Complex Obstetrical Surgery: Building a Team and Defining Roles.

As the number of placenta accreta spectrum (PAS) cases continues to rise, the gap in surgical skills in labor and delivery units becomes more apparent. Recent scholarly work has highlighted the diminishing advanced surgical skills among obstetricians-gynecologists, particularly among new graduates. Therefore, it has become a practice in many institutions to refer complex cesarean deliveries (CD) and obstetrical hysterectomies to subspecialists, specifically gynecologic oncologists. Hence, in this commentary, we propose a process whereby key personnel within departments of obstetrics and gynecology are identified, and their appropriate level of involvement in cases of complex obstetrical surgery is delineated. In doing so, we describe the surgical skills expected from each provider level so that the CD complexity level can be matched to specific surgical expertise. Through this process, an obstetrician-led complex obstetrical surgery team is formed. Ultimately, the goal of this process is twofold: first, to return cases with higher levels of surgical complexity back to obstetricians, and second, to reduce the surgical back-up burden from gynecology subspecialists such as gynecologic oncologists.