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Purpose: To investigate the capacity of chat-generative pre-trained transformer (Chat-GPT) to understand the S2k guideline of the German Society for Gynecology and Obstetrics on intrauterine growth restriction., Methods: The German-language free Chat-GPT version was used to test the ability of Chat-GPT to understand the definition of small for gestational age and intrauterine growth restriction, to indicate the correct time and place of delivery and to evaluate ist ability to recommend a spontaneous delivery versus a primary caesarean section in accordance with the guideline recommendations. In order to objectively evaluate the suggestions a simple three-color 'traffic light' evaluation system was employed., Results: Almost all Chat-GPT's suggestions in the context of definition of small for gestational age/intrauterine growth restriction as well as correct time of delivery were adequate, whereas more than half of the suggestions made in terms of correct delivery mode needed reformulation or even correction., Conclusion: Chat-GPT appears to be a valuable form of artificial intelligence that could be integrated into everyday clinical practice., (© 2024. The Author(s).)

Objective:  To evaluate the reliability of three artificial intelligence (AI) chatbots (ChatGPT, Google Bard, and Chatsonic) in generating accurate references from existing obstetric literature., Study Design:  Between mid-March and late April 2023, ChatGPT, Google Bard, and Chatsonic were prompted to provide references for specific obstetrical randomized controlled trials (RCTs) published in 2020. RCTs were considered for inclusion if they were mentioned in a previous article that primarily evaluated RCTs published by the top medical and obstetrics and gynecology journals with the highest impact factors in 2020 as well as RCTs published in a new journal focused on publishing obstetric RCTs. The selection of the three AI models was based on their popularity, performance in natural language processing, and public availability. Data collection involved prompting the AI chatbots to provide references according to a standardized protocol. The primary evaluation metric was the accuracy of each AI model in correctly citing references, including authors, publication title, journal name, and digital object identifier (DOI). Statistical analysis was performed using a permutation test to compare the performance of the AI models., Results:  Among the 44 RCTs analyzed, Google Bard demonstrated the highest accuracy, correctly citing 13.6% of the requested RCTs, whereas ChatGPT and Chatsonic exhibited lower accuracy rates of 2.4 and 0%, respectively. Google Bard often substantially outperformed Chatsonic and ChatGPT in correctly citing the studied reference components. The majority of references from all AI models studied were noted to provide DOIs for unrelated studies or DOIs that do not exist., Conclusion:  To ensure the reliability of scientific information being disseminated, authors must exercise caution when utilizing AI for scientific writing and literature search. However, despite their limitations, collaborative partnerships between AI systems and researchers have the potential to drive synergistic advancements, leading to improved patient care and outcomes., Key Points: · AI chatbots often cite scientific articles incorrectly.. · AI chatbots can create false references.. · Responsible AI use in research is vital.., Competing Interests: None declared., (Thieme. All rights reserved.)

Cervical cancer poses a significant health burden, particularly in low- and middle-income countries, where access to screening and treatment remains limited. Asia Oceania Federation of Obstetrics and Gynecology (AOFOG)'s response, guided by the World Health Organization's global strategy, emphasizes three key targets: achieving high HPV vaccination coverage among girls, ensuring widespread screening with high-performance tests, and guaranteeing timely treatment for precancerous and cancerous lesions. AOFOG supports member countries through initiatives such as educational campaigns, guidelines development, and collaboration with local and international partners. Variations in screening methods across AOFOG member countries reflect diverse socioeconomic contexts and healthcare infrastructures, ranging from HPV testing in countries like Australia and Malaysia to cytology and visual inspection methods in others. Innovations such as HPV self-testing and AI-enhanced screening are emerging to improve accessibility and accuracy, addressing barriers like stigma and resource scarcity. Despite challenges, AOFOG remains committed to reducing cervical cancer incidence and mortality through coordinated regional efforts, aiming for equitable access to preventive measures and treatment across the diverse landscape of the Asia-Pacific region., (© 2024 Japan Society of Obstetrics and Gynecology.)

Cervical cancer remains a disease burden in Asia. The Asia and Oceania Federation of Obstetrics and Gynecology envisages a need to produce a set of recommendations on the implementation of human papilloma virus vaccination program for both lower-middle-income countries (LMICs) and high-income countries (HICs), with an attempt to harmonize the practices yet allow flexibility to cater for different cultures, religions, needs and background of individual countries/cities. International guidelines and literature were sought, and recommendations were made in seven selected areas, including (i) the target groups for vaccination, (ii) the doses of vaccination including the use of single-dose vaccination, (iii) the types of vaccines, (iv) suggestions for special populations including those with previous HPV infection, human immunodeficiency virus carriers, and lesbian, gay, bisexual, transgender, questioning/queer group, (v) inter-changeability and the need of revaccination/booster, (vi) novel technologies and vaccines, and (vii) public education., (© 2024 The Author(s). Journal of Obstetrics and Gynaecology Research published by John Wiley & Sons Australia, Ltd on behalf of Japan Society of Obstetrics and Gynecology.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Obstetrics and gynecologic hospitalists play a pivotal role in the evolution of perinatal care. Hospitalists improve patient safety by providing on-site, reliable, high-quality care. Hospitalists help to reduce the rates of unnecessary cesarean deliveries and increase the rates of vaginal deliveries., Competing Interests: Disclosure The authors have no commercial or financial conflicts of interest and no funding sources., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to explore how obstetricians-gynecologists in low- and middle-income countries (LMICs) can apply current international clinical practice guidelines (CPGs) for the management of placenta accreta spectrum (PAS) in limited resource settings., Methods: This was an observational, survey-based study. Clinicians with expertise in managing patients with PAS in LMICs were contacted for their evaluation of the recommendations included in four PAS clinical practice guidelines., Results: Out of the 158 clinicians contacted, we obtained responses from 65 (41.1%), representing 27 middle income countries (MICs). The results of this survey suggest that the care of PAS patients in middle income countries is very different from what is recommended by international CPGs. Participants in the survey identified that their practice was limited by insufficient availability of hospital infrastructure, low resources of local health systems and lack of trained multidisciplinary teams (MDTs) and this did not enable them to follow CPG recommendations. Two-thirds of the participants surveyed describe the absence of centers of excellence in their country. In over half of the referral hospitals with expertise in managing PAS, there are no MDTs. One-third of patients with intraoperative findings of PAS are managed by the team initially performing the surgery (without additional assistance)., Conclusion: The care of patients with PAS in middle income countries frequently deviates from established CPG recommendations largely due to limitations in local resources and infrastructure. New practical guidelines and training programs designed for low resource settings are needed., (© 2024 International Federation of Gynecology and Obstetrics.)

Purpose: This study examined demographic, practice, and area-level characteristics associated with family physicians' (FP) provision of maternity care., Methods: Using the American Board of Family Medicine Certification examination application survey data, we investigated the relationship between FPs' maternity care service provision and (1) demographic (gender, years in practice, race/ethnicity), (2) practice characteristics (size, ownership, rurality), and (3) county-level factors (percentage of reproductive-age women, the number of obstetrician-gynecologists (OBGYNs) and certified nurse midwives (CNMs) per 100,000 reproductive-age women). We performed summary statistics and multivariate logistic regression analyses., Results: Of the 59,903 FPs in the sample, 7.5% provided maternity care. FPs practicing in rural were 2.5 times more likely to provide maternity care than those practicing in urban areas. FPs in academic (odds ratio [OR] 4.6, 95% confidence interval [CI] 4.1-5.1) and safety-net settings (OR 1.9, 1.7-2.1) had greater odds of providing maternity care. FPs in the bottom quintile with no or fewer OBGYNs and CNMs had a higher likelihood of maternity care provision (OR 2.1, 1.8-2.3) than those in the top quintile, with more OBGYNs and CNMs., Conclusions: FPs in high-needs areas, such as rural and safety net settings, and areas with fewer CNMs or OBGYNs are more likely to provide maternity care, demonstrating the importance of FPs in meeting the needs of women with limited maternity care access. Our study findings highlight the importance of considering the contributions of FPs to maternity care as the organizations prioritize resource allocation to areas of highest need., (© 2024 National Rural Health Association.)

The Association of Professors of Gynecology and Obstetrics created the Diversity, Equity, and Inclusion Guidelines Task Force to develop best practices to establish a diverse physician workforce and eliminate racism in medical education. Using the guidelines, educators are impacting their communities and, in some areas, leading their institutions toward greater diversity and inclusion. The guidelines are organized by 4 domains: learning environment, grading and assessment, pathway programs, and metrics. This manuscript uses that framework to highlight the work of individual educators who are moving the needle towards racism-free health care and aims to inspire others contemplating incorporation into their programs., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the quality of ChatGPT responses to common issues in obstetrics and assess its ability to provide reliable responses to pregnant individuals. The study aimed to examine the responses based on expert opinions using predetermined criteria, including "accuracy," "completeness," and "safety.", Methods: We curated 15 common and potentially clinically significant questions that pregnant women are asking. Two native English-speaking women were asked to reframe the questions in their own words, and we employed the ChatGPT language model to generate responses to the questions. To evaluate the accuracy, completeness, and safety of the ChatGPT's generated responses, we developed a questionnaire with a scale of 1 to 5 that obstetrics and gynecology experts from different countries were invited to rate accordingly. The ratings were analyzed to evaluate the average level of agreement and percentage of positive ratings (≥4) for each criterion., Results: Of the 42 experts invited, 20 responded to the questionnaire. The combined score for all responses yielded a mean rating of 4, with 75% of responses receiving a positive rating (≥4). While examining specific criteria, the ChatGPT responses were better for the accuracy criterion, with a mean rating of 4.2 and 80% of the questions received a positive rating. The responses scored less for the completeness criterion, with a mean rating of 3.8 and 46.7% of questions received a positive rating. For safety, the mean rating was 3.9 and 53.3% of questions received a positive rating. There was no response with an average negative rating below three., Conclusion: This study demonstrates promising results regarding potential use of ChatGPT's in providing accurate responses to obstetric clinical questions posed by pregnant women. However, it is crucial to exercise caution when addressing inquiries concerning the safety of the fetus or the mother., (© 2024 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

The global challenge of preterm birth persists with little or no progress being made to reduce its prevalence or mitigate its consequences, especially in low-resource settings where health systems are less well developed. Improved delivery of respectful person-centered care employing effective care models delivered by skilled healthcare professionals is essential for addressing these needs. These FIGO good practice recommendations provide an overview of the evidence regarding the effectiveness of the various care models for preventing and managing preterm birth across global contexts. We also highlight that continuity of care within existing, context-appropriate care models (such as midwifery-led care and group care), in primary as well as secondary care, is pivotal to delivering high quality care across the pregnancy continuum-prior to conception, through pregnancy and birth, and preparation for a subsequent pregnancy-to improve care to prevent and manage preterm birth., (© 2024 The Author(s). International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

An obstetric emergency department (OBED) allows for timely, standardized and quality care by a clinician for pregnant patients presenting unscheduled to a hospital. Understanding the differences between a traditional labor and delivery triage model and an OBED are important in developing a successful, safe, and quality obstetric program that meets the needs of the community with appropriate resource allocation. The benefits in an OBED of every patient seen in a timely fashion by a clinician, and ultimately the impact on outcomes are noteworthy and should be considered when developing a labor and delivery unit., Competing Interests: Disclosure Both authors are employees of Ob Hospitalist Group. There are no other conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To summarize the current evidence and to make recommendations for the diagnosis and management of intrahepatic cholestasis of pregnancy., Target Population: Pregnant people with intrahepatic cholestasis of pregnancy., Options: Diagnosing the condition using fasting or non-fasting bile acids, classifying disease severity, determining what treatment to offer, establishing how to monitor for antenatal fetal wellbeing, identifying when to perform elective birth., Benefits, Harms, and Costs: Individuals with intrahepatic cholestasis of pregnancy are at increased risk of adverse perinatal outcomes including preterm birth, neonatal respiratory distress and admission to a neonatal intensive care unit, with an increased risk of stillbirth when bile acid levels are ≥100 μmol/L. There is inequity in bile acid testing availability and timely access to results, along with uncertainly of how to treat, monitor. and ultimately deliver these pregnancies. Optimization of diagnostic and management protocols can improve maternal and fetal postnatal outcomes., Evidence: Medline, PubMed, Embase, and the Cochrane Library were searched from inception to March 2023, using medical subject headings (MeSH) and keywords related to pregnancy, intrahepatic cholestasis of pregnancy, bile acids, pruritis, ursodeoxycholic acid, and stillbirth. This document presents an abstraction of the evidence rather than a methodological review., Validation Methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations)., Intended Audience: Obstetric care providers, including obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, and radiologists., Social Media Abstract: Intrahepatic cholestasis of pregnancy requires adequate diagnosis with non-fasting bile acid levels which guide optimal management and delivery timing., Summary Statements: RECOMMENDATIONS., (Copyright © 2024. Published by Elsevier Inc.)

Background: Letters of recommendation for Maternal-Fetal Medicine(MFM) fellowship are a critical part of the applicant selection process. However, data regarding best practices for how to write LOR for MFM is limited. Similarly, within letters of recommendation, differences in the "code" or meaning of summative words/phrases used at the end of letters of recommendation are seen between surgery, pediatrics, and medicine. However, data regarding code MFM Letters of recommendation are quite limited., Objective: We sought to describe what Maternal-Fetal Medicine program directors value in letters of recommendation for fellowship applicants and how PDs interpret commonly used summative words/phrases., Study Design: After IRB exemption, subject matter experts developed an e-survey querying the importance of various letters of recommendation "best practices" described by other specialties. Content and face validation were performed prior to dissemination. This cross-sectional survey was administered to MFM program directors in February 2023. The primary outcome was the relative importance of letters of recommendation content areas. Secondary outcomes included the strength of each summative "code" phrase. Descriptive analysis was performed and principal component analysis (PCA) was then used to reduce the list of phrases to their underlying dimensions. Statistical analysis was performed by SPSS 29.0., Results: Of 104 MFM program directors sent the survey, 70 (67%) responded. MFM program directors reviewed an average of 78 applications (SD, 30) with 60% writing ≥3 letters/year. Ninety-one percent of respondents noted that letters of recommendation are important/very important in shaping impressions of an applicant. Respondents reported the depth of interaction with an applicant, the applicant's specific behavior traits, the applicant's abilities and a summative statement including strength of the recommendation as important content for MFM fellowship letters of recommendation. Letter length, use of bold/italics, and restating the applicant's curriculum vitae were considered not important. Following PCA with varimax rotation, 14 specific phrases used in letters of recommendation were reduced to 5 themes: high qualitative assessments, average qualitative assessments, objective metrics, exceeding expectations and grit. These themes accounted for 64.6% of the variance in the model (KMO 0.7, Bartlett's Test of Sphericity p<.01). Phrases that respondents considered positive included: "Top 5%," "Want to keep," and "highest recommendation," (all mean score≥4.5/5), while "expected level," "showed improvement," and "2nd quartile" were negatively associated code words (all mean score <2.5/5)., Conclusion: MFM program directors reported that descriptions of an applicant's abilities, behavior traits, and depth of the writer's interactions with the applicant were all important components of an MFM fellowship letters of recommendation. Letter length, bold/italics, and highlights from the CV were not important. A clear "code" emerged regarding summative phrases included in letters of recommendation. Dissemination of these data might help less experienced letter writers send a clearer message and ensure all letter writers have a shared mental model., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Maternal mortality data and review are important indicators of the effectiveness of maternity healthcare systems and an impetus for action. Recently, a rising incidence of maternal mortality in high income countries has been reported. Various publications have raised concern about data collection methods at country level, as this usually relies mainly on national vital statistics. It is therefore essential that the collected data are complete and accurate and conform to international definitions and disease classification. Accurate data and review can only be truly available when an Enhanced Obstetric Surveillance System is in place. EBCOG calls for action by national societies to work closely with their respective ministries of health to ensure that high quality surveillance systems are in place., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Professional societies such as the American College of Obstetricians and Gynecologists (ACOG) promote the idea that postpartum care is an ongoing process where there is adequate opportunity to provide services and support. Nonetheless, in practice, the guidelines ask clinicians to perform more clinical responsibilities than they might be able to do with limited time and resources., Methods: We conducted an online survey among practicing obstetric clinicians (obstetrician/gynecologists (OB/GYNs), midwives, and family medicine doctors) in California about their priorities and care practices for the first postpartum visit and explored how they prioritize multiple clinical responsibilities within existing time and resources. Between September 2023 and February 2024, 174 out of 229 eligible participants completed the survey, a 76% response rate. From a list of care components, we used descriptive statistics to identify those that were highly prioritized by most clinicians and those that were considered a priority by very few and examined the alignment between prioritized components and recommended care practices., Results: Clinicians were highly invested in the care components that they rated as most important, indicating that they always check these components or assess them when they perceive patient need. Depression and anxiety, breast health/breast feeding issues, vaginal birth complications and family planning counseling were highly ranked components by all clinicians. In contrast, clinicians more often did not assess those care components that infrequently ranked highly among the priority listing, consisting mainly of social drivers of health such as screening and counseling for intimate partner violence, working conditions and food/housing insecurity. In both instances, we found little discordance between priorities and care practices. However, OB/GYNs and midwives differed in some care components that they prioritized highly., Conclusions: While there is growing understanding of how important professional society recommendations are for maternal-infant health, clinicians face barriers completing all recommendations, especially those components related to social drivers of health. However, what the clinicians do prioritize highly, they are likely to perform. Now that Medi-Cal (Medicaid) insurance is available in California for up to 12 months postpartum, there is a need to understand what care clinicians provide and what gaps remain., (© 2024. The Author(s).)

Objective: This document addresses the clinical application of next-generation sequencing (NGS) technologies for prenatal genetic diagnosis and aims to establish clinical practice recommendations in Spain to ensure uniformity in implementing these technologies into prenatal care., Methods: A joint committee of expert obstetricians and geneticists was created to review the existing literature on fetal NGS for genetic diagnosis and to make recommendations for Spanish healthcare professionals., Results: This guideline summarises technical aspects of NGS technologies, clinical indications in prenatal setting, considerations regarding findings to be reported, genetic counselling considerations as well as data storage and protection policies., Conclusions: This document provides updated recommendations for the use of NGS diagnostic tests in prenatal diagnosis. These recommendations should be periodically reviewed as our knowledge of the clinical utility of NGS technologies, applied during pregnancy, may advance., Competing Interests: Competing interests: MG-H works in NIMGenetics, a private genetics lab currently performing prenatal NGS., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A1C ≥6.0% is associated with increased risk of adverse outcomes in pregnant diabetic patients. A1C testing is recommended by the American Diabetes Association as a secondary measure of glycemic control in pregnant patients., Objective: To determine the utility of A1C point-of-care testing (POCT) during pregnancy to facilitate rapid counseling and diabetes care, particularly in relatively low-income transient patient populations., Methods: We performed a single-center, retrospective analysis of patients presenting to an outpatient obstetrics office with routine, in-laboratory A1C testing, before and after the implementation of POCT for A1C (n = 70 and n = 75, respectively). Demographics, results, physician referral to a nutritionist, counseling, and outcomes were retrieved from patient electronic medical records., Results: In total, 9% and 23% of the in-laboratory and POCT groups, respectively, were referred for nutrition services (P = .02). Of these, 22% of the in-laboratory group and 42% of the POCT group received immediate counseling (P < .01). An inverse correlation was observed between A1C level at study entry and gestational weeks at delivery, with a Pearson r value of -0.39 (-0.58 to -0.16) for the in-laboratory group and -0.38 (-0.57 to -0.14) for the POCT group. No statistically significant difference in pregnancy outcomes was observed., Conclusion: Implementation of A1C POCT was associated with immediate counseling and management of the health of pregnant patients, but was not associated with improved outcomes, in a low-resource patient population., (© The Author(s) 2024. Published by Oxford University Press on behalf of American Society for Clinical Pathology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Twelve years after the first edition of The Guideline for Gynecological Practice, which was jointly edited by The Japan Society of Obstetrics and Gynecology and The Japan Association of Obstetricians and Gynecologists, the 5th Revised Edition was published in 2023. The 2023 Guidelines includes 5 additional clinical questions (CQs), which brings the total to 103 CQ (12 on infectious disease, 30 on oncology and benign tumors, 29 on endocrinology and infertility and 32 on healthcare for women). Currently, a consensus has been reached on the Guidelines, and therefore, the objective of this report is to present the general policies regarding diagnostic and treatment methods used in standard gynecological outpatient care that are considered appropriate. At the end of each answer, the corresponding Recommendation Level (A, B, C) is indicated., (© 2024 The Authors. Journal of Obstetrics and Gynaecology Research published by John Wiley & Sons Australia, Ltd on behalf of Japan Society of Obstetrics and Gynecology.)

Introduction: Hypertensive disorders of pregnancy (HDP) affect up to 10% of all pregnancies annually and are associated with an increased risk of maternal and fetal morbidity and mortality. This guideline represents an update of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) guidelines for the management of hypertensive disorders of pregnancy 2014 and has been approved by the National Health and Medical Research Council (NHMRC) under section 14A of the National Health and Medical Research Council Act 1992. In approving the guideline recommendations, NHMRC considers that the guideline meets NHMRC's standard for clinical practice guidelines., Main Recommendations: A total of 39 recommendations on screening, preventing, diagnosing and managing HDP, especially preeclampsia, are presented in this guideline. Recommendations are presented as either evidence-based recommendations or practice points. Evidence-based recommendations are presented with the strength of recommendation and quality of evidence. Practice points were generated where there was inadequate evidence to develop specific recommendations and are based on the expertise of the working group., Changes in Management Resulting From the Guideline: This version of the SOMANZ guideline was developed in an academically robust and rigorous manner and includes recommendations on the use of combined first trimester screening to identify women at risk of developing preeclampsia, 14 pharmacological and two non-pharmacological preventive interventions, clinical use of angiogenic biomarkers and the long term care of women who experience HDP. The guideline also includes six multilingual patient infographics which can be accessed through the main website of the guideline. All measures were taken to ensure that this guideline is applicable and relevant to clinicians and multicultural women in regional and metropolitan settings in Australia and New Zealand., (© 2024 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Introduction: The Rural Surgical Obstetrical Networks (RSON) initiative in BC was developed to stabilize and grow low volume rural surgical and obstetrical services. One of the wrap-around supportive interventions was funding for Continuous Quality Improvement (CQI) initiatives, done through a local provider-driven lens. This paper reviews mixed-methods findings on providers' experiences with CQI and the implications for service stability., Background: Small, rural hospitals face barriers in implementing quality improvement initiatives due primarily to lack of resource capacity and the need to prioritize clinical care when allocating limited health human resources. Given this, funding and resources for CQI were key enablers of the RSON initiative and seen as an essential part of a response to assuaging concerns of specialists at higher volume sites regarding quality in lower volume settings., Methods: Data were derived from two datasets: in-depth, qualitative interviews with rural health care providers and administrators over the course of the RSON initiative and through a survey administered at RSON sites in 2023., Findings: Qualitative findings revealed participants' perceptions of the value of CQI (including developing expanded skillsets and improved team function and culture), enablers (the organizational infrastructure for CQI projects), challenges in implementation (complications in protecting/prioritizing CQI time and difficulty with staff engagement) and the importance of local leadership. Survey findings showed high ratings for elements of team function that relate directly to CQI (team process and relationships)., Conclusion: Attention to effective mechanisms of CQI through a rural lens is essential to ensure that initiatives meet the contextual realities of low-volume sites. Instituting pathways for locally-driven quality improvement initiatives enhances team function at rural hospitals through creating opportunities for trust building and goal setting, improving communication and increasing individual and team-wide motivation to improve patient care., Competing Interests: Sean Ebert received sessional funding from the Rural Coordination Centre of BC (RCCbc) in his role as medical lead for the Quality Improvement Pillar for the Rural Surgical and Obstetrical Networks (RSON) initiative. In his capacity as medical lead he received funding to travel to the rural communities where the participants we report on in this manuscript work and provide care. Tom Skinner is employed by the Rural Coordination Centre of BC (RCCbc) as the Project Manager of the RSON Initiative. The findings reported in the survey are part of the evaluation of RSON. As an employee, his travel to the rural communities were covered because he was supporting hospital teams in implementing the PROES survey and interpreting the result. Kim Williams received salary funding from the Rural Coordination Centre of BC (RCCbc) in her capacity as administrative co-lead for the Rural Surgical and Obstetrical Networks (RSON) initiative. She received funding to travel to the rural communities where the participants whom we report on in this manuscript work and provide care. Nancy Humber received funding from the Rural Coordination Centre of BC (RCCbc) in her role as a clinical lead for the Rural Surgical Obstetrical Network. In her capacity as a clinical lead, she received funding for travel to the rural communities where the participants whom we report on in this manuscript work and provide care. All other authors are part of the RSON evaluation team at the University of British Columbia, Canada and have no conflicts of interest to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Kornelsen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Maternal and/or perinatal death review or audits aim to improve the quality of health services and reduce deaths due to causes identified. A death review audit cycle identifies causes of deaths and possible modifiable factors, these can point to potential breaks in the continuity of health care and other health systems faults and challenges. It is an important function of audit cycles to develop, implement, monitor, and review action plans to improve the service. The WHO has produced two handbooks (Making Every Baby Count and Monitoring Emergency Obstetric Care) to guide maternal and perinatal death reviews. Health worker related factors accounts for two thirds of aspects that, if done differently may have prevented the adverse outcome. This emphasises the need for skilled health care workers at every delivery and for deliveries to take place in health facilities., Competing Interests: Declaration of competing interest The authors have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Little is known about the care provided following positive depression screens in obstetrics and gynecology (Ob/Gyn) patients., Method: This study evaluated documented care plans and outcomes for 445 Ob/Gyn patients with positive depression screens between January 2018 and December 2020. Logistic regression models were estimated to identify predictors of changes in documented care plans and to test if a documented plan was associated with a reduction in depression severity in 6 months., Results: The sample consisted of 445 patients who were on average 35.5 ( SD = 12.8) years; 206 (46.3%) were White and 178 (40.0%) were Black. A total of 64 (14.4%) had a depression care plan documenting antidepressant initiation or change and/or psychotherapy referral. Relative to those aged 18-29, patients 40 or older had approximately 60% lower odds of a documented care plan change ( OR = 0.394; p < .05). Relative to those seen by nurses, patients seen by physicians had approximately 70% lower odds of having treatment change ( OR = 0.282; p < .05). Patients with a depression care plan documented had approximately 2.7 times higher odds of achieving 50% or more reduction in their Patient Health Questionnaire-9 depression severity score than those without a documented plan ( OR = 2.685; p = .009)., Discussion: While most patients did not experience an initiation or change in their depression care plan on the same day as their positive screen, those patients with a plan documented showed significantly more improvement than those who did not. Standardized recommendations may improve depression outcomes among patients with positive depression screens. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Purpose of Review: The worldwide leading cause of maternal death is severe maternal hemorrhage. Maternal hemorrhage can be profound leading to an entire loss of blood volume. In the past two decades, Patient Blood Management has evolved to improve patient's care and safety. In surgeries with increased blood loss exceeding 500 ml, the use of cell salvage is strongly recommended in order to preserve the patient's own blood volume and to minimize the need for allogeneic red blood cell (RBC) transfusion. In this review, recent evidence and controversies of the use of cell salvage in obstetrics are discussed., Recent Findings: Numerous medical societies as well as national and international guidelines recommend the use of cell salvage during maternal hemorrhage., Summary: Intraoperative cell salvage is a strategy to maintain the patient's own blood volume and decrease the need for allogeneic RBC transfusion. Historically, cell salvage has been avoided in the obstetric population due to concerns of iatrogenic amniotic fluid embolism (AFE) or induction of maternal alloimmunization. However, no definite case of AFE has been reported so far. Cell salvage is strongly recommended and cost-effective in patients with predictably high rates of blood loss and RBC transfusion, such as women with placenta accreta spectrum disorder. However, in order to ensure sufficient practical experience in a multiprofessional obstetric setting, liberal use of cell salvage appears advisable., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Triaging of obstetric patients by emergency care providers is paramount. It helps provide appropriate and timely management to prevent further injury and complications. Standardised trauma acuity scales have limited applicability in obstetric triage. Specific obstetric triage index tools improve maternal and neonatal outcomes but remain underused. The aim was to introduce a validity-tested obstetric triage tool to improve the percentage of correctly triaged patients (correctly colour-coded in accordance with triage index tool and attended to within the stipulated time interval mandated by the tool) from the baseline of 49% to more than 90% through a quality improvement (QI) process.A team of nurses, obstetricians and postgraduates did a root cause analysis to identify the possible reasons for incorrect triaging of obstetric patients using process flow mapping and fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles to address issues identified.The interventions included introduction and application of an obstetric triage index tool, training of triage nurses and residents. We implemented these interventions in eight PDSA cycles and observed outcomes by using run charts. A set of process, output and outcome indicators were used to track if changes made were leading to improvement.Proportion of correctly triaged women increased from the baseline of 49% to more than 95% over a period of 8 months from February to September 2020, and the results have been sustained in the last PDSA cycle, and the triage system is still sustained with similar results. The median triage waiting time reduced from the baseline of 40 min to less than 10 min. There was reduction in complications attributable to improper triaging such as preterm delivery, prolonged intensive care unit stay and overall morbidity. It can be thus concluded that a QI approach improved obstetric triaging in a rural maternity hospital in India., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Delineate the scope of teleconsultation services that can be effectively performed to provide women with comprehensive gynaecological and obstetrical care., Design: Based on the literature and experts' insights, we identified a list of gynaecological and obstetrical care practices suitable for teleconsultation. A three-round Delphi consensus survey was then conducted online among a panel of French experts. Experts using a 9-point Likert scale assessed the relevance of each teleconsultation practice in four key domains: prevention, gynaecology and antenatal and postnatal care. Consensus was determined by applying a dual-criteria approach: the median score on a 9-point Likert scale and the percentage of votes either below 5 or 5 and higher., Setting: The study was conducted at a national level in France and involved multiple healthcare centres and professionals from various geographical locations., Participants: The panel comprised 22 French experts with 19 healthcare professionals, including 12 midwives, 3 obstetricians-gynaecologists, 4 general practitioners and 3 healthcare system users. Participants were selected to include diverse practice settings encompassing hospital and private practices in both rural and urban areas., Primary and Secondary Outcome Measures: The study's primary outcome was the identification of gynaecological and obstetrical care practices suitable for teleconsultation. Secondary outcomes included the level of professional consensus on these practices., Results: In total, 71 practices were included in the Delphi survey. The practices approved for teleconsultation were distributed as follows: 92% in prevention (n=12/13), 55% in gynaecology (n=18/33), 31% in prenatal care (n=5/16) and 12% in postnatal care (n=1/9). Lastly, 10 practices remained under discussion: 7 in gynaecology, 2 in prenatal care and 1 in postnatal care., Conclusions: Our consensus survey highlights both the advantages and limitations of teleconsultations for women's gynaecological and obstetrical care, emphasising the need for careful consideration and tailored implementation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The Canadian Association of Radiologists (CAR) Obstetrics and Gynecology Expert Panel consists of radiologists specializing in obstetrics and gynecology, obstetrics and gynecology physicians, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 12 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 46 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 68 recommendation statements across the 12 scenarios related to the evaluation of obstetrics and gynecology clinical and diagnostic scenarios. This guideline presents the methods of development and the imaging recommendations for a variety of obstetrical and gynecological conditions including pregnancy assessment, recurrent first trimester pregnancy loss, post-partum indications, disorders of menstruation, localization of intra-uterine contraceptive device, infertility assessment, assessment of adnexal mass, pelvic pain of presumed gynecological origin, and pelvic floor evaluation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The negative effects of excessive gestational weight gain (GWG) and obesity during pregnancy are well documented in the literature. However, lack of time, education, comfort, and confidence among health care providers often make it difficult to provide proper nutrition and weight gain guidance for pregnant persons. In response, the International Federation of Gynecology and Obstetrics (FIGO) has developed a nutrition checklist that can standardize recommendations for GWG, facilitate discussions with pregnant persons, and aid providers with nutrition education. The checklist is an innovative tool that can help reduce complications associated with excessive GWG. This article discusses the benefits of FIGO Nutrition Checklist and its implementation at a midwifery clinic that primarily serves Native American women. By using this quick, simple, guided, time-efficient tool, clinics can be successful in facilitating important conversations and education about nutrition and GWG during pregnancy., (© 2024 by the American College of Nurse‐Midwives.)

Objective: This study aimed to evaluate the reported amount of the American College of Obstetricians and Gynecologists (ACOG) recommended nutrients in commercially available, over-the-counter prenatal vitamins (PNVs) in the United States, to assess their adequacy compared with the ACOG guidelines, and to compare these supplements by cost., Study Design: The top 30 online Amazon and Google shopping items found using "prenatal vitamins" in September 2022 were included for analysis if they included the words "prenatal" and "vitamin" in the label and contained multiple nutrients. Duplicates between Amazon and Google were excluded as well as vitamins that did not list all ingredients. The reported amounts of 11 key nutrients, as recommended by the ACOG, for each product were recorded, as well as supplemental form and cost per 30-day supply. A cost analysis was done of PNVs that met the ACOG recommendations for the highlighted nutrients compared with those that did not. Five out of the 11 key nutrients (folic acid, iron, docosahexaenoic acid, vitamin D, and calcium) were specifically highlighted, as deficiencies in these nutrients are known to correlate with significant clinical outcomes in pregnancy., Results: A total of 48 unique PNVs were included for final analysis. Of these PNVs, none were compliant with suggested amounts of all five key vitamins and nutrients. No products met daily recommendations for calcium. Only five PNVs were compliant with recommendations with 4/5 key nutrients. Of note, 27% of PNVs did not have the recommended amount of folic acid (13/48). The median cost of PNVs that were not compliant with the four nutrients mentioned above was $18.99 (interquartile range [IQR]: $10.00-30.29), which was not statistically different from the median cost of the PNVs that did meet compliance with the four nutrients, which was $18.16 (IQR: $9.13-26.99), p  = 0.55., Conclusion: There were significant variations in the level of nutrients and cost of commercially available, over-the-counter PNVs in the United States. This raises concern that there should be more regulation of PNVs., Key Points: · Commercially available over the counter PNVs vary in their content of the ACOG recommended nutrients and vitamins for pregnancy.. · None of these studied PNVs contain adequate amounts of all five key nutrients.. · Cost is not correlated with more compliance with the ACOG recommendations.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: In France, in 2007-2009, the risk of peripartum maternal mortality, especially the one due to hemorrhage, was higher in the private for-profit maternity units than in university maternity units. Our research, a component of the MATORG project, aimed to characterize the organization of care around childbirth in these private clinics to analyze how it might influence the quality and safety of care., Material and Methods: We conducted a qualitative survey in 2018 in the maternity units of two private for-profit clinics in the Paris region, interviewing 33 staff members (midwives, obstetricians, anesthesiologists, childcare assistants and managers) and observing in the delivery room for 20 days. The perspective of the sociology of organizations guided our data analysis., Findings/results: Our study distinguished three principal risk factors for the safety of care in maternity clinics. The division of labor among healthcare professionals threatens the maintenance of midwives' competencies and makes it difficult for these clinics to keep midwives on staff. The mode of remuneration of both midwives and obstetricians incentivizes overwork by both, inducing fatigue and decreasing vigilance. Finally the clinical decision-making of some obstetricians is not collegial and creates conflicts with midwives, who criticize the technicization of childbirth. Some demotivated midwives no longer consider themselves responsible for patients' safety., Conclusions: The organization of work in private maternity units can put the safety of care around childbirth at risk. The division of labor, staff scheduling/planning, and a lack of collegiality in decision-making increase the risk of deprofessionalizing midwives., Competing Interests: Declarations of competing interest None., (Copyright © 2024. Published by Elsevier Masson SAS.)

Objective: The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine endorse checklist use to improve obstetric care. However, there is limited research into development, implementation, and sustained use of perinatal emergency checklists to inform individual institutions. This study aimed to investigate the development and implementation of perinatal emergency checklists in diverse hospital settings in the United States., Study Design: A qualitative study was conducted individually with clinicians from three health care systems. The participants developed and implemented institution-tailored perinatal emergency checklists. Interview transcriptions were coded using the Consolidated Framework for Implementation Research., Results: The study sites included two health care systems and one individual hospital. Delivery volumes ranged from 3,500 to 48,000 deliveries a year. Interviews were conducted with all 10 participants approached. Checklists for 19 perinatal emergencies were developed at the three health care systems. Ten of the checklist topics were the same at all three institutions. Participants described the checklists as improving patient care during crises. The tools were viewed as opportunities to promote a shared mental model across clinical roles, to reduce redundancy and coordinate obstetric crisis management. Checklist were developed in small groups. Implementation was facilitated by those who developed the checklists. Participants agreed that simulation was essential for checklist refinement and effective use by response teams. Barriers to implementation included limited clinician availability. There was also an opportunity to strengthen integration of checklists workflow early in perinatal emergencies. Participants articulated that culture change took time, active practice, persistence, reinforcement, and process measurement., Conclusion: This study outlines processes to develop, implement, and sustain perinatal emergency checklists at three institutions. Participants agreed that multiple, parallel implementation tactics created the culture shift for integration. The overview and specific Consolidated Framework for Implementation Research components may be used to inform adaptation and sustainability for others considering implementing perinatal emergency checklists., Key Points: · Perinatal emergency checklists reduce redundancy and coordinate obstetric crisis management.. · Perinatal emergency simulation is essential for checklist refinement and effective team use.. · Integrations of perinatal emergency checklists requires culture change and process measurement.., Competing Interests: None declared., (Thieme. All rights reserved.)

Despite significant improvement in perinatal care and research, hypoxic ischemic encephalopathy (HIE) remains a global healthcare challenge. From both published research and reports of QI initiatives, we have identified a number of distinct opportunities that can serve as targets of quality improvement (QI) initiatives focused on reducing HIE. Specifically, (i) implementation of perinatal interventions to anticipate and timely manage high-risk deliveries; (ii) enhancement of team training and communication; (iii) optimization of early HIE diagnosis and management in referring centers and during transport; (iv) standardization of the approach when managing neonates with HIE during therapeutic hypothermia; (v) and establishment of protocols for family integration and follow-up, have been identified as important in successful QI initiatives. We also provide a framework and examples of tools that can be used to support QI work and discuss some of the perceived challenges and future opportunities for QI targeting HIE., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Aim: Development of an algorithm of management actions for the formation of a resilient system of quality of medical care in health care institutions of obstetric and gynecological profile and formalization of its closed structural and logical scheme., Patients and Methods: Materials and Methods: A set of theoretical approaches of social medicine and methods of business process reengineering is used, taking into account the dominant ones: systemic and integrated approach and alarm and process approaches; the concept of resilience; quality of medical care; reproductive health care using business ecosystem methods., Results: Results: The algorithm of management actions for the formation of a resilient system of quality of medical care in obstetric and gynecological health care institutions, which is formalized in nine stages: analysis of needs and identification of problems; substantiation of performance requirements; development of a health care quality strategy; involvement of stakeholders; formation of a system of relative indicators; development of an action plan; implementation of a set of measures; monitoring and evaluation; improving the quality of health care., Conclusion: Conclusions: The results made it possible: construction of a closed structural and logical scheme of management actions, taking into account the combination of factors of influence, harmonized with the main functions of the resilient system, which determine the peculiarities of its functioning; justification of the boundaries of managerial and social responsibility of management entities according to the binary components of the medical and social justification of the process of improving the quality of medical care.

Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general anesthesia than in the non-obstetric population. The inability to ventilate and oxygenate is one of the most common causes of morbidity and mortality associated with general anesthesia for cesarean section. The aim of this paper is to present and analyze modern guidelines and algorithms for the management of difficult airway in obstetrics as an important segment of anesthesiology practice. Modern difficult airway management guidelines for pregnant women describe the procedure of difficult facemask ventilation, difficult airway management by using supraglottic devices, difficult endotracheal intubation, and emergency cricothyrotomy or tracheotomy in a situation where oxygenation and ventilation are impossible. Algorithms describe the procedures and equipment for each variant of difficult airway and decision-making strategies in situations when neither airway nor adequate oxygenation can be provided. Croatian anesthesiologists in most obstetric departments have appropriate equipment, as well as necessary experience in difficult airway management for pregnant women, and modern algorithms from the most developed countries can be adopted and accommodated to our daily practice, as well as incorporated into the training curricula of residents., (Sestre Milosrdnice University Hospital.)

Objective: To identify procedures to reduce maternal morbidity during cesarean., Material and Methods: The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations., Results: Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds., Conclusion: In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Summary: Preterm birth affects 12.5% of all births in the USA. Infants of Black mothers are disproportionately affected, with 1.5 times the risk of preterm birth and 3.4 times the risk of preterm-related mortality. The preterm birth rate has increased by 33% in the last 25 years, almost entirely due to the rise in late preterm births (34–36 weeks’ gestation). Recently attention has been given to uncovering the often subtle morbidity and mortality risks associated with moderate (32–33 weeks’ gestation) and late preterm delivery, including respiratory, infectious, and neurocognitive complications and infant mortality. This section summarizes the epidemiology of moderate and late preterm birth, case definitions, risk factors, recent trends, and the emerging body of knowledge of morbidity and mortality associated with moderate and late preterm birth. [ABSTRACT FROM AUTHOR]

Objective: To assess the presentation of risk information in American College of Obstetricians and Gynecologists (ACOG) obstetrical Practice Bulletins., Methods: We reviewed B- and C-graded recommendations in Practice Bulletins published from January 2017 to March 2020. We calculated the proportion of recommendations and outcomes that were presented numerically and, of these, the proportion that were presented in accordance with best practices of risk communication - in absolute formats, or as absolute changes in risk from baseline risks. We categorized outcomes as harms or benefits to compare their risk presentation., Results: In 21 obstetrical Practice Bulletins, there were 125 recommendations, with 46 (37%) describing risks numerically. Sixteen of these 46 recommendations (35%) presented an absolute change in risk from a baseline risk. For harms, 65% were presented as absolute risks and 25% as relative risks. For benefits, this was 55% and 48% respectively., Conclusion: Most recommendations do not present numeric risk information. Of those that do, most do not use absolute risk measures., Practice Implications: Obstetrical practice guidelines should present numerical risk information wherever possible to support recommendations, increasing the use of absolute risk formats and absolute changes from baseline risks to increase risk comprehension., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: Mistreatment, discrimination, and poor psycho-social support during childbirth at health facilities are common in lower- and middle-income countries. Despite a policy directive from the World Health Organisation (WHO), no operational model exists that effectively demonstrates incorporation of these guidelines in routine facility-based maternity services. This early-phase implementation research aims to develop, implement, and test the feasibility of a service-delivery strategy to promote the culture of supportive and dignified maternity care (SDMC) at public health facilities., Methods: Guided by human-centred design approach, the implementation of this study will be divided into two phases: development of intervention, and implementing and testing feasibility. The service-delivery intervention will be co-created along with relevant stakeholders and informed by contextual evidence that is generated through formative research. It will include capacity-building of maternity teams, and the improvement of governance and accountability mechanisms within public health facilities. The technical content will be primarily based on WHO's intrapartum care guidelines and mental health Gap Action Programme (mhGAP) materials. A mixed-method, pre-post design will be used for feasibility assessment. The intervention will be implemented at six secondary-level healthcare facilities in two districts of southern Sindh, Pakistan. Data from multiple sources will be collected before, during and after the implementation of the intervention. We will assess the coverage of the intervention, challenges faced, and changes in maternity teams' understanding and attitude towards SDMC. Additionally, women's maternity experiences and psycho-social well-being-will inform the success of the intervention., Expected Outcomes: Evidence from this implementation research will enhance understanding of health systems challenges and opportunities around SDMC. A key output from this research will be the SDMC service-delivery package, comprising a comprehensive training package (on inclusive, supportive and dignified maternity care) and a field tested strategy to ensure implementation of recommended practices in routine, facility-based maternity care. Adaptation, Implementation and evaluation of SDMC package in diverse setting will be way forward. The study has been registered with clinicaltrials.gov (Registration number: NCT05146518)., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Intra-Uterine Device (IUD) insertion is possible in early postpartum. Although this contraception method is recognized and used in lots of country, it seems infrequent and poorly known in France. Our study aims to assess the barriers to the application of this method in France., Methods: A questionnaire was sent to obstetricians-gynaecologist professionals and midwives in France, through the affiliation to CNGOF (French National College of Obstetricians and Gynecologists) and to CNSF (French National College of Midwives). Questions were focused on the practices and knowledge about the insertion of IUD in early postpartum., Results: four hundred eight practitioners responded. Amongst them, 63% knew about the possibility to use IUDs after a vaginal delivery and 31% knew it could be inserted during cesarean section. Ten percent of them used this method. Most of these practitioners (80% of them) would like to discuss the insertion of an IUD in early postpartum with their patients and 71% would like to perform the insertion themselves after training. Besides, this study shows that contraception is rarely addressed by physicians during the follow-up of pregnancies. Less than 15% of respondents report discussing the topic systematically with the patient during the pregnancy follow during pregnancy follow., Conclusion: insertion of IUDs in early postpartum is uncommon in France. The main limitation seems to be a lack of knowledge, but practitioners seem to be interested in this practice. Training courses could be created in order to rase up the adoption of this practice., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Diabetes in pregnancy is associated with an increased risk to the woman and to the developing fetus. Currently, there is no consensus on the optimal management strategies for the follow-up and the timing of delivery of pregnancies affected by gestational and pregestational diabetes, with different international guidelines suggesting different management options., Materials and Methods: We conducted a retrospective cohort study from January 2017 to January 2021, to compare maternal and neonatal outcomes of pregnancies complicated by gestational and pregestational diabetes, followed-up and delivered in a third level referral center before and after the introduction of a standardized multidisciplinary management protocol including diagnostic, screening, and management criteria., Results: Of the 131 women included, 55 were managed before the introduction of the multidisciplinary management protocol and included in group 1 (preprotocol), while 76 were managed according to the newly introduced multidisciplinary protocol and included in group 2 (after protocol). We observed an increase in the rates of vaginal delivery, rising from 32.7% to 64.5% (<0.001), and the rate of successful induction of labor improved from 28.6% to 86.2% ( P < 0.001). No differences were found in neonatal outcomes, and the only significant difference was demonstrated for the rates of fetal macrosomia (20% versus 5.3%, P : 0.012). Therefore, the improvements observed in the maternal outcomes did not impact negatively on fetal and neonatal outcomes., Conclusion: The introduction of a standardized multidisciplinary management protocol led to an improvement in the rates of vaginal delivery and in the rate of successful induction of labor in our center. A strong cooperation between obstetricians, diabetologists, and neonatologists is crucial to obtain a successful outcome in women with diabetes in pregnancy., Competing Interests: All the authors declare no conflicts of interest., (Copyright © 2021 Maddalena Morlando et al.)

Objective: The Nuchal Translucency Quality Review (NTQR) program has provided standardized education, credentialing and epidemiological monitoring of nuchal translucency (NT) measurements since 2005. Our aim was to review the effect on NT measurement of provider characteristics since the program's inception., Methods: We evaluated the distribution of NT measurements performed between January 2005 and December 2019, for each of the three primary performance indicators of NT measurement (NT median multiples of the median (MoM), SD of log 10 NT MoM and slope of NT with respect to crown-rump length (CRL)) for all providers within the NTQR program with more than 30 paired NT/CRL results. Provider characteristics explored as potential sources of variability included: number of NT ultrasound examinations performed annually (annual scan volume of the provider), duration of participation in the NTQR program, initial credentialing by an alternative pathway, provider type (physician vs sonographer) and number of NT-credentialed providers within the practice (size of practice). Each of these provider characteristics was evaluated for its effect on NT median MoM and geometric mean of the NT median MoM weighted for the number of ultrasound scans, and multiple regression was performed across all variables to control for potential confounders., Results: Of 5 216 663 NT measurements from 9340 providers at 3319 sites, the majority (75%) of providers had an NT median MoM within the acceptable range of 0.9-1.1 and 85.5% had NT median MoM not statistically significantly outside this range. Provider characteristics associated with measurement within the expected range of performance included higher volume of NT scans performed annually, practice at a site with larger numbers of other NT-credentialed providers, longer duration of participation in the NTQR program and alternative initial credentialing pathway., Conclusions: Annual scan volume, duration of participation in the NTQR program, alternative initial credentialing pathway and number of other NT-credentialed providers within the practice are all associated with outcome metrics indicating quality of performance. It is critical that providers participate in ongoing quality assessment of NT measurement to maintain consistency and precision. Ongoing assessment programs with continuous feedback and education are necessary to maintain quality care. © 2021 International Society of Ultrasound in Obstetrics and Gynecology., (© 2021 International Society of Ultrasound in Obstetrics and Gynecology.)

Background: In maternity services, as in other areas of healthcare, increasing emphasis is placed on improving "efficiency" or "productivity". The first step in any efficiency and productivity analysis is the selection of relevant input and output measures. Within healthcare quantifying what is produced (outputs) can be difficult. The aim of this paper is to identify a potential output measure, that can be used in an assessment of the efficiency and productivity of labour and birth in-hospital care in Australia and to assess the extent to which it reflects the principles of woman-centred care., Methods: This paper will survey available perinatal and maternal datasets in Australia to identify potential output measures; map identified output variables against the principles of woman-centred care outlined in Australia's national maternity strategy; and based on this, create a preliminary composite outcome measure for use in assessing the efficiency and productivity of Australian maternity services., Results: There are significant gaps in Australia's maternity data collections with regard to measuring how well a maternity service is performing against the values of respect, choice and access; however safety is well measured. Our proposed composite measure identified that of the 63,215 births in Queensland in 2014, 67% met the criteria of quality outlined in our composite measure., Conclusions: Adoption in Australia of the collection of woman-reported maternity outcomes would substantially strengthen Australia's national maternity data collections and provide a more holistic view of pregnancy and childbirth in Australia beyond traditional measure of maternal and neonate morbidity and mortality. Such measures to capture respect, choice and access could complement existing safety measures to inform the assessment of productivity and efficiency in maternity care., (© 2021. The Author(s).)

Objective: The aim of this national study was to examine the incidence of preterm pre-eclampsia (PE) and the proportion of women with risk factors for PE, according to the criteria suggested by the National Institute for Health and Care Excellence (NICE) and the American College of Obstetricians and Gynecologists (ACOG), during a 10-year period in Denmark., Methods: Data from The Danish National Patient Registry and the Danish Medical Birth Registry were used to obtain the incidence of preterm PE with delivery < 37 weeks' gestation and risk factors for PE for all deliveries in Denmark from 1 January 2008 to 31 December 2017. The proportion of women with at least one high-risk factor and/or at least two moderate-risk factors for PE, according to the NICE and ACOG criteria, and the detection rate for preterm PE were examined. Race, socioeconomic status and the woman's weight at birth were not available from the registries used, and information on Type-2 diabetes was found to be invalid., Results: Of the 597 492 deliveries during the study period, any PE was registered in 3.2%, preterm PE < 37 weeks in 0.7% and early-onset PE < 34 weeks' gestation in 0.3%. These proportions remained largely unchanged from 2008 to 2017. Overall, the NICE criteria were fulfilled in 7.5% of deliveries and the ACOG criteria in 17.3%. In the total population, the NICE criteria identified 47.6% of those with preterm PE and the ACOG criteria identified 60.5%. The current criteria for offering aspirin treatment in Denmark largely correspond to having at least one NICE high-risk factor. In 2017, a total of 3.5% of deliveries had at least one NICE high-risk factor, which identified 28.4% of cases that later developed preterm PE., Conclusions: The incidence of preterm PE remained largely unchanged in Denmark from 2008 to 2017. Prediction of PE according to high-risk maternal factors could be improved by addition of moderate-risk factors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology., (© 2021 International Society of Ultrasound in Obstetrics and Gynecology.)

Evidence-based medicine tries to support clinicians through research, integrated with clinical skill and patient values. This pilot study aimed to assess appropriateness and level of evidence of current clinical practices, through evaluating availability and quality of guidelines.A prospective observational study in a large tertiary hospital network was performed, sampling diagnostic and therapeutic interventions in obstetrics and gynaecology. Interventions performed were justified against knowledge in the published literature, and guideline recommended practice. We collected 58 patient observations, 40(69%) in obstetrics, 18(31%) in gynaecology. There were local guidelines relevant in 52%, national in 22%, and international guidelines in 12%. In 50 interventions with available guidelines, 54% provided strong and clear recommendations for practice, and were supported by research-based knowledge. Similarly, 66% of encounters were thought to be in concordance with research-based knowledge.There was good concordance between interventions and guideline recommendations. However, half of guidelines reviewed had limited or no knowledge to justify their recommendations.IMPACT STATEMENT What is already known on this subject? Evidence based medicine should aim to improve patient outcomes. However, available trials assessing effectiveness of established practices suggest that they convey little to no benefit to patients. There remains a paucity of evidence for established practices in obstetrics and gynaecology What do the results of this study add? This pilot study assesses the usefulness of interventions in obstetrics and gynaecology and confirms the feasibility of collecting and coding our interventions and clinical practices with a traffic light system. What are the implications of these findings for clinical practice and/or further research? These findings demonstrate the feasibility of our traffic lights grading system within obstetrics and gynaecology. It demonstrates this method is useful to assess what knowledge base is guiding clinical practice, how well practice concords with guidelines and literature, as well as the presence and significance of any gaps in knowledge. These early findings will be used in an expanded study and have implications on the way healthcare effectiveness is evaluated, as well as reducing healthcare expenditure in obstetrics and gynaecology.