Abortion education in the medical curriculum: a survey of student attitudes.

BACKGROUND: The purpose of this study was to evaluate student attitudes toward the inclusion of abortion education in the preclinical and clinical medical school curriculum. STUDY DESIGN: All students completing the OB-GYN rotation from May 2004 through January 2005 (n=118) were asked to complete a 21-item survey. Survey questions focused on students' attitudes about the appropriateness of abortion education, reasons for participation or nonparticipation in the abortion care experiences in the clinical curricula and the value of abortion education. RESULTS: One hundred students completed the survey for a response rate of 85%. Nearly all respondents indicated that abortion education was appropriate in the preclinical and clinical curricula (96%). Fifty-three percent of students participated in a clinical abortion care experience. The majority of these students rated it as valuable (84%) and would recommend it to a friend (73%). Most students who planned a career in Family Medicine and OB-GYN preferred the integration of abortion training into the residency curriculum (74%). CONCLUSIONS: Abortion education is acceptable and valued by medical students and should be integrated into the curricula of all medical schools.

Why obstetrics/gynecology, and what if it were not an option? A survey of resident applicants.

OBJECTIVE: The purpose of this study was to assess the secondary residency choice of obstetrics/gynecology and family medicine residency applicants and to determine the most and least appealing aspects of each specialty. STUDY DESIGN: This prospective cohort study surveyed residency applicants in obstetrics/gynecology and family medicine from 2004-2007 at the University of New Mexico (obstetrics/gynecology and family medicine) and the University of California-San Francisco (obstetrics/gynecology). Applicants completed an anonymous 5-question survey about their secondary choice of specialty, least likely residency choice, and the most and least appealing aspects of their chosen specialty. RESULTS: Forty-six percent obstetrics/gynecology applicants would have chosen a primary care specialty, and 37% would have chosen a surgical specialty. The most appealing aspects of obstetrics/gynecology were surgery and obstetrics. The least appealing aspects were work hours and liability concerns. CONCLUSION: Obstetrics/gynecology applicants are divided between primary care and surgical specialties as their secondary choice. Core aspects of surgery and obstetrics are most appealing. Emphasis on these components of the specialty in medical school may improve student recruitment into obstetrics/gynecology.

Postpartum genitourinary changes.

Genitourinary changes following childbirth and pregnancy are common, and include urinary and anal incontinence, pelvic pain, sexual dysfunction, and pelvic organ prolapse. At present, it is unclear whether or not these changes are a result of the pregnancy itself or the mode of delivery (cesarean section or vaginal birth). In this article, the authors aim to describe genitourinary postpartum pelvic floor changes, and review the literature regarding the impact of pregnancy or childbirth on these changes. Data is needed that compare the effects of pregnancy alone, cesarean delivery (labored and unlabored), and vaginal birth, so that physicians can better advise patients about the postpartum genitourinary tract changes they might expect.

Family Medicine Maternity Care Call to Action: Moving Toward National Standards for Training and Competency Assessment.

BACKGROUND: Maternity care is an integral part of family medicine, and the quality and cost-effectiveness of maternity care provided by family physicians is well documented. Considering the population health perspective, increasing the number of family physicians competent to provide maternity care is imperative, as is working to overcome the barriers discouraging maternity care practice. A standard that clearly defines maternity care competency and a systematic set of tools to assess competency levels could help overcome these barriers. National discussions between 2012 and 2014 revealed that tools for competency assessment varied widely. These discussions resulted in the formation of a workgroup, culminating in a Family Medicine Maternity Care Summit in October 2014. This summit allowed for expert consensus to describe three scopes of maternity practice, draft procedural and competency assessment tools for each scope, and then revise the tools, guided by the Family Medicine and OB/GYN Milestones documents from the respective residency review committees. The summit group proposed that achievement of a specified number of procedures completed should not determine competency; instead, a standardized competency assessment should take place after a minimum number is performed. The traditionally held required numbers for core procedures were reassessed at the summit, and the resulting consensus opinion is proposed here. Several ways in which these evaluation tools can be disseminated and refined through the creation of a learning collaborative across residency programs is described. The summit group believed that standardization in training will more clearly define the competencies of family medicine maternity care providers and begin to reduce one of the barriers that may discourage family physicians from providing maternity care.

Conformity with current guidelines on oral contraceptive prescribing for breastfeeding women: a New Mexico survey.

BACKGROUND: National and international contraceptive guidelines reflect expert opinion that recommends against the use of estrogen-containing hormonal contraception in the early postpartum period. This study was undertaken to estimate providers' practices in prescribing hormonal contraception to breastfeeding women. METHODS: A 19-item survey was mailed to 397 obstetrician gynecologists, midwives and family physicians in the state of New Mexico. The survey included items covering attitudes about the impact of hormonal contraception on breastfeeding and prescribing practices. One hundred ninety-nine (50%) providers completed the survey. RESULTS: The majority (70%) of providers prescribe progestin-only contraceptive methods to breastfeeding women within the first 6 weeks. Despite these recommendations, a sizable minority of providers prescribe combined pills in the early postpartum period: 27% of providers have prescribed combined pills and 13% of providers, mostly those in a university setting, routinely recommend them within the first 6 weeks postpartum. CONCLUSION: Most providers follow expert recommendations regarding the initiation of hormonal contraception for breastfeeding women.

A breastfeeding curriculum for residents and medical students: a multidisciplinary approach.

Medical school and residency training programs, in which practice patterns are established, frequently lack formal education in breastfeeding in the United States. This project, a curriculum based on the Wellstart Lactation Management Guide, was developed for resident physicians and medical students at the University of New Mexico to address the deficiency in formal education about breastfeeding. The curriculum, developed and implemented by faculty members from obstetrics/gynecology, pediatrics, and family medicine, includes formal interactive teaching sessions, discussion of breastfeeding issues on daily clinical rounds, and patient visits with lactation support personnel. Interns from the Departments of Pediatrics, Obstetrics/Gynecology, and Family Medicine participate. Surveys of participating residents and faculty demonstrate highly favorable attitudes. In conclusion, a multidisciplinary approach to breastfeeding education is feasible and well received by both teachers and residents.

Has mifepristone medical abortion expanded abortion access in New Mexico? A survey of OB-GYN and Family Medicine physicians.

BACKGROUND: The FDA approval of mifepristone in 2000 broadened the available options for abortion. The aim of this study was to evaluate whether physicians in New Mexico have integrated the use of mifepristone into their practice. STUDY DESIGN: We performed a mail-out survey of New Mexico Obstetrician Gynecologists (Ob-Gyn) and Family Medicine (FM) physicians in 2001 and 2008. Questions addressed integration of abortion services, attitudes towards providing abortion in different scenarios and barriers to offering abortion services. RESULTS: The response rates were 59% for the 2001 survey and 54% in 2008. In 2001 and 2008, 11% and 15% (p=.26) of physicians, respectively, provided any abortion - medical or surgical. Similarly, in 2001 and 2008, 5% and 10% (p=.07) provided medical abortion. Commonly cited barriers to provision of abortion in both years were beliefs against abortion and lack of training. CONCLUSIONS: The number of physicians offering any abortion or medical abortion in New Mexico has not changed since the FDA approval of mifepristone. Residency training programs in FM and in Ob-gyn should include training in medical abortion.

Compliance with mandated emergency contraception in New Mexico emergency departments.

OBJECTIVE: New Mexico enacted a law in 2003 requiring that emergency departments (EDs) offer emergency contraception (EC) to survivors of sexual assault and that both doses be administered in the ED. This investigation sought to examine practices and knowledge of ED providers about EC in the setting of sexual assault. METHODS: We visited hospitals in New Mexico from July 2005 to December 2005 and administered an 18-item questionnaire to three providers-a physician, a nurse, and a clerk-in the ED. The questionnaire included items related to characteristics of the hospital, knowledge of providers about EC and the law, and ED practices relevant to EC for sexual assault survivors as well as for women who had consensual unprotected intercourse. RESULTS: Surveys were completed at 33 of 38 hospitals (87%). Overall, 52% of respondents reported that EC was routinely offered to sexual assault survivors, and 33% reported that both doses were administered in the ED. Forty-one percent of RNs, MDs, and clerks reported that EC was offered to sexual assault survivors who were minors regardless of age. Overall, 64% of respondents knew that EC may prevent pregnancy up to 72 hours after unprotected intercourse, and only 12% of respondents reported awareness of any requirements to offer EC to sexual assault survivors. Respondents reported that physicians in the ED more often routinely offered EC to sexual assault survivors (52%) than to women who requested it after consensual sex (20%). Thirty-three percent of respondents indicated parental consent was necessary for minors in the setting of sexual assault, although there is no requirement for parental notification in New Mexico. CONCLUSIONS: EDs in New Mexico are not universally complying with the law. Better dissemination of the law and education about EC could improve care of sexual assault survivors in New Mexico.

Venous thromboembolism during pregnancy.

Venous thromboembolism is the leading cause of maternal death in the United States. Pregnancy is a risk factor for deep venous thrombosis, and risk is further increased with a personal or family history of thrombosis or thrombophilia. Screening for thrombophilia is not recommended for the general population; however, testing for inherited or acquired thrombophilic conditions is recommended when personal or family history suggests increased risk. Factor V Leiden and prothrombin G20210A mutation are the most common inherited thrombophilias, and antiphospholipid antibody syndrome is the most important acquired defect. Clinical symptoms of deep venous thrombosis may be subtle and difficult to distinguish from gestational edema. Venous compression (Doppler) ultrasonography is the diagnostic test of choice. Pulmonary embolism typically presents postpartum with dyspnea and tachypnea. Multidetector-row (spiral) computed tomography is the test of choice for pulmonary embolism. Warfarin is contraindicated during pregnancy, but is safe to use postpartum and is compatible with breastfeeding. Low-molecular-weight heparin has largely replaced unfractionated heparin for prophylaxis and treatment in pregnancy.

Dystocia in nulliparous women.

Dystocia is common in nulliparous women and is responsible for more than 50 percent of primary cesarean deliveries. Because cesarean delivery rates continue to rise, physicians providing maternity care should be skilled in the diagnosis, management, and prevention of dystocia. If labor is not progressing, inadequate uterine contractions, fetal malposition, or cephalopelvic disproportion may be the cause. Before resorting to operative delivery for arrested labor, physicians should ensure that the patient has had adequate uterine contractions for four hours, using oxytocin infusion for augmentation as needed. For nulliparous women, high-dose oxytocin-infusion protocols for labor augmentation decrease the time to delivery compared with low-dose protocols without causing adverse outcomes. The second stage of labor can be permitted to continue for longer than traditional time limits if fetal monitoring is reassuring and there is progress in descent. Prevention of dystocia includes encouraging the use of trained labor support companions, deferring hospital admission until the active phase of labor when possible, avoiding elective labor induction before 41 weeks' gestation, and using epidural analgesia judiciously.