Sherri Jackson

Cesarean versus vaginal delivery: whose risks? Whose benefits?

We reviewed the risks and benefits of vaginal and cesarean delivery to help frame the inherent trade-offs that should be considered as part of the informed consent discussion between patients and providers. We performed a targeted literature review for common complications of childbirth. Approximately 30% of women will experience a maternal or neonatal complication during childbirth. Both cesarean and vaginal delivery is associated with well-known measurable short- and long-term maternal and neonatal complications and benefits. Childbirth is not risk free. There are data available that can guide the informed consent process with objective quantifiable data that patients and providers can use to weigh risks and benefits of delivery methods.

Pregnancy outcomes in very advanced maternal age pregnancies: the impact of assisted reproductive technology

OBJECTIVE To determine whether there are differences in adverse pregnancy outcomes in very advanced maternal age (vAMA) women who conceived with assisted reproductive technologies (ART) compared with spontaneous conceptions. DESIGN Retrospective cohort study. SETTING Academic tertiary care medical center. PATIENT(S) A total of 472 women aged ≥45 years who delivered at one institution. INTERVENTION(S) Mode of conception. MAIN OUTCOME MEASURE(S) Maternal and neonatal outcomes. RESULT(S) For singleton pregnancies, vAMA women who conceived with ART were significantly older (47.0 ± 2.3 vs. 45.6 ± 0.1 years), more likely to be white (88.1% vs. 75.6%), and less parous (0.4 ± 0.9 vs. 1.2 ± 1.8) than vAMA women who conceived spontaneously. They were at significantly increased risk for cesarean delivery (CD) (75.1% vs. 49.7%) and were more likely to undergo elective primary CD without labor (25.4% vs. 9.4%). Risk of retained placenta was also significantly higher (2.7% vs. 0%). Rates of other maternal complications and neonatal outcomes were similar. Subgroup analysis of ART singleton pregnancies did not demonstrate differences in women using autologous oocytes versus donor oocytes. CONCLUSION(S) Very advanced maternal age women who conceive after ART are more likely to be white, older, primiparous, and are more likely to proceed with an elective CD compared with vAMA women who conceive spontaneously. The increased risk of retained placenta in women who conceive with ART may indicate an underlying risk for placentation defects.

Morbidity following primary cesarean delivery in the Danish National Birth Cohort.

OBJECTIVE Cesarean delivery rates are on the rise in many countries, including the United States. There is mounting evidence that cesarean delivery is associated with adverse reproductive outcomes in subsequent pregnancies. The purpose of this article is to review those outcomes in a well-defined cohort of pregnant women. STUDY DESIGN In a cohort of primigravid women from the Danish National Birth Cohort with known baseline exposure characteristics, we stratified women by method of first delivery, vaginal or cesarean, and evaluated for appearance of adverse reproductive events in subsequent pregnancies. RESULTS After adjusting for age, body mass index, alcohol, smoking, and socioeconomic status, women who underwent cesarean delivery at first birth were at increased risk in their subsequent pregnancy for anemia (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.3-3.4), placental abruption (OR, 2.3; 95% CI, 1.5-3.6), uterine rupture (OR, 268; 95% CI, 65.6-999), and hysterectomy (OR, 28.8; 95% CI, 3.1-263.8). CONCLUSION Women who deliver their first baby with a cesarean are at increased risk of adverse reproductive outcomes in subsequent pregnancies and should be counseled accordingly.

Teaching forceps: the impact of proactive faculty

OBJECTIVE The objective of the study was to evaluate the impact on resident forceps experience by a single proactive teacher. STUDY DESIGN A study was performed to assess the impact on delivery statistics and outcome following the assignment of a single attending to teach forceps to residents. A 2 year period immediately preceding and 2 years following the study was compared using χ(2) and Student t tests. RESULTS After appointment of the specific teaching attending, forceps deliveries increased by 59% (8% of all births), whereas vacuum procedures decreased to 3% of births (P < .0001) compared with the prior 2 years. The overall percentage of operative vaginal deliveries remained unchanged (11%). Cesarean section rates were unchanged during the study period at 27% of all births. Perineal laceration, 5 minute Apgar less than 7, and birth injuries were also not statistically different. There were fewer fetal pH events less than 7.1 in the teaching period (P = .003). CONCLUSION In the population studied, there was an association between increasing resident forceps use and a positive impact on birth outcomes from the designation of a full-time, experienced, and proactive faculty member to obstetrics teaching duty.

Are open box gloves clean enough to perform vaginal examinations

the average of the past two years (16.5%). In May 2003, B. cepacia was detected in 17 (19.3%) of 88 patients (Figure 1); therefore we concluded that an outbreak had occurred. In the patients in whom B. cepacia was detected, however, subjective symptoms such as fever, an increase of discharge or objective symptoms such as increases in C-reactive protein or white blood cells were not detected. Environmental research was carried out to investigate the common source of infection. There were ten irrigators at outpatient and inpatient wards in our hospital. The benzalkonium chloride solution in all the irrigators was cultured. Next, undiluted solutions of benzalkonium chloride and the distilled water used for preparation were cultured. A total of nine environmental samples were collected. B. cepacia was cultured from all irrigators whereas Pseudomonas aeruginosa was not cultured from any. B. cepacia was also detected in the unopened 0.02% benzalkonium chloride liquid prepared in our hospital. In addition, B. cepacia was not grown from undiluted benzalkonium chloride and distilled water manufactured in our hospital. We stopped using irrigators immediately. When patients needed vagina disinfection, we used commercially available 0.25% inverted soap. Examining hands or vaginal speculi were moistened with saline when we performed pelvic or speculum examinations. By stopping use of the irrigators and using commercial 0.025% benzalkonium chloride, no more B. cepacia was found in patient specimens. We had used exclusive containers for the 0.02% benzalkonium chloride prepared in our hospital. We washed them with heat-disinfected distilled water after returning from each ward before filling, but we did not dry the containers each time. The benzalkonium chloride solution in all irrigators in each ward had been exchanged once a week. The exchange method was such that fresh solution was poured into the irrigator after discarding old solution and rinsing gently. Therefore, we suspect that the 0.02% benzalkonium chloride prepared in our hospital for pelvic examinations was the common source of B. cepacia infection. We considered that B. cepacia had colonised the container and increased within containers or irrigators, and that the patients vagina had been exposed to B. cepacia at the time of an internal examination. After use of irrigators had been stopped at each ward and commercial benzalkonium chloride had been adopted, B. cepacia was not seen. We use saline for internal examinations and there are no clinical problems without using irrigators. We should not overestimate the ability of a disinfectant to prevent nosocomial infection, and prohibition of any additional antiseptics should be mandatory. Moreover, as a prompt intervention measure against infection at the time of the outbreak was useful for preventing further cases, it seems that surveillance of vaginal culture results should be considered for early detection of an outbreak.

Management of the first stage of labor: potential strategies to lower the cesarean delivery rate.

To review management strategies associated with lower risk for cesarean delivery. Targeted literature review for labor interventions during the first stage of labor. There is evidence that policies regarding labor admission criteria, standardized policies regarding labor management including judicious use of oxytocin, standardized terminology and treatment for electronic fetal monitoring, standardized criteria for dystocia, and systematic implementation of policies that incorporate continuous supportive care during labor are associated with lower risk for cesarean. Evidence regarding use of amniotomy is conflicting. Management of the first stage of labor can affect the risk for cesarean delivery.