Crises and Turnaround Management: Lessons Learned from Recovery of New Orleans and Tulane University Following Hurricane Katrina

By their very nature both man-made and natural disasters are unpredictable, and so we recommend that all health-care institutions be prepared. In this paper, the authors describe and make a number of recommendations, regarding the importance of crisis and turnaround management using as a model the New Orleans public health system and Tulane University Medical School post-Hurricane Katrina. Leadership skills, articulation of vision, nimble decision making, and teamwork are all crucial elements of a successful recovery from disaster. The leadership team demonstrated courage, integrity, entrepreneurship, and vision. As a result, it led to a different approach to public health and the introduction of new and innovative medical education and research programs.

The "for-benefit" academic medical center: a solution for survival

Academic medical centers (AMCs) are the backbone of the U.S. health care system. They provide a disproportionate share of charity care and serve as a training ground for future physicians. Yet, AMCs face profound economic challenges, from changes in funding to changes in the health care market. To survive, many AMCs will need to form integrated health systems, a process expected to cost tens, if not hundreds, of millions of dollars. Nearly all AMCs are structured as not-for- profit entities, which places restrictions on their ability to forge partnerships, pursue joint ventures, and access private capital, often essential elements for forming such integrated systems. An alternative model known as the "for-benefit" corporation can allow AMCs to retain their important social mission and the other advantages of their not-for-profit status while allowing them flexibility and access to both investment and philanthropic capital. To pursue the for-benefit pathway, AMCs have two options-either they could work within the constraints of existing laws to restructure themselves as for-benefit entities, or they could create, under federal law, a new for-benefit AMC model, allowing for the orderly conversion of not-for-profit AMCs. Essential components of a for-benefit AMC include a social purpose, access to multiple forms of capital, the use of earnings to support its purpose, transparency, aligned compensation, and tax exemptions. Restructuring an AMC as a for-benefit entity enables it to both advance shareholder value and further the public good.

A case for change: disruption in academic medicine

Disruptive technologies allow less expensive and more efficient processes to eventually dominate a market sector. The academic health center's tripartite mission of education, clinical care, and research is threatened by decreasing revenues and increasing expenses and is, as a result, ripe for disruption. The authors describe current disruptive technologies that threaten traditional operations at academic health centers and provide a prescription not only to survive, but also to prosper, in the face of disruptive forces.

Light-scattering spectroscopy differentiates fetal from adult nucleated red blood cells: may lead to noninvasive prenatal diagnosis

Present techniques for prenatal diagnosis are invasive and present significant risks of fetal loss. Noninvasive prenatal diagnosis utilizing fetal nucleated red blood cells (fNRBC) circulating in maternal peripheral blood has received attention, since it poses no risk to the fetus. However, because of the failure to find broadly applicable identifiers that can differentiate fetal from adult NRBC, reliable detection of viable fNRBC in amounts sufficient for clinical use remains a challenge. In this Letter we show that fNRBC light-scattering spectroscopic signatures may lead to a clinically useful method of minimally invasive prenatal genetic testing.

Confocal light absorption and scattering spectroscopic microscopy monitors organelles in live cells with no exogenous labels

This article reports the development of an optical imaging technique, confocal light absorption and scattering spectroscopic (CLASS) microscopy, capable of noninvasively determining the dimensions and other physical properties of single subcellular organelles. CLASS microscopy combines the principles of light-scattering spectroscopy (LSS) with confocal microscopy. LSS is an optical technique that relates the spectroscopic properties of light elastically scattered by small particles to their size, refractive index, and shape. The multispectral nature of LSS enables it to measure internal cell structures much smaller than the diffraction limit without damaging the cell or requiring exogenous markers, which could affect cell function. Scanning the confocal volume across the sample creates an image. CLASS microscopy approaches the accuracy of electron microscopy but is nondestructive and does not require the contrast agents common to optical microscopy. It provides unique capabilities to study functions of viable cells, which are beyond the capabilities of other techniques.

Diagnostic utility of soluble fms-like tyrosine kinase 1 and soluble endoglin in hypertensive diseases of pregnancy

OBJECTIVE

The objective of this pilot study was to evaluate the clinical utility of soluble fms-like tyrosine kinase 1 (sFlt 1) and soluble endoglin (sEng) in the differential diagnosis of hypertension in late pregnancy.

STUDY DESIGN

We analyzed serum levels of sFlt 1 and sEng in women with gestational hypertension (GHTN; n = 17), chronic hypertension (CHTN; n = 19), preeclampsia (n = 19), and normal pregnancy (n = 20) in the third trimester. We calculated the sensitivity, specificity, and positive and negative likelihood ratio (LR) for each factor in diagnosing preeclampsia.

RESULTS

The sensitivity and specificity of sFlt 1 in differentiating preeclampsia from normal pregnancy were 90% and 90%, respectively, and 90% and 95% for sEng. In women with GHTN, they were 79% and 88% for sFlt 1; 84% and 88% for sEng; 90% and 63% for uric acid. In women with CHTN, they were 84% and 95% for sFlt 1; 84% and 79% for sEng; 68%; and 78% for uric acid. The positive LR for preeclampsia was 9 for sFlt 1 and 7 for sEng in women with normal pregnancy; in women with GHTN; 6.7 for sFlt 1 and 7.2 for sEng; in CHTN, 16 for sFlt 1 and 4 for sEng. Serum uric acid had a positive LR of only 2.4 in women with GHTN and 3.1 in women with CHTN.

CONCLUSION

Both sFlt 1 and sEng may prove useful in differentiating preeclampsia from other hypertensive diseases of pregnancy. A prospective cohort study should be performed determine the clinical utility of measuring these proteins.

Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial

OBJECTIVE

To evaluate the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery.

METHODS

A cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals. The intervention was a standardized teamwork training curriculum based on crew resource management that emphasized communication and team structure. The primary outcome was the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes or both occurred (Adverse Outcome Index). Additional outcomes included 11 clinical process measures.

RESULTS

A total of 1,307 personnel were trained and 28,536 deliveries analyzed. At baseline, there were no differences in demographic or delivery characteristics between the groups. The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). The intracluster correlation coefficient was 0.015, with a resultant wide confidence interval for the difference in mean Adverse Outcome Index between groups (-5.6% to 3.2%). One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03).

CONCLUSION

Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement.

CLINICAL TRIAL REGISTRATION

(www.ClinicalTrials.gov), NCT00381056

LEVEL OF EVIDENCE

I.

Soluble endoglin and other circulating antiangiogenic factors in preeclampsia

BACKGROUND

Alterations in circulating soluble fms-like tyrosine kinase 1 (sFlt1), an antiangiogenic protein, and placental growth factor (PlGF), a proangiogenic protein, appear to be involved in the pathogenesis of preeclampsia. Since soluble endoglin, another antiangiogenic protein, acts together with sFlt1 to induce a severe preeclampsia-like syndrome in pregnant rats, we examined whether it is associated with preeclampsia in women.

METHODS

We performed a nested case-control study of healthy nulliparous women within the Calcium for Preeclampsia Prevention trial. The study included all 72 women who had preterm preeclampsia (<37 weeks), as well as 480 randomly selected women--120 women with preeclampsia at term (at > or =37 weeks), 120 women with gestational hypertension, 120 normotensive women who delivered infants who were small for gestational age, and 120 normotensive controls who delivered infants who were not small for gestational age.

RESULTS

Circulating soluble endoglin levels increased markedly beginning 2 to 3 months before the onset of preeclampsia. After the onset of clinical disease, the mean serum level in women with preterm preeclampsia was 46.4 ng per milliliter, as compared with 9.8 ng per milliliter in controls (P<0.001). The mean serum level in women with preeclampsia at term was 31.0 ng per milliliter, as compared with 13.3 ng per milliliter in controls (P<0.001). Beginning at 17 weeks through 20 weeks of gestation, soluble endoglin levels were significantly higher in women in whom preterm preeclampsia later developed than in controls (10.2 ng per milliliter vs. 5.8 ng per milliliter, P<0.001), and at 25 through 28 weeks of gestation, the levels were significantly higher in women in whom term preeclampsia developed than in controls (8.5 ng per milliliter vs. 5.9 ng per milliliter, P<0.001). An increased level of soluble endoglin was usually accompanied by an increased ratio of sFlt1:PlGF. The risk of preeclampsia was greatest among women in the highest quartile of the control distributions for both biomarkers but not for either biomarker alone.

CONCLUSIONS

Rising circulating levels of soluble endoglin and ratios of sFlt1:PlGF herald the onset of preeclampsia.

Circulating angiogenic proteins in trisomy 13

OBJECTIVE

Women who are carrying a trisomy 13 fetus are more prone to develop preeclampsia. Excess circulating soluble fms-like tyrosine kinase-1 has been implicated recently in the pathogenesis of preeclampsia. Since the fms-like tyrosine kinase-1/soluble fms-like tyrosine kinase-1 gene is located on chromosome 13q12, we hypothesized that the extra copy of this gene in trisomy 13 may lead to excess circulating soluble fms-like tyrosine kinase-1, reduced free placental growth factor level, and increased soluble fms-like tyrosine kinase-1/placental growth factor ratio. This may then contribute to the increased risk of preeclampsia that has been observed in these patients. Our objective was to characterize the maternal circulating angiogenic proteins in trisomy 13 pregnancies.

STUDY DESIGN

Maternal serum samples of trisomy 13, 18, 21 and normal karyotype pregnancies were obtained from first and second trimester screening programs. We chose 17 cases of trisomy 13 that were matched for maternal age, freezer storage time, and parity with 85 normal karyotype control samples. Additionally, 20 cases of trisomy 18 and 17 cases of trisomy 21 were included. Cases and control samples were assayed for levels of soluble fms-like tyrosine kinase-1 and placental growth factor by enzyme-linked immunosorbent assay in a blinded fashion. Because of the skewed distributions of soluble fms-like tyrosine kinase-1 and placental growth factor, nonparametric analytic techniques were used, and the results are reported as median and ranges.

RESULTS

In early pregnancy trisomy 13 cases and control samples, the median circulating soluble fms-like tyrosine kinase-1/placental growth factor ratios were 17.0 (range, 1.2-61.3) and 6.7 (range, 0.8-62.9), respectively (P = .003). The median soluble fms-like tyrosine kinase-1/placental growth factor ratios in trisomy 18 and 21 were 4.8 (range, 0.9-53.9) and 5.1 (range, 1.0-18.1), which were not significantly different than the control samples. Furthermore, the differences between trisomy 13 and control samples were more pronounced in the second trimester specimens than in the specimens from the first trimester.

CONCLUSION

These data suggest that alterations in circulating angiogenic factors may be involved intimately in the pathogenesis of preeclampsia in trisomy 13. A larger clinical study that measures these factors longitudinally and correlates them with pregnancy outcomes is needed to further establish the link between trisomy 13, altered angiogenic factors, and preeclampsia.

Recent advances in understanding of preeclampsia

Despite intensive research, preeclampsia still accounts for significant morbidity and mortality for the mother and the neonate, especially in developing countries. Recent studies have suggested that excess secretion of a naturally occurring anti-angiogenic molecule of placental origin referred to as soluble fms-like tyrosine kinase-1 (sFlt-1, also referred to as sVEGFR-1) may contribute to the pathogenesis of preeclampsia. sFlt-1 acts by antagonizing two pro-angiogenic molecules - vascular endothelial growth factor (VEGF) and placental growth factor (PlGF). Abnormalities in the angiogenic balance have been proposed as having a major role in the molecular cascade leading to proteinuria, hypertension, and endothelial dysfunction. Further evidence supports the hypothesis that angiogenic balance is crucial to differentiation and invasion of cytotrophoblasts. The abnormal placentation and the accompanying hypoxia may, in turn, result in more sFlt-1 production, thus leading to a vicious cycle of sFlt-1 production, eventually causing preeclampsia. These recent discoveries may facilitate the development of novel strategies for the diagnosis and therapy of preeclampsia.

Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists

OBJECTIVE

To assess obstetrician-gynecologists' current practice patterns and opinions regarding vaginal birth after cesarean delivery (VBAC).

STUDY DESIGN

Questionnaires were mailed to a random sample of 1,200 American College of Obstetricians and Gynecologists (ACOG) fellows in July 2003. Information was gathered on percentage of cesarean and VBAC deliveries performed, factors influencing changes in these rates in the past 5 years, hospital protocol regarding VBAC and factors influencing the recommendation of VBAC.

RESULTS

Fifty-three percent of questionnaires were returned to ACOG after 3 mailings. Approximately 49% of respondents reported that they were performing more cesarean deliveries than they were 5 years earlier. The primary reasons for this increase were the risk of liability and patient preference for delivery method. More than 25% of physicians reported that they practiced in hospitals that do not follow the ACOG guidelines with respect to resources and immediate availability. Almost all (98.2%) respondents agreed that they knew the risks and benefits of VBAC. However, only 61% reported feeling competent in determining which patients will have a successful VBAC.

CONCLUSION

Obstetrician-gynecologists seem to be aware of the risks and benefits of VBAC; however, there is some doubt as to who should be offered a trial of labor and what predicts a successful VBAC.

Urinary placental growth factor and risk of preeclampsia

CONTEXT

Preeclampsia may be caused by an imbalance of angiogenic factors. We previously demonstrated that high serum levels of soluble fms-like tyrosine kinase 1 (sFlt1), an antiangiogenic protein, and low levels of placental growth factor (PlGF), a proangiogenic protein, predict subsequent development of preeclampsia. In the absence of glomerular disease leading to proteinuria, sFlt1 is too large a molecule to be filtered into the urine, while PlGF is readily filtered.

OBJECTIVE

To test the hypothesis that urinary PlGF is reduced prior to onset of hypertension and proteinuria and that this reduction predicts preeclampsia.

DESIGN, SETTING, AND PATIENTS

Nested case-control study within the Calcium for Preeclampsia Prevention trial of healthy nulliparous women enrolled at 5 US university medical centers during 1992-1995. Each woman with preeclampsia was matched to 1 normotensive control by enrollment site, gestational age at collection of the first serum specimen, and sample storage time at -70 degrees C. One hundred twenty pairs of women were randomly chosen for analysis of serum and urine specimens obtained before labor.

MAIN OUTCOME MEASURE

Cross-sectional urinary PlGF concentrations, before and after normalization for urinary creatinine.

RESULTS

Among normotensive controls, urinary PlGF increased during the first 2 trimesters, peaked at 29 to 32 weeks, and decreased thereafter. Among cases, before onset of preeclampsia the pattern of urinary PlGF was similar, but levels were significantly reduced beginning at 25 to 28 weeks. There were particularly large differences between controls and cases of preeclampsia with subsequent early onset of the disease or small-for-gestational-age infants. After onset of clinical disease, mean urinary PlGF in women with preeclampsia was 32 pg/mL, compared with 234 pg/mL in controls with fetuses of similar gestational age (P<.001). The adjusted odds ratio for the risk of preeclampsia to begin before 37 weeks of gestation for specimens obtained at 21 to 32 weeks, which were in the lowest quartile of control PlGF concentrations (<118 pg/mL), compared with all other quartiles, was 22.5 (95% confidence interval, 7.4-67.8).

CONCLUSION

Decreased urinary PlGF at mid gestation is strongly associated with subsequent early development of preeclampsia.

Circulating angiogenic factors and the risk of preeclampsia

BACKGROUND

The cause of preeclampsia remains unclear. Limited data suggest that excess circulating soluble fms-like tyrosine kinase 1 (sFlt-1), which binds placental growth factor (PlGF) and vascular endothelial growth factor (VEGF), may have a pathogenic role.

METHODS

We performed a nested case-control study within the Calcium for Preeclampsia Prevention trial, which involved healthy nulliparous women. Each woman with preeclampsia was matched to one normotensive control. A total of 120 pairs of women were randomly chosen. Serum concentrations of angiogenic factors (total sFlt-1, free PlGF, and free VEGF) were measured throughout pregnancy; there were a total of 655 serum specimens. The data were analyzed cross-sectionally within intervals of gestational age and according to the time before the onset of preeclampsia.

RESULTS

During the last two months of pregnancy in the normotensive controls, the level of sFlt-1 increased and the level of PlGF decreased. These changes occurred earlier and were more pronounced in the women in whom preeclampsia later developed. The sFlt-1 level increased beginning approximately five weeks before the onset of preeclampsia. At the onset of clinical disease, the mean serum level in the women with preeclampsia was 4382 pg per milliliter, as compared with 1643 pg per milliliter in controls with fetuses of similar gestational age (P<0.001). The PlGF levels were significantly lower in the women who later had preeclampsia than in the controls beginning at 13 to 16 weeks of gestation (mean, 90 pg per milliliter vs. 142 pg per milliliter, P=0.01), with the greatest difference occurring during the weeks before the onset of preeclampsia, coincident with the increase in the sFlt-1 level. Alterations in the levels of sFlt-1 and free PlGF were greater in women with an earlier onset of preeclampsia and in women in whom preeclampsia was associated with a small-for-gestational-age infant.

CONCLUSIONS

Increased levels of sFlt-1 and reduced levels of PlGF predict the subsequent development of preeclampsia.

Preventive health services received by minority women aged 45-64 and the goals of healthy people 2000

We attempted to evaluate the preventive health services received by minority women aged 45-64 in an underserved region of Boston. We compared two surveys of disease burden and preventive health services to national data sets and the goals of Healthy People 2000. We found that minority women seen both in community health centers and within the community had many cardiovascular risk factors (41-45% had hypertension, 24-29% had cholesterol > 200 mg/dL, and 49-56% had a body mass index of >27.3 kg/m(2)). Women reported that they received low rates of counseling on healthy behaviors but generally received breast and cervical cancer screening. Forty-three percent of women who were interviewed in the community had no health insurance and these women were less likely to have received a Papanicolaou test or mammogram than insured women. Lack of insurance did not predict cancer screening for women already being seen in the community health clinic.

Home uterine activity monitoring in the prevention of very low birth weight

OBJECTIVES

Despite controversy regarding the efficacy of home uterine activity monitoring (HUAM), it is currently licensed for detection of preterm labor in women with previous preterm deliveries. In practice, however, it is being more widely utilized in an effort to prevent preterm delivery. This study seeks to determine which group of mothers delivering very low birth weight (VLBW) infants would have qualified for HUAM given three different sets of criteria and in which women it could have been used to help prolong gestation.

METHODS

The authors reviewed the medical records of mothers of VLBW infants born in five U.S. locations (N = 1440), retrospectively applying three sets of eligibility criteria for HUAM use: (a) the current FDA licensing criterion for use of HUAM, a previous preterm birth; (b) indication for HUAM commonly cited in published reports; (c) a broad set of criteria based on the presence of any reproductive or medical conditions that might predispose to premature delivery. The authors then analyzed the conditions precipitating delivery for each group to determine whether delivery might have been prevented with HUAM and tocolytic therapy.

RESULTS

Only 4.4% of the total group of women delivering VLBW infants would have been eligible for HUAM under the FDA criterion and might potentially have benefited from this technology. If extremely broad criteria had been applied to identify those eligible for monitoring, under which almost 80% of all women who delivered VLBW infants would have been monitored, only 20.3% of the total group would have been found eligible and would potentially have benefited. If such broad criteria were applied to all pregnant women, a sizable proportion of pregnancies would be monitored at great expense with small potential clinical benefit.

CONCLUSIONS

Because VLBW births are usually precipitated by conditions that are unlikely to benefit from HUAM, this technology will have little impact on reducing VLBW and neonatal mortality rates. More comprehensive preventive strategies should be sought.

The impact of extreme prematurity and congenital anomalies on the interpretation of international comparisons of infant mortality

OBJECTIVE

To identify the potential impact that different definitions of live births and practice patterns have on infant mortality rates in England and Wales, France, Japan, and the United States.

METHODS

United States data were obtained from the 1986 linked national birth-infant death cohort, and those for the other countries came from either published sources or directly from the Ministries of Health.

RESULTS

In 1986 in the United States, infants weighing less than 1 kg accounted for 36% of deaths (32% white and 46% black); 32% resulted from fatal congenital anomalies. These rates were much higher in both categories than in England and Wales in 1990 (24 and 22%, respectively), France in 1990 (15 and 25%, respectively), and Japan in 1991 (9% for infants weighing less than 1 kg, percentage of fatal congenital anomalies unknown). These cases are more likely to be excluded from infant mortality statistics in their countries than in the United States.

CONCLUSIONS

In 1990, the United States infant mortality rate was 9.2 per 1000 live births, ranking the United States 19th internationally. However, infant mortality provides a poor comparative measure of reproductive outcome because there are enormous regional and international differences in clinical practices and in the way live births are classified. Future international and state comparisons of reproductive health should standardize the definition of a live birth and fatal congenital anomaly, and use weight-specific fetal-infant mortality ratios and perinatal statistics.

The role of obstetrical medical technology in preventing low birth weight

Technology plays an important role in the practice of medicine, and it is essential that controlled clinical trials be conducted before new technologies are widely disseminated. In this article, information from the medical literature is summarized and critiqued for several common obstetric technologies which are aimed at reducing the incidence or sequelae of low birth weight and preterm birth. These technologies include home uterine activity monitoring, tocolytic drugs to suppress uterine contractions, corticosteriods to accelerate fetal lung maturity, bed rest to prevent preterm delivery, delivery methods, multifetal pregnancy reduction, and cervical cerclage. A major challenge to the practice of medicine is to find effective ways to modify physician behavior to encourage the use of proven, effective technologies, and discourage the use of unproven, ineffective technologies. Despite widespread use, most obstetrical technologies appear to have had little impact on reducing the incidence of low birth weight or preterm births, as rates of low birth weight and preterm birth have not decreased appreciably in the past 25 years. Uncovering the basic mechanisms responsible for the onset of preterm labor will undoubtedly facilitate the discovery of new technologies to prevent low birth weight and preterm births.

The Human Genome Project: implications for the practicing obstetrician

The Human Genome Project is an international effort to discern the complete genetic makeup of human beings. The isolation and characterization of genes will offer tremendous opportunities for disease detection, diagnosis, screening, prevention, and counseling. Advances in genetic research are occurring simultaneously with the development of new techniques for prenatal genetic testing. Use of gene therapy in humans likely will lag behind our ability to detect genetic disorders. Consequently, obstetricians will be forced to face some difficult medical, ethical, and social challenges. The possibility of a national cystic fibrosis screening program is an example of the complex problems we will face as new genes are described. The obstetric community needs to participate actively in the debate surrounding the ethical and legal implications of the Human Genome Project. We need to establish clinical standards and use our professional organization to act as a resource for clinicians, the public, and legislatures. Because of the increased requirement for genetic counseling, we recommend an expansion of genetics training for residents and clinicians and the development of computer-based interactive video programs for genetic counseling.

Removal of retained intrauterine contraceptive devices in pregnancy

Using real-time ultrasound and clinical expertise gained from chorionic villus sampling, we describe a technique for ultrasound-guided intrauterine device removal in those cases in which the string is not visible. Utilizing a stone clamp for intrauterine manipulation, we were easily able to extract the device without interrupting the pregnancy. We concur with recent recommendations advocating all intrauterine devices can be removed if pregnancy termination is declined.

Cancer-related maternal mortality in Massachusetts, 1954-1985

Cancer-related maternal mortality is a rare event. We report the first population-based study of this issue using data collected by the Committee on Maternal Welfare of the Massachusetts Medical Society between 1954 and 1985. The incidence of cancer-related maternal mortality during the study period fell from 3.16 to 0 per 100,000 live births. The most common cancer-associated maternal deaths were due to central nervous system tumors and hematological cancers. To determine the effects of pregnancy on cancer mortality, we compared our data with figures from the Connecticut Register of Mortality for Women aged 15-44. In the pregnant group there was a significantly higher incidence of mortality due to central nervous system tumors and a significantly lower incidence of mortality due to breast cancer. The data suggest that pregnancy may not be contraindicated for a woman with a history of breast cancer, but may be contraindicated for a woman with a history of a central nervous system tumor.

The nonstress test. Transmission from the home

The Genesis Fetal Monitor System, which includes a recorder, a communication module and a receiver system, accurately and rapidly transmits a complete antenatal fetal monitor tracing over standard telephone lines and duplicates the original tracing at the receiver center. Transmission time for a 20-minute nonstress test is less than 2 minutes. The time required to generate a duplicate strip is less than 30 seconds. In all cases in this study the original and generated tracings were superimposable. No significant technical problems were encountered. Bioelectronic fetal assessment can be performed from a nonhospital setting, including the patient's home, with immediate interpretation of the tracing by skilled consultants.

Intrapartum and delivery room management of the very low birthweight infant

The management of a pregnant woman in premature labor is a challenge. The roles of the perinatologist as well as support people is discussed in this article.

Anesthetic-related maternal mortality, 1954 to 1985

This is a population-based study of the safety of obstetrical anesthesia in the Commonwealth of Massachusetts between 1954 and 1985. We used data collected by the state Committee on Maternal Mortality, which was founded in 1941. There were a total of 37 maternal deaths during the study period due to anesthetic-related complications. During the same time period, there were 886 maternal deaths. Thus, anesthetic-related mortality comprised 4.2% of all deaths, and the mortality rate was 1.5 per 100,000 live births between 1955 and 1964, 1.5 per 100,000 live births between 1965 and 1974, and 0.4 per 100,000 live births between 1975 and 1984. In the first decade of this study, aspiration during administration of a mask anesthetic was the primary cause of death. During the second decade, cardiovascular collapse associated with regional anesthesia was the primary cause of death. During the last decade of this study, all deaths were associated with general endotracheal anesthesia. As a result of this study and having identified the changes in the standard of care in Massachusetts that led to the reduction in maternal mortality, we offer recommendations to further improve the safety of anesthesia for childbirth in this country.

Ultrasonographic diagnosis of incompetent cervix. A case report

The ultrasonographic findings of an incompetent cervix, the protrusion of the lower pole of the fetal membranes through the dilated internal os, may precede physical changes in the cervix. The symptoms at that time may be nonspecific. As this case report indicates, we believe that action--either close observation, conservative treatment or surgical intervention--should follow the detection of this condition.

Cesarean birth rate: small-geographic-area analysis

Population-based analysis of cesarean section rates within 172 geographic areas in the Commonwealth of Massachusetts during fiscal year 1985 revealed a nearly normal distribution of observed-to-expected rates, implying that the forces that compel obstetricians to perform this surgical procedure are pervasive. However, a small number of areas were identified in which the number of procedures performed was significantly different from the state mean. During fiscal years 1982 to 1985, certain geographic subgroups consistently demonstrated incidence rates significantly greater than the state mean. Although variation (either overutilization or underutilization) from the state rate is not synonymous with inappropriate care, those physicians within the identified geographic areas must take responsibility for ascertaining the explanation for the variance.

Hemorrhage, infection, toxemia, and cardiac disease, 1954-85: causes for their declining role in maternal mortality

Hemorrhage, infection, toxemia, and cardiac disease are no longer the leading causes of maternal death. We studied factors causing their decline in incidence using data collected by the Committee on Maternal Welfare of the Massachusetts Medical Society between 1954 and 1985. The dramatic decline in incidence of these conditions in the Commonwealth during the study period appears to have been due to both legislative actions and improvements in medical practice. The legislative actions included licensing of maternity services, blood banks, and legalization of abortion. Cardiac-related mortality has declined due to a reduction in the prevalence of rheumatic heart disease. Changes in clinical practice that stand out were the aggressive control of the hypertensive component of toxemia leading to a reduced incidence of intracranial hemorrhage, the prompt recourse to blood transfusion for hemorrhage, and the use of broad spectrum antibiotics.

Cesarean section-related maternal mortality in Massachusetts, 1954-1985

We analyzed the data of the Maternal Mortality Committee of the Massachusetts Medical Society to investigate cesarean section-associated maternal deaths. Between 1954-1985, the number of cesarean section-related deaths per 100,000 live births did not significantly change despite a quadrupling of the cesarean section rate. Between 1976-1984, there were 649,375 births and 121,217 cesarean sections in the state. Seven deaths were directly related to cesarean section, a rate of 5.8 per 100,000 cesarean sections. In contrast, the rate for vaginal deliveries was 10.8 per 100,000 vaginal deliveries. We conclude that the risk of maternal death from cesarean section is low.

Risk factors for Erb-Duchenne palsy

The risk factors associated with the occurrence of Erb-Duchenne palsy were examined. Of 22 palsies, 18 were noted among 32,088 nondiabetic gravidas (0.56 per 1000) compared with four among 380 diabetic gravidas (10.5 per 1000), a statistically significant difference. One in six infants of diabetic gravidas who sustained shoulder dystocia experienced an Erb-Duchenne palsy. The incidence of precipitate second-stage labors was high (31.8%) among those infants who experienced the neurologic complication. This labor abnormality is not preventable and may contribute, in many ways, to the neurologic complication. Although recently graduated (less than four years' postresidency training) obstetricians, especially if placed in a high-volume practice, were more likely to experience this adverse outcome than more experienced physicians, even the most senior clinicians delivered infants who were affected.

Acquired immunodeficiency syndrome: suggested protocol for counseling and screening in pregnancy

The Centers for Disease Control (CDC) has recorded 35,900 cases of acquired immunodeficiency syndrome (AIDS) in the United States, including 2447 infected females, as of May 25, 1987. These cases include 503 children under the age of 13, of whom 80% were thought to have been affected through perinatal transmission. The prevalence of AIDS-related complex and human immunodeficiency virus in the United States is far greater than these numbers. The CDC has recommended screening those pregnant women with risk factors for human immunodeficiency virus. With the help of a wide range of professionals, we have developed a screening protocol for human immunodeficiency virus in pregnancy. In the first six months, 3-4% of prenatal patients used this counseling service, and 11 human immunodeficiency virus-positive women delivered. This paper discusses the medical and ethical issues that were raised and the problems that we faced in establishing this protocol.

The normal parturient's admission temperature

The relationship between oral temperature taken at the time of admission and the duration of elapsed labor was evaluated. Onset of labor data revealed a diurnal distribution with an apogee at midnight to 2 AM and a nadir at 11 AM to noon. Temperature data ranged from 94.3 degrees to 99.7 degrees F (34.6 degrees to 37.6 degrees C). The mean temperature of 97.8 degrees +/- 0.8 degrees F (36.6 degrees +/- 0.44 degrees C) is significantly lower (p less than 0.001) than the clinical reference temperature of 98.6 degrees F (37.0 degrees C). A likely explanation is the coincidental admission time (early to late morning) and the nadir of the diurnal variation in temperature. Linear regression fitted to the data (after deletion of six hypothermic outliers) yielded the relationship: temperature = 97.8 degrees F + 0.0115 X duration of elapsed labor (temperature = 36.6 degrees C + 0.0064 X duration of elapsed labor) for which the correlation coefficient is not statistically significant.

The incidence of symptomatic intracranial hemorrhage in term appropriate-for-gestation-age infants

Symptomatic intracranial hemorrhage in term infants is rare. In over 23,000 deliveries the authors were only able to find 12 diagnosed cases for an incidence of 5.9/10,000 livebirths (greater than or equal to 2,500 g and greater than or equal to 37 weeks' gestation). No consistent clinical patterns were identified. However, the obstetrical risk factors were a precipitate delivery, a second stage of more than 2 hours, the use of pitocin, and a forceps delivery. The number of cases of asymptomatic ICH was unknown because routine surveillance was not done. Furthermore, some infants may have become symptomatic following discharge, which may have resulted in an undercounting of the incidence of ICH. Most infants, however, became symptomatic by the second day.

Maternal mortality in Massachusetts. Trends and prevention

To identify ways in which the safety of childbirth might be increased, we investigated the causes of death among the 886 women who died during pregnancy or within 90 days post partum ("maternal deaths") in Massachusetts from 1954 through 1985. The maternal mortality rate declined from 50 per 100,000 live births in the early 1950s to the current rate of 10 per 100,000 live births. Between one third and one half of the maternal deaths were considered to have been preventable. The leading causes of maternal death from 1954 through 1957 were infection, cardiac disease, pregnancy-induced hypertension, and hemorrhage. In contrast, from 1982 through 1985 the leading causes of death were trauma (suicide, homicide, and motor vehicle accidents) and pulmonary embolus. We observed a rapid increase in the frequency of death among women who received little or no antenatal care. From 1980 through 1984 the maternal mortality rate for white women was 9.6 per 100,000 live births, whereas for nonwhites it was 35 per 100,000 live births (relative risk, 2.9; 95 percent confidence limits, 2.5 and 3.2). Fifty percent of the nonwhite women who died during pregnancy or within 90 days post partum received little or no antenatal care, in contrast to only 15 percent of the white women. These data show that the leading causes of maternal death have changed markedly in Massachusetts during the past 30 years. Although the overall maternal mortality rate has declined sharply, further improvement may occur with better antenatal care and specific efforts to prevent trauma and pulmonary embolus.

Is maternal alkalosis harmful to the fetus?

Normal pregnancy is characterized by a compensated respiratory alkalosis. The effect of maternal alkalosis on the fetus is less well understood than the more common problem of maternal acidosis. We present a case of maternal alkalosis, complicated by bronchial asthma, in which the fetus was stillborn. The pathophysiology of this condition is discussed with data to support the potential harm of maternal alkalosis in pregnancies complicated by a fetus with borderline reserve. In such instances, the fetus should be carefully monitored and consideration might be given to therapy such as the use of acetozolomide, discouraging hyperventilation by the mother and even early delivery of the fetus.

Diagnostic related groups and the obstetrician: antepartum admission

A retrospective review was conducted of all pregnant women discharged undelivered during fiscal year 1985. If the current Medicare prospective payment plan were applied to these admissions, Diagnostic Related Group 383 (other antepartum diagnoses with medical complications) and Diagnostic Related Group 384 (other antepartum diagnoses without medical complications) would together generate a negative cash flow. Supplementation for capital costs and direct and indirect medical education costs would result in a positive cash flow; however, the supplementation is vulnerable to political and social forces that will tend to diminish or eliminate it.

Risk factors for shoulder dystocia in the average-weight infant

Almost half (47.6%) of all deliveries with shoulder dystocia occurred in association with the delivery of an average-weight infant (under 4000 g). Of 4294 nondiabetic gravidas delivering infants of birth weight 3500 to 3999 g, 94 (2.2%) experienced a shoulder dystocia. Protraction and arrest disorders were associated with a statistically significant increase in the incidence of shoulder dystocia, and this effect was further augmented by low forceps delivery. Among 6252 infants weighing 3000 to 3499 g, there were 40 instances of shoulder dystocia (0.6%). Only arrest disorders were associated with an increased rate.

Results of an epidemiologic study of postdate pregnancy

Obstetric and neonatal data on 18,610 deliveries between 1975 and 1982 were analyzed to determine the risks associated with postdate pregnancy in an era of routine fetal heart rate monitoring. Thirteen percent of the deliveries occurred between 42 and 43 weeks' gestation, and 1% occurred at 44 weeks or later. There was a nonsignificant rise in the perinatal mortality rates for 38-41-week deliveries as compared to those delivered at 42 weeks or later. However, the perinatal mortality rate was six times higher for small-for-gestational-age infants. There was a significant rise in the perinatal morbidity in infants delivered at or beyond 42 weeks (5% incidence). This finding implies that the sensitivity of currently used screening tests for perinatal mortality is good but that it is unsatisfactory for the detection and prevention of morbidity.

Constrictive pericarditis and pregnancy

A case discussing the medical management of a 30-year-old gravid patient with recurrent pericarditis and pericardial constriction secondary to juvenile rheumatoid arthritis is presented.

The leukocyte count in labor

The leukocyte count was evaluated in 479 laboring gravida women. Increasing leukocyte counts appeared to be linearly related to the duration of elapsed labor (y = 0.2174x + 10.31; p less than 0.001; 95% confidence interval of the slope = 0.1414 to 0.2934). Isolated mild elevations and mild increases of leukocyte count in labor may be managed expectantly. Elevations greater than 2 SD are unlikely to represent normal variation; a diligent search for unapparent infection is warranted.

Risk factors for shoulder dystocia

The risk factors associated with the occurrence of shoulder dystocia were examined in the general obstetrical population of women delivering vaginally. An increasing incidence of shoulder dystocia was found as infant birth weight increased. Although one-third of shoulder dystocia occurred in pregnancies at 42 + weeks, except for those resulting in infants weighing 4500 + g, the vast majority was unaffected by shoulder dystocia. The incidence of shoulder dystocia in nondiabetic gravidas delivering an infant weighing 4000 to 4499 and 4500 + g vaginally was 10.0 and 22.6%, respectively. Within the 4000- to 4499-g group, no labor abnormality was clearly predictive; however, in the heaviest birth weight group, an arrest disorder heralded a shoulder dystocia in 55.0% of cases. Diabetics experienced more shoulder dystocia than nondiabetics. Among them, 31% of vaginally delivered neonates weighing 4000 + g experienced shoulder dystocia. Nevertheless, the risk factors of diabetes and large fetus (4000 + g) could predict 73% of shoulder dystocia among diabetics; large fetus along flagged 52% of shoulder dystocia in nondiabetics. Cesarean section is recommended as the delivery method for diabetic gravidas whose estimated fetal weight is 4000 + g. If others confirm the risk, the authors advise serious consideration of cesarean section for gravidas who are carrying fetuses estimated to be 4500 + g and who experience an abnormal labor.

New multipronged fetal scalp electrode: a preliminary report

Presented is a preliminary report of the use of a new type of scalp electrode (patent pending), which, because of its design, may have the advantage of improved safety. It was used on 40 patients in labor. To confirm the quality of the recording, in all cases, a fetal electrocardiogram was also obtained. Application was achieved on the first attempt in 37 cases in two additional cases on the second attempt. There were no reported cases of the electrode being dislodged during labor. The quality of the recording was reported to be good. There were no reported cases of trauma to the fetal scalp nor were there any cases of infection noted.

Neonatal transport in Georgia: implications for maternal transport in high-risk pregnancies

We analyzed population-based data from the Georgia Neonatal Surveillance Network from 1974 to 1978 to determine the effect of the hospital of delivery on the neonatal mortality rate (NMR) of infants later admitted to neonatal intensive case units (NICUs). The NMR of 3,524 infants transported from primary centers to NICUs was significantly higher [relative risk (RR) = 2.1; 95% CL = 1.9 to 2.3] than that of 10,764 infants born in tertiary centers and admitted directly to an NICU. This effect persisted even after adjustment for birth-weight differences (RR = 1.6; 95% CL = 1.5 to 1.8). The relative risk in favor of delivery in a tertiary center increased with increasing birth weight. However, the proportion of infants of less than 1,000 gm surviving was higher for transported infants and increased with distance transported. This finding suggests that, at these very low birth weights, the hardiest infants were selectively transported. A surprising finding was the very low proportion of low-birth-weight infants delivered in primary centers and transported to NICUs (eg, 32% of infants weighing between 1,001 and 1,200 gm). Our findings support previous reports that delivery in a hospital with an NICU is preferable to later neonatal transport and suggest that efforts to increase the rate of maternal transport in high-risk pregnancies can lead to a substantial reduction in infant deaths.