Objective We sought to assess body mass index (BMI) effect on cesarean risk during labor. Study Design The Consortium on Safe Labor collected electronic data from 228,668 deliveries. Women with ...singletons ≥37 weeks and known BMI at labor admission were analyzed in this cohort study. Regression analysis generated relative risks for cesarean stratifying for parity and prior cesarean while controlling for covariates. Results Of the 124,389 women, 14.0% had cesareans. Cesareans increased with increasing BMI for nulliparas and multiparas with and without a prior cesarean. Repeat cesareans were performed in >50% of laboring women with a BMI >40 kg/m2 . The risk for cesarean increased as BMI increased for all subgroups, P < .001. The risk for cesarean increased by 5%, 2%, and 5% for nulliparas and multiparas with and without a prior cesarean, respectively, for each 1-kg/m2 increase in BMI. Conclusion Admission BMI is significantly associated with delivery route in term laboring women. Parity and prior cesarean are other important predictors.
Objective To describe contemporary cesarean delivery practice in the United States. Study Design Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic ...medical records from 19 hospitals across the United States, 2002-2008. Results The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation. Conclusion To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.
Objective The decision of whether to retain or remove a previously placed cervical cerclage in women who subsequently rupture fetal membranes in a premature gestation is controversial and all studies ...to date are retrospective. We performed a multicenter randomized controlled trial of removal vs retention of cerclage in these patients to determine whether leaving the cerclage in place prolonged gestation and/or increased the risk of maternal or fetal infection. Study Design A prospective randomized multicenter trial of 27 hospitals was performed. Patients included were those with cerclage placement at ≤23 weeks 6 days in singleton or twin pregnancies, with subsequent spontaneous rupture of membranes between 22 weeks 0 days and 32 weeks 6 days. Patients were randomized to retention or removal of cerclage. Patients were then expectantly managed and delivered only for evidence of labor, chorioamnionitis, fetal distress, or other medical or obstetrical indications. Management after 34 weeks was at the clinician's discretion. Results The initial sample size calculation determined that a total of 142 patients should be included but after a second interim analysis, futility calculations determined that the conditional power for showing statistical significance after randomizing 142 patients for the primary outcome of prolonging pregnancy was 22.8%. Thus the study was terminated after a total of 56 subjects were randomized with complete data available for analysis, 32 to removal and 24 to retention of cerclage. There was no statistical significance in primary outcome of prolonging pregnancy by 1 week comparing the 2 groups (removal 18/32, 56.3%; retention 11/24, 45.8%) P = .59; or chorioamnionitis (removal 8/32, 25.0%; retention 10/24, 41.7%) P = .25, respectively. There was no statistical difference in composite neonatal outcomes (removal 16/33, 50%; retention 17/30, 56%), fetal/neonatal death (removal 4/33, 12%; retention 5/30, 16%); or gestational age at delivery (removal mean 200 days; retention mean 198 days). Conclusion Statistically significant differences were not seen in prolongation of latency, infection, or composite neonatal outcomes. However, there was a numerical trend in the direction of less infectious morbidity, with immediate removal of cerclage. These findings may not have met statistical significance if the original sample size of 142 was obtained, however they provide valuable data suggesting that there may be no advantage to retaining a cerclage after preterm premature rupture of membranes and a possibility of increased infection with cerclage retention.
Objective We sought to determine maternal and neonatal outcomes by labor onset type and gestational age. Study Design We used electronic medical records data from 10 US institutions in the Consortium ...on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age. Results Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks ( P < .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio OR, 0.38; 95% confidence interval CI, 0.28–0.53), sepsis (OR, 0.36; 95% CI, 0.26–0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48–0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08–9.54) with elective induction, 1.16 (95% CI, 0.24–5.58) with indicated induction, and 6.57 (95% CI, 1.78–24.30) with cesarean without labor compared to spontaneous labor. Conclusion Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk.
This article reviews the essential criteria for inductions of labor, weighing both the advantages and disadvantages of labor induction, and the various mechanical and pharmacologic agents available ...for cervical ripening. At the end of this article, one should be able to counsel women about the potential risks and benefit of labor induction and understand the neonatal consequences of elective induction of labor before 39 weeks of gestation. This article also discusses the different mechanical and pharmacologic agents available for cervical ripening.
Isolated fallopian tube torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of fallopian tube torsion that was managed laparoscopically at 35 weeks of gestation.
Obesity in women of reproductive age is increasing. Gynecologic laparoscopy in the morbidly obese pregnant patient presents challenges, and is not often attempted. Herein is reported a successful ...case using a modified Foley lap-lift technique, which improved visualization and facilitated mechanical ventilation.
This retrospective cohort study sought to assess the effectiveness of comprehensive geriatric assessment (CGA) for older patients at an HIV clinic in a large US city. We systematically reviewed ...medical records of all patients who underwent CGA from June 2013 to July 2017. In addition, physicians and social workers completed an anonymous survey about the impact of CGA on their patients. For the 76 patients (median age 67.2; Q1, Q3 = 60.9, 72.6) seen by geriatricians at the clinic, there were 184 recommendations, 54 instances of counseling, and 11 direct actions. Overall adherence to recommendations was 32.8%, 34.9% for patient-directed, and 31.7% for provider-directed recommendations. No demographic or CGA variables were associated with adherence. Despite this lack of adherence, surveyed providers reported that they usually or always followed recommendations; the most frequently cited barrier to implementation was lack of feasibility. Further research will be needed to determine how CGA can improve outcomes for this population.
Abstract Context Family satisfaction is an important and commonly used research measure. Yet current measures of family satisfaction are lengthy and may be unnecessarily burdensome—particularly in ...the setting of serious illness. Objectives To use an item bank to develop short forms of the Family Satisfaction with End-of-Life Care (FAMCARE) scale, which measures family satisfaction with care. Methods To shorten the existing 20-item FAMCARE measure, item response theory parameters from an item bank were used to select the most informative items. The psychometric properties of the new short-form scales were examined. The item bank was based on data from family members from an ethnically diverse sample of 1983 patients with advanced cancer. Results Evidence for the new short-form scales supported essential unidimensionality. Reliability estimates from several methods were relatively high, ranging from 0.84 for the five-item scale to 0.94 for the 10-item scale across different age, gender, education, ethnic, and relationship groups. Conclusion The FAMCARE-10 and FAMCARE-5 short-form scales evidenced high reliability across sociodemographic subgroups and are potentially less burdensome and time-consuming scales for monitoring family satisfaction among seriously ill patients.
To (1) develop a patient-reported, multidomain functional assessment tool focused on medically ill patients in acute care settings; (2) characterize the measure's psychometric performance; and (3) ...establish clinically actionable score strata that link to easily implemented mobility preservation plans.
This article describes the approach that our team pursued to develop and characterize this tool, the Functional Assessment in Acute Care Multidimensional Computer Adaptive Test (FAMCAT). Development involved a multistep process that included (1) expanding and refining existing item banks to optimize their salience for hospitalized patients; (2) administering candidate items to a calibration cohort; (3) estimating multidimensional item response theory models; (4) calibrating the item banks; (5) evaluating potential multidimensional computerized adaptive testing (MCAT) enhancements; (6) parameterizing the MCAT; (7) administering it to patients in a validation cohort; and (8) estimating its predictive and psychometric characteristics.
A large (2000-bed) Midwestern Medical Center.
The overall sample included 4495 adults (2341 in a calibration cohort, 2154 in a validation cohort) who were admitted either to medical services with at least 1 chronic condition or to surgical/medical services if they required readmission after a hospitalization for surgery (N=4495).
Not applicable.
Not applicable.
The FAMCAT is an instrument designed to permit the efficient, precise, low-burden, multidomain functional assessment of hospitalized patients. We tried to optimize the FAMCAT's efficiency and precision, as well as its ability to perform multiple assessments during a hospital stay, by applying cutting edge methods such as the adaptive measure of change (AMC), differential item functioning computerized adaptive testing, and integration of collateral test-taking information, particularly item response times. Evaluation of these candidate methods suggested that all may enhance MCAT performance, but none were integrated into initial MCAT parameterization.
The FAMCAT has the potential to address a longstanding need for structured, frequent, and accurate functional assessment among patients hospitalized with medical diagnoses and complications of surgery.
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