Population risk factors for nulliparous, term, singleton, vertex caesarean birth: a national cross-sectional study.

OBJECTIVE: To characterise medical, obstetric and demographic risk factors associated with nulliparous, term, singleton, vertex (NTSV) caesarean birth. STUDY DESIGN: Cross-sectional study. SETTING: United States delivery hospitalisations. POPULATION: NTSV births in 2016-18 US natality data. METHODS: This study analysed a national sample of natality data generated by the United States National Vital Statistics System. NTSV deliveries were identified. The primary outcome was caesarean birth. Risk factors including maternal age, body mass index (BMI) and pregestational diabetes were analysed. Multivariable log-linear regression models analysed factors associated with NTSV caesarean with adjusted risk ratios (aRR) as measures of effect. RESULTS: Of 11 622 400 deliveries, 3 764 707 met NTSV criteria, and their caesarean section rate was 25.9%. Maternal age 35-39 years (aRR 1.51, 95% CI 1.50-1.52) and 40-54 years (aRR 2.03, 95% 2.00-2.05) compared with age 19-34 years; BMI 25 to <30 kg/m2 (aRR 1.32, 95% CI 1.31-1.33), 30 to <35 kg/m2 (aRR 1.57 95% CI 1.56-1.58), 35 to <40 kg/m2 (aRR 1.82, 95% CI 1.80-1.83) and ≥40 kg/m2 (aRR 2.17, 95% CI 2.15-2.19) compared with BMI 18.5-24.9 kg/m2; and pregestational diabetes (aRR 1.54, 95% CI 1.51-1.57) were all associated with increased risk. Risk factors allowed stratification of patients into high-risk versus low-risk groups. The NTSV caesarean rate was 37.9% in women who had one or more of the following characteristics: age ≥35 years, BMI ≥30 kg/m2 or pregestational diabetes. In comparison, the NTSV caesarean rate was 20.8% among women without any of these three risk factors (P < 0.01). CONCLUSION: Among NTSV births, BMI, maternal age and medical conditions are important risk factors for caesarean delivery.

Opinions regarding neonatal resuscitation training for the obstetric physician: a survey of neonatal and obstetric training program directors.

PURPOSE: Our goal was to garner opinions regarding neonatal resuscitation training for obstetric physicians. We sought to evaluate obstacles to neonatal resuscitation training for obstetric physicians and possible solutions for implementation challenges. MATERIALS AND METHODS: We distributed a national survey via email to all neonatal-perinatal medicine fellowship directors and obstetrics & gynecology residency program directors in the United States. This survey was designed by a consensus method. RESULTS: Ninety-eight (53%) obstetric and fifty-seven (51%) neonatal program directors responded to our surveys. Eighty-eight percent of neonatologists surveyed believe that obstetricians should be neonatal resuscitation program (NRP) certified. The majority of surveyed obstetricians (>89%) believe that obstetricians should have some neonatal resuscitation training. Eighty-six percent of obstetric residents have completed training in NRP, but only 19% of obstetric attendings are NRP certified. Major barriers to NRP training that were identified include time, lack of national requirement, lack of belief it is helpful, and cost. CONCLUSIONS: Most obstetric attendings are not NRP certified, but the majority of respondents believe that obstetric providers should have some neonatal resuscitation training. Our study demonstrates that most respondents support a modified neonatal resuscitation course for obstetric physicians.

Simulation as a tool for improving acquisition of neonatal resuscitation skills for obstetric residents.

OBJECTIVE: Our goal was to compare the confidence, knowledge, and performance of obstetric residents taught initial neonatal resuscitation steps in a simulation-based versus lecture-based format. METHODS: Our study was a prospective randomized controlled trial of 33 obstetric residents. Baseline confidence, knowledge, and clinical skills assessments were performed. Subjects were randomized to traditional lecture (n = 14) or simulation-based (n = 19) neonatal resuscitation curriculum with a focus on initial steps. Follow-up assessments were performed at 3 and 6 months. Total confidence, knowledge, and clinical performance scores and change from baseline in these scores were calculated and compared between groups. RESULTS: Both the lecture-based and simulated-based groups demonstrated significant improvement in confidence, knowledge, and performance over time. However, compared with the lecture group, the magnitude of the mean change from baseline in performance scores was significantly greater in the simulation group at 3 months (2.9 versus 10.1; p < 0.001), but not at 6 months (7.0 versus 9.3; p = 0.11). CONCLUSIONS: Our study demonstrates the superiority of simulation in teaching obstetric residents initial neonatal resuscitation steps compared with a traditional lecture format. Skills are retained for upwards of 3-6 months. Refresher instruction by 6 months post-instruction may be beneficial.

Predictors of maternal mortality and near-miss maternal morbidity.

OBJECTIVE: To identify risk factors for life-threatening maternal outcomes. STUDY DESIGN: Hospital charts were reviewed for cases of maternal mortality or near-miss and for controls overmatched 1:3. Significant risk factors were identified through simple and best subsets multiple logistic regression. RESULT: Eight cases of mortality and 69 near-miss cases were found. Significant risk factors with their odds ratios and 95% confidence intervals are: age 35 to 39 years (2.3, 1.2 to 4.4) and >39 years (5.1, 1.8 to 14.4); African-American race (7.4, 2.5 to 22.0) and Hispanic ethnicity (4.2, 1.3 to 13.2); chronic medical condition (2.7, 1.5 to 4.8); obesity (3.0, 1.7 to 5.3); prior cesarean (5.2, 2.8 to 9.8) and gravidity (1.2, 1.1 to 1.5 per pregnancy). In multivariable logistic regression, race remained significant while controlling for other significant factors and markers of socioeconomic status. CONCLUSION: Some risk factors can be modified through medical care, education or social support systems. Racial disparity in outcome is confirmed and is unexplained by traditional risk factors.

Failed methotrexate termination of pregnancy: a case report.

We report a case of a fetus with shortened proximal long bones, ambiguous genitalia, intrauterine growth restriction and abnormal umbilical artery Doppler velocities observed on antenatal ultrasound exam. At 34 weeks the patient revealed methotrexate/misoprostol exposure at 6 weeks gestational age in attempted medical termination of pregnancy. On newborn exam, the baby had dysmorphic facial features, a short torso, scoliosis, a micropenis (phallus <1 cm) and shortened proximal long bones both upper and lower extremities. X-ray exam revealed a hemivertebra at T10 level, rib abnormalities, shortened proximal long bones, an absent pubic bone and bilateral knee ossification centers. With methotrexate exposure, improved counseling and surveillance could potentially avoid these significant abnormalities and prevent psychological distress.

How the neonatal rat gets to the nipple. II. Changes during development.

In the course of postnatal development, the motor sequence executed by pups in order to attach to the dam's nipple undergoes extensive changes. During the 1st postnatal week, the pup performs a rotation along the longitudinal axis of its trunk to achieve a supine posture under the mother. The pup then crawls on the maternal ventrum while in the supine posture, searching for, finding, and attaching to a nipple. During the 2nd postnatal week, this sequence is modified and the pup first searches and establishes contact with a nipple before rotating to the supine posture. This sequence of movements is then truncated. By postnatal Day 11, pups may attach to a nipple while in a prone posture. Developmental changes in supination before attaching to the nipple are reminiscent of changes in righting during a similar period of development. These observations support the idea that both righting and postural adjustments involved in attachment to the nipple derive from common motor modules, with righting executed in the direction of gravity and rotation to the nipple executed against the force of gravity. The parallel structure of these behaviors is consistent with a common origin and similar control mechanisms for these distinct motor behaviors that are expressed early in postnatal development.

Oral grasping of a surrogate nipple by the newborn rat.

Newborn rat pups exhibit oral appetitive behaviors when presented with an artificial nipple. These behaviors include mouthing and licking movements and expression of stereotyped oral grasp response. Caesarean-delivered pups show increased responding to the nipple over the first 5 h after birth that is independent of experience with the nipple. Mimicking maternal licking by stimulating the anogenital region of the newborn rat with a soft paintbrush increases response to the nipple. Pups tested after 24 hr of normal experience respond to the artificial nipple when tested immediately after separation from the mother. However, oral grasping of the nipple is more frequent in 1-day-old pups tested 3 or 5 hr after separation from the mother. Study of behavioral responses to the artificial nipple promises to provide information about sensory and neurochemical controls of the initial suckling episode.