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A survey of liability claims against obstetric providers highlights major areas of contention
An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common patient allegations:
- a delay in treatment of fetal distress (22%). The term fetal distress remains a common allegation in malpractice claims. Cases in this category most often reflected a delay or failure to act in the face of Category II or III fetal heart-rate tracings.
- improper performance of vaginal delivery (20%). Almost half of the cases in this category involved brachial plexus injuries linked to shoulder dystocia. Patients alleged that improper maneuvers were used to resolve the dystocia. The remainder of cases in this category involved forceps and vacuum extraction deliveries.
- improper management of pregnancy (17%). Among the allegations were a failure to test for fetal abnormalities, failure to recognize complications of pregnancy, and failure to address abnormal findings.
Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.1
The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.1 Susan Mann, MD, a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco. (Listen to this accompanying audiocast featuring her comments.) Dr. Mann practices obstetrics and gynecology in Brookline, Massachusetts, and at Beth Israel Deaconess Medical Center in Boston. She is president of the QualBridge Institute, a consulting firm focused on issues of quality and safety.
Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims:
1. Selection and management of therapy (34%). Among the issues here were decisions involving augmentation of labor, route of delivery, and the timing of interventions. This factor also related to medications—for example, a failure to order antibiotics for Group A and Group B strep, a failure to order Rho(D) immune globulin for Rh-negative mothers, and a failure to provide magnesium sulfate for women with eclampsia.
2. Patient-assessment issues (32%). The Doctors Company reviewers found that physicians frequently failed to consider information that was available, or overlooked abnormal findings.
3. Technical performance (18%). This factor involved problems associated with known risks of various procedures, such as postpartum hemorrhage and brachial plexus injuries. It also included poor technique.
4. Communication among providers (17%)
5. Patient factors (16%). These factors included a failure to comply with therapy or to show up for appointments.
6. Insufficient or lack of documentation (14%)
7. Communication between patient/family and provider (14%).
“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”
“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.
Tips for reducing malpractice claims in obstetrics
The Obstetrics Closed Claim Study identified a number of “underlying vulnerabilities” that place patients at risk and increase liability for clinicians. The Doctors Company offers the following tips to help reduce these claims:
• Require periodic training and certification for physicians and nurses to maintain competency and facilitate conversations about fetal heart-rate (FHR) tracing interpretation. Both parties should use the same terminology when discussing the strips.
• Use technology that allows physicians to review FHR patterns from remote locations so that physicians and nurses are able to see the same information when discussing next steps.
• When operative vaginal delivery is attempted in the face of a Category III FHR tracing, a contingency team should be available for possible emergent cesarean delivery.
• Foster a culture in which caregivers feel comfortable speaking up if they have a concern. Ensure that the organization has a well-defined escalation guideline.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Reference
- The Doctors Company. Obstetrics Closed Claim Study. http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/CON_ID_011803. Published April 2015. Accessed May 6, 2015.
An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common patient allegations:
- a delay in treatment of fetal distress (22%). The term fetal distress remains a common allegation in malpractice claims. Cases in this category most often reflected a delay or failure to act in the face of Category II or III fetal heart-rate tracings.
- improper performance of vaginal delivery (20%). Almost half of the cases in this category involved brachial plexus injuries linked to shoulder dystocia. Patients alleged that improper maneuvers were used to resolve the dystocia. The remainder of cases in this category involved forceps and vacuum extraction deliveries.
- improper management of pregnancy (17%). Among the allegations were a failure to test for fetal abnormalities, failure to recognize complications of pregnancy, and failure to address abnormal findings.
Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.1
The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.1 Susan Mann, MD, a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco. (Listen to this accompanying audiocast featuring her comments.) Dr. Mann practices obstetrics and gynecology in Brookline, Massachusetts, and at Beth Israel Deaconess Medical Center in Boston. She is president of the QualBridge Institute, a consulting firm focused on issues of quality and safety.
Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims:
1. Selection and management of therapy (34%). Among the issues here were decisions involving augmentation of labor, route of delivery, and the timing of interventions. This factor also related to medications—for example, a failure to order antibiotics for Group A and Group B strep, a failure to order Rho(D) immune globulin for Rh-negative mothers, and a failure to provide magnesium sulfate for women with eclampsia.
2. Patient-assessment issues (32%). The Doctors Company reviewers found that physicians frequently failed to consider information that was available, or overlooked abnormal findings.
3. Technical performance (18%). This factor involved problems associated with known risks of various procedures, such as postpartum hemorrhage and brachial plexus injuries. It also included poor technique.
4. Communication among providers (17%)
5. Patient factors (16%). These factors included a failure to comply with therapy or to show up for appointments.
6. Insufficient or lack of documentation (14%)
7. Communication between patient/family and provider (14%).
“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”
“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.
Tips for reducing malpractice claims in obstetrics
The Obstetrics Closed Claim Study identified a number of “underlying vulnerabilities” that place patients at risk and increase liability for clinicians. The Doctors Company offers the following tips to help reduce these claims:
• Require periodic training and certification for physicians and nurses to maintain competency and facilitate conversations about fetal heart-rate (FHR) tracing interpretation. Both parties should use the same terminology when discussing the strips.
• Use technology that allows physicians to review FHR patterns from remote locations so that physicians and nurses are able to see the same information when discussing next steps.
• When operative vaginal delivery is attempted in the face of a Category III FHR tracing, a contingency team should be available for possible emergent cesarean delivery.
• Foster a culture in which caregivers feel comfortable speaking up if they have a concern. Ensure that the organization has a well-defined escalation guideline.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common patient allegations:
- a delay in treatment of fetal distress (22%). The term fetal distress remains a common allegation in malpractice claims. Cases in this category most often reflected a delay or failure to act in the face of Category II or III fetal heart-rate tracings.
- improper performance of vaginal delivery (20%). Almost half of the cases in this category involved brachial plexus injuries linked to shoulder dystocia. Patients alleged that improper maneuvers were used to resolve the dystocia. The remainder of cases in this category involved forceps and vacuum extraction deliveries.
- improper management of pregnancy (17%). Among the allegations were a failure to test for fetal abnormalities, failure to recognize complications of pregnancy, and failure to address abnormal findings.
Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.1
The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.1 Susan Mann, MD, a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco. (Listen to this accompanying audiocast featuring her comments.) Dr. Mann practices obstetrics and gynecology in Brookline, Massachusetts, and at Beth Israel Deaconess Medical Center in Boston. She is president of the QualBridge Institute, a consulting firm focused on issues of quality and safety.
Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims:
1. Selection and management of therapy (34%). Among the issues here were decisions involving augmentation of labor, route of delivery, and the timing of interventions. This factor also related to medications—for example, a failure to order antibiotics for Group A and Group B strep, a failure to order Rho(D) immune globulin for Rh-negative mothers, and a failure to provide magnesium sulfate for women with eclampsia.
2. Patient-assessment issues (32%). The Doctors Company reviewers found that physicians frequently failed to consider information that was available, or overlooked abnormal findings.
3. Technical performance (18%). This factor involved problems associated with known risks of various procedures, such as postpartum hemorrhage and brachial plexus injuries. It also included poor technique.
4. Communication among providers (17%)
5. Patient factors (16%). These factors included a failure to comply with therapy or to show up for appointments.
6. Insufficient or lack of documentation (14%)
7. Communication between patient/family and provider (14%).
“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”
“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.
Tips for reducing malpractice claims in obstetrics
The Obstetrics Closed Claim Study identified a number of “underlying vulnerabilities” that place patients at risk and increase liability for clinicians. The Doctors Company offers the following tips to help reduce these claims:
• Require periodic training and certification for physicians and nurses to maintain competency and facilitate conversations about fetal heart-rate (FHR) tracing interpretation. Both parties should use the same terminology when discussing the strips.
• Use technology that allows physicians to review FHR patterns from remote locations so that physicians and nurses are able to see the same information when discussing next steps.
• When operative vaginal delivery is attempted in the face of a Category III FHR tracing, a contingency team should be available for possible emergent cesarean delivery.
• Foster a culture in which caregivers feel comfortable speaking up if they have a concern. Ensure that the organization has a well-defined escalation guideline.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Reference
- The Doctors Company. Obstetrics Closed Claim Study. http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/CON_ID_011803. Published April 2015. Accessed May 6, 2015.
Reference
- The Doctors Company. Obstetrics Closed Claim Study. http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/CON_ID_011803. Published April 2015. Accessed May 6, 2015.
Active treatment of extremely preterm infants varies
For extremely preterm infants in the United States, there is considerable variation among hospitals in terms of the gestational age at which they begin active treatment as well as the survival outcomes, according to a study of nearly 5,000 infants born before 27 weeks’ gestation.
The overall rates of active treatment ranged from 22.1% (interquartile range, 7.7-100) among infants born at 22 weeks’ gestation to 99.8% (interquartile range, 100-100) among those born at 26 weeks’ gestation.
Currently, both the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists recommend that clinicians and families make individualized decisions about the treatment of extremely preterm infants based on parental preference and the latest available data on survival and morbidity.
Matthew A. Rysavy of the University of Iowa College Of Public Health, Iowa City, and his colleagues identified 4,987 infants born between April 1, 2006, and March 31, 2011, at 24 hospitals included in the National Institute of Child Health and Human Development’s Neonatal Research Network.
Overall, 4,329 (86.8%) received active treatment, including surfactant therapy, tracheal intubation, ventilatory support, parenteral nutrition, epinephrine, or chest compressions.
Treatment was administered to 22.1% of infants born at 22 weeks and 71.8% born at 23 weeks. For those born at 24 weeks’ gestation, the overall percentage receiving active treatment was 97.1%, while 99.6% born at 25 weeks received active treatment, and 99.8% born at 26 weeks received active treatment.
“We found that rates of active treatment among infants born at the end of 22 or 23 weeks of gestation were significantly higher than the rates among infants born earlier during the same weeks,” the researchers wrote. “Our findings suggest that physicians and families may ‘round up’ when considering gestational age in the decision to initiate potentially lifesaving treatment.”
The decision to provide active treatment varied widely between hospitals. The interquartile ranges for hospital rates of active treatment stretched from 7.7% to 100% among infants born at 22 weeks’ gestation, from 52.5% to 96.5% among infants born at 23 weeks’ gestation, and from 95.2% to 100% among infants born at 24 weeks’ gestation.
At 25 and 26 weeks’ gestation, most hospitals provided active treatment, but only 5 of the 24 hospitals in the study provided active treatment to all infants born at 22 through 26 weeks’ gestation, Mr. Rysavy and his associates reported.
Overall survival and survival without severe impairment ranged from 5.1% and 3.4%, respectively, among infants born at 22 weeks’ gestation, to 81.4% and 75.6%, respectively, among those born at 26 weeks’ gestation (N. Engl. J. Med. 2015;372:1801-11 [doi:10.1056/NEJMoa1410689]).
The researchers found that hospital rates of active treatment accounted for 78% and 75% of the between-hospital variation in survival and survival without severe impairment, respectively, for infants born at 22 or 23 weeks’ gestation. For infants born at 24 weeks’ gestation, rates of active treatment accounted for 22% of between-hospital variation in survival and 16% of variation in survival without severe impairment.
The rates, however, did not account for the variation in outcomes for infants born at 25 and 26 weeks’ gestation, Mr. Rysavy and his associates noted.
The study was supported by the National Institutes of Health. One of the researchers reported receiving personal fees from MedNax that were unrelated to the submitted work. Another researcher reported receiving a grant from the Bill and Melinda Gates Foundation that was not associated with the study.
This article raises important questions about what information should be given to parents during counseling about risks after an extremely preterm birth. To give crude data on the survival rate among all such infants, regardless of whether treatment efforts were made, is misleading and helps to make poor survival a self-fulfilling prophecy.
This report underscores the need for unbiased data to inform chances of overall survival and survival without major neurodevelopmental impairment in extremely preterm infants. Information on survival, morbidity, and policies regarding active intervention should be available to assist parents in making an informed choice about transfer to a specialist hospital, if feasible, and the level of intervention provided after birth.
Neil Marlow, D.M., is professor of neonatal medicine at the Garrett Anderson Institute for Women’s Health, University College London. Dr. Marlow reported that he had no relevant financial disclosures related to the study. He has received personal fees from Novartis, Shire, and GlaxoSmithKline outside the submitted work. He is also a member of the Executive Board of the European Foundation for the Care of Newborn Infants. These comments were taken from an accompanying editorial (N. Engl. J. Med. 2015 May 6 [doi:10.1056/NEJMe1502250]).
This article raises important questions about what information should be given to parents during counseling about risks after an extremely preterm birth. To give crude data on the survival rate among all such infants, regardless of whether treatment efforts were made, is misleading and helps to make poor survival a self-fulfilling prophecy.
This report underscores the need for unbiased data to inform chances of overall survival and survival without major neurodevelopmental impairment in extremely preterm infants. Information on survival, morbidity, and policies regarding active intervention should be available to assist parents in making an informed choice about transfer to a specialist hospital, if feasible, and the level of intervention provided after birth.
Neil Marlow, D.M., is professor of neonatal medicine at the Garrett Anderson Institute for Women’s Health, University College London. Dr. Marlow reported that he had no relevant financial disclosures related to the study. He has received personal fees from Novartis, Shire, and GlaxoSmithKline outside the submitted work. He is also a member of the Executive Board of the European Foundation for the Care of Newborn Infants. These comments were taken from an accompanying editorial (N. Engl. J. Med. 2015 May 6 [doi:10.1056/NEJMe1502250]).
This article raises important questions about what information should be given to parents during counseling about risks after an extremely preterm birth. To give crude data on the survival rate among all such infants, regardless of whether treatment efforts were made, is misleading and helps to make poor survival a self-fulfilling prophecy.
This report underscores the need for unbiased data to inform chances of overall survival and survival without major neurodevelopmental impairment in extremely preterm infants. Information on survival, morbidity, and policies regarding active intervention should be available to assist parents in making an informed choice about transfer to a specialist hospital, if feasible, and the level of intervention provided after birth.
Neil Marlow, D.M., is professor of neonatal medicine at the Garrett Anderson Institute for Women’s Health, University College London. Dr. Marlow reported that he had no relevant financial disclosures related to the study. He has received personal fees from Novartis, Shire, and GlaxoSmithKline outside the submitted work. He is also a member of the Executive Board of the European Foundation for the Care of Newborn Infants. These comments were taken from an accompanying editorial (N. Engl. J. Med. 2015 May 6 [doi:10.1056/NEJMe1502250]).
For extremely preterm infants in the United States, there is considerable variation among hospitals in terms of the gestational age at which they begin active treatment as well as the survival outcomes, according to a study of nearly 5,000 infants born before 27 weeks’ gestation.
The overall rates of active treatment ranged from 22.1% (interquartile range, 7.7-100) among infants born at 22 weeks’ gestation to 99.8% (interquartile range, 100-100) among those born at 26 weeks’ gestation.
Currently, both the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists recommend that clinicians and families make individualized decisions about the treatment of extremely preterm infants based on parental preference and the latest available data on survival and morbidity.
Matthew A. Rysavy of the University of Iowa College Of Public Health, Iowa City, and his colleagues identified 4,987 infants born between April 1, 2006, and March 31, 2011, at 24 hospitals included in the National Institute of Child Health and Human Development’s Neonatal Research Network.
Overall, 4,329 (86.8%) received active treatment, including surfactant therapy, tracheal intubation, ventilatory support, parenteral nutrition, epinephrine, or chest compressions.
Treatment was administered to 22.1% of infants born at 22 weeks and 71.8% born at 23 weeks. For those born at 24 weeks’ gestation, the overall percentage receiving active treatment was 97.1%, while 99.6% born at 25 weeks received active treatment, and 99.8% born at 26 weeks received active treatment.
“We found that rates of active treatment among infants born at the end of 22 or 23 weeks of gestation were significantly higher than the rates among infants born earlier during the same weeks,” the researchers wrote. “Our findings suggest that physicians and families may ‘round up’ when considering gestational age in the decision to initiate potentially lifesaving treatment.”
The decision to provide active treatment varied widely between hospitals. The interquartile ranges for hospital rates of active treatment stretched from 7.7% to 100% among infants born at 22 weeks’ gestation, from 52.5% to 96.5% among infants born at 23 weeks’ gestation, and from 95.2% to 100% among infants born at 24 weeks’ gestation.
At 25 and 26 weeks’ gestation, most hospitals provided active treatment, but only 5 of the 24 hospitals in the study provided active treatment to all infants born at 22 through 26 weeks’ gestation, Mr. Rysavy and his associates reported.
Overall survival and survival without severe impairment ranged from 5.1% and 3.4%, respectively, among infants born at 22 weeks’ gestation, to 81.4% and 75.6%, respectively, among those born at 26 weeks’ gestation (N. Engl. J. Med. 2015;372:1801-11 [doi:10.1056/NEJMoa1410689]).
The researchers found that hospital rates of active treatment accounted for 78% and 75% of the between-hospital variation in survival and survival without severe impairment, respectively, for infants born at 22 or 23 weeks’ gestation. For infants born at 24 weeks’ gestation, rates of active treatment accounted for 22% of between-hospital variation in survival and 16% of variation in survival without severe impairment.
The rates, however, did not account for the variation in outcomes for infants born at 25 and 26 weeks’ gestation, Mr. Rysavy and his associates noted.
The study was supported by the National Institutes of Health. One of the researchers reported receiving personal fees from MedNax that were unrelated to the submitted work. Another researcher reported receiving a grant from the Bill and Melinda Gates Foundation that was not associated with the study.
For extremely preterm infants in the United States, there is considerable variation among hospitals in terms of the gestational age at which they begin active treatment as well as the survival outcomes, according to a study of nearly 5,000 infants born before 27 weeks’ gestation.
The overall rates of active treatment ranged from 22.1% (interquartile range, 7.7-100) among infants born at 22 weeks’ gestation to 99.8% (interquartile range, 100-100) among those born at 26 weeks’ gestation.
Currently, both the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists recommend that clinicians and families make individualized decisions about the treatment of extremely preterm infants based on parental preference and the latest available data on survival and morbidity.
Matthew A. Rysavy of the University of Iowa College Of Public Health, Iowa City, and his colleagues identified 4,987 infants born between April 1, 2006, and March 31, 2011, at 24 hospitals included in the National Institute of Child Health and Human Development’s Neonatal Research Network.
Overall, 4,329 (86.8%) received active treatment, including surfactant therapy, tracheal intubation, ventilatory support, parenteral nutrition, epinephrine, or chest compressions.
Treatment was administered to 22.1% of infants born at 22 weeks and 71.8% born at 23 weeks. For those born at 24 weeks’ gestation, the overall percentage receiving active treatment was 97.1%, while 99.6% born at 25 weeks received active treatment, and 99.8% born at 26 weeks received active treatment.
“We found that rates of active treatment among infants born at the end of 22 or 23 weeks of gestation were significantly higher than the rates among infants born earlier during the same weeks,” the researchers wrote. “Our findings suggest that physicians and families may ‘round up’ when considering gestational age in the decision to initiate potentially lifesaving treatment.”
The decision to provide active treatment varied widely between hospitals. The interquartile ranges for hospital rates of active treatment stretched from 7.7% to 100% among infants born at 22 weeks’ gestation, from 52.5% to 96.5% among infants born at 23 weeks’ gestation, and from 95.2% to 100% among infants born at 24 weeks’ gestation.
At 25 and 26 weeks’ gestation, most hospitals provided active treatment, but only 5 of the 24 hospitals in the study provided active treatment to all infants born at 22 through 26 weeks’ gestation, Mr. Rysavy and his associates reported.
Overall survival and survival without severe impairment ranged from 5.1% and 3.4%, respectively, among infants born at 22 weeks’ gestation, to 81.4% and 75.6%, respectively, among those born at 26 weeks’ gestation (N. Engl. J. Med. 2015;372:1801-11 [doi:10.1056/NEJMoa1410689]).
The researchers found that hospital rates of active treatment accounted for 78% and 75% of the between-hospital variation in survival and survival without severe impairment, respectively, for infants born at 22 or 23 weeks’ gestation. For infants born at 24 weeks’ gestation, rates of active treatment accounted for 22% of between-hospital variation in survival and 16% of variation in survival without severe impairment.
The rates, however, did not account for the variation in outcomes for infants born at 25 and 26 weeks’ gestation, Mr. Rysavy and his associates noted.
The study was supported by the National Institutes of Health. One of the researchers reported receiving personal fees from MedNax that were unrelated to the submitted work. Another researcher reported receiving a grant from the Bill and Melinda Gates Foundation that was not associated with the study.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: Decisions on how to treat extremely premature births vary considerably between hospitals, as do outcomes.
Major finding: Overall rates of survival and survival without severe impairment ranged from 5.1% and 3.4%, respectively, among infants born at 22 weeks’ gestation, to 81.4% and 75.6%, respectively, among infants born at 26 weeks’ gestation.
Data source: Data for 4,987 infants born before 27 weeks’ gestation without congenital anomalies at 24 U.S. hospitals over a 5-year period.
Disclosures: The study was supported by the National Institutes of Health. One of the researchers reported receiving personal fees from MedNax that were unrelated to the submitted work. Another researcher reported receiving a grant from the Bill and Melinda Gates Foundation that was not associated with the study.
Youth may counteract weight gain when it comes to cesarean risk
SAN FRANCISCO – Excessive gestational weight gain increased the risk of cesarean delivery in all ages; however, less so in pregnant teens than in adults in a population-based cohort study of more than 1,000,000 births.
Dr. Margaret E. Beaudrot and her colleagues at the University of Cincinnati looked at all births in Ohio from 2006 to 2012, focusing on the 309,935 live singleton births to first-time mothers.
They assessed the association between body mass index, gestational weight gain, and cesarean delivery risk among four groups: teens younger than 15 years, teens aged 15-17 years, teens aged 18-19 years, and adult women aged 20-34. Data were adjusted for breech presentation and labor induction.
Most births (78.5%) were to adult women. Among teen mothers, 15% were aged 18-19 years, 6% were aged 15-17 years, and less than 1% were under age 15.
The overall cesarean rate was 27%. Cesareans were significantly more common in adults (29%) than in mothers younger than 15 years (18%), 15-17 years (18%), and teens aged 18-19 years (21%).
Three factors were associated with having a cesarean delivery: maternal age, BMI, and excessive gestational weight gain, Dr. Beaudrot said at the annual meeting of the American College of Obstetricians and Gynecologists.
More than half of women in all groups had excessive gestational weight gain based on 2009 recommendations from the Institute of Medicine.
Close to half (44%) of obese adult women with excessive gestational weight gain had a cesarean, as did about a third (32%) of overweight adult women with excessive gestational weight gain. Even in women who started their pregnancy at a normal BMI, 26% with excessive weight gain had a cesarean delivery.
Compared with adults, teens had a 47% lower risk of cesarean delivery (adjusted OR 0.53). Across all BMI categories, cesarean rates were higher in teens based on excessive weight gain, with rates ranging from 14% in 15- to 17-year olds who gained too little weight to 24% in 18- to 19-year olds who gained too much weight.
Cesarean rates were lowest in normal-weight teens under 18 years who gained an appropriate amount of weight.
The data “highlight the importance of [patient] education on optimal gestational weight gain, regardless of age in an attempt to reduce the primary c-section rate overall, especially in those at highest risk, obese women of all ages,” Dr. Beaudrot said.
On Twitter @denisefulton
SAN FRANCISCO – Excessive gestational weight gain increased the risk of cesarean delivery in all ages; however, less so in pregnant teens than in adults in a population-based cohort study of more than 1,000,000 births.
Dr. Margaret E. Beaudrot and her colleagues at the University of Cincinnati looked at all births in Ohio from 2006 to 2012, focusing on the 309,935 live singleton births to first-time mothers.
They assessed the association between body mass index, gestational weight gain, and cesarean delivery risk among four groups: teens younger than 15 years, teens aged 15-17 years, teens aged 18-19 years, and adult women aged 20-34. Data were adjusted for breech presentation and labor induction.
Most births (78.5%) were to adult women. Among teen mothers, 15% were aged 18-19 years, 6% were aged 15-17 years, and less than 1% were under age 15.
The overall cesarean rate was 27%. Cesareans were significantly more common in adults (29%) than in mothers younger than 15 years (18%), 15-17 years (18%), and teens aged 18-19 years (21%).
Three factors were associated with having a cesarean delivery: maternal age, BMI, and excessive gestational weight gain, Dr. Beaudrot said at the annual meeting of the American College of Obstetricians and Gynecologists.
More than half of women in all groups had excessive gestational weight gain based on 2009 recommendations from the Institute of Medicine.
Close to half (44%) of obese adult women with excessive gestational weight gain had a cesarean, as did about a third (32%) of overweight adult women with excessive gestational weight gain. Even in women who started their pregnancy at a normal BMI, 26% with excessive weight gain had a cesarean delivery.
Compared with adults, teens had a 47% lower risk of cesarean delivery (adjusted OR 0.53). Across all BMI categories, cesarean rates were higher in teens based on excessive weight gain, with rates ranging from 14% in 15- to 17-year olds who gained too little weight to 24% in 18- to 19-year olds who gained too much weight.
Cesarean rates were lowest in normal-weight teens under 18 years who gained an appropriate amount of weight.
The data “highlight the importance of [patient] education on optimal gestational weight gain, regardless of age in an attempt to reduce the primary c-section rate overall, especially in those at highest risk, obese women of all ages,” Dr. Beaudrot said.
On Twitter @denisefulton
SAN FRANCISCO – Excessive gestational weight gain increased the risk of cesarean delivery in all ages; however, less so in pregnant teens than in adults in a population-based cohort study of more than 1,000,000 births.
Dr. Margaret E. Beaudrot and her colleagues at the University of Cincinnati looked at all births in Ohio from 2006 to 2012, focusing on the 309,935 live singleton births to first-time mothers.
They assessed the association between body mass index, gestational weight gain, and cesarean delivery risk among four groups: teens younger than 15 years, teens aged 15-17 years, teens aged 18-19 years, and adult women aged 20-34. Data were adjusted for breech presentation and labor induction.
Most births (78.5%) were to adult women. Among teen mothers, 15% were aged 18-19 years, 6% were aged 15-17 years, and less than 1% were under age 15.
The overall cesarean rate was 27%. Cesareans were significantly more common in adults (29%) than in mothers younger than 15 years (18%), 15-17 years (18%), and teens aged 18-19 years (21%).
Three factors were associated with having a cesarean delivery: maternal age, BMI, and excessive gestational weight gain, Dr. Beaudrot said at the annual meeting of the American College of Obstetricians and Gynecologists.
More than half of women in all groups had excessive gestational weight gain based on 2009 recommendations from the Institute of Medicine.
Close to half (44%) of obese adult women with excessive gestational weight gain had a cesarean, as did about a third (32%) of overweight adult women with excessive gestational weight gain. Even in women who started their pregnancy at a normal BMI, 26% with excessive weight gain had a cesarean delivery.
Compared with adults, teens had a 47% lower risk of cesarean delivery (adjusted OR 0.53). Across all BMI categories, cesarean rates were higher in teens based on excessive weight gain, with rates ranging from 14% in 15- to 17-year olds who gained too little weight to 24% in 18- to 19-year olds who gained too much weight.
Cesarean rates were lowest in normal-weight teens under 18 years who gained an appropriate amount of weight.
The data “highlight the importance of [patient] education on optimal gestational weight gain, regardless of age in an attempt to reduce the primary c-section rate overall, especially in those at highest risk, obese women of all ages,” Dr. Beaudrot said.
On Twitter @denisefulton
AT THE ACOG ANNUAL CLINICAL MEETING
Key clinical point: Counsel all patients regarding excessive weight gain in pregnancy, especially those who are overweight or obese.
Major finding: Close to half (44%) of obese adult women with excessive gestational weight gain had a cesarean section compared to 13% of normal-weight women 18 years and under with appropriate weight gain.
Data source: Population-based cohort study of all 1,000,000-plus births in Ohio during 2006-2012.
Disclosures: Dr. Beaudrot reported having no conflicts of interest.
NASPAG: Migraines don’t always preclude combined OCs
ORLANDO– Most adolescent girls who report having headaches – including some of those who report migraines with aura – can safely use combined oral contraceptive pills, according to Dr. Sari Kives.
The available literature suggests that there is some resistance to prescribing such contraception for adolescents with headaches, but most adolescents don’t have the types of headaches that are of concern, Dr. Kives of the University of Toronto said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
owever, it is important to get a good characterization of the headaches, keeping in mind that teens may have difficulty relating their symptoms, she said.
“It’s important to understand what the headache actually is. Is it a tension headache, which is by far the most common headache you will see in adolescents?” she said, noting that menstrual migraines and classical migraines are less common in adolescents.
Menstrual migraines account for about 7%-8% of migraines, occur 2-3 days before menses, can last throughout the period, don’t occur any other time of the month, and can be quite debilitating. They usually are secondary to estrogen withdrawal, Dr. Kives said, adding that a decade ago, add-back estrogen was commonly given during the week off of oral contraceptives in those with menstrual headaches.
Now it is common practice to use continuous pills or extended-cycle pills, she said, explaining that eliminating the estrogen fluctuation improves the headaches.
Classical migraines also occur commonly in adolescent girls. Some may include focal neurological symptoms that may be triggered by hormonal changes, stress, certain foods and beverages, certain scents or fumes, fatigue, hunger, or trauma.
It is important to ask about such symptoms, Dr. Kives said.
“And that’s probably the most important question you can ask. For me, a focal neurological symptom is, ‘I go blind in my left eye. I lose sensation in my right arm,’ ” she said, providing examples.
Some symptoms are characteristic of “atypical aura,” and some are associated with “typical aura” – an important distinction when determining whether combined OCs are safe for a given patient.
Atypical aura usually has sudden unilateral onset and lasts more than 30-60 minutes. Headache may or may not be present, and visual symptoms may include loss of vision, amaurosis fugax (painless transient monocular visual loss), and visual field anomaly. Sensory and motor symptoms can include lower limb anesthesia or hypoesthesia (decrease in sensation).
Typical aura has more progressive onset, lasts less than an hour, and precedes migraine. Patients may experience bilateral scintillating scotoma, fortification spectra, and blurred vision. These are usually limited to visual symptoms, Dr. Kives said, but sensory and motor symptoms can occur. They tend to occur in relation to the visual symptoms, and may affect the upper limbs, mouth, and tongue – causing tingling or pinching sensations.
Individuals who have migraine with aura account for only about 20% of those with migraine headaches, and the vast majority are going to have visual aura.
“They can have sensory and motor symptoms, but the visual ones are the ones where you have to be very specific,” she said, noting that in her experience, 99% of cases are visual.
“If it’s a short visual aura, less than an hour, and it’s not repetitive, I will consider an oral contraceptive pill in this group of patients, but you have to balance it against what their history sounds like,” she said.
Typically, combined OCs are contraindicated in patients with migraine with aura because of an increased risk of cerebrovascular accident, but in Canada, guidelines provide allowances for this “unique group of individuals with migraines with aura that are limited to visual symptoms and that last less than 1 hour,” she said.
Remember that photophobia, phonophobia, nausea and vomiting, visual blurring, and generalized visual spots/flashing lights do not constitute aura, she said.
This is important, because using too stringent a definition of “migraine with aura” will leave a substantial number of individuals with limited contraceptive options, particularly options that are effective and promote cycle control and compliance, she said.
Although there is a definite risk associated with combined OCs in those with migraine with aura – with an added risk in those who smoke, the risks are low in adolescents, compared with older patients.
“The adult women who walks in with hypertension, or who is a smoker who gets oral contraception – that is a very different patient than the 14-year-old who says, ‘I may get flashing lights before my headache, but not on a regular basis.’ Those are completely different entity patients, in my opinion,” Dr. Kives said.
If she does prescribe combined OCs for an adolescent with migraines, she advises the patient to stop the pills if the headaches get worse, she said. In many cases, however, headaches improve, because they were menstrual migraines and not classical migraines, she said, adding that “improvement in headaches is a reassuring sign.” The bottom line, Dr. Kives said, is that migraine without aura doesn’t preclude prescribing of any contraceptive options in adolescents, and that migraine with aura is a relative contraindication; low-dose combined oral contraceptive pills are safe for those with migraine with aura that primarily includes visual symptoms lasting less than an hour.
However, the risk of cerebrovascular accidents is increased in those with migraines, so other risk factors, such as family history, obesity, hypertension, and smoking, should be considered.
“If they have no other risk factors, their risk probably is quite low,” Dr. Kives said.
She reported having no relevant financial disclosures.
ORLANDO– Most adolescent girls who report having headaches – including some of those who report migraines with aura – can safely use combined oral contraceptive pills, according to Dr. Sari Kives.
The available literature suggests that there is some resistance to prescribing such contraception for adolescents with headaches, but most adolescents don’t have the types of headaches that are of concern, Dr. Kives of the University of Toronto said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
owever, it is important to get a good characterization of the headaches, keeping in mind that teens may have difficulty relating their symptoms, she said.
“It’s important to understand what the headache actually is. Is it a tension headache, which is by far the most common headache you will see in adolescents?” she said, noting that menstrual migraines and classical migraines are less common in adolescents.
Menstrual migraines account for about 7%-8% of migraines, occur 2-3 days before menses, can last throughout the period, don’t occur any other time of the month, and can be quite debilitating. They usually are secondary to estrogen withdrawal, Dr. Kives said, adding that a decade ago, add-back estrogen was commonly given during the week off of oral contraceptives in those with menstrual headaches.
Now it is common practice to use continuous pills or extended-cycle pills, she said, explaining that eliminating the estrogen fluctuation improves the headaches.
Classical migraines also occur commonly in adolescent girls. Some may include focal neurological symptoms that may be triggered by hormonal changes, stress, certain foods and beverages, certain scents or fumes, fatigue, hunger, or trauma.
It is important to ask about such symptoms, Dr. Kives said.
“And that’s probably the most important question you can ask. For me, a focal neurological symptom is, ‘I go blind in my left eye. I lose sensation in my right arm,’ ” she said, providing examples.
Some symptoms are characteristic of “atypical aura,” and some are associated with “typical aura” – an important distinction when determining whether combined OCs are safe for a given patient.
Atypical aura usually has sudden unilateral onset and lasts more than 30-60 minutes. Headache may or may not be present, and visual symptoms may include loss of vision, amaurosis fugax (painless transient monocular visual loss), and visual field anomaly. Sensory and motor symptoms can include lower limb anesthesia or hypoesthesia (decrease in sensation).
Typical aura has more progressive onset, lasts less than an hour, and precedes migraine. Patients may experience bilateral scintillating scotoma, fortification spectra, and blurred vision. These are usually limited to visual symptoms, Dr. Kives said, but sensory and motor symptoms can occur. They tend to occur in relation to the visual symptoms, and may affect the upper limbs, mouth, and tongue – causing tingling or pinching sensations.
Individuals who have migraine with aura account for only about 20% of those with migraine headaches, and the vast majority are going to have visual aura.
“They can have sensory and motor symptoms, but the visual ones are the ones where you have to be very specific,” she said, noting that in her experience, 99% of cases are visual.
“If it’s a short visual aura, less than an hour, and it’s not repetitive, I will consider an oral contraceptive pill in this group of patients, but you have to balance it against what their history sounds like,” she said.
Typically, combined OCs are contraindicated in patients with migraine with aura because of an increased risk of cerebrovascular accident, but in Canada, guidelines provide allowances for this “unique group of individuals with migraines with aura that are limited to visual symptoms and that last less than 1 hour,” she said.
Remember that photophobia, phonophobia, nausea and vomiting, visual blurring, and generalized visual spots/flashing lights do not constitute aura, she said.
This is important, because using too stringent a definition of “migraine with aura” will leave a substantial number of individuals with limited contraceptive options, particularly options that are effective and promote cycle control and compliance, she said.
Although there is a definite risk associated with combined OCs in those with migraine with aura – with an added risk in those who smoke, the risks are low in adolescents, compared with older patients.
“The adult women who walks in with hypertension, or who is a smoker who gets oral contraception – that is a very different patient than the 14-year-old who says, ‘I may get flashing lights before my headache, but not on a regular basis.’ Those are completely different entity patients, in my opinion,” Dr. Kives said.
If she does prescribe combined OCs for an adolescent with migraines, she advises the patient to stop the pills if the headaches get worse, she said. In many cases, however, headaches improve, because they were menstrual migraines and not classical migraines, she said, adding that “improvement in headaches is a reassuring sign.” The bottom line, Dr. Kives said, is that migraine without aura doesn’t preclude prescribing of any contraceptive options in adolescents, and that migraine with aura is a relative contraindication; low-dose combined oral contraceptive pills are safe for those with migraine with aura that primarily includes visual symptoms lasting less than an hour.
However, the risk of cerebrovascular accidents is increased in those with migraines, so other risk factors, such as family history, obesity, hypertension, and smoking, should be considered.
“If they have no other risk factors, their risk probably is quite low,” Dr. Kives said.
She reported having no relevant financial disclosures.
ORLANDO– Most adolescent girls who report having headaches – including some of those who report migraines with aura – can safely use combined oral contraceptive pills, according to Dr. Sari Kives.
The available literature suggests that there is some resistance to prescribing such contraception for adolescents with headaches, but most adolescents don’t have the types of headaches that are of concern, Dr. Kives of the University of Toronto said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
owever, it is important to get a good characterization of the headaches, keeping in mind that teens may have difficulty relating their symptoms, she said.
“It’s important to understand what the headache actually is. Is it a tension headache, which is by far the most common headache you will see in adolescents?” she said, noting that menstrual migraines and classical migraines are less common in adolescents.
Menstrual migraines account for about 7%-8% of migraines, occur 2-3 days before menses, can last throughout the period, don’t occur any other time of the month, and can be quite debilitating. They usually are secondary to estrogen withdrawal, Dr. Kives said, adding that a decade ago, add-back estrogen was commonly given during the week off of oral contraceptives in those with menstrual headaches.
Now it is common practice to use continuous pills or extended-cycle pills, she said, explaining that eliminating the estrogen fluctuation improves the headaches.
Classical migraines also occur commonly in adolescent girls. Some may include focal neurological symptoms that may be triggered by hormonal changes, stress, certain foods and beverages, certain scents or fumes, fatigue, hunger, or trauma.
It is important to ask about such symptoms, Dr. Kives said.
“And that’s probably the most important question you can ask. For me, a focal neurological symptom is, ‘I go blind in my left eye. I lose sensation in my right arm,’ ” she said, providing examples.
Some symptoms are characteristic of “atypical aura,” and some are associated with “typical aura” – an important distinction when determining whether combined OCs are safe for a given patient.
Atypical aura usually has sudden unilateral onset and lasts more than 30-60 minutes. Headache may or may not be present, and visual symptoms may include loss of vision, amaurosis fugax (painless transient monocular visual loss), and visual field anomaly. Sensory and motor symptoms can include lower limb anesthesia or hypoesthesia (decrease in sensation).
Typical aura has more progressive onset, lasts less than an hour, and precedes migraine. Patients may experience bilateral scintillating scotoma, fortification spectra, and blurred vision. These are usually limited to visual symptoms, Dr. Kives said, but sensory and motor symptoms can occur. They tend to occur in relation to the visual symptoms, and may affect the upper limbs, mouth, and tongue – causing tingling or pinching sensations.
Individuals who have migraine with aura account for only about 20% of those with migraine headaches, and the vast majority are going to have visual aura.
“They can have sensory and motor symptoms, but the visual ones are the ones where you have to be very specific,” she said, noting that in her experience, 99% of cases are visual.
“If it’s a short visual aura, less than an hour, and it’s not repetitive, I will consider an oral contraceptive pill in this group of patients, but you have to balance it against what their history sounds like,” she said.
Typically, combined OCs are contraindicated in patients with migraine with aura because of an increased risk of cerebrovascular accident, but in Canada, guidelines provide allowances for this “unique group of individuals with migraines with aura that are limited to visual symptoms and that last less than 1 hour,” she said.
Remember that photophobia, phonophobia, nausea and vomiting, visual blurring, and generalized visual spots/flashing lights do not constitute aura, she said.
This is important, because using too stringent a definition of “migraine with aura” will leave a substantial number of individuals with limited contraceptive options, particularly options that are effective and promote cycle control and compliance, she said.
Although there is a definite risk associated with combined OCs in those with migraine with aura – with an added risk in those who smoke, the risks are low in adolescents, compared with older patients.
“The adult women who walks in with hypertension, or who is a smoker who gets oral contraception – that is a very different patient than the 14-year-old who says, ‘I may get flashing lights before my headache, but not on a regular basis.’ Those are completely different entity patients, in my opinion,” Dr. Kives said.
If she does prescribe combined OCs for an adolescent with migraines, she advises the patient to stop the pills if the headaches get worse, she said. In many cases, however, headaches improve, because they were menstrual migraines and not classical migraines, she said, adding that “improvement in headaches is a reassuring sign.” The bottom line, Dr. Kives said, is that migraine without aura doesn’t preclude prescribing of any contraceptive options in adolescents, and that migraine with aura is a relative contraindication; low-dose combined oral contraceptive pills are safe for those with migraine with aura that primarily includes visual symptoms lasting less than an hour.
However, the risk of cerebrovascular accidents is increased in those with migraines, so other risk factors, such as family history, obesity, hypertension, and smoking, should be considered.
“If they have no other risk factors, their risk probably is quite low,” Dr. Kives said.
She reported having no relevant financial disclosures.
EXPERT ANALYSIS FROM THE NASPAG ANNUAL MEETING
VIDEO: Cervicovaginal microbiome holds promise in preventing preterm birth
SAN FRANCISCO– Predicting and preventing preterm birth continues to be a challenge for clinicians, but new research into the cervicovaginal microbiome could help explain the premature cervical remodeling that precedes preterm birth and ultimately lead to the development of novel therapeutics.
Researchers at the University of Pennsylvania recently found that there is a distinct molecular profile in the cervix that is associated with preterm birth and can be assessed noninvasively using RNA Pap testing.
In a video interview at the annual meeting of the American Congress of Obstetricians and Gynecologists, Dr. Michal Elovitz, director of the maternal and child health research program and the prematurity prevention program at the University of Pennsylvania, Philadelphia, said that the findings represent a “fork in the road” that could change how clinicians treat preterm birth, provided the findings can be validated in other studies.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @maryellenny
SAN FRANCISCO– Predicting and preventing preterm birth continues to be a challenge for clinicians, but new research into the cervicovaginal microbiome could help explain the premature cervical remodeling that precedes preterm birth and ultimately lead to the development of novel therapeutics.
Researchers at the University of Pennsylvania recently found that there is a distinct molecular profile in the cervix that is associated with preterm birth and can be assessed noninvasively using RNA Pap testing.
In a video interview at the annual meeting of the American Congress of Obstetricians and Gynecologists, Dr. Michal Elovitz, director of the maternal and child health research program and the prematurity prevention program at the University of Pennsylvania, Philadelphia, said that the findings represent a “fork in the road” that could change how clinicians treat preterm birth, provided the findings can be validated in other studies.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @maryellenny
SAN FRANCISCO– Predicting and preventing preterm birth continues to be a challenge for clinicians, but new research into the cervicovaginal microbiome could help explain the premature cervical remodeling that precedes preterm birth and ultimately lead to the development of novel therapeutics.
Researchers at the University of Pennsylvania recently found that there is a distinct molecular profile in the cervix that is associated with preterm birth and can be assessed noninvasively using RNA Pap testing.
In a video interview at the annual meeting of the American Congress of Obstetricians and Gynecologists, Dr. Michal Elovitz, director of the maternal and child health research program and the prematurity prevention program at the University of Pennsylvania, Philadelphia, said that the findings represent a “fork in the road” that could change how clinicians treat preterm birth, provided the findings can be validated in other studies.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @maryellenny
AT THE ACOG ANNUAL CLINICAL MEETING
VIDEO: Are birthing centers a safe choice for women?
SAN FRANCISCO – The number of babies delivered at birthing centers in the United States is still very low, but freestanding birthing facilities are growing rapidly. Are these centers, many of which are not accredited, safe choices for women who are looking for a noninstitutional birth experience?
At the annual meeting of the American Congress of Obstetricians and Gynecologists, Dr. Edward R. Yeomans, chair of the department of ob.gyn. at Texas Tech University, Lubbock, faced off against Ginger Breedlove, Ph.D., president of the American College of Nurse-Midwives, in a debate about the preferred site for delivery.
Dr. Yeomans, who favors hospital-based deliveries, said that safety is the major issue. Birthing centers are not equipped to deal with emergencies that can arise even in low-risk pregnancies and may require immediate access to surgery or a blood bank.
Dr. Breedlove countered that accredited birthing centers have strict standards for the cases they accept and have transport plans in place for emergencies. She added that she supports accreditation for all freestanding birthing centers.
On Twitter @maryellenny
SAN FRANCISCO – The number of babies delivered at birthing centers in the United States is still very low, but freestanding birthing facilities are growing rapidly. Are these centers, many of which are not accredited, safe choices for women who are looking for a noninstitutional birth experience?
At the annual meeting of the American Congress of Obstetricians and Gynecologists, Dr. Edward R. Yeomans, chair of the department of ob.gyn. at Texas Tech University, Lubbock, faced off against Ginger Breedlove, Ph.D., president of the American College of Nurse-Midwives, in a debate about the preferred site for delivery.
Dr. Yeomans, who favors hospital-based deliveries, said that safety is the major issue. Birthing centers are not equipped to deal with emergencies that can arise even in low-risk pregnancies and may require immediate access to surgery or a blood bank.
Dr. Breedlove countered that accredited birthing centers have strict standards for the cases they accept and have transport plans in place for emergencies. She added that she supports accreditation for all freestanding birthing centers.
On Twitter @maryellenny
SAN FRANCISCO – The number of babies delivered at birthing centers in the United States is still very low, but freestanding birthing facilities are growing rapidly. Are these centers, many of which are not accredited, safe choices for women who are looking for a noninstitutional birth experience?
At the annual meeting of the American Congress of Obstetricians and Gynecologists, Dr. Edward R. Yeomans, chair of the department of ob.gyn. at Texas Tech University, Lubbock, faced off against Ginger Breedlove, Ph.D., president of the American College of Nurse-Midwives, in a debate about the preferred site for delivery.
Dr. Yeomans, who favors hospital-based deliveries, said that safety is the major issue. Birthing centers are not equipped to deal with emergencies that can arise even in low-risk pregnancies and may require immediate access to surgery or a blood bank.
Dr. Breedlove countered that accredited birthing centers have strict standards for the cases they accept and have transport plans in place for emergencies. She added that she supports accreditation for all freestanding birthing centers.
On Twitter @maryellenny
AT THE ACOG ANNUAL CLINICAL MEETING
ACOG, SMFM, and others address safety concerns in labor and delivery
At least half of all cases of maternal morbidity and mortality could be prevented, or so studies suggest.1,2
The main stumbling block?
Faulty communication.
That’s the word from the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American College of Nurse-Midwives, and the Association of Women’s Health, Obstetric and Neonatal Nurses.3
In a joint “blueprint” to transform communication and enhance the safety culture in intrapartum care, these organizations, led by Audrey Lyndon, PhD, RN, FAAN, from the University of California, San Francisco, School of Nursing, describe the extent of the problem, steps that various team members can take to improve safety, notable success stories, and communication strategies.3 In this article, the joint blueprint is summarized, with a focus on steps obstetricians can take to improve the intrapartum safety culture.
Scope of the problem
A study of more than 3,282 physicians, midwives, and registered nurses produced a troubling statistic: More than 90% of respondents said that they had “witnessed shortcuts, missing competencies, disrespect, or performance problems” during the preceding year of practice.4 Few of these clinicians reported that they had discussed their concerns with the parties involved.
A second study of 1,932 clinicians found that 34% of physicians, 40% of midwives, and 56% of registered nurses had witnessed patients being put at risk within the preceding 2 years by other team members’ inattentiveness or lack of responsiveness.5
These findings suggest that health care providers often witness weak links in intrapartum safety but do not always address or report them. Among the reasons team members may be hesitant to speak up when they perceive a potential problem:
- feelings of resignation or inability to change the situation
- fear of retribution or ridicule
- fear of interpersonal or intrateam conflict.
Although Lyndon and colleagues acknowledge that it is impossible to eliminate adverse outcomes entirely or completely eradicate human error, they argue that significant improvements can be made by adopting a number of manageable strategies.
Recommended strategies
Lyndon and colleagues describe some of the challenges of effective communication in a health care setting:
Lyndon and colleagues go on to mention a number of strategies to improve communication, boost safety, and reduce medical errors.
1. Remember that the patient is part of the team
The patient and her family play a key role in identifying the potential for harm during labor and delivery, Lyndon and colleagues assert. They should be considered members of the intrapartum team, care should be patient-focused, and any communications from the patient should not only be heard but fully considered. In fact, explicit elicitation of her experience and concerns is recommended.
2. Consider that you might be part of the problem
It is human nature to attribute a communication problem to the other people involved, rather than take responsibility for it oneself. One potential solution to this mindset is team training, where all members are encouraged to communicate clearly and listen attentively. Organizations that have been successful at improving their culture of safety have implemented such training, as well as the use of checklists, training in fetal heart-rate monitoring, formation of a patient safety committee, external review of safety practices, and designation of a key clinician to lead the safety program and oversee team training.
3. Structure handoffs
The team should standardize handoffs so that they occur smoothly and all channels of communication remain open and clear.
“Having structured formats for debriefing and handoffs are steps in the right direction, but solving the problem of communication breakdowns is more complicated than standardizing the flow and format of information transfer,” Lyndon and colleagues assert. “Indeed, solving communication breakdowns is a matter of individual, group, organizational, and professional responsibility for creating and sustaining an environment of mutual respect, curiosity, and accountability for behavior and performance.”3
4. Learn to communicate responsibly
“Differences of opinion about clinical assessments, goals of care, and the pathway to optimal outcomes are bound to occur with some regularity in the dynamic environment of labor and delivery,” note Lyndon and colleagues. “Every person has the responsibility to contribute to improving how we relate to and communicate with each other. Collectively, we must create environments in which every team member (woman, family member, physician, midwife, nurse, unit clerk, patient care assistant, or scrub tech) is comfortable expressing and discussing concerns about safety or performance, is encouraged to do so, and has the support of the team to articulate the rationale for and urgency of the concern without fear of put-downs, retribution, or receiving poor-quality care.”3
5. Be persistent and proactive
When team members have differing expectations and communication styles, useful approaches include structured communication tools such as situation, background, assessment, recommendation (SBAR); structured handoffs; board rounds; huddles; attentive listening; and explicit elicitation of the patient’s concerns and desires.3
If someone fails to pay attention to a concern you raise, be persistent about restating that concern until you elicit a response.
If someone exhibits disruptive behavior, point to or establish a code of conduct that clearly describes professional behavior.
If there is a difference of opinion on patient management, such as fetal monitoring and interpretation, conduct regular case reviews and standardize a plan for notification of complications.
6. If you’re a team leader, set clear goals
Then ask team members what will be needed to achieve the outcomes desired.
“Team leaders need to develop outstanding skills for listening and eliciting feedback and cross-monitoring (being aware of each other’s actions and performance) from other team members,” note Lyndon and colleagues.
7. Increase public awareness of safety concepts
When these concepts and best practices are made known to the public, women and families become “empowered” to speak up when they have concerns about care.
And when they do speak up, it pays to listen.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
1. Geller SE, Rosenberg D, Cox SM, et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol. 2004;191(3):939–944.
2. Mitchell C, Lawton E, Morton C, McCain C, Holtby S, Main E. California Pregnancy-Associated Mortality Review: mixed methods approach for improved case identification, cause of death analyses and translation of findings. Matern Child Health J. 2014;18(3):518–526.
3. Lyndon A, Johnson MC, Bingham D, et al. Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. Obstet Gynecol. 2015;125(5):1049–1055.
4. Maxfield DG, Lyndon A, Kennedy HP, O’Keeffe DF, Ziatnik MG. Confronting safety gaps across labor and delivery teams. Am J Obstet Gynecol. 2013;209(5):402–408.e3.
5. Lyndon A, Zlatnik MG, Maxfield DG, Lewis A, McMillan C, Kennedy HP. Contributions of clinical disconnections and unresolved conflict to failures in intrapartum safety. J Obstet Gynecol Neonatal Nurs. 2014;43(1):2–12.
At least half of all cases of maternal morbidity and mortality could be prevented, or so studies suggest.1,2
The main stumbling block?
Faulty communication.
That’s the word from the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American College of Nurse-Midwives, and the Association of Women’s Health, Obstetric and Neonatal Nurses.3
In a joint “blueprint” to transform communication and enhance the safety culture in intrapartum care, these organizations, led by Audrey Lyndon, PhD, RN, FAAN, from the University of California, San Francisco, School of Nursing, describe the extent of the problem, steps that various team members can take to improve safety, notable success stories, and communication strategies.3 In this article, the joint blueprint is summarized, with a focus on steps obstetricians can take to improve the intrapartum safety culture.
Scope of the problem
A study of more than 3,282 physicians, midwives, and registered nurses produced a troubling statistic: More than 90% of respondents said that they had “witnessed shortcuts, missing competencies, disrespect, or performance problems” during the preceding year of practice.4 Few of these clinicians reported that they had discussed their concerns with the parties involved.
A second study of 1,932 clinicians found that 34% of physicians, 40% of midwives, and 56% of registered nurses had witnessed patients being put at risk within the preceding 2 years by other team members’ inattentiveness or lack of responsiveness.5
These findings suggest that health care providers often witness weak links in intrapartum safety but do not always address or report them. Among the reasons team members may be hesitant to speak up when they perceive a potential problem:
- feelings of resignation or inability to change the situation
- fear of retribution or ridicule
- fear of interpersonal or intrateam conflict.
Although Lyndon and colleagues acknowledge that it is impossible to eliminate adverse outcomes entirely or completely eradicate human error, they argue that significant improvements can be made by adopting a number of manageable strategies.
Recommended strategies
Lyndon and colleagues describe some of the challenges of effective communication in a health care setting:
Lyndon and colleagues go on to mention a number of strategies to improve communication, boost safety, and reduce medical errors.
1. Remember that the patient is part of the team
The patient and her family play a key role in identifying the potential for harm during labor and delivery, Lyndon and colleagues assert. They should be considered members of the intrapartum team, care should be patient-focused, and any communications from the patient should not only be heard but fully considered. In fact, explicit elicitation of her experience and concerns is recommended.
2. Consider that you might be part of the problem
It is human nature to attribute a communication problem to the other people involved, rather than take responsibility for it oneself. One potential solution to this mindset is team training, where all members are encouraged to communicate clearly and listen attentively. Organizations that have been successful at improving their culture of safety have implemented such training, as well as the use of checklists, training in fetal heart-rate monitoring, formation of a patient safety committee, external review of safety practices, and designation of a key clinician to lead the safety program and oversee team training.
3. Structure handoffs
The team should standardize handoffs so that they occur smoothly and all channels of communication remain open and clear.
“Having structured formats for debriefing and handoffs are steps in the right direction, but solving the problem of communication breakdowns is more complicated than standardizing the flow and format of information transfer,” Lyndon and colleagues assert. “Indeed, solving communication breakdowns is a matter of individual, group, organizational, and professional responsibility for creating and sustaining an environment of mutual respect, curiosity, and accountability for behavior and performance.”3
4. Learn to communicate responsibly
“Differences of opinion about clinical assessments, goals of care, and the pathway to optimal outcomes are bound to occur with some regularity in the dynamic environment of labor and delivery,” note Lyndon and colleagues. “Every person has the responsibility to contribute to improving how we relate to and communicate with each other. Collectively, we must create environments in which every team member (woman, family member, physician, midwife, nurse, unit clerk, patient care assistant, or scrub tech) is comfortable expressing and discussing concerns about safety or performance, is encouraged to do so, and has the support of the team to articulate the rationale for and urgency of the concern without fear of put-downs, retribution, or receiving poor-quality care.”3
5. Be persistent and proactive
When team members have differing expectations and communication styles, useful approaches include structured communication tools such as situation, background, assessment, recommendation (SBAR); structured handoffs; board rounds; huddles; attentive listening; and explicit elicitation of the patient’s concerns and desires.3
If someone fails to pay attention to a concern you raise, be persistent about restating that concern until you elicit a response.
If someone exhibits disruptive behavior, point to or establish a code of conduct that clearly describes professional behavior.
If there is a difference of opinion on patient management, such as fetal monitoring and interpretation, conduct regular case reviews and standardize a plan for notification of complications.
6. If you’re a team leader, set clear goals
Then ask team members what will be needed to achieve the outcomes desired.
“Team leaders need to develop outstanding skills for listening and eliciting feedback and cross-monitoring (being aware of each other’s actions and performance) from other team members,” note Lyndon and colleagues.
7. Increase public awareness of safety concepts
When these concepts and best practices are made known to the public, women and families become “empowered” to speak up when they have concerns about care.
And when they do speak up, it pays to listen.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
At least half of all cases of maternal morbidity and mortality could be prevented, or so studies suggest.1,2
The main stumbling block?
Faulty communication.
That’s the word from the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American College of Nurse-Midwives, and the Association of Women’s Health, Obstetric and Neonatal Nurses.3
In a joint “blueprint” to transform communication and enhance the safety culture in intrapartum care, these organizations, led by Audrey Lyndon, PhD, RN, FAAN, from the University of California, San Francisco, School of Nursing, describe the extent of the problem, steps that various team members can take to improve safety, notable success stories, and communication strategies.3 In this article, the joint blueprint is summarized, with a focus on steps obstetricians can take to improve the intrapartum safety culture.
Scope of the problem
A study of more than 3,282 physicians, midwives, and registered nurses produced a troubling statistic: More than 90% of respondents said that they had “witnessed shortcuts, missing competencies, disrespect, or performance problems” during the preceding year of practice.4 Few of these clinicians reported that they had discussed their concerns with the parties involved.
A second study of 1,932 clinicians found that 34% of physicians, 40% of midwives, and 56% of registered nurses had witnessed patients being put at risk within the preceding 2 years by other team members’ inattentiveness or lack of responsiveness.5
These findings suggest that health care providers often witness weak links in intrapartum safety but do not always address or report them. Among the reasons team members may be hesitant to speak up when they perceive a potential problem:
- feelings of resignation or inability to change the situation
- fear of retribution or ridicule
- fear of interpersonal or intrateam conflict.
Although Lyndon and colleagues acknowledge that it is impossible to eliminate adverse outcomes entirely or completely eradicate human error, they argue that significant improvements can be made by adopting a number of manageable strategies.
Recommended strategies
Lyndon and colleagues describe some of the challenges of effective communication in a health care setting:
Lyndon and colleagues go on to mention a number of strategies to improve communication, boost safety, and reduce medical errors.
1. Remember that the patient is part of the team
The patient and her family play a key role in identifying the potential for harm during labor and delivery, Lyndon and colleagues assert. They should be considered members of the intrapartum team, care should be patient-focused, and any communications from the patient should not only be heard but fully considered. In fact, explicit elicitation of her experience and concerns is recommended.
2. Consider that you might be part of the problem
It is human nature to attribute a communication problem to the other people involved, rather than take responsibility for it oneself. One potential solution to this mindset is team training, where all members are encouraged to communicate clearly and listen attentively. Organizations that have been successful at improving their culture of safety have implemented such training, as well as the use of checklists, training in fetal heart-rate monitoring, formation of a patient safety committee, external review of safety practices, and designation of a key clinician to lead the safety program and oversee team training.
3. Structure handoffs
The team should standardize handoffs so that they occur smoothly and all channels of communication remain open and clear.
“Having structured formats for debriefing and handoffs are steps in the right direction, but solving the problem of communication breakdowns is more complicated than standardizing the flow and format of information transfer,” Lyndon and colleagues assert. “Indeed, solving communication breakdowns is a matter of individual, group, organizational, and professional responsibility for creating and sustaining an environment of mutual respect, curiosity, and accountability for behavior and performance.”3
4. Learn to communicate responsibly
“Differences of opinion about clinical assessments, goals of care, and the pathway to optimal outcomes are bound to occur with some regularity in the dynamic environment of labor and delivery,” note Lyndon and colleagues. “Every person has the responsibility to contribute to improving how we relate to and communicate with each other. Collectively, we must create environments in which every team member (woman, family member, physician, midwife, nurse, unit clerk, patient care assistant, or scrub tech) is comfortable expressing and discussing concerns about safety or performance, is encouraged to do so, and has the support of the team to articulate the rationale for and urgency of the concern without fear of put-downs, retribution, or receiving poor-quality care.”3
5. Be persistent and proactive
When team members have differing expectations and communication styles, useful approaches include structured communication tools such as situation, background, assessment, recommendation (SBAR); structured handoffs; board rounds; huddles; attentive listening; and explicit elicitation of the patient’s concerns and desires.3
If someone fails to pay attention to a concern you raise, be persistent about restating that concern until you elicit a response.
If someone exhibits disruptive behavior, point to or establish a code of conduct that clearly describes professional behavior.
If there is a difference of opinion on patient management, such as fetal monitoring and interpretation, conduct regular case reviews and standardize a plan for notification of complications.
6. If you’re a team leader, set clear goals
Then ask team members what will be needed to achieve the outcomes desired.
“Team leaders need to develop outstanding skills for listening and eliciting feedback and cross-monitoring (being aware of each other’s actions and performance) from other team members,” note Lyndon and colleagues.
7. Increase public awareness of safety concepts
When these concepts and best practices are made known to the public, women and families become “empowered” to speak up when they have concerns about care.
And when they do speak up, it pays to listen.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
1. Geller SE, Rosenberg D, Cox SM, et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol. 2004;191(3):939–944.
2. Mitchell C, Lawton E, Morton C, McCain C, Holtby S, Main E. California Pregnancy-Associated Mortality Review: mixed methods approach for improved case identification, cause of death analyses and translation of findings. Matern Child Health J. 2014;18(3):518–526.
3. Lyndon A, Johnson MC, Bingham D, et al. Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. Obstet Gynecol. 2015;125(5):1049–1055.
4. Maxfield DG, Lyndon A, Kennedy HP, O’Keeffe DF, Ziatnik MG. Confronting safety gaps across labor and delivery teams. Am J Obstet Gynecol. 2013;209(5):402–408.e3.
5. Lyndon A, Zlatnik MG, Maxfield DG, Lewis A, McMillan C, Kennedy HP. Contributions of clinical disconnections and unresolved conflict to failures in intrapartum safety. J Obstet Gynecol Neonatal Nurs. 2014;43(1):2–12.
1. Geller SE, Rosenberg D, Cox SM, et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol. 2004;191(3):939–944.
2. Mitchell C, Lawton E, Morton C, McCain C, Holtby S, Main E. California Pregnancy-Associated Mortality Review: mixed methods approach for improved case identification, cause of death analyses and translation of findings. Matern Child Health J. 2014;18(3):518–526.
3. Lyndon A, Johnson MC, Bingham D, et al. Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. Obstet Gynecol. 2015;125(5):1049–1055.
4. Maxfield DG, Lyndon A, Kennedy HP, O’Keeffe DF, Ziatnik MG. Confronting safety gaps across labor and delivery teams. Am J Obstet Gynecol. 2013;209(5):402–408.e3.
5. Lyndon A, Zlatnik MG, Maxfield DG, Lewis A, McMillan C, Kennedy HP. Contributions of clinical disconnections and unresolved conflict to failures in intrapartum safety. J Obstet Gynecol Neonatal Nurs. 2014;43(1):2–12.
ACOG: IV regimen safely resolved acute headache in pregnant women
SAN FRANCISCO – Intravenous metoclopramide and diphenhydramine given together provided more effective headache relief than did codeine in pregnant women who did not respond initially to acetaminophen in an obstetrical triage unit.
Unexplained headache is a fairly common occurrence in pregnancy, estimated to occur in 15%-20% of patients, according to Dr. Katherine Scolari Childress of Saint Louis University.
Acetaminophen is the recommended first-line therapy, she said. But when it does not work, second-line therapy is more controversial. Opiates, NSAIDs, and triptans have all been used; however, these medications have been classified as category C in pregnancy, and there can be the potential for abuse, maternal dependence, neonatal withdrawal, and safety, Dr. Scolari Childress said.
She presented data on 46 normotensive pregnant women in their second or third trimester who presented with headache to an obstetric triage unit. Patients were initially treated with 650-1,000 mg of acetaminophen, which did not adequately resolve their pain. They then were randomized to receive either intravenous metoclopromide and diphenhydramine (MAD) (10 mg and 25 mg, respectively) or 30 mg oral codeine.
Patients who received MAD were significantly more likely to respond to just one dose (100% vs. 62% of patients receiving codeine), significantly more likely to experience full relief of headache pain (65% vs. 29%), and significantly more likely to say they would use the medication again (96% vs. 37%), Dr. Scolari Childress reported at the annual meeting of the American College of Obstetricians and Gynecologists.
Patients treated with MAD also spent less time on the unit – 231 minutes vs. 242 minutes for those treated with codeine – although the difference was not significant.
While the MAD regimen was more expensive than codeine – $1.54 per dose vs. $0.84 – both are low-cost treatments, she said.
Dr. Scolari Childress noted that few studies have been done on treating acute headache in pregnancy; most recommendations are based on studies of nonpregnant patients taking medications that are thought to be safe in pregnancy.
[email protected]
On Twitter @denisefulton
SAN FRANCISCO – Intravenous metoclopramide and diphenhydramine given together provided more effective headache relief than did codeine in pregnant women who did not respond initially to acetaminophen in an obstetrical triage unit.
Unexplained headache is a fairly common occurrence in pregnancy, estimated to occur in 15%-20% of patients, according to Dr. Katherine Scolari Childress of Saint Louis University.
Acetaminophen is the recommended first-line therapy, she said. But when it does not work, second-line therapy is more controversial. Opiates, NSAIDs, and triptans have all been used; however, these medications have been classified as category C in pregnancy, and there can be the potential for abuse, maternal dependence, neonatal withdrawal, and safety, Dr. Scolari Childress said.
She presented data on 46 normotensive pregnant women in their second or third trimester who presented with headache to an obstetric triage unit. Patients were initially treated with 650-1,000 mg of acetaminophen, which did not adequately resolve their pain. They then were randomized to receive either intravenous metoclopromide and diphenhydramine (MAD) (10 mg and 25 mg, respectively) or 30 mg oral codeine.
Patients who received MAD were significantly more likely to respond to just one dose (100% vs. 62% of patients receiving codeine), significantly more likely to experience full relief of headache pain (65% vs. 29%), and significantly more likely to say they would use the medication again (96% vs. 37%), Dr. Scolari Childress reported at the annual meeting of the American College of Obstetricians and Gynecologists.
Patients treated with MAD also spent less time on the unit – 231 minutes vs. 242 minutes for those treated with codeine – although the difference was not significant.
While the MAD regimen was more expensive than codeine – $1.54 per dose vs. $0.84 – both are low-cost treatments, she said.
Dr. Scolari Childress noted that few studies have been done on treating acute headache in pregnancy; most recommendations are based on studies of nonpregnant patients taking medications that are thought to be safe in pregnancy.
[email protected]
On Twitter @denisefulton
SAN FRANCISCO – Intravenous metoclopramide and diphenhydramine given together provided more effective headache relief than did codeine in pregnant women who did not respond initially to acetaminophen in an obstetrical triage unit.
Unexplained headache is a fairly common occurrence in pregnancy, estimated to occur in 15%-20% of patients, according to Dr. Katherine Scolari Childress of Saint Louis University.
Acetaminophen is the recommended first-line therapy, she said. But when it does not work, second-line therapy is more controversial. Opiates, NSAIDs, and triptans have all been used; however, these medications have been classified as category C in pregnancy, and there can be the potential for abuse, maternal dependence, neonatal withdrawal, and safety, Dr. Scolari Childress said.
She presented data on 46 normotensive pregnant women in their second or third trimester who presented with headache to an obstetric triage unit. Patients were initially treated with 650-1,000 mg of acetaminophen, which did not adequately resolve their pain. They then were randomized to receive either intravenous metoclopromide and diphenhydramine (MAD) (10 mg and 25 mg, respectively) or 30 mg oral codeine.
Patients who received MAD were significantly more likely to respond to just one dose (100% vs. 62% of patients receiving codeine), significantly more likely to experience full relief of headache pain (65% vs. 29%), and significantly more likely to say they would use the medication again (96% vs. 37%), Dr. Scolari Childress reported at the annual meeting of the American College of Obstetricians and Gynecologists.
Patients treated with MAD also spent less time on the unit – 231 minutes vs. 242 minutes for those treated with codeine – although the difference was not significant.
While the MAD regimen was more expensive than codeine – $1.54 per dose vs. $0.84 – both are low-cost treatments, she said.
Dr. Scolari Childress noted that few studies have been done on treating acute headache in pregnancy; most recommendations are based on studies of nonpregnant patients taking medications that are thought to be safe in pregnancy.
[email protected]
On Twitter @denisefulton
AT THE ACOG ANNUAL CLINICAL MEETING
Key clinical point: Intravenous metoclopramide and diphenhydramine relieved headaches more effectively than did codeine in pregnant patients who presented urgently.
Major finding: Patients who received MAD were significantly more likely than those who received codeine to experience full relief of headache pain (65% vs. 29%).
Data source: A randomized study of 46 normotensive pregnant women in their second or third trimester with headache that was not resolved with acetaminophen.
Disclosures: The investigators reported no relevant conflicts of interest.
When Wrong Test Is Ordered, “Wrongful Birth” Results
At a New Jersey hospital, a pregnant woman underwent an ultrasound examination with results suggesting a possible fetal abnormality. In response, DNA testing of the patient and her husband was ordered to investigate for a suspected hormonal disorder. But the wrong test was ordered, and the results of that test were negative.
A baby girl was born with congenital adrenal hyperplasia, a condition causing ambiguous genitalia due to exposure to high concentrations of androgens in utero. She underwent genital reconstructive surgery at age 4 months and is expected to require additional surgery, lifelong hormone replacement therapy, and lifelong monitoring.
The parents claimed that they would have elected to terminate the pregnancy if they had been properly informed of the child’s condition.
What was the outcome? >>
OUTCOME
A jury returned a ruling of 75% liability to the hospital and 25% liability to a hospital lab technician. The verdict was for $1 million, comprising $625,000 for the child and $375,000 for her parents.
COMMENT
The controversial legal theory of recovery in this case is known as “wrongful life” or “wrongful birth.” To prevail on these tort actions, one must prove that the defendant’s negligence led to the birth of an infant following a pregnancy that would have been terminated, had the parents been given all the prenatal screening information required by the standard of care.
The goal of any prenatal screening program should be to provide parents with information that is adequate, accurate, and timely. In this case, after the suspicious sonographic findings were encountered, the wrong test was ordered and the diagnosis was missed. Each practice providing prenatal screening should have a checklist to confirm that the correct test was ordered, completed, and documented—not to mention discussed with the patient in a timely manner.
In this case, the clinician ordered the wrong test, which left the patient with inadequate information. From the facts given, it is unclear if the ordering clinician became aware of this fact and what information, if any, the patient was given regarding the error. Importantly, information must also be given in a timely manner, leaving the patient adequate time to make an informed decision regarding termination—before fetal viability. But how is viability defined?
Although a detailed discussion of the constitutional principles of fetal viability is beyond the scope of this commentary, three US Supreme Court cases paved the way for successful wrongful life/wrongful birth actions. In Griswold v Connecticut (1965), the court held that decisions regarding birth control were protected by the right to privacy. In Roe v Wade (1973), the court held that a constitutionally protected right to privacy exists with regard to pregnancy terminations until the point of “viability,” originally defined as between 24 and 28 gestational weeks. Planned Parenthood v Casey (1991) held that advances in neonatal care required a revised definition of viability to a point “somewhat earlier,” without establishing a specific bright-line rule for viability.
To complicate matters, in recent years, at least 14 states (Alabama, Arizona, Arkansas, Georgia, Idaho, Indiana, Kansas, Louisiana, Mississippi, Nebraska, North Carolina, North Dakota, Oklahoma, and Texas) have redefined viability and passed laws banning therapeutic abortion beyond week 20 (although some of these bans have been judicially blocked). In states with this type of legislation, whether a clinician could be held legally responsible for failing to provide information necessary to permit an informed decision prior to the 20-week mark is unclear.
Questions as to whether these state laws were in conflict with Roe v Wade led to a constitutional challenge. In 2013, the US Court of Appeals for the Ninth Circuit (the highest level before the Supreme Court) ruled that a 20-week cutoff was unconstitutional because it violated the “viability rule” established by Roe and Casey. The Supreme Court declined to review that decision.1
Damage awards in wrongful life/wrongful birth cases are often substantial. The verdict in this case was relatively restrained.
Without doubt, this is a sensitive issue, and respect for our fellow clinicians’ opinions is warranted. However, from a liability standpoint, the safest course of action is to provide patients with all the necessary information—including prenatal testing results—as soon as possible, allowing them to make an informed decision before viability (however that is defined in your state). —DML
REFERENCE
1. Isaacson v. Horne, 716 F.3d 1213, 1225 (9th Cir. 2013), cert denied, 134 S. Ct. 905 (2014).
At a New Jersey hospital, a pregnant woman underwent an ultrasound examination with results suggesting a possible fetal abnormality. In response, DNA testing of the patient and her husband was ordered to investigate for a suspected hormonal disorder. But the wrong test was ordered, and the results of that test were negative.
A baby girl was born with congenital adrenal hyperplasia, a condition causing ambiguous genitalia due to exposure to high concentrations of androgens in utero. She underwent genital reconstructive surgery at age 4 months and is expected to require additional surgery, lifelong hormone replacement therapy, and lifelong monitoring.
The parents claimed that they would have elected to terminate the pregnancy if they had been properly informed of the child’s condition.
What was the outcome? >>
OUTCOME
A jury returned a ruling of 75% liability to the hospital and 25% liability to a hospital lab technician. The verdict was for $1 million, comprising $625,000 for the child and $375,000 for her parents.
COMMENT
The controversial legal theory of recovery in this case is known as “wrongful life” or “wrongful birth.” To prevail on these tort actions, one must prove that the defendant’s negligence led to the birth of an infant following a pregnancy that would have been terminated, had the parents been given all the prenatal screening information required by the standard of care.
The goal of any prenatal screening program should be to provide parents with information that is adequate, accurate, and timely. In this case, after the suspicious sonographic findings were encountered, the wrong test was ordered and the diagnosis was missed. Each practice providing prenatal screening should have a checklist to confirm that the correct test was ordered, completed, and documented—not to mention discussed with the patient in a timely manner.
In this case, the clinician ordered the wrong test, which left the patient with inadequate information. From the facts given, it is unclear if the ordering clinician became aware of this fact and what information, if any, the patient was given regarding the error. Importantly, information must also be given in a timely manner, leaving the patient adequate time to make an informed decision regarding termination—before fetal viability. But how is viability defined?
Although a detailed discussion of the constitutional principles of fetal viability is beyond the scope of this commentary, three US Supreme Court cases paved the way for successful wrongful life/wrongful birth actions. In Griswold v Connecticut (1965), the court held that decisions regarding birth control were protected by the right to privacy. In Roe v Wade (1973), the court held that a constitutionally protected right to privacy exists with regard to pregnancy terminations until the point of “viability,” originally defined as between 24 and 28 gestational weeks. Planned Parenthood v Casey (1991) held that advances in neonatal care required a revised definition of viability to a point “somewhat earlier,” without establishing a specific bright-line rule for viability.
To complicate matters, in recent years, at least 14 states (Alabama, Arizona, Arkansas, Georgia, Idaho, Indiana, Kansas, Louisiana, Mississippi, Nebraska, North Carolina, North Dakota, Oklahoma, and Texas) have redefined viability and passed laws banning therapeutic abortion beyond week 20 (although some of these bans have been judicially blocked). In states with this type of legislation, whether a clinician could be held legally responsible for failing to provide information necessary to permit an informed decision prior to the 20-week mark is unclear.
Questions as to whether these state laws were in conflict with Roe v Wade led to a constitutional challenge. In 2013, the US Court of Appeals for the Ninth Circuit (the highest level before the Supreme Court) ruled that a 20-week cutoff was unconstitutional because it violated the “viability rule” established by Roe and Casey. The Supreme Court declined to review that decision.1
Damage awards in wrongful life/wrongful birth cases are often substantial. The verdict in this case was relatively restrained.
Without doubt, this is a sensitive issue, and respect for our fellow clinicians’ opinions is warranted. However, from a liability standpoint, the safest course of action is to provide patients with all the necessary information—including prenatal testing results—as soon as possible, allowing them to make an informed decision before viability (however that is defined in your state). —DML
REFERENCE
1. Isaacson v. Horne, 716 F.3d 1213, 1225 (9th Cir. 2013), cert denied, 134 S. Ct. 905 (2014).
At a New Jersey hospital, a pregnant woman underwent an ultrasound examination with results suggesting a possible fetal abnormality. In response, DNA testing of the patient and her husband was ordered to investigate for a suspected hormonal disorder. But the wrong test was ordered, and the results of that test were negative.
A baby girl was born with congenital adrenal hyperplasia, a condition causing ambiguous genitalia due to exposure to high concentrations of androgens in utero. She underwent genital reconstructive surgery at age 4 months and is expected to require additional surgery, lifelong hormone replacement therapy, and lifelong monitoring.
The parents claimed that they would have elected to terminate the pregnancy if they had been properly informed of the child’s condition.
What was the outcome? >>
OUTCOME
A jury returned a ruling of 75% liability to the hospital and 25% liability to a hospital lab technician. The verdict was for $1 million, comprising $625,000 for the child and $375,000 for her parents.
COMMENT
The controversial legal theory of recovery in this case is known as “wrongful life” or “wrongful birth.” To prevail on these tort actions, one must prove that the defendant’s negligence led to the birth of an infant following a pregnancy that would have been terminated, had the parents been given all the prenatal screening information required by the standard of care.
The goal of any prenatal screening program should be to provide parents with information that is adequate, accurate, and timely. In this case, after the suspicious sonographic findings were encountered, the wrong test was ordered and the diagnosis was missed. Each practice providing prenatal screening should have a checklist to confirm that the correct test was ordered, completed, and documented—not to mention discussed with the patient in a timely manner.
In this case, the clinician ordered the wrong test, which left the patient with inadequate information. From the facts given, it is unclear if the ordering clinician became aware of this fact and what information, if any, the patient was given regarding the error. Importantly, information must also be given in a timely manner, leaving the patient adequate time to make an informed decision regarding termination—before fetal viability. But how is viability defined?
Although a detailed discussion of the constitutional principles of fetal viability is beyond the scope of this commentary, three US Supreme Court cases paved the way for successful wrongful life/wrongful birth actions. In Griswold v Connecticut (1965), the court held that decisions regarding birth control were protected by the right to privacy. In Roe v Wade (1973), the court held that a constitutionally protected right to privacy exists with regard to pregnancy terminations until the point of “viability,” originally defined as between 24 and 28 gestational weeks. Planned Parenthood v Casey (1991) held that advances in neonatal care required a revised definition of viability to a point “somewhat earlier,” without establishing a specific bright-line rule for viability.
To complicate matters, in recent years, at least 14 states (Alabama, Arizona, Arkansas, Georgia, Idaho, Indiana, Kansas, Louisiana, Mississippi, Nebraska, North Carolina, North Dakota, Oklahoma, and Texas) have redefined viability and passed laws banning therapeutic abortion beyond week 20 (although some of these bans have been judicially blocked). In states with this type of legislation, whether a clinician could be held legally responsible for failing to provide information necessary to permit an informed decision prior to the 20-week mark is unclear.
Questions as to whether these state laws were in conflict with Roe v Wade led to a constitutional challenge. In 2013, the US Court of Appeals for the Ninth Circuit (the highest level before the Supreme Court) ruled that a 20-week cutoff was unconstitutional because it violated the “viability rule” established by Roe and Casey. The Supreme Court declined to review that decision.1
Damage awards in wrongful life/wrongful birth cases are often substantial. The verdict in this case was relatively restrained.
Without doubt, this is a sensitive issue, and respect for our fellow clinicians’ opinions is warranted. However, from a liability standpoint, the safest course of action is to provide patients with all the necessary information—including prenatal testing results—as soon as possible, allowing them to make an informed decision before viability (however that is defined in your state). —DML
REFERENCE
1. Isaacson v. Horne, 716 F.3d 1213, 1225 (9th Cir. 2013), cert denied, 134 S. Ct. 905 (2014).
Is it time to revive rotational forceps?
The relative safety of instrumental rotations in the second stage of labor remains controversial. Older reports suggest an unacceptable risk of fetal injury, while recent studies demonstrate more favorable outcomes without significant fetal or maternal morbidity. This study by Aiken and colleagues goes one step further by using propensity analysis to adjust for the likelihood of receiving an attempted instrumental rotation.
Details of the study
With a cohort of 833 women with second-stage positional abnormalities, Aiken and colleagues compared maternal and newborn outcomes associated with cesarean delivery (n = 534) with those of an attempted rotational procedure (n = 334). Among the attempted instrumental rotations, 299 (90%) were successful. By intention to treat, failed attempts at rotation and vaginal delivery were included in the instrumental rotation group. The authors relied on propensity analysis to adjust for selection bias.
Strengths and weaknesses
The main strengths of this study are the relatively large sample size, the inclusion of failed procedures in the forceps group based on intention to treat, the robust approach to adjusting for the likelihood of undergoing an attempted rotation, and the contemporary nature of the cohort.
However, the study has 4 important limitations:
- More than 30% of rotations were attempted with vacuum devices. Many clinicians, including me, eschew vacuum deliveries for rotation due to reported higher failure rates and more scalp lacerations or other trauma. The analysis was not stratified by whether the rotation was attempted with a vacuum or Kielland forceps.
- Information about maternal pelvic features, critical in determining the safety of any operative vaginal delivery, was not included. When the pelvis has anthropoid features, such as more room in the posterior segment, rotation is not needed and may be counterproductive. Android features raise the likelihood of dangerous outlet obstruction and generally suggest the need for cesarean delivery.
- As Aiken and colleagues note, manual rotations followed by instrumental delivery from an occiput anterior position were not included.
- The study was not stratified by whether the abnormal position was occiput posterior (OP) or occiput transverse (OT). Although the degree of rotation is greater with OP position, operative vaginal delivery from OT can be far more challenging.
What this evidence means for practice
Although this study does have limitations, it adds to the increasing number of contemporary reports suggesting that instrumental rotational procedures are safe. Though it is not without challenges, training in rotational forceps should continue.
— William H. Barth Jr, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
The relative safety of instrumental rotations in the second stage of labor remains controversial. Older reports suggest an unacceptable risk of fetal injury, while recent studies demonstrate more favorable outcomes without significant fetal or maternal morbidity. This study by Aiken and colleagues goes one step further by using propensity analysis to adjust for the likelihood of receiving an attempted instrumental rotation.
Details of the study
With a cohort of 833 women with second-stage positional abnormalities, Aiken and colleagues compared maternal and newborn outcomes associated with cesarean delivery (n = 534) with those of an attempted rotational procedure (n = 334). Among the attempted instrumental rotations, 299 (90%) were successful. By intention to treat, failed attempts at rotation and vaginal delivery were included in the instrumental rotation group. The authors relied on propensity analysis to adjust for selection bias.
Strengths and weaknesses
The main strengths of this study are the relatively large sample size, the inclusion of failed procedures in the forceps group based on intention to treat, the robust approach to adjusting for the likelihood of undergoing an attempted rotation, and the contemporary nature of the cohort.
However, the study has 4 important limitations:
- More than 30% of rotations were attempted with vacuum devices. Many clinicians, including me, eschew vacuum deliveries for rotation due to reported higher failure rates and more scalp lacerations or other trauma. The analysis was not stratified by whether the rotation was attempted with a vacuum or Kielland forceps.
- Information about maternal pelvic features, critical in determining the safety of any operative vaginal delivery, was not included. When the pelvis has anthropoid features, such as more room in the posterior segment, rotation is not needed and may be counterproductive. Android features raise the likelihood of dangerous outlet obstruction and generally suggest the need for cesarean delivery.
- As Aiken and colleagues note, manual rotations followed by instrumental delivery from an occiput anterior position were not included.
- The study was not stratified by whether the abnormal position was occiput posterior (OP) or occiput transverse (OT). Although the degree of rotation is greater with OP position, operative vaginal delivery from OT can be far more challenging.
What this evidence means for practice
Although this study does have limitations, it adds to the increasing number of contemporary reports suggesting that instrumental rotational procedures are safe. Though it is not without challenges, training in rotational forceps should continue.
— William H. Barth Jr, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
The relative safety of instrumental rotations in the second stage of labor remains controversial. Older reports suggest an unacceptable risk of fetal injury, while recent studies demonstrate more favorable outcomes without significant fetal or maternal morbidity. This study by Aiken and colleagues goes one step further by using propensity analysis to adjust for the likelihood of receiving an attempted instrumental rotation.
Details of the study
With a cohort of 833 women with second-stage positional abnormalities, Aiken and colleagues compared maternal and newborn outcomes associated with cesarean delivery (n = 534) with those of an attempted rotational procedure (n = 334). Among the attempted instrumental rotations, 299 (90%) were successful. By intention to treat, failed attempts at rotation and vaginal delivery were included in the instrumental rotation group. The authors relied on propensity analysis to adjust for selection bias.
Strengths and weaknesses
The main strengths of this study are the relatively large sample size, the inclusion of failed procedures in the forceps group based on intention to treat, the robust approach to adjusting for the likelihood of undergoing an attempted rotation, and the contemporary nature of the cohort.
However, the study has 4 important limitations:
- More than 30% of rotations were attempted with vacuum devices. Many clinicians, including me, eschew vacuum deliveries for rotation due to reported higher failure rates and more scalp lacerations or other trauma. The analysis was not stratified by whether the rotation was attempted with a vacuum or Kielland forceps.
- Information about maternal pelvic features, critical in determining the safety of any operative vaginal delivery, was not included. When the pelvis has anthropoid features, such as more room in the posterior segment, rotation is not needed and may be counterproductive. Android features raise the likelihood of dangerous outlet obstruction and generally suggest the need for cesarean delivery.
- As Aiken and colleagues note, manual rotations followed by instrumental delivery from an occiput anterior position were not included.
- The study was not stratified by whether the abnormal position was occiput posterior (OP) or occiput transverse (OT). Although the degree of rotation is greater with OP position, operative vaginal delivery from OT can be far more challenging.
What this evidence means for practice
Although this study does have limitations, it adds to the increasing number of contemporary reports suggesting that instrumental rotational procedures are safe. Though it is not without challenges, training in rotational forceps should continue.
— William H. Barth Jr, MD
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