LESSON 12
Paying for Care and Health Information
LEARNING OUTCOMES
______________________________________________________________________________
In this lesson, you will do the following:
Describe how coding, reimbursement, and billing are impacted by health information systems.
READINGS
The following reading assignments are for Lessons 9 through 12:
Gartee Text:
Chapter 4, pp. 74 - 95
Chapter 5, pp. 98 - 126
Chapter 6, pp. 127 - 151
Chapter 9, pp. 208 - 236
Chapter 10, pp. 237 - 259
ACTIVITIES / ASSESSMENTS
The following activities/assessments are for Lessons 9 through 12:
1. Read the assigned pages from the Gartee text.
2. Review the Lecture Notes, Unit 3 PowerPoint, and Voice Pod.
3. Participate in the weekly discussion question.
4. Complete the written assignment.
WRITTEN ASSIGNMENTS
Hospital Medicare Payment System - DRGs:
Research how large hospitals are paid by a Medicare fee for service reimbursements (DRG’s).
Include a brief history and relate how health information supports the request for a payment.
PLEASE NOTE: All graded assignments for the lessons in this unit should be grouped together
and submitted as ONE document using the Assignment Submission form accessed from your
course homepage or http://www.sjcme.edu/gps/assignments.
All activities/assignments for this unit should be as follows:
1. Should include a cover sheet for each assignment stating the following:
Course (HA 214)
Your Name
Unit and Lesson Number
Date Submitted
2. Each individual assignment number and copy of the assignment directions should be
included in the submission as the starting header of each lesson.
3. Carefully check grammar and spelling.
4. Use APA format for any research or sources that are being used or quoted.
5. Email the instructor if you have questions regarding the assignments.
http://www.sjcme.edu/gps/assignments
g
Research www.AJOG.org
O B S T E T R I C S
Preterm premature rupture of membranes >32 weeks’
estation: impact of revised practice guidelines
Arij Faksh, DO; Joseph R. Wax, MD; F. Lee Lucas, PhD; Angelina Cartin; Michael G. Pinette, MD
OBJECTIVE: The purpose of this study was to determine the perinatal
impact of the 2007 American College of Obstetricians and Gynecolo-
gists Practice Bulletin on preterm premature membrane rupture.
STUDY DESIGN: Perinatal outcomes were compared in women who
had experienced preterm membrane rupture in the 3 years before the
2007 Practice Bulletin to similar women who experienced preterm pre-
mature rupture of membranes in the 3 years after the issue and imple-
mentation of the guideline.
RESULTS: After adjustment for gestational age at membrane rupture
and steroids, composite severe morbidity (death, respiratory distress
Obstet Gynecol 2011;205:340.e1-5.
p
remained uncertain, p
doi: 10.1016/j.ajog.2011.05.036
340.e1 American Journal of Obstetrics & Gynecology OCTOB ...
Current Point of View in Preterm Labor Management in AlbaniaRustem Celami
The document discusses a study conducted in Albania on the use of maintenance tocolysis therapy to prevent preterm labor. The study included 325 pregnant women between 28-32 weeks gestation hospitalized for preterm labor. Women received tocolysis therapy for over one month. Those between 28-30 weeks gestation saw more prolonged pregnancies compared to the 30-32 weeks group. The study concluded that maintenance tocolysis therapy can considerably benefit women diagnosed with preterm labor and help prolong their singleton pregnancies when medical intervention is not urgently needed. However, more research is still required.
The comparison of dinoprostone and vagiprost for induction of lobar in post t...iosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Current point of view in preterm labor management in albania (2)Alexander Decker
This study examined the use of maintenance tocolysis therapy to prevent preterm labor in Albania. The study included 325 pregnant women between 28-32 weeks gestation hospitalized for preterm labor. Women received tocolysis therapy for over one month. Those between 28-30 weeks (n=200) had greater benefits, with pregnancy prolonged by 6-8 weeks on average. The authors conclude maintenance tocolysis therapy can considerably prolong pregnancy for women diagnosed with preterm labor between 28-32 weeks gestation, though larger studies are still needed.
Evidence-based intrapartum practice and.pdfheidilee52
The study aimed to describe evidence-based intrapartum care practices and associated factors at a tertiary hospital in the Philippines through direct observation of 170 deliveries and interviews with healthcare providers. While recommended practices like prophylactic oxytocin were followed in most cases, potentially harmful practices like episiotomy in 92% of first-time mothers and fundal pressure in 31% of mothers were also observed. Factors associated with episiotomy included being a first-time mother, longer second stage of labor, and assisted delivery. Factors linked to fundal pressure were being a first-time mother, oxytocin augmentation, and assisted delivery. Healthcare providers believed these practices can prevent tearing, though the rate of severe
Randomized, Controlled Trial Of A Prenatal And Postnatal Lactation ConsultantBiblioteca Virtual
This randomized controlled trial evaluated the effectiveness of a prenatal and postnatal lactation consultant intervention on the duration and intensity of breastfeeding up to 12 months. Over 300 low-income women receiving prenatal care at two community health centers were randomly assigned to an intervention or control group. The intervention group received individualized support from lactation consultants including prenatal meetings, a postpartum hospital visit, and home visits/phone calls. The trial found the intervention group was more likely to breastfeed through 20 weeks and had higher breastfeeding intensity scores at 13 and 52 weeks compared to the control group. US-born women in the control group had the lowest breastfeeding intensity. The study concluded the "best-practices" lactation
Repeat steroids when is it okay review 2012 ron wapnerAsha Reddy
This document discusses the history and efficacy of antenatal corticosteroids in managing preterm birth. It notes that while antenatal corticosteroids have been shown to significantly reduce neonatal mortality and morbidity rates, questions remain about their efficacy in specific patient populations and safety with repeat courses. The history demonstrates how clinical practices can be adopted before sufficient evidence is available and how arbitrary choices can become standardized. Further research is still needed to determine optimal dosing schedules and administration in special cases.
The document discusses the definition of term pregnancy. Previously, term was considered 37-42 weeks of gestation, but research shows neonatal outcomes vary within this range. To address this, a work group in 2012 recommended replacing "term" with more specific designations: early term (37-38 weeks), full term (39-40 weeks), late term (41 weeks) and post-term (42+ weeks). They encourage clinicians and researchers to uniformly use these new designations to facilitate data reporting, quality care and research.
The document summarizes a study on women's awareness of initiating and continuing breastfeeding after cesarean section in Baghdad, Iraq. The study involved surveying 30 women who had cesarean sections using a questionnaire. The results showed that 43.3% initiated breastfeeding within 24 hours of their c-section. 76.7% continued breastfeeding, though only 26% practiced exclusive breastfeeding. The study aimed to identify factors influencing breastfeeding initiation and continuation after c-sections. It recommended promoting breastfeeding through baby-friendly hospital initiatives and counseling women during pregnancy and after birth.
Current Point of View in Preterm Labor Management in AlbaniaRustem Celami
The document discusses a study conducted in Albania on the use of maintenance tocolysis therapy to prevent preterm labor. The study included 325 pregnant women between 28-32 weeks gestation hospitalized for preterm labor. Women received tocolysis therapy for over one month. Those between 28-30 weeks gestation saw more prolonged pregnancies compared to the 30-32 weeks group. The study concluded that maintenance tocolysis therapy can considerably benefit women diagnosed with preterm labor and help prolong their singleton pregnancies when medical intervention is not urgently needed. However, more research is still required.
The comparison of dinoprostone and vagiprost for induction of lobar in post t...iosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Current point of view in preterm labor management in albania (2)Alexander Decker
This study examined the use of maintenance tocolysis therapy to prevent preterm labor in Albania. The study included 325 pregnant women between 28-32 weeks gestation hospitalized for preterm labor. Women received tocolysis therapy for over one month. Those between 28-30 weeks (n=200) had greater benefits, with pregnancy prolonged by 6-8 weeks on average. The authors conclude maintenance tocolysis therapy can considerably prolong pregnancy for women diagnosed with preterm labor between 28-32 weeks gestation, though larger studies are still needed.
Evidence-based intrapartum practice and.pdfheidilee52
The study aimed to describe evidence-based intrapartum care practices and associated factors at a tertiary hospital in the Philippines through direct observation of 170 deliveries and interviews with healthcare providers. While recommended practices like prophylactic oxytocin were followed in most cases, potentially harmful practices like episiotomy in 92% of first-time mothers and fundal pressure in 31% of mothers were also observed. Factors associated with episiotomy included being a first-time mother, longer second stage of labor, and assisted delivery. Factors linked to fundal pressure were being a first-time mother, oxytocin augmentation, and assisted delivery. Healthcare providers believed these practices can prevent tearing, though the rate of severe
Randomized, Controlled Trial Of A Prenatal And Postnatal Lactation ConsultantBiblioteca Virtual
This randomized controlled trial evaluated the effectiveness of a prenatal and postnatal lactation consultant intervention on the duration and intensity of breastfeeding up to 12 months. Over 300 low-income women receiving prenatal care at two community health centers were randomly assigned to an intervention or control group. The intervention group received individualized support from lactation consultants including prenatal meetings, a postpartum hospital visit, and home visits/phone calls. The trial found the intervention group was more likely to breastfeed through 20 weeks and had higher breastfeeding intensity scores at 13 and 52 weeks compared to the control group. US-born women in the control group had the lowest breastfeeding intensity. The study concluded the "best-practices" lactation
Repeat steroids when is it okay review 2012 ron wapnerAsha Reddy
This document discusses the history and efficacy of antenatal corticosteroids in managing preterm birth. It notes that while antenatal corticosteroids have been shown to significantly reduce neonatal mortality and morbidity rates, questions remain about their efficacy in specific patient populations and safety with repeat courses. The history demonstrates how clinical practices can be adopted before sufficient evidence is available and how arbitrary choices can become standardized. Further research is still needed to determine optimal dosing schedules and administration in special cases.
The document discusses the definition of term pregnancy. Previously, term was considered 37-42 weeks of gestation, but research shows neonatal outcomes vary within this range. To address this, a work group in 2012 recommended replacing "term" with more specific designations: early term (37-38 weeks), full term (39-40 weeks), late term (41 weeks) and post-term (42+ weeks). They encourage clinicians and researchers to uniformly use these new designations to facilitate data reporting, quality care and research.
The document summarizes a study on women's awareness of initiating and continuing breastfeeding after cesarean section in Baghdad, Iraq. The study involved surveying 30 women who had cesarean sections using a questionnaire. The results showed that 43.3% initiated breastfeeding within 24 hours of their c-section. 76.7% continued breastfeeding, though only 26% practiced exclusive breastfeeding. The study aimed to identify factors influencing breastfeeding initiation and continuation after c-sections. It recommended promoting breastfeeding through baby-friendly hospital initiatives and counseling women during pregnancy and after birth.
This document describes a study that examined practice variation in the diagnosis and treatment of chorioamnionitis among US obstetricians. The study involved distributing a survey to 500 obstetricians querying their demographics, practice setting, and chorioamnionitis management strategies. 212 surveys were analyzed. The results found wide variation in diagnostic criteria, antibiotic regimens, and postpartum treatment duration. Specifically, over 25 different antibiotic regimens were reported, with 30% using a single agent. Postpartum treatment duration ranged from no treatment to 48 hours. No practitioner characteristics were independently associated with diagnostic or treatment strategies. This variation may reflect a lack of high-quality evidence on best practices for chorio
Dr. Ankit Jain et al conducted a study to evaluate neonatal outcomes in mothers with premature rupture of membranes (PROM) at a tertiary care hospital. They analyzed 85 neonates born to mothers with PROM. Most neonates were born at 35-36 weeks gestation to primigravid mothers aged 21-25 years via normal vaginal delivery. The most common neonatal complications were jaundice, respiratory distress, and hypoglycemia. Over half of neonates were admitted to the NICU. Most had normal CBC and CRP reports, and the majority exhibited no complications. Common issues during hospitalization included decreased activity, fever, and feeding difficulties.
The document outlines Methodist Dallas Medical Center's plan to achieve Baby-Friendly designation by adopting several evidence-based practices. The plan includes having a neonatal admission nurse care for infants in the same location as mothers to promote skin-to-skin contact and rooming-in. Research shows these practices improve breastfeeding and maternal-infant bonding. The plan also delays unnecessary interventions like early infant bathing to prevent hypothermia and supports breastfeeding within one hour of birth.
Medically Complex Pregnancies and Early BreastfeedingBehavio.docxARIV4
Medically Complex Pregnancies and Early Breastfeeding
Behaviors: A Retrospective Analysis
Katy B. Kozhimannil1*, Judy Jou1, Laura B. Attanasio1, Lauren K. Joarnt2, Patricia McGovern3
1 Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota, United States of America, 2 Harvard University,
Cambridge, Massachusetts, United States of America, 3 Division of Environmental Health Sciences, University of Minnesota School of Public Health, Minneapolis,
Minnesota, United States of America
Abstract
Background: Breastfeeding is beneficial for women and infants, and medical contraindications are rare. Prenatal and labor-
related complications may hinder breastfeeding, but supportive hospital practices may encourage women who intend to
breastfeed. We measured the relationship between having a complex pregnancy (entering pregnancy with hypertension,
diabetes, or obesity) and early infant feeding, accounting for breastfeeding intentions and supportive hospital practices.
Methods: We performed a retrospective analysis of data from a nationally-representative survey of women who gave birth
in 2011–2012 in a US hospital (N = 2400). We used logistic regression to examine the relationship between pregnancy
complexity and breastfeeding. Self-reported prepregnancy diabetes or hypertension, gestational diabetes, or obesity
indicated a complex pregnancy. The outcome was feeding status 1 week postpartum; any breastfeeding was evaluated
among women intending to breastfeed (N = 1990), and exclusive breastfeeding among women who intended to exclusively
breastfeed (N = 1418). We also tested whether breastfeeding intentions or supportive hospital practices mediated the
relationship between pregnancy complexity and infant feeding status.
Results: More than 33% of women had a complex pregnancy; these women had 30% lower odds of intending to breastfeed
(AOR = 0.71; 95% CI, 0.52–0.98). Rates of intention to exclusively breastfeed were similar for women with and without
complex pregnancies. Women who intended to breastfeed had similar rates of any breastfeeding 1 week postpartum
regardless of pregnancy complexity, but complexity was associated with .30% lower odds of exclusive breastfeeding 1
week among women who intended to exclusively breastfeed (AOR = 0.68; 95% CI, 0.47–0.98). Supportive hospital practices
were strongly associated with higher odds of any or exclusive breastfeeding 1 week postpartum (AOR = 4.03; 95% CI, 1.81–
8.94; and AOR = 2.68; 95% CI, 1.70–4.23, respectively).
Conclusions: Improving clinical and hospital support for women with complex pregnancies may increase breastfeeding
rates and the benefits of breastfeeding for women and infants.
Citation: Kozhimannil KB, Jou J, Attanasio LB, Joarnt LK, McGovern P (2014) Medically Complex Pregnancies and Early Breastfeeding Behaviors: A Retrospective
Analysis. PLoS ONE 9(8): e104820. doi:10.1371/journal.pone.0104820
Editor: Katariina Laine, Oslo Uni ...
Interventions In Primary Care To Promote Breastfeeding An Evidence Review For...Biblioteca Virtual
Primary care-initiated interventions can effectively promote breastfeeding. A systematic review of 38 randomized controlled trials found that breastfeeding promotion interventions in developed countries significantly increased short-term (1 to 3 months) and long-term (6 to 8 months) exclusive breastfeeding rates. Combining pre- and postnatal interventions and including lay support, such as peer counseling, were most effective in increasing breastfeeding duration. No harms from breastfeeding promotion interventions were reported.
Introduction: Though there are many studies on the effects of anesthesia methods used for cesarean section on the newborn,
research on this topic still continues. In our prospective observational study, we investigated the effects of different anesthesia techniques used in routine cesarean deliveries on early neonatal outcomes in our hospital. This prospective, observational, randomized study included a total of 222 ASA II risk group pregnant women undergoing elective cesarean section at term (38-41 weeks’ gestation) without fetal distress. The women were randomized into three groups. In the general anesthesia with propofol group (Group P, n = 74), anesthesia was induced with 2 mg∙kg-1 propofol and 0.6-0.9 mg∙kg-1
rocuronium. In the general anesthesia with thiopental sodium group (Group T, n = 74), anesthesia was induced with 5 mg∙kg-1 thiopental sodium and 0.6-0.9 mg∙kg-1 rocuronium. Women in the spinal anesthesia group (Group SA, n = 74) were administered 0.5% (10 mg) hypertonic bupivacaine and 10 mcg fentanyl.
Aim: To predict the probability of stone free status calculated by CROES nomogram and to test the accuracy of our fi tted regression model to predict outcomes of PCNL. Methods: From July 2018 to May 2019, data of 100 patients underwent PCNL procedure for renal stones at Urology department at Menoufi a University was collected and postoperative results were compared to the preoperative predicted stone free status. The CROES nomogram was applied to the data of all cases using its scale to calculate the total score and corresponding percent of stone free status after the procedure. We used binary logistic regression to test whether the six factors in the study can predict the PCNL outcome. We compared the calculated probabilities of stone free by our fitted regression model to the traditional method using the whole 6 parameters on the scale of nomogram.
1) The study examined the effect of probiotics in preventing necrotizing enterocolitis (NEC) in preterm neonates compared to a control group.
2) 115 preterm infants weighing 750-1500g or less than 32 weeks gestation received probiotics or did not (control). The probiotic group had significantly lower incidence of NEC and fewer cases of elevated C-reactive protein.
3) However, there were no significant differences between the groups in duration of oxygen therapy, total parenteral nutrition, time to full feeding, or length of hospital stay. The study results suggest probiotics have a protective effect against NEC in preterm infants.
This study examines labor patterns in over 26,000 women using data from the National Collaborative Perinatal Project collected between 1959-1966. The researchers found that the median time to progress from one centimeter of cervical dilation to the next decreased as labor advanced. Nulliparous women had the longest labor curves, while multiparous women had similar curves. The study suggests that the active phase of labor may not start until 5 cm of dilation in nulliparas and that a graduated approach based on cervical dilation is needed to properly diagnose abnormal labor progression.
Mothers And Clinicians Perspectives On Breastfeeding Counseling During Routin...Biblioteca Virtual
This document summarizes a study examining breastfeeding counseling provided during routine preventive visits from the perspectives of both mothers and their clinicians. The study involved surveying 429 mother-newborn pairs and their 121 obstetric and pediatric clinicians. The results identified several areas of disagreement between what mothers reported discussing with clinicians regarding breastfeeding duration, continuation after returning to work, and specific advice provided, highlighting potential unintentional gaps in communication around breastfeeding counseling during routine visits.
Study of Incidence and Etiology of Prolapse at Rural Based Teaching Hospitaltheijes
In our country as large number of woman deliver at home, usually conducted by untrained dias, incidence of prolapse is higher. The etiology of prolapse was discussed by ARETAEUS, a Greek physician who believed procedentiato be result of weakness of ligaments of the uterus. There are multiple etiological factors in the developed of prolapse. Diagnosis of prolapse at the earliest will help to reduce the complications of prolapse as well as continue child bearing function of the young woman.
The document discusses recommendations for antenatal corticosteroid therapy for fetal maturation. It recommends a single course of corticosteroids between 24-34 weeks gestation for women at risk of preterm birth within 7 days. It also recommends corticosteroids before 32 weeks for premature rupture of membranes to reduce risks. While a single rescue course may be considered if more than 2 weeks have passed, regularly scheduled repeat courses are not recommended due to limited data and potential risks. The document discusses different corticosteroid regimens and their efficacy based on available evidence.
perineal outcome after restrictive use of episiotomyarbin joshi
This study evaluated perineal outcomes in primi-gravidas after restrictive use of episiotomy in Nepal. The episiotomy rate was 22% and the majority (43.2%) experienced first degree tears. Only one woman (1.4%) experienced a third degree tear, with no long-term complications. Having a baby weighing 2.5kg or more significantly increased mean tear length and nearly doubled the risk of a second or third degree tear. The restrictive episiotomy protocol was successfully implemented with no significant complications observed.
Nurse staffing problems are a widespread issue facing the nursing profession globally. Inadequate nurse staffing can overwork nurses and lead to burnout, while also negatively impacting patient care. The purpose of the discussion is to outline a PICOT statement to study the effects of poor nurse staffing in healthcare facilities. The population would be critical care patients, the intervention would be collecting data from patients and nurses, the comparison would look at outcomes between units with staffing issues and those without, and the outcomes would be measured over two weeks to determine the effects of nurse staffing problems on patient care.
Pediatric Nurses’ Knowledge and Practices Regarding Nursing Management of Pre...paperpublications3
Abstract: Prematurity used to be a major cause of infant deaths. The premature babies need improved medical and nursing techniques by highly competence nursing team.
Material and Methods: This descriptive hospital based study was conducted at Soba university hospital, Khartoum state in the period from January to March 2014. The study aimed at assessing the knowledge and practices of pediatric nurses in neonatal intensive care unit concerning nursing management of preterm babies. The sample size compromised of 50 nurses that constituted the total coverage of study population during the period of the study. Data were collected using structured interview questionnaire and observation check list designed f or the study. The data was analyzed using statistical package for social sciences (SPSS). Results:The results obtained that the majority of nurses were knowledgeable about the characteristics of preterm babies, causes of prematurity, immediate nursing care of preterm, signs of hypothermia were adequate (100%, 92%, 100%,100% respectively). Half of them (50%) identify the breathing pattern of preterm baby. The nurses clinical performance were inadequate where 70% of them recorded pulse rate only when recorded the baby pulse.100% did not wear mask, 80% find a difficulty on selecting appropriate vein for sampling . Also 48% of nurses gave feeding incorrect and 60% of them did not aspirate gastric contents before feeding.
Conclusion: The study concluded that the majority of pediatric nurses had adequate knowledge about prematurity, but they were lacking in their clinical skills to manage the preterm baby. So the study recommended continuous training programs for the nurses to refresh their knowledge and practices towards management of preterm babies to ideal standards.Keywords: Pediatric Nurses’ Knowledge, Practices Regarding Nursing Management, Premature Babies.
Title: Pediatric Nurses’ Knowledge and Practices Regarding Nursing Management of Premature Babies in Neonatal Intensive Care Unit at Soba University Hospital, Khartoum State, Sudan
Author: Widad Ibrahim A/gadir A/moula, Ietimad Ibrahim Abd Elrahman kambal
ISSN 2349-7823
International Journal of Recent Research in Life Sciences (IJRRLS)
Paper Publications
Evidence Based Practice_lecture 5_slidesZakCooper1
This document provides an overview of evidence-based practice as it relates to assessing questions about harm or etiology. It discusses how these types of questions are best assessed through randomized controlled trials or observational studies like cohort and case-control studies. Examples are provided of questions about harm that have been studied, like whether silicone breast implants or weight-loss drugs cause certain health issues. The limitations of different study types are also outlined. Finally, the document discusses how prognosis questions are typically assessed through survival curve analysis and provides some examples of prognosis studies.
Objective: To evaluate the utility of a targeted lecture in improving FP awareness amongst clinicians.
Design: This is a dual institution, prospective survey-based study assessing if an educational lecture can increase the likelihood of FP consideration, discussion, and referral.
The document summarizes the key discussions and outcomes of the 2008 National Institute of Child Health and Human Development Workshop on Electronic Fetal Monitoring. The workshop aimed to update definitions, interpretations, and research guidelines for intrapartum electronic fetal monitoring. Participants reached consensus on standardized terminology and a three-tier system for interpreting fetal heart rate tracings. They also prioritized topics for future research on electronic fetal monitoring.
1) The document proposes a new model of prenatal care based on a comprehensive assessment at 11-13 weeks of gestation. This assessment uses maternal characteristics, ultrasound findings, and biochemical testing to determine patient-specific risks for various pregnancy complications.
2) Most major fetal aneuploidies, structural abnormalities, and a variety of pregnancy complications can potentially be identified or assessed at high risk during the 11-13 week assessment.
3) Based on the risk assessment, most women would be classified as low risk and require fewer prenatal visits, while high risk women would receive specialized monitoring and treatment. This shifts prenatal care from routine visits to a personalized, disease-specific approach.
Why Do Women Stop Breastfeeding Findings From The Pregnancy RiskBiblioteca Virtual
This study examined breastfeeding behaviors using data from the Pregnancy Risk Assessment and Monitoring System (PRAMS) from 2000-2001. The authors found that 32% of women did not initiate breastfeeding, 4% stopped within the first week, 13% stopped within the first month, and 51% continued for over 4 weeks. Younger women and those with limited socioeconomic resources were more likely to stop breastfeeding early. Common reasons for stopping included sore nipples, perceived inadequate milk supply, and difficulties with breastfeeding. Women's predelivery intentions impacted their likelihood of initiating and continuing breastfeeding.
Answer the following questions in a minimum of 1-2 paragraphs ea.docxSHIVA101531
Answer the following questions in a minimum of
1-2 paragraphs
each. Be sure to explain your answers and give reasons for your views.
When you talk about the meaning of life, which sense of the term do you use-- external meaning or internal meaning?
What bearing, if any, does the ephemeral nature of our existence have on the question of whether life has meaning? Does the fact that we die negate the possibility of meaning in life?
Is Schopenhauer right about the meaninglessness of life? Does the wretchedness of our existence show that life has no meaning?
Note:
All journal entries must be submitted as attachments (
in Microsoft Word format
) in order to generate an originality report.
.
Answer the following questions using scholarly sources as references.docxSHIVA101531
Answer the following questions using scholarly sources as references. Add references at the end of the page.
Answer each question with at least 300 words counter.
1.What is your assessment of Frantz Fanon's argument that “The wealth of the imperialist nations is also our wealth”? Do you believe "developed nations" owe some form of reparations to colonized peoples?
2.How would you account for revolutionaries in Spain such as the CNT and FAI having more success than in other European countries leading up to 1936?
3.How you can you account for the outcome of the Russian Revolution?
4.Why do you think that acts of violence against tyrannical leaders in the era did not inspire the masses to rise up in revolution?
.
More Related Content
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This document describes a study that examined practice variation in the diagnosis and treatment of chorioamnionitis among US obstetricians. The study involved distributing a survey to 500 obstetricians querying their demographics, practice setting, and chorioamnionitis management strategies. 212 surveys were analyzed. The results found wide variation in diagnostic criteria, antibiotic regimens, and postpartum treatment duration. Specifically, over 25 different antibiotic regimens were reported, with 30% using a single agent. Postpartum treatment duration ranged from no treatment to 48 hours. No practitioner characteristics were independently associated with diagnostic or treatment strategies. This variation may reflect a lack of high-quality evidence on best practices for chorio
Dr. Ankit Jain et al conducted a study to evaluate neonatal outcomes in mothers with premature rupture of membranes (PROM) at a tertiary care hospital. They analyzed 85 neonates born to mothers with PROM. Most neonates were born at 35-36 weeks gestation to primigravid mothers aged 21-25 years via normal vaginal delivery. The most common neonatal complications were jaundice, respiratory distress, and hypoglycemia. Over half of neonates were admitted to the NICU. Most had normal CBC and CRP reports, and the majority exhibited no complications. Common issues during hospitalization included decreased activity, fever, and feeding difficulties.
The document outlines Methodist Dallas Medical Center's plan to achieve Baby-Friendly designation by adopting several evidence-based practices. The plan includes having a neonatal admission nurse care for infants in the same location as mothers to promote skin-to-skin contact and rooming-in. Research shows these practices improve breastfeeding and maternal-infant bonding. The plan also delays unnecessary interventions like early infant bathing to prevent hypothermia and supports breastfeeding within one hour of birth.
Medically Complex Pregnancies and Early BreastfeedingBehavio.docxARIV4
Medically Complex Pregnancies and Early Breastfeeding
Behaviors: A Retrospective Analysis
Katy B. Kozhimannil1*, Judy Jou1, Laura B. Attanasio1, Lauren K. Joarnt2, Patricia McGovern3
1 Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota, United States of America, 2 Harvard University,
Cambridge, Massachusetts, United States of America, 3 Division of Environmental Health Sciences, University of Minnesota School of Public Health, Minneapolis,
Minnesota, United States of America
Abstract
Background: Breastfeeding is beneficial for women and infants, and medical contraindications are rare. Prenatal and labor-
related complications may hinder breastfeeding, but supportive hospital practices may encourage women who intend to
breastfeed. We measured the relationship between having a complex pregnancy (entering pregnancy with hypertension,
diabetes, or obesity) and early infant feeding, accounting for breastfeeding intentions and supportive hospital practices.
Methods: We performed a retrospective analysis of data from a nationally-representative survey of women who gave birth
in 2011–2012 in a US hospital (N = 2400). We used logistic regression to examine the relationship between pregnancy
complexity and breastfeeding. Self-reported prepregnancy diabetes or hypertension, gestational diabetes, or obesity
indicated a complex pregnancy. The outcome was feeding status 1 week postpartum; any breastfeeding was evaluated
among women intending to breastfeed (N = 1990), and exclusive breastfeeding among women who intended to exclusively
breastfeed (N = 1418). We also tested whether breastfeeding intentions or supportive hospital practices mediated the
relationship between pregnancy complexity and infant feeding status.
Results: More than 33% of women had a complex pregnancy; these women had 30% lower odds of intending to breastfeed
(AOR = 0.71; 95% CI, 0.52–0.98). Rates of intention to exclusively breastfeed were similar for women with and without
complex pregnancies. Women who intended to breastfeed had similar rates of any breastfeeding 1 week postpartum
regardless of pregnancy complexity, but complexity was associated with .30% lower odds of exclusive breastfeeding 1
week among women who intended to exclusively breastfeed (AOR = 0.68; 95% CI, 0.47–0.98). Supportive hospital practices
were strongly associated with higher odds of any or exclusive breastfeeding 1 week postpartum (AOR = 4.03; 95% CI, 1.81–
8.94; and AOR = 2.68; 95% CI, 1.70–4.23, respectively).
Conclusions: Improving clinical and hospital support for women with complex pregnancies may increase breastfeeding
rates and the benefits of breastfeeding for women and infants.
Citation: Kozhimannil KB, Jou J, Attanasio LB, Joarnt LK, McGovern P (2014) Medically Complex Pregnancies and Early Breastfeeding Behaviors: A Retrospective
Analysis. PLoS ONE 9(8): e104820. doi:10.1371/journal.pone.0104820
Editor: Katariina Laine, Oslo Uni ...
Interventions In Primary Care To Promote Breastfeeding An Evidence Review For...Biblioteca Virtual
Primary care-initiated interventions can effectively promote breastfeeding. A systematic review of 38 randomized controlled trials found that breastfeeding promotion interventions in developed countries significantly increased short-term (1 to 3 months) and long-term (6 to 8 months) exclusive breastfeeding rates. Combining pre- and postnatal interventions and including lay support, such as peer counseling, were most effective in increasing breastfeeding duration. No harms from breastfeeding promotion interventions were reported.
Introduction: Though there are many studies on the effects of anesthesia methods used for cesarean section on the newborn,
research on this topic still continues. In our prospective observational study, we investigated the effects of different anesthesia techniques used in routine cesarean deliveries on early neonatal outcomes in our hospital. This prospective, observational, randomized study included a total of 222 ASA II risk group pregnant women undergoing elective cesarean section at term (38-41 weeks’ gestation) without fetal distress. The women were randomized into three groups. In the general anesthesia with propofol group (Group P, n = 74), anesthesia was induced with 2 mg∙kg-1 propofol and 0.6-0.9 mg∙kg-1
rocuronium. In the general anesthesia with thiopental sodium group (Group T, n = 74), anesthesia was induced with 5 mg∙kg-1 thiopental sodium and 0.6-0.9 mg∙kg-1 rocuronium. Women in the spinal anesthesia group (Group SA, n = 74) were administered 0.5% (10 mg) hypertonic bupivacaine and 10 mcg fentanyl.
Aim: To predict the probability of stone free status calculated by CROES nomogram and to test the accuracy of our fi tted regression model to predict outcomes of PCNL. Methods: From July 2018 to May 2019, data of 100 patients underwent PCNL procedure for renal stones at Urology department at Menoufi a University was collected and postoperative results were compared to the preoperative predicted stone free status. The CROES nomogram was applied to the data of all cases using its scale to calculate the total score and corresponding percent of stone free status after the procedure. We used binary logistic regression to test whether the six factors in the study can predict the PCNL outcome. We compared the calculated probabilities of stone free by our fitted regression model to the traditional method using the whole 6 parameters on the scale of nomogram.
1) The study examined the effect of probiotics in preventing necrotizing enterocolitis (NEC) in preterm neonates compared to a control group.
2) 115 preterm infants weighing 750-1500g or less than 32 weeks gestation received probiotics or did not (control). The probiotic group had significantly lower incidence of NEC and fewer cases of elevated C-reactive protein.
3) However, there were no significant differences between the groups in duration of oxygen therapy, total parenteral nutrition, time to full feeding, or length of hospital stay. The study results suggest probiotics have a protective effect against NEC in preterm infants.
This study examines labor patterns in over 26,000 women using data from the National Collaborative Perinatal Project collected between 1959-1966. The researchers found that the median time to progress from one centimeter of cervical dilation to the next decreased as labor advanced. Nulliparous women had the longest labor curves, while multiparous women had similar curves. The study suggests that the active phase of labor may not start until 5 cm of dilation in nulliparas and that a graduated approach based on cervical dilation is needed to properly diagnose abnormal labor progression.
Mothers And Clinicians Perspectives On Breastfeeding Counseling During Routin...Biblioteca Virtual
This document summarizes a study examining breastfeeding counseling provided during routine preventive visits from the perspectives of both mothers and their clinicians. The study involved surveying 429 mother-newborn pairs and their 121 obstetric and pediatric clinicians. The results identified several areas of disagreement between what mothers reported discussing with clinicians regarding breastfeeding duration, continuation after returning to work, and specific advice provided, highlighting potential unintentional gaps in communication around breastfeeding counseling during routine visits.
Study of Incidence and Etiology of Prolapse at Rural Based Teaching Hospitaltheijes
In our country as large number of woman deliver at home, usually conducted by untrained dias, incidence of prolapse is higher. The etiology of prolapse was discussed by ARETAEUS, a Greek physician who believed procedentiato be result of weakness of ligaments of the uterus. There are multiple etiological factors in the developed of prolapse. Diagnosis of prolapse at the earliest will help to reduce the complications of prolapse as well as continue child bearing function of the young woman.
The document discusses recommendations for antenatal corticosteroid therapy for fetal maturation. It recommends a single course of corticosteroids between 24-34 weeks gestation for women at risk of preterm birth within 7 days. It also recommends corticosteroids before 32 weeks for premature rupture of membranes to reduce risks. While a single rescue course may be considered if more than 2 weeks have passed, regularly scheduled repeat courses are not recommended due to limited data and potential risks. The document discusses different corticosteroid regimens and their efficacy based on available evidence.
perineal outcome after restrictive use of episiotomyarbin joshi
This study evaluated perineal outcomes in primi-gravidas after restrictive use of episiotomy in Nepal. The episiotomy rate was 22% and the majority (43.2%) experienced first degree tears. Only one woman (1.4%) experienced a third degree tear, with no long-term complications. Having a baby weighing 2.5kg or more significantly increased mean tear length and nearly doubled the risk of a second or third degree tear. The restrictive episiotomy protocol was successfully implemented with no significant complications observed.
Nurse staffing problems are a widespread issue facing the nursing profession globally. Inadequate nurse staffing can overwork nurses and lead to burnout, while also negatively impacting patient care. The purpose of the discussion is to outline a PICOT statement to study the effects of poor nurse staffing in healthcare facilities. The population would be critical care patients, the intervention would be collecting data from patients and nurses, the comparison would look at outcomes between units with staffing issues and those without, and the outcomes would be measured over two weeks to determine the effects of nurse staffing problems on patient care.
Pediatric Nurses’ Knowledge and Practices Regarding Nursing Management of Pre...paperpublications3
Abstract: Prematurity used to be a major cause of infant deaths. The premature babies need improved medical and nursing techniques by highly competence nursing team.
Material and Methods: This descriptive hospital based study was conducted at Soba university hospital, Khartoum state in the period from January to March 2014. The study aimed at assessing the knowledge and practices of pediatric nurses in neonatal intensive care unit concerning nursing management of preterm babies. The sample size compromised of 50 nurses that constituted the total coverage of study population during the period of the study. Data were collected using structured interview questionnaire and observation check list designed f or the study. The data was analyzed using statistical package for social sciences (SPSS). Results:The results obtained that the majority of nurses were knowledgeable about the characteristics of preterm babies, causes of prematurity, immediate nursing care of preterm, signs of hypothermia were adequate (100%, 92%, 100%,100% respectively). Half of them (50%) identify the breathing pattern of preterm baby. The nurses clinical performance were inadequate where 70% of them recorded pulse rate only when recorded the baby pulse.100% did not wear mask, 80% find a difficulty on selecting appropriate vein for sampling . Also 48% of nurses gave feeding incorrect and 60% of them did not aspirate gastric contents before feeding.
Conclusion: The study concluded that the majority of pediatric nurses had adequate knowledge about prematurity, but they were lacking in their clinical skills to manage the preterm baby. So the study recommended continuous training programs for the nurses to refresh their knowledge and practices towards management of preterm babies to ideal standards.Keywords: Pediatric Nurses’ Knowledge, Practices Regarding Nursing Management, Premature Babies.
Title: Pediatric Nurses’ Knowledge and Practices Regarding Nursing Management of Premature Babies in Neonatal Intensive Care Unit at Soba University Hospital, Khartoum State, Sudan
Author: Widad Ibrahim A/gadir A/moula, Ietimad Ibrahim Abd Elrahman kambal
ISSN 2349-7823
International Journal of Recent Research in Life Sciences (IJRRLS)
Paper Publications
Evidence Based Practice_lecture 5_slidesZakCooper1
This document provides an overview of evidence-based practice as it relates to assessing questions about harm or etiology. It discusses how these types of questions are best assessed through randomized controlled trials or observational studies like cohort and case-control studies. Examples are provided of questions about harm that have been studied, like whether silicone breast implants or weight-loss drugs cause certain health issues. The limitations of different study types are also outlined. Finally, the document discusses how prognosis questions are typically assessed through survival curve analysis and provides some examples of prognosis studies.
Objective: To evaluate the utility of a targeted lecture in improving FP awareness amongst clinicians.
Design: This is a dual institution, prospective survey-based study assessing if an educational lecture can increase the likelihood of FP consideration, discussion, and referral.
The document summarizes the key discussions and outcomes of the 2008 National Institute of Child Health and Human Development Workshop on Electronic Fetal Monitoring. The workshop aimed to update definitions, interpretations, and research guidelines for intrapartum electronic fetal monitoring. Participants reached consensus on standardized terminology and a three-tier system for interpreting fetal heart rate tracings. They also prioritized topics for future research on electronic fetal monitoring.
1) The document proposes a new model of prenatal care based on a comprehensive assessment at 11-13 weeks of gestation. This assessment uses maternal characteristics, ultrasound findings, and biochemical testing to determine patient-specific risks for various pregnancy complications.
2) Most major fetal aneuploidies, structural abnormalities, and a variety of pregnancy complications can potentially be identified or assessed at high risk during the 11-13 week assessment.
3) Based on the risk assessment, most women would be classified as low risk and require fewer prenatal visits, while high risk women would receive specialized monitoring and treatment. This shifts prenatal care from routine visits to a personalized, disease-specific approach.
Why Do Women Stop Breastfeeding Findings From The Pregnancy RiskBiblioteca Virtual
This study examined breastfeeding behaviors using data from the Pregnancy Risk Assessment and Monitoring System (PRAMS) from 2000-2001. The authors found that 32% of women did not initiate breastfeeding, 4% stopped within the first week, 13% stopped within the first month, and 51% continued for over 4 weeks. Younger women and those with limited socioeconomic resources were more likely to stop breastfeeding early. Common reasons for stopping included sore nipples, perceived inadequate milk supply, and difficulties with breastfeeding. Women's predelivery intentions impacted their likelihood of initiating and continuing breastfeeding.
Similar to LESSON 12 Paying for Care and Health Information LEA.docx (20)
Answer the following questions in a minimum of 1-2 paragraphs ea.docxSHIVA101531
Answer the following questions in a minimum of
1-2 paragraphs
each. Be sure to explain your answers and give reasons for your views.
When you talk about the meaning of life, which sense of the term do you use-- external meaning or internal meaning?
What bearing, if any, does the ephemeral nature of our existence have on the question of whether life has meaning? Does the fact that we die negate the possibility of meaning in life?
Is Schopenhauer right about the meaninglessness of life? Does the wretchedness of our existence show that life has no meaning?
Note:
All journal entries must be submitted as attachments (
in Microsoft Word format
) in order to generate an originality report.
.
Answer the following questions using scholarly sources as references.docxSHIVA101531
Answer the following questions using scholarly sources as references. Add references at the end of the page.
Answer each question with at least 300 words counter.
1.What is your assessment of Frantz Fanon's argument that “The wealth of the imperialist nations is also our wealth”? Do you believe "developed nations" owe some form of reparations to colonized peoples?
2.How would you account for revolutionaries in Spain such as the CNT and FAI having more success than in other European countries leading up to 1936?
3.How you can you account for the outcome of the Russian Revolution?
4.Why do you think that acts of violence against tyrannical leaders in the era did not inspire the masses to rise up in revolution?
.
Answer the following questions about this case studyClient .docxSHIVA101531
Answer the following questions about this case study:
Client with Pneumonia
Mr Edwards is a 75 yr old man who has a history of chronic obstructive pulmonary disease for the last two years. He continues to smoke ½ pack of cigarettes a day and does not participate in any exercise regimen and must do self-care activities slowly because of fatigue. He does not see any reason to increase his fluid intake. Presently, he is admitted for right upper lobe pneumonia and reports having an intermittent cough that produces thick, yellow sputum. He has more episodes of coughing when lying flat. He is married and his wife, Kathy is at his bedside.
Assessment
Mr Edwards SpO2 ranges from 78%-84%, and currently this am is 84%. His other vital signs are T 101.4F, HR 102/min, RR 30/min, BP 130/90mmHg. He is chilled and has had some diaphoresis. He reports that his ribs are sore and that his mouth is dry. Upon inspection, Mr Edwards mucous membranes are dry, as is his skin. Crackles are auscultated in the lower lobes bilaterally. His sputum is thick, and a yellow to yellow green in color. His health care provider has told him that if he gradually increases his exercise, drinks more fluids and stops smoking, his respiratory status will improve. He is lying in a semi-fowlers position in bed.
What relevant assessment data would you cluster to support a nursing diagnosis?
What priority nursing diagnosis would you identify for this patient? List five and give both Problem focused and Risk for nursing diagnoses.
What short term goal would you identify for the priority nursing diagnosis you identified? What long term goal would you identify?
List all the nursing interventions that you would perform for identified goals and nursing diagnosis. Give a rationale for each.
If you implemented all of the identified interventions, how would you evaluate that your interventions were successful and that the goals were met?
.
Answer the following questions using art vocabulary and ideas from L.docxSHIVA101531
Answer the following questions using art vocabulary and ideas from Lectures 2, 3, & 4 and Chapter 2 in your textbook. Please make
sure each answer is thoughtful, edited for grammar and spelling errors, and
at least
4-5
COMPLETE
sentences. Also, be as
specific as possible and
use examples to support EVERY statement. Write your answers in your own words (not taken
directly from your readings or outside resources).
A grading rubric is attached to this assignment.
**When answering the questions/prompts below,
write in PARAGRAPH FORM
(while making sure each question is addressed in your paragraph).
**Copy the photos of the artworks and the questions BEFORE each paragraph answer.
PROMPTS
:
1.
-Is Henri Matisse's 1947 print,
Icarus
,
an example of Representational Art, Abstracted Art, or Non-Representational Art? Explain your reasoning.
-Describe the use of
SHAPE
in Henri Matisse's 1947 print,
Icarus
. Are the shapes organic or geometric? Which ones? Describe how the shapes interact, or "touch" each other. Are the edges of the shapes soft or hard? Do they bump, blend, or overlap?
-Which theme(s) best describe the content of Matisse's
Icarus
?
Support your answers with specific examples from the painting.
2.
-Is Kathe Kollwitz' 1903 etching,
Mother with Dead Child
an example of Representational Art, Abstracted Art, or Non-Representational Art? Explain your reasoning.
-Describe the use of
LINE
in this print. What types of line (geometric, organic, implied) are present? What do you believe these lines express? Are there any contour lines? Hatching or cross-hatching? Where? In what direction(s) do the lines move?
-Which theme(s) best describe the content of Kollwitz'
Mother with Dead Child?
Support your answers with specific examples from the etching.
3.
-Is the
Colossal 8-feet-tall Olmec Head
(1500-300 BCE) an example of Representational Art, Abstracted Art, or Non-Representational Art? Explain your reasoning.
-Describe the
FORM/MASS
of the Olmec Head. Address the size, density, material(s) used, and how it may have interacted with it's original location.
-Is the sculpture an example of
Closed Form
or
Open Form
? Explain your answer.
-Which theme(s) best describe the content of the Olmec Heads? Support your answers with specific examples from the sculpture.
4.
-Is Jan van Eyck's 1434 oil painting,
The Arnolfi Portrait
,
an example of Representational Art, Abstracted Art, or Non-Representational Art? Explain your reasoning.
-Discuss the use of
TEXTURE
in van Eyck's painting. Does the work have actual/tactile texture, visual/simulated texture, or a combination of both? Explain your answer.
-Which theme(s) best describe the content of van Eyck's
The Arnolfi Portrait
? Support your answers with specific examples from the painting.
5.
Is George Caleb Bingham's 1845 painting,
Fur Traders Descending the Missouri
, an example of Representational Art, Abstracted Art, or Non-Represen.
Answer the following questions in a total of 3 pages (900 words). My.docxSHIVA101531
Answer the following questions in a total of 3 pages (900 words). My budget is between $50-60. Deadline is 5 hours
What, in your opinion, are the salient attributes of indigenous African religious cultures?
Do you feel western scholars were justified in tagging negative labels on African religions?
Would you say African religions are polytheistic because of the belief in numerous deities?
Describe the Core Elements of Yoruba or Fon Cosmology
.
Answer the following questions No single word responses (at lea.docxSHIVA101531
Answer the following questions: No single word responses (at least 70+ words in each response)
Give the questions some thought and answer honestly
1. What is happening?
2. What issues does it raise?
3. What emotions come to your awareness?
4. What implications does it have for how we practice?
.
Answer the following questions based on the ethnography Dancing Skel.docxSHIVA101531
Answer the following questions based on the ethnography Dancing Skeletons. It is not necessary to write
an essay, but do engage the questions at a thoughtful level. Be sure to answer the question thoroughly as
each has several parts and use examples from the ethnography.
1. Why is it important for an anthropologist to be able to speak the local language? What
advantages did the author enjoy because of her language ability? What difficulties ensue when a
researcher is not able to speak the local language? If all contact with the population is through an
interpreter, what sorts of bias might arise in the data collection?
2. What was the outcome of the author’s visit to #104’s compound? What had happened to the
child since her last visit several years earlier? Why did the author use numbers to refer to people
in her study, instead of their names? Do you think it was right for Dettwyler to intervene in the
case of child #104, or should anthropologists just study people in other cultures and endeavor to
have as little impact on them as possible? Is it possible to conduct anthropological research
without having some effect on the people you study?
3. How do the medical resources of Magnambougou compare to those available in the United
States? What are the main diseases children in Mali must contend with?
4. Using female circumcision as the focus, discuss the concept of cultural relativism as used by
anthropologists. Even though we may understand the beliefs behind the practice, does cultural
relativism compel us to approve of female circumcision? What are some of the rationales
provided by cultures that practice female circumcision? What was Agnes’s attitude (Chapter 3)
when she found out that neither the author nor her daughter had been, or where intending to be
circumcised?
5. Aminata’s parents could see that she was very skinny even though she ate a lot of food.
“Everyone knows that you can eat a lot and still be skinny” (Dettwyler 1994: 44). How do
observations such as these contribute to the belief among some Malians that food intake and
health are not related?
Essay and Homework Requirements:
• Minimum of 2 typed pages of your writing (not including heading or prompt)
• 12 point font size
• 1 inch margins on all sides
• Double-spaced throughout
• Spell-checked, grammar-checked
.
Answer the following questions to the best of your ability1) De.docxSHIVA101531
Answer the following questions to the best of your ability:
1) Describe Native America societies prior to European contact. What are some examples of how their civilizations varied by region across North and South America?
2) What was the Columbian Exchange? Give at least 5 examples,
(be specific with details)
. What are some effects this had on both the Old and New Worlds?
3) Briefly describe the relationship between Powhatan and the English colonists of Virginia Colony in the 17thcentury. How did they help one another? How did they oppose one another?
4) Refer to the website below on the
Mayflower Compact, 1620
. What do the writers claim their purpose was in founding a colony (Plymouth)? What do the writers claim is their purpose in establishing this charter?
*copy/paste into your browser to answer the questions above:
https://avalon.law.yale.edu/17th_century/mayflower.asp
5) What was the major cash crop of the English colonies around the Chesapeake Bay (e.g., Virginia and Maryland)? What unfree laborers primarily worked that crop for wealthier landowners in the 17th century? What unfree laborers were the predominant labor force on plantations as the 18th century wore on?
6) Describe the First and Second Great Awakenings. What were some similarities between those movements? What were some differences?
7) What are at least 4 factors that led to the American Revolution? Briefly describe each one.
8) Describe the influence of Enlightenment ideals on the Constitution? What were three (3) major compromises that were necessary to gain enough support to ratify the Constitution
(describe them)
?
9) What was the “Revolution of 1800” and why is it important, even today?
10) What was the Louisiana Purchase? Give three examples of long-term consequences of the US acquiring that territory?
11) Throughout the 17th, 18th, and 19th centuries, what are some of the ways in which American Indian peoples interacted with European (and later, American) settlers? What were some of the strategies which American Indian tribes used to navigate European and US expansion?
12) Describe the difference between northern and southern states in the US between 1800 and 1850. What were some of their defining characteristics?
13) What factors prompted the South to secede from the United States in 1860/1861? What was Pres. Lincoln’s response? What were 3 consequences of the Civil War?
14) Describe Reconstruction. Did it work (how and/or how not)?
.
Answer the following questionDo you think it is necessary to .docxSHIVA101531
Answer the following question:
Do you think it is necessary to create a different law to serve minors who violate the law or should they be processed in the same way that adults are processed? Explain.
**Arguments in response to the question must be supported by at least two academic sources.**
Essay ( 1-3 pages)
.
Answer the following question. Use facts and examples to support.docxSHIVA101531
Answer the following question. Use facts and examples to support your answer. Use APA style for any references.
Due June 14, 11:59 p.m. EST
Using Figure 5.4 as the target architecture, who are the threat agents who will be most interested in attacking Web applications created through AppMaker?
.
Answer the bottom questions in apa format and decent answer no shor.docxSHIVA101531
Answer the bottom questions in apa format and decent answer no short answer please.
Subaru's Sales Boom Thanks to the Weaker Yen For the Japanese carmaker Subaru, a sharp fall in the value of yen against the U.S. dollar has turned a problem—the lack of U.S. production—into an unexpected sales boom. Subaru, which is a niche player in the global auto industry, has long bucked the trend among its Japanese rivals of establishing significant manufacturing facilities in the North American market. Instead, the company has chosen to concentrate most of its manufacturing in Japan in order to achieve economies of scale at its home plants, exporting its production to the United States. Subaru still makes 80 percent of its vehicles at home, compared with 21 percent for Honda. Back in 2012, this strategy was viewed as something of a liability. In those days, one U.S. dollar bought only 80 Japanese yen. The strong yen meant that Subaru cars were being priced out of the U.S. market. Japanese companies like Honda and Toyota, which had substantial production in the United States, gained business at Subaru's expense. But from 2012 onward, with Japan mired in recession and consumer prices falling, the country's central bank repeatedly cut interest rates in an attempt to stimulate the economy. As interest rates fell in Japan, investors moved money out of the country, selling yen and buying the U.S. dollar. They used those dollars to invest in U.S. stocks and bonds where they anticipated a greater return. As a consequence, the price of yen in terms of dollars fell. By December 2015, one dollar bought 120 yen, representing a 50 percent fall in the value of the yen against the U.S. dollar since 2012. For Subaru, the depreciation in the value of the yen has given it a pricing advantage and driven a sales boom. Demand for Subaru cars in the United States has been so strong that the automaker has been struggling to keep up. The profits of Subaru's parent company, Fuji Heavy Industries, have surged. In February 2015, Fuji announced that it would earn record operating profits of around ¥410 billion ($3.5 billion) for the financial year ending March 2015. Subaru's profit margin has increased to 14.4 percent, compared with 5.6 percent for Honda, a company that is heavily dependent on U.S. production. The good times continued in 2015, with Subaru posting record profits in the quarter ending December 31, 2015. Despite its current pricing advantage, Subaru is moving to increase its U.S. production. It plans to expand its sole plant in the United States, in Indiana, by March 2017, with a goal of making 310,000 a year, up from 200,000 currently. When asked why it is doing this, Subaru's management notes that the yen will not stay weak against the dollar forever, and it is wise to expand local production as a hedge against future increases in the value of the yen. Indeed, when the Bank of Japan decided to set a key interest rate below zero in early February 2016, the yen .
Answer the following below using the EXCEL attachment. chapter 5.docxSHIVA101531
This document requests that someone answer Excel exercise questions from chapter 5, including questions 9 through 12. It also asks the person to post at least two points they learned from the questions and two additional questions they have. Finally, it mentions completing an appendix exercise question from chapter 5.
Answer the following prompts about A Germanic People Create a Code .docxSHIVA101531
Answer the following prompts about “A Germanic People Create a Code of Law” on pgs. 104-108 from the
Sources of
World Societies: Volume 1: To 1600
book. your answer should include one original question that you have about the readings.
1. Compare and contrast this law code with the Twelve Tables and the Code of Hammurabi.
2. Where do you see major similarities, and differences?
3. Of the three codes, which would you prefer to live under, and why?
.
Answer the following discussion board question below minumun 25.docxSHIVA101531
Answer the following discussion board question below: minumun 250 words in total.
[1] How did the attempted impeachment of President Clinton come about? What do you think about this attempt at impeachment and the surrounding controversies and circumstances?
[2] What parallels, if any, do you see between the impeachment efforts against President Clinton and those today against President Trump? Are they comparable or completely different, in your view? Explain.
.
Answer the following questions about IT Project Management. What.docxSHIVA101531
Answer the following questions about IT Project Management.
What is a project, and what are its main attributes? How is a project different from what most people do in their day-to-day jobs? Discuss the importance of top management commitment and the development of standards for successful project management. Provide examples to illustrate the importance of these items based on your experience on any type of project. Discuss the unique challenges that an IT project presents.
.
Answer the following in at least 100 words minimum each1.Of.docxSHIVA101531
Answer the following in at least 100 words minimum each:
1.Often times we will see data that goes up and down and doesn’t appear to be moving at a steady rate in either direction. Can we draw any conclusion from data like that?
2.
Time series and future prediction of value is something that many of you likely deal with at work. You may see the type of future prediction in a retirement or investment account on a personal level. When would this type of analysis be important in your industry?
.
Answer the following questions(at least 200 words) and responses 2 p.docxSHIVA101531
Answer the following questions(at least 200 words) and responses 2 posts(not word limitation):
Should the federal, state, or local governments pass legislation that requires organizations to offer voluntary benefits? Why or why not?
You need to find a source and make reference
.
Answer the following questions in a Word document and upload it by M.docxSHIVA101531
Answer the following questions in a Word document and upload it by March 19. Answers should be one paragraph each.
1. What arguments can you provide to show there is or is not political bias in the media?
2. Do you feel that the existence of Wikileaks helps or undermines America's national security?
3. Why do you feel that polling errors occur in gathering data on Presidential elections?
4. Do you feel the Fairness Doctrine was justified, or do you feel it was right to repeal it?
5. Is the rise of digital citizenship a good or bad thing for the media?
.
Answer the following questions in complete sentences. Each answer sh.docxSHIVA101531
This document contains two questions about the emergence and economic policies of communism in Russia and China. It asks how communism emerged in each country, noting both the similarities and differences between the two processes. It also asks about the main economic policies pursued by communist regimes, and their degrees of success and failure. Responses to each question should be one or two paragraphs with examples and quotes from the textbook.
ANSWER THE DISCUSSION QUESTION 250 WORDS MINDiscussion Q.docxSHIVA101531
**ANSWER THE DISCUSSION QUESTION 250 WORDS MIN**
Discussion Questions:
How should the United States government deal with the heightened concern about homegrown violent extremism and the growing concern for the preservation of civil liberties? What are the political and constitutional consequences of counter-terrorism? Lastly, how do we assess the tradeoffs between freedom and security?
***REPLY TO EACH POST 100 WORDS MIN EACH***
1. The United States government will always have to face the homegrown violent extremist because with the internet alone people are able to research just about anything and find their answers. The civil liberties are being violated because you have FBI and CIA looking into what people on doing on the webs. I personally believe that you gave up the right when you decided to goggle whatever it is you’re looking up. It’s also like social media site take Facebook for example people are willing to give up their rights so they can be on Facebook and be able to look or post whatever they want. But just like ever website the owner of that site has a right to delete what they don’t want on it as well. So why can’t the FBI/CIA look into and potentially stop a homegrown extremist from attacking the nation or even just attacking schools, churches, and retail stores like the mall or Wal-Mart. All these locations have had attacks from violent extremist when if they were being watched or monitored those attacks could have been stopped or at least less death could have occurred. From a political and constitutional stand point, consequences of counter-terrorism can vary. I political stand is to protect and preserve the freedom for the people. Protecting one’s Constitutional rights depends on what the politician’s plans on policies and procedures that could begin to take away those civil rights that were granted and give people the sense of freedom that the nation is built on. Policies and procedures can change everything take the mask wearing and social distancing for Covid-19, you have the people that are okay with it all and are following the rules but then you have the ones that have been protesting or fighting people over the fact that they don’t want to wear a mask. To me personally it’s simple to wear a mask but to others it’s a reason of rights being taken away by mandating it. Working for the military and DHS I personally don’t see freedom and security as a tradeoff. If agencies do their jobs correctly and protect the United States and National Security then freedom wouldn’t be at stake. I believe in freedom but the security measures in place are to help protect that freedom, without the security measures the nation would be under attack like 9/11 or worse.
2. The internal terrorist threat in the United States is operational and complicated, with continuing threats from extreme left- and right-wing extremist groups and radicalization and recruitment efforts by international terrorist groups. Since Sept/11, our.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
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Date: May 29, 2024
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Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
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Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
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LESSON 12 Paying for Care and Health Information LEA.docx
1. LESSON 12
Paying for Care and Health Information
LEARNING OUTCOMES
_____________________________________________________
_________________________
In this lesson, you will do the following:
Describe how coding, reimbursement, and billing are impacted
by health information systems.
READINGS
The following reading assignments are for Lessons 9 through
12:
Gartee Text:
Chapter 4, pp. 74 - 95
Chapter 5, pp. 98 - 126
2. Chapter 6, pp. 127 - 151
Chapter 9, pp. 208 - 236
Chapter 10, pp. 237 - 259
ACTIVITIES / ASSESSMENTS
The following activities/assessments are for Lessons 9 through
12:
1. Read the assigned pages from the Gartee text.
2. Review the Lecture Notes, Unit 3 PowerPoint, and Voice
Pod.
3. Participate in the weekly discussion question.
4. Complete the written assignment.
WRITTEN ASSIGNMENTS
Hospital Medicare Payment System - DRGs:
3. Research how large hospitals are paid by a Medicare fee for
service reimbursements (DRG’s).
Include a brief history and relate how health information
supports the request for a payment.
PLEASE NOTE: All graded assignments for the lessons in this
unit should be grouped together
and submitted as ONE document using the Assignment
Submission form accessed from your
course homepage or http://www.sjcme.edu/gps/assignments.
All activities/assignments for this unit should be as follows:
1. Should include a cover sheet for each assignment stating the
following:
2. Each individual assignment number and copy of the
assignment directions should be
included in the submission as the starting header of each lesson.
4. 3. Carefully check grammar and spelling.
4. Use APA format for any research or sources that are being
used or quoted.
5. Email the instructor if you have questions regarding the
assignments.
http://www.sjcme.edu/gps/assignments
g
Research www.AJOG.org
O B S T E T R I C S
Preterm premature rupture of membranes >32 weeks’
estation: impact of revised practice guidelines
Arij Faksh, DO; Joseph R. Wax, MD; F. Lee Lucas, PhD;
Angelina Cartin; Michael G. Pinette, MD
OBJECTIVE: The purpose of this study was to determine the
perinatal
impact of the 2007 American College of Obstetricians and
Gynecolo-
gists Practice Bulletin on preterm premature membrane rupture.
STUDY DESIGN: Perinatal outcomes were compared in women
who
had experienced preterm membrane rupture in the 3 years before
5. the
2007 Practice Bulletin to similar women who experienced
preterm pre-
mature rupture of membranes in the 3 years after the issue and
imple-
mentation of the guideline.
RESULTS: After adjustment for gestational age at membrane
rupture
and steroids, composite severe morbidity (death, respiratory
distress
Obstet Gynecol 2011;205:340.e1-5.
p
remained uncertain, p
doi: 10.1016/j.ajog.2011.05.036
340.e1 American Journal of Obstetrics & Gynecology
OCTOBER 2011
syndrome, assisted ventilation for �6 hours, sepsis, pneumonia,
grade
3 or 4 intraventricular hemorrhage, or necrotizing enterocolitis)
was
similar by group. Infants in the “after” group experienced less
pneumo-
nia and sepsis, similar respiratory morbidity, but more labor
inductions
and postpartum hemorrhage.
CONCLUSION: The new guideline significantly decreases
severe neo-
natal infections but is associated with more frequent labor
6. induction and
postpartum hemorrhage.
Key words: neonatal morbidity, prematurity, preterm premature
rupture of membranes
Cite this article as: Faksh A, Wax JR, Lucas FL, et al. Preterm
premature rupture of membranes �32 weeks’ gestation: impact
of revised practice guidelines. Am J
m
c
p
o
t
Preterm premature rupture of mem-branes (PPROM) affects 1-
2% of
pregnancies but is associated with up to
30-40% of preterm births.1 In the ab-
sence of labor or complications that war-
rant delivery, expectant care is often
practiced until a gestational age is
reached beyond which further observa-
tion does not significantly reduce pre-
maturity complications but potentially
exposes the fetus to infection and in-
flammation with associated long-term
From the Division of Maternal-Fetal
Medicine, Department of Obstetrics and
Gynecology (Drs Faksh, Wax, and Pinette
and Ms Cartin), and the Maine Center for
Outcome Research and Evaluation (Dr Lucas),
Maine Medical Center, Portland, ME.
Received Feb. 9, 2011; revised April 5, 2011;
8. gestation. An additional recommendation
to consider a single course of corticoste-
roids at 32-33 weeks’ gestation, particu-
larly if pulmonary immaturity was docu-
mented, was based primarily on consensus
and expert opinion (level C). Moreover,
many supporting studies were conducted
among predominantly African American
women,3-5 whose offspring demonstrate
accelerated lung maturation compared
with white women.7,8 Thus, the antici-
ated benefits of the new practice guideline
articularly in a pri-
arily white population. We therefore
onducted a retrospective study that com-
ared short-term maternal and neonatal
utcomes before vs after the implementa-
ion of the 2007 Practice Bulletin.
ME T H O D S
This retrospective, institutional review
board– exempt study included all women
with a single living nonanomalous fetus
who had experienced PPROM at 32 0/7 to
35 6/7 weeks’ gestation from January 1,
2004, to April 1, 2010, and who received
care in a single tertiary teaching hospital. A
best obstetric estimate of gestational age
was determined with the use of menstrual
data and first- or second-trimester ultra-
sonography. Rupture of membranes was
diagnosed by sterile speculum examina-
tion that confirmed the pooling of amni-
9. otic fluid in the vagina, positive nitrazine
paper test, and positive ferning test. Those
women with PPROM in the 3 years before
guideline implementation on April 1,
2007, were compared with those with
PPROM in the subsequent 3 years with re-
gard to maternal and newborn character-
istics and outcomes. The primary outcome
was composite severe neonatal morbidity
(any one of the following occurrences:
death, respiratory distress syndrome [RDS],
assisted ventilation for �6 hours, sepsis,
t
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pneumonia, grade 3 or 4 intraventricular
hemorrhage [IVH], or necrotizing entero-
colitis). Secondary outcomes included
neonatal intensive care unit (NICU) ad-
mission, NICU length of stay, respiratory
morbidity (RDS or assisted ventilation for
�6 hours), and infectious morbidity (cul-
ture-proven sepsis or pneumonia).
Women in the “before” group re-
ceived inpatient care that consisted of a
single course of glucocorticoid therapy
at 32 0/7 to 33 6/7 weeks’ gestation, a
2-day course of intravenous ampicillin
followed by 5 days of oral amoxicillin,
and a single 1-g oral dose of azithromy-
cin. Tocolytics were used at physician
discretion for up to 48 hours to permit
steroid administration. Fetal surveil-
lance included daily biophysical profiles
and nonstress tests every 4-8 hours. De-
livery ensued after spontaneous labor,
documentation of fetal lung maturity by
the presence of phosphatidylglycerol in
amniotic fluid that was obtained from
the vaginal pool or by amniocentesis at
32-36 weeks’ gestation, when 35-36
weeks’ gestation was achieved or sooner
11. for nonreassuring fetal status or clinical
chorioamnionitis.
Women in the “after” group received
identical care, which varied only with re-
gard to delivery timing. Again, delivery
followed spontaneous labor, nonreas-
suring fetal status, or clinical chorioam-
nionitis. Alternatively, women in the af-
TABLE 1
Maternal characteristics
Demographic Before
Age, ya 28.4 �
...............................................................................................
....................
Body mass index, kg/m2a 31.2 �
...............................................................................................
....................
White, n (%) 103 (96
...............................................................................................
....................
Parity, n
...............................................................................................
...........
0 69
...............................................................................................
...........
1 19
12. ...............................................................................................
...........
�2 19
...............................................................................................
....................
Tobacco use, n (%) 34 (31
...............................................................................................
....................
Previous loop electric excision
procedure/cone biopsy, n (%)
8 (7.
...............................................................................................
....................
a Data are given as mean � SD.
Faksh. Revised PPROM guideline. Am J Obstet Gynecol 2
ter group were also delivered at 32 0/7 to t
33 6/7 weeks’ gestation if amniotic fluid
was obtained from the vaginal pool or by
amniocentesis and demonstrated that
phosphatidylglycerol was present. If the
fluid could not be collected or lung ma-
turity was not demonstrated, delivery
was initiated at 34 0/7 weeks’ gestation.
Finally, delivery was expedited on ad-
mission for PPROM after 34 0/7 weeks’
gestation. As of September 2008, a
change in NICU admission policy oc-
curred, whereby all infants who were
born after PPROM �36 0/7 weeks’ ges-
tation were admitted to the NICU or
13. intermediate care nursery where they re-
mained until hospital discharge. Pre-
viously, 35-week infants were triaged in
the delivery room based on respiratory
status. Infants who were born at �35 0/7
in both time periods routinely were ad-
mitted to the NICU; those infants who
were born at �36 weeks’ gestation in
both time periods were triaged in the de-
livery room based on respiratory status.
Maternal characteristics, management,
interventions, and outcomes were com-
pared by study group. Morbidity included
chorioamnionitis (diagnosed by �2 of
he following occurrences: maternal fever
38.0°C, uterine tenderness, malodorous
aginal discharge, maternal leukocytosis,
r fetal tachycardia), postpartum hemor-
hage (estimated blood loss �500 mL after
vaginal delivery and �1000 mL after a
esarean delivery), postpartum endome-
107) After (n � 64) P value
.8 26.4 � 6.1 .04
...............................................................................................
...................
.9 31.5 � 7.9 .81
...............................................................................................
...................
62 (96.9) .83
15. Data were abstracted from the mater-
al prenatal record, and the maternal
nd newborn inpatient records. Dichot-
mous and continuous variables were
nalyzed with the chi-square and un-
aired t-test, respectively. Logistic and
inear regression analyses were adjusted
or covariates. Significance was consid-
red for a probability value of � .05.
RE S U L T S
One hundred seventy-one eligible subjects
were included: 107 women before and 64
women after guideline implementation.
Maternal demographics were similar by
study group (Table 1). Women who were
cared for under the new guideline were less
likely to be treated expectantly, despite
having experienced PPROM at an earlier
average gestational age. They also more of-
ten received steroids to accelerate fetal lung
maturity. After adjustment for differences
in gestational age at PPROM, this group
more often had labor induced and deliv-
ered on average 1 week earlier than women
with PPROM before the new guideline
(Table 2). Despite the increased induction
rate, primary and total cesarean delivery
rates were similar by group. Maternal mor-
bidity, including clinical and histologic
chorioamnionitis, occurred with similar
frequency by study group, except for the
later cohort that experienced more post-
partum hemorrhages. There were no
16. blood transfusions, however, in any sub-
jects (Table 3).
Newborn infant outcomes were ad-
justed for differences in gestational age at
PPROM and steroid administration.
There was no significant difference in the
frequency of composite morbidity by
time period (Table 4). No infant had a
severe IVH or necrotizing enterocolitis.
There were 2 cases of suspected intra-
uterine growth restriction (estimated fe-
tal weight or abdominal circumference
�10% for gestational age) in the before
group and 1 case in the after group. The
(n �
5
.........
6
.........
.3)
.........
.........
.........
.........
.........
.8)
.........
17. 5)
.........
only death occurred from disseminated
an Journal of Obstetrics & Gynecology 340.e2
.
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Research Obstetrics www.AJOG.org
herpes infection in a newborn infant of a
mother with no history or physical find-
ings of infection. Neonates who were
born after guideline implementation
were more likely to be admitted to the
NICU and experience longer NICU
stays. These offspring had significantly
fewer diagnoses of severe infections, yet
no significantly increased rate of respira-
tory complications (Table 4). Infants in
the before group weighed more than
those in the after group (2387 � 373 g vs
2233 � 365 g; P � .009). There was no
difference in the frequency of 5-minute
Apgar scores of �7 (1.9% vs 4.7%; P �
3).Umbilical arterial cord blood pH was
btained in all cases; no infant demon-
trated a pH �7.00.
CO M M E N T
Our study demonstrates that the imple-
19. mentation of and adherence to recent
PPROM management guidelines signif-
icantly reduces the composite outcome
of neonatal sepsis and pneumonia with-
out increasing newborn infant compos-
ite morbidity among women who expe-
rience PPROM at �32 weeks’ gestation.
However, this benefit is associated with
significantly more frequent maternal la-
bor induction, postpartum hemorrhage,
increased NICU use, and a statistically
nonsignificant increase in respiratory
morbidity. Importantly, the increased
induction rate did not raise the primary
or overall cesarean delivery rates, and no
maternal transfusions were required.
The increased NICU use that was ob-
served under the new guideline likely re-
flects, at least in part, the described
change in neonatal admission policy.
These results provide important data
regarding the 2007 ACOG PPROM prac-
tice bulletin recommendations, particu-
larly regarding delivery timing. Several
supporting studies that were referenced
by the bulletin included mostly urban
African American women, who com-
prised 55-79.6% of the subjects.3-5 After
ontrolling for population differences,
reterm infants born to black women ex-
erience significantly less hyaline mem-
rane disease than those born to white
omen on a week-by-week basis from
6-37 weeks.7 Therefore, the generaliz- B
20. 340.e3 American Journal of Obstetrics & Gynecolo
bility of the earlier findings and result-
ng practice recommendations to dis-
imilar populations remained uncertain.
lthough the difference in respiratory
orbidity rates between our study
roups was not statistically significant, a
arger study population could result in
his difference becoming significant. A
ost hoc sample size calculation showed
hat 257 patients in each group would
chieve statistical significance with 80%
ower at the .05 level.
A recent evaluation of ACOG Practice
TABLE 2
Management of preterm premature
Characteristics Be
Gestational age at PPROM, wka 3
...............................................................................................
....................
Gestational age at delivery, wka 3
...............................................................................................
....................
Expectant care, n (%) 7
...............................................................................................
....................
Latency, da,c
21. ...............................................................................................
....................
Steroids, n (%) 6
...............................................................................................
....................
Antibiotics, n (%) 10
...............................................................................................
....................
Tocolytic, n (%) 2
...............................................................................................
....................
Amniotic fluid tested for maturity, n (%) 7
...............................................................................................
....................
Amniotic fluid test mature, n (%) 3
...............................................................................................
....................
Labor induction, n (%) 2
...............................................................................................
...........
Indications
...............................................................................................
..
34 wk
...............................................................................................
..
Lung maturity 2
22. ...............................................................................................
..
Clinical chorioamnionitis
...............................................................................................
..
Nonreassuring fetal status
...............................................................................................
....................
Cesarean delivery, n (%)
...............................................................................................
...........
Primary 2
...............................................................................................
...........
Total 3
...............................................................................................
...........
Indications
...............................................................................................
..
Nonreassuring fetal status 1
...............................................................................................
..
Malpresentation
...............................................................................................
..
Cephalopelvic disproportion
30. a
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www.AJOG.org Obstetrics Research
populations that are different from those
that generated the recommendations, par-
ticularly when the recommendations were
based on inconsistent supporting evi-
dence. Our data confirm the anticipated
benefits of less frequent neonatal infec-
tious morbidity. However, the results raise
questions about the neonatal respiratory
consequences of current delivery recom-
mendations after PPROM in a 97% white
population. The increased frequencies of
labor induction and postpartum hemor-
rhage also deserve further attention.
Seven randomized trials that have cov-
31. ered a total of 690 subjects have examined
expectant vs planned early delivery in
TABLE 3
Maternal morbidity
Outcome Be
Chorioamnionitis, n (%)
...............................................................................................
...........
Clinical 10
...............................................................................................
...........
Histologic 47
...............................................................................................
....................
Postpartum hemorrhage, n (%) 5
............................................................................................. ..
....................
Transfusion, n 0
...............................................................................................
....................
Endometritis or wound infection, n (%) 4
...............................................................................................
....................
Faksh. Revised PPROM guideline. Am J Obstet Gynecol 2
TABLE 4
Neonatal outcomesa
33. ...............................................................................................
....................
Secondary
...............................................................................................
...........
Neonatal intensive care unit
............................................................................................. ..
..
Admission, n (%)
...............................................................................................
..
Stay, db
...............................................................................................
...........
Respiratory morbidity, n (%)
...............................................................................................
...........
Infectious morbidity, n (%)
...............................................................................................
....................
a Adjusted for gestational age at preterm premature rupture o
Faksh. Revised PPROM guideline. Am J Obstet Gynecol 2011.
pregnancies that were complicated by
PPROM.3-5,11-14 These studies are difficult
o compare with each other and with our
nvestigation because of many methodo-
ogic differences, such as the time period
overed by the study, the gestational ages
f included subjects, the administration of
ntibiotics and steroids, tocolytic use, the
34. ole of amniotic fluid fetal lung maturity
esting in pregnancy management, the
iming of planned delivery after PPROM,
nd the outcome measures. A recent meta-
nalysis of these trials found that planned
arly delivery was associated with in-
reased rates of labor induction, cesarean
elivery, and endometritis but less fre-
e (n � 107) After (n � 64) P value
...............................................................................................
...................
3) 5 (7.8) .73
............................................................................... ................
...................
.9) 20 (31.3) .10
...............................................................................................
...................
7) 12 (18.8) .003
...............................................................................................
...................
0 —
...............................................................................................
...................
7) 1 (1.6%) .39
...............................................................................................
...................
ore (n � 107) After (n � 64) P value
36. ...................
...............................................................................................
...................
(72.9) 62 (96.9) .03
...............................................................................................
...................
2 � 3.3 5.0 � 3.2 .05
...............................................................................................
...................
(18.9) 21 (32.8) .09
...............................................................................................
...................
(11.2) 2 (3.2) .04
...............................................................................................
...................
mbranes and steroids; b Data are given as mean � SD.
OCTOBER 2011 Americ
uently with suspected neonatal infection
nd newborn infant antibiotic treatment.
here were no differences by group re-
arding perinatal, neonatal, or intrauterine
etal deaths or morbidities of IVH or RDS.
nterestingly, frequencies of chorioamnio-
itis, positive neonatal blood cultures, and
neumonia were not significantly different
y management approach. The authors
oncluded that insufficient evidence exists
o guide clinical decision-making regard-
ng immediate delivery vs expectant man-
gement of PPROM, citing inadequate sta-
37. istical power.1
A prospective cohort study compared
neonatal outcomes after expectant vs elec-
tive delivery of PPROM between 24 0/7 to
33 6/7 weeks’ gestation. Similar to our
management, antepartum care included
antibiotics and steroids. As in the current
report, the frequency of RDS was statisti-
cally similar in both groups, although sep-
sis was less frequent with elective delivery.
Contrasting our findings, a significant re-
duction in the rate of grade 3 or 4 IVH led
to a decrease in severe composite morbid-
ity among electively delivered infants,
probably related to the earlier gestational
ages of included PPROM subjects. This
group also had a higher cesarean delivery
rate, which reflected the increased inci-
dence of nonvertex presenting fetuses,
again likely a consequence of early gesta-
tional ages at membrane rupture.2
A retrospective investigation of pa-
tients who experience PPROM at �24
weeks’ gestation and who delivered at
�37 weeks’ gestation from 1998-2000
examined maternal and neonatal com-
plications to determine an ideal gesta-
tional age for delivery. Steroids and
broad-spectrum antibiotics were admin-
istered routinely. If phosphatidylglycerol
was present in vaginal pool fluid at �32
weeks’ gestation, delivery was expedited.
When compared with pregnancies with
PPROM delivery at 36 0/7 to 36 6/7 weeks’
38. gestation, major and minor composite
neonatal morbidity were increased among
those infants who were delivered at �33
and �34 weeks’ gestation, respectively.
he authors questioned the benefit of ex-
ectant management of PPROM at �34
eeks’ gestation.15
The limited short-term neonatal bene-
for
.........
(9.
.........
(43
.........
(4.
.........
.........
(3.
.........
Bef
.........
1
.........
12
.........
40. fits of expectant management of PPROM
an Journal of Obstetrics & Gynecology 340.e4
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that were noted in the current and earlier
studies likely reflect several factors. Con-
temporary maternal and neonatal care that
features antepartum steroids, broad-spec-
trum antibiotics, selective tocolytic use,
and improved NICU care are probable
contributors to the observed outcomes.
Additionally, the relatively short latency
period that is anticipated with expectant
care of PPROM at �34 weeks’ gestation
may be insufficient to favorably impact
short-term neonatal outcomes. One re-
port noted latencies at �48 hours in only
0.4% of such cases.16 Another article de-
cribed a mean latency of 2.4 � 3.1 days
mong these women.15 The similarly short
mean latency intervals that we observed,
coupled with later mean gestational ages of
PPROM that were studied, support this
41. explanation.
Chorioamnionitis and the accompa-
nying inflammatory response have been
implicated in adverse long-term neuro-
logic sequelae among exposed offspring.17
An important rationale for the active man-
agement of PPROM is to minimize the
risks that are associated with such expo-
sures. However, contrasting most previous
studies, we found no differences in the
rates of clinical or histologic chorioamnio-
nitis between expectantly and actively
managed PPROM.3,4,5,11 We suspect that
ur findings reflect the shorter latencies
nd less frequent inflammation that are
oted with PPROM at later gestational
ges, such as those included in our study.18
This observation is strengthened by the
availability of placental pathologic findings
for all subjects in both time periods of our
study.
Our report offers several strengths be-
yond those already mentioned. Data were
drawn from a single institution with 1 ma-
ternal fetal medicine group and 1 neona-
tology group providing consistent patient
care. One institutional guideline for ante-
partum care was in effect for each time pe-
riod. No obstetrical practice changes other
than delivery timing resulted from guide-
line implementation. Neonatal practice
42. changed only with regard to the described
admission policy. Therefore, we believe
that the observed results, with the possible
exception of NICU use, likely stem from
the revised delivery policy. We recognize
several limitations, including the retro-
340.e5 American Journal of Obstetrics & Gynecolo
spective study design and population
differences among subjects in the 2 time
periods that were examined. However, re-
gression analyses adjusted for differences
in confounders between the 2 groups. Be-
cause the patients were drawn from a ter-
tiary referral center, the data may not re-
flect population-based rates of the various
outcome measures. Although the homo-
geneity of our population was a strength in
addressing our research question, it may
limit generalizability of our results to dis-
similar patients.
In summary, the implementation of the
2007 ACOG PPROM Practice Bulletin
guidelines in our population significantly
reduced severe neonatal infectious mor-
bidity without significantly exacerbating
composite morbidity. However, these
benefits must be balanced against in-
creased induction and hemorrhage rates,
coupled with concerns for increased neo-
natal respiratory morbidity. We also ob-
served increased intensive care use, even
after adjusting for earlier gestational age at
43. PPROM and increased steroid use, which
may reflect changes in neonatal admission
policy. Additional research should also
evaluate the cost-effectiveness of imple-
mentation of the guideline’s recommen-
dations and the subsequent impact on
long-term childhood pulmonary, neuro-
logic, and developmental sequelae. A ran-
domized trial of expectant vs active man-
agement of PPROM at �32 weeks’
gestation would shed important light on
these uncertainties. f
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2. Pasquier JC, Picaud JC, Rabilloud M, et al.
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3. Mercer BM, Crocker LB, Boe NM, Sibai BM.
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mature rupture of the membranes with mature
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4. Naef RW, Allbert JR, Ross EL, Weber BM,
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aggressive versus conservative management.
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5. Cox SM, Leveno KJ. Intentional delivery ver-
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study of corticosteroids in the management of
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13. Iams JD, Talbert ML, Barrows H, Sacks L.
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14. Nelson LH, Meis PJ, Hatjis C, Ernest JM,
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Preterm premature rupture of membranes ≥32 weeks` gestation:
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...MethodsResultsCommentReferences
46. 918 VOL. 122, NO. 4, OCTOBER 2013 OBSTETRICS &
GYNECOLOGY
Background
The definition of PROM is rupture of membranes before
the onset of labor. Membrane rupture before labor and
before 37 weeks of gestation is referred to as preterm
PROM. Management is influenced by gestational age
and the presence of complicating factors, such as clini-
cal infection, abruptio placentae, labor, or nonreasurring
fetal status. An accurate assessment of gestational age
and knowledge of the maternal, fetal, and neonatal risks
are essential to appropriate evaluation, counseling, and
care of patients with PROM.
Etiology of Premature Rupture of
Membranes
Membrane rupture may occur for a variety of reasons.
Although membrane rupture at term can result from
a normal physiologic weakening of the membranes
combined with shearing forces created by uterine
contractions, preterm PROM can result from a wide
array of pathologic mechanisms that act individually
or in concert (4, 5). Intraamniotic infection has been
shown to be commonly associated with preterm PROM,
especially at earlier gestational ages (6). A history of
preterm PROM is a major risk factor for preterm PROM
or preterm labor in a subsequent pregnancy (7, 8).
Additional risk factors associated with preterm PROM
are similar to those associated with spontaneous preterm
birth and include short cervical length, second-trimester
47. and third-trimester bleeding, low body mass index, low
socioeconomic status, cigarette smoking, and illicit drug
use (9–12). Although each of these risk factors is associ-
ated with preterm PROM, it often occurs in the absence
of recognized risk factors or an obvious cause.
Term Premature Rupture of Membranes
At term, PROM complicates approximately 8% of preg-
nancies and generally is followed by the prompt onset of
spontaneous labor and delivery. In a large randomized
trial, one half of women with PROM who were managed
expectantly gave birth within 5 hours and 95% gave birth
within 28 hours of membrane rupture (13). The most
Premature Rupture of Membranes
Preterm delivery occurs in approximately 12% of all births in
the United States and is a major factor that contributes
to perinatal morbidity and mortality (1, 2). Preterm premature
rupture of membranes (PROM) complicates approxi-
mately 3% of all pregnancies in the United States (3). The
optimal approach to clinical assessment and treatment of
women with term and preterm PROM remains controversial.
Management hinges on knowledge of gestational age and
evaluation of the relative risks of delivery versus the risks of
expectant management (eg, infection, abruptio placentae,
and umbilical cord accident). The purpose of this document is to
review the current understanding of this condition
and to provide management guidelines that have been validated
by appropriately conducted outcome-based research
when available. Additional guidelines on the basis of consensus
and expert opinion also are presented.
Committee on Practice Bulletins—Obstetrics. This Practice
Bulletin was developed by the Committee on Practice
Bulletins—Obstetrics with the assis-
tance of Robert Ehsanipoor, MD. The information is designed to
48. aid practitioners in making decisions about appropriate obstetric
and gynecologic care.
These guidelines should not be construed as dictating an
exclusive course of treatment or procedure. Variations in
practice may be warranted based on the
needs of the individual patient, resources, and limitations
unique to the institution or type of practice.
NUMBER 139, OCTOBER 2013 (Replaces Practice Bulletin
Number 80, April 2007 and
Committee Opinion Number 475, February 2011)
P RACTICE BULLET IN
CLINICAL MANAGEMENT GUIDELINES FOR
OBSTETRICIAN–GYNECOLOGISTS
The American College of
Obstetricians and Gynecologists
WOMEN’S HEALTH CARE PHYSICIANS
VOL. 122, NO. 4, OCTOBER 2013 Practice Bulletin
Premature Rupture of Membranes 919
significant maternal consequence of term PROM is
intrauterine infection, the risk of which increases with
the duration of membrane rupture.
Preterm Premature Rupture of
Membranes
Regardless of obstetric management or clinical presen-
tation, birth within 1 week of membrane rupture occurs
in at least one half of patients with preterm PROM (5).
Latency after membrane rupture is inversely correlated
with the gestational age at membrane rupture (14).
49. Cessation of amniotic fluid leakage with restoration of
normal amniotic fluid volume may occur in the setting
of spontaneous preterm PROM and is associated with
favorable outcomes (15).
Among women with preterm PROM, clinically
evident intraamniotic infection occurs in approxi-
mately 15–25% (16), and postpartum infection occurs
in approximately 15–20%; the incidence of infection is
higher at earlier gestational ages (6, 17). Abruptio pla-
centae complicates 2–5% of pregnancies with preterm
PROM (18, 19).
The most significant risks to the fetus after preterm
PROM are complications of prematurity. Respiratory
distress has been reported to be the most common com-
plication of preterm birth (20). Sepsis, intraventricular
hemorrhage, and necrotizing enterocolitis also are asso-
ciated with prematurity, but these are less common near
to term. Preterm PROM with intrauterine inflammation
has been associated with an increased risk of neurode-
velopmental impairment (21, 22), and early gestational
age at membrane rupture also has been associated with
an increased risk of neonatal white matter damage (23).
However, there are no data that suggest that immediate
delivery after presentation with PROM will avert these
risks. Infection and umbilical cord accident contribute
to the 1–2% risk of antenatal fetal demise after preterm
PROM (24).
Previable Premature Rupture of
Membranes
Rupture of the membranes before viability occurs in
less than 1% of pregnancies. The probability of neonatal
death and morbidity associated with PROM decrease with
longer latency and advancing gestational age (25). In a
50. review of preterm PROM between 14 weeks and 24 weeks
of gestation, perinatal deaths were more or less equally
divided between stillbirths and neonatal deaths. Survival
rates were much improved with expectant management
following membrane rupture after 22 weeks of gestation
compared with membrane rupture before 22 weeks of
gestation (57.7% versus 14.4%, respectively) (26).
Most studies of second-trimester and previable
PROM are retrospective and include only expectantly
managed cases. Thus, they likely overestimate survival
rates because of selection bias. Survival data may vary
by institution.
Significant maternal complications that occur after
previable PROM include intraamniotic infection, endo-
metritis, abruptio placentae, and retained placenta (26).
Although it occurs infrequently, life-threatening mater-
nal infection may complicate expectant management of
previable PROM. Maternal sepsis is reported in approxi-
mately 1% of cases (26), and isolated maternal deaths
due to infection have been reported in this setting.
Latency periods appear to be prolonged with
second-trimester preterm PROM compared with later
gestational ages. However, 40–50% of patients with
previable PROM will give birth within the first week and
approximately 70–80% will give birth 2–5 weeks after
membrane rupture (26–28).
The rate of pulmonary hypoplasia after PROM
before 24 weeks of gestation varies widely among
reports, but is likely in the range of 10–20%. Pulmonary
hypoplasia is associated with a high risk of mortality
(26), but is rarely lethal with membrane rupture sub-
sequent to 23–24 weeks of gestation (29), presumably
51. because alveolar growth adequate to support postnatal
development already has occurred. Early gestational age
at membrane rupture, and low residual amniotic fluid
volume are the primary determinants of the incidence of
pulmonary hypoplasia (30, 31).
Prolonged oligohydramnios also can result in fetal
deformations, including Potter-like facies (eg, low-set
ears and epicanthal folds) and limb contractures or other
positioning abnormalities. The reported frequency of
skeletal deformations varies widely (1.5–38%) but many
of these resolve with postnatal growth and physical
therapy (26, 32).
Clinical Considerations and
Recommendations
How is premature rupture of membranes
diagnosed?
Most cases of PROM can be diagnosed on the basis of
the patient’s history and physical examination. Exam-
ination should be performed in a manner that minimizes
the risk of introducing infection. Because digital cervical
examinations increase the risk of infection and add little
information to that available with speculum examina-
tion, digital examinations generally should be avoided
unless the patient appears to be in active labor or delivery
920 Practice Bulletin Premature Rupture of Membranes
OBSTETRICS & GYNECOLOGY
seems imminent (33, 34). Sterile speculum examination
provides an opportunity to inspect for cervicitis and
52. umbilical cord prolapse or fetal prolapse, assess cervi-
cal dilatation and effacement, and obtain cultures as
appropriate.
The diagnosis of membrane rupture typically is
confirmed by the visualization of amniotic fluid pass-
ing from the cervical canal and pooling in the vagina; a
basic pH test of vaginal fluid; or arborization (ferning)
of dried vaginal fluid, which is identified under micro-
scopic evaluation. The normal pH of vaginal secretions
is generally 4.5–6.0, whereas amniotic fluid usually has
a pH of 7.1–7.3. False-positive test results may occur
in the presence of blood or semen, alkaline antiseptics,
or bacterial vaginosis. Alternatively, false-negative test
results may occur with prolonged membrane rupture and
minimal residual fluid.
In equivocal cases, additional tests may aid in the
diagnosis. Ultrasonographic examination of amniotic
fluid volume may be a useful adjunct, but is not diag-
nostic. Fetal fibronectin is a sensitive but nonspecific
test for ruptured membranes; a negative test result is
strongly suggestive of intact membranes, but a positive
test result is not diagnostic of PROM (35). Several com-
mercially available tests for amniotic proteins are cur-
rently on the market, with high reported sensitivity for
PROM (36, 37). However, false-positive test result rates
of 19–30% have been reported in patients with clinically
intact membranes and symptoms of labor (38, 39). These
test kits should be considered ancillary to standard meth-
ods of diagnosis. If the diagnosis remains unclear after
a full evaluation, membrane rupture can be diagnosed
unequivocally with ultrasonographically-guided transab-
dominal instillation of indigo carmine dye, followed by
the passage of blue-dyed fluid into the vagina, which is
documented by a stained tampon or pad. It is important
53. to note that the maternal urine also will turn blue and
should not be confused with amniotic fluid.
What does the initial management involve
once PROM has been confirmed?
In all patients with PROM, gestational age, fetal presen-
tation, and fetal well-being should be determined. The
examination should evaluate for evidence of intrauterine
infection, abruptio placentae, and fetal compromise.
If results are not already available and if an indication
for treatment is not already present, culture for group B
streptococci (GBS) should be obtained when expectant
management is being considered.
In patients with preterm PROM, an initial period of
electronic fetal heart rate monitoring and uterine activity
monitoring offers the opportunity to identify abnormal
fetal heart rate tracings and to evaluate for contrac-
tions (40). Management after confirmation of the diag-
nosis of PROM is dependent primarily on gestational
age and is discussed in more detail in the follow-
ing paragraphs. Nonreassuring fetal status and clinical
chorioamnionitis are indications for delivery. Vaginal
bleeding should raise concern for abruptio placentae and
also should prompt consideration of delivery, with the
decision based on fetal status, the amount of bleeding,
and gestational age.
What is the optimal method of initial
management for a patient with PROM
at term?
Gestational age and fetal position should be confirmed
and fetal heart rate monitoring should be used to assess
54. fetal status. Group B streptococcal prophylaxis should
be given based on prior culture results or intrapartum
risk factors if cultures have not been previously per-
formed (41).
A meta-analysis of 12 randomized controlled trials
(6,814 women) found that induction of labor reduced the
time to delivery and the rates of chorioamnionitis, endo-
metritis, and admission to the neonatal intensive care
unit without increasing the rates of cesarean delivery or
operative vaginal delivery (42). The largest of these trials
also found that women viewed induction of labor more
positively than expectant management (13). Induction of
labor with prostaglandins has been shown to be equally
effective for labor induction compared with oxytocin but
is associated with higher rates of chorioamnionitis (13).
Infection is also a concern with mechanical methods of
cervical ripening, such as the Foley balloon, but there are
insufficient data on which to base a recommendation for
mechanical methods of cervical ripening in the setting of
PROM. A meta-analysis of two trials suggests that use
of prophylactic antibiotics may reduce infectious mor-
bidity, but prompt induction of labor was not standard
care in either study. Thus, there is insufficient evidence
to justify the routine use of prophylactic antibiotics with
PROM at term in the absence of an indication for GBS
prophylaxis (43–45).
These meta-analysis data indicate that patients ben-
efitted from induction of labor compared with expectant
management and suggest that for women with PROM
at 37 0/7 weeks of gestation or more, if spontaneous
labor does not occur near the time of presentation in
those who do not have contraindication to labor, labor
should be induced, generally with oxytocin infusion.
However, a course of expectant management may
55. be acceptable for a patient who declines induction of
labor as long as the clinical and fetal conditions are
VOL. 122, NO. 4, OCTOBER 2013 Practice Bulletin
Premature Rupture of Membranes 921
reassuring and she is adequately counseled regarding
the risks of prolonged PROM. During induction of labor
with oxytocin, a sufficient period of adequate contrac-
tions (at least 12–18 hours) should be allowed for the
latent phase of labor to progress before diagnosing failed
induction and moving to cesarean delivery (46–48).
When is delivery recommended for the
preterm fetus in the presence of premature
rupture of membranes?
Nonreassuring fetal status, clinical chorioamnionitis,
and significant abruptio placentae are clear indications
for delivery. Otherwise, gestational age is a primary fac-
tor when considering delivery versus expectant manage-
ment (Box 1).
However, the optimal gestational age for delivery
is unclear and controversial. A meta-analysis of seven
randomized controlled trials, including 690 women,
concluded there was insufficient evidence to guide clini-
cal practice regarding the risks and benefits of expectant
management versus delivery in the setting of preterm
PROM (49). The trials were insufficiently powered, had
methodological weaknesses, and were variable in the
gestational ages included.
More recently, two randomized controlled trials
56. evaluated delivery versus expectant management between
34 weeks and 37 weeks of gestation and included a total
of 736 women (50, 51). Combining data from the two
studies, induction of labor did not produce a statisti-
cally significant reduction in the rate of neonatal sepsis
(2.7% at 34 weeks versus 4.1% at 37 weeks of gestation,
relative risk [RR], 0.66; 95% confidence interval [CI],
0.3–1.5). However, induction of labor did significantly
reduce the risk of chorioamnionitis (1.6% at 34 weeks
versus 5.3% at 37 weeks of gestation, RR, 0.31; 95%
CI, 0.1–0.8), although there were no other significant
differences between the two groups. These studies did
not have sufficient power to show a statistically signifi-
cant reduction in the rate of neonatal sepsis because the
overall rate of sepsis was lower than anticipated. These
findings are consistent with other smaller, similarly
designed trials (52, 53) and those conducted in women
at term (13, 42).
Despite these data, the optimal gestational age for
delivery remains controversial. Recently there has been
a focus on the short-term (54) and long-term (55)
risks associated with late preterm birth. However, the
relevance of this to the management of women with
ruptured membranes is unclear because neonates born
from pregnancies complicated by preterm PROM have a
higher rate of adverse outcomes compared with controls
matched for gestational age (56). Furthermore, chorio-
amnionitis, prolonged membrane rupture, and oligohy-
dramnios are risk factors for adverse neonatal outcomes
with preterm PROM (56, 57).
At 34 0/7 weeks or greater of gestation, delivery is
recommended for all women with ruptured membranes.
If expectant management is continued beyond 34 0/7
57. weeks of gestation, the balance between benefit and risk
should be carefully considered and discussed with the
patient, and expectant management should not extend
beyond 37 0/7 weeks of gestation. Patients with PROM
before 34 0/7 weeks of gestation should be managed
Box 1. Chronologic Management of
Premature Rupture of Membranes
Early Term and Term (37 0/7 weeks of gestation or
more)
Late Preterm (34 0/7–36 6/7 weeks of gestation)
Preterm (24 0/7–33 6/7 weeks of gestation)* †
Less than 24 weeks of gestation‡
†
‡
922 Practice Bulletin Premature Rupture of Membranes
OBSTETRICS & GYNECOLOGY
Should antenatal corticosteroids be
administered to patients with preterm
PROM?
The use of antenatal corticosteroid administration after
preterm PROM has been evaluated in a number of
clinical trials and has been shown to reduce neonatal
mortality, respiratory distress syndrome, intraventricu-
lar hemorrhage, and necrotizing enterocolitis (64, 65).
58. Current data suggest that antenatal corticosteroids are not
associated with increased risks of maternal or neonatal
infection regardless of gestational age. A single course
of corticosteroids is recommended for pregnant women
between 24 0/7 weeks and 34 0/7 weeks of gestation
who are at risk of preterm delivery (66). A Cochrane
meta-analysis reinforces the beneficial effect of this
therapy regardless of membrane status and concludes
that a single course of antenatal corticosteroids should be
considered routine for all preterm deliveries (64). There
are no data that support the use of corticosteroids before
viability, and administration of corticosteroids in this
setting is not currently recommended.
Weekly administration of corticosteroids has been
associated with a reduction in birth weight and head cir-
cumference and is not recommended (67–69). Whether
to administer a rescue course of corticosteroids with
PROM is controversial, and there is insufficient evi-
dence to make a recommendation for or against.
Should magnesium sulfate for fetal neuro-
protection be administered to patients with
preterm PROM?
Randomized controlled trials have demonstrated that
maternal administration of magnesium sulfate used for
fetal neuroprotection when birth is anticipated before 32
0/7 weeks of gestation reduces the risk of cerebral palsy
in surviving infants (RR, 0.71; 95% CI, 0.55–0.91) (70).
In the largest of these trials, 85% of the women enrolled
had preterm PROM between 24 weeks and 32 weeks
of gestation (71). The optimal treatment regimen for
fetal neuroprotection remains unclear, and different
regimens were used in different trials. Hospitals that
elect to use magnesium sulfate for fetal neuroprotec-
59. tion should develop uniform and specific guidelines
for their departments regarding inclusion criteria, treat-
ment regimens, concurrent tocolysis, and monitoring
in accordance with one of the larger trials (71–73).
Regardless of the treatment regimen used, women with
preterm PROM before 32 0/7 weeks of gestation who
are thought to be at risk of imminent delivery should
be considered candidates for fetal neuroprotective treat-
ment with magnesium sulfate.
expectantly if no maternal or fetal contraindications
exist (53).
What general approaches are used in cases
of preterm PROM managed expectantly?
Expectant management of preterm PROM generally
consists of hospital admission with periodic assess-
ment for infection, abruptio placentae, umbilical cord
compression, fetal well-being, and labor. There is no
consensus on the optimal frequency of assessment, but
an acceptable strategy would include periodic ultraso-
nographic monitoring of fetal growth and periodic fetal
heart rate monitoring. A temperature elevation may indi-
cate intrauterine infection. Prompt diagnosis of chorio-
amnionitis in preterm pregnancy requires a high index
of suspicion because early signs and symptoms may
be subtle. In the absence of fever, other clinical criteria
have variable sensitivity and specificity for diagnosing
infection. Serial monitoring of leukocyte counts and
other markers of inflammation have not been proved to
be useful and are nonspecific when there is no clinical
evidence of infection, especially if antenatal corticoste-
roids have been administered (58). Specific management
considerations regarding tocolytics, corticosteroids, anti-
biotics, magnesium sulfate, and timing of delivery are
60. discussed in detail as follows.
Should tocolytics be considered for patients
with preterm PROM?
The use of tocolysis in the setting of preterm PROM is
controversial and practice patterns among specialists
vary widely (59). There are insufficient data to support
or refute the use of prophylactic tocolysis in the setting
of preterm PROM. A meta-analysis of eight trials that
included 408 women is of limited use because women
were only treated in two of the trials (60, 61) with
latency antibiotics and corticosteroids, both of which
have become part of standard management (62). The use
of tocolysis was associated with a longer latency period
and a lower risk of delivery within 48 hours but also was
associated with a high risk of chorioamnionitis in preg-
nancies before 34 0/7 weeks of gestation. In summary,
prophylactic tocolysis may be associated with a prolon-
gation of pregnancy and an increased risk of chorioam-
nionitis without significant maternal or neonatal benefit,
although its use has not been evaluated adequately with
latency antibiotics and corticosteroids. In the setting of
ruptured membranes with active labor, therapeutic tocol-
ysis has not been shown to prolong latency or improve
neonatal outcomes. Therefore, therapeutic tocolysis is
not recommended (63).
VOL. 122, NO. 4, OCTOBER 2013 Practice Bulletin
Premature Rupture of Membranes 923
Should antibiotics be administered to patients
with preterm PROM?
61. Administration of broad-spectrum antibiotics prolongs
pregnancy, reduces maternal and neonatal infections, and
reduces gestational age-dependent morbidity (16, 74, 75).
The optimal antibiotic regimen is unclear because mul-
tiple regimens have demonstrated benefit. Based on avail-
able information, in order to reduce maternal and neonatal
infections and gestational-age dependent morbidity, a
7-day course of therapy with a combination of intravenous
ampicillin and erythromycin followed by oral amoxicil-
lin and erythromycin is recommended during expectant
management of women with preterm PROM who are
less than 34 0/7 weeks of gestation (16, 74). The regimen
used in the Eunice Kennedy Shriver National Institute of
Child Health and Human Development Maternal–Fetal
Medicine Units Network trial was intravenous ampicillin
(2 g every 6 hours) and erythromycin (250 mg every 6
hours) for 48 hours followed by oral amoxicillin (250 mg
every 8 hours) and erythromycin base (333 mg every
8 hours) (75). The use of amoxicillin–clavulanic acid
has been associated with increased rates of necrotiz-
ing enterocolitis and it is not recommended (16, 74).
Although there are no well-studied alternative regimens
for women allergic to β-lactam antibiotics, it may be rea-
sonable to administer erythromycin alone. Women with
preterm PROM and a viable fetus who are candidates for
intrapartum GBS prophylaxis should receive intrapartum
GBS prophylaxis to prevent vertical transmission regard-
less of earlier treatments (41, 76, 77).
Should preterm PROM be managed with
home care?
The outpatient management of preterm PROM with a
viable fetus has not been sufficiently studied to establish
safety and, therefore, is not recommended. Two small ran-
domized controlled trials that compared hospitalization to
62. home care of women with preterm PROM had insufficient
power to demonstrate a meaningful difference in outcome
because only 11–18% of the women were eligible for ante-
partum home care (78, 79). Because latency is frequently
brief, infection may present suddenly and the fetus is at
increased risk of umbilical cord compression, hospital-
ization with surveillance of the woman and her fetus is
recommended once viability has been reached.
How should a patient with preterm PROM
and a cervical cerclage be treated?
There are no prospective studies with which to guide the
care of women with preterm PROM who have a cervi-
cal cerclage. Results from retrospective studies have not
been consistent, but generally have found that cerclage
retention for more than 24 hours after preterm PROM is
associated with pregnancy prolongation (80); however,
because of the nonrandomized nature of the reports, it
is unclear how factors, such as labor or infection, con-
tributed to decisions for cerclage removal, which may
have yielded biased results. In some, but not all studies,
cerclage retention with preterm PROM has been associ-
ated with increased rates of neonatal mortality from sep-
sis, neonatal sepsis, respiratory distress syndrome, and
maternal chorioamnionitis (80, 81).
A firm recommendation whether a cerclage should
be removed after premature PROM cannot be made, and
either removal or retention is reasonable. Regardless,
if a cerclage remains in place with preterm PROM,
prolonged antibiotic prophylaxis beyond 7 days is not
recommended.
What is the optimal management of a patient
63. with preterm PROM and herpes simplex virus
infection or human immunodeficiency virus?
Neonatal herpes simplex virus (HSV) infection usually
results from maternal–fetal transmission during delivery.
The risk of vertical transmission with delivery in primary
HSV is reported to be between 30% and 50%, compared
with only 3% in cases of recurrent HSV (82). The litera-
ture regarding expectant management of preterm PROM
with active maternal HSV infection is limited to small
case series and case reports (83, 84). All patients were
treated with acyclovir, and cesarean delivery was per-
formed if lesions were present at the time of delivery. No
cases of vertical transmission were reported.
The risk of prematurity should be weighed against
the potential risk of neonatal HSV infection. In the set-
ting of PROM with recurrent active infection, expectant
management is recommended before 34 0/7 weeks of
gestation. Herpes simplex virus therapy should be initi-
ated, and corticosteroids, antibiotics, and magnesium
sulfate for neuroprotection should be provided as clini-
cally indicated. If active disease or prodromal symptoms
are present at the onset of labor or when delivery is indi-
cated, cesarean delivery is recommended.
Optimal management of preterm PROM in the
setting of primary HSV infection is less clear because
of the increased risk of vertical transmission. Herpes
simplex virus therapy is recommended, and if lesions
are present at the time of delivery, cesarean delivery is
recommended.
The optimal management of the patient with HIV
and preterm PROM is also uncertain because there are
no adequate data from patients with prolonged rupture
64. of the membranes. Early observations showed that the
924 Practice Bulletin Premature Rupture of Membranes
OBSTETRICS & GYNECOLOGY
duration of membrane rupture in labor correlated with
risk of transmission to the newborn (85), but current data
suggest that the duration of membrane rupture is not cor-
related with risk of vertical transmission in patients who
receive highly-active antiretroviral therapy, have a low
viral load, and receive antepartum and intrapartum zid-
ovudine (86). Also, a series of 10 patients with preterm
PROM who were managed expectantly while receiving
antiretroviral therapy, had no cases of HIV transmission
to the newborn despite viral loads as high as 23,000 cop-
ies per mL; the latent periods ranged from 4 hours to 4
days in this series, and all patients were delivered by
cesarean (87).
The management of patients with HIV infection who
have preterm PROM should be individualized, with con-
sideration of factors, including gestational age, current
antiretroviral regimen, and viral load. In cases where the
gestational age is very early, the patient is being treated
with antiretroviral medications, and the viral load is low,
a period of expectant management may be appropriate.
In all cases, the patient should be managed in consulta-
tion with a physician with expertise in management of
HIV in pregnancy. Furthermore, standard antepartum
and intrapartum treatment guidelines should be followed
and management choices should be fully discussed with
the patient (88).
How does care differ for patients with PROM
65. that occurs before neonatal viability?
Women presenting with PROM before neonatal viability
should be counseled regarding the risks and benefits
of expectant management versus immediate delivery.
Counseling should include a realistic appraisal of neo-
natal outcomes. Immediate delivery should be offered.
Attempts should be made to provide parents with the
most current and accurate information possible (89).
If the patient opts for expectant management and is
clinically stable with no evidence of infection, outpatient
surveillance can be considered. Precautions should be
reviewed with the patient and she should come to the
hospital if she develops symptoms of infection, labor, or
abruptio placentae. It may be useful to instruct patients
to monitor temperatures. Typically, women with previ-
able PROM who have been cared for as outpatients are
admitted to the hospital once the pregnancy has reached
viability.
Administration of antenatal corticosteroids and
latency antibiotics for fetal maturation upon reach-
ing viability is appropriate given that early delivery
remains likely. Multiple ultrasonographic methods (such
as thoracic measurements and ratios, flow velocities in
pulmonary vessels, and three-dimensional estimations of
lung volume) have been studied to evaluate pulmonary
development in the antepartum period, but all are of lim-
ited accuracy and cannot be considered sufficiently reli-
able for clinical management (30). There is insufficient
evidence to support the use of latency antibiotics with
PROM before viability. Similarly, there is no evidence
to support the use of tocolytics in the setting of previable
preterm PROM, and in this setting, tocolytics should not
66. be used.
What is the expected outcome of PROM after
second-trimester amniocentesis?
In studies of women undergoing second-trimester amni-
ocentesis for prenatal diagnosis of genetic disorders, the
risk of PROM is approximately 1% (90, 91). In contrast
to patients with spontaneous PROM in the second
trimester, reaccumulation of normal amniotic fluid vol-
ume and favorable outcomes are expected. In one series
of 11 patients with PROM after genetic amniocentesis,
there was one previable pregnancy loss, reaccumula-
tion of normal amniotic fluid occurred within 1 month
in 72% of patients, and the perinatal survival rate was
91% (90).
After appropriate counseling, patients with PROM
after genetic amniocentesis typically are managed expec-
tantly as outpatients. Precautions regarding symptoms
of chorioamnionitis and miscarriage should be given.
Regular follow-up visits with ultrasonographic examina-
tions to assess amniotic fluid volume are recommended.
How should a patient with a history of
preterm PROM be managed in future
pregnancies?
Patients with prior preterm PROM have an increased
risk of recurrent PROM and preterm birth, and a detailed
medical history should be taken. However, there are few
studies that examine interventions to prevent recurrent
PROM. Patients with a history of preterm PROM were
included in studies of progesterone supplementation for
preterm birth recurrence reduction, but most studies did
not report the specific proportion of women with PROM
67. in the study group or separately analyze results in those
patients (92, 93). However, given the potential benefit
of progesterone therapy, women with a single gestation
and a prior spontaneous preterm birth (due to either labor
with intact membranes or PROM) should be offered
progesterone supplementation starting at 16 weeks to 24
weeks of gestation to reduce the risk of recurrent sponta-
neous preterm birth.
Although vaginal ultrasonographic measurement of
the cervix is a safe and reliable means of evaluating the risk
of preterm birth related to cervical length, there have been
VOL. 122, NO. 4, OCTOBER 2013 Practice Bulletin
Premature Rupture of Membranes 925
no well-designed trials of cervical surveillance in women
with a history of PROM. Similar to the progesterone
studies, women with prior PROM were included in trials
that evaluated cervical assessment, vaginal progesterone,
and cerclage but their specific data were not reported
(94, 95). Thus, as with women with spontaneous preterm
births, consideration can be given to transvaginal cervi-
cal length screening. Cerclage placement is associated
with significant decreases in preterm birth outcomes,
offers perinatal benefits, and may be considered in
women with the following combination of history and
ultrasound findings: a current singleton pregnancy,
prior spontaneous preterm birth at less than 34 weeks of
gestation, and short cervical length (less than 25 mm)
before 24 weeks of gestation (96). There are no data on
which to base a recommendation regarding the optimal
gestational age for initiating surveillance or frequency
of monitoring.
68. Summary of
Recommendations and
Conclusions
The following recommendations are based on
good and consistent scientific evidence (Level A):
Patients with PROM before 34 0/7 weeks of gesta-
tion should be managed expectantly if no maternal
or fetal contraindications exist.
To reduce maternal and neonatal infections and
gestational-age dependent morbidity, a 7-day course
of therapy with a combination of erythromycin and
ampicillin or amoxicillin is recommended during
expectant management of women with preterm
PROM who are less than 34 0/7 weeks of gestation.
Women with preterm PROM and a viable fetus
who are candidates for intrapartum GBS prophy-
laxis should receive intrapartum GBS prophylaxis
to prevent vertical transmission regardless of earlier
treatments.
A single course of corticosteroids is recommended
for pregnant women between 24 0/7 weeks and 34
0/7 weeks of gestation who are at risk of preterm
delivery.
Women with preterm PROM before 32 0/7 weeks of
gestation who are thought to be at risk of imminent
delivery should be considered candidates for fetal
neuroprotective treatment with intravenous magne-
sium sulfate.
The following recommendations and conclusions
69. are based on limited and inconsistent scientific
evidence (Level B):
For women with PROM at 37 0/7 weeks of gesta-
tion or more, if spontaneous labor does not occur
near the time of presentation in those who do not
have contraindications to labor, labor should be
induced.
At 34 0/7 weeks or greater gestation, delivery
is recommended for all women with ruptured
membranes.
In the setting of ruptured membranes with active
labor, therapeutic tocolysis has not been shown to
prolong latency or improve neonatal outcomes.
Therefore, therapeutic tocolysis is not recommended.
The following conclusion is based primarily on
consensus and expert opinion (Level C):
The outpatient management of preterm PROM with
a viable fetus has not been sufficiently studied to
establish safety and, therefore, is not recommended.
Proposed Performance
Measure
The percentage of expectantly managed patients with
preterm PROM (up to 34 0/7 weeks of gestation) that
receive latency antibiotics and corticosteroids
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