Amos Grunebaum

Risk factors for prematurity and premature rupture of membranes a prospective study of the vaginal flora in pregnancy

Prematurity remains a major cause of perinatal mortality in the United States. Some research has indicated that infectious agents play a role in either initiating preterm labor, causing premature rupture of the membranes, or preventing tocolysis. This study attempted to determine if the presence of various vaginal pathogens in early pregnancy was associated with the subsequent development of premature rupture of membranes or preterm labor. We found that among 233 evaluable patients those with Trichomonas vaginalis were significantly more likely to have premature rupture of the membranes (p less than 0.03), and those with Bacteroides sp. were more likely to be delivered of their infants before 37 weeks (p less than 0.03) and to have infants weighing less than 2500 gm (p less than 0.05). Those with Ureaplasma urealyticum more frequently began preterm labor (p less than 0.05). Preterm premature rupture of the membranes was found significantly more often among patients with Bacteroides sp. Stepwise multiple logistic regression analysis indicated that those associations were not related to the number of previous abortions, deliveries, or preterm deliveries or to maternal age. We conclude that microbiologic screening in early pregnancy may aid in the assessment of patient risk for preterm delivery.

Intrauterine restriction (IUGR)

Abstract Perinatal mortality and morbidity is markedly increased in intrauterine growth restricted (IUGR) fetuses. Prenatal identification of IUGR is the first step in clinical management. For that purpose a uniform definition and criteria are required. The etiology of IUGR is multifactorial and whenever possible it should be assessed. When the cause is of placental origin, it is possible to identify the affected fetuses. The major complication is chronic fetal hypoxemia. By monitoring the changes of fetal vital functions it is thus possible to improve both management and outcome. The timing of delivery is crucial but the optimal management scheme has not yet been identified. When IUGR is identified at very early gestational ages, serial assessments of the risk of continuing the in utero fetal life under adverse conditions versus the risks of the prematurity should be performed. Delivery of IUGR fetuses should take place in centers where appropriate neonatal assistance can be provided. Careful monitoring of the IUGR fetus during labor is crucial as the IUGR fetus can quickly decompensate once uterine contractions have started.

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events

Our objective was to describe a comprehensive obstetric patient safety program and its effect on reducing compensation payments and sentinel adverse events. From 2003 to 2009, we implemented a comprehensive obstetric patient safety program at our institution with multiple integrated components. To evaluate its effect on compensation payments and sentinel events, we gathered data on compensation payments and sentinel events retrospectively from 2003, when the program was initiated, through 2009. Average yearly compensation payments decreased from

Reducing Hypothermia in Preterm Infants Following Delivery

27,591,610 between 2003-2006 to

Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009

2,550,136 between 2007-2009, sentinel events decreased from 5 in 2000 to none in 2008 and 2009. Instituting a comprehensive obstetric patient safety program decreased compensation payments and sentinel events resulting in immediate and significant savings.

Acute twin-twin transfusion syndrome in labor: pathophysiology and associated factors

BACKGROUND: Moderate hypothermia (temperature <36°C) at birth is common in premature infants and is associated with increased mortality and morbidity. METHODS: A multidisciplinary practice plan was implemented to determine in premature infants <35 weeks old whether a multifaceted approach would reduce the number of inborn infants with an admitting axillary temperature <36°C by 20% without increasing exposure to a temperature >37.5°C. The plan included use of occlusive wrap a transwarmer mattress and cap for all infants and maintaining an operating room temperature between 21°C and 23°C. Data were obtained at baseline (n = 66), during phasing in (n = 102), and at full implementation (n = 193). RESULTS: Infant axillary temperature in the delivery room (DR) increased from 36.1°C ± 0.6°C to 36.2°C ± 0.6°C to 36.6°C ± 0.6°C (P < .001), and admitting temperature increased from 36.0°C ± 0.8°C to 36.3°C ± 0.6°C to 36.7°C ± 0.5°C at baseline, phasing in, and full implementation, respectively (P < .001). The number of infants with temperature <36°C decreased from 55% to 6.2% at baseline versus full implementation (P < .001), and intubation at 24 hours decreased from 39% to 17.6% (P = .005). There was no increase in the number of infants with a temperature >37.5°C over time. The use of occlusive wrap, mattress, and cap increased from 33% to 88% at baseline versus full implementation. Control charts showed significant improvement in DR ambient temperature at baseline versus full implementation. CONCLUSIONS: The practice plan was associated with a significant increase in DR and admitting axillary infant temperatures and a corresponding decrease in the number of infants with moderate hypothermia. There was an associated reduction in intubation at 24 hours. These positive findings reflect increased compliance with the practice plan.

Neonatal Mortality of Planned Home Birth in the United States in Relation to Professional Certification of Birth Attendants

OBJECTIVE We examined neonatal mortality in relation to birth settings and birth attendants in the United States from 2006 through 2009. STUDY DESIGN Data from the Centers for Disease Control and Prevention-linked birth and infant death dataset in the United States from 2006 through 2009 were used to assess early and total neonatal mortality for singleton, vertex, and term births without congenital malformations delivered by midwives and physicians in the hospital and midwives and others out of the hospital. Deliveries by hospital midwives served as the reference. RESULTS Midwife home births had a significantly higher total neonatal mortality risk than deliveries by hospital midwives (1.26 per 1000 births; relative risk [RR], 3.87 vs 0.32 per 1000; P < .001). Midwife home births of 41 weeks or longer (1.84 per 1000; RR, 6.76 vs 0.27 per 1000; P < .001) and midwife home births of women with a first birth (2.19 per 1000; RR, 6.74 vs 0.33 per 1000; P < .001) had significantly higher risks of total neonatal mortality than deliveries by hospital midwives. In midwife home births, neonatal mortality for first births was twice that of subsequent births (2.19 vs 0.96 per 1000; P < .001). Similar results were observed for early neonatal mortality. The excess total neonatal mortality for midwife home births compared with midwife hospital births was 9.32 per 10,000 births, and the excess early neonatal mortality was 7.89 per 10,000 births. CONCLUSION Our study shows a significantly increased total and early neonatal mortality for home births and even higher risks for women of 41 weeks or longer and women having a first birth. These significantly increased risks of neonatal mortality in home births must be disclosed by all obstetric practitioners to all pregnant women who express an interest in such births.

Planned Home Birth: A Violation of the Best Interests of the Child Standard?

Objective: To review reported cases of acute twin-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies to help define variants of disease and determine associated factors. Methods: PubMed literature review using the search terms, “acute” and “twin transfusion.” Articles were reviewed for clinical factors. Reference lists were carefully assessed for any additional articles. In order to rule out sudden progression of chronic TTTS as the cause, gestational age ≥31 weeks was chosen. Cases were classified into subsets of acute TTTS. Results: There were 150 publications from 1942–2010. There were 51 cases that were classified into four variants of acute TTTS. Four cases were difficult to classify, with hemoglobin levels that were high normal and low normal, high normal and anemic, or low normal and polycythemic. Three publications defined the incidence for acute perinatal TTTS of 1.8–5.5% of monochorionic twins. Common factors associated with acute perinatal TTTS included monochorionicity and labor. Conclusions: Monochorionicity and labor are common factors underlying the propensity to acute perinatal TTTS. A spectrum of severity is for acute TTTS was seen. Perinatal specialists and neonatologists should be aware of the possibility of acute TTTS during labor, so rapid volume replacement can be performed for neonatal resuscitation.

Reduction of cesarean delivery rates after implementation of a comprehensive patient safety program.

Introduction Over the last decade, planned home births in the United States (US) have increased, and have been associated with increased neonatal mortality and other morbidities. In a previous study we reported that neonatal mortality is increased in planned home births but we did not perform an analysis for the presence of professional certification status. Purpose The objective of this study therefore was to undertake an analysis to determine whether the professional certification status of midwives or the home birth setting are more closely associated with the increased neonatal mortality of planned midwife-attended home births in the United States. Materials and Methods This study is a secondary analysis of our prior study. The 2006–2009 period linked birth/infant deaths data set was analyzed to examine total neonatal deaths (deaths less than 28 days of life) in term singleton births (37+ weeks and newborn weight ≥ 2,500 grams) without documented congenital malformations by certification status of the midwife: certified nurse midwives (CNM), nurse midwives certified by the American Midwifery Certification Board, and “other” or uncertified midwives who are not certified by the American Midwifery Certification Board. Results Neonatal mortality rates in hospital births attended by certified midwives were significantly lower (3.2/10,000, RR 0.33 95% CI 0.21–0.53) than home births attended by certified midwives (NNM: 10.0/10,000; RR 1) and uncertified midwives (13.7/10,000; RR 1.41 [95% CI, 0.83–2.38]). The difference in neonatal mortality between certified and uncertified midwives at home births did not reach statistical levels (10.0/10,000 births versus 13.7/10,000 births p = 0.2). Conclusions This study confirms that when compared to midwife-attended hospital births, neonatal mortality rates at home births are significantly increased. While NNM was increased in planned homebirths attended by uncertified midwives when compared to certified midwives, this difference was not statistically significant. Neonatal mortality rates at home births were not significantly different in relationship to professional certification status of the birth attendant, whether the delivery was by a certified or an uncertified birth attendant.

Justified skepticism about Apgar scoring in out-of-hospital birth settings

* Abbreviations: AAP — : American Academy of Pediatrics The American Academy of Pediatrics (AAP) has long and consistently championed the best interests of the child standard as the foundation of pediatric ethics.1 This standard obligates pediatricians to protect and promote the biopsychosocial interests of children who are patients, as these interests are determined in deliberative (evidence-based, rigorous, transparent, and accountable) clinical judgment and practice. The interests of parents do not play a direct role in the conceptualization of this standard, although the ability and willingness of parents to participate in the health care of their child can become ethically relevant considerations in some cases. It is worth noting that, in pediatric ethics, the best interests of the child standard generates the ethical obligation of parents to protect and promote the biopsychosocial interests of their children when their children are patients. The recent AAP statement, “Planned Home Birth,” endorses the ethical position of the American College of Obstetricians and Gynecologists in its statement on planned home birth2: “The American Academy of Pediatrics concurs with the recent statement of the American College of Obstetricians and Gynecologists affirming that hospitals and birthing centers are the safest settings for birth in the United States while respecting the right of women to make an informed decision about delivery.”3 The AAP statement also recommends that “there should be at least 1 person present at every delivery whose primary responsibility is the care of the newborn infant.”3 The AAP can take these positions only if they are consistent with the best interests of the child standard. The purpose of this article is to call into question whether the AAP statement is indeed consistent with this foundational standard of pediatric ethics. The resolution of this question depends directly on the preventable, increased perinatal risks of planned home birth. … Address correspondence to Frank A. Chervenak, MD, New York Presbyterian Hospital, 525 East 68th St, M-724, Box 122, New York, NY 10065. E-mail: fac2001{at}med.cornell.edu