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Background: The disease and treatment burden of uterine fibroids (UF) in Black women is substantially greater compared with other racial groups, with higher rates of complications and poorer outcom...

Over the past decade, increasing attention has been paid to intervening in individuals' health in the "preconception" period as an approach to optimizing pregnancy outcomes. Increasing attention to the structural and social determinants of health and to the need to prioritize reproductive autonomy has underscored the need to evolve the preconception health framework to center race equity and to engage with the historical and social context in which reproduction and reproductive health care occur. In this commentary, we describe the results of a meeting with a multidisciplinary group of maternal and child health experts, reproductive health researchers and practitioners, and Reproductive Justice leaders to define a new approach for clinical and public health systems to engage with the health of nonpregnant people. We describe a novel "Reproductive and Sexual Health Equity" framework, defined as an approach to comprehensively meet people's reproductive and sexual health needs, with explicit attention to structural influences on health and health care and grounded in a desire to achieve the highest level of health for all people and address inequities in health outcomes. Principles of the framework include centering the needs of and redistributing power to communities, having clinical and public health systems acknowledge historical and ongoing harms related to reproductive and sexual health, and addressing root causes of inequities. We conclude with a call to action for a multisectoral effort centered in equity to advance reproductive and sexual health across the reproductive life course.

Physicians are experiencing overwhelming demands to generate revenue and complete ever-increasing administrative tasks. Whether employed by large health systems, academic centers or still struggling in small private practices, the autonomy so valued by medical professionals, and our ability to influence policies impacting our patients and the public, has diminished. In order to regain the joy in practicing medicine and overcome the sense of "burn-out" and frustration so many of us experience, it is essential to dedicate ourselves to becoming leaders in our communities, in our institutions and in our medical schools. We must apply the triad of evidence-based medicine - the data derived from randomized clinical trials, our learned experience, and our patients' values - to become leaders in the path towards reasoned public policy and institutional procedures that improve the care for individual patients and the community. Through advocacy and leadership, we can re-engage with the passion that drove us to our profession and renew our commitment to the patients we serve. The energy and time required for these activities will be more than repaid with joy and passion in our daily work and a sense of purpose in our lives.

Summary In high-income countries, medical interventions to address the known risks associated with pregnancy and birth have been largely successful and have resulted in very low levels of maternal and neonatal mortality. In this Series paper, we present the main care delivery models, with case studies of the USA and Sweden, and examine the main drivers of these models. Although nearly all births are attended by a skilled birth attendant and are in an institution, practice, cadre, facility size, and place of birth vary widely; for example, births occur in homes, birth centres, midwifery-led birthing units in hospitals, and in high intervention hospital birthing facilities. Not all care is evidenced-based, and some care provision may be harmful. Fear prevails among subsets of women and providers. In some settings, medical liability costs are enormous, human resource shortages are common, and costs of providing care can be very high. New challenges linked to alteration of epidemiology, such as obesity and older age during pregnancy, are also present. Data are often not readily available to inform policy and practice in a timely way and surveillance requires greater attention and investment. Outcomes are not equitable, and disadvantaged segments of the population face access issues and substantially elevated risks. At the same time, examples of excellence and progress exist, from clinical interventions to models of care and practice. Labourists (who provide care for all the facility's women for labour and delivery) are discussed as a potential solution. Quality and safety factors are informed by women's experiences, as well as medical evidence. Progress requires the ability to normalise birth for most women, with integrated services available if complications develop. We also discuss mechanisms to improve quality of care and highlight areas where research can address knowledge gaps with potential for impact. Evaluation of models that provide woman-centred care and the best outcomes without high costs is required to provide an impetus for change.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

Advancing the quality and safety of maternity care should be data-driven. Defining a standard set of clinical data elements, across electronic health record platforms and facilities, could accelerate performance measurement, benchmarking, and identification of better practices. In 2014, the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists launched the Maternal Quality Improvement Program, a data-driven national clinical registry for maternity care. Having an agreed-on set of discrete data elements related to labor and delivery will set the stage for analysis of this care. Through the use of clinical performance measures and data quality metrics, the Maternal Quality Improvement Program will provide an opportunity for health care providers to better understand the overall quality and safety of the maternity care provided within their institution.

Recognition of the need to reduce maternal mortality and morbidity in the United States has led to the creation of the National Partnership for Maternal Safety. This collaborative, broad-based initiative will begin with three priority bundles for the most common preventable causes of maternal death

Surgical site infections are the most common complications of surgery in the United States. Of surgeries in women of reproductive age, hysterectomy is one of the most frequently performed, second only to cesarean birth. Therefore, prevention of surgical site infections in women undergoing gynecologic surgery is an ideal topic for a patient safety bundle. The primary purpose of this safety bundle is to provide recommendations that can be implemented into any surgical environment in an effort to reduce the incidence of surgical site infection. This bundle was developed by a multidisciplinary team convened by the Council on Patient Safety in Women's Health Care. The bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. In addition to recommendations for practice, each of the domains stresses communication and teamwork between all members of the surgical team. Although the bundle components are designed to be adaptable to work in a variety of clinical settings, standardization within institutions is encouraged.

Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.

The recent focus on health care safety is a response to the central ethical tenet of medicine--to do no harm. The delivery of safe hospital care has led to demonstrable reductions in medical errors, adverse events, and patient injuries. These improvements have led to a commensurate reduction of legal risk and the emotional toll on caregivers as well as families. It also has reinvigorated the reason many physicians went into medicine--to make a difference for women's health. The new, voluntary Safety Certification in Outpatient Practice Excellence (SCOPE) for Women's Health program of the American Congress of Obstetricians and Gynecologists is a means to both evaluate and recognize work in a critical but often neglected arena--the outpatient setting. It builds on infrastructure created for safety programs in hospital settings. Strong physician leadership, the development of an office culture committed to safety, communication and teamwork skills, safety programs for office-based surgery, medication safety, and tracking systems are all important for safe treatment of our patients in the office setting. The SCOPE Program defines the necessary safety goals for ambulatory women's health care and provides an educational pathway to reach those goals. SCOPE certification is an achievement recognizing the commitment of physicians and their staff to the health and safety of their patients.

Study objective To examine the reliability and practicality of performing office-based transvaginal ultrasound for determining the ease of locating the Essure hysteroscopic sterilization micro-insert and compare its usefulness against established radiologic evaluations. Design Prospective single-center, single-arm, clinical study (Canadian Task Force classification xx). Setting Hospital-based clinical research center. Patients One hundred forty-five women of reproductive age and proven fertility. Intervention Thirty-seven women who underwent the Essure hysteroscopic method of sterilization had routine radiologic and transvaginal ultrasound assessments for determining the retention of these micro-inserts from 3 months to 2 years after placement. An additional 108 women had ultrasound assessment as the only means of micro-insert localization 3 months after placement. Measurements and main results The 145 women (100%) who underwent an ultrasound assessment at a 3-month, posthysteroscopic-sterilization office visit had their micro-inserts readily identified and localized to the uterotubal area due to the micro-inserts’ dense echogenic properties. For the 37 women who had both assessments, the ultrasound findings correlated with pelvic radiograph and hysterosalpingogram assessments of micro-insert location in all instances. In addition, the ultrasound evaluations provided additional information about the micro-inserts relative position to the surrounding, less-echogenic soft tissue structures of the upper uterotubal area. In the 37 women who had serial ultrasound and radiologic evaluations performed for up to 2 years after micro-insert placement, ultrasound was found to be equally effective in identifying the location of the micro-inserts and indicted that their position remained identifiable and stable over time. Conclusion A single transvaginal ultrasound in-office examination, performed 3 months after hysteroscopic micro-insert placement, was found to be a simple, reliable, and convenient method of assessing micro-insert location, when compared with radiologic assessments.

OBJECTIVE: To compare blood loss and procedure time of vaginal hysterectomy using an electrosurgical bipolar vessel sealer versus using sutures. METHODS: Sixty patients scheduled for vaginal hysterectomy in a single surgical practice were randomized to either electrosurgical bipolar vessel sealer or sutures as the hemostasis technique. Procedure time was defined as time from initial mucosal injection to closure of the vaginal cuff with satisfactory hemostasis. Blood loss was estimated by the anesthesia service. Statistical methodology included the Student t and Wilcoxon rank-sum tests, and all comparisons were two tailed, with P

In 1997 the Board of the AAGL decided to use its surveying capacity to learn more about its membership with respect to current practices, including office procedures, types of patients, drug prescriptions, and fees and reimbursement. A list of such questions was sent to 6058 members in July 1997, and responses were analyzed from October to February 1998. The purpose was to provide information about who and what our membership currently is and how we practice, as well as to inform potential vendors as to the nature of the AAGL membership for their marketing considerations. Information of primary interest to fiscal and commercial purposes will be used by the AAGL for the benefit of its members. Information relevant to dayto-day practice is presented here.

The following article will give you the opportunity to assess your understanding and knowledge of the material and earn continuing medical education (CME) credit. Review articles will be published in many issues of the Journal of the American Association of Gynecologic Laparoscopists. They will be designated as course reading and offer physicians a chance to earn up to 1 CME credit hour per article.

Study Objective To identify factors that might contribute to pregnancies reported after hysteroscopic sterilization worldwide. Design Retrospective review of commercial data compiled from the MAUDE database, medical literature, and manufacturer reports received during commercial distribution of hysteroscopic sterilization micro-inserts from 2001 through 2010 (Canadian Taskforce classification III descriptive study). Measurements and Main Results From 2001 through 2010, 497 305 hysteroscopic sterilization kits were distributed worldwide, and 748 pregnancies were reported, i.e., 0.15% of the estimated user population based on the number of distributed kits. The data were sufficient to enable analysis of 508 pregnancies for potential contributing factors and showed most to be associated with patient or physician noncompliance (n = 264) or misinterpreted confirmation tests (n = 212). Conceptions deemed to have occurred within 2 weeks of the procedure and therefore too early for detection were identified in 32 cases. Conclusion Although there are limitations to the dataset and the study design is retrospective, it represents the largest body of cumulative hysteroscopic sterilization data available to date. Of the 748 pregnancies reported, it is apparent that some might have been prevented with greater patient and clinician attention to interim contraceptive use and counseling and with more rigorous evaluation and informed interpretation of the procedure confirmation tests. Although the estimated pregnancy rate based on such a dataset is likely an underestimation, it does suggest that the evaluable field performance of hysteroscopic sterilization micro-inserts is consistent with the labeled age-adjusted effectiveness of 99.74% at 5 years.

As we embark on our twenty-fifth year let's take a few moments to evaluate our course. Can we measure our progress in real improvement in health care for women, or are we looking at shadows on the sand? Medicine has changed dramatically since the AAGL was founded in 1971. Laparoscopy has been transformed from a diagnostic tool into an approach for even the most complex of operative procedures. Reflections, however, give us pause to evaluate the direction of our journey. What roads have we traveled and where are we headed? Have we defined our goals and do we know which way to go? Is all this progress benefiting our patients? How do we measure the success of our journey? Over the past century medicine evolved from Sir William Osler's study of the diagnosis and prognosis of disease to the science of treating and curing disease using technologies and pharmacology beyond comprehension only a few decades--and sometimes only a few years--ago. The extraordinary pace of development has left little time for us to contemplate or evaluate our achievements. Without question we have successfully accomplished remarkable technologic feats. Surgical practice, the art, the craft, and more recently the science, has always been defined by its tools. Let us remember, however, that the quality of our journey will not be measured by new inventions. Ultimately it will be measured by our ability to affect the health and well-being of our patients and to improve the quality of their lives. We risk falling in love with technology, but will this compromise the care we provide? As technology swiftly develops we must understand the difference between seeing and vision. Only vision will enable us to incorporate these advances appropriately as instruments for healing. Endoscopy began as a relatively crude and invasive diagnostic procedure. The ability to harness and amplify light triggered provided an impetus for advances in the firle. We have come a great distance from Max Nitze's electrically lighted cystoscope in 1879 to the fiberoptic microendoscope in 1995. Surgery, which began as a magical art, changed and grew into a science with the integration of physiology, pathology, and technology. Endoscopic surgery was initiated by Nitze's adaptation of electric light for the cystoscope. He performed endoscopic excision of bladder tumors in situ in the 1890s, but his tools were crude by our standards. Progress in surgical instrumentation and surgical techniques went hand in hand. 1 Yet many surgeons continue to function as technicians, incorporating new procedures without first subjecting them to the rigors of scientific study. Science and technology enable us to perform intricate surgical procedures successfully. We have demonstrated that many things can be done endoscopically, but should they be? We now have smaller, clearer, cheaper instruments with which to view and manipulate the organs of the human body. Have they improved the health of patients? Are they safe, useful, or cost effective? Is our ability to look directly at the abdomen, pelvis, and uterus an advantage? We can easily be seduced by more refined technology, computerized tomographic scans, magnetic resonance imaging, and endoscopy. However, our enthusiasm for everything new must be justified with

Our AAGL family lost a treasured friend and colleague on February 4th. Jay Cooper, our 26th president, was the quintessential academic clinician. Early on, and throughout his career, Jay not only sustained a successful private practice but also actively participated in clinical research. He left an unsurpassed legacy in minimally invasive gynecologic surgery. His intelligence, innovations, and integrity will continue to be benchmarks for all of us. Jay had clarity of vision and a unique gift for communication. His passion for excellence in women's healthcare in research and in surgical education was unwavering over the 30 years of his career. Above all, however, Jay's dedication to the important values in life—his dedication to family and friends; his sense of balance; and his teaching, guidance, wisdom, and support—has left a lasting legacy among those of us privileged to know him. We dedicate this issue of the Journal of the AAGL to Jay.

Objective To present tactics for optimizing outpatient vaginal hysterectomy and describe perioperative outcomes in a large consecutive case series. Methods This is a descriptive study and review of clinical outcomes in 1,071 patients selected to undergo vaginal hysterectomy for benign indications from 2000 to 2010. The setting is a single-surgeon private practice in a community hospital. Outcome measures include length of hospital stay, estimated blood loss, operative time, uterine weight, and perioperative complications, including hospital readmissions and emergency room visits. Results One thousand seventy-one of 1,162 cases (92%, 95% confidence interval [CI] 90.5-93.7) were total vaginal hysterectomies, of which 1,029 (96%, 95% CI 94.9-97.3) were discharged the same day after surgery. The median operative time was 34 minutes (range 17-210 minutes), and estimated blood loss was 45 mL (range 5-800 mL). The median patient age was 46 years (range 27-86 years), and median uterine weight was 160 g (range 25-1,380 g). One hundred ninety-three patients (18%, 95% CI 15.8-20.5) were nulliparous and 218 (20%, 95% CI 18-22.9) had prior pelvic surgery. Five patients (0.5%, 95% CI 0.2-1.1) required readmission or emergency room evaluation within the first 30 days. Conclusion Vaginal hysterectomy can be successfully adopted as a same-day discharge procedure. In this population, regardless of previous pelvic surgery or nulliparity, good perioperative outcomes have been achieved.

Study Objective Current Procedural Terminology and ICD-9-CM codes are tools used in clinical medicine to define work done and diagnoses or conditions for which the work was performed. It is important that all physicians become knowledgeable about these schemes to describe services provided correctly and accurately.

Uterine fibroids are the most common tumor of the reproductive tract in women of reproductive age. Although they are benign tumors that are often asymptomatic, uterine fibroids may cause debilitating symptoms in many women, such as abnormal uterine bleeding, abdominal pain, increased abdominal girth, urinary frequency, constipation, pregnancy loss, dyspareunia, and in some cases infertility. Several approaches are available for the treatment of uterine fibroids. These include pharmacologic options, such as hormonal therapies and gonadotropin-releasing hormone agonists; surgical approaches, such as hysterectomy, myomectomy, myolysis, laparoscopic uterine artery occlusion, magnetic resonance imaging-guided focused ultrasound surgery, and uterine artery embolization. The choice of approach may be dictated by factors such as the patient's desire to become pregnant in the future, the importance of uterine preservation, symptom severity, and tumor characteristics. New treatment options for uterine fibroids would be minimally invasive, have long-term data demonstrating efficacy and safety, have minimal or no incidence of fibroid recurrence, be easy to perform, preserve fertility, and be cost effective. New treatment approaches are under investigation, with the goals of being effective, safe, and less invasive.

The purpose of this article is to describe 64 unintended pregnancies reported by patients who had undergone hysteroscopic sterilization and to provide recommendations for avoiding post-procedure pregnancies. Sixty-four pregnancies out of an estimated 50,000 procedures were reported to the device manufacturer from 1997 through December 2005. Most occurred in patients without appropriate follow-up. Other causes included misread hysterosalpingograms, undetected preprocedure pregnancies, and failure to follow product-labeling guidelines. The risk of pregnancy with hysteroscopic sterilization may be reduced by educating patients about the necessity of follow-up, ensuring that patients use effective contraception before and after placement, following the instructions for use, and adhering to the hysterosalpingography protocol.

Objective To evaluate a management protocol based on scientific evidence in the care of patients undergoing vaginal hysterectomy. Study design (Canadian Task Force classification II-2). Setting 110-bed community hospital. Patients Women with vaginal hysterectomy between 2000 and 2003. Intervention Data were collected on all vaginal hysterectomies performed by a single surgeon over a 4-year period. Demographics, surgical indications, procedural parameters, length of stay, and postoperative complications were evaluated. Hospital costs for all vaginal hysterectomies performed over a 2-year period at the same hospital also were examined. An analysis of the literature was performed to develop a protocol for optimizing patients’ surgical experience. All patients were managed using the protocol. These patients were compared with a cohort at the same institution. Measurements and main results Four hundred twelve vaginal hysterectomies were performed by the lead author during the 4-year time period. Three hundred eighty-four patients (93%) were discharged within 12 hours of admission. There were no readmissions for bleeding, pain management, urinary retention, or nausea and vomiting. Four hundred nineteen vaginal hysterectomies were performed by 10 surgeons from 2002 through 2003 at the same institution, including 219 by the lead author. The average direct cost for outpatient vaginal hysterectomy was 21.3% lower than for inpatient vaginal hysterectomy. Conclusion Incorporating a protocol based on scientific evidence into the management of surgical patients facilitated safe outpatient vaginal hysterectomy in a majority of patients. This optimized management may save up to 25% of the cost for these procedures.

roscopists (AAGL) has been conducting membership surveys since 1976. Originally, surveys were designed to evaluate only sterilization techniques. As increasingly complicated operative laparoscopic operations became more widely accepted, it was apparent that laparoscopic-assisted vaginal hysterectomy (LAVH) was the most significant surgical procedure performed by most of the membership. Since 1989 the AAGL has actively attempted to document various aspects of LAVH through surveys of its members. The first survey in 1995 attempted to gain information as to current performance of the procedure and to assess relative frequencies and complications. Dr. Barbara S. Levy, who designed the 1995 survey with Drs. Jaroslav F. Hulka and William H. Parker, wrote this instrument, which was developed with few modifications from the earlier one to allow comparisons to be made between time periods. A total of 4437 surveys were mailed to AAGL members and contained 50 questions on laparoscopy, particularly LAVH, performed from January 1, 2000, to December 31, 2000. As in all AAGL surveys, the replies were strictly anonymous and confidential so that reporting of complications might be as frank as possible.

A questionnaire was mailed to all members of the AAGL to determine the current performance of laparoscopic-assisted vaginal hysterectomy (LAVH), and to assess the relative frequencies of techniques and complications. Answers of the 1092 members who responded were entered into a database computer program and analyzed. The analysis revealed 14,911 LAVHs performed by 767 members. Complication rates appeared to be in the same range as those reported for vaginal hysterectomy and total abdominal hysterectomy. Inferior epigastric injury was the most common complication. Physicians showed a shift in their practices away from abdominal hysterectomy after they learned LAVH.

The clinical anesthesia, general surgery, and gynecology literature addressing the pathophysiology and management strategies for perioperative pain were reviewed. There are few prospective, randomized studies from which to draw meaningful conclusions. Nevertheless, a theoretical construct has been developed which may help the gynecologic surgeon optimizing pain management. The era of managed care and shorter hospital stays has focused physicians and, in particular, surgeons on elements of patient care that can be addressed and improved. Reducing or eliminating postoperative pain without excessive sedation promotes rapid mobilization and return to self-care. Strategies for pain management can be adopted that reduce postoperative ileus and other adverse reactions to analgesics.

cal complications comes from studying the accumulated experiences of others. In gynecology, rates for major complications are low, on the order of 1% to 2%. Most of us are statistically unlikely to see many devastating injuries, therefore it is critical for us to understand the etiology, characteristics, and treatment of these complications if we are to recognize and manage them appropriately when they do occur. And they will occur. I have reviewed gynecologic surgery cases for plaintiff and defense attorneys as well as hospitals and insurance companies since 1984. This experience has been enlightening and highly educational. I now evaluate potential surgical patients with a more careful assessment of the risk: benefit ratio and intervention, and I am a more cautious surgeon when I enter the operating room. Having vicariously witnessed the severe consequences of surgical injuries, I am consciously meticulous both technically and in decision making in the surgical suite as well as in postoperative management of patients. In reality, medical litigation cases are about adverse outcomes and resulting patient injury, not about negligent medical care. In gynecology, most particularly with minimally invasive surgery, patient and surgeon expectations for rapid recovery and excellent outcomes are high. Unfortunately, no surgery is without complications, and substantial patient injuries occur despite our best effort to avoid them. In this issue of the journal Corson and colleagues accumulated a series of litigation cases involving laparoscopic entry injuries. We should consider litigation as a proxy for significant adverse outcomes in these procedures, since the cost of discovery and deposition of legal cases is prohibitive enough to prevent most cases that result in insignificant damage from reaching court. This series likely represents the tip of the iceberg; that is, complications that were related to patient injuries important enough to warrant the time and expense of litigation. We know from published reports that a minimum of 25% of practicing