Quality of Care and Patient Safety

This issue of Proceedings in Obstetrics and Gynecology (POG) is devoted to exploring issues related to the quality of care provided to patients and to patient safety

Importance of the physical exam and in-office tests in the evaluation of vulvovaginal irritation

Background: Vulvovaginal irritation is a common gynecologic complaint. A number of factors may lead to a trial of therapy without undertaking a physical exam or diagnostic testing. Case Report: A 45 year-old woman presented to our colposcopy clinic for evaluation of an abnormal Papanicolaou (Pap) test. She reported a one month history of vulvovaginal irritation, for which Premarin vaginal cream had been empirically prescribed. Examination of the external genitalia showed ulcers and erythema of the labia minora. Speculum exam was deferred because of the patient’s discomfort. Wet mount microscopy from a vaginal swab revealed evidence of Trichomonas vaginalis, bacterial vaginosis (BV), and yeast. A swab of the ulcers was sent for herpes simplex virus (HSV) polymerase chain reaction (PCR); this confirmed HSV-2. Treatment was initiated for each of these conditions, and the patient returned for colposcopy 21 days later. Conclusion: This case illustrates the importance of the physical exam when evaluating a complaint of vulvovaginal irritation. In many cases, the cause(s) of vulvovaginal irritation can be identified based on physical exam findings and in-office testing with wet mount microscopy, vaginal pH, and the amine “whiff” test. In some cases, additional testing may be required to establish or confirm a diagnosis. Accurate diagnosis is essential not only to initiate appropriate therapy, but also to prevent the transmission of sexually transmitted infections. In some cases, this may decrease the delay in diagnosing vulvar gynecologic malignancies

Recovery from cesarean delivery at UIHC: a comparison to Enhanced Recovery Protocols

Enhanced Recovery After Surgery programs (ERAS) have been used by some specialties for years, and are now becoming popular for gynecologic and obstetrics surgeries. ERAS programs consist of evidence-based interventions during a patient’s hospital stay that are intended to promote early return to activities such as eating, ambulation, and voiding and to manage pain. These programs reduce the risk of complications post-operatively and shorten a patient’s hospital stay. The University of Iowa Hospitals and Clinics (UIHC) is developing an ERAS protocol for cesarean deliveries. Our goal was to determine how current practices and outcomes for cesarean deliveries at UIHC compare to established ERAS programs. We also sought to identify which patients would be appropriate candidates for an ERAS protocol at UIHC

Quantitative Blood Loss (QBL) at every delivery: a quality improvement initiative utilizing Electronic Medical Record tools

Maternal hemorrhage is a major cause of maternal morbidity and mortality in the United States and efforts are in place to eliminate preventable harm. Accurate assessment of blood lost around the time of birth is essential for timely recognition and intervention. As part of the Alliance for Innovation on Maternal Health (AIM) Obstetrical Hemorrhage Patient Safety Bundle at our institution a quantitative blood loss (QBL) calculator was created within the electronic medical record. This process allows for real-time tracking of cumulative blood loss measurements and is built with triggers to alert the care team when criteria for various hemorrhage stages are achieved along with suggested interventions and assessments. The consistency of implementation and efficacy of the QBL calculator was evaluated by following both utilization of the calculator flowsheet as well as tracking of rates of erroneous QBL values, defined by negative values and cesarean deliveries with QBL2019, 14 months after implementation and post three system-based improvements. By the end of this implementation review the calculator was in use consistently at all cesarean deliveries with improved confidence in the process by providers

Does leptin predict successful induction of labor?

Obesity in pregnancy is becoming increasingly common and is associated with many pregnancy-related complications such as failed induction of labor (IOL). Leptin, an adipocytokine important in energy homeostasis, is found in higher levels in obese individuals. Leptin has also been demonstrated to have an inhibitory effect on myometrial contractility in vitro. We hypothesize that leptin may play a part in the mechanism of dysfunctional labor. Thus, we sought to compare the maternal plasma leptin levels in women that had a successful vaginal delivery post-IOL vs. those who had a C-section post-IOL

Importance of the physical exam and in-office tests in the evaluation of vulvovaginal irritation

Background: Vulvovaginal irritation is a common gynecologic complaint. A number of factors may lead to a trial of therapy without undertaking a physical exam or diagnostic testing.Case Report: A 45 year-old woman presented to our colposcopy clinic for evaluation of an abnormal Papanicolaou (Pap) test. She reported a one month history of vulvovaginal irritation, for which Premarin vaginal cream had been empirically prescribed. Examination of the external genitalia showed ulcers and erythema of the labia minora. Speculum exam was deferred because of the patient’s discomfort. Wet mount microscopy from a vaginal swab revealed evidence of Trichomonas vaginalis, bacterial vaginosis (BV), and yeast. A swab of the ulcers was sent for herpes simplex virus (HSV) polymerase chain reaction (PCR); this confirmed HSV-2. Treatment was initiated for each of these conditions, and the patient returned for colposcopy 21 days later.Conclusion: This case illustrates the importance of the physical exam when evaluating a complaint of vulvovaginal irritation. In many cases, the cause(s) of vulvovaginal irritation can be identified based on physical exam findings and in-office testing with wet mount microscopy, vaginal pH, and the amine “whiff” test. In some cases, additional testing may be required to establish or confirm a diagnosis. Accurate diagnosis is essential not only to initiate appropriate therapy, but also to prevent the transmission of sexually transmitted infections. In some cases, this may decrease the delay in diagnosing vulvar gynecologic malignancies