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PubMed2004

Obstetric patient satisfaction: asking patients what they like.

OBJECTIVE: This study was undertaken to determine pertinent attributes of women's hospital experience related to the delivery of their children and to use open-ended responses from women to develop a taxonomy for classifying patient satisfaction in obstetrics. STUDY DESIGN: By using clinimetric methods, we interviewed 67 obstetric patients during their postpartum hospital stays, asking open-ended questions about their satisfaction with care. Responses were transcribed, arranged into distinct groups, and organized as a taxonomy of patient satisfaction. RESULTS: The final taxonomy derived from patient responses was divided into six main axes related to physicians, nurses, other staff, special services, hospital attributes, and personal focus; a total of 51 individual items were identified related to patient satisfaction. These items have face validity, and many are not routinely included in assessments of patient satisfaction. CONCLUSION: A simple strategy of using open-ended questions leads to a clinically relevant and easily understood classification scheme for patient satisfaction with in-hospital obstetric services.

Female↗
PubMed2004

Obstetrics and gynecology medical student outcomes: longitudinal multispecialty clerkship versus traditional block rotations.

OBJECTIVE: To evaluate outcomes of students in a longitudinal clerkship. STUDY DESIGN: Clerkship grades, written examination scores, and clinical evaluations were compared between students participating in a longitudinal clerkship and students in block rotations. The percent of students pursuing an obstetrics and gynecology residency from each group was evaluated. RESULTS: There was no difference in clerkship grade (3.3 versus 3.5, P = .158). Longitudinal and block students received similar clinical evaluations with no significant difference in any category. The average written examination score was lower for students in the longitudinal clerkship (76.9% versus 80.0%, P = .008). A higher percent of students in the longitudinal program chose an obstetrics and gynecology residency, 12.5% versus 6.17% (odds ratio = 2.17, 95% confidence interval 0.57-6.89, P = .18). CONCLUSIONS: Longitudinally trained students received similar clinical evaluations to their colleagues but may need assistance in acquiring the knowledge needed for the written examination. This program should be examined closely for factors influencing a higher percent of students to pursue a residency in obstetrics and gynecology.

Clinical Clerkship↗
PubMed2004

Identification of educational objectives for obstetrics and gynecology residents in the ambulatory setting.

OBJECTIVE: The primary objective of this study was to identify specific educational goals for obstetrics and gynecology residents in the ambulatory setting. STUDY DESIGN: A cross-sectional study of current practice patterns in primary care, benign gynecology, and office procedures was performed with mailings to local private practice obstetrician-gynecologists. Questions for the anonymous written survey were generated using the Council on Resident Education in Obstetrics and Gynecology educational objectives. Telephone interviews with staff from billing offices confirmed practitioner responses. RESULTS: Of 88 practitioners, 43 (49%) responded. Diagnoses made in the office correlated well with the topics considered important for resident knowledge. Most important primary care diagnoses were depression and abdominal pain; important gynecologic diagnoses were abnormal uterine bleeding, chronic pelvic pain, contraception, and vulvovaginal infection. CONCLUSION: This study offers a valid, practical foundation for developing a focused ambulatory resident education program based on current outpatient obstetrics-gynecology practice patterns.

Ambulatory Care↗
PubMed2006

Obstetric risk factors for symptomatic prolapse: a population-based approach.

OBJECTIVE: The purpose of this study was to identify obstetric risk factors for symptomatic prolapse. STUDY DESIGN: This was a population-based case-control study of prolapse prevalence. RESULTS: Four hundred fifty-four women with self-reported symptomatic pelvic organ prolapse who were identified among 5489 women who participated in a population survey (cases) and 405 control subjects without symptoms were selected randomly from the same survey. All cases and control subjects received a mailed questionnaire with 72 questions about factors that were suspected to be linked to risk and that included obstetric history. The response rate was 76%. Among parous women, the odds for symptomatic pelvic organ prolapse increased with number of childbirths and were 3.3-fold higher among mothers of 4 than among mothers of 1. Indices of excessive stretching and tearing during labor (vaginal lacerations or episiotomies) were associated with increased risk for symptomatic pelvic organ prolapse. Instrumental delivery with forceps or vacuum did not seem to increase the risk of symptomatic pelvic organ prolapse, nor did length of delivery or maternal age at time for delivery. Abdominal deliveries appeared to be protective; the age- and parity-adjusted odds ratio of symptomatic pelvic organ prolapse after > or =1 abdominal deliveries was 0.5 (95% CI, 0.3-0.9), relative to women who had had only vaginal deliveries. A positive association with child birth weight in unadjusted analyses disappeared after adjustments for attained age and parity of the mother. CONCLUSION: Excessive stretching and tearing and multiple deliveries seem to be the main predisposing obstetric factors for symptomatic pelvic organ prolapse. Abdominal delivery emerged as a comparably strong protective factor.

Adult↗
PubMed2005

Do factors that are important during obstetrics and gynecology residency program selection differ by applicant gender?

OBJECTIVE: The purpose of this study was to examine the relationship between applicant gender and factors that influence obstetrics and gynecology residency program selection. STUDY DESIGN: A national survey was conducted of graduates of US allopathic medical schools who were registered with the Electronic Residency Application Service for the year 2003 and who indicated that obstetrics and gynecology was their primary specialty choice. The selection prevalence of 20 possible influential factors was analyzed by gender. RESULTS: Our study cohort consisted of 450 eligible respondents, 80.4% of whom were female. There were no significant differences by gender in regards to applicant age, race, marital status, number of dependents, or geographic region of medical school. Overall, the 4 factors with the highest selection prevalence in both gender groups were all related to workplace environment. Compared with male respondents, female respondents were more likely to consider how well the current residents seemed to work together (99.2% vs 94.3%; P = .002) and the amount of conference/didactic teaching (80.4% vs 68.2%; P = .01). Male respondents were more likely to consider the quality of the hospital facility (92% vs 82%; P = .02), salary (28.4% vs 17.1%; P = .02), and supplemental income (moonlighting) opportunities (18.2% vs 8.6%; P = .008), as compared with female respondents. CONCLUSION: Significant differences in gender-associated preferences that are related to obstetrics and gynecology residency program selection exist and include both curricular and financial factors.

Adult↗
PubMed2005

Perinatal risk management: obstetric methods to prevent birth asphyxia.

Because obstetric care frequently is associated with the potential for liability, the purpose of this article is to familiarize the reader with perinatal risk management using the concept of foreseeability of harm and its potential application to obstetric care. At the same time, this article introduces the concept of notice, and explains the critical conduct intervals that are used to gauge how well the health care teams handle obstetric emergencies. The focus then shifts to incorporate these concepts into several maternal-child health quality management programs. It is hoped that this article will result in an improvement of perinatal outcome for pregnant women and their unborn children.

Asphyxia Neonatorum↗
PubMed2005

Diagnostic criteria and reporting procedures for pre-eclampsia: a national survey among obstetrical departments in Denmark.

OBJECTIVE: A precondition for the rational use of obstetric databases in biomedical research is detailed knowledge on how data are being generated. We identified the diagnostic procedures and criteria for pre-eclampsia (PE) and assessed the level of obstetric training of the personnel responsible for the records submitted to the patient registry at the Danish National Board of Health. STUDY DESIGN: A structured questionnaire, including three case stories, was sent to the chief consultant of the department. RESULTS: Thirty-three out of the 34 Danish departments (97%) returned the questionnaire. Reporters of pregnancy diagnoses to the National Patient Registry differed widely in training. For complicated pregnancies, departments ranged from having only specialists reporting all cases to secretaries reporting up to 50%. Cut off limits of blood pressure (BP) and protein loss used to diagnose pre-eclampsia showed large differences across departments. The diagnoses given to three case stories showed little correlation to the criteria the departments reported using. CONCLUSION: Even in a small country like Denmark with 34 obstetrical departments, there was little consensus on the diagnostic criteria for pre-eclampsia. The findings emphasize the need for standardizing diagnostic criteria and reporting practice and may have implications on how to interpret data regarding pre-eclampsia.

Blood Pressure↗
PubMed2005

Obstetric complications in Marfan syndrome.

OBJECTIVE: To investigate the obstetric maternal and neonatal outcome of pregnancy in women with Marfan syndrome. METHODS: Retrospective observational multi-center study based on congenital heart disease registry. RESULTS: Sixty-three of the 122 enrolled women with Marfan syndrome had been pregnant 142 times (including 111 pregnancies>20 weeks, 28 (20%) miscarriages and 3 elective abortions). In 40% of all completed pregnancies an obstetric and/ or neonatal complication occurred. The most important complications were an increased percentage of premature deliveries (n=17, 15%) mainly due to preterm premature rupture of membranes and cervical incompetence and a markedly increased combined fetal and neonatal mortality of 7.1%. An obstetric and/or neonatal complication occurred in a similar proportion of pregnancies in women with a diagnosis of Marfan syndrome before pregnancy versus women with a diagnosis of Marfan syndrome after pregnancy (39% vs. 41%, p=0.85, respectively). CONCLUSION: In addition to cardiovascular complications, pregnancy in women with Marfan syndrome is associated with a high rate of premature deliveries, preterm premature rupture of membranes and increased mortality in the offspring.

Abortion, Spontaneous↗
PubMed2004

Experience from Bangladesh: implementing emergency obstetric care as part of the reproductive health agenda.

This paper describes the activities of the Ministry of Health and Family Welfare of the Government of Bangladesh and UNFPA to introduce emergency obstetric care (EmOC) services into the reproductive health care agenda. Working through the existing system of Maternal and Child Welfare Centers (MCWC), the quality and availability of comprehensive Reproductive Health and Emergency Obstetric Care services was improved. Investments in training, infrastructure, management information systems, quality assurance mechanisms and linkages between health care facilities in Bangladesh, have produced positive results in terms of increased utilization of these services. The Ministry of Health first implemented services in one division of the country and later scaled up to include all of the MCWCs nationally. While there are still obstacles to preventing obstetric deaths in Bangladesh, this experience shows that improvements in the quality and expansion of the range of services in existing health systems is an important step toward increasing the use of reproductive health care services by the women who need them most.

Bangladesh↗
PubMed2006

Global patterns in availability of emergency obstetric care.

OBJECTIVE: This paper examines the availability of basic and comprehensive emergency obstetric care (EmOC), interventions used to treat direct obstetric complications. Determining what interventions are provided in health facilities is the first priority in analyzing a country's capabilities to treat obstetric emergencies. There are eight key interventions, six constitute basic EmOC and all eight comprehensive EmOC. METHODS AND RESULTS: Based on data from 24 needs assessments, the following global patterns emerge: comprehensive EmOC facilities are usually available to meet the recommended minimum number for the size of the population, basic EmOC facilities are consistently not available in sufficient numbers, both in countries with high and moderate levels of maternal mortality, and the majority of facilities offering maternity services provide only some interventions indicating an unrealized potential. CONCLUSION: Upgrading maternities, health centers and hospitals to at least basic EmOC status would be a major contributing step towards maternal mortality reduction in resource-poor countries.

Emergency Medical Services↗
PubMed2006

Optimizing umbilical cord blood collection: impact of obstetric factors versus quality of cord blood units.

INTRODUCTION: The main limitation factor for wide use of umbilical cord blood units (UCBs) as a source of hematopoietic progenitors for transplantation is cell dose. International standard guidelines recommend 2 x 10(7)/kg as the minimal nucleated cell dose for UCB transplantation for adults and 3.7 x 10(7)/kg for children. Therefore it is important to the optimize donor selection and the collection method so as to achieve high cell doses. In this study our main purpose was to determine whether obstetric factors influence UCBs collected. STUDY DESIGN: The study involved 304 UCBs collected from January to December 2004. The UCBs were collected after donor selection based on international criteria for cord blood banking. We analyzed UCB biological features such as collected volume, total nucleated cells (TNC), and CD34-positive cells, and obstetric factors. RESULTS: First, our study showed by multivariate analysis that infant weight was the main factor that influenced biologic features of UCB collected such as total volume (P = .000), TNC (P = .000), CD34 total count (P = .003), and CFU-GM (P = .004). Placental weight > 600 g produced a better volume (P = .007) and increased TNC (P = .056). Gestational age > 39 weeks enhanced CD34% (P = .016). Regarding route of delivery, we found that cesarean section produced higher volume and reduced WBC count compared to vaginal delivery, regarding cord length, it increased TNC (P = .037). And last, we noticed that female infants increased WBC (P = .013) and CD34(+) total count (P = .019) more than male ones. CONCLUSIONS: Our results confirm that volume and TNC are influenced by several obstetric factors, such as greater infant and placental weight, predicting a better collection.

Birth Weight↗
PubMed1992

Leadership qualities of obstetrics and gynecology department chairmen of United States medical schools.

OBJECTIVE: The purpose of this study is to examine leadership qualities, preparation for leadership, and perceptions of skills needed for academic leaders in obstetrics and gynecology. STUDY DESIGN: Chairmen and acting chairmen of the 122 United States medical schools with residency training programs in obstetrics and gynecology were surveyed about the stated objectives of the study. Differences in proportions were analyzed by means of the chi 2 test; the Student t test was used to compare mean ranks. RESULTS: Information was obtained from 98 (80.3%) of those surveyed. Interpersonal skills and knowledge of the specialty were identified as most important qualities leading to appointment; financial management skills were identified as most frequently lacking. Having a mentor prior to appointment was found to be associated with several characteristics. Those chairmen who had mentors were more likely to have these characteristics: (1) to have completed a subspecialty fellowship, (2) to command a larger departmental budget (greater than $4 million), (3) to have been a board examiner before appointment, and (4) to have received support in obtaining their appointment from recognized leaders in the specialty. CONCLUSION: Current academic leaders in obstetrics and gynecology must identify and prepare protégés (protégées) for future leadership roles.

Data Collection↗
PubMed1993

Frequency of glove perforations and subsequent blood contact in association with selected obstetric surgical procedures.

OBJECTIVE: One purpose of this prospective investigation was to assess the frequency of glove perforations and subsequent blood contact associated with selected obstetric procedures. The second purpose was to assess the relative risk of perforation among different members of the surgical team and determine if time of day or urgency of the procedure affected the frequency of perforation. STUDY DESIGN: Over a 3-month period, obstetric personnel were asked to double glove for all surgical procedures. After surgery, they placed their gloves in plastic bags and noted the type of procedure, time of day, and position on the surgical team. They also indicated whether they were aware of a glove tear and, if so, whether blood or fluid was on their hands. Gloves were tested for injury by two methods: by inflating them with air and subsequently immersing them in water to detect air bubbles and by directly filling them with water to observe for leaks. RESULTS: A total of 540 glove sets (2160 individual gloves) were examined; 407 sets were from cesarean deliveries, 65 from puerperal tubal ligations, and 68 from vaginal deliveries. Sixty-seven of the sets (12.4%, 95% confidence interval 9.6% to 15.2%) had at least one hole; the total number of holes was 78. Sixty-six holes were in the outer glove only, and 7 were in the inner glove only. In five sets (0.9%, 95% confidence interval 0.5% to 1.3%) there were matching holes in the outer and inner gloves. In two of these cases (0.4%, 95% confidence interval 0.1% to 0.7%) the surgeons noted blood on their hands at the conclusion of the procedure. The difference in frequency of injury in outer versus inner gloves was highly significant (p < 0.005). Forty-six of the 78 holes (59%) were on the thumb or first two fingers of the nondominant hand. Only 2 (3%) of the glove tears were recognized by the surgeon. There was no difference in frequency of glove tears when cesarean sections were classified as urgent versus nonurgent. There also was no difference in frequency of glove tears in procedures performed at night compared with those during the daytime. Surgical nurses had 36% of all glove injuries and were more likely than physicians or medical students to sustain perforations (p < 0.005). Primary surgeons and first assistants were more likely than second assistants to sustain glove injuries (p < 0.05). For primary surgeons and first assistants, level of training did not significantly affect the frequency of glove perforations. CONCLUSIONS: Glove perforations occur in approximately 12% of obstetric surgical procedures. Surgical nurses are at greatest risk for perforation. Double gloving reduces the likelihood of penetrating injury to the inner glove and subsequent risk of blood contact.

Blood↗
PubMed1998

The influence of obstetric no-fault compensation on obstetricians' practice patterns.

OBJECTIVES: The objectives were to determine level of satisfaction among obstetricians with the no-fault insurance programs in Florida and Virginia and to study any reported practice patterns attributable to implementation of no-fault compensation. STUDY DESIGN: Structured surveys were conducted with 119 obstetricians in Florida and Virginia. RESULTS: More than 90% of obstetricians were enrolled in no-fault insurance programs, but only 13% reported having had a patient compensated by a no-fault program. Only 14% knew of a colleague with a patient who had been compensated. Despite no-fault compensation, threat of lawsuits was a factor in 39% of cases of physicians who quit practicing obstetrics. The no-fault programs did not cause obstetricians to report increases in their obstetric caseloads or in their fraction of patients at high risk. Overall, obstetricians were far more satisfied with the no-fault system than with the tort system. Still, more than half of the respondents expressed dissatisfaction with premiums assessed by no-fault insurance. CONCLUSION: Obstetricians who knew about the no-fault programs were generally satisfied with their performance. However, the no-fault programs have not built a constituency with physicians, and the programs are relatively small in their scope of coverage. No-fault compensation thus has had minor impact on reported obstetric practice. To be effective in improving patient access, no-fault compensation must be broader in scope.

Data Collection↗
PubMed1998

Pulmonary edema in obstetric patients is rapidly resolved except in the presence of infection or of nitroglycerin tocolysis after open fetal surgery.

OBJECTIVES: This study was designed to determine the etiology, course, and severity of pulmonary edema in obstetric patients in a tertiary care center. STUDY DESIGN: A retrospective study was carried out on 16,810 deliveries from University of California, San Francisco, 1985-1995. Diagnosis and severity of lung injury were defined by a 4-point system that was based on the chest radiograph, oxygenation, positive end-expiratory pressure, and lung compliance. Resolution of pulmonary edema was defined by improvement in the chest radiograph and hypoxemia (ratio of arterial oxygen tension to inspired oxygen concentration) scores or by extubation. RESULTS: Pulmonary edema developed in 86 patients, or 0.5% of all obstetric cases. It usually showed extensive air space consolidation on the chest radiograph and arterial hypoxemia. Although 43% of the patients had severe pulmonary dysfunction, the average time to resolution of pulmonary edema was 2.4 days. Only 45% of patients required admission to the intensive care unit and only 15% required intubation and positive-pressure ventilation. Patients with infection (mean of 7.2 days) or fetal surgery (mean of 3.8 days) had the most severe, protracted course. CONCLUSION: Although obstetric pulmonary edema is associated with extensive radiographic infiltrates and severe hypoxemia, resolution occurs rapidly in most patients, limiting the need for intensive care support.

Critical Care↗
PubMed1999

Response of obstetrics and gynecology program directors to a domestic violence lecture module.

OBJECTIVE: Our goal was to determine the use by obstetrics and gynecology residency program directors of The American College of Obstetricians and Gynecologists' domestic violence slide lecture module and the opinions of the directors regarding its efficacy. STUDY DESIGN: A 6-question survey was mailed to 289 directors of accredited obstetrics and gynecology programs in the United States and Canada 9 and 13 months after a learning module on domestic violence was mailed to these same persons. The questions related to receipt and use of the module in the curriculum, target audiences, future plans for integration of the module into curricula, and recommendations for future supplemental topics in the same format. RESULTS: The return rate for the survey was 57% (164/289). The responses represented university-affiliated, community- and military-based programs with representation from all geographic areas of the country. Fourteen directors who had no recollection of receiving the package were sent a second set. The lecture had been presented by 72% of the respondents' departments to audiences of residents (89%), medical students (55%), practicing physicians (41%), and the lay public (11%). Two thirds of the nonusers and 87% of the users intended to use the module as a formal lecture in the curriculum of both residents and medical students in the coming school year. Recommendations for future supplemental lecture packages included abuse during pregnancy, screening women with different cultural backgrounds, and how to ask tough questions. CONCLUSION: The majority of obstetrics and gynecology resident program directors who responded to the survey integrated or will integrate an American College of Obstetricians and Gynecologists-created learning module on domestic violence into their residents' and medical students' formal curricula.

Community Health Services↗
PubMed2003

HIV infection in critically ill obstetrical patients.

OBJECTIVES: The effect of HIV-infection on the clinical course of critically ill obstetrical patients by means of a case-control study was evaluated. METHODS: Over one calendar year 440 patients were admitted to a high risk obstetrical unit. All patients were tested for HIV-infection. HIV-positive patients were included in the study group and two HIV-negative patients for every HIV-positive patient were included in the control group. RESULTS: No differences were found between the two groups regarding demographic data, diagnosis, antibiotic use, mode of delivery, duration of hospital stay and mortality. More complications occurred in the HIV-negative group. Eclampsia recorded for the HIV-negative group was 17.1% and 4.7% for the HIV-positive group (P=0.04; 95% CI: -17.1%; -0.9%) and lung edema was 18.2% and 6.2%, respectively (P=0.01; 95% CI: -19.3%; -3.5%). The median CD4/CD8 ratio was significantly lower in the HIV-positive group (0.43) than the HIV-negative group (1.37) (P<0.01; 95% CI: -1.04; -0.79). CONCLUSIONS: HIV-infection did not significantly alter the clinical course of critically ill patients in an obstetrical high care unit.

Adult↗
PubMed1997

Upgrading obstetric care at a secondary referral hospital, Ogun State, Nigeria. The Lagos PMM Team.

PRELIMINARY STUDIES: A 1991 inventory at the State Hospital, Ota, in Ogun State, Nigeria, showed inadequate surgical equipment, drugs, blood and power supply. A time-motion study indicated substantial delays in receiving obstetric care. INTERVENTIONS: In 1994, medical officers and midwives were given refresher courses in emergency obstetric skills. In 1995, the surgical theater, labor ward and laboratory were provided with the necessary supplies and equipment. A reliable electrical supply was set up, but problems were encountered in establishing blood services. Subsequent community interventions focused on improving access and reducing delay in seeking care. RESULTS: The annual number of women with complications seen, which had been declining--from 123 in 1992 to 55 in 1994--increased to 91 in 1995. Case fatality rate (CFR) due to major direct obstetric complications did not change appreciably, i.e. it was 6.6% in 1995, as compared with 7.3%, 8.3% and 7.3% for the years 1992-1994, respectively. COSTS: The cost of hospital improvements was approximately US $46,000. CONCLUSIONS: The facility improvements were completed only recently in mid-1995. It is hoped that improved services will result in reductions in CFR and motivate more women with complications to seek hospital care, despite difficult economic conditions prevailing in Nigeria.

Female↗