Resolving the Uncertainty of Preterm Symptoms: Women’s Experiences With the Onset of Preterm Labor

Objective: To describe expectant women\u27s experiences with the onset of preterm labor. Design: Qualitative, using grounded theory methods. Setting: Southwestern tertiary women\u27s hospital. Participants: Thirty pregnant women who were less than 35 weeks gestation, had experienced preterm labor within the past 7 days, and had no previous experience with preterm labor. Data Source: Taped and transcribed interviews. Results: Themes that emerged from the interview data included the following: recognition and naming of sensations, a consistent pattern of attribution of symptoms, the threat or risk inferred by the attributed cause of the symptom pattern, the associated certainty or uncertainty about these attributions, the process of interpreting and verifying symptom meaning, and the decision to self-manage the symptoms or engage health care assistance. The core process of women experiencing the onset of preterm labor symptoms was identified as resolving the uncertainty of preterm labor symptoms: recognizing and responding to the possibilities. Conclusions: Preterm labor often is not within expectant women\u27s consciousness. They may attribute the symptoms to nonthreatening causes, which results in delays in seeking care for preterm labor. Education about symptom patterns at the onset of preterm labor will increase the probability that women and their health care providers will recognize and interpret the early, subtle symptoms that herald the onset of preterm labor. Uncertainty in illness theory and attribution theory offer frameworks for understanding women\u27s experiences with the onset of preterm labor

Not Always Black and White: Racial Bias for Birth Disparities from Excluding Hispanic Identification

Despite gains in prenatal care (PNC) usage and birth outcomes for minority women during the past few decades, observed disparities between non-Hispanic Whites, Blacks, and Hispanics persist. Using the National Center for Health Statistics’ (NCHS) natality files from 1981 through 1998, Alexander, Kogan, & Nabukera (2002) examined live births of U.S. residents by trimester in which PNC was initiated and the appropriateness of that care based on the Adequacy of Prenatal Care Utilization Index (APNCU) (Kotelchuck, 1994). They found racial disparities between White and Black women in both the trimester of PNC initiation and the number of PNC visits made. Alexander et al.(2002) noted reductions in racial disparities in PNC; specifically, Blacks were steadily increasing in the number of prenatal visits and in first trimester initiation of PNC. However, a weakness of their study was the exclusivity of racial categories; only White and Black racial groups were analyzed based on the mother’s self reported race. Other racial groups were not included because Hispanic data were not identifiable for some states during part of the study period, and other racial groups lacked sufficient numbers to establish trending in the categories of interest (Alexander et al., 2002). Thus Hispanics identified their race as White and their ethnicity as Hispanic. Alexander et al. counted both non-Hispanic Whites and Hispanics as ‘Whites’ regardless of ethnicity or the availability of ethnicity in their analysis. This created a potential source of bias, as one could speculate that the reported narrowing of racial disparities in the number of PNC visits and earlier initiation of care between Whites and Blacks could be the result of increasing births to Hispanic women included in the ‘White’ birth group. The reported narrowing of disparities could simply be the result of failing to separate Hispanic women in the analysis, a potentially significant portion of the ‘White’ group given their high fertility rates and increased percentage of the total U.S. population. While the expansion of Medicaid-sponsored funding for pregnant women likely contributed to some of the reported increases in earlier PNC initiation and the number of prenatal visits in the late 1980s and early 1990s (Hessol, Vittingoff, & Fuentes-Afflick, 2004; Hueston, Geesey, & Diaz, 2008), it is not clear if this expansion benefited one racial group over another, particularly when Hispanic ethnicity is taken into account. Therefore, the purpose of this study was to evaluate differentials in birth outcomes for singletons by race for Whites, Blacks, and Hispanics beginning in 1979 (the year when Hispanic identifiers became available in the natality files) through 2006. Specifically, we examined trends the trimester that PNC was initiated, the number of PNC visits, and birth weight by race and ethnicity. While previous studies have evaluated pregnancy outcomes based on race, the exclusion of Hispanic identifiers in the analysis (Alexander, Kogan, Himes, Mor, & Goldenberg, 1999; Alexander et al., 2002; Alexander, Wingate, Bader, & Kogan, 2008; Cox, Zhang, & Zotti, 2009; Hunsley, Levkoff, Alexander, & Tompkins, 1991) potentially introduced a bias in results reported. We estimated racial disparities between Blacks and Whites with and without Hispanic identification. Hence, we quantified the bias created due to Hispanics being identified as Whites. Although Gavin et al. (Gavin, Adams, Hartmann, Benedict, & Chireau, 2004) attempted to address this gap by including Hispanics in their analysis, only pregnancy-related care among Medicaid recipients in four states (Florida, Georgia, New Jersey, and Texas) was examined, therefore omitting a significant portion of the childbearing population. In this current study, the addition of Hispanics as a separate racial group and the extension of analysis back to 1979 through 2006 provide an additional decade of observations over previous reports. Hence this analysis is unique and more comprehensive than previous reports

Spontaneous Rupture of the Anterior Vaginal Wall during the First Stage of Labour

The risk of uterine rupture during attempted trial of labor after caesarean delivery (TOLAC) is well documented. However, vaginal rupture (in the absence of obstructed labour) is exceptionally uncommon. Below is described the rare case of a 37-year-old multiparous woman attempting TOLAC, who suffered a vaginal—rather than uterine—rupture, during the first stage of spontaneous labour. This case is an important reminder to obstetricians that concealed ruptures of both the vagina and uterus do occur and must be considered in clinical situations where another explanation is not apparent

Anterior cervico-vaginal tear along with posterior bladder wall rupture: a rare case report

A 25 year old female presented to our emergency as a case of G3P2+0 (2A and H), full term pregnancy with intrauterine foetal demise with obstructed labour with severe anaemia. In view of obstructed labour with severe anaemia suspicion of rupture uterus was raised. Abnormal contour of abdomen also raised suspicion of bladder tumour. Here emergency caesarean section was done, peroperatively she was diagnosed as a case of anterior cervico-vaginal rupture along with posterior bladder wall rupture which is a rare entity. Uterine closure was done along with anterior cervico-vaginal wall with posterior bladder wall repair. This repair was done through trans- bladder route. Unique finding of this case was tear of anterior cervico-vaginal region with associated posterior bladder wall tear without rupture of uterus despite of obstructed labour in multiparous women. Most probable cause behind this type of injury is impacted head in neglected or obstructed labour responsible for ischemia and necrosis

Preterm Birth in Twins

Multiple pregnancy differs from singleton pregnancy in several aspects, including increased risk of preeclampsia, fetal malformation, maternal morbidity, and mortality. However, certainly, prematurity is a fundamental concern when twin gestation is approached, due to the frequency of this disease and also to the severity of preterm birth, which unfortunately can also occur near to the fetal viability limit. Labor in twin pregnancy generally occurs before singleton pregnancy. Nevertheless, another factor can contribute to raise even more preterm birth rates in this already high-risk gestation: the short cervix. Although only 1–2% of twin pregnancy present short cervix at transvaginal ultrasound, this association increases the chance of unfavorable outcome for the newborn, frequently causing death of one or both twins. So, many strategies were proposed to minimize this catastrophic situation: follow-up of cervical length to prevent preterm birth, pessary use, progesterone, tocolysis to postpone birth in 48 hours to 7 days in order to use corticosteroids in fetal pulmonary maturation, and magnesium sulfate use to neuroprotection

“WE’RE HAVING THIS BABY TONIGHT!” INFORMED CONSENT AND MEDICAL DECISIONMAKING REGARDING OXYTOCIN AUGMENTATION

The medical indications for oxytocin augmentation in childbirth are inconsistent, the benefits of the intervention are often ambiguous and value-dependent, and there are significant risks, which are still being evaluated and elucidated. Providers tend to make the decision to augment labor without inquiring into patient preference. Rather providers declare their intent to augment with little or no discussion with patients, not even regarding risks, benefits and alternatives. In this thesis I argue that augmenting with oxytocin, in the absence of informed consent, violates norms of ethical clinical practice: seeking consent in cases of significant risk or ambiguous indications, avoidance of the generalization of medical expertise and bias in medical decisionmaking, and incorporation of patient preferences in shared decisionmaking. The introduction examines the goals and requirements of informed consent in general and as they relate to oxytocin augmentation. Chapter 1 argues that determination of medical need for oxytocin augmentation is complex and controversial. Chapter 2 explores a distinct hierarchy of stakeholders involved in the decision to augment, many of whom have self-interests that should be elucidated with patients when oxytocin is used. Chapter 3 argues, with particular attention to recent feminist work, that informed consent for oxytocin augmentation should be a meaningful process that promotes patient autonomy and well-being, not just an expansion of a range of choices. Using this construction of informed consent as process, it may, at least, be possible to address all three of the violated norms of ethical clinical practice, even those concerned with bias, power structure, and preference. In addition to extensive research of the literature, the material presented here draws from the author’s observations during shadowing, experiences on the labor and delivery ward as a medical student, and from discussions with clinicians, nurses, and other medical students

Implementation Of New Definitions Of Labor Arrest Disorders And Failed Induction Can Decrease The Cesarean Rate

Cesarean delivery for labor arrest currently makes up the largest proportion of primary cesarean delivery in the United States. Because cesarean delivery is associated with significant morbidity, it is important to limit its use to ensure the benefits outweigh the risks. New diagnostic criteria to limit the diagnosis of labor arrest have the potential to decrease the cesarean delivery rate. To investigate how cesarean delivery for arrest of dilation or descent and failed induction contributed to the primary cesarean delivery rate, we analyzed rates of primary cesarean for these indications among 17,864 live births at our institution from 2010 through 2013. We used multiple logistic regression modeling to identify predictors of meeting diagnostic criteria for these indications based on guidelines published in 2012 by Spong et al. From 2010 through 2013 the total primary cesarean delivery rate decreased from 23.5% to 21.1%. Over the same period, primary cesarean delivery due specifically to arrest of dilation or descent and failed induction decreased from 8.5% to 6.7%. Primary cesarean delivery due to arrest of dilation alone decreased from 5.1% to 3.4%. The rate of meeting minimum criteria for arrest of dilation increased from 18.8% to 34.9%. Primary cesarean delivery due to arrest of descent alone remained relatively stable, however, the percent of cases meeting minimum criteria increased from 57.8% to 71.0%. The rate of primary cesarean delivery due to failed induction alone also remained relatively stable, as did the percent of cases meeting minimum criteria with 50.00% meeting criteria in 2013. Attending type was a significant predictor of meetingiii criteria for all three indications. Hospitalist cases were two to seven times as likely to meet criteria compared with private cases. Dilation on admission increased, as well as the likelihood of meeting criteria for arrest of dilation and arrest of descent. Epidural use decreased the likelihood of meeting criteria for arrest of descent. In summary, the decrease in primary cesarean delivery from 2010 through 2013 is significantly attributable to a decrease in the diagnosis of labor arrest disorders and failed induction, and specifically to a decrease in diagnosis of arrest of dilation. An increased likelihood of meeting minimum criteria for arrest of dilation in 2012 and 2013 compared to 2010 suggests that applying new definitions of labor arrest published in 2012 can decrease the overall primary cesarean rate. As of 2013, only 34.9% of primary cesareans performed for arrest of dilation, 71.0% for arrest of descent, and 50.0% for failed induction, met new respective minimum diagnostic criteria. This suggests that an even bigger decrease in the primary cesarean rate can be achieved if a greater effort is made to meet minimum criteria before moving to cesarean

Nifedipine-Induced Changes in the Electrohysterogram of Preterm Contractions: Feasibility in Clinical Practice

Objective. Evaluating changes in the power spectral density (PSD) peak frequency of the electrohysterogram (EHG) caused by nifedipine in women with preterm contractions. Methods. Calculation of the PSD peak frequency in EHG contraction bursts at different times of nifedipine treatment in women in gestational age 24 to 32 weeks with contractions. Results. A significant (P < .05) decrease of PSD peak frequency between EHG signals measured before and 15 minutes after administration of nifedipine. A significant (P < .05) decrease in PSD peak frequency comparing signals recorded within 24 hours after administration of nifedipine to signals 1 day after tocolytic treatment. A higher average PSD peak frequency for patients delivering within 1 week than that for patients delivering after 1 week from nifedipine treatment (P > .05). Conclusions. EHG signal analysis has great potential for quantitative monitoring of uterine contractions. Treatment with nifedipine leads to a shift to lower PSD peak frequency in the EHG signal