Francis S. Nuthalapaty

The association of maternal weight with cesarean risk, labor duration, and cervical dilation rate during labor induction

OBJECTIVE: To assess the relationship among maternal weight and cesarean delivery, cervical dilation rate, and labor duration. METHODS: We used a secondary analysis of 509 term women who were previously enrolled in a prospective observational study of a labor induction protocol in which standardized criteria were used for labor management. A variety of analyses were performed, both unadjusted and adjusted. P < .05 was considered significant. RESULTS: The mean ± standard deviation weight of women who underwent a cesarean (97 ± 29 kg) was significantly higher than that of women who were delivered vaginally (87 ± 22 kg, P < .001). In a logistic regression model of nulliparas who comprised 71% of the study population, after adjustment for the confounding effects of infant birth weight, maternal age, initial cervical dilation, and diabetes, for each 10-kg increase in maternal weight, the odds ratio for cesarean delivery was significantly increased (odds ratio 1.17; 95% confidence interval 1.04, 1.28). In a linear regression model also limited to nulliparas and after adjusting for the same confounders, the rate of cervical dilation was inversely associated with maternal weight: for each 10-kg increment, the rate of dilation was decreased by 0.04 cm/h (P = .05). Similarly, labor duration was positively associated with maternal weight: for each 10-kg increment, an increase in the oxytocin to delivery interval of 0.3 hours was observed in nulliparas (P = .02). Neither lower rates of oxytocin administration to heavier women nor diminished uterine responsiveness (as reflected in measured Montevideo units) accounted for the slower labor progress. CONCLUSION: In nulliparous women undergoing labor induction, maternal weight was associated with a higher cesarean risk and longer labor and was inversely proportional to the cervical dilation rate. LEVEL OF EVIDENCE: II-2OBJECTIVE To identify risk factors and outcomes associated with a short umbilical cord. METHODS We conducted a population-based case-control study using linked Washington State birth certificate-hospital discharge data for singleton live births from 1987 to 1998 to assess the association between maternal, pregnancy, delivery, and infant characteristics and short umbilical cord. Cases (n = 3565) were infants diagnosed with a short umbilical cord. Controls (n = 14260) were randomly selected from among births without a diagnosis of short umbilical cord. RESULTS Case mothers were less likely to be overweight (body mass index 25 or more, odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6, 0.8) and more likely to be primiparous (OR 1.4; 95% CI 1.3, 1.6). Case infants were more likely to be female (OR 1.3; 95% CI 1.2, 1.4), have a congenital malformation (OR 1.6; 95% CI 1.4, 1.8), and be small for their gestational age (risk ratio [RR] 1.6; 95% CI 1.4, 1.9). A short cord was associated with increased risk for maternal labor and delivery complications, including retained placenta (RR 1.6; 95% CI 1.2, 2.3) and operative vaginal delivery (RR 1.4; 95% CI 1.3, 1.5). Adverse fetal and infant outcomes in cases included fetal distress (RR 1.8; 95% CI 1.6, 2.1) and death within the first year of life among term infants (RR 2.4; 95% CI 1.2, 4.6). CONCLUSION Modifiable risk factors associated with the development of a short cord were not identified. Case mothers and infants are more likely to experience labor and delivery complications. Term case infants had a 2-fold increased risk of death, which suggests closer postpartum monitoring of these infants.

To the point: medical education review of the role of simulators in surgical training

Simulation-based training (SBT) is becoming widely used in medical education to help residents and medical students develop good technical skills before they practice on real patients. SBT seems ideal because it provides a nonthreatening controlled environment for practice with immediate feedback and can include objective performance assessment. However, various forms of SBT and assessment often are being used with limited evidence-based data to support their validity and reliability. In addition, although SBT with high-tech simulators is more sophisticated and attractive, this is not necessarily superior to SBT with low-tech (and lower cost) simulators. Therefore, understanding the types of surgical simulators and appropriate applications can help to ensure that this teaching and assessment modality is applied most effectively. This article summarizes the key concepts that are needed to use surgical simulators effectively for teaching and assessment.

The impact of obesity on obstetrical practice and outcome.

A central problem in the characterization of obesity during pregnancy has been the lack of a standard definition. In addition, the terms overweight and obese are often used interchangeably, adding further confusion. Overweight refers to aweight above the ‘‘normal’’ range, whereas obesity is defined by the presence of excess body fat. Therefore, the determination of the degree and type of obesity requires an assessment of adiposity or body fat composition and not merely weight. In the past, obesity in pregnancywas commonly defined using 1 of 2 approaches: either an absolute weight cutoff of 90 kg (200 lb) or a weight 50% to 300% greater than the ideal weight for height as defined using weightfor-height tables, such as the Metropolitan Life Insurance Company tables. The former approach ignores height, and the latter relies upon an estimate of frame size and is primarily derived frommortality data. Another issue unique to pregnancy is the distinction between prepregnancy obesity and weight gain during the course of pregnancy as a result of advancing gestation. In an effort to provide guidance on this issue, in 1990, the Institute of Medicine (IOM) recommended that the body mass index (BMI) be used to define maternal weight groups. Body mass index is calculated by dividing body weight in kilograms by height in meters squared (kg/m). Body mass index is believed to be a superior measure of adiposity than weight-for-height, but it, too, has several limitations. Body mass index does not incorporate a direct measure of body fat composition or distribution. Therefore, it does not differentiate betweenmuscle and fat and distorts body composition, which results in minimization of adiposity in taller individuals, and exaggeration in shorter individuals. In 1993, the American College of Obstetrician Gynecologists (ACOG) released its BMI classifications of maternal weight and optimal weight gain during pregnancy (Table 1). As a result, BMI now serves as a standardized means of evaluating Correspondence: Francis S. Nuthalapaty, MD, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, 619 19th Street South, OHB 451, Birmingham, AL 35249-7333. E-mail: francis@nuthalapaty. net

Misoprostol for labor induction in women with term premature rupture of membranes: a meta-analysis.

Objective: To systematically review published data evaluating the comparative use of misoprostol with placebo/expectant management or oxytocin for labor induction in women with term (≥ 36 weeks of gestation) premature rupture of membranes. Data Sources: PubMed (1966–2005), Ovid (1966–2005), CINAHL, The Cochrane Library, ACP Journal Club, OCLC, abstracts from scientific forums, and bibliographies of published articles were searched using the following keywords: premature rupture of membranes, misoprostol, labor induction, and cervical ripening. Primary authors were contacted directly if the data sought were unavailable or only published in abstract form. Methods of Study Selection: Only randomized controlled trials evaluating the efficacy and safety of misoprostol in comparison with placebo or expectant management (n = 6) and oxytocin (n = 9) published in either article or abstract form were analyzed and included in the meta-analysis. Tabulation, Integration, and Results: Studies were reviewed independently by all authors. Meta-analysis was performed, and the relative risks (RRs) were calculated and pooled for each study outcome. Misoprostol, compared with placebo, significantly increased vaginal delivery less than 12 hours (RR 2.71, 95% confidence interval [CI] 1.87–3.92, P < .001). Misoprostol was similar to oxytocin with respect to vaginal delivery less than 24 hours (RR 1.07, 95% CI 0.88–1.31, P = .50) and less than 12 hours (RR 0.98, 95% CI 0.71–1.35, P = .90). Misoprostol was not associated with an increased risk of tachysystole, hypertonus, or hyperstimulation syndrome when compared with oxytocin and had similar risks for adverse neonatal and maternal outcomes. Conclusion: Misoprostol is an effective and safe agent for induction of labor in women with term premature rupture of membranes. When compared with oxytocin, the risk of contraction abnormalities and the rate of maternal and neonatal complications were similar among the 2 groups.

e-Professionalism: a new frontier in medical education.

Background: This article, prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, discusses the evolving challenges facing medical educators posed by social media and a new form of professionalism that has been termed e-professionalism. Summary: E-professionalism is defined as the attitudes and behaviors that reflect traditional professionalism paradigms but are manifested through digital media. One of the major functions of medical education is professional identity formation; e-professionalism is an essential and increasingly important element of professional identity formation, because the consequences of violations of e-professionalism have escalated from academic sanctions to revocation of licensure. Conclusion: E-professionalism should be included in the definition, teaching, and evaluation of medical professionalism. Curricula should include a positive approach for the proper professional use of social media for learners.

Transcervical Foley catheter with and without extraamniotic saline infusion for labor induction: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of transcervical Foley catheter alone (Foley) to transcervical Foley catheter with extraamniotic saline infusion for labor induction and cervical ripening in women with an unfavorable cervix. METHODS: This was a multicenter, randomized, controlled trial of women presenting for labor induction with a singleton, cephalic fetus, intact membranes, and unfavorable cervix (Bishop score 6 or less). Eligible women were randomly assigned to receive either Foley catheter alone or Foley catheter with extraamniotic saline infusion. All women received concurrent oxytocin administration. The primary study outcome was the induction-to-delivery interval. Secondary outcomes included cesarean delivery, maternal infectious outcomes, and immediate neonatal outcomes. Analysis was by intent to treat. RESULTS: One hundred eighty-eight women met eligibility criteria and were randomly assigned (Foley plus extraamniotic saline infusion, n=97; Foley, n=91). Baseline demographic characteristics, including parity, gestational age, and Bishop score were similar between the study groups. The median induction-to-delivery interval in the extraamniotic saline infusion arm (12.6 hours, interquartile range 9.3–18.8 hours) was similar to that in the Foley arm (13.4 hours, interquartile range 9.6–17.5 hours) (P=. 70). The proportion of women delivered by 24 hours was comparable between groups (delivery 24 hours, extraamniotic saline infusion 89.7%, Foley 87.9%, P=.70), as was the rate of cesarean delivery (Foley 18.7%, extraamniotic saline infusion 27.8%, P=.14). No significant differences were noted between the study groups with respect to rate of chorioamnionitis, endometritis, or immediate birth outcomes. CONCLUSION: In women with an unfavorable cervix, the addition of extraamniotic saline infusion to a transcervical Foley catheter does not improve efficacy for labor induction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00442663 LEVEL OF EVIDENCE: I

To the point: Medical education reviewsongoing call for faculty development

This article in the To the Point series will focus on best practices regarding faculty development in medical education in the field of obstetrics and gynecology. Faculty development is an essential component in achieving teacher and learner satisfaction as well as improving learner outcomes. The Liaison Committee on Medical Education requires medical school faculty to have the capability and longitudinal commitment to be effective teachers. Although many programs have been created to address faculty development, there remains a paucity of literature documenting the impact of these programs on learner outcomes. We reviewed the qualities of an excellent medical educator, expectations regarding medical school teaching faculty, elements of comprehensive faculty development programs, and outcome measures for evaluating the effectiveness of these programs.

Is there a preferred gestational age threshold of viability?: a survey of maternal-fetal medicine providers.

Objective. To characterize variation and factors associated with the perceived gestational age for the threshold of viability among maternal-fetal medicine (MFM) providers. Methods. We performed a web-based online survey of 1375 MFM providers. For this secondary analysis, a subset of survey questions targeted toward perceptions of the limit of viability was analyzed to identify how the respondents viewed the optimal threshold of viability gestational age. Comparative statistics were performed to assess various characteristics that influence the perceived threshold of viability. Results. Five hundred and eight providers (37%), representing all 50 states and 13 countries, responded to the survey. The reported threshold of viability varied among survey respondents: 22 weeks, 2.0%; 23 weeks, 37.2%; 24 weeks, 55.3%; 25 weeks, 3.4%; and 26 weeks, 2.2%. No significant differences were noted in the reported threshold of viability with respect to practitioner age (<50 years old vs. ≥50 years old, p = 0.42), nursery availability (level III vs. other, p = 0.46), and years in practice (<10 years vs. ≥10 years, p = 0.86). Significant differences in the reported threshold of viability were noted with respect to practitioner gender with males tending to have a lower gestational age threshold than females (p = 0.005). Significant differences were also noted among practitioners from academic vs. community/private practice settings (p = 0.008). A logisitic regression model, adusting for both gender and practice setting, revealed that male gender was independently associated with selection of a threshold of viability less than 24 weeks of gestation: male gender OR 1.8 (95% CI 1.3–2.7, p = 0.002); academic practice setting OR 1.1 (95% CI 0.8–1.6, p = 0.50). Conclusions. Perceived threshold of viability among MFM providers varies with the majority of practitioners identifying 23–24 weeks of gestation. Significant difference, however, exists between practitioner genders.

The obstetrics and gynaecology resident as teacher.

In this article we discuss the role residents play in the clinical training and evaluation of medical students. A literature search was performed to identify articles dealing with research, curriculum, and the evaluation of residents as teachers. We summarize the importance of resident educators and the need to provide appropriate resources for house staff in this role, and we review evidence-based literature in the area of residents as teachers. Specific attention is given to the unique circumstances of the obstetrics and gynaecology resident, who is often faced with teaching in an emotionally charged and stress-filled environment. We present examples of curricula for residents as teachers and describe barriers to their implementation and evaluation.

A Randomized Controlled Trial of Early Versus Delayed Skin Staple Removal Following Caesarean Section in the Obese Patient

OBJECTIVE To compare wound complications after Caesarean section in the obese patient, following early versus delayed skin staple removal. METHODS We conducted a single-centre, non-inferiority, randomized controlled trial. Following Caesarean section, obese women (BMI ≥ 30 kg/m(2)) with subcutaneous wound depth ≥ 2.0 cm and skin staple closure of a transverse incision were randomized to staple removal on postoperative day 3 (early) or between postoperative day 7 and postoperative day 10 (delayed). The primary outcome was superficial wound dehiscence; a rate of 8% or higher in the early group was defined as inferior. Secondary outcomes were seroma/hematoma, surgical site infection, and visual analogue pain score. The planned sample size was 250 patients per group. RESULTS The study was halted after 295 patients were randomized because of slow enrolment and exhaustion of funding. The rate of superficial wound dehiscence was 15.2% in the early group (n = 145) versus 11.5% in the delayed group (n = 148). The point estimate for this difference (3.7 %; 95% CI -4.4 to 12.4) favours delayed removal. However, because the 95% CI includes zero and the upper CI exceeds the predefined limit for non-inferiority (8%), non-inferiority was not demonstrated. The rates of all secondary outcomes were similar in the early group and the delayed group: seroma/hematoma (6.9% vs. 4.7%; RR 1.4, 95% CI 0.6 to 3.7, P = 0.4); surgical site infection (9.7% vs. 4.8%; RR 2.0, 95% CI 0.8 to 4.9, P = 0.1); and composite (superficial wound dehiscence, seroma/hematoma, and surgical site infection) wound complication (17.2% vs. 12.8%; RR 1.3, 95% CI 0.8 to 2.3, P = 0.3). CONCLUSION The non-inferiority of early skin staple removal was not demonstrated. Delayed removal of staples should remain the accepted standard in the obese patient following Caesarean section.