# Two News Flashes: {#two-news-flashes .Style-Heading-1-+-Underline}

-Welcome our new columnist, Peter Stuart, IHS Psychiatry Consultant

See Behavioral Health Insights, below

# -New Perinatology Corner Module: {#new-perinatology-corner-module .Style-Heading-1-+-Underline}

# Preconception Counseling for Women with Diabetes and Hypertension {#preconception-counseling-for-women-with-diabetes-and-hypertension .Style-Heading-1-+-Underline}

# See Featured Website, below {#see-featured-website-below .Style-Heading-1-+-Underline}

# ![](media/image1.jpeg){width="5.992361111111111in" height="1.33125in"} {#section .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

 

OB/GYN Chief Clinical Consultant's Corner

Volume 6, No. 1, 2008

# Contents {#contents .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### Abstract of the Month page 5 {#abstract-of-the-month-page-5 .Style-Heading-4-+-Arial-14-pt-Underline}

What happens if a patient hears their results are Negative? Positive?
Normal? Abnormal?

#### From your colleagues page 7 {#from-your-colleagues-page-7 .Style-Heading-4-+-Arial-14-pt-Underline}

David Gahn

You can make a big difference in women's and children's lives

Scott Giberson

-Second annual Native HIV/AIDS Awareness Day coming March 20, 2008

-Updated U.S. DHHS Guidelines for Treatment of Adults and Adolescents
with HIV

-Funding opportunity for HIV Prevention programs through CDC

**Steve Holve**

Update on Pedvax Hib

**Mary Wachacha**

Seeking 2 Physicians for national IHS Patient Education Protocols and
Codes Committee

#### Hot Topics {#hot-topics .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics page 14

-Cesarean delivery on request not recommended if desiring several
children, ACOG

-Sense of coherence and symptoms of post-traumatic stress after
emergency caesarean

-Late-preterm (34-36 weeks) infants have higher mortality rate than term
at one year of age

-Spinal analgesia increases the success rate of external cephalic
version from 32% to 67%

-Milk consumption during pregnancy is associated with increased infant
size at birth

**Gynecology page 15**

-Early feeding within the first 24 hours after major abdominal
gynecologic surgery is safe

\-[Abnormal Uterine Bleeding: A Management
Algorithm](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0I8OU0Gx)

-Addition of HPV to Pap test to screen in mid-30s for cervical cancer
reduces in CIN 2 or 3

\-[Medical Therapy for Ectopic
Pregnancy](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0IwfQ0GL)

-A cautionary case: Balloon occlusion of internal iliac arteries for
abnormal placentation

**Child Health page 16**

-Rapid response team: Implications of findings on mortality rates for
children are dramatic

-What are the effects of lifestyle interventions for the treatment of
childhood obesity?

-Newborn Screening. ACOG Committee Opinion

**Chronic Illness and Disease page 18**

-Reconsider use of rosiglitazone

-Therapy Insight: Management of Graves\' Disease During Pregnancy 

-Antithrombotic therapy and pregnancy: consensus report and
recommendations

-Cholesterol \<10th population percentile was strongly associated with
preterm delivery

-Cisplatin with RT improves long-term progression-free survival in 1B
cervical carcinoma

#### Features page 19 {#features-page-19 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Human Immunodeficiency Virus

-Ethical Decision Making in Obstetrics and Gynecology

-Invasive Prenatal Testing for Aneuploidy

##### American Family Physician

-Patient-Controlled Analgesia for Postoperative Pain: Cochrane Briefs

-ASA and Clopidogrel Decreases Cardiovascular Events in Acute Coronary
Syndrome

**Agency for Healthcare Research and Quality**

##### -Women leaving the hospital AMA after delivering should be targeted for more services

##### -Full disclosure of medical errors to patients is becoming more and more transparent

-Colorectal cancer screening can be improved at primary care practices

-Family-centered, high quality primary care linked to fewer nonurgent ED
visits by children

**Ask a Librarian**

-Prevention, Assessment, and Treatment of Child and Adolescent
Overweight and Obesity

## -The Healthy Heart Handbook for Women \'07 - 20th Anniversary Edition

**Behavioral Health Insights**

Teens, Depression, Black Box Warnings and Suicide

**Breastfeeding**

-Breastfeeding, it is not just about the baby

-Milk pollution due to alcohol

-Special journal issue offers guidance on promoting and supporting
breastfeeding

#### -Lactation complicated by overweight and obesity: Many challenges {#lactation-complicated-by-overweight-and-obesity-many-challenges .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

\-[30 minute rule not a requirement and 'immediately available' defined
locally](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_AOM.cfm)

\-[Random glucose test would have missed 5 of 6 women with
GDM](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Coll.cfm)

\-[Cesarean delivery in Native American women: Low rates explained by
practice
style?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#ob)

\-[HPV test beats Pap in detecting cancer - Use new  ASCCP Consensus
Guidelines](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#gyn)

\-[Long-term prognosis for infants after massive fetomaternal
hemorrhage](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#child)

\-[Heart Disease Kills More Younger
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#chrIll)

\-[Use of Psychiatric Medications During Pregnancy and
Lactation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#acog)

\-[Predicting the Likelihood of Successful Vaginal Birth After Cesarean
Delivery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#afp)

\-[The Healthy Heart Handbook for Women \'07 - 20th Anniversary
Edition](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#AskLib)

\-[Breastfeeding Promotion: Good Public Health Policy: Part 2 of
2](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#breast)

\-[Adolescent primary prevention programs for DV which are school
based](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#dv)

\-[New module: Lack of VZIG and new prenatal assessment of varicella
immunity](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#webSite)

\-[Special Global Issue - Obstetrics and
Gynecology](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#ih)

\-[Tightening the \"holes\" in the Swiss cheese model of patient safety
in
obstetrics](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#alert)

\-[Frequently Asked Questions about Infant Feeding
Choice](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#headlines)

\-[What is the presenting
part?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#mmtour)

-Vaginal birth after cesarean (VBAC) in rural hospitals -
[Counterpoint](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#MidWives)

\-[Which caused more deaths in the United States in 2005, MRSA or
HIV?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#navajo)

\-[2008 Long Term IHS Training-- NURSE ANESTHESIA -- Apply
Soon](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#nurseCorner)

\-[Cancer in American Indians and Alaska
Natives](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#owh)

\-[Methicillin-resistant Staphylococcus aureus in women's
health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#okie)

\-[A cost decision analysis of 4 tocolytic
drugs](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#periPicks)

\-[Traditional AI/AN Medicine: Incorporating Into I/T/U Clinical
Practice](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#pcf)

\-[Prevention of Mother-to-Child HIV Transmission in Resource-Limited
Settings](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#std)

\-[Hypertension Triples Womens' Risk for
Diabetes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#stillW)

\-[Alaska Native FASD and Suicidality in a Healthcare
setting](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#wheadlines)

**Domestic Violence**

-Improving Domestic Violence Law Enforcement Response on the Tohono
O\'odham Nation

-Child abuse funding offered: CCTV / Recording Technology Grant Program

**Elder Care News**

-Training in Palliative and End of Life Care -- Offered twice - SAVE THE
DATES

-Physician-pharmacist collaboration reduces inappropriate drug
prescribing in elderly

**Family Planning**

-Intrauterine Device and Adolescents, ACOG Committee Opinion

#### -Prescription contraceptive use increased reflecting state mandates on private insurers {#prescription-contraceptive-use-increased-reflecting-state-mandates-on-private-insurers .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Advance provision of EC does not reduce pregnancy rates, nor affect sexual behavior {#advance-provision-of-ec-does-not-reduce-pregnancy-rates-nor-affect-sexual-behavior .Style-Heading-4-+-Arial-14-pt-Underline}

\-[Ethinyl Estradiol/Drospirenone for the Symptoms of Premenstrual
Dysphoric
Disorder](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0IwfG0GB)

**Featured Website**

Preconception Counseling for Women with Diabetes and Hypertension: New
module

**Frequently asked questions**

-How should we manage a patient with a previous abruptio placenta?

-Frequently Asked Questions about Infant Feeding Choice

**Indian Child Health Notes**

**-**No more cough syrup says the FDA

-No more cavities says Dr. Esposito

-Not enough Hib vaccine says Dr. Singleton

**Information Technology**

iCare Training

International Health

Disparities, Inequalities, or Inequities?

#### MCH Alert

Insights on Implementing Cultural and Linguistic Competence in MCH

#### MCH Headlines

-Oral Health for Head Start Children: Best Practices

-Safer infant sleep environment through crib giveaways and education

-Alcohol Screening Brief Intervention: Cooperative Agreement
announcement by SAMHSA

-Child abduction Amber Alert Article

-Childhood Obesity: AMA expert committee recommendations released

#### Medical Mystery Tour

#### -What is the presenting part? {#what-is-the-presenting-part .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

-Making Sense of the Complex:Point of Care Approach to Chronic Pelvic
Pain / Interstitial Cystitis

-Management of Premenstrual Dysphoric Disorder: A Series of Interactive
Cases

-Commonly Administered Vaccines and Associated Illnesses

-Understanding Triglycerides: Beyond LDL Cholesterol

**Menopause Management**

Treating Sexual Difficulties in Menopause

**Midwives Corner**

ACNM seeks Midwifery Expertise on an as-needed basis

**Navajo News**

Which caused more deaths in the United States in 2005, MRSA or HIV?

**Nurses Corner**

-Scope of Practice and the Nurse Practitioner: Regulation, Competency,
and Expansion

-Overweight Children and Adolescents - National Association of School
Nurses

#### Office of Women's Health, CDC

-Cancer in American Indians and Alaska Natives

-Vaccination of Pregnant Women (2007 Update)

#### -ACIP Releases 2007-08 Adult Immunization Schedule {#acip-releases-2007-08-adult-immunization-schedule .Style-Heading-4-+-Arial-14-pt-Underline}

**Oklahoma Perspective**

-Methicillin-resistant Staphylococcus aureus in women's health

Osteoporosis

Effects of Steroidal and Nonsteroidal Aromatase Inhibitors on Markers of
Bone Turnover

Patient Education

#### -Assessing Health Literacy in Clinical Practice {#assessing-health-literacy-in-clinical-practice .Style-Heading-4-+-Arial-14-pt-Underline}

-Pregnant or Thinking About Getting Pregnant?

#### -Pregnancy Loss: What You Should Know {#pregnancy-loss-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Caring for Your Premature Baby {#caring-for-your-premature-baby .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Meth Abuse: What You Should Know {#meth-abuse-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Less errors with more standardization of corticosteroid regimens

-Conservative checklist protocol for oxytocin: improves maternal and
newborn outcomes

-Does the dose of oxytocin affect uterine rupture in candidates for
VBAC?

-Terbutaline provided more tocolysis with less impact on BP than NTG in
resuscitation

-Exam-indicated cerclage prolongs gestation / improves survival vs
expectant management

and more....

Primary Care Discussion Forum

#### Traditional AI/AN Medicine: Incorporating Into I/T/U Clincial Practice

STD Corner

Screening for Chlamydial Infection: Recommendation Statement, USPSTF

#### Barbara Stillwater, Alaska Diabetes Prevention and Control

#### -Family History more relevant to risk of GDM in nulliparous women than in parous subjects {#family-history-more-relevant-to-risk-of-gdm-in-nulliparous-women-than-in-parous-subjects .Style-Heading-4-+-Arial-14-pt-Underline}

-Hypertensive disorders of pregnancy are predictive of diabetes mellitus
21 years later

-Continuous subcutaneous insulin: No improvement in pregnant diabetic
outcomes

-A fetal weight estimation at 29-34 weeks in diabetic pregnancies: Can
it predict LGA ?

-The Reproductive Phenotype in Polycystic Ovary Syndrome 

**Women's Health Headlines**

-Making a business case for investing in Maternal and Child Health

-Depression and Initiation of Cigarette, Alcohol, and Other Drug Use
among Young Women

###### Save the Dates: Upcoming events of interest page 58

#### What's new on the ITU MCH web pages page 59

Preconception Counseling for Women with Diabetes and Hypertension: New
Module

**Did you miss something in the last OB/GYN Chief Clinical Consultant
(CCC) Corner?**

#  {#section-1 .Style-Heading-1-+-Underline}

# Abstract of the Month {#abstract-of-the-month .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**What happens if your patient hears her results as Negative? Positive?
Normal? Abnormal?**

We tested whether adding interpretive labels (eg, "negative test") to
prenatal genetic screening test results changes perceived risk and
preferences for amniocentesis.

[Study Design]{.underline}

Women (N = 1688) completed a hypothetical pregnancy scenario on the
Internet. We randomly assigned participants into 2 groups: high risk of
fetal chromosomal problems (12.5/1000) or low risk (2/1000). After
prenatal screening, estimated risk was identical (5/1000) for all
participants, but results were provided either alone or with
interpretive labels.

[Results]{.underline}

When receiving test results without labels, all participants react
similarly. With labels, the participants who received "positive" or
"abnormal" results reported a higher perceived risk (P \< .001), greater
worry (P \< .001), and greater interest in amniocentesis (57% vs 37%; P
\< .001) than did the participants who received "negative" or "normal"
results.

[Conclusion]{.underline}

Interpretive labels for test results can induce larger changes to a
woman's risk perception and behavioral intention than can numeric
results alone, which create decision momentum. This finding has broad
clinical implications for patient--provider communication.

[Zikmund-Fisher
BJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Zikmund-Fisher BJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Does labeling prenatal screening test results as negative or
positive affect a woman\'s responses? Am J Obstet Gynecol. 2007
Nov;197(5):528

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17880902>

#### [Editorial comment: Barry Weiss M.D., Tucson]{.underline}

**Do you understand everything the networking folks in your IT Dept. say
about your own facility's server?**

If you understood everything they said the first time you heard it, then
you can probably stop reading right here.

On the other hand, have you ever been called on the phone by a friend or
relative, who asked you to explain to them something they were told by
their doctor but which they didn\'t understand?  You then explain things
to your friend or relative in a simple, easy-to-understand way.  Did you
ever ask yourself why their physician didn\'t use an easy-to-understand
explanation in the first place?  Did you ever wonder why we don\'t all
use those simple explanations with our patients every day?

Data from the recent National Assessment of Adult Literacy (NAAL) show
that about 1/3 of all American adults have limited health literacy. 
Such individuals do not do not understand what you\'ve told them, nor
what they are supposed to do in response to advice you have given them. 
NAAL data show that the rate is even higher - approaching 50% - among
Native Americans and Alaska Natives.   So, whether you know it or not,
you are seeing patients - many patients - every day who have difficulty
understanding what you\'ve told them.

Two of the most important things you can do to address this problem are
first, explain things to patients using easy-understand words, like you
might explain them to your grandmother.  The other is to use the
\"teach-back\" technique, in which you ask patients to explain back to
you what you have just told them.  This helps verify that they have
understood what they need to know.

Zikmund-Fisher et al, above, illustrate a simple point that interpretive
labels for test results can induce larger changes to a woman's risk
perception and behavioral intention than can numeric results alone,
which creates decision momentum.

####  {#section-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Clinicians routinely underestimate the prevalence of limited health literacy among their patients and frequently overestimate the ability of individual patients to understand the information they provide. For more information and a helpful perspective go to the 'Assessing Health Literacy in Clinical Practice' link below {#clinicians-routinely-underestimate-the-prevalence-of-limited-health-literacy-among-their-patients-and-frequently-overestimate-the-ability-of-individual-patients-to-understand-the-information-they-provide.-for-more-information-and-a-helpful-perspective-go-to-the-assessing-health-literacy-in-clinical-practice-link-below .Style-Heading-4-+-Arial-14-pt-Underline}

#### Assessing Health Literacy in Clinical Practice, Barry D. Weiss, MD {#assessing-health-literacy-in-clinical-practice-barry-d.-weiss-md .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/566053**](http://www.medscape.com/viewarticle/566053) Medscape CME {#httpwww.medscape.comviewarticle566053-medscape-cme .Style-Heading-4-+-Arial-14-pt-Underline}

**Other recent Health Literacy resources:**

**Health Literacy. ACOG Committee Opinion**

ABSTRACT: According to the U.S. Department of Health and Human Services,
health literacy is the degree to which individuals have the capacity to
obtain, process, and understand basic health information and services
needed to make appropriate health decisions. The American College of
Obstetricians and Gynecologists (ACOG) is committed to the promotion of
health literacy for all. The purpose of this committee opinion is to
outline the complex issues surrounding health literacy and offer
strategies for increasing health literacy in clinical practice.

Health Literacy. ACOG Committee Opinion no. 391. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1489-91.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055753>

####  {#section-3 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Also see MCH Alerts below {#also-see-mch-alerts-below .Style-Heading-4-+-Arial-14-pt-Underline}

**Insights on Implementing Cultural and Linguistic Competence in MCH**

####  {#section-4 .Style-Heading-4-+-Arial-14-pt-Underline}

# From your colleagues {#from-your-colleagues .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### David Gahn, Tahlequah {#david-gahn-tahlequah .Style-Heading-4-+-Arial-14-pt-Underline}

**You can make a big difference in women's and children's lives**

Colleagues,

Here are some unique opportunities that are available for Indian Health
staff 

1\) The Office of Global Health Affairs (OGHA), within the Department of
Health and Human Services (HHS), has invested in improving the level of
care at Rabia Balkhi Hospital (RBH), one of four maternity hospitals in
Kabul, Afghanistan. HHS/OGHA has also contracted with a few
non-governmental organizations (NGOs) to provide expertise in certain
aspects of the program, run with the permission of and under the
supervision of the Afghanistan Ministry of Public Health (MoPH).  HHS
partners include the Centers for Disease Control and Prevention (CDC) ,
the Health Resources and Services Administration (HRSA), the Agency for
Health-Care Research and Quality (AHRQ) and the Indian Health Service
(IHS).

 

2) RBH provides care to women, mostly in obstetrics.  There is also a
small component of general surgeons, internists, and dermatologists.  40
to 60 women a day deliver at RBH.  One of the other four hospitals in
Kabul, Malalai, is also this busy.  Because of the U.S. presence at RBH,
it has become the main referral hospital in Kabul, and receives the
sickest women for delivery.  RBH also houses an residency program in
obstetrics and gynecology, with about 50 residents and 14 faculty.

 

3\) The current focus of the HHS project is a Cesarean section
quality-assurance (QA) program.  The project is starting at RBH, but
will branch out to collaborate with the other hospitals in Kabul.  Over
the last several years, HHS/CDC has developed a system within the MoPH
for collecting data on maternal and child health in Kabul. The current
data show an increase in the Cesarean section rate from 4% to 10%, which
the Ministry and our partners thought would decrease maternal and
perinatal morbidity and mortality.  However, the data also show a
concurrent *increase* in mortality.

 

4) HHS/OGHA is looking for obstetricians/gynecologists and pediatricians
to go to RBH to work as advisors to the local physicians, to improve
their skills, and to work on the QA programs as well the Cesarean
section quality-assurance collaborative.  The primary role for HHS/IHS
staff would be to serve as advisors, by working at the bedside with the
Afghan doctors and residents to improve the level of care.

 

5\) The role of IHS CNM\'s has not been completely clarified, but
deployment in 2008 is highly likely.  I encourage CNM\'s who are
interested to contact me.

 

6\) The length of the tour would be 1-3 months, and could start as early
as January 6, 2008.  This is a TDY assignment.  Candidates must
be Federal employees (civil service or Commissioned Corps). HHS/OGHA
will pay travel and per diem and will also reimburse service units
for the salary.  The interagency agreement between HHS/IHS and
HHS/OGHA is under negotiation, and should be complete in the next two
weeks.

 

7\) Security in Afghanistan is always an issue. HHS personnel in Kabul
will stay on the U.S Embassy compound.  Trained security personnel in
armored SUVs will accompany HHS staff to RBH.  Leisurely travel about
town is absolutely forbidden, but HHS staff may go to the army base, the
International Security Assistance Force (ISAF) base, and the MoPH.

 

8)The U.S. Embassy itself is self-sufficient, and has two post exchanges
(PXs), two dining halls, a gym, a swimming pool, etc.  The rooms in
which HHS staff will stay are converted shipping containers called
\"hooches.\"  The rooms are relatively small, but include all the
amenities: fridge, microwave, TV with cable, DVD player, bed and linens,
desk, Internet access, phone, shower, toilet, sink, and hot-water
heater.

 

9\) My role in all of this is to coordinate recruitment and scheduling
within HHS/IHS, and to participate in the operational aspects of the
project.  I will be going to Kabul in January with a pediatrician, a
pharmacist, and a scrub tech.  If you are interested in going to Kabul,
please send me a CV, and we can discuss things over the phone. 
Afghanistan is an exciting place, and I can promise you a life-changing
experience, as well as provide an opportunity to improve some of the
highest maternal-mortality rates ever recorded.  This is also a chance
to contribute meaningfully to international efforts to stabilize
Afghanistan.

Regards,

 

Dave Gahn

 

David R. Gahn, MD, FACOG

Hastings Indian Medical Center

Tahlequah, OK

#### [**David.Gahn@ihs.gov**](mailto:David.Gahn@ihs.gov) {#david.gahnihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-5 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Scott Giberson, HQE {#scott-giberson-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Second annual Native HIV/AIDS Awareness Day coming March 20, 2008**

Saturday December 1, 2007 was the 19th anniversary of World AIDS Day

This day gave us an opportunity to remind people the HIV/AIDS pandemic
continues to be a threat and reality. It was very important to raise
awareness, encourage education, and continue to make a difference.
([www.worldaidscampaign.info/](http://www.worldaidscampaign.info/)). 

Recently UNAIDS reduced its estimates of how many people are infected
with HIV/AIDS worldwide from nearly 40 million to 33 million. However,
these numbers don't tell the whole story. A large portion of this
reduction was due in part to an overestimate of prevalence in one
country, India. HIV impacts all countries and incidence rates are
actually increasing in a number of areas. Officials said evidence showed
the epidemic was creeping back into developed countries - where many
people with AIDS have access to drugs that can extend their lives. \"We
are seeing a return of the epidemic,\" Paul De Lay of UNAIDS told
reporters. \"We are seeing that in the U.S., we are seeing that in the
UK, we are seeing that in Germany and we are seeing that in the
developing world also.\" This demonstrates, given the huge impact of
HIV/AIDS worldwide, that we must continue the fight. This is a virus
with explosive potential that (barring a vaccine or cure) will be with
us for generations.

HIV/AIDS is a disease that goes beyond traditional prevention and
treatment paradigms. Through 2005, AI/AN are ranked third in the US
(among all ethnicities) in rates of HIV/AIDS cases. According to this
CDC report, incidence of HIV/AIDS has remained relatively stable among
AI/AN over the previous 6 years, however a steady rise in prevalence has
been observed. Health disparities and disproportionate co-risk factors
(such as STDs, substance use and domestic violence) among the AI/AN can
contribute both directly and indirectly to the risk of HIV transmission.
Therefore, HIV/AIDS poses a significant and ongoing risk to the American
Indian / Alaska Native population.\
\
World AIDS Day raised our awareness of the issues and also set the stage
for the second annual Native HIV/AIDS Awareness Day to be observed on
March 20, 2008. I look forward to working with you on our program
initiatives and improving and protecting the health of the American
Indian/Alaska Native population.

For more information and resources, please visit our IHS HIV website at:
[www.ihs.gov/medicalprograms/hivaids/](http://www.ihs.gov/medicalprograms/hivaids/)

The UNAIDS report, discussing the revised worldwide HIV/AIDS estimates,
can be found at:
<http://data.unaids.org/pub/EPISlides/2007/071119_epi_pressrelease_en.pdf>

**Updated U.S. DHHS Guidelines for Treatment of Adults and Adolescents
with HIV**

See below for some very pertinent changes to the DHHS Guidelines on the
Treatment of those with HIV. Of particular interest may be that the
guidelines now recommend (after much consideration and the most recent
findings at the International AIDS Conference) that HAART be initiated
in patients with history of an AIDS-defining illness **or with a CD4
T-cell count \< 350 cells/mm^3^.** This means initiation of therapy in a
much less immunocompromised state.  In addition, the new guidelines
address the new classes of HAART including integrase inhibitors and CCR5
antagonists. For more detailed information, see below and/or the actual
.pdf attached of the full and updated guidelines.

Updated U.S. DHHS Guidelines for Treatment of Adults and Adolescents
with HIV

An updated version of the U.S. Department of Health and Human Services
(DHHS) Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected
Adults and Adolescents has been released.

The latest revision, dated December 1, 2007, includes new information
on:

-   Lab tests during the initial clinic visit for newly diagnosed
    patients;

-   Updated recommendations on when to start antiretroviral treatment;

-   Management of treatment-experienced patients, including suggestions
    on use of the recently FDA-approved entry inhibitor (CCR5
    antagonist) maraviroc (Selzentry/Celsentri) and integrase inhibitor
    raltegravir (Isentress).

-   

**[Changes to the guidelines are summarized in the \"What\'s New in the
Document?\" section located at the front of the
guidelines.]{.underline}** The changes are also highlighted in yellow
throughout the text and tables. Following are the specific changes to
this latest edition of the guidelines, made since the previous revision
dated October 10, 2006. Additional revisions to other sections of the
guidelines will be released in 2008.

The strength of the recommendations is included in parentheses, with "A"
indicating the strongest recommendation, "C" indicating optional, and
"E" indicating never recommended; the quality of scientific evidence
supporting the recommendations is ranked from I (at least 1 randomized
clinical trial) to III (expert opinion).

**Laboratory Assessment**

-   Drug-resistance Testing \-- The DHHS Panel on Antiretroviral
    Guidelines for Adults and Adolescents recommends genotypic drug
    resistance testing for all treatment-naive patients entering
    clinical care, regardless of whether they will immediately start
    antiretroviral therapy **(AIII)**. This recommendation is based on
    the fact that transmitted drug-resistance mutations may be detected
    soon after infection. Repeat testing may be considered when therapy
    is to be initiated **(CIII)**.

```{=html}
<!-- -->
```
-   Viral Tropism Assay \-- The panel recommends tropism testing prior
    to the initiation of a CCR5 antagonist, such as maraviroc **(AII)**,
    to determine which co-receptors a person's HIV is using; these drugs
    should only be used by patients with exclusively CCR5-tropic virus.
    Co-receptor tropism testing might also be considered for patients
    exhibiting virological failure while taking maraviroc or another
    CCR5 antagonist **(BIII)**.

```{=html}
<!-- -->
```
-   [HLA-B\*5701
    [Testing]{.underline}](http://www.hivandhepatitis.com/2007icr/ias/docs/072707_h.html)
    \-- The panel recommends HLA-B\*5701 testing prior to initiating
    abacavir (Ziagen) to reduce the risk of hypersensitivity reactions
    **(AI).** HLA-B\*5701 positive patients should not be given abacavir
    **(AI)**, and the positive status should be recorded as an abacavir
    allergy in the patient's medical record **(AII)**.

When HLA-B\*5701 screening is not readily available, it remains
reasonable to initiate abacavir with appropriate clinical counseling and
monitoring for any signs of abacavir-associated hypersensitivity
reactions **(CIII)**.

#### When to Start Antiretroviral Therapy

-   **The panel now recommends that antiretroviral therapy should be
    initiated in patients with history of an AIDS-defining illness or
    with a CD4 T-cell count \< 350 cells/mm^3^.** The data supporting
    this recommendation are stronger for patients with a CD4 count \<
    200 cells/mm^3^ and with a history of AIDS **(AI)** than for those
    with CD4 counts between 200 and 350 cells/mm^3^ **(AII)**. This
    recommendation is consistent with the latest revision of the
    [European AIDS Clinical Society (EACS)
    [guidelines]{.underline}](http://www.hivandhepatitis.com/recent/2007/103007_b.html),
    presented this past October. 

```{=html}
<!-- -->
```
-   The panel also recommends treatment for the following groups
    regardless of CD4 -cell count:

    -   Pregnant women **(AI)**;

    -   Patients with HIV-associated nephropathy (kidney disease)
        **(AI)**;

    -   Patients coinfected with hepatitis B virus (HBV) when anti-HBV
        treatment is indicated **(BIII)**.

```{=html}
<!-- -->
```
-   **The optimal time to initiate therapy in asymptomatic patients with
    a CD4 cell count \> 350 cells/mm^3^ is not well defined.** The
    decision about whether or to start treatment in these patients
    should take into account the potential benefits and risks associated
    with therapy, co-morbidities, and patient readiness and willingness
    to adhere to long-term treatment.

**Management of Treatment-Experienced Patients**

This section was revised to include a review of the newer classes of
antiretroviral agents (CCR5 antagonists and integrase inhibitors) and
their roles in the management of treatment-experienced patients with
virological failure; and a discussion of immunological failure (lack of
adequate CD4 cell recovery).

**Updated Tables**

Various tables in the guidelines have been updated to reflect new
recommendations and new information on specific antiretroviral drugs.

<http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search=Off&GuidelineID=7&ClassID=1>

**Source:\
**DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents.
[Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected
Adults and
Adolescents](http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL_PDA.pdf).
December 1, 2007).

**Funding opportunity for HIV Prevention programs through CDC**

(federally recognized tribes are eligible)

**Fund Number:** 3470\
\
**Fund Title:** 2008 USCM HIV/AIDS Prevention Grants Program\
\
**Fund Category:**\
HIV/AIDS\
\
**Description:**\
Total Grant Amounts: Approximately \$420,000.\
\
The United States Conference of Mayors (USCM), in cooperation with the
U.S. Centers for Disease Control and Prevention, National Center for
HIV, STD and TB Prevention, is issuing this Request for Proposals (RFP)
for the HIV/AIDS Prevention Grants Program to strengthen local
capacities to carry out effective HIV/AIDS prevention activities.\
\
Proposals will be accepted for the following funding priority:
Implementation of HIV/AIDS Prevention Services Targeting Women of Color
at High Risk of HIV Infection.\
\
The purpose of these grants is to reduce risk behaviors associated with
HIV/AIDS among women of color at high risk of HIV infection, and to
strengthen the ability of organizations - in particular organizations
with direct ties to the target populations - to respond to future needs
for HIV prevention services among these groups.\
\
Programs selected for funding will be required to:\
(1) Implement activities that respond to HIV/AIDS prevention needs
identified in a previous needs assessment, with specific reference to
priorities determined in a community planning process (i.e., the HIV
Prevention Community Planning Initiative, which began in 1994, to
establish plans for the use of HIV prevention resources awarded under
program announcement #300 to CDC\'s state and local health department
HIV Prevention Cooperative Agreement grantees), or\
(2) Demonstrate clearly how previous needs assessment and community
planning activities have not adequately identified the needs of women of
color at high risk of HIV infection and propose to carry out some very
limited, specific assessment activities (e.g., focus groups, small
surveys) to guide the implementation of the proposed intervention.\
\
**Sponsor(s):**\
US Conference of Mayors\
Health Programs\
HIV/AIDS Prevention Program\
\
**Funder\'s Fund ID:**\
\
**Web Page:**
[usmayors.org/hivprevention/rfp08.pdf](http://usmayors.org/hivprevention/rfp08.pdf)\
\
**Application Due Date:** 02/25/2008\
\
**Fund Duration:** Grants are for a 12-month period and are
non-renewable (though no-cost extensions may be granted upon request).\
\
**Application Process:**\
To request a copy of the USCM\'s new Technical Assistance Report
\"Writing Proposals for HIV/AIDS Prevention Grants,\" write to HIV/AIDS
Program Publications, HIV/AIDS Prevention Grants Program, The United
States Conference of Mayors, 1620 Eye St, NW, Washington, DC 20006; fax
(202) 429-0422/(202) 293-2352; or e-mail: lbrown@usmayors.org.\
\
**Number of Awards:** 6 grants\
\
**Total Award:** \$420,000.00\
\
**Award Notes:**\
USCM plans to award grants totaling approximately \$420,000 to local
health departments, non-profit\
community-based organizations and Native American tribes for
implementation of HIV/AIDS prevention\
projects for high-risk women of color. Funding will be divided into six
grants of approximately \$70,000\
each. (Note: in some years extra funds have become available, and
additional grants have been made\
from the same pool of applicants. Prospects for this year are unknown.)\
\
\
**Eligible Locations:**\
- National\
\
**Technical Contact Name:**\
Lillie Brown\
**Technical Contact Address:**\
HIV/AIDS Program Publications\
HIV/AIDS Prev Grants Program\
The US Conference of Mayors\
1620 Eye St, NW\
Washington, DC 20006\
United States\
**Email:** <lbrown@usmayors.org>\
**Phone:** 202-293-7330\
**Fax:** 202-429-0422\
\
**Support Types:**\
- Technical Assistance\
\
**Subject Areas:**\
- Community Health Education\
- Community Health Services\
- High Risk Behaviors\
- HIV/AIDS Prevention\
- Risk Reduction\
\
**Audiences:**\
- African Americans/Blacks\
- At Risk Persons\
- Women\
\
**Eligibility:**\
- City Agencies\
- Community Based Organizations\
- Consortia\
- County Agencies\
- IRS 501 (c)(3) Organizations\
\
**Eligibility Notes:**\
Eligible applicants include: Local health departments (LHDs);
Community-based organizations (CBOs); Federally recognized Indian
tribes; Existing agencies/consortia which have formed collaborative
efforts between multiple groups or agencies.\
Any CBO applying under this program must have been certified by the
Federal Internal Revenue Service as a 501 (c)(3) organization prior to
February 25, 2008, or certified by the state as a nonprofit agency.
(State certification will be considered a temporary measure; if USCM
funding is granted, CBOs must obtain certification by the IRS under
501(c)(3) before contracts with USCM are signed.) A copy of either the
IRS or state certificate of non-profit status must be included with the
application.

**Steve Holve, Tuba City**

**Update on Pedvax Hib**

CDC has sent out to state immunization programs regarding the current
PedvaxHIB® (PRP-OMP \[Merck\]) supply.  CDC is controlling the release
of PedvaxHIB®  so that states can continue to receive the same amount of
PedvaxHIB®  This means that providers SHOULD NOT have to change current
Hib vaccination practices -- e.g. if you have been using PedvaxHIB®  to
vaccinate children, you can continue to do so. If your site has been
using PedvaxHIB® and you are told by the state that there is not
sufficient supply to continue using PedvaxHIB®  for all doses, PLEASE
CONTACT AMY GROOM, Phone: (505) 248 -- 4374, <amy.groom@ihs.gov>

There are provisions to target stockpiled supplies of Pedvaxhib to AI/AN
children if the shortage persists beyond early 2008.

**Mary Wachacha, HQE**

**Seeking 2 Physicians for national IHS Patient Education Protocols and
Codes Committee**

The IHS has a national committee (IHS Patient Education Protocols and
Code Committee -- PEPC) which writes up all patient education protocols
that are used by all I/T/Us in the documentation and coding of patient
education.  This national committee has a long-standing partnership with
OIT ensuring that all issues concerning RPMS, PCC, PCC+, and EHR are
addressed.

We are a long standing committee of 12-14 IHS staff that meets **once a
year** to update the IHS Patient Education Protocols and Codes found at
[www.ihs.gov](http://www.ihs.gov/) under Nationwide Programs and
Initiatives:  Look in the upper right corner of the webpage and you will
see the Patient Education Protocols and Codes.  The committee is made-up
of 2 physicians, 2 RDs, 2 Pharmacists, one Health Educator, one Clinical
Psychologist, one representative from the DM program and one HPDP
representative, 1PHN and 3 RNs and an OIT Tech Writer.  Four of these
committee members are CDEs.  It is a very dedicated group.  It is a very
hard working group.  We meet face-to-face **once every year** with
occasional conference calls if we are faced with the need for a quick
decision by the Committee -- otherwise, any revisions or changes to the
protocols have to wait until the next face-to-face committee meeting. 
The committee works with a wide range of clinical experts within IHS --
obviously, if we need expertise on nephrology education -- we contact an
IHS Nephrologist.  We work extensively with the Diabetes, Nutrition
program and MCH, etc.  All travel to the single committee meeting is
paid for by the IHS Health Education program.

The dilemma is that our two physicians are a husband and wife team (CCOs
from Alaska; Family Practice and Peds) that has been with the committee
for at least 8 years now.  We could go on with these two physicians
forever but each year it becomes harder and harder for them to get
permission from Southcentral Foundation for them to travel to our
meetings (even though prior to accepting employment with SCF, they
originally obtained permission from SCF to attend the annual meetings.) 
Therefore, I would prefer that their replacements not come from the
Alaska Area since it is totally compacted.

These two dedicated physicians have indicated that perhaps it is time
they stepped down as the Co-Chairs of this Committee - their names are
Dr. Michale Ratzlaff and Dr. Kelton Oliver.  While I would hate to lose
them, I feel that the inevitable is looming over me.....I need to find
physician replacements to serve on this committee.  I am seeking two
physicians that might like to serve on this national committee? 

The physicians that I am looking for would most definitely have to have
a keen interest in educating our AI/AN clients....but you do not need
any special background in education -- (Health Education ensures that
all aspects of education are met) you only need to be committed to the
importance of educating our clients..,...your clinical expertise will be
your greatest asset.  If any of you are aware of any such physicians
that might be interested, please forward this letter and have them
contact me with any additional questions.  Our next FY2008 meeting is
scheduled for March 10-14^th^ in Tucson, AZ. 

We would ask any physician that accepts this challenge to commit at
least 3 years to this project.  

Thank you for your time and I appreciate any assistance.

Mary Wachacha, Lead Consultant

IHS Health Education Program

828-292-1175 <mary.wachacha@ihs.gov>

# Hot Topics {#hot-topics-1 .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### Obstetrics {#obstetrics .Style-Heading-4-+-Arial-14-pt-Underline}

**Cesarean delivery on request not recommended if desiring several
children, ACOG**

ABSTRACT: Cesarean delivery on maternal request is defined as a primary
cesarean delivery at maternal request in the absence of any medical or
obstetric indication. A potential benefit of cesarean delivery on
maternal request is a decreased risk of hemorrhage for the mother.
Potential risks of cesarean delivery on maternal request include a
longer maternal hospital stay, an increased risk of respiratory problems
for the baby, and greater complications in subsequent pregnancies,
including uterine rupture and placental implantation problems. Cesarean
delivery on maternal request should not be performed before gestational
age of 39 weeks has been accurately determined unless there is
documentation of lung maturity. Cesarean delivery on maternal request
should not be motivated by the unavailability of effective pain
management. Cesarean delivery on maternal request is not recommended for
women desiring several children, given that the risks of placenta
previa, placenta accreta, and the need for gravid hysterectomy increase
with each cesarean delivery.

Cesarean Delivery on Maternal Request. ACOG Committee Opinion no. 394.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:1501-4.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055756>

**Other Cesarean Delivery related resources**

**Placenta previa: Increasing cesareans is associated with adverse
maternal outcomes**

CONCLUSION: Among women with a placenta previa, an increasing number of
prior cesarean deliveries is associated with increasing maternal, but
not perinatal, morbidity. LEVEL OF EVIDENCE: II.

[Grobman
WA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Grobman WA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Pregnancy Outcomes for Women With Placenta Previa in Relation to
the Number of Prior Cesarean Deliveries. Obstet Gynecol. 2007
Dec;110(6):1249-1255.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=18055717&dopt=AbstractPlus>

**Sense of coherence and symptoms of post-traumatic stress after
emergency caesarean**

CONCLUSIONS: Symptoms of post-traumatic stress following emergency
caesarean delivery are associated both with the new mother\'s personal
coping style and with the circumstances of the event. We recommend that
women who belong to groups who more often report a low of coherence or
who had imminent asphyxia as an indication for the operation should be
offered support and follow-up.

[Tham
V](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tham V"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Sense of coherence and symptoms of post-traumatic stress after
emergency caesarean. Acta Obstet Gynecol Scand. 2007;86(9):1090-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17712650>

**Late-preterm (34-36 weeks) infants have higher mortality rate than
term at one year of age**

OBJECTIVE: To assess differences in mortality between late-preterm
(34-36 weeks) and term (37-41 weeks) infants.

RESULTS: Significant declines in mortality rates were observed for
late-preterm and term infants at all age-at-death categories, except the
late-neonatal period. Despite the decline in rates since 1995, infant
mortality rates in 2002 were 3 times higher in late-preterm infants than
term infants (7.9 versus 2.4 deaths per 1000 live births); early, late,
and postneonatal rates were 6, 3, and 2 times higher, respectively.
During infancy, late-preterm infants were approximately 4 times more
likely than term infants to die of congenital malformations (leading
cause), newborn bacterial sepsis, and complications of placenta, cord,
and membranes. Early-neonatal cause-specific mortality rates were most
disparate, especially deaths caused by atelectasis, maternal
complications of pregnancy, and congenital malformations.

CONCLUSIONS: Late-preterm infants have higher mortality rates than term
infants throughout infancy. Our findings may be used to guide
obstetrical and pediatric decision-making.

[Tomashek
KM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tomashek KM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
Differences in mortality between late-preterm and term singleton infants
in the United States, 1995-2002. J Pediatr. 2007 Nov;151(5):450-6,
456.e1. Epub 2007 Jul 24.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17961684>

**Spinal analgesia increases the success rate of external cephalic
version from 32% to 67%**

CONCLUSION: Administration of spinal analgesia significantly increases
the success rate of external cephalic version among nulliparous women at
term, which allows possible normal vaginal delivery.

[Weiniger
CF](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Weiniger CF"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al External cephalic version for breech presentation with or without
spinal analgesia in nulliparous women at term: a randomized controlled
trial.

Obstet Gynecol. 2007 Dec;110(6):1343-50

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=18055730&dopt=AbstractPlus>

**Milk consumption during pregnancy is associated with increased infant
size at birth**

CONCLUSION: Milk intake in pregnancy was associated with higher birth
weight for gestational age, lower risk of SGA, and higher risk of LGA.

[Olsen
SF](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Olsen SF"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Milk consumption during pregnancy is associated with increased
infant size at birth: prospective cohort study. Am J Clin Nutr. 2007
Oct;86(4):1104-10.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17921389>

#### Gynecology {#gynecology .Style-Heading-4-+-Arial-14-pt-Underline}

**Early feeding within the first 24 hours after major abdominal
gynecologic surgery is safe**

SELECTION CRITERIA: Randomized controlled trials that compared the
effect of early versus delayed initiation of oral intake of food and
fluids after major abdominal gynecologic surgery were considered. Early
feeding was defined as having oral intake of fluids or food within the
first 24 hours after surgery regardless of the presence or absence of
the signs that indicate the return of bowel function and delayed feeding
was defined after first 24 hours following surgery and only after
clinical signs of resolution of postoperative ileus

CONCLUSIONS: Early feeding after major abdominal gynecologic surgery is
safe however associated with the increased risk of nausea and a reduced
length of hospital stay. Whether to adopt the early feeding approach
should be individualised. Further studies should focus on the
cost-effectiveness, patient\'s satisfaction, and other physiological
changes.

[Charoenkwan
K](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Charoenkwan K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Early versus delayed (traditional) oral fluids and food for
reducing complications after major abdominal gynecologic surgery.
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004508. Review.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17943817>

[**Abnormal Uterine Bleeding: A Management
Algorithm**](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0I8OU0Gx)

Abnormal uterine bleeding is a common problem, and its management can be
complex. Because of this complexity, concise guidelines have been
difficult to develop. We constructed a concise but comprehensive
algorithm for the management of abnormal uterine bleeding between
menarche and menopause that was based on a systematic review of the
literature as well as the actual management of patients seen in a
gynecology clinic. We started by drafting an algorithm that was based on
a MEDLINE search for relevant reviews and original research. We compared
this algorithm to the actual care provided to a random sample of 100
women with abnormal bleeding who were seen in a university gynecology
clinic. Discrepancies between the algorithm and actual care were
discussed during audiotaped meetings among the 4 investigators (2 family
physicians and 2 gynecologists). The audiotapes were used to revise the
algorithm. After 3 iterations of this process (total of 300 patients),
we agreed on a final algorithm that generally followed the practices we
observed, while maintaining consistency with the evidence. In clinic,
the gynecologists categorized the patient\'s bleeding pattern into 1 of
4 types: irregular bleeding, heavy but regular bleeding (menorrhagia),
severe acute bleeding, and abnormal bleeding associated with a
contraceptive method. Subsequent management involved both diagnostic and
treatment interventions, which often occurred simultaneously. The
algorithm in this article is designed to help primary care physicians
manage abnormal uterine bleeding using strategies that are consistent
with the evidence as well as the actual practice of gynecologists.

[Ely
JW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ely JW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al [Abnormal Uterine Bleeding: A Management
Algorithm](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0I8OU0Gx)
[J Am Board Fam
Med.](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0Ixse0Gt)
2006;19(6):590-602

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17090792>

**Addition of HPV to Pap test to screen in mid-30s for cervical cancer
reduces in CIN 2 or 3**

CONCLUSIONS: The addition of an HPV test to the Pap test to screen women
in their mid-30s for cervical cancer reduces the incidence of grade 2 or
3 cervical intraepithelial neoplasia or cancer detected by subsequent
screening examinations.

[Naucler
P](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Naucler P"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Human papillomavirus and Papanicolaou tests to screen for cervical
cancer. N Engl J Med. 2007 Oct 18;357(16):1589-97.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17942872>

[**Medical Therapy for Ectopic
Pregnancy**](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0IwfQ0GL)

Methotrexate for treatment of ectopic tubal pregnancy has become an
accepted alternative to surgical options. Methotrexate is a folic acid
analog that interferes with DNA synthesis. Protocols using planned
multiple doses of methotrexate alternating with citrovorum rescue factor
and one protocol using only a single planned dose are both currently
used in the treatment of ectopic pregnancy. In remains unclear which
protocol is superior. This article reviews the indications,
contraindications, and specifics of using methotrexate for this purpose.
Also reviewed are predictors of success and management of usual
complications associated with methotrexate therapy.

Lipscomb GH. [Medical Therapy for Ectopic
Pregnancy](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0IwfQ0GL)
[Semin Reprod
Med.](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0IwfO0GJ)
2007;25(2):93-98.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17377896>

**A cautionary case: Balloon occlusion of internal iliac arteries for
abnormal placentation**

Massive hemorrhage from abnormal placentation is a leading cause of
postpartum maternal death and hysterectomy after cesarean section. The
endovascular surgeon and radiologist are increasingly asked to assist in
the management of these complex patients with the placement of bilateral
internal iliac artery balloon catheters. We report the case of a
27-year-old woman with placenta percreta with preemptive bilateral
internal iliac artery balloons who had iliac artery thrombosis and acute
limb ischemia develop 7 hours after cesarean hysterectomy. This is the
first report of iliac artery thrombosis in this setting. A review of the
vascular and obstetrical literature reveals divergent recommendations
for the use of this technique in patients with abnormal placentation. No
guidance from rigorous prospective evidence is available and thus we
offer recommendations for the cautious use of this modality.

[Greenberg
JI](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Greenberg JI"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Prophylactic balloon occlusion of the internal iliac arteries to
treat abnormal placentation: a cautionary case. Am J Obstet Gynecol.
2007 Nov;197(5):470

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17980178>

#### Child Health {#child-health .Style-Heading-4-+-Arial-14-pt-Underline}

**Rapid response team: Implications of findings on mortality rates for
children are dramatic**

Implementation of an RRT \[rapid-response team\] in our free-standing,
quaternary care academic children\'s hospital was associated with
statistically significant reductions in hospital-wide mortality rates
and code rates outside the ICU \[intensive care unit\] setting.

The authors found that

\* A significant decrease in the hospital-wide mortality rate of 18%
occurred after RRT implementation. Mean monthly mortality rates
preintervention and postintervention were 1.01 and 0.83 deaths per 100
discharges, respectively.

\* The rate of codes outside the ICU per 1,000 eligible patient-days
decreased by 71.2% after RRT implementation, with preintervention and
postintervention rates of 0.52 and 0.15, respectively.

\* The rate of codes outside the ICU per 1,000 eligible admissions
decreased by 71.7%, with preintervention and postintervention rates of

2.45 and 0.69, respectively.

\* The estimated code rate per 1,000 admissions for the postintervention
group was 0.28 times that for the preintervention group.

The potential implications of these findings on national mortality rates
for children could be dramatic.

Sharek PJ, Parast LM, Leong K, et al. 2007. Effect of a rapid response
team on hospital-wide mortality and code rates outside the ICU in a
children's hospital. JAMA, the Journal of the American Medical
Association 298(19):2267-2274

[[http://jama.ama-assn.org/cgi/content/abstract/298/19/2267?etoc]{.underline}](http://jama.ama-assn.org/cgi/content/abstract/298/19/2267?etoc)

Obesity In Children

What are the effects of lifestyle interventions for the treatment of
childhood obesity?

[Likely to be beneficial]{.underline}

Multifactorial Interventions. Multifactorial interventions (particularly
those that included problem solving) delivered to the family were more
effective at reducing body mass index (BMI), decreasing the number of
overweight children, or both, than the interventions delivered to
children alone.

[Unknown effectiveness]{.underline}

Behavioral Interventions Alone. We found insufficient evidence that
behavioral interventions alone can effectively promote weight loss in
children and adolescents.

Diet Alone. One randomized controlled trial found no significant
difference in reduction in overweight between two dietary interventions
of higher and lower protein levels.

Physical Activity Alone. We found insufficient evidence that physical
activity interventions alone can effectively promote weight loss in
children and adolescents.

[Definition]{.underline}

Obesity is a chronic condition characterized by an excess of body fat.
It is most often defined by the BMI, which is highly correlated with
body fat.1 BMI is weight in kilograms divided by height in meters
squared (kg per m2). In children and adolescents, BMI varies with age
and sex. It typically rises during the first months after birth, falls
after the first year, and rises again around the sixth year of life.2 A
given BMI value is usually compared against reference charts to obtain a
ranking of BMI percentile for age and sex. The BMI percentile indicates
the relative position of the child\'s BMI compared with a historical
reference population of children of the same age and sex. Worldwide,
there is little agreement on the definition of overweight and obesity
among children; however, a BMI above the 85th percentile is generally
considered to be at least \"at risk for overweight\" in the United
States and United Kingdom. A BMI above the 95th percentile is variably
defined as overweight or obese, but generally indicates a need for
intervention.

[Prevalence]{.underline}

The prevalence of obesity (generally BMI above the 95th percentile) is
steadily increasing among children and adolescents. In the United
Kingdom in 2004, it was estimated that 14 percent of boys and 17 percent
of girls two to 15 years of age were obese.3 The prevalence of
overweight among children and adolescents in the United States increased
from 14 percent in 1999 to 2000, to 16 percent in 2003 to 2004, among
females and from 14 to 18 percent among males.4

[Etiology]{.underline}

Obesity is the result of long-term energy imbalances in which daily
energy intake exceeds daily energy expenditure.5 Energy balance is
modulated by a myriad of factors, including metabolic rate, appetite,
diet, and physical activity.6 Although these factors are influenced by
genetic traits in a moderate number of children, the increase in obesity
prevalence in the past few decades cannot be explained by changes in the
human gene pool, and is more often attributed to environmental changes
that promote excessive food intake and discourage physical activity.6,7
The risk of childhood obesity is related to childhood diet and sedentary
time. Other risk factors are parental obesity, low parental education,
social deprivation, infant feeding patterns, early or more rapid puberty
(both a risk factor and an effect of obesity), extreme (both high and
low) birth weights, and gestational diabetes.2 Specifically, physical
activity levels have decreased over the years and now only 36 percent of
children and adolescents in the United States are meeting recommended
levels of physical activity.8 Less commonly, obesity may also be induced
by medications (e.g., high-dose glucocorticoids), neuroendocrine
disorders (e.g., Cushing\'s syndrome), or inherited disorders (e.g.,
Down syndrome, Prader-Willi syndrome).2 In this review, we have
considered treatment of children for overweight and obesity in a
clinical setting (not broader public health settings, such as
interventions given to a whole school). We have included interventions
given to the children, their parents, or both.

[Prognosis]{.underline}

Most obese adolescents will become obese adults. For example, a
five-year longitudinal study of obese adolescents, 13 to 19 years of
age, found that 86 percent remained obese as young adults.9 Obesity is
associated with a higher prevalence of insulin resistance, elevated
blood lipid levels, increased blood pressure, and impaired glucose
tolerance, which in turn may increase the risk of several chronic
diseases in adulthood, including hypertension, dyslipidemia, diabetes,
cardiovascular disease, sleep apnea, osteoarthritis, and some
cancers.2,10 Perhaps the most significant short-term morbidities for
overweight and obese children are psychosocial, and include social
marginalization, low self-esteem, and an impaired quality of life.2
Physicians should emphasize improvements in diet, physical activity, and
health independent of changes in body weight.

Arterburn DE. Obesity in children. Clin Evid Handbook Dec 2007:110-1.

Clinical Evidence Concise A Publication of BMJ Publishing Group

<http://www.aafp.org/afp/20071201/bmj.html>

**Newborn Screening**

ABSTRACT: Newborn screening tests are designed to detect infants with
specific conditions whose families also would benefit from early
diagnosis and treatment. These conditions include disorders of
metabolism, endocrinopathies, hemoglobinopathies, hearing loss, and
cystic fibrosis. Each state program must have a system in place for
notification, timely follow-up, and evaluation of any infant with a
positive screening result. Newborn screening programs have enormous
public health benefits and have been effective in identifying newborns
that can benefit from early treatment.

Newborn Screening. ACOG Committee Opinion no. 393. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1497-500.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055755>

#### Chronic disease and Illness {#chronic-disease-and-illness .Style-Heading-4-+-Arial-14-pt-Underline}

**Reconsider use of rosiglitazone**

A 2004 meta-anylsis described both drugs have similar effects on
glycemic control and body weight. Both drugs appear to have a beneficial
effect on serum lipids. In a meta-analysis comparing the effect of
thiazolidinediones on cardiovascular risk factors, pioglitazone produced
a more favorable lipid profile. The Proactive study measurement of
macrovascular events included all cause mortality and non-fatal stroke
with combined endpoints. It was noted the study narrowly made
statistical significance. Both drugs increased HDL, rosiglitazone
increased LDL and had a neutral effect on TG whereas pioglitazone had a
neutral effect on LDL and lowered TG. Rosiglitzone was shown in JAMA
June and September 2007 meta-analysis to increase macrovascular events.
The first study demonstrated increase risk of MI with rosiglitazone and
the 2nd study displayed increased risk of MI but not death. No
head-to-head trials have been conducted to date. In regards to adverse
effects, both drugs may cause fluid retention which may exacerbate or
lead to heart failure. Thiazolidinediones are not recommended for
patients with NYHA Class 3 & 4 cardiac status. Some clinicians chose to
avoid this class of drugs in NYHA Class 2 as well. Edema was more
pronounced as a side effect with both drugs; rosiglitazone 4.8% and
pioglitazone 4.8% versus placebo 1.3% and 1.2%, respectively. LFT
monitoring is recommended for both drugs. Post-marketing experience with
rosiglitazone reported some cases of angioedema and urticaria. Rifampin
decreased rosiglitazone AUC by 66% and the clinical significance of this
is unknown. Look-alike, sound-alike: Avandia and either Coumadin or
Prandin; Actos and Actonel noted by the Institute for Safe Medication
Practices. Use of rosiglitazone has changed from 2005 to 2007, from 170
to 119 patients, respectively. Use of pioglitazone has increased from
2005 to 2007, from 66 to 128 patients. Clinical trials have shown
similar decreases in A1C between pioglitazone 15 and 30mg. Based on
safety, pioglitazone has been shown better safety profile than
rosiglitazone. Dialogue regarding the Accord trial pointed out the study
is still in progress, and results inconclusive with cardiovascular
events. Pioglitazone has a significantly lower risk of death. Today,
rosiglitazone is not as cost effective as it was back in 2005. The
current data describes a potential increase in cardiovascular events
associated with rosiglitazone that has not been seen with pioglitazone.
Questions: <ggivens@anmc.org>

**Conclusion:**

Reconsider use of rosiglitazone. Patients who are taking rosiglitazone 2
or 4 mg can be switched to pioglitazone 15mg and those taking
rosiglitazone 8mg can be switched to 45mg of pioglitazone.

**Resource:**

[Charbonnel
B](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Charbonnel B"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Glitazones in the treatment of diabetes mellitus: clinical outcomes in
large scale clinical trials. Fndam Clin Pharmacol. 2007 Nov;21 Suppl
2:19-20.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18001315

**Therapy Insight: Management of Graves\' Disease During Pregnancy **

The diagnosis of Graves\' disease in pregnancy can be complex because of
normal gravid physiologic changes in thyroid hormone metabolism. Mothers
with active Graves\' disease should be treated with antithyroid drugs,
which impact both maternal and fetal thyroid function. Optimally, the
lowest possible dose should be used to maintain maternal free thyroxine
levels at or just above the upper limit of the normal nonpregnant
reference range. Fetal thyroid function depends on the balance between
the transplacental passage of thyroid-stimulating maternal antibodies
and thyroid-inhibiting antithyroid drugs. Elevated levels of serum
maternal anti-TSH-receptor antibodies early in the third trimester are a
risk factor for fetal hyperthyroidism and should prompt evaluation of
the fetal thyroid by ultrasound, even in women with previously ablated
Graves\' disease. Maternal antithyroid medication can be modulated to
treat fetal hyperthyroidism. Serum TSH and either total or free
thyroxine levels should be measured in fetal cord blood at delivery in
women with active Graves\' disease, and those with a history of
(131)I-mediated thyroid ablation or thyroidectomy who have
anti-TSH-receptor antibodies. Neonatal thyrotoxicosis can occur in the
first few days of life after clearance of maternal antithyroid drug, and
can last for several months, until maternal antibodies are also cleared.

Chan GW, Mandel SJ. Therapy Insight: Management of Graves\' Disease
During Pregnancy [Nat Clin Pract Endocrinol
Metab.](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0I8OY0G2)
2007; 3(6):470-478

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17515891>

**Antithrombotic therapy and pregnancy: consensus report and
recommendations**

Venous thromboembolism and adverse pregnancy outcomes are potential
complications of pregnancy. Numerous studies have evaluated both the
risk factors for and the prevention and management of these outcomes in
pregnant patients. This consensus group was convened to provide concise
recommendations, based on the currently available literature, regarding
the use of antithrombotic therapy in pregnant patients at risk for
venous thromboembolic events and adverse pregnancy outcomes.

[Duhl
AJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Duhl AJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Antithrombotic therapy and pregnancy: consensus report and
recommendations for prevention and treatment of venous thromboembolism
and adverse pregnancy outcomes.Am J Obstet Gynecol. 2007 Nov;197(5):457

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17980177>

**Cholesterol \<10th population percentile was strongly associated with
preterm delivery**

CONCLUSIONS: Total serum cholesterol \<10th population percentile was
strongly associated with preterm delivery among otherwise low-risk white
mothers in this pilot study population. Term infants of mothers with low
total cholesterol weighed less than control infants among both racial
groups

[Edison
RJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Edison RJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Adverse birth outcome among mothers with low serum cholesterol.
Pediatrics. 2007 Oct;120(4):723-33

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17908758>

**Cisplatin with RT improves long-term progression-free survival in 1B
cervical carcinoma**

CONCLUSION: Concurrent weekly cisplatin with radiation therapy
significantly improves long-term progression-free survival and overall
survival when compared with radiation therapy alone. Serious late
effects were not increased. The inclusion of hysterectomy has been
discontinued on the basis of another trial. Pending further trials,
weekly cisplatin with radiation

[Stehman
FB](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Stehman FB"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Radiation therapy with or without weekly cisplatin for bulky stage
1B cervical carcinoma: follow-up of a Gynecologic Oncology Group trial.
Am J Obstet Gynecol. 2007 Nov;197(5):503

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17980189>

# Features {#features .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### ACOG, American College of Obstetricians and Gynecologists {#acog-american-college-of-obstetricians-and-gynecologists .Style-Heading-4-+-Arial-14-pt-Underline}

**Human Immunodeficiency Virus**

ABSTRACT: Because human immunodeficiency virus (HIV) infection often is
detected through prenatal and sexually transmitted disease testing, an
obstetrician--gynecologist may be the first health professional to
provide care for a woman infected with HIV. Universal testing with
patient notification and right of refusal (\"opt-out\" testing) is
recommended by most national organizations and federal agencies.
Although opt-out and \"opt-in\" testing (but not mandatory testing) are
both ethically acceptable, the former approach may identify more women
who are eligible for therapy and may have public health advantages. It
is unethical for an obstetrician--gynecologist to refuse to accept a
patient or to refuse to continue providing health care for a patient
solely because she is, or is thought to be, seropositive for HIV. Health
care professionals who are infected with HIV should adhere to the
fundamental professional obligation to avoid harm to patients.
Physicians who believe that they have been at significant risk of being
infected should be tested voluntarily for HIV.

Human immunodeficiency virus. ACOG Committee Opinion no. 389. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:1473-8.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055751>

**Ethical Decision Making in Obstetrics and Gynecology**

ABSTRACT: Physicians vary widely in their familiarity with ethical
theories and methods and their sensitivity toward ethical issues. It is
important for physicians to improve their skills in addressing ethical
questions. Obstetrician--gynecologists who are familiar with the
concepts of medical ethics will be better able to approach complex
ethical situations in a clear and structured way. By considering the
ethical frameworks involving principles, virtues, care and feminist
perspectives, concern for community, and case precedents, they can
enhance their ability to make ethically justifiable clinical decisions.
Guidelines, consisting of several logical steps, are offered to aid the
practitioner in analyzing and resolving ethical problems.

Ethical Decision Making in Obstetrics and Gynecology\*. ACOG Committee
Opinion no. 390. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2007;110:1479-87.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055752>

**Invasive Prenatal Testing for Aneuploidy**

***Summary of Recommendations and Conclusions***

***The following recommendation is based on good and consistent
scientific evidence (Level A):***

-   Early amniocentesis (at less than 15 weeks of gestation) should not
    be performed because of the higher risk of pregnancy loss and
    complications compared with traditional amniocentesis (15 weeks of
    gestation or later)

***The following conclusions are based on limited or inconsistent
scientific evidence (Level B):***

-   Amniocentesis at 15 weeks of gestation or later is a safe procedure.
    The procedure-related loss rate after midtrimester amniocentesis is
    less than 1 in 300--500.

-   In experienced individuals and centers, CVS procedure-related loss
    rates may be the same as those for amniocentesis.

***The following recommendation and conclusions are based primarily on
consensus and expert opinion (Level C):***

-   Invasive diagnostic testing for aneuploidy should be available to
    all women, regardless of maternal age.

-   Patients with an increased risk of fetal aneuploidy include women
    with a previous fetus or child with an autosomal trisomy or sex
    chromosome abnormality, one major or at least two minor fetal
    structural defects identified by ultrasonography, either parent with
    a chromosomal translocation or chromosomal inversion, or parental
    aneuploidy.

-   Nondirective counseling before prenatal diagnostic testing does not
    require a patient to commit to pregnancy termination if the result
    is abnormal.

Invasive Prenatal Testing for Aneuploidy. ACOG Practice Bulletin No. 88.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2007; 110:1179-98.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055749>

#### AFP, American Family Physician {#afp-american-family-physician .Style-Heading-4-+-Arial-14-pt-Underline}

Patient-Controlled Analgesia for Postoperative Pain: Cochrane Briefs

[Clinical Question]{.underline}

Is patient-controlled opioid analgesia more effective than conventional
analgesia for postoperative pain?

[Evidence-Based Answer]{.underline}

Patient-controlled opioid analgesia is safe and provides a statistically
significant improvement in analgesia in postoperative patients, but the
clinical significance of the improvement is marginal.

[Practice Pointers]{.underline}

Patient-controlled analgesia (PCA) using opioids (e.g., morphine) has
become the standard of care at many institutions for the management of
postoperative pain. However, previous systematic reviews in 1992 and
2001 found conflicting results regarding the effectiveness of this
approach compared with traditional analgesia.1,2 The authors of this
Cochrane review identified 55 studies with a total of 3,861 patients,
and they compared these studies with the 16 studies1 and 33 studies2
found in the previous systematic reviews. None of the studies were
double-blinded and, in general, the studies were of poor quality.

Most studies measured pain on a visual analog scale (e.g., a scale with
zero meaning the patient had no pain, and 100 meaning that the patient
had severe pain) at various points in time. A change of 10 to 15 points
on a 100-point visual analog scale is generally considered to be
clinically significant and detectable by patients as an improvement.3 In
these studies, the average pain intensity during a time period or the
final pain intensity at the end of a time period was measured. The study
durations generally ranged from 24 to 72 hours.

Pain intensity during the first 24 hours was eight points lower in the
PCA group than in a group receiving conventional analgesia (95% CI, -12
to -4 points), nine points lower between 25 and 48 hours (95% CI, -14 to
-5 points), and 13 points lower between 49 and 72 hours (95% CI, -20 to
-6 points).3 Patients in the PCA group used more opioids than those in
the control group over 72 hours; however, with the exception of a small
increase in pruritus, there was no difference in other adverse effects
such as nausea, vomiting, sedation, or urinary retention. Overall, more
patients were more satisfied with the mode of analgesia in the PCA group
(84 versus 65 percent; number needed to treat = 5.3).

Hudcova J, McNicol E, Quah C, Lau J, Carr DB. Patient controlled opioid
analgesia versus conventional opioid analgesia for postoperative pain.
Cochrane Database Syst Rev 2006;(4):CD003348.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17054167>

Aspirin Combined With Clopidogrel (Plavix) Decreases Cardiovascular
Events in Patients with Acute Coronary Syndrome

[Clinical Scenario]{.underline}

A 65-year-old man with a history of myocardial infarction is on low-dose
aspirin. His peripheral vascular disease has worsened over the past
year.

[Clinical Question]{.underline}

Should physicians combine aspirin with clopidogrel (Plavix) in patients
with a high risk of cardiovascular disease or in patients with acute
coronary syndrome?

[Evidence-Based Answer]{.underline}

A combination of aspirin and clopidogrel decreased cardiovascular events
in patients at high risk of cardiovascular disease and in those with
acute coronary syndrome. However, the risk of major bleeding events
outweighed the benefits in all high-risk patients except those with
acute coronary syndrome.

Keller TT, Squizzato A, Middeldorp S. Clopidogrel plus aspirin versus
aspirin alone for preventing cardiovascular disease. Cochrane Database
Syst Rev 2007;(3):CD005158.

Cochrane for Clinicians Putting Evidence into Practice

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636787>

#### AHRQ, Agency for Healthcare Research and Quality  {#ahrq-agency-for-healthcare-research-and-quality .Style-Heading-4-+-Arial-14-pt-Underline}

##### Women leaving the hospital against medical advice after delivering a baby should be targeted for more services [**http://www.ahrq.gov/research/dec07/1207RA11.htm**](http://www.ahrq.gov/research/dec07/1207RA11.htm)

##### Full disclosure of medical errors to patients is becoming more and more transparent

<http://www.ahrq.gov/research/dec07/1207RA7.htm>

**Colorectal cancer screening can be improved at primary care
practices**

<http://www.ahrq.gov/research/dec07/1207RA21.htm>

**Family-centered, high quality primary care is linked to fewer
nonurgent emergency department visits by children**

<http://www.ahrq.gov/research/dec07/1207RA4.htm>

#### Ask a Librarian Diane Cooper, M.S.L.S. / NIH {#ask-a-librarian-diane-cooper-m.s.l.s.-nih .Style-Heading-4-+-Arial-14-pt-Underline}

**Recommendations Regarding the Prevention, Assessment, and Treatment of
Child and Adolescent Overweight and Obesity**

In February 2004, the American Medical Association convened a second
expert committee to guide the development of 3 articles that would
explore current evidence-based science and form the basis of new
recommendations on the assessment, prevention, and treatment of child
and adolescent overweight and obesity. Representatives from 15 national
organizations

formed the second expert committee. The committee used a
multidisciplinary model and integrated approaches across disciplines.
The conceptual framework is the chronic care model with the goal of
achieving family/self-management of childhood obesity.

The product was 4 articles, 1 on each of the aforementioned overview
areas of the management of obesity and 1 overarching support document.
The articles were written by national experts in the field of childhood
obesity who were nominated jointly by the members of the expert and
steering committees.

-Barlow SE and the Expert Committee Expert Committee. Recommendations
Regarding the

Prevention, Assessment, and Treatment of Child and Adolescent Overweight
and Obesity:

Summary Report PEDIATRICS Volume 120, Supplement 4, December 2007 S164 -
S192

-Krebs NF et al Assessment of Child and Adolescent Overweight and
Obesity. PEDIATRICS Volume 120, Supplement 4, December 2007: S193 - S228

-Davis MM Recommendations for Prevention of Childhood Obesity PEDIATRICS
Volume 120, Supplement 4, December 2007 S229 - S253

-Spear BA et al Recommendations for Treatment of Child and Adolescent
Overweight and Obesity PEDIATRICS Volume 120, Supplement 4, December
2007 S254 - S288

<http://pediatrics.aappublications.org/content/vol120/Supplement_4/index.shtml>

or

[www.pediatrics.org]{.underline}

## The Healthy Heart Handbook for Women \'07 - 20th Anniversary Edition

![](media/image2.png){width="1.3854166666666667in"
height="2.0833333333333335in"}

This newly revised handbook, with a special message from First Lady
Laura Bush, provides new information on women's heart disease and
practical suggestions for reducing your own personal risk of
heart-related problems. The handbook presents the latest information on
how to live a healthier and longer life, by taking action steps to
prevent and control heart disease risk factors.

You'll also find new tips on following a nutritious eating plan,
tailoring your physical activity program to your particular goals,
quitting smoking, and getting your whole family involved in heart
healthy living. *The Healthy Heart Handbook for Women* is part of *The
Heart Truth for Women*, a national public awareness campaign for women
about heart disease sponsored by the National Heart, Lung and Blood
Institute (NHLBI) and many other groups.

[http://www.nhlbi.nih.gov/health/public/heart/other/hhw/hdbk_wmn.pdf[\
]{.underline}](http://www.nhlbi.nih.gov/health/public/heart/other/hhw/hdbk_wmn.pdf)

##### Behavioral Health Insights, Peter Stuart, IHS Psychiatry Consultant

**Teens, Depression, Black Box Warnings and Suicide**

After a substantial period of gradually decreasing rates of suicide in
adolescents including AI/AN adolescents , recent 2004 data documenting
increased suicide rates for adolescents suggests more attention will be
coming to adolescent mood problems. The increase in suicides was most
dramatic in female populations with rates rising dramatically in younger
female populations ages 10-14 (75.9%) and significantly so in older
adolescent females ages 15-19 (32.3%) and males ages 15-19 (9%). The
increases coincide with the FDA's black box requirement for many
antidepressants that is likely responsible for an overall reduction in
the prescription of antidepressants for teenagers. Does this mean
decreased antidepressant prescription was causally related to the
increase in suicides? We don't know but the temporal association is
suggestive.

Our adolescents are unfortunately at the forefront of the suicide curve.
Indian country has received significant attention recently due to
increasing concern about suicide clusters in adolescent populations and
more generally young adults. Theories abound as to why this is occurring
-- and given the low base rates of the event and the high frequency of
conditions and behaviors associated with increased risk real
understanding is still some time away.

There is a general consensus, however, that part of the solution lies in
identifying and treating depression in Primary Care. The American
Academy of Pediatrics recently released GLAD-PC (Guidelines for
Adolescent Depression in Primary Care) I and II which include excellent
resources for developing primary care based approaches to management.
The full documents can be found at
[www.glad-pc.org](http://www.glad-pc.org/) and include screening and
assessment instruments as well as treatment tracking tools.

The recent publication of further results from the TADS (Treatment of
Adolescent Depression Study) is also encouraging as it suggests that
risks related to antidepressant treatment can be mitigated with
appropriate therapy and management.

Combined Depression Regimen Appears to Reduce Suicidality. Psychiatr
News, Mar 2007; 42: 28 -- 35

Also see
<http://www.nimh.nih.gov/health/trials/practical/tads/questions-and-answers-about-the-nimh-treatment-for-adolescents-with-depression-study-tads.shtml>

Some basic recommendations for tackling adolescent depression:

1.  Screen using a systematic assessment (screening tool) -- for those
    of you familiar with the PHQ-9 there is a slightly modified
    instrument for adolescents available on

> [www.glad-pc.org](http://www.glad-pc.org/) Other instruments with
> established psychometric properties are also
>
> available for use and several are free.

2.  Develop relationships with your local BH system -- you can treat and
    manage many patients successfully with fairly limited consultative
    support,

3.  Take adequate time -- pediatric and primary care schedules are often
    crazy and packed -- this is for better or for worse one of those
    occasions where time up front reduces emergencies and time later. If
    you have the opportunity to integrate BH care into your primary care
    services your schedule interruptions can be minimized.

4.  Treatment works -- and while there may be issues with the relative
    strength of psychotherapy vs. medications both have demonstrated
    efficacy over placebo or treatment as usual approaches. Keys to
    successful treatment include having a plan, reassessing progress
    frequently particularly in the early stages of treatment, and
    getting help if there is no improvement or improvement plateaus
    before full resolution.

5.  Access to lethal means restriction counseling may reduce risk of
    self-injury (see
    http://www.sprc.org/featured_resources/bpr/ebpp_PDF/emer_dept.pdf).

6.  The "Medical Home" is an encompassing model that if applied properly
    in conjunction with developmentally appropriate preventive
    counseling provides maximum opportunity to identify, intervene and
    mitigate at least some of the risk for self-destructive behaviors in
    adolescence -- whether that behavior be self-injury, smoking,
    unprotected sex or drug and alcohol use.

If you decide to use medications, keep in mind the following:

1.  Medications should be used to treat full MH disorders and generally
    avoided in sub-syndromic states in children and adolescents,

2.  Fluoxetine remains the best option to start with for adolescents --
    it has the best risk profile and is indicated for treatment of
    adolescent depression.

3.  Educate the patient and parents/guardians/family members about use
    of the medication, including the possible development of agitation,
    restlessness, and anxiety -- these symptoms may portend the
    development of medication-induced suicidal thinking. The FDA and
    AACAP guidelines suggest initial weekly face-to-face visits -- while
    this is desirable it is often not feasible or practical but the
    pearl here is to plan regular weekly contact whether in person, by
    phone or through other means, with the patient and family and
    identify this in your documentation. Follow-up may actually need to
    be more frequent if there is any significant suicidal ideation or
    self-harm concerns.

4.  Screen for history of bipolar symptoms both in the patient and
    through the family history -- be very cautious using medications
    without consultation where there is a history of mania-like symptoms
    or family bipolar disorder.

5.  Stop medications gradually -- risk periods for increased suicidal
    thinking appear to be both around the initial time of initiation of
    antidepressant therapy AND AFTER sudden discontinuation.

6.  Limit refills. Keep dispensed amounts to only slightly more than
    necessary to get to the next contact or appointment for the first
    three months of treatment.

**Resources / References:**

**Academy of Child and Adolescent Psychiatry Practice Parameters**

<http://www.aacap.org/galleries/PracticeParameters/InPress_2007_DepressiveDisorders.pdf>

**CDC suicide rate increase article focusing on 10-19 year olds**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5635a2.htm>

#### Breastfeeding Suzan Murphy, PIMC {#breastfeeding-suzan-murphy-pimc .Style-Heading-4-+-Arial-14-pt-Underline}

**Breastfeeding, it is not just about the baby**

According to a 2005 meta-analysis by the Agency for Healthcare Research
and Quality (AHRQ), postpartum depression (PPD) is a major depressive
disorder that effects between 5-25% of women in developed nations.
Compared to men, women are twice as likely to experience depression in
their lifetime.

Risk factors for PPD include:

+-------------------------------+--------------------------------------+
| -   adolescence               | -   unplanned/unwanted pregnancy     |
+-------------------------------+--------------------------------------+
| -   poverty                   | -   life stress (including           |
|                               |     child-care issues)               |
+-------------------------------+--------------------------------------+
| -   family or personal        | -   challenging infant temperament   |
|     history of depression     |     (fussy, colicky)                 |
+-------------------------------+--------------------------------------+
| -   relationship discord      | -   low self-esteem                  |
+-------------------------------+--------------------------------------+
| -   lack of social support    | -   prenatal anxiety                 |
+-------------------------------+--------------------------------------+

Symptoms include:

+---------------------------------+------------------------------------+
| -   Loss of interest or         | -   Feelings of worthlessness,     |
|     enthusiasm for daily        |     hopelessness,                  |
|     activities                  |     excessive/inappropriate guilt  |
|                                 |     or shame                       |
+---------------------------------+------------------------------------+
| -   Depressed mood              | -   Suicidal ideation              |
+---------------------------------+------------------------------------+
| -   Difficulty making decisions | -   Somatic complaints such as     |
|     or concentrating            |     headaches, g.i. distress       |
+---------------------------------+------------------------------------+
| -   Fatigue                     | -   Psychomotor disturbance        |
+---------------------------------+------------------------------------+
| -   Appetite disturbance        | -   Sleep changes                  |
+---------------------------------+------------------------------------+

For many reasons, PPD is often undiagnosed. PPD left untreated can be
devastating for new mothers and their families..

A recent study by Mancini et al (cited below), described using the
Postpartum Depression Screening Scale (PDSS) developed by Beck et al to
screen women in large midwifery and obstetric practice in Albuquerque,
New Mexico. The practice saw approximately 2000 deliveries per year, 40%
enrolled in the Medicaid program. The goals of the study were to look at
prevalence of positive PDSS screen at 6 weeks, determine the benefits
and challenges of using the PDSS screening tool and find demographic and
clinical characteristics that were related to positive screens.

In a 12 month period, 755 women were screened, 740 with complete data
sets. Data was collected on PDSS score, age, parity, race/ethnicity,
education, marital status, infant feeding, type of delivery, and history
of depression. The prevalence of a positive screen at 6 weeks was 16%
with major PPD and 20% with symptoms suggesting potential PPD risk. The
PDSS was integrated into the patient care routine ultimately with
positive feed back by the staff and patients. A total of 75% of the
providers participated, 6 of 11 obstetricians, all of 9 CNMs. They
reported a sense of providing more comprehensive care and the
opportunity to gently educate about mental illness. Patients reported
appreciating the chance to talk about mental wellness issues.

The study found that women who had a positive screen at 6 weeks
postpartum were more likely to not have completed high school, not be
partnered, be exclusively bottle feeding, and have a history of
depression. The 2 characteristics that were statistically significant as
predictors of a positive PDSS screen were history of depression (risk
ratio, 4.8; 95% CI, 4.4-5.2) and exclusive bottle feeding (risk ratio,
2.0; CI, 1.6-2.4). The possible reasons suggested for breastfeeding
reducing risk of PPD included decreased maternal stress sensitivity, and
enhanced response/action of the parasympathetic nervous system.

Like many other articles about PPD, the authors reiterated the need for
more research and attention to timely screening and early intervention.

A side note: Other possible reasons for reduced PPD risk with
breastfeeding mothers include increased levels of prolactin and
oxytocin, shortened duration of post partum bleeding with enhanced
involution, possible delayed return to menses -- and so less risk of PMS
symptoms, possible weight loss, reduced stress due to less infant
illness, and likely increase in maternal self-esteem.

Mancini F, Carlson C, Albers L; Use of the Postpartum Depression
Screening Scale in a collaborative obstetric practice, Journal of
Midwifery & Women's Health 2007;52:429-434.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17826704>

Driscoll JW; Postpartum depression, How nurses can identify and care for
women grappling with this disorder, AWHONN Lifelines, 2006
Oct-Nov;10(5):400-9.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17069572>

####  {#section-6 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Other {#other .Style-Heading-4-+-Arial-14-pt-Underline}

**Milk pollution due to alcohol**

RESULTS: The elimination of alcohol and time-to-zero levels in breast
milk are described in a nomogram as a function of the amount of alcohol
consumed and the body weight of the woman. CONCLUSIONS: Careful planning
of a breast feeding schedule, by storing milk before drinking and/or
waiting for complete alcohol elimination from the breast milk, can
ensure women that their babies are not exposed to any alcohol.

[Ho
E](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ho E"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Alcohol and Breast Feeding: Calculation of Time to Zero Level in
Milk Alcohol and breast feeding: calculation of time to zero level in
milk. Biol Neonate. 2001;80(3):219-22

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11585986>

####  {#section-7 .Style-Heading-4-+-Arial-14-pt-Underline}

**Special journal issue offers guidance on promoting and supporting
breastfeeding**

#### The November-December 2007 issue of the Journal of Midwifery and Women\'s Health is dedicated to lactation and reflects a commitment of the American College of Nurse-Midwives to promote breastfeeding and improve the clinical practice of midwives and other women\'s health professionals. The issue provides recent research about the science of lactation, including new information about breast anatomy and the physiology of lactation. Topics include new information about the best way to bring the infant to the breast and help the infant latch, how to assess breastfeeding and how to assist mothers with specific breastfeeding problems, how to appropriately counsel women about the benefits of breastfeeding, and what can be done during labor and birth to minimize the impact of birth practices on breastfeeding. The issue is available at [[http://www.sciencedirect.com/science/journal/15269523]{.underline}](http://www.sciencedirect.com/science/journal/15269523) {#the-november-december-2007-issue-of-the-journal-of-midwifery-and-womens-health-is-dedicated-to-lactation-and-reflects-a-commitment-of-the-american-college-of-nurse-midwives-to-promote-breastfeeding-and-improve-the-clinical-practice-of-midwives-and-other-womens-health-professionals.-the-issue-provides-recent-research-about-the-science-of-lactation-including-new-information-about-breast-anatomy-and-the-physiology-of-lactation.-topics-include-new-information-about-the-best-way-to-bring-the-infant-to-the-breast-and-help-the-infant-latch-how-to-assess-breastfeeding-and-how-to-assist-mothers-with-specific-breastfeeding-problems-how-to-appropriately-counsel-women-about-the-benefits-of-breastfeeding-and-what-can-be-done-during-labor-and-birth-to-minimize-the-impact-of-birth-practices-on-breastfeeding.-the-issue-is-available-at-httpwww.sciencedirect.comsciencejournal15269523 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-8 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Lactation complicated by overweight and obesity: Many challenges {#lactation-complicated-by-overweight-and-obesity-many-challenges-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Research shows that mothers who are obese (with a BMI \>30) are less likely to initiate lactation, have delayed lactogenesis II, and are prone to early cessation of breastfeeding. Black women, with the highest rates of American obesity, have the lowest rates and shortest duration of breastfeeding compared to Hispanic and white women. Women who are overweight and obese have lowered prolactin responses to suckling. Women who are obese are at risk for prolonged labors, excessive labor stress, and cesarean birth, all of which delay lactogenesis II. Lactation has a small but significant role in preventing future obesity in the mother and child. Midwifery management of obesity-related lactation problems begins with education about optimal prenatal weight gain and regular weight assessment to avoid excessive gain. Support of physiologic birth processes to avoid stress, prolonged labor, and surgical birth and limit maternal-newborn separation enhances the onset of lactogenesis II. Massage or pumping may soften and extend the obese nipple for easier latch. Infants of lactating women with prior bariatric surgery are at risk for B12 deficiency and require regular nutrition and growth assessment. Five hundred calorie per day restriction paired with aerobic exercise for intentional postpartum weight loss does not affect milk quality or infant growth. {#research-shows-that-mothers-who-are-obese-with-a-bmi-30-are-less-likely-to-initiate-lactation-have-delayed-lactogenesis-ii-and-are-prone-to-early-cessation-of-breastfeeding.-black-women-with-the-highest-rates-of-american-obesity-have-the-lowest-rates-and-shortest-duration-of-breastfeeding-compared-to-hispanic-and-white-women.-women-who-are-overweight-and-obese-have-lowered-prolactin-responses-to-suckling.-women-who-are-obese-are-at-risk-for-prolonged-labors-excessive-labor-stress-and-cesarean-birth-all-of-which-delay-lactogenesis-ii.-lactation-has-a-small-but-significant-role-in-preventing-future-obesity-in-the-mother-and-child.-midwifery-management-of-obesity-related-lactation-problems-begins-with-education-about-optimal-prenatal-weight-gain-and-regular-weight-assessment-to-avoid-excessive-gain.-support-of-physiologic-birth-processes-to-avoid-stress-prolonged-labor-and-surgical-birth-and-limit-maternal-newborn-separation-enhances-the-onset-of-lactogenesis-ii.-massage-or-pumping-may-soften-and-extend-the-obese-nipple-for-easier-latch.-infants-of-lactating-women-with-prior-bariatric-surgery-are-at-risk-for-b12-deficiency-and-require-regular-nutrition-and-growth-assessment.-five-hundred-calorie-per-day-restriction-paired-with-aerobic-exercise-for-intentional-postpartum-weight-loss-does-not-affect-milk-quality-or-infant-growth. .Style-Heading-4-+-Arial-14-pt-Underline}

[Jevitt
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Jevitt C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Lactation complicated by overweight and obesity: supporting the
mother and newborn. J Midwifery Womens Health. 2007 Nov-Dec;52(6):606-13

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17983998>

####  {#section-9 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CCC Corner Digest {#ccc-corner-digest .Style-Heading-4-+-Arial-14-pt-Underline}

#### Nicely laid out hard copy - A compact digest of last month's CCC Corner {#nicely-laid-out-hard-copy---a-compact-digest-of-last-months-ccc-corner .Style-Heading-4-+-Arial-14-pt-Underline}

#### December Highlights include  {#december-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

\-[30 minute rule not a requirement and 'immediately available' defined
locally](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_AOM.cfm)

\-[Random glucose test would have missed 5 of 6 women with
GDM](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Coll.cfm)

\-[Cesarean delivery in Native American women: Low rates explained by
practice
style?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#ob)

\-[HPV test beats Pap in detecting cancer - Use new  ASCCP Consensus
Guidelines](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#gyn)

\-[Long-term prognosis for infants after massive fetomaternal
hemorrhage](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#child)

\-[Heart Disease Kills More Younger
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#chrIll)

\-[Use of Psychiatric Medications During Pregnancy and
Lactation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#acog)

\-[Predicting the Likelihood of Successful Vaginal Birth After Cesarean
Delivery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#afp)

\-[The Healthy Heart Handbook for Women \'07 - 20th Anniversary
Edition](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#AskLib)

\-[Breastfeeding Promotion: Good Public Health Policy: Part 2 of
2](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#breast)

\-[Adolescent primary prevention programs for DV which are school
based](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#dv)

\-[New module: Lack of VZIG and new prenatal assessment of varicella
immunity](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#webSite)

\-[Special Global Issue - Obstetrics and
Gynecology](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#ih)

\-[Tightening the \"holes\" in the Swiss cheese model of patient safety
in
obstetrics](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#alert)

\-[Frequently Asked Questions about Infant Feeding
Choice](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#headlines)

\-[What is the presenting
part?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#mmtour)

-Vaginal birth after cesarean (VBAC) in rural hospitals -
[Counterpoint](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#MidWives)

\-[Which caused more deaths in the United States in 2005, MRSA or
HIV?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#navajo)

\-[2008 Long Term IHS Training-- NURSE ANESTHESIA -- Apply
Soon](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#nurseCorner)

\-[Cancer in American Indians and Alaska
Natives](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#owh)

\-[Methicillin-resistant Staphylococcus aureus in women's
health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#okie)

\-[A cost decision analysis of 4 tocolytic
drugs](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#periPicks)

\-[Traditional AI/AN Medicine: Incorporating Into I/T/U Clinical
Practice](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#pcf)

\-[Prevention of Mother-to-Child HIV Transmission in Resource-Limited
Settings](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#std)

\-[Hypertension Triples Womens' Risk for
Diabetes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#stillW)

\-[Alaska Native FASD and Suicidality in a Healthcare
setting](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#wheadlines)

#### If you want a copy of the CCC Digest mailed to you each month, please contact [**nmurphy@scf.cc**](mailto:nmurphy@scf.cc) {#if-you-want-a-copy-of-the-ccc-digest-mailed-to-you-each-month-please-contact-nmurphyscf.cc .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-10 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Domestic Violence Denise Grenier, Tucson / Rachel Locker, Warm Springs {#domestic-violence-denise-grenier-tucson-rachel-locker-warm-springs .Style-Heading-4-+-Arial-14-pt-Underline}

**Improving Domestic Violence Law Enforcement Response on the Tohono
O\'odham Nation**

The IHS Office of Emergency Services is happy to share with you that
Emerging Leader, Michelle Begay\'s, article \"Improving Domestic
Violence Law Enforcement Response on the Tohono O\'odham Nation\" has
been published in The IHS Primary Care Provider.

It was published in the October edition - October being DV Awareness
Month.

Thanks

Denise

Improving Domestic Violence Law Enforcement Response on the Tohono
O\'odham Nation

Vol. 32 #10 Oct 2007 Issue.

[[http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1007.pdf]{.underline}](http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1007.pdf)

**Child abuse funding offered: CCTV / Recording Technology Grant
Program**

The American Bar Association/Center on Children and the Law has recently
announced a second round of funding for the CCTV/Recording Technology
Grant Program.  This program provides funds to states and local units of
government (including Indian tribes and Alaska Native villages) to
purchase and/or upgrade CCTV and recording equipment for use in child
abuse cases.  One exciting feature of the program is that Indian tribes
are exempt from the 25% match requirement.

Applications are due February 15, 2008. A 30-minute web-based
information session on December 18, 2007, at 1:00 p.m. EST. Please
register for the information session by sending your name, email address
and phone number to: <cctv@staff.abanet.org>

More information --- including the full text of the request for
proposals, FAQs and a sample application --- can be found online at
<http://www.abanet.org/child/videotape.shtml>

You can also contact Molly Hicks by email or phone if you have any
questions.

Molly A. Hicks, MPA

Phone/Fax: 703-451-5468

Email: <mhicks@keenemillconsulting.com>

#### Elder Care News {#elder-care-news .Style-Heading-4-+-Arial-14-pt-Underline}

**Training in Palliative and End of Life Care** - **SAVE THE DATE**

March 25 -27, 2008 - Minneapolis, MN

and

April 22-24, 2008 -- Flagstaff, AZ

The Education in End of Life and Palliative Care -- Oncology (EPEC-O)
for Indian Health is a 3 day training program designed to improve
knowledge in pain and symptom management and end-of-life care. The
format includes formal presentations and small group discussions and
will provide those who attend with a modular curriculum to bring home
for training and program development at their home facilities.

This training, using the NCI EPEC-O with AI/AN Cultural Considerations
curriculum, is designed to provide a basic introduction to palliative
and end-of-life care and familiarity with the modular EPEC-O
curriculum.Those attending last year's session in Window Rock were able
to take home the curriculum to use for local training and program
development.

The target audience includes IHS, Tribal, and Urban physicians, nurses,
PAs and APNs, behavioral health providers, and pharmacists.

EPEC --O for Indian Health is a collaboration between the IHS and the
National Cancer Institute (NCI), with funding provided for travel and
per diem. Location and application information coming soon. For
questions, contact Tim Domer MD at <tim.domer@ihs.gov>

**A pharmacy alert system plus physician-pharmacist collaboration can
reduce inappropriate drug prescribing among elderly outpatients**

<http://www.ahrq.gov/research/dec07/1207RA16.htm>

#### Family Planning {#family-planning .Style-Heading-4-+-Arial-14-pt-Underline}

**Intrauterine Device and Adolescents, ACOG Committee Opinion**

ABSTRACT: The intrauterine device (IUD) is highly effective and widely
used by women throughout the world. Data support the safety of IUDs for
most women, including adolescents. This document addresses the major
benefits of IUD use in adolescents, a population at particular risk of
unintended pregnancy.

Intrauterine Device and Adolescents. ACOG Committee Opinion no. 392.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:1493-5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055754>

####  {#section-11 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Prescription contraceptive use increased reflecting state mandates on private insurers {#prescription-contraceptive-use-increased-reflecting-state-mandates-on-private-insurers-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Prescription contraceptive use increased most significantly among privately insured women between 1995 and 2002, potentially reflecting state mandates enacted during that period requiring contraceptive coverage by private insurers. It is important for clinicians to understand these differences and address issues of insurance coverage with patients when discussing contraceptive options. LEVEL OF EVIDENCE: III. {#conclusion-prescription-contraceptive-use-increased-most-significantly-among-privately-insured-women-between-1995-and-2002-potentially-reflecting-state-mandates-enacted-during-that-period-requiring-contraceptive-coverage-by-private-insurers.-it-is-important-for-clinicians-to-understand-these-differences-and-address-issues-of-insurance-coverage-with-patients-when-discussing-contraceptive-options.-level-of-evidence-iii. .Style-Heading-4-+-Arial-14-pt-Underline}

[Culwell
KR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Culwell KR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Changes in prescription contraceptive use, 1995 2002: the effect
of insurance status. Obstet Gynecol. 2007 Dec;110(6):1371-8.

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=18055734&dopt=AbstractPlus**](http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=18055734&dopt=AbstractPlus) {#httpwww.ncbi.nlm.nih.govsitesentrezcmdretrievedbpubmedlist_uids18055734doptabstractplus .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-12 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Advance provision of EC does not reduce pregnancy rates, nor affect sexual behavior {#advance-provision-of-ec-does-not-reduce-pregnancy-rates-nor-affect-sexual-behavior-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Advance provision of emergency contraception did not reduce pregnancy rates and did not negatively affect sexual and reproductive health behaviors and outcomes compared with conventional provision. LEVEL OF EVIDENCE: III {#conclusion-advance-provision-of-emergency-contraception-did-not-reduce-pregnancy-rates-and-did-not-negatively-affect-sexual-and-reproductive-health-behaviors-and-outcomes-compared-with-conventional-provision.-level-of-evidence-iii .Style-Heading-4-+-Arial-14-pt-Underline}

[Polis
CB](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Polis CB"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Advance Provision of Emergency Contraception for Pregnancy
Prevention: A Meta-Analysis. Obstet Gynecol. 2007 Dec;110(6):1379-1388.

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=18055735&dopt=AbstractPlus**](http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=18055735&dopt=AbstractPlus) {#httpwww.ncbi.nlm.nih.govsitesentrezcmdretrievedbpubmedlist_uids18055735doptabstractplus .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-13 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Ethinyl Estradiol/Drospirenone for the Symptoms of Premenstrual Dysphoric Disorder](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0IwfG0GB) {#ethinyl-estradioldrospirenone-for-the-symptoms-of-premenstrual-dysphoric-disorder .Style-Heading-4-+-Arial-14-pt-Underline}

#### A combined oral contraceptive pill containing 20 µg of ethinyl estradiol and 3 mg of the progestin drospirenone in a novel dose regimen (24 active pills followed by 4 placebo pills), has demonstrated efficacy for the symptoms of premenstrual dysphoric disorder, a severe form of premenstrual syndrome, with an emphasis on the affective symptoms. Drospirenone has progestagenic, anti-androgenic and anti-aldosterone properties, which differ from earlier generations of progestins, and reducing the hormone pill-free interval allows for better suppression of ovarian steroid production. {#a-combined-oral-contraceptive-pill-containing-20-µg-of-ethinyl-estradiol-and-3-mg-of-the-progestin-drospirenone-in-a-novel-dose-regimen-24-active-pills-followed-by-4-placebo-pills-has-demonstrated-efficacy-for-the-symptoms-of-premenstrual-dysphoric-disorder-a-severe-form-of-premenstrual-syndrome-with-an-emphasis-on-the-affective-symptoms.-drospirenone-has-progestagenic-anti-androgenic-and-anti-aldosterone-properties-which-differ-from-earlier-generations-of-progestins-and-reducing-the-hormone-pill-free-interval-allows-for-better-suppression-of-ovarian-steroid-production. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Rapkin AJ, McDonald M, Winer SA. [Ethinyl Estradiol/Drospirenone for the Treatment of the Emotional and Physical Symptoms of Premenstrual Dysphoric Disorder](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0IwfG0GB). [Women\'s Health.](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0IwfF0GA) 2007;3(4):395-408. {#rapkin-aj-mcdonald-m-winer-sa.-ethinyl-estradioldrospirenone-for-the-treatment-of-the-emotional-and-physical-symptoms-of-premenstrual-dysphoric-disorder.-womens-health.-200734395-408. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/561680?sssdmh=dm1.324491&src=journalnl**](http://www.medscape.com/viewarticle/561680?sssdmh=dm1.324491&src=journalnl) {#httpwww.medscape.comviewarticle561680sssdmhdm1.324491srcjournalnl .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-14 .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website David Gahn, IHS MCH Portal Web Site Content
Coordinator**

**Preconception Counseling for Women with Diabetes and Hypertension: New
module**

This is a new module in the Perinatology Corner Series

This particular topic is coming up a lot more frequently in our
patients.

What can you treat with and not endanger the fetus?

What you can't treat with?

This module offers good advice on these and many other issues, plus lots
of resources, even if you don't want the free CME

<http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/PreconCouns01.cfm>

and

**It was low hanging fruit before: Now it is even easier - Perinatology
Corner**

#### The Perinatology Corner, a great Indian Health resource on many obstetric topics, plus free CME, has just gotten easier to use. Once you create an IHS login username and password (which takes about 30 seconds) the system will remember you and make it easier each time you want to take another module.

#### [Submitting a Posttest]{.underline}

To take a posttest, log in with an IHS login now

The link to log in is in the leftside menu of each module\'s posttest
page. (You will only need to log in once to any page that provides the
link in the IHS site.) Once you fill in the registration information on
the posttest page of one module, the demographics will self populate all
future modules, thereby saving you time and effort.

You can take and retake any posttest. Any time you take a posttest, an
email will sent to you with answers. You only get credit for the first
time you take a module\'s posttest.

You can change your contact information (except their email address,
through this system) in the form of any module\'s posttest once you\'ve
submitted your contact information in the first posttest you take.

You can update your contact information on the form when you\'re
submitting a new posttest, when retaking a test with or without retaking
the posttest.

Here is how to complete the Posttest and Evaluation\
It is easy. Ptease log in and the Posttest page will become available

> -If you have logged into the to the Indian Health registration before,
> then go directly to Login (choose the \"Login\" link):
>
> Hit Login or Register
>
> -If haven\'t completed the Registration process before, it is easy,
> secure, and relatively quick.\
> -It will also allow you to take future modules without having to
> repeat your contact information each time.\
> Choose the \"Register\" link:

Once you have successfully logged into your web account, then hit the
Return button on the\
Successful Login page and it will take you to the Posttest and
Evaluation

**Perinatology Corner**

<http://www.ihs.gov/MedicalPrograms/MCH/M/perCrnr.cfm>

#### Frequently asked questions {#frequently-asked-questions .Style-Heading-4-+-Arial-14-pt-Underline}

**Q. How should we manage a patient with a previous abruptio placenta?**

**A. There are significant risks after 2 previous abruptions or if fetal
death resulted**

(See details)

**Short take**

In the vast majority of cases no change in management is required in
subsequent pregancies. Reversible risk factors can be modified (eg,
avoid cigarette smoking or cocaine use) and women with nonrecurrent risk
factors (eg, trauma) may be reassured.

In selected patients, such as those with two or more prior perinatal
deaths or one perinatal death with persistent nonmodifiable risk factors
for abruption, offering patients the option of preterm delivery upon
documentation of fetal lung maturity is reasonable.

**Background**

The risk of recurrence has been reported as 5 to 15 percent, compared to
a baseline incidence of 0.4 to 1.3 percent in the general population.
After two consecutive abruptions, the risk of a third rises to 25
percent. (Clark) When the abruption is severe enough to kill the fetus,
there is a 7 percent incidence of the same outcome in a future
pregnancy.( Pritchard)

Placental abruption may also predict a greater likelihood of other
problems in subsequent pregnancies. A cohort study that examined
pregnancy outcome in the pregnancy immediately following a placental
abruption found higher rates of small for gestational age infants,
spontaneous preterm birth, and preeclampsia, even in the absence of
recurrent abruption .

**Management in subsequent pregnancy** --- There are no data on which to
base a recommendation for management of women with a history of abruptio
placenta in a previous pregnancy. Risk factors for abruption should be
identified (Table below). Reversible risk factors can be modified (eg,
avoid cigarette smoking or cocaine use) and women with nonrecurrent risk
factors (eg, trauma) may be reassured. It is not known whether
thromboprophylaxis is effective in reducing the risk of recurrent
abruption in women with inherited thrombophilias, but we treat such
women.

In women who smoke, smoking cessation reduces the risk of recurrent
abruption by 50 percent and to the same level as nonsmokers with a
history of abruption, but their risk is still higher than in women with
no history of abruption.

A cohort study based upon data from the Medical Birth Registry of Norway
calculated gestational age-specific risks of complicated placental
abruption (preterm, small for gestational age, or perinatal death) in a
second pregnancy: 7 per 1000 for an initial event and 33 per 1000 for a
first recurrence. During the subsequent pregnancy, special surveillance
and delivery six weeks prior to the gestational age of the initial
abruption would be necessary to reduce the risk of recurrent abruption
to the baseline rate.

We do not use antepartum fetal monitoring tests in women with a history
of abruption since these tests are not predictive of acute placental
insufficiency. We typically await spontaneous labor until the estimated
date of confinement or perform a repeat cesarean delivery at 39 to 40
weeks of gestation. In selected patients, such as those with two or more
prior perinatal deaths or one perinatal death with persistent
nonmodifiable risk factors for abruption, offering patients the option
of preterm delivery upon documentation of fetal lung maturity is
reasonable.

Risk factors for abruptio placenta

  -----------------------------------------------------------------------
  Trauma

  Rapid uterine decompression

  Hypertension

  Cigarette smoking

  Cocaine abuse

  Increasing parity

  Preterm premature rupture of membranes

  Inherited thrombophilia

  Multifetal gestation

  Uterine leiomyoma

  Previous abruption

  Uterine or placental anomalies
  -----------------------------------------------------------------------

**Resources**

**How should we manage a patient with a previous abruptio placenta?**

**MCH FAQ site**

[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/AbruptioRec12907.doc]{.underline}

**Management and outcome of abruptio placentae, UpToDate Software**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=pregcomp/31354>

Clark, SL. Placentae Previa and Abruptio Placentae. In: Maternal Fetal
Medicine, 4th ed, Creasy, RK, Resnik, R, (Eds), WB Saunders Company,
Philadelphia, Pennsylvania 1999. p.623.

Pritchard, JA, Mason, R, Corley, M, Pritchard, SA. Genesis of severe
placental abruption. Am J Obstet Gynecol 1970; 108:22.

**Other**

**Frequently Asked Questions about Infant Feeding Choice**

BACKGROUND INFORMATION

Why collect this data? Because it is used in the clinical performance
measure called Breastfeeding Rates that is reported in the RPMS Clinical
Reporting System (CRS). While this measure is currently not a GPRA
measure (one reported to Congress and OMB) it is used in support of the
GPRA measure Childhood Weight Control with the goal of lowering the
incidence of childhood obesity in the IHS patient population.
Additionally, facilities can use this data to track infant feeding
patterns and breastfeeding rates within their own patient population.

Research indicates that children who were breastfed have lower
incidences of overweight or obesity. For additional information, please
click the link below to review the article in the March 2007 IHS Primary
Care Provider.

<http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0307.pdf>

How is this data used? It is used in the CRS Breastfeeding Rates topic
in several measures that report:

1.  How many patients approximately 2 months through 1 year of age were
    ever screened for infant feeding choice.

2.  How many patients were screened at the approximate ages of 2 months,
    6 months, 9 months, and 1 year.

3.  How many patients who were screened were either exclusively or
    mostly breastfed at those age ranges.

Users may run the CRS Selected Measures (Local) Reports to view all of
the breastfeeding performance measures. The report also provides the
option to include a list of patients and identifies the dates and ages
they were screened and their infant feeding choice values. Click the
link below to learn how to run this report in CRS, starting on page 206
(as numbered in the document itself, not in Adobe).

<http://www.ihs.gov/misc/links_gateway/download.cfm?doc_id=10716&app_dir_id=4&doc_file=bgp_070u.pdf>

Is Infant Feeding Choice data the same as the data included in the Birth
Measurements section of the EHR and with the PIF (Infant Feeding Patient
Data) mnemonic in PCC? No, it is different. The information collected in
these sections are intended for one-time collection of birth weight,
birth order, age when formula was started, breastfeeding was stopped and
solid foods started, and linking to mother/guardian. Shown below is a
screen shot of this section from EHR. While this information is
important, none of it is used in the logic for the CRS Breastfeeding
Rates measure; only the Infant Feeding Choice data is used.

![](media/image3.png){width="4.5in" height="3.8229166666666665in"}

What are the definitions for the Infant Feeding Choices? The definitions
are shown below and are the same definitions used in both EHR and PCC.

-   Exclusive Breastfeeding: Formula supplementing less than 3 times per
    week (\<3x per week)

```{=html}
<!-- -->
```
-   Mostly Breastfeeding: Formula supplementing 3 or more times per week
    (\>3x per week) but otherwise mostly breastfeeding

-   ½ Breastfeeding, ½ Formula Feeding: Half the time breastfeeding,
    half the time formula feeding

-   Mostly Formula: The baby is mostly formula fed, but breastfeeds at
    least once a week

-   Formula Only: Baby receives only formula

Who should be collecting this information and how often? It depends on
how your facility is set up but any provider can collect this
information. At a minimum, all providers in Well Child and Pediatric
clinics should be collecting this information for patients 45-394 days
old at all visits occurring during that age range. Public Health Nurses
should also be collecting this information. This data can be entered in
EHR or PCC/PCC+, as described below.

ENTERING INFANT FEEDING CHOICE DATA IN EHR

In which version of EHR is Infant Feeding Choice data able to be
entered? EHR Version 1.1, which was deployed nationally on October 3,
2007.

How do I enter Infant Feeding Choice in EHR?

1.  After you have selected the patient and the visit, go to the
    Personal Health section. For some EHR sites, this may be included on
    the Wellness tab.

2.  ![](media/image4.png){width="7.260416666666667in"
    height="3.326388888888889in"}From the Personal Health dropdown list,
    select Infant Feeding, then click the Add button.

NOTE: The age of the patient must be five years or less to be able to
select Infant Feeding; otherwise, Infant Feeding will not be listed in
the dropdown list.

3.  ![](media/image5.png){width="3.1145833333333335in"
    height="1.4583333333333333in"}At the Add Infant Feeding Record
    window, click the appropriate checkbox to select the type of infant
    feeding, and then click the OK button to save the value.

4.  The patient's value for Infant Feeding Choice for this visit is now
    displayed in the Personal Health section, as shown below.

![](media/image6.png){width="6.385416666666667in"
height="2.5729166666666665in"}

ENTERING INFANT FEEDING CHOICE DATA IN PCC/PCC+

Which data entry patch do I need? You will need to have data entry patch
8 (apcd0200.08k) installed, which was released on October 19, 2005.

How do I enter Infant Feeding Choice in PCC?

1.  Create a new visit or select an existing visit to append.

2.  At the Mnemonic prompt, type "IF" (Infant Feeding Choices) and press
    Enter.

![](media/image7.png){width="5.9944444444444445in"
height="4.393055555555556in"}

3.  Type the number corresponding to the type of feeding and press
    Enter. If you do not know the number, type "??" and press Enter to
    see a list of choices.

4.  You are returned to the Mnemonic prompt. Continue with data entry of
    other items.

Stephanie Klepacki

CRS Project Manager/Lead Analyst

November 2, 2007

#### [MCH Coordinator Editorial comment:]{.underline}

**The infant feeding choice functionality is supported in the newly
released EHR 1.1 **

The clinical performance measure called Breastfeeding Rates reported in
the RPMS Clinical Reporting System (CRS) is a measure of interest.  We
wish to emphasize that while this measure is currently not a GPRA
measure (one reported to Congress and OMB) it is used in support of the
GPRA measure Childhood Weight Control with the goal of lowering the
incidence of childhood obesity in the IHS patient population. 
Additionally, facilities can use this data to track infant feeding
patterns and breastfeeding rates within their own patient population in
the first year of life.

To capture this data Stephanie Klepacki, the CRS Project Manager/ Lead
Analyst has developed: Frequently Asked Questions:  Infant Feeding
Choice in EHR.  A team of analysts and clinicians have been involved in
developing and testing this functionality.  Kudos go to Phoenix Indian
Medical Center's Department of Pediatrics, to Sherry Allison,
Information Processing Supervisor and her staff for getting the data
entered pre EHR, and the ever diligent and nurturing Suzan Murphy, RD,
IBLCE who have done the lion's share of the clinical testing.  

From an MCH standpoint expanding this functionality into toddler and
early childhood feeding choices seems a natural next step as later
versions are developed. 

We look forward to your feedback, comments and use of this functionality
in the universal documentation of feeding choice during the first year
of life for our American Indian and Alaska Native families.

Lastly, new to the Indian Health Breastfeeding page\* is the Lactation
Support in the Workplace Toolkit. This document includes information on:
how to get started, drafting local policy, evaluation tools, resources
available on the Indian Health Breastfeeding page, as well as FAQs.

[**Lactation Support Policy in the Workplace\
**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Lactation%20Support%20in%20the%20Workplace%20TOOLKIT_Breastfeeding%20is%20Good%20Business_October%202007.doc](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Lactation Support in the Workplace TOOLKIT_Breastfeeding is Good Business_October 2007.doc)

\*Indian Health Breastfeeding page

<http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm>

**Indian Child Health Notes Steve Holve, Pediatrics Chief Clinical
Consultant**

**January 2008**

-Trajectories of growth among children who have coronary events as
adults

-2008 Childhood Immunization Schedule: Few changes planned.

-Pattern of diarrhea-associated hospitalization and outpatient visits
for AI/AN children by region

[http://www.ihs.gov/MedicalPrograms/MCH/M/ChPedNotes.cfm]{.underline}

#### Information Technology {#information-technology .Style-Heading-4-+-Arial-14-pt-Underline}

**iCare Training**

The IHS Office of Information Technology continues to offer WebEx
training for the iCare (Population Management) software application. You
will be able to participate in the training from the comfort of your
office or conference room and will not be required to travel to obtain
this training.

iCare is a tool with multiple uses for a wide variety of providers that
presents diverse RPMS data through an easy to use graphical user
interface (GUI).

We will continue to offer a brief intro session that will just
[introduce]{.underline} the software to participants. This session does
not offer any training.

1\. A Brief Introduction to iCare 30 minutes

The 2 standard training sessions are again offered and we recommend they
be taken sequentially.

1.  iCare - Nuts and Bolts 2.0 hours

2.  the Practical Use of iCare 1.5 hours

**[Coming Soon!!!!]{.underline}**

We will be adding a new training session called \"What\'s New in
iCare?\". This session will cover the new functionality that will be
delivered in the next version of iCare. The dates for this training are
yet to be decided so stay tuned for this new session.

The target audience for all of these sessions is [any]{.underline}
provider who cares for patients (e.g. physicians, mid-level providers,
nurses, case managers, public health personnel, pharmacists etc.)

**[NOTE:]{.underline}** **You must register for these classes.** They
are NOT limited to participants in a particular Area; they are open to
all. Below are the agendas and date/times for both classes.

You can choose to register individually or as a group. If you register
individually, all you need is your computer, the ability to sign on to
the internet and a telephone. If you\'d like to attend as a group, one
person will need to register and then sign in at the designated time.
You will need a conference room, conference phone, computer and
projector.  Please ensure someone at your facility is responsible for
taking care of these arrangements.

Please note that these are live, internet-based trainings, not recorded
sessions, and people will be able to ask questions and actively
participate in the class.

**[NOTE:  All training times shown above are for the Mountain Standard
Time (Arizona Time) zone.  Please ensure you adjust the time for your
particular time zone.]{.underline}**

**[Training Schedule]{.underline}**

1.  **[iCare -- Nuts and Bolts]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   Introductions and Context

-   Set Up

-   Background Processes

-   Establishing and Changing User Preferences

-   Panel Creation

-   Panel Modification

-   Patient Record

**[Session                          Date and Time                Reg
Password]{.underline}**

iCare Nuts and Bolts Thur 12/13/2007 11:00-13:00 MST coyote

Tues 01/08/2008 13:00-15:00 MST coyote

2.  **[The Practical Use of iCare]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   Introductions and Context

-   Scenarios

-   Tips

-   Using the Performance Measure views to improve outcomes

**[Session                         Date and
Time                              Reg Password]{.underline}**

The Practical Use of iCare Mon 12/17/2007 14:00-15:30 MST coyote

Thur 01/10/2008 10:00-11:30 MST coyote

3.  **[A Brief Introduction to iCare]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.) who don\'t have time to attend a longer session.
>
> **[Agenda]{.underline}**

-   Highlights

-   Background Processes

-   Panel Creation and Modification

**[Session Date and Time Reg Password]{.underline}**

A Brief Introduction to iCare Wed 12/12/2007 11:00-11:30 MST coyote

Mon 01/14/2008 14:00-14:30 MST coyote

**[Registration Information]{.underline}**

1.  Click this link:

> [https://ihs-hhs.webex.com](https://ihs-hhs.webex.com/)

1.  In the Search box, type in \"iCare\" (do not type in the quotation
    marks) and click the Search button.  **NOTE:  If you do not see the
    Search For box, ensure the Training Center tab is selected at the
    top of the WebEx window.**

2.  All of the scheduled sessions will then be displayed in the window
    below.  Choose the one you want to attend and click "Registration"
    in the Status column.

3.  Enter the Registration password that is shown above that corresponds
    to the class you want to attend.

4.  Click the OK button.

5.  Complete the registration form.

6.  Click the Register button.

7.  A Registration confirmation is displayed that contains all of the
    information for the training session, including the link for the
    session and the password to enter when you are ready to attend the
    session.  Click the OK button to finish.

**[Setup (Software Install) Information:]{.underline}**

You must have the WebEx software installed on your computer prior to
attending the WebEx session.  **[You should setup the software at least
a day before the training session.]{.underline}**  You should not need
anyone such as the Site Manager to install it for you.  Below are the
instructions.

1.  Click this link:

> [https://ihs-hhs.webex.com](https://ihs-hhs.webex.com/)

1.  On the left side of the window, locate Set Up

2.  Click Training Manager

3.  A message is displaying giving you information about the setup
    process. Click the Set Up button

4.  After the software is installed, click the OK button.

**[Attending the Session:]{.underline}**

On the day of the scheduled training, you will receive a confirmation
email. When you are ready to attend the session, connect to the WebEx
session by clicking on the link in that email. You will then need to
connect to the conference line.  The dial information for the conference
line is shown below and is also included in your registration
confirmation message.

Phone Number:  (877) 781-4791

Passcode:         135963#

#### International Health Update Claire Wendland, Madison, WI {#international-health-update-claire-wendland-madison-wi .Style-Heading-4-+-Arial-14-pt-Underline}

**Disparities, Inequalities, or Inequities?**

Everyone knows that the average health status of people living in poor
countries is generally worse than that of people living in wealthier
ones. When health outcomes differ among different population groups, are
they health disparities or inequalities? Or, in the only term that
implies a moral wrong, are they health inequities? Inequities based on
differential access to a society's resources are difficult to detect
without some sort of assessment of wealth. Because of technical problems
with the measurement of wealth, and perhaps because of a lack of
political will, we've had a real dearth of information on inequality
within countries -- especially poor countries -- until recently. Now a
new World Bank report focuses on the correlations between economic
status and health within fifty-six poor countries in Africa, Asia, the
former Soviet Union, and Latin America. The authors made female-male and
rural-urban comparisons as well, but their focus is primarily on
economics.

Why is this data so late to the scene? Economic status was neglected in
most of the earlier studies of health disparities because it is very
hard to measure. Household income may not be in cash at all, especially
where unemployment is high; people may be much more reluctant to
estimate family income for analysts than to check a box revealing gender
or race; and proxy measures like education or occupation did not prove
to be good analogues for wealth. All of these problems were magnified in
poor countries. In the late 1990s, researchers realized that various
assets (for instance bicycles, radios, piped water, or corrugated iron
roofing rather than thatch) could be compiled into an "asset index" that
worked very well to rank economic status. It's only been in the last
decade, therefore, that researchers were able to correlate economic
status and health with reasonable accuracy.

I urge you to check out the report itself. For those of us interested in
maternal and child health, it includes detailed tables on child and
infant health, basic fertility indicators and STD prevalence, and some
maternal health indicators (such as deliveries attended by skilled
staff). The results are sobering, though preliminary. Infant and child
mortality, fertility, and malnutrition are all much greater among the
poor than the rich. Immunization, antenatal care, medical treatment of
respiratory infections, oral rehydration for diarrhea and other basic
health interventions are all less likely to be used (or available) the
poorer the household. Even primary health care offers greater benefits
to the better-off than to the poor -- 12% of benefits accrue to the
poorest 20% of the population, 29% to the richest 20% -- though it isn't
as skewed in this regard as hospital care, where 10% of benefits go to
the poorest quintile and over forty percent to the richest. The only
indicator in which the poor do better is breastfeeding: in nearly every
country surveyed, the poorest were more likely to breastfeed their
infants. (Other studies have shown that the richer are also more likely
to get unnecessary operations like excess Cesarean sections, and to
suffer the associated morbidity. That particular issue is not addressed
in this report.)

Most sobering of all, the authors predict that as new health
improvements find their way into poor countries, inequalities are likely
to worsen. Whether it is antiretrovirals for HIV or surfactant for
prematurity, the rich have means to learn about these improvements and
to access them long before the poor do. Average health status may
improve even as inequalities -- and inequities -- worsen. As the authors
conclude, "Much more will be needed if the global health community is to
move beyond platitudes about improving the health of the poor to
effective action that can do so."

Gwatkin DR, Rutstein S, Johnson K et al. 2007 Socio-economic differences
in health, nutrition, and population within developing countries: an
overview. Washington DC: World Bank.
<http://go.worldbank.org/XJK7WKSE40>

#### MCH Alert {#mch-alert-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Insights on Implementing Cultural and Linguistic Competence in MCH**

And the Journey Continues: Achieving Cultural and Linguistic Competence
in Systems Serving Children and Youth with Special Health Care Needs and
Their Families highlights experiences in infusing cultural and
linguistic competence into the policies, structures, and practices of
selected state programs. The monograph, developed by the National Center
for Cultural Competence (NCCC) at Georgetown University with support
from the Maternal and Child Health Bureau, presents stories collected
from 23 Title V Children with Special Health Care Needs programs. Also
included are key lessons that NCCC faculty, staff, and consultants have
learned about providing program guidance, as well as an analysis of the
various aspects of linguistic and cultural competence described in each
state\'s story. A list of references and state and territorial contacts
is included.
[[http://www.gucchdgeorgetown.net/NCCC/journey]{.underline}](http://www.gucchdgeorgetown.net/NCCC/journey)

**MCH Headlines Judy Thierry HQE**

**Oral Health for Head Start Children: Best Practices**

This 12 page document provides evidence-based approaches and
interventions to improve the oral health of Head Start children and
their families. The Best Practices are divided into three key points of
intervention;

-   pregnancy,

-   birth through two years, and

-   two years through five years of age.  

Readership should include: Head Start administration and staff, medical,
dental, and community health staff who will need to work together to
effectively improve the future oral health of American Indian and Alaska
Native children.   

IHS Head Start Program website:
[www.ihs.gov/nonmedicalprograms/headstart/](http://www.ihs.gov/nonmedicalprograms/headstart/)

You can also find current information and bulletins on oral health as it
relates to Head Start at the Head Start Bureau Learning Center at the
following website:  <http://www.eclkc.ohs.acf.hhs.gov/hslc>

**Safer infant sleep environment through crib giveaways and education**

Bedtime Basics for Babies is a national campaign designed to give
families both the equipment and the information they need to ensure a
safe sleep environment for infants. The Bedtime Basics campaign,
initially launched by First Candle in April 2007, builds on the success
of the national Back to Sleep campaign in reducing the risk of sudden
infant death, while also emphasizing other aspects of infant sleep
surroundings. In response to growing national concern about the number
of infants dying in unsafe sleep conditions, the Bill and Melinda Gates
Foundation recently awarded First Candle a multimillion-dollar grant to
combine two components: (1) a crib-distribution component for families
in need and at risk and (2) a public- and professional-education
component. During the 7-year initiative, First Candle will work with
public and private groups already involved with new parents and
infant-mortality prevention in the target states of Indiana and
Washington, as well as in the District of Columbia. A research team will
track families who receive cribs, information, and support on safe sleep
practices starting before their infant is born through the first year.
The team will also follow infant death patterns in the targeted states.
[[http://www.firstcandle.org/bedtimebasics]{.underline}](http://www.firstcandle.org/bedtimebasics)

**Alcohol Screening Brief Intervention: Cooperative Agreement
announcement by SAMHSA**

The IHS under the direction of Dr. David Boyd has disseminated ASBI
information to the IHS-Tribal hospital and EMS system.  Service Unit
"Champions" are developing local hospital ASBI programs.  Five Area
Office ASBI Train-The-Trainers (TTT) Conferences and several other local
and service unit TTT presentations have been conducted.  A funding
opportunity may open wide the door.  

 

CSAT Grant: Cooperative Agreements for Screening, Brief Intervention,
Referral, and Treatment (SBIRT)

Request for Applications (RFA) No. TI-08-001\
Posting on Grants.gov: November 27, 2007\
Receipt Date: January 31, 2008\
Announcement Type: Initial

The Substance Abuse and Mental Health Services Administration, Center
for Substance Abuse Treatment is accepting applications for fiscal year
(FY) 2008 for Cooperative Agreements for Screening, Brief Intervention,
Referral, and Treatment (SBIRT). The purpose of this program is to
expand and enhance state/tribal substance abuse treatment service
systems by:

Expanding the state's/tribe's continuum of care to include SBIRT in
general medical and other community settings (e.g., community health
centers, nursing homes, schools and student assistance programs,
occupational health clinics, hospitals, and emergency departments);

Supporting clinically appropriate services for persons at risk for, or
diagnosed with, a substance use disorder (i.e., substance abuse or
dependence). (Note: for the purpose of this RFA, "at risk" is defined as
persons who are using substances but who do not yet meet the criteria
for a diagnosis of substance use disorders); and

Identifying systems and policy changes to increase access to treatment
in generalist and specialist settings.

Proposals due 31 Jan 2008

Download the Complete Announcement No. TI-08-001:

<http://www.samhsa.gov/Grants/2008/ti_08_001.pdf>  

Please contact David Boyd for more information AND if your tribe is
planning to submit a proposal.

 

David R. Boyd MDCM, FACS

National Trauma Systems Coordinator

<David.Boyd@ihs.gov>

301-443-1557

**Child abduction Amber Alert Article**

A pdf version of the August 2007 article from The American Legion
Magazine which provides much space in its publications and web site for
its commitment to child issues is available upon request.  Written by
Marc Klaas whose daughter Polly was abducted and murdered in 1993 the
nonprofit KlaasKids Foundation's mission is to stop crimes against
children.  The 3 page article presents for a wide audience simple tips
-- what children can do, what custodians MUST do to responsibly protect
their children.  Readable, realistic and relevant in 2007 as in 1993 the
article focuses on basic public health assurances that neighborhoods,
parents, caregivers and providers can do.  Legislation is chronicled in
sufficient detail with clear examples -- California "Three Strikes...,"
Megan's Law and the Walsh Act.  There is no online version or link to
the publication without subscription.  <Judith.Thierry@ihs.gov>

**Childhood Obesity: AMA expert committee recommendations released**

The expert committee final papers on the assessment, prevention, and
treatment of childhood obesity in clinical settings are now available in
Pediatrics as supplements. I don\'t think the link is accessible outside
CDC because we have an e-subscription through library resources. You
should be able to access it here and if interested can download the
PDF\'s for each article.

(See Ask a Librarian, above, for more details)

<http://pediatrics.aappublications.org/content/vol120/Supplement_4/index.shtml>

#### Medical Mystery Tour {#medical-mystery-tour-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### What is the presenting part? {#what-is-the-presenting-part-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### You may recall we presented the case of a 20 year old gravida 4 para 1,0,2,1 at 40 2/7 weeks in active labor. The patient had had a 39 pound weight gain throughout her otherwise unremarkable prenatal care. The patient's obstetric history was significant for one previous vaginal delivery of a term 9 pound 15 ounce infant. Laboratory testing was essentially unremarkable. On admission the patient's exam was cephalic presentation, 4 cm dilation, -1 station. The cervix was soft and in a mid position. External fetal monitoring was reassuring. Sixty second contractions were noted every 5 minutes. {#you-may-recall-we-presented-the-case-of-a-20-year-old-gravida-4-para-1021-at-40-27-weeks-in-active-labor.-the-patient-had-had-a-39-pound-weight-gain-throughout-her-otherwise-unremarkable-prenatal-care.-the-patients-obstetric-history-was-significant-for-one-previous-vaginal-delivery-of-a-term-9-pound-15-ounce-infant.-laboratory-testing-was-essentially-unremarkable.-on-admission-the-patients-exam-was-cephalic-presentation-4-cm-dilation--1-station.-the-cervix-was-soft-and-in-a-mid-position.-external-fetal-monitoring-was-reassuring.-sixty-second-contractions-were-noted-every-5-minutes. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-15 .Style-Heading-4-+-Arial-14-pt-Underline}

#### At 01:30 the CNM noted that patient had progressed nicely in labor to 7 cm dilated and 100% effaced. The presenting part was still at -1 station. The membranes were intact. The CNM was unable to completely identify the presenting part. The FHR tracing was reassuring. The CNM noted that a suture line and fontanelle were palpable, but other tissue may have been present. The MD on call was asked to perform a bedside ultrasound to confirm the presenting part.  {#at-0130-the-cnm-noted-that-patient-had-progressed-nicely-in-labor-to-7-cm-dilated-and-100-effaced.-the-presenting-part-was-still-at--1-station.-the-membranes-were-intact.-the-cnm-was-unable-to-completely-identify-the-presenting-part.-the-fhr-tracing-was-reassuring.-the-cnm-noted-that-a-suture-line-and-fontanelle-were-palpable-but-other-tissue-may-have-been-present.-the-md-on-call-was-asked-to-perform-a-bedside-ultrasound-to-confirm-the-presenting-part. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-16 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The bedside ultrasound confirmed a cephalic presentation which was slightly oblique. The physician proceeded to perform a digital exam.  {#the-bedside-ultrasound-confirmed-a-cephalic-presentation-which-was-slightly-oblique.-the-physician-proceeded-to-perform-a-digital-exam. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-17 .Style-Heading-4-+-Arial-14-pt-Underline}

#### What did the physician find on digital exam? {#what-did-the-physician-find-on-digital-exam .Style-Heading-4-+-Arial-14-pt-Underline}

#### In the interim since the physician had been initially called, the patient's membranes had ruptured and the FHR remained reassuring. The physician noted several long loops of umbilical cord presenting. Otherwise the fetus was in cephalic presentation with complete cervical dilation and effacement. The CNM then elevated the fetus's head out of the pelvis with her hand and the patient was moved to the operative suite in an expeditious manner while in knee-chest position.  {#in-the-interim-since-the-physician-had-been-initially-called-the-patients-membranes-had-ruptured-and-the-fhr-remained-reassuring.-the-physician-noted-several-long-loops-of-umbilical-cord-presenting.-otherwise-the-fetus-was-in-cephalic-presentation-with-complete-cervical-dilation-and-effacement.-the-cnm-then-elevated-the-fetuss-head-out-of-the-pelvis-with-her-hand-and-the-patient-was-moved-to-the-operative-suite-in-an-expeditious-manner-while-in-knee-chest-position. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-18 .Style-Heading-4-+-Arial-14-pt-Underline}

#### As the obstetric team reached the OR table before the anesthesia team was ready and the patient was completely dilated, an attempt was made at funic reduction. This manuever was only successful for part of the prolapsed cord, but loops remained distal to the fetal skull. {#as-the-obstetric-team-reached-the-or-table-before-the-anesthesia-team-was-ready-and-the-patient-was-completely-dilated-an-attempt-was-made-at-funic-reduction.-this-manuever-was-only-successful-for-part-of-the-prolapsed-cord-but-loops-remained-distal-to-the-fetal-skull. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-19 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The maternal skin incision was made within 13 minutes of anesthesia's notification and the fetus was delivered within one minute as a Joel-Cohen technique was used. The infant female was delivered from an occiput posterior position and weighed 3450 g with Apgars of 8 and 9. At the time of surgery the cord was felt to be clinically 'long' plus had a true, but loose, knot with no proximal edema. A generous section of umbilical cord was obtained for possible cord gases.  {#the-maternal-skin-incision-was-made-within-13-minutes-of-anesthesias-notification-and-the-fetus-was-delivered-within-one-minute-as-a-joel-cohen-technique-was-used.-the-infant-female-was-delivered-from-an-occiput-posterior-position-and-weighed-3450-g-with-apgars-of-8-and-9.-at-the-time-of-surgery-the-cord-was-felt-to-be-clinically-long-plus-had-a-true-but-loose-knot-with-no-proximal-edema.-a-generous-section-of-umbilical-cord-was-obtained-for-possible-cord-gases. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-20 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The arterial pH was 7.17 with a base excess of -5.4. The venous pH was 7.23 with a base excess of -4.0. Of note, the arterial C02 was 70.5 (mmHg) (49.2 to 50.3) so some cord occlusion had begun shortly before delivery. {#the-arterial-ph-was-7.17-with-a-base-excess-of--5.4.-the-venous-ph-was-7.23-with-a-base-excess-of--4.0.-of-note-the-arterial-c02-was-70.5-mmhg-49.2-to-50.3-so-some-cord-occlusion-had-begun-shortly-before-delivery. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-21 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Examination of the placenta in the pathology department the next day revealed a somewhat eccentric umbilical cord insertion, 4 cm from the placental margin. Even after formalin fixation and not measuring the either portion of the umbilical cord sent for cord blood gases, nor the area remaining on the infant at surgery, the cord was still 53 cm. There was a true knot at 17 cm from the insertion. As you will see below the most accurate measurement of cord is actually done in the delivery suite, not after formalin fixation and other incisions for cord gases, etc\... {#examination-of-the-placenta-in-the-pathology-department-the-next-day-revealed-a-somewhat-eccentric-umbilical-cord-insertion-4-cm-from-the-placental-margin.-even-after-formalin-fixation-and-not-measuring-the-either-portion-of-the-umbilical-cord-sent-for-cord-blood-gases-nor-the-area-remaining-on-the-infant-at-surgery-the-cord-was-still-53-cm.-there-was-a-true-knot-at-17-cm-from-the-insertion.-as-you-will-see-below-the-most-accurate-measurement-of-cord-is-actually-done-in-the-delivery-suite-not-after-formalin-fixation-and-other-incisions-for-cord-gases-etc... .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-22 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Both the patient and her new daughter had unremarkable hospital courses for two days prior to discharge. {#both-the-patient-and-her-new-daughter-had-unremarkable-hospital-courses-for-two-days-prior-to-discharge. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-23 .Style-Heading-4-+-Arial-14-pt-Underline}

#### So, what was the presentation the CNM had noted? {#so-what-was-the-presentation-the-cnm-had-noted .Style-Heading-4-+-Arial-14-pt-Underline}

#### The patient had a funic presentation prior to SROM.  {#the-patient-had-a-funic-presentation-prior-to-srom. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-24 .Style-Heading-4-+-Arial-14-pt-Underline}

#### In this case there was so much cord that it essentially filled the pelvic outlet. By the time the physician performed a digital exam after SROM and the ultrasound exam, the patient had been in an unrecognized cord prolapse with reassuring FHRs for approximately 10-15 minutes. {#in-this-case-there-was-so-much-cord-that-it-essentially-filled-the-pelvic-outlet.-by-the-time-the-physician-performed-a-digital-exam-after-srom-and-the-ultrasound-exam-the-patient-had-been-in-an-unrecognized-cord-prolapse-with-reassuring-fhrs-for-approximately-10-15-minutes. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-25 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Long umbilical cord {#long-umbilical-cord .Style-Heading-4-+-Arial-14-pt-Underline}

Cord length increases with advancing gestational age. The average length
at term is 55 cm (22 inches), with a wide normal range (35 to 80 cm) (14
-- 32 inches) (Rayburn). The length should be noted and compared with
published standards (Table below). Umbilical cord accidents were most
frequent in the presence of a long cord (20 of 32 cases, 62%). In
addition, mothers with a history of an excessively long umbilical cords
are at increased risk of a second long cord.

The length measurement should include the portion of cord on the infant
after cord transection at delivery as well as the part remaining with
the placenta, thus it is best determined in the delivery room.

Cord length is determined in part by hereditary factors, but also by the
tension the fetus places on the cord when it moves. For this reason,
short cords are associated with fetal inactivity related to fetal
malformations, myopathic and neuropathic diseases, and oligohydramnios.
Long cords may be caused by a hyperactive fetus and have been associated
with cord accidents, such as entanglement, knotting, and prolapse
(Rayburn). Long cords are also associated with placental lesions
indicative of intrauterine hypoxia, as well as fetal death, fetal growth
restriction, and long term adverse neurologic outcome (Baergen)

Normal umbilical cord length

  ----------------------------------------- -----------------------------
  Gestation, weeks                          Length, cm

  20                                        32 +/- 9

  24                                        40 +/- 10

  28                                        45 +/- 10

  32                                        50 +/- 12

  36                                        56 +/- 13

  38                                        57 +/- 13

  40                                        60 +/- 13
  ----------------------------------------- -----------------------------

####  {#section-26 .Style-Heading-4-+-Arial-14-pt-Underline}

**Fetal malpresentation** --- Abnormal fetal presentation (breech,
transverse, or oblique lie) is consistently associated with a high risk
of UCP
\[[1,3-5](http://www.uptodateonline.com/utd/content/abstract.do?topicKey=labordel/2191&refNum=1,3-5)\].
In one review, the overall frequency of UCP in vertex, breech, and
transverse lies was 0.24, 3.5, and 9.6 percent, respectively. Footling
breech presentations carry a higher risk of UCP than other types of
breech presentation. However, the majority of UCPs occur with vertex
presentations because of the relatively low incidence of noncephalic
presentation.

**Knots** --- False knots are tortuosities of the umbilical vessels that
form bulges; they are not associated with any adverse outcome.

True knots occur in 1 percent of births and are generally single and
loose. However, tight or multiple true knots and knots associated with
coiling or twisting of the cord increase the risk of intrauterine
demise, particularly if the cord is long and during the second trimester
when the fetus has a lot of room to move. The medical record should
document the presence of a true knot, the tightness or laxity of the
knot, the presence of unilateral edema of the cord relative to the knot,
and whether there are thrombi in the vessels. A pathologist should
obtain a section through the knot for histologic examination. The
appropriate management of true knots identified by ultrasound
examination antepartum is unclear.

**MANAGEMENT: Umbilical cord prolapse**

Standard obstetric management of Umbilical cord prolapse (UCP) requires
prompt delivery to avoid fetal compromise or death from compression of
the cord between the presenting fetal part and the margin of the pelvic
inlet. We suggest cesarean delivery as the safest clinical course of
management for the viable fetus, especially in the first and early
second stages of labor. There are no data from prospective or randomized
studies on which to base recommendations because of the infrequent and
urgent nature of this problem.

Various preoperative maneuvers can be helpful to reduce pressure on the
cord:

**Funic decompression** --- This is the most common method to alleviate
cord compression. After diagnosis of UCP, the examiner\'s hand is
maintained in the vagina to elevate the presenting part off of the cord
while preparations for an emergency cesarean delivery are being made.
The patient can be placed in steep Trendelenburg or the knee-chest
position to try to move the fetus and further alleviate cord occlusion.
Manipulation of the cord and exposure to a cool environment may
exacerbate poor perfusion by inducing spasm of the cord vessels.

**Funic reduction** --- Funic reduction is a controversial approach to
the management of cord prolapse. It is employed to alleviate pressure on
the cord from the presenting part while preparations for cesarean
delivery are being made. This procedure involves lifting the fetal head
from the vagina and then digitally elevating the cord above the widest
part of the vertex so as to place it in the nuchal area. Gentle
suprapubic pressure can help with raising the fetal head and decreases
the chance of creating an oblique or transverse lie.

Funic reduction had been considered an appropriate initial step in
management of UCP, but was subsequently discarded in favor of cesarean
delivery because the procedure appeared to be associated with an
increase in intrapartum asphyxia and demise. However, this association
was observed prior to the advent of continuous fetal monitoring. With
use of continuous fetal monitoring, this technique may permit vaginal
delivery and avoid emergent cesarean delivery in some patients. This was
suggested by a small series of eight patients with UCP in which five
vaginal deliveries were achieved 14 to 512 minutes after a successful
funic reduction without anesthesia. The other three patients either
delivered vaginally shortly after the diagnosis of UCP or were delivered
by cesarean. All of the fetuses were in vertex presentation and had less
than 25 cm of cord prolapsing. There was no morbidity or mortality
reported. Thus, funic reduction in the setting of continuous fetal
monitoring can be considered a viable approach if vaginal delivery is
considered imminent or if cesarean delivery cannot be performed
immediately.

**Bladder filling** --- A temporizing technique involves insertion of a
Foley catheter into the maternal bladder immediately upon diagnosis of
UCP. The bladder is then rapidly filled with 500 to 700 milliliters of
normal saline with the patient in Trendelenburg position. The distended
bladder elevates the presenting part and keeps it off of the cord, thus
relieving the compression and potentially obviating the need for
prolonged vaginal digital decompression.

One series of 51 cases employed both a tocolytic (ritodrine) and bladder
filling to relieve cord compression. The mean interval from diagnosis to
delivery was 35 minutes and there were no fetal or neonatal deaths; the
majority of infants had Apgar scores
![](media/image8.png){width="8.333333333333333e-2in"
height="9.375e-2in"}7 at five minutes. Tocolytic use in this series was
not associated with postpartum uterine atony or hemorrhage. Thus, the
technique of bladder filling may be a useful approach, particularly when
immediate cesarean delivery is not possible.

**Delivery** --- There are few data regarding attempted vaginal delivery
in the setting of UCP. Successful operative vaginal delivery with vacuum
or forceps has been reported when cesarean delivery could not be
performed immediately.

Despite these case reports, immediate cesarean delivery remains the
optimal mode of delivery. While preparations are being made for cesarean
delivery, it is important to ensure adequate intrauterine resuscitation
by changing maternal position, cord decompression by funic decompression
or bladder distention, and tocolysis, where appropriate.

**Resources:**

Rayburn WF; Beynen A; Brinkman DL Umbilical cord length and intrapartum
complications. Obstet Gynecol. 1981 Apr;57(4):450-2.

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=7243092**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=7243092) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch7243092 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-28 .Style-Heading-4-+-Arial-14-pt-Underline}

Baergen RN; Malicki D; Behling C; Benirschke K Morbidity, mortality, and
placental pathology in excessively long umbilical cords: retrospective
study.Pediatr Dev Pathol. 2001 Mar-Apr;4(2):144-53.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11178630>

####  {#section-29 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Umbilical cord prolapse, UpToDate software {#umbilical-cord-prolapse-uptodate-software .Style-Heading-4-+-Arial-14-pt-Underline}

#### [http://www.uptodateonline.com/utd/content/topic.do?topicKey=labordel/2191&selectedTitle=2\~150&source=search_result]{.underline} {#httpwww.uptodateonline.comutdcontenttopic.dotopickeylabordel2191selectedtitle2150sourcesearch_result .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-30 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Gross examination of the placenta, UpToDate software {#gross-examination-of-the-placenta-uptodate-software .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/utd/content/topic.do?topicKey=fet_phys/2144**](http://www.uptodateonline.com/utd/content/topic.do?topicKey=fet_phys/2144) {#httpwww.uptodateonline.comutdcontenttopic.dotopickeyfet_phys2144 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-31 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Umbilical cord blood acid-base analysis, UpToDate software {#umbilical-cord-blood-acid-base-analysis-uptodate-software .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/utd/content/topic.do?topicKey=labordel/11115&selectedTitle=2\~150&source=search_result**](http://www.uptodateonline.com/utd/content/topic.do?topicKey=labordel/11115&selectedTitle=2~150&source=search_result) {#httpwww.uptodateonline.comutdcontenttopic.dotopickeylabordel11115selectedtitle2150sourcesearch_result .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-32 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape\* {#medscape-1 .Style-Heading-4-+-Arial-14-pt-Underline}

######### Making Sense of the Complex: A Point of Care Approach to Managing Chronic Pelvic Pain / Interstitial Cystitis [**http://www.medscape.com/viewarticle/566953**](http://www.medscape.com/viewarticle/566953)

**Management of Premenstrual Dysphoric Disorder Throughout the Ages: A
Series of Interactive Cases**
<http://www.medscape.com/viewarticle/558957>

**Commonly Administered Vaccines and Associated Illnesses**

<http://www.medscape.com/viewarticle/566528>

**Understanding Triglycerides: Beyond LDL Cholesterol**

<http://www.medscape.com/viewarticle/566766>

######### Ask the Experts topics in Women\'s Health and OB/GYN Index, by specialty, Medscape

######### [**http://www.medscape.com/pages/editorial/public/ate/index-womenshealth**](http://www.medscape.com/pages/editorial/public/ate/index-womenshealth)

#########  {#section-33}

######### OB GYN & Women\'s Health Clinical Discussion Board Index, Medscape

<http://boards.medscape.com/forums?14@@.ee6e57b>

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

<http://boards.medscape.com/forums?14@@.ee6e57b>

**Free CME: MedScape CME Index by specialty**

<http://www.medscape.com/cmecenterdirectory/Default>

\*NB: Medscape is free to all, but registration is required. It can be
accessed from anywhere with Internet access. You just need to create a
personal username and password.

**Menopause Management**

Treating Sexual Difficulties in Menopause

**Background:** Women often experience changes in sexual function after
menopause. Although changes in desire are not inevitable, postmenopausal
women consistently experience a decrease in arousal, manifested by
decreases in genital perfusion, engorgement, vaginal lubrication, and
response to touch and vibration. Many also experience a decrease in the
intensity of orgasm.

In addition to the physiologic changes that occur during menopause (most
likely because of a drop in estrogen), psychological factors and
expectations may also play a role in sexual satisfaction.
Iatrogenically, surgical treatment of stress incontinence and
hysterectomy have variable effects on sexual function, depending on
preoperative factors and surgical technique. Atherosclerosis and
hyperglycemia can impair sexual function in women, as can certain
medications, such as selective serotonin reuptake inhibitors and
dopamine receptor blockers.

**Recommendations:** Evaluation should include a comprehensive medical,
sexual, and psychosocial history. A genital examination should include
evaluation of resting pelvic floor muscle tone and voluntary vaginal and
anal sphincter tone. Laboratory testing such as testosterone measurement
is not indicated. However, targeted testing is appropriate for suspected
disorders.

Treatment addressing sexual complaints should take into account the
importance of sex to the patient. Other treatment recommendations
include addressing unrealistic expectations, using lubricants, and
creating romantic environments. Sex therapy can be helpful for
psychological problems.

Estrogen improves vaginal lubrication and may improve orgasm. Although
high doses of estrogen can achieve central effects that are more broadly
beneficial to sexual function, the progesterone required for endometrial
protection negates many of these benefits. If estrogens are used in
patients who have an intact uterus and no risk factors, transdermal
formulations should be prescribed, because oral estrogens increase
sex-hormone binding globulin and decrease desire. Vaginal estrogen
increases lubrication, may increase vasocongestion, and is safer than
systemic estrogen, but long-term use should be avoided. Combination
estrogen/testosterone increases sexual desire and responsiveness but
lowers high-density lipoprotein cholesterol levels. Using a testosterone
patch may avoid this adverse effect and, in combination with systemic
estrogen, may improve the number of satisfying sexual episodes.

Other medications that may be helpful include bupropion (Wellbutrin) and
phosphodiesterase inhibitors. Bupropion may increase arousal and orgasm
completion. Phosphodiesterase inhibitors increase genital perfusion but
have no significant effect on arousal. A subgroup of women taking
phosphodiesterase inhibitors had improved overall satisfaction with
changes in vaginal lubrication, genital sensation, and ability to
achieve orgasm. The same cautions that apply to men in the use of these
agents are relevant to women.

Several mechanical devices are available. Vibrators supply
high-intensity, direct clitoral stimulation. A hand-held vacuum pump
also increases clitoral blood flow and has been shown to increase sexual
satisfaction. Some data suggest that pelvic floor exercises can be
beneficial and can decrease sexual incontinence. New products to improve
desire-including androgen delivery systems and dopamine agonists-as well
as agents targeting genital arousal are currently in development.

Potter JE. Clinical crossroads. A 60-year-old woman with sexual
difficulties. JAMA February 14, 2007;297:620-33.
<http://www.aafp.org/afp/20071201/tips/3.html>

####  {#section-34 .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**, **Lisa Allee, CNM, Chinle**

**ACNM seeks Midwifery Expertise on an as-needed basis**

Dear Colleague,

As the ACNM grows in size and stature, we receive an increasing number
of invitations to be present at meetings and events.   For instance, the
ACNM was recently asked to send a representative to a meeting organized
by the Gynecologic Cancer Foundation to discuss a public education
campaign regarding HPV and the new vaccines.

These meetings vary in length from an hour or two to a couple of days,
usually on weekdays, and are generally held in DC and the surrounding
area.  Sometimes we merely gather information and write a brief report;
at other meetings, we provide basic information about midwives and
midwifery practice; sometimes our goal is to advance a particular
agenda.

With limited CNM staff in Professional Services, we cannot always have a
staff member attend.  We have been fortunate to have a cadre of willing
and able local midwives on whom we can call.  (Many of you responded to
a similar call for help 10 years ago!)  We know, however, that the
growing pool of local midwives must contain other willing and able
members on whom we have not yet called.

So, we are asking your help.  If you are willing to represent ACNM at a
meeting or event, probably not more than once per year, please complete
the [online
form](http://www.magnetmail1.net/ls.cfm?r=101712213&sid=3145699&m=400881&u=ACNM&s=http://www.midwife.org/volunteer_application_form.cfm).  
When were offered a seat at the table, and need a CNM to fill it, we
will use the information to contact you.    We will provide whatever
background material, ACNM Position Statements, etc. that might be
relevant and, depending on the event, there may be reimbursement for
expenses.

If you have represented the ACNM in the past, please accept our thanks. 
If you wish to continue to be available, please provide updated
information by using the [online
form](http://www.magnetmail1.net/ls.cfm?r=101712213&sid=3146879&m=400881&u=ACNM&s=http://www.midwife.org/volunteer_application_form.cfm). 
If you have questions, you can reach us at 240-485-1840 or via e-mail.

Sincerely,

Lisa Summers, CNM, DrPH, FACNM\
Director of Professional Services \
[lsummers@acnm.org](../mailtlsummers@acnm.org)   

**Navajo News** **Jean Howe, Chinle**

**Informed Refusal, Leaving Against Medical Advice, and Asking
Questions**

A recent article in the "Clinical Practice" series of the New England
Journal of Medicine addresses the assessment of patient's competence to
consent to (and decline) treatment. This series uses a case vignette and
discussion to address common clinical problems. In this case, a 75 year
old woman with type II diabetes, peripheral vascular disease, and a
gangrenous foot ulcer who refuses a recommended amputation is described.
The patient states that she "prefers to die with her body intact" and
the provider is concerned about apparent increasing confusion and
possible depression limiting her ability to provide informed consent.
Legally relevant criteria for evaluating decision-making capacity are
outlined for the patient's tasks of communicating a choice,
understanding the relevant information, appreciating the situation and
its consequences, and reasoning about treatment options. Approaches to
assessment and the consequences of a finding of incompetence are
reviewed. The lack of formal practice guidelines for assessment of
competence to consent is highlighted.

Refusal of treatment is also the focus of an overview of hospital
discharge "against medical advice" in this month's American Journal of
Public Health. This database audit of over 3 million discharges from
U.S. non-federal acute care hospitals identified a rate of 1 in 70
(1.44%) of "self-discharges". Higher rates were associated with young
age, male gender, African American race, and low socio-economic status.
Because this study is a database review only, no information is
available on the reasons for AMA discharge. The authors discuss possible
reasons, including frustration with administrative delays in the
discharge process, pressing domestic or social concerns, and
disagreement with their physician's assessment of their health status.
They also discuss the public health significance of these discharges and
the importance of addressing shortcomings of the health care system that
may place underserved patients at higher risk for this event.

Meanwhile, the Agency for HealthCare Research and Quality is launching a
campaign called "Questions are the Answer" encouraging patients to ask
questions about their healthcare as a safety measure and in an effort to
improve overall health through greater understanding and ownership of
health care decisions. Their sample questions for patients and more
information about this campaign, including video clips of singing and
dancing health care workers are available at the AHRQ website.

I happened to encounter all three of these articles/information on the
same day and was struck by the increased attention to patient autonomy
and recognition that medical advice may be rejected, ignored, or poorly
understood. We, as healthcare providers, have an ongoing duty to
encourage our patients' understanding and ownership of their health and
their right to make informed decisions about their care. Vulnerable
groups may benefit from additional attention to their needs, whether for
respectful assessment of decision-making capacity or for culturally
appropriate hospital care that minimizes the risks of "self-discharge".
I'm not sure if the singing health care workers in the AHRQ videos will
help but we must continue our efforts to welcome, encourage, and respect
our patients' efforts to make truly informed health care decisions.

**Resources:**

Paul S. Appelbaum, Clinical practice. Assessment of patients\'
competence to consent to treatment, N Engl J Med. 2007 Nov
1;357(18):1834-40

[http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17978292]{.underline}

Said A. Ibrahim, C. Kent Kwoh, and Eswar Krishnan, Factors Associated
With Patients Who Leave Acute-Care Hospitals Against Medical Advice, Am
J Public Health 2007 97: 2204-2208, 10.2105/AJPH.2006.100164

<http://www.ajph.org/cgi/content/abstract/97/12/2204>

AHRQ

<http://www.ahrq.gov/questionsaretheanswer/index.html>

####  {#section-35 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [CCC Editorial comment:]{.underline}

#### What are the elements of a patient decision making? {#what-are-the-elements-of-a-patient-decision-making .Style-Heading-4-+-Arial-14-pt-Underline}

#### This is a very timely topic as ACOG has just released the three Committee Opinions below that relate to a patient's decision making process. We need to have made all efforts possible to assure that the decision is informed, on the patient's actual educational level, as well as ethical. Please also note this month's Abstact of the Month and Dr. Weiss's comments on Health Literacy, above. {#this-is-a-very-timely-topic-as-acog-has-just-released-the-three-committee-opinions-below-that-relate-to-a-patients-decision-making-process.-we-need-to-have-made-all-efforts-possible-to-assure-that-the-decision-is-informed-on-the-patients-actual-educational-level-as-well-as-ethical.-please-also-note-this-months-abstact-of-the-month-and-dr.-weisss-comments-on-health-literacy-above. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-36 .Style-Heading-4-+-Arial-14-pt-Underline}

#### ACOG {#acog .Style-Heading-4-+-Arial-14-pt-Underline}

#### Health Literacy. ACOG Committee Opinion no. 391. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1489-91. {#health-literacy.-acog-committee-opinion-no.-391.-american-college-of-obstetricians-and-gynecologists.-obstet-gynecol-20071101489-91. .Style-Heading-4-+-Arial-14-pt-Underline}

#### **http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055753** {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch18055753 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-37 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Limits of Conscientious Refusal in Reproductive Medicine ACOG Committee Opinion no. 385. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1203-8. {#the-limits-of-conscientious-refusal-in-reproductive-medicine-acog-committee-opinion-no.-385.-american-college-of-obstetricians-and-gynecologists.-obstet-gynecol-20071101203-8. .Style-Heading-4-+-Arial-14-pt-Underline}

#### **http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055753** {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch18055753-1 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-38 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Ethical Decision Making in Obstetrics and Gynecology\*. ACOG Committee Opinion no. 390. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1479-87. {#ethical-decision-making-in-obstetrics-and-gynecology.-acog-committee-opinion-no.-390.-american-college-of-obstetricians-and-gynecologists.-obstet-gynecol-20071101479-87. .Style-Heading-4-+-Arial-14-pt-Underline}

#### **http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055752** {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch18055752 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-39 .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner, Sandra Haldane, HQE**

**Scope of Practice and the Nurse Practitioner: Regulation, Competency,
Expansion, and Evolution**

\"I\'m an NP \-- can I work as an RN? As an acute care NP, can I work in
primary care? I\'m prepared as an adult NP \-- can I see children too?\"
Learn the answers to these questions and many more.
<http://www.medscape.com/viewarticle/506277>

**Overweight Children and Adolescents** - **National Association of
School Nurses**

POSITION STATEMENT:\
Abstract.  The fastest rising public health problem in our nation is
obesity, second only to tobacco use. Over the last two decades the
percentage of overweight children has almost doubled and the percentage
of overweight adolescents has almost tripled. Currently, in the United
States, 13% of children 6 to 11 years of age and 14% of teens 12 to 19
years of age are categorized as overweight (NCHS, CDC 2001; USDHHS,
2000).\
\
Healthy People 2010 (USDHHS, 2000) identifies specific goals to reduce
the prevalence of overweight and obesity. Since most children spend a
large portion of their day at school, the school can become a key
setting in which to implement strategies to address this issue. The
school nurse has the capacity to reach a large number of youth from
varied backgrounds. The school can provide a healthy environment that
supports balanced nutrition and activity.

ACTIONS:

• assisting students in developing good decision-making skills related
to nutrition and in establishing activity patterns to maintain normal
body mass indices throughout their lives

• educating students, faculty, and parents on the following:

•           the importance of positive role modeling

•           dietary guidelines that promote balanced meals low in
dietary fat

•           the need for 60 minutes of physical activity daily

•           the potential negative influence of inactivity

•           reading and interpreting dietary information on food
products

•           relating dietary guidelines to food preparation

• educating coaches on the importance of proper nutrition on the
athletes' peak performance

• initiating school policies that provide for a healthy school
environment, policies that relate to:

•           school breakfast and lunch programs

•           vending machines

•           prevention of discrimination or abuse toward overweight
youth

•           school-based counseling

•           health promotion for school staff

•           supporting families as they assist their children to achieve
and/ or maintain a healthy BMI

•           encouraging acceptance of body type that has been inherited,
individual diversity, and a positive self-image

• identifying students who are overweight and educating and encouraging
these students to find and use acceptable weight loss programs

• implementing and managing school-based weight reduction programs

• providing community-based referral sources, as appropriate

• supporting students in understanding that once weight loss is
achieved, the changes must be continued throughout their lives to
maintain their healthier weight

• advocating for daily physical education for all grades

<http://www.nasn.org/Portals/0/positions/2002psoverweight.pdf>

####  {#section-40 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Office of Women's Health, CDC {#office-of-womens-health-cdc-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Cancer in American Indians and Alaska Natives**

Annual Report to the Nation on the Status of Cancer, 1975-2004

A new report, Annual Report to the Nation on the Status of Cancer,
1975-2004, Featuring Cancer in American Indians and Alaska Natives,
shows cancer death rates decreased on average 2.1 percent per year from
2002 through 2004, nearly twice the annual decrease of 1.1 percent per
year from 1993 through 2002. Declines were observed in the incidence of
lung cancer in men, colorectal cancer in men and women, and in breast
cancer incidence in women from 2001 through 2004. For women, incidence
rates for all cancers combined stabilized from 1999 through 2004 after
years of increases. Death rates among women decreased for 10 of the 15
most common cancers. The American Cancer Society, the National Cancer
Institute, CDC, and the North American Association of Central Cancer
Registries collaborate to provide this annual update on cancer
occurrence and trends in the United States.

<http://www.cdc.gov/Features/CancerReport/>

**Vaccination of Pregnant Women (2007 Update)**

Risk to a developing fetus from vaccination of the mother during
pregnancy is primarily theoretical. No evidence exists of risk from
vaccinating pregnant women with inactivated virus or bacterial vaccines
or toxoids. Live vaccines pose a theoretical risk to the fetus. Benefits
of vaccinating pregnant women usually outweigh potential risks when the
likelihood of disease exposure is high, when infection would pose a risk
to the mother or fetus, and when the vaccine is unlikely to cause harm.
  <http://www.cdc.gov/vaccines/pubs/preg-guide.htm>

####  {#section-41 .Style-Heading-4-+-Arial-14-pt-Underline}

#### ACIP Releases 2007-08 Adult Immunization Schedule {#acip-releases-2007-08-adult-immunization-schedule-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### *Morbidity and Mortality Weekly Report,* October 19, 2007 {#morbidity-and-mortality-weekly-report-october-19-2007 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641-Immunizationa1.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641-Immunizationa1.htm) {#httpwww.cdc.govmmwrpreviewmmwrhtmlmm5641-immunizationa1.htm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-42 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Oklahoma Perspective Greggory Woitte -- Hastings Indian Medical Center {#oklahoma-perspective-greggory-woitte-hastings-indian-medical-center .Style-Heading-4-+-Arial-14-pt-Underline}

**Methicillin-resistant Staphylococcus aureus in women's health**

Methicillin-resistant Staphylococcus aureus (MRSA) has become a hot
topic in the media recently. In October, the CDC released a report that
there was 18,650 deaths from MRSA in 2005. This was more than the number
of deaths due to AIDS in the same year. MRSA has been a well known
superbug in Hospitals for years. MRSA has been a growing problem due to
its resistance to many common antibiotics including beta lactam
antibiotics including methicillin. While most invansive MRSA infections
can still be traced to hospital exposure, approximately 15% of invasive
infections are occurring in individuals with no known health care risk.
These infections are primarily occurring in people over the age of 65
and 2/3 of infections that can be traced back to a health care exposure
occur in patients that are no longer hospitalized.

<http://www.webmd.com/news/20071016/more-us-deaths-from-mrsa-than-aids?src=rss_psychtoday>

As I am sitting her writing this and watching the football game, a
report came on the TV about two High School students who are recovering
from the Superbug. What can we as women's health providers do? Start
with the basics that we learned in medical school. Wash your hands, Wash
your hands, Wash your hands. The use of appropriate hand washing or the
use of alcohol based rubs have been shown to decrease hospital
infections, but compliance rates are rarely 100%. Next, use the right
antibiotic for the appropriate infection. The days of shot gunning
antibiotics can no longer be tolerated. The use of prophylactic
antibiotics for surgeries or obstetrical procedures should comply with
ACOG recommendations.

Even with diligent hand washing, and appropriate use of antibiotics,
there will still be MRSA infections. Here at Hastings Indian Medical
Center, we are fortunate to have Dr. Greg Felzien, a board certified
Infectious Disease specialist, however I have included a list of
treatment recommendations that was July 2006 ACOG Green Journal and
reprinted from The Medical Letter for community acquired MRSA
infections. In addition, a high index of suspicion is important, culture
all wounds that open or that you opened. This includes all seromas,
hematomas, as well as all obvious infected wounds.

As the media continues to pick up and publicize MRSA infections, you can
educate your patients with handouts from the CDC at this website:
<http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_posters.html>

**Treatment Recommendations**

<http://www.greenjournal.org/cgi/reprint/108/1/198>

**ACOG Practice Bulletin #47 October 2003 - Prophylactic Antibiotics in
Labor and Delivery**

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=14551023>

**ACOG Practice Bulletin No. 80: Premature Rupture of Membranes.
Clinical management guidelines for obstetrician-gynecologists**

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17400872>

**ACOG Practice Bulletin #74 July 2006 --Prophylactic Antibiotics in
Gynecological Procedures**

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16816087>

#### Osteoporosis {#osteoporosis .Style-Heading-4-+-Arial-14-pt-Underline}

**Effects of Steroidal and Nonsteroidal Aromatase Inhibitors on Markers
of Bone Turnover in Healthy Postmenopausal Women**

CONCLUSION: Exemestane increased serum levels of the bone-formation
marker PINP after 24 weeks, suggesting a specific bone-formation effect
related to its androgenic structure. Potential effects on cortical bone
and reduced fracture risk must be verified in a comparative clinical
trial.

[Goss
PE](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Goss PE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Effects of steroidal and nonsteroidal aromatase inhibitors on
markers of bone turnover in healthy postmenopausal women.

Breast Cancer Res. 2007 Aug 10;9(4):R52

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17692126>

#### Patient Information {#patient-information .Style-Heading-4-+-Arial-14-pt-Underline}

#### Assessing Health Literacy in Clinical Practice {#assessing-health-literacy-in-clinical-practice-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/566053**](http://www.medscape.com/viewarticle/566053) {#httpwww.medscape.comviewarticle566053 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-43 .Style-Heading-4-+-Arial-14-pt-Underline}

**Pregnant or Thinking About Getting Pregnant?**

These tips can help you prevent infections that could harm your unborn
baby. You won't always know if you have an infection - sometimes you
won't even feel sick. If you think you might have an infection or think
you are at risk, see your doctor.

<http://www.cdc.gov/ncbddd/pregnancy_gateway/infection.htm>

####  {#section-44 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Pregnancy Loss: What You Should Know {#pregnancy-loss-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20071101/1347ph.html**](http://www.aafp.org/afp/20071101/1347ph.html) {#httpwww.aafp.orgafp200711011347ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-45 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Caring for Your Premature Baby {#caring-for-your-premature-baby-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20071015/1165ph.html**](http://www.aafp.org/afp/20071015/1165ph.html) {#httpwww.aafp.orgafp200710151165ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-46 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Meth Abuse: What You Should Know {#meth-abuse-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20071015/1175ph.html**](http://www.aafp.org/afp/20071015/1175ph.html) {#httpwww.aafp.orgafp200710151175ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-47 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Perinatology Picks George Gilson, MFM, ANMC {#perinatology-picks-george-gilson-mfm-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

**Less errors with more standardization of corticosteroid regimens**

**Repeat doses of corticosteroids reduces neonatal morbidity at 2 years
of age**

CONCLUSIONS: Administration of repeat doses of antenatal corticosteroids
reduces neonatal morbidity without changing either survival free of
major neurosensory disability or body size at 2 years of age

[Crowther
CA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Crowther CA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Outcomes at 2 years of age after repeat doses of antenatal
corticosteroids. N Engl J Med. 2007 Sep 20;357(12):1179-89

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17881750>

and

**Repeat vs single dose corticosteroids did not differ significantly,
except NS cerebral palsy**

CONCLUSIONS: Children who had been exposed to repeat as compared with
single courses of antenatal corticosteroids did not differ significantly
in physical or neurocognitive measures. Although the difference was not
statistically significant, the higher rate of cerebral palsy among
children who had been exposed to repeat doses of corticosteroids is of
concern and warrants further study.

[Wapner
RJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wapner RJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Long-term outcomes after repeat doses of antenatal
corticosteroids.

N Engl J Med. 2007 Sep 20;357(12):1190-8.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17881751>

#### [Editorial comment: George Gilson,MFM]{.underline}

**Less errors with more standardization of corticosteroid regimens**

It would probably be good if we all standardized our use of antenatal
corticosteroids for fetal lung maturation. I have seen various regimens
being used, but the one below is the one recommended by ACOG on the
basis of the available evidence. Steroids are given over a 48 hour
interval. Their maximum effect is maintained for 7 days, although a
lesser, but still significant, effect is seen for a considerably longer
interval. Giving the doses at closer intervals will not speed up the
fetal lung maturation process, even though you think the baby needs to
deliver sooner than later!

 

Betamethasone 12 mg IM x2 at 24 hour intervals -or-

Dexamethasone 6 mg IM x4 at 12 hour intervals

 

Steroids are appropriate between 24 and 34 weeks gestation (some
authorities would restrict their use to 32 weeks or less in women with
PPROM). There is no consensus on whether betamethasone or dexamethasone
is better, so either regimen is fine. Steroids should ideally only be
given once, so you should carefully consider if they are really needed
at the time. (One \"rescue\" dose later, while not recommended, has not
been associated with significant adverse neonatal effects, and is also
acceptable on an individualized basis.)

 

**Reference:**

Antenatal corticosteroid therapy for fetal maturation. ACOG Committee
Opinion No. 273. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2002;99:871-873

[http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12197491]{.underline}

**NEJM Comment**

[Stiles
AD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Stiles AD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Prenatal corticosteroids\--early gain, long-term questions. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Sep
20;357(12):1248-50

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17881757>

**Conservative checklist protocol for oxytocin: improves maternal and
newborn outcomes**

CONCLUSION: Implementation of a specific and conservative
checklist-based protocol for oxytocin infusion based on maternal and
fetal response results in a significant reduction in maximum infusion
rates of oxytocin without lengthening labor or increasing operative
intervention. Cesarean delivery rate declined system-wide following
implementation of this protocol. Newborn outcome also appears to be
improved.

[Clark
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Clark S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Implementation of a conservative checklist-based protocol for
oxytocin administration: maternal and newborn outcomes. Am J Obstet
Gynecol. 2007 Nov;197(5):480

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17980181>

**Does the dose of oxytocin affect uterine rupture in candidates for
VBAC?**

Results

Of the 13,523 patients who elected a VBAC trial, 128 women experienced a
uterine rupture; 80 of these ruptures were in women who received
oxytocin (62.5%). There was evidence of "dose response" for maximum
oxytocin amount and uterine rupture, with a uterine rupture rate of 2.07
% (adjusted odds ratio, 2.98; 95% CI 1.51-5.90) at the highest dosages.

Conclusion

In VBAC attempts, a dose-response relationship of maximum oxytocin and
uterine rupture exists. These results provide evidence for vigilance
when higher doses of oxytocin are given to patients who attempt VBAC.

[Cahill
AG](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Cahill AG"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Does a maximum dose of oxytocin affect risk for uterine rupture in
candidates for vaginal birth after cesarean delivery? Am J Obstet
Gynecol. 2007 Nov;197(5):495

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17714683>

**Terbutaline provided more tocolysis with less impact on BP than NTG in
resuscitation**

CONCLUSION: Although terbutaline provided more effective tocolysis with
less impact on maternal blood pressure, no difference was noted between
nitroglycerin and terbutaline in successful acute intrapartum fetal
resuscitation.

[Pullen
KM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Pullen KM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Randomized comparison of intravenous terbutaline vs nitroglycerin
for acute intrapartum fetal resuscitation. Am J Obstet Gynecol. 2007
Oct;197(4):414

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904983>

**Exam-indicated cerclage prolongs gestation / improves survival vs
expectant management**

CONCLUSION: In this study, the largest cohort reported to date, physical
examination-indicated cerclage appears to prolong gestation and improve
neonatal survival, compared with expectant management in selected women
with cervical dilation between 14(0/7) and 25(6/7) weeks. A randomized,
controlled trial should be conducted to determine whether these
potential benefits outweigh the risks of cerclage placement in this
population.

[Pereira
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Pereira L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Expectant management compared with physical examination-indicated
cerclage (EM-PEC) in selected women with a dilated cervix at
14(0/7)-25(6/7) weeks: results from the EM-PEC international cohort
study. Am J Obstet Gynecol. 2007 Nov;197(5):483

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17980182>

**Mid-pregnancy cytokines in predicting spontaneous preterm delivery
appears limited**

CONCLUSION: Elevated mid-pregnancy plasma IL-2, TNF-alpha, and GM-CSF
did not appear to be associated with an increased risk of spontaneous
preterm delivery, while elevated IFN-gamma and IL-6 levels were weakly
associated with moderate and late spontaneous preterm delivery. The
value of using mid-pregnancy cytokines in predicting spontaneous preterm
delivery appears limited.

[Curry
AE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Curry AE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Mid-pregnancy maternal plasma levels of interleukin 2, 6, and 12,
tumor necrosis factor-alpha, interferon-gamma, and
granulocyte-macrophage colony-stimulating factor and spontaneous preterm
delivery. Acta Obstet Gynecol Scand. 2007;86(9):1103-10

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17712652>

**Colonization with specific microbes interacted with antibiotics to
increase preterm birth**

CONCLUSION: Neither baseline endometrial microbial colonization nor
plasma cell endometritis were risk factors for adverse pregnancy
outcome. However, colonization with specific microbes interacted with
antibiotics to increase adverse outcomes.

[Tita
AT](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tita AT"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Clinical trial of interconceptional antibiotics to prevent preterm
birth: subgroup analyses and possible adverse antibiotic-microbial
interaction. Am J Obstet Gynecol. 2007 Oct;197(4):367

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904962>

**Cardiotocography with ST-segment analysis not associated with less
operative deliveries**

CONCLUSION: In a population with abnormal cardiotocography in labor,
cardiotocography combined with ST-segment analysis was not associated
with a reduction in operative deliveries for nonreassuring fetal status.
The proportion of infants without scalp pH sampling during labor
increased substantially, however.

[Vayssière
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Vayssière C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al A French randomized controlled trial of ST-segment analysis in a
population with abnormal cardiotocograms during labor. Am J Obstet
Gynecol. 2007 Sep;197(3):299

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17826428>

#### Primary Care Discussion Forum Ann Bullock, Cherokee, NC {#primary-care-discussion-forum-ann-bullock-cherokee-nc .Style-Heading-4-+-Arial-14-pt-Underline}

#### Traditional AI/AN Medicine: Incorporating Into I/T/U Clincial Practice

#### Ongoing now

Moderator: Theresa Maresca, M.D., University of Washington School of
Medicine

-   What are the pros and cons of asking my patients about their
    traditional medicine use?

-   How do I learn more about what traditional practices are common in
    my area?

-   What specific strategies can be used to ask my patients
    diplomatically about their traditional medicine views?

-   Where can I find resources about plant medicine?

-   Is there a \"right way\" to work collaboratively with a traditional
    healer?

-   What if I do not agree with my patient\'s views of traditional
    medicine

### How to subscribe / unsubscribe to the Primary Care Discussion Forum?

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

Questions on how to subscribe, contact <nmurphy@scf.cc> directly

**STD Corner, Lori de Ravello, National IHS STD Program**

Screening for Chlamydial Infection: Recommendation Statement, USPSTF

Summary of Recommendations and Evidence

The USPSTF recommends screening for chlamydial infection in all sexually
active, nonpregnant women 24 years or younger and in older nonpregnant
women who are at increased risk. **A recommendation.**

The USPSTF recommends screening for chlamydial infection in all pregnant
women 24 years or younger and in older pregnant women who are at
increased risk. **B recommendation.**

The USPSTF recommends against routinely providing screening for
chlamydial infection in women 25 years or older, whether or not they are
pregnant, if they are not at increased risk. **C recommendation.**

The USPSTF concludes that the current evidence is insufficient to assess
the balance of benefits and harms of screening for chlamydial infection
in men. **I statement.**

#### Meyers D, Halvorson H, Luckhaupt S. Screening for chlamydial infection: a focused evidence update for the U.S. Preventive Services Task Force. Evidence synthesis no. 48. Rockville, Md.: Agency for Healthcare Research and Quality.  {#meyers-d-halvorson-h-luckhaupt-s.-screening-for-chlamydial-infection-a-focused-evidence-update-for-the-u.s.-preventive-services-task-force.-evidence-synthesis-no.-48.-rockville-md.-agency-for-healthcare-research-and-quality. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ahrq.gov/clinic/uspstf07/chlamydia/chlamydiasyn.pdf**](http://www.ahrq.gov/clinic/uspstf07/chlamydia/chlamydiasyn.pdf) {#httpwww.ahrq.govclinicuspstf07chlamydiachlamydiasyn.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-48 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Barbara Stillwater Alaska State Diabetes Program  {#barbara-stillwater-alaska-state-diabetes-program .Style-Heading-4-+-Arial-14-pt-Underline}

#### Family History more relevant to risk of GDM in nulliparous women than in parous subjects {#family-history-more-relevant-to-risk-of-gdm-in-nulliparous-women-than-in-parous-subjects-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: There were no significant differences between the two groups in ethnicity, prepregnancy BMI, the insulin-sensitizing protein adiponectin, glucose tolerance status and area-under-the-glucose-curve (AUC(gluc)). In women with Familial history of type 2 diabetes (FHD), a multiple linear regression model of established GDM risk factors reconciled 35% of the variance in AUC(gluc), with (i) previous GDM (t = 3.74, P = 0.0003) identified as a positive independent determinant and (ii) log adiponectin (t = -3.48, P = 0.0008) and, unexpectedly, parity (t = -3.19, P = 0.0021) emerging as negative independent covariates of AUC(gluc). In contrast, in women without FHD, the same multivariate model reconciled only 15% of the variance in AUC(gluc), with no significant variables identified. Interestingly, in the entire population (n = 173), parity significantly modified the relationship between FHD and AUC(gluc) (FHD-parity interaction: t = -2.29, P = 0.0235). Indeed, FHD was an independent determinant of AUC(gluc) in nulliparous women (n = 91), but not in parous women (n = 82).  {#results-there-were-no-significant-differences-between-the-two-groups-in-ethnicity-prepregnancy-bmi-the-insulin-sensitizing-protein-adiponectin-glucose-tolerance-status-and-area-under-the-glucose-curve-aucgluc.-in-women-with-familial-history-of-type-2-diabetes-fhd-a-multiple-linear-regression-model-of-established-gdm-risk-factors-reconciled-35-of-the-variance-in-aucgluc-with-i-previous-gdm-t-3.74-p-0.0003-identified-as-a-positive-independent-determinant-and-ii-log-adiponectin-t--3.48-p-0.0008-and-unexpectedly-parity-t--3.19-p-0.0021-emerging-as-negative-independent-covariates-of-aucgluc.-in-contrast-in-women-without-fhd-the-same-multivariate-model-reconciled-only-15-of-the-variance-in-aucgluc-with-no-significant-variables-identified.-interestingly-in-the-entire-population-n-173-parity-significantly-modified-the-relationship-between-fhd-and-aucgluc-fhd-parity-interaction-t--2.29-p-0.0235.-indeed-fhd-was-an-independent-determinant-of-aucgluc-in-nulliparous-women-n-91-but-not-in-parous-women-n-82. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Established risk factors for GDM are relevant in women with FHD but may not be the principal determinants of gestational hyperglycaemia in women without FHD. Moreover, FHD may be more relevant to risk of GDM in nulliparous women than in parous subjects. These findings highlight the complex relationship between FHD and gestational hyperglycaemia, and may hold implications for selective screening for GDM. {#conclusion-established-risk-factors-for-gdm-are-relevant-in-women-with-fhd-but-may-not-be-the-principal-determinants-of-gestational-hyperglycaemia-in-women-without-fhd.-moreover-fhd-may-be-more-relevant-to-risk-of-gdm-in-nulliparous-women-than-in-parous-subjects.-these-findings-highlight-the-complex-relationship-between-fhd-and-gestational-hyperglycaemia-and-may-hold-implications-for-selective-screening-for-gdm. .Style-Heading-4-+-Arial-14-pt-Underline}

[Retnakaran
R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Retnakaran R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al The impact of family history of diabetes on risk factors for
gestational diabetes. Clin Endocrinol (Oxf). 2007 Nov;67(5):754-60.

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17608815**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17608815) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17608815 .Style-Heading-4-+-Arial-14-pt-Underline}

**Hypertensive disorders of pregnancy are predictive of diabetes
mellitus 21 years later**

RESULTS: Of the women without hypertensive disorders of pregnancy (HDP),
7.4% reported a diagnosis of diabetes mellitus compared with 15.3% of
the women with HDP (unadjusted odds ratio \[OR\], 2.03; 95% CI, 1.42,
2.91). After adjustment for all potentially explanatory variables, only
prepregnancy body mass index (BMI) and BMI at 21 years after delivery
resulted in attenuation of the association (fully adjusted OR, 1.76; 95%
CI, 1.21, 2.56). In a smaller subgroup, waist circumference and BMI at
21 years had similar effects on point estimates (fully adjusted OR with
BMI, 1.64 \[95% CI, 1.11, 2.42\]; fully adjusted OR with waist, 1.60
\[95% CI, 1.08, 2.40\]). CONCLUSION: Hypertensive disorders of pregnancy
are associated with reported diagnosis of diabetes mellitus 21 years

[Callaway
LK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Callaway LK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Diabetes mellitus in the 21 years after a pregnancy that was
complicated by hypertension: findings from a prospective cohort study.Am
J Obstet Gynecol. 2007 Nov;197(5):492

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17980185>

**Continuous subcutaneous insulin: No improvement in pregnant diabetic
outcomes**

Pregnancy outcomes and glycemic control were not significantly different
among treatment groups. Higher number of ketoacidotic episodes and
diabetic retinopathy found in the CSII group did not reach statistical
significance. This systematic review does not show any advantage or
disadvantage of using CSII over MDI in pregnant diabetic women. Large
multicenter, randomized, controlled trials addressing the quality of
life/cost effectiveness are required.

[Mukhopadhyay
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mukhopadhyay A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Continuous subcutaneous insulin infusion vs intensive conventional
insulin therapy in pregnant diabetic women: a systematic review and
metaanalysis of randomized, controlled trials. Am J Obstet Gynecol. 2007
Nov;197(5):447-56

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17678864>

**A fetal weight estimation at 29-34 weeks in diabetic pregnancies: Can
it predict LGA ?**

RESULTS: The mean birthweight percentile at term was significantly
higher than the estimated fetal weight percentile at 29-34 weeks\'
gestation in the women with poor glycemic control, but not the women
with good control. On multivariate analysis, the estimated fetal weight,
interval from ultrasound to delivery, hemoglobin A1C level, gestational
age at ultrasound, and classification of glycemic control were
independently associated with the birthweight. Both the estimated fetal
weight and the calculated birthweight had a low sensitivity and a low
positive predictive value for predicting large-for-gestational-age
infants. CONCLUSION: Accelerated fetal growth is evident primarily in
diabetic women with poor glycemic control. These fetuses cannot be
identified by a single ultrasound examination at 29-34 weeks\'
gestation.

[Ben-Haroush
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ben-Haroush A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Accuracy of a single fetal weight estimation at 29-34 weeks in
diabetic pregnancies: can it predict large-for-gestational-age infants
at term? Am J Obstet Gynecol. 2007 Nov;197(5):497

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17980186>

**The Reproductive Phenotype in Polycystic Ovary Syndrome **

The symptoms of women with polycystic ovary syndrome (PCOS) include
hirsutism and irregular menstrual bleeding due to ovarian androgen
excess and chronic anovulation. Typically, these features emerge late in
puberty or shortly thereafter. The proposed mechanism(s) responsible for
increased ovarian androgen production include heightened theca cell
responsiveness to gonadotropin stimulation, increased pituitary
secretion of luteinizing hormone, and hyperinsulinemia. The cause of
ovulatory dysfunction is not well understood, but is linked to abnormal
follicle growth and development within the ovary. As a result,
infertility is common among women with PCOS and, in many instances, is
the initial presenting complaint. Insulin resistance and obesity are
frequently associated with PCOS and probably contribute to the severity
of symptoms. The polycystic ovary that accompanies the syndrome has
recently been defined as having 12 or more follicles per ovary or an
ovarian volume greater than 10 ml as determined by ultrasonography. In
addition, there is an increased number of growing follicles in the
polycystic ovary. Despite this distinctive appearance, the cause and
development of the polycystic ovary are completely unknown.

Chang RJ. The Reproductive Phenotype in Polycystic Ovary Syndrome  [Nat
Clin Pract Endocrinol
Metab.](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0I8OY0G2)
2007; 3(10):688-695.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17893687>

####  {#section-49 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Women's Health Headlines, Carolyn Aoyama, HQE {#womens-health-headlines-carolyn-aoyama-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Making a business case for investing in Maternal and Child Health**

Healthcare services for children and pregnant women account for \$1 out
of every \$5 large employers spend on health care. A substantial
proportion of employee's lost work time can be attributed to children's
health problems, and pregnancy is a leading cause of short- and
long-term disability and turnover for most companies. Yet most companies
don't have a strategy for promoting the health of mothers and children.\
In November, the Business Group released a new toolkit aimed at
improving employer-sponsored health benefits and programs for children,
adolescents, and pregnant women. The core component of this toolkit is
the Maternal and Child Health Plan Benefit Model, which outlines 34
evidence-informed health, pharmacy, vision, and dental benefits
recommended by the Business Group.\
This webinar provided an overview of the new toolkit. The speakers will
also discuss:\
\
\*       The business case for investing in healthy pregnancies and
healthy children.\
\*       Benefit design recommendations.\
\*       Recommended cost-sharing strategies to promote appropriate
utilization and incentive for

prevention.\
\*       Data on the cost-offsets associated with prevention.\
\*       "Lessons learned" from Marriott on communicating health
benefits and engaging beneficiaries in health promotion and disease
prevention.\
\
Speakers:\
Kathryn Phillips Campbell, MPH, Manager, National Business Group on
Health\
Scott Rothermel, Consultant and member of the Benefits Advisory Board\
Rebecca L. Main, Senior Manager, Benefits, Marriott International\
\
To view Investing in Maternal and Child Health: An Employer's Toolkit,
visit:\
<http://www.businessgrouphealth.org/healthtopics/maternalchild/investing/index.cfm>

The webinar recording will be posted for all members on the Business
Group website at:
<http://www.businessgrouphealth.org/opportunities/webinars.cfm>

**Depression and Initiation of Cigarette, Alcohol, and Other Drug Use
among Young Women**\
SAMHSA\'s Office of Applied Studies (OAS) has released the following
report on the web:   

The NSDUH Report:  Depression and the Initiation of Cigarette, Alcohol,
and Other Drug Use among Young Adults, a 3 page short report based on
SAMHSA\'s National Survey on Drug Use and Health provides prevalences of
the following among young adults in the past year: major depressive
episode, initiation of alcohol or illicit drug use, and the association
between such new alcohol and/or illicit drug use and major depressive
episode by gender, racial group, and Hispanic status.  The full report
is at <http://oas.samhsa.gov/2k7/newUsers/depression.cfm>

# Save the dates {#save-the-dates .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**23nd Annual Midwinter Indian Health OB/PEDS Conference**

-   February 8 - 10, 2008

-   For providers caring for Native women and children

-   Telluride, CO

-   Contact <AWaxman@salud.unm.edu>

**Training in Palliative and End of Life Care**

-   March 25 -27, 2008

-   Minneapolis, MN

-   Contact Tim Domer MD at <tim.domer@ihs.gov>

**Keeping Native Women & Families Healthy & Strong**

-   April 23-25, 2008

-   Milwaukee, WI

-   Great Lakes Tribal Epidemiology Center

-   E-mail contact <EpidemiologyCenter@gmail.com>

**IHS Basic Colposcopy Course**

-   April 9 - 11, 2008

-   Albuquerque, NM

-   Contact
    [[AWaxman@salud.unm.edu]{.underline}](mailto:AWaxman@salud.unm.edu)

**IHS Colposcopy Update & Refresher Course**

-   April 9 - 11, 2008

-   Albuquerque, NM

-   Contact
    [[AWaxman@salud.unm.edu]{.underline}](mailto:AWaxman@salud.unm.edu)

**Training in Palliative and End of Life Care**

-   April 22-24, 2008

-   Flagstaff, AZ

-   Contact Tim Domer MD at <tim.domer@ihs.gov>

# What's new on the ITU MCH web pages? {#whats-new-on-the-itu-mch-web-pages .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**Preconception Counseling for Women with Diabetes and Hypertension: New
Module**

<http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/PreconCouns01.cfm>

There are several upcoming **Conferences**

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#top>

and **Online CME/CEU resources**, etc....

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN13.cfm>

and the latest **Perinatology Corners** (free online CME from IHS) are
at

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHpericrnr.asp>

...or just take a look at the **What's New** page

<http://www.ihs.gov/MedicalPrograms/MCH/W/WN00.asp#top>

# Did you miss something in the last OB/GYN Chief Clinical Consultant Corner? {#did-you-miss-something-in-the-last-obgyn-chief-clinical-consultant-corner .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

The **December 2007 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/medicalprograms/mch/M/obgyn1207.cfm>

#### Abstract of the Month page 6 {#abstract-of-the-month-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

**30 minute rule not a requirement and 'immediately available' defined
locally**

#### From your colleagues page 8 {#from-your-colleagues-page-8 .Style-Heading-4-+-Arial-14-pt-Underline}

Burt Attico

#### Random glucose test would have missed 5 of 6 women with GDM {#random-glucose-test-would-have-missed-5-of-6-women-with-gdm .Style-Heading-4-+-Arial-14-pt-Underline}

Gordon Belcourt

#### Infant Mortality Disparities {#infant-mortality-disparities .Style-Heading-4-+-Arial-14-pt-Underline}

Terry Cullen

Call for Presentation Abstracts Announced for U.S. Public Health
Symposium

Tony Dekker

#### IHS Comprehensive Updates in Substance Abuse and Dependence {#ihs-comprehensive-updates-in-substance-abuse-and-dependence .Style-Heading-4-+-Arial-14-pt-Underline}

Scott Giberson

**HEAR ME Project: HIV/AIDS Story-Writing/Video Competition**

**Sheila Mahoney**

-Round out the VBAC debate

-Increased Cesareans in Women at No Medical Risk

-The Business of Being Born

**Caroline Peck**

Want to improve maternal morbidity / mortality and maternal mental
health?

#### Hot Topics {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics page 13

-Risk and benefits of cesarean delivery and other cesarean delivery
articles

-Clear liquids in limited quantities does not increase labor
complications

-Preterm birth and its recurrence increases with short interpregnancy
intervals

-Maternal obesity is associated with an increased risk of stillbirth

-Optimal Gestational Weight Gain Improves Obstetric and Neonatal
Outcomes

...and more

**Gynecology page 16**

-HPV test beats Pap in detecting cervical cancer and other screening
aticles

-New Guidelines for Assessing Gynecologic Cancer Predispositions

-Which Factors Influence Progression of Pelvic Prolapse?

-Despite shorter length of stay TVH / LAVH far less common than TAH for
benign disease

-Abdominal sacrocolpopexy: Lower rate of recurrent vault prolapse than
SSLS

...and more

**Child Health page 18**

-Long-term prognosis for infants after massive fetomaternal hemorrhage

-Increasing hyperglycemia in pregnancy associated with increased
childhood obesity

-Family-Based Strategies for Controlling Childhood Obesity

-Effectiveness of a Novel Infant Tooth Wipe in High Caries-risk Babies 8
to 15 Months Old

-ACIP Recommendations for the Prevention of Varicella

**Chronic Illness and Disease page 21**

-Heart Disease Kills More Younger Women

-Low-Carbohydrate Diet Effective in Women

-Does Aspirin Use Affect Mortality in Women?

-High suicide and heart disease deaths with bariatric surgery

######### -Hypertension in Pregnancy: An Emerging Risk Factor for Cardiovascular Disease

#### Features page 22 {#features-page-22 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Use of Psychiatric Medications During Pregnancy and Lactation

-Cesarean Delivery on Maternal Request

-Colonoscopy and Colorectal Cancer Screening and Prevention

-The Limits of Conscientious Refusal in Reproductive Medicine

-Supracervical Hysterectomy

...and more

##### American Family Physician

-Predicting the Likelihood of Successful Vaginal Birth After Cesarean
Delivery

-Effectiveness of Insulin Sensitizing Drugs for Polycystic Ovary
Syndrome

-Second Trimester Pregnancy Loss

-AAFP and ACP Publish Recommendations on Diagnosis and Management of VTE

-Methamphetamine Abuse

...and more

**Agency for Healthcare Research and Quality**

-Study documents the health costs of being a woman

-Death and complications after breast cancer surgery rare: Wound
infection most common

-Women suffer fewer postoperative problems after vascular surgery at VA
hospitals

-Skin condition may identify young patients at risk for developing type
2 diabetes

**Ask a Librarian**

## The Healthy Heart Handbook for Women \'07 - 20th Anniversary Edition

**Breastfeeding**

-Getting it Right - Breastfeeding Promotion: Good Public Health Policy
(Part 2 of 2)

-Rare Side-Effect of Codeine in Nursing Mothers: Ultra-rapid
metabolizers

-Nicotine In Breast Milk Disrupts Infants' Sleep Patterns

-Formula free zone - Sion Baby Friendly
Hospital                                                     

-The yeast connection: is Candida linked to breastfeeding associated
pain?

**CCC Corner Digest**

\-[Hospital brought rapid cesarean delivery times into range of 10.9
minutes: Can
you?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_AOM.cfm)

\-[Let's clear up any confusion over the availability of the HPV
vaccine](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Coll.cfm)

\-[SBE prophylaxis not recommended for cesarean delivery and other GU
procedures](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_HT.cfm#ob)

\-[2006 consensus guidelines for the management of abnormal cervical
cancer
screening](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_HT.cfm#gyn)

\-[Traumatic events and alcohol use disorders among American Indian
adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_HT.cfm#child)

\-[Aging and prevalence of CVD risk factors in American Indians: the
Strong Heart
Study](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_HT.cfm#chrIll)

\-[Viral Hepatitis in
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#acog)

\-[The HSR Library- a branch of the NIH Library Provides Access to Many
Online
Journals](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#AskLib)

\-[Breastfeeding Promotion: Good Public Health
Policy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#breast)

\-[Coaching Boys Into Men AI/AN
Poster](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#dv)

\-[Transdermal hormonal contraception: benefits and
risks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#fp)

\-[EHR graphical user interface (GUI) application, version 1.1. --
National
Release](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#it)

\-[Treating schizophrenia in poorer countries: Old dilemmas and new
directions](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#ih)

\-[Having more family meals during adolescence is associated with
improved diet
quality](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#alert)

\-[Child passengers are exposed to secondhand
smoke](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#headlines)

-Endometriosis: Where is the real truth? [It's
here](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#mmtour)

\-[Hormone therapy had no effect on memory, but increases sexual
interest](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#menopause)

\-[If you have to use something, nitrous oxide might be better than
narcotics and
epidurals](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#MidWives)

\-[Acute Appendicitis and
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#navajo)

\-[Nurses and physicians have different perspectives in medical
decisions](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#nurseCorner)

\-[Training for Shoulder
Dystocia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#okie)

\-[Ordinary Doses of Vitamin D Linked to Lower
Mortality](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#oste)

\-[No, I don't mean THAT Dating
Game](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#periPicks)

\-[Magic Pill Improves Glycemic Control and Decreases Death by 25% for
Type
2\'s](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#stillW)

\-[Planning Group - conference on midwifery models of
care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107_Feat.cfm#wheadlines)

**Domestic Violence**

Adolescent primary prevention programs for domestic violence which are
school based

**Elder Care News**

-Postdischarge management that integrates social care can improve
outcomes of elderly

-Principles of Effective Pain Management at the End of Life

**Family Planning**

#### A novel acid buffering gel is safe and acceptable and has contraceptive efficacy  {#a-novel-acid-buffering-gel-is-safe-and-acceptable-and-has-contraceptive-efficacy .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

Lack of VZIG and new prenatal assessment of varicella immunity
addressed: New CME module

**Frequently asked questions**

Where can I get lecture notes from the 2007 Women's Health and MCH
Conference?

**Indian Child Health Notes**

-No more cough syrup says the FDA

-No more cavities says Dr. Esposito

-Not enough Hib vaccine says Dr. Singleton

**Information Technology**

-Patient-Physician Email Communication May Be Effective

-Frequently Asked Questions: Clinical Performance Measurement, GPRA and
CRS

-Medicine Dish - Broadcast Schedule

International Health

Special Global Issue - Obstetrics and Gynecology

-Ghana postgraduate training program: 37 or 38 OB/GYNs remained in the
country

-Traditional birth attendant training for improving health behavior and
pregnancy outcomes

-Vaginal and neonatal chlorhexidine wipes applied in home settings are
well tolerated

-Everybody has a story

...and more

#### MCH Alert

-Tightening the \"holes\" in the Swiss cheese model of patient safety in
obstetrics

-Electronic resource updates state action on HPV Vaccine

-Improving the health of women and children benefits an employer's
bottom line

-Lower socioeconomic status and poor perinatal outcomes: Even with
universal access

#### MCH Headlines

-Frequently Asked Questions about Infant Feeding Choice

-First Nations and Inuit Health Health Canada HHS and Indian Health
Service MOU

-New Guidelines on Fish Consumption for Females of Childbearing Age,
Young Children\
-26th Annual "Protecting Our Children"

-Early child health caries reduction tool kit

...and more

#### Medical Mystery Tour

#### What is the presenting part? {#what-is-the-presenting-part-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

######### -Recognizing and Treating Excessive Sleepiness: Circadian Rhythm Sleep Disorders

######### -Small Steps and Practical Approaches to the Treatment of Obesity

-Challenges of Treating Tobacco Users in High-Risk Populations

-Newly Diagnosed Breast Cancer: Moving Toward Individualized Treatment
Planning

-Ageing in Marfan Syndrome

**Menopause Management**

#### -Lowest effective transdermal 17beta-estradiol dose for relief of hot flushes: RCT {#lowest-effective-transdermal-17beta-estradiol-dose-for-relief-of-hot-flushes-rct .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Low-Fat Diet May Reduce Incidence of Ovarian Cancer in Postmenopausal Women {#low-fat-diet-may-reduce-incidence-of-ovarian-cancer-in-postmenopausal-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Hormones and heart disease in women: the timing hypothesis {#hormones-and-heart-disease-in-women-the-timing-hypothesis .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

Vaginal birth after cesarean (VBAC) in rural hospitals: Counterpoint:
David Gahn, M.D.

**Navajo News**

Which caused more deaths in the United States in 2005, MRSA or HIV?

**Nurses Corner**

-2008 LONG TERM TRAINING -- NURSE ANESTHESIA -- Apply Soon

-Scope of Practice and the NP: Regulation, Competency, Expansion, and
Evolution

-Overweight Children and Adolescents - National Association of School
Nurses

#### Office of Women's Health, CDC

-Cancer in American Indians and Alaska Natives

-Vaccination of Pregnant Women (2007 Update)

#### -ACIP Releases 2007-08 Adult Immunization Schedule {#acip-releases-2007-08-adult-immunization-schedule-2 .Style-Heading-4-+-Arial-14-pt-Underline}

**Oklahoma Perspective**

Methicillin-resistant Staphylococcus aureus in women's health

Osteoporosis

Effects of Aromatase Inhibitors on Bone Turnover in Healthy
Postmenopausal Women

Patient Education

-Pregnant or Thinking About Getting Pregnant?

#### -Pregnancy Loss: What You Should Know {#pregnancy-loss-what-you-should-know-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Caring for Your Premature Baby {#caring-for-your-premature-baby-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Meth Abuse: What You Should Know {#meth-abuse-what-you-should-know-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Headaches and Mind-Body Therapy: What You Should Know {#headaches-and-mind-body-therapy-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

...and more

Perinatology Picks

-Detection of intraamniotic infection/inflammation at bedside: Predicts
adverse outcomes

-Ferric carboxymaltose IV corrects postpartum anemia faster than ferrous
sulfate PO

-Alloimmune thrombocytopenia fetus can be safely treated in utero,
without cordocentesis

-Adequate dietary calcium in before and in early pregnancy: Prevent
pre-eclampsia

-A cost decision analysis of 4 tocolytic drugs

...and more

Primary Care Discussion Forum

#### -Traditional AI/AN Medicine: Incorporating Into I/T/U Clincial Practice

Starts December 3, 2007

STD Corner

-Special issue of the American Journal of Obstetrics & Gynecology:

Achievements, Issues, and Challenges: Prevention of Mother-to-Child HIV
Transmission in the United States and in Resource-Limited Settings.

#### -Racial Disparities Persist Across All Reportable STDs - CDC's 2006 STD Surveillance Report

#### Barbara Stillwater, Alaska Diabetes Prevention and Control

#### -Hypertension Triples Women\'s Risk for Diabetes {#hypertension-triples-womens-risk-for-diabetes .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Prenatal programming of childhood overweight and obesity: opportunity for prevention {#prenatal-programming-of-childhood-overweight-and-obesity-opportunity-for-prevention .Style-Heading-4-+-Arial-14-pt-Underline}

#### -American Dietetic Association: Nutrition and lifestyle for a health pregnancy outcome  {#american-dietetic-association-nutrition-and-lifestyle-for-a-health-pregnancy-outcome .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Researchers Shed Light On Black Box Of Gestational Diabetes {#researchers-shed-light-on-black-box-of-gestational-diabetes .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Prenatal exposure to alcohol and conduct problems: A clearer link {#prenatal-exposure-to-alcohol-and-conduct-problems-a-clearer-link .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

-Alaska Native Fetal Alcohol Spectrum Disorders and Suicidality in a
Healthcare setting

-ACNM and AWHONN nursing representation educational activities involving
women\'s health

-Report: State of Women\'s Health Poor Nationwide

-Advanced Practice Nursing Brochure Available

-Women's Health Data Book Available

###### Save the Dates: Upcoming events of interest page 70

#### What's new on the ITU MCH web pages page 71

-Lack of VZIG and new prenatal assessment of varicella immunity
addressed: New CME module

-Where can I get lecture notes from the 2007 Women's Health and MCH
Conference?

**-**[Frequently Asked Question about Capturing Infant Feeding Choice on
RPMS and EHR](http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

**Did you miss something in the last OB/GYN Chief Clinical Consultant
(CCC) Corner?**

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm#top>

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages.

Let me know if you want to add something to next month's CCC Corner at
<nmurphy@scf.cc>

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here
<http://www.ihs.gov/MedicalPrograms/MCH/F/MCHdiscuss.cfm>

12/12/07