Stephanie J. Handler

PAMUS: placenta accreta management across the United States

Objective: There is lack of consensus regarding the optimal strategy for management of abnormal placentation. We set out to determine the actual practices of providers across the United States (U.S.). Methods: This was a cross-sectional survey of maternal-fetal medicine providers in the U.S. registered with the Society for Maternal Fetal Medicine (SMFM). Questions regarding management strategies for placenta accreta were addressed by the survey. Both univariable and multivariable analyses were performed to determine if a relationship between demographic factors and management strategies exists. Results: Approximately 64% of responders were male and 62% had been in practice less than or equal to 20 years. The respondents represented all the major regions of the U.S. and the majority had performed one to five cases in the past year. The gestational age at delivery varied by both the number of years in practice and by geographic location. About 35% of providers report the use of ureteral stents and 36% of providers use internal femoral artery balloons though this varied by region. Regional differences and recent experience play a role in whether to attempt placental removal first. Though the majority of providers believe hysterectomy is the only management option for accreta, 32% of providers have attempted conservative management. Conclusions: There is wide variation in the actual practices of physicians in the U.S. with regard to management of placenta accreta.

Litigation in obstetrics: does defensive medicine contribute to increases in cesarean delivery?

Abstract Objective: Obstetrics is one of the most sued subspecialties in the US. This study aimed to examine clinicians’ medical-legal experience and its association with recommending cesarean delivery. Design: Cross-sectional convenience survey. Population or sample: This is a survey study of clinicians in the US. Methods: Survey included eight common obstetric clinical vignettes and 27 questions regarding clinicians’ practice environment. Chi-square test, multivariable logistic regression models were used for statistical comparisons. Main outcome measures: Likelihood of recommending cesarean delivery. Results: There were 1486 clinicians who completed the survey. Clinicians were categorized based on answers to clinical vignettes. Having had lawsuits and daily worry of suits were associated with higher likelihood of recommending cesarean, compared to those without lawsuits (17.2 versus 11.3%, respectively; p = 0.008) as was frequent worry of lawsuits (every day, 20.3% more likely; every week/month, 12.3%; few times a year/never, 11.4%, p < 0.001). Conclusion: Obstetric malpractice lawsuit and frequent worry about lawsuit are associated with higher propensity of recommending cesarean delivery in common obstetric settings.

Clinicians’ practice environment is associated with a higher likelihood of recommending cesarean deliveries

Abstract Objective: Little data exist regarding clinicians’ role in the rising annual incidence rate of cesarean delivery in the US. We aimed to examine if clinicians’ practice environment is associated with recommending cesarean deliveries. Study design: This is a survey study of clinicians who practice obstetrics in the US. This survey included eight clinical vignettes and 27 questions regarding clinicians’ practice environment. Chi-square test and multivariable logistic regression were used for statistical comparison. Results: Of 27 675 survey links sent, 3646 clinicians received and opened the survey electronically, and 1555 (43%) participated and 1486 (94%) completed the survey. Clinicians were categorized into three groups based on eight common obstetric vignettes as: more likely (n = 215), average likelihood (n = 1099), and less likely (n = 168) to recommend cesarean. Clinician environment factors associated with a higher likelihood of recommending cesarean included Laborists/Hospitalists practice model (p < 0.001), as-needed anesthesia support (p = 0.003), and rural/suburban practice setting (p < 0.001). Conclusion: We identified factors in clinicians’ environment associated with their likelihood of recommending cesarean delivery. The decision to recommend cesarean delivery is a complicated one and is likely not solely based on patient factors.

Racial/ethnic variations in perineal length and association with perineal lacerations: a prospective cohort study.

Abstract Objective: To examine the association between race/ethnicity, perineal length and the risk of perineal laceration. Methods: This is a prospective cohort study of a diverse group of women with singleton gestations in the third trimester of pregnancy. Perineal length was measured and mean values calculated for several racial/ethnic groups. Chi-squared analyses were used to examine rates of severe perineal laceration (third or fourth degree laceration) by race/ethnicity among women considered to have a short perineal length. Further, subgroup analyses were performed comparing nulliparas to multiparas. Results: Among 344 study participants, there was no statistically significant difference in mean perineal length by race/ethnicity (White 4.0 ± 1.1 cm, African-American 3.7 ± 1.0 cm, Latina 4.1 ± 1.1 cm, Asian 3.8 ± 1.0 cm, and other/unknown 4.0 ± 0.9 cm). Considering parity, more multiparous Asian and African-American women had a short perineal length (20.7 and 23.5%, respectively, p = 0.05). Finally, the rate of severe perineal lacerations in our cohort was 2.6% overall, but was 8.2% among Asian women (p = 0.04). Conclusions: We did not find a relationship between short perineal length and risk of severe perineal laceration with vaginal delivery, or a difference in mean perineal length by maternal race/ethnicity. However, we did find that women of different racial/ethnic groups have varying rates of severe perineal laceration, with Asian women comprising the highest proportion.

Preference toward future mode of delivery: how do antepartum preferences and prior delivery experience contribute?

Abstract Objective: Examine postpartum preferences toward future mode of delivery (MOD), considering recent MOD, antepartum preferences, and demographics. Study design: Prospective cohort study where a survey was distributed in outpatient obstetrics clinics to pregnant women over 18 years at 28 weeks gestation or later. Surveys gathered demographics, obstetric history, and preference toward vaginal delivery (VD) versus cesarean delivery (CD). Women were again surveyed at 6–8 weeks postpartum. Chi-square test compared proportions, and logistic regression controlled for potential confounders. Results: A total of 299 women returned postpartum surveys and expressed preferences. Comparing women who experienced VD versus CD, the majority who had a VD (92.1%) would choose this again, while only 1.9% preferred CD. Among the CD group, preferences were mixed: 29.4% desired repeat CD, 34.1% preferred VD, and 36.5% were undecided (p < 0.001). Adjusted odds were 34.4 (95% CI 9.4–126.1) for preferring VD over CD among women who experienced a recent VD, adjusting for parity, age, ethnicity, education, possible depression, and type of provider. Conclusions: The majority of women preferred VD postpartum. Of the minority who desired CD, antenatal preference for cesarean and prior experience with CD were important factors. This highlights the impact of individual desires and experience, and underscores importance of antenatal counseling.

How do maternal views of delivery outcomes vary by demographics and preferred mode of delivery

OBJECTIVE To investigate how maternal views of delivery outcomes vary by demographic characteristics and preference toward mode of delivery (MOD). STUDY DESIGN Survey of 719 pregnant women in outpatient clinics at an academic institution during their third trimester. Women ranked outcomes such as vaginal delivery (VD), cesarean delivery (CD), urinary incontinence, perineal lacerations, and induction of labor (IOL) on a visual analog scale (VAS) in order of worst imaginable (0) to best possible (100) outcomes. RESULTS Women of all ages ranked VD as more desirable than CD. However, women ≥ 35 years of age had greater valuations of both MOD compared with women <35 years, with mean VAS scores of 88.4 versus 86.4 for VD (p < 0.001) and 61.5 versus 51.9 for CD (p < 0.001). Women with a college education or higher also rated both MOD as more desirable than women with less than a college education. Additionally, women who preferred VD rather than CD had greater valuations of perineal laceration (43.3 vs. 31.5, p = 0.001) and urinary incontinence (40.7 vs. 30.1, p = 0.002). CONCLUSION Significant differences exist in womens views toward MOD and peripartum outcomes, by demographics and preferred MOD. Understanding delivery preferences better enables clinicians to counsel women about labor and management options.