Faculty Bibliography

BACKGROUND:It remains uncertain whether clinical factors known prior to delivery can predict which women are more likely to experience shoulder dystocia in the setting of operative vaginal delivery. OBJECTIVE:We sought to identify whether shoulder dystocia can be accurately predicted among women undergoing an operative vaginal delivery. STUDY DESIGN/METHODS:This was a case-control study of women undergoing a low or outlet operative vaginal delivery from 2005 through 2014 in a single tertiary care center. Cases were defined as women who experienced a shoulder dystocia at the time of operative vaginal delivery. Controls consisted of women without a shoulder dystocia at the time of operative vaginal delivery. Variables previously identified to be associated with shoulder dystocia that could be known prior to delivery were abstracted from the medical records. Bivariable analyses and multivariable logistic regression were used to identify factors independently associated with shoulder dystocia. A receiver operating characteristic curve was created to evaluate the predictive value of the model for shoulder dystocia. RESULTS:Of the 4080 women who met inclusion criteria, shoulder dystocia occurred in 162 (4.0%) women. In bivariable analysis, maternal age, parity, body mass index, diabetes, chorioamnionitis, arrest disorder as an indication for an operative vaginal delivery, vacuum use, and estimated fetal weight >4 kg were significantly associated with shoulder dystocia. In multivariable analysis, parity, diabetes, chorioamnionitis, arrest disorder as an indication for operative vaginal delivery, vacuum use, and estimated fetal weight >4 kg remained independently associated with shoulder dystocia. The area under the curve for the generated receiver operating characteristic curve was 0.73 (95% confidence interval, 0.69-0.77), demonstrating only a modest ability to predict shoulder dystocia before performing an operative vaginal delivery. CONCLUSION/CONCLUSIONS:While risk factors for shoulder dystocia at the time of operative vaginal delivery can be identified, reliable prediction of shoulder dystocia in this setting cannot be attained.

INTRODUCTION:The impact of obstetric perineal trauma on timing of return to intercourse is unclear, although sexual desire is clearly decreased in these women. In addition, studies examining timing of return to intercourse are cross-sectional and therefore cannot delineate potential reasons that patients might delay return to intercourse. AIM:To identify factors associated with delayed return to intercourse after obstetric anal sphincter injuries. METHODS:This was a planned secondary analysis of a prospective cohort study of women sustaining obstetric anal sphincter injuries during delivery of a full-term singleton infant. Patients completed the Fecal Incontinence Severity Index at every postpartum visit (1, 2, 6, and 12 weeks) and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 once resuming vaginal intercourse. Intercourse was considered "delayed" if patients did not resume intercourse by the 12-week visit. This cutoff was chosen because it was subsequent to the 6-week visit, when patients were instructed to return to normal pelvic activity. Continuous variables were compared using the Student t-test (parametric) or Mann-Whitney U-test (non-parametric). The χ(2) test was used for categorical variables. Statistical significance was assigned with a P value less than .05. MAIN OUTCOME MEASURES:Primary outcome measurements were differences in pelvic floor symptoms on validated surveys between the "delayed" and "not-delayed" groups at the first postpartum visit and at the time the subjects returned to intercourse. We used the Patient Health Questionnaire-9 for depression, the Urinary Distress Inventory-6 and Incontinence Impact Questionnaire-7 for urinary symptoms, the visual analog scale for pain, the Fecal Incontinence Severity Index for bowel symptoms, and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 at the return to intercourse visit only. RESULTS:One hundred ninety-nine women were included in this analysis. Most were Caucasian (77%) and primiparous (86%). One hundred nineteen women (60%) did not resume vaginal intercourse until after the 12-week visit and were deemed "delayed." Patients who delayed intercourse scored higher on the Fecal Incontinence Severity Index (more anal incontinence) than those who resumed intercourse before 12 weeks (15.4 ± 12.3 vs 12.0 ± 12.8, P = .02). The delayed group also had worse sexual function, shown as lower Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 scores (35.4 ± 5.9 vs 38.4 ± 4.1, P ≤ .001) and persistently higher Fecal Incontinence Severity Index scores (4.1 ± 7.3 vs 1.6 ± 4.4, P = .001), at the first visit after returning to intercourse. CONCLUSION:Patients with obstetric anal sphincter injuries who do not resume intercourse by 12 weeks postpartum report more severe anal incontinence symptoms and worse sexual function after return to coitus.

OBJECTIVE:To evaluate the association of a forceps simulation training curriculum for obstetrics residents on rates of severe perineal lacerations after forceps deliveries. METHODS:This was a retrospective cohort study. We created a novel simulation curriculum for forceps-assisted vaginal delivery based on the best practices of local experts, and trained all residents beginning in 2013. We then retrospectively reviewed all forceps deliveries performed in the 2.5 years after initiation of the training and the 7.5 years before the training program. We identified patients who experienced a severe perineal laceration (third- or fourth-degree) and examined the relationship of resident training status and perineal laceration. Known risk factors for lacerations were identified and a multilevel multivariable model was created including these factors as well as resident training. RESULTS:During the study period, we identified 6,058 forceps-assisted vaginal deliveries. We examined temporal trends in rates of forceps of severe perineal laceration. We identified a decrease in severe lacerations between 2005 and 2008, ending 5 years before the initiation of the training curriculum. These years were censored from the data, yielding a baseline observational period of 4,279 deliveries with no significant trend in laceration rate. Univariate analysis reveals a 22% reduction in severe perineal laceration (odds ratio [OR] 0.78; P=.005) among women delivered by residents who had completed forceps simulation training compared with women delivered by residents who had not. After adjusting for known maternal and delivery risk factors for perineal laceration, the magnitude of the reduction increased to 26% in the full data set model (OR 0.74; P=.002). CONCLUSION:A forceps simulation curriculum for obstetrics residents was associated with a significant reduction in severe perineal lacerations.

OBJECTIVE:To evaluate the effect of high-risk pregnancy status on antepartum contraceptive planning and postpartum use. METHODS:We performed a retrospective cohort study of women delivering at a university hospital during 2009-2010 who received prenatal care in the faculty or resident clinics. We defined high-risk status by Society for Maternal-Fetal Medicine guidelines. We abstracted contraceptive planning and postpartum administration from medical records and categorized these into World Health Organization tiers of contraceptive effectiveness. We identified subsequent pregnancies through March 2013. Chi-squared tests and binary logistic regression were used to assess correlations between risk status and contraceptive choice, actual postpartum use, and subsequent pregnancy. RESULTS:This study included 2048 low-risk and 1015 high-risk parturients. The index pregnancy was more likely to be unintended among low-risk than high-risk women (48.4% vs. 42.9%, p=.02). Low-risk and high-risk women showed interest in Tier 1 contraceptives while antepartum (54.4% low-risk vs. 58.0% high-risk, p=.2), with lower interest at discharge (42.3% vs. 50.7%, p<.001) and at the postpartum visit (33.8% vs. 40.1%, p=.002). Just 776 women (25.3%) actually received a Tier 1 method. 656 women (21.4%) had a subsequent pregnancy lasting more than 20weeks. Unintended pregnancy rates did not differ between low (36.6%) and high-risk (32.4%) women (p=.38). CONCLUSION:High-risk women had similar rates of planning for Tier 1 contraceptives but similar rates of subsequent unplanned pregnancy. Intention to use highly effective contraception did not translate into actual use. Further work is needed to identify barriers to uptake. IMPLICATIONS:Identification of barriers to uptake of highly effective contraceptive methods after high-risk pregnancy represents an important area for future research. Providers should continue to address postpartum contraception throughout pregnancy and be prepared to address barriers to such methods in the postpartum period.

PURPOSE/OBJECTIVE:To evaluate whether intra-abdominal hemorrhage is visible on a modified focused assessment with sonography for trauma (FAST) examination in stable obstetrics patients after a nonemergent cesarean delivery. METHODS:This was a prospective observational study of patients who underwent nonemergent cesarean delivery at a single institution. Patients provided written informed consent to participate in the study preoperatively and underwent a modified FAST examination in the recovery room within 2 hours of completion of surgery. A sonographic examination was considered positive for hemorrhage if an anechoic pocket consistent with free fluid was present. RESULTS:One hundred patients underwent suprapubic and bilateral upper-quadrant sonographic evaluations. The mean (±SD) time of the evaluation was 74.2 ± 36 minutes after the end of surgery. Among the 100 sonographic examinations of each upper quadrant, 194 (97.0%) were negative, 5 (2.5%) were indeterminate, and 1 (0.5%) was positive for fluid. All suprapubic sonographic examinations were considered inadequate. CONCLUSIONS:Sonographic evaluation immediately after cesarean delivery is feasible in most patients and was overwhelmingly negative for intra-abdominal hemorrhage in a group of patients who did not require reoperation or unexpected blood transfusion.

OBJECTIVE:To identify factors associated with failed operative vaginal delivery in contemporary parturients and evaluate whether these factors can be used to accurately predict failed operative vaginal delivery. METHODS:This was a case-control study of women undergoing a trial of operative vaginal delivery from a low or outlet station between 2005 and 2014. Women in the case group were defined as women who had an attempted operative vaginal delivery but ultimately required cesarean delivery. Women in the control group were defined as women who delivered vaginally. Bivariable and multivariable analyses were performed to determine factors that were independently associated with failed operative vaginal delivery. A receiver operating characteristic curve was created and area under the curve calculated to estimate the predictive capacity of these associations. RESULTS:Of 4,352 women who met inclusion criteria, 2,527 underwent an attempt at operative vaginal delivery using forceps and 1,825 using vacuum. Failure occurred in 272 (6.3%). In bivariable analysis, nulliparity, white race, induction of labor, chorioamnionitis, second stage 2 hours or greater, fetal occiput-posterior position, low station at application (compared with outlet), larger estimated fetal weight, and arrest or exhaustion as an indication for operative vaginal delivery (compared with a fetal indication) were significantly associated with a failed operative vaginal delivery. In multivariable analysis, factors that remained independently associated with operative vaginal delivery failure were race-ethnicity, arrest or exhaustion as an indication for operative vaginal delivery, occiput-posterior position, and a low pelvic application. The area under the curve for this regression was 0.74 (95% confidence interval 0.69-0.77) demonstrating less than optimal prediction of operative vaginal delivery failure. CONCLUSION/CONCLUSIONS:Risk factors identified before an operative vaginal delivery attempt cannot be used to accurately predict whether an operative vaginal delivery attempt will fail.

This study aims to estimate if diabetic women were more likely to experience postpartum depression symptoms than women without diabetes. This was a prospective cohort of women who received prenatal care at a hospital-affiliated prenatal clinic serving low-income women in Chicago, Illinois. For the primary analysis, women were divided by diabetes status (i.e., no diabetes or either gestational diabetes or pre-pregnancy diabetes). Postpartum depression was defined as a positive screen on the Patient Health Questionnaire-9. Rates of postpartum depression were compared, stratified by diabetic status. A multivariable logistic regression was performed to control for potential confounders. A planned secondary analysis compared women with pre-pregnancy diabetes to those without pre-pre-pregnancy diabetes. Three hundred and five women consented to participate of whom 100 (30.5 %) had gestational diabetes mellitus (GDM) and 33 (10.8 %) had pre-pregnancy diabetes. Compared to women without any diabetes, women with diabetes (either GDM or pre-pregnancy diabetes) had similar rates of antenatal [(OR) 0.69, 95 % CI) 0.44-1.08] and postpartum depression (OR 0.74, 95 % CI 0.33-1.66). However, postpartum depression was more common among women with pre-pregnancy diabetes (34.8 %) compared to non-diabetic women (16.7 %) (OR 2.67, 95 % CI 1.05-6.78). This association persisted even after adjusting for potential confounders (aOR 2.67, 95 % CI 1.05-9.79). Gestational diabetes was not associated with increased rates of depression. However, women with pre-pregnancy diabetes are more likely to experience postpartum depression compared to women without pre-pregnancy diabetes, even after adjusting for related comorbidities.

OBJECTIVE:To estimate the relationship between a passive second stage of labor and obstetric anal sphincter injuries (OASIS). METHODS:A retrospective, case-control study was undertaken of women who delivered at a tertiary-care center in Chicago, IL, USA, between November 2005 and December 2012. Cases had sustained OASIS and were matched on the basis of parity with controls who had no OASIS. Data were obtained from an electronic repository and chart review. Participants with a passive second stage of labor lasting 60 minutes or more were deemed to have "labored down." A logistic regression model to predict OASIS was created. RESULTS:Overall, 1629 cases were compared with 1312 controls. OASIS were recorded among 1452 (57.8%) of 2510 women who did not labor down compared with 169 (40.0%) of 423 women who labored down (P<0.001). However, in binary logistic regression, the addition of laboring down to the model only increased the predictive accuracy from 80.1% to 80.7%. CONCLUSION/CONCLUSIONS:When known risk factors for OASIS are accounted for, the effect of laboring down on perineal outcome is negligible.

BACKGROUND:To describe the prevalence of obsessions and compulsions and the specific symptoms present in postpartum women without obsessive compulsive disorder (OCD). METHODS:In this prospective cohort, women were screened with the Yale Brown Obsessive Compulsive Scale at 2 weeks postpartum. Demographics and comorbid psychiatric symptoms were compared between women with screen-positive OCD, screen-negative OCD but with some endorsed symptoms (subclinical OCD), and no OCD symptoms. The prevalence of each specific set of obsessive and compulsive symptoms and the rate of impairment from those symptoms were compared. RESULTS:Of the 461 women included, 52 (11.2%) screened positive for OCD, while 173 (37.5%) reported experiencing subclinical obsessions or compulsions. This subclinical OCD was associated with an increased rate of depression (24%) and state-trait anxiety (8%) compared with women who did not endorse experiencing any obsessions or compulsions. Aggressive, religious, and somatic obsessions as well as obsessions with symmetry, when present, were most likely to result in OCD screen positivity. CONCLUSIONS:Nearly half of all women who screen negative for OCD experienced obsessions or compulsions that did not result in OCD screen positivity. However, the presence of these subclinical obsessions and compulsions is associated with an increased rate of depression or anxiety.

We sought to examine the evolution of postpartum anxiety, obsessions and compulsions over time, and the influence of depression on their clinical course. This was a prospective cohort of obstetric patients enrolled at a tertiary care women's hospital. Women were recruited immediately postpartum and followed for 6 months. Women were screened for depression, state-trait anxiety, and obsessive-compulsive symptoms and dichotomized by the presence of depression. Four hundred sixty-one women agreed to participate in the study and completed the 2 weeks postpartum assessment; 331 (72 %) women completed the assessment at 6 months postpartum. At 2 weeks postpartum, 28 (19.9 %) women with depression had anxiety symptoms, compared to 4 (1.3 %) women who screened negative for depression (p < 0.001). Similarly, 36 (25.7 %) women with depression endorsed obsessions and compulsions compared to 19 (8.4 %) women without depression (p < 0.001). A significant interaction effect was present with anxiety over time such that by 6 months postpartum, there were no differences in symptoms in women with and without depression (p = 0.860). Conversely, the differences in obsessions and compulsions between depressed and non-depressed women persisted (p = 0.017). Women with postpartum depression are more likely to experience comorbid state-trait anxiety and obsessive-compulsive symptoms in the immediate postpartum period. While state-trait anxiety symptoms tend to resolve with time, obsessive-compulsive symptoms persist. Understanding these temporal trends is critical to tailor appropriate monitoring and treatment.