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A 19-year-old G1P0 was seen for her initial obstetrical visit by a certified nurse-midwife (CNM) at 9 weeks, 2 days by dates. Her exam revealed a height of 5’1”, weight of 141 lb, with a body mass index of 26.6 kg/m². Her exam revealed a gynaecoid pelvis, with a diagonal conjugate >11.5 cm, which was felt to be “adequate.” 

The patient underwent an ultrasound at 13 weeks, 2 days, which confirmed her dates, with a subsequent ultrasound at 22 weeks, 1 day, consistent with the previous study and with appropriate interval fetal growth. The patient had an uncomplicated pregnancy.

The patient presented to the hospital at 39 weeks, 2 days with irregular contractions. She was evaluated by the CNM at 3 a.m. with her cervix being 1.5-cm dilated, 50% effaced, with a vertex at a -2 station. She was felt to be in early labor, with the fetal heart rate (FHR) in the 140s, with good variability (a Category 1). 

For context, the hospital is a private academic hospital with an ob/gyn residency, and a full-time CNM service, which works collaboratively with the residents and the attending physicians. The CNMs are hospital employees who deliver patients in a birthing unit located in Labor and Delivery.

Despite being in very early labor, the patient did not feel comfortable going home. Thus, she was allowed to rest throughout the night. 

A re-examination at 7:45 a.m. revealed a cervix being 2.5 cm dilated, 100% effaced, a vertex at a -2 station, with a bulging bag of water (BBOW). The estimated fetal weight (EFW) was 7 lb 2 oz. There was a Category 1 FHR tracing. The patient was allowed to ambulate throughout the morning, with periodic FHR monitoring confirming a continued Category 1 tracing. At 11:30 a.m., her cervix was 3-cm dilated, 100% effaced, a vertex at a -1 station, with a BBOW.

A Category 1 tracing documented contractions every 5 to 7 minutes of mild to moderate strength. At 3 p.m., there was no change in the patient’s examination. 

Thus, membranes were ruptured, noting clear fluid. At 5 p.m., the cervix was 4- to 5-cm dilated, 100% effaced, with a vertex at a -2 station. Contractions were every 2 to 5 minutes of moderate strength.

., the cervix was 5-cm dilated, 100% effaced, with the vertex at a -1 station, in a left occiput posterior (LOP) position. Contractions were every 2 to 6 minutes of moderate strength, lasting 60 seconds. There was a Category 1 tracing. At 7:15 p.m., her exam remained unchanged. A continuous lumbar epidural was placed.

At 8 p.m., her cervix was 5- to 6-cm dilated, 100% effaced, the vertex was at a -1 station, with caput at a 0 station. It was elected to augment labor with oxytocin. An intrauterine pressure catheter was placed. 

, the cervix was 6-cm dilated, 100% effaced, with the vertex at a -1 station, in a LOP position. There were occasional mild variable decelerations, with the baseline FHR in the 140s. The oxytocin was increased to 8 mU/minute, with occasional coupling and tripling. 

At 11 p.m., the cervix was 6 to 7 cm, with the vertex at a -1 station, 100% effaced, in a persistent LOP position. The FHR was in the 170s. The patient’s temperature was 101.4º F. The CNM consulted with the chief resident (R4), who consulted with the attending physician. It was elected to begin antibiotics and acetaminophen, with a diagnosis of chorioamnionitis. At 1:20 a.m., the cervix was 7-cm dilated, 100% effaced, with the vertex at a 0 station. The contractions were irregular with occasional variables. 

The attending physician’s note at 1:30 a.m. indicated that they would proceed with a cesarean delivery if there were repetitive late decelerations or there was no progress in the next 2 hours. At 3:45 a.m., the R4 examined the patient with the CNM. The patient’s cervix was 7-cm dilated, 80% effaced, at a 0 station. It was elected to recheck the patient in 2 hours, at which time the cervix was 8-cm dilated, 100% effaced, at a 0 station. 

, a new CNM assumed care of the patient. Her exam revealed the cervix being 8- to 9-cm dilated, 100% effaced, with molding to a +1 station. The EFW was 8.5 lb. The oxytocin was at 30 mU/min. The documented diagnosis was “Protracted active phase. Consult MD at 9 a.m.” 

., there were two episodes of prolonged decelerations, the lowest being to the 60s for 4 minutes, returning to the 120s and upward to the 140s. A fetal scalp electrode was placed. 

At 7:57 a.m., the previous R4 and a new attending physician evaluated the patient. Oxygen was placed via nasal cannula at 10 L/minute. At 8 a.m., the R4 and attending physician were called to the room when the FHR had spontaneous decelerations to the 70s and 80s for 4 to 5 minutes. The oxytocin was turned off. The attending physician discussed a cesarean delivery with the patient. There was good documentation of the risks of surgery and options in management.

., a male infant was delivered, weighing 7 lb 9 oz, with Apgar scores of 9 and 9, at 1 and 5 minutes, respectively.

Umbilical cord gases were obtained with the following results:

Arterial=7.30 (Normal = 7.18-7.38);
PCO² = 43 mmHg
(Normal = 32-66 mmHg);
HCO³ <40
(Normal = 17-27 mmol/L);
Base excess = -5.7
(Normal -8 to 0 mmol/L)

 = 31 mmHg;
HCO³ <40; Base excess = -4.9

The placenta was delivered manually at 9:21 a.m., with oxytocin administered shortly thereafter.

Methylergonovine, 0.2 mg IM, was administered at 9:23 a.m. due to excessive bleeding. With continued bleeding, misoprostol, 800 mcg, was placed rectally at 9:34 a.m. At 9:40 a.m., carboprost, 0.25 mg, was administered, as the patient’s bleeding was not responsive to the prior medications. 

, a “Code White” was called as a general alert for excessive bleeding, which brought additional resources and personnel to the operating suite. Surgical maneuvers performed included a B-Lynch suture and O’Leary stitches. They considered and rejected uterine artery embolization. An attempt was made to place an intrauterine compression balloon, which was unsuccessful. 

, the attending decided to perform a hysterectomy. A second opinion was provided by the department chair. A supracervical hysterectomy was performed without complication. The procedure, which was completed at 11:49 a.m., had an estimated blood loss of 3000 mL, and 4200 mL of crystalloid fluids was administered intraoperatively. 

Blood product replacement included 6 units of packed red blood cells, 4 units of fresh frozen plasma, with 1 unit of apheresis platelets. It was noted that labs sent at 11:04 a.m. revealed early disseminated intravascular coagulation (DIC).

Pertinent labs included a hemoglobin and hematocrit with the following levels:

The baby had a normal hospital and neonatal course. The patient had an uncomplicated postoperative and postpartum course. 

Of note, the anesthesiologist, while evaluating the patient on the day following surgery, documented the following, “She expressed confidence that proper decisions were made, and she is grateful for her life and her baby.”

Two years later, the patient filed a suit against the physicians and the hospital for an unnecessary hysterectomy following her cesarean delivery. As a result, the patient and her husband have suffered significant pain and suffering. 

After discovery, the case proceeded to trial. The plaintiff’s maternal-fetal medicine (MFM) expert opined that there were remarkable changes in the FHR, with fetal tachycardia, decreased beat-to-beat variability, and intermittent decelerations. Further, there was abnormal progress in labor, with a failure to descend. As such, the patient should have been delivered by a cesarean at 3:30 a.m. 

In addition, due to poor communication, there was a lack of personal involvement of the attending physician in managing the patient, which led to a delay in performing the cesarean delivery. 

The delay, with the resultant uterine atony, resulted in the need for a hysterectomy. Uterine atony was predictable, as the patient had been on oxytocin for more than 12 hours and she had chorioamnionitis. The expert quoted literature stating that 71% of such patients experience atony. 

Thus, the patient should have been appropriately counseled preoperatively about the need for a hysterectomy. As a result of the unnecessary hysterectomy, the patient will not be able to have further children.

The defense’s MFM expert testified that the record reflected ongoing, timely, and appropriate evaluation and communication regarding the patient’s status by the CNMs, the chief resident, and the attending physicians. 

He further testified that the collaboration among these care providers was well within the standard of care required in the setting of a delivery primarily managed by a CNM and met all applicable hospital protocols. Oxytocin was appropriately and timely initiated and was appropriately monitored and adjusted throughout the labor. He testified that the signs and symptoms of chorioamnionitis were timely and appropriately recognized and treated. 

Chorioamnionitis can lead to a protracted labor, which, with generally reassuring maternal and fetal status, does not compel an earlier cesarean delivery. In addition, an occiput posterior position can lead to a desultory labor. However, with no evidence of fetal macrosomia, pursuing a vaginal delivery was appropriate. 

In addition, despite being desultory, the patient did not meet the American College of Obstetricians and Gynecologists’ definition for an arrest of labor in the first stage, which requires either 4 or more hours of adequate contractions, or at least 6 hours of inadequate contractions, and no cervical change. He further testified that there is no literature to support the contention that an earlier cesarean would have prevented the ultimate need for hysterectomy.

After 4 hours of deliberation, the jury returned a defense verdict.

This case presented a unique dynamic, with CNMs providing the primary management of the patient. In contrast to a separate birthing center, this hospital had established a birthing unit in Labor and Delivery, allowing CNMs to manage patients with immediate physician consultation if needed. 

The hospital had established protocols with guidelines for CNM consultation with a senior resident or the attending physician. This patient’s management complied with these protocols. Of note, some departments are reluctant to have such protocols, fearful that they will be used against physicians in the event of a malpractice suit. 

Although deviations from protocols, without appropriate documentation, can place providers at risk, deviations with documented reasoning are quite defensible. However, as in this case, following protocols enhances the defense of a case.

Documentation of the rationale for various interventions, e.g. oxytocin augmentation and antibiotic treatment, resident and attending involvement, and surgical counseling, was excellent. Such documentation enhances case defensibility. Oxytocin use is often present in obstetrical malpractice actions. 

Thus, clear documentation regarding the decision to use oxytocin, as well as carefully documented monitoring is critical. Although the patient initially expressed that she was satisfied with her care, the realization that she could have no further children naturally resulted in her questioning her prior care. Being sensitive to such concerns and addressing them during future appointments can often allay a patient’s misgivings. Studies support that good communication with the patient is one of the best ways to avert litigation. 

Find more Legally Speaking columns here. 

This case presents a unique dynamic involving certified nurse midwives; following protocols enhanced defensibility.

Cesarean delivery leads to unexpected outcome

A 44-year-old woman presents to your clinic in consultation due to issues with vaginal itching and irritation. She has noted yellowish discharge on her pad on a daily basis. No odor noted. 

Previously, she underwent treatment with intravaginal clindamycin for 1 week that somewhat helped her symptoms. On examination with a speculum, she is noted to have copious thin yellow discharge on her vaginal mucosa. A wet mount was obtained, with a pH of 6.0. 

, clue cells, hyphae, trichomonads. Parabasal cells and white blood cells were seen and the whiff test is negative.

This patient is presenting with signs and symptoms of vaginitis. There is a broad differential, including candidiasis, bacterial vaginosis, trichomoniasis, gonorrhea or chlamydia infection, lichen planus, atrophic vaginitis, desquamative inflammatory vaginitis (DIV), or a less commonly discussed condition, cytolytic vaginosis. Based on her presentation and her wet mount results, a diagnosis of DIV is made and the patient is treated with intravaginal clindamycin for 3 weeks with resolution of her symptoms.

Gray and Barnes first introduced the DIV condition with their 1965 case series of six women with a “reddened” vagina and “numerous pus cells…with oval and round parabasal cells.”

 The etiology is unclear but this condition is consistent with a loss of the normal vaginal flora and increase in inflammation. 

 and an increase in the concentration of obligate or facultative anaerobic flora.

 There is limited literature available about this condition but available studies suggest a prevalence of 2 to 20%.

 It tends to occur more commonly in perimenopausal women but can occur at any age.

Classically, the patient presents complaining of vaginal discharge, itching, vaginal discomfort or dyspareunia.

 Externally, the patient may have vulvar erythema (Figure 1). 

On speculum examination, yellow discharge will be apparent, as well as vaginal petechaie.

The patient may have mucosal erythema with bruising or erosions. Approximately 27% ofpatients with DIV will have colpitis macularis or small erythematous macules on their ectocervix.

The diagnosis is made based on clinical symptoms and physical examination. You should obtain a complete medical history, including sexual history, associated symptoms, and failed treatments. The physical exam consists of placing a vaginal speculum, obtaining a pH from the lateral sidewall of the vagina, and microscopic evaluation of vaginaltions.

On examination, be sure to evaluate the color, consistency, amount, and odor of vaginal discharge.

In addition, perform an examination for cutaneous, oral, and vulvovaginal changes to rule out lichen planus.

 Vaginal atrophy needs to be excluded, as atrophic vaginitis and DIV appear similar on microscopic evaluation.

To obtain a sample of the discharge, use a cotton-tipped applicator or sterile 10-microliter plastic loop from the vaginal side wall. A pH of the discharge should also be obtained. The cotton swab is placed directly on the pH paper without adding any saline or potassium hydroxide (KOH), since these will alter the pH. Typically, the pH is greater than or equal to 4.7 in DIV. 

Of note, a gram stain alone cannot discriminate between bacterial vaginosis and DIV, and thus, will not be useful.

Another cotton swab containing vaginal secretions should be placed in a glass tube to which a few drops of saline are added. Spread the sample on two locations on a slide. 

On one of the locations, add a drop of KOH. Place coverslips over each sample. Then examine the slide under a microscope at low power (10x) and high power (40x). 

On wet mount, there will be an absence of clue cells, hyphae, trichomonads and 

. Immature vaginal epithelial cells or parabasal cells will be seen. Parabasal cells are typically round or oval in shape with a high nuclear/cytoplasmic ratio.

You will also see an increase in inflammatory cells (e.g. the ratio of leukocytes to epithelial cells is greater than 1:1).

 No amine odor will be detected on the KOH specimen, in contrast to bacterial vaginosis and trichomonas, which often have this feature. 

One might also consider obtaining a yeast culture with speciation as part of the evaluation for vaginal discharge. Nucleic acid amplification tests should also be obtained to rule out other infectious etiologies of vaginitis if indicated.

As with any vulvovaginal condition, it is important to reinforce appropriate vulvar care measures, including keeping the area dry, avoiding constricting clothing, irritants in detergents, soaps, or over-the-counter medications like benzocaine, and wearing cotton underwear.

Initial treatment for DIV should begin with topical intravaginal clindamycin or intravaginal hydrocortisone. There are a variety of regimens that may be used. For the intravaginal clindamycin, 5g of 2% cream is inserted vaginally once a night for 3 weeks. 

Alternatively, 200 mg clindamycin can be inserted intravaginally at night for 3 weeks. For both of these regimens, consider maintenance therapy twice a week, for 2 months, since DIV frequently recurs. Another treatment is intravaginal hydrocortisone. The dosing regimens for intravaginal hydrocortisone are 25 mg suppositories twice a day, for 3 weeks. 

Consider maintenance therapy, three times a week for 2 months, following this treatment. At times, a higher dose of hydrocortisone may be required. Hydrocortisone, 300 to 500 mg, is inserted vaginally at night for 3 weeks. 

Maintenance therapy, twice a week for 2 months, should be considered with this regimen

; other causes of purulent vaginitis should be excluded. 

The main symptoms include purulent discharge, vestibulo-vaginal irritation, and dyspareunia. Examination of vaginal walls will show signs of inflammation with increased erythema and petechiae. 

These recommendations are based on an observational study published by Sobel et al in 2011 that looked at the prognosis of 98 patients meeting diagnostic criteria for DIV and a publication by Reichman and Sobel in2014.9,10

In this same 2011 series by Sobel et al, almost a third of patients who had initial resolution of symptoms relapsed within 6 weeks of stopping therapy and approximately 40% relapsed within 26 weeks off therapy.

 Thus, maintenance therapy should be considered as mentioned.

Regular assessments of signs and symptoms with microscopy and measurement of pH are critical to assess for improvement or remission, as many patients will require maintenance therapy for longer than 2 months.

 In Sobel et al’s 2011 observational study, 58% of the women diagnosed with DIV were still on treatment or had required maintenance therapy 1 year from initial treatment.

Of note, there do not appear to be systemic effects from prolonged intravaginalsteroid use. However, clindamycin or intravaginal corticosteroids can increase the risk of vulvovaginal candidiasis.

 Thus, an antifungal may be warranted, such as oral fluconazole, for patients more likely to get symptomatic candida infections. 

 should occur when choosing a treatment regimen in order to weigh the pros and cons of maintenance therapy, including the risk of vulvovaginal 

For challenging cases in which there is no improvement, and in which the patient may have atrophic vaginitis as well, adding intravaginal estrogen may be beneficial.

 The presence of estrogen facilitates colonization of the vaginal microbiome with 

which helps to decrease the pH to less than 4.7.

1. Gray L, Barnes M. Vaginitis in women, diagnosis and treatment. 

2. Gardner H. Desquamative inflammatory vaginitis: a newly defined entity. 

3. Donders GGG, Bellen G, Grinceviciene S, Ruban K, Vieira-Baptista P. Aerobic vaginitis: no longer a stranger. 

. 2017;168(9-10):845-858. doi:10.1016/j.resmic.2017.04.004

4. Sobel JD. Desquamative inflammatory vaginitis: a new subgroup of purulent vaginitis responsive to topical 2% clindamycin therapy. 

5. Mitchell L, King M, Brillhart H, Goldstein A. Cervical Ectropion May Be a Cause of Desquamative Inflammatory Vaginitis. 

. 2017;5(3):e212-e214. doi:10.1016/j.esxm.2017.03.001

6. Paavonen J, Brunham RC. Bacterial vaginosis and desquamative inflammatory vaginitis. 

. 2018;379(23):2246-2254. doi:10.1056/NEJMra1808418

7. Sherrard J, Wilson J, Donders G, Mendling W, Jensen JS. 2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge. 

. 2018;29(13):1258-1272. doi:10.1177/0956462418785451

8. Mason MJ, Winter AJ. How to diagnose and treat aerobic and desquamative inflammatory vaginitis. 

. 2017;93(1):8-10. doi:10.1136/sextrans-2015-052406

9. Sobel JD, Reichman O, Misra D, Yoo W. Prognosis and treatment of desquamative inflammatory vaginitis. 

. 2011;117(4):850-855. doi:10.1097/AOG.0b013e3182117c9e

10. Mills BB. Vaginitis: Beyond the Basics. 

. 2017;44(2):159-177. doi:10.1016/j.ogc.2017.02.010

11. Hasteh F. Parabasal cells. Pathology Outlines. http://www.pathologyoutlines.com/topic/cervixcytologyparabasalcells.html. Published 2020.

12. Reichman O, Sobel J. Desquamative inflammatory vaginitis. 

. 2014;28(7):1042-1050. doi:10.1016/j.bpobgyn.2014.07.003

The etiology of this condition is unclear but is consistent with a loss of the normal vaginal flora and increase in inflammation.

Desquamative inflammatory vaginitis

Do you believe that shared decision-making has effective outcomes when implemented in an ob/gyn practice? Have you used it with your patients or have you gone through specific training for it? 

Let us know what you think by using the hashtag #SDMConvo to tweet to @ContempOBGYN.

Shared decision-making (SDM) is a core element of patient-centered care.Amid increasing calls for SDM in health care, one of the greatest obstacles to implementation may be the fact that many clinicians believe this is their normal practice, when in fact it may not be. 

In this article, we describe SDM and discuss approaches to care that may support this process, highlighting ways in which it differs from informed consent and the skills needed to ensure that decision-making is truly shared.

SDM brings together patient-centered communication and evidence-based medicine to achieve high-quality, patient-centered care.

 The SDM process involves patients and clinicians making decisions collaboratively, informed by the best available scientific evidence as well as each patient’s values and informed preferences.

There are several important concepts outlined above. “Patient-centered communication” is another widely used but perhaps not universally understood term. Epstein et al.

 define patient-centered communication as:

(1) Eliciting and understanding the patient’s perspective—concerns, ideas, expectations, needs, feelings, and functioning. (2) Understanding the patient within his or her unique psychosocial context. (3) Reaching a shared understanding of the problem and its treatment with the patient that is concordant with the patient’s values. (4) Helping patients to share power and responsibility by involving them in choices to the degree that they wish.

In the busy world of clinical practice, it can be a challenge to elicit and understand the patient’s perspective as well as her unique psychosocial context. Reaching a shared understanding of both problems and treatments can likewise require time to ensure understanding and to address issues such as health literacy and numeracy. 

Finally, in a profession with a long and strong tradition of hierarchy and paternalism, we may struggle with sharing power and responsibility with patients. SDM does not mean ceding all decision-making to the patient, however. Crucially, it incorporates the best available evidence into the decision-making process.

There are a number of frameworks or conceptual models for SDM. The three-talk SDM model

Let the patient know that there is a decision to be made, and that you will work together to make a plan focused on her or their individual needs and goals.

: Share with the patient high-quality, easy-to-understand information about the benefits and harms of each option under consideration. Consider offering the patient a decision aid to visually compare options.

 Identify the patient’s priorities and plan next steps together according to the patient’s informed preferences.

Informed consent also is described as a means of achieving patient-centered care

 through disclosing information to the patient with her or their subsequent “comprehension, voluntary choice, and authorization” of a procedure or treatment.

SDM goes a step beyond informed consent, requiring active collaboration in decision-making between patient and clinician.

Patient-centered communication as defined above is clearly central to identifying and understanding patient preferences. While undergraduate and graduate medical education curricula formally address communication skills, these are often neglected with practicing clinicians, unless a clear problem has arisen or “refresher courses” are available. 

Even now, SDM may not be part of medical school or residency curricula, so this is a new skill for many. It is likely that many experienced and skilled clinicians could actually benefit from education and coaching related to communication, especially if it includes skills practice. 

Many clinicians are surprised to learn that applying the principles of patient-centered communication may not actually increase visit duration.

 Organizations that invest in efforts to develop communication skills of providers often see improvements in patient experience scores and other metrics. 

The Academy for Communication in Healthcare is one organization that offers both in-person and online training in relationship-centered communication.

Decision aids supplement the information and counseling that is provided directly by clinicians.

 These tools include a description of the decision to be made and balanced, and evidence-based information about the options, including benefits and harms.

 They also help to clarify patients’ values and communicate that the ‘right’ decision depends on the patient’s priorities.

Decision aids each are designed for a specific treatment or screeningdecision. They are available in multiple formats, including videos, brochures, and web-based tools.

Some decision aids are designed to be used independently by patients outside the health care setting, while others are made for collaborative use by patients and clinicians during a clinic visit. 

A variety of decision aids, covering topics like cervical cancer screening, prenatal testing, childbirth, infertility, and uterine fibroids, are available through the Ottawa Hospital Research Institute’s website,

 which also offers helpful materials on how to evaluate the quality of a decision aid. 

Additionally, health systems are increasingly subscribing to online decision aid suites that are integrated into their electronic health record systems to facilitate access and use by clinical teams. These tools often have the added benefit of regular updating by an editorial team so that the information presented is up to date.

Patients who use decision aids are better informed about the available options and have a better understanding of what treatment-related priorities matter most to them than those who do not use these tools.

In ob/gyn, decision aids also have been shown to reduce patients’ decisional conflict, thereby increasing overall comfort with the decision that is made.

Decision aids are increasingly being designed for use together by patients and clinicians at the point of care.

 Decision aids made for patients’ independent use generally include lengthy explanations of options and exercises to help patients explicitly clarify their values. In contrast, decision aids used at the point of care (often called ‘encounter decision aids’ or ‘conversation aids’) are brief; they provide a basic evidence overview about key aspects of each option in plain language. 

These point-of-care decision aids are “not designed to be comprehensive” and rely on clinicians’ “just-in-time, tailored explanations and information.”

 When paired with the three SDM steps outlined above, these aids help to improve deliberation by patients and clinicians without increasing the duration of clinic visits.

They also provide a framework for the clinician to incorporate patient preferences and values; for example, desire to preserve fertility might frame the choices for fibroid treatment discussed during a visit. Clinicians report becoming comfortable using this type of decision aid with patients after a brief education and minimal practice.

SDM is a cornerstone of patient-centered care,

 and is therefore often considered a moral imperative. However, implementation challenges persist, including competing clinical priorities in clinical workflows and actual practice habits.

Efforts are currently underway to explore how best to implement SDM in ob/gyn contexts, including ensuring that decision aids are provided to the right patients at the right time in their decision-making processes.

 Inclusion of online decision aids in electronic health records is one promising approach under exploration.

In other contexts, sweeping policy-level implementation efforts have mandated SDM. The Centers for Medicare and Medicaid Services, the largest healthcare payer organization in the United States, now requires documentation of SDM using a high-quality decision aid as a prerequisite to payment for lung cancer screening,

implantable cardioverter-defibrillator implant,

It is unknown whether future SDM mandates will impact the ob/gyn practice, but given the many relevant decisions our patients face (genetic screening, medical vs. surgical abortion, trial of labor after cesarean, management of pelvic organ prolapse, et cetera), they may be on the horizon. 

More importantly, it is our obligation to provide the best evidence while working to understand our patients’ values, preferences, and context.

While SDM is critical to patient-centered care, it is not yet universal in care or training in ob/gyn. As there are many opportunities for SDM in ob/gyn, it will be important for trainees and practicing providers to understand the principles of SDM, learn skills that support patient-centered communication, and become familiar with and develop new decision aids. 

Patient-centered communication includes: 1) eliciting and understanding the patient’s perspective; 2) understanding the patient within her or their unique psychosocial context; 3) reaching a shared understanding of the problem and treatment that is concordant with the patient’s values; and 4) helping patients to share power and responsibility by involving them in the choice to be made.

SDM requires that clinicians: 1) identify that there is a decision to be made; 2) share evidence-based information about the benefits and harms of each potential option; and 3) plan next steps together according to the patient’s informed preferences.

Using decision aids as part of an SDM process at the point of care improves decision-making outcomes without increasing clinic visit duration.

Clinicians and patients report ease of use and satisfaction with point-of-care decision aids.

Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making. 

Elwyn G, Durand MA, Song J, et al. A three-talk model for shared decision making: multistage consultation process. 

 Epstein RM, Franks P, Fiscella K, et al. Measuring patient-centered communication in Patient–Physician consultations: Theoretical and practical issues. 

. 2005;61(7):1516-1528. doi:10.1016/j.socscimed.2005.02.001.

Krumholz HM. Informed consent to promote patient-centered care. 

Grady C. Enduring and emerging challenges of informed consent. 

Laws MB, Epstein L, Lee Y, et al. The association of visit length and measures of patient-centered communication in HIV care: A mixed methods study. 

Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. 

Drug and Therapeutics Bulletin. An introduction to patient decision aids. 

Ottawa Hospital Research Institute Decision Aid Inventory. Accessed August 25, 2020. https://decisionaid.ohri.ca/AZlist.html.

Poprzeczny AJ, Stocking K, Showell M, Duffy JMN. Patient Decision Aids to Facilitate Shared Decision Making in Obstetrics and Gynecology. 

. 2020;135(2):444-451. doi:10.1097/aog.0000000000003664.

Agoritsas T, Heen AF, Brandt L, et al. Decision aids that really promote shared decision making: the pace quickens. 

Elwyn G, Rasmussen J, Kinsey K, et al. On a learning curve for shared decision making: Interviews with clinicians using the knee osteoarthritis Option Grid. 

Barry MJ, Edgman-Levitan S. Shared decision making—pinnacle of patient-centered care. 

Scalia P, Durand M-A, Forcino RC, et al. Implementation of the uterine fibroids Option Grid patient decision aids across five organizational settings: a randomized stepped-wedge study protocol. 

Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N). Accessed August 25, 2020. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274

Decision Memo for Implantable Cardioverter Defibrillators (CAG-00157R4). Accessed August 25, 2020. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=288

Decision Memo for Percutaneous Left Atrial Appendage (LAA) Closure Therapy (CAG-00445N). Accessed August 25, 2020. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=281

Sweeping policy-level implementation efforts have mandated SDM in other areas of medicine; similar mandates could impact ob/gyn.

Why shared decision-making matters more than ever

Type 1 diabetes mellitus (T1DM) is an autoimmune condition that causes pancreatic beta-cell destruction and complete absence of native insulin production. Risk factors for development of T1DM include family history, genetic predisposition (specific human leukocyte antigen gene variants), and viral triggers.

While T1DM affects only 5% of patients with pregestational diabetes and less than 1% of overall pregnancies, it is important that obstetricians are aware of the pathophysiology, basic management principles, and rapidly evolving insulin pump and continuous glucose monitoring (CGM) technologies.

Patients with poorly controlled T1DM have higher risks of preeclampsia, fetal growth abnormalities, polyhydramnios, intrauterine fetal demise, diabetic ketoacidosis, cesarean delivery, and wound infections.

In order to optimize glycemic control and pre-conception hemoglobin A1c, referral to both a maternal-fetal medicine physician and an endocrinologist is important for all individuals with reproductive potential. 

Preemptive optimization of comorbidities and hemoglobin A1c levels may decrease the risk of congenital birth defects and miscarriage.

Over the past 20 years, there has been a paradigm shift in management of T1DM from self-monitoring of fingerstick capillary blood glucose to CGM and from multiple daily injections (MDI) of insulin to continuous subcutaneous insulin infusion (CSII, colloquially known as “insulin pumps”). 

This review will discuss the science and rationale behind these technologies.

CGMs were first introduced in 1999, with the clinical intent of improving patient’s self-awareness of real-time glycemic control, and reducing the cumulative burden of disease management.

 These monitors utilize a glucose-oxidase enzyme reaction to measure the glucose concentration in interstitial fluid and converts the value via algorithms to expected glucose concentration in the blood.

A review of the science and technology behind current insulin pumps and
CGMs for managing type 1 diabetes mellitus in pregnancy.

Vol 65 No 11

What did you think of the November cover story?

Cesarean delivery leads to unexpected outcome

Desquamative inflammatory vaginitis

Why shared decision-making matters more than ever

Advancing technology in diabetes management

The state of gynecologic robotic surgery

How much is my idea worth?

Innovating for improved patient outcomes

Abdominal entry in laparoscopic surgery

Vaginal Dilators: A guide for health care professionals

Vasomotor symptom severity not linked to any clinical event in menopause