The obstetrical emergency department: need, rationale, and guide to implementation.

The past 2 decades have seen dramatic growth in the number of obstetrics and gynecology hospitalists, and many hospitals have created obstetrical-specific emergency departments. The goals of an obstetrics emergency department are to provide safe and efficient care to the pregnant dyad and postpartum patient, while generating revenue for emergency services provided. In an obstetrics emergency department, all patients must be evaluated in person by a licensed practitioner, whereas historically they may have been evaluated in person by nursing staff or a trainee. We make the argument that formation of an obstetrics emergency department has the potential to improve the safety and quality of patient care. In addition, the financial benefits to institutions are substantial and can subsidize the cost of maintaining obstetrician presence all the time in the hospital. There are various regulatory requirements to become certified, accredited, and licensed as an emergency department. In addition, there are many operational and systems issues that institutions should consider before implementation. We provide a guide for healthcare systems considering creating an obstetrics emergency department.

Out of Sight, Out of Mind or Just Something in the Way? Visual Barriers Do Not Reduce Intraspecific Agonism in an All-Male Group of Nile Crocodiles (Crocodylus niloticus).

Here, we evaluated if visual barriers could reduce intraspecific agonism in an all-male group of Nile crocodiles (Crocodylus niloticus) living in a zoo. Crocodiles were monitored for nearly 100 h, and four "hotspots" of aggression within their exhibit were identified. Within these four locations, visual barriers were placed at the surface of the water with the goal of reducing agonism by targeting sight lines associated with their species-typical minimum exposure posture, where crocodiles submerge their body but maintain facial sensory organs above the water line. Crocodile behavior was then monitored for 226 h, evaluating both short- and long-term effects of the visual barriers. In both observation periods, intraspecific agonism was unaffected by visual barriers. However, crocodiles were more likely to be on land and closer together, after the barriers were installed, showing the barriers affected nonagonistic behaviors. Monitoring of such unintended effects is significant to ensure no welfare concerns are created in any exhibit or husbandry modification attempt. Additionally, time of day and temperature were significant predictors of behavior, highlighting the importance of such factors in the analysis of reptilian behavior. While ineffective at reducing agonism, this is the first published study evaluating exhibit design and behavior of crocodilians in zoos and aquariums. The methodologies and findings here should provide useful information for future behavioral and welfare studies of this understudied taxa.

Subspecific identity and a comparison of genetic diversity between wild and ex situ wildebeest.

The original North American ex situ wildebeest population was believed to originate from the white-bearded wildebeest (Connochaetes taurinus albojubatus), which is both morphologically distinct and geographically separated from the brindled wildebeest (C. t. taurinus). However, after an import of wildebeest into North America in 2001, managers have suspected that white-bearded and brindled wildebeest were mixed in herds at multiple institutions. We sequenced the mitochondrial control region (d-loop) from a portion of the managed North American population and compared our sequences with previously published sequences from wild individuals to determine the subspecific identity and genetic diversity of our ex situ population. We were able to confidently identify C. t. albojubatus as the subspecies identity of the sampled portion of our population. Within our population, haplotype and nucleotide diversity were low (0.169 and 0.001, respectively) with a single common haplotype (H1) containing 41 of the 45 individuals sequenced, while two rare haplotypes (H2 and H3) were derived from three individuals and a single individual, respectively. Nucleotide and haplotype diversity were greater overall in the wild populations compared with our managed population. However, C. t. albojubatus was found to exhibit lower nucleotide diversity in both wild and ex situ populations when compared to other wild subspecies. Though the overall goal of the North American wildebeest population is for public education and not reintroduction, maintaining genetic diversity is vital for the long-term viability of this managed population, which may benefit from periodic supplementation of wild animals.

An updated assessment of postpartum sterilization fulfillment after vaginal delivery.

OBJECTIVE: To describe sterilization completion rates after vaginal delivery and indications for unfulfilled procedures. STUDY DESIGN: We used labor and delivery operating room and delivery logs to identify all women over 20years of age with a completed live vaginal birth beyond 24weeks gestation over a 33-month period (March 1, 2012 to November 30, 2014). We reviewed the electronic medical records of all of these patients and identified those who requested a sterilization procedure as indicated in a physician's admission note or antenatal record. RESULTS: We identified 3514 live vaginal births beyond 24weeks gestation during the study period of which 219 requested postpartum sterilization. Sterilization occurred in 114 (52%). The most common reason for unfulfilled procedures was lack of valid federally mandated consent (n=46 [44%]). Fifty-nine percent (27 of 46) of these women had little or no prenatal care. Only one (0.5%) woman had documented completion of consent with the required time elapsed prior to delivery and no consent form available. Of the women with valid consent documentation, the most common indication for an unfulfilled procedure was patient refusal (n=30 [51%]). Body mass index was an independent predictor of an unfulfilled procedure (p<.001) among women with adequate consent. CONCLUSIONS: Inability to complete federally mandated consent is a principal cause of unfulfilled postpartum sterilization and primarily affects women desiring sterilization who lack sufficient prenatal care. Of women who meet consent criteria, the primary reason women eligible for sterilization did not undergo the procedure was due to withdrawing their request. IMPLICATIONS: Because women commonly do not undergo a requested sterilization after vaginal deliveries, antepartum counseling should include alternate contraception choices. Documented consent that fulfills all federally mandated criteria remains the most common barrier to requested sterilization after vaginal delivery; providers and policymakers should work together to help unburden women from this mandate.