Time from insertion to expulsion of cervical ripening balloon in preterm versus term inductions of labor.

OBJECTIVE: Preterm induction of labor can be necessary for maternal and fetal wellbeing. Duration of cervical ripening balloon (CRB) use has been studied in only term inductions. Our study investigated duration of time in hours for CRB expulsion and vaginal delivery in preterm inductions of labor. METHODS: This was a single-institution retrospective cohort study of preterm (< 37 weeks) and term (≥ 37 weeks) inductions with CRB between 2010 and 2021. Cesarean deliveries were excluded. Primary outcome was insertion to expulsion time of CRB. Secondary outcomes included induction to delivery time, cervical dilation after expulsion, misoprostol, and Pitocin use. Institutional review board (IRB) approval was obtained prior to the study. RESULTS: Ninety-eight patients with vaginal delivery after preterm CRB use were identified and matched 1:1 on baseline characteristics (p > 0.05) to term patients with vaginal delivery after CRB use. Mean insertion to expulsion time was significantly shorter for term than preterm inductions (mean 7.2 ± 3.09 h versus 8.5 ± 3.38 h; p < 0.01). Mean induction to delivery time was significantly shorter for term than preterm inductions (18.4 ± 7.6 h versus 22.5 ± 9.01 h; p < 0.01). Increased use of misoprostol, Pitocin, and second CRB were noted among the preterm cohort. Among term patients, more CRB placement at start of induction and greater cervical dilation post-balloon were found in comparison to preterm patients. CONCLUSION: Among patients undergoing preterm induction, longer insertion to expulsion time of CRB, longer induction to delivery time, and increased interventions should be expected. Different standards for labor management should be considered for achieving vaginal delivery in preterm inductions.

Patient Experience with Telehealth Medicine During the Ongoing COVID-19 Pandemic in New York City.

Background: The COVID-19 pandemic accelerated integration of telehealth services into OBGYN practices in New York City. Since then, studies have shown high patient satisfaction with OBGYN telehealth services. However, few studies have compared satisfaction between obstetric and gynecologic patients. The primary objective of this study was to compare satisfaction with telehealth services between obstetric and gynecologic patients. Methods: This was an institutional review board-approved cross-sectional survey study among patients who had a telehealth visit at NYU OBGYN Faculty Group Practice from March 2020 to March 2021. Results: Gynecologic patients had higher rates of being "completely satisfied" compared with obstetric patients (40% vs. 24%, p < 0.001). Gynecologic patients were more likely to opt for telehealth services than obstetric patients both during a pandemic (70% vs. 59%, p < 0.001) and in the absence of a pandemic (53% vs. 37%, p < 0.001). Discussion: Prior studies have demonstrated high satisfaction with OBGYN telehealth. However, obstetric patients were less likely than gynecologic patients to feel satisfied with and opt for telehealth services.

Ugandan Health Care Professionals' Response to Sexual Violence Survivors: Exploring Local Strategy and International Guidelines.

This survey-based study gathered information on health professionals' attitudes and behaviors regarding victims of sexual assault, focusing on the applicability and utility of best practices put forth by the World Health Organization and the United Nations. This cross-sectional study involved a self-administered, 84-question survey to health care professionals affiliated with Mulago National Referral and Kayunga Hospitals in Uganda. The survey included demographic questions as well as questions about participants' attitudes toward sexual violence and the role of HPs in addressing sexual violence. The remainder of the survey transformed two sets of international guidelines into a series of statements with which participants could agree or disagree using a Likert-type scale. In total, 75 partially or fully completed surveys were collected, 45 from Mulago, and 30 from Kayunga. A minority of participants indicated that the guidelines were unrealistic (4.1%) or culturally inappropriate (14.1%). Most HPs agreed (91.8%) with the key components of recommended care. However, many respondents highlighted the need for additional training (68%). Nearly half of participants were uncertain or disagreed that there was a clear protocol for care of survivors of sexual violence (48%). Targets for improvement identified by participants included enhanced support of staff, access to resources, and relationships with community partners. Ugandan HPs have been receptive to the World Health Organization and United Nations guidelines. The majority of participants felt that the guidelines were realistic and culturally appropriate. Furthermore, many of these guidelines have been implemented. However, additional steps identified by Ugandan health workers could be undertaken to further improve the care received by survivors of sexual violence.

Screening and Treatment After Implementation of a Universal Perinatal Depression Screening Program.

OBJECTIVE: To evaluate whether initiation of an institutional policy of universal perinatal depression screening was associated with sustained increases in frequency in screening and of depression treatment subsequent to a positive screen. METHODS: This retrospective cohort study included women receiving prenatal care in outpatient offices at a single academic medical center from 2008 to 2015. In 2009, an institutional policy of universal perinatal depression screening was disseminated in which screening twice antenatally and again postpartum were recommended. The frequency of screen completion at each recommended time point was compared between the prepolicy and postpolicy cohorts. A test of trend that assessed the frequency of screening each year after policy initiation was used to assess changes over time. The frequency with which care plans were created for women who screened positive for perinatal depression were compared before and after implementation. RESULTS: Of the 5,127 women who met inclusion criteria, 4,005 (78%) were in the postpolicy cohort. The frequency of completion of depression screening at the first prenatal visit (0.1% vs 65.5%), in the third trimester (0.0% vs 42.7%), and at the postpartum visit (69.5% vs 90.0%) increased after initiation of the policy (P<.001 for all). The improvement in postpartum depression screening completion persisted after controlling for potential confounders (adjusted odds ratio 5.3, 95% CI 4.4-6.5). After the initial increase in uptake of screening, the frequency of screening at the first and third trimester prenatal visits continued to increase over time (P<.001 for each), although this frequency remained stable for the postpartum visit (P=.29). Women with a positive postpartum depression screen were more likely to have depression treatment recommended or provided by their obstetrician postpolicy (64.7% vs 30.1%, P<.001). CONCLUSION: Implementation of an institutional policy of universal perinatal depression screening was associated with improvements in perinatal depression screening with concomitant improvements in depression treatment recommendations for women with a positive postpartum depression screen.

Gender Differences in Academic Rank and NIH Funding among Academic Maternal-Fetal Medicine Physicians in the United States.

OBJECTIVE: This article evaluates gender differences in academic rank and National Institutes of Health (NIH) funding among academic maternal-fetal medicine (MFM) physicians. STUDY DESIGN: This was a cross-sectional study of board-certified academic MFM physicians. Physicians were identified in July 2017 from the MFM fellowship Web sites. Academic rank and receipt of any NIH funding were compared by gender. Data on potential confounders were collected, including years since board certification, region of practice, additional degrees, number of publications, and h-index. RESULTS: We identified 659 MFM physicians at 72 institutions, 312 (47.3%) male and 347 (52.7%) female. There were 246 (37.3%) full, 163 (24.7%) associate, and 250 (37.9%) assistant professors. Among the 154 (23.4%) MFM physicians with NIH funding, 89 (57.8%) were male and 65 (42.2%) were female (p = 0.003). Adjusting for potential confounders, male MFM physicians were twice as likely to hold a higher academic rank than female MFM physicians (adjusted odds ratio [aOR], 2.04 [95% confidence interval, 1.39-2.94], p < 0.001). There was no difference in NIH funding between male and female MFM physicians (aOR, 1.23 [0.79-1.92], p = 0.36). CONCLUSION: Compared with female academic MFM physicians, male academic MFM physicians were twice as likely to hold a higher academic rank but were no more likely to receive NIH funding.

Labor Curves in Multiparous Women Related to Interbirth Intervals.

OBJECTIVE: Previous studies have shown that risk of cesarean section increases among multiparous women as interbirth interval increases. One possibility is that progress of labor may vary with interbirth interval, such that with longer intervals, labor curves of multiparas more closely resemble those of nulliparas. We sought to define labor curves among a cohort of multiparas with varying interbirth intervals. STUDY DESIGN: This was a retrospective cohort study of term multiparas with known interval from last delivery and only vaginal deliveries. Subjects were grouped by interval between the studied pregnancy and the most recent birth: 0 to 59, 60 to 119, and ≥120 months. Statistical analysis was performed using linear mixed effects model. Group slopes and intercepts were compared using model t-tests for individual effects. Length of second stage was compared using a Wilcoxon's rank-sum test. RESULTS: Groups did not differ significantly in demographic or obstetrical characteristics. Rate of dilation was similar between the 0 to 59 and 60 to 119 month groups (p = 0.38), but faster in the ≥120 month group compared with the 60 to 119 month group (p = 0.037). Median duration of second stage increased slightly with increased interbirth interval (p = 0.003). CONCLUSION: Prolonged interbirth interval is not associated with slower active phase of labor.

Long-Term Sexual Function After Obstetric Anal Sphincter Injuries.

OBJECTIVES: Obstetric anal sphincter injuries (OASIS) are associated with severe short and long-term morbidities, although little is known about the long-term sexual function or satisfaction of women and partners of women with history of OASIS. The objective of this study was to describe the long-term sexual function and satisfaction of women who previously sustained OASIS and to assess sexual satisfaction among their male partners. METHODS: This was a follow-up study of participants enrolled in the For Optimal Recovery: Care After Severe Tears (FORCAST) prospective cohort study of women with a history of OASIS after delivery of a full-term singleton infant between 2011 and 2013. A total of 47 women and 25 male partners at a mean of 45 months ± 8 months after incident delivery completed online validated questionnaires assessing current sexual functioning and satisfaction. The Female Sexual Functioning Index (FSFI) was completed by female participants, whereas the Golombok-Rust Inventory of Sexual Satisfaction (GRISS) was completed by both female participants and their male partners. RESULTS: Nearly half (47%) of women met the criteria for female sexual dysfunction according to the Female Sexual Functioning Index. One-third of women (34%) had an overall GRISS score of 5 or greater, indicating sexual dysfunction. Sixty-two percent of women had a subsequent delivery. Seven male partners (28%) met the criteria for sexual dysfunction according to the GRISS. The most problematic GRISS subscale reported by both men and women was that of infrequency of intercourse. CONCLUSIONS: Even 3 years after sustaining OASIS, up to half of women and many male partners meet the criteria for sexual dysfunction. Future studies including women without history of OASIS are needed to further investigate the role OASIS may play in the development of long-term sexual dysfunction.

Request and fulfillment of postpartum tubal ligation in patients after high-risk pregnancy.

OBJECTIVE: Female sterilization is one of the most prevalent methods of contraception in the United States. Prior studies have shown that nearly half of postpartum tubal ligation (PPTL) requests go unfulfilled. This study seeks to establish whether obstetric or medical risk status influences patients' request for or subsequent completion of PPTL. METHODS: This study was a retrospective cohort study of women delivering at a university hospital in 2009-2010 who received prenatal care in the faculty and resident clinics. High-risk status was defined by Society for Maternal-Fetal Medicine guidelines. Documentation of contraceptive plan and administration of contraceptive methods was abstracted from patient records. Subsequent pregnancies through March 1, 2013, were abstracted. RESULTS: Of 3063 participants (2048 low risk and 1015 high risk), 231 requested PPTL (7.5%). This was more likely among high-risk patients than low-risk patients (10.0% vs. 6.3%, p<.001), those with public insurance (13.8% vs. 3.2%, p<.001) and those with an unintended index pregnancy (13.8% vs. 4.1%, p<.001). Of the patients requesting PPTL, 118 (51.1%) underwent the procedure immediately postpartum. Completion was not associated with high-risk status (54.0%), or with race, insurance status or parity. Among 113 women with an unfulfilled PPTL request, there were 17 subsequent pregnancies (15.0%) during the 27 months of follow-up. CONCLUSIONS: Though women with high-risk pregnancies were more likely to request PPTL, they were not more likely to complete the procedure. Over one third of high-risk patients' requests were unfulfilled, indicating that significant barriers may remain. IMPLICATIONS: Though women with high-risk pregnancies were more likely to request PPTL, they were not more likely to complete the procedure. Providers should consider these procedures urgent, especially in high-risk women, and advocate for their patients' access to this procedure.

Simulation Training for Forceps-Assisted Vaginal Delivery and Rates of Maternal Perineal Trauma.

OBJECTIVE: To evaluate the association of a forceps simulation training curriculum for obstetrics residents on rates of severe perineal lacerations after forceps deliveries. METHODS: This was a retrospective cohort study. We created a novel simulation curriculum for forceps-assisted vaginal delivery based on the best practices of local experts, and trained all residents beginning in 2013. We then retrospectively reviewed all forceps deliveries performed in the 2.5 years after initiation of the training and the 7.5 years before the training program. We identified patients who experienced a severe perineal laceration (third- or fourth-degree) and examined the relationship of resident training status and perineal laceration. Known risk factors for lacerations were identified and a multilevel multivariable model was created including these factors as well as resident training. RESULTS: During the study period, we identified 6,058 forceps-assisted vaginal deliveries. We examined temporal trends in rates of forceps of severe perineal laceration. We identified a decrease in severe lacerations between 2005 and 2008, ending 5 years before the initiation of the training curriculum. These years were censored from the data, yielding a baseline observational period of 4,279 deliveries with no significant trend in laceration rate. Univariate analysis reveals a 22% reduction in severe perineal laceration (odds ratio [OR] 0.78; P=.005) among women delivered by residents who had completed forceps simulation training compared with women delivered by residents who had not. After adjusting for known maternal and delivery risk factors for perineal laceration, the magnitude of the reduction increased to 26% in the full data set model (OR 0.74; P=.002). CONCLUSION: A forceps simulation curriculum for obstetrics residents was associated with a significant reduction in severe perineal lacerations.

Factors Associated With Timing of Return to Intercourse After Obstetric Anal Sphincter Injuries.

INTRODUCTION: The impact of obstetric perineal trauma on timing of return to intercourse is unclear, although sexual desire is clearly decreased in these women. In addition, studies examining timing of return to intercourse are cross-sectional and therefore cannot delineate potential reasons that patients might delay return to intercourse. AIM: To identify factors associated with delayed return to intercourse after obstetric anal sphincter injuries. METHODS: This was a planned secondary analysis of a prospective cohort study of women sustaining obstetric anal sphincter injuries during delivery of a full-term singleton infant. Patients completed the Fecal Incontinence Severity Index at every postpartum visit (1, 2, 6, and 12 weeks) and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 once resuming vaginal intercourse. Intercourse was considered "delayed" if patients did not resume intercourse by the 12-week visit. This cutoff was chosen because it was subsequent to the 6-week visit, when patients were instructed to return to normal pelvic activity. Continuous variables were compared using the Student t-test (parametric) or Mann-Whitney U-test (non-parametric). The χ(2) test was used for categorical variables. Statistical significance was assigned with a P value less than .05. MAIN OUTCOME MEASURES: Primary outcome measurements were differences in pelvic floor symptoms on validated surveys between the "delayed" and "not-delayed" groups at the first postpartum visit and at the time the subjects returned to intercourse. We used the Patient Health Questionnaire-9 for depression, the Urinary Distress Inventory-6 and Incontinence Impact Questionnaire-7 for urinary symptoms, the visual analog scale for pain, the Fecal Incontinence Severity Index for bowel symptoms, and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 at the return to intercourse visit only. RESULTS: One hundred ninety-nine women were included in this analysis. Most were Caucasian (77%) and primiparous (86%). One hundred nineteen women (60%) did not resume vaginal intercourse until after the 12-week visit and were deemed "delayed." Patients who delayed intercourse scored higher on the Fecal Incontinence Severity Index (more anal incontinence) than those who resumed intercourse before 12 weeks (15.4 ± 12.3 vs 12.0 ± 12.8, P = .02). The delayed group also had worse sexual function, shown as lower Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 scores (35.4 ± 5.9 vs 38.4 ± 4.1, P ≤ .001) and persistently higher Fecal Incontinence Severity Index scores (4.1 ± 7.3 vs 1.6 ± 4.4, P = .001), at the first visit after returning to intercourse. CONCLUSION: Patients with obstetric anal sphincter injuries who do not resume intercourse by 12 weeks postpartum report more severe anal incontinence symptoms and worse sexual function after return to coitus.

Predictors of shoulder dystocia at the time of operative vaginal delivery.

BACKGROUND: It remains uncertain whether clinical factors known prior to delivery can predict which women are more likely to experience shoulder dystocia in the setting of operative vaginal delivery. OBJECTIVE: We sought to identify whether shoulder dystocia can be accurately predicted among women undergoing an operative vaginal delivery. STUDY DESIGN: This was a case-control study of women undergoing a low or outlet operative vaginal delivery from 2005 through 2014 in a single tertiary care center. Cases were defined as women who experienced a shoulder dystocia at the time of operative vaginal delivery. Controls consisted of women without a shoulder dystocia at the time of operative vaginal delivery. Variables previously identified to be associated with shoulder dystocia that could be known prior to delivery were abstracted from the medical records. Bivariable analyses and multivariable logistic regression were used to identify factors independently associated with shoulder dystocia. A receiver operating characteristic curve was created to evaluate the predictive value of the model for shoulder dystocia. RESULTS: Of the 4080 women who met inclusion criteria, shoulder dystocia occurred in 162 (4.0%) women. In bivariable analysis, maternal age, parity, body mass index, diabetes, chorioamnionitis, arrest disorder as an indication for an operative vaginal delivery, vacuum use, and estimated fetal weight >4 kg were significantly associated with shoulder dystocia. In multivariable analysis, parity, diabetes, chorioamnionitis, arrest disorder as an indication for operative vaginal delivery, vacuum use, and estimated fetal weight >4 kg remained independently associated with shoulder dystocia. The area under the curve for the generated receiver operating characteristic curve was 0.73 (95% confidence interval, 0.69-0.77), demonstrating only a modest ability to predict shoulder dystocia before performing an operative vaginal delivery. CONCLUSION: While risk factors for shoulder dystocia at the time of operative vaginal delivery can be identified, reliable prediction of shoulder dystocia in this setting cannot be attained.

Postpartum contraceptive choice after high-risk pregnancy: a retrospective cohort analysis.

OBJECTIVE: To evaluate the effect of high-risk pregnancy status on antepartum contraceptive planning and postpartum use. METHODS: We performed a retrospective cohort study of women delivering at a university hospital during 2009-2010 who received prenatal care in the faculty or resident clinics. We defined high-risk status by Society for Maternal-Fetal Medicine guidelines. We abstracted contraceptive planning and postpartum administration from medical records and categorized these into World Health Organization tiers of contraceptive effectiveness. We identified subsequent pregnancies through March 2013. Chi-squared tests and binary logistic regression were used to assess correlations between risk status and contraceptive choice, actual postpartum use, and subsequent pregnancy. RESULTS: This study included 2048 low-risk and 1015 high-risk parturients. The index pregnancy was more likely to be unintended among low-risk than high-risk women (48.4% vs. 42.9%, p=.02). Low-risk and high-risk women showed interest in Tier 1 contraceptives while antepartum (54.4% low-risk vs. 58.0% high-risk, p=.2), with lower interest at discharge (42.3% vs. 50.7%, p<.001) and at the postpartum visit (33.8% vs. 40.1%, p=.002). Just 776 women (25.3%) actually received a Tier 1 method. 656 women (21.4%) had a subsequent pregnancy lasting more than 20weeks. Unintended pregnancy rates did not differ between low (36.6%) and high-risk (32.4%) women (p=.38). CONCLUSION: High-risk women had similar rates of planning for Tier 1 contraceptives but similar rates of subsequent unplanned pregnancy. Intention to use highly effective contraception did not translate into actual use. Further work is needed to identify barriers to uptake. IMPLICATIONS: Identification of barriers to uptake of highly effective contraceptive methods after high-risk pregnancy represents an important area for future research. Providers should continue to address postpartum contraception throughout pregnancy and be prepared to address barriers to such methods in the postpartum period.

Predictors of Failed Operative Vaginal Delivery in a Contemporary Obstetric Cohort.

OBJECTIVE: To identify factors associated with failed operative vaginal delivery in contemporary parturients and evaluate whether these factors can be used to accurately predict failed operative vaginal delivery. METHODS: This was a case-control study of women undergoing a trial of operative vaginal delivery from a low or outlet station between 2005 and 2014. Women in the case group were defined as women who had an attempted operative vaginal delivery but ultimately required cesarean delivery. Women in the control group were defined as women who delivered vaginally. Bivariable and multivariable analyses were performed to determine factors that were independently associated with failed operative vaginal delivery. A receiver operating characteristic curve was created and area under the curve calculated to estimate the predictive capacity of these associations. RESULTS: Of 4,352 women who met inclusion criteria, 2,527 underwent an attempt at operative vaginal delivery using forceps and 1,825 using vacuum. Failure occurred in 272 (6.3%). In bivariable analysis, nulliparity, white race, induction of labor, chorioamnionitis, second stage 2 hours or greater, fetal occiput-posterior position, low station at application (compared with outlet), larger estimated fetal weight, and arrest or exhaustion as an indication for operative vaginal delivery (compared with a fetal indication) were significantly associated with a failed operative vaginal delivery. In multivariable analysis, factors that remained independently associated with operative vaginal delivery failure were race-ethnicity, arrest or exhaustion as an indication for operative vaginal delivery, occiput-posterior position, and a low pelvic application. The area under the curve for this regression was 0.74 (95% confidence interval 0.69-0.77) demonstrating less than optimal prediction of operative vaginal delivery failure. CONCLUSION: Risk factors identified before an operative vaginal delivery attempt cannot be used to accurately predict whether an operative vaginal delivery attempt will fail.

A case-control study of the relationship between a passive second stage of labor and obstetric anal sphincter injuries.

OBJECTIVE: To estimate the relationship between a passive second stage of labor and obstetric anal sphincter injuries (OASIS). METHODS: A retrospective, case-control study was undertaken of women who delivered at a tertiary-care center in Chicago, IL, USA, between November 2005 and December 2012. Cases had sustained OASIS and were matched on the basis of parity with controls who had no OASIS. Data were obtained from an electronic repository and chart review. Participants with a passive second stage of labor lasting 60 minutes or more were deemed to have "labored down." A logistic regression model to predict OASIS was created. RESULTS: Overall, 1629 cases were compared with 1312 controls. OASIS were recorded among 1452 (57.8%) of 2510 women who did not labor down compared with 169 (40.0%) of 423 women who labored down (P<0.001). However, in binary logistic regression, the addition of laboring down to the model only increased the predictive accuracy from 80.1% to 80.7%. CONCLUSION: When known risk factors for OASIS are accounted for, the effect of laboring down on perineal outcome is negligible.

Sonographic evaluation for intra-abdominal hemorrhage after cesarean delivery.

PURPOSE: To evaluate whether intra-abdominal hemorrhage is visible on a modified focused assessment with sonography for trauma (FAST) examination in stable obstetrics patients after a nonemergent cesarean delivery. METHODS: This was a prospective observational study of patients who underwent nonemergent cesarean delivery at a single institution. Patients provided written informed consent to participate in the study preoperatively and underwent a modified FAST examination in the recovery room within 2 hours of completion of surgery. A sonographic examination was considered positive for hemorrhage if an anechoic pocket consistent with free fluid was present. RESULTS: One hundred patients underwent suprapubic and bilateral upper-quadrant sonographic evaluations. The mean (±SD) time of the evaluation was 74.2 ± 36 minutes after the end of surgery. Among the 100 sonographic examinations of each upper quadrant, 194 (97.0%) were negative, 5 (2.5%) were indeterminate, and 1 (0.5%) was positive for fluid. All suprapubic sonographic examinations were considered inadequate. CONCLUSIONS: Sonographic evaluation immediately after cesarean delivery is feasible in most patients and was overwhelmingly negative for intra-abdominal hemorrhage in a group of patients who did not require reoperation or unexpected blood transfusion.