic fluid volume at presentation with early preterm prelabor rupture of membranes and association with severe neonatal respiratory morbidity.

OBJECTIVE: Amniotic fluid volume (AFV) plays an important role in early fetal lung development, and oligohydramnios in early pregnancy is associated with pulmonary hypoplasia. The aim of this study was to evaluate the association between AFV at the time of presentation with early preterm prelabor rupture of membranes (PPROM) and severe neonatal respiratory morbidity and other adverse pregnancy outcomes. METHODS: This was a retrospective study of all women with a singleton pregnancy, admitted to a single tertiary referral center between 2004 and 2014, for expectant management of PPROM at 20 + 0 to 28 + 6 weeks' gestation. The primary exposure was AFV at presentation, classified according to sonographic maximum vertical pocket (MVP) as: normal AFV (> 2 cm), oligohydramnios (≤ 2 cm and > 1 cm) or severe oligohydramnios (≤ 1 cm). The primary outcome was a composite variable of severe respiratory morbidity, defined as either of the following: (1) need for respiratory support in the form of mechanical ventilation using an endotracheal tube for ≥ 72 h and need for surfactant; or (2) bronchopulmonary dysplasia, defined as requirement for oxygen at postmenstrual age of 36 weeks or at the time of transfer to a Level-II facility. Adjusted odds ratios (aOR) and 95% CI for the primary and secondary outcomes were calculated for each AFV-at-presentation group (using normal AFV as the reference), adjusting for gestational age (GA) at PPROM, latency period, birth weight, mode of delivery and chorioamnionitis. RESULTS: In total, 580 women were included, of whom 304 (52.4%) had normal AFV, 161 (27.8%) had oligohydramnios and 115 (19.8%) had severe oligohydramnios at presentation. The rates of severe respiratory morbidity were 16.1%, 26.7% and 45.2%, respectively. Compared with normal AFV at presentation, oligohydramnios (aOR, 3.27; 95% CI, 1.84-5.84) and severe oligohydramnios (aOR, 4.11; 95% CI, 2.26-7.56) at presentation were associated independently with severe respiratory morbidity. Other variables that were associated independently with the primary outcome were GA at PPROM (aOR, 0.54; 95% CI, 0.43-0.69), latency period (aOR, 0.94; 95% CI, 0.91-0.98) and Cesarean delivery (aOR, 2.01; 95% CI, 1.21-3.32). CONCLUSIONS: In women with early PPROM, AFV at presentation, as assessed by the MVP on ultrasound examination, is associated independently with severe neonatal respiratory morbidity. This information may be taken into consideration when counseling women with early PPROM regarding neonatal outcome and management options. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos / Avances en la asistencia al parto en Brasil: resultados preliminares de dos estudios evaluativos / Progress in childbirth care in Brazil: preliminary results of two evaluation studies

Resumo: Este artigo tem como objetivo descrever os primeiros resultados de dois estudos avaliativos, um sobre a Rede Cegonha e outro sobre o projeto Parto Adequado, denominados, respectivamente, de avaliação da Rede Cegonha e Nascer Saudável, e identificar possíveis melhorias em comparação ao estudo Nascer no Brasil. Ambos os estudos têm desenho seccional, realizados em 2017. O estudo avaliação da Rede Cegonha incluiu todas as 606 maternidades públicas e mistas envolvidas na Rede Cegonha e um total de 10.675 puérperas. O estudo Nascer Saudável incluiu uma amostra de conveniência de 12 hospitais da rede privada e um total de 4.798 mulheres. Os indicadores de atenção ao parto e nascimento avaliados foram: presença de acompanhante, atendimento por enfermeira obstétrica, preenchimento de partograma, uso de métodos não farmacológicos, deambulação, alimentação, uso de cateter venoso periférico, analgesia, posição da mulher para o parto, episiotomia e manobra de Kristeler. Esses indicadores foram comparados aos encontrados no Nascer no Brasil, estudo de base nacional realizado em 2011-2012, antes do início dos dois programas de intervenção. Para as comparações utilizamos o teste do qui-quadrado para amostras independentes e nível de 95% de confiança. Houve um aumento significativo do número de mulheres com acesso à tecnologia apropriada ao parto entre os anos de 2011 e 2017 e redução de práticas consideradas prejudiciais. No setor privado, observou-se também redução nas taxas de cesariana e aumento da idade gestacional ao nascer. Os resultados deste estudo mostram que políticas públicas bem conduzidas podem mudar o cenário da atenção ao parto e nascimento, promovendo a redução de desfechos maternos e neonatais negativos.

Resumen: El objetivo de este artículo es describir los primeros resultados de dos estudios evaluativos, uno sobre la Red Cigüeña y otro sobre el proyecto Parto Adecuado, denominados respectivamente como evaluación de la Red Cigüeña y Nacer Sano, e identificar posibles mejorías en comparación con el estudio Nacer en Brasil. Ambos estudios tienen un diseño transversal, realizados en 2017. El estudio evaluación de la Red Cigüeña incluyó todas las maternidades públicas (606) y mixtas implicadas en la Red Cigüeña y a un total de 10.675 puérperas. El estudio Nacer Sano incluyó una muestra de conveniencia de 12 hospitales privados y a un total de 4.798 mujeres. Los indicadores de atención al parto y nacimiento evaluados fueron: presencia de acompañante, atención por enfermera obstetra, cumplimentación de partograma, uso de métodos no farmacológicos, deambulación, alimentación, uso de catéter venoso periférico, analgesia, posición de la mujer para el parto, episiotomía y maniobra de Kristeler. Estos indicadores se compararon con los encontrados en Nacer en Brasil, un estudio a nivel nacional, realizado en 2011-2012, antes del inicio de los dos programas de intervención. Para las comparaciones utilizamos el test del chi-cuadrado para muestras independientes y nivel de confianza de un 95%. Hubo un aumento significativo del número de mujeres con acceso a la tecnología apropiada para el parto entre los años de 2011 y 2017 y una reducción de las prácticas consideradas perjudiciales. En el sector privado, se observó también una reducción en las tasas de cesárea y aumento de la edad gestacional al nacer. Los resultados de este estudio muestran que las políticas públicas bien dirigidas pueden cambiar el escenario de la atención al parto y nacimiento, promoviendo la reducción de desenlaces maternos y neonatales negativos.

Abstract: This article aims to describe the preliminary results of two evaluations studies, one about the Stork Network program and the other about the Adequate Birth program, called Stork Network Assessment and Healthy Birth, and to identify possible improvements in comparison to the Birth in Brazil study. Both studies used a cross-sectional design and were conducted in 2017. The Stork Network Assessment study included all 606 public and mixed maternity hospitals from the Stork Network and a total of 10,675 postpartum women. The Healthy Birth study included a convenience sample of 12 private hospitals and 4,798 women. Indicators of labour and childbirth care were: presence of a companion person, care by obstetric nurse, use of partograph, use of non-pharmacological methods, walking during labor, eating, use of peripheral venous catheter, position for delivery, episiotomy, and Kristeller maneuver. The indicators were compared to those verified in Birth in Brazil, a nationwide population-based study in 2011-2012, before the start of the two intervention programs. Comparisons used the chi-square test for independent samples and 95% confidence interval. There was a significant increase in the number of women with access to appropriate technology for labour and childbirth from 2011 to 2017 and a reduction in harmful practices. The private sector also showed a decrease in cesarean rates and an increase in gestational age at birth. The study's results show that properly conducted public policies can change the scenario of care for labor and childbirth, helping to reduce in negative maternal and neonatal outcomes.

Obstetric complications after laparoscopic excision of posterior deep infiltrating endometriosis: a case-control study.

OBJECTIVE: To study obstetric outcomes and complications in women with previously excised posterior deep infiltrating endometriosis (DIE) in comparison with women without endometriosis. DESIGN: Matched case-control study. SETTING: Tertiary-level academic center. PATIENT(S): All surgeries for endometriosis performed in the Department of Gynecology and Gynecological Oncology, University of Bern between March 2004 and July 2015, were assessed. Inclusion criteria included complete laparoscopic excision of posterior DIE. Exclusion criteria included concomitant hysterectomies, refusal to participate, and patients lost to follow-up. Each subsequent pregnancy was matched to three controls by maternal age, parity, history of cesarean, and mode of conception. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Obstetric complications. RESULT(S): Among 841 patients with surgically diagnosed endometriosis, 125 satisfied the inclusion and exclusion criteria. Of these, 73 pregnancies resulted, although a further 11 patients were excluded owing to early miscarriages or extrauterine pregnancies. The final study cohort included 62 singleton pregnancies matched to 186 controls. The analysis identified an increased risk of placenta previa, gestational hypertension, and intrauterine growth restriction for the case group. The possibility of successful vaginal delivery was similar between groups. Moreover, no significant increase in risk of maternal and neonatal delivery complications, except for a slightly higher postpartum blood loss in the case group, was observed. CONCLUSION(S): Despite previous surgical excision, women with history of DIE present a higher risk of placenta previa, gestational hypertonia, and intrauterine growth restriction during pregnancy. Previous surgery for DIE does not seem to predispose to failed vaginal delivery.

A retrospective study of supplemental iron intake in singleton pregnancy women with risk of developing gestational diabetes mellitus.

This study investigated the effect of supplemental iron intake (SII) in early singleton pregnancy women with the risk of developing gestational diabetes mellitus (GDM) among Chinese population.This study included 259 singleton pregnancy participants. Of those, 135 women underwent SII and were assigned to an intervention group, while 124 participants received no SII and were assigned to a control group. The outcome measurements consisted of the number of patients with GDM development, the levels of hemoglobin (Hb) and ferritin, and the outcomes of infant at delivery.No significant difference in the number of patients with GDM development was found between 2 groups at delivery. However, when compared with control group, subjects in the intervention group showed greater efficacy in delivery mode choice of vaginal delivery (P = .04), and cesarean section (P = .01), as well as the birthweight of infants (P < .01). Moreover, Hb and ferritin levels were also significantly higher in the intervention group than those in the control group (P < .01).The results of this retrospective study showed that SII may not increase risk of developing GDM in singleton pregnancy women; and also may benefit both pregnancy women and infants among Chinese population.

Discurso de mulheres sobre a experiência do parto normal e da cesariana / Habla de las mujeres en la experiencia el parto y normal cesareo / Speech of women on the experience the normal birth and cesarean section

Objective: this study aimed to comprehend the experience of vaginal delivery and caesarean section in women from Riachão Jacuípe-Ba. Method: A descriptive exploratory qualitative research study was conducted. Ten residents women between 20 years or greater in the immediate postpartum period were interviewed. Data were collected through semi-structured interview and analyzed by Fiorin speech analysis technique. Results: The analysis revealed that the technocratic model of childbirth care, dominant today, has been influencing the experience of women, both in relation to vaginal birth and caesarean section. It was further proved the lack of guidance from professionals that accompanied the prenatal of the interviewees. Conclusion: A woman to be an active part in childbirth, she needs to be clarified about this since pregnancy.

Objetivo: compreender a vivência do parto normal e cesáreo por mulheres de Riachão do Jacuípe-Ba. Método: Pesquisa exploratória de caráter qualitativo. Foram entrevistadas dez puérperas com idade maior ou igual a 20 anos. Os dados foram coletados através de entrevista semi-estruturada e analisados por meio da técnica de análise de discurso segundo Fiorin. Resultados: A análise indicou que o modelo tecnocrático de atenção ao parto vem influenciando a vivência das mulheres, tanto com relação ao parto normal quanto em relação à cesariana. Faltaram também orientações por parte dos profissionais que acompanharam o pré-natal das entrevistadas. Conclusão: Para que a mulher seja protagonista no parto, é preciso que ela esteja esclarecida sobre isso desde a gestação.

Meta: comprender la experiencia del parto normal y cesáreo por mujeres de Riachão do Jacuípe-Ba. Método: estudio exploratorio de carácter cualitativo. Diez mujeres de edad mayor o igual a 20 años fueron entrevistados en el período inmediatamente después del parto. Los datos fueron colectados a través de entrevista semi estructurada y analizados mediante técnica de análisis de discurso según Fiorin. Resultados: El análisis reveló que el modelo tecnocrático de atención al parto viene influyendo en la experiencia de las mujeres, tanto con respecto al parto normal cuanto al cesáreo. Conclusión: Para que la mujer sea un sujeto activo en el parto, es necesario aclarar con esto desde el embarazo.

What's New in Obstetric Anesthesia: The 2016 Gerard W. Ostheimer Lecture.

This special article presents potentially important trends and issues affecting the field of obstetric anesthesia drawn from publications in 2015. Both maternal mortality and morbidity in the United States have increased in recent years because, in part, of the changing demographics of the childbearing population. Pregnant women are older and have more pre-existing conditions and complex medical histories. Cardiovascular and noncardiovascular medical diseases now account for half of maternal deaths in the United States. Several national and international organizations have developed initiatives promoting optimal obstetric and anesthetic care, including guidelines on the obstetric airway, obstetric cardiac arrest protocols, and obstetric hemorrhage bundles. To deal with the increasing burden of high-risk parturients, the national obstetric organizations have proposed a risk-based classification of delivery centers, termed as Levels of Maternal Care. The goal of this initiative is to funnel more complex obstetric patients toward high-acuity centers where they can receive more effective care. Despite the increasing obstetric complexity, anesthesia-related adverse events and morbidity are decreasing, possibly reflecting an ongoing focus on safe systems of anesthetic care. It is critical that the practice of obstetric anesthesia expand beyond the mere provision of safe analgesia and anesthesia to lead in developing and promoting comprehensive safety systems for obstetrics and team-based coordinated care.

Epidemiology of Cardiac Arrest During Hospitalization for Delivery in Canada: A Nationwide Study.

BACKGROUND: Cardiac arrest in pregnancy is a rare and devastating condition with high mortality and morbidity. The objective of this study was to generate information about maternal cardiac arrest in Canada by examining the frequency, temporal incidence, associated conditions, potential etiologies, and survival rates. METHODS: This retrospective population-based study used hospitalization data from the discharge abstract database of the Canadian Institute for Health Information relating to obstetric deliveries in Canada from April 1, 2002, to March 31, 2015. The data were accessed through the Public Health Agency of Canada's (PHAC) Canadian Perinatal Surveillance System. Cases of cardiac arrest were identified using the diagnostic and intervention codes from the International Statistical Classification of Diseases and the Canadian Classification of Health Interventions, respectively. Data on patient demographics, medical and obstetrical conditions, and potential etiologies of cardiac arrest were collected. Multivariable logistic regression analysis was used to identify conditions associated with cardiac arrest. RESULTS: There were 286 cases of maternal cardiac arrest among 3,568,597 hospitalizations for delivery during the 13-year period. A total of 204 (71.3%) women survived to hospital discharge (95% confidence interval, 65.7%-76.5%). There was no significant variation in the incidence of cardiac arrest or survival from arrest over time or across provinces. Among the pre-existing conditions, hypertensive disorders of pregnancy, gestational diabetes, malignancy, and diseases of the respiratory and nervous system were found to be significantly associated with cardiac arrest. Among the obstetrical conditions, placental abnormalities and polyhydramnios were associated with cardiac arrest. The common potential etiologies included postpartum hemorrhage, heart failure, amniotic fluid embolism, and complications of anesthesia. CONCLUSIONS: In this first Canadian study, the incidence of cardiac arrest during pregnancy was found to be 1:12,500 deliveries. The survival rate reported in our study is higher than reported previously in other countries. Our study findings contribute to better inform the development and implementation of policies and programs in an effort to prevent and manage this condition.

Elevated levels of Hs-CRP and IL-6 after delivery are associated with depression during the 6 months post partum.

The objective of this study is to determine whether inflammatory markers (high-sensitivity C-reactive protein (Hs-CRP) and interleukin (IL)-6) early in the postpartum period contribute to the development of postpartum depression (PPD). From 4 May 2014 to 30 June 2014, all eligible women not on medication for depression giving birth at the Beijing Chao-Yang hospital were consecutively recruited and followed up for 6 months. Depression symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS), and inflammatory biomarkers (Hs-CRP and IL-6) were tested. During the study period, 296 women were enrolled and completed follow-up. In these women, 45 (15.2%) were considered as meeting the criteria for PPD. Serum levels of Hs-CRP and IL-6 in women with PPD were significantly higher than those without PPD (all P<0.0001). Receiver operating characteristics to predict PPD demonstrated areas under the curve of IL-6 of 0.861 (95% confidence interval (CI), 0.801-0.922), which was superior to Hs-CRP (0.837 (95% CI, 0.781-0.894), P<0.01). In multivariate logistic regression analysis, IL-6 and Hs-CRP were independent predictors of PPD. The present study demonstrates a strong relationship between elevated serum Hs-CRP and IL-6 levels at admission and the development of PPD within 6 months.

Obstetric and offspring risks of women's morbid conditions linked to prior anticancer treatments.

BACKGROUND: Literature shows the effects of type of cancer and/or anticancer treatment on live birth percentages and/or pregnancy and neonatal complications in female cancer survivors. However, studies analyzing the obstetric and offspring risks of the morbid conditions associated with previous anti-cancer treatments are missing. The present review aims to uncover these risks. METHODS: A literature search based on publications up to March 2016 identified by PubMed and references cited in relevant articles. RESULTS: The morbid conditions associated with prior anticancer treatments including chemotherapy, radiotherapy, surgery, and/or hematopoietic stem-cell transplant may induce not only obstetric and neonatal complications but also long-term effects on offspring. Whereas some risks are predominantly evidenced in untreated women others are observed in both treated and untreated women. These risks may be superimposed on those induced by the current women's trend in Western societies to postpone maternity. CONCLUSIONS: Medical professionals should be aware and inform female cancer survivors wishing to have a child not only of the short- and long-term risks to themselves and their prospective offspring of previous anticancer treatments, fertility-preservation technologies, and pregnancy itself, but also of those risks linked to the morbid conditions induced by prior anticancer treatments. Once female cancer survivors wishing to have a child have been properly informed about the risks of reproduction, they will be best placed to make decisions of whether or not to have a biological or donor-conceived child. In addition, when medical professionals be aware of these risks, they will be also best placed to provide appropriate treatments before/during pregnancy in order to prevent or alleviate the impact of these morbid conditions on maternal and offspring health.

The Validity of Discharge Billing Codes Reflecting Severe Maternal Morbidity.

BACKGROUND: Discharge diagnoses are used to track national trends and patterns of maternal morbidity. There are few data regarding the validity of the International Classification of Diseases (ICD) codes used for this purpose. The goal of our study was to try to better understand the validity of administrative data being used to monitor and assess trends in morbidity. METHODS: Hospital stay billing records were queried to identify all delivery admissions at the Massachusetts General Hospital for the time period 2001 to 2011 and the University of Michigan Health System for the time period 2005 to 2011. From this, we identified patients with ICD-9-Clinical Modification (CM) diagnosis and procedure codes indicative of severe maternal morbidity. Each patient was classified with 1 of 18 different medical/obstetric categories (conditions or procedures) based on the ICD-9-CM code that was recorded. Within each category, 20 patients from each institution were selected at random, and the corresponding medical charts were reviewed to determine whether the ICD-9-CM code was assigned correctly. The percentage of correct codes for each of 18 preselected clinical categories was calculated yielding a positive predictive value (PPV) and 99% confidence interval (CI). RESULTS: The overall number of correctly assigned ICD-9-CM codes, or PPV, was 218 of 255 (86%; CI, 79%-90%) and 154 of 188 (82%; CI, 74%-88%) at Massachusetts General Hospital and University of Michigan Health System, respectively (combined PPV, 372/443 [84%; CI, 79-88%]). Codes within 4 categories (Hysterectomy, Pulmonary edema, Disorders of fluid, electrolyte and acid-base balance, and Sepsis) had a 99% lower confidence limit ≥75%. Codes within 8 additional categories demonstrated a 99% lower confidence limit between 74% and 50% (Acute respiratory distress, Ventilation, Other complications of obstetric surgery, Disorders of coagulation, Cardiomonitoring, Acute renal failure, Thromboembolism, and Shock). Codes within 6 clinical categories demonstrated a 99% lower confidence limit <50% (Puerperal cerebrovascular disorders, Conversion of cardiac rhythm, Acute heart failure [includes arrest and fibrillation], Eclampsia, Neurotrauma, and Severe anesthesia complications). CONCLUSIONS: ICD-9-CM codes capturing severe maternal morbidity during delivery hospitalization demonstrate a range of PPVs. The PPV was high when objective supportive evidence, such as laboratory values or procedure documentation supported the ICD-9-CM code. The PPV was low when greater judgment, interpretation, and synthesis of the clinical data (signs and symptoms) was required to support a code, such as with the category Severe anesthesia complications. As a result, these codes should be used for administrative research with more caution compared with codes primarily defined by objective data.

Trends in Perinatal Care and Implications for Frontline Nurse Leaders.

The perinatal trends presented in this article are based on recent topics from conferences, journals, the media, as well as from input from perinatal nurses. Trends in patient care are influenced by evidence known for decades, new research, emerging and innovative concepts in healthcare, patient and family preferences, and the media. Trends discussed in this article are rethinking the due date, birth outside the hospital setting, obstetric hospitalists as birth attendants, nitrous oxide for pain in childbirth, hydrotherapy and waterbirth in the hospital setting, delayed cord clamping, disrupters of an optimal infant microbiome, skin-to-skin care during cesarean surgery, and breast-sleeping and the breast-feeding dyad. In addition, the authors developed implications for perinatal nurses related to each trend. The goal is to stimulate reflection on evidence that supports or does not support current practice and to stimulate future research by discussing some of the current trends that may influence the care that perinatal nurses provide during the birthing year.

The association between temporal changes in the use of obstetrical intervention and small-for-gestational age live births.

BACKGROUND: The literature attributes secular declines in small-for-gestational age (SGA) live births to changes in maternal smoking and other maternal characteristics. However, there are reasons to believe that the observed reductions in SGA may be a consequence of early delivery following obstetric intervention. METHODS: We examined temporal trends in obstetrical intervention and SGA among singleton live births in the United States from 1990 to 2010. The modified Kitagawa decomposition, based on the fetuses-at-risk approach, was used to assess the relative contribution of changes in the gestational age distribution and gestational age-specific SGA to overall changes in SGA. Reductions in SGA rates due to a left shift in the gestational age distribution were assumed to primarily reflect increased obstetrical intervention, whereas decreases in overall SGA due to decreases in gestational-age-specific SGA rates were assumed to reflect declines in risk factors. RESULTS: Temporal trends in SGA followed a non-linear pattern, with substantial declines from 10.1% in 1990-92 to 8.9% in 2002-04, followed by a small increase to 9.1% in 2008-10. Rates of maternal smoking steadily decreased throughout the same time period and changes in SGA rates were more consistent with changes in the gestational age distribution. The modified Kitagawa decomposition analysis also attributed the initial decline in SGA rates to changes in the gestational age distribution. CONCLUSIONS: Complex temporal pattern in SGA rates cannot be explained by the linear pattern of changes in factors like maternal smoking. Changes in the gestational age distribution are more consistent with the observed secular trends in SGA rates.