Routine Prenatal Care.

The one-size-fits-all model of prenatal care has remained largely unchanged since 1930. New models of prenatal care delivery can improve its efficacy, equity, and experience through tailoring prenatal care to meet pregnant people's medical and social needs. Key aspects of recently developed prenatal care models include visit schedules based on needed services, telemedicine, home measurement of routine pregnancy parameters, and interventions that address social and structural drivers of health. Several barriers that affect the individual, provider, health system, and policy levels must be addressed to facilitate implementation of new prenatal care delivery models.

The 2015 US Food and Drug Administration Pregnancy and Lactation Labeling Rule.

As of 2015, the US Food and Drug Administration (FDA) discontinued the pregnancy risk categories (ABCDX) that had been used to denote the putative safety of drugs for use among pregnant women. The ABCDX system has been replaced by the FDA Pregnancy and Lactation Labeling Rule (PLLR) that requires narrative text to describe risk information, clinical considerations, and background data for the drug. The new rule includes 3 overarching categories: 1) pregnancy, which includes labor and birth; 2) lactation; and 3) females and males of reproductive potential. This article reviews the key components of the PLLR and clinical implications, and provides resources for clinicians who prescribe drugs for women of reproductive age.

Interprofessional collaborative practice in obstetrics and midwifery.

As the health care system transforms to accommodate an increased need for primary care services and more patients, new models of health care delivery are needed that can provide quality health care services efficiently. An integrated collaborative practice of certified nurse-midwives, obstetrician-gynecologists, and perinatologists is best suited to meet the rapidly changing needs of the maternity health care delivery system. This article reviews the literature on interprofessional collaborative practice and describes the structure, function, and essential elements of successful collaboration in health care.

NIH consensus development conference draft statement on vaginal birth after cesarean: new insights.

OBJECTIVE: To provide health care providers, patients, and the general public with a responsible assessment of currently available data on vaginal birth after cesarean (VBAC). PARTICIPANTS: A non-DHHS, nonadvocate 15-member panel representing the fields of obstetrics and gynecology, urogynecology, maternal and fetal medicine, pediatrics, midwifery, clinical pharmacology, medical ethics, internal medicine, family medicine, perinatal and reproductive psychiatry, anesthesiology, nursing, biostatistics, epidemiology, health care regulation, risk management, and a public representative, and a public representative. In addition, 21 experts from pertinent fields presented data to the panel and conference audience. EVIDENCE: Presentations by experts and a systematic review of the literature prepared by the Oregon Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience. CONFERENCE PROCESS: The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government. CONCLUSIONS: Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision. The data reviewed in this report show that both trial of labor and elective repeat cesarean delivery for a pregnant woman with one prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman, as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about trial of labor compared with elective repeat cesarean delivery. The panel was mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations. One of the panel's major goals is to support pregnant women with one prior transverse uterine incision to make informed decisions about trial of labor compared with elective repeat cesarean delivery. The panel recommends that clinicians and other maternity care providers use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decisionmaking process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When trial of labor and elective repeat cesarean delivery are medically equivalent options, a shared decisionmaking process should be adopted and, whenever possible, the woman's preference should be honored. The panel is concerned about the barriers that women face in gaining access to clinicians and facilities that are able and willing to offer trial of labor. Given the low level of evidence for the requirement for "immediately available" surgical and anesthesia personnel in current guidelines, the panel recommends that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their trial of labor policies and VBAC rates, as well as their plans for responding to obstetric emergencies. The panel recommends that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor. The panel is concerned that medical-legal considerations add to, and in many instances exacerbate, these barriers to trial of labor. Policymakers, providers, and other stakeholders must collaborate in developing and implementing appropriate strategies to mitigate the chilling effect the medical-legal environment has on access to care. High-quality research is needed in many areas. The panel has identified areas that need attention in response to question 6. Research in these areas should be given appropriate priority and should be adequately funded--especially studies that would help to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of trial of labor and elective repeat cesarean delivery.

The 2008 National Institute of Child Health and Human Development report on fetal heart rate monitoring.

Standardization of fetal heart rate (FHR) interpretation and management guidelines has been elusive, and no system is currently widely accepted in the United States. The recently summarized 2008 Eunice Kennedy Shriver National Institute of Child Health and Human Development workshop proposed a three-tier system of interpretation of FHR patterns, but left management recommendations to the professional associations. The middle tier, called indeterminate Category II, which contains the variant FHR patterns seen most frequently, is vast and heterogeneous. We propose that this category can be subcategorized at least tentatively, based on evidence available from previously published studies. Such subcategorization will allow the organizations proposing management recommendations to more readily set up guidelines for graded interventions and clinical responses to the spectrum of FHR patterns, with the aim of minimizing fetal acidemia without excessive obstetric intervention. Such management algorithms will need to be tested by appropriately designed clinical studies.