Delivery room intubation and severe intraventricular hemorrhage in extremely preterm infants without low Apgar scores: A Japanese retrospective cohort study.

The purpose of this study was to assess the associations between delivery room intubation (DRI) and severe intraventricular hemorrhage (IVH), as well as other neonatal outcomes, among extremely preterm infants without low Apgar scores using data from a large-scale neonatal registry data in Japan. We analyzed data for infants born at 24-27 gestational weeks between 2003 and 2019 in Japan using robust Poisson regression. Infants with low Apgar scores (≤ 1 at 1 min or ≤ 3 at 5 min) were excluded. The primary outcome was severe IVH. Secondary outcomes were other neonatal morbidities and mortality. The full cohort included 16,081 infants (intubation cohort, 13,367; no intubation cohort, 2714). The rate of DRI increased over time (78.6%, 2003-2008; 83.4%, 2009-2014; 87.8%, 2015-2019), while the rate of severe IVH decreased (7.1%, 2003-2008; 5.7%, 2009-2014; 5.3%, 2015-2019). Infants with DRI had a higher risk of severe IVH than those without DRI (6.8% vs. 2.3%; adjusted risk ratio, 1.86; 95% confidence interval, 1.33-2.58). The results did not change substantially when stratified by gestational age. Despite conflicting changes over time in DRI and severe IVH, DRI was associated with an increased risk of severe IVH among extremely preterm infants in Japan.

Outpatient Cervical Ripening with Balloon Catheters: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate whether outpatient cervical ripening with a balloon catheter results in a shorter amount of time in the labor and delivery unit when compared with use in the inpatient setting. DATA SOURCES: PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov were searched from their inception until December 2020. No restrictions for language or geographic location were applied. METHODS OF STUDY SELECTION: Using a predefined protocol and search strategy, 1,152 titles were identified and screened. Randomized controlled trials that compared outpatient and inpatient cervical ripening with balloon catheters were included. TABULATION, INTEGRATION, AND RESULTS: Data extraction and risk of bias assessments were performed by two reviewers. Meta-analysis was performed to produce mean difference for continuous data and risk ratio (RR) for dichotomous data, both with a 95% CI. The primary outcome was the amount of time from admission to the labor ward until delivery. Additional secondary maternal and neonatal outcomes were evaluated. Eight trials (740 patients) were included; six studies (571 patients) reported on our primary outcome. Compared with the inpatient group, outpatient balloon cervical ripening was associated with significantly less time in the labor and delivery unit (outpatient 16.3±9.7 hours vs inpatient 23.8±14.0 hours; mean difference -7.24 hours, 95% CI -11.03 to -3.34). There were no differences in total induction time or total hospital admission. The outpatient group was significantly less likely than the inpatient group to undergo cesarean delivery (21% vs 27%), RR 0.76 (95% CI 0.59-0.98). There were no differences in other maternal or neonatal outcomes. There were no deliveries outside of the hospital and no stillbirths. CONCLUSION: Outpatient balloon cervical ripening in low-risk patients is associated with a decreased amount of time from admission to labor and delivery until delivery. Outpatient balloon cervical ripening is a safe alternative for low-risk patients and has the potential for significant benefits to patients, and labor and delivery units. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019140503.

The contemporary value of dedicated preterm birth clinics for high-risk singleton pregnancies: 15-year outcomes from a leading maternal centre.

OBJECTIVES: Preterm birth clinics provide dedicated obstetric care to women at high risk of spontaneous preterm birth (SPTB). There remains a lack of conclusive evidence to support the overall utility of such clinics, attributable to a paucity and heterogeneity of primary data. This study audits Australia's largest and oldest dedicated preterm birth clinic with the aim to add primary data to the area and offer opportunities for similar clinics to align practice. METHODS: A retrospective audit of referrals to the Preterm Labour Clinic at the Royal Women's Hospital, Melbourne, Australia, between 2004 and 2018 was conducted. 1,405 singleton pregnancies met inclusion criteria. The clinic's key outcomes, demographics, predictive tests and interventions were analysed. The primary outcomes were SPTB before 37, 34 and 30 weeks' gestation. RESULTS: The overall incidence of SPTB in the clinic was 21.2% (n=294). Linear regression showed reductions in the adjusted rates of overall SPTB and pre-viable SPTB (delivery <24 weeks) from 2004 (108%; 8%) to 2018 (65%; 2% respectively). Neonatal morbidity and post-delivery intensive care admission concurrently declined (p=0.02; 0.006 respectively). Rates of short cervix (cervical length <25 mm) increased over time (2018: 30.9%) with greater uptake of vaginal progesterone for treatment. Fetal fibronectin, mid-trimester short cervix, and serum alkaline phosphatase were associated with SPTB on logistic regression. CONCLUSIONS: Dedicated preterm birth clinics can reduce rates of SPTB, particularly deliveries before 24 weeks' gestation, and improve short-term neonatal outcomes in pregnant women at risk of preterm birth.

The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: a 16-month retrospective study.

BACKGROUND: No Pain Labor &Delivery (NPLD) is a nongovernmental project to increase access to safe neuraxial analgesia through specialized training. This study explores the change in overall cesarean delivery (CD) rate and maternal request CD(MRCD) rate in our hospital after the initiation of neuraxial analgesia service (NA). METHODS: NA was initiated in May 1st 2015 by the help of NPLD. Since then, the application of NA became a routine operation in our hospital, and every parturient can choose to use NA or not. The monthly rates of NA, CD, MRCD, multiparous women, intrapartum CD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia were analyzed from January 2015 to April 2016. RESULTS: The rate of NA in our hospital was getting increasingly higher from 26.1% in May 2015 to 44.6% in April 2016 (p < 0.001); the rate of CD was 48.1% (3577/7360) and stable from January to May 2015 (p>0.05), then decreased from 50.4% in May 2015 to 36.3% in April 2016 (p < 0.001); the rate of MRCD was 11.4% (406/3577) and also stable from January to May 2015 (p>0.05), then decreased from 10.8% in May 2015 to 5.7% in April 2016 (p < 0.001). At the same time, the rate of multiparous women remained unchanged during the 16 month of observation (p>0.05). There was a negative correlation between the rate of NA and rate of overall CD, r = - 0.782 (95%CI [- 0.948, - 0.534], p<0.001), and between the utilization rate of NA and rate of MRCD, r = - 0.914 (95%CI [- 0.989, - 0.766], p<0.001). The rates of episiotomy, PPH, operative vaginal delivery and neonatal asphyxia in women who underwent vaginal delivery as well as the rates of intrapartum CD, neonatal asphyxia, and PPH in women who underwent CD remained unchanged, and there was no correlation between the rate of NA and anyone of those rates from January 1st 2015 to April 30th 2016 (p>0.05). CONCLUSIONS: Our study shows that the rates of CD and MRCD in our department were significantly decreased from May 1st 2015 to April 30th 2016, which may be due to the increasing use of NA during vaginal delivery with the help of NPLD.

Maternal and neonatal outcome of births planned in alongside midwifery units: a cohort study from a tertiary center in Germany.

BACKGROUND: For healthy women entering birth after uneventful pregnancy, midwife-led models of care have the potential to reduce interventions and increase the vaginal birth rate. In Germany, 98.4% of women are giving birth in consultant-led obstetric units. Alongside midwifery units (AMU) have been established in 2003. We compared the outcome of women registered for planned birth in the AMU at our hospital with a matched group of low-risk women who gave birth in standard obstetric care during the same period of time. METHODS: We used a retrospective cohort study design. The study group consisted of all women admitted to labor ward who had registered for birth in AMU from 2010 to 2017. For the control group, low-risk women were selected; additionally, matching was performed for parity. Mode of birth was chosen as primary outcome parameter for the mother. For the neonate, a composite primary outcome (5-min Apgar < 7 or umbilical cord arterial pH < 7.10 or transfer to specialist neonatal care) was defined. Secondary outcomes included epidural anesthesia, duration of the second stage of labor, episiotomy, obstetric injury, and postpartum hemorrhage. Non-inferiority was assessed, and multiple logistic regression analysis was performed. RESULTS: Six hundred twelve women were admitted for labor in AMU, the control group consisted of 612 women giving birth in standard obstetric care. Women in the study group were on average older and had a higher body mass index (BMI); birthweight was on average 95 g higher. Non-inferiority could be established for the primary outcome parameters. Epidural anesthesia and episiotomy rates were lower, and the mean duration of the second stage of labor was shorter in the study group; second-degree perineal tears were less common, higher-order obstetric lacerations occurred more frequently. Overall, 50.3% of women were transferred to standard obstetric care. Regression analysis revealed effects of parity, age and birthweight on the chance of transfer. CONCLUSION: Compared to births in our consultant-led obstetric unit, the outcome of births planned in the AMU was not inferior, and intervention rates were lower. Our results support the integration of AMU as a complementary model of care for low-risk women.

Comparison of Neonatal Intubation Practice and Outcomes between the Neonatal Intensive Care Unit and Delivery Room.

BACKGROUND: Characteristics of neonatal tracheal intubations (TI) may vary between the neonatal intensive care unit (NICU) and delivery room (DR). The impact of the setting on TI outcomes is not well characterized. OBJECTIVE: The aim of this study was to define variation in neonatal TI practice between settings, and identify the association between setting and TI success and safety outcomes. DESIGN: This was a retrospective cohort study of TIs in the National Emergency Airway Registry for Neonates from October 2014 to September 2017. The setting (NICU vs. DR) was the exposure of interest. The outcomes were first attempt success, course success, success within 4 attempts, adverse TI-associated events, severe desaturation, and bradycardia. We compared TI characteristics and outcomes between settings in univariable analysis. Factors significant in univariable analysis (p < 0.1) were included in a logistic regression model, with adjustment for clustering by center, to identify the independent impact of the setting on TI outcomes. RESULTS: There were 3,145 TI encounters (2279 NICU, 866 DR) in 9 centers. Almost all baseline characteristics significantly varied between settings. First attempt success rates were 48% (NICU) and 46% (DR). In multivariable analysis, the setting was not associated with first attempt success. DR was associated with a higher adjusted OR (aOR) of success within 4 attempts (1.48, 95% CI 1.06-2.08) and a lower aOR for bradycardia (0.43, 95% CI 0.26-0.71). CONCLUSION: Significant differences in patient, provider, and practice characteristics exist between NICU and DR TIs. There is substantial room for improvement in first attempt success rates. These results suggest interventions to improve safety and success need to be targeted to the distinct setting.

Association of early postnatal transfer and birth outside a tertiary hospital with mortality and severe brain injury in extremely preterm infants: observational cohort study with propensity score matching.

OBJECTIVE: To determine if postnatal transfer or birth in a non-tertiary hospital is associated with adverse outcomes. DESIGN: Observational cohort study with propensity score matching. SETTING: National health service neonatal care in England; population data held in the National Neonatal Research Database. PARTICIPANTS: Extremely preterm infants born at less than 28 gestational weeks between 2008 and 2015 (n=17 577) grouped based on birth hospital and transfer within 48 hours of birth: upward transfer (non-tertiary to tertiary hospital, n=2158), non-tertiary care (born in non-tertiary hospital; not transferred, n=2668), and controls (born in tertiary hospital; not transferred, n=10 866). Infants were matched on propensity scores and predefined background variables to form subgroups with near identical distributions of confounders. Infants transferred between tertiary hospitals (horizontal transfer) were separately matched to controls in a 1:5 ratio. MAIN OUTCOME MEASURES: Death, severe brain injury, and survival without severe brain injury. RESULTS: 2181 infants, 727 from each group (upward transfer, non-tertiary care, and control) were well matched. Compared with controls, infants in the upward transfer group had no significant difference in the odds of death before discharge (odds ratio 1.22, 95% confidence interval 0.92 to 1.61) but significantly higher odds of severe brain injury (2.32, 1.78 to 3.06; number needed to treat (NNT) 8) and significantly lower odds of survival without severe brain injury (0.60, 0.47 to 0.76; NNT 9). Compared with controls, infants in the non-tertiary care group had significantly higher odds of death (1.34, 1.02 to 1.77; NNT 20) but no significant difference in the odds of severe brain injury (0.95, 0.70 to 1.30) or survival without severe brain injury (0.82, 0.64 to 1.05). Compared with infants in the upward transfer group, infants in the non-tertiary care group had no significant difference in death before discharge (1.10, 0.84 to 1.44) but significantly lower odds of severe brain injury (0.41, 0.31 to 0.53; NNT 8) and significantly higher odds of survival without severe brain injury (1.37, 1.09 to 1.73; NNT 14). No significant differences were found in outcomes between the horizontal transfer group (n=305) and controls (n=1525). CONCLUSIONS: In extremely preterm infants, birth in a non-tertiary hospital and transfer within 48 hours are associated with poor outcomes when compared with birth in a tertiary setting. We recommend perinatal services promote pathways that facilitate delivery of extremely preterm infants in tertiary hospitals in preference to postnatal transfer.

The EASE Project Revisited: Improving Safe Sleep Practices in Ohio Birthing and Children's Hospitals.

Literature has shown hospitalized infants are not often observed in recommended safe sleep environments. Our objective was to implement a quality improvement program to improve compliance with appropriate safe sleep practices in both children's and birthing hospitals. Hospitalists from both settings were recruited to join an Ohio American Academy of Pediatrics collaborative to increase admitted infant safe sleep behaviors. Participants used a standardized tool to audit infants' sleep environments. Each site implemented 3 PDSA (Plan-Do-Study-Act) cycles to improve safe sleep behaviors. A total of 37.0% of infants in children's hospitals were observed to follow the current American Academy of Pediatrics recommendations at baseline; compliance improved to 59.6% at the project's end (P < .01). Compliance at birthing centers was 59.3% and increased to 72.5% (P < .01) at the collaborative's conclusion. This study demonstrates that a quality improvement program in different hospital settings can improve safe sleep practices. Infants in birthing centers were more commonly observed in appropriate sleep environments than infants in children's hospitals.

Assessing the Feasibility of Measuring Variation in Facility Design Among American Childbirth Facilities.

OBJECTIVE: To assess the feasibility of quantifying variation in childbirth facility design and explore the implications for childbirth service delivery across the United States. BACKGROUND: Design has been shown to impact quality of care in childbirth. However, most prior studies use qualitative data to examine associations between the design of patient rooms and patient experience. There has been limited exploration of measures of unit design and its impact on care provision. METHOD: We recruited 12 childbirth facilities that were diverse with regard to facility type, location, delivery volume, cesarean delivery rate, and practice model. Each facility provided annotated floor plans and participated in a site visit or telephone interview to provide information on their design and clinical practices. These data were analyzed with self-reported primary cesarean delivery rates to assess associations between design and care delivery. RESULTS: We observed wide variation in childbirth unit design. Deliveries per labor room per year ranged from 75 to 479. The ratio of operating rooms to labor rooms ranged from 1:1 to 1:9. The average distance between labor rooms and workstations ranged from 23 to 114 ft, and the maximum distance between labor rooms ranged from 9 to 242 ft. More deliveries per room, fewer labor rooms per operating room, and longer distances between spaces were all associated with higher primary cesarean delivery rates. CONCLUSIONS: Clinically relevant differences in design can be feasibly measured across diverse childbirth facilities. The design of these facilities may not be optimally matched to service delivery needs.

Impact of surfactant administration through a thin catheter in the delivery room: A quality control chart analysis coupled with a propensity score matched cohort study in preterm infants.

INTRODUCTION: Most infants born before 30 weeks gestational age (GA) develop respiratory distress syndrome soon after birth. Methods of surfactant administration that avoid ventilation have been recently introduced. The aim of this study was to evaluate the impact of implementing a new procedure of less invasive surfactant administration (LISA) and determine whether it is associated with an improvement in respiratory outcome. METHODS: This single center cohort quality improvement study analyzed preterm infants born before 30 weeks GA between May 2010 and April 2016. Changes in health care practices and respiratory outcomes following the implementation of a LISA, i.e. the administration of surfactant through a thin catheter, were analyzed using quality control charts. Then, the effect of LISA on respiratory outcome was assessed by propensity score matching and logistic regression weighted by the inverse of the propensity score. RESULTS: During the study period, 379 infants were included. Of those that were not intubated at ten minutes of life, 129 received surfactant and were ventilated for one hour or more (InVent), 127 received LISA, five received surfactant with tracheal mechanical ventilation for less than one hour (InSurE), and 55 were only treated with nasal continuous positive pressure during the first hour of neonatal care (nCPAP). Quality-chart analysis revealed rapid implementation of the method with a concomitant decrease in required ventilation. LISA was associated with fewer tracheal ventilation days and a lower incidence of supplemental oxygen on day 28. When controlling for the propensity to be exposed or not to LISA, this procedure was not associated with a lower risk of death or bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age. CONCLUSION: In this study, the successful implementation of the new method was associated with lower rates of mechanical ventilation, but without a significant reduction of grade I/II/III BPD or death.

[Impact of organizational factors on the cesarean delivery occurrence in a low-risk population]. / Facteurs organisationnels associés à la réalisation d'une césarienne dans une population à bas risque.

OBJECTIVE: Huge differences in cesarean delivery rate exist between maternities in a same region. In recent years, the cesarean delivery rate has increased in the low-risk population. The objective of this study was to assess the impact of organizational factors on the cesarean delivery occurence in a low-risk population. METHODS: We performed a population-based cohort study in the MYPA perinatal network from 2009 to 2015. A low-risk population was selected, keeping only groups 1 and 3 of the Robson classification. The studied organizational factors included the structural characteristics of maternity (academic or not, public or private, number of annual births, maternal intensive care unit, neonatal intensive care unit, number of delivery rooms) and the organization of the health care team (number of midwives and obstetricians, on call duty, workload and implementation of a morbi-mortality review). We used a logistic multilevel model, based on random center effect, for both univariable and multivariable analysis. RESULTS: Our study population included 64,100 women. The cesarean delivery rate ranged from 5.5 to 11.3 % among the 10 maternities. In univariate analysis, the organizational variables significantly associated with the cesarean delivery rate were maternity status (university hospital, non-university public hospital and private hospital) and the implementation of a morbi-mortality review. However, after adjustment, none of these organizational factors were significantly associated with the cesarean delivery occurence. When multivariate analysis was restricted to the nulliparous subgroup, the private status of maternity was significantly associated with a higher rate of cesarean deliveries (OR=1.39 [1.09-1.76]). Also, the probability of cesarean delivery was higher when the number of births by delivery room increased (OR=1.15 [1.01-1.31]). For the multiparous subgroup, no variable was significantly associated with cesarean delivery occurence. CONCLUSION: In our global low-risk population, no organizational factors appeared to be associated with an increase in cesarean delivery rate. On the other hand, in the low-risk nulliparous population, the private status of the maternity and a high number of births by delivery room were associated with more cesarean deliveries. Increasing the number of delivery rooms could be a way to reduce the number of cesarean deliveries. Future researches should also try to identify specific factors that can reduce differences in cesarean delivery rates between private and public maternities.

Historical and clinical factors associated with positive urine toxicology screening on labor and delivery.

OBJECTIVE: Illicit drug use in pregnancy may lead to adverse outcomes. Although the American College of Obstetricians and Gynecologists recommends that all pregnant women be screened for substance use by questionnaire or conversation, it remains unclear how well these methods identify women with illicit drug use. Drug use may also be suspected based on clinical complications, such as fetal demise or placental abruption. There are currently no formal recommendations to guide targeted laboratory testing in women perceived to be at risk based on historical or clinical factors. Our objective was to determine which historical and clinical factors are associated with positive urine toxicology screens in women admitted to labor and delivery. STUDY DESIGN: Historical cohort study of all women admitted to labor and delivery at our county hospital over a 5-year period (2010-2014). All patients underwent historical and clinical risk assessment and women perceived to be at increased risk of illicit drug use and who consented to testing had urine toxicology performed. We conducted a detailed chart review on all women with a positive test during this 5-year period and compared them to all women with a negative test in 2014, reporting values significant at a p-value of ≤0.05. RESULTS: Amongst the 19,604 admissions during this period, 850 women underwent urine toxicology testing, accounting for 4.8% of all admissions. We compared the 83 women who tested positive for illicit drugs (9.8% of all women tested) to the 179 women who tested negative in 2014. Historical drug use was the factor most strongly associated with a positive test. Other historical and demographic factors associated with a positive test included single relationship status, lack of employment, lack of high school education, nulliparity and history of a prior sexually-transmitted or blood-borne infection. Regarding clinical risk factors, maternal medical complications were not associated with a positive test, and obstetrical complications, like preterm labor, were associated with a negative test. CONCLUSIONS: A positive urine toxicology test was most strongly associated with maternal historical factors, especially known drug use. No clinical risk factor was associated with a positive test. The implications of our findings in guiding targeted laboratory testing are discussed.

Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

OBJECTIVES: Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU). METHODS: Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week 0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU. RESULTS: A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03). CONCLUSIONS: This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

Births in Norwegian midwife-led birth units 2008-10; a population-based study. / Fødestuefødsler i Norge 2008­10 ­ en populasjonsbasert studie.

BAKGRUNN: Fødestuene utgjør en del av en differensiert og desentralisert fødselsomsorg i Norge. Hensikten med studien var å undersøke forekomst og karakteristika ved planlagte og ikke-planlagte fødestuefødsler og årsaker til overflytting samt resultater for mor og barn. MATERIALE OG METODE: I perioden 2008-10 ble et tilleggsskjema til rutinemeldingen til Medisinsk fødselsregister fortløpende utfylt av jordmor for 2 514 av i alt 2 556 (98,4 %) fødestuefødsler og for 220 fødsler som var planlagt i fødestue, men der fødselen foregikk andre steder. Data fra tilleggsskjema ble så koblet med rutinedata i Medisinsk fødselsregister og resultater fra fødestuefødsler sammenlignet med resultater fra en lavrisikofødepopulasjon i sykehus. RESULTATER: Av de 2 514 fødestuefødslene var 2 320 (92,3 %) planlagt å foregå der, mens 194 (7,7 %) ikke var det. Ved planlagt fødestuefødsel ble totalt 6,9 % overflyttet til sykehus under fødsel, hvorav 19,5 % blant førstegangsfødende. Det var 0,4 % operative vaginale fødsler ved vanlige fødestuer, 3,5 % ved forsterkede fødestuer og 12,7 % ved fødsler overflyttet fra fødestue til sykehus. Blant barn født i fødestue hadde 0,6 % apgarskår < 7 ved 5 minutter, mot 1,0 % blant barn født i lavrisikosammenligningsgruppen i sykehus (p = 0,04). FORTOLKNING: Fødestuer bør rapportere resultater for alle som var selektert for å føde der, uansett om fødselen endte med å foregå i fødestuen eller andre steder.

Risk-stratification, resource availability, and choice of surgical location for the management of parturients with abnormal placentation: a survey of United States-based obstetric anesthesiologists.

BACKGROUND: Parturients with abnormally adherent placentas present anesthetic challenges that include risk-stratification, management planning and resource utilization. The labor and delivery unit may be remote from the main operating room services. METHODS: Division chiefs of North American obstetric anesthesiology services were surveyed about their practices and management of parturients with an abnormally adherent placenta. RESULTS: Eighty-four of 122 chiefs, representing 103 hospital sites, responded to the survey (response rate 69%). Sixty-one percent of respondents agreed that women with preoperative placental imaging that was "suspicious" of placenta accreta represented a lower risk category; all other suggested descriptions fell into a higher risk category. Seventy-nine percent of respondents indicated that lower risk cases were managed on the labor and delivery unit, while 71% indicated that higher risk cases would be managed in the main operating room. Institutions where all cases were managed on the labor and delivery unit had better access to human and technical resources, were less remote from their main operating areas, and promoted neuraxial rather than general anesthesia, even for parturients perceived to be at higher risk. CONCLUSIONS: Obstetric anesthesia leaders identified patients at lower clinical risk and those less likely to require greater resources. Additional resources were available in institutions where all abnormal placentation cases were managed on the labor and delivery unit. Practitioners should consider risk-stratification and resource availability when planning high-risk cases.

Physical stimulation of newborn infants in the delivery room.

OBJECTIVE: Neonatal resuscitation guidelines recommend that newborn infants are stimulated to assist with the establishment of regular respirations. The mode, site of application and frequency of stimulations are not stipulated in these guidelines. The effectiveness of stimulation in improving neonatal transition outcomes is poorly described. METHODS: We conducted a retrospective review of video recordings of neonatal resuscitation at a tertiary perinatal centre. Four different types of stimulation (drying, chest rub, back rub and foot flick) were defined a priori and the frequency and infant response were documented. RESULTS: A total of 120 video recordings were reviewed. Seventy-five (63%) infants received at least one episode of stimulation and 70 (58%) infants were stimulated within the first minute after birth. Stimulation was less commonly provided to infants <30 weeks' gestation (median (IQR) number of stimulations: 0 (0-1)) than infants born ≥30 weeks' gestation (1 (1-3); p<0.001). The most common response to stimulation was limb movement followed by infant cry and facial grimace. Truncal stimulation (drying, chest rub, back rub) was associated with more crying and movement than foot flicks. CONCLUSION: Less mature infants are stimulated less frequently compared with more mature infants and many very preterm infants do not receive any stimulation. Most infants were stimulated within the first minute as recommended in resuscitation guidelines. Rubbing the trunk may be most effective but this needs to be confirmed in prospective studies.

Do time of birth, unit volume, and staff seniority affect neonatal outcome in deliveries at ≥34+0 weeks of gestation?

OBJECTIVE: We investigated whether time of birth, unit volume, and staff seniority affect neonatal outcome in neonates born at ≥34+0 weeks of gestation. DESIGN: Population-based prospective cohort study. SETTING: Ten public hospitals in the Austrian province of Styria. SAMPLE: A total of 87 065 neonates delivered in the period 2004-2015. METHODS: Based on short-term outcome data, generalised linear mixed models were used to calculate the risk for adverse and severely adverse neonatal outcomes according to time of birth, unit volume, and staff seniority. MAIN OUTCOME MEASURES: Neonatal composite adverse and severely adverse outcome measures. RESULTS: The odds ratio for severely adverse events during the night-time (22:01-07:29 hours) compared with the daytime (07:30-15:00 hours) was 1.35 (95% confidence interval, 95% CI 1.13-1.61). There were no significant differences in neonatal outcome comparing weekdays and weekends, and comparing office hours and shifts. Units with 500-1000 deliveries per year had the lowest risk for adverse events. Adverse and severely adverse neonatal outcomes were least common for midwife-guided deliveries, and became more frequent with the level of experience of the doctors attending the delivery. With increasing pregnancy risks, senior staff attending delivery and delivering in a tertiary centre reduce the odds ratio for adverse events. CONCLUSIONS: Different times of delivery were associated with increased adverse neonatal outcomes. The management of uncomplicated deliveries by less experienced staff showed no negative impact on perinatal outcome. In contrast, riskier pregnancies delivered by senior staff in a tertiary centre favour a better outcome. Achieving a better balance in the total number of labour ward staff during the day and the night appears to be a greater priority than increasing the continuous presence of senior obstetrical staff on the labour ward during the out-of-hours period. TWEETABLE ABSTRACT: Deliveries during night time lead to a greater number of neonates experiencing severely adverse events.