Advancing research transdisciplinarity within our discipline.

Advancing biomedical knowledge is crucial to the understanding of disease pathophysiology, diagnosis, treatment, and the maintenance of health. Whereas collaborative pursuits among basic and translational scientists, clinical researchers, and clinicians should advance biomedical progress and its translation to better medicine. The field of obstetrics and gynecology and its subspecialties has not escaped this problem. Obstetrics and gynecology specialists and subspecialists have limited opportunities to interact with translational or basic investigators, and cross-fertilization and collaborations are further challenged by the current healthcare and funding climate. This opinion manuscript focuses on the field of maternal-fetal medicine, serving as an example that illustrates the risks and opportunities that might exist within our obstetrics and gynecology academic community. A Pregnancy Task Force recently sought to identify ways to overcome hurdles related to research training, and ensure a sufficient pool of physician-scientists pursuing pertinent questions in the field. The group discussed strategies to promote a culture of intellectual curiosity and research excellence, securing additional resources for trainees, and attracting current and next generation basic, translational, and clinical scholars to our field. Recommendations encompassed activities within annual academic meetings, training initiatives, and additional funding opportunities. Inferences from these discussions can be made to all obstetrics and gynecology subspecialty areas.

How do we deal with the legal risks?

Do obstetricians as a profession risk losing credibility as cesarean section rates continue to rise to once unimaginable levels? Physician practice style and fear of litigation have contributed to the escalation in abdominal delivery but so have societal expectations and patient perspectives. At the same time, some patients are so motivated for a vaginal delivery that they choose to have a home birth after cesarean section as opposed to submitting to a repeat cesarean delivery. Amid a medical-legal environment that "exerts a chilling effect on a trial of labor," what is the obstetrician to do?

VBAC--is it worth the risk?

Enthusiasm for vaginal birth after cesarean section has waned. As a result, the cesarean birth rate is again on the rise. As a medical community and society we must decide whether the most appropriate question is "What is safest for my baby?" or "Is the risk associated with vaginal birth after cesarean acceptable?" There are risks associated with vaginal birth after cesarean, but in a hospital setting with appropriate resources these risks are low and would still seem to be acceptable.

The influence of practice management on primary cesarean birth.

As the cesarean delivery rate has increased to once unimaginable levels, obstetricians should question the loss of our credibility. Older mothers, obesity, larger birth weights, too many twins, and no more breech vaginal deliveries have all been cited as contributing factors to the increase in primary cesarean birth, but one cannot neglect the influence of physician practice style. Attempts to curtail or reverse the escalating incidence of primary abdominal deliveries should focus on caution with inductions of labor, patience with the management of arrest disorders, more accurate assessment of fetal compromise, patient education and informed decision making about the benefits/risks of operative delivery, and improvement in the medicolegal environment.

Trial of labor versus elective repeat cesarean: an administrator's perspective.

Hospital administrators are most concerned with the quality of medical care. With specific regard to vaginal birth after cesarean, it is essential that the surgical personnel and anesthesia be able to intervene in a timely manner for an obstetrical emergency. Other considerations are patient satisfaction, perception by the community, and cost. Budgets and balancing resources are important factors but pale in decision-making compared with the ill-publicity and medicolegal risk associated with an untoward outcome.