(Abstracted from Birth 2024;51:659–666) Professional organizations, including the American College of Obstetrics and Gynecologists, American College of Nurse-Midwives, and American Academy of Pediatrics, support informed decision-making when choosing a birth setting—whether it is at home, in a birth center, or in a hospital. Freestanding birth centers accredited by the Commission for the Accreditation of Birth Centers (CABC) only provide intrapartum care to those with low risk factors for a physiologic birth, excluding at-risk pregnancies.

Background: Many studies reporting neonatal outcomes in birth centers include births with risk factors not acceptable for birth center care using the evidence-based CABC criteria. Accurate comparisons of outcomes by birth setting for low-risk patients are needed. Methods: Data from the public Natality Detailed File from 2018 to 2021 were used. Logistic regression, including adjusted and unadjusted odds ratios, compared neonatal outcomes (chorioamnionitis, Apgar scores, resuscitation, intensive care, seizures, and death) between centers and hospitals. Covariates included maternal diabetes, body mass index, age, parity, and demographic characteristics. Results: The sample included 8,738,711 births (8,698,432 (99.53%) in hospitals and 40,279 (0.46%) in birth centers). There were no significant differences in neonatal deaths (aOR 1.037; 95% CI [0.515, 2.088]; p-value 0.918) or seizures (aOR 0.666; 95% CI [0.315, 1.411]; p-value 0.289). Measures of morbidity either not significantly different or less likely to occur in birth centers compared to hospitals included chorioamnionitis (aOR 0.032; 95% CI [0.020, 0.052]; p-value < 0.001), Apgar score < 4 (aOR 0.814, 95% CI [0.638, 1.039], p-value 0.099), Apgar score < 7 (aOR 1.075, 95% CI [0.979, 1.180], p-value 0.130), ventilation >6 h (aOR 0.349; [0.281,0.433], p-value < 0.001), and intensive care admission (aOR 0.356; 95% CI [0.328, 0.386], p-value < 0.001). Birth centers had higher odds of assisted neonatal ventilation for <6 h as compared to hospitals (aOR 1.373; 95% CI [1.293, 1.457], p-value < 0.001). Conclusion: Neonatal deaths and seizures were not significantly different between freestanding birth centers and hospitals. Chorioamnionitis, Apgar scores < 4, and intensive care admission were less likely to occur in birth centers.

Study objective:To determine the incidence of and risk factors for HF after successful electrical and ablative cardioversion (CV) of atrial fibrillation (AF) and atrial flutter (AFL). Design:Retrospective cohort study. Setting:Single center academic institution. Participants:Seven hundred fifty-five patients underwent successful elective CV from July 1, 2018 to May 20, 2019. Patients presenting in arrhythmias other than AF or AFL, those who developed HF due to alternative etiologies, and those who developed arrhythmia recurrence within 30 days were excluded. Medical records of the remaining 451 patients were reviewed before and after CV. Main outcomes measured:Development of heart failure despite sinus rhythm following CV and the risk factors associated with this outcome. Results:Thirty-three (7.3 %) of 451 patients who met inclusion criteria for our study developed new or worsening HF symptoms while maintaining sinus rhythm (SR) after successful CV. Symptoms were reported an average of 5.1 days following CV (range 0-17 days, SD 4.71). Following a multivariate stepwise logistic regression model, prior HF hospitalization (OR 3.91, 95 % CI 1.82-8.39), BMI (OR 1.06, 95 % CI 1.02-1.11), and valve disease (OR 2.51, 95 % CI 1.12-5.60) remained significant risk factors, and anti-arrhythmic drug (AAD) use was marginally significant (OR 2.02, 95 % CI 0.95-4.31). Conclusion:Despite maintenance of SR, 7.3 % of patients developed decompensated HF in the 30 days following successful CV of AF or AFL, indicating this complication may be more frequent than previously believed. Predictors of HF post-CV included elevated BMI, valve disease, previous HF hospitalization, and prior AAD use.

Background:Cerebral thromboembolism during atrial fibrillation (AF) ablation is an infrequent (0.17%) complication in part owing to strict adherence to intraprocedural anticoagulation. Failure to maintain therapeutic anticoagulation can lead to an increase in events, including silent cerebral ischemia. Objective:To evaluate a computerized, clinical decision support system (CDSS) to dose intraprocedural anticoagulation and determine if it leads to improved intraprocedural anticoagulation outcomes during AF ablation. Methods:The Digital Intern dosing algorithm is an adaptive, rule-based CDSS for heparin dosing. The initial dose is calculated from the patient's weight, baseline activated clotting time (ACT), and outpatient anticoagulant. Subsequent recommendations adapt based on individual patient ACT changes. Outcomes from 50 cases prior to algorithm introduction were compared to 139 cases using the algorithm. Results:Procedures using the dosing algorithm reached goal ACT (over 300 seconds) faster (17.6 ± 11.1 minutes vs 33.3 ± 23.6 minutes pre-algorithm, P < .001). ACTs fell below goal while in the LA (odds ratio 0.20 [0.10-0.39], P < .001) and rose above 400 seconds less frequently (odds ratio 0.21 [0.07-0.59], P = .003). System Usability Scale scores were excellent (96 ± 5, n = 7, score >80.3 excellent). Preprocedure anticoagulant, weight, baseline ACT, age, sex, and renal function were potential predictors of heparin dose to achieve ACT >300 seconds and final infusion rate. Conclusion:A heparin dosing CDSS based on rules and adaptation to individual patient response improved maintenance of therapeutic ACT during AF ablation and was rated highly by nurses for usability.

Background: Invasive arterial catheter (IAC) placement can lead to hematoma, vessel occlusion, pain and & procedure delay. The ClearSight System™ (CSS) is a non-invasive blood pressure (NIBP) device that measures beat-to-beat arterial pressures (AP) via a finger cuff. The validity of CSS during cardiac ablation & transvenous pacemaker lead removal has not been described. Therefore, we performed a single center observational study to validate AP monitoring by CSS compared to IAC in such patients (pts). Methods: Pts undergoing cardiac ablation or lead removal from June-November 2022 were included. AP was simultaneously measured via CSS & IAC. Measurements were compared using Bland-Altman analysis. Acceptable bias & precision (standard deviation) were defined as <5 mm Hg & <8 mm Hg respectively based on Association for the Advancement of Medical Instrumentation standards. An exploratory analysis on impacts of BMI, sex, & type of procedure on validity of CSS was also assessed. Results: Paired AP measurements were available for 61 pts (6967 paired measurements). Median age was 67 (IQR 60.5-73.5), BMI 29.2 (IQR 26.1-37.1) & 31% of pts were female. Procedures included atrial fibrillation ablation (n=32), SVT ablation (n=13), lead extraction (n=9), & VT ablation (n=7). Bland-Altman analysis comparing AP via CSS vs IAC showed that the CSS overestimated systolic arterial pressure (SAP) & underestimated both diastolic arterial pressure (DAP) & mean arterial pressure (MAP). Mean bias was 4.2 ± 12.9 (SAP), -4.99 ± 9.2 (DAP) & -2.4 ± 11.78 (MAP) (Figure 1). Exploratory analysis showed that CSS was not interchangeable with IAC monitoring regardless of subgroup (MAP male sex -1.9 ± 11.1; BMI ≥30 -2.7 ± 9.7; ablation -1.8 ± 12.2). Conclusion: Continuous NIBP monitoring via CSS was not interchangeable with IAC monitoring in pts undergoing cardiac ablation & lead extraction.

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States.1 Cardiac biomarkers are often analyzed in patients presenting with AF with rapid ven-tricular response (RVR). However, there is a paucity of evi-dence to inform the appropriate diagnostic strategy when the clinical presentation is not consistent with the Fourth Univer-sal Definition of Myocardial Infarction description of type I myocardial infarction (MI).2 We examined the impact of ischemic evaluations on outcomes in patients with AF with RVR and clinically labeled type II MI in an effort to provide further insight into the appropriate management strategy.

IntroductionThe Birth Center model of care is a health care delivery innovation in its fourth decade of demonstration across the United States. The purpose of this research was to evaluate the model's potential for decreasing poverty-related health disparities among childbearing families. MethodsBetween 2013 and 2017, 26,259 childbearing people received care within the 45 Center for Medicare and Medicaid Innovation Strong Start birth center sites. Secondary analysis of the prospective American Association of Birth Centers Perinatal Data Registry was conducted. Descriptive statistics described sociobehavioral, medical risk factors, and core clinical outcomes to inform the logistic regression model. Privately insured consumers were independently compared with 2 subgroups of Medicaid beneficiaries: Strong Start enrollees (midwifery-led care with peer counselors) and non-Strong Start Medicaid beneficiaries (midwifery-led care without peer counselors). ResultsAfter controlling for medical risk factors, Strong Start Medicaid beneficiaries achieved similar outcomes to privately insured consumers with no significant differences in maternal or newborn outcomes between groups. Perinatal outcomes included induction of labor (adjusted odds ratio [aOR], 0.86; 95% CI 0.61-1.13), epidural analgesia use (aOR, 1.00; 95% CI, 0.68-1.48), cesarean birth (aOR, 1.16; 95% CI, 0.87-1.53), exclusive breastfeeding on discharge (aOR, 1.11; 95% CI, 0.48-2.56), low Apgar score at 5 minutes (aOR, 1.23; 95% CI, 0.86-1.83), low birth weight (aOR, 1.12; 95% CI, 0.77-1.64), and antepartum transfer of care after the first prenatal appointment (aOR, 1.53; 95% CI, 0.97-2.40). Medicaid beneficiaries who were not enrolled in the Strong Start midwifery-led, peer counselor program demonstrated similar results except for having higher epidural analgesia use (aOR, 1.30; 95% CI, 1.10-1.53) and significantly lower exclusive breastfeeding on discharge (aOR, 0.57; 95% CI, 0.40-0.81) than their privately insured counterparts. DiscussionThe midwifery-led birth center model of care complemented by peer counselors demonstrated a pathway to achieve health equity.

Atrial fibrillation (AF), the most common arrhythmia in the United States, carries with it a well-known association with stroke that is approximately 5 times the general population.1 Consequently, for over two decades, clinical practice guidelines have recommended anticoagulation in AF patients most at risk for stroke or systemic embolism.2

There is a growing appreciation for differences in epidemiology, treatment, and outcomes of cardiovascular conditions by sex. Historically, cardiovascular clinical trials have under-represented females, but findings have nonetheless been applied to clinical care in a sex-agnostic manner. Thus, much of the collective knowledge about sex-specific cardiovascular outcomes result from post hoc and secondary analyses. In some cases, these investigations have revealed important sex-based differences with implications for optimizing care for female patients with arrhythmias. This review explores the available evidence related to cardiac arrhythmia care among females, with emphasis on areas in which important sex differences are known or suggested. Considerations related to improving female enrollment in clinical trials as a way to establish more robust clinical evidence for the treatment of females are discussed. Areas of remaining evidence gaps are provided, and recommendations for areas of future research and specific action items are suggested. The overarching goal is to improve appreciation for sex-based differences in cardiac arrhythmia care as 1 component of a comprehensive plan to optimize arrhythmia care for all patients.

Introduction Slow or arrested progress in labor is the most frequent (64%) indication for nonemergent transfer of laboring people from freestanding birth centers to the hospital. After the 2014 publication of the Consensus Statement on Safe Prevention of Primary Cesarean Delivery (Consensus Statement), many freestanding birth centers changed their clinical practice guidelines to allow more time for active labor in the birth center prior to hospital transfer. The result of these changes has not been evaluated in birth centers. Evaluation of adoption of guidelines based on the Consensus Statement in hospitals has shown inconsistent results. Methods Birth centers were contacted to determine whether they changed clinical practice guidelines in response to the Consensus Statement. A before-after analysis compared outcomes for the 2 calendar years before and the 2 calendar years after adoption of new guidelines with a retrospective analysis of deidentified client-level data collected in the American Association of Birth Centers Perinatal Data Registry. Results A third of responding birth centers (11 of 33) changed their clinical practice guidelines, mostly redefining the onset of active labor as beginning at 6 cm cervical dilatation and allowing 4 hours of arrest of dilatation in active labor before transfer to the hospital. These changes were associated with fewer diagnoses of prolonged first stage of labor (13.8% vs 8.0%, P < .01) but not with fewer intrapartum transfers (14.0% vs 14.7%, P = .55) or cesarean births (5.0 vs 4.1%, P = .26.) Discussion We found no evidence that making these practice changes was associated with better outcomes. Two hours of a lack of documented cervical change in active labor is likely long enough to diagnose arrested progress in labor. Research on proportion of morbidity and mortality associated with prolonged labor could inform practice guidelines for transfers.

Acute pulmonary edema following cardioversion (CV) of atrial fibrillation (AF) or atrial flutter (AFL) has been previously reported. Mechanisms including left atrial mechanical failure have been postulated, yet no studies to our knowledge have revealed the etiology and no predictive clinical biomarkers are available.

Intraprocedural anticoagulation during atrial fibrillation (AF) ablation reduces the risk of cerebral thromboembolism during ablation. Heparin dosing strategies vary, can result in sub-therapeutic levels, and require frequent physician decisions if not protocol driven.

PURPOSE:The purpose of this study was to describe sociodemographic variations in client preference for birthplace and relationships to perinatal health outcomes.METHODS:Descriptive data analysis (raw number, percentages, and means) showed that preference for birthplace varied across racial and ethnic categories as well as sociodemographic categories including educational status, body mass index, payer status, marital status, and gravidity. A subsample of medically low-risk childbearing people, qualified for birth center admission in labor, was analyzed to assess variations in maternal and newborn outcomes by site of first admission in labor.RESULTS:While overall clinical outcomes exceeded national benchmarks across all places of admission in the sample, disparities were noted including higher cesarean birth rates among Black and Hispanic people. This variation was larger within the population of people who preferred to be admitted to the hospital in labor in the absence of medical indication.CONCLUSION:This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation.