In past editions of this textbook, the rising cesarean delivery rate was considered problematic. his rate has leveled, but there are still imperatives in progress to help lower this rate. One collateral source of cesarean delivery morbidity is from the growing incidence of morbidly adherent placentas encountered in women with a prior hysterotomy incision, discussed in Chapters 31 and 41.
Breakthroughs in fetal testing and diagnosis continue to stun. By 2012, prenatal gene micro array techniques were used for clinical management (Dugof, 2012). he advantages of these techniques are outlined in Chapters 13 and 14. Wapner and coworkers (2012) compared chromosomal microarray analysis of maternal blood with karyotyping for chromosomal anomalies. Reddy and associates (2012) applied this technology to stillbirth evaluation and reported it to be superior to karyotyping. Another report by Talkowski and colleagues (2012) described whole-genome sequencing of a fetus using maternal blood.
Screening for fetal aneuploidy using cell-free DNA (cDNA) was first introduced in 2011. The technique is described in Chapter 14 (p. 284), and it is based on isolation of free fetal (placental) DNA in maternal blood. In a landmark study, Norton and associates (2015) found that cDNA had a higher sensitivity and speciicity compared with standard prenatal screening for trisomy 21 fetuses. Still, invasive testing is currently necessary to confirm a positive cDNA test result (Chitty, 2015; Snyder, 2015).
• The Ob/Gyn Hospitalist he term "hospitalist" was coined in the 1990s and referred to physicians whose primary professional focus was generalized care of hospitalized patients. From this concept came the obstetrical and gynecological hospitalist whose primary role was to care for hospitalized obstetrical patients and to help manage their emergencies. These physicians could also provide urgent gynecological care and emergency department consultation. Alternative terms include "obstetrical hospitalist" or "laborist," but the preferred standardized term by the American College of Obstetricians and Gynecologists (2016e) is "Ob/Gyn hospitalist." lthough not a recognized subspecialty of obstetrics and gynecology, the Ob/Gyn hospitalist movement has gained momentum. he Society of Ob-Gyn Hospitalists had 528 members in 2017 (Burkard, 2017). Various practice models are described to fit the needs of a wide spectrum of obstetrical volumes (McCue, 2016). In addition to providing lifestyle modifications, Ob/Gyn hospitalists are used by some hospitals to improve the quality and safety of their women's services and to reduce adverse events. Aside from a possible lowering of the labor induction rate, studies are needed to demonstrate improved outcomes with these providers (American College of Obstetricians and Gynecologists, 2016e; Srinivas, 2016).
he American College of Obstetricians and Gynecologists periodically surveys its fellows concerning the efect of liability on their practice. he 2015 Survey on Professional Liability is the 12th such report since 1983 (Carpentieri, 2015). From this survey, it appears that there is still a "liability crisis," and the reasons for it are complex. Because it is largely driven by money and politics, a consensus seems unlikely. Although some interests are diametrically opposite, other factors contribute to the problem's complexity. For example, each state has its own laws and opinions on tort reform. In some states, annual premiums for obstetricians approach $300,000-expenses that at least partially are borne by the patient and certainly by the entire health-care system. In 2011, all tort costs in the United States totaled nearly $265 billion. his is an astounding 1.8 percent of the gross domestic product and averages to a cost of $838 per citizen (Towers Watson, 2015).