Publications by authors named "Rebecca F Hamm"

15 Publications

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Identifying the effective components of a standardized labor induction protocol: secondary analysis of a randomized, controlled trial.

J Matern Fetal Neonatal Med 2021 Apr 13:1-7. Epub 2021 Apr 13.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Objective: Standardized labor induction protocols utilizing evidence-based active management practices are associated with improved obstetric outcomes. However, these protocols are complex and include multiple components. We aimed to identify which of the individual components of an evidence-based labor induction protocol are most associated with reduced rates of cesarean delivery, maternal morbidity, and neonatal morbidity.

Study Design: This is a secondary analysis of a randomized trial comparing time to delivery among four labor induction methods. All patients enrolled in the trial had their labor managed with a multidisciplinary-developed, evidence-based standardized labor induction protocol. For each patient's induction, we assessed adherence to seven components of the protocol. Primary outcomes included cesarean delivery, maternal morbidity, and neonatal morbidity. Bivariate analyses assessed the association of each protocol component with each outcome. Multivariable logistic regression determined independent predictors of each outcome.

Results: The 491 patients enrolled in the randomized trial were included in this analysis. For cesarean delivery, while adherence to four of the seven protocol components was associated with the outcome in bivariate analyses, only adherence to "cervical exams should be performed every 1-2 h in active labor" was associated with reduced cesarean rates when controlling for age, body mass index, and parity. For maternal morbidity, while adherence to "if misoprostol is utilized, it should not be continued beyond 6 doses or 24 h of use" was associated in bivariate analysis, it was no longer associated with the outcome in multivariable analysis. Finally, "cervical exams should be performed every 1-2 h in active labor" and "cervical exams should be performed every 2-4 h in latent labor" were associated with reduced neonatal morbidity both in bivariate analyses as well as when controlling for age, body mass index, and parity.

Conclusions: Within a standardized labor induction protocol, adherence to cervical exams every 1-2 h in active labor was associated with reduced cesarean rate, and adherence to cervical exams every 2-4 h in latent labor, as well as every 1-2 h in active labor is associated with reduced neonatal morbidity. Regular cervical examination during labor induction likely allows for intervention when cervical change is not made. This data warrants further investigation into the optimal frequency of cervical exams during labor induction. Furthermore, an understanding of which components of a complex, evidence-based labor induction protocol are most effective may be helpful for streamlining and education around this protocol as implementation occurs across diverse sites.
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http://dx.doi.org/10.1080/14767058.2021.1909561DOI Listing
April 2021

Prioritize implementation research to effectively address the maternal health crisis.

Am J Obstet Gynecol 2021 Feb 7. Epub 2021 Feb 7.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.ajog.2021.02.005DOI Listing
February 2021

Implementation of a calculator to predict cesarean delivery during labor induction: a qualitative evaluation of the clinician perspective.

Am J Obstet Gynecol MFM 2021 Jan 22;3(3):100321. Epub 2021 Jan 22.

Departments of Psychiatry, Medical Ethics and Health Policy, and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Dr Beidas); Penn Implementation Science Center (PISCE@LDI), Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Dr Beidas).

Background: We previously conducted a prospective cohort study (n=1610) demonstrating that the implementation of a validated calculator to predict likelihood of cesarean delivery during labor induction was associated with reduced maternal morbidity, reduced cesarean delivery rate, and improved birth satisfaction.

Objective: To optimize future implementation, we used qualitative interviews to understand the clinician perspective on: (1) the cesarean delivery risk calculator implementation and (2) the mechanisms by which the use of the calculator resulted in the observed improved outcomes.

Study Design: After completion of the prospective study (June 30, 2019), 20 trainees and attending clinicians (including nurse-midwives, obstetrical physicians, and family medicine physicians) at the study site participated in a single, brief semistructured interview from March 1, 2020, to June 30, 2020. Transcriptions were coded using a systematic approach.

Results: Overall, clinicians had favorable perspectives regarding the cesarean delivery risk calculator. Clinicians described the calculator as offering "objective data" and a "standardized snapshot of the labor trajectory." Concerns were raised regarding "overreliance" on calculator output. Barriers to use included time for patient counseling and "awkwardness" around the interactions and perceived patient misunderstanding of the calculator result. Although most senior clinicians (n=8) reported that the calculator did not impact patient management, trainee clinicians (n=12) more often felt that the calculator influenced care at the extremes of cesarean delivery risk. Furthermore, more senior clinicians felt "neutral" regarding any impact of counseling patients on cesarean delivery risk compared with trainee clinicians, who felt that the counseling "built [patient-clinician] trust."

Conclusion: This qualitative evaluation characterized the generally positive clinician perspective around the cesarean delivery risk calculator, while identifying specific facilitators and barriers to implementation. In addition, we elucidated potential mechanisms by which the calculator may have been related to clinician decision making and patient-clinician interactions, leading to reduced maternal morbidity and improved patient birth satisfaction. This information is important as widespread implementation of the cesarean delivery risk calculator begins.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100321DOI Listing
January 2021

A multidisciplinary approach to improving process and outcomes in unscheduled cesarean deliveries.

Am J Obstet Gynecol MFM 2020 02 16;2(1):100070. Epub 2019 Nov 16.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Program Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Background: Effective communication between providers of various disciplines is crucial to the quality of care provided on labor and delivery. The lack of standardized language for communicating the clinical urgency of cesarean delivery and the lack of standardized processes for responding were identified as targets for improvement by the Obstetric Patient Safety Committee at the Hospital of the University of Pennsylvania. The committee developed and implemented a protocol aimed at improving the performance of our multidisciplinary team and patient outcomes.

Objective: To evaluate whether implementation of a multidisciplinary protocol that standardizes the language and process for performing unscheduled cesarean deliveries had reduced the decision to incision interval and improved maternal and neonatal outcomes.

Materials And Methods: This was a retrospective cohort study of patients who underwent unscheduled cesarean delivery pre- and postimplementation of a protocol standardizing language, communication, provider roles, and processes. The primary outcome was cesarean decision to incision interval overall and stratified by fetal and nonfetal indications for delivery. Secondary outcomes included decision to operating room and operating room to incision intervals, operative complications, use of general anesthesia, maternal transfusion, 5-minute Apgar score <6, and umbilical cord arterial pH <7.2. Descriptive statistics were calculated. Continuous variables were tested for normality and compared using the Student t test or Mann-Whitney U test as appropriate. Categorical variables were characterized by proportions and compared by the χ or Fisher exact test as appropriate.

Results: There were 121 and 119 subjects in the pre-and postimplementation groups respectively, collected from corresponding 3-month periods. There were no significant differences in demographics, comorbidities, or indications for cesarean delivery between groups. Overall median decision to incision interval did not differ between the pre- and postimplementation groups. There was a significant decrease in median decision to incision interval (63 versus 50 minutes, P = .02) in cesarean deliveries performed for nonfetal indications. This was driven by a shorter median decision to operating room interval (32.5 versus 23 minutes, P = .01). The incidences of operative complications (35% [19/55] versus 11% [6/53], P < .01) and cord pH <7.2 (36% [20/55] versus 17% [9/53], P = .02) were also decreased in cesarean deliveries performed for nonfetal indications. The incidences of general anesthesia, maternal transfusion, and 5-minute Apgar score <6 did not differ. Outcomes did not differ between the pre- and postimplementation groups in cesarean deliveries performed for fetal indications.

Conclusion: Implementation of a multidisciplinary process improvement protocol that standardizes language, roles, and processes for unscheduled cesarean deliveries was associated with a reduced decision to incision interval and improved maternal and neonatal outcomes in cesarean deliveries performed for nonfetal indications. Standardized process implementation on labor and delivery has the potential to improve patient outcomes.
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http://dx.doi.org/10.1016/j.ajogmf.2019.100070DOI Listing
February 2020

A standardized labor induction protocol: impact on racial disparities in obstetrical outcomes.

Am J Obstet Gynecol MFM 2020 08 5;2(3):100148. Epub 2020 Jun 5.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Background: There are marked disparities between black and nonblack women in the United States in birth outcomes. Yet, there are little data on methods to reduce these disparities. Although the cause of racial disparities in health is multifactorial, implicit bias is thought to play a contributing role. To target differential management, studies in nonobstetrical populations have demonstrated disparity reduction through care standardization. With wide variation by site and provider, labor management practices are the ideal target for standardization.

Objective: In this study, we aimed to evaluate the effect of a standardized induction of labor protocol on racial disparities in cesarean delivery rate and maternal and neonatal morbidity.

Study Design: We performed a prospective cohort study of women undergoing an induction from 2013 to 2015. Full-term (≥37 weeks' gestation) women carrying a singleton pregnancy with intact membranes and an unfavorable cervix (dilation ≤2 cm, Bishop score of ≤6) were included. We compared the cesarean delivery rate and maternal and neonatal morbidity between 2 groups stratified by race (black vs nonblack) as follows: (1) women induced in a randomized trial (n=491) that utilized an induction protocol with standardized recommendations for interventions such as oxytocin and amniotomy at particular time points and (2) women in an observational arm (n=364) enrolled at the same time whose induction and labor management occurred at provider discretion. Regression modeling was used to test an interaction between the induction protocol and race.

Results: A significant reduction in cesarean delivery rate in black women managed with the induction protocol was noted when compared with those in the observational group (25.7% vs 34.2%; P=.02), whereas there was no difference in cesarean delivery rate in nonblack women (34.6% vs 29.9%; P=.41). The induction protocol reduced the racial disparity in cesarean delivery rate (interaction term, P=.04), even when controlling for parity, body mass index, indication for labor induction, and Bishop score at induction start. In addition, a significant reduction in neonatal morbidity was found in black women managed with the induction protocol (2.9% vs 8.9%; P=.001), with no difference in nonblack women (3.6% vs 5.5%; P=.55). The induction protocol did not significantly affect maternal morbidity for either race.

Conclusion: A standardized induction protocol is associated with reduced cesarean delivery rate and neonatal morbidity in black women undergoing induction. Further studies should determine whether implementation of induction protocols in diverse settings could reduce national racial disparities in obstetrical outcomes.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100148DOI Listing
August 2020

Implementation Science is Imperative to the Optimization of Obstetric Care.

Am J Perinatol 2020 Dec 15. Epub 2020 Dec 15.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

In an effort aimed at improving outcomes, obstetric teams have enacted comprehensive care bundles and other clinical tools. Yet, these practices have had limited degrees of success on a national scale. Implementation science aims to bridge the divide between the development of evidence-based interventions and their real-world utilization. This emerging field takes into account key stakeholders at the clinician, institution, and health policy levels. Implementation science evaluates how well an intervention is or can be delivered, to whom, in which context, and how it may be up-scaled and sustained. Other medical disciplines have embraced these concepts with success. The frameworks and theories of implementation science can and should be incorporated into both obstetric research and practice. By doing so, we can increase widespread and timely adoption of evidence and further our common goal of decreasing maternal morbidity and mortality. KEY POINTS: · Evidence-based practices have been implemented in obstetrics with variable success.. · Implementation science aims to bridge the divide between the development of evidence-based interventions and their real-world utilization.. · The methodologies of implementation science may be helpful to obstetric research and practice..
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http://dx.doi.org/10.1055/s-0040-1721728DOI Listing
December 2020

Maternal Morbidity and Birth Satisfaction After Implementation of a Validated Calculator to Predict Cesarean Delivery During Labor Induction.

JAMA Netw Open 2020 11 2;3(11):e2025582. Epub 2020 Nov 2.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia.

Importance: A previously created and validated calculator provides an individualized cesarean delivery risk score for women undergoing labor induction. A higher predicted risk of cesarean delivery on the calculator has been associated with increased maternal and neonatal morbidity regardless of ultimate delivery mode. The effect of this calculator when implemented in clinical care has yet to be evaluated.

Objective: To determine whether implementation of a validated calculator that predicts the likelihood of cesarean delivery at the time of labor induction is associated with maternal morbidity and birth satisfaction.

Design, Setting, And Participants: This prospective cohort study used medical record review to compare the 1 year before calculator implementation (July 1, 2017, to June 30, 2018) with the 1 year after implementation (July 1, 2018, to June 30, 2019) at a US urban, university labor unit. Women admitted for labor induction with singleton gestation in cephalic presentation, intact membranes, and an unfavorable cervix were included. Data were analyzed from August 1, 2019, to September 13, 2020.

Exposures: Patient and clinician knowledge of the calculated cesarean delivery risk score based on the validated calculator.

Main Outcomes And Measures: The primary outcomes were (1) composite maternal morbidity defined by at least 1 of the following within 30 days of delivery: endometritis, postpartum hemorrhage (estimated or quantitative blood loss >1000 mL), blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and readmission and (2) patient satisfaction assessed via Birth Satisfaction Scale-Revised (BSS-R) scores. Secondary outcomes included rate of cesarean delivery and neonatal morbidity.

Results: A total of 1610 women were included in the analysis (788 in the preimplementation and 822 in the postimplementation periods) with a median age of 29 (interquartile range [IQR], 24-34) years. There were no significant baseline differences between groups except fewer inductions at a gestational age of 40 weeks or later in the postimplementation period (256 [31.1%] vs 298 [37.8%]). Calculator implementation was associated with decreased maternal morbidity overall, even when adjusting for confounders (141 [17.9%] vs 95 [11.6%]; adjusted absolute risk difference [aARD], -6.3%; 95% CI, -9.7% to -2.8%). Although there was no difference in birth satisfaction overall, calculator implementation was associated with improvements on items pertaining to quality of care provision (median BSS-R score, 19 [IQR, 16-20] vs 19 [IQR, 17-20]; P = .006). Calculator implementation was also associated with a decrease in cesarean delivery rate (228 [28.9%] vs 167 [20.3%]; aARD, -8.5% [95% CI, -12.6% to -4.5%]). There were no significant differences in neonatal morbidity.

Conclusions And Relevance: These findings suggest that implementation of a validated calculator to predict risk of cesarean delivery in clinical care is associated with reduced maternal morbidity. Implementation should occur broadly to determine whether calculator use improves national maternal outcomes.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.25582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666421PMC
November 2020

Single-unit vs multiple-unit transfusion in hemodynamically stable postpartum anemia: a pragmatic randomized controlled trial.

Am J Obstet Gynecol 2021 01 9;224(1):84.e1-84.e7. Epub 2020 Jul 9.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Background: The American Academy of Blood Banks recommends single-unit red cell transfusion protocols across medicine to reduce transfusion complications and the use of a scarce resource. There are minimal data regarding single-unit protocols in obstetrics.

Objective: We aimed to compare single-unit vs multiple-unit transfusion protocols for treatment of hemodynamically stable postpartum anemia.

Study Design: We performed a randomized trial comparing initial transfusion with 1 unit of packed red blood cells (single-unit protocol) to 2 units of packed red blood cells (multiple-unit protocol) from March 2018 to July 2019. Women who required transfusion >6 hours postpartum were approached for consent. Unstable vital signs, hemoglobin level <5 g/dL, hemoglobinopathy, and cardiomyopathy were exclusion criteria for enrollment. Hemoglobin assessment and standardized clinical evaluation were performed 4 to 6 hours posttransfusion; additional packed red blood cells were given if indicated. The primary outcome was total units transfused. Secondary outcomes included length of stay, endometritis, wound separation or infection, venous thromboembolism, and intensive care unit admission within 30 days postpartum. Breastfeeding, depression, maternal attachment, and fatigue scores were assessed at 4 to 9 weeks postpartum. A total of 66 women were required to detect a 20% reduction in units transfused with a single-unit protocol (power=80%; α=0.05).

Results: A total of 66 women were randomized (33 per arm). There were no differences between groups in demographic or clinical characteristics, including delivery mode, blood loss, and randomization hemoglobin levels. The mean number of units transfused was lower in the single-unit protocol than in the multiple-unit protocol (1.2 U vs 2.1 U; P<.001). Only 18.2% of women in the single-unit arm required additional packed red blood cells. At posttransfusion assessment, women in the single-unit arm had lower hemoglobin levels (7.8 g/dL vs 8.7 g/dL; P<.001), but there were no differences in vital signs or symptoms between groups. There were also no differences in length of stay, 30-day complications, or 4 to 9 week postpartum outcomes.

Conclusion: In women with hemodynamically stable postpartum anemia, a single-unit protocol avoided a second unit of packed red blood cells in >80% of women without significant impact on morbidity. Our work supports the use of single-unit initial transfusion in this population.
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http://dx.doi.org/10.1016/j.ajog.2020.07.007DOI Listing
January 2021

Labor and Delivery Outcomes with the Sequential Use of Misoprostol Followed by Cervical Foley Catheter.

Am J Perinatol 2020 Jun 28. Epub 2020 Jun 28.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Objective:  Studies demonstrate shorter time to delivery with concurrent use of misoprostol and cervical Foley catheter. However, concurrent placement may not be feasible. If misoprostol is used to start an induction, little is known regarding the benefit of sequentially using Foley catheter. We examine obstetrical outcomes in women with Foley catheter placed after misoprostol compared with those only requiring misoprostol.

Study Design:  Retrospective cohort study of singleton pregnancies, intact membranes, and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) undergoing term induction May 2013 to June 2015. We compared obstetrical outcomes between women receiving misoprostol alone versus those that had a Foley catheter placed after misoprostol. Outcomes are mode of delivery, time to delivery, chorioamnionitis, admission to neonatal intensive care unit, and maternal morbidity. Chi-square and Fisher's exact tests were used for categorical variables, Mann-Whitney -tests compared continuous variables.

Results:  Among 364 women, 281 began induction with misoprostol alone. A total of 135 (48%) subsequently had a Foley catheter placed. Characteristics were similar between the groups, although nulliparity and cervical dilation <1 cm at start of induction were more likely to have subsequent Foley catheter. Women with Foley catheter placement after misoprostol had a longer median time to delivery (15 vs. 11 hours,  < 0.001), twofold higher rate of cesarean (42 vs. 26%, odds ratio: 2.1, 95% confidence interval: 1.26-3.44,  = 0.004), and increased risk of neonatal intensive care unit (NICU) admission (21 vs. 11%,  = 0.024). There was a nonsignificant increased risk of chorioamnionitis (12 vs. 7%,  = 0.1) and maternal morbidity (15 vs. 8%,  = 0.08) in the misoprostol followed by Foley catheter group.

Conclusion:  In women receiving misoprostol for induction, nulliparas and those with dilation <1 cm are more likely to have subsequent Foley catheter placement. Sequential use of cervical Foley catheter after misoprostol is associated with longer labor, higher cesarean rate, and increased NICU admission. Requirement of Foley catheter after misoprostol confers higher risk and may guide counseling.

Key Points: · Little is known regarding efficacy of misoprostol followed by cervical Foley catheter.. · Nulliparas and dilation <1 cm increases need for Foley after misoprostol.. · Complications were more common in women requiring Foley after misoprostol..
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http://dx.doi.org/10.1055/s-0040-1713818DOI Listing
June 2020

Society for Maternal-Fetal Medicine Special Statement: Reducing the risk of transmitting infection by transvaginal ultrasound examination.

Am J Obstet Gynecol 2020 09 26;223(3):B2-B6. Epub 2020 May 26.

Patient Safety and Quality Improvement Committee, Society for Maternal-Fetal Medicine, Washington, DC.

Recent surveys have shown widespread lapses in the procedures used to reduce the risk of transmitting infection via medical devices. Transvaginal ultrasound examination has the potential to transmit vaginal infections, including human papillomavirus. Areas of particular concern are the use of probe covers with high rates of leakage, disinfectants that are not effective against human papillomavirus, and coupling gel from multiple-use containers. We reviewed these issues, and we recommend 4 steps to reduce the risk of transmitting infection. First, during every transvaginal ultrasound exam, the probe should be covered with a sterile, single-use "viral barrier" cover or a condom. Second, sterile, single-use ultrasound gel packets should be used. Third, after every examination, the probe should be cleaned to remove any visible gel or debris. Finally, after cleaning, the probe should undergo high-level disinfection using an agent with proven efficacy against the human papillomavirus, including hydrogen peroxide, hypochlorite, or peracetic acid. Glutaraldehyde, orthophthalaldehyde, phenols, and isopropyl alcohol have virtually no efficacy against the human papillomavirus.
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http://dx.doi.org/10.1016/j.ajog.2020.05.043DOI Listing
September 2020

Risk factors and racial disparities related to low maternal birth satisfaction with labor induction: a prospective, cohort study.

BMC Pregnancy Childbirth 2019 Dec 30;19(1):530. Epub 2019 Dec 30.

Department of Obstetrics & Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA, 19104, USA.

Background: Decreased birth satisfaction has been associated with labor induction. Yet, there is a paucity of data evaluating risk factors for decreased satisfaction associated with labor induction. We aimed to determine what factors impact low birth satisfaction in labor induction and evaluate racial disparities in birth satisfaction.

Methods: We performed a prospective cohort study of women with term, singleton gestations undergoing labor induction at our institution from Jan 2018 to Jun 2018. Women completed the validated Birth Satisfaction Scale-Revised postpartum, which is subdivided into 3 domains: (1) quality of care provision, (2) women's personal attributes, and (3) stress experienced during labor. A total satisfaction score above the mean was classified as "satisfied", and below as "unsatisfied." Domain and item scores were compared by race.

Results: Three hundred thirty of 414 (79.7%) eligible women were included. There was no significant difference in birth satisfaction by age, body mass index, Bishop score, or labor induction agent. Black women were 75% more likely to be unsatisfied than non-Black women (54.0% vs. 37.2%, OR 1.75 [95% CI 1.11-2.76], p = 0.037), nulliparas were 71% more  likely to be unsatisfied than multiparas (54.2% vs. 40.9%, OR 1.71 [95% CI 1.09-2.67], p = 0.019), and women whose labor resulted in cesarean birth were almost 3 times more likely to be unsatisfied than women with a vaginal birth (67.4% vs. 42.3%, OR 2.82 [95% CI 1.69-4.70], p < 0.001). Additionally, increased labor length quartile was associated with decreased satisfaction >(p = 0.003). By race, domain 3 scores, which reflect preparedness for labor, were lower for Black women. No differences were seen for domain 1 or 2.

Conclusions: Black race, cesarean birth, and increasing labor length were identified as risk factors for low birth satisfaction among women who underwent labor induction. Further studies should explore interventions to target women at risk for low birth satisfaction.
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http://dx.doi.org/10.1186/s12884-019-2658-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6937753PMC
December 2019

Evaluating the impact of a standardized induction protocol to reduce adverse perinatal outcomes: a prospective cohort study.

J Matern Fetal Neonatal Med 2019 Oct 24:1-8. Epub 2019 Oct 24.

Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA.

Our objective was to evaluate the impact of a standardized induction protocol on reducing maternal and neonatal morbidity in women undergoing an induction with an unfavorable cervix. We performed a prospective cohort study of women undergoing an induction from May 2013 to June 2015. Women who were ≥18 years, ≥37 weeks with intact membranes and an unfavorable cervix (Bishop score of ≤6 and cervical dilation ≤2 cm) with no prior cesarean were included. We compared the following outcomes between women managed with the labor protocol versus women in an observation group, managed at the discretion of the provider: Labor length, cesarean delivery, maternal and neonatal morbidity, and neonatal intensive care unit admission for >48 hours. Multivariable models incorporated confounders specific to each outcome. 855 women were included (491: labor protocol group; 364: observational group). Women in the labor protocol group had a shorter time to delivery (15.7 hours vs. 18.0 hours, < .001), a decrease in maternal morbidity (7.3% vs. 11.5%, = .04), lower rates of NICU admission >48 hours (3.5% vs 8%, = .005), and a lower neonatal morbidity (3.0% vs. 7.7%, = .003) compared to women in the observational group. There was no difference in rate of cesarean between the labor protocol and observational groups (27.7% vs. 32.7%, = .13). When adjusting for confounders, women in the labor protocol group had a 60% reduction in NICU admission >48 hours (RR: 0.41, 95% CI: 0.22-0.76) and a 70% reduction in neonatal morbidity (RR: 0.31, 95% CI: 0.13-0.70). Time to delivery and maternal morbidity were not significantly different in adjusted models. Utilization of a standardized induction protocol was associated with a significant reduction in neonatal morbidity without increasing the risk of cesarean or maternal morbidity.
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http://dx.doi.org/10.1080/14767058.2019.1680629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180115PMC
October 2019

Effectiveness of antepartum intravenous iron sucrose: dose timing and impact on outcomes.

J Matern Fetal Neonatal Med 2021 Jun 25;34(12):1983-1990. Epub 2019 Aug 25.

Department of Obstetrics & Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Objective: Studies have demonstrated that antepartum intravenous iron sucrose infusion (IVFe) is safe and improves predelivery hemoglobin (Hb). Yet, there is little data guiding timing of administration or number of doses required to be impactful. We sought to determine if timing of antepartum IVFe and number of doses provided impacts efficacy.

Methods: We performed a retrospective cohort study of women who obtained prenatal care and delivered at our institution 10/1/2015-10/30/2017. Women with a third-trimester hemoglobin (Hb) < 9.5 g/dL were included. Women with hemoglobinopathies and those who received an antepartum blood transfusion were excluded. Women receiving ≥1 antepartum 300 mg IVFe dose were considered in the IVFe group.

Results: Five-hundred-twenty-three (6.1%) of 8563 delivering women were included. Sixty-five (12.4%) of included women received IVFe. By timing of IVFe, the earlier IVFe was received before delivery, the greater the median Hb increase (No IVFe: Δ0.8g/dL, IVFe 0-1 weeks predelivery: Δ0.05 g/dL, 1-2 weeks: Δ0.9 g/dL, 2-4 weeks: Δ1.5 g/dL, 4-6 weeks: Δ1.8 g/dL, 6-8 weeks: Δ1.8 g/dL, 8-12 weeks: Δ2.75 g/dL,  = .0001). When comparing each stratum to the No IVFe group, only those receiving IVFe >2 weeks before delivery had a significant increase in Hb level from third trimester to delivery. By the number of IVFe doses, increasing administrations incrementally impacted Hb difference from third trimester to delivery, with only those receiving at least 3 doses demonstrating statistically significant Hb change compared to the No IVFe group.

Conclusion: Antepartum IVFe effectively increases Hb from the third trimester to delivery admission when administered 2-12 weeks predelivery. There is increasing benefit the further out the IVFe is administered and with an increasing number of doses. Initiatives to combat antepartum anemia should focus on early detection and treatment to best optimize outcomes.
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http://dx.doi.org/10.1080/14767058.2019.1656189DOI Listing
June 2021

Using the Probability of Cesarean from a Validated Cesarean Prediction Calculator to Predict Labor Length and Morbidity.

Am J Perinatol 2019 05 3;36(6):561-566. Epub 2018 Dec 3.

Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Objective: To determine if increasing predicted risk of cesarean was associated with longer labor length and increased morbidity among women undergoing induction with an unfavorable cervix.

Study Design: Using a publically available database, we evaluated whether a previously validated prediction model for cesarean delivery after induction was associated with labor length, maternal morbidity (third-/fourth-degree lacerations, endometritis, blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and death), and neonatal morbidity (blood transfusion, encephalopathy, intraventricular hemorrhage, severe respiratory distress syndrome, necrotizing enterocolitis, and sepsis). Full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix (Bishop score ≤6 and dilation ≤2 cm) undergoing induction of labor were included.

Results: A total of 8,466 women met the inclusion criteria. Each category increase in cesarean probability (<20, 20-39.9, 40-59.9, ≥60%) was associated with an increase in labor length (9.6, 10.8, 11.7, and 11.9 hours, respectively;  < 0.001). With increasing predicted probability of cesarean there, was also a significant increase in maternal morbidity with each category (2.6, 4.7, 5.1, 6.1%;  = 0.001) and increase in neonatal morbidity (0.9, 1.5, 2, 2.2%;  = 0.002).

Conclusion: Using a validated prediction model for cesarean delivery among women induced with an unfavorable cervix, increasing predicted probability of cesarean is associated with longer labor length and increased maternal and neonatal morbidity.
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http://dx.doi.org/10.1055/s-0038-1675625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6491246PMC
May 2019

Implementation of Quantification of Blood Loss Does Not Improve Prediction of Hemoglobin Drop in Deliveries with Average Blood Loss.

Am J Perinatol 2018 Jan 24;35(2):134-139. Epub 2017 Aug 24.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Program, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania.

Objective:  The National Partnership for Maternal Safety released a postpartum hemorrhage bundle in 2015 recommending quantification of blood loss (QBL) for all deliveries. We sought to determine whether QBL more accurately predicts hemoglobin (Hb) drop than visually estimated blood loss (EBL).

Study Design:  This is a prospective observational study. Preintervention data (PRE) were collected on all deliveries between October 15, 2013 and December 15, 2013. Deliveries were included if EBL, admission Hb, and 12-hour postpartum Hb (12hrCBC) were available. QBL was implemented in July 2015. Postintervention data (POST) were collected between October 20, 2015 and December 20, 2015. A total of 500 mL EBL was predicted to result in 1 g/dL Hb drop at 12hrCBC. Student's -test was used to compare the means.

Results:  A total of 592 of 626 (95%) PRE and 583 of 613 (95%) POST deliveries were included. Overall, 278 (48%) POST deliveries had QBL recorded. In both PRE and POST, actual Hb drop differed from predicted by 0.6 g/dL in both groups of deliveries. When evaluating deliveries with EBL > 1,000 mL, QBL in POST was slightly better at predicting Hb drop versus EBL in PRE, although not statistically significant (0.2 vs. 0.5 g/dL,  = 0.17).

Conclusion:  In all deliveries, QBL does not predict Hb drop more accurately than EBL. The decision to perform QBL needs to balance accuracy with a resource intense measurement process.
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http://dx.doi.org/10.1055/s-0037-1606275DOI Listing
January 2018