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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: 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: 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.)

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.)

Third trimester ultrasound has long been in obstetrics a topic of debate. This issue is framed in a historical debate on the effectiveness of routine obstetrical ultrasound and two opposing trends originated in America and Europe, respectively. Primary function of this ultrasound has been to detect fetal growth restriction, but no study has shown evidence of improving perinatal outcomes. Other secondary functions are detection of fetal abnormalities or evaluation of fetal presentation, and they have also shown no evidence. Despite the continuous appearance of works in this regard, health policies of both american and european trends have not been modified. Future seems to show a prolongation of the stalemate. Those health systems with a universal third trimester policy should propose an optimization of the test, in order to improve the benefits and obtain data for future studies that could resolve this longstanding debate., Competing Interests: Declaration of competing interest The authors report no conflict of interest., (Copyright © 2021. Published by Elsevier B.V.)

Individuals require access to safe, legal abortion. Abortion, although legal, is increasingly out of reach because of numerous restrictions imposed by the government that target patients seeking abortion and their health care practitioners. Insurance coverage restrictions, which take many forms, constitute a substantial barrier to abortion access and increase reproductive health inequities. Adolescents, people of color, those living in rural areas, those with low incomes, and incarcerated people can face disproportionate effects of restrictions on abortion access. Stigma and fear of violence may be less tangible than legislative and financial restrictions, but are powerful barriers to abortion provision nonetheless. The American College of Obstetricians and Gynecologists, along with other medical organizations, opposes such interference with the patient-clinician relationship, affirming the importance of this relationship in the provision of high-quality medical care. This revision includes updates based on new restrictions and litigation related to abortion.

Individuals require access to safe, legal abortion. Abortion, although legal, is increasingly out of reach because of numerous restrictions imposed by the government that target patients seeking abortion and their health care practitioners. Insurance coverage restrictions, which take many forms, constitute a substantial barrier to abortion access and increase reproductive health inequities. Adolescents, people of color, those living in rural areas, those with low incomes, and incarcerated people can face disproportionate effects of restrictions on abortion access. Stigma and fear of violence may be less tangible than legislative and financial restrictions, but are powerful barriers to abortion provision nonetheless. The American College of Obstetricians and Gynecologists, along with other medical organizations, opposes such interference with the patient-clinician relationship, affirming the importance of this relationship in the provision of high-quality medical care. This revision includes updates based on new restrictions and litigation related to abortion.

Purpose: The purpose of this article is to illustrate and discuss the impact the 2019 novel Coronavirus (COVID-19) pandemic on the delivery of obstetric care, including a discussion on the preexisting barriers, prenatal framework and need for transition to telehealth., Description: The COVID-19 was first detected in China in December of 2019 and by March 2020 spread to the United States. As this virus has been associated with severe illness, it poses a threat to vulnerable populations-including pregnant women. The obstetric population already faces multiple barriers to receiving quality healthcare due to personal, environmental and economic barriers, now challenged with the additional risks of COVID-19 exposure and limited care in times much defined by social distancing., Assessment: The current prenatal care framework requires patients to attend multiple in-office prenatal visits that can exponentially multiply depending on maternal and fetal comorbidities. To decrease the rate of transmission of the COVID-19 and limit exposure to patients, providers in Hillsborough County, Florida (and nationwide) are rapidly transitioning to telehealth. The use of a virtual care model allows providers to reduce in-person visits and incorporate virtual visits into the schedule of prenatal care., Conclusion: Due to the COVID-19 pandemic, implementation of telehealth and telehealth have become crucial to ensure the safe and effective delivery of obstetric care. This implementation is one that will continue to require attention to planning, procedures and processes, and thoughtful evaluation to ensure the sustainability of telehealth and telehealth post COVID-19 pandemic.

In the United States, there is a widespread belief that the overall cesarean birth rate is higher than necessary. Efforts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean birth, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.

Despite a national plan to eliminate syphilis by 2005, recent trends have reversed previously achieved progress in the United States. After a nadir between 2000 and 2013, rates of primary and secondary syphilis among women and congenital syphilis rose by 172% and 185% between 2014 and 2018, respectively. Screening early in pregnancy, repeat screening in the third trimester and at delivery among women at high risk, adherence to recommended treatment regimens, and prompt reporting of newly diagnosed syphilis cases to local public health authorities are strategies that obstetrician-gynecologists can employ to fight the current epidemic. In this report, clinical manifestations and management of syphilis in pregnancy are reviewed, and both traditional and reverse sequence screening algorithms are reviewed in detail in the context of clinical obstetrics.

In the United States, there is a widespread belief that the overall cesarean birth rate is higher than necessary. Efforts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean birth, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.

Background: Recent increases in maternal mortality and severe maternal morbidity highlight the need to improve systems for safe maternity care. We sought to identify whether publicly available state perinatal guidelines incorporate levels of maternal care (LoMC) criteria. Materials and Methods: We searched websites for 50 U.S. states and Washington, D.C. for LoMC guidelines. The Health Resources and Services Administration's Title V Program directors confirmed/updated search results through January 2018. Data abstracted included: (1) definitions of levels; (2) provider types; (3) facility capabilities and services; and (4) programmatic responsibilities as promoted in the 2015 Society for Maternal/Fetal Medicine and American College of Obstetricians and Gynecologists consensus document on LoMC. Results: LoMC guidelines were identified for 17 states; 12 defined four levels and five defined three levels of care. In Level I, 14/17 states specified obstetric provider availability for every birth and five specified an available surgeon to perform emergency cesareans. Fourteen states specified the availability of blood bank and laboratory services at all times. In the highest level (III or IV), 16/17 state guidelines specified a maternal/fetal medicine specialist; all but two specified anesthesia providers or services. Ten states referenced availability of an onsite intensive care unit in their highest level. All 17 state guidelines specified maternal transport and referral systems. Conclusions: Only one-third of states have publicly available perinatal guidelines incorporating LoMC criteria. Definitions, criteria, and nomenclature varied. Lack of LoMC guidelines with standardized criteria limits monitoring and evaluation of regionalized systems of maternal care.

Background: As Medicaid has increasingly financed managed care plans since the 1990s, it is important to understand the corresponding impacts on the well-being of disadvantaged mothers and infants. This study examines how a Medicaid managed care (MMC) program in Pennsylvania (PA) impacts disadvantaged women's obstetrical care utilization and access as well as their birth outcomes. Materials and Methods: This study uses a dataset of PA disadvantaged women who had multiple singleton births in 1994-2004. As to the empirical approach, we apply a linear multiple regression model to implement a pre-post design with control groups. The model also controls for unmeasured maternal birth-invariant characteristics, which affect take-up of Medicaid coverage and managed care plans. Results: The sample for the main analysis consists of 78,346 sibling births. We find the program roll-out reduces usage of some high-tech obstetrical services and limits access to high-quality hospital services, thereby contributing to cost savings. However, implementation of the program is also associated with deterioration in birth outcomes, worse prenatal care, and an elevated risk of inappropriate gestational weight gain. Conclusions: Cost containment through transition to MMC can be fulfilled at the price of maternal health care utilization and infant welfare. Therefore, caution is needed in design and delivery of managed care to low-income women.

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

Residency programs across the United States are searching for ways to improve surgical skills and operative experiences in obstetrics and gynecology residencies. We developed an obstetrics and gynecology residency program that offers a flexible curriculum, referred to as tracking, to address these needs. Curriculum content was developed using a modified Delphi method, using input from experts in medical education and obstetrics and gynecology. Outcome data were collected on trainees who graduated between 2016 and 2019, including postgraduate fellowship placement and our residents' achievement of surgical minimum requirements based on procedure logs. Trainees from this program have consistently exceeded minimal surgical requirements in all areas, regardless of tracking preference. Since the beginning of the program in 2012, more than 60% of graduates have matriculated into fellowships. Flexible curricula, such as tracking, offer one approach to a changing climate of medicine. The ability to offer flexible, focused, and individualized training is an approach with great potential to produce graduates who excel in all areas of obstetrics and gynecology while sharpening skills specific to their areas of interest.

Zika virus is a flavivirus with the potential to cause serious adverse pregnancy and infant outcomes. Although rates of Zika virus infection have decreased in the United States, obstetrician-gynecologists and other health care providers should continue to assess their patients for potential exposure based on travel or sexual history and test symptomatic patients with possible exposure and pregnant women with ongoing exposure regardless of symptoms in accordance with the Centers for Disease Control and Prevention recommendations. Pregnant women and those planning a pregnancy should talk to their health care providers about potential risks before traveling to an area where current or past Zika virus transmission has occurred. Testing recommendations for pregnant women with possible Zika virus exposure differ based on the presence or absence of symptoms of Zika virus infection and the circumstances of possible exposure. If obstetrician-gynecologists or other health care providers identify a patient who has possibly been exposed to the Zika virus and may require testing, they should contact their local or state health department for assistance. Consultation with a maternal-fetal medicine specialist or an infectious disease specialist with expertise in the management of infectious diseases in pregnancy may be useful for pregnant women with possible maternal Zika virus infection or concerning fetal findings. Zika virus identification and follow-up care of infants born to women with possible exposure to Zika virus during pregnancy are critical and can ensure that appropriate intervention services are available to affected infants. Obstetrician-gynecologists and other obstetric care providers should have a system to ensure relevant information regarding a woman's Zika infection status is communicated to pediatric care providers.

Zika virus is a flavivirus with the potential to cause serious adverse pregnancy and infant outcomes. Although rates of Zika virus infection have decreased in the United States, obstetrician-gynecologists and other health care providers should continue to assess their patients for potential exposure based on travel or sexual history and test symptomatic patients with possible exposure and pregnant women with ongoing exposure regardless of symptoms in accordance with the Centers for Disease Control and Prevention recommendations. Pregnant women and those planning a pregnancy should talk to their health care providers about potential risks before traveling to an area where current or past Zika virus transmission has occurred. Testing recommendations for pregnant women with possible Zika virus exposure differ based on the presence or absence of symptoms of Zika virus infection and the circumstances of possible exposure. If obstetrician-gynecologists or other health care providers identify a patient who has possibly been exposed to the Zika virus and may require testing, they should contact their local or state health department for assistance. Consultation with a maternal-fetal medicine specialist or an infectious disease specialist with expertise in the management of infectious diseases in pregnancy may be useful for pregnant women with possible maternal Zika virus infection or concerning fetal findings. Zika virus identification and follow-up care of infants born to women with possible exposure to Zika virus during pregnancy are critical and can ensure that appropriate intervention services are available to affected infants. Obstetrician-gynecologists and other obstetric care providers should have a system to ensure relevant information regarding a woman's Zika infection status is communicated to pediatric care providers.

Racial/ethnic disparities persist in obstetrical outcomes. In this paper, we ask how research in obstetrical quality can go beyond a purely quantitative approach to tackle the challenge of health inequity in quality and safety. This overview debriefs the use of positive deviance and mixed methods in others areas of medicine, describes the shortcomings of quantitative methods in obstetrics and presents qualitative studies carried out in obstetrics as well as the insights provided by this method. The article concludes by proposing positive deviance as a mixed methods approach to generate new knowledge for addressing racial and ethnic disparities in maternal outcomes.

Human trafficking, or modern-day slavery, is a global problem with broad reach that is often underrecognized in the United States. Victims of trafficking have been found in a wide range of legal and illegal business settings, and this frequently hidden population is most often exploited in the commercial sex industry, agriculture, factories, hotels, restaurants, as domestic workers, and by marriage brokers and some adoption firms. Human trafficking disproportionately affects underserved women and children, with more than 70% of trafficking cases involving women and girls and more than 90% of victims trafficked into the sex industry. Obstetrician-gynecologists and other women's health care providers are well-situated to identify and assist victims of human trafficking. Many trafficked individuals present to outpatient obstetrics and gynecology clinics, community health centers, family planning clinics, urgent care centers, and adolescent medicine clinics, and one half of all female victims of sex trafficking have visited the emergency department while involved in sex trafficking. Obstetrician-gynecologists and other women's health care providers should be aware of human trafficking, recognize signs of human trafficking, and be prepared to assist patients who are victims or who have been victims of human trafficking. This Committee Opinion has been updated to include screening questions and indicators to identify victims of human trafficking, additional information regarding reporting obligations for suspected human trafficking, and additional resources for survivors of human trafficking.

Human trafficking, or modern-day slavery, is a global problem with broad reach that is often underrecognized in the United States. Victims of trafficking have been found in a wide range of legal and illegal business settings, and this frequently hidden population is most often exploited in the commercial sex industry, agriculture, factories, hotels, restaurants, as domestic workers, and by marriage brokers and some adoption firms. Human trafficking disproportionately affects underserved women and children, with more than 70% of trafficking cases involving women and girls and more than 90% of victims trafficked into the sex industry. Obstetrician-gynecologists and other women's health care providers are well-situated to identify and assist victims of human trafficking. Many trafficked individuals present to outpatient obstetrics and gynecology clinics, community health centers, family planning clinics, urgent care centers, and adolescent medicine clinics, and one half of all female victims of sex trafficking have visited the emergency department while involved in sex trafficking. Obstetrician-gynecologists and other women's health care providers should be aware of human trafficking, recognize signs of human trafficking, and be prepared to assist patients who are victims or who have been victims of human trafficking. This Committee Opinion has been updated to include screening questions and indicators to identify victims of human trafficking, additional information regarding reporting obligations for suspected human trafficking, and additional resources for survivors of human trafficking.

Importance: Physical activity during pregnancy can offer many maternal and fetal health benefits., Objective: The aim was to summarize American, Canadian, and international recommendations published recently on physical activity during pregnancy to aid health care providers in their delivery of advice on the topic., Evidence Acquisition: A descriptive review of 3 national guidelines and 1 international guideline on physical activity during pregnancy was conducted. The guidelines included the 2019 Canadian recommendations, the 2018 United States' Physical Activity Guidelines for Americans (second edition), the 2015 (reaffirmed in 2017) American College of Obstetrics and Gynecology guideline, and the 2016-2018 International Olympic Committee recommendations for recreational and elite athletes., Results: For apparently healthy women, under the guidance of their health care provider, moderate-intensity physical activity using both aerobic and muscle conditioning activities is recommended. The guidelines recommended at least 150 min/wk spread throughout the week (Canada, United States) or at least 20 to 30 min/d (American College of Obstetrics and Gynecology)., Conclusions and Relevance: This summary of 4 recent guidelines can facilitate use of updated recommendations by health care providers regarding physical activity during pregnancy. More detailed evidence-based guidelines on physical activity during postpartum are needed.

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

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

Background The purpose of this initial investigation was to begin to understand the routine twin anemia-polycythemia sequence (TAPS) monitoring practices of maternal-fetal medicine specialists (MFM specialists) in the United States in the absence of a formal guideline. Methods This study used an anonymous, online survey of 90 MFM specialists who were practicing in the United States. A $5 gift card to an online store was used to incentivize participants. Descriptive statistics were calculated. Results All MFM specialists reported at least some familiarity (100.00%) with TAPS. Most participants (92.94%) were familiar with methods for monitoring patients for TAPS and nearly all (97.50%) responded that they use 'Doppler MCA-PSV' to make a prenatal TAPS diagnosis. Nearly two-thirds of MFM specialists surveyed (65.06%) reported performing regular TAPS monitoring for patients with monochorionic-diamniotic (MCDA) pregnancies. Conclusion Despite no formal guidelines, the majority of American MFM specialists surveyed are using routine TAPS screening in their management of MCDA twin pregnancies, suggesting that the MFM specialists included in this study consider it a valuable diagnostic tool. Future research should further explore this possible trend toward routine TAPS monitoring amongst MFM specialists in the United States, as well as the potential value of routine TAPS monitoring in MCDA pregnancy.

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.

Newborn screening is the largest genetic screening program in the United States, with approximately 4 million infants screened annually. Newborn screening is a mandatory state-based public health program that provides all newborns in the United States with testing and necessary follow-up health care for a variety of medical conditions. The goal of this public health program is to decrease morbidity and mortality by screening for disorders in which early intervention will improve neonatal and long-term health outcomes. The program's functions include the initial screening of all newborns, identifying screen-positive newborns, diagnosing conditions, communicating with families, ensuring that affected children are referred to treatment centers, following up with long-term outcomes, and educating physicians and the public according to individual state or jurisdictional guidelines. All states and the District of Columbia have newborn screening programs with varying screening panels, policies, statutes, and regulations. Most programs have adopted the guidelines suggested by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children. Obstetrician-gynecologists and other obstetric care providers should make resources about newborn screening available to patients during pregnancy. Providing newborn screening information during prenatal care visits can be accomplished in several ways and should be adapted to individual practice style. Integrating education about newborn screening into prenatal care allows parents to be prepared for having their child undergo screening as well as for receiving newborn screening test results. This document includes updated information on the Recommended Uniform Screening Panel (RUSP) and recommendations for incorporating newborn screening into obstetric practice.

Newborn screening is the largest genetic screening program in the United States, with approximately 4 million infants screened annually. Newborn screening is a mandatory state-based public health program that provides all newborns in the United States with testing and necessary follow-up health care for a variety of medical conditions. The goal of this public health program is to decrease morbidity and mortality by screening for disorders in which early intervention will improve neonatal and long-term health outcomes. The program's functions include the initial screening of all newborns, identifying screen-positive newborns, diagnosing conditions, communicating with families, ensuring that affected children are referred to treatment centers, following up with long-term outcomes, and educating physicians and the public according to individual state or jurisdictional guidelines. All states and the District of Columbia have newborn screening programs with varying screening panels, policies, statutes, and regulations. Most programs have adopted the guidelines suggested by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children. Obstetrician-gynecologists and other obstetric care providers should make resources about newborn screening available to patients during pregnancy. Providing newborn screening information during prenatal care visits can be accomplished in several ways and should be adapted to individual practice style. Integrating education about newborn screening into prenatal care allows parents to be prepared for having their child undergo screening as well as for receiving newborn screening test results. This document includes updated information on the Recommended Uniform Screening Panel (RUSP) and recommendations for incorporating newborn screening into obstetric practice.

Maternal heart disease has emerged as a major threat to safe motherhood and women's long-term cardiovascular health. In the United States, disease and dysfunction of the heart and vascular system as "cardiovascular disease" is now the leading cause of death in pregnant women and women in the postpartum period () accounting for 4.23 deaths per 100,000 live births, a rate almost twice that of the United Kingdom (). The most recent data indicate that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths (). Of further concern are the disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.

Maternal heart disease has emerged as a major threat to safe motherhood and women's long-term cardiovascular health. In the United States, disease and dysfunction of the heart and vascular system as "cardiovascular disease" is now the leading cause of death in pregnant women and women in the postpartum period () accounting for 4.23 deaths per 100,000 live births, a rate almost twice that of the United Kingdom (). The most recent data indicate that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths (). Of further concern are the disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.

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.

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

Information from vital records is critical to identify and quantify health-related issues and to measure progress toward quality improvement and public health goals. In particular, maternal and infant mortality serve as important indicators of the nation's health, thereby influencing policy development, funding of programs and research, and measures of health care quality. Accurate and timely documentation of births and deaths is essential to high-quality vital statistics. This Committee Opinion describes the process by which births, maternal deaths, and fetal deaths are registered; the challenges faced with a decentralized reporting system; and the important role for obstetrician-gynecologists in improving the accuracy, reliability, and timeliness of vital records.

Unsustainable health care costs combined with suboptimal patient outcomes have led health policy experts and payers to consider value-based payment or alternative payment models. Replacing fee-for-service reimbursement, these models link payment to value by rewarding efforts to enhance the quality of care at similar or reduced costs. Although many of the models employed to date have focused on primary care, management of chronic disease in the Medicare population, and episodes of care for common procedures, models for primary and specialty care of women are in the early stages of development. As specialists in women's health, obstetrician-gynecologists need to be actively engaged in this fundamental shift in the payment and delivery system.

The American College of Obstetricians and Gynecologists reaffirms its support of unrestricted access to legal marriage for all adults. The American College of Obstetricians and Gynecologists believes that no matter how a child comes into a family, all children and parents deserve equitable protections and access to available resources to maximize the health of that family unit. Obstetrician-gynecologists should recognize the diversity in parenting desires that exists in the lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming communities and should take steps to ensure that clinical spaces are affirming and open to all patients, such that equitable and comprehensive, reproductive health care can meet the needs of these communities. This Committee Opinion is updated to include and capture a broader diversity of the lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming communities, and their desires surrounding family formation, including legal recognition and benefits, and additional support of the positive effect marriage equality has on physical, mental, and financial health.

Competing Interests: The American Heart Association and the American College of Obstetricians and Gynecologists make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

The American Medical Association reported in 2015 that physicians 65 years and older currently represent 23% of the physicians in the United States. Unlike other professions such as commercial airline pilots, who by law must have regular health screenings starting at 40 years and must retire at 65 years, few health care institutions or systems have any policies regarding the late-career physician. Although there is an increase in accumulated wisdom and verbal knowledge with age, there is also an overall decline in recall memory, cognitive processing efficiency, and executive reasoning. The goal of physicians and health care institutions is to provide safe and competent care to their patients. Therefore, when considering the performance of a physician, the quality of care provided and safety of the patient are of the utmost importance. It is important to establish systems-based competency assessments to monitor and address physicians' health and the effect age has on performance and outcomes. Retention strategies can support areas of cognitive or technical decline while capitalizing on the aging doctor's strengths, and workplace adaptations should be adopted to help obstetrician-gynecologists transition and age well in their practice and throughout their careers.

The American Medical Association reported in 2015 that physicians 65 years and older currently represent 23% of the physicians in the United States. Unlike other professions such as commercial airline pilots, who by law must have regular health screenings starting at 40 years and must retire at 65 years, few health care institutions or systems have any policies regarding the late-career physician. Although there is an increase in accumulated wisdom and verbal knowledge with age, there is also an overall decline in recall memory, cognitive processing efficiency, and executive reasoning. The goal of physicians and health care institutions is to provide safe and competent care to their patients. Therefore, when considering the performance of a physician, the quality of care provided and safety of the patient are of the utmost importance. It is important to establish systems-based competency assessments to monitor and address physicians' health and the effect age has on performance and outcomes. Retention strategies can support areas of cognitive or technical decline while capitalizing on the aging doctor's strengths, and workplace adaptations should be adopted to help obstetrician-gynecologists transition and age well in their practice and throughout their careers.

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: The Royal College of Obstetricians and Gynaecologists (RCOG) defines fetal growth restriction as ultrasound-estimated fetal weight less than the 10th percentile or abdominal circumference less than the 10th percentile; the American College of Obstetricians and Gynecologists (ACOG) defines fetal growth restriction as estimated fetal weight less than the 10th percentile alone. We compared each method's ability to predict small for gestational age (SGA) at birth., Methods: For this retrospective study of diagnostic accuracy, we reviewed deliveries at the University of New Mexico Hospital from January 1, 2013, to March 31, 2017. We included mothers with singleton, well-dated pregnancies and nonanomalous fetuses undergoing indicated fetal growth restriction surveillance with an ultrasound-estimated fetal weight within 30 days of delivery. Estimated fetal weights and percentiles were calculated using the Hadlock intrauterine growth curve. Small for gestational age was defined as birth weight less than the 10th percentile based on a recent, sex-specific curve. We calculated the area under the curve, sensitivity, specificity, and positive and negative likelihood ratios for various approaches using abdominal circumference and estimated fetal weight to diagnose fetal growth restriction, including the definitions endorsed by ACOG and RCOG., Results: We included 1,704 pregnancies with a mean ultrasonography-to-delivery interval of 14.0 days (±8.6). There were 235 SGA neonates (13.8%). The rate of fetal growth restriction was 13.6% when using ACOG's criteria and 16.9% according to RCOG's criteria (P=.007). The area under the curve of RCOG's diagnostic approach was 0.78 (95% CI 0.76-0.80), which was higher than ACOG's (0.76, 95% CI 0.74-0.78, P=.01). Sensitivities and specificities of the various methods were similar. Adopting estimated fetal weight or abdominal circumference less than the 10th percentile instead of estimated fetal weight alone to predict SGA at birth would correctly identify one additional case of SGA for each 14 patients assessed., Conclusion: The diagnostic approach endorsed by RCOG is a marginally better predictor of SGA at birth compared with the method endorsed by ACOG. Future research should consider the potential benefits and harms of the different methods in different populations.

Objective The purpose of this study was to examine the content of the first prenatal visit within an academic medical center clinic and to compare the topics discussed to 2014 American College of Obstetrics and Gynecologists guidelines for the initial prenatal visit. Methods Clinical interactions were audio recorded and transcribed (n = 30). A content analysis was used to identify topics discussed during the initial prenatal visit. Topics discussed were then compared to the 2014 ACOG guidelines for adherence. Coded data was queried though the qualitative software and reviewed for accuracy and content. Results First prenatal visits included a physician, nurse practitioner, nurse midwife, medical assistant, medical students, or a combination of these providers. In general, topics that were covered in most visits and closely adhered to ACOG guidelines included vitamin supplementation, laboratory testing, flu vaccinations, and cervical cancer screening. Topics discussed less often included many components of the physical examination, education about pregnancy, and screening for an identification of psychosocial risk. Least number of topics covered included prenatal screening. Conclusions for Practice While the ACOG guidelines may include many components that are traditional in addition to those based on evidence, the guidelines were not closely followed in this study. Identifying new ways to disseminate information during the time constrained initial prenatal visit are needed to ensure improved patient outcomes.

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.)

Quality improvement efforts are an increasingly expanding focus for perinatal care providers across the United States. From successful hospital-level initiatives, there has been a growing effort to use and implement quality improvement work in substantive and meaningful ways. This article summarizes the foundations of maternal-focused, birth-focused, and neonatal-focused quality improvement initiatives to highlight the underpinnings and potential future directions of current state-level perinatal quality care collaboratives., (Copyright © 2017 Elsevier Inc. All rights reserved.)