Early vs delayed amniotomy following transcervical Foley balloon in the induction of labor: a randomized clinical trial.

BACKGROUND: The optimal timing of amniotomy during labor induction is a topic of ongoing debate due to the potential risks associated with both amniotomy and prolonged labor. As such, individuals in the field of obstetrics and gynecology must carefully evaluate the associated benefits and drawbacks of this procedure. While amniotomy can expedite the labor process, it may also lead to complications such as umbilical cord prolapse, fetal distress, and infection. Therefore, a careful and thorough examination of the risks and benefits of amniotomy during labor induction is essential in making an informed decision regarding the optimal timing of this procedure. OBJECTIVE: This study aimed to determine if an amniotomy within 2 hours after Foley balloon removal reduced the duration of active labor and time taken to achieve vaginal delivery when compared with an amniotomy ≥4 hours after balloon removal among term pregnant women who underwent labor induction. STUDY DESIGN: This was an open-label, randomized controlled trial that was conducted at a single academic center from October 2020 to March 2023. Term participants who were eligible for preinduction cervical ripening with a Foley balloon were randomized into 2 groups, namely the early amniotomy (rupture of membranes within 2 hours after Foley balloon removal) and delayed amniotomy (rupture of membranes performed more than 4 hours after Foley balloon removal) groups. Randomization was stratified by parity. The primary outcome was time from Foley balloon insertion to active phase of labor. Secondary outcomes, including time to delivery, cesarean delivery rates, and maternal and neonatal complications, were analyzed using intention-to-treat and per-protocol analyses. RESULTS: Of the 150 participants who consented and were enrolled, 149 were included in the analysis. In the intention-to-treat population, an early amniotomy did not significantly shorten the time between Foley balloon insertion and active labor when compared with a delayed amniotomy (885 vs 975 minutes; P=.08). An early amniotomy was associated with a significantly shorter time from Foley balloon placement to active labor in nulliparous individuals (1211; 584-2340 vs 1585; 683-2760; P=.02). When evaluating the secondary outcomes, an early amniotomy was associated with a significantly shorter time to active labor onset (312.5 vs 442.5 minutes; P=.02) and delivery (484 vs 587 minutes; P=.03) from Foley balloon removal with a higher rate of delivery within 36 hours (96% vs 85%; P=.03). Individuals in the early amniotomy group reached active labor 1.5 times faster after Foley balloon insertion than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1.1-2.2; P=.02). Those with an early amniotomy also reached vaginal delivery 1.5 times faster after Foley balloon removal than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1-2.2; P=.03). A delayed amniotomy was associated with a higher rate of postpartum hemorrhage (0% vs 9.5%; P=.01). No significant differences were observed in the cesarean delivery rates, length of hospital stay, maternal infection, or neonatal outcomes. CONCLUSION: Although an early amniotomy does not shorten the time from Foley balloon insertion to active labor, it shortens time from Foley balloon removal to active labor and delivery without increasing complications. The increased postpartum hemorrhage rate in the delayed amniotomy group suggests increased risks with delayed amniotomy.

New definitions, old complications: The association between duration of transition from latent to active labor and adverse obstetrical outcomes.

OBJECTIVE: To explore the relationship between the duration of transition from latent to active labor and various obstetric, maternal, fetal, and neonatal outcomes. METHODS: A retrospective cohort study was conducted on term, singleton deliveries at Soroka University Medical Center from 2013 to 2018. Data were extracted from electronic medical records. The exposure variable was defined as prolonged transition, which was itself defined as the upper 10th centile of dilation duration from 4 to 6 cm. Clinical and demographic characteristics were compared using χ2 test. Multivariate logistic regression was used to estimate the contribution of a prolonged transition with each adverse outcome adjusting for potential confounders. RESULTS: In all, 12 104 deliveries met the inclusion criteria. The mean ± standard deviation of duration of dilation from 4 to 6 cm was 03:07:58 ± 03:03:42 (hours:minutes:seconds). Progress curves varied significantly among patients with different obstetrical and demographic characteristics. Prolonged transition was significantly linked to an increased risk of cesarean delivery (adjusted odds raito 2.607, 95% confidence interval 2.171-3.130, area under the curve 0.689) and higher rates of maternal and neonatal morbidity. CONCLUSIONS: Patients experiencing transition phases exceeding the 90th centile faced an elevated risk of cesarean delivery and postpartum complications. Future studies should focus on interventions during the transition phase to improve pregnancy outcomes and enhance patient safety.

Gestational diabetes mellitus and time in active labor: A population-based cohort study.

INTRODUCTION: Women with gestational diabetes mellitus (GDM) have higher rates of adverse perinatal outcomes compared with women without GDM, including an increased risk for having labor induced and for cesarean section. The findings from previous studies analyzing duration of labor in women with GDM are contradictory. The aim of the study was to evaluate the impact of GDM on time in spontaneous and induced active labor. MATERIAL AND METHODS: This was a population-based cohort study including 247 524 primiparous women who gave birth to a singleton fetus with cephalic presentation, ≥34+0 (completed gestational weeks + additional days) between January 2014 and May 2020 in Sweden. Data was obtained from the Swedish Pregnancy Register. Time in active labor was compared between women with GDM and without GDM with a spontaneous labor onset or induction of labor using Kaplan Meier survival analysis and Cox regression analysis. RESULTS: Women with GDM had significantly longer time in active labor, both with a spontaneous onset and induction of labor compared to women without GDM. Women with GDM had a decreased chance of vaginal delivery at a certain time-point compared to women without GDM, with adjusted hazard ratio of 0.92 (0.88-0.96) and 0.83 (0.76-0.90) for those with spontaneous onset and induction of labor, respectively. Women with GDM had increased risk for time in active labor ≥12 h both in spontaneous labor onset (adjusted odds ratio 1.14 [1.04-1.25]) and in induction of labor (adjusted odds ratio 1.55 [1.28-1.87]). CONCLUSIONS: Women with GDM seem to spend a longer time in active labor, both in spontaneous and induced active labor compared to women without GDM. To be able to individualize care intrapartum, there is a need for more studies demonstrating the impact of hyperglycemia during pregnancy on outcomes during childbirth.

Preventing a Scarring Start into the Labor Market: Integration Strategies for Young Persons with Disabilities.

PURPOSE: Sociodemographic and structural conditions have consequences for the labor market participation of young persons with disabilities (YPWD) in vocational rehabilitation (VR). As the type of program determines the labor market chances, we analyze the processes of selecting active labor market programs (ALMP) in VR. Which factors determine the allocation to (1) programs in general and (2) moreover, the allocation to specific programs? MATERIALS AND METHODS: We conduct logistic (1) and multinomial regression (2) using register data of the German Federal Employment Agency. Besides variables on the micro level, we control for a wide range of structural and organizational influences. The sample comprises VR and employment biographies of 255,009 YPWD accepted to VR between 2010 and 2015. Program participation is restricted to start 180 days after VR acceptance. RESULTS: Sociodemographic factors, like age and the status before entering VR as well as the local apprenticeship market as a structural condition, highly influence the general allocation to ALMP. For the allocation to specific ALMP, sociodemographics (age, education, type of disability, status before entering VR) are highly relevant. Furthermore, structural conditions (regional structure of subsidized vocational training and of the apprenticeship market as well as local work possibilities on a special labor market for PWD) and - to a lesser extent - re-organization processes at the FEA (NEO, VR cohort) are important determinants. CONCLUSION: (Automatic) paths into VR programs for especially persons with mental disabilities in sheltered workshop are clearly shown. Furthermore, it is somewhat questionable that YPWD participate more often in sheltered workshops in regions where sheltered work possibilities are more common, as well as where NEO was implemented locally; and participate more often in company-external vocational training where VR service providers are commissioned to a greater extent.

The effect of cervical cerclage on the labor curve.

BACKGROUND: Cervical cerclage is an effective intervention to prevent preterm birth among individuals with a history of cervical insufficiency, individuals with a short cervix and history of preterm birth, or individuals with second-trimester painless dilation. Although cerclage reduces the mechanical stress on the cervix by reinforcing it with sutures, cerclage could also cause scarring of the cervix, which may affect the progress of labor. OBJECTIVE: This study aimed to compare the labor curves between individuals who underwent cerclage and those who did not undergo cerclage. STUDY DESIGN: This was a retrospective cohort study of individuals with singleton term pregnancy, vertex presentation, and vaginal delivery, using the data from the Consortium on Safe Labor. We excluded individuals with fetal anomalies, stillbirth, or abnormal perinatal outcomes, including 5-minute Apgar score of <7, birth injury, and neonatal intensive care unit admission. We modeled the course of cervical dilation using repeated-measures analysis with a polynomial function and generated smoothed labor curves. An interval-censored regression analysis was performed to estimate traverse times (the elapsed time between 2 cervical dilation measures). The traverse times were compared between individuals who underwent cerclage and those who did not undergo cerclage, controlling for induction of labor and parity. RESULTS: There were 245 individuals who underwent cerclage and 110,080 individuals who did not undergo cerclage. Individuals who underwent cerclage compared with those who did not undergo cerclage had a similar traverse time from 1 to 6 cm (median, 9.1 vs 10.3 hours; adjusted P=.37) and from 6 to 10 cm (median, 1.5 vs 1.5 hours; adjusted P=.23). Individuals who underwent cerclage compared with those who did not undergo cerclage had a longer traverse time from rupture of membranes to delivery (median, 4.0 vs 3.0 hours; adjusted P<.01). CONCLUSION: Cervical cerclage did not affect the overall progress of labor.

Development and validation of a predictive model to identify the active phase of labor.

BACKGROUND: The diagnosis of the active phase of labor is a crucial clinical decision, thus requiring an accurate assessment. This study aimed to build and to validate a predictive model, based on maternal signs and symptoms to identify a cervical dilatation ≥4 cm. METHODS: A prospective study was conducted from May to September 2018 in a II Level Maternity Unit (development data), and from May to September 2019 in a I Level Maternity Unit (validation data). Women with singleton, term pregnancy, cephalic presentation and presence of contractions were consecutively enrolled during the initial assessment to diagnose the stage of labor. Women < 18 years old, with language barrier or induction of labor were excluded. A nomogram for the calculation of the predictions of cervical dilatation ≥4 cm on the ground of 11 maternal signs and symptoms was obtained from a multivariate logistic model. The predictive performance of the model was investigated by internal and external validation. RESULTS: A total of 288 assessments were analyzed. All maternal signs and symptoms showed a significant impact on increasing the probability of cervical dilatation ≥4 cm. In the final logistic model, "Rhythm" (OR 6.26), "Duration" (OR 8.15) of contractions and "Show" (OR 4.29) confirmed their significance while, unexpectedly, "Frequency" of contractions had no impact. The area under the ROC curve in the model of the uterine activity was 0.865 (development data) and 0.927 (validation data), with an increment to 0.905 and 0.956, respectively, when adding maternal signs. The Brier Score error in the model of the uterine activity was 0.140 (development data) and 0.097 (validation data), with a decrement to 0.121 and 0.092, respectively, when adding maternal signs. CONCLUSION: Our predictive model showed a good performance. The introduction of a non-invasive tool might assist midwives in the decision-making process, avoiding interventions and thus offering an evidenced-base care.

Anesthetic Management of a Parturient with an Unruptured Basilar Artery Aneurysm.

Parturients with unruptured intracranial aneurysms present a unique challenge to anesthesia practitioners due to confounding concerns related to cerebrovascular and obstetrical physiologic changes. This case report presents a term parturient with an unruptured basilar artery aneurysm that received spinal anesthesia without adverse maternal or fetal sequelae. This report describes risk factors for aneurysmal rupture and a comparison of neuraxial versus general anesthesia in a parturient with cerebrovascular pathology.

Jobcenters' strategies to promoting the inclusion of immigrant and native job seekers: a comparative analysis based on PASS survey data.

This paper comparatively analyzes strategies of German Jobcenters to bring native and immigrant job seekers into employment. It focuses on clients who receive means-tested basic income for the unemployed, based on data from the Panel Study Labour Market and Social Security (PASS) from year 2015 to 2020. By way of logistic regression, the study identifies the impact of being an immigrant on the clients' probability of reporting different kinds of offers like job referrals or courses, controlling for a number of other influential factors. The study also looks deeper into the effects of immigrant-specific attributes, such as heterogeneous German language skills. We found that the likelihood of offers by Jobcenters largely depends on the amount of time since immigration. Recent immigrants have the lowest chance of reporting most of the studied measures of active labor market policies. For immigrants having stayed more than 4 years in Germany, however, we do not find a disadvantage, and some measures out of Jobcenters' toolbox are even more often offered to the longer-settled immigrants than to native clients. A possible explanation for the moderately under-average support of recent immigrants in terms of Jobcenters' measures could be an institutional focus on improving German language skills prior to approaching the labor market. Supplementary Information: The online version contains supplementary material available at 10.1186/s12651-022-00313-8.

The impact of EMTALA on medical malpractice framework models: a review.

The Emergency Medical Treatment & Active Labor Act (EMTALA) is a healthcare law specific to screening, stabilizing, and transferring (or accepting) patients with emergency medical conditions and active labor. This law, contextual to Medicare-participating hospitals, ensures public access to emergency medical services, regardless of the individual's ability to pay. The Defensive Medicine (DM) model and Physician Responsiveness to Standard-of-care Reforms (PRSRs) model are two medical malpractice frameworks leveraged in this paper. The nodes of these frameworks comprise of the treatment-versus-no-treatment dynamics and cutoff thresholds. Cutoff thresholds are specific to health risks and treatment price rates. Health risks stem from those with treating or not treating a patient as well as those inherent from the patient's ailment. Treatment price rates are subcategorized into customary and efficient price rates. Given the above nodes of these frameworks, this paper examines how the above medical malpractice models synchronize and sequentially align with the legal obligations of this law. This paper, furthermore, contemplatively describes how the incentivize/penalize dynamics interrelate to the push/pull dynamics of the PRSRs malpractice model. Thereafter, this paper applies the above push/pull dynamics contextual to the three specific obligations of this law, essentially, screening, stabilizing, and transferring (or accepting) emergency care patients. Conclusively, this paper illustrates the above network in a cascading algorithm that ligates the nodes of these frameworks to EMTALA's obligations.

Predictive value of new onset versus primary meconium-stained amniotic fluid.

BACKGROUND: Transition of clear amniotic fluid to meconium-stained fluid is a relatively common occurrence during labor. However, data regarding the clinical significance and the prognostic value of the presence of meconium-stained amnionic fluid (MSAF) are scarce. This study aimed to investigate delivery and neonatal outcomes according to the presence of MSAF and the timing of the meconium passage. METHODS: We used an historical cohort study at a single tertiary medical center in Israel between the years 2011 and 2018. Women were divided into two groups according to timing of meconium passage: primary MSAF (MSAF present at membrane rupture) and secondary MSAF (clear amnionic fluid that transitioned to MSAF during labor). Neonatal complication rates were compared between groups. Composite adverse neonatal outcome was defined as arterial cord blood pH <7.1, 5 min Apgar score ≤7, and/or neonatal intensive care unit admission. RESULTS: The study cohort included 56 863 singleton term births. Of these, 9043 (15.9%) were to women who had primary MSAF, and 1484 (2.6%) to those with secondary MSAF. Secondary MSAF compared with primary MSAF increased the risks of cesarean birth and operative vaginal delivery, increased the risks of low one- and five-minute Apgar scores and low arterial cord blood pH, and increased hospital stay duration. Multivariate analysis revealed that secondary MSAF was independently associated with an increased risk of composite adverse neonatal outcome (OR1.68, 95% CI 1.25-2.24, p < 0.001) compared with primary MSAF. CONCLUSIONS: In this sample, secondary MSAF was associated with more adverse neonatal outcomes than primary MSAF. Closer monitoring of fetal well-being may be prudent in these cases.

Labor dystocia and oxytocin augmentation before or after six centimeters cervical dilatation, in nulliparous women with spontaneous labor, in relation to mode of birth.

BACKGROUND: The effects of diagnosing and treating labor dystocia with oxytocin infusion at different cervical dilatations have not been fully evaluated. Therefore, we aimed to examine whether cervical dilatation at diagnosis of dystocia and initiation of oxytocin infusion at different stages of cervical dilatation were associated with mode of birth, obstetric complications and women's birthing experience. METHODS: A retrospective cohort study, including 588 nulliparous term women with spontaneous onset of labor and dystocia requiring oxytocin augmentation. The study population was divided into three groups according to cervical dilatation at diagnosis of dystocia and initiation of oxytocin-infusion (≤ 5 cm, 6-10 cm, fully dilated) with mode of birth as the primary outcome. Secondary outcomes were obstetrical and neonatal complications and women´s experience of childbirth. Statistical comparison between groups using Chi-square and ANOVA was performed. The risk of operative birth (cesarean section and instrumental birth) was assessed using binary logistic regression with suitable adjustments (maternal age, body mass index and risk assessment on admission to the labor ward). RESULTS: The cesarean section rate differed between the groups (p < 0.001); 12% in the ≤ 5 cm group, 6% in the 6-10 cm group and 0% in the fully dilated group. There was no increased risk for operative birth in the ≤ 5 cm group compared to the 6-10 cm group, adjusted OR 1.28 95%CI (0.78-2.08). The fully dilated group had a decreased risk of operative birth (adjusted OR 0.48 95%CI (0.27-0.85). The rate of a negative birthing experience was high in all groups (28.5%, 19% and 18%) but was only increased among women in the ≤ 5 cm group compared with the 6-10 cm group, adjusted OR 1.76 95%CI (1.05-2.95). CONCLUSIONS: Although no difference in the risk of operative birth was found between the ≤ 5 cm and 6-10 cm cervical dilatation-groups, the cesarean section rate was highest in women with dystocia requiring oxytocin augmentation at ≤ 5 cm cervical dilatation. This might indicate that oxytocin augmentation before 6 cm cervical dilatation could be contra-productive in preventing cesarean sections. Further, the increased risk of negative birth experience in the ≤ 5 cm group should be kept in mind to improve labor care.

A Rare Complication during Vaginal Delivery, Hamman's Syndrome: A Case Report and Systematic Review of Case Reports.

BACKGROUND: Spontaneous pneumomediastinum (SPM) during pregnancy or labor is a rare event. We presented a case report and a systematic review of the literature to provide comprehensive symptoms, treatments, and complications analysis in the pregnant population affected by SPM. METHODS: We conducted a comprehensive search of four databases for published papers in all languages from the beginning to 1 September 2021; Results: We included 76 papers with a total of 80 patients. A total of 76% patients were young primiparous, with a median age of 24 ± 5.4 years. The median gestational age was 40 ± 2.4 weeks, with a median duration of labor of 7.4 ± 4.2 h. In 86%, the ethnic origin was not specified. SPM develops in 55% of cases during the second stage of labor. Subcutaneous swelling and subcutaneous emphysema were present in 91.4%. Chest pain and dyspnea were present in 51.4% and 50% of the patients, respectively. We found that 32.9% patients had crepitus, and less common symptoms were dysphonia and tachycardia (14.3% and 14.3%, respectively). Oxygen and bronchodilators were used in 37.7% of the cases. Analgesics or sedatives were administered in 27.1%. Conservative management or the observation was performed in 21.4% and 28.6%, respectively. Antibiotics treatment was offered in 14.3%, whereas invasive procedures such as chest-tube drainage were used in just 5.7% of patients. There were no complications documented in most SPM (70.0%). We found that 16.7% of the SPM developed a pneumothorax and 5% developed a pneumopericardium.; Conclusions: In pregnancy, SPM occurs as subcutaneous swelling or emphysema during the second stage of labor. The treatment is usually conservative, with oxygen and bronchodilators and a low sequela rate. A universal consensus on therapy of spontaneous pneumomediastinum in pregnancy is necessary to reduce the risk of complications.

Changes in the obstetrical emergency department profile during the COVID-19 pandemic.

BACKGROUND: The COVID-19 outbreak caused persons to be reluctant to seek medical care due to fear of contracting the infection. OBJECTIVES: To evaluate the effect of the COVID-19 pandemic on admission rates to the delivery room and the feto-maternal unit, and to assess the effect on the nature of presenting obstetrical complaints to the emergency department. STUDY DESIGN: A retrospective cohort study in one medical center. The population was women > 20 weeks pregnant who presented to the obstetrical emergency department with self-complaints during 29 days at the peak of the pandemic outbreak, and a matched group during the exact period in the previous year. We compared between the groups: clinical, obstetrical, and demographic data, including age, area of residence, gravidity, parity, previous cesarean deliveries, high-risk pregnancy follow-up, the last 30 days admissions to the obstetrical emergency department, gestational age, chief complaints, cervical dilatation, cervical effacement, admissions to the delivery room or feto-maternal unit, time from admissions to the delivery room to birth, if applicable, and acute obstetrical complications diagnosed at the emergency department. RESULTS: During the pandemic outbreak, 398 women met study inclusion criteria, compared to 544 women in the matched period of the previous year. During the COVID-19 period, women visited the obstetrical emergency department at a more advanced mean gestational age (37.6 ± 3.7 vs. 36.7 ± 4.6, p = .001). Higher proportions of women in the COVID-19 cohort presented in active labor, defined by cervical dilation of at least 5 cm on admission to the labor ward [37 (9.3%) vs 28 (5.1%), p = .013)] and with premature rupture of membranes [82 (20.6%) vs 60 (11.0%), p < .001)], and consequently with more admissions to the delivery room [198 (49.7%) vs 189 (34.7%), p < .001)]. We also recorded a significant increase in urgent obstetrical events in the emergency department during the recorded COVID-19 pandemic [23 (5.8%) vs 12 (2.2%)), p = .004]. However, the rates of neonatal and maternal morbidity did not change. During the outbreak the proportion of visits during the night was higher than during the matched period of the previous year: [138 (34.7%) vs 145 (26.6%)), p = .008]. In a multivariate logistic regression, the higher rates of admission to the delivery room during active labor and of urgent events during the pandemic outbreak compared to the matched period in the previous year remained statistically significant. CONCLUSIONS: The pandemic outbreak of COVID-19 caused a behavioral change among women who presented to the obstetrical emergency department. This was characterized by delayed arrival to the obstetrical emergency department and the delivery room, which led to a significant increase in urgent and acute interventions. The change in behavior did not affect the rates of maternal and neonatal morbidity.

Increased length of active labor is associated with adverse perinatal outcomes among nulliparous women undergoing labor induction.

OBJECTIVE: Evaluate the association between current recommendations for active labor duration in nulliparous women undergoing labor induction and adverse perinatal outcomes. STUDY DESIGN: Retrospective cohort study from 2012 to 2015. Subjects were nulliparous, 18-44 years, cephalic, singleton ≥37 weeks undergoing labor induction who reached active labor. We created three subgroups, defined by active labor duration from 6 to 10cm as < the median, median-95th percentile, and >95th percentile based on contemporary labor curves. We evaluated the association between subgroups and cesarean delivery, chorioamnionitis, blood loss (EBL), 5-minute Apgar score < 7, and neonatal intensive care unit (NICU) admission using logistic regression. RESULTS: Among 356 women, 34.8% had an active labor duration < median, 43.3% were between the median-95th percentile, and 21.9% were >95th percentile. The risk of cesarean delivery increased with longer active labor duration; 1.8-fold (95%CI = 1.1-3.1) and 4.0-fold (95%CI = 2.5-6.5) for women whose active labors were between the median-95th percentile and >95th percentile, respectively. Chorioamnionitis increased by 3.9-fold (95%CI = 1.2-13.2) in the >95th percentile subgroup. Active labor length was not associated with EBL, Apgar scores, or NICU admission. CONCLUSIONS: Cesarean delivery and chorioamnionitis increased significantly as induced active labor duration exceeded the median. This study provides a better understanding regarding the risks of longer active labor as defined by contemporary labor curves.

Refining the clinical definition of active phase arrest of dilation in nulliparous women to consider degree of cervical dilation as well as duration of arrest.

BACKGROUND: Maternal and neonatal outcomes associated with duration of arrest of dilation beyond 4 hours are not well known. In addition, the current definition of arrest does not consider the degree of cervical dilation (6 cm vs 7 cm vs 8 cm vs 9 cm) when arrest occurs. OBJECTIVE: We sought to examine maternal and neonatal outcomes in nulliparous women who achieved the active phase of labor according to the duration they required to achieve a cervical change of at least 1 cm (<4 hours vs 4-5.9 hours vs ≥6 hours) beginning at 6, 7, 8 and 9 cm. STUDY DESIGN: This was a retrospective cohort study of nulliparous women with term singleton cephalic pregnancies in spontaneous or induced active labor (≥6 cm). To evaluate the effect of labor duration on maternal and fetal outcomes at different degrees of cervical dilation, we categorized women based on time intervals they required to achieve a cervical change of at least 1 cm after membrane rupture ("<4 hours," "4-5.9 hours," and "≥6 hours"), and we correlated each time interval with referent cervical dilation status (6 cm, 7 cm, 8 cm, and 9 cm). Maternal and neonatal outcomes were analyzed according to the duration to progress at least 1 cm starting from each degree of cervical dilation. Our primary outcome was a composite of neonatal outcomes, including intensive care unit admission, neonatal death, seizure, ventilator use, birth injury, and neonatal asphyxia. In addition, we examined maternal outcomes. Adjusted odds ratios with 95% confidence intervals were calculated, controlling for predefined covariates. RESULTS: Of 31,505 nulliparous women included in this study, 13,142 (42%), 10,855 (34%), 11,761 (37%), and 17,049 (54%) reached documented cervical dilation of 6, 7, 8, and 9 cm, respectively. At cervical dilation of 6 or 7 cm, the arrest of dilation of <4 hours compared with arrest of dilation of 4 to 5.9 hours was associated with decreased risks of adverse maternal outcomes. When cervical dilation was 8 or 9 cm, arrest of dilation of <4 hours compared with arrest of dilation of 4 to 5.9 hours was associated with decreased risks of adverse maternal and neonatal outcomes. For example, women starting at a cervical dilation of 8 cm who required <4 hours to achieve a cervical change of 1 cm compared with those who required 4 to 5.9 hours had lower rates of cesarean delivery (adjusted odds ratio, 0.40; 95% confidence interval, 0.28-0.55), chorioamnionitis (adjusted odds ratio, 0.42; 95% confidence interval, 0.29-0.60), and the neonatal composite outcome (adjusted odds ratio, 0.51; 95% confidence interval, 0.36-0.72). CONCLUSION: When cervical dilation is 6 or 7 cm, allowing arrest of dilation of ≥4 hours is reasonable because it was not associated with increased risks of adverse neonatal outcomes. When cervical dilation is 8 or 9 cm, the benefit of allowing arrest of dilation of ≥4 hours should be balanced against the risk of adverse maternal and neonatal outcomes.

Emergency Care EMTALA Alterations During the COVID-19 Pandemic in the United States.

The coronavirus 2019 pandemic has affected almost every aspect of health care delivery in the United States, and the emergency medicine system has been hit particularly hard while dealing with this public health crisis. In an unprecedented time in our history, medical systems and clinicians have been asked to be creative, flexible, and innovative, all while continuing to uphold the important standards in the US health care system. To continue providing quality services to patients during this extraordinary time, care providers, organizations, administrators, and insurers have needed to alter longstanding models and procedures to respond to the dynamics of a pandemic. The Emergency Medicine Treatment and Active Labor Act of 1986, or EMTALA, is 1 example of where these alterations have allowed health care facilities and clinicians to continue their work of caring for patients while protecting both the patients and the clinicians themselves from infectious exposures at the same time.

Examining the Emergency Medical Treatment and Active Labor Act: impact on telemedicine for neurotrauma.

The Emergency Medical Treatment and Active Labor Act (EMTALA) protects patient access to emergency medical treatment regardless of insurance or socioeconomic status. A significant result of the COVID-19 pandemic has been the rapid acceleration in the adoption of telemedicine services across many facets of healthcare. However, very little literature exists regarding the use of telemedicine in the context of EMTALA. This work aimed to evaluate the potential to expand the usage of telemedicine services for neurotrauma to reduce transfer rates, minimize movement of patients across borders, and alleviate the burden on tertiary care hospitals involved in the care of patients with COVID-19 during a global pandemic. In this paper, the authors outline EMTALA provisions, provide examples of EMTALA violations involving neurosurgical care, and propose guidelines for the creation of telemedicine protocols between referring and consulting institutions.

Evidence of non-economic indicators as markers of success for youth in youth employability programs: Insights from a South African study.

Evaluation studies of youth employment programs prioritize employment and earnings outcomes and use these indicators to determine what labor market interventions are most successful. Evidence from pre and post data of a cluster randomized controlled longitudinal study, consisting of 1 892 youth between 18 and 25 years who participated in Youth Employability Programs (YEPs) in South Africa, confirms the importance of the inclusion of non-economic indicators to measure success for youth. This study provides evidence that non-economic markers of success such as job-search resilience, self-esteem, self-efficacy and future orientation are potentially important in the transition to employment in the longer term and points to the need for more evaluations that use these markers to predict youth's success in employment. The findings further suggest that these non-economic outcomes, which were conceptualized as intermediary outcomes, can influence how young people manage the increasingly protracted and difficult transition to work. The study enlarges our understanding of the non-linear and protracted pathways of youth transitions to work in a development context, and how to best support youth in this transition period. These findings have implications for rethinking YEP evaluation outcomes that could lead to adaptive programming and management of interventions.

ACR Appropriateness Criteria® Assessment of Gravid Cervix.

Preterm birth remains the leading cause of perinatal morbidity and mortality. Although the greatest risk factor for preterm birth is a history of prior preterm birth, a short cervical length (≤25 mm) before 24 weeks' gestational age is also associated with increased risk of spontaneous preterm delivery. As such, cervical length assessment has become of particular interest in predicting those patients at risk for preterm birth. Other clinical scenarios (eg, preterm labor, induction of labor, and active labor) may arise, in which assessment of the cervix may be of interest. Ultrasound is the mainstay imaging modality for assessing the gravid cervix, with transvaginal ultrasound recommended in patients at high risk for preterm birth or suspected preterm labor. Transperineal ultrasound is an alternate approach in those cases where transvaginal ultrasound in contraindicated. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Employment in the neighborhoods of Barcelona: health effects of an active labor market program in Southern Europe.

BACKGROUND: The aim of this study was to analyze the changes in self-perceived health status and mental health among participants in an active labour market policy (ALMP) of Barcelona, and to assess whether the results differed according to the participants' social characteristics and their program trajectories. METHODS: A pre-post intervention study was designed, including unemployed people participating in a return-to-work ALMP in 13 deprived neighborhoods of Barcelona; using one survey upon entering the program (pre), and another 1 year later (post). We assessed the prevalence of poor self-perceived health status and poor mental health (Goldberg-12 questionnaire) in both periods of time. We fit five Poisson regression models using generalized estimating equations (GEE) to measure changes in self-perceived health and mental health between pre- and post-intervention. RESULTS: About 696 individuals (48% women) participated in the study, mainly manual workers. In both sexes, mental health improved (prevalence ratio [PR]-comparing post- and pre-periods for women: 0.49, 95% confidence interval [CI]: 0.39-0.61 and men: PR: 0.41, 95% CI: 0.32-0.53), whereas self-perceived health status remained stable or worsened. Men who remained unemployed reported poorer self-perceived health status, while no such association was observed among women. CONCLUSIONS: This study shows a mental health improvement among male and female participants.