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OBJECTIVE: To compare medical student performance on the obstetrics and gynecology national board subject examination during two different clerkship rotation formats. METHODS: We compared medical student performance on the National Board of Medical Examiners (NBME) subject examination in obstetrics and gynecology for 2 years before and 2 years after the length of the clerkship at the University of Florida was decreased from 8 to 6 weeks. Medical College Admission Test (MCAT) and United States Medical Licensing Examination (USMLE) step 1 and step 2 scores were used to assess comparability between groups. Student t test and chi2 analysis were used as appropriate. RESULTS: Medical school classes were similar with respect to MCAT and USMLE step 1 and step 2 scores. Collectively, 231 students who completed the 8-week clerkship scored significantly higher on the subject examination than 239 who completed the 6-week clerkship (618.6 versus 593.5, P = .001). When analyzed by semester, students who completed the clerkship in the second half of the academic year scored similarly regardless of clerkship length (630.6 versus 616.7, P = .11); however, students who completed the clerkship during the first half of the academic year scored significantly higher with the 8-week than the 6-week clerkship (607.3 versus 569.7, P < .001). Students who took the clerkship in the last half of the academic year scored higher than students who took the clerkship in the first half for both the 8-week (630.6 versus 607.3; P = .02) and 6-week (616.7 versus 569.7; P < .001) formats. Those differences persisted on examination letter grade assignment. CONCLUSION: Decreasing the duration of the obstetrics-gynecology medical student clerkship resulted in lower subject examination scores, especially for students who matriculated in the first half of the academic year.

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Perinatal death is a tragic occurrence, and parents vary in their needs and how they express grief. This prospective study describes choices parents made regarding contact with their baby following stillbirth or immediate neonatal death. Between 1 January 1979 and 1 March 1991, 808 consecutive families were enrolled in the Perinatal Mortality Counseling Program at the University of Florida. Following perinatal death, most parents wanted contact with their baby to personalize the event, information about the death and follow-up from their health care providers. However, no option was chosen by all parents. This large study strongly supports offering choices to all parents. Providers should neither bias parents nor make presumptions that would limit parental choices.

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Scholarship in academic medicine includes the discovery of new knowledge as well as the integration, application, and teaching of existing knowledge. Although all components are vital, the rewards for each may vary considerably. Many medical educators have recommended that the teaching of medical students be given the same level of esteem traditionally awarded to research and patient care, and that the same level of excellence must be expected from teachers as from researchers and clinicians. Common facets of three successful reward systems in place include documenting quality as well as quantity; rewarding all excellent teachers, not just "the best"; and publicizing the rewards to students, peers, and administrators.

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This study describes paternal involvement after perinatal death in a large, mostly minority, lower socioeconomic status sample. Paternal presence at birth, holding the baby, and presence at a follow-up appointment were the indicators of paternal involvement. Perinatal death was defined as miscarriage, stillbirth, or neonatal death within 12 hours of birth. Data were collected from a retrospective chart review under the auspices of the Perinatal Mortality Counseling Program at Shands Hospital at the University of Florida, a tertiary care referral center in north central Florida. The sample included 722 cases of perinatal death between July 1978 and April 1991. The results indicated that many fathers experienced perinatal grief. More than half attended the birth, a quarter chose to hold their baby, and one fifth returned with the mother to follow-up appointments. Paternal-maternal cohabitation was the variable most predictive of the fathers' involvement after perinatal death. Race was predictive of the father being present at birth and at the follow-up visit, with white fathers more likely to be present than black fathers. Married fathers and those employed in a professional or manual labor occupation were more likely to be present at the birth than fathers who were unemployed, students, incarcerated, or in the military. Gestational age was predictive of the father holding the baby, with the likelihood increasing 1.04 times for each week of increase in gestational age. This study supports the need to include fathers in grief counseling, and the further investigation of the involvement of fathers when a perinatal death occurs.

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Two cases are presented of incomplete vaginal delivery because of fetal sacrococcygeal teratomas. Prompt recognition and aggressive therapy resulted in favorable outcomes with minimal morbidity. The combined vaginal and abdominal manipulations involved repositioning the arms, shoulders, and vertex in the vagina, as the breech was extracted abdominally in a direction opposite to that ordinarily used. While this procedure seemed to work well, it is only applicable when the diagnosis of fetal tumor is made too late to prevent an obstructed delivery. Optimally, obstructed delivery is prevented by early ultrasonographic diagnosis and cesarean delivery before advanced labor.

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Three primigravidas developed Rh sensitization after unexplained third-trimester fetal death. One patient manifested sensitization after the diagnosis of fetal death had been made but before delivery occurred. The other two demonstrated anti-D antibodies early in the next pregnancy, despite having received postpartum Rh immunoglobulin. Unsensitized Rh-negative women with unexplained third-trimester fetal death should be screened routinely for fetomaternal hemorrhage when fetal death is discovered, so that adequate prophylaxis against Rh sensitization can be given.

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A case of congenital herpes simplex virus type II infection acquired in utero is reported. The issue of congenital infection due to the herpes simplex viruses is discussed.

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Traditional care for mothers after stillbirth has been based on untested assumptions about appropriate parental behavior. To evaluate these assumptions, 165 families cared for by the Perinatal Mortality Counseling Program because of stillbirth or immediate neonatal death were offered a series of choices about their care, including how they wished to deal with their baby's death. Parental decisions were compared with selected demographic and obstetric features considered as underlying those decisions that traditionally have been made by physicians or the hospital staff. The authors found that parents desire contact with their baby, attention to their feelings, counseling from those providing their care, and information about their baby's death. Few demographic and obstetric features seemed to influence the choices. This suggests that physicians and hospital staff should not presume to determine the wishes of any parent or family faced with this tragedy.

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The emotional impact of a stillbirth on a family has only recently begun to be appreciated. Literature regarding the grieving process in these families has been relatively scant and does not often facilitate applied approaches. The Perinatal Mortality Counseling Program (PMCP) at Shands Teaching Hospital, Gainesville, Florida, provides crisis intervention and support for these families as well as serving a research function. This article outlines the program, including its history, composition, procedures, and research.

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Continuous tissue pH monitoring of the fetus was successfully conducted in 13 of 21 patients (61.9%) during labor. There was a significant correlation between the tissue pH and both the scalp capillary blood pH (r = 0.94, P less than 0.001) and the umbilical artery blood pH (r = 0.92, P less than 0.01). These findings confirm the accuracy of the tissue pH instrumentation in reflecting fetal acid-base status and support the potential usefulness of the instrumentation in perinatal medicine for continuous fetal acid-base monitoring.

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Three perinatal health indicators (serum human placental lactogen [hPL] levels, serum free estriol [E3] levels, and OCT) were simultaneously completed in 149 high-risk women who were more than 34 weeks pregnant. There was a significant correlation between the hPL and E3 results (r = 0.28, p less than 0.01). There was a 15.4% positive OCT result rate and the blood hormone values for the negative and positive OCT groups were compared. There was a significantly lower hPL value in the positive OCT group (4.7 +/- S.E.M. 0.4 vs. 6.2 +/- S.E.M. 0.2 micrograms/ml for positive and negative groups, respectively), whereas the free E3 levels were not different in these two OCT groups (14.8 +/- S.E.M. 1.5 vs. 16.3 +/- S.E.M. 0.7 ng/ml for positive and negative groups, respectively). The free E3 value did not help in predicting the OCT result as the low free E3 subgroup had the same frequency of positive OCT result as did the over-all group. There was a highly significant increase in the positive OCT results (42.9%) in women with a low hPL value (p less than 0.01). In those women with an hPL value of 6.0 microgram/ml or more there were only 8% positive OCT's. It is concluded that on hPL test at about 34 weeks of gestation could be used to screen pregnant women, and if the value were low (less than 4.0 microgram/ml) an OCT evaluation test would be indicated, for there is a very high frequency of positive results in that subgroup of women.

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The validity of continuous tissue pH measurements was established in the fetal and neonatal goat model. Simultaneous determinations of tissue, arterial, and venous pH were done during alterations in acid-base status. A highly significant correlation was found between tissue and blood pH levels (r = 0.89, p less than 0.001). These data confirm the accuracy of the tissue pH instrumentation in predicting core blood pH status and support the potential usefulness of the instrumentation in perinatal medicine for continuous fetal acid-base monitoring.

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Seventy-eight amniotic fluid samples were obtained by transabdominal amniocentesis and were analyzed for their L/S ratio and optical density at 400 and 650 nm. The L/S ratio was considered to be mature if the values were greater than 2.0. The optical density of the fluids decreased with prolonged refrigeration. With freshly centrifuged samples, the OD650 reading of greater than 0.15 gave the best correlation with the mature L/S ratio. There were 3.8% false positive results and 14.1% false negative results. The study confirms that the OD650 test on fresh amniotic fluid is a rapid and inexpensive way to determine fetal maturity. All samples with values of less than 0.15 must, however, also be tested for their L/S ratio since some of the infants with these values may also be mature.

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