ABSTRACT
Obstetrician-gynecologists (OB-GYNs) are the fourth largest group of physicians and the only specialty dedicated solely to women's health care. The specialty is unique in providing 24-hour inpatient coverage, surgical care and ambulatory preventive health care. This article identifies and reviews changes in the OB-GYN workforce, including more female OB-GYNs, an increasing emphasis on work-life balance, more sub-specialization, larger group practices with more employed physicians and, finally, an emphasis on quality and performance improvement. It then describes the evolution of the OB-GYN hospitalist movement to date and the role of OB-GYN hospitalists in the future with regard to these workforce changes.
Subject(s)
Gynecology , Hospitalists/organization & administration , Obstetrics , Quality Improvement/standards , Quality of Health Care/standards , Women's Health , Career Choice , Cost-Benefit Analysis , Female , Gynecology/trends , Health Knowledge, Attitudes, Practice , Hospitalists/trends , Humans , Job Satisfaction , Male , Obstetrics/trends , Practice Patterns, Physicians' , WorkloadSubject(s)
Delivery of Health Care/standards , Gynecology , Hospitalists/statistics & numerical data , Obstetrics , Quality of Health Care/standards , Career Choice , Cost-Benefit Analysis , Female , Gynecology/standards , Health Care Surveys , Humans , Job Satisfaction , Obstetrics/standards , Practice Patterns, Physicians' , United States , WorkforceABSTRACT
Ninety-three percent of pediatric AIDS cases are the result of perinatal HIV transmission, a disease that is almost entirely preventable with early intervention, which reduces the risk of perinatal HIV infection from 25% to <2%. The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics both recommend routine HIV testing of all pregnant women and at-risk newborn infants. When pregnant women decline HIV testing and/or treatment, public health, legal, and ethical dilemmas can result. Federal courts consistently uphold a woman's right to refuse medical testing and treatment, even though it may benefit her fetus/newborn infant. Federal courts also reliably respect the rights of parents to make health care decisions for their newborn infants, which may include declining medical testing and treatment. Confusing the issue of HIV testing and treatment, however, is the fact that there is no definitive United States Supreme Court ruling on the issue. State laws and standards vary widely and serve as guiding principles for practicing clinicians, who must be vigilant of ongoing legal challenges and changes in the states in which they practice. We present a case of an HIV-positive pregnant woman who declined treatment and then testing or treatment of her newborn infant. Ultimately, the legal system intervened. Given the rarity of such cases, we use this as a primer for the practicing clinician to highlight the public health, legal, and ethical issues surrounding prenatal and newborn infant HIV testing and treatment in the United States, including summarizing key state-to-state regulatory differences.
Subject(s)
HIV Infections/transmission , Infant Welfare/legislation & jurisprudence , Infectious Disease Transmission, Vertical/legislation & jurisprudence , Pregnancy Complications, Infectious/diagnosis , Treatment Refusal/legislation & jurisprudence , Anti-HIV Agents/therapeutic use , Female , HIV Infections/diagnosis , HIV Infections/drug therapy , Humans , Infant Welfare/ethics , Infant, Newborn , Infectious Disease Transmission, Vertical/ethics , Informed Consent , Patient Rights/ethics , Patient Rights/legislation & jurisprudence , Pregnancy , Pregnancy Complications, Infectious/drug therapy , Public Health , Treatment Refusal/ethics , United States , Young AdultABSTRACT
OBJECTIVE: To develop a model to predict vaginal birth after cesarean (VBAC) in our population and to compare the accuracy of this model to the accuracy of a previously published widely used model. MATERIALS AND METHODS: Women attempting trial of labor after cesarean delivery (TOLAC) at our institution from January 1, 2000 through May 30, 2010 were evaluated for inclusion. Demographic and clinical data were collected. Associations of these characteristics with VBAC were evaluated with univariate and multivariate logistic regression. We critically compared the accuracy of the resulting model to a previously published widely utilized model for predicting VBAC. RESULTS: A total of 2,635 deliveries with at least 1 prior cesarean delivery were identified. TOLAC was attempted in 599 (22.7%) and resulted in 456 VBACs (76.0%) and 143 repeat cesareans (24.0%). VBAC success was independently associated with age <30 years, a body mass index <30, prior vaginal delivery, prior VBAC, and absence of a recurrent indication for cesarean. This model provided a range of successful probability of VBAC (38-98%) with an area under the receiver operating characteristic curve of 0.723. CONCLUSIONS: This study provides an accurate and simple model that can be utilized to guide decisions related to TOLAC.
Subject(s)
Cesarean Section, Repeat/statistics & numerical data , Models, Statistical , Nomograms , Trial of Labor , Vaginal Birth after Cesarean/statistics & numerical data , Adolescent , Adult , Cohort Studies , Female , Humans , Logistic Models , Middle Aged , Pregnancy , ROC Curve , Young AdultABSTRACT
A supportive medical team should be well informed on the various pharmacologic and nonpharmacologic modalities of coping with or mitigating labor pain to appropriately support and respectfully care for parturients. Using the methodical rigor of previously published Cochrane systematic reviews, this summary evaluates and discusses the efficacy of nonpharmacologic labor analgesic interventions.
Subject(s)
Analgesia, Obstetrical/methods , Labor Pain/therapy , Acupressure/methods , Acupuncture Analgesia/methods , Aromatherapy/methods , Doulas , Evidence-Based Medicine , Female , Humans , Hydrotherapy/methods , Hypnosis/methods , Pregnancy , Relaxation Therapy/methods , Social Support , Transcutaneous Electric Nerve Stimulation/methods , Treatment Outcome , YogaABSTRACT
Although some women want to experience childbirth without medications, most women in the United States labor with an epidural or spinal analgesic. Epidurals provide relatively consistent pain relief, are long-lasting, can be titrated according to the analgesic needs of the mother, and can be bolused for procedures such as forceps, vacuum, or cesarean delivery. But they can have undesirable side effects including lower-extremity motor block, hypotension, urinary retention, and pruritus, and they may increase the risk for a slightly prolonged labor, a forceps or vacuum delivery, and fever during labor. This article describes the current thinking regarding labor analgesia and how anesthesiologists and obstetricians can help women have a birth experience that is both safe and satisfying.