Changes in obstetrical practices and pregnancy outcomes following the ARRIVE trial.

Background: The ARRIVE trial demonstrated the benefit of induction of labor at 39 weeks gestation. Obstetrics departments across the United States faced the challenge of adapting clinical practice in light of these data while managing logistical constraints.

Objective: To determine if there were changes in obstetrical practices and perinatal outcomes in the United States after the ARRIVE trial publication.

How to value patient values: Cesarean sections for the periviable fetus, and home births.

Respect for patient autonomy involves providing sufficient information to patients to allow them to make informed decisions, and then honoring their requests unless they are unethical or futile. At times, the factors that patients consider may not be purely biologic ones but rather will include "spiritual" factors (a sense of control in a home birth). When patients balance biologic risks against spiritual gain, physicians may not be comfortable giving deference to patients' choice.

Physicians' obligations to patients infected with Ebola: echoes of acquired immune deficiency syndrome.

Physicians across the United States are engaged in training in the identification, isolation, and initial care of patients with Ebola. Some will be asked to do more. The issue this viewpoint will address is the moral obligation of physicians to participate in these activities.

A reconsideration of home birth in the United States.

Home births continue to constitute only a small percentage of all deliveries in the United States, in part because of concerns about their safety. While the literature is decidedly mixed in regard to the degree of risk, there are several studies that report that home birth may at times entail a small absolute increase in perinatal risks in circumstances that cannot always be anticipated prior to the onset of labor. While the definition of "small" will vary between individuals, and publications vary in the level of risk they ascribe to birth at home, studies with the least methodological flaws and with adequate power often cite an excess death rate in the range of one per thousand.

The immediately available physician standard.

The promulgation of the immediately available physician standard has contributed to the rapid decline in vaginal birth after cesareans (VBACs). While having an immediately available obstetrician during a VBAC trial will reduce risk, it is not clear that similar advantage wouldn't also accrue to women without uterine scars. However, many hospitals can't staff up to that standard.

"Doctor, what would you do?".

Patients making difficult choices among therapeutic options often ask their physicians what they would do if they were in the same situation. When faced with that question, physicians might be concerned that a direct answer could infringe on a patient's autonomy by substituting the physician's unique worldview or experience for their patients'. However, refusing to answer the question might lead a patient to feel unsupported at a difficult time.

The relationship between cocaine use and human papillomavirus infections in HIV-seropositive and HIV-seronegative women.

Objective: Animal data suggest that cocaine has an immunosuppressive effect, but no human studies have been conducted to assess the relation of cocaine use with human papillomavirus (HPV) infection, the viral cause of cervical cancer. Since both cocaine use and HPV infection are common among HIV-positive women, we sought to determine whether use of cocaine and/or crack influences the natural history of HPV among women with or at high risk of HIV.

Methods: Women enrolled in the Women's Interagency HIV Study (2278 HIV-seropositive and 826 high-risk seronegative women) were examined every six months for up to 9.

Obstetricians, health attorneys, and court-ordered cesarean sections.

Purpose: Despite court rulings suggesting that court-ordered cesarean sections should rarely be undertaken, they are performed. Our objective was to determine those characteristics of providers and patients that make their use more likely.

Methods: A convenience sample of obstetricians attending the annual meeting of the American College of Obstetricians and Gynecologists (n=229) and lawyers attending the annual meeting of the American Health Lawyers Association (n=126) read a vignette describing a woman who refused a cesarean section after being told that her fetus would die unless she received the operation.

Ethical dimensions of elective primary cesarean delivery.

Cesarean deliveries are among the most common surgical procedures performed in the United States. Recent publications demonstrate the reduced risks of these operations and describe their potential benefits to both mothers and children. Recent surveys show that a substantial minority of obstetricians would accede to patients' requests for elective primary cesarean delivery, and some of these professionals would prefer that mode of delivery for themselves or their partners.