Nicole S. Carlson

CenteringPregnancy: a new approach in prenatal care.

CenteringPregnancy is an innovative model of prenatal care that emphasizes risk assessment, education, and support within a group setting. Created by a nurse midwife and encompassing a midwifery focus on womens health, the CenteringPregnancy program allows prenatal care providers and the women they serve to accomplish care goals by allowing more than 20 hours of contact time throughout pregnancy and early postpartum. Amid new studies revealing traditional prenatal cares lack of effectiveness in reducing low birthweight and calls from public health sectors for more comprehensive prenatal care programs, the CenteringPregnancy model is one new approach in response to these challenges.

Parturition dysfunction in obesity: time to target the pathobiology

Over a third of women of childbearing age in the United States are obese, and during pregnancy they are at increased risk for delayed labor onset and slow labor progress that often results in unplanned cesarean delivery. The biology behind this dysfunctional parturition is not well understood. Studies of obesity-induced changes in parturition physiology may facilitate approaches to optimize labor in obese women. In this review, we summarize known and proposed biologic effects of obesity on labor preparation, contraction/synchronization, and endurance, drawing on both clinical observation and experimental data. We present evidence from human and animal studies of interactions between obesity and parturition signaling in all elements of the birth process, including: delayed cervical ripening, prostaglandin insensitivity, amniotic membrane strengthening, decreased myometrial oxytocin receptor expression, decreased myocyte action potential initiation and contractility, decreased myocyte gap junction formation, and impaired myocyte neutralization of reactive oxygen species. We found convincing clinical data on the effect of obesity on labor initiation and successful delivery, but few studies on the underlying pathobiology. We suggest research opportunities and therapeutic interventions based on plausible biologic mechanisms.

Intrapartum Management Associated with Obesity in Nulliparous Women

INTRODUCTION The objective of this systematic review was to determine the current state of knowledge about intrapartum management associated with obesity in healthy nulliparous women. Nulliparous obese women are at higher risk for unplanned cesarean birth when compared with their normal-weight counterparts, and much of this increased risk is associated with labor management differences. There is a need to better understand the differences in intrapartum management of nulliparous women who are obese. METHODS The PubMed, CINAHL, EBSCO, Google Scholar, and MEDLINE databases were searched in August 2012, with identified studies then assessed for applicability and quality. Eight studies were retained for the review. RESULTS Intrapartum interventions used significantly more often for healthy, obese nulliparous women when compared with normal-weight women were induction of labor, augmentation of labor, and cesarean birth. It is unclear if assisted vaginal birth occurs more frequently among obese women. Epidural anesthesia, artificial rupture of membranes prior to 6 cm of cervical dilation, and early hospital admission were shown in separate studies to be used more often in obese women. Intrapartum interventions were used more frequently in obese women in a dose-dependent manner by body mass index. DISCUSSION Future studies examining the intrapartum management of obese nulliparous women are needed with: 1) samples defined by standardized obesity classifications; 2) further analysis of diverse intrapartum interventions; and 3) prospective, randomized designs to allow for causality conclusions linking intrapartum intervention use to an obese womans risk for cesarean birth. Implications for clinical practice from this systematic review are that healthy, nulliparous obese women are exposed to common intrapartum interventions more often than normal-weight women. In the absence of evidence on the use of appropriate use of intrapartum interventions in this population, health care providers should carefully monitor management choices when working with healthy, nulliparous obese women.

Labor Intervention and Outcomes in Women Who Are Nulliparous and Obese: Comparison of Nurse-Midwife to Obstetrician Intrapartum Care

Background: Women who are obese have slower labors than women of normal weight, and show reduced response to interventions designed to speed labor progress like oxytocin augmentation and artificial rupture of membranes. The optimal labor management for these women has not been described. Methods: This retrospective cohort study compared 2 propensity score‐matched groups of women (N = 360) who were healthy, nulliparous, spontaneously laboring, and obese (body mass index ≥ 30 kg/m2). Labors were managed by either a certified nurse‐midwife (CNM) or an obstetrician at one hospital from 2005 through 2012. Comparisons were made on a range of labor processes and outcomes. Results: Women who were obese and cared for in labor by CNMs were 87.0% less likely to have operative vaginal birth (adjusted odds ratio [aOR], 0.15; 95% confidence interval [CI], 0.06‐0.41) and 76.3% less likely to have third‐ or fourth‐degree perineal lacerations (aOR, 0.31; 95% CI, 0.13‐0.79) compared to a matched group of women who were obese and had similarly sized neonates but who were cared for by obstetricians. The rates of unplanned cesarean birth, postpartum hemorrhage, maternal intrapartum fever, and neonatal intensive care unit admission were similar between groups. CNM patients were significantly less likely than patients of obstetricians to have labor anesthesia, synthetic oxytocin augmentation, or intrauterine pressure catheters. By contrast, CNM patients were significantly more likely than patients of obstetricians to use physiologic labor interventions, including intermittent fetal monitoring, ambulation, and hydrotherapy. Discussion: In women with spontaneous labor onset who were healthy, obese, and nulliparous, watchful waiting and use of physiologic labor interventions, characterizing CNM intrapartum care, were associated with outcomes that were similar to, or better than, those of women who were obese and exposed to more high‐technology interventions characterizing intrapartum care by obstetricians. In women who were obese, physiologic labor interventions were safe for both mothers and neonates.

Overview of breast cancer treatment and reconstruction for primary care providers.

More women are diagnosed and treated for breast cancer today than at any time in the past. New technologies in the treatment of breast cancer and breast reconstruction are changing morbidity and mortality realities for women diagnosed with breast cancer. Primary care providers in womens health care can provide valuable support, education, and advocacy for their clients who are dealing with breast cancer. This article reviews current breast cancer treatment guidelines, information on breast reconstruction after cancer, and primary care recommendations for post-breast cancer care.

Utilizing Datasets to Advance Perinatal Research

Many organizations collect and make available perinatal data for research and quality improvement initiatives. Analysis of existing data and use of retrospective study design has many advantages for perinatal researchers. These advantages include large samples, inclusion of women from diverse groups, data reflective of actual clinical processes and outcomes, and decreased risk of direct maternal and fetal harm. We review 11 publicly available datasets relevant to perinatal research and quality improvement, detail the availability of interactive websites, and discuss strategies to locate additional datasets. While analysis of existing data has limitations, it may provide statistical power to study rare perinatal outcomes, support research applicable to diverse populations, and facilitate timely and ethical well-woman research immediately relevant to clinical care.

Antepartum Care of Women Who Are Obese During Pregnancy: Systematic Review of the Current Evidence

INTRODUCTION Nearly 40% of US women of childbearing age are obese. Obesity during pregnancy is associated with multiple risks for both the woman and fetus, yet clinicians often feel unprepared to provide optimal antepartum care for this group of women. We collected and reviewed current evidence concerning antepartum care of women who are obese during pregnancy. METHODS We conducted a systematic review using PRISMA guidelines. Current evidence relating to the pregnancy care of women with a prepregnancy body mass index of 30kg/m2 or higher was identified using MEDLINE databases via PubMed, Embase, and Web of Science Core Collection between January 2012 and February 2018. RESULTS A total of 354 records were located after database searches, of which 63 met inclusion criteria. Topic areas for of included studies were: pregnancy risk and outcomes related to obesity, communication between women and health care providers, gestational weight gain and activity/diet, diabetic disorders, hypertensive disorders, obstructive sleep apnea, mental health, pregnancy imaging and measurement, late antepartum care, and preparation for labor and birth. DISCUSSION Midwives and other health care providers can provide better antepartum care to women who are obese during pregnancy by incorporating evidence from the most current clinical investigations.

Current Resources for Evidence-Based Practice, January/February 2016

How Traditional Research Design and Settings Make It Difficult to Prove the Benefits of Normal Labor and Birth A few weeks ago, I attended the Tri-State American College of Nurse-Midwives (ACNM) conference hosted by the South Carolina ACNM affiliate for midwives from South Carolina, North Carolina, and Georgia. At the conference, Amy Romano reviewed the evidence for various practices in labor and birth, including ambulation in labor, early cord clamping, elective induction, and routine neonatal suctioning following birth (Romano, 2015). In her review of the evidence, she mentioned several times that the optimal care for women and neonates may not be easy to discern in many studies of labor and birth, largely due to traditional settings for research studies and traditional research designs (Romano, 2015).

Likelihood of cesarean birth among parous women after applying leading active labor diagnostic guidelines

OBJECTIVES Hospital admission during early labor may increase womens risk for medical and surgical interventions. However, it is unclear which diagnostic guideline is best suited for identifying the active phase of labor among parous women. Dr. Emanuel Friedman, the United Kingdoms National Institute for Health and Care Excellence (NICE), and the American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine (ACOG/SMFM) support different active labor diagnostic guidelines. Our aims were (1) to determine the proportions of parous women admitted to the hospital before or in active labor per these leading guidelines and (2) to compare associations of labor status at admission (i.e., early labor or active labor) with oxytocin augmentation, cesarean birth, and adverse birth outcomes when using the different active labor diagnostic guidelines. DESIGN Active labor diagnostic guidelines were applied retrospectively to cervical examination data. Binomial logistic regression was used to assess associations of labor status at admission (i.e., early labor relative to active labor) and outcomes. SETTING A large, academic, tertiary medical center in the Midwestern United States. PARTICIPANTS Parous women with spontaneous labor onset who gave birth to a single, cephalic-presenting fetus at term gestation between 2006 and 2010 (n = 3,219). FINDINGS At admission, 28.8%, 71.9%, and 24.4% of parous women were in active labor per Friedman, NICE, and ACOG/SMFM diagnostic guidelines, respectively. Oxytocin augmentation was more likely among women admitted in early labor, regardless of the diagnostic strategy used (p < 0.001 for each guideline). Cesarean birth was also more likely among women admitted before versus in active labor according to all guidelines (Friedman: adjusted odds ratio [AOR] 3.63 [95% CI 1.46-9.03]), NICE: AOR 2.71 [95% CI 1.47-4.99]), and ACOG/SMFM: AOR 2.11 [95% CI 1.02-4.34]). There were no differences in a composite measure of adverse outcomes within active labor diagnostic guidelines after adjusting for covariates. KEY CONCLUSIONS Many parous women with spontaneous labor onset are admitted to the hospital before active labor. These women are more likely to receive oxytocin augmentation during labor and are more likely to have a cesarean birth. IMPLICATIONS FOR PRACTICE Diagnosing active labor prior to admission or prior to intervention aimed at speeding labor after admission may decrease likelihoods for primary cesarean births. The NICE dilation-rate based active labor diagnostic guideline is more inclusive than Friedman or ACOG/SMFM guidelines and its use may be the most clinically-useful for improving the likelihood of vaginal birth among parous women.

Current Resources for Evidence-Based Practice, May/June 2018

A Randomized Trial of Induction Versus Expectant Management (ARRIVE) was a federally-funded, multi-site, clinical trial to compare elective induction of labor at 39 weeks’ gestation to expectant management until 40 5/7 weeks’ gestation for low-risk, nulliparous women.1 Initial results for ARRIVE were announced on February 1, 2018 at the annual meeting of the Society for Maternal-Fetal Medicine, which prompted a flurry of reactions from clinicians, researchers, and the public. Readers of this columnmay remember past discussions of ARRIVE and its potential to serve as rationale for a nationwide shift toward labor induction.2–5 The trial of 6106 nulliparous women is now complete, and initial results include significant reductions in the following: cesarean birth (18.6% in the induction group vs 22.2% expectant management group; risk ratio [RR], 0.84; 95% CI, 0.76-0.93), maternal admission to intensive care unit (0.1% in the induction group vs 0.3% in the expectant management group; RR, 0.50; 95% CI, 0.13-1.55), neonatal respiratory support in first 72 hours following birth (3.0% in the induction group vs 4.2% in the expectant management group; RR, 0.71; 95% CI, 0.55-0.93), and diagnosis of preeclampsia or gestational hypertension (9.1% in the induction group vs 14.1% in the expectant management group; RR, 0.64; 95% CI, 0.56-0.74).6 Many people are asking what these results could mean for the future of labor and birth in the United States. Are we on the precipice of a new age in which almost all women will have their labors induced? Is physiologic labor to become a higher risk option that requires informed consent? Before we jump to any dire predictions, let’s first review some key points about ARRIVE. First, the results of ARRIVE have not yet been published in a peer-reviewed journal. To date, only the conference abstract and clinical trial guidelines have been made public.1,6 Until we can examine the full report of the study results after peer review, we do not know critical details necessary to interpret the findings. Second, it is not appropriate for ARRIVE results to be translated into practice at this time, and clinicians should not use preliminary findings to justify increased use of labor induction or to counsel women to consider elective induction at 39 weeks’ gestation. In statements released directly after the ARRIVE results were presented in an abstract, the Society forMaternal-FetalMedicine7 and theAmericanCollege of Nurse-Midwives8 urged patience formaternity care providers; elective induction of labor at less than 41 0/7 weeks’ gestation