Infection and Sepsis Trends during United States' Delivery Hospitalizations from 2000 to 2020.

OBJECTIVE: This study aimed to evaluate trends, risk factors, and outcomes associated with infections and sepsis during delivery hospitalizations in the United States. STUDY DESIGN: The 2000-2020 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of patients aged 15 to 54 with and without infection and sepsis were identified. Common infection diagnoses during delivery hospitalizations analyzed included (i) pyelonephritis, (ii) pneumonia/influenza, (iii) endometritis, (iv) cholecystitis, (v) chorioamnionitis, and (vi) wound infection. Temporal trends in sepsis and infection during delivery hospitalizations were analyzed. The associations between sepsis and infection and common chronic health conditions including asthma, chronic hypertension, pregestational diabetes, and obesity were analyzed. The associations between clinical, demographic, and hospital characteristics, and infection and sepsis were determined with unadjusted and adjusted logistic regression models with unadjusted odds ratio (OR) and adjusted odds ratios with 95% confidence intervals as measures of association. RESULTS: An estimated 80,158,622 delivery hospitalizations were identified and included in the analysis, of which 2,766,947 (3.5%) had an infection diagnosis and 32,614 had a sepsis diagnosis (4.1 per 10,000). The most common infection diagnosis was chorioamnionitis (2.7% of deliveries) followed by endometritis (0.4%), and wound infections (0.3%). Infection and sepsis were more common in the setting of chronic health conditions. Evaluating trends in individual infection diagnoses, endometritis and wound infection decreased over the study period both for patients with and without chronic conditions, while risk for pyelonephritis and pneumonia/influenza increased. Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Risks for adverse outcomes including mortality, severe maternal morbidity, the critical care composite, and acute renal failure were all significantly increased in the presence of sepsis and infection. CONCLUSION: Endometritis and wound infections decreased over the study period while risk for sepsis increased. Infection and sepsis were associated with chronic health conditions and accounted for a significant proportion of adverse obstetric outcomes including severe maternal morbidity. KEY POINTS: · Sepsis increased over the study period for deliveries with and without chronic condition diagnoses.. · Endometritis and wound infection decreased over the study period.. · Infection and sepsis accounted for a significant proportion of adverse obstetric outcomes..

Understanding Clinician Knowledge About Race Adjustment in the Vaginal Birth After Cesarean Calculator.

Disparities in maternal health outcomes are striking. Historical and biased clinical support tools have potential to exacerbate inequities. In 2022, NewYork-Presbyterian, with ∼25,000 annual births, and our academic partners, Columbia and Weill Cornell, launched a program to better understand practice patterns and clinician attitudes toward a vaginal birth after cesarean (VBAC) calculator, which predicts VBAC success. This article summarizes the program, focusing on the VBAC calculator utilization survey, which measured provider awareness of the revised calculator and key factors considered in patient counseling. Our preliminary findings warrant future research and education on the calculator's implications for counseling and outcomes.

Risk Factors, Trends, and Outcomes Associated With Postpartum Sepsis Readmissions.

OBJECTIVE: To evaluate the prevalence, timing, clinical risk factors, and adverse outcomes associated with postpartum readmissions for maternal sepsis. METHODS: We conducted a retrospective cohort study of delivery hospitalizations and 60-day postpartum readmissions for females aged 15-54 years with and without sepsis using the 2016-2020 Nationwide Readmissions Database. Temporal trends in sepsis diagnoses during delivery hospitalizations and 60-day postpartum readmissions were analyzed with the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% CIs. Logistic regression models were fit to determine whether delivery hospitalization characteristics were associated with postpartum sepsis readmissions, and unadjusted and adjusted odds ratios with 95% CIs were reported. Adverse outcomes associated with sepsis during delivery hospitalization and readmission were described, including death, severe morbidity, a critical care composite, and renal failure. RESULTS: Overall, 15,268,190 delivery hospitalizations and 256,216 associated 60-day readmissions were included after population weighting, of which 16,399 (1.1/1,000 delivery hospitalizations) had an associated diagnosis of sepsis at delivery, and 20,130 (1.3/1,000 delivery hospitalizations) had an associated diagnosis of sepsis with postpartum readmission. A sepsis diagnosis was present in 7.9% of all postpartum readmissions. Characteristics associated with postpartum sepsis readmission included younger age at delivery, Medicaid insurance, lowest median ZIP code income quartile, and chronic medical conditions such as obesity, pregestational diabetes, and chronic hypertension. Postpartum sepsis readmissions were associated with infection during the delivery hospitalization, including intra-amniotic infection or endometritis, wound infection, and delivery sepsis. Sepsis diagnoses were associated with 24.4% of maternal deaths at delivery and 38.4% postpartum, 2.2% cases of nontransfusion severe morbidity excluding sepsis at delivery and 13.6% postpartum, 15.6% of critical care composite diagnoses at delivery and 30.1% postpartum, and 11.1% of acute renal failure diagnoses at delivery and 36.4% postpartum. CONCLUSION: Sepsis accounts for a significant proportion of postpartum readmissions and is a major contributor to adverse outcomes during delivery hospitalizations and postpartum readmissions.

Acquired Hemophilia A: A Rare, Acquired Coagulopathy in the Postpartum Setting.

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity. Pregnancy-associated acquired hemophilia A (AHA) caused by autoantibodies against factor VIII can present with recurrent episodes of postpartum bleeding. Case 1 A 50-year-old G2P0112 presented with vaginal bleeding 22 days postcaesarean. She underwent dilation and curettage, hysterectomy, and interventional radiology (IR) embolization before AHA diagnosis. She was hospitalized for 32 days and received 23 units of blood product. She remains without relapse of AHA after 5 years. Case 2 A 48-year-old G3P1021 presented with vaginal bleeding 8 days postcaesarean. She underwent three surgeries and IR embolization before AHA diagnosis. She was hospitalized for 18 days and received 39 units of blood product. Prednisone and cyclophosphamide were continued after discharge. AHA is a rare cause of PPH. An isolated prolonged activated partial thromboplastin time (aPTT) should prompt further workup in postpartum patients with refractory bleeding. Rapid recognition of AHA can prevent significant morbidity related to hemorrhage, massive transfusion, and multiple surgeries.

Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage.

Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.

Inpatient obstetric consultation-liaison services: Meeting unmet needs in perinatal mental health.

Obstetric patients are at increased risk for psychological distress and the development or exacerbation of mental illness, particularly in the setting of pregnancy or delivery complications. Inpatient antepartum, labor and delivery, and postpartum hospitalization is an important opportunity for psychiatric support and intervention. The aims of this paper are to review the unmet mental health needs in obstetric inpatient care, examine the current state of obstetric consultation-liaison (OB CL) psychiatry services, present one existing model of such a service at the authors' institution, provide broad recommendations for the structure and implementation of this service, and detail areas of future research within the area of OB CL psychiatry. We argue that the inpatient obstetric setting is a critical space for mental health evaluation, education and intervention, and that dedicated OB CL psychiatry services are a potentially valuable tool in addressing the perinatal mental health crisis.

Cesarean Delivery Trends Among Patients at Low Risk for Cesarean Delivery in the US, 2000-2019.

Importance: Reducing rates of unnecessary cesarean deliveries is both a national and a global health objective. However, there are limited national US data on trends in indications for low-risk cesarean delivery. Objective: To determine temporal trends in and indications for cesarean delivery among patients at low risk for the procedure over a 20-year period. Design, Setting, and Participants: This cross-sectional study analyzed 2000 to 2019 delivery hospitalizations using the National Inpatient Sample. Births at low risk for cesarean delivery were identified using a definition from the Society for Maternal-Fetal Medicine and additional criteria. Temporal trends in cesarean birth were analyzed using joinpoint regression to estimate the average annual percentage change (AAPC) with 95% CIs. Data analysis was performed from August 2022 to January 2023. Exposure: This analysis evaluated cesarean birth trends in a population at low risk for this procedure over a 20-year period. Main Outcomes and Measures: In addition to overall cesarean birth risk, cesarean deliveries for nonreassuring fetal status and labor arrest were individually analyzed. Results: Of an estimated 76.7 million delivery hospitalizations, 21.5 million were excluded according to the Society for Maternal-Fetal Medicine definition, and 14.7 million were excluded according to additional criteria. Of the estimated 40 517 867 deliveries included, 12.1% (4 885 716 deliveries) were by cesarean delivery. Cesarean deliveries among patients at low risk for the procedure increased from 9.7% to 13.9% between 2000 and 2009, plateaued, and then decreased from 13.0% to 11.1% between 2012 and 2019. The AAPC for cesarean delivery was 6.4% (95% CI, 5.2% to 7.6%) from 2000 to 2005, 1.2% from 2005 to 2009 (95% CI, -1.2% to 3.7%), and -2.2% from 2009 to 2019 (95% CI, -2.7% to -1.8%). Cesarean delivery for nonreassuring fetal status increased from 3.4% of all deliveries in 2000 to 5.1% in 2019 (AAPC, 2.1%; 95% CI, 1.7% to 2.5%). Cesarean delivery for labor arrest increased from 3.6% in 2000 to a peak of 4.8% in 2009 before decreasing to 2.7% in 2019. Cesarean deliveries for labor arrest increased during the first half of the study (2000-2009) for the active phase (from 1.5% to 2.1%), latent phase (from 1.1% to 1.5%), and second stage (from 0.9% to 1.3%) and then decreased from 2010 to 2019, from 2.1% to 1.7% for the active phase, from 1.5% to 1.2% for the latent phase, and from 1.2% to 0.9% for the second stage. Conclusions and Relevance: Cesarean deliveries among patients at low risk for cesarean birth appeared to decrease over the latter years of the study period, with cesarean deliveries for labor arrest becoming less common.

Intracranial ultrasound abnormalities and mortality in preterm infants with and without fetal growth restriction stratified by fetal Doppler study results.

OBJECTIVE: To evaluate whether fetal growth restriction (FGR) with or without abnormal Dopplers is associated with intracranial abnormalities and death in premature infants. STUDY DESIGN: Premature infants with and without FGR born between 2016 and 2019 were included. Primary outcome was death, severe intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL). Groups were compared using standard bivariate testing and multivariable regression. RESULTS: Among 168 FGR and 560 non-FGR infants, FGR infants with abnormal Dopplers had an increased incidence of death, severe IVH or PVL compared to non-FGR infants (13% (16/123) vs. 7% (41/560); p = 0.03) while FGR infants with normal Dopplers had a nonsignificant decrease. In a logistic regression model, FGR with abnormal Dopplers was associated with more than three times higher odds of death, severe IVH or PVL (OR 3.2, 95% CI 1.54,6.49; p < 0.001). CONCLUSIONS: Growth-restricted infants with abnormal Dopplers had an increased risk of death, intracranial abnormalities, and prematurity-related morbidities.

Simulation in Obstetric Emergencies.

Simulation is a critical part of training for obstetric emergencies. Incorporation of this training modality has been shown to improve outcomes for patients and is now required by national accrediting organizations.

Measurement of hemorrhage-related severe maternal morbidity with billing versus electronic medical record data.

OBJECTIVE: Measurement of obstetric hemorrhage-related morbidity is important for quality assurance purposes but presents logistical challenges in large populations. Billing codes are typically used to track severe maternal morbidity but may be of suboptimal validity. The objective of this study was to evaluate the validity of billing code diagnoses for hemorrhage-related morbidity compared to data obtained from the electronic medical record. STUDY DESIGN: Deliveries occurring between July 2014 and July 2017 from three hospitals within a single system were analyzed. Three outcomes related to obstetric hemorrhage that are part of the Centers for Disease Control and Prevention definition of severe maternal morbidity (SMM) were evaluated: (i) transfusion, (ii) disseminated intravascular coagulation (DIC), and (iii) acute renal failure (ARF). ICD-9-CM and ICD-10-CM for these conditions were ascertained and compared to blood bank records and laboratory values. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) with 95% confidence intervals (CI) were calculated. Ancillary analyses were performed comparing codes and outcomes between hospitals and comparing ICD-9-CM to ICD-10-CM codes. Comparisons of categorical variables were performed with the chi-squared test. T-tests were used to compare continuous outcomes. RESULTS: 35,518 deliveries were analyzed. 786 women underwent transfusion, 168 had serum creatinine ≥1.2 mg/dL, and 99, 40, and 16 had fibrinogen ≤200, ≤150, and ≤100 mg/dL, respectively. Transfusion codes were 65% sensitive (95% CI 62-69%) with a 91% PPV (89-94%) for blood bank records of transfusion. DIC codes were 22% sensitive (95% CI 15-32%) for a fibrinogen cutoff of ≤200 mg/dL with 15% PPV (95% CI 10-22%). Sensitivity for ARF was 33% (95% CI 26-41%) for a creatinine of 1.2 mg/dL with a PPV of 63% (95% CI 52-73%). Sensitivity of ICD-9-CM for transfusion was significantly higher than ICD-10-CM (81%, 95% CI 76-86% versus 56%, 95% CI 51-60%, p < .01). Evaluating sensitivity of codes by individual hospitals, sensitivity of diagnosis codes for transfusion varied significantly (Hospital A 47%, 95% CI 36-58% versus Hospital B 63%, 95% CI 58-67% versus Hospital C 80%, 95% CI 74-86%, p < .01). CONCLUSION: Use of administrative billing codes for postpartum hemorrhage complications may be appropriate for measuring trends related to disease burden and resource utilization, particularly in the case of transfusion, but may be suboptimal for measuring clinical outcomes within and between hospitals.

Obstetric Inpatient and Ultrasound Clinical Personnel Absences during the COVID-19 Pandemic in New York City.

OBJECTIVE: To review obstetric personnel absences at a hospital during the initial peak of coronavirus disease 2019 (COVID-19) infection risk in New York City from March 25 to April 21, 2020. STUDY DESIGN: This retrospective study evaluated absences at Morgan Stanley Children's Hospital. Clinical absences for (1) Columbia University ultrasonographers, (2) inpatient nurses, (3) labor and delivery operating room (OR) technicians, (4) inpatient obstetric nurse assistants, and (5) attending physicians providing inpatient obstetric services were analyzed. Causes of absences were analyzed and classified as illness, vacation and holidays, leave, and other causes. Categorical variables were compared with the chi-square test or Fisher's exact test. RESULTS: For nurses, absences accounted for 1,052 nursing workdays in 2020 (17.2% of all workdays) compared with 670 (11.1%) workdays in 2019 (p < 0.01). Significant differentials in days absent in 2020 compared with 2019 were present for (1) postpartum nurses (21.9% compared with 12.9%, p < 0.01), (2) labor and delivery nurses (14.8% compared with 10.6%, p < 0.01), and (3) antepartum nurses (10.2% compared with 7.4%, p = 0.03). Evaluating nursing assistants, 24.3% of workdays were missed in 2020 compared with 17.4% in 2019 (p < 0.01). For ultrasonographers, there were 146 absences (25.2% of workdays) in 2020 compared with 96 absences (16.0% of workdays) in 2019 (p < 0.01). The proportion of workdays missed by OR technicians was 22.6% in 2020 and 18.3% in 2019 (p = 0.25). Evaluating attending physician absences, a total of 78 workdays were missed due to documented COVID-19 infection. Evaluating the causes of absences, illness increased significantly between 2019 and 2020 for nursing assistants (42.6 vs. 57.4%, p = 0.02), OR technicians (17.1 vs. 55.9%, p < 0.01), and nurses (15.5 vs. 33.7%, p < 0.01). CONCLUSION: COVID-19 outbreak surge planning represents a major operational issue for medical specialties such as critical care due to increased clinical volume. Findings from this analysis suggest it is prudent to devise backup staffing plans. KEY POINTS: · 1) COVID-19 outbreak surge planning represents a major operational issue for obstetrics.. · 2) Inpatient obstetric volume cannot be reduced.. · 3) Staffing contingencies plans for nurses, sonographers, and physicians may be required..

Racial and Ethnic Disparities in Peripartum Hysterectomy Risk and Outcomes.

OBJECTIVE: This study aimed to determine whether race and ethnicity contribute to risks associated with peripartum hysterectomy. STUDY DESIGN: This retrospective cross-sectional study utilized the 2000-2014 Nationwide Inpatient Sample to analyze risk of peripartum hysterectomy and associated severe maternal morbidity, mortality, surgical injury, reoperation, surgical-site complications, and mortality by maternal race and ethnicity. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, other, and unknown. Multivariable log-linear regression models including patient, clinical, and hospital risk factors were performed with adjusted risk ratios (aRRs) and 95% confidence intervals (CIs). RESULTS: Of 59,854,731 delivery hospitalizations, there were 45,369 peripartum hysterectomies (7.6 per thousand). Of these, 37.8% occurred among non-Hispanic white, 13.9% among non-Hispanic black, and 22.8% among Hispanic women. In adjusted analyses, non-Hispanic black (aRR: 1.21, 95% CI: 1.17-1.29) and Hispanic women (aRR: 1.25, 95% CI: 1.22-1.29) were at increased risk of hysterectomy compared with non-Hispanic white women. Risk for severe morbidity was increased for non-Hispanic black (aRR: 1.25, 95% CI: 1.19-1.33), but not for Hispanic (aRR: 1.02, 95% CI: 0.97-1.07) women. Between these three groups, risk for intraoperative complications was highest among non-Hispanic white women, risk for reoperation was highest among Hispanic women, and risk for surgical-site complications was highest among non-Hispanic black women. Evaluating maternal mortality, non-Hispanic black women (RR: 3.83, 95% CI: 2.65-5.53) and Hispanic women (RR: 2.49, 95% CI: 1.74-3.59) were at higher risk than non-Hispanic white women. CONCLUSION: Peripartum hysterectomy and related complications other than death differed modestly by race. In comparison, mortality differentials were large supporting that differential risk for death in the setting of this high-risk scenario may be an important cause of disparities. KEY POINTS: · Peripartum hysterectomy and related complications differed modestly by race.. · Mortality differentials in the setting of peripartum hysterectomy were large.. · Failure to rescue may be an important cause of peripartum hysterectomy disparities..

Clinical and Demographic Risk Factors for COVID-19 during Delivery Hospitalizations in New York City.

OBJECTIVE: This study was aimed to review 4 weeks of universal novel coronavirus disease 2019 (COVID-19) screening among delivery hospitalizations, at two hospitals in March and April 2020 in New York City, to compare outcomes between patients based on COVID-19 status and to determine whether demographic risk factors and symptoms predicted screening positive for COVID-19. STUDY DESIGN: This retrospective cohort study evaluated all patients admitted for delivery from March 22 to April 18, 2020, at two New York City hospitals. Obstetrical and neonatal outcomes were collected. The relationship between COVID-19 and demographic, clinical, and maternal and neonatal outcome data was evaluated. Demographic data included the number of COVID-19 cases ascertained by ZIP code of residence. Adjusted logistic regression models were performed to determine predictability of demographic risk factors for COVID-19. RESULTS: Of 454 women delivered, 79 (17%) had COVID-19. Of those, 27.9% (n = 22) had symptoms such as cough (13.9%), fever (10.1%), chest pain (5.1%), and myalgia (5.1%). While women with COVID-19 were more likely to live in the ZIP codes quartile with the most cases (47 vs. 41%) and less likely to live in the ZIP code quartile with the fewest cases (6 vs. 14%), these comparisons were not statistically significant (p = 0.18). Women with COVID-19 were less likely to have a vaginal delivery (55.2 vs. 51.9%, p = 0.04) and had a significantly longer postpartum length of stay with cesarean (2.00 vs. 2.67days, p < 0.01). COVID-19 was associated with higher risk for diagnoses of chorioamnionitis and pneumonia and fevers without a focal diagnosis. In adjusted analyses, including demographic factors, logistic regression demonstrated a c-statistic of 0.71 (95% confidence interval [CI]: 0.69, 0.80). CONCLUSION: COVID-19 symptoms were present in a minority of COVID-19-positive women admitted for delivery. Significant differences in obstetrical outcomes were found. While demographic risk factors demonstrated acceptable discrimination, risk prediction does not capture a significant portion of COVID-19-positive patients. KEY POINTS: · COVID-19 symptoms were present in a minority of COVID-19-positive women admitted.. · COVID-19 symptomatology did not appear to differ before or after the apex of infection in New York.. · Demographic risk factors are unlikely to capture a significant portion of COVID-19-positive patients..

Risk for postpartum readmissions and associated complications based on maternal age.

PURPOSE: To evaluate risk for postpartum readmissions and associated severe morbidity by maternal age. MATERIALS AND METHODS: This retrospective cohort study used the Nationwide Readmissions Database to analyze 60-day all-cause postpartum readmission risk from 2010 to 2014. Risk for severe maternal morbidity (SMM) during readmission was ascertained using criteria from the Centers for Disease Control and Prevention. The primary exposure of interest was maternal age. Outcomes included time to readmission, risk of readmission, and risk for SMM during readmission. Multivariable log linear analyses adjusting for patient, obstetric, and hospital factors were conducted to assess readmission and SMM risk with adjusted risk ratios (aRRs) with 95% confidence intervals (CIs) as measures of effect. RESULTS: Between 2010 and 2014, we identified 15.7 million deliveries, 15% of which were to women aged 35 or older. The 60-day all-cause readmission rate was 1.7%. Of these, 13% were complicated by SMM. Age-stratification revealed that women 35 and older were at increased risk for readmission and increased risk for SMM. The majority of readmissions occurred within the first 20 days regardless of age; although, women 35 and older were more likely to be admitted within the first 10 days of discharge. Patients ages 35-39, 40-44, and >44 years had 9% (95% CI 7-10%), 37% (95% CI 34-39%), and 66% (95% CI 55-79%) significantly higher rates of postpartum readmission when compared to women age 25-29. Women 35-39, 40-44, and >44 years of age had a 15% (95% CI 10-21%), 26% (95% CI 18-34%), and 56% (95% CI 25-94%) higher risk of a readmission with SMM than women 25-29. CONCLUSIONS: AMA women are at higher risk for both postpartum readmission and severe morbidity during readmission. Women older than 35 years represent the group most likely to experience complications requiring readmission, with the highest risk age 40 and older.

A SWIFT Method for Handing Off Obstetrical Patients on the Labor Floor.

OBJECTIVE: The aim of this study was to improve patient handoffs on the labor floor. METHODS: A prospective cohort study of obstetrics residents at Montefiore Medical Center was performed between 2012 and 2014. Labor-floor handoffs were recorded before and after didactic sessions as well as after installation of whiteboards formatted with the mnemonic SWIFT (Subject, Why?, Issues, Fetus, Tasks). Handoff transcripts were evaluated by obstetricians blinded to timing and speaker identity. An intraclass correlation coefficient accounted for evaluator differences. Data analysis was by ordinal logistic regression, the generalized estimating equations method (correlated data), and Bonferroni adjustment (multiple comparisons). RESULTS: Forty-five handoffs were evaluated (15 each predidactics, postdidactics, and postwhiteboard revision). Higher completeness scores over time were noted for admission reason, labor concerns, and task list (not statistically significant). Comprehensive score increases prelecture to postwhiteboard were seen in handoff clarity (2.81 versus 2.91) and overall quality (2.77 versus 2.81) (not statistically significant). A subanalysis of four residents who gave multiple handoffs over different periods revealed few significant changes over time. Greater interevaluator consistency was noted with more objective elements. CONCLUSIONS: The mnemonic SWIFT, with formalized curricula for obstetrical resident training focusing on new learners and increased faculty involvement and reinforcement, may result in improvement of handoffs on the labor floor.

Hospital Safety-Net Burden and Risk for Readmissions and Severe Maternal Morbidity.

OBJECTIVE: This study aimed to analyze whether hospital safety-net burden status is associated with increased risk for severe maternal morbidity (SMM) and postpartum readmissions. STUDY DESIGN: The 2010 to 2014 Nationwide Readmissions Database was utilized for this retrospective cohort study. Hospitals were categorized as high-burden hospitals (25% of hospitals with the highest safety-net burden), medium-burden hospitals (50% of hospitals with intermediate safety-net burden), and low-burden hospitals (25% of hospitals with the lowest safety-net burden) based on the proportions of Medicaid or uninsured patients. Risk for (1) SMM, (2) 60-day postpartum readmissions, and (3) SMM during postpartum readmissions was analyzed. Unadjusted and adjusted log-linear regression models were performed, respectively, for these outcomes with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Adjusted models included demographic, hospital, and clinical factors. RESULTS: High-burden safety-net status was associated with increased risk for SMM compared with low-burden safety-net status in both unadjusted (RR: 1.51, 95% confidence interval [CI]: 1.50-1.53) and adjusted analyses (aRR: 1.27, 95% CI: 1.25-1.30). High-burden status was also associated with increased risk for readmissions in unadjusted analyses (RR: 1.42, 95% CI: 1.40-1.44), although this risk was attenuated in adjusted analyses (aRR: 1.07, 95% CI: 1.06-1.08). High-burden status was associated with significantly increased risk for readmission for uterine infections, hypertensive diseases of pregnancy, and psychiatric diagnoses. High-burden status was not associated with severe morbidity during readmissions in adjusted or unadjusted analyses (RR: 1.02, 95% CI: 0.98-1.05; aRR: 0.95, 95% CI: 0.92-0.99). CONCLUSION: This study found that high safety-net burden hospitals may be a higher risk setting for obstetric care. Improvement of outcomes in high-burden settings may be important in overall efforts to reduce maternal risk.

Advances in Management for Preterm Fetuses at Risk of Delivery.

Preterm birth accounts for only 11% of live births but contributes to up to 75% of neonatal mortality and more than half of long-term morbidity. Targeted interventions to reduce the most common causes of perinatal morbidity and mortality include intrapartum group B Streptococcus prophylaxis, magnesium sulfate for fetal neuroprotection, antenatal corticosteroids for fetal lung maturity, latency antibiotics for preterm premature rupture of membranes, and tocolysis to allow corticosteroid administration and transfer to a tertiary care center. This article reviews the evidence for interventions to improve outcomes for fetuses at risk for preterm delivery at different gestational ages.