Impact of obesity on rates of successful vaginal delivery after term induction of labor

Objective: Determine success of term inductions of labor among an obese patient population. Methods: A retrospective chart review of all women greater than 37 weeks gestation who underwent induction of labor at University of Iowa Hospital and Clinics (12-2012 to 03-2013). Chart abstraction included data from the patient’s prenatal care, medical history, labor history, delivery and postpartum course. Subjects were stratified by pre-pregnancy BMI. Results: 74 inductions occurred at greater than 37 weeks gestation during the study period. Successful vaginal delivery (operative and spontaneous) occurred for 80.4% of normal weight women versus 82.6% for women who were obese pre-pregnancy (p=0.85). Induction of obese women was associated with significantly longer infant admission (2.82 days vs 6.09 days, p=0.03) and a higher likelihood to be admitted to neonatal intensive care (5.88% vs 26.09%, p=.021). Conclusions: While rates of successful vaginal delivery following induction were similar between normal weight and obese women, infants of obese women were more likely to require admission to neonatal intensive care and require longer hospital stays

New directions in medical student clerkship evaluations

Purpose: To compare the number of requested medical student evaluations with mean evaluation scores and final clerkship grades. Background: The University of Iowa Obstetrics & Gynecology (OBGYN) clerkship requires six evaluations for each student: two assigned and four requested by the student. Many students request more evaluations than required, contributing to a backlog that slows the grading process. Methods: Medical student evaluations from 2014 to 2016 were analyzed. Three groups were created based on the number of evaluations an individual student received. Group 1 received 3-4 evaluations (73), Group 2 received 5-6 evaluations (240) and Group 3 received 7-16 evaluations (222). A paired T-test compared mean evaluation scores and a chi-square test was used to compare mean shelf exam scores and percentages of pass, near honors, and honors grades. Results: A total of 535 independent students and their evaluations were reviewed for the study. The difference in mean evaluation scores for groups 1 and 2 and groups 2 and 3 were statistically significant (p 0.05). Similarly, the differences in rates of pass, near honors, and honors grades between groups were not statistically significant (p > 0.05). Discussion: Increased number of requested evaluations did not translate to differences in rates of pass, near honors, and honors grades for medical students on their OBGYN clerkship, indicating that decreasing the mandatory evaluations per student would not be detrimental to student outcomes and would potentially expedite the grading process

Prevalence, attitudes and knowledge of misoprostol for self-induction of abortion in women presenting for abortion at Midwestern reproductive health

Expansive restrictions to legal abortion have led to reports of self-induced termination of undesired pregnancies with misoprostol obtained without a prescription or provider. This study seeks to describe the prevalence of women seeking or employing misoprostol for self-induced abortion and how they access information. Women are accessing information regarding misoprostol for self-induction of abortion on the internet and as barriers to legal abortion increase, women may be more likely to self-induce abortion

The effects of obesity with pregnancy termination: a literature review

Obesity has become a major health problem in the United States as well as globally which may affect the safety of pregnancy termination. Thus, a literature review was conducted to determine the available evidence regarding the effects of obesity with pregnancy termination to assist with patient care and counseling. The available evidence is limited by small numbers and descriptive study design. While pregnancy termination upon obese women may impart additional technical challenges, experienced providers complete procedures upon obese women without statistically significant differences in procedure or patient outcomes compared to normal weight women for first trimester gestations. Pharmacological abortion may be a more practical option in some very obese women

Effect of chlorhexidine skin prep and subcuticular skin closure on post-operative infectious morbidity and wound complications following cesarean section

Abstract: Background: The obstetrical department at University of Iowa implemented several interventions at reducing post-operative infections and wound complication rates following a cesarean delivery. We implemented subcuticular closure of the skin following all cesarean sections in February of 2011 and switched from a povidone/iodine skin prep to a chlorhexidine-alcohol prep April 19th 2011. Based on prior studies, we hypothesized a 50% reduction in post cesarean wound complications Objective: To determine if changes in skin prep type and closure method decreases post-operative infectious morbidity and wound complications. Methods: The study reviewed charts of women who underwent a cesarean section between 7/1/2010 and 12/31/2010 compared to those that underwent a cesarean section between 4/19/2011 and 9/7/2011. A total of 568 charts were reviewed. Women were divided into two groups; the control group included those who had a povidone/iodine skin prep and staple closure, the intervention group included those women who had chlorhexidine skin prep and skin closure with subcuticular suture. Results: A total of 568 charts were reviewed and 190 control (iodine/staples) subjects and 139 intervention (chlorhexidine-alcohol/suture) subjects were identified. We found no statistical difference in the overall wound complication rates between the control and intervention groups, 22.1% vs 17.4% (p.22). We did however find a significant decrease in wound separation rates: 8.4% vs 3% (p.014) Analysis showed significant risk factors for infectious morbidity and wound separation to be labor prior to surgery (p Conclusion: In our population the implementation of a chlorhexidine skin prep and closure of the skin with a subcuticular suture did not decrease overall infectious morbidity, it did however decrease our wound separation rate

Look before you LEEP: patient reported pain with IV sedation vs local analgesia

Objective: Examine the effectiveness of IV sedation in addition local analgesia compared to local analgesia alone for LEEP pain management. Methods: This quality improvement project surveyed 89 patients who underwent a LEEP procedure: 26 in the local only group and 63 in the IV + local group. Patients completed a visual analog scale and pain survey immediately following their LEEP. Results: The local analgesia + IV sedation group reported a lower average pain score compared to the local analgesia only group (2.4 ± 2.2 v 3.6 ± 2.7). However, this was not statistically significant, p 0.47. Patients found it was helpful to know what to expect prior to the LEEP and utilized various means of pain relief in addition to the primary treatments assessed. Conclusions: There is a need for high quality trials to determine best practices of pain management

Retroperitoneal hematoma following hysteroscopic removal of levonorgestrel intrauterine system: a case report

Long acting reversible contraceptive (LARC) devices such as the levonorgestrel intrauterine system (LNG-IUS) have increased in use. Care should be taken with insertion and removal of the device as, although rare, serious complications can occur. We present a case of retroperitoneal hematoma following hysteroscopic removal of LNG-IUS

A select issue in the postpartum period: contraception

One half of pregnancies in the United States are unintended and associated with adverse pregnancy outcomes. The postpartum period is an important, yet underutilized, time to initiate contraception. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 provides evidence-based guidelines for choosing a contraceptive method and an update in 2011 specifically addresses contraceptive method use in the puerperium. The variety of contraceptive methods include hormonal contraception, lactational amenorrhea, barrier contraception, natural family planning, and sterilization. Ideally, counseling about contraceptive choice should begin early in pregnancy care and continue postpartum; it should also include a variety of teaching modalities. Specifically we recommend LARC options such as intrauterine devices and etonorgestrel implants, postpartum tubal sterilization, and progestin-only pills for those desiring an oral method

A select issue in the postpartum period: contraception

One half of pregnancies in the United States are unintended and associated with adverse pregnancy outcomes. The postpartum period is an important, yet underutilized, time to initiate contraception. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 provides evidence-based guidelines for choosing a contraceptive method and an update in 2011 specifically addresses contraceptive method use in the puerperium. The variety of contraceptive methods include hormonal contraception, lactational amenorrhea, barrier contraception, natural family planning, and sterilization. Ideally, counseling about contraceptive choice should begin early in pregnancy care and continue postpartum; it should also include a variety of teaching modalities. Specifically we recommend LARC options such as intrauterine devices and etonorgestrel implants, postpartum tubal sterilization, and progestin-only pills for those desiring an oral method

Planned use of long acting reversible postpartum contraception in low-risk women in CenteringPregnancy® group versus individual physician prenatal care

Introduction: Education on effective contraceptive methods is necessary during the prenatal period to help women achieve optimal birth spacing. This study identified rates of long-acting reversible contraception (LARC) uptake in women who attended CenteringPregnancy® (CP) group prenatal care versus individual physician care (IP). Methods: Charts for low-risk women who participated in group CP or IP prenatal care between March 2012 and May 2016 were reviewed. Charts of IP subjects were randomly selected in each year to achieve a CP:IP ratio of at least 1:3. The primary outcome was rate of LARC use at discharge and within 8 weeks postpartum. Pearson chi-squared test and Wilcoxon rank-sum tests were performed, and a p-value <0.05 was considered significant. Results: 129 women participated in CP care and 412 in IP care. CP women were more likely nulliparous (91, or 70.5% vs 212, or 51.5%, p=0.0001) and more likely to attend at least 15 prenatal visits (54, or 41.9% vs 62, or 15.1%, p<0.0001). LARC use rates at discharge and at the postpartum visit were similar (36, or 27.9% vs 89, or 21.6%, p=0.142; 39, or 32.2% vs 110, or 29.4%, p=0.557). Rates of women using effective contraception (LARC and other hormonal options, including oral contraceptives and Depo Provera) at discharge and at the postpartum visit were similar (59, or 45.7% vs 206, or 50.0%, p=0.177; 72, or 59.5% vs 229, or 61.2%, p=0.157). IUD use was greater than subdermal implant use in both groups (31, or 24.0% vs 5, or 3.9%; 72, or 17.5% vs 17, or 4.1%; p=0.081). Rates of routine postpartum visit attendance at 6-8 weeks postpartum were similar and high in both groups (121, or 93.8% vs 374, or 90.8%; adjusted p-value=0.164). Conclusion: Although CP subjects had more prenatal visits and spent more time with providers, there was no difference on uptake of LARC or effective contraception at discharge or at the postpartum visit when compared to IP subjects