Evidence-based cesarean delivery: preoperative management (part 7).

Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.

Patient Perception of Telemedicine in Maternal-Fetal Medicine.

Background: Maternal-fetal medicine (MFM) is a medical subspecialty that cares for patients with high-risk pregnancies. Methods: An IRB-approved survey was offered to patients in MFM offices of a tertiary health care system from March 2022 to May 2022. Demographics and responses to 15 statements about telemedicine were collected via a 5-point Likert scale. Exploratory factor analysis was performed to identify factors affecting patient perception of the telemedicine experience. We sought to examine perception of telemedicine in MFM, identify factors affecting perception, and identify whether specific demographics were associated with patients who view telemedicine appointments favorably. Results: Surveys were completed by 327 of 347 (94%) patients. A total of 233 (71%) patients felt that the telemedicine experience was equal in quality to in-person appointments, and 257 (79%) were open to telemedicine appointments in the future. Exploratory factor analysis yielded two factors: "physician attentiveness" and "technology comfort." Telemedicine was viewed favorably or neutrally for both factors. Education (lower) and marital status (single) were associated with a favorable perception of physician attentiveness. Ethnicity (Hispanic), employment status (employed), and prior telemedicine experience were associated with a favorable perception of technology comfort. Conclusion: Most patients felt the quality of telemedicine appointments was equal to those completed in person. Physician attentiveness and technology comfort affect telemedicine perception. Specific patient demographic characteristics were associated with differing perceptions of telemedicine in MFM. Our findings suggest that telemedicine is positively viewed for MFM and can be used for improving health care delivery efficiency in MFM.

Preeclampsia and Long-term Kidney Outcomes: An Observational Cohort Study.

RATIONALE & OBJECTIVE: Preeclampsia is a pregnancy-related complication characterized by acute hypertension and end-organ dysfunction. We evaluated the long-term association between preeclampsia and the risk of developing chronic hypertension and kidney disease. STUDY DESIGN: Observational cohort study. SETTING & PARTICIPANTS: 27,800 adults with deliveries in the Geisinger Health System between 1996 and 2019. EXPOSURE: Preeclampsia. OUTCOME: Hypertension, reduced estimated glomerular filtration rate (eGFR)<60mL/min/1.73m2), and albuminuria>300mg/g. ANALYTICAL APPROACH: Propensity-score matching and Cox proportional hazards models to evaluate the association between preeclampsia and incident hypertension, reduced eGFR, and albuminuria. RESULTS: Of 27,800 adults with pregnancies during the study period (mean age, 28 years; 3% Black race), 2,977 (10.7%) had at least 1 pregnancy complicated by preeclampsia. After matching for multiple characteristics, individuals with preeclampsia had a higher risk of developing chronic hypertension (HR, 1.77 [95% CI, 1.45-2.16]), eGFR<60mL/min/1.73m2 (HR, 3.23 [95% CI, 1.64-6.36]), albuminuria (HR, 3.60 [95% CI, 2.38-5.44]), and a subsequent episode of preeclampsia (HR, 24.76 [95% CI, 12.47-48.36]), compared with matched controls without preeclampsia. Overall, postpartum follow-up testing was low. In the first 6 months after delivery, 31% versus 14% of individuals with and without preeclampsia had serum creatinine tests, respectively, and testing for urine protein was the same in both groups, with only 26% having follow-up testing. LIMITATIONS: Primarily White study population, observational study, reliance on ICD codes for medical diagnosis. CONCLUSIONS: Individuals with a pregnancy complicated by preeclampsia had a higher risk of hypertension, reduced eGFR, and albuminuria compared with individuals without preeclampsia. PLAIN-LANGUAGE SUMMARY: Preeclampsia is a significant contributor to perinatal and maternal morbidity and is marked by new-onset hypertension and end-organ damage, including acute kidney injury or proteinuria. To gain insight into the long-term kidney effects of the disease, we compared adults with deliveries complicated by preeclampsia with those without preeclampsia in the Geisinger Health System, while also assessing postpartum testing rates. Our results demonstrate that pregnant individuals with preeclampsia are at a heightened risk for future hypertension, reduced eGFR, and albuminuria, with overall low rates of postpartum testing among both individuals with and without preeclampsia. These findings underscore the need to consider preeclampsia as an important risk factor for the development of chronic kidney disease. Further studies are required to determine optimal postpreeclampsia monitoring strategies.

Comparison of three antepartum risk assessment tools to predict significant postpartum hemorrhage in livebirths.

BACKGROUND: To adequately predict significant postpartum hemorrhage (PPH) at hospital admission, we evaluated and compared the accuracy of three risk assessment tools: 1. California Maternal Quality Care Collaborative (CMQCC), 2. American College of Obstetrics and Gynecology Safe Motherhood Initiative (ACOG SMI) and 3. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). STUDY DESIGN AND METHODS: This is a retrospective cohort study of people who delivered liveborn infants from January 2018 to June 2021 at our center. Patients with comorbidities necessitating higher hemoglobin values, those who refused blood transfusions, and missing pertinent data were excluded. Significant PPH was defined as a blood transfusion within 48 hours following delivery. Diagnostic statistics were calculated for each tool. RESULTS: Of the 11,679 included pregnancies, 232 (1.9%) people had significant PPH. Amongst those diagnosed as high-risk by the CMQCC tool, 67/1485 (4.5%) had significant PPH; 62/1672 (3.7%) by the ACOG SMI tool, and 85/1864 (4.6%) by the AWHONN tool had significant PPH. All tools have low sensitivity and high negative predictive values. The area under the receiver operating characteristics curve of the three tools is moderately poor (CMQCC: 0.58, ACOG SMI: 0.55, AWHONN:0.61). DISCUSSION: Upon admission to labor and delivery, all three studied tools are poor predictors of significant PPH. The development and validation of better PPH risk stratification tools are required with the inclusion of additional important variables.

Pregnancy Outcomes in Patients Enrolled in the Healthy Beginnings Plus Program.

OBJECTIVE: To evaluate the effectiveness of enrollment in the Healthy Beginnings Plus Program (HB) on pregnancy outcomes. DESIGN: Retrospective cohort study of 12,299 singleton pregnancies birthed between January 2007 and December 2018. SETTING/LOCAL PROBLEM: Individuals of low socioeconomic status are at increased risk for adverse pregnancy outcomes, such as preterm birth (PTB) and low-birth-weight (LBW) neonates. Pennsylvania offers HB to pregnant individuals with Medical Assistance insurance to provide additional psychosocial and obstetric resources to routine prenatal care to minimize risk. PARTICIPANTS: Individuals with Medical Assistance insurance enrolled in HB (n = 4,645), individuals with Medical Assistance insurance not enrolled in HB (n = 2,874), and individuals with private insurance (n = 4,780). MEASUREMENTS: Primary outcomes were rates of PTB and LBW neonates. Secondary outcomes included rates of gestational diabetes, gestational hypertension, small-for-gestational-age neonates, and admission to the NICU. RESULTS: There were no differences in PTB (adjusted OR [aOR] = 0.93, 95% confidence interval [CI] [0.76, 1.13]) or LBW neonates (aOR = 1.06, 95% CI [0.86, 1.31]) between individuals with Medical Assistance enrolled in HB versus those with Medical Assistance insurance not enrolled in HB. Individuals with Medical Assistance enrolled in HB were less likely to develop gestational hypertension compared to individuals with Medical Assistance insurance not enrolled in HB (aOR = 1.41, 95% CI [1.25, 1.59]) and individuals with private insurance (aOR = 0.85, 95% CI [0.76, 0.96]). They also attended more prenatal visits than individuals with Medical Assistance insurance not enrolled in HB (12.0 vs. 14.0, p < .01). CONCLUSION: Although there was no significant difference between groups for the primary outcomes studied, individuals with Medical Assistance insurance enrolled in HB attended more prenatal visits than those who did not enroll in HB. Similar programs should evaluate outcomes and consider whether changes are needed.

Women's beliefs of pain after childbirth: Critical insight for promoting behavioral strategies to regulate pain and reduce risks for maternal mortality.

OBJECTIVE: Promoting behavioral strategies to better regulate pain and decrease the use of prescription pain medications immediately after childbirth is an attractive approach to reduce risks for adverse outcomes associated with the maternal mortality crisis. This study aimed to understand women's beliefs and experiences about pain management to identify important insights for promoting behavioral strategies to control postpartum pain. METHODS: N = 32 postpartum women participated in a semi-structured interview about beliefs/experiences with managing postpartum pain. Higher- and lower-order themes were coded; descriptive statistics were used to summarize results. RESULTS: Major trends emerging from the data were: (1) most women used a combination of medications (e.g., oxycodone and acetaminophen) and behavioral strategies (e.g., physical activity) in the hospital (94 %) and at discharge (83 %); (2) some women reported disadvantages like negative side effects of medications and fatigue from physical activity; and (3) some women reported they would have preferred to receive more evidence-based education on behavioral strategies during prenatal visits. CONCLUSION: Our findings showed that most women were prescribed medications while in the hospital and at discharge, and used non-prescription, behavioral strategies. PRACTICAL IMPLICATIONS: Future research is needed to test behavioral strategies in randomized clinical trials and clinical care settings to identify impact on reducing adverse maternal health outcomes.

Retrospective application of algorithms to improve identification of pregnancy outcomes from the electronic health record.

OBJECTIVE: To improve upon the accuracy of ICD codes for identifying maternal and neonatal outcomes by developing algorithms that incorporate readily available EHR data. STUDY DESIGN: Algorithms were developed for gestational hypertension (GHTN), pre-eclampsia (PreE), gestational diabetes mellitus (GDM) and were compared to ICD codes and chart review. Accuracy and sensitivity analyses were calculated with their respective 95% confidence limits for each of the comparisons between algorithms, ICD codes alone, and chart review. RESULTS: Sensitivity of GHTN ICD codes was 8.1% vs. 83.8% for the algorithm when compared to chart review. In comparison to chart review, sensitivity of ICD codes for PreE was 7.5% vs. 71.4% for the algorithm. GDM had similar sensitivity rates for both ICD codes and the algorithm. CONCLUSION: Application of algorithms, validated by chart review, enhanced capture of several outcomes. Algorithms should be obligatory adjunct tools to the ICD codes for identification of outcomes of interest.

Suture Compared With Staples for Skin Closure After Cesarean Delivery: A Systematic Review and Meta-analysis.

OBJECTIVE: Absorbable suture is the preferred method of cesarean skin closure compared with metal staples, because it decreases wound complications. Two recently published trials in patients with obesity contradict this evidence. The goal of this meta-analysis was to assess whether suture remains the recommended method of cesarean skin closure, regardless of obesity status. DATA SOURCES: MEDLINE through OVID, PubMed, Cochrane Database, and ClinicalTrials.gov were searched from inception until September 24, 2021. METHOD OF STUDY SELECTION: Published randomized controlled trials (RCTs) comparing subcuticular absorbable suture with nonabsorbable metal staples for cesarean skin closure were included. Non-RCTs, RCTs that did not compare staples with suture, and ongoing trials were excluded. Fourteen studies met inclusion criteria. TABULATION, INTEGRATION AND RESULTS: Data were individually abstracted and entered into RevMan. Fixed and random effects models were used. The Cochrane risk-of-bias tool was used to assess each study. The primary outcome, a sensitivity analysis of wound complications (excluding studies at high risk of bias), showed a significant decrease in wound complications when the cesarean skin incision was closed with suture compared with staples (10 studies; 71/1,497 vs 194/1,465; risk ratio [RR] 0.47, 95% CI 0.25-0.87). When all studies were analyzed, there remained a significant decrease in wound complications when the skin was closed with suture (14 studies; 121/1,780 vs 242/1,750; RR 0.59, 95% CI 0.36-0.97). Of the individual wound complications, wound separation was significantly decreased with suture closure compared with staples (11 studies; 55/1,319 vs 129/1,273; RR 0.43, 95% CI 0.32-0.58). In patients with obesity, there remained a significant decrease in wound complications with suture closure of the skin incision compared with staples (five studies; 34/507 vs 67/522; RR 0.51, 95% CI 0.34-0.75). CONCLUSION: Closure of the cesarean skin incision with suture decreased composite wound complications by 50% as compared with closure with staples; a significant decrease persisted regardless of obesity status. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021270378.

Factors that shape pregnant women's perceptions regarding the safety of cannabis use during pregnancy.

BACKGROUND: Cannabis use among pregnant women has increased. We surveyed pregnant women in rural Pennsylvania to examine cannabis use and opinions regarding its safety during pregnancy. We examined associations between challenges of pregnancy (e.g., exhaustion, pain, nausea) and cannabis use. METHODS: A cross-sectional survey was administered to a convenience sample of English-speaking pregnant women receiving prenatal care at Geisinger, May-June 2019. Principal component analysis (PCA) was used to construct three scores (overwhelmed/exhausted, happy/optimistic, and health worries) based on 10 questions regarding common experiences during pregnancy (e.g., nausea/vomiting, pain, exhaustion, mood). A score based on four questions regarding cannabis safety during pregnancy was also constructed. RESULTS: From a maximum of 300 surveys distributed, 284 were completed (95%). Most participants were white (87%), married (49%) or living with a partner (38%), and had private health insurance (62%). Most women indicated it was unsafe to use alcohol and tobacco products during pregnancy (> 90%), but that proportion dropped to 82% and 63% regarding recreational cannabis and medical cannabis, respectively. Only women with prior cannabis use (23% of sample) continued to do so during pregnancy: 57% of women reporting daily cannabis use prior to pregnancy continued to use cannabis during pregnancy with 33% reporting daily use. Two thirds of users during pregnancy indicated they were self-medicating for: nausea (90%), anxiety (70%), insomnia (30%), and pain management (30%). Many (56%) of the women who used cannabis during pregnancy believed it is safe. Younger women and women who were overwhelmed/exhausted or less happy/optimistic were more likely to believe cannabis use is safe. Women valued healthcare provider advice more than advice from family and friends. Study strengths include a high response rate. Weaknesses include self-report and that is was a convenience sample; however, the demographics of the sample were similar to past studies. CONCLUSION: Women with a history of cannabis use, especially daily use, are at risk of continuing during pregnancy and should receive counseling. Younger women and women with greater stressors during pregnancy also are at greater risk. Screening for prior use and for stressors may identify patients that would benefit from enhanced counseling.

Obstetricians' prescribing practices for pain management after delivery.

Aim: To examine postpartum opioid prescribing practices. Materials & methods: Obstetricians were interviewed about opioids: choice of opioid, clinical factors considered when prescribing, thoughts/beliefs about prescribing, and typical counseling provided. Inductive thematic analyses were used to identify themes. Results: A total of 38 interviews were analyzed. Several key points emerged. The choice of opioid, dosing and number of pills prescribed varied widely. The mode of delivery is the primary consideration for prescribing opioids. All providers would prescribe opioids to breastfeeding women. Some providers offered counseling on nonopioid treatment of pain. Discussion: At two large tertiary centers in Pennsylvania, the 38 physicians interviewed wrote 38 unique opioid prescriptions. Patient counseling addressed short-term pain management, but not the chronic overuse of opioids.

We wanted to look at the way opioid pain drugs are provided to mothers after the birth of their children and see what doctors tell mothers about the pain drugs. We interviewed doctors and asked which opioid pain drug they would choose, what made them prescribe the drug, the thoughts about giving mothers the drug and what they told the mothers about the drug. We then looked at all the responses to look for patterns in how doctors gave pain drugs to mothers. Our team interviewed 38 doctors. Some key points were seen; first is that the choice of opioid pain drug, dose and number of pills prescribed was different from doctor to doctor; second is that whether the baby was delivered vaginally or by cesarean was the main factor upon which doctors based their decisions for giving opioid pain drugs. Whether a mother was taking medications that help with addiction, the doctor's assessment of the mother's pain and the doctor's thoughts on the mother's risk of opioid addiction were also considered. All doctors would give opioid pain drugs to breastfeeding mothers. Finally, some doctors talked to mothers about using other medications for pain, but not about the overuse of opioid pain drugs. At our two hospital centers in Pennsylvania, the 38 doctors gave opioid pain drugs to mothers in 38 different ways. Doctors said that opioids are necessary after cesarean, but not after vaginal birth, unless there is a problem. A mother's history and social situation inform decision making. Doctors talk to mothers about short-term pain, but not about the overuse of opioid pain drugs.

A retrospective review of pregnancy outcomes in women with uncomplicated mild to moderate chronic hypertension.

OBJECTIVE: To examine pregnancy complications in women with uncomplicated mild-moderate chronic hypertension (CHTN) treated with antihypertensives prior to 20 weeks compared to those not on antihypertensives. STUDY DESIGN: This retrospective cohort study examined singleton pregnancies of women with mild-moderate CHTN who delivered from 01/2014-3/2019. Pregnancies complicated by hypertension at ≥ 20 weeks, end organ damage, preexisting diabetes mellitus, early-onset gestational diabetes, multifetal gestation, and fetal anomalies were excluded. Adjusted logistic regression analyses were performed for each of the outcomes. Adjusted odds ratios (aOR) were reported along with associated 95% confidence intervals (CI) and p-values. MAIN OUTCOME MEASURES: Primary outcome was superimposed preeclampsia with severe features. Additional maternal outcomes were superimposed preeclampsia without severe features, severe hypertension, indicated preterm delivery, placental abruption, and mode of delivery. Neonatal outcomes included composite perinatal outcomes (fetal growth restriction, intrauterine fetal demise, and small for gestational age neonate), low birth weight, very low birth weight, admission to the neonatal intensive care unit, and Apgar score <7 at 5-minutes. RESULTS: 345 women were identified: 232 (67.2%) were not taking antihypertensives and 113 (32.8%) were taking ≥1 antihypertensive. There was no significant difference in the primary outcome (p = 0.65; aOR = 0.88; 95% CI 0.51-1.52) among the group taking antihypertensive therapy as compared to those not taking antihypertensives. No statistically significant differences were seen for any of the other secondary maternal or neonatal outcomes. CONCLUSIONS: Our data supports that the use of antihypertensive therapy in women with mild-moderate CHTN does not reduce the risk of developing superimposed preeclampsia.

Comparison of different methods of patient education on preeclampsia: a randomized controlled trial.

BACKGROUND: Preeclampsia is a life-threatening condition unique to pregnancy that contributes to maternal mortality worldwide. Delays in diagnosis and treatment are contributing factors for most maternal deaths from preeclampsia. Patients who are educated and knowledgeable regarding this disease process may present earlier for care. OBJECTIVE: To assess whether two different visual aids are effective methods to educate patients about preeclampsia, and to evaluate the potential impact of these visual aids on patient anxiety. STUDY DESIGN: Primigravid participants at a tertiary care center were given a survey regarding preeclampsia knowledge 18-25 weeks gestation. Participants were then randomized to preeclampsia education with a graphic card, an educational video, or through routine prenatal care. Participants completed the survey again at 32-37 weeks gestation. We compared the follow-up preeclampsia knowledge score for each type of education as well as the level of anxiety after viewing the video or graphic card. RESULTS: Recruitment began 9 May 2016 and ceased 18 January 2017. A total of 179 patients were randomized and 150 participants completed the study, with 56 shown the graphic card, 45 shown the educational video, and 49 who had only routine prenatal counseling. The remaining 28 patients were lost to follow up and 1 was withdrawn. There was no significant difference in preeclampsia knowledge score at follow-up. There was no significant difference in anxiety score before and after viewing either educational tool for those randomized to either the graphic card (p = .64) or the video (p = .63). CONCLUSIONS: There is no additional improvement of patient knowledge retention when patients receive education with a graphic card versus an educational video over routine prenatal counseling. Patient anxiety does not appear to be impacted by preeclampsia education with a graphic card or an educational video.

Duration of postpartum magnesium sulfate for seizure prophylaxis in women with preeclampsia: a systematic review and meta-analysis.

OBJECTIVE: Pregnant women diagnosed with preeclampsia are at increased risk of eclampsia. Magnesium sulfate is the standard of care for maternal seizure prophylaxis. Traditional regimens of magnesium sulfate have continued infusions for 24 h postpartum. More recent evidence suggests shortened courses of postpartum magnesium sulfate. The purpose of this systematic review is to evaluate whether the duration of postpartum magnesium sulfate for seizure prophylaxis in women with preeclampsia affects the incidence of seizures postpartum. DATA SOURCE: MEDLINE, Cochrane Library, and clinicaltrials.gov were reviewed from inception until 1 May 2020. METHODS OF STUDY SELECTION: Two hundred and fifty-three studies were reviewed by three individual authors. Inclusion criteria were as follows: published, randomized controlled trials (RCTs) that included pregnant women diagnosed with preeclampsia who received a maintenance infusion of magnesium sulfate in the postpartum period. Studies were excluded if either arm did not provide maintenance dosing of magnesium sulfate in the postpartum period. We also excluded ongoing, unpublished, and non-randomized trials. RESULTS: Nine RCTs (n = 1369) were included in the systematic review. Data were abstracted and reviewed by three authors, then entered into Review Manager data software. The primary outcome of eclampsia was reported in all nine studies. An eclamptic event occurred in 2/696 women who received <24 h of postpartum magnesium compared to 0/673 events in women who received ≥24 h of postpartum magnesium (RD 0.00, 95% CI -0.01, 0.01; p=.71). Women who received <24 h of postpartum magnesium sulfate had a significantly faster time to ambulation postpartum (MD -10.57, 95% CI -17.43, -3.71; p=.003) and shorter durations of indwelling urinary catheter placement (MD -18.97, 95% CI -34.64, -3.29; p=.02). CONCLUSIONS: As eclampsia is a rare occurrence, this review was not powered to show a difference in the rate of eclampsia. However, the two cases of eclampsia that were reported occurred in the group of women who received <24 h of postpartum magnesium sulfate. Therefore, the results of this systematic review support continued use of 24 h of postpartum magnesium sulfate for seizure prophylaxis.

Obstetric Physicians' Beliefs and Knowledge on Guidelines and Screening Tools to Reduce Opioid Use After Childbirth.

OBJECTIVE: To examine obstetric physicians' beliefs about using professional or regulatory guidelines, opioid risk-screening tools, and preferences for recommending nonanalgesic therapies for postpartum pain management. METHODS: A qualitative study design was used to conduct semi-structured interviews with obstetric and maternal-fetal medicine physicians (N=38) from two large academic health care institutions in central Pennsylvania. An interview guide was used to direct the discussion about each physicians' beliefs in response to questions about pain management after childbirth. RESULTS: Three trends in the data emerged from physicians' responses: 1) 71% of physicians relied on their clinical insight rather than professional or regulatory guidelines to inform decisions about pain management after childbirth; 2) although many reported that a standard opioid patient screening tool would be useful to inform clinical decisions about pain management, nearly all (92%) physician respondents reported not currently using one; and 3) 63% thought that nonpharmacologic pain management therapies should be used whenever possible to manage pain after childbirth. Key physician barriers (eg, lack time and evidence, being unaware of how to implement) and patient barriers (eg, take away from other responsibilities, no time or patience) to implementation were also identified. CONCLUSION: These findings suggest that obstetric physicians' individual beliefs and clinical insight play a key role in pain management decisions for women after childbirth. Practical and scalable strategies are needed to: 1) encourage obstetric physicians to use professional or regulatory guidelines and standard opioid risk-screening tools to inform clinical decisions about pain management after childbirth, and 2) educate physicians and patients about nonopioid and nonpharmacologic pain management options to reduce exposure to prescription opioids after childbirth.

Patient preferences for method of cesarean skin closure: secondary outcomes from a randomized trial.

Objective: To assess patient preference for sutures or staples for cesarean wound closure.Methods: This is a planned secondary analysis of a randomized controlled trial of 746 women in which suture and staples were compared for cesarean skin closure. Enrolled patients were asked to complete preoperative and postoperative surveys to assess preferred closure. Reasons for expressed preferences were elicited for each patient. Preferences were stratified by a number of cesarean deliveries (CD). We sought to determine if patients had a specific preference for wound closure due to personal experience or a personal belief that one method may be more beneficial with respect to pain and appearance.Results: We surveyed 550 patients preoperatively and 627 postoperatively. Women with a prior CD were more likely to have a skin closure preference compared with women having a primary CD (p < .05). Women who had a prior closure with suture rather than staples were significantly more likely to have a preference for the same wound closure method (p < .01). Avoiding the need for staple removal was the main reason women preferred suture closure, both preoperatively and postoperatively. The higher the number of the previous CD, the greater the preference for future closure with suture over staples (p < .05).Conclusions: Women undergoing cesarean delivery prefer suture as the method for skin closure compared with staples.

Comparing Diagnosis of Fetal Growth Restriction and the Potential Impact on Management and Outcomes Using Different Growth Curves.

OBJECTIVES: The diagnosis of fetal growth restriction (FGR) is managed with close fetal surveillance and often requires iatrogenic delivery, as there is an associated increased risk of fetal demise. However, there is no standard reference for fetal growth. We sought to compare the intrauterine growth curve of Hadlock et al (Radiology 1991; 181:129-133) to other known growth curves to determine which one best identifies fetuses at risk without overburdening the patient and health care system with unnecessary intervention. METHODS: We retrospectively reviewed charts of singleton euploid pregnancies with a diagnosis of FGR (per Hadlock) at a tertiary care center from June 2014 to May 2015. We applied the estimated fetal weights from ultrasound at diagnosis of FGR to 4 population-based growth curves by Brenner et al (Am J Obstet Gynecol 1976; 126:555-564), Williams et al (Obstet Gynecol 1982; 59:624-632), Alexander et al (Obstet Gynecol 1996; 87:163-168), and Duryea et al (Obstet Gynecol 2014; 124:16-22) and reassessed the incidence of FGR using each curve. We reviewed pregnancy demographics, risk factors, pregnancy management, and outcomes of FGR cohorts on each curve to evaluate whether poor outcomes may be missed or interventions may be avoided using the population-based curves. A sensitivity analysis was also done to see how well each curve predicted small-for-gestational-age birth weights. RESULTS: Applying any of the population-based growth curves decreased the number of FGR diagnoses, iatrogenic deliveries, and primary cesarean deliveries. Brenner's growth curve identified the least number of FGR diagnoses at 22 of the 107 identified by Hadlock. Williams' growth curve performed best in the sensitivity analysis with sensitivity of 99% and specificity of 97%. A small number of patients with absent/reversed end-diastolic flow would have been missed by applying the population curves. CONCLUSIONS: Applying the population-based growth curves instead of Hadlock's for diagnosis of FGR decreases its incidence, therefore decreasing the number of visits for ultrasound and fetal surveillance and the number of iatrogenic deliveries. However, using these curves could miss a few fetuses with increased risk of fetal demise.

Associations Between Maternal Body Mass Index, Gestational Weight Gain, Maternal Complications, and Birth Outcome in Singleton, Term Births in a Largely Non-Hispanic White, Rural Population.

Background: In 2009, the Institute of Medicine (IOM) published guidance on gestational weight gain (GWG) modified by body mass index (BMI). GWG outside of IOM recommendations negatively affects birth outcomes and child health. This study examined the relationship between BMI, GWG, birth complications, and birth outcomes in a rural, non-Hispanic white population over 10 years. Materials and Methods: We examined maternal BMI, GWG, birth weight, birth complications, and Apgar score in 18,217 term singleton births from medical records at Geisinger, PA from 2006 to 2015. Primary outcomes were GWG, delivery mode, Apgar score, and infant birth weight. Results: A majority of women (74.2%) had GWG outside of recommendations. Prevalence of cesarean delivery was highest for women with GWG above recommendations regardless of BMI. One in five neonates of obese women with GWG above recommendations had Apgar scores below eight. Although most births were normal for gestational age (88%), underweight women who gained below recommendations had the highest percentage of small for gestational age (SGA) births (10.4%) and obese women who gained above recommendations had the highest percentage of large for gestational age (LGA) births (22.2%). Among women with BMIs above 35 kg/m2 and GWG within recommendations, 18.9% of births were LGA. Conclusions: Most pregnant women are not gaining weight within recommendations. GWG outside of IOM recommendations resulted in poorer birth outcomes, particularly in underweight and obese women. Underweight women with GWG below recommendations are at increased risk for SGA neonates. We suggest reducing GWG recommendations for women above 35 kg/m2 to decrease LGA births and pregnancy complications.