OBJECTIVE:Magnesium sulfate administration for preeclampsia with severe features during labor induction has been associated with increased risk of cesarean delivery (CD). We aim to evaluate associations with successful vaginal delivery (VD) in nulliparous patients undergoing labor induction while receiving magnesium sulfate. METHODS:This was a secondary analysis from the Consortium on Safe Labor, a multicenter cohort study of 228,438 deliveries in 19 U.S. hospitals. The analysis included nulliparous women ≥18 years old with singleton gestation undergoing induction of labor for preeclampsia with severe features and receiving magnesium sulfate. Primary outcome was characteristics associated with successful VD. Secondary outcomes were maternal and neonatal outcomes. Chi-square and independent samples t-tests were used to compare groups. Multivariate logistic regression was performed to adjust for baseline characteristics that differed between groups. RESULTS:A total of 4122 women met inclusion criteria, of whom 2256 (54.7%) had a VD. Patients who had a VD were more likely to have lower maternal age (24.8 ± 5.7 years vs. 27.0 ± 6.6 years; p < 0.001) and BMI (25.9 ± 6.5 kg/m2 vs. 27.8 ± 7.4 kg/m2; p < 0.001), higher gestational age (36w1 ± 4d vs. 35w ± 0d; p < 0.001), and lower admission systolic blood pressure (142.4 mmHg ± 17.2 vs. 146.0 mmHg ± 18.4; p = 0.049). Labor factors associated with VD included higher Bishop's score on admission (5.0 ± 3.1 vs. 3.2 ± 2.5; p < 0.001) and undergoing artificial rupture of membranes (aOR, 1.30; 95% confidence interval (CI), 1.02-1.65; p = 0.036) or oxytocin administration (aOR, 1.27; 95% CI, 1.07-1.50; p = 0.006). Successful VD was associated with lower postpartum hemorrhage (aOR, 0.15; 95% CI, 0.11-0.21; p < 0.001), blood transfusion (aOR, 0.61; 95% CI, 0.43-0.87; p = 0.007), and composite maternal morbidity (aOR, 0.66; 95% CI, 0.49-0.90; p = 0.009). In neonatal outcomes, VD was associated with higher one-minute APGAR (7.3 ± 2.1 vs. 6.8 ± 2.2; p < 0.001), and lower rates of NICU admission (aOR, 0.46; 95% CI, 0.39-0.55; p < 0.001) and composite neonatal morbidity (aOR, 0.66; 95% CI, 0.55-0.80; p < 0.001). CONCLUSIONS:Rates of CD are high in patients undergoing induction of labor for preeclampsia with severe features and receiving magnesium sulfate. Various characteristics are associated with an increased rate of successful VD. Appropriate care should be taken in labor management for this high-risk patient cohort.

Magnesium sulfate administration for preeclampsia with severe features during labor induction has been associated with increased risk of cesarean delivery (CD). We aim to evaluate provider and hospital associations with successful vaginal delivery (VD) in nulliparous patients undergoing labor induction while receiving magnesium sulfate. This was a secondary analysis from the Consortium on Safe Labor, a multicenter cohort study of 228,438 deliveries in 19 U.S. hospitals. The analysis included nulliparous women ≥ 18 years old with singleton gestation undergoing induction of labor for preeclampsia with severe features and receiving magnesium sulfate. Primary outcome was physician and hospital characteristics associated with successful VD. Chi-square and independent samples t-test were used to compare groups. The study was deemed IRB exempt #20-000360. Total 4,122 women met inclusion criteria, of whom 2256 (54.7%) had a successful VD. Patients who had a VD were more likely to have had a female physician (p< 0.001), midwife or resident involvement (p< 0.001), government, OB hospitalist, or university practice model over private practice (p< 0.001), and government or hospital insurance over group or self-pay model (p=0.003). Hospital type, level of care, or types of physician coverage (MFM, hospitalist, midwife) did not differ between groups. NICU level of care did not differ between groups. The number of hospital deliveries per year was slightly lower in those with successful VDs (p< 0.001). Rates of cesarean delivery are high in patients undergoing induction of labor for severe preeclampsia receiving magnesium sulfate. Various physician and hospital characteristics are associated with increased rate of successful VD. These findings suggest the need to study practice patterns by different providers in various settings to appropriately manage labor in this high risk patient cohort.

We aimed to quantify the effect of magnesium sulfate on duration of labor induction in nulliparous women with hypertensive disorders of pregnancy and maternal and neonatal outcomes.

INTRODUCTION: Prolonged induction of labor is associated with increased morbid maternal outcomes. Induction of labor length varies by institution and labor management. The objective of this study was to determine the risk of morbid outcomes increasing hours of labor induction in a multiethnic tertiary care center. METHODS: We conducted a retrospective cohort study on patients undergoing scheduled induction of labor from June 2020 to May 2021 at a tertiary care center. Nulliparous singleton term pregnancies with intact membranes who had an initial cervical dilation less than 3 were included. Length of labor induction was defined as first intervention to birth. Morbid outcomes included suspected intraamniotic infection (IAI), postpartum hemorrhage (PPH), and cesarean birth. Multivariable logistic regressions were performed relative to the length of labor. RESULTS: Two hundred sixty-seven patients were included in our study, with 18.0% Asian American/Pacific Islander, 6.4% Black/non-Hispanic, 20.2% Hispanic, 32.6% White/non-Hispanic, 17.6% multiracial/other, and 5.2% unknown. The median labor length was 28.5 hours (interquartile range 21.2–38.5). The rates of IAI was 22%, PPH 12%, and cesarean birth 22%. For every hour of labor, there was 1.04 increased odds of IAI, 1.08 odds of cesarean birth, and 1.05 odds of PPH after adjusting for confounders (PP=.46) and no differences in IAI, PPH, and cesarean. CONCLUSION: For each hour of labor, the risk of IAI, PPH, and cesarean birth increased by 4%, 8%, and 5%, respectively. Characteristics contributing to this association may be multifactorial and suggest labor management should aim for an expedient birth.

•Healthcare worker burnout, depression, negative emotions and suicidal ideation were highly prevalent pre-Covid.•Burnout, depression and intense negative emotions were significantly more frequent since Covid.•No difference were seen in drinking behaviors, suicidal ideation, level of suicide risk, or treatment since Covid.•Organizational support to mitigate health worker distress and suicide risk factors is needed.

BACKGROUND: A favorable Simplified Bishop Score (>5) before the induction of labor is associated with successful vaginal birth. Patients with an unfavorable Simplified Bishop Score (<= 5) undergo cervical ripening before the administration of oxytocin. However, data are limited regarding the utility of the Simplified Bishop Score after cervical ripening. OBJECTIVE: The objective of this study was to determine if the Simplified Bishop Score before oxytocin induction but after cervical ripening is associated with cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study on patients undergoing induction of labor from the Consortium on Safe Labor. The patients with a singleton term pregnancy who initially underwent cervical ripening were included. Those with a history of cesarean delivery were excluded. The outcomes of patients with a favorable Simplified Bishop Score after cervical ripening were compared with those with an unfavorable Simplified Bishop Score. The primary outcome was the mode of birth. A log-binomial regression was performed to calculate the relative risk and control for confounders such as admission Simplified Bishop Score and parity. RESULTS: A total of 5807 patients met the criteria to be included in the study. 4235 (73%) patients had a favorable cervix, and 1572 (27%) patients had an unfavorable cervix after cervical ripening. The favorable group had a decreased rate of cesarean delivery than the unfavorable group (risk ratio, 0.35; 95% confidence interval, 0.30-0.40). Both the groups had low rates of maternal chorioamnionitis, though the patients with an unfavorable cervix were at a higher risk. There was no significant difference in the rates of postpartum hemorrhage or neonatal intensive care unit admission. Lower rates of cesarean delivery among the favorable group persisted when stratifying by parity (nulliparous: risk ratio, 0.37; 95% confidence interval, 0.31-0.43; multiparous: risk ratio, 0.22; 95% confidence interval, 0.14-0.36). After controlling for maternal age, prepregnancy body mass index, parity, gestational age, and Simplified Bishop Score at admission, a favorable cervix remained significantly associated with fewer cesarean births (risk ratio, 0.55; 95% confidence interval, 0.46-0.66). CONCLUSION: In women undergoing labor induction, a favorable Simplified Bishop Score after cervical ripening and before the start of oxytocin is associated with a decreased rate of cesarean delivery, even after adjusting for parity and Simplified Bishop Score at admission. Moreover, the Simplified Bishop Score assigned after cervical ripening could be used to inform the timing of oxytocin initiation. However, further research is necessary to determine the ideal endpoint of cervical ripening.

Part of the art of anesthesia is performing timely emergence and extubation. There are multiple ways to safely and efficiently perform an anesthetic. This chapter is simply one option for performing emergence without the use of nitrous oxide, in particular.