Interprofessional obstetric simulation training improves postpartum haemorrhage management and decreases maternal morbidity: a before-and-after study.

OBJECTIVE: To determine the impact of the Obstetric Simulation Training and Teamwork (OB-STaT) curriculum on postpartum haemorrhage (PPH) rates and outcomes. DESIGN: Before-and-after study. SETTING: Maternity care hospitals within the USA. POPULATION: Patients who delivered between February 2018 and November 2019. METHODS: Interprofessional obstetric teamwork training (OB-STaT) conducted at each hospital. Electronic medical records for deliveries were reviewed for 6 months before and after conducting OB-STaT at participating hospitals. MAIN OUTCOME MEASURES: The PPH rate (blood loss of ≥1000 ml), uterotonic medications used, tranexamic acid use, blood product transfusion, hysterectomy, length of stay and composite maternal morbidity (postpartum haemorrhage, hysterectomy, transfusion of ≥4 units of blood products and intensive care unit admission for PPH). RESULTS: A total of 9980 deliveries were analysed: 5059 before and 4921 after OB-STaT. The PPH rates did not change significantly (5.48% before vs 5.14% after, p = 0.46). Composite maternal morbidity decreased significantly by 1.1% (6.35%-5.28%, p = 0.03), massive transfusions decreased by 57% (0.42%-0.18%, p = 0.04) and the mean postpartum length of stay decreased from 2.05 days (1.05 days SD) to 2.01 days (0.91 days SD) (p = 0.04). Following OB-STaT, haemorrhage medication use increased by 36% (14.8%-51.2%, p = 0.03), the use of tranexamic acid for PPH treatment almost doubled (2.7%-4.8%, p < 0.001) and the rate of hysterectomy significantly increased (0%-0.1%, p = 0.03). CONCLUSIONS: Although the PPH rates did not decrease, OB-STaT significantly improved maternal morbidity, decreased massive transfusions, and improved PPH management by increasing the utilization of uterotonic medications, tranexamic acid and hysterectomy.

Risk Assessment and Treatment Guide for Obstetric Thromboprophylaxis: Comprehensive Review of Current Guidelines.

OBJECTIVE: Currently, there are numerous recommendations and often conflicting guidance provided for venous thromboembolism (VTE) prophylaxis in pregnancy. Our objective was to create a one-page risk assessment and treatment guide based on a review of the most recent and evidence-based publications on this subject to simplify the approach and allow all obstetric patients to be properly assessed for risk of VTE and treated if indicated. STUDY DESIGN: We identified studies by completing a PubMed and MEDLINE search from January of 1980 through March 2017 with articles utilizing a specific combination of the selected general keywords (thrombophilia, pregnancy, VTE, prophylaxis, hypercoagulability, antepartum, postpartum, risk, etc.). We completed the search at the saturation point, meaning that all combinations of the relevant words were directing us to the same articles. After collecting the relevant sources and reviewing them, a total of 10 articles/guidelines were selected for inclusion in the analysis. RESULTS: We outlined every recommendation in the identified articles and guidelines and included any recommendation that was cited in at least three different sources in the final guide. We used American College of Obstetrics and Gynecology recommendations as the base for screening and dosing guidelines and utilized known and published absolute risk values and odds ratios to stratify risk factors. This stratification was used for both antepartum and postpartum recommendations and a single-page guideline was created. CONCLUSION: This compilation of guidelines integrates the complicated topic into a simple comprehensive guide where women can be identified early and accurately for appropriate VTE prophylaxis to protect them during and after pregnancy.

Simulation and Shoulder Dystocia.

Shoulder dystocia is an unpredictable obstetric emergency that requires prompt interventions to ensure optimal outcomes. Proper technique is important but difficult to train given the urgent and critical clinical situation. Simulation training for shoulder dystocia allows providers at all levels to practice technical and teamwork skills in a no-risk environment. Programs utilizing simulation training for this emergency have consistently demonstrated improved performance both during practice drills and in actual patients with significantly decreased risks of fetal injury. Given the evidence, simulation training for shoulder dystocia should be conducted at all institutions that provide delivery services.

Accuracy of the Adverse Outcome Index: An Obstetrical Quality Measure.

BACKGROUND: In obstetrics, a nationally accepted set of quality indicators for patient safety was not available in the United States until the development of a set of 10 adverse outcome measures-the Adverse Outcome Index (AOI). The National Perinatal Information Center (NPIC) developed hospital discharge data-based algorithms combined with a small set of supplemental patient data for calculation of the AOI. A study was conducted to determine the specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of the AOI by using the National Perinatal Information Center (NPIC) algorithm. METHODS: A retrospective chart review of 4,252 obstetrical and neonatal charts from 2003 through 2007 was performed. NPIC definitions were compared with the "gold standard"-chart review. RESULTS: A total of 229 deliveries among the 4,000 randomly selected charts had at least one adverse outcome, reflecting an AOI of 5.7%. For detection of the 10 adverse outcomes within the AOI, the overall sensitivity of the AOI was 81.7%, specificity was 98.2%, PPV was 86.3%, and NPV was 97.4%. The Kappa value for agreement between the coded charts and the chart review was 0.82 (standard deviation=0.01, 95% confidence interval [CI]=0.80-0.85), which is considered very good. DISCUSSION: The AOI is highly reliant on accurate coding and provider documentation and requires validation with manual chart review. Concurrent chart review improves the accuracy of the AOI. Caution is advised when using the AOI as an exclusive measure of assessing obstetric quality because it may be heavily influenced by a single outcome measure; perineal laceration rates represented twice the frequency of all other outcomes combined. The AOI should be modified to better measure preventable adverse events and include a means of accounting for preexisting conditions.

Adaptation of the World Health Organization (WHO) Safe Surgery Checklist for Use With Cesarean Sections: Implementation and Outcomes With the Safe Cesarean Section Checklist.

Introduction The World Health Organization (WHO) Safe Surgery Checklist significantly decreases morbidity and mortality in regular operating room cases. However, significant differences in workflow and processes exist between regular operating room cases and cesarean sections performed on the labor and delivery unit. The aim of this study is to adapt the WHO Safe Surgery Checklist for the labor and delivery unit and cesarean sections to improve communication and patient safety. Methods A multidisciplinary team consisting of all major stakeholders reviewed and revised the WHO Safe Surgery Checklist making it more applicable to cesarean section operations. The new Safe Cesarean Section Checklist was tested and then integrated into the electronic medical record and utilized on the labor and delivery unit. A specific cesarean section safety attitudes questionnaire was developed, validated, and administered prior to and one year after implementation. Results Usage of the Safe Cesarean Section Checklist was greater than 95% after initial implementation. Significant improvements were reported by the staff on the cesarean section attitudes questionnaire for several key areas including the feeling that all necessary information was available at the beginning of the procedure, decreases in communication breakdowns and delays, and fewer issues related to not knowing who was in charge during the procedure. Discussion Implementation of the Safe Cesarean Section Checklist was successfully adopted by the staff, and improvements in staff perceptions of several key safety issues on our unit were demonstrated. Additional studies should be undertaken to determine if clinical outcomes from this intervention are comparable to those seen with the use of the WHO Safe Surgery Checklist.

Emergency physician evaluation of a novel surgical cricothyroidotomy tool in simulated combat and clinical environments.

We sought to investigate the performance of a novel cricothyroidotomy CRIC device compared to the traditional surgical in both simulated combat environments and the emergency department (ED) setting. Twenty U.S. Army staff and resident emergency medicine physicians were randomized to device and simulated setting order and performed cricothyroidotomies in the standard manner and with the CRIC device via the TraumaMan surgical simulator in three simulated settings: the ED, a day combat environment, and a night combat environment. Differences in procedural completion for the two methods in different settings were compared by two-tailed paired t-tests. The occurrence of major and minor procedural complications and questions presented as 5-point Likert scales to describe participants' preferences of cricothyroidotomy methods were compared by chi2 analysis. Time to incision, time to procedural completion, and rate of major and minor complications were not significantly different between the standard surgical method and the CRIC device (p > 0.05). In the simulated ED setting, 60% of participants preferred the standard surgical method (95% confidence interval: 38.5-81.5), whereas in the simulated combat settings, 50% of participants preferred each device (95% confidence interval: 28.1-71.9). In our population, we observed similar operator performance characteristics and physician preferences between the 2 methods in all simulated cricothyroidotomy settings.

Validation of a Simulation-Based Resuscitation Curriculum for Maternal Cardiac Arrest.

OBJECTIVE: To assess the knowledge, skills, and self-efficacy of health care participants completing a simulation-based blended learning training curriculum on managing maternal medical emergencies and maternal cardiac arrest (Obstetric Life Support). METHODS: A formative assessment of the Obstetric Life Support curriculum was performed with a prehospital cohort comprising emergency medical services professionals and a hospital-based cohort comprising health care professionals who work primarily in hospital or urgent care settings and respond to maternal medical emergencies. The training consisted of self-guided precourse work and an instructor-led simulation course using a customized low-fidelity simulator. Baseline and postcourse assessments included multiple-choice cognitive test, self-efficacy questionnaire, and graded Megacode assessment of the team leader. Megacode scores and pass rates were analyzed descriptively. Pre- and post-self-confidence assessments were compared with an exact binomial test, and cognitive scores were compared with generalized linear mixed models. RESULTS: The training was offered to 88 participants between December 2019 and November 2021. Eighty-five participants consented to participation; 77 participants completed the training over eight sessions. At baseline, fewer than half of participants were able to achieve a passing score on the cognitive assessment as determined by the expert panel. After the course, mean cognitive assessment scores improved by 13 points, from 69.4% at baseline to 82.4% after the course (95% CI 10.9-15.1, P <.001). Megacode scores averaged 90.7±6.4%. The Megacode pass rate was 96.1%. There were significant improvements in participant self-efficacy, and the majority of participants (92.6%) agreed or strongly agreed that the course met its educational objectives. CONCLUSION: After completing a simulation-based blended learning program focused on managing maternal cardiac arrest using a customized low-fidelity simulator, most participants achieved a defensible passing Megacode score and significantly improved their knowledge, skills, and self-efficacy.

The case for simulation as part of a comprehensive patient safety program.

Simulation in obstetrics allows us to practice in a safe environment. Simulations can improve the performance of individuals and obstetric teams. The evidence is overwhelming that, with simulated practice, obstetricians improve their technical and communication skills. Evidence is emerging that simulation ultimately may improve clinical outcomes. It stands to reason that simulation in obstetrics should be incorporated into comprehensive patient safety programs.

The Central Simulation Committee (CSC): a model for centralization and standardization of simulation-based medical education in the U.S. Army healthcare system.

In this report, we describe the organizational framework, operations and current status of the Central Simulation Committee (CSC). The CSC was established in 2007 with the goals of standardizing simulation-based training in Army graduate medical education programs, assisting in redeployment training of physicians returning from war, and improving patient safety within the Army Medical Department. Presently, the CSC oversees 10 Simulation Centers, controls over 21,000 sq ft of simulation center space, and provides specialty-specific training in 14 medical specialties. In the past 2 years, CSC Simulation Centers have trained over 50,000 Army medical students, residents, physician assistants, nurses, Soldiers and DoD civilian medical personnel. We hope this report provides simulation educators within the military, and our civilian simulation colleagues, with insight into the workings of our organization and provides an example of centralized support and oversight of simulation-based medical education.

Simulation in Obstetric Emergencies.

Simulation is a critical part of training for obstetric emergencies. Incorporation of this training modality has been shown to improve outcomes for patients and is now required by national accrediting organizations.

Maintaining access to maternal fetal medicine care by telemedicine during a global pandemic.

OBJECTIVE: This study aims to compare a conventional medical treatment model with a telehealth platform for Maternal Fetal Medicine (MFM) outpatient care during the global novel coronavirus pandemic. METHODS: In this study, we described the process of converting our MFM clinic from a conventional medical treatment model to a telemedicine platform. We compared clinical productivity between the two models. Outcomes were analysed using standard statistical tests. RESULTS: We suffered three symptomatic COVID-19 infections among our clinical providers and staff prior to the conversion, compared with none after the conversion. We had a significant decrease in patient visits following the conversion (53.35 visits per day versus 40.3 visits per day, p < 0.0001). However, our average daily patient visits per full-time equivalent (FTE) were only marginally reduced (11.1 visit per FTE versus 7.6 visits per FTE, p < 0.0001), resulting in a relative decrease in adjusted work relative value units (6987 versus 5440). There was an increase in more basic follow-up ultrasound procedures, complexity (current procedural technology [CPT] code 76816 (10.7% versus 19.5%, relative risk [RR] 1.81, 95% CI 1.60-2.05, p < 0.0001)) over comprehensive follow-up ultrasound procedures, CPT code 76805 (17.2% versus 7.8%, RR 0.46, 95% CI 0.39-0.53, p < 0.0001) after conversion. Despite similar proportions of new consults, there was an increase in the proportion of follow-up visits and medical decision-making complexity evaluation and management CPT codes (e.g. 99214/99215) after the conversion (17.2% versus 24.6%, RR 1.43, 95% CI 1.26-163, p < 0.0001). There were no differences between amniocentesis procedures performed between the two time periods (0.3% versus 0.2%, p = 0.5805). CONCLUSION: The rapid conversion of an MFM platform from convention medical treatment to telemedicine platform in response to the novel coronavirus pandemic resulted in protection of healthcare personnel and MFM patients, with only a modest decrease in clinical productivity during the initial roll-out. Due to the ongoing threat from the novel coronavirus-19, an MFM telemedicine platform is a practicable and innovative solution and merits the continued support of CMS and health care administrators.

Correlation between medical management and teamwork in multidisciplinary high-fidelity obstetrics simulations.

BACKGROUND: Teamwork and communication gaps are consistently cited as contributors to adverse outcomes in obstetrics. The Critical Care in Obstetrics Course provides an innovative experience by combining brief interactive didactics with the opportunity to practice and implement the knowledge gained with hands-on simulation. Most participants have never worked together, which creates a unique environment to evaluate the importance of teamwork and communication. OBJECTIVE: This study aimed to evaluate the association between teamwork and medical management in high-fidelity critical care simulations. STUDY DESIGN: The participants were separated into multidisciplinary teams and taken through simulations, including placental abruption, hypertensive emergency, eclampsia, sepsis, cardiac arrest, venous thromboembolism, diabetic ketoacidosis, and thyroid storm. Facilitators completed a validated checklist assessment for each group's performance in medical care and teamwork. Each element was rated on a scale from 1 to 5, with 1 being unacceptable and 5 being perfect. We evaluated 5 communication measures, including the use of closed-loop communication and orientation of new team members. A Spearman correlation was used to evaluate the relationship between total medical management and total teamwork scores and specific measures of team communication. Receiver operating characteristic curves were created for total teamwork score as a predictor of good or perfect medical management. RESULTS: A total of 354 multidisciplinary teams participated in 1564 high-fidelity simulations. There was a significant correlation between medical management and teamwork and communication scores for all scenarios. The strongest correlation was for the total teamwork score for all simulations (ρ=0.84). Teamwork scores were highly predictive of medical management scores with an area under the curve of at least 0.88 for all simulations, although this was not significant for diabetic ketoacidosis. CONCLUSION: The quality of teamwork and communication correlated with the quality of clinical performance in newly formed multidisciplinary teams. This demonstrates the importance of teamwork training, with a focus on key communication tools and strategies, among medical providers to optimize the management of complex and emergent obstetrical conditions.

Evaluation of force applied during deliveries complicated by shoulder dystocia using simulation.

OBJECTIVE: We sought to objectively evaluate the amount of force applied during deliveries complicated by shoulder dystocia among different providers. STUDY DESIGN: Providers who do deliveries at our institution were approached for participation. The simulation exercise used a childbirth mannequin that measures the amount of force the provider applies to the fetal head during delivery. The amount of force applied and information regarding the provider's level of experience, height, weight, and gender was recorded. This study was approved by the hospital institutional review board. RESULTS: A total of 47 providers participated. The mean force applied during each situation was not associated with the provider's experience, height, weight, or gender. CONCLUSION: Provider experience, gender, and body habitus were not associated with the amount of force applied during delivery. We found differences between family medicine and obstetrics/gynecology providers. In addition, a significant number of all providers (19/47, 40%) pulled >100 N.

On the front lines of patient safety: implementation and evaluation of team training in Iraq.

BACKGROUND: Team training has been identified as a key strategy for reducing medical errors and building a culture of safety in health care. Communication and coordination skills can serve as barriers to potential errors, as in the modern deployed U.S. Military Healthcare System (MHS), which emphasizes rapid movement of critically injured patients to facilities capable of providing definitive care. A team training intervention--TeamSTEPPS--was implemented on a large scale during one of the most intense phases of the conflict in Iraq. This evaluation of the program constituted the first undertaken in a combat theater of operations. IMPLEMENTING TEAMSTEPPS IN IRAQ: The Baghdad combat support hospital (CSH) conducted continuous operations from a fixed facility for a 13-month deployment--between November 2007 and December 2008. The TeamSTEPPS implementation in Iraq began at this facility and spread throughout the combat theater of operations. Teamwork training was implemented in two primary training sessions, followed up with reinforcement of team behaviors on the unit by hospital leadership. RESULTS: A total of 153 patient safety reports were submitted during the 13 months reviewed, 94 before TeamSTEPPS implementation and 59 afterwards. After training, there were significant decreases in the rates of communication-related errors, medication and transfusion errors, and needlestick incidents. There was a significant decrease in the rate of incidents coded communication as the primary teamwork skill that could have potentially prevented the event. CONCLUSIONS: Process improvement programs such as TeamSTEPPS implementation can be conducted under the extremely austere conditions of a CSH in a combat zone. Teamwork training decreased medical errors in the CSH while deployed in the combat theater in Iraq.

Mobile in situ obstetric emergency simulation and teamwork training to improve maternal-fetal safety in hospitals.

BACKGROUND: Evidence from other high-risk industries has demonstrated that teamwork skills can be taught and effective teamwork may improve safety. Increasingly, health care providers, hospital administrators, and quality and safety professionals are considering simulation as a strategy to improve quality and patient safety. MOBILE OBSTETRIC SIMULATION AND TEAM TRAINING PROGRAM: A mobile obstetric emergency simulation and team training program was created to bring simulation technology and teamwork training used routinely in other high reliability fields directly to health care institutions. A mobile unit constituted a practical approach, given the expense of simulation equipment, the time required for staff to develop educational materials and simulation scenarios, and the need to have a standardized program to promote consistent evaluation across sites. Between 2007 and 2009, in situ simulation of obstetric emergencies and teamwork training was tested with more than 150 health care professionals in labor and delivery units across four rural and two community hospitals in Oregon. HOW DO ORGANIZATIONS DETERMINE WHICH TYPE OF SIMULATION IS BEST FOR THEM? Because simulation technologies are relatively costly to start and maintain, it can be challenging for hospitals and health care professionals to determine which format (send staff to a simulation center, develop in-house simulation program, develop a consortium of hospitals that run a simulation program, or use a mobile simulation program) is best for them. CONCLUSIONS: In situ simulation is an effective way to develop new skills, to maintain infrequently used clinical skills even among experienced clinical teams, and to uncover and address latent safety threats in the clinical setting.

Obstetric simulation for a pandemic.

OBJECTIVE: In the middle of the COVID-19 pandemic, guidelines and recommendations are rapidly evolving. Providers strive to provide safe high-quality care for their patients in the already high-risk specialty of Obstetrics while also considering the risk that this virus adds to their patients and themselves. From other pandemics, evidence exists that simulation is the most effective way to prepare teams, build understanding and confidence, and increase patient and provider safety. FINDING: Practicing in-situ multidisciplinary simulations in the hospital setting has illustrated key opportunities for improvement that should be considered when caring for a patient with possible COVID-19. CONCLUSION: In the current COVID-19 pandemic, simulating obstetrical patient care from presentation to the hospital triage through postpartum care can prepare teams for even the most complicated patients while increasing their ability to protect themselves and their patients.

Creation and Evaluation of a Cesarean Section Simulator Training Program for Novice Obstetric Surgeons.

BACKGROUND: We evaluated a novel simulation-based cesarean section training program to teach critical techniques for cesarean section and hemorrhage management.  Methods: This was a prospective educational intervention. After Institutional Review Board approval, we recruited Obstetrics and Gynecology, Family Medicine, and General Surgery residents at three hospitals. All participants received didactic education. Participants were then randomized into two arms with one group to receive task-trainer based training and the other no training. Afterwards, all residents had their performance of a complete cesarean section and management of a post-partum hemorrhage evaluated on a high-fidelity simulator. Evaluators were blinded to randomization. EXPERIENCE: Thirty-three participants were recruited between July 2017 and January 2019. There were 19 trainees in the control group and 14 in the intervention group. The intervention group scored significantly higher on performance of the cesarean delivery (p-value 0.007), hemorrhage management (p-value 0.0002), and overall skill (p-value 0.008). There were no differences in the other categories. CONCLUSION: Participants trained with a combination of didactic education and task-trainers versus didactic education alone performed significantly better on all procedural aspects of a cesarean section and hemorrhage management on a high-fidelity simulator, demonstrating that simulation-based training allows trainees to gain procedural experience while decreasing patient risk.

Improved ultrasonographic estimation of birth weight in macrosomic fetuses by application of a correction factor to the gestation-adjusted projection method.

OBJECTIVE: The purpose of this study was to improve estimated birth weight (EBW) determination in macrosomic fetuses (estimated fetal weight >or=4000 g) by application of a correction factor to the gestation-adjusted projection (GAP) method. METHODS: A review was performed of 411 singleton pregnancies delivered at term. On the basis of ultrasonographic examinations previously performed between 34.0 and 36.9 weeks' gestation, an EBW was calculated for each patient by the GAP method (EBW(GAP)). Using linear regression, a correction factor was developed that minimized the systematic error in the EBW(GAP). The model was then tested retrospectively on a second group of 317 patients. RESULTS: The GAP method systematically overestimated weights of the heavier fetuses in our population. The model we derived showed improved accuracy compared with the GAP method. When applied to a second group of 317 patients, our correction to the GAP method improved specificity for macrosomia from 94.7% to 98.6% (P = .003). Stated differently, the false-positive rate was reduced from 5.3% to 1.4%. The difference in sensitivity for macrosomia was not significant: 41.2% and 35.3% (P = .68). CONCLUSIONS: Application of our model to our study population reduced the number of false-positive results for fetal macrosomia.

Earlier gestational age at ultrasound evaluation predicts adverse neonatal outcomes in the preterm appropriate-for-gestational-age fetus with idiopathic oligohydramnios.

Oligohydramnios is related to adverse perinatal outcomes particularly when associated with fetal growth restriction. The purpose of this study was to delineate predictors of adverse perinatal outcomes in cases of preterm idiopathic oligohydramnios associated with appropriate-for-gestational-age (AGA) fetal biometry. A database of preterm AGA fetuses (< 37 weeks) presenting for evaluation of idiopathic oligohydramnios (defined as an amniotic fluid index [AFI] < 10th percentile) in the third trimester with delivery information and uterine artery Doppler indices (average resistance index [RI] and bilateral notching) available was prospectively collected ( N = 90). AFI and birth weight (BW) percentiles were calculated using standard tables. Chi-square and Student T test were used to evaluate for predictors of adverse perinatal outcomes including BW < or = 10th percentile, stillbirth, neonatal intensive care unit admission, 5-minute Apgar score < 7, preterm delivery < 35 weeks, and preeclampsia. Patients destined to experience poor perinatal outcomes (22%) were demographically similar to those experiencing normal outcomes in terms of maternal age ( P = 0.5), ethnicity ( P = 0.9), body mass index ( P = 0.3), and parity ( P = 0.9). However, at-risk patients were more likely to present with oligohydramnios at an earlier gestational age (GA) than those not at risk (33.0 +/- 3.0 versus 34.4 +/- 2.0 weeks; P = 0.02). There were no differences in perinatal outcomes associated with AFI percentile ( P = 0.9), increased average uterine artery RI ( P = 0.5), bilateral notching ( P = 0.4) or a combination of increased uterine artery RI and bilateral notching ( P = 0.2). Patients with preterm AGA fetuses who present with idiopathic oligohydramnios at an earlier GA are at risk for adverse perinatal outcomes compared with those presenting later in gestation. Sonographic indices, particularly uterine artery Doppler findings, were not found to be useful predictors of adverse outcomes.

Female soldiers' gynecologic healthcare in Operation Iraqi Freedom: a survey of camps with echelon three facilities.

OBJECTIVE: To describe female soldiers' predeployment gynecologic healthcare screening, common symptoms, and availability of gynecologic care during Operation Iraqi Freedom. METHODS: A questionnaire distributed to U.S. military females presenting to outpatient facilities in level 3 echelon of care between August 2005 and March 2006. RESULTS: Three-hundred ninety seven of 401 surveys (99%) were returned. Ten percent of deployed females (40) had no cervical cytology screening 1 year before deployment and 27% of the 399 required additional treatments for abnormal cervical cytology during deployment. Thirty-five percent reported a gynecologic problem and 44% received care at their base. Irregular bleeding was the most common gynecologic problem. Forty-four percent of women used some form of hormonal contraception; however, 43% changed methods because of unavailability. One-third of soldiers received pre-deployment menses regulation counseling, with 48% of those using continuous oral contraceptive pills for cycle control. CONCLUSION: Gaps remain in predeployment gynecologic screening and counseling. These critical predeployment medical evaluations must remain a priority for all female soldiers to ensure unit readiness.