The Collaborative Laborist and Midwifery Model: An Accepted and Sustainable Model.

In 2010, the OB/GYN physicians at this mid-sized midwestern medical center implemented a laborist model on the obstetrics ward. A laborist is a dedicated obstetrician within the obstetric ward who oversees the management of labor and performs deliveries as both the primary physician and also when consulted by other providers, including community obstetricians, family physicians and nurse midwives. In 2014, a collaborative obstetric model was implemented with the addition of an in-house certified nurse midwife (CNM) to assist the laborist in obstetric care. This retrospective study analyzes the impact of these care models on clinical outcomes, including rates of induction of labor, total (primary and repeat) cesarean sections, and vaginal births after cesarean section. The three time periods (i.e., pre-laborist, laborist, laborist plus CNM) periods are compared. Induction rates decreased from 48.6 percent to 46.5 percent to 28.8 percent during the three time periods. Primary cesarean section rates decreased from 15.9 percent to 14.6 percent to 13.6 percent. Total cesarean section rates slightly decreased but this was not statistically significant, going from 28.9 percent to 28.4 percent, to 27.7 percent. Vaginal births after cesarean section increased from 9.2 percent to 12.9 percent to 15 percent. Staff satisfaction was also measured utilizing anonymous surveys during the first two time periods. There was improvement in seven of the eight questions from the pre-laborist to the laborist model. In conclusion, a collaborative care model on the obstetric floor at this Institution has had a positive impact on patient care outcomes and staff satisfaction.

Preconception and prenatal care--useful tools for providers of women's health.

Health care providers have a unique opportunity to change the behaviors of their patients. Preconception and prenatal care allow for interventions to abate risky behaviors that can affect not only the woman but also her developing fetus. If we can assist the reproductive age woman in modifying her high-risk activities, there will be improved birth outcomes and healthier mothers to care for their offspring. Alcohol and tobacco use, sexually transmitted infections and obesity are the top four modifiable risk factors. This article will address the impact that these behaviors have on women and tools to assist the health care provider in changing these bad habits and promoting healthy pregnancies. The theory of "fetal origins of disease" is emerging as one of the most powerful and compelling reasons to engage our patients before and during their pregnancy. Preventive medicine needs to start in the womb if we want to have the highest impact on healthy adulthood.

Clinical and cost comparisons for hysterectomy via abdominal, standard laparoscopic, vaginal and robot-assisted approaches.

INTRODUCTION: The goal of this study was to compare outcomes and costs of four methods of hysterectomy: abdominal, standard laparoscopic, vaginal and robot-assisted approaches. METHODS: We conducted a retrospective medical chart review of 1474 consecutive hysterectomy patients with benign indications. RESULTS: Implementation of a robotics program at our institution resulted in reductions in abdominal (33 percent to 8 percent) and laparoscopic (29 percent to 5 percent) hysterectomies. Robotic surgery demonstrated the least blood loss and shortest hospital stays (both p < 0.0001), despite greater case complexity. Overall complication rates were highest for abdominal procedures (14 percent) and similar across minimally invasive approaches (8 to 9 percent). Conversion rates were four times greater in laparoscopic than vaginal or robotic hysterectomy (p = 0.01). Vaginal hysterectomy, performed in the least complex cases, had the lowest major complication rate (1.5 percent) and lowest costs. Costs for robotic surgery were similar to abdominal and laparoscopic approaches when robots were not depreciated as direct surgical expenses. CONCLUSIONS: Vaginal hysterectomy was the least expensive surgical option. Robotic surgery reduced morbidity, conversions and hospital stays even in complex cases, without incurring additional costs beyond purchase of the robotic system.

Vaginal cuff dehiscence: a randomized trial comparing robotic vaginal cuff closure methods.

The purpose of this study is to compare the rate of vaginal cuff dehiscence between two different methods of closure in patients undergoing robotic-assisted total laparoscopic hysterectomy and explore variables related to postoperative breakdown. This was a prospective, randomized controlled study with two arms. The control group (Arm 1) underwent single-layer continuous closure while the study group (Arm 2) had three additional imbricating figure-of-X sutures placed in addition to the standard protocol. Of the 263 patients who completed the study, 4 patients (1.49 %) experienced dehiscence of the vaginal cuff. Three of the four patients with dehiscence received the standard single vaginal cuff closure (Arm 1) and the one remaining case of dehiscence underwent the protocol with additional sutures (Arm 2). All patients who experienced dehiscence were current smokers. Our study suggests that there may be benefit in adding additional sutures to the standard single-layer vaginal cuff closure procedure. Physicians should evaluate smoking status before deciding on a vaginal cuff closure method.