Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy.

Although perimortem delivery has been recorded in the medical literature for millennia, the procedural intent has evolved to the current fetocentric approach, predicating timing of delivery following maternal cardiopulmonary arrest to optimize neonatal outcome. We suggest a call to action to reinforce the concept that if the uterus is palpable at or above the umbilicus, preparations for delivery should be made simultaneous with initiation of maternal resuscitative efforts; if maternal condition is not rapidly reversible, hysterotomy with delivery should be performed regardless of fetal viability or elapsed time since arrest. Cognizant of the difficulty in determining precise timing of arrest in clinical practice, if fetal status is already compromised further delay while attempting to assess fetal heart rate, locating optimal surgical equipment, or transporting to an operating room will result in unnecessary worsening of both maternal and fetal condition. Even if intrauterine demise has already occurred, maternal resuscitative efforts will typically be markedly improved following delivery with uterine decompression. Consequently we suggest that perimortem cesarean delivery be renamed "resuscitative hysterotomy" to reflect the mutual optimization of resuscitation efforts that would potentially provide earlier and more substantial benefit to both mother and baby.

OB Nest: Reimagining Low-Risk Prenatal Care.

Using a human-centered design method, our team sought to envision a new model of care for women experiencing low-risk pregnancy. This model, called OB Nest, aimed to demedicalize the experience of pregnancy by providing a supportive and empowering experience that fits within patients' daily lives. To explore this topic, we invited women to use self-monitoring tools, a text-based smartphone application to communicate with their care team, and moderated online communities to connect with other pregnant women. Through observations of tool use and patient- and care team-provided feedback, we found that self-measurement and access to a fetal heart monitor provided women with confidence and joy in the progress of their pregnancies while shifting their position to being an active participant in their care. The smartphone application gave women direct access to their care team, provided continuity, and removed hurdles in establishing communication. The online community platform was a space where women in the same obstetric clinic could share nonmedical questions and advice with one another. This created a sense of community, leveraged the knowledge of women, and provided a venue beyond the clinic visit for information exchange. These findings were integrated into the design of the Mayo Clinic OB Nest model. This model redistributes care based on the individual needs of patients by providing self-measurement tools and continuous flexible access to their care team. By enabling women to meaningfully participate in their care, there is potential for cost savings and improved patient satisfaction.

Effectiveness of a Labor Cervical Exam Model in Family Medicine and OB-GYN Residents.

BACKGROUND AND OBJECTIVES: Labor cervical exam accuracy is an essential skill for family medicine and OB-GYN residents to master. To determine the effectiveness of simulation on labor cervical exam training, family medicine and OB-GYN residents were trained using a self-constructed PVC pipe-based cervical exam model during a short and intensive simulation workshop or "boot camp." METHODS: A task trainer was constructed that allows for the blind examination of cervical dilation and effacement. This model was used in the training of first-year family medicine and OB-GYN residents during an 8 day simulation course. A longitudinal comparison of pre- and post-training accuracy was performed. Using a cohort design, the post-training accuracy of first-year family medicine and OB-GYN residents (interns) was also compared to second-fourth year OB-GYN residents. RESULTS: Use of the model by interns (n=25) resulted in significant improvements in the accuracy of their assessments of cervical dilation, but not effacement, and decreased intra-rater variability. When compared to the second-fourth year residents (n=25) who received traditional training, but not simulation training, interns were significantly more accurate and showed less intra-rater variability in their assessments of both dilation and effacement immediately after training compared to their senior colleagues. CONCLUSIONS: Training with the cervical exam model improved interns' accuracy and precision immediately after an 8-day simulation course. Use of this model in resident education may aid in the early stages of training and benefit more experienced trainees by augmenting traditional clinical training.

Shrinking lung syndrome in pregnancy complicated by antiphospholipid antibody syndrome.

BACKGROUND: Shrinking lung syndrome is characterized by pulmonary compromise secondary to unilateral or bilateral paralysis of the diaphragm. CASE: Shrinking lung syndrome was diagnosed in a patient with antiphospholipid syndrome after a cesarean delivery at 28 4/7 weeks of gestation. Signs and symptoms included unexplained right-side chest pain, dyspnea, tachypnea, and absent breath sounds at the right base of the lungs. After initiation of corticosteroids, her symptoms resolved. CONCLUSION: Although seen in association with systemic lupus erythematosus, shrinking lung syndrome has not been described with antiphospholipid syndrome or during pregnancy. Diagnosis and awareness are important because treatment with moderate- to high-dose corticosteroids appears to improve the clinical outcome.

Pregnancy and delivery in patients with fontan circulation: a case report and review of obstetric management.

UNLABELLED: The Fontan connection, originally described in 1971, is used to provide palliation for patients with many forms of congenital heart disease that cannot support a biventricular circulation. An increasing number of women who have undergone these connections in childhood are now surviving into adulthood, and some are becoming pregnant. The low flow and fixed cardiac output of a Fontan circulation pose a number of problems during pregnancy. Here, we report a case of a woman who underwent a Fontan procedure at age 7 and experienced significant cardiovascular decline before successfully delivering a viable infant at 33 weeks gestation. In addition, we reviewed the pertinent published data in this area, which suggests that pregnant patients with a Fontan circulation are more likely to face obstetrical, rather than cardiovascular, complications, including preterm labor, intrauterine growth restriction, an increased risk of cesarean section, and the potential need for anticoagulation. The review provides the obstetrician with the information needed to take a prominent role in the appropriate management of this rare, but growing, patient population. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Leaning Objectives: After completion of this article, the reader will be able to describe the Fontan circulation, describe the importance of the collaborative practice model for patients with Fontan circulation, and identify potential complications in the pregnancy of women with Fontan circulation.