PURPOSE: To determine if a significant difference exists in the bleeding complications following circumcision in neonates admitted to neonatal intensive care unit (NICU) versus the normal newborn nursery (NNN).MATERIALS AND METHODS: Observational cohort study of 260 infants undergoing circumcision with Gomco clamp. Vitamin K was given to neonates at delivery.Demographic data, procedural characteristics, bleeding complications, and interventions were recorded. The bleeding rates of the two groups were compared using chi square.RESULTS: NICU neonates experienced increased bleeding complications versus NNN neonates (22% vs 9.6%, P=0.029). No differences were found regarding gestational age at delivery, age at circumcision, and birth weight. Neonates with circumcision performed at ≥ 5 days of life experienced increased rates of bleeding complications versus those performed at ≤ 4 days (28% vs. 10.3%, P=0.023). All neonates with circumcision performed ≥ 5 days of life were initially admitted to the NICU. CONCLUSION: NICU neonates had increased rate of bleeding complications following circumcision when compared to the NNN neonates. There was an increased rate of bleeding complications in neonates who undergo circumcision at ≥ 5 days of life. Further research may help to determine if redosing of Vitamin K is necessary for circumcision at > 4 days.Circumcision bleeding complications 3

Background: It is estimated that one-third of women will experience abnormal menstrual

Introduction: Although shared decision making (SDM) is optimal for trial of labor after cesarean (TOLAC) counseling, resources to assess residents' clinical competency and communication skills are lacking. We addressed this gap by developing and testing an objective structured clinical examination (OSCE) to evaluate whether learners were able to use SDM in TOLAC counseling. Methods: We created three simulation scenarios with increasing complexity to assess the skills of residents in their first, second, or third postgraduate year in using SDM in TOLAC counseling. All cases involved a standardized patient requesting a TOLAC consultation. Residents were provided with a medical history and instructed to counsel and develop a care plan. A 10-item scoring rubric was used, and each item was rated 0 (absent), 1 (partial), or 2 (complete). Three coders independently rated the encounters; discrepancies were resolved by consensus. Results: Over 3 years, 39 residents participated in 60 OSCE encounters. The majority provided complete discussions of the clinical issue (93%), chances of success (72%), and maternal and fetal risks (100% and 85%, respectively) but obtained partial assessments of understanding (78%). Discussions of benefits were typically absent, with the exception of the maternal benefits (47%). More than 40% of residents did not discuss the patient's goals, 53% lacked discussion of uncertainties related to TOLAC, and half failed to explore the patient's preference, with most deferring a decision to a future encounter. Discussion: Residents consistently discussed diagnosis, prognosis, and maternal risks yet infrequently addressed goals and preferences-two critical elements of SDM.

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