Anne M. Fullilove

Postpartum perineal pain in a low episiotomy setting: association with severity of genital trauma, labor care, and birth variables.

BACKGROUND Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative vaginal delivery. METHODS A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the present pain intensity (PPI) and visual analog scale (VAS) components of the validated short-form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. RESULTS At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 +/- 1.61 vs 1.48 +/- 1.40; p < 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, p = 0.002) than women with minor or no trauma. By 3 months, average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non-Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model, only trauma group and length of active pushing predicted the pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on the level of pain at discharge beyond its effect on the incidence of major trauma. CONCLUSIONS Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain.

Contribution of the second stage of labour to pelvic floor dysfunction: a prospective cohort comparison of nulliparous women.

Maternal expulsive efforts are thought to damage the pelvic floor. We aimed to compare pelvic floor function and anatomy between women who delivered vaginally (VB) versus those with caesarean delivery (CD) prior to the second stage of labour.

Does a Large Infant Head or a Short Perineal Body Increase the Risk of Obstetrical Perineal Trauma

BACKGROUND Perineal trauma after vaginal delivery can have significant long-term consequences. It is unknown if a larger infant head circumference or smaller maternal perineal anatomy are risk factors for perineal trauma after vaginal delivery. METHODS We conducted a prospective cohort study of low-risk nulliparous women. Data collected included maternal characteristics, antepartum Pelvic Organ Prolapse Quantification measurements of the perineal body and genital hiatus, labor characteristics, perineal trauma, and infant head circumference. Perineal trauma was defined as trauma that extended into the muscles of the perineum (second-degree or deeper). Univariate and multivariate logistic models were created to calculate odds ratios (OR) and 95 percent confidence intervals (CI). RESULTS We observed 448 vaginal births. Multivariate analysis demonstrated a significant association between infant head circumference at birth and perineal trauma: OR 1.22 for each increase of 1 cm in head circumference (95% CI 1.05-1.43). There was no association between perineal body or genital hiatus length and perineal trauma. CONCLUSIONS In nulliparous low-risk women a larger infant head circumference at birth increases the likelihood of perineal trauma, although the effect is modest. Antenatal perineal body and genital hiatus measurements do not predict perineal trauma. These results do not support alteration in mode of delivery or other obstetric practices.

Promotion rates for assistant and associate professors in obstetrics and gynecology.

OBJECTIVE: To estimate promotion rates of physician faculty members in obstetrics and gynecology during the past 30 years METHODS: Data were collected annually by the Association of American Medical Colleges from every school between 1980 and 2009 for first-time assistant and associate professors to determine whether and when they were promoted. Data for full-time physician faculty were aggregated by decade (1980–1989, 1990–1999, 2000–2009). Faculty were included if they remained in academia for 10 years after beginning in rank. Data were analyzed by constructing estimated promotion curves and extracting 6-year and 10-year promotion rates. RESULTS: The 10-year promotion rates (adjusted for attrition) declined significantly for assistant professors from 35% in 1980–1989 to 32% in 1990–1999 to 26% in 2000–2009 (P<.001), and for associate professors from 37% to 32% to 26%, respectively (P<.005). These declines most likely resulted from changes in faculty composition. The most recent 15 years saw a steady increase in the proportion of entry-level faculty who were women (now 2:1) and primarily on the nontenure track. The increasing number of faculty in general obstetrics and gynecology had lower promotion probabilities than those in the subspecialties (odds ratio 0.16; P<.001). Female faculty on the nontenure track had lower promotion rates than males on the nontenure track, males on the tenure track, and females on the tenure track (odds ratio 0.8 or less; P<.01). CONCLUSION: A decline in promotion rates during the past 30 years may be attributable to changes in faculty composition. LEVEL OF EVIDENCE: II

Retention of chairs in obstetrics and gynecology: a comparison with other clinical departments.

OBJECTIVE: To compare the retention of chairs in academic obstetrics and gynecology with other core clinical departments. METHODS: Ongoing data were collected from each medical school for the Association of American Medical Colleges Faculty Roster between 1979 and 2007. Primary outcome measures included 5-year and 10-year retention rates and survival curves of first-time chairs. Comparisons were made between first-time chairs in obstetrics and gynecology and other core clinical departments: internal medicine, family medicine, pediatrics, psychiatry, and surgery. RESULTS: Five-year retention rates of obstetrics and gynecology chairs declined from 80% for those who began in 1979–1982 to 53% for those who began in 1998–2002. Ten-year retention in obstetrics and gynecology declined from 54% for those beginning in 1979–1982 to 26% for those beginning in 1993–1997. Other clinical departments experienced more stable 5-year and 10-year retention rates. Although substantially longer than other clinical departments in the 1979–1982 cohort, the median tenure of obstetrics and gynecology chairs who began in 1993–1997 was comparable with or less than that of other clinical departments. Discrete-time survival analysis revealed this decline in obstetrics and gynecology chair retention to be significant (P<.001) and more consistent than in other departments. CONCLUSION: Compared with other core clinical departments, retention of first-time chairs in obstetrics and gynecology declined more consistently from the highest to among the lowest. Chairs were inclined to not remain in office for a prolonged period. LEVEL OF EVIDENCE: II

Trends in salaries of obstetrics-gynecology faculty, 2000-01 to 2008-09

OBJECTIVE We sought to determine whether downward trends in inflation-adjusted salaries (1989-99) continued for obstetrics and gynecology faculty. STUDY DESIGN Data were gathered from the Faculty Salary Survey from the Association of American Medical Colleges for academic years 2001 through 2009. We compared median physician salaries adjusted for inflation according to rank and specialty. RESULTS While faculty compensation increased by 24.8% (2.5% annually), change in salaries was comparable to the cumulative inflation rate (21.3%). Salaries were consistently highest among faculty in gynecologic oncology (P < .001), next highest among maternal-fetal medicine specialists (P < .001), and were not significantly different between general obstetrics-gynecology and reproductive-endocrinology-infertility. Inflation-adjusted growth of salaries in general obstetrics-gynecology was not significantly different from that in general internal medicine and pediatrics. CONCLUSION Growth in salaries of physician faculty in obstetrics and gynecology increased from 2000-01 through 2008-09 with real purchasing power keeping pace with inflation.

Retention of entry-level faculty members in obstetrics and gynecology.

OBJECTIVE The purpose of this study was to examine retention rates of entry-level physician faculty members in obstetrics and gynecology. STUDY DESIGN Ongoing data were collected by the Association of American Medical Colleges between 1981 and 2009 for full-time, entry-level assistant professors to determine whether they remained at their original departments, switched to another school, or left academia. Retention curves and 5- and 10-year retention rates at their original department and for academia were determined. RESULTS The number of entry-level faculty members per year increased significantly for women and those faculty members in general obstetrics and gynecology. Retention rates at the original departments improved for all disciplines in recent years (2000-09), regardless of sex. Among those faculty members who left their original department, faculty members in general obstetrics/gynecology were more likely than subspecialists to leave academia. CONCLUSION Growth in the number of entry-level physician faculty members was accompanied by higher retention rates at their original departments only in recent years.