Faculty Bibliography

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.

OBJECTIVE:We sought to describe the incidence of venous thromboembolism (VTE) following hysterectomy for benign conditions and to estimate if VTE incidence differs for abdominal and minimally invasive hysterectomy. STUDY DESIGN/METHODS:Data for patients who underwent hysterectomy for benign conditions from 2010 through 2012 were abstracted from the American College of Surgeons National Surgical Quality Improvement Program database. Cases of VTE were compared to those without VTE. Minimally invasive hysterectomy was defined as both vaginal and laparoscopic hysterectomy. Pearson χ2 test, Student t test, and binary logistic regression were used for analysis. RESULTS:A total of 44,167 patients underwent hysterectomy; 12,733 (28.8%) underwent open hysterectomy, 22,559 (51.1%) underwent laparoscopic hysterectomy, and 8875 (20.1%) underwent vaginal hysterectomy. The incidence of VTE for open hysterectomy was higher (0.6%, 81/12,733) than minimally invasive hysterectomy (0.2% 73/31,434, P<.001). Open surgery (P<.001), body mass index (P=.006), race (P<.001), diabetes (P=.037), preoperative functional status (P<.001), American Society of Anesthesiologists class (P<.001), total operative time (P<.001), and time from surgery to discharge (P<.001) were each associated with VTE. Age, hypertension, current smoking, pack-year history, and year operation was performed were not associated with VTE. Using binary logistic regression, open surgery (P<.001), operative time (P<.001), and length of stay (P<.001) remained associated with VTE. The odds ratio for VTE after open hysterectomy compared with minimally invasive hysterectomy was 2.45 (95% confidence interval, 1.77-3.40). CONCLUSION/CONCLUSIONS:In this large quality database, a minimally invasive approach to hysterectomy was independently associated with a decreased incidence of VTE when compared with open hysterectomy.

OBJECTIVE:To estimate the incidence of and risk factors for wound complications in women who sustain obstetric anal sphincter injuries. METHODS:This was a prospective cohort study of women who sustained obstetric anal sphincter injuries during delivery of a full-term neonate between September 2011 and August 2013. Women were seen in the urogynecology clinic within 1 week of delivery and at 2, 6, and 12 weeks postpartum for perineal wound assessment. A visual analog scale for pain was administered at each visit. RESULTS:Five hundred two women met inclusion criteria for the study, and, ultimately, 268 women (54%) were enrolled. Eighty-seven percent of the cohort was nulliparous and 81% had a third-degree laceration. The majority (n=194) underwent an operative vaginal delivery (66.0% forceps and 6.0% vacuum). The overall risk was 19.8% (95% confidence interval [CI] 15.2-25.1%) for wound infection (n=53) and 24.6% (95% CI 19.6-30.2%) for wound breakdown (n=66). Operative vaginal delivery was associated with wound complications (infection, breakdown, or both) (adjusted odds ratio [OR] 2.54, 95% CI 1.32-4.87, P=.008). Intrapartum antibiotic therapy for obstetric indications was associated with a decreased risk of wound complications (adjusted OR 0.50, 95% CI 0.27-0.94, P=.03). Women with a wound complication reported significantly more pain within 1 week of delivery than women with a normally healing perineum (visual analog scale: 40.1±25.6 compared with 31.0±23, P=.002); this persisted at 12 weeks postpartum (6.6±7.5 compared with 3.4±7.1, P=.005). CONCLUSION/CONCLUSIONS:Women who sustain obstetric anal sphincter injuries are at high risk for the development of wound complications in the early postpartum period, warranting immediate and consistent follow-up. LEVEL OF EVIDENCE/METHODS:II.