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Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation., (Copyright © 2019 American College of Obstetricians and Gynecologists. Published by Elsevier Inc. All rights reserved.)

Background: Unexpected admissions of term neonates to the neonatal intensive care unit and unexpected postnatal complications have been proposed as neonatal-focused quality metrics for intrapartum care. Previous studies have noted significant variation in overall hospital neonatal intensive care unit admission rates; however, little is known about the influence of obstetric practices on these rates or whether variation among unanticipated admissions in low-risk, term neonates can be attributed to systemic hospital practices., Objective: The objective of the study was to examine the relative effects of patient characteristics and intrapartum events on unexpected neonatal intensive care unit admissions and to quantify the between-hospital variation in neonatal intensive care unit admission rates among this group of neonates., Study Design: We performed a retrospective cross-sectional study using data collected as part of the Consortium for Safe Labor study. Women who delivered term (≥37 weeks), singleton, nonanomalous, liveborn infants without an a priori risk for neonatal intensive care unit admission were included. The primary outcome was neonatal intensive care unit admission among this population. Multilevel mixed-effect models were used to calculate adjusted odds ratios for demographics (age, race, insurer), pregnancy characteristics (parity, gestational age, tobacco use, birthweight), maternal comorbidities (chronic and pregnancy-induced hypertension), hospital characteristics (delivery volume, hospital and neonatal intensive care unit level, academic affiliation), and intrapartum events (prolonged second stage, induction of labor, trial of labor after cesarean delivery, chorioamnionitis, meconium-stained amniotic fluid, and abruption). Intraclass correlation coefficients were used to estimate the between-hospital variance in a series of hierarchical models., Results: Of the 143,951 infants meeting all patient and hospital inclusion criteria, 7995 (5.6%) were admitted to the neonatal intensive care unit after birth. In the fully adjusted model, the factors associated with the highest odds for neonatal intensive care unit admission included: nulliparity (adjusted odds ratio, 1.62 [95% confidence interval, 1.53-1.71]), large for gestational age (adjusted odds ratio, 1.59 [95% confidence interval, 1.47-1.71]), and small for gestational age (adjusted odds ratio, 1.60 [95% confidence interval, 1.47-1.73]). Induction of labor (adjusted odds ratio, 0.95 [95% confidence interval, 0.89-1.01]) was not associated with increased odds of neonatal intensive care unit admission compared with women who labored spontaneously. The events associated with higher odds of neonatal intensive care unit admission included: prolonged second stage (adjusted odds ratio, 1.66 [95% confidence interval, 1.51-1.83]); chorioamnionitis (adjusted odds ratio, 3.89 [95% confidence interval, 3.42-4.44]), meconium-stained amniotic fluid (adjusted odds ratio, 1.96 [95% confidence interval, 1.82-2.10]), and abruption (adjusted odds ratio, 2.64 [95% confidence interval, 2.16-.21]). Compared with women who did not labor, the odds of neonatal intensive care unit admission were lower for women who labored: adjusted odds ratio, 0.48 (95% confidence interval, 0.45-0.52) for women with no uterine scar and adjusted odds ratio, 0.83 (95% confidence interval, 0.73-0.94) for women with a uterine scar. There was significant variation in neonatal intensive care unit admission rates by hospital, ranging from 2.9% to 11.2%. After accounting for case mix and hospital characteristics, the between-hospital variance was 1.9%, suggesting that little of the variation was explained by the effect of the hospital., Conclusion: This study contributes to the currently limited understanding of term, neonatal intensive care unit admission rates as a marker of obstetrical care quality. We demonstrated that significant variation exists in hospital unexpected neonatal intensive care unit admission rates and that certain intrapartum events are associated with an increased risk for neonatal intensive care unit admission after delivery. However, the between-hospital variation was low. Unmeasured confounders and extrinsic factors, such as neonatal intensive care unit bed availability, may limit the ability of unexpected term neonatal intensive care unit admissions to meaningfully reflect obstetrical care quality., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Clinical research should ultimately improve patient care. To enable this, randomized controlled trials must select, collect, and report outcomes that are both relevant to clinical practice and genuinely reflect the perspectives of key stakeholders including health care professionals, researchers, and patients. Unfortunately, many randomized controlled trials fall short of this requirement. Complex issues, including a failure to take into account the perspectives of key stakeholders when selecting outcomes, variations in outcome definitions and measurement instruments, and outcome reporting bias make research evidence difficult to interpret, undermining the translation of research into clinical practice. Problems with poor outcome selection, measurement, and reporting can be addressed by developing, disseminating, and implementing core outcome sets. A core outcome set represents a minimum data set of outcomes developed using robust consensus science methods engaging diverse stakeholders including health care professionals, researchers, and patients. Core outcomes should be routinely utilized by researchers, collected in a standardized manner, and reported consistently in the final publication. They are currently being developed across our specialty including infertility, endometriosis, and preeclampsia. Recognizing poorly selected, collected, and reported outcomes as serious hindrances to progress in our specialty, more than 80 journals including the Journal, have come together to support the Core Outcomes in Women's and Newborn Health (CROWN) initiative. The consortium supports researchers to develop, disseminate, and implement core outcome sets. Implementing core outcome sets could make a profound contribution to addressing poorly selected, collected, and reported outcomes. Implementation should ensure future randomized controlled trials hold the necessary reach and relevance to inform clinical practice, enhance patient care, and improve patient outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

At the 36th Annual meeting of the Society for Maternal-Fetal Medicine (SMFM), leaders in the field of maternal-fetal medicine (MFM) convened to address maternal outcome and care inequities from 3 perspectives: (1) education, (2) clinical care, and (3) research. Meeting attendees identified knowledge gaps regarding disparities within the provider community; reviewed possible frameworks to address these knowledge gaps; and identified models with which to address key clinical issues. Collaboration and communication between all stakeholders will be needed to gain a better understanding of these prevailing disparities and formulate strategies to eliminate them., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Racial and ethnic disparities in maternal morbidity and mortality rates are an important public health problem in the United States. Because racial and ethnic minorities are expected to comprise more than one-half of the US population by 2050, this issue needs to be addressed urgently. Research suggests that the drivers of health disparities occur at 3 levels: patient, provider, and system. Although we have recognized this issue and identified elements that contribute to it, knowledge must be converted into action to address it. In addition, despite available funding and databases, research directed towards understanding and reducing these disparities is lacking. This document summarizes findings of a workshop convened at the 2016 Society for Maternal-Fetal Medicine's 36th Annual Pregnancy meeting in Atlanta, GA, to review and make recommendations about immediate actions in clinical care and research that will serve to reduce racial and ethnic disparities in maternal morbidity and mortality rates in the United States., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Checklists have been long used as a cognitive aid in various high-stakes environments to improve the reliability and performance of individuals and teams. When designed well, implemented thoughtfully, and monitored closely, they offer the opportunity to improve the performance of health care teams and advance patient safety. There are different types of checklists; examples include task lists, troubleshooting lists, coordination lists, discipline lists, and to-do lists. Each is useful in different situations and requires different implementation strategies. Checklists also are different from algorithms, care maps and protocols, and educational tools. Therefore, they are not useful in all situations. In appropriate selected clinical circumstances, checklists are tools that can help standardize care, improve communication, and help teams perform optimally., (Copyright © 2017. Published by Elsevier Inc.)

Heath care measurement and evaluation is an integral piece of the health care system. The creation and assessment of care performance metrics are important and relevant for the obstetric community including both clinicians and patients. Careful deliberation is required to create a measurement system that results in optimal care for women and families. This article reviews the current approaches to measuring quality in obstetrics., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to estimate interobserver variability and correct classification of preterm birth into spontaneous and indicated subtypes., Study Design: This was a cross-sectional study in which a trained obstetric nurse, maternal fetal medicine (MFM) fellow, and MFM faculty member independently reviewed discharge summaries and full medical records to classify preterm birth into "spontaneous" and "indicated" subtypes. Consensus classification was obtained with a senior faculty member and was considered the correct classification. Proportions of correct classification by both discharge summary and full medical record review and by level of reviewer were compared with the use of the χ(2) test. Interobserver variability was estimated with the use of Fleiss' kappa., Results: Of 132 preterm births, 58.8% were spontaneous. Interrater agreement for classification of preterm birth subtype based on the full medical record review was substantial (0.79; 95% confidence interval, 0.76-0.80). Interrater agreement was slightly less, based on discharge summary classification alone (Kappa, 0.73; 95% confidence interval, 0.71-0.79) compared with a full medical record review, but this difference was not significant (P = .3). Correct classifications for research nurse, MFM fellow, and MFM faculty member were 85%, 95%, and 93%, respectively, for the full medical records and 85%, 93%, and 92%, respectively, for the discharge summaries alone. There was no significant improvement in correct classification based on full medical record review compared with discharge summary alone for any level of reviewer (P > .6)., Conclusion: There is substantial, but imperfect, agreement between reviewers for classification of preterm birth into spontaneous and indicated subtypes. Incorrect classification may occur 5-15% of the time, even with experienced research personnel. Discharge summaries that are populated with pertinent clinical data may streamline accuracy for research efficiency., (Copyright © 2014. Published by Elsevier Inc.)

We assessed the occurrence of 4 safety concerns among labor and delivery teams: dangerous shortcuts, missing competencies, disrespect, and performance problems. A total of 3282 participants completed surveys, and 92% of physicians (906 of 985), 93% of midwives (385 of 414), and 98% of nurses (1846 of 1884) observed at least 1 concern within the preceding year. A majority of respondents said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving their positions. Only 9% of physicians, 13% of midwives, and 13% of nurses shared their full concerns with the person involved. Organizational silence is evident within labor-and-delivery teams. Improvement will require multiple strategies, used at the personal, social, and structural levels., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: Less-than-annual cervical cancer screening is now recommended for most US women, raising questions about the need for routine annual bimanual pelvic examinations. Little is known about clinicians' bimanual pelvic examination practices, their beliefs about its importance, or the reasoning underlying its performance in asymptomatic women., Study Design: We conducted a nationwide survey of US obstetrician-gynecologists. Respondents (n = 521) reported their examination practices and beliefs based on vignettes for asymptomatic women across the lifespan., Results: Nearly all obstetrician-gynecologists perform bimanual pelvic examinations in asymptomatic women across the lifespan, although it is viewed as less important for a newly sexually active 18-year-old. Reasons cited as very important included adherence to standard medical practices (45%), patient reassurance (49%), detection of ovarian cancer (47%), and identification of benign uterine (59%) and ovarian (54%) conditions., Conclusion: Obstetrician-gynecologists perform bimanual pelvic examinations in the vast majority of asymptomatic women, but the importance placed on the examinations and reasons for conducting them vary., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: We sought to describe obstetric care capacity of nongovernment organization (NGO)-/faith-based organization (FBO)-run institutions compared to government-run institutions in 3 African countries using the World Health Organization Global Survey. We also compared delivery characteristics and outcomes., Study Design: This is a descriptive analysis of the 22 NGO-/FBO-run institutions in Uganda, Kenya and Democratic Republic of Congo delivering 11,594 women, compared to 20 government-run institutions delivering 25,825 women in the same countries and period., Results: Infrastructure, obstetric services, diagnostic facilities, and anesthesiology at NGO/FBO institutions were comparable to government institutions. Women delivering at NGO/FBO institutions had more antenatal care, antenatal complications, and cesarean delivery. NGO/FBO institutions had higher obstetrician attendance and lower rates of eclampsia, preterm birth, stillbirth, Apgar <7, and neonatal near miss., Conclusion: NGO/FBO institutions are comparable to government institutions in capacity to deliver obstetric care. NGO/FBOs have been found effective in providing delivery care in developing countries and should be appropriately recognized by stakeholders in their efforts to assist nations achieve international goals., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Simulation in obstetrics allows us to practice in a safe environment. Simulations can improve the performance of individuals and obstetric teams. The evidence is overwhelming that, with simulated practice, obstetricians improve their technical and communication skills. Evidence is emerging that simulation ultimately may improve clinical outcomes. It stands to reason that simulation in obstetrics should be incorporated into comprehensive patient safety programs., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objective: To determine whether clinics that serve indigent patients demonstrate equal compliance with sexually transmitted infection testing guidelines when compared with private clinics., Study Design: One hundred eighty-three women were divided into cohorts based on whether they received prenatal care at a private or indigent clinic. Timing of required antenatal sexually transmitted infection screening was collected for 8 tests and compliance scores were calculated. Primary outcome was average compliance score compared between clinic types. Secondary outcomes included disease-specific compliance and percent of perfect compliance at different office types., Results: Compliance was found to be different between clinic types (P = .023). Indigent clinics had the same median with slightly higher inner-quartile range than private clinics (7 [7-8], 7 [7-7]). Indigent clinics had higher mean compliance scores (7.1 vs 6.9) and a greater percentage of patients demonstrating perfect compliance (42% vs 14%, P < .001)., Conclusion: Clinics serving indigent patient populations had a higher compliance with required testing compared to private clinics. HIV testing in the third trimester remains the greatest need for improvement for all practice types., (Copyright © 2012 Mosby, Inc. All rights reserved.)

One standard by which obstetrical practice is measured is the ability to achieve a time line of ≤ 30 minutes from decision for surgery to time of surgical incision for women in labor for whom a cesarean delivery is indicated due to fetal intolerance to labor. We reviewed our institution's performance regarding this standard and identified an initial rate of 25% of cases actually meeting this standard. Using a program of continuous quality improvement, various systematic and individual barriers were identified and overcome resulting in a significant change in performance. This is a report of the various processes and identified areas of challenge encountered to improve on the ability to achieve this important standard of care., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objective: The purpose of this study was to determine the effect of an obstetrics patient safety program on staff safety culture., Study Design: We implemented (1) obstetrics patient safety nurse, (2) protocol-based standardization of practice, (3) crew resource management training, (4) oversight by a patient safety committee, (5) 24-hour obstetrics hospitalist, and (6) an anonymous event reporting system. We administered the Safety Attitude Questionnaire on 4 occasions over 5 years (2004-2009) to all staff members that assessed teamwork and safety cultures, job satisfaction, working conditions, stress recognition, and perceptions of management., Results: We observed significant improvements in the proportion of staff members with favorable perceptions of teamwork culture (39% in 2004 to 63% in 2009), safety culture (33% to 63%), job satisfaction (39% to 53%), and management (10% to 37%). Individual roles (obstetrics providers, residents, and nurses) also experienced improvements in safety and teamwork, with significantly better congruence between doctors and nurses., Conclusion: Safety programs can improve workforce perceptions of safety and an improved safety climate., (Copyright © 2011 Mosby, Inc. All rights reserved.)

In the 11 years since the Institute of Medicine reported ubiquitous problems with the quality and safety of patient care in the United States, efforts been made to improve health care. Obstetrics and gynecology has made some improvements; however, similar to other areas of health care, progress has been slow. The major deterrents are complexities in our health care system and culture and an immature science of safety and quality that makes measurement and evaluation of progress difficult. This article describes the efforts that have been made in obstetrics and gynecology to identify causes or factors that contribute to adverse outcomes, to develop measures of quality and safety, and to make improvements. It also offers a framework to help organize patient safety research and improvement. Finally, this article offers ways the American Congress of Obstetricians and Gynecologists can organize and support future work., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Advances in modern medicine invite the assumption that medicine can control human biology. There is a perilous logic that leads from expectations of medicine's control over reproductive biology to the expectation of having a perfect baby. This article proposes that obstetricians should take a preventive ethics approach to the care of pregnant women with expectations for a perfect baby. We use Nathaniel Hawthorne's classic short story, "The Birthmark," to illustrate the perils of the logic of control and perfection through science and then identify possible contemporary sources of the expectation of the perfect baby. We propose that the informed consent process should be used as a preventive ethics tool throughout the course of pregnancy to educate pregnant women about the inherent errors of human reproduction, the highly variable clinical outcomes of these errors, the limited capacity of medicine to detect these errors, and the even more limited capacity to correct them., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

"Women and children first" is a familiar phrase and comes down to us from the heroic sacrifice of their lives by British soldiers on the HMS Birkenhead in 1852. "Women and children first," the New York Declaration of the International Academy of Perinatal Medicine, has defined biases in the allocation of health care resources for women and children in the developing world. In this clinical opinion, we identify challenges to the just allocation of resources for fetal, neonatal, and pregnant patients and provide ethically appropriate responses to these challenges. We distinguish substantive justice from procedural justice and identify biases against pregnant, fetal, and neonatal patients related to both substantive and procedural justice. We then identify ethically justified responses to these biases that obstetricians should adopt in reforming organizational and public policy by responsibly advocating for fetal, neonatal, and pregnant patients, whose health care otherwise is at risk of unacceptable compromise.

Recent advances in basic science have expanded our understanding of the function of sleep and of the effects of sleep deprivation on human cognitive and psychomotor performance. In addition, a growing volume of data documents potential detrimental effects of sleep deprivation on medical practice. Such data have special implications for a specialty in which sleep deprivation is sometimes the norm. A review of this evidence suggests the pressing need for a reassessment of individual and small group obstetric practice, particularly as it relates to labor and delivery care; the current model of care in which each woman is delivered by the same provider who delivers prenatal care is generally not tenable in a culture increasingly focused on patient safety.

Objective: The purpose of this study was to determine changes in screening and performance of invasive diagnostic procedures for Down syndrome between 2001 and 2007., Study Design: The Society for Maternal-Fetal Medicine members completed a survey in 2007 regarding screening tests and diagnostic procedures for Down syndrome. With the use of descriptive statistics, the chi(2) test, and the Student t test, responses from 2007 were compared with responses from a similar 2001 survey., Results: Performance of first-trimester screening more than doubled from 2001-2007 (43.1% in 2001, 97.3% in 2007; P < .0001). Between 2001 and 2007, the use of the quad screen increased 10-fold (8.5% in 2001, 85.6% in 2007; P < .0001). There was an estimated 20% decrease in invasive diagnostic procedures that were performed in risk-positive women (53.7% in 2001, 34.2% in 2007; P < .0001). In 2007, the average fetal loss rates that were quoted by maternal-fetal medicine specialists after chorionic villous sampling was 1:160 and after an amniocentesis was 1:493., Conclusion: Down syndrome screening evolved from 2001-2007, with an increasing emphasis on first-trimester screening. With more efficacious screening, the number of invasive procedures has declined.

Objective: We implemented a comprehensive strategy to track and reduce adverse events., Study Design: We incrementally introduced multiple patient safety interventions from September 2004 through November 2006 at a university-based obstetrics service. This initiative included outside expert review, protocol standardization, the creation of a patient safety nurse position and patient safety committee, and training in team skills and fetal heart monitoring interpretation. We prospectively tracked 10 obstetrics-specific outcome. The Adverse Outcome Index, an expression of the number of deliveries with at least 1 of the 10 adverse outcomes per total deliveries, was analyzed for trend., Results: Our interventions significantly reduced the Adverse Outcome Index (linear regression, r(2) = 0.50; P = .01) (overall mean, 2.50%). Concurrent with these improvements, we saw clinically significant improvements in safety climate as measured by validated safety attitude surveys., Conclusion: A systematic strategy to decrease obstetric adverse events can have a significant impact on patient safety.

Objective: The objective of the study was to review all patient records discharged with codes for uterine rupture in 2006 in Hospital Corporation of America hospitals., Study Design: All patient charts were distributed to a committee of perinatologists and general obstetricians. Case report forms were analyzed for variables of interest to determine validity of coding and quality of care., Results: Of 69 cases identified, only 41 were true ruptures. Twenty patients had previous cesareans, and in 9 of these patients, concurrent use of oxytocics was documented. Among the 21 patients without previous cesareans, 7 had previous uterine surgery, and oxytocics were documented in 12 of the remaining 14 patients. Standard of care violations were identified in 10 of 41 true rupture cases., Conclusion: Epidemiological data on uterine rupture based on hospital discharge codes without concurrent chart review may be invalid. Patients with previous cesareans represent only half of true uterine ruptures in contemporary practice.

Our objective was to provide evidence-based guidance for management decisions during labor and delivery. We performed MEDLINE, PubMed, and COCHRANE searches with the terms labor, delivery, pregnancy, randomized trials, plus each management aspect of labor and delivery (eg, early admission). Each management step of labor and delivery was reviewed separately. Evidence-based good quality data favor hospital births, delayed admission, support by doula, training birth assistants in developing countries, and upright position in the second stage. Home-like births, enema, shaving, routine vaginal irrigation, early amniotomy, "hands-on" method, fundal pressure, and episiotomy can be associated with complications without sufficient benefits and should probably be avoided. We conclude that labor and delivery interventions supported by good quality data as just described should be routinely performed. All aspects with lower data quality should be researched with adequately powered and designed trials.

In a health care delivery system with an annual delivery rate of approximately 220,000, a comprehensive redesign of patient safety process was undertaken based on the following principles: (1) uniform processes and procedure result in an improved quality; (2) every member of the obstetric team should be required to halt any process that is deemed to be dangerous; (3) cesarean delivery is best viewed as a process alternative, not an outcome or quality endpoint; (4) malpractice loss is best avoided by reduction in adverse outcomes and the development of unambiguous practice guidelines; and (5) effective peer review is essential to quality medical practice yet may be impossible to achieve at a local level in some departments. Since the inception of this program, we have seen improvements in patient outcomes, a dramatic decline in litigation claims, and a reduction in the primary cesarean delivery rate.

Objective: To determine how unprofessional behavior by residents is identified/ managed within residency programs, and under what conditions concerns are communicated to potential employers., Study Design: A web-based survey was emailed to 241 directors of US obstetrics and gynecology residency programs., Results: 141 program directors (PDs) responded (58%). 84% of PDs indicated that problems with professionalism most commonly come to their attention through personal communication. Methods of addressing the problem included expression of expectation of improvement (95%), psychological counseling (68%), placing resident on probation (59%), and dismissal (30%). The majority of PDs felt remediation was not completely successful. All PDs are willing to communicate professionalism concerns to potential employers, but 42% provide this information only if asked., Conclusion: Resident unprofessional behavior is a common problem for program directors, and remediation is challenging. PDs are willing to express concerns to potential employers, but a significant percentage indicate concerns only if asked.

Objective: The purpose of this study was to compare adherence to American College of Obstetricians and Gynecologists guidelines for the timing of scheduled cesarean delivery in patients of a resident teaching service and patients of a private service to determine the neonatal intensive care unit admission rate and the most frequent admission diagnoses after scheduled cesarean delivery and to compare neonatal outcomes between the groups., Study Design: A retrospective cohort was reviewed by medical record at a tertiary care center. The cases of 609 patients who were delivered by scheduled cesarean delivery were reviewed, and 296 patients were included. Data regarding demographics, dating, delivery, and outcome were collected and compared with the use of statistical software., Results: Significant differences were noted between patients of a teaching service and patients of a private service, with respect to patient age (26.9 vs 30.7 years; P < .001), body mass index (33.7 vs 31.9 kg/m2; P = .030), race (40.4% white patients in resident teaching services vs 86.0% white patients in private services; P < .001), primary elective cesarean delivery (4 vs 23 deliveries; P = .013), and adherence to American College of Obstetricians and Gynecologists guidelines for the timing of elective delivery (96.3% vs 62%; P < .001), with no significant difference in number of neonatal intensive care unit admissions, severity of neonatal disease, or length of stay in the neonatal intensive care unit. The overall neonatal intensive care unit admission rate for all deliveries by scheduled cesarean delivery was 3.7%. The most frequent neonatal intensive care unit admission diagnoses were hypoglycemia and transient tachypnea of the newborn infant, with no severe sequelae of prematurity in either group. When controlled for fetal anomalies and infants who were born to pregestational diabetic mothers, no significant differences in number of admissions or outcomes were noted; however, 50% of the admissions to the neonatal intensive care units in both groups resulted from violations in American College of Obstetricians and Gynecologists criteria., Conclusion: The overall neonatal intensive care unit admission rate after scheduled cesarean delivery in this study is consistent with that reported in the neonatology literature. Patients of a teaching service were a demographically different group than those on the private service, were less likely to get an elective primary cesarean delivery, and were more likely to be delivered in adherence to American College of Obstetricians and Gynecologists guidelines, although this did not significantly affect the rates of admission to the neonatal intensive care unit or neonatal outcome.

Objective: This study was undertaken to investigate the relationship of demographics, medical school performance, and licensing examination scores to board certification., Study Design: A longitudinal follow-up study of graduates of Jefferson Medical College between 1968 and 1994 identified in the AMA Physicians' Professional Data (AMA-PPD) file as practicing obstetrics and gynecology in 2003. Demographics, grades, and licensing examination scores had been collected prospectively. Board certification status was obtained from the AMA-PPD in 2003. Bivariate differences were evaluated with t tests. Logistic regression was used to evaluate multivariate relationships to board certification status., Results: Of 310 physicians in obstetrics and gynecology, 291 (94%) were board certified. Those without certification were more likely to be underrepresented minorities, to have been older in medical school, and to have weaker academic records. Logistic regression indicated that scores on step 2 of the United States Medical Licensing Examination were the single most important predictor of achieving board certification. Those with scores of 200 or higher were 7 times more likely to achieve certification than those below 200., Conclusion: Age, gender, and minority status are not independent predictors of achieving board certification. A low score on United States Medical Licensing Examination step 2 is a risk factor for not achieving certification.

Objective: The purpose of this study was to describe current practice patterns for 7 controversial topics in Maternal-Fetal Medicine., Study Design: An interactive survey of obstetric treatment was performed as part of a postgraduate course at the 2004 Annual Meeting of the Society for Maternal-Fetal Medicine. Seven controversial topics were addressed, which included tocolytic therapy, progesterone supplementation for the prevention of preterm birth, screening for inherited thrombophilia, cervical cerclage for a shortened cervix, treatment of preterm premature rupture of membranes, magnesium sulfate seizure prophylaxis, and dexamethasone therapy for HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome., Results: A total of 298 obstetric care providers attended the postgraduate course. By report, most attendees were maternal-fetal medicine specialists (60.7% of respondents) who were >10 years out from specialty training (56.3% of respondents) and who were practicing in a university-based setting (52.9% of respondents). An average of 233 practitioners (range, 157-298 practitioners) answered each question. An analysis of the responses allowed for the determination of current practice patterns in the 7 controversial areas addressed., Conclusion: Contemporary practice patterns for 7 controversial topics in obstetric medicine are described. Such surveys may be useful in defining standards of care in maternal-fetal medicine.

Objective: The purpose of this study was to identify an appropriate population and a balanced set of maternal and neonatal measures to drive a hospital network obstetric quality improvement program., Study Design: Sutter Health, a large Northern California health care system with>40,000 births annually, served as the site for this project. We chose to focus on the standardized nulliparous patients: term, singleton, and vertex. A multidisciplinary task force evaluated and selected perinatal outcome and process measures. Data from every hospital were collected prospectively electronically and analyzed centrally., Results: Outcome measures that were selected included term, singleton, and vertex rates of 3rd/4th-degree laceration, cesarean birth, 5-minute Apgar score of <7, and patient satisfaction. The process measures included episiotomy, induction (37-41 weeks), and admittance with cervical dilation of > or =3 cm. Data collection completeness improved each quarter; by the end of 2002, the data collection completeness rate had reached 99.7%. Every measure demonstrated a large variation among our hospitals, which indicates opportunities for improvement., Conclusion: This balanced set of measures for term, singleton, and vertex patients has been straightforward to collect over a large and diverse hospital system and has engaged all participants successfully.

Objective: The study objective was to examine the neonatal outcome in pregnancies with early preterm premature rupture of the membranes (PPROM) who were managed expectantly despite the development of recurrent active genital herpes., Study Design: Pregnancies complicated by PPROM at < or =14;31 weeks' gestation that developed an active recurrent genital herpes lesion were collected. The latency time from herpes lesion development to delivery and the neonatal outcome were analyzed. A control group of patients with PPROM at < or =14;31 weeks' gestation with no herpes infection was also obtained., Results: A total of 29 patients were identified during the study period. The mean gestational age at herpes lesion development after PPROM was 28.7 weeks (range 24.6-31.0 weeks). The mean latency period from herpes development to delivery was 13.2 days (range 1-35 days). No cases of neonatal herpes developed in the delivered newborn infants and all neonatal cultures were negative (0 of 29 cases, 95% CI 0%-10.4%). Twelve newborn infants (41%) had major morbidity caused by prematurity and 3 of these (10.3%) died. There were no differences seen between the study cases and the control group. In the study, 15 of the 29 pregnancies were delivered beyond 30 weeks' gestation. If delivery had occurred on the day the herpes lesion developed, only 5 pregnancies would have been delivered beyond 30 weeks' gestation., Conclusion: On the basis of the 95% CI of these data, the maximum risk for development of a neonatal herpes infection in the face of PPROM and active recurrent genital herpes was 10.4%. This was equal to the mortality rate and was 75% lower than the major morbidity rate caused by prematurity. If delivery had occurred on the day the herpes lesions developed, on average, the neonates would have been nearly 2 weeks more premature, thereby potentially increasing the morbidity and mortality related to prematurity. These data concur with the American College of Obstetricians and Gynecologists consensus and expert opinion and would suggest that expectant management of PPROM at

Objective: The acceptance or rejection of obstetric technologies in clinical practice is not always based on the results of randomized controlled trials (RCTs). In this study, possible reasons for this discordance are examined., Study Design: Eleven technologies introduced over the past 30 years were examined. RCT results were determined from the published literature, with emphasis on meta-analyses and the Cochrane reviews. Results were graded for quality of evidence (I-III) and strength of recommendations (A-E) on the basis of criteria adopted by the United States Preventive Services Task Force. Clinical use was based on data from the literature, or when this was lacking, on an estimate, and graded + to +++ or - to - - -, based on degree of acceptance or rejection., Results: There was concordance of results with midtrimester ultrasound (US) imaging, home uterine activity monitoring (HUAM), Doppler velocimetry in high-risk pregnancy, short-term tocolysis, single-course antenatal corticosteroids (BMZ), thyroid-releasing hormone (TRH), and fetal fibronectin (fFN). There was discordance of results with fetal heart rate monitoring (FHRM), fetal blood sampling (FBS), US imaging in late pregnancy, Doppler velocimetry in low-risk pregnancy, and tocolysis beyond 7 days. In several cases there are published RCTs, but clinical acceptance is still evolving (multiple course BMZ, pulse oximetry, and electrocardiogram ST-segment analysis)., Conclusion: These observations suggest that technologies which are simple to apply, and have a single endpoint, show concordance between RCT results and clinical use (HUAM, short-term tocolysis, single-course BMZ, TRH, and fFN). Those that are complex to apply (FBS), or interpret (FHRM), and/or do not have a single clear end point (FHRM, Doppler), or have results that are of great personal interest to the patient (FHRM, US imaging, long-term tocolysis), are more likely to show discordance. In several cases despite published RCTs, clinical acceptance or rejection is still evolving (multiple course BMZ, pulse oximetry, and electrocardiogram ST-segment analysis). These inconsistent relationships suggest that the decision-making processes of obstetric providers and patients would be a fruitful area of investigation.

Objective: Our purpose was to assess the accuracy and intraobserver variability of clinical cervical diameter measurements among obstetric health care providers., Study Design: Polyvinyl chloride pipes 1 to 10 cm in diameter were mounted in cardboard boxes and used to simulate cervical examinations. The boxes were designed so that the examiner had to rely solely on proprioception to determine the inner diameter., Results: A total of 1574 simulated cervical diameter measurements were obtained from 102 different examiners in a two-part study. The overall accuracy for determining the exact diameter was 56.3%, which improved to 89.5% when an error of +/- 1 cm was allowed. Intraobserver variability for a given diameter measurement was 52.1%, which decreased to 10.5% when an error of +/- 1 cm was allowed., Conclusions: Cervical diameter measurements obtained by digital examination are precise when an error of +/- 1 cm is allowed for. Intraobserver variability is > 50% and is an important consideration when evaluating dysfunctional labor.