Marya G. Zlatnik

Forceps compared with vacuum: Rates of neonatal and maternal morbidity

OBJECTIVE: To compare perinatal outcomes between forceps- and vacuum-assisted deliveries. Our hypothesis was that the force vectors achieved in forceps delivery will lead to fewer shoulder dystocias, but greater perineal lacerations. METHODS: This was a retrospective cohort study of 4,120 term, cephalic, singleton, nonrotational operative vaginal deliveries at a single institution. Outcomes examined included rates of neonatal trauma, shoulder dystocia, and perineal lacerations. Potential confounders, including maternal age, birthweight, ethnicity, parity, station at delivery, episiotomy, attending physician, anesthesia, and length of labor, were controlled for using multivariate logistic regression. RESULTS: Among the 2,075 (50.4%) forceps- and 2,045 (49.6%) vacuum-assisted deliveries, the rate of shoulder dystocia was lower among women undergoing forceps delivery (1.5% compared with 3.5%, P < .001), as was the rate of cephalohematoma (4.5% compared with 14.8%, P < .001), whereas the rate of third- or fourth-degree perineal laceration was higher (36.9% compared with 26.8%, P < .001). These differences in perinatal complications persisted when controlling for the confounders listed above. The adjusted odds ratio for shoulder dystocia was 0.34 (95% confidence interval [CI] 0.20–0.57), for cephalohematoma was 0.25 (95% CI 0.19–0.33), and for third- or fourth-degree lacerations was 1.79 (95% CI 1.52–2.10) when comparing forceps to vacuum. CONCLUSION: Vacuum-assisted vaginal birth is more often associated with shoulder dystocia and cephalohematoma. Forceps delivery is more often associated with third- and fourth-degree perineal lacerations. These differences in complications rates should be considered among other factors when determining the optimal mode of delivery. LEVEL OF EVIDENCE: II-2

Effect of a change in policy regarding the timing of prophylactic antibiotics on the rate of postcesarean delivery surgical-site infections.

OBJECTIVE The purpose of this study was to examine the effect of a change in policy regarding the timing of antibiotic administration on the rates of postcesarean delivery surgical-site infections (SSI). STUDY DESIGN This was a retrospective cohort study of 1316 term, singleton cesarean deliveries at 1 institution. A policy change was instituted wherein prophylactic antibiotics were given before skin incision rather than after cord clamp. The primary outcome that was examined was SSI; secondary outcomes were the rates of endometritis and cellulitis. Multivariable regression was performed to control for potential confounders. RESULTS The overall rate of SSI fell from 6.4-2.5% (P = .002). When we controlled for potential confounders, there was a decline in overall SSI with an adjusted odds ratio (aOR) of 0.33 (95% CI, 0.14,0.76), a decrease in endometritis (aOR, 0.34; 95% CI, 0.13,0.92), and a trend towards a decrease in cellulitis (aOR, 0.22; 95% CI, 0.05,1.22). CONCLUSION At our institution, a change in policy to administer prophylactic antibiotics before skin incision led to a significant decline in postcesarean delivery SSIs.

Effective physician-nurse communication: a patient safety essential for labor and delivery

Effective communication is a hallmark of safe patient care. Challenges to effective interprofessional communication in maternity care include differing professional perspectives on clinical management, steep hierarchies, and lack of administrative support for change. We review principles of high reliability as they apply to communication in clinical care and discuss principles of effective communication and conflict management in maternity care. Effective clinical communication is respectful, clear, direct, and explicit. We use a clinical scenario to illustrate an historic style of nurse-physician communication and demonstrate how communication can be improved to promote trust and patient safety. Consistent execution of successful communication requires excellent listening skills, superb administrative support, and collective commitment to move past traditional hierarchy and professional stereotyping.

Placenta previa and the risk of preterm delivery

Objectives. We aimed to quantify the risk of preterm delivery and maternal and neonatal morbidities associated with placenta previa. Study design. We conducted a retrospective cohort study of singleton births that occurred between 1976 and 2001, examining outcomes including preterm delivery and perinatal complications. Multivariate logistic regression was used to control for potential confounders. Kaplan–Meier survival curves were constructed to compare preterm delivery in pregnancies complicated by previa vs. no previa. Results. Among the 38 540 women, 230 women had previas (0.6%). Compared to controls, pregnancies with previa were significantly associated with preterm delivery prior to 28 weeks (3.5% vs. 1.3%; p = 0.003), 32 weeks (11.7% vs. 2.5%; p < 0.001), and 34 weeks (16.1% vs. 3.0%; p < 0.001) of gestation. Patients with previa were more likely to be diagnosed with postpartum hemorrhage (59.7% vs. 17.3%; p < 0.001) and to receive a blood transfusion (11.8% vs. 1.1%; p < 0.001). Survival curves demonstrate the risk of preterm delivery at each week and showed an overall higher rate of preterm delivery for patients with a placenta previa. Conclusions. Placenta previa is associated with maternal and neonatal complications, including preterm delivery and postpartum hemorrhage. These specific outcomes can be used to counsel women with previa.

Detection of Viral Deoxyribonucleic Acid in Amniotic Fluid: Association with Fetal Malformation and Pregnancy Abnormalities

Objective: To first test the hypothesis that the presence of viral nucleic acid in amniotic fluid (AF) is associated with an abnormal pregnancy outcome, and second, to determine if the overall rate of polymerase chain reaction (PCR) positivity and the distribution of virus types vary geographically. Study Design: Cytomegalovirus (CMV), parvovirus B19, adenovirus, enterovirus, herpes simplex virus, Epstein-Barr virus, and respiratory syncytial virus nucleic acids were sought in 423 AF samples obtained for clinical indications: 284 from the East Coast (EC) and 139 from the Midwest (MW). Results: Gestational age at sampling was 19.1 weeks for EC and 20.1 weeks for MW. 13.5% of karyotypically normal singleton pregnancies (57/423) had a positive AF PCR. 11% of AF PCR from the EC while 18% of AF PCR from the MW were positive (p = 0.06). The most commonly detected viruses were adenovirus (77%), enterovirus (12%), and CMV and parvovirus B19 (5% each). Twenty-four percent of sonographically abnormal pregnancies (33/136) had a positive AF PCR compared to only 8.4% (24/287) of normal pregnancies (p < 0.001). Conclusion: A positive AF PCR is associated with an increased rate of fetal structural malformations, intrauterine growth restriction, hydrops and other fetal abnormalities. There were no significant geographic differences in the incidence of AF viral PCR positivity.

Confronting Safety Gaps across Labor and Delivery Teams

We assessed the occurrence of 4 safety concerns among labor and delivery teams: dangerous shortcuts, missing competencies, disrespect, and performance problems. A total of 3282 participants completed surveys, and 92% of physicians (906 of 985), 93% of midwives (385 of 414), and 98% of nurses (1846 of 1884) observed at least 1 concern within the preceding year. A majority of respondents said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving their positions. Only 9% of physicians, 13% of midwives, and 13% of nurses shared their full concerns with the person involved. Organizational silence is evident within labor-and-delivery teams. Improvement will require multiple strategies, used at the personal, social, and structural levels.

Contributions of Clinical Disconnections and Unresolved Conflict to Failures in Intrapartum Safety

OBJECTIVE To explore clinician perspectives on whether they experience difficulty resolving patient-related concerns or observe problems with the performance or behavior of colleagues involved in intrapartum care. DESIGN Qualitative descriptive study of physician, nursing, and midwifery professional association members. PARTICIPANTS AND SETTING Participants (N = 1932) were drawn from the membership lists of the Association of Womens Health, Obstetric, and Neonatal Nurses (AWHONN), American College of Obstetricians and Gynecologists (ACOG), American College of Nurse Midwives (ACNM), and Society for Maternal-Fetal Medicine (SMFM). METHODS Email survey with multiple choice and free text responses. Descriptive statistics and inductive thematic analysis were used to characterize the data. RESULTS Forty-seven percent of participants reported experiencing situations in which patients were put at risk due to failure of team members to listen or respond to a concern. Thirty-seven percent reported unresolved concerns regarding another clinicians performance. The overarching theme was clinical disconnection, which included disconnections between clinicians about patient needs and plans of care and disconnections between clinicians and administration about the support required to provide safe and appropriate clinical care. Lack of responsiveness to concerns by colleagues and administration contributed to resignation and defeatism among participants who had experienced such situations. CONCLUSION Despite encouraging progress in developing cultures of safety in individual centers and systems, significant work is needed to improve collaboration and reverse historic normalization of both systemic disrespect and overt disruptive behaviors in intrapartum care.

Oxytocin Receptor Regulation and Action in a Human Granulosa-Lutein Cell Line

Abstract Although oxytocin and its receptor have been identified in human ovary, its regulatory role in granulosa cell or corpus luteum function has not been clearly defined. To better understand oxytocin action in the human ovary, we have characterized the expression and function of oxytocin receptors in an immortalized human granulosa-lutein cell line, HGL5. Expression of oxytocin receptor mRNA was demonstrated by reverse transcriptase-polymerase chain reaction analysis, and by specific binding of an iodinated oxytocin antagonist (apparent dissociation constant of 131 ± 0.15 pM, and a Bmax of 12 ± 0.5 fmol/μg DNA). Receptor levels were down-regulated by serum starvation, and rapidly up-regulated by serum restoration. Stimulation of protein kinase C activity increased oxytocin receptor levels in a concentration-dependent manner. Conversely, protein kinase C inhibition blocked up-regulation of oxytocin receptors. Treatment of cells with 10 nM oxytocin resulted in a rapid, transient increase in intracellular Ca2+, and the response was blocked by an oxytocin antagonist. Because HGL5 cells secrete progesterone and estradiol in response to agents that elevate intracellular cAMP concentrations, we studied the effect of oxytocin on steroid production. Oxytocin enhanced the effects of forskolin on progesterone production. These results suggest that oxytocin augments the activity of luteotropins in vivo. Our studies are the first to show an ovarian cell line that expresses functional oxytocin receptors. These cells can serve as a useful model for studying oxytocin signal pathways and their cross-talk with respect to progesterone synthesis. These cells also will be useful in the analysis of mechanisms of oxytocin receptor regulation, including regulation of its gene.

PULMONARY EDEMA : ETIOLOGY AND TREATMENT

Pulmonary edema, a serious complication of pregnancy and the puerperium, can result in maternal and fetal morbidity and mortality. Pulmonary edema in pregnancy can be categorized by the primary mechanisms from which it results. An analysis of lung physiology using the Starling equation suggests that increased hydrostatic pressure, increased permeability, and osmotic imbalance can all lead to the development of pulmonary edema. These factors explain many of the common settings of pulmonary edema, including preeclampsia, tocolysis, and cardiac disease. This article will discuss the etiology and pathophysiology of pulmonary edema, how pregnancy influences it, and issues in its management.

Fetal growth and maternal glomerular filtration rate: A systematic review

Abstract Objective: Glomerular filtration rate (GFR) may influence concentrations of biomarkers of exposure and their etiologic significance in observational studies of associations between environmental contaminants and fetal growth. It is unknown whether the size of a developing fetus affects maternal GFR such that a small fetus leads to reduced plasma volume expansion (PVE), reduced GFR and subsequent higher concentrations of biomarkers in maternal serum. Our objective was to answer the question: “Is there an association between fetal growth and maternal GFR in humans?” Methods: We adapted and applied the Navigation Guide systematic review methodology to assess the evidence of an association between fetal growth and GFR, either directly or indirectly via reduction in PVE. Results: We identified 35 relevant studies. We rated 31 human and two non-human observational studies as “low” quality and two experimental non-human studies as “very low” quality. We rated all three evidence streams as “inadequate”. The association between fetal growth and GFR was “not classifiable” according to pre-specified definitions. Conclusions: There is currently insufficient evidence to support the plausibility of a reverse causality hypothesis for associations between exposure to environmental chemicals during pregnancy and fetal growth. Further research would be needed to confirm or disprove this hypothesis.