Cynthia Chazotte

Catastrophic complications of previous cesarean section

Of 711 patients who were delivered after one or more previous cesarean sections, 17 (2.4%) had an extremely serious complication. Uterine rupture and placenta previa or placenta accreta with accompanying hemorrhage were the major contributors to mortality and major morbidity. Nine uterine ruptures occurred, including five associated with labor with a low transverse uterine scar and one with an unknown scar (1.4% of trials of labor). There were two cases of placenta previa and five with varying degrees of placenta accreta. The nature and frequency of the observed complications emphasize the potentially serious remote consequences of cesarean section.

Using Simulation Training to Improve Shoulder Dystocia Documentation

OBJECTIVE: To estimate whether shoulder dystocia documentation could be improved with a simulation-based educational experience. METHODS: Obstetricians at our institution (n=71) participated in an unanticipated simulated shoulder dystocia followed by an educational debriefing session. A second shoulder dystocia simulation was completed at a later date. Delivery notes were a required component of each simulation. Notes were evaluated using a standardized checklist for 16 key components. One point was awarded for each element present. Wilcoxon signed rank tests were used to compare documentation between simulations. RESULTS: Participants consisted of 43 (61%) attending and 28 (39%) resident physicians. Ages ranged from 25–63 years (mean±standard deviation 37.0±9.0), and 75% were female. Years of obstetric experience for our attendings ranged from 4 to 31 years (14.5±8.1). Documentation scores were significantly improved after training. Attendings’ baseline documentation scores were 8.5±2.2 and improved to 9.4±2.3, P=.03. Residents’ documentation scores also improved (9.0±2.1 compared with 10.6±2.2, P=.001). In particular, improvement was seen in two components of documentation: 1) providers present for shoulder dystocia (P=.007) and 2) which shoulder was anterior (P<.001). No improvement was seen in standard delivery note components (eg, date, time) or infant characteristics (eg, weight, Apgar scores). CONCLUSION: Although we showed a significant improvement in the quality of documentation through this simulation program, notes were still suboptimal. Use of standardized forms for shoulder dystocia delivery notes may provide the best solution to ensure appropriate documentation. LEVEL OF EVIDENCE: II

First-trimester 3-dimensional power Doppler of the uteroplacental circulation space: a potential screening method for preeclampsia

OBJECTIVE The objective of the study was to compare 3-dimensional power Doppler (3DPD) of the uteroplacental circulation space (UPCS) in the first trimester between women who develop preeclampsia (PEC) and those who do not and to assess the 3DPD method as a screening tool for PEC. STUDY DESIGN This was a prospective observational study of singleton pregnancies at 10 weeks 4 days to 13 weeks 6 days. The 3DPD indices, vascularization index (VI), flow index (FI), and vascularization flow index (VFI), were determined on a UPSC sphere biopsy with the virtual organ computer-aided analysis (VOCAL) program. RESULTS Of 277 women enrolled, 24 developed PEC. The 3DPD indices were lower in women who developed PEC. The area under the receiver-operating characteristics curve for the prediction of PEC was 78.9%, 77.6%, and 79.6% for VI, FI, and VFI, respectively. CONCLUSION Patients who develop PEC have lower 3DPD indices of their UPCS during the first trimester. Our findings suggest that this ultrasonographic tool has the potential to predict the development of PEC.

Cocaine use during pregnancy and low birth weight: The impact of prenatal care and drug treatment

Cocaine use in pregnancy has been associated with low birth weight. Large population-based studies suggest that 5 to 7% of pregnant women have used cocaine, with much higher rates in low income inner-city women. Among 140 births at our institution of cocaine-using women, we found a lower rate of low birth weight in those who received prenatal care compared with those without prenatal care: 33 of 96 (34.3%) versus 23 of 44 (52.3%), P

Spontaneous infarction of placental chorioangioma and associated regression of hydrops fetalis

We report a case of a large chorioangioma diagnosed prenatally with concomitant meconium peritonitis and hydrops fetalis in the second trimester. Spontaneous regression of the tumor occurred, associated with some resolution of the fetal hydrops and delivery near term with good neonatal outcome.

Interdisciplinary development of a preconception health curriculum for four medical specialties.

A group of obstetricians and gynecologists, along with physicians from three other medical specialties, nurses, and midwives, developed a curriculum on preconception health care for women. This curriculum was specifically aimed at residents in obstetrics and gynecology, internal medicine, pediatrics, and family medicine. The curriculum was designed to convince these physicians that they needed to participate in promotion of preconception health for many reasons, such as the need to teach women to take folic acid daily because it significantly decreases the incidence of neural tube defects. Because over 50% of all pregnancies are unplanned, it is imperative that all physicians think of themselves as preconception health providers. Our group then taught the curriculum to medical students, residents, fellows, and attending physicians in all specialties at four hospitals affiliated with the medical college. Evaluation of the curriculum in 171 physicians who participated revealed that only a small percentage of physicians took folic acid daily themselves. Almost 36% of the obstetricians did not currently provide preconception care for their patients. Most physicians in all specialties believed that the curriculum provided them with useful information for their practice. The March of Dimes is currently distributing this curriculum on its Web site.

Simulation: Improving communication with patients

Patient-doctor communication has become a topic of increasing importance and attention, with both personal and public health ramifications. Despite this, formal training in communication is rare in later professional life, and the best way of improving these skills is unknown. Recently, attention has turned to simulation as a way to teach communication skills to medical providers. In this article, we review the history and current evidence behind utilizing simulation for patient-doctor communication teaching, as well as the challenges for future research in this field as it progresses into mainstream practice.

Healthcare Workers' Attitudes Toward Patients With Ebola Virus Disease in The United States

Healthcare workers willingness to care for Ebola patients did not precisely mirror their beliefs about the ethics of refusing to provide care, they were strongly influenced by concerns about potentially exposing families and friends to Ebola virus disease.

Is obesity an independent barrier to obtaining prenatal care

OBJECTIVE Obesity is a demonstrated barrier to obtaining health care. Its impact on obtaining prenatal care (PNC) is unknown. Our objective was to determine if obesity is an independent barrier to accessing early and adequate PNC. STUDY DESIGN We performed a retrospective cohort study of women who initiated PNC and delivered at our institution in 2005. Body mass index (BMI) was categorized by World Health Organization guidelines: underweight (<18.5 kg/m(2)), normal weight (18.5 to 24.9 kg/m(2)), overweight (25.0 to 29.9 kg/m(2)), and obese (≥30 kg/m(2)). Maternal history and delivery information were obtained through chart abstraction. Differences in gestational age at first visit (GA-1) and adequate PNC were evaluated by BMI category. Data were compared using χ(2) and nonparametric analyses. RESULTS Overall, 410 women were evaluated. The median GA-1 was 11.1 weeks and 69% had adequate PNC. There was no difference in GA-1 or adequate PNC by BMI category (p = 0.17 and p = 0.66, respectively). When BMI groups were dichotomized into obese and nonobese women, there was no difference in GA-1 or adequate PNC (p = 0.41). CONCLUSION In our population, obesity is not an independent barrier to receiving early and adequate PNC. Future work is warranted in evaluating the association between obesity and PNC and the perceived barriers to obtaining care.

Validating Obstetric Emergency Checklists using Simulation: A Randomized Controlled Trial

Background The World Health Organizations Surgical Safety Checklist has demonstrated significant reduction in surgical morbidity. The American Congress of Obstetricians and Gynecologists District II Safe Motherhood Initiative (SMI) safety bundles include eclampsia and postpartum hemorrhage (PPH) checklists. Objective To determine whether use of the SMI checklists during simulated obstetric emergencies improved completion of critical actions and to elicit feedback to facilitate checklist revision. Study Design During this randomized controlled trial, teams were assigned to use a checklist during one of two emergencies: eclampsia and PPH. Raters scored teams on critical step completion. Feedback was elicited through structured debriefing. Results In total, 30 teams completed 60 scenarios. For eclampsia, trends toward higher completion were noted for blood pressure and airway management. For PPH, trends toward higher completion rates were noted for PPH stage assessment and fundal massage. Feedback resulted in substantial checklist revision. Participants were enthusiastic about using checklists in a clinical emergency. Conclusion Despite trends toward higher rates of completion of critical tasks, teams using checklists did not approach 100% task completion. Teams were interested in the application of checklists and provided feedback necessary to substantially revise the checklists. Intensive implementation planning and training in use of the revised checklists will result in improved patient outcomes.