These are just some preliminary ideas. It is not a proposal to start all at once, nor is it a thought out blueprint. Possible funding is guess work All of this would take a lot of leg work.

1. Emergency team for abnormal FHR:

Experience: I have reviewed over 600 “bad baby” cases.

Insights:A. An obstetrician with a difficult decision based on fetal monitoring might benefit by real time consultation with a team that works on this specific management problem all the time.

1. I don’t think (tell me if I am wrong) that the obstetrician usually knows anatomically what is causing the abnormal heart rate. It is not enough to know that there are deep variables, I would want to know how is the cord compressed.

Response:1. Team MFM and Nursing that keeps up with the literature, reviews hospital cases, but also legal cases, and is on call by phone to look at tracings, and manage in consultation with obstetricians including hospitalists.

2. Develop research protocols such as immediate imaging options to identify cord compression or fetal risk such as NMR of brain pH to better evaluate new therapeutic options for in utero rescue.

Goals:A. Prevent low Apgars while still reducing C-sections for non-reassuring heart tracings.

1. Convince liability insurers to reduce our rates because of the program

Funding:Liability insurers, NICHD

2. Improved stillbirth care:

Experience: I have preformed around 2000 perinatal autopsies. I have participated on and off in FIMR since its beginning.

Insights: A. The precise cause of death is often unknown. The autopsy in cases of unknown cause often shows features that are the same as those found in deaths due to known causes of asphyxia.

1. Parents often don’t truly understand what we do or don’t know after the autopsy.

Response: A. Develop research protocols that include offering an MRI of the stillborn infant before delivery. B. Create a stillbirth team that can be consulted for patient interview at the time of discovery of the death and post autopsy review that included the parents, caregivers and pathologist with training similar to that of Dr. Orsini for newborn deaths.

Goals: A. Learn information that may improve prevention of stillbirth

1. Improve the caring part of obstetrical care.

Funding:Parent groups like Star Legacy (I am currently working on a meta-review on umbilical cord with Dr. Heazell in Manchester England funded by the group); NICHD

4. Placenta diagnostic utility to maximize value:

Experience:I have examined more than 50,000 placentas. I have organized many studies of placenta pathology clinical correlation, but 2 stand out (see foot note *). I participated in the just published monograph of the international consensus on placental pathology. (Pathology of the Placenta, a Practical Guide, editors Khong et.al., Springer)

Insight:Placental diagnostic examination requires better standardization, and better understanding of its diagnostic implication by both clinicians and pathologists. Criteria for submitting placentas to pathology are still subjective, and not based on clinical utility.

Response: The use of the placenta examination needs to be critically reviewed by a maternal fetal medicine specialist, pathologist, and neonatologist team, to develop guidelines for submission and interpretation.

Goals:A. To reduce unnecessary placental examination, and to better utilize placental examinations that are performed.

Funding:Medical Insurers, NICHD

5. Research into how to meet the logistical needs of patients:

Experience:Observation of the obstetrical care of my wife for 4 daughters, and for my 8 grandchildren.

Insight:Problems with transportation, baby sitting, communication, finances, etc. have a large impact on the quality of care received and the patient’s evaluation of the institutional experience.

Response: A team to review patient concerns and problems with the aim of developing and testing creative solutions.

Goals:Better patient care and better perception of the hospital system as a caring place for obstetrics.

Funding:Hospital funding, State funding

6 . A center for improved obstetrical technology:

Experience:Submission of a proposal for a device to detect preterm labor for Coulter grant. (see footnote **)

Insight:There is a need for a center to focus on sophisticated obstetrical technology, for example devices to detect and monitor early signs of and progression of labor and of fetal well being. There is a need for new diagnostic tests, for example to detect molecules in cord blood to detect timing of brain injury or identify pathogens quickly.

Response:To create a group of obstetricians, engineers, and pathologists to meet regularly to discuss potential technical solutions to problems in obstetrics. The goal would then be to develop those ideas into useful tests or devices.

Goals:To develop patentable devices that would improve patient care and generate income for the participating parties.

Funding: Industry, NICHD

Footnotes:

*When I first started in obstetrical pathology I initiated and completed a project that asked obstetricians to check on a list what they hoped to learn from the placenta examination. The placenta pathology reports were then analyzed in a conference with the MFM fellow (Dart Mostello) MFM (Menachem Miodovnik) and Neonatologist (Uma Kotagal) as to whether the question was answered, but even more importantly whether the exam was useful for clinical care of the patient in the current or future pregnancies, for potential quality control value, for teaching value, for medico legal value, research or of no value. The results showed very disappointing utility. I forget how many we did or the exact numbers, but clinical utility was close to zero. I submitted the paper to AJOG who trashed it as non-scientific. I foolishly gave up trying to get it published. Wind the clock ahead thirty five years and I did the PROOF study here based in part on Dr. Stan Gall’s contention that all placentas should be looked at since they might contain information that we could not at the current time appreciate. I went a step further and suggested two hypotheses that I thought had a strong chance of showing utility of the placental examination, yet did not necessarily have any clinical signs. These were severe villitis as a predictor of the risk of autoimmune disease and small placental separations as impacting neurologic outcome. The study demonstrated that at least up to age 7 years, the lesions were not predictive of disease.

**A few years back I worked with Dr. Harnett from the U of L engineering school to try to apply for a Coulter grant for a device that measured cervical changes. It was a simple grid on a silicon rubber band that fit over the cervix and generated a signal without a battery if the band was distorted. It works well on the skin surface, but the signal did not penetrate to the outside when we put it around the cervix of a dead sheep. But there is no reason that it could not be made to work, and could probably also detect softening as well, and signal this to a smart phone or watch.

Another example of useful technology occurred to me as I watched a nurse spend the majority of her time repositioning the fetal heart beat sensor over the two heartbeats of my daughter’s twins. If the sensor had servomotors and could follow the signal strength by angling the sensor, it could save a lot of nursing time and produce a more reliable tracing.