In low-income countries, ALSO training was associated with decreased in-hospital maternal mortality, episiotomy use, and PPH. AMTSL and vacuum-assisted vaginal delivery increased in frequency after ALSO training.

Family physicians in Cuba and the United States operate within very different health systems. Cuba's health system is notable for achieving developed country health outcomes despite a developing country economy. The authors of this study traveled to Cuba and reviewed the literature to investigate which practices of Cuban family physicians might be applicable for US family physicians wishing to learn from the Cuban experience. We found that community-oriented primary care (

PURPOSE Recent national guidelines encourage a trial of labor after cesarean (TOLAC) as a means of increasing vaginal births after cesarean (VBACs) and decreasing the high US cesarean birth rate and its consequences (2010 National Institute of Health Consensus Statement and American College of Obstetricians and Gynecologists revised guideline). A birthing center serving Amish women in Southwestern Wisconsin offered an opportunity to look at the effects of local culture and practices that support vaginal birth and TOLAC. This study describes childbirth and perinatal outcomes during a 17-year period in LaFarge, Wisconsin. METHODSWe undertook a retrospective analysis of the records of all women admitted to the birth center in labor. Main outcome measures include rates of cesarean deliveries, TOLAC and VBAC deliveries, and perinatal outcomes for 927 deliveries between 1993 and 2010. RESULTSThe cesarean rate was 4% (35 of 927), the TOLAC rate was 100%, and the VBAC rate was 95% (88 of 92). There were no cases of uterine rupture and no maternal deaths. The neonatal death rate of 5.4 of 1,000 was comparable to that of Wisconsin (4.6 of 1,000) and the United States (4.5 of 1,000).CONCLUSIONS Both the culture of the population served and a number of factors relating to the management of labor at the birthing center have affected the rates of cesarean delivery and TOLAC. The results of the LaFarge Amish study support a low-technology approach to delivery where good outcomes are achieved with low cesarean and high VBAC rates. Ann Fam Med 2012;10:530-537. doi:10.1370/afm.1403. INTRODUCTIONT he cesarean rate in the United States has risen from 5.5% in 1970 to 16.5% in 1980 1 to 21% in 1996 to 32.9% in 2009. 2,3 A 2011 study calculates that if trends continue, the 2020 cesarean rate will be 56.2%. 4 The 2007 primary cesarean rate was 23.4%. 5 The vaginal birth after cesarean (VBAC) rate-the percentage of pregnant women who give birth vaginally after a previous cesarean-has fallen from a high of 28.3% in 1996 1 to 8.5% in 2006. 6 The World Health Organization (WHO) and Healthy People 2020 have suggested the ideal cesarean rate should be around 15%. 7,8 The 2010 National Institutes of Health consensus conference on VBAC highlighted high-grade evidence that maternal mortality risk is decreased by VBAC compared with a repeat cesarean (3.8 vs 13.4 of 100,000).2 Data suggest decreasing the primary cesarean delivery rate and increasing the VBAC rate as key strategies to decrease the US cesarean rate. 9Amish communities ascribe religious and cultural value to childbearing. 10,11 Contraception, including sterilization, may be prohibited. 10Advanced maternal age and grand multiparity are common. Amish women of Southwest Wisconsin generally give birth at home attended by an unlicensed birth attendant, mother, mother-in-law, or neighbor. Formal education for men and women is through 8th grade, and women do not work outside the home. Amish culture prohibits electricity, telephone service, and car ownership, leading to delays ...

Background:The Advanced Life Support in Obstetrics (ALSO®) program is a highly structured, evidence-based, two-day course designed to provide healthcare professionals with the knowledge and skills to manage the emergency conditions that can occur during childbirth.Objectives:To document the number of ALSO®-trained clinicians and instructors in the United States and internationally and to promote ALSO® training among prehospital and disaster medicine professionals.Methods:Records maintained by the American Academy of Family Physicians (AAFP) for each country where ALSO® is taught were reviewed for: (1) the years and locations of the ALSO® courses; (2) the number of ALSO®-trained caregivers; and (3) the number of ALSO® instructors.Results:Between 1991 and 2005, 54,071 ALSO®-trained caregivers and 2,251 instructors have completed provider and instructor ALSO® courses in 25 countries. Of these, 17,755 caregivers and 1,220 instructors are from outside the United States.Conclusion:The ALSO® program is a popular, multi-disciplinary course for preparing maternity caregivers to manage obstetric emergencies. Limited evidence suggests it can be effective and efficient in enhancing the knowledge and skills of prehospital and disaster medicine clinicians. Hong Kong provides a model in which emergency physicians have taken the lead in promoting the ALSO® course. As the ALSO® program expands, additional research is needed to assess its impact on educational and health outcomes.

Cesarean delivery rates rose from 20 to 33% of births in the United States from 2006-2009 without an accompanying improvement in neonatal outcomes. The cesarean rate may be safely decreased by increasing vaginal birth after cesarean, encouraging external cephalic version for breech presentation, maintaining operative vaginal delivery skills, and applying stricter criteria for operative intervention in labor dystocia. A variety of cesarean operative techniques are supported by randomized controlled trials. Optimal maternity care outcomes depend on sound medical decision-making, appropriate operative technique and skills, and effective communication between maternity care team members.

Colposcopy is a diagnostic procedure, most commonly used in the diagnosis of cervical intraepithelial neoplasia and lower genital tract carcinoma.

The advanced life support in obstetrics (ALSO) course is designed to help maternity care providers prepare for obstetrical emergencies. A team of 12 US physicians and a medical interpreter recently taught the ALSO course in Ecuador, with the goal of addressing Ecuador's high maternal and infant mortality rates. To have a greater impact, a teach-the-teacher model was used so that Ecuadorian physicians can now hold their own ALSO courses. In the process of implementing the courses, valuable lessons were learned which can be applied to future ALSO courses in developing countries and in the United States. "Give someone a fish and you feed them for a day; teach someone to fish and you feed them for a lifetime." Following this proverbial advice, a teachthe-teacher model was used when 12 physicians and a medical interpreter went to Ecuador in February 2003 to teach the advanced life support in obstetrics (ALSO) course. This article describes why the ALSO course was chosen, how Ecuador was chosen, how the courses were implemented, and what lessons might be useful for organizers of future international and US ALSO courses. Why the ALSO Course?In 1991, the ALSO course was developed by 2 Wisconsin family physicians, James Damos and John Beasley.1-3 The course was obtained by the American Academy of Family Physicians (AAFP) in 1993. The curriculum focuses on the management of obstetrical emergencies and is modeled after the advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) courses. Now in its fourth edition, the ALSO course is evidence-based, categorizing its recommendations according to the strength of supporting evidence. The course uses an adult-learning model, emphasizing interactive workshops and hands-on learning through the use of mannequins, and the course lends itself well to a teach-the-teacher model, whereby students are trained to become future instructors.The ALSO course has been taught outside of the United States since 1995. In Latin America and the Caribbean, courses have been taught in Haiti and Paraguay. To date, more than 30,000 providers have take the ALSO course in the United States and 12,239 have taken the course internationally. The United States has 987 approved instructors and 238 advisory faculty, compared with 900 international approved instructors.Instead of teaching 1 course and then leaving, we wanted to increase our impact by teaching Ecuadorian physicians to put on their own courses. After discussing how we chose Ecuador, we discuss use of a teach-the-teacher model with the Ecuador ALSO courses. Why Ecuador?The decision to teach the ALSO courses in Ecuador was based on its location in Latin America, its high maternal and infant mortality rates, the presence of a family medicine residency, and personal connections with Ecuadorian faculty members.We speak Spanish and we wanted to introduce the ALSO course to Spanish-speaking Latin America. In preparation for the Ecuador courses, the

This case report summarizes the sequence of events that led to the detection of a molar pregnancy missed by ultrasound and initial pathology examinations. This patient illustrates that following serial quantitative ␤-human chorionic gonadotropin (B-hCG) levels after spontaneous, therapeutic, and elective abortions will help detect potentially life-threatening molar and ectopic pregnancies. Further research is needed to determine the optimal frequency of B-hCG testing. For now, maternity care providers can follow the American College of Obstetrics and Gynecology recommendation that abnormal bleeding for more than 6 weeks after any pregnancy should be evaluated with B-hCG testing. Earlier testing may be considered. (J Am Board Fam Pract 2005;18:570 -3.)