Faculty Bibliography

BACKGROUND: The aim of this study was to identify factors associated with variability in Cesarean delivery (CD) rates amongst providers at a single institution. METHODS: A retrospective cohort analysis was carried out on all births at NYU Langone Medical Center from 2005-2013. Data was collected for subjects and linked to diagnosis codes for singleton and twin deliveries. Descriptive characteristics were generated for all deliveries, and inferential analysis was performed including multiple covariates for singleton deliveries in the 2010-2013 cohort, including both univariate and multivariate regression analyses to identify factors associated with higher CD rates. RESULTS: 37,692 deliveries were identified at our institution during the study period, performed by 88 unique providers. The mean CD rate was 29.6%, with a range for individual physicians from 9.9% to 75.6%. In multivariate regression analysis, CD rate was directly correlated with average patient age, physician male gender, proportion of high-risk deliveries, and Maternal-Fetal Medicine specialty, and it was inversely correlated with total number of deliveries by physician and forceps delivery rate. There was no significant difference in CD rates between group and solo practices. Within the same group practice, each member's CD rate was strongly correlated with the average CD rate of the group. CONCLUSION: Our study demonstrates the wide range of CD rates for providers practicing within the same institution and reiterates the association of CD rates with patient age, high-risk pregnancy, and provider volume. Among operative vaginal deliveries, forceps delivery rate was associated with lower CD rates whereas vacuum delivery rate was not. Despite these findings, practice patterns within individual practices appear to contribute significantly to the wide range of CD rates.

Objectives/UNASSIGNED:In 2014, the American College of Obstetrics and Gynecology published guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) to prevent cesarean delivery (CD). The objectives of this study were to determine the rate of adherence to these guidelines and to compare the association of guideline adherence with physician CD rates and obstetric/neonatal outcomes. Methods/UNASSIGNED:Retrospective cohort review of singleton primary cesarean deliveries for FIOL and AOD at a single academic institution from 2014 to 2016. Univariate and multivariate analyses were used to compare adherence to the guidelines with physician CD rates and obstetric/neonatal outcomes. Results/UNASSIGNED:Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003). Conclusions/UNASSIGNED:Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.

Objective: Randomized controlled trials (RCTs) are the gold standard in evaluating cause-effect relationships as they eliminate bias and minimize confounding factors. The generalizability of the findings in RCTs depends on the extent to which the study's population reflects the general population. The objective of this research was to examine a cohort of RCTs and determine the degree to which the distributions of ethnic populations are correctly represented.
Study Design: A retrospective review was conducted on all RCTs published in the Obstetrics and Gynecology Journal (The Green Journal) from 1990-2018 and the American Journal of Obstetrics & Gynecology(AJOG) from 1993-2018. For each journal, studies that met inclusion criteria (performed in the US and contained participant racial/ethnic information) were categorized as "obstetric" or "gynecologic" and were analyzed separately. Subjects of the included RCTs were separated into four ethnic groups (Non-Hispanic White, Non-Hispanic Black, Hispanic, and Other) and then compared to the general US population.
Result(s): 41% of papers were gynecologic and 59% were obstetric (n=140). The averages of each ethnic group for obstetrics and gynecology papers were calculated. c-square analysis depicted no difference between US demographic data and ethnic distribution for gynecologic papers (p=0.50) but demonstrated a significant deviation for obstetric papers (p< 0.001, Table 1). Furthermore, the obstetrics papers demonstrate an overrepresentation of the Non-Hispanic Black population and an under-representation of the Non-Hispanic White population.
Conclusion(s): When analyzing two of the leading journals in the field, we found that published gynecologic papers revealed a study population similar to that of the general US. However, interestingly, the distribution of subjects included in the obstetrics papers was shown to be less representative. While the reason for this deviation from general US demographics is unclear, based on these results, readers should be cautious of their interpretation of these RCTs and their generalizability. [Formula presented]
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OBJECTIVES: To assess whether cesarean delivery changes the natural position of the uterus. METHODS: In this retrospective Institutional Review Board-approved cohort study, we conducted a search of our university gynecologic ultrasonography (US) database. Patients with transvaginal US images before and after either vaginal or cesarean delivery between 2012 and 2015 were included. Women with prior cesarean delivery were excluded. Two readers independently measured antepartum and postpartum flexion angles between the longitudinal axis of the uterine body and the cervix. We calculated intraclass correlation coefficients to measure inter-reader agreement. Antepartum and postpartum uterine flexion angles were compared between patients with vaginal and cesarean delivery. RESULTS: We included 173 patients (107 vaginal and 66 cesarean delivery). The mean interval between scans +/- SD was 18 +/- 10 months. Inter-reader agreement for flexion angles was almost perfect (intraclass correlation coefficients: antepartum, 0.939; postpartum, 0.969; both P < .001). There was no difference in mean antepartum flexion angles for cesarean delivery (154.8 degrees +/- 45.7 degrees ) versus vaginal delivery (145.8 degrees +/- 43.7 degrees ; P = .216). Mean postpartum flexion angles were higher after cesarean delivery (180.4 degrees +/- 51.2 degrees ) versus vaginal delivery (152.8 degrees +/- 47.7 degrees ; P = .001. Differences in antepartum and postpartum flexion angles between cesarean and vaginal delivery were statistically significant (25.6 degrees versus 7.0 degrees ; P = .027). CONCLUSIONS: Cesarean delivery can change the uterine flexion angle to a more retroflexed position. Therefore, all women with a history of cesarean delivery should undergo a transvaginal US examination before any gynecologic surgery or intrauterine device placement to reduce the possibility of surgical complications.