Definitions of Obstetric and Gynecologic Hospitalists.

The obstetric hospitalist and the obstetric and gynecologic hospitalist evolved in response to diverse forces in medicine, including the need for leadership on labor and delivery units, an increasing emphasis on quality and safety in obstetrics and gynecology, the changing demographics of the obstetric and gynecologic workforce, and rising liability costs. Current (although limited) research suggests that obstetric and obstetric and gynecologic hospitalists may improve the quality and safety of obstetric care, including lower cesarean delivery rates and higher vaginal birth after cesarean delivery rates as well as lower liability costs and fewer liability events. This research is currently hampered by the use of varied terminology. The leadership of the Society of Obstetric and Gynecologic Hospitalists proposes standardized definitions of an obstetric hospitalist, an obstetric and gynecologic hospitalist, and obstetric and gynecologic hospital medicine practices to standardize communication and facilitate program implementation and research. Clinical investigations regarding obstetric and gynecologic practices (including hospitalist practices) should define inpatient coverage arrangements using these standardized definitions to allow for fair conclusions and comparisons between practices.

Roles of Obstetrician-Gynecologist Hospitalists with Changes in the Obstetrician-Gynecologist Workforce and Practice.

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.

Medical, legal, and ethical challenges associated with pregnancy and catastrophic brain injury.

In late 2013, two women from North America gained attention after sustaining catastrophic brain injuries while pregnant. After Marlise Muñoz--who was at 14 weeks of pregnancy when she developed a pulmonary embolism--was pronounced brain dead, hospital officials initially refused to withdraw support, citing a Texas state law requiring them to maintain life-sustaining treatment for a pregnant patient to help to save the fetus. By contrast, when Robyn Benson was pronounced brain dead after a brain hemorrhage at 22 weeks of pregnancy, both her husband and the physicians agreed to continue support until a viable child could be delivered. The Muñoz and Benson cases offer an opportunity to explore the medical, legal, and ethical issues surrounding catastrophic brain injury in pregnant women. It is hoped that the present article will enable clinicians to better appreciate the history and present state of issues involving advance directives for pregnant women, maternal versus fetal interests, and the impact of fetal viability on medical decision making, as well as offer a practical assessment of the various US state laws concerning the rare, yet catastrophic event of brain injury in a pregnant woman.

Dengue serosurvey in Sint Eustatius.

Four distinct serotypes of dengue viruses (DENV) are the cause of re-emerging dengue fever (DF) and dengue hemorrhagic fever (DHF). Dengue circulation in the Caribbean has gone from none or single serotype to multiple serotypes co-circulating with reports of continuing cycles of progressively more severe disease in the region. Few studies have investigated dengue on Sint Eustatius. Blood samples were collected to determine the prevalence of antibodies against dengue in the Sint Eustatius population. Greater than 90% of the serum samples (184 of 204) were positive for anti-flavivirus antibodies by enzyme linked immunosorbance assay (ELISA). Plaque reduction neutralization test (PRNT), specific for dengue viruses, showed that 171 of these 184 flavivirus antibody positive sera had a neutralization titer against one or more DENV serotypes. A majority of the sera (62%) had neutralizing antibody to all four dengue serotypes. Only 26 PRNT positive sera (15%) had monotypic dengue virus neutralizing antibody, most of which (20 of 26) were against DENV2. Evidence of infection with all four serotypes was observed across all age groups except in the youngest age group (10-19 years) which contained only DENV2 positive individuals. In a multiple logistic regression model, only the length of residence on the island was a predictor of a positive dengue PRNT50 result. To our knowledge this is the first dengue serosurveillance study conducted on Sint Eustatius since the 1970s. The lack of antibodies to the DEN1, 3, and 4 in the samples collected from participants under 20 years of age suggests that only DEN2 has circulated on island since the early 1990s. The high prevalence of antibodies against dengue (83.8%) and the observation that the length of time on the island was the strongest predictor of infection suggests dengue is endemic on Sint Eustatius and a public health concern that warrants further investigation.

When courts intervene: public health, legal and ethical issues surrounding HIV, pregnant women, and newborn infants.

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.

Predicting vaginal birth after cesarean section: a cohort study.

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.

Nonpharmacologic labor analgesia.

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.

Safe and individualized labor analgesia: A review of the current options.

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.