OBJECTIVE: To use a large national database to compare composite maternal or neonatal morbidity among low-risk, full-term women.

METHODS: This cohort study, using the U.S. vital statistics datasets (2011-2015), evaluated low-risk nulliparous women with nonanomalous singleton gestations who labored at 39, 40, or 41 weeks of gestation (as reported in completed weeks of gestation; eg, 39 weeks include 39 0/7 to 39 6/7 weeks). The primary outcome, composite neonatal morbidity, included any of the following: Apgar score below 5 at 5 minutes, assisted ventilation longer than 6 hours, seizure, or mortality. The secondary outcome, composite maternal morbidity, included any of the following: intensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy. Multivariable Poisson regression was used to estimate the association between gestational age and morbidity (using adjusted relative risk [aRR] and 95% CI).

RESULTS: Of 19.8 million live births during the study interval, 3.3 million met inclusion criteria: 43.5% were delivered at 39 weeks of gestation, 41.4% at 40 weeks, and 15.1% at 41 weeks. The overall rates of composite neonatal and maternal morbidity were 8.8 and 2.8 per 1,000 live births, respectively. Composite neonatal morbidity was higher for those delivered at 40 (aRR 1.22; 95% CI 1.19-1.25) and 41 (aRR 1.53; 95% CI 1.49-1.58) weeks of gestation when compared with 39 weeks. Composite maternal morbidity was also significantly higher with delivery at 40 (aRR 1.19; 95% CI 1.14-1.25) and 41 weeks of gestation (aRR 1.56; 95% CI 1.47-1.65).

CONCLUSION: Among low-risk nulliparous women, the rate of composite neonatal and maternal morbidity increases, albeit modestly, from 39 through 41 weeks of gestation.

BACKGROUND: Uterine myomas encountered at cesarean delivery increase the complexity and risk of the procedure. Preoperative planning of such deliveries may help optimize patient outcomes. The application of three-dimensional printing technology is rapidly expanding in many surgical specialties. We created a three-dimensional-printed model from the magnetic resonance images (MRIs) of a gravid uterus with multiple myomas for surgical planning of cesarean delivery.

INSTRUMENT: A three-dimensional-printed uterine model from MRIs of a pregnant patient with multiple uterine myomas as a tool for planning cesarean delivery.

EXPERIENCE: A 33-year-old woman with a myomectomy history presented to our institution for prenatal care. Initial ultrasound imaging revealed multiple uterine myomas. A three-dimensional-printed uterine model, based on subsequent MRI, was created for presentation at an obstetric multidisciplinary meeting. The model accurately represented the number, size, and locations of uterine myomas, aiding surgical planning, including skin and uterine incisions. At the time of cesarean delivery, the model was directly correlated with patient anatomy to further determine the optimal placement of uterine incision. Maternal and fetal outcomes were excellent.

CONCLUSION: Three-dimensional-printed models, through improved surgical planning, could optimize outcomes for patients with uterine myomas undergoing cesarean delivery.

Postoperative infections remain a serious concern after cesarean delivery, the most common major surgical procedure in the United States. Multiple strategies have been proposed to combat this problem, including the addition of azithromycin to the standard preoperative antibiotic prophylaxis. However, as obstetricians, we have failed to uniformly adopt precesarean vaginal preparation despite convincing evidence from randomized controlled trials that this technique reduces postoperative rates of endometritis by more than 50%. This reduction is similar to that seen with the addition of azithromycin. Vaginal preparation with povidone-iodine solution may target the same genital pathogens as azithromycin, which are commonly implicated in endometritis, a polymicrobial infection that may be under-addressed by our current antiseptic techniques. A recent review of maternal-fetal medicine fellows' practices at the time of cesarean delivery and recent publications on precesarean vaginal cleansing suggest that this practice has not yet gained hold in the United States.

OBJECTIVE: To evaluate the association of a standardized, structured approach to in-hospital postcesarean delivery pain management with maternal opioid use after cesarean delivery.

METHODS: We conducted a retrospective cohort study of women who underwent cesarean delivery before and after a quality improvement intervention at a single tertiary care center. A multidisciplinary task force revised electronic order sets for all patients who underwent cesarean delivery with neuraxial anesthesia. The revised order set separated acetaminophen from opioids, scheduled acetaminophen and nonsteroidal antiinflammatory drug administration, and limited opioid use to breakthrough pain. Data were collected by electronic chart review. The primary outcome was median morphine milligram equivalents per hospital stay. Secondary outcomes included median morphine milligram equivalents per day, median pain scores, time to discharge, and opioid-nonopioid pain medication use. Descriptive and bivariable analyses were performed.

RESULTS: There were no significant differences in baseline characteristics in the preintervention (n=283) and postintervention (n=286) groups. There was a 75% reduction in median morphine milligram equivalents per stay from 120 (90-176 interquartile range) preintervention to 30 (5-68) postintervention (P<.001) and a 77% reduction in median morphine milligram equivalents per day (51 [41-60] vs 12 [2-25], P<.001). There was no difference between groups in time to discharge or median pain scores. There was no difference in ketorolac use (80% preintervention vs 75% postintervention, P=.14) or in median ibuprofen mg per day (1,391 preintervention vs 1,347 postintervention, P=.22). There was an increase in median acetaminophen mg per day (753 preintervention vs 2,340 postintervention, P<.001). There was a significant increase in patients who used no opioids during their hospital stay (6% preintervention vs 19% postintervention, P<.001).

CONCLUSION: A multimodal stepwise approach to postcesarean delivery pain control was associated with markedly reduced opioid consumption without increasing hospital stay or median pain scores. By separating acetaminophen from opioids and limiting opioids to breakthrough pain, we were able to operationalize a tier-based approach to pain management.

This ambitious undertaking involved 56 hospitals (comprising more than 119,000 annual births), divided into teams of six to eight. Each team was led by a physician and nurse mentor, who directed a broad-based educational program, which included training materials, grand rounds for physicians and nurses, webinars, and onsite assistance. Teams engaged in monthly check-in phone calls, received monthly progress reports, and were able to network with other teams through a dedicated email distribution list. The focus of the educational program was on encouraging adherence to American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) guidelines for labor management,2 specifically for the latent and active phases (but not the second stage), and on increasing nursing support during labor.
The collaborative activities were initiated in mid-2016, and the frequencies of various outcomes for nulliparous women at term carrying vertex, singleton fetuses were compared between calendar year 2015 and calendar year 2017-the first full year of the collaboration. The proportion of women who delivered by cesarean declined significantly, from 29.3% to 25.0%, and the frequency of severe unexpected newborn complications (a composite of hypoxic ischemic encephalopathy, seizures, ventilation, sepsis, major birth injuries, and transfer to a higher level of care) was essentially unchanged. The frequencies of other outcomes, including chorioamnionitis, blood transfusion, third- and fourth-degree perineal laceration, operative vaginal delivery, and 5-minute Apgar score less than 5, were also stable. In the tercile of hospitals with the greatest decline in the frequency of cesarean delivery, from 31.2% to 20.6%, a concomitant reduction in the frequency of unexpected newborn complications was also observed, from 3.2% to 2.2% (adjusted odds ratio 0.71, 95% CI 0.55-0.92).
This study tells us two important things: first, that a lower frequency of cesarean delivery needn't be accompanied by a higher frequency of maternal or neonatal complications and, indeed, may even be associated with fewer adverse outcomes; and, second, that the success associated with implementation of the ACOG-SMFM guidelines for labor management achieved by single centers 3,4 may, with a well-coordinated collaborative effort, be writ large.
As with all research investigations, there are limitations to the Main et al study. Before-after studies generally do not provide direct cause-and-effect evidence. Therefore, we cannot know whether the lower frequency of cesarean delivery observed after the collaborative effort was the result of the effort itself or some other factor(s), especially because adherence to the ACOG-SMFM guidelines was not assessed, nor the level of nursing support actually measured. The 1-year-after period does not provide evidence that the decline in the frequency of cesarean delivery will endure. Further, one hopes that, because a cesarean delivery frequency of 25% is not particularly low for nulliparous women at term carrying vertex, singleton fetuses, the frequency will decline even further.
Two other important contemporary studies also support realistic hopes that a lower frequency of cesarean delivery and improved neonatal outcomes are compatible. The French study by Schmitz et al 5 demonstrates that it is possible on a national level to achieve a high proportion of twin vaginal delivery and that twins delivered vaginally have better neonatal outcomes than those delivered by cesarean. More recently, Grobman et al 6 reported the results of the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management), in which more than 6,000 low-risk nulliparous women at term were randomly allocated to induction of labor at 39 weeks of gestation or to expectant management. Not only did induction result in a significantly lower frequency of cesarean delivery (18.6% vs 22.2%), but it came within a whisker of significantly lowering the composite outcome of perinatal death or severe neonatal outcomes (4.3% vs 5.4%; relative risk 0.80, 95% CI 0.64-1.00). Taken together, the three studies provide reason to believe that, just maybe, we can have our cake and eat it too.

Lymphoepithelioma-like carcinoma (LELC) is an uncommon variant of squamous cell carcinoma, which is histologically identical to lymphoepithelial carcinoma of the nasopharynx. LELCs have been reported at a variety of sites, including the stomach, salivary gland, thymus, cervix, endometrium, breast, skin, bladder, and lung. We report 2 LELCs of the vagina and 1 of the anal canal, the first report of LELC at the latter site. All 3 neoplasms were diffusely positive with p16 (block-type immunoreactivity) and the anal canal lesion contained high-risk human papillomavirus type 16; the 2 vaginal neoplasms underwent human papillomavirus testing but were unsuitable for analysis. All cases were Epstein-Barr virus negative. In reporting these cases, we highlight the potential for misdiagnosis and suggest an association with human papillomavirus infection similar to LELCs in the uterine cervix.