Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity

BACKGROUND

Studies of early-term birth after demonstrated fetal lung maturity show that respiratory and other outcomes are worse with early-term birth (37⁰-38⁶ weeks) even after demonstrated fetal lung maturity when compared with full-term birth (39⁰-40⁶ weeks). However, these studies included medically indicated births and are therefore potentially limited by confounding by the indication for delivery. Thus, the increase in adverse outcomes might be due to the indication for early-term birth rather than the early-term birth itself.

OBJECTIVE

We examined the prevalence and risks of adverse neonatal outcomes associated with early-term birth after confirmed fetal lung maturity as compared with full-term birth in the absence of indications for early delivery.

STUDY DESIGN

This is a secondary analysis of an observational study of births to 115,502 women in 25 hospitals in the United States from 2008 through 2011. Singleton nonanomalous births at 37-40 weeks with no identifiable indication for delivery were included; early-term births after positive fetal lung maturity testing were compared with full-term births. The primary outcome was a composite of death, ventilator for ≥2 days, continuous positive airway pressure, proven sepsis, pneumonia or meningitis, treated hypoglycemia, hyperbilirubinemia (phototherapy), and 5-minute Apgar <7. Logistic regression and propensity score matching (both 1:1 and 1:2) were used.

RESULTS

In all, 48,137 births met inclusion criteria; the prevalence of fetal lung maturity testing in the absence of medical or obstetric indications for early delivery was 0.52% (n = 249). There were 180 (0.37%) early-term births after confirmed pulmonary maturity and 47,957 full-term births. Women in the former group were more likely to be non-Hispanic white, smoke, have received antenatal steroids, have induction, and have a cesarean. Risks of the composite (16.1% vs 5.4%; adjusted odds ratio, 3.2; 95% confidence interval, 2.1-4.8 from logistic regression) were more frequent with elective early-term birth. Propensity scores matching confirmed the increased primary composite in elective early-term births: adjusted odds ratios, 4.3 (95% confidence interval, 1.8-10.5) for 1:1 and 3.5 (95% confidence interval, 1.8-6.5) for 1:2 matching. Among components of the primary outcome, CPAP use and hyperbilirubinemia requiring phototherapy were significantly increased. Transient tachypnea of the newborn, neonatal intensive care unit admission, and prolonged neonatal intensive care unit stay (>2 days) were also increased with early-term birth.

CONCLUSION

Even with confirmed pulmonary maturity, early-term birth in the absence of medical or obstetric indications is associated with worse neonatal respiratory and hepatic outcomes compared with full-term birth, suggesting relative immaturity of these organ systems in early-term births.

Honeycomb micro-textures for light trapping in multi-crystalline silicon thin-film solar cells

The liquid phase crystallization (LPC) of silicon is an emerging technology for fabricating 10 - 20 µm thin multi-crystalline silicon layers on glass. LPC silicon solar cells exhibit similar electronic performance to multi-crystalline wafer-based devices. Due to the reduced absorber thickness, however, effective measures for light trapping have to be taken. We present tailor-made micro-structures for light trapping at the LPC silicon back-side, whereby a nano-imprinted resist layer serves as a three-dimensional etching mask in subsequent reactive ion etching. Contrary to state-of-the-art random pyramid textures produced by wet-chemical etching, this method allows to produce tailor-made textures independent of grain orientation. Differently shaped micro-textures were replicated in LPC silicon. Absorptance and external quantum efficiency of periodic honeycomb patterns and random pyramids were found to be equivalent. Thus, the method enables the potential to further optimize light trapping in LPC silicon solar cells.

Preterm neonatal morbidity and mortality by gestational age: a contemporary cohort

BACKGROUND

Although preterm birth <37 weeks' gestation is the leading cause of neonatal morbidity and mortality in the United States, the majority of data regarding preterm neonatal outcomes come from older studies, and many reports have been limited to only very preterm neonates. Delineation of neonatal outcomes by delivery gestational age is needed to further clarify the continuum of mortality and morbidity frequencies among preterm neonates.

OBJECTIVE

We sought to describe the contemporary frequencies of neonatal death, neonatal morbidities, and neonatal length of stay across the spectrum of preterm gestational ages.

STUDY DESIGN

This was a secondary analysis of an obstetric cohort of 115,502 women and their neonates who were born in 25 hospitals nationwide, 2008 through 2011. All liveborn nonanomalous singleton preterm (23.0-36.9 weeks of gestation) neonates were included in this analysis. The frequency of neonatal death, major neonatal morbidity (intraventricular hemorrhage grade III/IV, seizures, hypoxic-ischemic encephalopathy, necrotizing enterocolitis stage II/III, bronchopulmonary dysplasia, persistent pulmonary hypertension), and minor neonatal morbidity (hypotension requiring treatment, intraventricular hemorrhage grade I/II, necrotizing enterocolitis stage I, respiratory distress syndrome, hyperbilirubinemia requiring treatment) were calculated by delivery gestational age; each neonate was classified once by the worst outcome for which criteria was met.

RESULTS

In all, 8334 deliveries met inclusion criteria. There were 119 (1.4%) neonatal deaths. In all, 657 (7.9%) neonates had major morbidity, 3136 (37.6%) had minor morbidity, and 4422 (53.1%) survived without any of the studied morbidities. Deaths declined rapidly with each advancing week of gestation. This decline in death was accompanied by an increase in major neonatal morbidity, which peaked at 54.8% at 25 weeks of gestation. As frequencies of death and major neonatal morbidity fell, minor neonatal morbidity increased, peaking at 81.7% at 31 weeks of gestation. The frequency of all morbidities fell >32 weeks. After 25 weeks, neonatal length of hospital stay decreased significantly with each additional completed week of pregnancy; among babies delivered from 26-32 weeks of gestation, each additional week in utero reduced the subsequent length of neonatal hospitalization by a minimum of 8 days. The median postmenstrual age at discharge nadired around 36 weeks' postmenstrual age for babies born at 31-35 weeks of gestation.

CONCLUSION

Our data show that there is a continuum of outcomes, with each additional week of gestation conferring survival benefit while reducing the length of initial hospitalization. These contemporary data can be useful for patient counseling regarding preterm outcomes.

Sinusoidal nanotextures for light management in silicon thin-film solar cells

Recent progresses in liquid phase crystallization enabled the fabrication of thin wafer quality crystalline silicon layers on low-cost glass substrates enabling conversion efficiencies up to 12.1%. Because of its indirect band gap, a thin silicon absorber layer demands for efficient measures for light management. However, the combination of high quality crystalline silicon and light trapping structures is still a critical issue. Here, we implement hexagonal 750 nm pitched sinusoidal and pillar shaped nanostructures at the sun-facing glass-silicon interface into 10 μm thin liquid phase crystallized silicon thin-film solar cell devices on glass. Both structures are experimentally studied regarding their optical and optoelectronic properties. Reflection losses are reduced over the entire wavelength range outperforming state of the art anti-reflective planar layer systems. In case of the smooth sinusoidal nanostructures these optical achievements are accompanied by an excellent electronic material quality of the silicon absorber layer enabling open circuit voltages above 600 mV and solar cell device performances comparable to the planar reference device. For wavelengths smaller than 400 nm and higher than 700 nm optical achievements are translated into an enhanced quantum efficiency of the solar cell devices. Therefore, sinusoidal nanotextures are a well-balanced compromise between optical enhancement and maintained high electronic silicon material quality which opens a promising route for future optimizations in solar cell designs for silicon thin-film solar cells on glass.

Nonmedically indicated induction vs expectant treatment in term nulliparous women

OBJECTIVE

The purpose of this study was to compare maternal and neonatal outcomes in nulliparous women with nonmedically indicated inductions at term vs those expectantly treated.

STUDY DESIGN

Data were obtained from maternal and neonatal charts for all deliveries on randomly selected days across 25 US hospitals over a 3-year period. A low-risk subset of nulliparous women with vertex nonanomalous singleton gestations who delivered 38 0/7 to 41 6/7 weeks were selected. Maternal and neonatal outcomes for nonmedically indicated induction within each week were compared with women who did not undergo nonmedically indicated induction during that week. Multivariable analysis was used to adjust for hospital, maternal age, race/ethnicity, body mass index, cigarette use, and insurance status.

RESULTS

We found 31,169 women who met our criteria. Neonatal complications were either less frequent with nonmedically indicated induction or no different between groups. Nonmedically indicated induction was associated with less frequent peripartum infections (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.16-0.98) at 38 weeks of gestation and less frequent third- and fourth-degree lacerations (OR, 0.60; 95% CI, 0.42-0.86) and less frequent peripartum infections (OR, 0.66; 95% CI, 0.49-0.90) at 39 weeks of gestation. Nonmedically indicated induction was associated with a longer admission-to-delivery time by approximately 3-4 hours and increased odds of cesarean delivery at 38 (OR, 1.50; 95% CI, 1.08-2.08) and 40 weeks (OR, 1.30; 95% CI, 1.15-1.46) of gestation.

CONCLUSION

At 39 weeks of gestation, nonmedically indicated induction is associated with lower maternal and neonatal morbidity than women who are expectantly treated.

Metastable defect formation at microvoids identified as a source of light-induced degradation in a-Si:H

Light-induced degradation of hydrogenated amorphous silicon (a-Si:H), known as the Staebler-Wronski effect, has been studied by time-domain pulsed electron-paramagnetic resonance. Electron-spin echo relaxation measurements in the annealed and light-soaked state revealed two types of defects (termed type I and II), which can be discerned by their electron-spin echo relaxation. Type I exhibits a monoexponential decay related to indirect flip-flop processes between dipolar coupled electron spins in defect clusters, while the phase relaxation of type II is dominated by 1H nuclear spin dynamics and is indicative for isolated spins. We propose that defects are either located at internal surfaces of microvoids (type I) or are isolated and uniformly distributed in the bulk (type II). The concentration of both defect type I and II is significantly higher in the light-soaked state compared to the annealed state. Our results indicate that in addition to isolated defects, defects on internal surfaces of microvoids play a role in light-induced degradation of device-quality a-Si:H.

Atomic structure of interface states in silicon heterojunction solar cells

Combining orientation dependent electrically detected magnetic resonance and g tensor calculations based on density functional theory we assign microscopic structures to paramagnetic states involved in spin-dependent recombination at the interface of hydrogenated amorphous silicon crystalline silicon (a-Si:H/c-Si) heterojunction solar cells. We find that (i) the interface exhibits microscopic roughness, (ii) the electronic structure of the interface defects is mainly determined by c-Si, (iii) we identify the microscopic origin of the conduction band tail state in the a-Si:H layer, and (iv) present a detailed recombination mechanism.

Large-area 2D periodic crystalline silicon nanodome arrays on nanoimprinted glass exhibiting photonic band structure effects

Two-dimensional silicon nanodome arrays are prepared on large areas up to 50 cm² exhibiting photonic band structure effects in the near-infrared and visible wavelength region by downscaling a recently developed fabrication method based on nanoimprint-patterned glass, high-rate electron-beam evaporation of silicon, self-organized solid phase crystallization and wet-chemical etching. The silicon nanodomes, arranged in square lattice geometry with 300 nm lattice constant, are optically characterized by angular resolved reflection measurements, allowing the partial determination of the photonic band structure. This experimentally determined band structure agrees well with the outcome of three-dimensional optical finite-element simulations. A 16% photonic bandgap is predicted for an optimized geometry of the silicon nanodome arrays. By variation of the duration of the selective etching step, the geometry as well as the optical properties of the periodic silicon nanodome arrays can be controlled systematically.

Band alignment at amorphous/crystalline silicon hetero-interfaces

We present an investigation of the band offsets in amorphous/crystalline silicon heterojunctions (a-Si:H/c-Si) using low energy photoelectron spectroscopy, ellipsometry and surface photovoltage data. For a variation of deposition conditions that lead to changes in hydrogen content and the thereby the a-Si:H band gap by ∼180 meV, we find that mainly the conduction band offset ΔEV varies, while ΔEC stays constant within experimental error. This result can be understood in the framework of charge neutrality (CNL) band lineup theory.

Investigation of Textured Back Reflectors for Microcrystalline Silicon Based Solar Cells

Microcrystalline silicon (μc-Si:H) solar cells require an effective light trapping in the near infrared (NIR) to enhance the long wavelength spectral response. For this purpose we investigated back reflectors based on texture-etched ZnO/Ag stacks prepared on glass substrates by magnetron sputtering. With decreasing sputter pressure the resulting surface texture of the glass/Ag/ZnO substrates after etching exhibits a larger feature size and root mean square roughness. The increase in feature size corresponds to an increase of diffuse reflectivity. Applied in microcrystalline solar cells prepared by VHF plasma enhanced chemical vapour deposition (PECVD), the reflectors showing the largest feature size (prepared at the lowest possible sputter pressure) yielded the highest long wavelength spectral response. The μc-Si n-i-p cells prepared on the latter back reflector exhibited efficiencies of 6.9 % (short circuit current density jsc= 18.8 mA/cm2) and 7.5 % (jsc=25 mA/cm2) for an i-layer thickness of 1 μm and 3.5 μm, respectively.

More Insights Into the ZnO/a-SiC:H(B) Interface - An Improved TCO/p Contact

Solar cells based on amorphous silicon (a-Si:H) exhibit a decreased fill factor if ZnO is used as front electrode instead of SnO2. This is due to a poor electric contact between the ZnO and the p-type a-SiC:H(B) layer. To gain a deeper understanding of the chemical and electronic properties of the ZnO/p interface, in-situ XPS measurements were applied to thin a-SiC:H(B) films deposited on ZnO. The effects of CO2 and H2 plasma pretreatments on clean ZnO surfaces and the influence of deposition conditions on the ZnO/a-SiC:H interface were investigated. Upon H2 plasma treatment the formation of SiOx by chemical transport of Si from the reactor walls is observed. Furthermore, a shift of all core levels towards higher binding energies indicates the formation of an accumulation layer. CO2 plasma treatments show no effects on ZnO. Depth profiling across the ZnO/a-SiC:H interface indicates SiO2 formation on ZnO. The depth profile of ZnO related core levels exhibits two features: a reduction of the ZnO at the interface, and, after longer sputter times, a core level shift towards higher binding energy due to an hydrogen induced accumulation layer in the n-type ZnO. The latter causes a depletion of the p-layer resulting in an enhanced series resistance and diminished fill factor. To reduce the depletion layer thin highly conductive microcrystalline layers were introduced, increasing the fill factor up to 74%.

Optoelectronic Properties of Thin Amorphous and Micro-Crystalline p-Type Films Developed for Amorphous Silicon-Based Solar Cells

VIIF-PECVD at 110 MI-z was used to deposit micro-crystalline p-layers on glass substrates for detailed analysis and onto ZnO coated substrates for incorporation into p-i-n solar cell structures. Solar cell and film analysis confirmed that the films incorporated into the solar cells contained significant crystalline silicon volume fractions despite being only 30 nm thick. The p-i-n solar cells employing a micro-crystalline silicon p-layer deposited on ZnO coated substrates had series resistances, fill factors and Voc similar to those of the reference solar cells deposited onto SnO2 coated substrates and having optimized amorphous silicon-carbon p-layers. The short circuit current of the micro-crystalline p-layer case was 10 percent lower than that of the reference cell indicating that further optimization is required.