Understanding the Postpartum Cesarean Pain Experience Among Individuals With Publicly Funded Insurance: A Qualitative Investigation.

INTRODUCTION: Pain is the most common postpartum concern and has been associated with adverse outcomes, such as difficulty with neonatal bonding, postpartum depression, and persistent pain. Furthermore, racial and ethnic disparities in the management of postpartum pain are well described. Despite this, less is known regarding patients' lived experiences regrading postpartum pain. The purpose of this study was to assess patient experiences related to postpartum pain management after cesarean birth. METHODS: This is a prospective qualitative study of patients' experiences with postpartum pain management after cesarean birth at a single large tertiary care center. Individuals were eligible if they had publicly funded prenatal care, were English or Spanish speaking, and underwent a cesarean birth. Purposive sampling was used to ensure a racially and ethnically diverse cohort. Participants underwent in-depth interviews using a semistructured interview guide at 2 time points: postpartum day 2 to 3 and 2 to 4 weeks after discharge. Interviews addressed perceptions and experiences of postpartum pain management and recovery. Data were analyzed using the constant comparative method. RESULTS: Of 49 participants, 40.8% identified as non-Hispanic Black and 40.8% as Hispanic. The majority (59.2%) had experienced a cesarean birth with a prior pregnancy. Thematic analysis yielded 2 overarching domains: (1) experience of pain after cesarean birth and (2) pain management and opioid use after cesarean birth. Themes related to the experience of pain included pain as a meaningful experience, pain not aligned with expectations, and limitations caused by pain. All participants discussed limitations caused by their pain, voicing frustration with pursuing activities of daily living, caring for home and family, caring for neonate, and impact on mood. Themes related to pain management and opioid use addressed a desire for nonpharmacologic pain management, positive and negative experiences using opioids, and hesitancy and perceived judgement regarding opioid use. Several participants described experiences of judgement regarding the request for opioids and needing stronger pain medications, such as oxycodone. DISCUSSION: Understanding experiences regarding postpartum cesarean pain management and recovery is essential to improving patient-centered care. The experiences identified by this analysis highlight the need for individualized postpartum pain management, improved expectation counseling, and the expansion of multimodal pain management options.

Content Quality of YouTube Videos About Pain Management After Cesarean Birth: Content Analysis.

BACKGROUND: YouTube is an increasingly common source of health information; however, the reliability and quality of the information are inadequately understood. Several studies have evaluated YouTube as a resource during pregnancy and found the available information to be of poor quality. Given the increasing attention to postpartum health and the importance of promoting safe opioid use after birth, YouTube may be a source of information for birthing individuals. However, little is known about the available information on YouTube regarding postpartum pain. OBJECTIVE: The purpose of this study is to systematically evaluate the quality of YouTube videos as an educational resource for postpartum cesarean pain management. METHODS: A systematic search of YouTube videos was conducted on June 25, 2021, using 36 postpartum cesarean pain management-related keywords, which were identified by clinical experts. The search replicated a default YouTube search via a public account. The first 60 results from each keyword search were reviewed, and unique videos were analyzed. An overall content score was developed based on prior literature and expert opinion to evaluate the video's relevance and comprehensiveness. The DISCERN instrument, a validated metric to assess consumer health information, was used to evaluate the reliability of video information. Videos with an overall content score of ≥5 and a DISCERN score of ≥39 were classified as high-quality health education resources. Descriptive analysis and intergroup comparisons by video source and quality were conducted. RESULTS: Of 73 unique videos, video sources included medical videos (n=36, 49%), followed by personal video blogs (vlogs; n=32, 44%), advertisements (n=3, 4%), and media (n=2, 3%). The average overall content score was 3.6 (SD 2.0) out of 9, and the average DISCERN score was 39.2 (SD 8.1) out of 75, indicating low comprehensiveness and fair information reliability, respectively. High-quality videos (n=22, 30%) most frequently addressed overall content regarding pain duration (22/22, 100%), pain types (20/22, 91%), return-to-activity instructions (19/22, 86%), and nonpharmacologic methods for pain control (19/22, 86%). There were differences in the overall content score (P=.02) by video source but not DISCERN score (P=.45). Personal vlogs had the highest overall content score at 4.0 (SD 2.1), followed by medical videos at 3.3 (SD 2.0). Longer video duration and a greater number of comments and likes were significantly correlated with the overall content score, whereas the number of video comments was inversely correlated with the DISCERN score. CONCLUSIONS: Individuals seeking information from YouTube regarding postpartum cesarean pain management are likely to encounter videos that lack adequate comprehensiveness and reliability. Clinicians should counsel patients to exercise caution when using YouTube as a health information resource.

Adherence to Sexually Transmitted Infection Screening in Pregnancy.

Objective: Professional guidelines and state law require screening for sexually transmitted infections (STI) during pregnancy. Our objective was to evaluate adherence to these recommendations. Methods: This is a retrospective cohort study of patients initiating prenatal care before 20 weeks' gestation. Demographic characteristics and STI screening were abstracted from prenatal records. Tests of interest included initial syphilis, human immunodeficiency virus (HIV), hepatitis B, chlamydia, and gonorrhea tests, as well as repeat (third trimester) syphilis and HIV tests. All patients were eligible for initial screening. Patients were eligible for analysis of whether they received adherent repeat third trimester screening for syphilis (mandated by state law) and HIV (institutional protocol) if they delivered at or after 32 weeks' gestation. Adherent screening was defined as performance of all recommended screening. Results: Of 2370 patients, 1816 (76.6%) received adherent initial STI screening and 181 (7.8% of 2308 patients who delivered at or after 32 weeks' gestation) received adherent repeat third trimester STI screening. After adjusting for covariates, private insurance (adjusted odds ratio [aOR] 1.45, confidence interval [95% CI] 1.12-1.95) was associated with adherent initial screening, whereas being non-Hispanic Black or Hispanic were associated with lower odds of adherent initial screening. Factors associated with adherent repeat third trimester STI screening were younger age (aOR 0.93, 95% CI 0.90-0.97) and non-Hispanic Black race (aOR 3.24, 95% CI 1.94-5.42). Those with private insurance (aOR 0.10, 95% CI 0.06-0.15) were less likely to receive adherent repeat third trimester screening. Conclusion: STI screening rates remain suboptimal. Multiple disparities exist in performance both of initial and repeat third trimester screening.

Maternal psychosocial factors associated with postpartum pain.

BACKGROUND: The experience of pain is shaped by a host of psychological, cultural, and social factors. Although pain is the most common postpartum complaint, data on its relationship with psychosocial factors and postpartum pain are limited. OBJECTIVE: This study aimed to examine the relationship between self-reported postpartum pain scores and patient-level psychosocial factors, including relationship status, pregnancy intendedness, employment, education, and psychiatric diagnosis. STUDY DESIGN: This was a secondary analysis of data from a prospective observational study of postpartum patients at 1 institution (May 2017 to July 2019) who used an oral opioid at least once during their postpartum hospitalization. Enrolled participants completed a survey, which included questions regarding their social situation (including relationship status), psychiatric diagnoses, and perceptions of their pain control during their postpartum hospitalization. The primary outcome was self-reported overall pain during the postpartum hospitalization (score of 0-100). Multivariable analyses accounted for age, body mass index, nulliparity, and mode of delivery. RESULTS: In this cohort of 494 postpartum patients, most patients (84.0%) underwent cesarean delivery, and 41.3% of patients were nulliparous. In a pain score of 0 to 100, participants reported a median pain score of 47. On bivariable analyses, there was no significant difference in pain score between patients with and without an unplanned pregnancy or a psychiatric diagnosis. Patients who were unpartnered, those without a college education, and those who were unemployed reported significantly higher pain scores (57.5 vs 44.8 [P<.01], 52.6 vs 44.6 [P<.01], and 53.6 vs 44.6 [P<.01], respectively). In multivariable analyses, patients who were unpartnered and unemployed reported significantly higher adjusted pain scores than patients who were partnered and employed (adjusted beta coefficients: 7.93 [95% confidence interval, 2.29-13.57] vs 6.67 [95% confidence interval, 2.28-11.05]). CONCLUSION: Psychosocial factors, such as relationship and employment statuses, which are indicators of social support, are associated with the experience of pain postpartum. These findings suggest that addressing social support, such as via enhanced support from the health care team, warrants exploration as a nonpharmacologic means of improving the postpartum pain experience.

Interventions to Reduce Inpatient and Discharge Opioid Prescribing for Postpartum Patients: A Systematic Review.

INTRODUCTION: As deaths related to opioids continue to rise, reducing opioid use for postpartum pain management is an important priority. Thus, we conducted a systematic review of postpartum interventions aimed at reducing opioid use following birth. METHODS: From database inception through September 1, 2021, we conducted a systematic search in Embase, MEDLINE, Cochrane Library, and Scopus including the following Medical Subject Heading (MeSH) terms: postpartum, pain management, opioid prescribing. Studies published in English, restricted to the United States, and evaluating interventions initiated following birth with outcomes including an assessment of change in opioid prescribing or use during the postpartum period (<8 weeks postpartum) were included. Authors independently screened abstracts and full articles for inclusion, extracted data, and assessed study quality using the Grading of Recommendations, Assessment, Development, and Evaluation tool and risk of bias using the Institutes of Health Quality Assessment Tools. RESULTS: A total of 24 studies met inclusion criteria. Sixteen studies evaluated interventions aimed at reducing postpartum opioid use during the inpatient hospitalization, and 10 studies evaluated interventions aimed at reducing opioid prescribing at postpartum discharge. Inpatient interventions included changes to standard order sets and protocols for the management of pain after cesarean birth. Such interventions resulted in significant decreases in inpatient postpartum opioid use in all but one study. Additional inpatient interventions, including use of lidocaine patches, postoperative abdominal binder, valdecoxib, and acupuncture were not found to be effective in reducing postpartum opioid use during inpatient hospitalization. Interventions targeting the postpartum period included individualized prescribing and state legislative changes limiting the duration of opioid prescribing for acute pain both resulted in decreased opioid prescribing or opioid use. DISCUSSION: A variety of interventions aimed at reducing opioid use following birth have shown efficacy. Although it is not known if any single intervention is most effective, these data suggest that implementation of any number of interventions may be advantageous in reducing postpartum opioid use.

Individuals' Experiences of Having an Unplanned Cesarean Birth: A Qualitative Analysis.

OBJECTIVE: The experience of an unplanned cesarean birth may be a risk factor for mood disorders and other challenges in the postpartum period, yet qualitative data on the patient experience are limited. We sought to understand individuals' experiences of having an unplanned cesarean birth. STUDY DESIGN: This was a secondary analysis of a prospective qualitative investigation among low-income postpartum individuals at a single-, tertiary-care center in which the primary aim was to evaluate patients' postpartum pain experience after a cesarean birth. Participants completed a 60-minute face-to-face interview on postpartum days 2 to 3. Only participants who labored prior to their cesarean birth were included in this analysis. Transcripts were analyzed by two separate authors using the constant comparative method. Themes are illustrated using direct quotes. RESULTS: A total of 22 individuals were included in this analysis; the majority (n=16, 72.7%) experienced a primary cesarean birth. Over half (n=12, 54.5%) identified as Hispanic and one-third (n=7, 31.8%) identified as non-Hispanic Black race and ethnicity. Four themes regarding the experience of a cesarean birth after labor were identified, including feelings of anguish, belief that vaginal birth is "normal," poor experiences with care teams, and feelings of self-efficacy. Subthemes were identified and outlined. CONCLUSION: In this cohort, individuals who experienced an unplanned cesarean birth after labor expressed feelings of self-blame, failure, and mistrust. Given the association of unplanned cesarean birth with mood disorders in the postpartum period, efforts to enhance communication and support may offer a means of improving individual experiences.Key Points · In this cohort, many individuals expressed negative feelings after an unplanned cesarean birth.. · Conversely, positive themes related to feelings of self-efficacy were identified.. · Efforts to enhance communication and support after an unplanned cesarean birth are warranted..

How Can We Get to Equitable and Effective Postpartum Pain Control?

Postpartum pain is common, yet patient experiences and clinical management varies greatly. In the United States, pain-related expectations and principles of adequate pain management have been framed within established norms of Western clinical medicine and a biomedical understanding of disease processes. Unfortunately, this positioning of postpartum pain and the corresponding coping strategies and pain treatments is situated within cultural biases and systemic racism. This paper summarizes the history and existing literature that examines racial inequities in pain management to propose guiding themes and suggestions for innovation. This work is critical for advancing ethical practice and establishing more effective care for all patients.

Association Between Patient-Prescriber Racial and Ethnic Concordance and Postpartum Pain and Opioid Prescribing.

Objective: To evaluate whether patient-prescriber racial and ethnic concordance is associated with postpartum opioid prescribing patterns and patient-reported pain scores. Methods: This is a retrospective cohort study of patients who delivered at a tertiary care center between December 1, 2015 and November 30, 2016. Self-identified non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, or Asian patients were included. Patient-prescriber pairs were categorized as racially and ethnically concordant if they shared the same racial and ethnic identity; the prescriber was defined as the obstetrical provider who was responsible for the postpartum discharge of the patient. Multivariable regression models controlling for demographic and clinical confounders were used to assess the relationship of patient-prescriber racial and ethnic concordance with receipt of an opioid prescription and patient-reported pain score at discharge. Results: Of 10,242 patients included in this analysis, 62.3% identified as NHW, 19.1% Hispanic, 9.7% NHB, and 8.9% Asian. About half (52.8%) of patients were discharged by a racially and ethnically concordant prescriber. Patient-prescriber racial and ethnic concordance was not associated with receipt of an opioid prescription (adjusted odds ratio [aOR] 0.82, confidence interval [95% CI] 0.67-1.00) or reporting a pain score ≥5 (aOR 0.90, 95% CI 0.69-1.16). However, NHB and Hispanic patients were less likely to receive an opioid prescription (aOR 0.73, 95% CI 0.56-0.95; aOR 0.73, 95% CI 0.57-0.92, respectively) and significantly more likely to report a pain score ≥5 (aOR 2.13, 95% CI 1.51-3.00; aOR 1.48 95% CI 1.08-2.01, respectively) than NHW patients, even when accounting for concordance. Conclusion: Disparities in postpartum opioid prescribing and pain perception are not ameliorated by patient-prescriber racial and ethnic concordance.

Nurses' Perspectives on Postpartum Pain Management.

Introduction: There is variation in postpartum opioid use by prescriber characteristics that cannot be explained by patient or birth factors. Thus, our objective was to evaluate nursing training, clinical practices, and perspectives on opioid use for postpartum pain management. Materials and Methods: In this survey study, postpartum bedside nurses at a single, large academic center were asked about training, factors influencing clinical decisions, and viewpoints regarding pain management and opioid use. Findings were summarized using descriptive analyses. Results: A total of 92 nurses completed the survey. A majority (77%) reported having received some formal training on opioid use for pain management. About a quarter (25.7%) felt their training was not adequate. Regarding clinical practices, the majority (71% and 70%, respectively) reported that "routine habit" and "patient preference" most influenced the type and amount of pain medication they administered. Finally, nurses' perspectives on pain management demonstrated a wide range of beliefs. Most nurses strongly agreed with the importance of maximizing nonopioid pain medication before opioid administration. The majority agreed that patient-reported pain score is important to consider when deciding to administer opioids. Conversely, most nurses disagreed that patients should be encouraged to endure as much pain as possible before using an opioid. Similarly, beliefs about the reliability of use of vital signs in assessing pain intensity varied widely. Conclusions: Bedside nurses rely on routine habits, patient preference, and patient-reported pain score when administering opioids for postpartum pain management. Increased training opportunities to improve consistency and standardization of opioid administration may be beneficial.

Temporal Trends in Postpartum Opioid Prescribing, Opioid Use, and Pain Control Satisfaction.

OBJECTIVE: The objective was to assess temporal trends in postpartum opioid prescribing, opioid use, and pain control satisfaction. STUDY DESIGN: This is a prospective observational study of postpartum patients who delivered at a large tertiary care center (May 2017-July 2019). Inpatient patients were screened for eligibility; those meeting eligibility criteria who used inpatient opioids were approached for prospective survey participation which probed inpatient and outpatient postpartum pain control. The amount of opioids used during inpatient hospitalization and the amount of opioids prescribed at discharge were obtained from medical records. The primary outcome was the difference in opioid prescribing at discharge over time, measured by (1) the proportion of participants who received an opioid prescription at discharge and (2) for those who received an opioid prescription, the total morphine milligram equivalents of the prescription. Additional outcomes were inpatient and outpatient opioid use and patient-reported satisfaction with postpartum pain control. Trends over time were evaluated using nonparametric tests of trend. RESULTS: Of 2,503 postpartum patients screened for eligibility, a majority (N = 1,425; 60.8%) did not use an opioid as an inpatient. Over the study period, there was a significant decline in the proportion of patients who used an opioid while inpatient (z-score = - 11.8; p < 0.01). Among these participants enrolled in the prospective survey study (N = 494), there was a significant decline over time in the amount of inpatient opioid use (z-score = - 2.4; p = 0.02), the proportion of participants who received an opioid prescription upon discharge (z-score = - 8.2; p < 0.01), and, when an opioid was prescribed at discharge, the total prescribed morphine milligram equivalents (z-score = - 4.3; p < 0.01). Both inpatient and outpatient satisfactions with pain control were unchanged over this time (z-score = 1.1, p = 0.27; z-score = 1.1, p = 0.29, respectively). CONCLUSION: In this population, both the frequency and amount of opioid use in the postpartum period declined from 2017 to 2019. This decrease in opioid prescribing was not associated with changes in patient-reported satisfaction with pain control. KEY POINTS: · From 2017 to 2019, there was a decrease in inpatient and outpatient postpartum opioid use.. · Both the proportion of postpartum patients receiving opioid prescriptions and the amount prescribed decreased.. · Patient satisfaction with postpartum pain control remained unchanged..

Association of Inpatient Postpartum Opioid Use with Bedside Nurse.

INTRODUCTION: Our objective was to assess the association between the nurse providing bedside care and women's postpartum opioid use. METHODS: Retrospective study of all women who birthed at a single center (December 2015 to November 2016). Patient, prescriber, and clinical data were abstracted. The postpartum nurse and total opioid use during the first 12-hour postpartum shift after birth were determined. A high amount of opioid use was defined as morphine milligram equivalents greater than or equal to 90% for this population (stratified by vaginal and cesarean births). A logistic regression model was fit with covariates entered in a step-wise manner to identify the extent to which individual nurses were associated with a greater likelihood of high opioid use by establishing one model in which the only covariate was nurse (model 1) and assessing whether the addition of patient (model 2), birth (model 3), and prescriber factors (model 4) altered the association. Kendall rank correlation assessed rank changes between models. RESULTS: Of the 8376 and 2957 women who had vaginal and cesarean births, 17.9% and 10.2%, respectively, had high opioid use. In the vaginal cohort, women cared for by 46 of 200 nurses were significantly less likely to have high opioid use. Following adjustment, patients cared for by 53 of 200 bedside nurses (model 4) had significantly lower odds of having high opioid use. The rank order of nurses, with respect to the likelihood of opioid use, remained similar after adjustment for patient, birth, and prescriber factors (Τ = 0.84). Findings were similar for the cesarean cohort: 35 of 113 nurses were associated with a significantly lower likelihood of their patients having high opioid use, and the rank order remained similar after covariate adjustment (Τ = 0.78). DISCUSSION: There is significant variation in postpartum women's opioid use based on the nurse that is not explained by patient, birth, or prescriber factors.

Providing Breastfeeding Support During COVID-19: A Survey of Staff Experiences.

BACKGROUND: The COVID-19 pandemic presents unique challenges to maternity settings. Its influence on providing in-hospital lactation support has not been well described. RESEARCH AIM: To describe the experiences of healthcare workers as they provided in-hospital lactation support during the pandemic. METHODS: A prospective, cross-sectional, online survey evaluated healthcare providers working with postpartum women and newborns affected by COVID-19 at an academic center during March-June 2020. Providers were queried regarding the influence of COVID-19 and COVID-19-specific policies on providing lactation support. Questions assessed guidance received, perceived stress, difficulty providing care, and solicited qualitative responses. The constant comparative method was used to analyze qualitative data. RESULTS: Of 108 providers, 70 (65%) completed the survey. Of 57 providing direct lactation support to women affected by COVID-19, most (n = 39, 67%) reported increased stress. Participants reported lower stress scores when receiving guidance through shift meetings or email compared to those not receiving this guidance [stress score with shift meeting guidance (M [SD]): 3.10 (0.88); score without guidance: 3.83 (0.66); n = 39, p = .009; score with email guidance: 3.79 (0.58); score without guidance: 4.50 (0.58); n = 18, p = .045). Qualitative responses (n = 67; 96%) identified three themes: visitor restrictions allowed less distraction during lactation support; physical separation disrupted maternal/infant bonding; workflow challenges resulted from policy changes and supply access. CONCLUSIONS: Most participating staff providing lactation support to participants affected by COVID-19 reported increased stress. Ensuring written or verbal guidance may reduce staff's experiences of stress. Efforts to optimize lactation support during COVID-19 should consider reducing distractions, physical separation, and logistic challenges.

Pregnancy Outcomes Associated with Introduction of Early Diabetes Screening Guidelines.

OBJECTIVE: The study aimed to evaluate perinatal outcomes associated with introduction of and adherence to early diabetes screening guidelines. STUDY DESIGN: Retrospective cohort study of all women who received prenatal care at a single, high-volume tertiary care center before ("preguidelines") and after ("postguidelines") American College of Obstetrics and Gynecology guidelines for early pregnancy diabetes screening for women at high risk for diabetes. Women with known pregestational diabetes, late entry to prenatal care, a fetus with a known anomaly, or multiple gestation were excluded. Multivariable linear and logistic regression models were constructed to compare maternal and neonatal outcomes between women in the preguidelines cohort to those in the postguidelines cohort. Similarly, adherence to screening guidelines was assessed, and among all women who were eligible for early diabetes screening, multivariable linear, and logistic models were created to compare outcomes between those women who were screened early to those who were not. RESULTS: Of the 2,069 women eligible for analysis, 64.6% (n = 1,337) were in the postguideline cohort. Women in the postguideline cohort were older, less likely to have a history of smoking, and more likely to be non-Hispanic white. On multivariable analysis, women in the postguideline cohort had significantly less gestational weight gain (aß = -2.3; 95% confidence interval [CI]: -3.4 to -1.1), but a higher odds of 5-minute Apgar's score of <7 (adjusted odds ratio: 2.51; 95% CI: 1.11-5.66). Of 461 women who met ACOG early diabetes screening criteria, 58.7% (n = 270) were screened appropriately. Adherence to screening was associated with parity, race, insurance, and BMI. On multivariable analysis, there were no significant differences in neonatal outcomes between women meeting early screening criteria who were screened early and those who were not. CONCLUSION: Introduction of early diabetes screening guidelines was associated with a significant decrease in gestational weight gain, but did not improve neonatal outcomes. KEY POINTS: · Introduction of early diabetes screening guideline did not improve rate of early screening.. · Detection and treatment of gestational diabetes may not improve perinatal outcomes.. · Early screening guidelines was associated with decreased gestational weight..

Neonatal hypoglycemia after antenatal late preterm steroids in individuals with diabetes.

OBJECTIVE: To establish whether administration of antenatal late preterm steroids to pregnant people with diabetes resulted in higher risk of neonatal hypoglycemia. STUDY DESIGN: This is a retrospective cohort study of individuals with pre-gestational or gestational diabetes admitted between 34 0/7-36 6/7 weeks' gestation before and after introduction of an antenatal late preterm steroids protocol. The primary outcome was any neonatal blood glucose ≤ 60 mg/dL in the first 24 h of life. RESULTS: Of 123 mother-neonate pairs, 52.8% (N = 65) delivered during the post-protocol period; 75.4% of those (N = 49) received late preterm steroids. 59.7% (N = 34) of the pre-protocol neonates and 81.5% (N = 53) of the post-protocol neonates had hypoglycemia (p = 0.008). After controlling for gestational age at delivery and mode of delivery, neonates in the post-protocol group had increased odds of hypoglycemia (adjusted odds ratio 2.96, 95% confidence interval 1.29-6.82). CONCLUSION: Neonates born to mothers with diabetes who received late preterm corticosteroids experienced greater odds of hypoglycemia.

Association of Tdap vaccine guidelines with vaccine uptake during pregnancy.

OBJECTIVE: In 2012, recommendations for universal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination during pregnancy were released. Our objective was to determine if Tdap, influenza, and pneumococcal vaccine uptake during pregnancy changed after the release of the guidelines, and identify factors associated with receiving the Tdap and influenza vaccine after 2012. METHODS: We conducted a retrospective cohort study on pregnant individuals who initiated prenatal care before 20 weeks' gestation between 11/2011-11/2012 ("pre-guideline") and 12/2012-12/2015 ("post-guideline"). Vaccine uptake dates were abstracted from medical records. The pre and post-guideline cohorts were compared to determine if Tdap vaccine uptake and timing improved after the new Tdap guidelines. We additionally examined influenza and pneumococcal vaccine uptake before and after guidelines. Factors associated with receipt of the Tdap and influenza vaccine during pregnancy in the post-guideline cohort were evaluated using multivariable logistic regression models. RESULTS: Of 2,294 eligible individuals, 1,610 (70.2%) received care in the post-guideline cohort. Among the pre-guideline cohort, 47.4% received Tdap, whereas Tdap uptake increased to 86.1% after the guidelines (p<0.001). Similarly, receiving the Tdap vaccine between the recommended time of 27-36 weeks gestational age improved from 52.5% to 91.8% after the guidelines (p<0.001). Vaccine frequency for influenza improved significantly from 61.2% to 72.0% (p<0.001), while frequency for pneumococcus were low and unchanged. An increased number of prenatal visits was associated with receiving the Tdap and influenza vaccines during pregnancy (respective, aOR 1.09 95% CI 1.05-1.13; aOR 1.50 95% CI 1.17-1.94). Non-Hispanic Black individuals were less likely to receive both the Tdap and influenza vaccines during pregnancy compared to non-Hispanic White individuals (respective, aOR 0.51 95% CI 0.33-0.80; aOR 0.68 95% CI 0.48-0.97). CONCLUSIONS: Receipt and timing of Tdap vaccine improved after implementation of the 2012 ACIP guidelines. Receipt of influenza vaccine uptake also improved during the study period, while uptake of the pneumococcal vaccine remained low. Significant racial disparities exist in receipt of Tdap and influenza vaccine during pregnancy.

Periconception glycemic control and congenital anomalies in women with pregestational diabetes.

INTRODUCTION: To assess the relationship between periconception glycemic control and congenital anomalies in a contemporary, diverse population of women with pregestational diabetes. RESEARCH DESIGN AND METHODS: This is a retrospective cohort study of all pregnant women with pregestational diabetes at a single institution (2003-2017) in the USA. The primary outcome was frequency of major or minor congenital anomalies. Glycemic control was assessed by periconception glycosylated hemoglobin (HbA1c). The association of periconception HbA1c with pregnancy outcomes was assessed using bivariable and multivariable analyses. RESULTS: Our sample included 351 women, of which 63.8% had type 2 diabetes. Our study cohort is racially and ethnically diverse, with approximately equal numbers of women identifying as white non-Hispanic, black non-Hispanic and Hispanic, with 3.4% identifying as Asian. Of these 351 women, 52 (14.8%) had a fetus with a congenital anomaly, of whom the majority (n=43) had a major anomaly. Over half (51.1%) of all major anomalies were cardiovascular. Compared with the group with the best glycemic control (HbA1c ≤7.4%), which had an anomaly frequency of 10.2%, the frequency of congenital anomalies increased significantly with each category of worsening glycemic control (HbA1c 7.5%-9.4%: 20.6%, adjusted OR (aOR) 2.35, 95% confidence interval (CI) 1.08 to 5.13; HbA1c 9.5% to 11.4%: 25.8%, aOR 2.86, 95% CI 1.08 to 7.59; HbA1c ≥11.5%: 37.5%, aOR 7.66, 95% CI 2.27 to 25.9). CONCLUSION: In a diverse cohort of women with pregestational diabetes, higher periconception HbA1c, especially HbA1c >9.5, was significantly associated with major congenital fetal anomalies. Our study sample is reflective of the current population of pregnant women with diabetes, including women with type 2 diabetes and from racial and ethnic minorities.

Patient Experience with Postpartum Pain Management in the Face of the Opioid Crisis.

INTRODUCTION: Professional societies have urged providers to reduce opioid use for pain management. Accordingly, the objective of this study was to assess patient experiences related to postpartum pain management in an effort to better understand potential paths to achieve such a reduction. METHODS: This is a planned secondary analysis of a prospective observational study of opioid use following birth. In the primary study, women who received opioids as inpatients were queried about their pain management, including questions about pain experience, pain satisfaction, perceived areas for practice improvement, and the opportunity to leave additional comments. Participants who were prescribed opioids upon discharge completed postdischarge surveys with a similar opportunity for qualitative input. Data were analyzed using the constant comparative method to identify themes and subthemes. RESULTS: Of the 493 women enrolled in the primary analysis, 125 provided qualitative data. Three overarching themes regarding pain management were identified: positive experiences (n = 22), negative experiences (n = 19), and beliefs and preferences on opioid use and pain management (n = 28). Women with positive experiences reported satisfaction with timely pain medication administration and appreciation of open dialogue with their care team. In contrast, several negative experiences centered on tardy administration of pain medications, resulting in increased pain. Patients also perceived judgment, accusation, and excessive lecturing by staff when requesting opioid medications. Finally, participants expressed the necessity for opioids for postpartum pain management, as well as their desires for limiting opioid use, improved options for multimodal pain management, and increased communication with providers about pain regimens. DISCUSSION: Understanding women's perspectives and experiences regarding postpartum pain control is essential to improving care. Amid growing research on the role of maternity care providers in addressing the opioid crisis, women's voices are rarely solicited. These findings stress the importance of open and frequent dialogue between patients and providers and a need for multimodal pain management options.

Neonatal Outcomes of Triplet Pregnancies Conceived via In Vitro Fertilization versus Other Methods of Conception.

OBJECTIVE: This study aims to investigate neonatal outcomes of triplet gestations conceived via in vitro fertilization (IVF) compared with those not conceived by IVF. STUDY DESIGN: This is a retrospective cohort study of women who delivered a triplet gestation ≥24 weeks at a large academic center (2005-2016). Women with unknown mode of conception were excluded. Women who conceived via IVF were compared with those conceiving spontaneously or through non-IVF fertility treatments. The primary outcome was a composite severe neonatal morbidity (respiratory distress syndrome, necrotizing enterocolitis, severe intraventricular hemorrhage, retinopathy of prematurity, neonatal sepsis, or death). Bivariate comparisons were made by mode of conception and unadjusted generalized estimating equations were used to estimate odds ratios (OR) after accounting for the clustering of neonate by mother. RESULTS: Among 82 women included in this analysis, 51 (62%) conceived via IVF. Women who conceived via IVF were older (35.2 vs. 30.7, p < 0.001) and more likely to be of non-Hispanic white race/ethnicity (91.8 vs. 70.0%, p < 0.01) and married (100 vs. 90.0%, p = 0.02) when compared with women who did not conceive via IVF. Although women who conceived via IVF delivered at an earlier gestational age than those who did not (32.9 ± 3.0 vs. 33.7 ± 2.6 weeks, p = 0.02), there was no significant difference in composite neonatal morbidity (34.0 vs. 28.0%, p = 0.32; OR: 1.33, 95% CI: 0.60-2.91). Additionally, there were no significant differences between the groups with regard to other neonatal outcomes examined, including fetal growth restriction, birthweight, umbilical artery pH <7, neonatal intensive care unit admissions, duration in the NICU, need for mechanical ventilation, or duration of mechanical ventilation. CONCLUSION: Neonatal outcomes among triplet gestations did not differ by IVF in this well-characterized, single-center cohort.

Implementation of an antenatal late-preterm corticosteroid protocol at a high-volume tertiary care center.

Background: Since publication of the sentinel antenatal late preterm steroids clinical trial, the use of antenatal steroids has become a routine aspect of the management of pregnancies at risk for late preterm delivery. However, in practice, the administration of antenatal corticosteroids in the late preterm period is widely varied across provider and institution, and the process of implementation of this new practice as well as outcomes associated with implementation are not well understood. Objective: The objective was to evaluate institutional adherence to an antenatal late preterm corticosteroid protocol and to assess neonatal outcomes associated with its introduction. Study Design: This is a retrospective cohort study of all women with singleton pregnancies admitted between 34 to 36 5/7 weeks who presented in the year before ("pre-protocol": November 2012 to October 2013) and after implementation ("post-protocol": April 2016 to March 2017). The protocol recommends corticosteroid administration to women 34 to 36 5/7 weeks gestation at risk for preterm birth who have not received prior corticosteroids. Women with fetal anomalies or pregestational or gestational diabetes were excluded from analysis. The frequency with which eligible women received corticosteroids and ineligible women were appropriately excluded (adherence) was calculated on a monthly basis. Neonatal outcomes of interest were hypoglycemia, receipt of dextrose, birth weight, 5 minute Apgar less than 7, receipt of surfactant, respiratory distress syndrome, transient tachypnea of the newborn, neonatal intensive care unit length of stay, intraventricular hemorrhage, necrotizing enterocolitis, culture positive sepsis, bronchopulmonary dysplasia, and death. Bivariable and multivariable analyses were used to compare neonatal outcomes between 1) all women in the post-protocol cohort to those in the pre-protocol cohort and 2) only women who received adherent care in the post-protocol cohort to all women in the pre-protocol cohort. Results: A total of 452 women were included in the pre-protocol cohort and 451 in the post-protocol cohort. The majority of the post-protocol women (N=366, 81.2%) received adherent care. Women in both cohorts were similar with the exception that women in the post-protocol cohort were more likely to be nulliparous (p=0.013). Compared to the pre-protocol period, neonates of women in the post-protocol period had significantly higher odds of hypoglycemia <50 mg/dL in the first 24 hours of life (aOR 1.37, 95% CI 1.05-1.80), without improvements in respiratory outcomes. Results were similar when restricting the analysis to only women in the post-protocol cohort who received care adherent care (glucose <50 mg/dL: aOR 1.52, 95% CI 1.14-2.03). No differences in composite respiratory morbidity or other neonatal outcomes were observed. Conclusion: Uptake of a new institutional protocol for antenatal late preterm corticosteroids was rapid. Compared with historic controls, neonates exposed to antenatal late preterm corticosteroid experienced increased odds of hypoglycemia, without significant improvements in respiratory morbidities.