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Background: Maternal mortality rate in developing countries is 20 times higher than in developed countries. Detailed reports surrounding maternal deaths have noted an association between substandard management during emergency events and death. In parallel with these findings, there is increasing evidence for cognitive aids as a means to prevent errors during perioperative crises. However, previously published findings are not directly applicable to cesarean delivery in low-income settings. Our hypothesis was that the use of obstetric anesthesia checklists in the management of high-fidelity simulated obstetrical emergency scenarios would improve adherence to best practice guidelines in low- and middle-income countries., Methods: Accordingly, with input from East African health care professionals, we created a context-relevant obstetric anesthesia checklist for cesarean delivery. Second, clinical observations were performed to assess in a real-world setting. Third, a pilot testing of the cognitive aid was undertaken., Results: Clinical observation data highlighted significant deficiencies in the management of obstetric emergencies. The use of the cesarean delivery checklist during simulations of peripartum hemorrhage and preeclampsia showed significant improvement in the percentage of completed actions (pretraining 23% ± 6% for preeclampsia and 22% ± 13% for peripartum hemorrhage, posttraining 75% ± 9% for preeclampsia, and 69% ± 9% for peripartum hemorrhage [P < .0001, both scenarios; data as mean ± standard deviation])., Conclusions: We developed, evaluated, and begun implementation of a context-relevant checklist for the management of obstetric crisis in low- and middle-income countries. We demonstrated not only the need for this tool in a real-world setting but also confirmed its potential efficacy through a pilot simulation study.

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.

Objective: To assess the existing knowledge and skills relating to Emergency Obstetrics Care (EMOC) among health providers in eight referral maternity hospitals in Nigeria., Study Design: A cross-sectional study of skilled health providers (doctors, nurses and midwives) working in the hospitals during the period., Setting: Six general hospitals (4 in the south and 2 in the north), and two teaching hospitals (both in the Northern part) of the country., Population: All skilled providers offering EMOC services in the hospitals during the study., Methods: A pre-tested self-administered questionnaire was used to obtain information relating to socio-demographic characteristics, the respondents' knowledge and skills in offering specific EMOC services (as compared to standard World Health Organization recommendations), and their confidence in transferring the skills to mid-level providers. Data were analyzed with univariate, bivariate, binary and multinomial logistic regression analyses. Main outcome measures: knowledge and skills in EMOC services by hospital and overall., Results: A total of 341 health providers (148 doctors and 193 nurses/midwives) participated in the study. Averagely, the providers scored less than 46% in a composite EMOC knowledge score, with doctors scoring considerable higher than the nurses/midwives. Similarly, doctors scored higher than nurses/midwives in the self-reporting of confidence in carrying out specific EMOC functions. Health providers that scored higher in knowledge were significantly more likely to report confidence in performing specific EMOC functions as compared to those with lower scores. The self-reporting of confidence in transferring clinical skills was also higher in those with higher EMOC knowledge scores., Conclusion: The knowledge and reported skills on EMOC by health providers in referral facilities in Nigeria was lower than average. We conclude that the in-service training and re-training of health providers should be included in national policy and programs that address maternal mortality prevention in referral facilities in the country., Trial Registration: Nigeria Clinical Trials Registry 91540209., Competing Interests: The authors have declared that no competing interests exist.

Menometrorrhagia is a frequent bleeding symptom in young women, and may be related to an inherited bleeding disorder. If there is no gynecological etiology, hemostasis tests are required. The early medical management of these teenage girls is important, especially when a bleeding disorder is known. The bleeding risk of the first periods may then be anticipated. Afterwards, the objective of the treatment is to keep the bleeding symptoms under control: anti-fibrinolytic treatment, specific replacement therapy for bleeding disorder and hormonal treatment. This management requires a multidisciplinary medical team, mainly hematologist and gynecologist, all along the genital lifespan, from the first periods to the desire for pregnancy., Competing Interests: A. Harroche déclare des liens ponctuels -interventions et prises en charge lors de congrès- avec Novo Nordisk, Bayer, Pfizer, Shire, Octopharma, LFB, CSL Behring, Sobi et Roche. S. Meunier déclare des liens ponctuels interventions et/ou prise en charge lors de congrès- avec Novo Nordisk, Bayer, Shire, Baxalta/Shire, Octapharma, Pfizer, LFB, CSL-Behring, Sobi et Roche. S. Da Costa déclare n’avoir aucun lien d’intérêts. C. Falaise déclare des liens ponctuels -interventions et/ou prise en charge lors de congrès avec Bayer, Octopharma, Pfizer, Roche, SOBI, Takeda, LFB et Novo Nordisk. C. Oudot déclare des liens -prise en charge lors de congrès avec Shire, Bayer, SOBI, CSL Behring, Octopharma et Novo Nordisk.

Background: Postpartum hemorrhage is the leading cause of maternal death. Recently, the WOMAN trial showed that early administration of tranexamic acid leads to a reduced mortality due to bleeding. The aim was to study whether the results of the WOMAN trial have influenced the institutional standard operating procedures in treating postpartum hemorrhage., Methods: We performed a paper-based survey during the German Perinatal Congress in 2017 located in Berlin. A total of thirteen questions covered the fields of incidence, training, and treatment of postpartum hemorrhage., Results: 250 questionnaires were handed out to all participants of three different sessions during the congress. 72 questionnaires were returned, resulting in a return rate of 29%. 94% (n = 65) of all participants stated that they had implemented a standard operating procedure to treat postpartum hemorrhage prior to the WOMAN trial. 18 of these standard operating procedures were revised after the publication of the WOMAN trial, resulting in an early inclusion of tranexamic acid in 100% of all standard operating procedures., Conclusion: We recognized a correlation between the publication of the WOMAN trial and the administration of tranexamic acid at an early time-point in all standard operating procedures of the participating institutions to treat postpartum hemorrhage. In all those clinics whose algorithms initially did not contain any tranexamic acid, it was supplemented. This resulted in a 100% implementation of tranexamic acid., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

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

Six years after the first edition of The Guideline for Gynecological Practice, which was jointly edited by The Japan Society of Obstetrics and Gynecology and The Japan Association of Obstetricians and Gynecologists, the third revised edition was published in 2017. The 2017 Guidelines includes 10 additional clinical questions (CQ), which brings the total to 95 CQ (12 on infectious disease, 28 on oncology and benign tumors, 27 on endocrinology and infertility and 28 on healthcare for women). Currently a consensus has been reached on the Guidelines and therefore the objective of this report is to present the general policies regarding diagnostic and treatment methods used in standard gynecological outpatient care that are considered appropriate. At the end of each answer, the corresponding recommendation level (A, B, C) is indicated., (© 2019 Japan Society of Obstetrics and Gynecology.)

Objective: To examine healthcare providers' adherence to professional recommendations for advanced prescription of emergency contraceptive pills (ECPs)., Methods: We conducted a retrospective chart review of 432 visits by 282 unique nonpregnant women 14 to 25 years of age seen at an obstetrics and gynecology teaching clinic to determine the percentage of visits during which advanced prescriptions of ECPs were provided when indicated. A logistic regression model, which accounted for nonindependent observations through generalized estimating equations, was used to identify factors associated with the provision of ECP advanced prescriptions., Results: Approximately one-fifth of eligible visits (19.9%) and eligible patients (19.1%) had documentation of an ECP advanced prescription when indicated. Healthcare providers in this clinical setting were more likely to prescribe ECPs to adolescents and women whose primary contraceptive methods were associated with higher failure rates in typical use, such as condoms. Compared with women aged 20 to 25 years, the adjusted odds ratio of receiving an advanced prescription for ECPs was 5.94 (95% confidence interval [CI] 2.85-12.41) for adolescents. Compared with users of depot medroxyprogesterone acetate, the adjusted odds ratio was 4.25 (95% CI 1.62-11.15) for condom users, and 3.90 (95% CI 1.54-9.86) for users of other short-term hormonal contraceptives., Conclusions: Despite clear professional recommendations for ECP advanced prescriptions for all women at risk for unintended pregnancy, a substantial gap exists between this standard of care and routine clinical service provision in an obstetrics and gynecology teaching clinic.

Background: Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for nontherapeutic indications. Due to changing patterns of migration, clinicians in high-income countries are seeing more women from countries where the practice is prevalent. This review aims to understand the sociocultural and health needs of these women and identify opportunities to improve the quality of maternity care for women with FGM., Methods: We undertook a systematic review and meta-synthesis of peer-reviewed primary qualitative research to explore the experience and needs of migrant women with FGM receiving maternity care. A structured search of nine databases was undertaken, screened papers appraised, and a thematic analysis undertaken on data extracted from the findings and discussion sections of included papers., Results: Sixteen peer-reviewed studies were included in the systematic review. Four major themes were revealed: Living with fear, stigma, and anxiety; Feelings of vulnerability, distrust, and discrimination; Dealing with past and present ways of life after resettlement; and Seeking support and involvement in health care., Conclusions: The findings suggest that future actions for improving maternity care quality should be focused on woman-centered practice, demonstrating cultural safety and developing mutual trust between a woman and her care providers. Meaningful consultation with women affected by FGM in high-income settings requires cultural sensitivity and acknowledgment of their specific circumstances. This can be achieved by engaging women affected by FGM in service design to provide quality care and ensure woman-focused policy is developed and implemented., (© 2018 Wiley Periodicals, Inc.)

As adolescents with a genetic syndrome transition to adult medical care, they may be referred to obstetrician-gynecologists for routine preventive or contraceptive services, screening, or counseling for sexually transmitted infection, or for menstrual management. Although some genetic syndromes have no physical or intellectual impairment, others have significant ones; therefore, education and gynecologic care should be based on a patient's intellectual and physical capabilities. It is important to remember that adolescents with or without a genetic syndrome are sexual beings. Thus, education about reproductive health, expectations for fertility, and healthy relationships is important when treating patients with genetic syndromes. Obstetrician-gynecologists must respect patient autonomy and avoid coercion in any discussions with a patient, including decisions about contraceptive choices, sexual activity, and pregnancy planning. Most patients who have genetic syndromes and are neurotypical can tolerate routine gynecologic examinations in the office, when necessary. A patient should not be forced to have an examination or be restrained for an examination. Obstetric care of adolescents and women with genetic syndromes can pose challenges and often requires a multidisciplinary approach from the time pregnancy is contemplated through the postpartum period. When caring for an adolescent with a genetic syndrome, individual patient and guardian concerns, medical diagnoses associated with the specific genetic syndromes, and medication interactions should be considered. Obstetrician-gynecologists are encouraged to seek out additional resources and expertise when caring for adolescents with underlying genetic syndromes.

Background: Increasing numbers of childbearing women with a history of female genital mutilation (FGM) are accessing maternity services in high-income countries across the world. For many of these women, their first contact with the health services in their host country is when they are pregnant. While the clinical consequences of certain categories of FGM are well documented, how high-risk maternity services - designed to mitigate the obstetric consequences of FGM - impact upon women's experience of childbearing is less clear., Methods: Using a meta-synthesis approach, this paper synthesizes 12 qualitative research papers, conducted in 5 high-income countries, to explore how migrant women with a history of FGM experience maternity care in their host countries., Results: One over-arching theme and four discrete subthemes of migrant women's experience of the maternity services in their host country were identified: feelings of alienation; fatalism and divine providence, positive and negative feelings about maternity care, different understandings of the birthing process, and feelings about FGM., Conclusions: The findings illustrate that migrant women with a history of FGM frequently encounter negative attitudes when accessing the maternity services in their host countries. Women's experiences suggest a concerning absence of sensitive and empathetic care; a more woman-centered approach is recommended., (© 2018 Wiley Periodicals, Inc.)

Objectives: Quality indicators are measurable elements widely used to assess the quality of care. They are often developed from the results of systematic reviews or clinical practice guidelines. These sources are regularly updated in line with new clinical evidence, but there are few articles on updating quality indicators based on clinical practice guidelines. This study aimed to update the quality indicators developed for low-risk labour care in Japan in 2012, mainly drawing on new or updated clinical practice guidelines, and making the process clearly visible and assessable., Design and Setting: We used a modified Delphi method for the update. The procedure included four steps: (1) updating the definition of low-risk labour; (2) reviewing the literature published between June 2012 and December 2015 using five guidelines and two quality indicator databases to extract potential candidate indicators; (3) formation of a multidisciplinary panel including mothers and (4) panel ratings (two rounds between February and April 2016) on the validity of the candidate indicators, and judging the validity of the previous quality indicators drawing on the new evidence., Participants: A multidisciplinary panel of 13 clinicians, including obstetricians, paediatricians and midwives, plus 3 non-clinician mothers., Results: The literature review identified 276 new recommendations from 27 clinical practice guidelines including 2 published in Japan and 21 quality indicators. We developed 13 new candidate indicators from these sources and panel recommendations, 12 of which were approved by the multidisciplinary panel. The panel also accepted all 23 existing quality indicators as still valid, resulting in a total of 35 quality indicators for low-risk labour., Conclusions: We successfully updated the quality indicators for low-risk labour care in Japan. The procedure developed may be useful for updating other quality indicators based on new clinical practice guidelines., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the impact of a standardized surgical technique for primary cesarean deliveries (CDs) on operative time and surgical morbidity., Materials and Methods: Two-year retrospective chart review of primary CD performed around the implementation of a standardized CD surgical technique. The primary outcome was total operative time (TOT). Secondary outcomes included incision-to-delivery time (ITDT), surgical site infection, blood loss, and maternal and fetal injuries., Results: When comparing pre- versus postimplementation surgical times, there was no significant difference in TOT (76.5 vs. 75.9 minutes, respectively; p  = 0.42) or ITDT (9.8 vs. 8.8 minutes, respectively; p  = 0.06) when the entire cohort was analyzed. Subgroup analysis of CD performed early versus late in an academic year among the pre- and postimplementation groups showed no significant difference in TOT (79.3 early vs. 73.8 minutes late; p  = 0.10) or ITDT (10.8 early vs. 8.8 minutes late; p  = 0.06) within the preimplementation group. In the postimplementation group, however, there was significant decrease in TOT (80.5 early vs. 71.3 minutes late; p  = 0.02) and ITDT (10.6 early vs. 6.8 minutes late; p  < 0.01). Secondary outcomes were similar for both groups., Conclusion: A standardized surgical technique combined with surgical experience can decrease TOT and ITDT in primary CD without increasing maternal morbidity., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Rationale: Defensive caesarean section (CS) has become one of the most common medical procedure worldwide. Additionally, performing CS in accordance with the patient's choice is an appropriate professional practice., Aims and Objective: This paper reports a prospective, observational, multicenter study to quantify the use of this type of practice that is performed by obstetricians to avoid medico-legal complaints and decrease the frequency of malpractice litigations., Methods: We interviewed 73 obstetricians from three distinct units of obstetrics and gynaecology, to assess their opinion regarding defensive caesarean delivery and caesarean delivery performed upon maternal request. We conducted an opinion-based survey using questionnaires based on nine, close-ended questions., Results: Out of 73 respondents, 51 (69.9%) stated that they perform defensive CS; 63 (86.3%) declared that their choice of birth delivery is influenced by the risk of being accused of malpractice; 60 (82.2%) indicated that it is normal for the patient to be able to decide on the type of delivery; and 63 (86.3%) declared that they consult their patients regarding their delivery preferences. We found statistically significant differences between the respondents who declare that they perform defensive CS (69.9%) and those who said that they are influenced by the risk of malpractice when they choose the method of delivery for their patients (86.3%) (P < .001; McNemar Test)., Conclusions: The results of our study indicate that defensive caesarean section is a widespread practice among obstetrics practitioners in Romania., (© 2018 The Authors Journal of Evaluation in Clinical Practice Published by John Wiley & Sons Ltd.)

Objective: To determine the factors contributing to hospital-based maternal deaths in Indonesia, given most women deliver with skilled birth attendants and in health facilities., Methods: A retrospective review of case records examined quality of care issues related to maternal mortality in hospital settings. The review abstracted information from blinded medical records of 90 women who died in 11 hospitals from January to June 2014. Specialists from the Indonesian Society of Obstetrics and Gynecology reviewed abstracted records to determine causes of death and identify contextual factors for these deaths., Results: Seventy-five of the 90 maternal deaths (83%) reviewed were due to direct obstetric causes. Severe pre-eclampsia and eclampsia combined were the leading direct cause of death (42%). Human resource/health worker factors were more frequently identified than supply, facility, or infrastructure factors. Ninety percent of maternal deaths were classified as preventable., Conclusion: The review exercise yielded useful information on factors contributing to preventable maternal mortality in hospitals in Indonesia. Results helped focus quality improvement efforts and increased awareness of the value of routine, in-depth facility-based maternal death reviews., (© 2019 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Checklists are memory aids comprised of various tasks to complete a process and have been successful in preventing errors and improving performance in various fields including aviation, aeronautics, and construction. (1) In recent years, use of safety checklists has increased within the medical field to standardize care and improve communication amongst providers and they hold significant promise to improve outcomes during obstetric emergencies., (Published by Elsevier Inc.)

Obstetric hemorrhage is the leading cause of maternal morbidity and mortality in the world. Disparities in the prevalence of obstetric hemorrhage and its related mortality both on a global scale and locally in the United States indicate that a significant proportion is preventable. In many parts of the world, including the United States, there has also been an unexplainable increase in rates of postpartum hemorrhage. Efforts should focus on implementing comprehensive hemorrhage toolkit/bundles, which research has shown may have the potential to reduce severe maternal morbidity from hemorrhage., (Copyright © 2018. Published by Elsevier Inc.)

Background: The increase in global health networks as mechanisms for improving health and affecting social change has been recognized as a key component of the global health landscape today. To successfully raise awareness of shared causes, global health networks need tools to help them plan successful campaigns and evaluate the impact of their work, as well as to coordinate and reinforce each other's efforts. One global health network, the Respectful Maternity Care (RMC) Global Council, can be credited with raising the profile of the issues of disrespect and abuse (D&A) in childbirth and the need for RMC within global maternal health. We set out to learn from the work of the RMC Global Council and the RMC movement at large to develop a tool-a framework for planning and evaluating awareness-raising efforts-useful for networks focused on global health and human rights., Methods: We reviewed the literature for theoretical models on awareness raising and, finding a lack of appropriate tools, developed a new, draft framework using components of the Framework for Effective Campaigns, the SpitFire SmartChart 3.0, and Network Theory. We conducted semi-structured interviews with members of the RMC Global Council to validate the draft framework and identify any additional strategies or tactics that were used during their efforts to raise awareness of D&A and RMC. We also interviewed "influenced" individuals to validate inputs from the influencers and determine the key documents, events, individuals, and organizations that made the greatest contribution to the increased awareness of D&A/RMC. Data were analyzed using deductive and inductive qualitative research methods., Results: The validated awareness-raising framework includes five strategies that characterize a successful awareness-raising effort. Each strategy has a set of tactics that can operationalize those strategies. Each tactic is classified as essential, helpful, or variable based on the number of key informants who utilized it., Conclusion: This case study offers an example of how global health networks can create a movement that effects change at global and local levels by providing an empirically-grounded framework to help plan, coordinate, and evaluate future campaigns designed to raise awareness and create momentum in global health, human rights, and quality of care.

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.)

Background: Malpractice liability is an ongoing problem in obstetrics. However, developing, sustaining, and spreading effective interventions is challenging. The aim of this study is to examine the spread and sustainability of a multilevel integrated practice and coordinated communication model 66 months after its original implementation., Methods: Data on labor and delivery patients from 37 hospitals (5 beta sites and 32 expansion sites) were analyzed for the 81-month time period from January 2010 through September 2016., Results: High-risk occurrence rates per 1000 live births decreased by over 70% at both beta and expansion sites. The likelihood of a high-risk occurrence was statistically significantly lower during the final study period than in the preintervention period at both beta sites (odds ratio [OR] = 0.218; p < .0001) and expansion sites (OR = 0.288; p < .001)., Conclusion: The multilevel integrated practice and coordinated communication model was successfully spread and sustained. Key elements contributing to this success included developing and maintaining evidence-based guidelines, ensuring leadership buy-in and support, collecting and reporting performance measures, holding teams accountable, providing training, and ensuring transparent communication., (© 2018 American Society for Health Care Risk Management of the American Hospital Association.)

The objective of this article is to present the results from a cross-sectional survey carried out to assess and compare knowledge, attitudes, and beliefs of the obstetrician-gynecologists and midwives, regarding a set of complementary and alternative therapies in the area of the Corredor del Henares in Spain. The results show a high percentage of acceptance regarding complementary and alternative therapies in the field of obstetrics and gynecology, and more than half of the Spanish professionals of reproductive health would like to learn more about these therapies.

Background: Substandard delivery care has been widely documented as a major cause of maternal mortality in health facilities globally. Health worker learning via mobile devices is increasing rapidly; however, there is little evidence of mLearning effectiveness. This study sought to determine the feasibility, acceptability, and potential effect of the Safe Delivery App (SDA) on health workers' practices in basic emergency obstetric and newborn care (BEmONC) in the Democratic Republic of the Congo (DRC). The Theoretical Domains Framework was used to guide this research., Methods: Eight BEmONC facilities in central DRC were randomized to either an mLearning intervention or to standard practice (control). Maternal and newborn health workers in intervention facilities (n=64) were trained on the use of smartphones and the French version of the SDA. The SDA is an evidence-based BEmONC training resource with visual guidance using animated videos and clinical management instructions developed by the Maternity Foundation and the Universities of Copenhagen and Southern Denmark. Knowledge on postpartum hemorrhage (PPH) and neonatal resuscitation (NR) and self-confidence in performing 12 BEmONC procedures were assessed at baseline and at 3 months post-intervention. Eighteen qualitative interviews were conducted with app users and key stakeholders to assess feasibility and acceptability of mLearning and the use of the SDA. Maternal mortality was compared in intervention and control facilities using a smartphone-based Open Data Kit (ODK) data application. One smartphone with SDA and ODK was entrusted to intervention facilities for the study period, whereas control facilities received smartphones with ODK only., Results: The analysis included 62 heath workers. Knowledge scores on postpartum hemorrhage and neonatal resuscitation increased significantly from baseline among intervention participants compared with controls at 3 months post-intervention (mean difference for PPH knowledge, 17.4 out of 100; 95% confidence interval [CI]=10.7 to 24.0 and 19.4 for NR knowledge; 95% CI=11.4 to 27.4), as did self-confidence scores on 12 essential BEmONC procedures (mean difference, 4.2 out of 48; CI=0.7 to 7.7). Increases were unaffected by health worker cadre and previous smartphone use. Qualitative interviews supported the feasibility and acceptability of the SDA and mLearning, and the potential for it to impact maternal and neonatal mortality in the DRC., Conclusion: Use of the Safe Delivery App supported increased health worker knowledge and self-confidence in the management of obstetric and newborn emergencies after 3 months. SDA and mLearning were found to be feasible and acceptable to health workers and key stakeholders in the DRC., (© Bolan et al.)

Objectives: Data was gathered to study the impact of a context-specific modified WHO Safe Childbirth Checklist (mSCC) at two tertiary care settings in Sri Lanka, as a part of an implementation program., Data Description: We provide data sets of a prospective observational study which was conducted in the University Obstetrics Unit at De Soysa Hospital for Women (DSHW), Colombo and two Obstetric Units at Teaching Hospital, Mahamodara, Galle (THMG), Sri Lanka. These consist of demographic and checklist implementation details and data on the level of acceptance. The study was conducted over 8 weeks at DSHW and over 4 weeks at THMG. Checklists were kept attached to clinical records at admission and collected on discharge. Level of acceptance was assessed using a self-administered questionnaire. Outcome measures were adoption rate (percentage of deliveries where mSCC was used), adherence to practices (mean percentage of items checked in each checklist), response rate (percentage of staff members who responded to questionnaire) and level of acceptance (percentage of "strongly agree/agree" in Likert scale to five questions regarding acceptance of modified SCC).

Background: Health service providers play a key role in addressing women's need for pregnancy prevention, especially during the postpartum period. Yet, in Nepal, little is known about their views on providing postpartum family planning (PPFP) services and postpartum contraceptive methods such as immediate postpartum intra-uterine devices (PPIUD). This paper explores the perspectives of different types of providers on PPFP including PPIUD, their confidence in providing PPFP services, and their willingness to share their knowledge and skills with colleagues after receiving PPFP and PPIUD training., Methods: In-depth interviews were conducted with 14 obstetricians/gynecologists and nurses from six tertiary level public hospitals in Nepal after they received PPFP and PPIUD training as part of an intervention aimed at integrating PPFP counseling and insertion into routine maternity care services. The interviews were audio recorded, transcribed, and analyzed using a thematic approach., Results: Providers identified several advantages of PPFP, supported the provision of such services, and were willing to transfer their newly acquired skills to colleagues in other facilities who had not received PPFP and PPIUD training. However, many providers identified several supply-side and training-related barriers to providing high quality PPFP services, such as, (i) lack of adequate human resources, particularly a FP counselor; (ii) work overload; (iii) lack of private space for counseling; (iv) lack of IUDs and information, education and counseling materials; and (v) lack of support from hospital management., Conclusions: Providers appeared to be motivated to deliver quality PPFP services and transfer their knowledge to colleagues but identified several barriers which prevented them from doing so. Future efforts to improve provision of quality PPFP services should address the barriers identified by providers.

Background: Maternal morbidity and mortality are still serious public health concerns in Brazil, and access to quality obstetric care is one critical point of this problem. Despite efforts, obstetric care quality problems and sub-optimal/poor outcomes persist. The study aimed to identify contextual elements that would potentially affect the implementation of an obstetric care quality improvement intervention., Methods: A qualitative study was conducted in three public maternity hospitals of a large Brazilian city, with high annual volume of births and buy-in from high-level managers. Individual interviews with doctors and nurses were conducted from July to October 2015. Semi-structured interviews sought to explore teamwork, coordination and communication, and leadership, being open to capture other contextual elements that could emerge. Interviews were recorded and transcribed, and the categories of analysis were identified and updated based on the constant comparative method., Results: Twenty-seven interviews were carried out. Extra-organizational context concerning the dependence of the maternity hospitals on primary care units, responsible for antenatal care, and on other healthcare organizations' services emerged from interviews, but the main findings of the study centered on intra-organizational context with potential to affect healthcare quality and actions for its improvement, including material resources, work organization design, teamwork, coordination and communication, professional responsibility vis-à-vis the patient, and leadership. A major issue was the divergence of physicians' and nurses' perspectives on care quality, which in turn negatively affected their capacity to work together., Conclusion: Overall, the findings suggest that care on the maternity hospitals was fragmented and lacked continuity, putting at risk the quality. Redesigning work organization, promoting conditions for multi-professional teamwork, better communication and coordination, improving more systemic accountability/lines of authority, and investing in team members' technical competence, and fitness of organizational structures and processes are all imbricated actions that may contribute to obstetric care quality improvement.

Introduction: Clinical decision support systems (CDSSs) are being developed to assist physicians in processing extensive data and new knowledge based on recent scientific advances. Structured medical knowledge in the form of clinical alerts or reminder rules, decision trees or tables, clinical protocols or practice guidelines, score algorithms, and others, constitute the core of CDSSs. Several medical knowledge representation and guideline languages have been developed for the formal computerized definition of such knowledge. One of these languages is Arden Syntax for Medical Logic Systems, an International Health Level Seven (HL7) standard whose development started in 1989. Its latest version is 2.10, which was presented in 2014. In the present report we discuss Arden Syntax as a modern medical knowledge representation and processing language, and show that this language is not only well suited to define clinical alerts, reminders, and recommendations, but can also be used to implement and process computerized medical practice guidelines., Methods: This section describes how contemporary software such as Java, server software, web-services, XML, is used to implement CDSSs based on Arden Syntax. Special emphasis is given to clinical decision support (CDS) that employs practice guidelines as its clinical knowledge base., Results: Two guideline-based applications using Arden Syntax for medical knowledge representation and processing were developed. The first is a software platform for implementing practice guidelines from dermatology. This application employs fuzzy set theory and logic to represent linguistic and propositional uncertainty in medical data, knowledge, and conclusions. The second application implements a reminder system based on clinically published standard operating procedures in obstetrics to prevent deviations from state-of-the-art care. A to-do list with necessary actions specifically tailored to the gestational week/labor/delivery is generated., Discussion: Today, with the latest versions of Arden Syntax and the application of contemporary software development methods, Arden Syntax has become a powerful and versatile medical knowledge representation and processing language, well suited to implement a large range of CDSSs, including clinical-practice-guideline-based CDSSs. Moreover, such CDS is provided and can be shared as a service by different medical institutions, redefining the sharing of medical knowledge. Arden Syntax is also highly flexible and provides developers the freedom to use up-to-date software design and programming patterns for external patient data access., (Copyright © 2016. Published by Elsevier B.V.)

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: The aim of the study was to assess whether a more context-specific modified version of WHO Safe Childbirth Checklist (mSCC) would result in improved adoption rate., Methods: A prospective observational study was conducted in University Obstetrics Unit at De Soysa Hospital for Women (DSHW), Colombo and two Obstetric Units at Teaching Hospital, Mahamodara, Galle (THMG), Sri Lanka. Study was conducted over 8 weeks at DSHW and over 4 weeks at THMG after introduction of the mSCC in 2017. The WHO SCC was in use at DSHW from 2013 until its replacement by the mSCC. Checklists were kept attached at admission and collected on discharge. Level of acceptance was assessed using a self-administered questionnaire at the end. Outcome measures were adoption rate (percentage of deliveries where mSCC was used and could be found), adherence to practices (mean percentage of items checked), response rate (percentage of staff members responded to questionnaire) and level of acceptance (percentage of "strongly agree/agree" in Likert scale to five questions regarding acceptance of mSCC). Responses were also taken to the open-ended question on barriers to implementation., Results: In DSHW, out of 606 births during study period, there were 329 live births in which the mSCC was used and could be found giving an adoption rate of 54.3%. In THMG adoption rate was 153/814 (18.8%). In DSHW, response rate for the questionnaire was 40.5% and in THMG, 40.0%. Level of acceptance was good among those who responded to the questionnaire. Mean (95% CI) adherence to the Checklist practices was 52.7% (44.1-58.5) in DSHW and 32.2% (24.5-39.1) in THMG with a range of 1-100% in both settings. Majority mentioned the lack of staff, lack of enthusiasm, inadequate training and advice on use of mSCC and lack of supervision from Ministry/institutional level. Majority suggested the involvement of medical doctors, removal of the need to place the signature and separate accountability to each 27-items and the desirability of proper training sessions regarding the mSCC., Conclusion: Checklist-based interventions in maternity care cannot be expected to improve by merely making them context-specific. Other approaches should be explored to maximize its benefits.

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.

Introduction: We aimed to determine how serious adverse events in obstetrics were assessed by supervision authorities., Material and Methods: We selected cases investigated by supervision authorities during 2009-2013. We analyzed information about who reported the event, the outcomes of the mother and infant, and whether events resulted from errors at the individual or system level. We also assessed whether the injuries could have been avoided., Results: During the study period, there were 303 034 births in Norway, and supervision authorities investigated 338 adverse events in obstetric care. Of these, we studied 207 cases that involved a serious outcome for mother or infant. Five mothers (2.4%) and 88 infants (42.5%) died. Of the 207 events reported to the supervision authorities, patients or relatives reported 65.2%, hospitals reported 39.1%, and others reported 4.3%. In 8.7% of cases, events were reported by more than 1 source. The supervision authority assessments showed that 48.3% of the reported cases involved serious errors in the provision of health care, and a system error was the most common cause. We found that supervision authorities investigated significantly more events in small and medium-sized maternity units than in large units. Eighteen health personnel received reactions; 15 were given a warning, and 3 had their authority limited. We determined that 45.9% of the events were avoidable., Conclusions: The supervision authorities investigated 1 in 1000 births, mainly in response to complaints issued from patients or relatives. System errors were the most common cause of deficiencies in maternity care., (© 2018 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

As reproductive health experts and advocates for women's health who work in conjunction with other obstetric and pediatric health care providers, obstetrician-gynecologists are uniquely positioned to enable women to achieve their infant feeding goals. Maternity care policies and practices that support breastfeeding are improving nationally; however, more work is needed to ensure all women receive optimal breastfeeding support during prenatal care, during their maternity stay, and after the birth occurs. Enabling women to breastfeed is a public health priority because, on a population level, interruption of lactation is associated with adverse health outcomes for the woman and her child, including higher maternal risks of breast cancer, ovarian cancer, diabetes, hypertension, and heart disease, and greater infant risks of infectious disease, sudden infant death syndrome, and metabolic disease. Contraindications to breastfeeding are few. Most medications and vaccinations are safe for use during breastfeeding, with few exceptions. Breastfeeding confers medical, economic, societal, and environmental advantages; however, each woman is uniquely qualified to make an informed decision surrounding infant feeding. Obstetrician-gynecologists and other obstetric care providers should discuss the medical and nonmedical benefits of breastfeeding with women and families. Because lactation is an integral part of reproductive physiology, all obstetrician-gynecologists and other obstetric care providers should develop and maintain skills in anticipatory guidance, support for normal breastfeeding physiology, and management of common complications of lactation. Obstetrician-gynecologists and other obstetric care providers should support women and encourage policies that enable women to integrate breastfeeding into their daily lives and in the workplace. This Committee Opinion has been revised to include additional guidance for obstetrician-gynecologists and other obstetric care providers to better enable women in unique circumstances to achieve their breastfeeding goals.

The aim of this commentary is to describe changes in women's care at an obstetric department that made it possible to reduce the number of beds from 40 to 29. Patient pathways were reviewed and revised using lean methodology. The mean length of stay was reduced from 70 to 59 h and the mean numbers of hospitalizations per woman from 1.26 to 1.20. At the organizational level, we introduced a Family Department, home management of newborns, home monitoring of the women with cardiotocography and blood samples, and intrapartum Group B Streptococcus-PCR. Additionally, an After Birth Clinic and network meetings for vulnerable women were established. In patient pathway, we reduced the hospitalization indicated by preterm premature rupture of membranes, preeclampsia and observation after birth laceration. According to National Patient Satisfaction surveys, there was no decrease in women's satisfaction after reducing the number of beds., (© 2018 Nordic Federation of Societies of Obstetrics and Gynecology.)

Purpose of Review: The purpose of this review is to outline surgical skills assessment tools for the purpose of training and competency evaluation, with a focus on recent literature in gynecology., Recent Findings: Objective standardized surgical skills assessment tools are increasingly being explored in multiple surgical disciplines including gynecology. Several small studies in gynecology have validated procedure-specific checklists, global rating scales, and other surgical proficiency examinations in their ability to differentiate trainee skill level or correlate with other standardized tests. Few studies have included gynecologic surgeons in practice, and no studies have investigated their use in credentialing and maintenance of certification., Summary: Surgical skills assessment tools may be a useful adjunct to gynecology training programs, with promising applications for practicing gynecologists.

Objective: Since publication of the Term Breech Trial in 2000 only 15% of term breech presentations is delivered vaginally in the Netherlands. This declined exposure to vaginal breech deliveries (VBD) is a problem for those who still need to be trained. The aim of this study was to evaluate the level of training of the Dutch gynecological residents, and their intentions on guiding VBDs during their careers., Study Design: Via an online questionnaire Dutch residents and starting gynecologists, were asked about their training, exposure and confidence in guiding VBDs during their residency., Main Outcome Measures: Number of VBDs performed, level of entrustment of independent practice in guiding VBDs, courses in guiding VBDs, confidence in guiding VBDs after finishing their residency., Results: The response rate was 64% (N = 294). Thirteen per cent performed less than three VBDs, 15% more than 15. Of sixth year residents 65% has not yet obtained entrustment for personally guiding VBDs. The residents are trained in VBDs at least once during a national mandatory course. Further training is strongly dependent on local hospital policy: 34% are trained every quarter versus 29% who never receive a local training., Conclusion: Our survey showed that more than half of the respondents judge the current residency program to be insufficient for guiding VBDs. This seems to be related to the low overall exposure to VBDs and the lack of quantity and quality of attended courses., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: To determine if faculty perceive standardized oral examinations to be more objective and useful than the non-standardized format in assessing third-year medical students' learning on the obstetrics and gynecology rotation., Methods: Obstetrics and gynecology faculty at three teaching hospitals were sampled to complete a survey retrospectively comparing the standardized oral examination (SOE) and non-standardized or traditional oral examinations (TOE).  A Likert scale (0-5) was used to assess satisfaction, objectivity, and usefulness of SOE and TOE.  Wilcoxon signed rank test was performed to compare median Likert scale scores for each survey item. A Spearman's correlation coefficient was used to investigate the relationship between the perceived level of objectivity and SOE characteristics. For qualitative measures, content analysis was applied., Results: Sixty-six percent (n=25) of eligible faculty completed the survey. Faculty perceived the standardized oral examination as significantly more objective compared with the non-standardized (z=-3.15, p=0.002). Faculty also found SOE to be more useful in assessing overall clerkship performance (z=-2.0, p<0.05). All of the survey participants were willing to administer the standardized examination again.  Faculty reported strengths of the SOE to be uniformity, fairness, and ease of use. Major weaknesses reported included inflexibility and decreased ability to assess students' higher order reasoning skills., Conclusions: Faculty found standardized oral examinations to be more objective in assessing third-year medical students' clinical competency when compared with a non-standardized approach.  This finding can be meaningfully applied to medical education programs internationally.

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background: Fetal echocardiography can accurately diagnose critical congenital heart disease prenatally, but relies on referrals from abnormalities identified on routine obstetrical ultrasounds. Critical congenital heart disease that is frequently missed due to inadequate outflow tract imaging includes anomalies such as truncus arteriosus, double outlet right ventricle, transposition of the great arteries, tetralogy of Fallot, pulmonary stenosis, and aortic stenosis., Objective: This study evaluated the prenatal detection rate of critical outflow tract anomalies in a single urban pediatric hospital before and after "AIUM Practice Guideline for the Performance of Obstetric Ultrasound Examinations," which incorporated outflow tract imaging., Design: Infants with outflow tract anomalies who required cardiac catheterization and/or surgical procedure(s) in the first 3 months of life were retrospectively identified. This study evaluated two time periods; pre-guidelines from June 2010 to May 2013 and post-guidelines from January 2015 to June 2016. June 2013-December 2014 was excluded as a theoretical period necessary for obstetrical practices to implement the revised guidelines., Results: Overall, prenatal diagnosis occurred in 55% of infants with critical outflow tract anomalies; of the three most common defects, prenatal diagnosis occurred in 53% of D-transposition of the great arteries, 63% of tetralogy of Fallot, and 80% of double outlet right ventricle patients. Pre-guidelines, prenatal diagnosis occurred in 52% (52 of 102) infants with critical outflow tract anomalies requiring early cardiac intervention. Post-guidelines, prenatal diagnosis occurred in 61% (33 of 54) infants, not significantly different than the prenatal detection rate pre-guidelines (P = .31)., Conclusions: Despite revised obstetrical guidelines highlighting the importance of outflow tract imaging, referrals and prenatal diagnosis of these types of critical congenital heart disease remain low. Education of obstetrical sonographers and practitioners who perform fetal anatomic screening is vital to increase referrals and prenatal detection of critical outflow tract anomalies., (© 2018 Wiley Periodicals, Inc.)

Background: Poor emergency obstetric care has been shown by national confidential enquiries into maternal deaths to contribute to a number of maternal deaths in South Africa., Objectives: To assess whether a structured training course can improve knowledge and skills and whether this can influence the capacity of a healthcare facility to provide basic and comprehensive emergency obstetric care signal functions., Methods: A baseline survey was conducted to assess the seven basic emergency obstetric and neonatal care signal functions in 51 community health centres (CHCs) and the nine comprehensive emergency care signal functions in 62 district hospitals (DHs). A re-assessment was conducted 1 year after saturation training had been provided in each district. The delegates were trained using a structured training programme (Essential Steps in Managing Obstetric Emergencies, ESMOE) and their knowledge and skills were tested before and after the training. Saturation training was considered to have been achieved once 80% of the healthcare professionals involved in maternity care had been trained., Results: There was a significant improvement in the knowledge and skills of doctors, namely by 16.8% and 32.8%, respectively, of advanced midwives by 13.7% and 29.0%, and of professional nurses with midwifery by 16.1% and 31.2%. The seven basic emergency care functions improved from 60.8% to 67.8% in the CHCs and from 90.7% to 92.5% in the DHs before and after training. If the two signal functions that are not within the scope of practice of professional nurses with midwifery are excluded (viz. assisted delivery and manual vacuum aspiration), the functionality of CHCs increased from 85.1% to 94.9%., Conclusions: The ESMOE training programme improved knowledge and skills, but there was a modest improvement in the functionality of the facilities. Improvement in functionality requires changes in the structure of the health system, including changing the scope of practice of professional nurses with midwifery and employing more advanced midwives in CHCs.

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.