Background Readmission rates are used as a quality metric in medical and surgical specialties; however, little is known about obstetrics readmissions. Objective Our goals for this study were to ...describe the trends in postpartum readmissions over time; to characterize the common indications and associated diagnoses for readmissions; and to determine maternal, delivery, and hospital characteristics that may be associated with readmission. Study Design Postpartum readmissions occurring within the first 6 weeks after delivery in California, Florida, and New York were identified between 2004 and 2011 in State Inpatient Databases. Of the 5,949,739 eligible deliveries identified, 114,748 women were readmitted over the 8-year period. We calculated the rates of readmissions and their indications by state and over time. The characteristics of the readmission stay, including day readmitted, length of readmission, and charge for readmission, were compared among the diagnoses. Odds ratios were calculated using a multivariate logistic regression to determine the predictors of readmission. Results The readmission rate increased from 1.72% in 2004 to 2.16% in 2011. Readmitted patients were more likely to be publicly insured (54.3% vs 42.0%, P < .001), to be black (18.7% vs 13.5%, P < .001), to have comorbidities such as hypertension (15.3% vs 2.4%, P < 0.001) and diabetes (13.1% vs 6.8%, P < .001), and to have had a cesarean delivery (37.2% vs 32.9%, P < .001). The most common indications for readmission were infection (15.5%), hypertension (9.3%), and psychiatric illness (7.7%). Patients were readmitted, on average, 7 days after discharge, but readmission day varied by diagnosis: day 3 for hypertension, day 5 for infection, and day 9 for psychiatric disease. Maternal comorbidities were the strongest predictors of postpartum readmissions: psychiatric disease, substance use, seizure disorder, hypertension, and tobacco use. Conclusion Postpartum readmission rates have risen over the last 8 years. Understanding the risk factors, etiologies, and cause-specific timing for postpartum readmissions may aid in the development of new quality metrics in obstetrics and targeted strategies to curb the rising rate of postpartum readmissions in the United States.
OBJECTIVE:To evaluate the effects of eliminating the routine use of oral opioids for postcesarean delivery analgesia on postcesarean opioid consumption.
METHODS:At a tertiary care center, we ...implemented a quality improvement intervention among faculty practice patients undergoing cesarean delivery, which consisted of 1) eliminating routine ordering of oral opioids after cesarean delivery, 2) implementing guidelines for ordering a short course of opioids when deemed necessary, and 3) coupling opioid prescribing at discharge to patterns of opioid use in-hospital combined with shared decision-making. All patients, both before and after the intervention, were administered neuraxial opioids and scheduled acetaminophen and nonsteroidal antiinflammatory medications in the absence of contraindications. The primary outcome was the percentage of women who used any opioids postoperatively in-hospital. Secondary outcomes included the percentage of women discharged with a prescription for opioids, the quantity of opioids used in-hospital, pain scores, satisfaction, opioid-related side effects, and opioid prescriptions ordered in the 6 weeks after delivery. The effects of this intervention were assessed based on a chart review of patient data and a survey of patients in the 12 weeks before and 12 weeks after the intervention.
RESULTS:We evaluated the records of 191 postcesarean delivery patients before and 181 after the intervention. Less than half of women used oral opioids in-hospital after the intervention, 82 (45%) compared with 130 (68%) before (P<.001). However, there was no change in pain scores or overall satisfaction with pain relief. Postintervention, only 40% of patients were discharged with prescriptions for opioids compared with 91% of patients before the intervention (P<.001).
CONCLUSION:Eliminating routine ordering of oral opioids after cesarean delivery is associated with a significant decrease in opioid consumption while maintaining the same levels of pain control and patient satisfaction. Oral opioids are not needed by a large proportion of women after cesarean delivery.
BACKGROUND:The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal ...medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this orderCSE > DPE > EPL techniques.
METHODS:A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125% bupivacaine plus fentanyl 2 μg/mL over 5 minutes, and for CSE, intrathecal 0.25% bupivacaine 1.7 mg and fentanyl 17 μg. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ≤ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the χ test with Yates continuity correction.
RESULTS:There was no significant difference in the time to NPRS ≤ 1 between DPE and EPL (hazard ratio 1.4; 95% confidence interval CI 0.83–2.4, P = .21). DPE achieved NPRS ≤ 1 significantly slower than CSE (hazard ratio 0.36; 95% CI 0.22–0.59, P = .0001). The median times (interquartile range) to NPRS ≤ 1 were 2 (0.5–6) minutes for CSE, 11 (4–120) minutes for DPE, and 18 (10–120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio RR 2.13; 95% CI 1.39–3.28; P < .001), 20 minutes (RR 1.60; 95% CI 1.26–2.03; P < .001), and 30 minutes (RR 1.18; 95% CI 1.01–1.30; P < .034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95% CI 0.07–0.51; P < .001) and physician top-up intervention (RR 0.45; 95% CI 0.23–0.86; P = .011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95% CI 0.06–0.38; P < .001), hypotension (RR 0.38; 95% CI 0.15–0.98; P = .032), combined uterine tachysystole and hypertonus (RR 0.22; 95% CI 0.08–0.60; P < .001), and physician top-up intervention (RR 0.45; 95% CI 0.23–0.86; p = .011).
CONCLUSIONS:Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.
Getting Risk Prediction Right Bateman, Brian T; Robinson, Julian N
Obstetrics and gynecology (New York. 1953),
2020-September, 2020-09-00, 20200901, Letnik:
136, Številka:
3
Journal Article
The obstetric comorbidity index summarizes the burden of maternal comorbidities into a single number and holds promise as a maternal risk-assessment tool.
The aim of this study was to assess the ...clinical performance of this comorbidity-based screening tool to accurately identify women on labor and delivery who are at risk of severe maternal morbidity on labor and delivery in real time.
All patients with pregnancies ≥23 weeks gestation presenting to labor and delivery at a single tertiary-care center from February through July 2018 were included in the study. The patient’s primary labor and delivery nurse assessed patient comorbidities and calculated the patient’s obstetric comorbidity index. The score was recalculated at each 12-hour shift change. A multidisciplinary panel of clinicians determined whether patients experienced severe maternal morbidity based on the American College of Obstetrics and Gynecology and Society for Maternal-Fetal Medicine consensus definition, blinded to the patient’s obstetric comorbidity index score. We analyzed the association between the obstetric comorbidity index score and the occurrence of severe maternal morbidity.
The study included 2828 women, of whom 1.73% experience severe maternal morbidity (n=49). The obstetric comorbidity index ranged from 0–15 for women in the study cohort, with a median obstetric comorbidity index of 1 (interquartile range, 0–3). The median obstetric comorbidity index score for women who experienced the severe maternal morbidity was 5 (interquartile range, 3–7) compared with a median of 1 (interquartile range, 0–3) for those without severe maternal morbidity (P<.01). The frequency of severe maternal morbidity increased from 0.41% for those with a score of 0 to 18.75% for those with a score ≥9. For every 1-point increase in the score, patients experienced a 1.55 increase in odds of severe maternal morbidity (95% confidence interval, 1.42–1.70). The c-statistic for the obstetric comorbidity index score was 0.83 (95% confidence interval, 0.76–0.89), which indicated strong discrimination.
The obstetric comorbidity index can prospectively identify women at risk of severe maternal morbidity in a clinical setting. A particular strength of the obstetric comorbidity index is its ability to integrate multiple compounding comorbidities and highlight the cumulative risk that is associated with the patients’ conditions. Routine clinical use of the obstetric comorbidity index has the potential to identify at-risk women whose condition warrants increased surveillance and targeted care to prevent adverse maternal outcomes.
Induction of labor is common in the United States. Multiple previous studies have tried to outline a faster time to delivery to improve maternal and fetal outcomes.
This study aimed to evaluate ...whether women who undergo induction of labor with a single-balloon catheter and oxytocin have a shorter time to delivery with planned removal of the catheter at 6 vs 12 hours.
In this randomized controlled trial, induction of labor was performed using a combination of single-balloon catheter and oxytocin. Term women, both nulliparous and multiparous, aged 18 to 50 years old with cephalic singletons were included if they were undergoing induction of labor with a Bishop score of <6 and cervical dilation of <2 cm. Women were randomized to planned removal of the single-balloon catheter at 6 hours vs 12 hours. The primary outcome was time from catheter insertion to delivery. We were powered to show a 4-hour time difference with a sample size of 89 women per group (n=178). Planned sensitivity analyses were performed to account for cesarean delivery in labor.
From February 2019 to June 2020, 237 women were screened, 178 women were randomized, and 177 women were included in the final analysis (89 women in the 6-hour group and 88 women in the 12-hour group). Insertion to delivery time was significantly shorter in the 6-hour group (19.2 vs 24.3 hours; P=.04), and the proportion of women delivered by 24 hours was significantly greater in the 6-hour group (67.4% vs 47.4%; P<.01). There was no difference in the Bishop score at removal of the catheter or secondary maternal or neonatal outcomes. In a Cox proportional-hazards model censoring for cesarean delivery, the 6-hour group had a significantly shorter insertion to delivery time (hazard ratio, 0.67; P=.02).
Induction of labor with a single-balloon catheter and oxytocin with planned removal of the catheter at 6 hours rather than 12 hours results in a shorter time from insertion to delivery without increasing the rate of cesarean delivery. Decreasing the length of time a single-balloon catheter is in place should be considered in clinical protocols.
Twin vaginal delivery: innovate or abdicate Easter, Sarah Rae, MD; Taouk, Laura, Ms; Schulkin, Jay, PhD ...
American journal of obstetrics and gynecology,
05/2017, Letnik:
216, Številka:
5
Journal Article
Recenzirano
Neonatal safety data along with national guidelines have prompted renewed interest in vaginal delivery of twins, particularly in the case of the noncephalic second twin. Yet, the rising rate of twin ...cesarean deliveries, coupled with the national decline in operative obstetrics, raises concerns about the availability of providers who are skilled in twin vaginal birth. Providers are key stakeholders for increasing rates of twin vaginal delivery. We surveyed a group of practicing obstetricians to explore potential barriers to the vaginal birth of twins with a focus on delivery of the noncephalic second twin. Among 107 responding providers, only 57% would deliver a noncephalic second twin by breech extraction. Providers who preferred breech extraction had a higher rate of maternal-fetal medicine subspecialty training (26.2% vs 4.3%; P <.01) and were more likely to be in an academic practice environment (36.1% vs 10.9%; P <.01) and to practice in high-volume centers that deliver >30 sets of twins annually (57.4% vs 34.8%; P =.02). Most providers (54.2%) were familiar with the findings from the recent randomized trial that demonstrated the safety of twin vaginal birth. However, knowledge of the trial was not associated statistically with a preference for breech extraction (62.3% vs 43.5%; P =.05). Providers who preferred breech extraction were more likely to agree with recent society guidelines that encourage the vaginal birth of twins (86.9% vs 63.0%; P <.01). In an adjusted analysis, the 46% of providers with a perceived need for more training were far less likely to prefer breech extraction for delivery of a noncephalic second twin (adjusted odds ratio, 0.38; 95% confidence interval, 0.16–0.95). Furthermore, 57% of providers who would not offer their patient breech extraction would be willing to consult a colleague for support with a noncephalic twin delivery. These results suggest that scientific evidence and society opinion are likely insufficient to reverse the national trends that favor cesarean delivery for twins. Instead, implementation of provider training and support programs is critical for increasing the rates of twin vaginal birth. Changing our national landscape of vaginal twin delivery may require innovation. Without novel provider-focused strategies, we may relinquish passively the requisite skills for not only our patients but also for future generations of obstetricians.
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