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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.)

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.)

The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.

Aim To determine whether the introduction of a clinical pathway for the treatment of pyelonephritis in obstetric patients would improve outcomes. Methods This was a retrospective study conducted in a maternity hospital using quantitative analysis methods. Patients who met laboratory and clinical criteria for pyelonephritis during data collection were included. Results The study included analysis of 23 patients pre-intervention and 19 post-intervention. Baseline and patient characteristics were similar for both groups. A statistically significant difference was seen in 3 of 7 outcome measures. Increased use of gentamicin (13% Vs 52% p=0.006), Increased number of renal ultrasounds (17% Vs 47%, p=0.04) and increased use of prophylaxis (21% Vs 68%, p=0.003). The proportion of patients receiving ≥ 10 days of IV antimicrobials decreased from 48% to 21% post-intervention (p=0.07). Discussion This study has shown that the introduction of a pathway for the treatment of pyelonephritis in pregnancy had a positive impact on several important clinical outcomes., Competing Interests: The authors report no conflicts of interest.

Critical care in pregnancy relies predominantly on recommendations from nonpregnant adult critical care with only limited research available for obstetric critical care specifically. The purpose of this document is to review available evidence, propose strategies for obstetric-related critical care, and highlight the need for additional research. Much of the review will, of necessity, focus on general principles of critical care, extrapolating when possible to critical care in pregnancy and the puerperium. This Practice Bulletin is updated to include information about unique issues to pregnancy when conditions such as sepsis or acute respiratory distress syndrome (ARDS) are encountered and the obstetrician's role in the management of the critically ill pregnant woman, which is dependent upon the care setting and the intensive care unit (ICU) model used. The role of the tele-intensive care unit in the care of critically ill pregnant women also is explored.

Critical care in pregnancy relies predominantly on recommendations from nonpregnant adult critical care with only limited research available for obstetric critical care specifically. The purpose of this document is to review available evidence, propose strategies for obstetric-related critical care, and highlight the need for additional research. Much of the review will, of necessity, focus on general principles of critical care, extrapolating when possible to critical care in pregnancy and the puerperium. This Practice Bulletin is updated to include information about unique issues to pregnancy when conditions such as sepsis or acute respiratory distress syndrome (ARDS) are encountered and the obstetrician's role in the management of the critically ill pregnant woman, which is dependent upon the care setting and the intensive care unit (ICU) model used. The role of the tele-intensive care unit in the care of critically ill pregnant women also is explored.

Acute cough is a common presenting symptom in the ambulatory care setting in the United States. It imposes a significant symptom burden on patients and financial burden on the health care system. In most cases, acute cough is caused by a benign viral infection that will resolve without intervention. When needed, there are few evidence-based interventions to hasten the resolution of cough symptoms. Patients may request antibiotics or prescription cough syrups; however, these medications have little evidence of benefit and can be potentially harmful to the patient. It can be challenging for the clinician to provide reassurance while minimizing unnecessary prescriptions. The health care provider also must be alert to signs and symptoms that could signal a high-risk diagnosis that requires urgent evaluation. This monograph provides a review of the differential diagnosis for acute cough, an algorithmic approach to the evaluation of cough, and evidence-based treatment recommendations. Also, it highlights warning signs and symptoms that should trigger an emergent referral and special clinical considerations in more vulnerable patient populations, including pregnant patients and geriatric patients.

Objectives: Management of rheumatic diseases (RD) is often problematic in pregnant patients, hence the need for guideline implementation. This survey-based study aimed to assess beliefs among obstetricians and rheumatologists about managing RD in pregnant Lebanese patients., Methods: Questionnaires were completed by a representative sample of rheumatologists and obstetricians practicing throughout Lebanon. Collected data included physicians' information, opinion on pregnancy in RD patients, compatible drugs with fertility, pregnancy and breastfeeding, references used in their clinical management, referral to specialists, and knowledge about guidelines. Qualitative variables were analysed using Chi-square or Fisher's exact tests, and quantitative variables using Wilcoxon or Student t-tests. Results were matched against a scoring system based on the EULAR/BSR guidelines. p-value <0.05 indicated statistical significance., Results: Analysis showed high response rates of physicians, especially among rheumatologists. Overall, physicians practice was in concordance with international guidelines and only few misconceptions were reported. Systemic lupus erythematosus (SLE) was associated with risk on fertility, foetal malformation and eclampsia while anti-phospholipid (APL) syndrome was associated with miscarriage and vasculitis with eclampsia. Spondyloarthritis was considered 'safe' in pregnancy. Most physicians think that cyclophosphamide, leflunomide, methotrexate, mycophenolate mofetil and azathioprine compromise fertility, pregnancy, and breastfeeding., Conclusions: Our data showed relatively good concordance of the physicians' beliefs with the current literature and recommendations. However, we identified misconceptions about anti-rheumatic drugs safety in pregnancy and discrepancy between rheumatologists and obstetricians practices; hence the need for promoting collaboration between both specialties and disseminating knowledge to physicians and patients in the Middle East region.

These are consensus statements on screening for hyperglycemia in pregnancy derived from AOFOG MFM Committee's Hyperglycemia in Pregnancy Consensus Working Group during a workshop in Singapore on 13 January 2018., (© 2018 Japan Society of Obstetrics and Gynecology.)

Background: Providers need to be comfortable addressing obesity and gestational weight gain so they may give appropriate care; however, health care providers lack guidelines for the most effective educational strategies to assist in providing optimal care., Objective: To identify studies that involved the obstetric provider in interventions for either the perinatal management of obesity and/or gestational weight gain in a systematic review., Search Strategy: A keyword search of databases was performed up to April 2017., Selection Criteria: Obstetric providers who participated in an intervention with the aim to change a provider's clinical practice, knowledge, and/or satisfaction with the intervention in relation to the perinatal management of obesity or gestational weight gain were included. Provider intervention could include training or education, changes in systems or organization of care, or resources to support practice. PROSPERO database #42016038921., Data Collection and Analysis: Bias was assessed according to the validated Mixed Methods Appraisal Tool. The following variables were synthesized: study location and setting, provider and patient characteristics, intervention features, outcomes and efficacy, and strengths and weakness., Main Results: Of the 6,821 abstracts screened, seven studies (4 quantitative, 3 mixed-methods) with a total of 335 providers met the inclusion criteria; two of which focused on the management of obesity, three focused on gestational weight gain, and two focused on both topics. Interventions that incorporated motivational interviewing skills (n = 2), required additional training for the research study and addressed specific knowledge deficits such as nutrition and exercise (n = 3), and interfaced with the electronic medical record (n = 1) demonstrated the greatest impact on provider outcomes. Provider reported satisfaction scores were generally favorable, but none addressed provider-level efficacy in practice change., Conclusions: Given the limited number of studies, varying range of provider participation, and lack of provider-level efficacy, further evaluation of provider training and involvement in interventions for perinatal obesity or gestational weight gain is indicated to determine best practices for provider and patient outcomes., Competing Interests: The authors have declared that no competing interests exist.

Background: The importance of contextual factors in influencing quality improvement and implementation (QI&I) initiatives is broadly acknowledged. Existing treatments of context have primarily viewed it as static and distinct from interventions themselves. The objective of this study was to advance understanding of the complex and dynamic interaction between context, intervention, and implementation strategies. Using the Model for Understanding Success in Quality (MUSIQ), we aimed to better understand the roles of, and inter-relationships between, contextual factors within QI&I initiatives., Methods: Secondary analysis was performed on qualitative data collected as part of two studies: (1) an evaluation of a state-wide obstetrical quality improvement (QI) initiative, and (2) a study of the use of Plan-Do-Study-Act cycle method in QI projects. Electronic coding databases from each study were reviewed jointly. Data analysis was initiated deductively using MUSIQ as a template. Codes were added in an inductive manner., Results: All original factors in MUSIQ were observed to be important in the QI initiatives studied and new factors were identified. Three distinct types of context were identified; the setting(s) of care in which QI&I takes place (Type 1); the context of the team conducting a specific project (Type 2); and the wider context supporting general QI&I (Type 3). The picture of context emerging from this study is a dynamic one with multiple, closely-linked factors operating at different levels in a system that is constantly changing in response to QI&I initiatives. To capture this complexity, a revised model (MUSIQ v2.0) was created positioning use of structured QI&I approaches as the focal point and demonstrating how context influenced effective use of these approaches, and in turn, how these approaches supported teams in navigating context by adapting interventions to fit local settings., Conclusions: MUSIQ is a useful tool to explore the roles of, and inter-relationships between, contextual factors within QI&I initiatives. The revised model may help address some existing controversies about how context influences QI&I success and help ensure that future research efforts consider context not as static background, but as a complex system that is constantly changing, tightly-linked, and governed by feedback loops.

In 2015, The American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine issued a joint care consensus document intended to develop standards for designations of levels of maternal care that are complimentary to, but distinct from, neonatal levels of care. Level III and Level IV centers must be prepared to provide obstetric intensive care services. Developing a critical care obstetric program is a resource-intensive process that requires a carefully planned strategic effort essential for successful program implementation and sustainability. In this article, a framework utilizing key components of program development is discussed including environment, scope, model, education and training, maternal transport, and unique aspects of care for women who become critically ill during pregnancy or the postpartum period.

Racial and ethnic disparities exist in both perinatal outcomes and health care quality. For example, black women are three to four times more likely to die from pregnancy-related causes and have more than a twofold greater risk of severe maternal morbidity than white women. In an effort to achieve health equity in maternal morbidity and mortality, a multidisciplinary workgroup of the National Partnership for Maternal Safety, within the Council on Patient Safety in Women's Health Care, developed a concept article for the bundle on reduction of peripartum disparities. We aimed to provide health care providers and health systems with insight into racial and ethnic disparities in maternal outcomes, the etiologies that are modifiable within a health care system, and resources that can be used to address these etiologies and achieve the desired end of safe and equitable health care for all childbearing women.

Objective: To more accurately estimate the 2012 maternal mortality ratio for Texas using an enhanced method for identifying maternal deaths., Methods: This population-based descriptive study used both data matching and record review to verify pregnancy or delivery within 42 days for 147 deaths with obstetric cause-of-death codes, and used data matching alone to identify additional maternal deaths within the same timeframe. Crude maternal mortality ratios were calculated for confirmed maternal deaths overall, by race and ethnicity, and by age. These maternal mortality ratios were compared with maternal mortality ratios computed using obstetric cause-of-death codes alone (standard method)., Results: Fifty-six maternal deaths were confirmed to have occurred during pregnancy or within 42 days postpartum. Using our enhanced method, the 2012 maternal mortality ratio for Texas was 14.6 maternal deaths per 100,000 live births, less than half that obtained using the standard method (n=147). Approximately half (50.3%) of obstetric-coded deaths showed no evidence of pregnancy within 42 days, and a large majority of these incorrectly indicated pregnancy at the time of death. Insufficient information was available to determine pregnancy for 15 obstetric-coded deaths, which were excluded from the 2012 maternal mortality ratio estimate; however, had these deaths been included, the resulting maternal mortality ratio would still be significantly lower than that reported using the standard method., Conclusion: Relying solely on obstetric codes for identifying maternal deaths appears to be insufficient and can lead to inaccurate maternal mortality ratios. A method enhanced with data matching and record review yields more accurate ratios. Results likely have national implications, because miscoding of obstetric deaths with the standard method may affect the accuracy of other states' maternal mortality ratios.

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.)

With an increasing prevalence of chronic medical conditions and the associated potential for decompensation to critical illness among modern day parturients, we present here the concept of the "virtual" intensive care unit. We challenge the traditional association of the word "unit" to extend beyond a fixed physical setting to portray an individualized, predetermined patient care team capable of managing these complex patients in a variety of settings. In this model, obstetric critical care is provided through a multidisciplinary patient care team, with emphasis on early identification of complicated pregnancies, detailed antepartum planning, anticipation of complications, and retrospective review of clinical outcomes aimed at continued quality improvement. This structured approach in the provision of care to the critically ill pregnant patient will serve as a foundation for future attempts at reduction in rates of maternal morbidity and mortality., (Copyright © 2018 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.)

Objective: To examine whether disparities in stillbirth, and neonatal and perinatal mortality rates, between public and private hospitals are the result of differences in population characteristics and/or clinical practices., Design: Retrospective cohort study., Setting: A metropolitan tertiary centre encompassing public and private hospitals. Women accessed care from either a private obstetrician or from public models of care - predominantly midwife-led care or care shared between midwives, general practitioners, and obstetricians., Population: A total of 131 436 births during 1998-2013: 69 037 public and 62 399 private., Methods: Propensity score matching was used to select equal-sized public and private cohorts with similar characteristics. Logistic regression analysis was then used to explore the impact of public-private differences in the use of assisted reproductive technologies, plurality, major congenital anomalies, birth method, and gestational age., Main Outcome Measures: Stillbirth, and neonatal and perinatal mortality rates., Results: After controlling for maternal and pregnancy factors, perinatal mortality rates were higher in the public than in the private cohort (adjusted odds ratio, aOR 1.53; 95% confidence interval, 95% CI 1.29-1.80; stillbirth aOR 1.56, 95% CI 1.26-1.94; neonatal death aOR 1.48, 95% CI 1.15-1.89). These disparities reduced by 15.7, 20.5, and 19.6%, respectively, after adjusting for major congenital anomalies, birth method, and gestational age., Conclusions: Perinatal mortality occurred more often among public than private births, and this disparity was not explained by population differences. Differences in clinical practices seem to be partly responsible. The impact of differences in clinical practices on maternal and neonatal morbidity was not examined. Further research is required., Tweetable Abstract: Private obstetrician-led care: more obstetric intervention and earlier births reduce perinatal mortality., Plain Language Summary: Background Babies born in Australian public hospitals tend to die more often than those born in private hospitals. Our aim was to determine whether this pattern is a result of public-private differences in care or merely linked with differences in the characteristics of the two groups. In Australian private hospitals, a private obstetrician almost always provides continuing care to each woman during pregnancy and birth. Public hospitals provide a number of care options, which usually involve midwives and/or a family doctor. Method The study population included 131 436 births (52.5% public; 47.5% private) from 1998-2013 at a single metropolitan centre with co-located public and private facilities. To isolate the effect of differences in care, we used a statistical technique called propensity score matching to select a public group and a private group with similar characteristics and equal size. This enabled us to compare 'apples with apples' when comparing public versus private perinatal death rates. Perinatal deaths include stillbirths and babies that die within 28 days of birth. Main findings After matching and after accounting for different patterns in the use of fertility treatments and multiple-birth pregnancies (such as twins), babies born in the public sector were approximately 1.5 times more likely to die than babies born in the private sector. This difference was reduced to 1.3 times more likely to die than babies born in the private sector after taking into account other factors that could skew the data, such as major congenital anomalies, birth method, and duration of pregnancy. Limitations This was a single-centre study, so the results may not apply to all settings. Despite our efforts to create highly similar public and private cohorts, some differences between the groups are likely to have remained and this may have affected the results. Implications Our findings suggest that private obstetrician-led care has a beneficial impact on perinatal deaths, despite, or possibly because of, higher obstetric intervention rates and earlier births in the private hospital. Further research is required., (© 2017 Royal College of Obstetricians and Gynaecologists.)

Cannabis sativa (marijuana) is the illicit drug most commonly used during pregnancy. The self-reported prevalence of marijuana use during pregnancy ranges from 2% to 5% in most studies. A growing number of states are legalizing marijuana for medicinal or recreational purposes, and its use by pregnant women could increase even further as a result. Because of concerns regarding impaired neurodevelopment, as well as maternal and fetal exposure to the adverse effects of smoking, women who are pregnant or contemplating pregnancy should be encouraged to discontinue marijuana use. Obstetrician-gynecologists should be discouraged from prescribing or suggesting the use of marijuana for medicinal purposes during preconception, pregnancy, and lactation. Pregnant women or women contemplating pregnancy should be encouraged to discontinue use of marijuana for medicinal purposes in favor of an alternative therapy for which there are better pregnancy-specific safety data. There are insufficient data to evaluate the effects of marijuana use on infants during lactation and breastfeeding, and in the absence of such data, marijuana use is discouraged.

Smoking is the one of the most important modifiable causes of poor pregnancy outcomes in the United States, and is associated with maternal, fetal, and infant morbidity and mortality. The physical and psychologic addiction to cigarettes is powerful; however, the compassionate intervention of the obstetrician-gynecologist can be the critical element in prenatal smoking cessation. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment or referral has been proved to increase quit rates. A short counseling session with pregnancy-specific educational materials and a referral to the smokers' quit line is an effective smoking cessation strategy. The 5A's is an office-based intervention developed to be used under the guidance of trained practitioners to help pregnant women quit smoking. Knowledge of the use of the 5A's, health care support systems, and pharmacotherapy add to the techniques providers can use to support perinatal smoking cessation. The use of alternative forms of nicotine, such as e-cigarettes and vaping, have increased substantially in recent years, but there are little data regarding the health effects of these agents, either in the general population or in pregnant women specifically.

Imaging studies are important adjuncts in the diagnostic evaluation of acute and chronic conditions. However, confusion about the safety of these modalities for pregnant and lactating women and their infants often results in unnecessary avoidance of useful diagnostic tests or the unnecessary interruption of breastfeeding. Ultrasonography and magnetic resonance imaging are not associated with risk and are the imaging techniques of choice for the pregnant patient, but they should be used prudently and only when use is expected to answer a relevant clinical question or otherwise provide medical benefit to the patient. With few exceptions, radiation exposure through radiography, computed tomography scan, or nuclear medicine imaging techniques is at a dose much lower than the exposure associated with fetal harm. If these techniques are necessary in addition to ultrasonography or magnetic resonance imaging or are more readily available for the diagnosis in question, they should not be withheld from a pregnant patient. Breastfeeding should not be interrupted after gadolinium administration.

Opioid use in pregnancy has escalated dramatically in recent years, paralleling the epidemic observed in the general population. To combat the opioid epidemic, all health care providers need to take an active role. Pregnancy provides an important opportunity to identify and treat women with substance use disorders. Substance use disorders affect women across all racial and ethnic groups and all socioeconomic groups, and affect women in rural, urban, and suburban populations. Therefore, it is essential that screening be universal. Screening for substance use should be a part of comprehensive obstetric care and should be done at the first prenatal visit in partnership with the pregnant woman. Patients who use opioids during pregnancy represent a diverse group, and it is important to recognize and differentiate between opioid use in the context of medical care, opioid misuse, and untreated opioid use disorder. Multidisciplinary long-term follow-up should include medical, developmental, and social support. Infants born to women who used opioids during pregnancy should be monitored for neonatal abstinence syndrome by a pediatric care provider. Early universal screening, brief intervention (such as engaging a patient in a short conversation, providing feedback and advice), and referral for treatment of pregnant women with opioid use and opioid use disorder improve maternal and infant outcomes. In general, a coordinated multidisciplinary approach without criminal sanctions has the best chance of helping infants and families.

Opioid use in pregnancy has escalated dramatically in recent years, paralleling the epidemic observed in the general population. To combat the opioid epidemic, all health care providers need to take an active role. Pregnancy provides an important opportunity to identify and treat women with substance use disorders. Substance use disorders affect women across all racial and ethnic groups and all socioeconomic groups, and affect women in rural, urban, and suburban populations. Therefore, it is essential that screening be universal. Screening for substance use should be a part of comprehensive obstetric care and should be done at the first prenatal visit in partnership with the pregnant woman. Patients who use opioids during pregnancy represent a diverse group, and it is important to recognize and differentiate between opioid use in the context of medical care, opioid misuse, and untreated opioid use disorder. Multidisciplinary long-term follow-up should include medical, developmental, and social support. Infants born to women who used opioids during pregnancy should be monitored for neonatal abstinence syndrome by a pediatric care provider. Early universal screening, brief intervention (such as engaging a patient in a short conversation, providing feedback and advice), and referral for treatment of pregnant women with opioid use and opioid use disorder improve maternal and infant outcomes. In general, a coordinated multidisciplinary approach without criminal sanctions has the best chance of helping infants and families.

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.)

In February 2015, given high rates of use of medications by pregnant women and the relative lack of data on safety and efficacy of many drugs utilized in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the Society for Maternal-Fetal Medicine (SMFM), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Pediatrics (AAP) convened a group of experts to review the "current" state of the clinical care and science regarding medication use during the perinatal period. The expert panel chose select medications to demonstrate what existing safety and efficacy data may be available for clinicians and patients when making decisions about use in pregnancy or lactation. Furthermore, these example medications also provided opportunities to highlight where data are lacking, thus forming a list of research gaps. Last, after reviewing the existing vaccine safety surveillance system as well as the legislative history surrounding the use of drugs for pediatric diseases, the expert panel made specific recommendations concerning policy efforts to stimulate more research and regulatory attention on drugs for pregnant and lactating women., Competing Interests: Conflict of Interest: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Despite our best intentions to improve health when a patient presents for care, adverse events are ubiquitous in medical practice today. Known complications related to the course of a patient's illness or condition or to the characteristics of the treatment have been an openly stated part of taking care of patients for centuries. However, it is only in the past decade that preventable adverse events, instances of harm related to error and deviations in accepted practice have become a primary part of these conversations. Human and system errors are an innate part of working in a complex environment like health care and we are now well aware of this burden in medicine. Now, we are building ways to react to adverse events from error in systematic ways. A systematic approach to identifying and classifying events is a critical part of any safety program, let alone an obstetric safety program. This article reviews the various systems that are used to identify adverse events, in particular sentinel events, state reportable events, and the significant local adverse "trigger" events in obstetrics. These events typically become identified through robust reporting systems where staff can report adverse, near-miss events, or precursor safety events. After events are reported, a system for classifying events, including a structured tracking and reporting system with built in accountability, is necessary. The concept of the "serious safety event," and how these differ from known complications or unpreventable events, and how this is classified are also reviewed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Regular physical activity during and after pregnancy has beneficial effects for mother and child. German recommendations for physical activity during pregnancy are still missing.We searched PubMed (MedLine) for guidelines published between January 2010 and September 2015 on physical activity during and after pregnancy.A systematic literature research identified 29 articles. Recommendations in the context of specific diseases (gestational diabetes, preeclampsia, obesity, hypertension, PCO, incontinence) or intervention programs were excluded. Only 2 articles met the criteria. 2 separate articles summarizing all international recommendations for physical activity during and after pregnancy were included.In order for mother and child to benefit from physical activity, pregnant women without contraindications should be encouraged to participate in regular physical activity or to remain active. Healthy pregnant and postpartum women should exercise for at least 150 min per week (analogically 20-30 min per day on most or all days of the week) in moderate to vigorous aerobic intensity., (© Georg Thieme Verlag KG Stuttgart · New York.)

The majority of women take at least one form of medication during pregnancy. Due to often discrepant information about the risk assessment of pharmaceuticals during pregnancy, physicians are often beset by uncertainty with respect to prescription and the fear of medicolegal consequences is high. As prospective clinical trials on drug safety during pregnancy are prohibited due to ethical reasons and animal studies are of limited applicability to humans, drug recommendations often only rely on observational data. An objective examination of the topic not only contributes to effective treatment of illnesses in pregnancy but also prevents impairment of fetal outcome by omission of necessary maternal treatment. The aim of this article is to give a structured presentation of medications that can be used during pregnancy for treating medical conditions of the ear, nose and throat, in the sense of practical guidelines.

Critical care in pregnancy is a field that remains unevenly researched. Although there is a body of evidence to guide many recommendations in critical care, limited research specifically addresses obstetric critical care. The purpose of this document is to review the available evidence, propose strategies for care, and highlight the need for additional research. Much of the review will, of necessity, focus on general principles of critical care, extrapolating where possible to obstetric critical care.

One of the most challenging scenarios in obstetric care occurs when a pregnant patient refuses recommended medical treatment that aims to support her well-being, her fetus's well-being, or both. In such circumstances, the obstetrician-gynecologist's ethical obligation to safeguard the pregnant woman's autonomy may conflict with the ethical desire to optimize the health of the fetus. Forced compliance-the alternative to respecting a patient's refusal of treatment-raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality. The purpose of this document is to provide obstetrician-gynecologists with an ethical approach to addressing a pregnant woman's decision to refuse recommended medical treatment that recognizes the centrality of the pregnant woman's decisional authority and the interconnection between the pregnant woman and the fetus.

One of the most challenging scenarios in obstetric care occurs when a pregnant patient refuses recommended medical treatment that aims to support her well-being, her fetus's well-being, or both. In such circumstances, the obstetrician-gynecologist's ethical obligation to safeguard the pregnant woman's autonomy may conflict with the ethical desire to optimize the health of the fetus. Forced compliance-the alternative to respecting a patient's refusal of treatment-raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality. The purpose of this document is to provide obstetrician-gynecologists with an ethical approach to addressing a pregnant woman's decision to refuse recommended medical treatment that recognizes the centrality of the pregnant woman's decisional authority and the interconnection between the pregnant woman and the fetus.

Natural fibres (bulk-forming agents), docusate sodium (stool-softener), mineral oils (lubricant laxatives), macrogol (polyethylene glycol, PEG), sugars and sugar alcohols (osmotic laxatives) and anthraquinones and diphenolic laxatives (stimulant laxatives) seem to be safe medicaments regarding teratogenicity and lactation. The US Food and Drug Administration (FDA) risk categories for these substances taken during pregnancy and lactation are often the result of the lack of studies than of evidence-based information. So risk categories do not help in the decision-making for the right laxative. Alternative solutions such as proposals of the American College of Gastroenterology's Committee on FDA related matters, (ACG-FDA) and the Motherisk Programme try to improve decision-making. For newer compounds such as chloride-channel-activators and procinetics no data regarding safe use in pregnancy and during breast-feeding are available as yet. We suggest the use of macrogol and lactulose as the first-line therapy in treating chronic constipation during pregnancy. Macrogol shows some advantages, such as faster onset of bowel action and fewer flatulences. If this treatment does not work or starts but then stops working, we recommend in the second and third trimenon a second-line treatment with diphenolic laxatives such as bisacodyl and and sodium picosulfate. During pregnancy the decision on the application of these laxatives is largely determined by the side-effects of tenesmus associated with preterm births. During lactation we recommend macrogol (preferable to lactulose due to the lack of data), lactulose, bisacodyl and sodium picosulfate, according to the nature of the conditions., (© Georg Thieme Verlag KG Stuttgart · New York.)

Critical care in pregnancy is a field that remains unevenly researched. Although there is a body of evidence to guide many recommendations in critical care, limited research specifically addresses obstetric critical care. The purpose of this document is to review the available evidence, propose strategies for care, and highlight the need for additional research. Much of the review will, of necessity, focus on general principles of critical care, extrapolating where possible to obstetric critical care.

Emerging research suggests that much pediatric affliction has origins in the vulnerable phase of fetal development. Prenatal factors including deficiency of various nutrients and exposure to assorted toxicants are major etiological determinants of myriad obstetrical complications, pediatric chronic diseases, and perhaps some genetic mutations. With recent recognition that modifiable environmental determinants, rather than genetic predestination, are the etiological source of most chronic illness, modification of environmental factors prior to conception offers the possibility of precluding various mental and physical health conditions. Environmental and lifestyle modification through informed patient choice is possible but evidence confirms that, with little to no training in clinical nutrition, toxicology, or environmental exposures, most clinicians are ill-equipped to counsel patients about this important area. With the totality of available scientific evidence that now exists on the potential to modify disease-causing gestational determinants, failure to take necessary precautionary action may render members of the medical community collectively and individually culpable for preventable illness in children. We advocate for environmental health education of maternity health professionals and the widespread adoption and implementation of preconception care. This will necessitate the translation of emerging knowledge from recent research literature, to health professionals, to reproductive-aged women, and to society at large.

The United States experienced a 6.1% annual increase in the maternal death rate from 2000 to 2013. Maternal deaths from hemorrhage and complications of preeclampsia are significant contributors to the maternal death rate. Many of these deaths are preventable. By virtue of their continuous care of laboring patients, active involvement in hospital safety initiatives, and immediate availability, obstetric hospitalists are uniquely positioned to evaluate patients, initiate care, and coordinate a multidisciplinary effort. In cases of significant maternal hemorrhage, hypertensive crisis, and acute pulmonary edema, the availability of an obstetrics hospitalist may facilitate improved patient safety and fewer maternal deaths., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Staffing models are critical aspects of care delivery. Provider staffing on the labor and delivery unit has recently received heightened attention. Based on the general medicine hospitalist model, the obstetrics and gynecology hospitalist or laborist model of obstetric care was introduced more than a decade ago as a plausible model-of-care delivery to improve provider satisfaction, with the goal of also improving safety and outcomes through continuous coverage by providers whose sole focus was on the labor and delivery unit without other competing clinical duties. It is plausible that this model of provider staffing and care delivery will increase safety., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The obstetrics/gynecology (OB/GYN) hospitalist is the latest subspecialist to evolve from obstetrics and gynecology. Starting in 2002, academic leaders recognized the impact of such coalescing forces as the pressure to reduce maternal morbidity and mortality, stagnant reimbursements and the increasing cost of private practice, the decrease in applications for OB/GYN residencies, and the demand among practicing OB/GYNs for work/life balance. Initially coined laborist, the concept of the OB/GYN hospitalist emerged. Thinking of becoming an OB/GYN hospitalist? Here is what you need to know., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Obstetric ultrasound has come to play a significant role in obstetrics since its introduction in clinical care. Today, most pregnant women in the developed world are exposed to obstetric ultrasound examinations, and there is no doubt that the advantages of obstetric ultrasound technique have led to improvements in pregnancy outcomes. However, at the same time, the increasing use has also raised many ethical challenges. This study aimed to explore obstetricians' experiences of the significance of obstetric ultrasound for clinical management of complicated pregnancy and their perceptions of expectant parents' experiences., Methods: A qualitative study was undertaken in November 2012 as part of the CROss-Country Ultrasound Study (CROCUS). Semi-structured individual interviews were held with 14 obstetricians working at two large hospitals in Victoria, Australia. Transcribed data underwent qualitative content analysis., Results: An overall theme emerged during the analyses, 'Obstetric ultrasound - a third eye', reflecting the significance and meaning of ultrasound in pregnancy, and the importance of the additional information that ultrasound offers clinicians managing the surveillance of a pregnant woman and her fetus. This theme was built on four categories: I:'Everyday-tool' for pregnancy surveillance, II: Significance for managing complicated pregnancy, III: Differing perspectives on obstetric ultrasound, and IV: Counselling as a balancing act. In summary, the obstetricians viewed obstetric ultrasound as an invaluable tool in their everyday practice. More importantly however, the findings emphasise some of the clinical dilemmas that occur due to its use: the obstetricians' and expectant parents' differing perspectives and expectations of obstetric ultrasound examinations, the challenges of uncertain ultrasound findings, and how this information was conveyed and balanced by obstetricians in counselling expectant parents., Conclusions: This study highlights a range of previously rarely acknowledged clinical dilemmas that obstetricians face in relation to the use of obstetric ultrasound. Despite being a tool of considerable significance in the surveillance of pregnancy, there are limitations and uncertainties that arise with its use that make counselling expectant parents challenging. Research is needed which further investigates the effects and experiences of the continuing worldwide rapid technical advances in surveillance of pregnancies.

Introduction: In Germany we find about 2 000 newborns per year with a mother misusing drugs. It is to be feared that there is a substantial amount of underreported substance abuse in pregnant women. To care for these pregnancies from an obstetric point of view as well as from an addiction treatment point of view is a challenge for all health-care professionals, due to multiple drugs being used and the special psychosocial and health issues these mothers and babies -present., Method: A selective search was undertaken in Pubmed, retrieving reviews and original articles from 2001-2013, with consideration of statements, recommendations and guidelines from national and international associations and committees on the topic. This review is intended to assist gynaecologists, obstetricians and paediatricians during the complex peripartum care for the drug abusing pregnant patient., Results: When offering obstetric care for these pregnancies, several issues have to be taken into account: the special psychological situation of the pregnant drug user, with frequent occurrence of psychiatric comorbidities like depression and anxiety disorders, as well as gynaecological complications like premature labour, intrauterine growth restriction and maternal infectious diseases. The pharmacological complexity of the substances abused and the possible side-effects on the foetus have to be explained to the mother. Maintenance medication for foetomaternal risk reduction and maternal stabilisation remains the state-of-the-art treatment. Furthermore, it is important to explain the neonatal abstinence syndrome to the mother as well as the result of breast-feeding in the presence of smoking and/or infectious diseases., Discussion: Professionalism and empathy are needed from gynaecologists in order to achieve risk reduction for mother and child in substance-using pregnancies. However, in spite of close cooperation of all health-care professionals and avoidance of stigma, it will be difficult to offer good obstetric care to the high-risk patients with poly-drug abuse., (© Georg Thieme Verlag KG Stuttgart · New York.)