• Composition of vaginal microbiota during labor and the effect of lubricant use

      McElroy, Kathleen Gresia; Regan, Mary J.; 0000-0002-6244-5529 (2016)
      Background: The composition of vaginal microbiota is critically important during pregnancy because maternal microbes transferred at birth form the basis of the neonate's microbiome. Vaginal dysbiosis, a disruption in composition, is linked with many biological and behavioral factors, including use of personal lubricants. Studies show that lubricants can alter microbial composition and damage the integrity of vaginal epithelium. These findings are concerning because similar lubricants are frequently used during labor. However, the effect of lubricant use on vaginal microbiota during labor has not been studied. Purpose: This study aimed to characterize the composition of vaginal microbiota during labor and to investigate the effect of lubricant use on its bacterial composition. Methods: The prospective cohort study was nested within a federally-funded study (R01NR014826). Fifteen participants collected mid-vaginal specimens during pregnancy, labor, and in the postpartum period, and clinical labor data were extracted from medical records. 16S rRNA gene profiling was used for bacterial composition and multiple linear regression was used to investigate the effect of intrapartum lubricant use. Results: The composition of vaginal microbiota varied among participants, with a notable high abundance of Lactobacillus iners and Gardnerella vaginalis. A significant bivariate negative correlation between lubricant use and relative abundance of L. crispatus disappeared when controlling for time since ruptured membranes. A trend between lubricant use and changes in the composition of vaginal microbiota as measured by the Jensen-Shannon distance was noted but not significant. Conclusions: The study offers novel information about the composition of vaginal microbiota during labor and the effect of lubricant use on its composition. The potential relationship between increased lubricant use and decreased L. crisptatus has important clinical significance for perinatal providers and can be used to begin to build evidence that supports a less invasive approach to perinatal practice. A larger study is needed to further elucidate the association between lubricant use and vaginal dysbiosis.
    • Factors Influencing the Use of Labor Management Interventions and Their Effect on Cesarean Birth

      Iobst, Stacey Elaine; Johantgen, Mary E.; 0000-0002-6954-2903 (2018)
      Background: The cesarean birth (CB) rate of 31.9% in the US is concerning because the procedure is associated with increased maternal mortality as well as increased maternal and neonatal morbidity. Women considered low-risk for CB are defined as nulliparous and pregnant with a term, singleton gestation in the vertex position (NTSV). Even among NTSV women, cesarean rates range from 2.4% to 36.5% across hospitals, suggesting that CB may be influenced by differences in practice patterns, including admission triage, the use of labor management interventions (e.g., amniotomy, epidural analgesia, and oxytocin augmentation), and availability of a laborist. Purpose: The following were examined in three manuscripts: (1) influence of cervical dilation at admission on labor management and CB, (2) influence of provider and hospital characteristics on labor management and CB, (3) influence of combinations of labor management interventions on likelihood of CB. Methods: All three manuscripts were cross-sectional, observational studies of NTSV women with spontaneous onset of labor whose births occurred from 2002-2007 at hospitals included in the National Institutes of Health Consortium on Safe Labor. Samples sizes varied due to missing data but ranged from 17,443 to 26,259. Generalized linear mixed modeling was used to account for the effects of hospital and provider clusters. Results: Greater dilation at admission (>6 cm) was associated with a lower likelihood of receiving all three interventions (RR 0.40, CI95 0.35-0.46) and a lower likelihood of CB (4-5 cm: RR 0.44, CI95 0.40-0.49; >6 cm: RR 0.20, CI95 0.17-0.24). Midwives were more likely to use no interventions compared to obstetrician/gynecologists (RR 1.81, CI95 1.50-2.19). Women delivering at hospitals with an as-needed laborist available had a greater likelihood of receiving no interventions (RR 4.27, CI95 1.43-12.70) compared to those at hospitals with a 24/7 laborist. Compared to no interventions, use of all three interventions was associated with an increased likelihood of CB (RR 1.84, CI95 1.53-2.21). Conclusion: Admitting women at more advanced cervical dilation may reduce the use of labor management interventions and CB. The combined use of labor management interventions should be considered carefully given the association with an increased likelihood of CB.
    • Implementation of Carbohydrate-Based Liquid Nutrition in Labor

      Conley, Richard P., Jr.; Bundy, Elaine Y. (2020-05)
      Problem and Purpose: At a large community hospital in the mid-Atlantic region, with over 2,400 deliveries yearly, all women were kept fasting during labor. This outdated practice can lead to increased stress, pain and dissatisfaction with the labor experience. The primary purpose of this quality improvement project was to implement an evidence-based policy for oral carbohydrate-based liquid nutrition in laboring women at low risk of operative delivery. Methods: An evidence-based tool was developed to assess risk of operative delivery. Women at low risk were cleared to receive a carbohydrate-based clear liquid diet. The unit personnel were educated on the new policy, assessment tool, and orders prior to implementation. Implementation tactics included staff specific policy verbal and email reminders. Inpatient charts were reviewed to track and evaluate the number of high and low risk patients, diet orders and frequency of high-risk characteristics. Data analysis included the use of descriptive statistics and a run chart with daily staff compliance rates. Results: A total of 235 women had vaginal deliveries (58% high-risk, 42% low risk) during the nine-week project implementation. Following staff education, diet order compliance rates in both high and low risk groups was 61%, increasing to 75% by the end of implementation. The initial compliance for low risk patients was only 38% following education but increased to 55% by the end of the implementation. In contrast, the compliance rate for high-risk women was 98% after education and 100% at the end of implementation. There were no recorded incidences of pulmonary aspiration or complications during implementation. Conclusion: This project was successful in implementing a policy and assessment tool for carbohydrate-based liquid nutrition for women in labor. Barriers to compliance included the additional step of adding the clear liquid diet order in the electronic medical record and disagreement with the high-risk characteristics in the assessment tool. Recommendations for continued success include adding the clear liquid diet order to the admission order set and adjusting the risk factors in the assessment tool to allow more women to be categorized as low risk of operative delivery and receive carbohydrate-based liquid nutrition.
    • Promoting admission in active labor for childbirth: Triage dynamics and early labor lounge use

      Breman, Rachel Blankstein; Johantgen, Mary E. (2018)
      Background: Cesarean birth is the most common surgery amongst women of reproductive age and nearly one third of term pregnant women will birth via cesarean. All professional organizations involved in intrapartum care are advocating for reducing the rate. Overwhelming evidence supports admission in active labor as an effective strategy to promote vaginal birth. Yet, how this evidence translates into decision-making during triage is unknown. Use of an early labor lounge (ELL) as an alternative to hospital admission is one care innovation that has not been evaluated. Purpose: The study aims were to: 1) examine the dynamics of triage from the clinician perspective, and 2) explore the facilitators and barriers to use of an ELL by clinicians. Patient use of the ELL and satisfaction was also explored. Methods: A mixed methods approach was used. Semi-structured interviews of clinical staff were conducted using a qualitative descriptive approach to explore the triage and admission process. A framework analysis utilized the domains of the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to ELL use. Surveys examined the satisfaction of women after childbirth; for women using the ELL, their experience was also assessed. Results: Interviews revealed the decision-making triad among the pregnant woman, the provider, and the triage nurse that influences admission. The category that emerged is "Admission of Low-Risk Pregnant Women Depends on Many Factors." Four themes revealed were: 1) woman's expectation about birth, 2) woman's coping with labor, 3) variation in care management, and, 4) maternal and fetal safety. Several barriers and facilitators to ELL use were identified. A higher proportion of ELL users received their prenatal care from a midwife, were informed about the ELL during their prenatal visits, and experienced vaginal deliveries. Conclusion: Obstetrical triage is a complex process with multiple factors to be considered when deciding to admit a woman in labor. The decision making process and the use of an ELL must be further examined in a variety of settings to get a better understanding of context, birth outcomes and satisfaction with birth.
    • Successful IT Initiative to Reduce the Rate of Excessive Uterine Contractions During Labor

      Bunting, Kari; Smith, Samuel, 1955-; Hamilton, Emily F. (2014)
      The Problem: Oxytocin, an effective drug to increase the rate and strength of uterine contractions, is used in more than half of all labors. Intravenous infusions are adjusted frequently at the bedside because the uterine response can vary greatly. Clinical protocols recommend discontinuing oxytocin in the presence of overly frequent contractions because they can decrease oxygen delivery to the fetus and result in brain injury. Despite well-established guidelines, incautious use of oxytocin is reported in 45-71% of births with severe asphyxia and subsequent litigation. IT Innovation: In 2011 Medstar Franklin Square Medical Center introduced specialized obstetrical software (PeriCALM Patterns V2.01 PeriGen, Cranbury, NJ) with electronic fetal monitor (EFM) pattern recognition and display features specifically designed to assist in the prompt recognition of uterine tachysystole. Uterine tachysystole (UT) is defined as the presence of more than 5 contractions per 10 minutes, averaged over a 30-minute period. Study Objective: The objective of this study was to compare the rates of UT in the periods "Before" and "After" the introduction of this software in women with induction or augmentation of labor...