The red hat - designating leadership using visual and verbal cues: a mixed-methods study.

BACKGROUND: During a critical event in the labor and delivery operating room, it is crucial for team members responding to the situation to be aware of the designated leaders. Visual and verbal cues have been utilized to designate leadership in various healthcare settings; however, previous research has indicated mixed results using visual cues for role designation. METHODS: The purpose of this study was to explore the use of the red surgical hat as a visual cue of leadership during obstetric emergency simulation training. We used a mixed-methods design to analyze simulation-based education video and debriefing transcripts. RESULTS: There was a statistically significant difference in the proportion of participants who declared leadership vs. those who donned the red hat. Participants were more likely to visually declare leadership utilizing a red surgical bouffant hat than to verbally declare leadership. Most participants indicated that observing the red hat to detect leadership in the operating room was more effective than when leaders used a verbal declaration to inform others who was leading. CONCLUSIONS: Our findings suggest that utilizing a visual cue of leadership with the red surgical bouffant hat improves participant perceptions of communication of the surgical team during an obstetrical critical event in a simulation environment.

Integrating simulation and interpretive description to explore operating room leadership: critical event continuing education.

In Obstetrics and Gynecologic operating room emergencies, the surgeon cannot both operate and lead a suddenly expanded and redirected team response. However, one of the most often used approaches to interprofessional continuing education designed to improve teams' ability to respond to unanticipated critical events still emphasizes surgeon leadership. We developed Explicit Anesthesia and Nurse Distributed (EXPAND) Leadership to imagine a workflow that might better distribute emergency leadership task responsibilities and practices. The purpose of this exploratory study was to investigate teams' responses to distributing leadership during an interprofessional continuing education simulated obstetrical emergency. We used interpretive descriptive design in a secondary analysis of teams' post-simulation reflective debriefings. One-hundred sixty providers participated, including OB-Gyn surgeons, anesthesiologists, CRNAs, scrub technicians, and nurses. Using reflective thematic analysis, we identified three core themes: 1) The surgeon is focused on the surgical field, 2) Explicit leadership initiates a nurse transition from follower to leader in a hierarchical environment, and 3) Explicit distributed leadership enhances teamwork and taskwork. Continuing education which uses distributed leadership to improve teams' ability to respond to an obstetric emergency is perceived to enhance team members' response to the critical event . The potential for nurses' career growth and professional transformation was an unexpected finding associated with this continuing education which used distributed leadership. Our findings suggest that healthcare educators should consider ways in which distributed leadership may improve teams' response to critical events in the operating room.

The AKT1-FOXO4 axis reciprocally regulates hemochorial placentation.

Hemochorial placentation involves the differentiation of invasive trophoblast cells, specialized cells that possess the capacity to exit the placenta and invade into the uterus where they restructure the vasculature. Invasive trophoblast cells arise from a well-defined compartment within the placenta, referred to as the junctional zone in rat and the extravillous trophoblast cell column in human. In this study, we investigated roles for AKT1, a serine/threonine kinase, in placental development using a genome-edited/loss-of-function rat model. Disruption of AKT1 resulted in placental, fetal and postnatal growth restriction. Forkhead box O4 (Foxo4), which encodes a transcription factor and known AKT substrate, was abundantly expressed in the junctional zone and in invasive trophoblast cells of the rat placentation site. Foxo4 gene disruption using genome editing resulted in placentomegaly, including an enlarged junctional zone. AKT1 and FOXO4 regulate the expression of many of the same transcripts expressed by trophoblast cells, but in opposite directions. In summary, we have identified AKT1 and FOXO4 as part of a regulatory network that reciprocally controls critical indices of hemochorial placenta development.

The cerebroplacental ratio and prediction of fetal growth restriction in twin pregnancies.

OBJECTIVES: The cerebroplacental ratio (CPR) represents the relationship between blood flow in the placenta and blood flow in the fetal brain. A low CPR in the third trimester has been associated with poor perinatal outcomes in both singleton and twin gestations. This study aimed to evaluate whether low CPR defined or high CPR discordance at 20-24 weeks in twin pregnancies is associated with an increased risk of fetal growth restriction (FGR) in the third trimester. METHODS: A total of 247 twin pregnancies were included in this retrospective cohort study. Monoamniotic monochorionic twins were excluded. An abnormal CPR was defined as one or both CPR <5%-ile or CPR discordance between fetuses >20%. FGR was evaluated using the last growth measurement performed between 28 and 36 weeks. RESULTS: Of the candidates for study, 177 twin pregnancies had normal CPRs and 70 twin pregnancies had abnormal CPRs. Maternal demographics were similar between groups. There was no difference in the risk of selective FGR, FGR of both twins, or growth discordance >20% in the third trimester between twin pregnancies with normal vs. abnormal CPRs at 20-24 weeks. The adjusted odds ratio for any growth disturbance was 1.00 (95% CI 0.56-1.79). CONCLUSIONS: This study suggests that FGR in twins may be the consequence of numerous maternal, fetal, and placental factors, and not fully explained by redistribution of blood flow or adaptive hypoxia in the mid-trimester.

Racial and Ethnic Differences in Urine Drug Screening on Labor and Delivery.

INTRODUCTION: This study evaluates racial and ethnic differences in urine drug screening and patient consent to urine drug screening at a single tertiary care center. METHODS: We conducted a retrospective cohort study of all deliveries at a single tertiary care center from January 1, 2015 to December 31, 2019. Medical records were queried for demographic data, performance of urine drug screening, commonly used diagnoses that prompted screening, documentation of patient consent, and result of screen. Associations between these outcomes were then assessed using Chi-square analysis and logistic regression. RESULTS: During the study period, 685 of 9953 (6.9%) of patients had a urine drug screen performed. Non-Hispanic Black patients comprised 33.6% of patients receiving screening, but only 16.6% of the total population. Of examined indications for urine drug screening, only insufficient prenatal care and trauma differed significantly between groups. After adjusting for commonly used diagnoses prompting screening, non-Hispanic black patients were significantly more likely to have urine drug screening performed (OR 2.0, 95% CI 1.6-2.4). Non-Hispanic Black and Hispanic patients were not significantly more likely to have a positive screen result when compared to Non-Hispanic White patients. Consent to urine drug screening was poorly documented (only 11.7% of patients had documented consent). This did not differ significantly between the major racial or ethnic groups. CONCLUSION: Non-Hispanic Black and Hispanic patients experience differences in urine drug screening during admission for delivery that cannot be solely explained by differences in incidence of diagnoses that typically trigger screening. Documentation of patient consent to urine drug screening is poor.

Second trimester cerebroplacental ratio versus umbilicocerebral ratio for the prediction of adverse perinatal outcomes.

INTRODUCTION: An abnormal third trimester cerebroplacental ratio has been previously associated with adverse perinatal outcome. The less studied inverse of the cerebroplacental ratio, the umbilicocerebral ratio, has been proposed as a better predictor of adverse perinatal outcome. However, little is known about the implication of either an abnormal cerebroplacental ratio or umbilicocerebral ratio in the second trimester. The objective of this study was to evaluate the relationship between an abnormal second trimester cerebroplacental ratio and adverse perinatal outcome and provide comparison to an abnormal second trimester umbilicocerebral ratio. MATERIALS AND METHODS: This retrospective cohort study in a single tertiary referral center utilized data from all non-anomalous singleton pregnancies that underwent Doppler assessment of the cerebroplacental ratio between 20 and 28 weeks gestation. The study period was 1 January 2015 to 31 July 2018. Abnormal cerebroplacental ratio was defined as less than the 5th percentile for gestational age. If patients had more than one ultrasound during the study period (i.e. for serial assessment of fetal growth), the lowest value of the cerebroplacental ratio was recorded. The primary outcome was a composite of clinically relevant adverse perinatal outcomes including preterm delivery, small for gestational age, and neonatal intensive care unit admission. Secondary outcomes included urgent delivery for fetal distress (operative vaginal delivery or cesarean section) and hypertensive disorders of pregnancy. An abnormal umbilicocerebral ratio was defined as greater than 95th percentile for gestational age. Areas under the curve were calculated and compared for cerebroplacental ratio and umbilicocerebral ratio. RESULTS: 2326 pregnancies met inclusion criteria. Of these, 91 (3.9%) had an abnormal second trimester cerebroplacental ratio. Fetuses with an abnormal second trimester cerebroplacental ratio had a 2.3-fold (95% CI 1.5-3.6, p < .05) increased risk of adverse perinatal outcome after adjusting for potential confounders such as chronic hypertension, pregestational diabetes, and smoking during pregnancy. Significantly increased risks of preterm delivery (OR 2.0, 95% CI 1.1-38, p < .05) and neonatal intensive care unit admission (OR 2.1, 95% CI 1.2-3.6, p < .05) were also seen in a subgroup analysis of abnormal cerebroplacental ratio in appropriate for gestational age infants. 132 (5.7%) fetuses had an abnormal second trimester umbilicocerebral ratio, and these fetuses had a 2.0-fold (95% CI 1.4-3.0, p < .05) increased risk of adverse perinatal outcome. The area under the curve for CPR and UCR for prediction of the primary outcome was 0.6 for both (95% CI 0.57-0.61 and 0.57-0.62, respectively, both p < .05). CONCLUSION: An abnormal second trimester cerebroplacental ratio or umbilicocerebral ratio is associated with adverse perinatal outcome. However, the predictive ability of either ratio remains suboptimal.

Left ventricular assist device in pregnancy: Case report and review of the literature.

Left ventricular assist devices have emerged as a safe and effective therapy for end-stage heart failure patients. However, little is known about the safety of these devices during pregnancy. We describe a 23-year-old woman who received a left ventricular device for nonischemic cardiomyopathy of uncertain origin. She became pregnant approximately 1 year later. With close monitoring of her hemodynamic parameters, she was able to achieve a gestational age of 34 weeks, at which time she delivered a healthy male infant by cesarean delivery. Pregnancies in women with left ventricular assist devices may be successful, but remain medically challenging and complex pregnancies. Close multidisciplinary involvement and frequent assessment of device parameters during pregnancy is warranted.

Eculizumab Maintenance and the Prevention of Atypical Hemolytic Uremic Syndrome Relapse During Pregnancy: A Case Report.

Atypical hemolytic uremic syndrome is a thrombotic microangiopathy that can cause life-threatening anemia, thrombocytopenia, and acute renal failure. When triggered during pregnancy or the acute postpartum period, the disease is referred to as pregnancy-associated atypical hemolytic uremic syndrome (P-aHUS). Women who suffer P-aHUS may later want to consider future pregnancy. These patients are at high, though not well-estimated, risk of relapse. Eculizumab, a monoclonal antibody against complement 5 (C5), has been highly successful in treating acute attacks of P-aHUS, but little is known about the effectiveness of eculizumab maintenance therapy throughout pregnancy. In this case report, we present a woman whose first pregnancy was complicated by severe P-aHUS. In her next pregnancy, she was maintained on eculizumab. She delivered a healthy infant at term and had no recurrences of P-aHUS during the pregnancy or in the postpartum period.