PubMed Health⌕ Search

Biomedical subjects

Steven L Bloom

Publications and source records attributed to Steven L Bloom.

12 recordsLinked to original sources
PubMed2006

Fetal pulse oximetry and cesarean delivery.

BACKGROUND: Knowledge of fetal oxygen saturation, as an adjunct to electronic fetal monitoring, may be associated with a significant change in the rate of cesarean deliveries or the infant's condition at birth. METHODS: We randomly assigned 5341 nulliparous women who were at term and in early labor to either "open" or "masked" fetal pulse oximetry. In the open group, fetal oxygen saturation values were displayed to the clinician. In the masked group, the fetal oxygen sensor was inserted and the values were recorded by computer, but the data were hidden. Labor complicated by a nonreassuring fetal heart rate before randomization was documented for subsequent analysis. RESULTS: There was no significant difference in the overall rates of cesarean delivery between the open and masked groups (26.3% and 27.5%, respectively; P=0.31). The rates of cesarean delivery associated with the separate indications of a nonreassuring fetal heart rate (7.1% and 7.9%, respectively; P=0.30) and dystocia (18.6% and 19.2%, respectively; P=0.59) were similar between the two groups. Similar findings were observed in the subgroup of 2168 women in whom a nonreassuring fetal heart rate was detected before randomization. The condition of the infants at birth did not differ significantly between the two groups. CONCLUSIONS: Knowledge of the fetal oxygen saturation is not associated with a reduction in the rate of cesarean delivery or with improvement in the condition of the newborn. (ClinicalTrials.gov number, NCT00098709 [ClinicalTrials.gov].).

Adult↗
PubMed2006

A randomized trial of coached versus uncoached maternal pushing during the second stage of labor.

OBJECTIVE: The objective of this study was to compare obstetrical outcomes associated with coached versus uncoached pushing during the second stage of labor. STUDY DESIGN: Upon reaching the second stage, previously consented nulliparous women with uncomplicated labors and without epidural analgesia were randomly assigned to coached (n = 163) versus uncoached (n = 157) pushing. Women allocated to coaching received standardized closed glottis pushing instructions by certified nurse-midwives with proper ventilation encouraged between contractions. These midwives also attended those women assigned to no coaching to ensure that any expulsive efforts were involuntary. RESULTS: The second stage of labor was abbreviated by approximately 13 minutes in coached women (P = .01). There were no other clinically significant immediate maternal or neonatal outcomes between the 2 groups. CONCLUSION: Although associated with a slightly shorter second stage, coached maternal pushing confers no other advantages and withholding such coaching is not harmful.

Adult↗
PubMed2006

Decision-to-incision times and maternal and infant outcomes.

OBJECTIVE: To measure decision-to-incision intervals and related maternal and neonatal outcomes in a cohort of women undergoing emergency cesarean deliveries at multiple university-based hospitals comprising the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. METHODS: All women undergoing a primary cesarean delivery at a Network center during a 2-year time span were prospectively ascertained. Emergency procedures were defined as those performed for umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, nonreassuring fetal heart rate pattern, or uterine rupture. Detailed information regarding maternal and neonatal outcomes, including the interval from the decision time to perform cesarean delivery to the actual skin incision, was collected. RESULTS: Of the 11,481 primary cesarean deliveries, 2,808 were performed for an emergency indication. Of these, 1,814 (65%) began within 30 minutes of the decision to operate. Maternal complication rates, including endometritis, wound infection, and operative injury, were not related to the decision-to-incision interval. Measures of newborn compromise including umbilical artery pH less than 7 and intubation in the delivery room were significantly greater when the cesarean delivery was commenced within 30 minutes, likely attesting to the need for expedited delivery. Of the infants with indications for an emergency cesarean delivery who were delivered more than 30 minutes after the decision to operate, 95% did not experience a measure of newborn compromise. CONCLUSION: Approximately one third of primary cesarean deliveries performed for emergency indications are commenced more than 30 minutes after the decision to operate, and the majority were for nonreassuring heart rate tracings. In these cases, adverse neonatal outcomes were not increased. LEVEL OF EVIDENCE: II-2.

Adolescent↗
PubMed2006

Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery.

OBJECTIVE: To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries. METHODS: We conducted a prospective multicenter observational study of women with prior cesarean delivery undergoing trial of labor and elective repeat operation. Maternal and perinatal outcomes were compared among women attempting vaginal birth after multiple cesarean deliveries and those with a single prior cesarean delivery. We also compared outcomes for women with multiple prior cesarean deliveries undergoing trial of labor with those electing repeat cesarean delivery. RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93). CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed2005

Obstetric antecedents for postpartum pelvic floor dysfunction.

OBJECTIVE: The purpose of this study was to evaluate prospectively the association between selected obstetric antecedents and symptoms of pelvic floor dysfunction in primiparous women up to 7 months after childbirth. STUDY DESIGN: All nulliparous women who were delivered between June 1, 2000, and August 31, 2002, were eligible for a postpartum interview regarding symptoms of persistent pelvic floor dysfunction. Responses from all women who completed a survey at or before their 6-month contraceptive follow-up visit were analyzed. Obstetric antecedents to stress, urge, and anal incontinence were identified, and attributable risks for each factor were calculated. RESULTS: During the study period, 3887 of 10,643 primiparous women (37%) returned within 219 days of delivery. Symptoms of stress and urge urinary incontinence, were significantly reduced (P < .01) in women who underwent a cesarean delivery. Symptoms of urge urinary incontinence doubled in women who underwent a forceps delivery (P = .04). Symptoms of anal incontinence were increased in women who were delivered of an infant who weighed >4000 g (P = .006) and more than doubled in those women who received oxytocin and had an episiotomy performed (P = .01). CONCLUSION: The likelihood of symptoms of pelvic floor dysfunction up to 7 months after delivery was greater in women who received oxytocin, who underwent a forceps delivery, who were delivered of an infant who weighed >4000 g, or who had an episiotomy performed. Women who underwent a cesarean delivery had fewer symptoms of urge and stress urinary incontinence.

Adult↗
PubMed2005

The MFMU Cesarean Registry: uterine atony after primary cesarean delivery.

OBJECTIVE: The purpose of this study was to define independent risk factors for uterine atony after primary cesarean delivery, and to assess their overall association with atony in the study cohort. STUDY DESIGN: This was a 13-university center prospective observational study. All women who underwent primary cesarean from January 1, 1999 to December 31, 2000 were eligible. Trained and certified research nurses performed systematic data abstraction. The definition of atony required both the clinical diagnosis and the use of methergine or a prostaglandin preparation. Risk factors for uterine atony were assessed in univariable and multivariable logistic regression analyses, and these analyses then used to inform an assessment of the association of the various risk factors with the occurrence of uterine atony in the overall cohort. RESULTS: Twenty-three thousand, three hundred and ninety pregnancies were analyzed. Uterine atony occurred in 1416 women (6%). Several variables were independently associated with atony in a multivariable model, including multiple gestation (odds ratio [OR] 2.40, 95% CI 1.95-2.93), maternal Hispanic race (2.21, 1.90-2.57), induced or augmented labor for >18 hours (2.23, 1.92-2.60), infant birth weight >4500 g (2.05, 1.53-2.69), and clinically diagnosed chorioamnionitis (1.80, 1.55-2.09). However, because the various risk factors were not very powerful, approximately half of the cases of atony were associated with the 2/3 of women lacking a given risk factor or combination of risk factors. CONCLUSION: Although certain risk factors and uterine atony were clearly associated, the associations are of limited practical clinical use.

Adult↗
PubMed2005

Hospitalization for women with arrested preterm labor: a randomized trial.

OBJECTIVE: To determine whether hospitalization of women with arrested preterm labor has an effect on delivery at 36 weeks or greater when compared with women discharged home. METHODS: All women with a singleton gestation and a diagnosis of arrested preterm labor with intact membranes between 24 and 33 weeks, 4 days of gestation were randomly assigned to home or hospital management. Upon completion of a dexamethasone course, women assigned to outpatient management were promptly discharged, and women in the inpatient group were advised to continue hospitalization until 34 weeks. Decreased activity was encouraged in both groups. Bed rest was not strictly enforced. The primary outcome was delivery at 36 weeks or greater. RESULTS: A total of 101 women of a planned 188 were enrolled at the time of an interim analysis. There was no difference in the primary study outcome between the 2 groups and the trial was terminated. Among the hospitalized women, 71% reached 36 weeks or greater, compared with 72% of those discharged home (P = .89). The mean cervical dilatation in hospitalized women was 2.7 +/- 0.5 cm, compared with 2.6 +/- 0.5 cm in women discharged home (P = .16). The overall length of hospital stay for the women allocated to hospitalization was 16 +/- 13 days. CONCLUSION: Compared with hospitalization, outpatient management of women with arrested preterm labor and intact membranes had no effect on the rate of preterm birth. LEVEL OF EVIDENCE: I.

Adolescent↗
PubMed2005

A prospective observational study of domestic violence during pregnancy.

OBJECTIVE: To assess whether women reporting domestic violence are at increased risk for adverse pregnancy outcomes. METHODS: A screening questionnaire, previously validated for the identification of female victims of domestic violence, was offered to women presenting to our Labor and Delivery Unit. The survey prompted women to indicate whether her partner or family member physically hurt her, insulted or talked down to her, threatened her with harm, or screamed or cursed at her. The primary study outcome was to detect a 3-fold increase in low birth weight infants (< or = 2,500 g) in women reporting physical abuse, compared with those not reporting domestic violence. RESULTS: A total of 16,041 women were approached to be interviewed. Of these, 949 (6%) women responded affirmatively to one or more of the survey questions, and another 94 (0.6%) declined to be interviewed. The incidence of low birth weight infants was significantly increased in women who reported verbal abuse, compared with the no-abuse group (7.6% versus 5.1%, respectively, P = .002). Physical abuse was associated with an increased risk of neonatal death (1.5% versus 0.2%, P = .004). Interestingly, women who declined to be interviewed had significantly increased rates of low birth weight infants (12.8% versus 5.1%, P < .001), preterm birth at 32 weeks of gestation or less (5.3% versus 1.2%, P = .002), placental abruptions (2.1% versus 0.2%, P < .001), and neonatal intensive care admissions (7.4% versus 2.2%, P = .008) when compared with women in the no-abuse group, respectively. CONCLUSION: Women who declined to be surveyed regarding domestic violence were at increased risk for adverse pregnancy outcome. LEVEL OF EVIDENCE: II-2.

Adolescent↗
PubMed2005

Complications of anesthesia for cesarean delivery.

OBJECTIVE: To quantify anesthesia-related complications associated with cesarean delivery in a well-described, prospectively ascertained cohort from multiple university-based hospitals in the United States and to evaluate whether certain factors would identify women at increased risk for a failed regional anesthetic. METHODS: A prospective observational study was conducted of women (n = 37,142) with singleton gestations undergoing cesarean delivery in the centers forming the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Detailed information was collected regarding choice of anesthesia and procedure-related complications, including failed regional anesthetic and maternal death. Potential risk factors for a failed regional anesthetic were analyzed. RESULTS: Of the women studied, 34,615 (93%) received a regional anesthetic. Few (3.0%) regional procedures failed, and related maternal morbidity was rare. Increased maternal size, higher preoperative risk, rapid decision-to-incision interval, and placement later in labor were all significantly related to an increased risk of a failed regional procedure. Of the general anesthetics, 38% were administered when the decision-to-incision interval was less than 15 minutes. Women deemed at the greatest preoperative risk (American Society of Anesthesiologists score > or = 4) were approximately 7-fold more likely to receive a general anesthetic (odds ratio 6.9, 95% confidence interval 5.83-8.07). There was one maternal death, due to a failed intubation, in which the anesthetic procedure was directly implicated. CONCLUSION: Regional techniques have become the preferred method of anesthesia for cesarean delivery. Procedure-related complications are rare and attest to the safety of modern obstetric anesthesia for cesarean delivery in the United States.

Adolescent↗
PubMed2004

A hospital-sponsored quality improvement study of pain management after cesarean delivery.

OBJECTIVE: We undertook this study to systematically assess prevailing pain management regimes used at our hospital in women after cesarean delivery. STUDY DESIGN: Between August 1999 and July 2000, all women delivered by cesarean section at Parkland Hospital were assigned to 1 of 4 different pain management strategies: (1). intramuscular (IM) meperidine, (2). patient-controlled analgesia (PCA) meperidine, (3). IM morphine sulfate, and (4). PCA morphine sulfate. A combination of methods were used to compare these different pain management strategies. A survey questionnaire, using Likert scale responses, was administered to evaluate maternal satisfaction with pain control. Visual Analog Scale (VAS) scores and information regarding breastfeeding and rooming-in were also collected. RESULTS: A total of 1256 women were allocated to the 4 analgesia study groups. The median meperidine dosages for the IM and PCA groups were 350 mg and 600 mg, respectively (P <or=.01). Conversely, the median IM morphine dose (65 mg) was significantly higher than that for the PCA group (60 mg). The percentage of women reporting moderate or worse pain (VAS scores 4 or more) was significantly lower in those women who received PCA meperidine compared with IM meperidine. Women who received morphine reported less severe pain compared with meperidine, regardless of route of administration. The patients' subjective report of satisfaction with pain management was not related to the method or drug used for pain control (P=.13). Fewer women assigned to morphine therapy stopped breastfeeding (P=.02) and more roomed-in with their infants (P <.01). CONCLUSION: Pain relief was superior with the morphine regimens used and was positively associated with breastfeeding and infant rooming-in.

Adolescent↗
PubMed2002

Cesarean delivery: a randomized trial of epidural analgesia versus intravenous meperidine analgesia during labor in nulliparous women.

BACKGROUND: Controversy concerning increased cesarean births as a result of epidural analgesia for relief of labor pain has been attributed, in large part, to difficulties interpreting published studies because of design flaws. In this study, the authors compared epidural analgesia to intravenous meperidine analgesia using patient-controlled devices during labor to evaluate the effects of labor epidural analgesia, primarily on the rate of cesarean deliveries while minimizing limitations attributable to study design. METHODS: Four hundred fifty-nine nulliparous women in spontaneous labor at term were randomly assigned to receive either epidural analgesia or intravenous meperidine analgesia. Epidural analgesia was initiated with 0.25% bupivacaine and was maintained with 0.0625% bupivacaine and fentanyl 2 microg/ml at 6 ml/h with 5-ml bolus doses every 15 min as needed using a patient-controlled pump. Women in the intravenous analgesia group received 50 mg meperidine with 25 mg promethazine hydrochloride as an initial bolus, followed by 15 mg meperidine every 10 min as needed, using a patient-controlled pump. A written procedural manual that prescribed the intrapartum obstetric management was followed for each woman randomized in the study. RESULTS: A total of 226 women were randomized to receive epidural analgesia, and 233 women were randomized to receive intravenous meperidine analgesia. Protocol violations occurred in 8% (38 of 459) of women. There was no difference in the rate of cesarean deliveries between the two analgesia groups (epidural analgesia, 7% [16 of 226; 95% confidence interval, 4-11%] vs. intravenous meperidine analgesia, 9% [20 of 233; 95% confidence interval, 5-13%]; P = 0.61). Significantly more women randomized to epidural analgesia had forceps deliveries compared with those randomized to meperidine analgesia (12% [26 of 226] vs. 3% [7 of 233]; P < 0.001). Women who received epidural analgesia reported lower pain scores during labor and delivery compared with women who received intravenous meperidine analgesia. CONCLUSIONS: Epidural analgesia compared with intravenous meperidine analgesia during labor does not increase cesarean deliveries in nulliparous women.

Adult↗