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

# -New Perinatology Corner Module: Varicella (Chickenpox) in Pregnancy  {#new-perinatology-corner-module-varicella-chickenpox-in-pregnancy .Style-Heading-1-+-Underline}

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

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

**- Lecture slides and notes from the 2007 Women's Health and MCH
Conference,**

**held in Albuquerque, August 15-17^th^ - now online**

(see Frequently Asked Questions, below)

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

# ![](media/image1.jpeg){width="5.992361111111111in" height="1.33125in"} {#section-2 .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

 

OB/GYN Chief Clinical Consultant's Corner

Volume 5, No. 11, December 2007

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

#### 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 .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 .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 .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 .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}

#### -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?**

#  {#section-3 .Style-Heading-1-+-Underline}

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

**30 minute rule not a requirement and 'immediately available' defined
locally**

Stanley Zinberg, M.D., ACOG Deputy Executive Vice President published
comments recently on the background and meaning of the so called '30
minute rule'. Dr. Zinberg references the 2006 National Institute of
Child Health and Human Development (NICHD) article by [Bloom
SL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bloom SL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al (below) and the subsequent letters to the editor.

The NICHD results found that in the great majority of cases, providers
effectively triage emergency cesarean deliveries when given the
capability to begin the operation within 30 minutes, which is what was
intended when the ACOG / AAP guideline was promulgated. In addition,
approximately one third of primary cesarean deliveries performed for
emergency indications are commenced more than 30 minutes after the
decision to operate, and the majority were for nonreassuring heart rate
tracings. In these cases, adverse neonatal outcomes were not increased.

The required personnel should be in the hospital, or immediately
available, to perform emergency cesarean delivery. The immediately
available phrase was intended to be a guideline that could be
implemented nationally, including in rural settings. ACOG recognizes
that each institution should define "immediately available" based on its
resources and geographic location.

The ACOG / AAP guideline on emergency cesarean delivery does not
establish the 30-minute interval to be a requirement that all cesarean
deliveries must be performed within 30 minutes of the decision. The
recent NICHD data found that most infants delivered for emergency
indications were not compromised, whether delivered less than or more
than 30 minutes from the decision to operate.

**Decision-to-incision times and maternal and infant outcomes**

OBJECTIVE: To measure decision-to-incision intervals and related
maternal and neonatal outcomes in a cohort of women undergoing emergency
cesarean deliveries at multiple university-based hospitals comprising
the National Institute of Child Health and Human Development
Maternal-Fetal Medicine Units Network. METHODS: All women undergoing a
primary cesarean delivery at a Network center during a 2-year time span
were prospectively ascertained. Emergency procedures were defined as
those performed for umbilical cord prolapse, placental abruption,
placenta previa with hemorrhage, nonreassuring fetal heart rate pattern,
or uterine rupture. Detailed information regarding maternal and neonatal
outcomes, including the interval from the decision time to perform
cesarean delivery to the actual skin incision, was collected. RESULTS:
Of the 11,481 primary cesarean deliveries, 2,808 were performed for an
emergency indication. Of these, 1,814 (65%) began within 30 minutes of
the decision to operate. Maternal complication rates, including
endometritis, wound infection, and operative injury, were not related to
the decision-to-incision interval. Measures of newborn compromise
including umbilical artery pH less than 7 and intubation in the delivery
room were significantly greater when the cesarean delivery was commenced
within 30 minutes, likely attesting to the need for expedited delivery.
Of the infants with indications for an emergency cesarean delivery who
were delivered more than 30 minutes after the decision to operate, 95%
did not experience a measure of newborn compromise. CONCLUSION:
Approximately one third of primary cesarean deliveries performed for
emergency indications are commenced more than 30 minutes after the
decision to operate, and the majority were for nonreassuring heart rate
tracings. In these cases, adverse neonatal outcomes were not increased.
LEVEL OF EVIDENCE: II-2.

[Bloom
SL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bloom SL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Decision-to-incision times and maternal and infant outcomes.
Obstet Gynecol. 2006 Jul;108(1):6-11.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16816049>

#### [OB/GYN CCC Editorial comment:]{.underline}

**The Rule of Parley was really more of a 'guideline'**

I assume most of you have seen the first of the three Pirates of the
Caribbean films, the 2003 Walt Disney film Curse of the Black Pearl. If
not, at one point Elizabeth Swann (Keira Knightley) daughter of the Port
Royal, Jamaica Governor, Weatherby Swann, finds herself captured by
pirates.

After her capture Ms Swann invokes the **'Rule of Parley'**---an
agreement ensuring one\'s safety until meeting and negotiating with the
opposing side -- when she is presented to the pirate Captain Hector
Barbossa (Geoffrey Rush) on the deck of the Black Pearl. Captain
Barbossa initially agrees not to harm his new prisoner, but in one of
the better lines in the movie he seeks to clarify that "the Rule of
Parley is really more of a **guideline**." when it comes to the actual
details of implementation.

This classic line\* intimates that institutionalized 'double speak' may
have been with us for centuries, and not invented during the recent era
of Dilbert like office cubicles. Though we can all empathize with Ms.
Swann's predicament, in much the same way some institutions and
providers have misconstrued ACOG's efforts.

ACOG has sought to educate its members, other providers, and their
facilities that a prompt systematic response needs to be immediately
available when intrapartum, or other obstetric emergencies, arise. The
30 minute rule is not a requirement, it really more of a guiding
principle for appropriate prompt action.

In those cases of successful intrauterine resuscitation, a longer
interval, or no cesarean delivery at all, may be appropriate, though all
the necessary resources were on standby in the interim.

**The '17 minute rule'**

In some cases, the clinical situation may require an immediate delivery,
or more precisely a delivery within 17 minutes.

One study looking at this question comes from U.S.C.- Los Angeles County
Medical Center, where, until the recent past, over 15,000 deliveries a
year were attended, the majority occurring to women recently immigrated
from Mexico with very little in the way of past obstetric records. Leung
et al reported in October 1993 that the clinical signs of actual uterine
rupture were not those classically described in the textbooks. Excessive
pain and vaginal bleeding were seen in less than 15% of the cases, loss
of the uterine pressure tracing in none, and recession of the presenting
part in only 6%.

All the infants that died were extruded from the uterus into the
abdominal cavity, and\--of special clinical significance\--all the
deaths, and all the neurologic injuries, occurred if the time from
suspicion of rupture to delivery exceeded 17 minutes.

In any case, each institution should perform periodic drills to
streamline their maternity team's prompt response to obstetric
emergencies. A stellar example of obstetric emergency drills is
available at Phoenix Indian Medical Center (PIMC).

Inspired by Dr. Michelle Lauria's presentation at the 2004 Native
Women's Health and MCH Conference entitled 'Emergency Delivery
Simulations: How to Develop Teamwork', PIMC began a successful organized
approach to obstetric emergencies. The PIMC experience with emergency
drills was subsequently reported at the 2007 version of the same
conference by Karen Carey CNM and Tami McBride CNM MS.

**30 minute rule is not a requirement. ACOG Today**

**October 2007 page 2**

ACOG Members

<http://www.acog.org/publications/acog_newsletters/acogToday1007.pdf>

Non ACOG Members

<http://www.acog.org/>

**Emergency Delivery Simulations: How to Develop Teamwork**, Dr. Michele
Laura

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Talk.ppt>

Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin
No. 54. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2004;104:203--12.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=15229039&dopt=AbstractPlus>

**Other**

[Schauberger
CW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Schauberger CW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Decision-to-incision times and maternal and infant outcomes. Obstet
Gynecol. 2006 Nov;108(5):1298; author reply 1298

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17077260>

[Dupuis
O](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dupuis O"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Decision-to-incision times and maternal and infant outcomes.Obstet
Gynecol. 2006 Nov;108(5):1297-8; author reply 1298.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17077258>

[Katz
VL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Katz VL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Cesarean birth: guidelines, not rules. Obstet Gynecol. 2006
Jul;108(1):2-3.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16816047>

\*Another classic line from Curse of the Black Pearl is noted in the
Medical Mystery Tour, below

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

#### Burt Attico, Phoenix {#burt-attico-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

#### Random glucose test would have missed 5 of 6 women with GDM {#random-glucose-test-would-have-missed-5-of-6-women-with-gdm-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### OBJECTIVE: To compare the accuracy measures of the random glucose test and the 50-g glucose challenge test as screening tests for gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: In this prospective cohort study, pregnant women without preexisting diabetes in two perinatal centers in the Netherlands underwent a random glucose test and a 50-g glucose challenge test between 24 and 28 weeks of gestation. If one of the screening tests exceeded predefined threshold values, the 75-g oral glucose tolerance test (OGTT) was performed within 1 week. Furthermore, the OGTT was performed in a random sample of women in whom both screening tests were normal. GDM was considered present when the OGTT (reference test) exceeded predefined threshold values. Receiver operating characteristic (ROC) analysis was used to evaluate the performance of the two screening tests. The results were corrected for verification bias.  {#objective-to-compare-the-accuracy-measures-of-the-random-glucose-test-and-the-50-g-glucose-challenge-test-as-screening-tests-for-gestational-diabetes-mellitus-gdm.-research-design-and-methods-in-this-prospective-cohort-study-pregnant-women-without-preexisting-diabetes-in-two-perinatal-centers-in-the-netherlands-underwent-a-random-glucose-test-and-a-50-g-glucose-challenge-test-between-24-and-28-weeks-of-gestation.-if-one-of-the-screening-tests-exceeded-predefined-threshold-values-the-75-g-oral-glucose-tolerance-test-ogtt-was-performed-within-1-week.-furthermore-the-ogtt-was-performed-in-a-random-sample-of-women-in-whom-both-screening-tests-were-normal.-gdm-was-considered-present-when-the-ogtt-reference-test-exceeded-predefined-threshold-values.-receiver-operating-characteristic-roc-analysis-was-used-to-evaluate-the-performance-of-the-two-screening-tests.-the-results-were-corrected-for-verification-bias. .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: We included 1,301 women. The OGTT was performed in 322 women. After correction for verification bias, the random glucose test showed an area under the ROC curve of 0.69 (95% CI 0.61-0.78), whereas the glucose challenge test had an area under the curve of 0.88 (0.83-0.93). There was a significant difference in area under the curve of the two tests of 0.19 (0.11-0.27) in favor of the 50-g glucose challenge test.  {#results-we-included-1301-women.-the-ogtt-was-performed-in-322-women.-after-correction-for-verification-bias-the-random-glucose-test-showed-an-area-under-the-roc-curve-of-0.69-95-ci-0.61-0.78-whereas-the-glucose-challenge-test-had-an-area-under-the-curve-of-0.88-0.83-0.93.-there-was-a-significant-difference-in-area-under-the-curve-of-the-two-tests-of-0.19-0.11-0.27-in-favor-of-the-50-g-glucose-challenge-test. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: In screening for GDM, the 50-g glucose challenge test is more useful than the random glucose test. {#conclusions-in-screening-for-gdm-the-50-g-glucose-challenge-test-is-more-useful-than-the-random-glucose-test. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The authors recommend that despite easy implementation, low costs, and relative high specificity, random glucose measurement should not be used as a screening test for GDM. Until superior screening alternatives become available, the 50-g glucose challenge test should be the preferred screening test for GDM. {#the-authors-recommend-that-despite-easy-implementation-low-costs-and-relative-high-specificity-random-glucose-measurement-should-not-be-used-as-a-screening-test-for-gdm.-until-superior-screening-alternatives-become-available-the-50-g-glucose-challenge-test-should-be-the-preferred-screening-test-for-gdm. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [OB/GYN CCC Editorial comment:]{.underline}

#### Glucose Challenge Better Than Random Glucose to Screen for Gestational Diabetes {#glucose-challenge-better-than-random-glucose-to-screen-for-gestational-diabetes .Style-Heading-4-+-Arial-14-pt-Underline}

#### Wouldn't it be easier just to perform a random blood glucose to be able to screen or diagnose gestational diabetes mellitus (GDM) ? {#wouldnt-it-be-easier-just-to-perform-a-random-blood-glucose-to-be-able-to-screen-or-diagnose-gestational-diabetes-mellitus-gdm .Style-Heading-4-+-Arial-14-pt-Underline}

#### Yes, it would be easier. {#yes-it-would-be-easier. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Unfortunately, the random glucose test would have missed 5 of 6 women with GDM. {#unfortunately-the-random-glucose-test-would-have-missed-5-of-6-women-with-gdm. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The van Leeeuwen et al study above confirms previous literature on GDM screening {#the-van-leeeuwen-et-al-study-above-confirms-previous-literature-on-gdm-screening .Style-Heading-4-+-Arial-14-pt-Underline}

-   The random glucose test would have missed 5 of 6 women with GDM.

-   2.8% had an abnormal random glucose test and 13.0% had an abnormal
    50-g glucose challenge test.

-   14.1% had at least 1 abnormal test result, and 1.5% had positive
    screen results on both tests.

-   The OGTT was performed in 24.8%, including 79.3% of those with an
    abnormal initial screening test.

-   A total of 3.7% of women were diagnosed with GDM based on the OGTT.

-   The 50-g glucose challenge test had 5 times the sensitivity of the
    random glucose test (70.2% vs 14.6%).

-   Specificity of the random glucose test was 97.6% vs 89.1% for the
    50-g glucose challenge test.

-   Positive predictive value was 18.9% for the random and 19.8% for the
    50-g glucose challenge test.

-   Negative predictive value was 96.8% for the random glucose and 98.7%
    for the 50-g glucose challenge test.

-   The diagnostic odds ratio was 7.0% for the random glucose and 19.4%
    for the 50-g glucose challenge test.

-   The likelihood ratio for a normal test result was 0.88 for the
    random glucose and 0.33 for the 50-g glucose challenge test.

-   Area under the ROC was 0.69 for the random glucose and 0.88 for the
    50-g glucose challenge test.

-   The 50-g glucose challenge test was a better predictor for GDM than
    the random glucose test based on the area under the ROC.

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

#### Though well meaning, some providers try apply the use of basal maintanence glucose levels to GDM screening. Instead these providers subject their patients to multiple other inaccurate screens, e. g., random blood glucose, fasting glucose, and 2 hour post prandial levels. In the end their patients are subject more individual venopunctures and less accruate screening. {#though-well-meaning-some-providers-try-apply-the-use-of-basal-maintanence-glucose-levels-to-gdm-screening.-instead-these-providers-subject-their-patients-to-multiple-other-inaccurate-screens-e.-g.-random-blood-glucose-fasting-glucose-and-2-hour-post-prandial-levels.-in-the-end-their-patients-are-subject-more-individual-venopunctures-and-less-accruate-screening. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### GDM is diagnosis based on a carbohydrate challenge, not basal levels. On the other hand, management after the diagnosis has been made, is based on daily fasting and post parandial levels. We should take care not to confuse the two different processes. {#gdm-is-diagnosis-based-on-a-carbohydrate-challenge-not-basal-levels.-on-the-other-hand-management-after-the-diagnosis-has-been-made-is-based-on-daily-fasting-and-post-parandial-levels.-we-should-take-care-not-to-confuse-the-two-different-processes. .Style-Heading-4-+-Arial-14-pt-Underline}

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

[van Leeuwen
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="van Leeuwen M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Comparison of accuracy measures of two screening tests for
gestational diabetes mellitus. Diabetes Care. 2007 Nov;30(11):2779-84.
Epub 2007 Aug 13.

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17698616**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17698616) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17698616 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Gordon Belcourt, Montana Wyoming Tribal Leaders {#gordon-belcourt-montana-wyoming-tribal-leaders .Style-Heading-4-+-Arial-14-pt-Underline}

#### 2007 URBAN INDIAN HEALTH REPORT  {#urban-indian-health-report .Style-Heading-4-+-Arial-14-pt-Underline}

#### Table 2 for your quick look {#table-2-for-your-quick-look .Style-Heading-4-+-Arial-14-pt-Underline}

![](media/image2.png){width="4.239583333333333in"
height="4.145833333333333in"}

Copies available from [Judith.Thierry@ihs.gov]{.underline}

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

#### Terry Cullen, Chief Information Officer,HQE {#terry-cullen-chief-information-officerhqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Call for Presentation Abstracts Announced for U.S. Public Health
Symposium**

The Scientific Program Committee for the 2008 U.S. Public Health Service
Scientific & Training Symposium has announced a Call for Presentation
Abstracts for the symposium, which will be held June 9-12 at the Tucson
(AZ) Convention Center. The symposium, which is organized by the PHS
Commissioned Officers Foundation, attracts more than 1,000 federal,
tribal, state and local public health officials each year.

Submission of abstracts are being sought for 30- and 60-minute
presentations to be made during concurrent track sessions that will
occur on Wednesday and Thursday. There will also be paper and poster
sessions. The theme for the 2008 symposium is Public Health Strategies
for the New Millennium. The tracks will focus on four themes:

-   Strategies for Improving Access to Health Care in the U.S.

-   Strategies for Addressing the Growing International Element of
    Public Health

-   Strategies for Improving Public Health Preparedness and Emergency
    Response

-   Strategies for Addressing the Impact of a Changing Environment on
    Public Health

The themes for the paper and poster session are wide open.

Submissions from the academic community are encouraged. The deadline for
submission of presentation abstracts is December 31, 2007. Abstracts
will be selected on or about February 15, 2008. Visit
[www.phscofevents.org](http://www.phscofevents.org/) for additional
details or to submit. 

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

#### Tony Dekker, PIMC {#tony-dekker-pimc .Style-Heading-4-+-Arial-14-pt-Underline}

#### IHS Comprehensive Updates in Substance Abuse and Dependence (CUSAD) {#ihs-comprehensive-updates-in-substance-abuse-and-dependence-cusad .Style-Heading-4-+-Arial-14-pt-Underline}

#### Every year the IHS offers two Comprehensive Updates in Substance Abuse and Dependence (CUSAD).  The programs are approved for physicians, nurses, pharmacists and licensed substance abuse counselors.  It is usually 30 hours of CE and IHS scholarships are available.  The 2008 programs will be in Phoenix (March 2008) and probably Seattle/Tacoma (date TBA) The programs in the past offers the DEA required OBOT waiver course. For any questions contact Anthony Dekker at [**anthony.dekker@ihs.gov**](mailto:anthony.dekker@ihs.gov) {#every-year-the-ihs-offers-two-comprehensive-updates-in-substance-abuse-and-dependence-cusad.-the-programs-are-approved-for-physicians-nurses-pharmacists-and-licensed-substance-abuse-counselors.-it-is-usually-30-hours-of-ce-and-ihs-scholarships-are-available.-the-2008-programs-will-be-in-phoenix-march-2008-and-probably-seattletacoma-date-tba-the-programs-in-the-past-offers-the-dea-required-obot-waiver-course.-for-any-questions-contact-anthony-dekker-at-anthony.dekkerihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**HEAR ME Project: HIV/AIDS Story-Writing/Video Competition**

The HEAR ME Project is again sponsoring its annual HIV/AIDS story
writing competition.  We need young American Indian / Alaska Native
youth to share their story. Please share this within your workplace,
clinics, community circles to raise awareness and open discussion. The
deadline is Dec 1, 2007. Young people ages 14 to 22 are encouraged to
submit their original stories, either real or made up, about
vulnerability to HIV and AIDS.  The HEAR ME Project has also launched a
new video contest that is taking place at the same time as the annual
story-writing contest.  Entry forms for both contests are included as
attachments to this e-mail.

Additional information on these contests may be obtained from the HEAR
ME Project Web site, <http://www.hearmeproject.org/>

**Sheila Mahoney, NIH / NICHD**

**Round out the VBAC debate: Two additional resources**

Sheila Mahoney forwarded the citations on several peer reviewed articles
on the risk of cesarean delivery vs vaginal delivery which are included
in the VBAC discussion below. Below are two other resources to round out
that debate.

**Increased Cesareans in Women at No Medical Risk**

Newsmaker Interview With Eugene Declercq, PhD

Cesarean deliveries have dramatically increased in women with no
reported medical risk, according to the results of a large,
cross-sectional analysis reported in the Nov. 19 Online First issue of
the British Medical Journal. Undergoing a cesarean delivery when there
is no medical indication raises serious questions and mandates more
research on whether the risks associated with surgery outweigh the
benefits in these circumstances.

This study analyzed U.S. national birth certificate data on
approximately four million births each year. The investigators defined a
new category of mothers at \"no indicated risk,\" defined as mothers
with singleton, full-term (37 weeks or longer), vertex presentation
births who were not reported to have any medical risk factors and for
whom no complications of labor or delivery were listed on the birth
certificate. They then examined the increase of primary cesarean
deliveries in these women from 1991 to 2001.

To learn more about the implications of this study for obstetrical
practice, Medscape\'s Laurie Barclay interviewed lead author Eugene
Declercq, PhD, a professor of obstetrics and gynecology at the Boston
University School of Medicine and assistant dean for doctoral education
at the Boston University School of Public Health in Massachusetts.
<http://www.medscape.com/viewarticle/494349>

A new documentary by Ricki Lake which addresses the increasing trend
towards medicalizaiton of childbirth which Sheila highly recommends

**The Business of Being Born**

<http://www.thebusinessofbeingborn.com/>

Contact Sheila Mahoney at <mahoneys@MAIL.NIH.GOV>

**Caroline Peck, Former IHS OB/GYN**

**Want to improve maternal morbidity / mortality and maternal mental
health?**

We have an opening for a physician position (public health medical
officer) at the California Department of Public Health in our Maternal
Child and Adolescent Health Program.  We are looking, preferably, for an
OBGYN with a public health background who would work with our MCAH
Programs with a particular emphasis on the issue of maternal morbidity
and mortality and other related programs such as maternal mental
health. 

Please spread the word about this position.  We are eager to find a
public health physician to join our MCAH team in CA!
<http://jobs.spb.ca.gov/wvpos/vadmin_moreinfo.cfm?recno=336037>

Contact Karen C. Ramstrom, DO, MSPH, Phone: (916) 650-0386     

# 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 in Native American women: are low rates explained by practice style? {#cesarean-delivery-in-native-american-women-are-low-rates-explained-by-practice-style .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Despite a higher prevalence of medical risk factors for cesarean delivery, the rate at this hospital was well below New Mexico (16.4%, all races) and national (21.2%, all races) cesarean rates for 1998. Medical and practice-related factors were the only observed independent correlates of cesarean delivery. Implementation of institutional and practitioner policies common to the Indian Health Service may reduce cesarean deliveries in other populations {#conclusions-despite-a-higher-prevalence-of-medical-risk-factors-for-cesarean-delivery-the-rate-at-this-hospital-was-well-below-new-mexico-16.4-all-races-and-national-21.2-all-races-cesarean-rates-for-1998.-medical-and-practice-related-factors-were-the-only-observed-independent-correlates-of-cesarean-delivery.-implementation-of-institutional-and-practitioner-policies-common-to-the-indian-health-service-may-reduce-cesarean-deliveries-in-other-populations .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Mahoney SF](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mahoney SF"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), [Malcoe LH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Malcoe LH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus). Cesarean delivery in Native American women: are low rates explained by practices common to the Indian health service? Birth. 2005 Sep;32(3):170-8. {#mahoney-sf-malcoe-lh.-cesarean-delivery-in-native-american-women-are-low-rates-explained-by-practices-common-to-the-indian-health-service-birth.-2005-sep323170-8. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16128970**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16128970) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch16128970 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Multiple cesarean deliveries not associated with significant risk for uterine rupture {#multiple-cesarean-deliveries-not-associated-with-significant-risk-for-uterine-rupture .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P \< .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93). {#results-uterine-rupture-occurred-in-9-of-975-0.9-women-with-multiple-prior-cesarean-compared-with-115-of-16915-0.7-women-with-a-single-prior-operation-p-.37.-multivariable-analysis-confirmed-that-multiple-prior-cesarean-delivery-was-not-associated-with-an-increased-risk-for-uterine-rupture.-the-rates-of-hysterectomy-0.6-versus-0.2-p-.023-and-transfusion-3.2-versus-1.6-p-.001-were-increased-in-women-with-multiple-prior-cesarean-deliveries-compared-with-women-with-a-single-prior-cesarean-delivery-attempting-trial-of-labor.-similarly-a-composite-of-maternal-morbidity-was-increased-in-women-with-multiple-prior-cesarean-deliveries-undergoing-trial-of-labor-compared-with-those-having-elective-repeat-cesarean-delivery-odds-ratio-1.41-95-confidence-interval-1.02-1.93. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. LEVEL OF EVIDENCE: II-2. {#conclusion-a-history-of-multiple-cesarean-deliveries-is-not-associated-with-an-increased-rate-of-uterine-rupture-in-women-attempting-vaginal-birth-compared-with-those-with-a-single-prior-operation.-maternal-morbidity-is-increased-with-trial-of-labor-after-multiple-cesarean-deliveries-compared-with-elective-repeat-cesarean-delivery-but-the-absolute-risk-for-complications-is-small.-vaginal-birth-after-multiple-cesarean-deliveries-should-remain-an-option-for-eligible-women.-level-of-evidence-ii-2. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Landon MB](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Landon MB"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol. 2006 Jul;108(1):12-20. {#landon-mb-et-al-risk-of-uterine-rupture-with-a-trial-of-labor-in-women-with-multiple-and-single-prior-cesarean-delivery.-obstet-gynecol.-2006-jul108112-20. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16816050**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16816050) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch16816050 .Style-Heading-4-+-Arial-14-pt-Underline}

**Trial of Labor Often Successful After Prior Cesarean Delivery for
Multiple Gestation**

CONCLUSION: Women with one previous cesarean delivery for a multifetal
gestation have high trial of labor success rates and low complication
rates.

[Varner
MW](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Varner MW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Risk of uterine rupture with a trial of labor in women with
multiple and single prior cesarean delivery. Obstet Gynecol. 2006
Jul;108(1):12-20.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17906014&dopt=AbstractPlus>

**Neonatal mortality rates were higher among infants delivered by
cesarean delivery**

RESULTS: Neonatal mortality rates were higher among infants delivered by
cesarean delivery (1.77 per 1,000 live births) than for those delivered
vaginally (0.62). The magnitude of this difference was reduced only
moderately on statistical adjustment for demographic and medical
factors, and when deaths due to congenital malformations and events with
Apgar scores less than 4 were excluded. The cesarean/vaginal mortality
differential was widespread, and not confined to a few causes of death.
CONCLUSIONS: Understanding the causes of these differentials is
important, given the rapid growth in the number of primary cesareans
without a reported medical indication.

[MacDorman
MF](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="MacDorman MF"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Infant and neonatal mortality for primary cesarean and vaginal
births to women with \"no indicated risk,\" United States, 1998-2001
birth cohorts. Birth. 2006 Sep;33(3):175-82.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16948717>

**Rehospitalizations after giving birth were more likely in planned
cesarean vs vaginal birth**

RESULTS: Rehospitalizations in the first 30 days after giving birth were
more likely in planned cesarean (19.2 in 1,000) when compared with
planned vaginal births (7.5 in 1,000). After controlling for age,
parity, and race or ethnicity, mothers with a planned primary cesarean
were 2.3 (95% confidence interval \[CI\] 1.74-2.9) times more likely to
require a rehospitalization in the first 30 days postpartum. The leading
causes of rehospitalization after a planned cesarean were wound
complications (6.6 in 1,000) (P\<.001) and infection (3.3 in 1,000). The
average initial hospital cost of a planned primary cesarean of US
dollars 4,372 (95% C.I. US dollars 4,293-4,451) was 76% higher than the
average for planned vaginal births of US dollars 2,487 (95% C.I. US
dollars 2,481-2,493), and length of stay was 77% longer (4.3 days to 2.4
days). CONCLUSION: Clinicians should be aware of the increased risk for
maternal rehospitalization after cesarean deliveries to low-risk mothers
when counseling women about their choices. LEVEL OF EVIDENCE: II.

[Declercq
E](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Declercq E"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Maternal outcomes associated with planned primary cesarean births
compared with planned vaginal births. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Mar;109(3):669-77.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17329519>

**Exteriorization of uterus at cesarean delivery: Patient discomfort -
Should not be routine**

CONCLUSION: Exteriorization of the uterus for repair is associated with
an increased incidence of nausea and vomiting and tachycardia during
cesarean delivery under spinal anesthesia. Uterine repair should be done
in situ where possible. LEVEL OF EVIDENCE: I.

[Siddiqui
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Siddiqui M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Complications of exteriorized compared with in situ uterine repair
at cesarean delivery under spinal anesthesia: a randomized controlled
trial. Obstet Gynecol. 2007 Sep;110(3):570-5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766602>

**Other**

**Clear liquids in limited quantities does not increase labor
complications**

[Revised Guidelines for Obstetric Anesthesia Issued]{.underline}

The American Society of Anesthesiologists (ASA) has issued revised,
evidence-based practice guidelines for anesthetic management of women
during labor, including operative and nonoperative deliveries,
postpartum care and pain control.

The guidelines update guidelines issued in 1998 and \"include data and
recommendations on a wider range of techniques than was previously
addressed.\"

The guidelines also provide information for women to consider before
receiving anesthetics during childbirth.

\"Not all women require anesthetic care during labor and delivery,\" Dr.
Joy L. Hawkins, from University of Colorado, Denver, and chair of the
ASA Task Force on Practice Guidelines for Obstetric Anesthesia said in a
statement.

If a woman does request pain relief during labor and delivery, there are
many options available, Dr. Hawkins said, depending on the patient\'s
medical status, progress of labor and the resources available at the
healthcare facility.

\"The revised practice guidelines do not guarantee specific outcomes,
but provide basic recommendations based on a synthesis of expert
research and recommendations,\" Dr. Hawkins continued.

Among the revised recommendations:

\* Women in early labor should be offered the option of spinal or
epidural analgesia when available and it should not be withheld to meet
arbitrary standards for cervical dilation. Women should be reassured
that neuraxial analgesia does not increase the incidence of cesarean
section.

\* The use of spinals or epidurals is preferred over general anesthesia
for most cesarean sections.

\* To minimize post dural (spinal) headache, pencil-point spinal needles
should be used instead of cutting-bevel spinal needles for spinal
anesthesia.

\* Drinking clear liquids in limited quantities has been found to bring
comfort to women in labor and does not increase labor complications.
Women with uncomplicated labor may drink small amounts of clear liquid,
while those scheduled for nonemergency cesarean section may drink small
amounts of clear liquids up to 2 hours before anesthesia administration.

\* Solid foods should be avoided by patients during labor. Women
scheduled for elective cesarean section or tubal ligation should fast
for 6 to 8 hours prior to anesthesia administration.

Practice guidelines for obstetric anesthesia: An updated report by the
American Society of Anesthesiologists Task Force on Obstetric
Anesthesia. [American Society of Anesthesiologists Task Force on
Obstetric
Anesthesia](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="American Society of Anesthesiologists Task Force on Obstetric Anesthesia"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
[Anesthesiology.](javascript:AL_get(this, 'jour', 'Anesthesiology.');)
2007 Apr;106(4):843-63

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17413923>

For more information on the revised practice guidelines for obstetric
anesthesia, visit

[www.anesthesiology.org](http://www.anesthesiology.org/) or
[www.asahq.org](http://www.asahq.org/).

**Preterm birth and its recurrence increases with short interpregnancy
intervals**

CONCLUSION: The risk of preterm birth and its recurrence increases with
short interpregnancy intervals, even after adjustment for coexisting
risk factors. This highlights the importance of counseling women with
either an initial term or preterm birth to wait at least 12 months
between delivery and subsequent conception.

[DeFranco
EA](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="DeFranco EA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
A short interpregnancy interval is a risk factor for preterm birth and
its recurrence.

Am J Obstet Gynecol. 2007 Sep;197(3):264.e1-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17826413>

**Maternal obesity is associated with an increased risk of stillbirth**

We conducted this metaanalysis to summarize the available epidemiologic
evidence on the relationship between maternal overweight and obesity and
the risk of stillbirth.

[Results]{.underline}: Nine studies were included in the metaanalysis.
The unadjusted odds ratios of a stillbirth were 1.47 (95% CI, 1.08-1.94)
and 2.07 (95% CI, 1.59-2.74) among overweight and obese pregnant women,
respectively, compared with normal-weight pregnant women. The
metaregression analysis found no evidence that these estimates were
affected by selected study characteristics. Maternal obesity is
associated with an increased risk of stillbirth, although the mechanisms
to explain this association are not clear.

[Chu
SY](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Chu SY"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
Maternal obesity and risk of stillbirth: a metaanalysis. Am J Obstet
Gynecol. 2007 Sep;197(3):223-8. Review.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17826400>

**Optimal Gestational Weight Gain Improves Obstetric and Neonatal
Outcomes**

CONCLUSION: The gestational weight gain limits for BMI categories
determined in this large population-based cohort study from Swedish
Medical Registers showed that a decreased risk of adverse obstetric and
neonatal outcomes was associated with lower gestational weight gain
limits than was earlier recommended, especially among obese women

[Cedergren
MI](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Cedergren MI"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
et al Optimal gestational weight gain for body mass index categories.

Obstet Gynecol. 2007 Oct;110(4):759-64.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17906006>

**Little basis for offering combined spinal-epidural over epidurals in
labour**

CONCLUSIONS: There appears to be little basis for offering combined
spinal-epidural (CSE) over epidurals in labour with no difference in
overall maternal satisfaction despite a slightly faster onset with CSE
and less pruritus with epidurals. There is no difference in ability to
mobilise, obstetric outcome or neonatal outcome. However, the
significantly higher incidence of urinary retention and rescue
interventions with traditional techniques would favour the use of
low-dose epidurals. It is not possible to draw any meaningful
conclusions regarding rare complications such as nerve injury and
meningitis.

[Simmons
SW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Simmons SW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Combined spinal-epidural versus epidural analgesia in labour.\
Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003401. Review.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636721>

**Adding extraamniotic saline infusion to Foley catheter does not
improve labor induction**

CONCLUSION: In women with an unfavorable cervix, the addition of
extraamniotic saline infusion to a transcervical Foley catheter does not
improve efficacy for labor induction. LEVEL OF EVIDENCE: I.

[Lin
MG](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Lin MG"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Transcervical Foley catheter with and without extraamniotic saline
infusion for labor induction: a randomized controlled trial. Obstet
Gynecol. 2007 Sep;110(3):558-65.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766600>

**Oral health for pregnant women discussion clinical setting and dental
home for children**

Preventive activities and education and awareness University of Albany
School of Public Health 1 hour 13 minute video -- This could be used as
a group CEU

Oral Health during Pregnancy (video and discussion) moves into Early
Childhood (full pediatric assessment and parent education visit on
video)

The program Oral Health during Pregnancy and Early Childhood is now
available online at:
<http://media.albany.edu:8080/ramgen/cellar/sph/oral_health_during_pregnancy.rm>

MUST view CEU VIDEO, 73 minutes

1.25 CEU's Continuing Education credits are available by filling out the
evaluation and post-test on the University at Albany School of Public
Health Web site.
[www.albany.edu/sph/coned/oralhealth.htm](http://www.albany.edu/sph/coned/oralhealth.htm)
  For questions, call Sue Brooks at 518/486-6453 or E-mail
<coned@albany.edu>.

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

**HPV test beats Pap in detecting cervical cancer**

A new study led by McGill University researchers shows that the human
papillomavirus (HPV) screening test is far more accurate than the
traditional Pap test in detecting cervical cancer.

Moreover, because of its higher sensitivity and only slightly lower
specificity, patients would only require an HPV test once every three
years instead of annually, as is necessary with the Pap test.

CONCLUSIONS: As compared with Pap testing, HPV testing has greater
sensitivity for the detection of cervical intraepithelial neoplasia

[Mayrand
MH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mayrand MH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Human papillomavirus DNA versus Papanicolaou screening tests for
cervical cancer.N Engl J Med. 2007 Oct 18;357(16):1579-88.
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17942871>

#### [OB/GYN CCC Editorial comment:]{.underline}

**We still use the new 2006 ASCCP Consensus Guidelines**

CCCaST is the first randomized controlled trial in North America of HPV
testing as a stand-alone screening test for cervical cancer. The first
round followed 10,154 women aged 30 to 69 in Montreal, Quebec and St.
John\'s, Newfoundland who were enrolled in the study from 2002 to 2005.

While the above results are of interest, we will adhere to the new 2006
ASCCP Consensus Guidelines which can be found here:
<http://www.asccp.org/consensus.shtml>

**Other Cervical Cancer Screening Articles**

**Value of HPV testing in LGSIL treated with LEEP per ASCCP guidelines**

OBJECTIVE: This study was undertaken to evaluate the value of high-risk
human papillomavirus (HPV) testing in the follow-up of cervical
intraepithelial neoplasia grade low-grade squamous intraepithelial
lesion treated by loop electrosurgical excision procedure because of the
risk criteria established by the American Society for Colposcopy and
Cervical Pathology (ie, unsatisfactory colposcopy or positive
endocervical curettage, persistence of cervical intraepithelial
neoplasia grade 1/low-grade squamous intraepithelial lesion, or
high-risk HPV infection for longer than 2 years and older than 40
years).

CONCLUSION: Patients with low-grade squamous intraepithelial
lesion/cervical intraepithelial neoplasia grade 1 and risk factors have
a significant risk of harboring a cervical intraepithelial neoplasia
grade 2-3 lesion. A conservative approach should be considered when
basal high-risk HPV test is negative. High pretreatment high-risk HPV
loads should be considered a risk factor for developing
residual/recurrent disease. Posttreatment Hybrid Capture II has an
extremely high sensitivity for detecting recurrences.

[Alonso
I](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Alonso I"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
High-risk cervical epithelial neoplasia grade 1 treated by loop
electrosurgical excision: follow-up and value of HPV testing. Am J
Obstet Gynecol. 2007 Oct;197(4):359.e1-6

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17714678>

**Risk assessment to guide the prevention of cervical cancer**

Advances in screening and diagnosis make it increasingly possible to
prevent cervical cancer. However, if misused or poorly understood, these
new tools will only increase costs and potentially harm patients without
benefit. As a framework for standardized care that maximizes patient
safety and well-being, we propose that a risk model be adopted to guide
clinical management now and in the future. The model would use
thresholds of increasing risk for cervical precancer and treatable
cancer to guide clinical decision making for screening intensity,
diagnostic evaluation, or treatment. Experts would decide on these risk
thresholds and stratum based on the patient risk to benefit, independent
of current (eg, cytology, carcinogenic HPV testing, and colposcopy) and
future methods of measuring risk. A risk management model for cervical
cancer prevention, based on appropriate clinical actions that correspond
to risk stratum, can result in better allocation of resources to and
increased safety for women at the greatest risk and increased well-being
for women at the lowest risk.

[Castle
PE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Castle PE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Risk assessment to guide the prevention of cervical cancer.

Am J Obstet Gynecol. 2007 Oct;197(4):356.e1-6. Review.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904958>

**Other topics**

**New Guidelines for Assessing Gynecologic Cancer Predispositions**

Women with germline mutations in the cancer susceptibility genes, BRCA1
or BRCA2, associated with Hereditary Breast/Ovarian Cancer syndrome,
have up to an 85% lifetime risk of breast cancer and up to a 46%
lifetime risk ovarian cancer. Similarly, women with mutations in the DNA
mismatch repair genes, MLH1, MSH2 or MSH6, associated with the
Lynch/Hereditary Non-Polyposis Colorectal Cancer (HNPCC) syndrome, have
up to a 40-60% lifetime risk of both endometrial and colorectal cancer
as well as a 9-12% lifetime risk of ovarian cancer. Genetic risk
assessment enables physicians to provide individualized evaluation of
the likelihood of having one of these gynecologic cancer predisposition
syndromes, as well the opportunity to provide tailored screening and
prevention strategies such as surveillance, chemoprevention, and
prophylactic surgery that may reduce the morbidity and mortality
associated with these syndromes. Hereditary cancer risk assessment is a
process that includes assessment of risk, education and counseling
conducted by a provider with expertise in cancer genetics, and may
include genetic testing after appropriate consent is obtained. This
commentary provides guidance on identification of patients who may
benefit from hereditary cancer risk assessment for Hereditary
Breast/Ovarian Cancer and the Lynch/Hereditary Non-Polyposis Colorectal
Cancer syndrome.

[Lancaster
JM](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Lancaster JM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Society of gynecologic oncologists education committee statement
on risk assessment for inherited gynecologic cancer predispositions.

Gynecol Oncol. 2007 Nov;107(2):159-62.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17950381>

**Which Factors Influence Progression of Pelvic Prolapse?**

**Conclusion:** The authors conclude that vaginal descent is common in
postmenopausal women, but that the rate of progression is variable and
the condition can regress. Only one in 10 women had descent of 2 cm or
more, and the risk of descent was related to obesity and a history of at
least five vaginal births. Clinically significant progression over the
three-year study was rare. The authors believe that women with evidence
of vaginal descent can be reassured that they are at low risk of
significant progression over three years.

Bradley CS, et al. Natural history of pelvic organ prolapse in
postmenopausal women. Obstet Gynecol April 2007;109:848-54

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17400845>

**Despite shorter length of stay TVH / LAVH far less common than TAH for
benign disease**

CONCLUSION: Despite a shorter length of stay, vaginal and laparoscopic
hysterectomies remain far less common than abdominal hysterectomy for
benign disease. LEVEL OF EVIDENCE: III.

[Wu
JM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wu JM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Hysterectomy rates in the United States, 2003. Obstet Gynecol.
2007 Nov;110(5):1091-5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17978124&dopt=AbstractPlus>

**Abdominal sacrocolpopexy: Lower rate of recurrent vault prolapse than
SSLS**

AUTHORS\' CONCLUSIONS: Abdominal sacrocolpopexy is associated with a
lower rate of recurrent vault prolapse and dyspareunia than the vaginal
sacrospinous colpopexy. These benefits must be balanced against a longer
operating time, longer time to return to activities of daily living and
increased cost of the abdominal approach. The use of mesh or graft
inlays at the time of anterior vaginal wall repair may reduce the risk
of recurrent cystocele. Posterior vaginal wall repair may be better than
transanal repair in the management of rectoceles in terms of recurrence
of prolapse. The addition of a continence procedure to a prolapse repair
operation may reduce the incidence of postoperative urinary incontinence
but this benefit needs to be balanced against possible differences in
costs and adverse effects. Adequately powered randomised controlled
clinical trials are urgently needed.

[Maher
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Maher C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Surgical management of pelvic organ prolapse in women. Cochrane
Database Syst Rev. 2007 Jul 18;(3):CD004014. Review.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636742>

**Tubal flushing with oil-soluble contrast media in increasing the odds
of pregnancy**

AUTHORS\' CONCLUSIONS: There is evidence of effectiveness of tubal
flushing with oil-soluble contrast media in increasing the odds of
pregnancy and live birth versus no intervention. Future robust
randomised trials, comparing oil-soluble versus water-soluble media,
water-soluble media versus no intervention and tubal flushing versus
established treatments for infertility would be a useful further guide
to clinical practice.

[Luttjeboer
F](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Luttjeboer F"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Tubal flushing for subfertility. Cochrane Database Syst Rev. 2007
Jul 18;(3):CD003718. Review.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636730>

**Urocortin plasma levels may differentiate endometrioma from other
benign ovarian cysts**

CONCLUSION: Plasma urocortin is increased in women with endometriomas,
and its measurement may be useful for the differential diagnosis of
endometrioma compared with other benign ovarian cysts. LEVEL OF
EVIDENCE: II.

Florio P; et al Plasma urocortin levels in the diagnosis of ovarian
endometriosis.Obstet Gynecol. 2007 Sep;110(3):594-600.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766605>

**Laparoscopic \'drilling\' by diathermy or laser for ovulation
induction in anovulatory PCOS**

CONCLUSIONS: There was no evidence of a difference in the live birth
rate and miscarriage rate in women with clomiphene-resistant PCOS
undergoing LOD compared to gonadotrophin treatment. The reduction in
multiple pregnancy rates in women undergoing LOD makes this option
attractive. However, there are ongoing concerns about long-term effects
of LOD on ovarian function

[Farquhar
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Farquhar C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Laparoscopic \'drilling\' by diathermy or laser for ovulation
induction in anovulatory polycystic ovary syndrome. Cochrane Database
Syst Rev. 2007 Jul 18;(3):CD001122. Review.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636653>

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

**Long-term prognosis for infants after massive fetomaternal
hemorrhage**

RESULTS: During the study period, 48 patients had massive fetomaternal
hemorrhage (crude incidence 1.1 per 1,000; corrected incidence for
Rh-negative women 4.6 per 1,000). Six fetal deaths were observed,
representing 1.6% of all fetal deaths during the period. Nine newborns
(18.7%) were transferred to neonatal intensive care unit (NICU) and five
(10.4%) had transfusions. Fetomaternal hemorrhages of 20 mL/kg or more
significantly increased the risk of fetal death, induced preterm
delivery, transfer to NICU, and neonatal anemia requiring transfusion.
Long-term follow-up was not associated with neurological sequelae (0%,
95% confidence interval 0.0-11.6%).

[Rubod
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rubod C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Long-term prognosis for infants after massive fetomaternal
hemorrhage.\
Obstet Gynecol. 2007 Aug;110(2 Pt 1):256-60.

CONCLUSION: When the transfused volume equals or exceeds 20 mL/kg,
massive fetomaternal hemorrhage may lead to severe prenatal or neonatal
complications. LEVEL OF EVIDENCE: III.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666598>

**Increasing hyperglycemia in pregnancy associated with increased
childhood obesity**

CONCLUSIONS: Our results in a multiethnic U.S. population suggest that
increasing hyperglycemia in pregnancy is associated with an increased
risk of childhood obesity. More research is needed to determine whether
treatment of GDM may be a modifiable risk factor for childhood obesity.

[Hillier
TA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hillier TA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Childhood obesity and metabolic imprinting: the ongoing effects of
maternal hyperglycemia. Diabetes Care. 2007 Sep;30(9):2287-92. Epub 2007
May 22.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17519427>

Family-Based Strategies for Controlling Childhood Obesity

[Discussion:]{.underline} In this study of a family-based program
involving parenting skills and lifestyle modification, all groups lost
weight, but there were no significant differences in BMI *z* scores
among the three groups. More children in the P+DA group had lower BMI
*z* scores after 12 months compared with the other two groups. Waist
circumference *z* scores were lower in the intervention groups compared
with the control group at 12 months, and boys appear to benefit from
intervention more than girls. Overall, the benefits of family training
and involvement in reducing adiposity were modest. Because the control
group also lost weight, the study might not have been adequately powered
to detect greater differences. The authors conclude that further studies
exploring a sex differential are warranted.

**Source:** Golley RK, et al. Twelve-month effectiveness of a
parent-led, family-focused weight-management program for prepubertal
children: a randomized, controlled trial. Pediatrics March
2007;119:517-25.

AFP EDITOR\'S NOTE: A BMI *z* score reflects each person\'s BMI relative
to the general population. One review observes that reference
measurements, such as *z* score and centile measurements, are adequate
for single BMI measurements, but do not assess within-child BMI changes
over time. However, if a raw BMI score is used, adult obesity
definitions do not apply because BMI is lower in children than in
adults.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17332205>

**Effectiveness of a Novel Infant Tooth Wipe in High Caries-risk Babies
8 to 15 Months Old**

[Purpose]{.underline}: The purpose of this study was to assess baby and
parental satisfaction and plaque-removal efficacy of a novel infant
tooth wipe (Spiffies) in high caries-risk babies.

[Methods:]{.underline} Thirty-five healthy and caries-free infants were
selected. Babies had never had their teeth cleaned and no primary molars
were yet present. Subjects were identified with the risk factor of
nightly feeding behaviors. Pre- and postcleaning oral hygiene plaque
measurements were recorded and then analyzed by a blinded examiner. A
manual ing toothbrush (Ultra Kids) was used as the control method.
Infants' caregivers used their randomly assigned cleaning method without
instruction. Babies returned to the clinic after a 48- to 72-hour
washout period, and the procedures were repeated before and after use of
the alternate method. Parental satisfaction and baby perceived
acceptance were evaluated by a questionnaire and were analyzed at the
time of the visit and at bedtime.

[Results:]{.underline} Both the infant tooth wipe and conventional
brushing significantly reduced plaque levels (P\<.001). Parents were
more satisfied with the wipes when compared to toothbrushing,
particularly after nightly feeding habits (P\<.001). Similarly, infant's
acceptance was higher with the wipes at daytime and significantly higher
at night-time (P=.002). Conclusions: The Novel Infant Tooth Wipe
provides an effective method of plaque removal before the eruption of
primary molars.           

Galganny-Almeida, A et al The Effectiveness of a Novel Infant Tooth Wipe
in High Caries-risk Babies 8 to 15 Months Old (Pediatr. Dent.
2007;29:337-42)

<http://www.aapd.org/searcharticles/article.asp?ARTICLE_ID=2183>

**ACIP Recommendations for the Prevention of Varicella**

[Routine Vaccination]{.underline}

Although one-dose vaccination coverage has been high and varicella
morbidity and mortality has diminished, the one-dose program did not
prevent varicella outbreaks completely. Therefore, two 0.5-mL doses of
varicella vaccine administered subcutaneously are recommended for
children 12 months and older, adolescents, and adults without evidence
of immunity.

The second dose should provide improved protection to children who do
not respond adequately to the first dose, and it should lower the risk
for breakthrough disease. In a follow-up from 1993 to 2003 of healthy
children 12 months to 12 years of age who were given one or two doses of
varicella vaccine, the annual risk for varicella after community
exposure was 0.8 percent in children who received one dose and 0.2
percent in children who received two doses (number needed to treat =
167). The rate in children without immunity is estimated at about 14
percent.

Because of the risk for transmission of VZV in schools, all children
entering school should receive two doses of varicella-containing vaccine
or have other evidence of immunity. All states should require that
students at all grade levels (including college) and those in child care
centers receive varicella vaccine unless they have evidence of immunity.

[CHILDREN 12 MONTHS TO 12 YEARS OF AGE]{.underline}

All healthy children should receive their first dose of
varicella-containing vaccine at 12 to 15 months of age, and a second
dose between the ages of four and six years (i.e., before entering
prekindergarten, kindergarten, or first grade). The second dose may be
administered earlier if the first dose was given more than three months
previously. These recommended ages are harmonized with the
recommendations for measles, mumps, and rubella vaccination and are
intended to limit the period when children have no varicella antibody.
Although the recommended minimum interval between the two doses for
children 12 months to 12 years of age is three months, if the second
dose was administered 28 days or more after the first dose, the second
dose is considered valid and need not be repeated.

Whenever any components of the combination vaccine are indicated and the
other components are not contraindicated, the use of licensed
combination vaccines, such as MMRV vaccine, is preferred over separate
injection of equivalent component vaccines. Single-antigen and
combination MMRV vaccines may be administered simultaneously with other
vaccines recommended for children 12 to 15 months of age and those four
to six years of age. Simultaneous administration is particularly
important if it is suspected a child will not return for subsequent
vaccination.

[PERSONS 13 YEARS AND OLDER]{.underline}

Persons 13 years and older without evidence of varicella immunity should
receive two doses of single-antigen varicella vaccine administered four
to eight weeks apart. However, if more than eight weeks elapse after the
first dose, the second dose may be administered without restarting the
schedule. Because the risk for transmission can be high among students
in schools, colleges, and other educational institutions, students
without evidence of immunity should routinely receive two doses of
vaccine.

Special consideration for vaccination should be given to persons without
evidence of immunity who have an increased risk of transmission to
persons at high risk for severe disease or who have an increased risk
for exposure. These include health care professionals; household
contacts of immunocompromised persons; those who live or work in
environments in which transmission of VZV is likely (e.g., teachers,
child care workers, residents and staff in institutional settings) or
has been reported (e.g., college students, inmates and staff members of
correctional institutions, military personnel); nonpregnant women of
childbearing age; adolescents and adults who live in households with
children; and international travelers.

[Catch-up Vaccination]{.underline}

A second dose is recommended for children, adolescents, and adults who
previously received one dose. The recommended minimum interval between
the first and second doses is three months for children 12 years or
younger and four weeks for persons 13 years or older. However, the
catch-up dose may be administered at any interval longer than the
minimum recommended.

Physicians should use the recommended health maintenance visit at 11 to
12 years of age and other routine visits to ensure that all children
without evidence of immunity have received two doses of varicella
vaccine.

[Prenatal Assessment and Postpartum Vaccination]{.underline}

Prenatal assessment of women for evidence of varicella immunity is
recommended. Varicella in pregnant women is associated with a risk of
VZV transmission to the child, which may cause congenital varicella
syndrome, neonatal varicella, or herpes zoster during infancy or early
childhood. Birth before 1980 is not considered evidence of immunity in
pregnant women because of the potential severe consequences of
infection.

Because the effects of the varicella vaccine on the fetus are unknown,
pregnant women should not be vaccinated. Women without evidence of
immunity should be vaccinated on completion or termination of pregnancy.
The first dose of vaccine should be administered before discharge from
the health care facility, and the second dose should be given four to
eight weeks later. Women should be counseled to avoid conception for one
month after each dose, but they may continue to breastfeed.

[Health Care Professionals]{.underline}

Health care institutions should ensure that all health care
professionals have evidence of immunity to varicella. Birth before 1980
is not considered evidence of immunity in this group because of the
possibility of nosocomial transmission to high-risk patients. Health
care professionals who have received two doses of vaccine and who are
exposed to VZV should be monitored daily during days 10 to 21 after
exposure and should be instructed to report fever, headache, or other
constitutional symptoms and any atypical skin lesions immediately.

Health care institutions should establish protocols and recommendations
for screening and vaccinating health care professionals and for
management after exposures in the workplace. Health care professionals
in whom a vaccine-related rash occurs should avoid contact with persons
without evidence of immunity who are at risk for severe disease and
complications until all lesions resolve (i.e., are crusted over or fade
away) or until no new lesions appear within 24 hours.

[Special Considerations]{.underline}

Vaccination with the single-antigen vaccine should be considered in
children who have HIV infection with an age-specific CD4 T-lymphocyte
percentage of 15 percent or more, and may be considered in adolescents
and adults with a CD4 T-lymphocyte count of 200 cells per µL or greater.
Persons with impaired humoral immunity may be vaccinated. Single-antigen
varicella vaccine should be used for persons with some degree of
immunodeficiency.

Outbreak Control and Postexposure Prophylaxis

A two-dose varicella vaccination policy is recommended for outbreak
control. In outbreaks among preschool-age children, two-dose vaccination
is recommended, and children vaccinated with one dose should receive a
second dose if three months have elapsed since the first. Although
outbreak control efforts should be implemented as soon as an outbreak is
identified, vaccination should still be offered when the outbreak is
identified late.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm>

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

**Heart Disease Kills More Younger Women**

For decades, heart disease death rates have been falling. But a new
study shows a troubling turn: more women under 45 are dying of heart
disease due to clogged arteries, and the death rate for men that age has
leveled off. Many aren\'t sure what went wrong, but they think
increasing rates of obesity and other risk factors are to blame.

[Conclusions:]{.underline} The mortality rates for CHD among younger
adults may serve as a sentinel event. Unfavorable trends in several risk
factors for CHD provide a likely explanation for the observed mortality
rates.

Ford ES,Capewell S. Coronary Heart Disease Mortality Among Young Adults
in the U.S. From 1980 Through 2002 J Am Coll Cardiol, 2007;
50:2128-2132,

<http://content.onlinejacc.org/cgi/content/abstract/50/22/2128>

**Low-Carbohydrate Diet Effective in Women**

**Conclusion:** The authors conclude that patients on the Atkins diet
have greater weight loss at two and six months than those on the Zone,
Ornish, or LEARN diets and have greater weight loss at one year than
those on the Zone diet. Atkins dieters also have more favorable lipid
profiles and blood pressures at various measurements, suggesting that
concerns about how low-carbohydrate diets affect cardiac risk factors
are unfounded.

Gardner CD, et al. Comparison of the Atkins, Zone, Ornish, and LEARN
diets for change in weight and related risk factors among overweight
premenopausal women. The A to Z weight loss study: a randomized trial.
JAMA March 7, 2007;297:969-77.

[**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17341711**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17341711)

Does Aspirin Use Affect Mortality in Women?

**Results:** Of the 79,439 participants, 9,477 died during the study.
Women who regularly used aspirin had a relative risk of death from any
cause of 0.75 (95% confidence interval, 0.71 to 0.81), compared with
women who did not take aspirin. In aspirin users, the relative risk of
death related to cardiovascular disease was less than that of
cancer-related death (0.62 versus 0.88). A significant reduction in
cardiovascular disease-related deaths occurred one to five years after
initiating aspirin therapy, whereas the reduction in cancer-related
deaths occurred after 10 years of aspirin use. Low and moderate doses of
aspirin were equally effective in reducing mortality. The greatest
benefit of aspirin use occurred in older participants and in those with
more cardiac risk factors.

**Conclusion:** Low and moderate doses of aspirin were associated with a
reduction in death from any cause in women, particularly in older women
and those with more cardiac risk factors. The reduction in
cardiovascular deaths occurred within five years, whereas the reduction
in cancer deaths occurred after 10 years of aspirin use.

Chan AT, et al. Long-term aspirin use and mortality in women. Arch
Intern Med March 26, 2007;167:562-72.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17389287>

**High suicide and heart disease deaths with bariatric surgery**

CONCLUSIONS: There was a substantial excess of deaths owing to suicide
and coronary heart disease. Careful monitoring of bariatric surgical
procedures and more intense follow-up could likely reduce the long-term
case fatality rate in this patient population.

[Omalu
BI](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Omalu BI"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Death rates and causes of death after bariatric surgery for
Pennsylvania residents, 1995 to 2004. Arch Surg. 2007 Oct;142(10):923-8;
discussion 929

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17938303>

######### Hypertension in Pregnancy: An Emerging Risk Factor for Cardiovascular Disease

<http://www.medscape.com/viewarticle/564295>

# 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}

**Use of Psychiatric Medications During Pregnancy and Lactation**

**Summary of Recommendations and Conclusions**

***The following recommendations and conclusions are based on good and
consistent scientific evidence (Level A):***

-   Lithium exposure in pregnancy may be associated with a small
    increase in congenital cardiac malformations, with a risk ratio of
    1.2--7.7.

-   Valproate exposure in pregnancy is associated with an increased risk
    of fetal anomalies, including neural tube defects, fetal valproate
    syndrome, and long-term adverse neurocognitive effects. It should be
    avoided in pregnancy, if possible, especially during the first
    trimester.

-   Carbamazepine exposure in pregnancy is associated with fetal
    carbamazepine syndrome. It should be avoided in pregnancy, if
    possible, especially during the first trimester.

-   Maternal benzodiazepine use shortly before delivery is associated
    with floppy infant syndrome.

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

-   Paroxetine use in pregnant women and women planning pregnancy should
    be avoided, if possible. Fetal echocardiography should be considered
    for women who are exposed to paroxetine in early pregnancy.

-   Prenatal benzodiazepine exposure increased the risk of oral cleft,
    although the absolute risk increased by 0.01%.

-   Lamotrigine is a potential maintenance therapy option for pregnant
    women with bipolar disorder because of its protective effects
    against bipolar depression, general tolerability, and a growing
    reproductive safety profile relative to alternative mood
    stabilizers.

-   Maternal psychiatric illness, if inadequately treated or untreated,
    may result in poor compliance with prenatal care, inadequate
    nutrition, exposure to additional medication or herbal remedies,
    increased alcohol and tobacco use, deficits in mother--infant
    bonding, and disruptions within the family environment.

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

-   Whenever possible, multidisciplinary management involving the
    patient's obstetrician, mental health clinician, primary health care
    provider, and pediatrician is recommended to facilitate care.

-   Use of a single medication at a higher dose is favored over the use
    of multiple medications for the treatment of psychiatric illness
    during pregnancy.

-   The physiologic alterations of pregnancy may affect the absorption,
    distribution, metabolism, and elimination of lithium, and close
    monitoring of lithium levels during pregnancy and postpartum is
    recommended.

-   For women who breastfeed, measuring serum levels in the neonate is
    not recommended.

-   Treatment with all SSRIs or selective norepinephrine reuptake
    inhibitors or both during pregnancy should be individualized.

-   Fetal assessment with fetal echocardiogram should be considered in
    pregnant women exposed to lithium in the first trimester.

Use of Psychiatric Medications During Pregnancy and Lactation. ACOG
Practice Bulletin No. 87. 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=17978143>

**Cesarean Delivery on Maternal Request**

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 39 weeks of
gestation or without verification 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. 386.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:1209-12.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17978146>

**Colonoscopy and Colorectal Cancer Screening and Prevention**

ABSTRACT: Most colorectal cancer can be detected by screening modalities
and treated at a preinvasive or early invasive stage, before it has
developed to a fully invasive and potentially fatal disease.
Obstetrician--gynecologists should counsel all patients aged 50 years
and older about the benefits of colorectal cancer screening and should
encourage colonoscopy as the preferred method of screening for women at
either average risk or high risk. The advantages and limitations of
other appropriate colorectal cancer screening methods also should be
discussed so that women may choose to be tested by whichever method they
are most likely to accept and complete.

Colonoscopy and Colorectal Cancer Screening and Prevention. ACOG
Committee Opinion No. 384. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2007;110:1199-1202.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17978144>

**The Limits of Conscientious Refusal in Reproductive Medicine**

ABSTRACT: Health care providers occasionally may find that providing
indicated, even standard, care would present for them a personal moral
problem---a conflict of conscience---particularly in the field of
reproductive medicine. Although respect for conscience is important,
conscientious refusals should be limited if they constitute an
imposition of religious or moral beliefs on patients, negatively affect
a patient's health, are based on scientific misinformation, or create or
reinforce racial or socioeconomic inequalities. Conscientious refusals
that conflict with patient well-being should be accommodated only if the
primary duty to the patient can be fulfilled. All health care providers
must provide accurate and unbiased information so that patients can make
informed decisions. Where conscience implores physicians to deviate from
standard practices, they must provide potential patients with accurate
and prior notice of their personal moral commitments. Physicians and
other health care providers have the duty to refer patients in a timely
manner to other providers if they do not feel that they can in
conscience provide the standard reproductive services that patients
request. In resource-poor areas, access to safe and legal reproductive
services should be maintained. Providers with moral or religious
objections should either practice in proximity to individuals who do not
share their views or ensure that referral processes are in place. In an
emergency in which referral is not possible or might negatively have an
impact on a patient's physical or mental health, providers have an
obligation to provide medically indicated and requested care.

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.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17978145>

**Supracervical Hysterectomy**

ABSTRACT: Women with known or suspected gynecologic cancer, current or
recent cervical dysplasia, or endometrial hyperplasia are not candidates
for a supracervical procedure. Patients electing supracervical
hysterectomy should be carefully screened preoperatively to exclude
cervical or uterine neoplasm and should be counseled about the need for
long-term follow-up, the possibility of future trachelectomy, and the
lack of data demonstrating clear benefits over total hysterectomy. The
supracervical approach should not be recommended by the surgeon as a
superior technique for hysterectomy for benign disease

Supracervical Hysterectomy. ACOG Committee Opinion no. 388. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:1215-7.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17978148>

**Pharmaceutical Compounding**

ABSTRACT: Compounding is the preparation of an individualized drug
product in response to a physician's prescription to create a medication
tailored to the specialized needs of an individual patient. There are
currently no specific prohibitions by the U.S. Food and Drug
Administration on what constitutes a legitimate claim for compounded
drug products, even if there is no efficacy, risk, or safety evidence to
support an advertised claim. Physicians and patients should exercise
caution in prescribing and using products that are largely untested for
safety and efficacy.

Pharmaceutical Compounding. ACOG Committee Opinion no. 387. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:1213-4.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17978147>

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

Predicting the Likelihood of Successful Vaginal Birth After Cesarean
Delivery

Clinical Question

Which patients are likely to have a successful vaginal birth after a
previous cesarean delivery?

Evidence Summary

The American College of Obstetricians and Gynecologists and the American
Academy of Family Physicians recommend that pregnant women with a single
previous cesarean delivery and a low-transverse incision be offered a
trial of labor. Although the rate of vaginal birth after cesarean
delivery (VBAC) increased from 19 percent of all deliveries in 1989 to a
peak of 28 percent in 1996, the rate decreased to only 9.2 percent of
all deliveries in 2004. The decline has been partially driven by
concerns about the small but measurable risk of uterine rupture with
VBAC, particularly when labor is induced or augmented.

At the same time, the total number of cesarean deliveries has been
increasing, largely because of an increase in primary cesarean
deliveries. A screening tool to help predict whether a woman will have a
successful VBAC may help patients and their physicians make more
informed shared decisions.

A 2003 evidence review by the Agency for Healthcare Research and Quality
found overall VBAC success rates between 60 and 82 percent in published
studies, with an estimated overall success rate of 75 percent at
teaching institutions and tertiary medical centers. The risks of
perinatal death or hysterectomy from uterine scar rupture were low (1.5
and 4.8 per 10,000 births, respectively). The review identified factors
associated with an increased likelihood of vaginal delivery (i.e.,
maternal age younger than 40 years, previous successful vaginal
delivery, and favorable cervical factors). The review also identified
factors that decreased the likelihood of vaginal birth (i.e., more than
one previous cesarean delivery; induction of labor; birth weight greater
than 4,000 g \[8 lb, 13 oz\]; and gestational age greater than 40
weeks).

A number of researchers have attempted to develop clinical decision
rules to predict the likelihood of a successful trial of labor after a
previous cesarean delivery. A 2004 systematic review identified six of
these clinical decision rules, two of which were validated (i.e., tested
in a new population to confirm accuracy of the rule). Three subsequent
rules were developed and validated. These five validated rules are
summarized in *Table 1* (see link below)

Although the Troyer rule was validated, the number of patients in the
validation group was small. The Hashima rule was also prospectively
validated; however, only three out of 5,414 women had a score of 0, and
only 101 had a score of 1 (low probability of success). The remaining
5,310 women had scores of 2 (53 percent success rate) or 3 (67 percent
success rate), which provides little useful information for decision
making.

The remaining three scores were well validated and were shown to be
accurate in a large, representative population. The Flamm rule (Table 2)
(see link below) is the simplest to use, although it is limited by its
age (data were gathered between 1990 and 1992) and by the requirement of
cervical effacement information, which makes it unhelpful for antepartum
planning.

The Smith rule is well validated but is based on a multivariate
equation, making it too complex for practical use at the point of care.
Although the Grobman rule is also based on a complex multivariate
equation, a nomogram (Figure 1) (see link below) is provided for use at
the point of care.

The Grobman rule has been well validated and all of the needed variables
are available to the patient and physician before the onset of labor.)

[Applying the Evidence]{.underline}

A 25-year-old, non-Hispanic, white woman with a body mass index (BMI) of
25 kg per m2 is in labor. Her cervix is 3 cm dilated and about 30 to 40
percent effaced. She has had one previous pregnancy, which resulted in
cesarean delivery because of failure to progress. She wonders how likely
it is that a trial of labor will be successful.

[Answer:]{.underline}

Using the Flamm rule (Table 2) (see link below) the patient receives two
points for age and one for cervical effacement. The total score of 3
gives her a 60 percent probability of vaginal delivery. Using the
Grobman nomogram (Figure 1), (see link below) the patient receives 10
points for age, 30 for body mass index, points each for being
non-African American and non-Hispanic, and 0 for no history of vaginal
birth or recurrent primary indication. The total score of 54 points
gives her a 68 percent probability of vaginal delivery. You advise the
patient that her chance of a successful trial of labor is about two out
of three.
[**http://www.aafp.org/afp/20071015/poc.html**](http://www.aafp.org/afp/20071015/poc.html)
Point-of-Care Guides

Effectiveness of Insulin Sensitizing Drugs for Polycystic Ovary Syndrome

[Clinical Question]{.underline}

Do insulin sensitizing drugs with or without oral contraceptive pills
improve clinical outcomes in women with polycystic ovary syndrome
(PCOS)?

[Evidence-Based Answer]{.underline}

Insulin sensitizing drugs are more effective than oral contraceptives
alone at improving fasting insulin levels in patients with PCOS.
Compared with metformin (Glucophage) alone, oral contraceptives alone
better control irregular menstrual cycles and reduce androgen levels.
There is insufficient evidence to recommend insulin sensitizing drugs
alone or in combination with oral contraceptives to decrease the risk of
diabetes, cardiovascular disease, or endometrial cancer.

[Practice Pointers]{.underline}

PCOS is defined by the presence of two of the following criteria:
oligomenorrhea or amenorrhea, clinical or biochemical hyperandrogenism,
or polycystic ovaries visible on ultrasonography. Family physicians
routinely treat symptoms of irregular menstrual cycles and excessive
androgen levels with combination oral contraceptives. The benefit of
using insulin sensitizing drugs is unclear. Ideally, treatment of PCOS
would improve clinical symptoms such as hirsutism and infertility and
decrease the risk of type 2 diabetes, cardiovascular disease, or
endometrial cancer.

In this Cochrane review, the authors searched the literature for
randomized controlled trials (RCTs) comparing treatment of PCOS with
insulin sensitizing drugs with or without oral contraceptives. They
found six RCTs that included 226 total patients, 20 to 52 years of age.
Patients were followed for four to 12 months, with a median study
duration of six months. Metformin, 500 mg orally three times per day,
was the only insulin sensitizing drug studied.

Oral contraceptives were more effective at improving menstrual cycle
regularity and lowering androgen levels compared with metformin.
Although these findings were statistically significant, only 104
participants in three trials were analyzed for these outcomes. Metformin
lowered fasting insulin levels and did not impact triglyceride levels
compared with oral contraceptives. However, metformin did not lower
fasting glucose levels in patients without impaired glucose tolerance
and did not reduce the risk of type 2 diabetes when used alone. Combined
therapy improved hirsutism in a single RCT with 34 participants.

No combined RCTs with acne as primary outcome were available. None of
the trials analyzed the primary outcomes of stroke, myocardial
infarction, or endometrial cancer.

This review was limited by small study sizes. Because outcomes addressed
chronic disease, the studies may not have followed patients long enough
to show prevention benefits. No studies were available comparing
alternative insulin sensitizing drugs such as rosiglitazone (Avandia) or
pioglitazone (Actos). There was insufficient evidence on the outcomes of
hirsutism, acne, body mass index, blood pressure, and other cholesterol
parameters.

Evaluating fertility rates as a primary outcome could provide
practice-modifying information for many physicians. Expert consensus by
the American Association of Clinical Endocrinologists states that
metformin should be considered in the initial treatment of PCOS,
especially for patients who are overweight or obese. The 2002 American
College of Obstetricians and Gynecologists guideline recommends
metformin as one measure to improve ovulatory frequency and to treat
risk factors for diabetes and cardiovascular disease. Cochrane Briefs

Costello M, Shrestha B, Eden J, Sjoblom P, Johnson N.
Insulin-sensitising drugs versus the combined oral contraceptive pill
for hirsutism, acne and risk of diabetes, cardiovascular disease, and
endometrial cancer in polycystic ovary syndrome. Cochrane Database Syst
Rev 2007(1):CD005552.

[**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17253562**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17253562)

Second Trimester Pregnancy Loss (See also Patient Education)

Second trimester pregnancy loss is uncommon, but it should be regarded
as an important event in a woman\'s obstetric history. Fetal
abnormalities, including chromosomal problems, and maternal anatomic
factors, immunologic factors, infection, and thrombophilia should be
considered; however, a cause-and-effect relationship may be difficult to
establish. A thorough history and physical examination should include
inquiries about previous pregnancy loss. Laboratory tests may identify
treatable etiologies. Although there is limited evidence that specific
interventions improve outcomes, management of contributing maternal
factors (e.g., smoking, substance abuse) is essential. Preventive
measures, including vaccination and folic acid supplementation, are
recommended regardless of risk. Management of associated chromosomal
factors requires consultation with a genetic counselor or obstetrician.
The family physician can play an important role in helping the patient
and her family cope with the emotional aspects of pregnancy loss. (Am
Fam Physician 2007;76:1341-6, 1347-8.

[**http://www.aafp.org/afp/20071101/1341.html**](http://www.aafp.org/afp/20071101/1341.html)

**AAFP and ACP Publish Recommendations on Diagnosis and Management of
VTE**

There are 600,000 cases of venous thromboembolism (VTE) in the United
States every year. Of all persons with undetected or untreated pulmonary
embolism, 26 percent will have a fatal embolic event, and another 26
percent will have a recurrent embolic event that could become fatal.
Therefore, an early diagnosis of VTE is important to prevent mortality
and morbidity in this population.

This guideline summarizes the current approaches for the diagnosis of
venous thromboembolism. The importance of early diagnosis to prevent
mortality and morbidity associated with venous thromboembolism cannot be
overstressed. This field is highly dynamic, however, and new evidence is
emerging periodically that may change the recommendations. The purpose
of this guideline is to present recommendations based on current
evidence to clinicians to aid in the diagnosis of lower extremity deep
venous thrombosis and pulmonary embolism.

[Qaseem
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Qaseem A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Current diagnosis of venous thromboembolism in primary care: a
clinical practice guideline from the American Academy of Family
Physicians and the American College of Physicians. Ann Fam Med. 2007
Jan-Feb;5(1):57-62.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17261865&dopt=AbstractPlus>

**Methamphetamine Abuse (See also Patient Education)**

Methamphetamine is a stimulant commonly abused in many parts of the
United States. Most methamphetamine users are white men 18 to 25 years
of age, but the highest usage rates have been found in native Hawaiians,
persons of more than one race, Native Americans, and men who have sex
with men. Methamphetamine use produces a rapid, pleasurable rush
followed by euphoria, heightened attention, and increased energy.
Possible adverse effects include myocardial infarction, stroke,
seizures, rhabdomyolysis, cardiomyopathy, psychosis, and death. Chronic
methamphetamine use is associated with neurologic and psychiatric
symptoms and changes in physical appearance. High-risk sexual activity
and transmission of human immunodeficiency virus are also associated
with methamphetamine use. Use of methamphetamine in women who are
pregnant can cause placental abruption, intrauterine growth retardation,
and preterm birth, and there can be adverse consequences in children
exposed to the drug. Treatment of methamphetamine intoxication is
primarily supportive. Treatment of methamphetamine abuse is behavioral;
cognitive behavior therapy, contingency management, and the Matrix Model
may be effective. Pharmacologic treatments are under investigation. Am
Fam Physician 2007;76:1169-74, 1175-6

<http://www.aafp.org/afp/20071015/1169.html>

**Outpatient Care of the Premature Infant (See also Patient Education)**

An increasing number of infants in the United States are born
prematurely, with current statistics estimating about 13 percent of all
births. Although survival rates and outcomes for premature infants have
dramatically improved in recent decades, morbidity and mortality are
still significant. Infants born prematurely are at increased risk of
growth problems, developmental delays, and complex medical problems. To
account for prematurity, growth and development monitoring should be
done according to adjusted age (age in months from term due date).
Premature infants should gain 20 to 30 g (0.71 to 1.06 oz) per day after
discharge from the hospital. Growth parameters may be improved in the
short term with the use of enriched preterm formula or breast milk
fortifier. Each well-child examination should include developmental
surveillance so that early intervention can be initiated if a
developmental delay is diagnosed. Routine vaccination should proceed
according to chronologic age with minor exceptions, and respiratory
syncytial virus immune globulin is indicated in preterm infants who meet
the criteria. Am Fam Physician 2007;76:1159-64, 1165-6.
<http://www.aafp.org/afp/20071015/1159.html>

**Somatoform Disorders (See also Patient Education)**

The somatoform disorders are a group of psychiatric disorders that cause
unexplained physical symptoms. They include somatization disorder
(involving multisystem physical symptoms), undifferentiated somatoform
disorder (fewer symptoms than somatization disorder), conversion
disorder (voluntary motor or sensory function symptoms), pain disorder
(pain with strong psychological involvement), hypochondriasis (fear of
having a life-threatening illness or condition), body dysmorphic
disorder (preoccupation with a real or imagined physical defect), and
somatoform disorder not otherwise specified (used when criteria are not
clearly met for one of the other somatoform disorders). These disorders
should be considered early in the evaluation of patients with
unexplained symptoms to prevent unnecessary interventions and testing.
Treatment success can be enhanced by discussing the possibility of a
somatoform disorder with the patient early in the evaluation process,
limiting unnecessary diagnostic and medical treatments, focusing on the
management of the disorder rather than its cure, using appropriate
medications and psychotherapy for comorbidities, maintaining a
psychoeducational and collaborative relationship with patients, and
referring patients to mental health professionals when appropriate. Am
Fam Physician 2007;76:1333-8
<http://www.aafp.org/afp/20071101/1333.html>

**Mind-Body Therapies for Headache (See also Patient Education)**

Headache is one of the most common and enigmatic problems encountered by
family physicians. Headache is not a singular entity, and different
pathologic mechanisms are involved in distinct types of headache. Most
types of headache involve dysfunction of peripheral or central
nociceptive mechanisms. Mind-body therapies such as biofeedback,
cognitive behavior therapy, hypnosis, meditation, and relaxation
training can affect neural substrates and have been shown to be
effective treatments for various types of headache. Meta-analyses of
randomized controlled trials show that the use of mind-body therapies,
alone or in combination, significantly reduces symptoms of migraine,
tension, and mixed-type headaches. Side effects generally are minimal
and transient. Am Fam Physician 2007;76:1518-22, 1523-4.

<http://www.aafp.org/afp/20071115/1518.html>

**Ulcerative Colitis: Diagnosis and Treatment (See also Patient
Education)**

Ulcerative colitis is a chronic disease with recurrent symptoms and
significant morbidity. The precise etiology is still unknown. As many as
25 percent of patients with ulcerative colitis have extraintestinal
manifestations. The diagnosis is made endoscopically. Tests such as
perinuclear antineutrophilic cytoplasmic antibodies and
anti-Saccharomyces cerevisiae antibodies are promising, but not yet
recommended for routine use. Treatment is based on the extent and
severity of the disease. Rectal therapy with 5-aminosalicylic acid
compounds is used for proctitis. More extensive disease requires
treatment with oral 5-aminosalicylic acid compounds and oral
corticosteroids. The side effects of steroids limit their usefulness for
chronic therapy. Patients who do not respond to treatment with oral
corticosteroids require hospitalization and intravenous steroids.
Refractory symptoms may be treated with azathioprine or infliximab.
Surgical treatment of ulcerative colitis is reserved for patients who
fail medical therapy or who develop severe hemorrhage, perforation, or
cancer. Longstanding ulcerative colitis is associated with an increased
risk of colon cancer. Patients should receive an initial screening
colonoscopy eight years after the onset of pancolitis and 12 to 15 years
after the onset of left-sided disease; follow-up colonoscopy should be
repeated every two to three years. Am Fam Physician 2007;76:1323-30,
1331. <http://www.aafp.org/afp/20071101/1323.html>

**Nonspecific Low Back Pain and Return to Work (See also Patient
Education)**

As many as 90 percent of persons with occupational nonspecific low back
pain are able to return to work in a relatively short period of time. As
long as no \"red flags\" exist, the patient should be encouraged to
remain as active as possible, minimize bed rest, use ice or heat
compresses, take anti-inflammatory or analgesic medications if desired,
participate in home exercises, and return to work as soon as possible.
Medical and surgical intervention should be minimized when abnormalities
on physical examination are lacking and the patient is having difficulty
returning to work after four to six weeks. Personal and occupational
psychosocial factors should be addressed thoroughly, and a
multidisciplinary rehabilitation program should be strongly considered
to prevent delayed recovery and chronic disability. Patient advocacy
should include preventing unnecessary and ineffective medical and
surgical interventions, prolonged work loss, joblessness, and chronic
disability. Am Fam Physician 2007;76:1497-1502, 1504.

<http://www.aafp.org/afp/20071115/1497.html>

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

**Study documents the health costs of being a woman**

<http://www.ahrq.gov/research/nov07/1107RA2.htm>

**Death and complications after breast cancer surgery are rare, with
wound infection the most common problem**

<http://www.ahrq.gov/research/nov07/1107RA3.htm>

**Women suffer fewer postoperative problems after vascular surgery at
Veterans Administration than at private hospitals**

<http://www.ahrq.gov/research/nov07/1107RA4.htm>

**A skin condition may identify young patients at risk for developing
type 2 diabetes**

<http://www.ahrq.gov/research/nov07/1107RA8.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}

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

![](media/image3.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)

#### Breastfeeding , Amy Patterson, California Area Indian Health Service {#breastfeeding-amy-patterson-california-area-indian-health-service .Style-Heading-4-+-Arial-14-pt-Underline}

**Getting it Right**

**Breastfeeding Promotion: Good Public Health Policy (Part 2 of 2)**

During pregnancy, the mother's body changes to prepare itself for
lactation so that she can successfully nurse her infant. There are truly
very few cases in which a mother is physically unable to breastfeed.

Breastfeeding is natural, but it takes some time to learn to do it
correctly. With few exceptions-discussed below- all pregnant women
should be encouraged to breastfeed, and to learn about breastfeeding
through classes run by hospitals or lactation consultants. Hospital
policies can also make a difference; in particular, "rooming-in" and
encouraging nursing within the first hour of birth both increase the
chance of breastfeeding success. After birth, nursing mothers should
receive help from their hospital's lactation consultant to make sure
they and their babies are getting off to the right start. If a nursing
mother is having problems with latching or is concerned about milk
supply, a lactation consultant can evaluate and help. An IBCLC
(International Board Certified Lactation Consultant) credential
represents the "gold standard" for lactation counseling. IBCLCs are
certified after hundreds of hours of consulting and academic training;
they must also pass a rigorous, comprehensive exam. To find a certified
consultant, go to [[www.ilca.org]{.underline}](http://www.ilca.org/),
and click on "Find a Lactation Consultant in Your Area."

Newborn babies who are breastfed need to eat frequently; it is not
uncommon for them to wake many times a night to nurse. Providers can let
new parents know that while this will interrupt their normal sleep
cycles for a while, it is temporary; as a baby gets older they go longer
in between feedings. Night waking is a normal feature of newborns; even
formula-fed babies wake at night to eat. There are also special
advantages to breastfeeding; although a nursing baby may wake a bit more
frequently than a formula-fed baby, the nursing mother has no bottles to
prepare in the middle of the night and can comfort her infant
immediately. Remind mothers that this is also true during the day when
they are out of the house, and means they will not have to carry bottles
or formula around. California law also protects the rights of mothers to
nurse in public.

Also, remind new mothers that there are significant health benefits from
nursing. Nursing infants also get sick less often, which means fewer
trips to the doctor, and fewer nights spent caring for a sick baby. The
longer a woman nurses, the greater the health benefits for her baby.
Breastfeeding can continue as long as it is beneficial for both mother
and child- there is no time limit on how many months or years a woman
should nurse.

Nursing can also continue after a mother returns to work. A nursing
mother can nurse her baby in the evenings, overnight, and in the
mornings. Then, she can pump her milk while at work and store it for
caregivers to give to her baby while she is at work. Nursing mothers
have rights under California State Law for break time and privacy to
pump milk while at work.

However, there are some women for whom breastfeeding is not advised.
Women who are HIV positive should not breastfeed because of the risk of
transmitting the virus to the baby. Also, women with active, untreated
TB (tuberculosis) or who are receiving any kind of chemotherapy should
not breastfeed.

Women who are breastfeeding should not take illegal drugs. Some drugs,
such as methamphetamine, cocaine and PCP, can affect the baby and cause
serious side effects. Other drugs, such as heroin and marijuana can
cause irritability, poor sleeping patterns, tremors, and vomiting.
Babies can become addicted to these drugs.  If a mother is addicted and
can not get off these drugs, she should not breastfeed. However, mothers
undergoing methadone treatment may breastfeed.

Mothers who smoke should be encouraged to quit as soon as possible.
However, even if they cannot, it is still better to breastfeed, as long
as they do not smoke near their infants.

Most common illnesses, such as colds, flu, or diarrhea, can not be
passed through breast milk. In fact, when a mother is sick, her breast
milk will have antibodies in it that will help protect infants from
getting the same sickness.

**GPRA**

The Indian Health Service has a developmental GPRA measure on exclusive
and near exclusive breastfeeding rates among 2 month old infants, with
the goal of increasing breastfeeding rates among these and older
infants. RPMS users can use a PCC Infant Feeding Tool to record infant
feeding status; this information is captured in RPMS and extracted by
the Clinical Reporting System (CRS). Sites using PCC, RPMS and CRS can
monitor the feeding status of their infant population by running CRS
reports.

The Indian Health Service uses Healthy People 2010 objectives whenever
possible for its GPRA targets. The Healthy People 2010 goal is to have
at least 75 percent of mothers breastfeeding during the early postpartum
period and 50 and 25 percent breastfeeding at 6 months and 1 year,
respectively. In 1998, 64 percent of all mothers breastfed their infants
during the early postpartum period. 29 and 16 percent of mothers
breastfed their infants at 6 months and 1 year, respectively. This data
is for all races; no comprehensive national data on breastfeeding rates
among American Indians and Alaska Natives yet exists.

**For More Information:**

Indian Health Service Breastfeeding Page

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

California State Breastfeeding Program

<http://www.mch.dhs.ca.gov/programs/bfp/>

LaLeche League International

<http://www.lalecheleague.org/>

Centers for Disease Control Breastfeeding Page

<http://www.cdc.gov/breastfeeding/>

National Women's Health Information Center (DHHS Breastfeeding resources
page)

<http://www.4woman.gov/Breastfeeding/index.cfm?page=227>

International Lactation Consultant Association\
<http://www.ilca.org/>

World Alliance for Breastfeeding Action

<http://worldbreastfeedingweek.org/downloads.htm>

**Other**

**Rare Side-Effect of Codeine in Nursing Mothers: Ultra-rapid
metabolizers**

FDA is alerting healthcare professionals about a very rare but serious
side effect that can affect the babies of nursing mothers who are taking
drugs that contain codeine. The problem affects mothers who are
\"ultra-rapid metabolizers\" of codeine. Ultra-rapid metabolizers have a
specific genotype that causes them to convert codeine to its active
metabolite, morphine, more rapidly and completely than other people.
This can result in the mother having unusually high morphine levels in
her serum and breast milk, and this can put her nursing infant at risk
of morphine overdose.\
\
A recent report in the literature described a healthy, 13-day-old
breast-feeding baby who died of a morphine overdose. His mother was
taking codeine at less than the usual analgesic dose.\
\
The prevalence of the ultra-rapid metabolizers of codeine varies for
different populations. Among Caucasians, the figure is about 1 to 10
percent. Among African-Americans, about 3 percent are ultra-rapid
metabolizers of codeine, and among Asians and Hispanics, about 1
percent. The highest prevalence is among some groups of North Africans,
Ethiopians and Saudis, where it can be as high as 28 percent.\
\
It is important to note that nursing mothers have used codeine safely
for many years. Many women are sent home after having a baby with
analgesics such as acetaminophen with codeine to relieve episiotomy pain
or abdominal cramping and many of these women are also breast feeding.
Despite this widespread use, FDA was able to find only the one case
where the baby clearly died as a result of morphine overdose from breast
milk. This means that many breast fed babies born to mothers who are
ultra-rapid metabolizers and who are taking codeine will not have a
problem, but some babies may.\
\
FDA has cleared a genetic test that can determine whether someone is a
rapid metabolizer of a number of drugs, but there\'s only limited
information on using it for codeine. Which means at this point, the test
result alone may not correctly predict whether the mother is an
ultra-rapid metabolizer of codeine. In other words, the test is not a
substitute for a doctor\'s judgment.\
\
FDA recommends that clinicians who prescribe codeine for a nursing
mother do so in the lowest dose for the shortest period of time in order
to relieve pain. Clinicians should also educate nursing mothers who may
be taking codeine about the signs of morphine overdose in themselves or
their infants.\
\
Mothers should understand that they don\'t need to go without pain
relief if they\'re breast feeding, but they should know what to look for
if there\'s a morphine overdose. For the mother herself, the signs
include extreme sleepiness and constipation. The mother should also
watch for increased sleepiness in her baby, keeping in mind that
breastfed babies usually nurse every two to three hours and shouldn\'t
sleep more than four hours at a time. She should also watch for trouble
breast feeding, breathing difficulties and limpness. Mothers should also
be aware that morphine may remain in the infant\'s body for up to
several days after the last codeine dose.\
\
Finally, in order to help the FDA understand and quantify this problem,
it\'s important to report possible cases of morphine overdose in mothers
and infants. To report an adverse event to the FDA please see the below
link.

[Additional Information]{.underline}:

FDA MedWatch Safety Alert. Codeine Products Used By Nursing Mothers.
August 17, 2007\
<http://www.fda.gov/medwatch/safety/2007/safety07.htm#Codeine>

FDA MedWatch. Reporting Adverse Events to FDA. April 19, 2007\
<http://www.fda.gov/medwatch/how.htm>

**Nicotine In Breast Milk Disrupts Infants' Sleep Patterns**

Infants spent less time sleeping overall and woke up from naps sooner
when their mothers smoked prior to breastfeeding,

CONCLUSIONS: An acute episode of smoking by lactating mothers altered
infants\' sleep/wake patterning. Perhaps concerns that their milk would
taste like cigarettes and their infants\' sleep patterning would be
disrupted would motivate lactating mothers to abstain from smoking and
to breastfeed longer.

[Mennella
JA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mennella JA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Breastfeeding and smoking: short-term effects on infant feeding
and sleep. Pediatrics. 2007 Sep;120(3):497-502

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766521>

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

**Formula free zone - Sion Baby Friendly
Hospital                                                     **

The Sion municipal hospital in Mumbai, which featured in the Yorkshire
TV film \"Bottle Feeding in India\" (contact Baby Milk Action for copies
of this), broadcast in the UK in 1995, is of more than 900 Baby Friendly
Hospitals in India. The Sion hospital caters for some of the poorest
families in Mumbai, including residents of Asia\'s largest slum,
Dharavi.  Approximately 6,000 babies are born in the Sion every year,
30 - 40% of them premature or low-birth weight. Between 1979 1986, the
Sion used invasive medical techniques such as prelacteal and
supplementary bottle feeds, assisted ventilation devices, frequent blood
investigations, etc.  However, these practices have changed and the
hospital has not used any baby milk for the last 10 years. Breastfeeding
has been as one of the key factors in a reduction in infant morbidity.
When bottle feeding was routine 7 out of 10 premature babies died, now
at least 8 out of 10 survive. Like all hospitals, the Sion Hospital is
badly in need of cash - but any                                       

suggestion that they take money from the baby food or drug industry was
dismissed by the staff as
unthinkable.                                                 

                                                                          

[Indian doctors reject baby food sponsorship]{.underline}

Aware that parents are receiving confusing messages from doctors; a
number of professional organizations in India are tackling the issue of
commercial sponsorship head on. After a thorough debate at its annual
conference in January 1997, the Indian Academy of Pediatrics
overwhelmingly passed a Resolution saying: \"The IAP shall not accept
the sponsorship in any form from any industry connected directly or
indirectly with the products covered by the \[Indian\]
Act.\"                                                                  

The Federation of Obstetrics and Gynecological Societies of India
(FOGSI), with 12,000 members throughout India, also rejects baby food
sponsorship, even though massive amounts have been offered. The
Federation has declared 1997 to be the FOGSI Breastfeeding
Year.                                                   

  
                                                                       

[J & J apologizes and withdraws]{.underline}

The Indian Act includes all the articles of the International Code and
one of its most unique and innovative aspects is its authorization of
voluntary organizations to bring criminal complaints for prosecution.
Over the last few years the ACASH has filed criminal complaints against
Nestle, Johnson and Johnson and more recently, Wockhardt. The company
reaction to these charges has been revealing: As Update readers will
know, Nestle has so far refused to apologize and has challenged the
validity of the Indian
Act.                                                    

                           
                                                                                                                       

#### Johnson & Johnson, in contrast, has submitted a letter of apology to ACASH and has stated that because bottle feeding may not be appropriate in the Indian context it is withdrawing from the market. The Wockhardt case involves its labeling of Dexolac, and the company has issued an apology to ACASH and to the courts.    [**Judith.Thierry@ihs.gov**](mailto:Judith.Thierry@ihs.gov) {#johnson-johnson-in-contrast-has-submitted-a-letter-of-apology-to-acash-and-has-stated-that-because-bottle-feeding-may-not-be-appropriate-in-the-indian-context-it-is-withdrawing-from-the-market.-the-wockhardt-case-involves-its-labeling-of-dexolac-and-the-company-has-issued-an-apology-to-acash-and-to-the-courts.-judith.thierryihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

**The yeast connection: is Candida linked to breastfeeding associated
pain?**

CONCLUSION: C. albicans is found more often in breastfeeding mothers who
report pain as compared with asymptomatic breastfeeding mothers. Further
studies, including treatment trials, are needed to determine whether
Candida plays an etiologic role in breastfeeding associated pain.

[Andrews
JI](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Andrews JI"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
The yeast connection: is Candida linked to breastfeeding associated
pain?

Am J Obstet Gynecol. 2007 Oct;197(4):424.e1-4.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904988>

####  {#section-15 .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}

#### November Highlights include: {#november-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

\-[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)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_10.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_10.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocumentscccc_v5_10.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 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-17 .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}

**Adolescent primary prevention programs for domestic violence which are
school based**

I have put together some slides that while not the clearest will have
you looking at the html versions. I adapted this chart into a ppt slide
"Breastfeeding, TV viewing and smoking in household by race and
ethnicity" And many more files.

recent years, a number of evaluations of primary prevention programs
targeting partner violence have been published. This article

presents a systematic review of recent interventions for primary
prevention of partner violence. A total of 11 programs met

inclusion criteria for the review. All 11 studies used some combination
of feminist theory and social learning theory as a basis for

the intervention.

-   All targeted middle- or high-school aged students, and all but one
    were set in a school setting and were universal interventions (i.e.,
    were not targeted to an at risk group).

```{=html}
<!-- -->
```
-   Interventions tended to be brief, with only two using interventions
    totaling more than 5 h in duration.

Although a majority of studies were randomized trials, study quality was
generally poor due to relatively short follow-up periods, high attrition
rates, and poor measurement. Of the four studies that measured behavior,
two found a positive intervention impact. Those two studies had the most
comprehensive interventions, using both individual-level curricula and
other community-based interventions. Both also employed rigorous
designs.

Conclusions about the overall efficacy of dating violence interventions
are premature, but such programs are promising. We discuss
recommendations regarding the content and evaluation of dating violence
prevention programs. <Judith.Thierry@ihs.gov>

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

**Postdischarge care management that integrates medical and social care
can improve outcomes of the low-income elderly**

<http://www.ahrq.gov/research/nov07/1107RA10.htm>

**Principles of Effective Pain Management at the End of Life**

<http://www.medscape.com/viewarticle/545562>

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

#### 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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: An acid buffering gel used with a diaphragm is a safe, acceptable contraceptive with efficacy comparable to that of a common commercial spermicide with diaphragm. LEVEL OF EVIDENCE: I. {#conclusion-an-acid-buffering-gel-used-with-a-diaphragm-is-a-safe-acceptable-contraceptive-with-efficacy-comparable-to-that-of-a-common-commercial-spermicide-with-diaphragm.-level-of-evidence-i. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Barnhart KT et al Contraceptive efficacy of a novel spermicidal microbicide used with a diaphragm: a randomized controlled trial. Obstet Gynecol. 2007 Sep;110(3):577-86. {#barnhart-kt-et-al-contraceptive-efficacy-of-a-novel-spermicidal-microbicide-used-with-a-diaphragm-a-randomized-controlled-trial.-obstet-gynecol.-2007-sep1103577-86. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766603**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766603) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17766603 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Lack of VZIG and new prenatal assessment of varicella immunity
addressed: New module**

New Perinatology Corner Module: Varicella (Chickenpox) in Pregnancy

-Unfortunately, the manufacturer has discontinued production, so the
availability of VZIG is rapidly declining, since the only manufacturer
of this product has ceased production.

What should you do about the lack of available VZIG?

-The CDC has recommended the use of "VariZIG", a purified lyophilized
human immune globulin preparation prepared from plasma with high levels
of anti-varicella antibodies. It is only available however under an
"investigational new\
drug application expanded access protocol" from the sole U.S.
distributor. And informed consent must be obtained prior to use. Turn
around time for your laboratory is obviously critical to stay within the
4-day window.\
How readily available is VariZIG at your service unit?\
Where will you obtain it ad how quickly can it arrive?

-Prenatal assessment of women for evidence of varicella immunity is
recommended. Birth before 1980 is not considered evidence of immunity
for pregnant women because of potential severe consequences of varicella
infection during pregnancy, including infection of the fetus.

How should that be implemented?

Go to this link. Get the free CME or just use the many resources

[[http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/VC01.cfm]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/VC01.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. Where can I get copies of the lecture notes from the 2007 Women's
Health and MCH**

**Conference that was held in Albuquerque on August 15-17^th^ ?**

**A. The lecture notes are posted on the MCH Meeting Notes web site, as
are the professional group reports. Go here**
<http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm>

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

**December 2007**

-   No more cough syrup says the FDA

-   No more cavities says Dr. Esposito

-   Not enough Hib vaccine says Dr. Singleton

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1207b.doc>

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

**Patient-Physician Email Communication May Be Effective**

CONCLUSIONS: Patient-physician e-mail is a service that patients will
use given the opportunity. The e-mail service enables physicians to
answer medical questions with less time spent compared with telephone
messaging. In our experience in an academic pediatric subspecialty
practice, patients reported enhanced communication and access with the
e-mail service.

Rosen P, Kwoh CK. Patient-physician e-mail: an opportunity to transform
pediatric health care delivery. Pediatrics. 2007 Oct;120(4):701-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17908755>

**Frequently Asked Questions: Clinical Performance Measurement, GPRA and
CRS**

-How does GPRA performance affect IHS and Tribal Programs

-What is clinical performance measurement?

-How does the Government Performance and Results Act (GPRA) relate to
clinical performance measurement

-These and many other questions are answered and are available

Contact: <Francis.frazier@ihs.gov> or <Stephanie.klepacki@ihs.gov>

Is more information available? Yes, CRS has its own web site and
contains a variety of information, such as the CRS User Manual, Fact
Sheet, and past training presentations.

The web site is: [www.ihs.gov/cio/crs](http://www.ihs.gov/cio/crs)

**Medicine Dish - Broadcast Schedule**

Rodger Goodacre, Tribal Affairs Group/ CMS

Please note that the Medicine Dish broadcasts are routinely scheduled
for the second Wednesday of every month at 1:30 Eastern.

Broadcast Schedule

Note: Broadcast topics are subject to change. Please review the
individual Program Announcement prior to each broadcast for the most
recent program information

  ----------------------- ----------------------- -----------------------
  Date                    Topic                   Presenters

  October 10, 2007        Maximizing              
                          reimbursement for       
                          Medicare Part D         

  November 14, 2007       Medicare 101 for Tribes 

  December 12, 2007       Medicaid 101 for Tribes 

  January 9, 2008         Survey and              
                          Certification 101 for   
                          Tribes                  

  February 13, 2008       Coding and Billing for  
                          M/M, including the All  
                          Inclusive Rate          

  March 12, 2008          How to access CMS       
                          tribal health care      
                          resources               

  April 9, 2008           Medicare Part B:        
                          requirements, processes 
                          for enrollment &        
                          participation           

  May 14, 2008            Cost reports for I/T/U: 
                          how to do them, what is 
                          in them, how they are   
                          used                    

  June 11, 2008           Electronic medical      
                          records                 

  July 9, 2008            CMS website: a tour and 
                          how to use it           

  August 13, 2008         Federally-Qualified     
                          Health Centers (FQHC)   
                          billing basics          

  September 10, 2008      Information about the   
                          treatment of specific   
                          diseases                
  ----------------------- ----------------------- -----------------------

If you have any questions, please contact Rodger Goodacre, Tribal
Affairs Group/ CMS at <Rodger.goodacre@cms.hhs.gov>

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

**Special Global Issue - Obstetrics and Gynecology**

**Ghana postgraduate training program: 37 or 38 OB/GYNs remained in the
country**

The Safe Motherhood Initiative has highlighted the need for improved
health services with skilled attendants at delivery and the provision of
emergency obstetric care. \"Brain drain\" has hampered this process and
has been particularly prevalent in Ghana. Between 1993 and 2000, 68% of
Ghanaian trained medical school graduates left the country. In 1989,
postgraduate training in obstetrics and gynecology was established in
Ghana, and as of November 2006, 37 of the 38 specialists who have
completed the program have stayed in the country, most working in the
public sector providing health care and serving as faculty. Interviews
with graduates in 2002 found that the first and single-most important
factor related to retention was the actual presence of a training
program leading to specialty qualification in obstetrics and gynecology
by the West African College of Surgeons. Economic and social factors
also played major roles in a graduates\' decision to stay in Ghana to
practice. This model deserves replication in other countries that have a
commitment to sustainable development, human resource and health
services capacity building, and maternal mortality reduction. A network
of University partnerships between departments of obstetrics and
gynecology in developed and developing countries throughout the world
sharing internet resources, clinical information, training curriculum
and assessment techniques could be created. Grand rounds could be shared
through teleconferencing, and faculty exchanges would build capacity for
all faculty and enrich both institutions. Through new partnerships,
creating opportunity for medical school graduates to become
obstetrician-gynecologists may reduce brain drain and maternal
mortality.

[Anderson
FW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Anderson FW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Who Will be There When Women Deliver?: Assuring Retention of
Obstetric Providers. Obstet Gynecol. 2007 Nov;110(5):1012-1016.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17978113&dopt=AbstractPlus>

**Traditional birth attendant training for improving health behavior and
pregnancy outcomes**

AUTHORS\' CONCLUSIONS: The potential of TBA training to reduce
peri-neonatal mortality is promising when combined with improved health
services. However, the number of studies meeting the inclusion criteria
is insufficient to provide the evidence base needed to establish
training effectiveness. - COCHRANE UPDATE

Traditional birth attendant training for improving health behaviours and
pregnancy outcomes. Obstet Gynecol. 2007 Nov;110(5):1017-8.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17978114&dopt=AbstractPlus>

**Vaginal and neonatal chlorhexidine wipes applied in home settings are
well tolerated**

CONCLUSION: Use of 0.6% chlorhexidine vaginal and neonatal wipes for the
prevention of neonatal infection is well-tolerated and seems safe. A
trial of this intervention by traditional birth attendants in a
home-delivery setting is feasible. LEVEL OF EVIDENCE: I.

[Saleem
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Saleem S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Chlorhexidine Vaginal and Neonatal Wipes in Home Births in
Pakistan: A Randomized Controlled Trial. Obstet Gynecol. 2007
Nov;110(5):977-985.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17978107&dopt=AbstractPlus>

**Everybody has a story**

Women\'s struggles in Malawi, Africa, lead to unacceptably high levels
of maternal morbidity and mortality. Everybody has a story. Every woman
in Malawi has her version of the common theme of struggling to survive,
raise her children, and keep them alive. This spring, I had the
privilege to care for many Malawian women as they sought help at their
local hospital. I was able to bear witness to the myriad challenges they
face and capture pieces of their stories along the way....

[Lathrop
E](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Lathrop E"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Everybody has a story. Obstet Gynecol. 2007 Nov;110(5):986-8.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17978108>

**Investment in family planning reduces global poverty and improves both
maternal and child health**

Family planning plays a pivotal role in population growth, poverty
reduction, and human development. Evidence from the United Nations and
other governmental and nongovernmental organizations supports this
conclusion. Failure to sustain family planning programs, both
domestically and abroad, will lead to increased population growth and
poorer health worldwide, especially among the poor. However, robust
family planning services have a range of benefits, including maternal
and infant survival, nutrition, educational attainment, the status of
girls and women at home and in society, human immunodeficiency virus
(HIV) prevention, and environmental conservation efforts. Family
planning is a prerequisite for achievement of the United Nations\'
Millennium Development Goals and for realizing the human right of
reproductive choice. Despite this well-documented need, the U.S.
contribution to global family planning has declined in recent years.

Allen RH. The role of family planning in poverty reduction. Obstet
Gynecol. 2007 Nov;110(5):999-1002.
<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17978110&dopt=AbstractPlus>

**The 12-month probability of pregnancy for injectable and pill users is
0.6% and 9.5%**

CONCLUSION: The overall risk of pregnancy for injectable contraceptive
users was substantially lower than for oral contraceptive pill users.
However, Thai participants had similarly low cumulative pregnancy
probabilities for both methods. Women receiving contraceptive counseling
should be informed that their experience with a given method may differ
from the average or typical-use pregnancy rates often discussed during
contraceptive counseling. Tailored counseling is necessary for women to
make informed choices. LEVEL OF EVIDENCE: II.

[Steiner
MJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Steiner MJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
Pregnancy Risk Among Oral Contraceptive Pill, Injectable Contraceptive,
and Condom Users in Uganda, Zimbabwe, and Thailand. Obstet Gynecol. 2007
Nov;110(5):1003-1009.
<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17978111&dopt=AbstractPlus>

**Safe motherhood strategies should include evidence of effectiveness**

After two decades of the Safe Motherhood Initiative, meaningful
reductions in maternal mortality and disability during pregnancy and
childbirth in developing countries have not been realized. Herein, we
present an overview of the Initiative and review the reasons for this
lack of impact, focusing on the issue of strategic effectiveness. An
appraisal of strategies that are currently recommended reveals a lack of
strong evidence to support their effectiveness. Drawing from the
Initiative\'s history, we propose that, among essential elements to
achieve safe motherhood, recommended public health strategies should be
supported by good evidence of effectiveness, through (cluster)
randomized trials when feasible, before their widespread implementation.

[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 Two Decades of the Safe Motherhood Initiative: Time for Another
Wooden Spoon Award? Obstet Gynecol. 2007 Nov;110(5):972-976.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17978106&dopt=AbstractPlus>

**A Skirt for a Life?**

Julia was a beautiful, young Ugandan woman, straight and graceful as she
walked along the dusty road, balancing a load of bananas on her head.

Her steps were light these days. She had recently met the man of her
dreams. He was from a far off town called Hoima. He came from a
different tribe than hers, but she felt she could live with that. And
her mother would soon stop grumbling about it.

Froese JC. A skirt for a life? Obstet Gynecol. 2007 Nov;110(5):1010-1.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17978112&dopt=AbstractPlus>

**HIV infection was not associated with increased stillbirth risk in a
large African cohort**

CONCLUSION: In this large cohort, HIV infection was not associated with
increased stillbirth risk. Further work is needed to elucidate the
relationship between chorioamnionitis and stillbirth in African
populations.

[Chi
BH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chi BH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Predictors of Stillbirth in Sub-Saharan Africa. Obstet Gynecol.
2007 Nov;110(5):989-997
<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17978109&dopt=AbstractPlus>

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

**Tightening the \"holes\" in the Swiss cheese model of patient safety
in obstetrics**

Most health care professionals who are involved in efforts to improve
patient safety are aware of James Reason's \"Swiss cheese\" model of how
accidents occur. Some elements and pressures of current obstetric
practice may weaken defenses and safeguards against perinatal injury.
Several components of obstetric care in labor and delivery units can be
used as targets for tightening the \"holes\" in the Swiss cheese model.
These include improving communications, preparing for rare critical
events through simulation training, developing protocols for
administration of important medications used in labor and delivery
(oxytocin, misoprostol, and magnesium sulfate), increasing the in-house
presence of obstetricians, developing an effective departmental
infrastructure that includes effective peer review, providing risk
management education about high-risk clinical areas that have the
potential to result in catastrophic injury, and staffing the unit for
all contingencies during all hours, day and night. Acceptance by the
obstetric medical staff is critical to the implementation of these
patient safety elements.

Veltman LL. Getting to havarti: moving toward patient safety in
obstetrics. Obstet Gynecol. 2007 Nov;110(5):1146-50.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17978131&dopt=AbstractPlus>

**Electronic resource updates state action on HPV Vaccine**

HPV Vaccine Legislation 2007 presents information on the June 2006
recommendation by the national Advisory Committee on Immunization
Practices (ACIP) for routine vaccination against Human Papillomavirus

(HPV) for girls ages 11-12, as well as on state activity to require,
fund, or educate the public about the HPV vaccine. The electronic
resource, produced by the National Conference of State Legislatures
(NCSL), addresses key issues such as school vaccine requirements and
financing. A table provides a state-by-state summary of 2007 legislation
introduced to date. Related resources from NCSL, the Centers for Disease
Control and Prevention, the Journal of the American Medical Association,
and the Kaiser Family Foundation are included.
[[http://www.ncsl.org/programs/health/HPVvaccine.htm]{.underline}](http://www.ncsl.org/programs/health/HPVvaccine.htm)

**Improving the health of women and children benefits an employer's
bottom line**

Investing in Maternal and Child Health: An Employer\'s Toolkit provides
information and resources employers can use to improve the health of
employees and their families. The toolkit, published by the National
Business Group on Health with support from the Maternal and Child Health
Bureau, outlines the unique opportunity that employers\' have to improve
the health of women and children through health benefit design,
beneficiary education and engagement, and health promotion programs. The
toolkit is divided into seven sections. Topics include recommendations
on evidence-informed, comprehensive health benefits to support child,
adolescent, and pregnancy health; cost-impact assessments of recommended
benefit changes; data on the cost of maternal and child health (MCH)
care services; the business case for investing in child and adolescent
health, healthy pregnancies, and primary care services for all
beneficiaries; tools employers can use to develop an MCH strategy,
communicate the value of their MCH benefits, and link MCH outcomes to
organizational performance; strategies employers can use to effectively
communicate with beneficiaries and to tailor existing health programs
and policies to the unique needs of children, adolescents, and pregnant
women; and health education information specifically developed for
beneficiaries.
[[http://www.businessgrouphealth.org/healthtopics/maternalchild/investing/docs/mch_toolkit.pdf]{.underline}](http://www.businessgrouphealth.org/healthtopics/maternalchild/investing/docs/mch_toolkit.pdf)

**Lower socioeconomic status and poor perinatal outcomes: Even with
universal access**

INTERPRETATION: Lower family income is associated with increased rates
of gestational diabetes, small-for-gestational-age live birth and
postneonatal death despite health care services being widely available
at no out-of-pocket expense

[Joseph
KS](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Joseph KS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Socioeconomic status and perinatal outcomes in a setting with
universal access to essential health care services. CMAJ. 2007 Sep
11;177(6):583-90.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17846440>

**MCH Headlines Judy Thierry HQE**

**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/image4.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/image5.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/image6.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/image7.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/image8.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>

**First Nations and Inuit Health Health Canada HHS and Indian Health
Service MOU**

A signing ceremony between HHS Secretary Mike Leavitt and the Canadian
Minister of Health, Tony Clement, is scheduled for November 1, 2007 in
the HHS Humphrey Building Great Hall. The signing of a Memorandum of
Understanding (MOU) is to improve the health status of indigenous
communities in the U.S. and Canada. Mr. Robert McSwain, Acting Director
of the Indian Health Service (IHS), will deliver a speech at the
ceremony. The MOU will foster enhanced international collaborations,
identification and reinforcement of best practices, and innovative
approaches to learning opportunities. The MOU, which continues the work
of a similar five-year MOU signed in 2002 and completed this year, will
focus on improving health care delivery and access to health services
for American Indians and Alaska Natives of the U.S. and the First Nation
and Inuit people of Canada.- Verna N. Miller, Office of the Director,
Public Affairs, Indian Health Service , (301) 443-3593

A focused collaboration on midwifery training, practice, traditions and
community awareness and outreach is being planned for year I. 

IHS Behavioral Health with First Nations and Inuit Health Branch (FNIHB)
collaborated on a FASD work group under the 2002 MOU.  Contact
<Judith.Thierry@ihs.gov>

**New Guidelines on Fish Consumption for Females of Childbearing Age,
Young Children**\
Alaska State health officials released new guidelines on the amount of
local fish women and girls of childbearing age, and young children
should consume, the [Anchorage Daily
News](http://www.adn.com/money/industries/fishing/story/9382952p-9296337c.html)
reports. According to the recommendations, these groups can eat salmon
from local waters in unlimited amounts without risking overexposure to
mercury but should limit consumption of large halibut, shark, large
lingcod, yelloweye rockfish and spiny dogfish because of mercury levels
found in the fish.\
\
The state previously said that females of childbearing age and young
children could eat an unlimited amount of local fish but changed its
guidelines because of mercury levels reported this year in certain fish
that never had been tested and in larger specimens of previously tested
fish, according to the Daily News. The state\'s fish tissue testing
program, which began in 2001, shows that most of Alaska\'s five species
of salmon and pollock contain safe levels of mercury, based on the
state\'s health standards. According to the Daily News, the state has
tested the hair of 359 pregnant women for mercury since 2002 and has
extended the studies to all females ages 15 to 45. The tests found that
hair mercury levels in all of the women were well below 14 parts per
million, which the [World Health Organization](http://www.who.int/en/)
says can cause harm to the health of a fetus.

Differing Guidelines\
Alaska\'s guidelines on fish consumption differ from
[FDA](http://www.fda.gov/) and [Environmental Protection
Agency](http://www.epa.gov/) guidelines, the Daily News reports
(Bluemink, Anchorage Daily News, 10/17). FDA and EPA in 2005 issued
warnings that advise young children, pregnant women, nursing women and
women of childbearing age to avoid consuming swordfish, king mackerel,
shark and tilefish because of high mercury levels. The warnings also
recommend that those groups eat no more than 12 ounces of fish weekly
and no more than six ounces of canned albacore tuna weekly ([Kaiser
Daily Women\'s Health Policy
Report](http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=2&DR_ID=48113),
10/11). Alaska officials said that fish from local waters are less
contaminated than fish from other areas and may be consumed in greater
amounts. According to the Daily News, the state on Monday also unveiled
a \"fish diet calculator\"  Attached to help families gauge how much of
the riskier fish they may consume weekly without health risk.
<http://www.epi.hss.state.ak.us/eh/fish/FishDietCalculator.pdf>

**26th Annual "Protecting Our Children"**

-   April 20-23, 2008

-   Minneapolis, MN

-   National American Indian Conference on Child Abuse and Neglect

-   <http://www.nicwa.org/>

**Early child health caries reduction tool kit**

Into the Mouths of Babe's Oral Health Tool Kit

(Scroll to bottom)

<http://www.communityhealth.dhhs.state.nc.us/dental/>

**Child-Oriented Clinical Practice in Process**

-Call new mothers at home 1-2 days after they leave the hospital.
(designate person(s), have simple script or prompts, make a chart note)

-Check immunizations at every patient visit

<http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable>

 -Plot accurate heights & weights on an appropriate growth chart
<http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm>

**Solicit feedback and acknowledge a parent's effort at all visits.**

Are patient encounter environment(s) infant, child and teen
appropriate?  (mobiles, toys, games, books, posters, Audio/visuals,
passive referral information and health literacy for 0 -- 20 year olds,
oriented staff)

-Address age appropriate prevention measures at each visit.
<http://www.aap.org/bst/showprod.cfm?DID=15&CATID=132&ObjectGroup_ID=812>

-Address a child or teen directly, appropriately and as soon as possible
during the encounter.

-All parental phone calls are returned no matter how trivial. Obtain a
pediatric telephone advise reference such as:
<http://worldcat.org/wcpa/oclc/36470676>

-Ask about parent forms at the start of the visit and complete the forms
before the patient leaves.  (saves time, reduces lost forms, saves
mailing, customer service, what you would want to have happen in a
visit)

-Discuss confidentiality with the patient and parent at the 11 or 12
year old visit; then consider seeing the patient alone for at least part
of every health visit thereafter.

**MCH\'s favorite website for referencing all things related to child
maltreatment**

I have sent this out previously and want to call your attention once
again to this child maltreatment tool kit / web site.  IHS HQ will be
updating its child neglect / CMT / child sexual abuse policy.  If you
are interested in participating please contact me.  Thanks Judy

Ann S. Botash, MD at Upstate New York and colleagues have developed a
comprehensive web site, cross referenced, appended, and up to
date\-\--consider this your go-to reference for all things related to
child maltreatment and child sexual abuse.    

<http://www.childabusemd.com/index.shtml>

The CPT code tells the insurer \"what\" was done (i.e. type of visit),
and the ICD-9 tells \"why\" or the diagnosis. In most office settings,
the patient who presents with a child abuse issue or diagnosis is an
\"established patient.\" However, occasionally the suspected abuse
patient may present as a \"new patient\" or even as a referral for
consultation. Depending on whether the patient is new, established, or a
consultation, separate CPT codes are used. In addition, when determining
the level of evaluation and management (E&M level for CPT codes), the
key components include the history, examination, and medical decision.
However, if counseling and coordination of care drive 50% or more of the
encounter, time determines the code for the visit.\
\
\
The CPT codes for new patients (99201-99205) and for established
patients (99211-99215) are usually at a level 4 or 5 for child abuse
encounters. Document each level in order to support the code. Using a
template that triggers coding for detailed or comprehensive histories
and physicals may assist in the documentation process.

[Prolonged Visit]{.underline}\
Preventive medicine codes are those commonly used to bill for the annual
well-patient visit. Because child abuse encounters often require
additional time, use modifiers with appropriate supporting
documentation. To capture billing on prolonged visits, add a two digit
modifier to the five digit CPT code. For example, add -21(visit takes
longer than the usual for well child care) or -25 (dealing with a
medical problem or child abuse issue at the same time as the well child
exam).

[Counseling]{.underline}\
The series 99401-99405 is used for individual counseling. Each
incremental increase in code equals 15 minutes of time. Parent-only
counseling can be coded as counseling time. Only mental health
clinicians can use the psychiatric CPT codes.

[Chart Review]{.underline}\
If the medical provider is reviewing a chart for Child Protective
Service, these can be billed as 99358 (60 minutes) and 99359 (each
additional 30 minutes). This is used for prolonged physician service
without direct face-to-face patient contact.

[Conference or Meeting]{.underline}\
A team conference or meeting with Child Protective Services, police,
rape crisis counselors, etc. can be coded as 99361 for 30 minutes and
99362 for 60 minutes. For these conferences, [document time spent,
people present, content of discussion, and plans for the
patient.]{.underline}

[Continuing Oversight]{.underline}\
When there needs to be continuing oversight to ensure that the patient
follows through and is protected, the bill should reflect 99374 (less
than 30 minutes per month) or 99375 (more than 30 minutes per month).

[Telephone Calls]{.underline}\
Telephone calls are generally not reimbursed, but can be billed as
99371-99373. If the calls are over 60 minutes, use the 99359 prolonged
physician service code.

Table of Contents includes:

Triage

history

physical exam

laboratory

radiology

diagnosis

treatment & follow-up

documentation -- sub section: billing excerpt see below!!!

reporting

foster care

children and adolescents with disabilities

juvenile sexualized behavior

MDT's (multi-disciplinary teams)

legal issues

Under the documentation section you will find sub-headings including:
"In order to correctly code and bill pediatric child abuse cases, you
need to understand the Current Procedural Terminology (CPT) published by
the American Medical Association and the International Classification of
Disease, Clinical Modification, 9th Edition (ICD-9 CM) published by the
World Health Organization."
<http://www.childabusemd.com/documentation/coding-billing.shtml#cpt>

**The 2006 National PedNSS report data tables are now online! WIC data**

Of the 33,489 \> 2 year olds -- AIAN - 20% were in the 85th to \<95th%
for weight and 19.4 % were in the \> 95th% for weight

The CDC web site has a robust 2006 data set on WIC pediatric and
prenatal indicators PEDNSS and PNS.

1.  Weight

```{=html}
<!-- -->
```
1.  Breastfeeding

2.  Anemia

3.  Health risk behaviors -- TV and smoking

[[http://www.cdc.gov/pednss/pednss_tables/index.htm]{.underline}](http://www.cdc.gov/pednss/pednss_tables/index.htm)

![](media/image9.png){width="5.0in" height="3.75in"}

**Half of U.S. Kids Skip Annual Dental Exam**

Dentists recommend a checkup every six months. But many kids,
particularly poor ones, aren\'t seeing the dentist even once a year. A
study has found that about half of children ages 2 to 17 do not get
annual dental checkups.

The study was called the Medical Expenditure Panel Survey. It showed
that 38% of low-income children (ages 2 to 17) had a dental checkup in
2003. Among higher-income children, 60% had a checkup that year. The
study included 8,983 U.S. children. Among middle- and high-income
children, those with other health problems were less likely to visit the
dentist. Researchers found that other health care professionals, such as
doctors and nurses, are just as likely to recommend a dental visit to
lower-income families as to higher-income families. But fewer poor
children actually make it to the dentist.

Like the more recent research, the NSCH study found that poor children
and younger children were less likely to visit the dentist. It also
found that children who did not have a regular doctor were less likely
to visit a dentist. That study was published in the March 2007 issue of
the journal Pediatrics.

The current study appears in the October issue of the Journal of the
American Dental Association. Access article online at:

<http://www.simplestepsdental.com/SS/ihtSS/r.EMIHC252/st.32571/t.32571/pr.3/d.dmtNewsContent/c.621210.html>

**An educational must! Tribal School Zone Safety video & toolkit**

Tribal School Zone Safety: Videos & Toolkit -- "look left, right,
left"..."walk with a partner"..."face the traffic"..."eyes ears and then
feet"..."make eye contact with the driver before moving"..."youth as
role models for younger peers" -- "watch the younger kids"..."buckle
up!"\..."flashlights, reflective materials and glow sticks at dusk and
night"..."Be seen"..."be aware"..."know your way"..."look and listen"

Many tribes contributed to this production: Eastern Band of Cherokee,
Osage Pawhuska Elementary, Indian Camp School Lummi Nation, Lummi School

"Native Americans have the highest rates of pedestrian injury and death
of any other group in the United States. In fact, adult pedestrian death
rates for Native Americans are almost 3.5 times that of the general
population. For Native American children, the pedestrian death rate is
almost four times that of the overall population of the United States."

"The need to educate younger road users (including drivers, riders, and
pedestrians) never ends. To address this need, this DVD contains the
following elements (you can **preview** the videos):"

Kelsey Falling Leaf engages kids in this 7.5 minute video on young
pedestrian awareness as

they negotiate the world of adult drivers, backing out vehicles,
distractions, weather, dusk and nighttime in tribal land settings.
Realistic attention getting, filled with messages for and by kids this
should run well in any outpatient clinic, pediatric waiting room and in
school classrooms or PTSA.   [Safety Doesn´t Happen by Accident (Windows
Media)](mms://video.fhwa.dot.gov/tribalsafety/children.wmv)                                                            
                                                                                  
-- Video designed for school-aged children.\*                    
                                   

Tribal Leaders direct attention to role of tribal leadership and child
safety; use of the built environment to protect and reduce injuries;
attention to traffic patterns; the importance of parental
responsibilities in this mix; as well as the roles of teachers in
modeling safe choices; while reinforcing attention to safe practices as
stressed in the first video. [Pedestrian Safety: A New Tradition
(Windows
Media)](mms://video.fhwa.dot.gov/tribalsafety/adults.wmv)                 
                                                                                                                       

-- Video for parents, guardians, transportation coordinators, and tribal
leaders.\*

"Tribal School Zones Safety Video Toolkit" -- (PDF document) Complement
to the above videos

as it provides additional educational materials, promotional tips, and
resource information.

"Tribal School Zones Safety Literature Review" -- (PDF document)
Comprehensive review that

shows facts and statistics and was used, in part, as the basis for
development of the above

materials.

Video clips and photos for making your own pedestrian safety materials.

*DVD Videos are Closed Captioned.*\
\
**To obtain the free DVD, please contact:**

-   [Chimai Ngo](mailto:chimai.ngo@dot.gov)  202.366.1231 or [Monica
    Gourdine](mailto:monica.gourdine@dot.gov)  202.366.1872

![](media/image10.jpeg){width="3.875in" height="5.166666666666667in"}

#### 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}

#### A 20 year old gravida 4 para 1,0,2,1 presented 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. {#a-20-year-old-gravida-4-para-1021-presented-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-19 .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 identifiy 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-identifiy-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-20 .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-21 .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}

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

#### Stay tuned till next issue to learn the rest of the story {#stay-tuned-till-next-issue-to-learn-the-rest-of-the-story .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Trivia fact from Abstract of the Month {#trivia-fact-from-abstract-of-the-month .Style-Heading-4-+-Arial-14-pt-Underline}

#### What is another classic line from the Pirates of the Caribbean: The Curse of the Black Pearl,, beside the Rule of Parlay line? {#what-is-another-classic-line-from-the-pirates-of-the-caribbean-the-curse-of-the-black-pearl-beside-the-rule-of-parlay-line .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Commodore Norrington](http://en.wikipedia.org/wiki/James_Norrington) ([Jack Davenport](http://en.wikipedia.org/wiki/Jack_Davenport)), an officer in the Royal Navy who is in love with Elizabeth Swann (Keira Knightley), also has a deep-seated dislike for pirates.  {#commodore-norrington-jack-davenport-an-officer-in-the-royal-navy-who-is-in-love-with-elizabeth-swann-keira-knightley-also-has-a-deep-seated-dislike-for-pirates. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### He mentions to Captian Jack Sparrow (Johnny Depp) that Sparrow is \"the worst pirate I have ever heard of\". {#he-mentions-to-captian-jack-sparrow-johnny-depp-that-sparrow-is-the-worst-pirate-i-have-ever-heard-of. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### As Jack Sparrow runs fingers his less than hygeinic beard he retorts, "Ahh, but you have heard of me" {#as-jack-sparrow-runs-fingers-his-less-than-hygeinic-beard-he-retorts-ahh-but-you-have-heard-of-me .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-27 .Style-Heading-4-+-Arial-14-pt-Underline}

#### \*If this is not amusing as presented here, then I suggest you consult Pirates of the Caribbean: The Curse of the Black Pearl, directly. (Needless to say, I have no financial conflict of interest.) {#if-this-is-not-amusing-as-presented-here-then-i-suggest-you-consult-pirates-of-the-caribbean-the-curse-of-the-black-pearl-directly.-needless-to-say-i-have-no-financial-conflict-of-interest. .Style-Heading-4-+-Arial-14-pt-Underline}

Pirates of the Caribbean: The Curse of the Black Pearl

<http://en.wikipedia.org/wiki/Pirates_of_the_Caribbean:_The_Curse_of_the_Black_Pearl>

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

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

######### Recognizing and Treating Excessive Sleepiness in Primary Care: Circadian Rhythm Sleep Disorders

What happens when the \"circadian pacemaker\" skips a few beats? Can you
reset the rhythm? Plus: narcolepsy, PMS, migraine, and sleep.

<http://www.medscape.com/viewprogram/7994?src=mp>

######### 

######### Small Steps and Practical Approaches to the Treatment of Obesity

<http://www.medscape.com/viewarticle/565822>

**Challenges of Treating Tobacco Users in High-Risk Populations**

<http://www.medscape.com/viewarticle/565309>

**Newly Diagnosed Breast Cancer: Moving Toward Individualized Treatment
Planning**

<http://www.medscape.com/viewprogram/8054?src=nlcmealert>

**Ageing in Marfan Syndrome**

<http://www.medscape.com/viewarticle/564064>

######### 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)

######### 

######### 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**

#### Lowest effective transdermal 17beta-estradiol dose for relief of hot flushes: RCT {#lowest-effective-transdermal-17beta-estradiol-dose-for-relief-of-hot-flushes-rct-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Micro-dose E2 (0.014 mg/d) was clinically and statistically significantly more effective than placebo in reducing the number of moderate and severe hot flushes, with a 41% responder rate, supporting the concept of the lowest effective dose.  {#conclusion-micro-dose-e2-0.014-mgd-was-clinically-and-statistically-significantly-more-effective-than-placebo-in-reducing-the-number-of-moderate-and-severe-hot-flushes-with-a-41-responder-rate-supporting-the-concept-of-the-lowest-effective-dose. .Style-Heading-4-+-Arial-14-pt-Underline}

[Bachmann
GA](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Bachmann GA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Lowest effective transdermal 17beta-estradiol dose for relief of
hot flushes in postmenopausal women: a randomized controlled trial.

Obstet Gynecol. 2007 Oct;110(4):771-9.

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17906008**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17906008) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17906008 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-31 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: A low-fat dietary pattern may reduce the incidence of ovarian cancer among postmenopausal women {#conclusions-a-low-fat-dietary-pattern-may-reduce-the-incidence-of-ovarian-cancer-among-postmenopausal-women .Style-Heading-4-+-Arial-14-pt-Underline}

[Prentice
RL](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Prentice RL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Low-fat dietary pattern and cancer incidence in the Women\'s
Health Initiative Dietary Modification Randomized Controlled Trial.

J Natl Cancer Inst. 2007 Oct 17;99(20):1534-43.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17925539>

####  {#section-32 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Largely on the basis of results from meta-analyses of observational studies, postmenopausal estrogen was widely prescribed to prevent coronary heart disease. However, epidemiologic studies, no matter how consistent and coherent, are not sufficient to recommend mass preventive therapy to healthy women. In fact, all three large clinical trials failed to confirm estrogen\'s expected cardiac protection. The most persistent explanatory hypothesis for the \"trial failure\" was the age of the participants, based on the thesis that estrogen in recently menopausal women could prevent the development of coronary artery plaque but, given to older women with vulnerable plaque, would have a null or even harmful effect. The timing hypothesis is plausible, but the prespecified subgroup analyses in both Women\'s Health Initiative trials showed no significant interaction with age or years since menopause. The best opportunity to test the timing hypothesis was lost when 1,000 Women\'s Health Initiative women younger than 60 years had coronary artery calcium scans to evaluate the effect of estrogen on plaque burden, but no women 60 years or over were similarly examined. Therefore, this ancillary study can examine the effect of estrogen treatment on coronary calcium in women younger than 60 years but will not be able to determine if the effect is different in older women. In the meantime, publicized statements in multiple venues have promoted the timing hypothesis as fact, confusing patients and physicians who do not realize that the hypothesis is stronger than the evidence. {#largely-on-the-basis-of-results-from-meta-analyses-of-observational-studies-postmenopausal-estrogen-was-widely-prescribed-to-prevent-coronary-heart-disease.-however-epidemiologic-studies-no-matter-how-consistent-and-coherent-are-not-sufficient-to-recommend-mass-preventive-therapy-to-healthy-women.-in-fact-all-three-large-clinical-trials-failed-to-confirm-estrogens-expected-cardiac-protection.-the-most-persistent-explanatory-hypothesis-for-the-trial-failure-was-the-age-of-the-participants-based-on-the-thesis-that-estrogen-in-recently-menopausal-women-could-prevent-the-development-of-coronary-artery-plaque-but-given-to-older-women-with-vulnerable-plaque-would-have-a-null-or-even-harmful-effect.-the-timing-hypothesis-is-plausible-but-the-prespecified-subgroup-analyses-in-both-womens-health-initiative-trials-showed-no-significant-interaction-with-age-or-years-since-menopause.-the-best-opportunity-to-test-the-timing-hypothesis-was-lost-when-1000-womens-health-initiative-women-younger-than-60-years-had-coronary-artery-calcium-scans-to-evaluate-the-effect-of-estrogen-on-plaque-burden-but-no-women-60-years-or-over-were-similarly-examined.-therefore-this-ancillary-study-can-examine-the-effect-of-estrogen-treatment-on-coronary-calcium-in-women-younger-than-60-years-but-will-not-be-able-to-determine-if-the-effect-is-different-in-older-women.-in-the-meantime-publicized-statements-in-multiple-venues-have-promoted-the-timing-hypothesis-as-fact-confusing-patients-and-physicians-who-do-not-realize-that-the-hypothesis-is-stronger-than-the-evidence. .Style-Heading-4-+-Arial-14-pt-Underline}

[Barrett-Connor
E](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Barrett-Connor E"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Hormones and heart disease in women: the timing hypothesis.

Am J Epidemiol. 2007 Sep 1;166(5):506-10.

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17849510**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17849510) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17849510 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-33 .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

**Vaginal birth after cesarean (VBAC) in rural hospitals**

**Counterpoint: David Gahn, M.D.**

At Hastings Indian Medical Center, the Ob/Gyn Department decided to stop
offering VBAC\'s routinely. None of the physicians or midwives is
"anti-TOLAC/VBAC" but we considered several factors:

 

1\) Our anesthesia department refuses to participate in a management
plan to facilitate VBAC despite any data we may present.  If we request
them to be in house during a VBAC, they will refuse.  Then I have to
document in the chart that I requested anesthesia and they would not
come in.  That is a terrible way to do business.  Our anesthesia
department does provide excellent care to our laboring patients and are
pros at emergent cesarean deliveries.  They are skilled professionals,
but the department is not staffed well enough to provide a CRNA or
anesthesiologist dedicated solely to L&D.

 

2\) Even though our Med Staff Rules and Regulations require on call
personnel to able to present themselves within 20 minutes, this is not
reliable.  Also, we have only one OR crew and only one anesthesia person
available in the evening.  We have a protocol for an emergency c/s when
the OR crew is already operating, but nothing is workable to do a
cesarean hysterectomy with no anesthesia or OR crew.  If you have ever
done an emergent c/s under local with a CNM and an L&D nurse, you will
appreciate this.

 

3\) We also considered the local standard of practice. The one insurance
company that covers physicians in the entire state of Oklahoma will not
cover a physician who performs TOLAC/VBAC\'s.  Therefore, there are no
physicians other than federally employed physicians and Oklahoma
University in Oklahoma City 3 hours away (they are self-insured) who
will allow TOLAC.  While this doesn\'t apply to the Federal Tort Claims
Act, it does apply to the physician tort database, our licensing
authorities, the physician\'s reputation, and the hospitals reputation. 
(Tort claims are printed in our local newspaper.)

 

4\) In order for us to offer TOLAC, all 6 of our Ob/Gyn\'s need to be on
board with the plan and they are not, mainly because anesthesia is not
in house.  There is data that supports VBAC without anesthesia present
in the hospital, but you don\'t know our anesthesia department or how
busy we are in the evenings.

 

5)  Unfortunately, the national data on c/s rates is usually 2-3 years
behind, and our hospital has matched those rates.  We deliver about 975
babies per year, and our c/s rate to date for CY 2007 is 37%.  Should we
be ashamed of the number or proud of the good outcomes? The balance
between risks and benefits in this regard in tenuous.

 

6\) I propose that every time a healthy mom walks out of the hospital
with a healthy baby, we have succeeded in our mission.  Is our cesarean
delivery rate too high?  Until I see the definition of \"too high\",
I\'ll argue with you.  I disagree with the argument that our rate is
what it is because we take care of higher risk patients.  I don\'t think
that is a reason.  We do have a high teen pregnancy rate, diabetes,
massive obesity, hypertension, etc., but we haven\'t studied it that
closely. We would love to decrease the c/s rate, but obstetrics is a
treacherous business and each physician is held responsible for the
health of patients, mom and baby. We have to face reality -- if a
patient does not have a perfect baby, the physician will suffer a tort
claim. (And I do mean suffer.)

7\) We can\'t and don\'t force women to have repeat cesarean deliveries,
for that would be assault.  We do *recommend* a repeat cesarean delivery
and tell patients of our policy.  We occasionally have a patient that
refuses a recommended c/s (breech, previous c/s, macrosomia, history of
shoulder dystocia with permanent injury) and we have them sign a consent
form and take care of her very well.  This is all well within the
standard of care.

On a similar topic, we don\'t offer women elective primary cesarean
delivery even if the patient should decide this is her preferred method
of delivery.  In this case, we do refuse to allow women to give birth
the way they choose.

 

8\) When we did offer TOLAC, we had about 2 per year.  We take this to
mean that the others, after being counseled by a physician, opted for
repeat c/s.  Considering this, our c/s rate would not appreciably change
if we offered VBACs.

 

9\) Please don\'t condemn us for a policy that does not recommend
VBAC\'s. Recognize that the data and ACOG support both options, and also
recognize that the data has to be applied to the hospital.  Because of
the number of deliveries we perform, we have reliable data on
post-operative infections (half the national average), TTN,
transfusions, IUFD\'s, etc.  Also know that we have excellent
collaboration between our 6 physicians, 7 midwives, and 1 nurse
practitioner.  We don\'t make policies like this lightly and we examine
the data carefully and applied it to our current practice.

 

So the bottom line is we might be more aggressive with TOLAC/VBACs if we
had additional support.  None of the physicians in our department
are concerned with our cesarean delivery rate.  One quote I heard is,
\"My cesarean delivery rate is 100% for everyone who needs a cesarean
delivery.\"  While this a bit crass, it is germane - the decision to
perform a c/s rests *solely* with the physician charged with the care of
the patient and the patient.  I would love for our cesarean delivery
rate to be 15%, but not at the expensive of a single injured child or
mother. I fully support TOLAC in the right environment. That environment
does not exist at Hastings Indian Medical Center. <David.Gahn@ihs.gov>

**Do you have another learned opinion?**

If so, please share it with me by December 10th and we will continue
this point / counterpoint discussion in the next issue. <nmurphy@scf.cc>

In the meantime the first 5 articles in the Obstetrics Section, above,
reveal a few of the advantages/disadvantages to vaginal after cesarean
and cesarean delivery.

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

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

A JAMA article estimating rates of invasive Methicillin Resistant
Staphylococcus Aureus (MRSA) associated death rates in the United
States, as well as several widely publicized deaths of children and
adolescents from invasive MRSA and subsequent school closures, have
brought new attention to the increasingly widespread problem of
antibiotic resistance. The JAMA article, by Klevens et al., uses active
population-based surveillance data from 7/04 through 12/05 from nine
sites in the United States to estimate national rates of invasive MRSA
in 2005. The sites, ranging in size from the state of Connecticut to
Ramsey County, Minnesota, also included several metropolitan areas. One
site (Baltimore) had exceptionally high rates and this outlier data was
excluded from the final analysis. The majority of the 8987 cases
identified were health care associated, with 58.4% of health care
associated cases having a community onset and 26.6% having a hospital
onset. Another 13.7% of the cases were not linked to health care and
1.3% could not be identified as conclusively hospital or community
associated. 1598 in-hospital deaths of patients with invasive MRSA were
recorded. The overall rate of invasive infection was 31.8/100,000 and
the mortality rate 6.3 per 100,000. The highest rates of invasive
infection were noted in those over 65 years old, African Americans, and
males.

Using this standardized rate of 31.8 per 100,000 for invasive MRSA, the
authors estimate that the national burden invasive MRSA infection was
94,360 cases in 2005 with 18,650 associated deaths. As an accompanying
editorial by Bancroft points out, if this projection is accurate, these
deaths would exceed the total number of deaths attributable to HIV/AIDS
in the United States in 2005. The editorial also points to several
effective interventions that would decrease spread of these pathogens
but are imperfectly implemented. These include thorough hand washing,
careful use of antibiotics, limiting invasive devices, decolonization,
and environmental cleaning. Clearly we can all do more to control the
spread of this pathogen and limit the ongoing development of antibiotic
resistance. A patient education sheet was also included in the same
issue.

MRSA infections of the skin and soft tissue have become a widespread
problem across the United States and have become quite common in many
Native American communities. For example, at the Annual Navajo Area
Women's Health Provider Meeting in September, Dr. Iralu, the Infectious
Disease Consultant for Navajo Area, discussed the fact that fully 50% of
staph isolates in Navajo Area are methcillin-resistant, leaving only a
few drugs that are effective for treatment when antibiotics are needed.
Incision and drainage is the foundation of management of local
infections suspicious for MRSA and cultures should be collected to guide
further treatment and for ongoing surveillance. Bactrim is one of the
few oral antibiotics still widely effective for MRSA skin and
soft-tissue infections; and Vancomycin is often used to treat invasive
disease.

For non-invasive disease, antibiotics are not always necessary and
incision and drainage with local wound care is often sufficient for
treatment. The proper technique for incision and drainage is reviewed in
the latest installment of the "Videos in Clinical Medicine" series from
the New England Journal of Medicine. This useful resource also includes
such topics as "Orotracheal Intubation", "Basic Laceration Repair", and
"Pelvic Examination" with new videos being added periodically. These
videos can be accessed from the NIH library web site with the access
codes available to IHS employees from the librarian, Diane Cooper.
Simply follow the online journal link to the New England Journal of
Medicine and look for the "Procedure Videos" link on the NEJM home page.

Oh, and don't forget to wash your hands!

Klevens RM, Invasive methicillin-resistant Staphylococcus aureus
infections in the United States, JAMA 2007 Oct 17;298 (15): 1763-1771.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17940231>

Bancroft, EA, Antimicrobial Resistance, It's not just for hospitals,
JAMA 2007 Oct 17;298(15):1803-1804.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17940239>

Zeller, JL, JAMA Patient Page; MRSA Infections, JAMA 2007 Oct
17;298(15)1826.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17940240>

[Fitch
MT](http://ezproxyhhs.nihlibrary.nih.gov:2067/sites/entrez?Db=pubmed&Cmd=Search&Term="Fitch MT"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Manthey
DE](http://ezproxyhhs.nihlibrary.nih.gov:2067/sites/entrez?Db=pubmed&Cmd=Search&Term="Manthey DE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[McGinnis
HD](http://ezproxyhhs.nihlibrary.nih.gov:2067/sites/entrez?Db=pubmed&Cmd=Search&Term="McGinnis HD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Nicks
BA](http://ezproxyhhs.nihlibrary.nih.gov:2067/sites/entrez?Db=pubmed&Cmd=Search&Term="Nicks BA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Pariyadath
M](http://ezproxyhhs.nihlibrary.nih.gov:2067/sites/entrez?Db=pubmed&Cmd=Search&Term="Pariyadath M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).,
Videos in clinical medicine. Abscess incision and drainage. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Nov
8;357(19):e20.

<http://content.nejm.org/cgi/content/video_preview/357/19/e20>

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

**Nurses Corner, Sandra Haldane, HQE**

**2008 LONG TERM TRAINING -- NURSE ANESTHESIA -- Apply Soon**

To All IHS Nurse Commissioned Officers:

The Indian Health Service (IHS) Headquarters Division of Nursing (DNS),
Rockville, Maryland, will sponsor one (1) Nurse Commissioned Officers in
30 months of Long-Term Training (LTT) in Nurse Anesthesia to begin in
June 2008 at the Uniformed Services University of Health Sciences
(USUHS) in Bethesda, MD. Nurse Anesthesia Students will complete Phase
I, 12 months of didactic, at USUHS in Bethesda, MD, followed by Phase
II, 18 months of clinical, at the Alaska Native Medical Center (ANMC) in
Anchorage, AK. The intent of this process is to supply the IHS with
Certified Registered Nurse Anesthetists (CRNAs). Upon completion of the
LTT, these CRNAs will serve their payback obligation as a CRNA in an
Operating Room (OR) at a tribal facility that has left its Tribal Shares
in the Headquarter's Nurse Initiatives, NECI Section 118, COSTEP, and
Continuing Education program budgets, or as a CRNA in an OR in an IHS
facility. In addition to providing anesthesia services to patients
undergoing surgical procedures, CRNA obligees will act as a resource for
staff development, policy formulation, and consultation in the provision
of anesthesia services to their local and Area facilities as well as
nationally as requested.

IMPORTANT NOTE:

-   Placement of nurses into this training and after training will be in
    accordance with the Indian Preference Act (Title 25 U.S. Code
    Section 472 and 473) in which absolute preference will be given to
    qualified Indian candidates.

-   Selection for this Long Term Training position is subject to
    acceptance into USUHS Graduate School of Nursing (GSN) Nurse
    Anesthesia Program that leads to certification eligibility

-   Sponsorship of this training is subject to the availability of
    Fiscal Year 2008 funds.

The solicitation of applications for the training cycle begins
immediately, November 5, 2007 and ceases at 5 PM Eastern Time December
15, 2007 and in accordance with the following:

-   One (1) original and two (2) copies of the IHS DNS application
    materials must be submitted and include copies of the full USUHS
    application materials

-   Incomplete applications will not be accepted.

-   Faxed applications will not be accepted

-   Late applications will not be accepted

-   Only applications meeting the following minimum criteria of the
    IHS/DNS will be considered.

Individuals must possess all the following minimum criteria in order to
apply.

1\) Must be a USPHS CO and have completed two years of service as a
registered nurse (RN) in any IHS, Tribal, or urban facility but have no
more than 12 years of creditable service toward retirement at the time
training begins (June 1, 2008).

2\) Must possess and maintain a current, active, and unrestricted
registered nurse license in a State, District of Columbia, the
Commonwealth of Puerto Rico, or a territory of the United States.

3\) Must have been recommended for promotion on last two Commissioned
Officers' Effectiveness Reports (COERs).

a\. At least an overall rating of \"D\" on each of their last two COERs.

4\) Must meet the Surgeon General/Office of Force Readiness'
requirements for Basic Ready Qualified.

5\) Must meet USUHS special extended application deadline of December
15, 2007 and minimum application requirements to USUHS found at the
following link:

<http://cim.usuhs.mil/gsn/admissions/requirements.htm>

6\) Must meet the IHS DNS LTT application deadline of 5 PM Eastern,
December 21, 2007.

Applicant must meet the application deadline for USUHS and in addition,
must submit the following application materials by close of business on
December 15, 2007. All application materials must be submitted as an
entire package. Incomplete applications will not be accepted. Submit
info to:

Sandra L. Haldane, BSN, RN, MS

Chief Nurse, Indian Health Service

OCPS/Division of Nursing

801 Thompson Ave., STE 300

Rockville, Maryland 20852

Admission Requirements for USUHS Masters Level Programs

<http://cim.usuhs.mil/gsn/admissions/requirements.htm>

**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>

#### 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-35 .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-36 .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}

**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-37 .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-38 .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-39 .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-40 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20071115/1523ph.html**](http://www.aafp.org/afp/20071115/1523ph.html) {#httpwww.aafp.orgafp200711151523ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Somatoform Disorder: What It Is and How to Cope {#somatoform-disorder-what-it-is-and-how-to-cope .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://familydoctor.org/online/famdocen/home/common/pain/disorders/162.html**](http://familydoctor.org/online/famdocen/home/common/pain/disorders/162.html) {#httpfamilydoctor.orgonlinefamdocenhomecommonpaindisorders162.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Ulcerative Colitis: What You Should Know {#ulcerative-colitis-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20071101/1331ph.html**](http://www.aafp.org/afp/20071101/1331ph.html) {#httpwww.aafp.orgafp200711011331ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Low Back Pain and Your Job: What You Can Do to Get Back to Work {#low-back-pain-and-your-job-what-you-can-do-to-get-back-to-work .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20071115/1504ph.html**](http://www.aafp.org/afp/20071115/1504ph.html) {#httpwww.aafp.orgafp200711151504ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-44 .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}

**Detection of intraamniotic infection/inflammation at bedside: Predicts
adverse outcomes**

CONCLUSION: The MMP-8 PTD Check test is a rapid, simple, and sensitive
bedside test to detect intraamniotic infection/inflammation and to
predict adverse outcome that includes short latency, chorioamnionitis,
and significant neonatal morbidity in patients with PPROM. The results
of this study bring the rapid detection of intraamniotic
infection/inflammation to the bedside in clinical obstetrics.

[Kim
KW](http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=Search&Term="Kim KW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al A rapid matrix metalloproteinase-8 bedside test for the detection
of intraamniotic inflammation in women with preterm premature rupture of
membranes. Am J Obstet Gynecol. 2007 Sep;197(3):292.e1-5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17826425>

**Ferric carboxymaltose IV corrects postpartum anemia faster than
ferrous sulfate PO**

CONCLUSION: Large-dose IV ferric carboxymaltose administration is a new
iron agent that is effective for the treatment of postpartum anemia.
When compared with oral ferrous sulfate, IV ferric carboxymaltose is
better tolerated, prompts a more rapid Hb response, and corrects anemia
more reliably. LEVEL OF EVIDENCE: I.

[Van Wyck
DB](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Van Wyck DB"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Intravenous ferric carboxymaltose compared with oral iron in the
treatment of postpartum anemia: a randomized controlled trial.\
Obstet Gynecol. 2007 Aug;110(2 Pt 1):267-78.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666600>

**Alloimmune thrombocytopenia fetus can be safely treated in utero,
without cordocentesis**

CONCLUSION: The outcomes of both treatment groups were excellent and
comparable. Early cordocentesis is not necessary when treating
alloimmune thrombocytopenia in patients who have not delivered an infant
with an intracranial hemorrhage in a prior pregnancy. LEVEL OF EVIDENCE:
I

[Berkowitz
RL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Berkowitz RL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Antepartum treatment without early cordocentesis for standard-risk
alloimmune thrombocytopenia: a randomized controlled trial. Obstet
Gynecol. 2007 Aug;110(2 Pt 1):249-55.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666597>

**Adequate dietary calcium in before and in early pregnancy: Prevent
pre-eclampsia**

COMMENTARY: We present the hypothesis that adequate dietary calcium
before and in early pregnancy may be needed to prevent the underlying
pathology responsible for pre-eclampsia. We suggest that the research
agenda be redirected towards calcium supplementation at a community
level

[Hofmeyr
GJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hofmeyr GJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Dietary calcium supplementation for prevention of pre-eclampsia
and related problems: a systematic review and commentary. BJOG. 2007
Aug;114(8):933-43. Epub 2007 Jun 12. Review.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17565614>

**A cost decision analysis of 4 tocolytic drugs**

CONCLUSION: If one elects a tocolytic, both nifedipine and indomethacin
should be the agents of choice, based on a cost decision analysis.

[Hayes
E](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hayes E"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A cost decision analysis of 4 tocolytic drugs. Am J Obstet
Gynecol. 2007 Oct;197(4):383.e1-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904969>

**Repeat dose(s) of prenatal corticosteroids reduce serious health
problems**

AUTHORS\' CONCLUSIONS: Repeat dose(s) of prenatal corticosteroids reduce
the occurrence and severity of neonatal lung disease and the risk of
serious health problems in the first few weeks of life. These short-term
benefits for babies support the use of repeat dose(s) of prenatal
corticosteroids for women at risk of preterm birth. However, these
benefits are associated with a reduction in some measures of weight, and
head circumference at birth, and

[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 Repeat doses of prenatal corticosteroids for women at risk of
preterm birth for preventing neonatal respiratory disease. Cochrane
Database Syst Rev. 2007 Jul 18;(3):CD003935. Review.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636741>

**Does knowledge of cervical length and fetal fibronectin affect
management: RCT** CONCLUSION: The knowledge of CL and FFN was associated
with reduction in length of evaluation in women with CL \> or = 30 mm
and in incidence of SPTB in all women with PTL.

[Ness
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ness A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Does knowledge of cervical length and fetal fibronectin affect
management of women with threatened preterm labor? A randomized trial.
Am J Obstet Gynecol. 2007 Oct;197(4):426.e1-7.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904989>

**Increases in prepregnancy BMI between pregnancies: Increased primary
cesarean**

CONCLUSION: Increases in prepregnancy BMI between first 2 pregnancies
from normal to obese is associated with increased risk of indications
for primary cesarean. The association between being overweight or obese
or increases in prepregnancy BMI between pregnancies and primary
cesarean in the second pregnancy suggests that counseling women with
regard to their high BMI may be beneficial.

[Getahun
D](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Getahun D"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Changes in prepregnancy body mass index between pregnancies and
risk of primary cesarean delivery. Am J Obstet Gynecol. 2007
Oct;197(4):376.e1-7.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904966>

**Metabolic score as a novel approach to assessing preeclampsia risk.**

CONCLUSION: Metabolic score appears to be associated independently with
developing preeclampsia, particularly severe disease.

[Mazar
RM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mazar RM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Metabolic score as a novel approach to assessing preeclampsia
risk. Am J Obstet Gynecol. 2007 Oct;197(4):411.e1-5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904982>

**Placenta accreta**: **Prophylactic placement of intravascular balloon
catheters**

CONCLUSION: Prophylactic intravascular balloon catheters did not benefit
women with placenta accreta undergoing cesarean hysterectomy.

[Shrivastava
V](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Shrivastava V"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Case-control comparison of cesarean hysterectomy with and without
prophylactic placement of intravascular balloon catheters for placenta
accreta. Am J Obstet Gynecol. 2007 Oct;197(4):402.e1-5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904978>

**Amnioreduction vs fetoscopic laser photocoagulation for twin-twin
transfusion syndrome**

CONCLUSION: The outcome of the trial did not conclusively determine
whether serial amnioreduction or selective fetoscopic laser
photocoagulation is a superior treatment modality. severe twin-twin
transfusion Syndrome cardiomyopathy appears to be an important factor in
recipient survival in severe twin-twin transfusion syndrome.

[Crombleholme
TM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Crombleholme TM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A prospective, randomized, multicenter trial of amnioreduction vs
selective fetoscopic laser photocoagulation for the treatment of severe
twin-twin transfusion syndrome. Am J Obstet Gynecol. 2007
Oct;197(4):396.e1-9.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904975>

**Addition of biochemistry may enhance first-trimester risk assessment
in twin pregnancies**

Results: Adding biochemistry resulted in 100% detection rates for both
conditions.

CONCLUSION: The addition of biochemistry may enhance first-trimester
risk assessment in twin pregnancies. Further studies with larger numbers
of affected pregnancies are needed.

[Chasen
ST](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chasen ST"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al First-trimester risk assessment for trisomies 21 and 18 in twin
pregnancy.

Am J Obstet Gynecol. 2007 Oct;197(4):374.e1-3.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904965>

**Magnesium supplementation did not reduce the incidence of HIE**

CONCLUSIONS: Magnesium supplementation did not reduce the incidence of
HIE significantly, probably because the study was underpowered and
compliance was relatively poor

Harrison V et al Magnesium supplementation and perinatal hypoxia:
outcome of a parallel group randomised trial in pregnancy. BJOG. 2007
Aug;114(8):994-1002.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17578470>

#### 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

#### December 3, 2007

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**

**Special issue of the American Journal of Obstetrics & Gynecology**

I wanted to draw some attention to the special issue of the American
Journal of Obstetrics & Gynecology which focused on Achievements,
Issues, and Challenges: Prevention of Mother-to-Child HIV Transmission
in the United States and in Resource-Limited Settings.\
Below is a list of the table of contents -- many of these articles
should be of interest

**S1** For whom the bell tolls

Howard Minkoff

**S3** Reducing the risk of mother-to-child human immunodeficiency virus
transmission: past successes, current progress and challenges, and
future directions

Mary Glenn Fowler; Margaret A. Lampe; Denise J. Jamieson; Athena P.
Kourtis; Martha F. Rogers

There have been major advances with the prevention of mother-to-child
human immunodeficiency virus transmission, and this paper summarizes the
successes and current challenges and provides suggestions for future
directions.

**S10** Recent trends in the incidence and morbidity that are associated
with perinatal human immunodeficiency virus infection in the United
States

Matthew T. McKenna; Xiaohong Hu

Population-based data sources regarding the incidence and morbidity that
are associated with perinatal human immunodeficiency virus infection are
improving and indicate that prevention efforts have been enormously
successful.

**S17** Utility of antenatal HIV surveillance data to evaluate
prevention of mother-to-child HIV transmission programs in
resource-limited

settings

Omotayo Bolu; Abhijeet Anand; Andrea Swartzendruber; Wolfgang Hladik;
Lawrence H, Marum; Abdullahi Ahmed Sheikh; Aseged Woldu;

Shabbir Ismail; Agnes Mahomva; Stacie Greby; Keith Sabin

This paper describes the utility of antenatal surveillance for
monitoring and evaluating prevention of mother-to-child human
immunodeficiency virus (HIV) transmission programs in resource-limited
countries with generalized HIV epidemics.

**S26** Recommendations for human immunodeficiency virus screening,
prophylaxis, and treatment for pregnant women in the United States

Denise J. Jamieson; Jill Clark; Athena P. Kourtis; Allan W. Taylor;
Margaret A. Lampe; Mary Glenn Fowler; Lynne M. Mofenson

The 25 year history of US recommendations for human immunodeficiency
virus screening, prophylaxis, and treatment of pregnant women is
summarized, highlighting the relevance for practitioners.

**S33** Use of enhanced perinatal human immunodeficiency virus
surveillance methods to assess antiretroviral use and perinatal human

immunodeficiency virus transmission in the United States, 1999-2001

Norma S. Harris; Mary Glenn Fowler; Stephanie L. Sansom; Nan Ruffo;
Margaret A. Lampe

The results of this study demonstrate that mother-infant pairs who
received all 3 arms of antiretroviral therapy had the lowest infant
human immunodeficiency virus infection rates.

**S42** International recommendations on antiretroviral drugs for
treatment of HIV-infected women and prevention of mother-to-child HIV

transmission in resource-limited settings: 2006 update

Halima Dao; Lynne M. Mofenson; Rene Ekpini; Charles F. Gilks; Matthew
Barnhart; Omotayo Bolu; Nathan Shaffer

Wereviewed the evidence and summarized the new 2006 World Health
Organization recommendations on antiretroviral drugs for the treatment
of women who are infected

with the human immunodeficiency virus and for the prevention of the
transmission of the human immunodeficiency virus from mother to child.

**S56** Use of single-dose nevirapine for the prevention of
mother-to-child transmission of HIV-1: does development of resistance
matter?

Michelle S. McConnell; Jeffrey S. A. Stringer; Athena P. Kourtis; Paul
J. Weidle; Susan H. Eshleman

Nevirapine resistance has been detected after single-dose nevirapine,
and there is concern about the effectiveness of subsequent
nevirapine-based treatment in HIV infected women; data on the impact of
single-dose nevirapine on subsequent treatment and pregnancies are
reviewed.

**S64** Infant human immunodeficiency virus diagnosis in
resource-limited settings: issues, technologies, and country experiences

Tracy L. Creek; Gayle G. Sherman; John Nkengasong; Lydia Lu; Thomas
Finkbeiner; Mary Glenn Fowler; Emilia Rivadeneira; Nathan Shaffer

This paper provides a description of challenges, progress, and
recommendations for infant human immunodeficiency virus (HIV) diagnosis
in resource-limited settings with high HIV prevalence.

**S72** Rapid human immunodeficiency virus-1 testing on labor and
delivery in 17 US hospitals: the MIRIAD experience

Denise J. Jamieson; Mardge H. Cohen; Robert Maupin; Steven Nesheim;
Susan P. Danner**;** Margaret A. Lampe; Mary Jo O'Sullivan; Mayris P.
Webber; Jeffrey Wiener; Rosalind J. Carter; Yvette Rivero; Mary Glenn
Fowler; Marc Bulterys

Routine rapid testing during labor provides a feasible, acceptable, and
accurate way to identify human immunodeficiency virus--infected women
before delivery.

**S83** Approaches for scaling up human immunodeficiency virus testing
and counseling in prevention of mother-to-child human immunodeficiency
virus transmission settings in resource-limited countries

Omotayo O. Bolu; Virginia Allread; Tracy Creek; Elizabeth Stringer; Fatu
Forna; Marc Bulterys; Nathan Shaffer

This paper provides a summary of approaches and recommendations for
scaling up human immunodeficiency virus testing and counseling in
prevention of mother-to child transmission settings in resource-limited
countries.

**S90** Toward elimination of perinatal human immunodeficiency virus
transmission in the United States: effectiveness of funded prevention
programs, 1999-2001

Stephanie L. Sansom; Norma S. Harris; Ramses Sadek; Margaret A. Lampe;
Nan M. Ruffo; Mary Glenn Fowler

The number of new perinatal human immunodeficiency virus infections in
funded states decreased by 56%, achieving Centers for Disease Control
and Prevention goal of a 50% reduction in incidence by 2005.

**S96** Cesarean delivery for HIV-infected women: recommendations and
controversies

Denise J. Jamieson; Jennifer S. Read; Athena P. Kourtis; Tonji M.
Durant; Margaret A. Lampe; Kenneth L. Dominguez

Cesarean delivery to prevent mother-to-child transmission of human
immunodeficiency virus is safe, effective, and relatively
cost-effective; accordingly, cesarean delivery rates among human
immunodeficiency virus--infected women have increased dramatically.

**S101** Prevention of mother-to-child transmission services as a
gateway to family-based human immunodeficiency virus care and treatment
in resource-limited settings: rationale and international experiences

Elaine J. Abrams; Landon Myer; Allan Rosenfield; Wafaa M. El-Sadr

Viewing preventing the mother-to-child transmission as a gateway to
family-based human immunodeficiency virus care and treatment will help
strengthen ties between the 2 programs.

**S107** Site-specific interventions to improve prevention of
mother-to-child transmission of human immunodeficiency virus programs in
less developed settings

Tabitha Sripipatana; Allison Spensley; Anna Miller; James McIntyre;
Gloria Sangiwa; Frederick Sawe; David Jones; Catherine M. Wilfert

This article discusses site-specific interventions to increase the
uptake of prevention of mother-to-child transmission programs based on
experiences in sub-Saharan Africa. Lessons learned can apply to many
resource-constrained settings.

**S113** Prevention of human immunodeficiency virus-1 transmission to
the infant through breastfeeding: new developments

Athena P. Kourtis; Denise J. Jamieson; Isabelle de Vincenzi; Allan
Taylor; Michael C. Thigpen; Halima Dao; Timothy Farley; Mary Glenn
Fowler

This paper focuses on current and planned research trials on strategies
to prevent breastfeeding transmission of human immunodeficiency virus
from mother to infant worldwide.

Edited by Margaret A. Lampe RN, MPH Denise J. Jamieson MD, MPH Nathan
Shaffer MD Martha F. Rogers MD from CDC) - Volume 197, Issue 3,
Supplement S (September 2007)

<http://journals.elsevierhealth.com/periodicals/ymob/issues/contents>

#### 

#### Other

#### Racial Disparities Persist Across All Reportable STDs

Racial and ethnic minorities continue to be disproportionately affected
by sexually transmitted diseases in the United States; data in CDC's
2006 STD Surveillance Report show higher rates of all STDs among
minority racial and ethnic populations when compared to whites, with the
exception of Asians/Pacific Islanders. These disparities may be, in
part, because racial and ethnic minorities are more likely to seek care
in public health clinics that report STDs more completely than private
providers. However, this reporting bias does not fully explain these
differences. Other contributing factors include limited access to
quality health care, poverty, and higher prevalence of disease in these
populations.

**Chlamydia**

In 2006, the rate of chlamydia among African Americans was more than
eight times higher than the rate among whites (1275.0 vs. 153.1 per
100,000 population), with approximately 46 percent of all chlamydia
cases reported among African Americans. Additionally, the rates among
American Indians/Alaska Natives (797.3 per 100,000) and Hispanics (477.0
per 100,000), were five times and three times higher than whites,
respectively. In 2006, chlamydia rates increased for all racial/ethnic
groups, except for Asians/Pacific Islanders.

**Gonorrhea**

Racial disparities in gonorrhea rates are even greater and racial gaps
in diagnosis of gonorrhea are more pronounced than any other disease.
The gonorrhea rate among African Americans was 18 times greater than
that for whites in 2006 (658.4 per 100,000 vs. 36.5 per 100,000). From
2005 to 2006, the gonorrhea rate among African Americans increased by
6.3 percent---the first increase since 1998. In 2006, African Americans
accounted for 69 percent of reported cases of gonorrhea.

In that same year, American Indians/Alaska Natives had the
second-highest gonorrhea rate (138.3 per 100,000), followed by Hispanics
(77.4), whites (36.5), and Asians/Pacific Islanders (21.1). In 2006,
there were increases in gonorrhea rates among all racial and ethnic
groups, except Asians/Pacific Islanders.

**Syphilis**

Although racial gaps in syphilis rates are narrowing, disparities
remain, with rates in 2006 approximately six times higher among blacks
than among whites. This represents a substantial decline from 1999, when
the rate among blacks was 29 times greater than among whites. It is
important to note that this narrowing reflects both declining disease
rates among African Americans as well as significant increases among
white males in recent years.

Despite some progress, African Americans continue to remain
disproportionately affected by syphilis with a rate of 11.3 cases per
100,000 population in 2006. This is more than three times the rate for
Hispanics, who have the second highest rate (3.6 cases per 100,000) as
well as American Indians/Alaska Natives (3.3 cases per 100,000).

In 2006, the P&S syphilis rate among blacks increased for the third
consecutive year, following more than a decade of declines. Between 2005
and 2006, the rate among blacks increased 16.5 percent (from 9.7 to
11.3), with the largest increase among black males (15.5 to 18.3, an
increase of 18.1 percent).

In 2006, the rate of P&S syphilis in black females was 16 times higher
than in white females. In that same year, 43.2 percent of all reported
P&S syphilis cases occurred among African Americans, while whites
accounted for 38.4 percent. Syphilis rates increased for all races and
ethnicities in 2006. <http://www.cdc.gov/std/stats/default.htm>

####  {#section-46 .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}

#### Hypertension Triples Women\'s Risk for Diabetes {#hypertension-triples-womens-risk-for-diabetes-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The link between high blood pressure and diabetes risk was independent of factors known to increase the odds of getting diabetes and cardiovascular disease."  {#the-link-between-high-blood-pressure-and-diabetes-risk-was-independent-of-factors-known-to-increase-the-odds-of-getting-diabetes-and-cardiovascular-disease. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Conclusion Baseline BP and BP progression are strong and independent predictors of incident type 2 diabetes among initially healthy women. {#conclusion-baseline-bp-and-bp-progression-are-strong-and-independent-predictors-of-incident-type-2-diabetes-among-initially-healthy-women. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Conen D](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Conen D"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Blood pressure and risk of developing type 2 diabetes mellitus: The Women\'s Health Study. Eur Heart J. 2007 Oct 9 {#conen-d-et-al-blood-pressure-and-risk-of-developing-type-2-diabetes-mellitus-the-womens-health-study.-eur-heart-j.-2007-oct-9 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17925342**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17925342) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17925342 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-47 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### METHODS: A systematic review of observational studies examining the relationship between prenatal exposures and childhood overweight and obesity was conducted using MOOSE guidelines. RESULTS: Four of six included studies of prenatal exposure to maternal diabetes found higher prevalence of childhood overweight or obesity among offspring of diabetic mothers, with the highest quality study reporting an odds ratio of adolescent overweight of 1.4 (95% CI 1.0-1.9). The Dutch famine study found that exposure to maternal malnutrition in early, but not late, gestation was associated with increased odds of childhood obesity (OR 1.9, 95% CI 1.5-2.4). All eight included studies of prenatal exposure to maternal smoking showed significantly increased odds of childhood overweight and obesity, with most odds ratios clustering around 1.5 to 2.0. The biological mechanisms mediating these relationships are unknown but may be partially related to programming of insulin, leptin, and glucocorticoid resistance in utero. {#methods-a-systematic-review-of-observational-studies-examining-the-relationship-between-prenatal-exposures-and-childhood-overweight-and-obesity-was-conducted-using-moose-guidelines.-results-four-of-six-included-studies-of-prenatal-exposure-to-maternal-diabetes-found-higher-prevalence-of-childhood-overweight-or-obesity-among-offspring-of-diabetic-mothers-with-the-highest-quality-study-reporting-an-odds-ratio-of-adolescent-overweight-of-1.4-95-ci-1.0-1.9.-the-dutch-famine-study-found-that-exposure-to-maternal-malnutrition-in-early-but-not-late-gestation-was-associated-with-increased-odds-of-childhood-obesity-or-1.9-95-ci-1.5-2.4.-all-eight-included-studies-of-prenatal-exposure-to-maternal-smoking-showed-significantly-increased-odds-of-childhood-overweight-and-obesity-with-most-odds-ratios-clustering-around-1.5-to-2.0.-the-biological-mechanisms-mediating-these-relationships-are-unknown-but-may-be-partially-related-to-programming-of-insulin-leptin-and-glucocorticoid-resistance-in-utero. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Our review supports prenatal programming of childhood overweight and obesity. MCH research, practice, and policy need to consider the prenatal period a window of opportunity for obesity prevention. {#conclusion-our-review-supports-prenatal-programming-of-childhood-overweight-and-obesity.-mch-research-practice-and-policy-need-to-consider-the-prenatal-period-a-window-of-opportunity-for-obesity-prevention. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Huang JS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Huang JS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Prenatal programming of childhood overweight and obesity. Matern Child Health J. 2007 Sep;11(5):461-73.  {#huang-js-et-al-prenatal-programming-of-childhood-overweight-and-obesity.-matern-child-health-j.-2007-sep115461-73. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17006770**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17006770) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17006770 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-48 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.eatright.org/ada/files/Pregnancynp.pdf**](http://www.eatright.org/ada/files/Pregnancynp.pdf) {#httpwww.eatright.orgadafilespregnancynp.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-49 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Transgenic expression of menin in maternal beta-cells prevented islet expansion and led to hyperglycemia and impaired glucose tolerance, hallmark features of gestational diabetes. Prolactin, a hormonal regulator of pregnancy, repressed islet menin levels and stimulated beta-cell proliferation. These results expand our understanding of mechanisms underlying diabetes pathogenesis and reveal potential targets for therapy in diabetes. {#transgenic-expression-of-menin-in-maternal-beta-cells-prevented-islet-expansion-and-led-to-hyperglycemia-and-impaired-glucose-tolerance-hallmark-features-of-gestational-diabetes.-prolactin-a-hormonal-regulator-of-pregnancy-repressed-islet-menin-levels-and-stimulated-beta-cell-proliferation.-these-results-expand-our-understanding-of-mechanisms-underlying-diabetes-pathogenesis-and-reveal-potential-targets-for-therapy-in-diabetes. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Karnik SK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Karnik SK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Menin Controls Growth of Pancreatic {beta}-Cells in Pregnant Mice and Promotes Gestational Diabetes Mellitus. Science. 2007 Nov 2;318(5851):806-809. {#karnik-sk-et-al-menin-controls-growth-of-pancreatic-beta-cells-in-pregnant-mice-and-promotes-gestational-diabetes-mellitus.-science.-2007-nov-23185851806-809. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17975067**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17975067) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17975067 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-50 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### An Indiana University study provides some of the strongest evidence yet that prenatal exposure to alcohol causes conduct problems in children, a finding that has been called into question in recent years. {#an-indiana-university-study-provides-some-of-the-strongest-evidence-yet-that-prenatal-exposure-to-alcohol-causes-conduct-problems-in-children-a-finding-that-has-been-called-into-question-in-recent-years. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: These results are consistent with PAE exerting an environmentally mediated causal effect on childhood CPs, but the relation between PAE and AIPs is more likely to be caused by other factors correlated with maternal drinking during pregnancy. {#conclusion-these-results-are-consistent-with-pae-exerting-an-environmentally-mediated-causal-effect-on-childhood-cps-but-the-relation-between-pae-and-aips-is-more-likely-to-be-caused-by-other-factors-correlated-with-maternal-drinking-during-pregnancy. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Causal Inferences Regarding Prenatal Alcohol Exposure and Childhood Externalizing Problems,\" Archives of General Psychiatry, vol. 64, no. 11, Nov. 2007 {#causal-inferences-regarding-prenatal-alcohol-exposure-and-childhood-externalizing-problems-archives-of-general-psychiatry-vol.-64-no.-11-nov.-2007 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17984398**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17984398) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17984398 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-51 .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}

**Alaska Native Fetal Alcohol Spectrum Disorders and Suicidality in a
Healthcare setting**

[Objectives.]{.underline} To present a clinical case report and provide
a review of the available literature

on fetal alcohol syndrome and the fetal alcohol spectrum disorders and
suicidality to highlight

important implications for providers.

[Study design]{.underline}. A case report and literature review.

[Results.]{.underline} Almost 6% of adolescents evaluated by the fetal
alcohol spectrum disorders diagnostic

clinic at the Alaska Native Medical Center had been seen for self-harm
related consultation.

[Conclusions.]{.underline} Persons with the fetal alcohol syndrome and
the fetal alcohol spectrum disorders,

as a result of their disability, demonstrate characteristics or features
that are commonly thought

to be risk factors for suicide---such as mental illness, alcohol and
other drug abuse, impulsivity,

history of trauma or abuse, and employment and relationship/social
difficulties. These persons

may experience mental health problems, including suicidal ideation and
attempts, over the course

of their life times.

Fetal Alcohol Spectrum Disorders and Suicidality in a Healthcare
setting\
Baldwin MR Int J Circumpolar Health 2007; 66(Suppl 1):54-60

[http://www.ijch.fi/issues/66%20Suppl%201/IJCH%2066%20Suppl%201_Baldwin.pdf](http://www.ijch.fi/issues/66 Suppl 1/IJCH 66 Suppl 1_Baldwin.pdf)

**ACNM and AWHONN nursing representation to site visit and educational
activities involving women\'s health**

I want to let you know that Indian Health Service now has a
representative from the American College of Nurse Midwives (ACNM) and
the Association of Women's Health, Obstetric and Neonatal Nurses
(AWHONN) representing the interests of nurse-midwives, labor and
delivery nurses, women's health and neonatal nurses on the annual site
visits to facilities providing perinatal services, and to the annual
OB-GYN, Neonatal and Women's Health Course. 

Marilyn Pierce-Bulger, CNM is our representative from ACNM.  Marilyn
practiced midwifery and was Chief of Midwifery at the Alaska Native
Medical Center from 1981 in to the 1990's.   Marilyn was not only
involved in building the midwifery practice at ANMC, she also worked to
reduce the infant mortality rate in Alaska through a program she
developed to provide close case management through public health nursing
to the mothers at highest risk of loosing their infant.  She has also
worked with the State of Alaska and CDC on various other health issues
such as FASD and SIDS. 

Karen Peddicord, RN, MSN is our representative from AWHONN.  Karen spent
her career as a labor and delivery nurse, OB Nurse Manager, a Professor
of Nursing and the OB-Neonatal Product Manager for a large hospital here
in the DC area.  Karen has been the Acting CEO for AWHONN and is
currently the Director of Research for AWHONN.   Karen has always loved
labor and delivery nursing.  She often cites the heroism that L&D nurses
display as just a routine part of their job.

Marilyn and Karen are part of the Post Graduate Course in OB, Neonatal
and Women's Health; the so-called Denver Course.   They both participate
in the planning committee meetings.  Karen will make a presentation on
'Creating a Nurse-Friendly Culture' and 'Creating a Culture of Safety
within Labor and Delivery'.  Karen will also be a part of the yearly
site visits to IHS facilities providing OB services and will be focusing
on nursing related issues.  Marilyn is also part of the planning process
for the OB, Neonatal and Women's Health Course.   She will be making a
presentation on FASD at the course.  Marilyn also will participate in
the site visits and will focus on midwifery.  She knows many of the
issues that midwives must deal with, such as the following:

1\) CNM roles in various sites differ but are almost always KEY to the
provision of a large percentage of health care to Native women, however
the CNM voice is not always \'at the table\' for planning/program
development purposes.  In addition, some sites do not have a sense of a
'CNM team' or of the larger 'OB team' which would benefit both women
being served and the CNM\'s themselves.

 

2\) The CNM role in some locations is being supervised (and/or
performance reviews are done) by non-CNM providers. Perhaps
encouragement and training/technical assistance could be provided
to sites that desire an enhanced understanding of the CNM role.  In
other words if the org charts can\'t change, maybe the \'reviewers\' can
be trained to do a more informed review.

 

IHS conducts site visits in one Area each year.   This year we will be
going to Phoenix.  I am interested in improving the nursing and
nurse-midwifery content of those reviews.  I believe that we are moving
in the right direction.  I will continue to work towards having adequate
midwifery and perinatal/L&D nursing on each of the site visit teams.
<Carolyn.Aoyama@ihs.gov>

**Report: State of Women\'s Health Poor Nationwide**

The 2007 edition of \"Making the Grade on Women\'s Health: A National
and State-by-State Report Card,\" which measured 27 benchmarks, found
that the United States now fails to meet 12 of the benchmarks, three
more than it did not meet in 2004. Two benchmarks---reducing obesity and
providing Pap smears to women age 18 and up---were met in 2004, but are
no longer met by any state, according the analysis.

Making the Grade on Women's Health: A National and State-by-State Report
Card is the first-ever report card to assess the overall health of women
at the national and state levels. The Report Card is designed to promote
the health and well-being of women in the United States by providing the
most comprehensive assessment to date of women's health.

[Benchmark Disparities]{.underline}\
The report found that several benchmarks \-- including the percentage of
women receiving prenatal care, infant mortality and the percentage of
uninsured women \-- varied significantly by race. American Indians and
Alaska Native women were twice as likely as white women to be uninsured,
the report found. Among white women, 16.9% were uninsured, compared with
22.7% of black women and 37.8% of Hispanic women, according to the
report. The percentage of uninsured women increased by 1.7% since 2004,
according to the report (CQ HealthBeat, 10/17). Minnesota had the lowest
percentage of uninsured with 9.1%, and Texas had the highest percentage
at 28.1%, the report said (Reuters, 10/17).\
\
The report found 85.7% of white women received prenatal care, compared
with 70.8% of American Indians, 75.9% of blacks and 77.5% of Hispanics.
According to the report, the percentage of women nationwide who received
prenatal care increased by 5% since 2004 but is still unsatisfactory.
The report found that white women have an infant mortality rate of 5.7
deaths for every 1,000 live births, compared with 13.5 deaths per 1,000
live births for blacks and 5.6 per 1,000 live births for Hispanics. The
overall infant mortality rate has remained the same since 2004

<http://hrc.nwlc.org/>

**Advanced Practice Nursing Brochure Available**

Hello APNs! 

I am wondering if you would like copies of the Nurse Practitioner
Brochure we have used in the past.  If there is demand for it, I will
print it again and send it out to the Area Offices for distribution.

Please let me know if there is demand for at least 1,000 per Area.   If
you think you need more than 1,000 in your Area, please let me know that
too. <Carolyn.Aoyama@ihs.gov>

**Women's Health Data Book Available**

The DRAFT Women's Health 2008 Databook (WHUSA) is available now. 
Contact Teddra Penland (301-443-1028) and let her know how many copies
of the Databook you would like -- Teddra will be ordering them.  Thanks.
<Carolyn.Aoyama@ihs.gov>

# Save the dates {#save-the-dates .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**2007 National HIV Prevention Conference**

-   December 2-5, 2007

-   Atlanta, Georgia

-   Center for Disease Control and Prevention

-   <http://www.2007nhpc.org/conferenceinfo.asp>

**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>

**Keeping Native Women & Families Healthy & Strong**

-   April 23-25, 2008

-   Milwaukee, WI

-   Great Lakes Tribal Epidemiology Center

-   E-mail contact <EpidemiologyCenter@gmail.com>

# 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}

**Where can I get copies of the lecture notes from the 2007 Women's
Health and MCH**

**Conference that was held in Albuquerque on August 15-17^th^ ?**

<http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm>

[**New Perinatology Corner Module - Varicella (Chickenpox) in
Pregnancy**](http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/VC01.cfm)

<http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/VC01.cfm>

[**Frequently Asked Question about Capturing Infant Feeding Choice on
RPMS and EHR**](http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

[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)

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 **November 2007 OB/GYN CCC Corner** is available at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1107.cfm>

#### Abstract of the Month page 6 {#abstract-of-the-month-page-6-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Hospital brought rapid cesarean delivery times into range of 10.9
minutes: Can you?**

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

Kelly Acton

The the exciting launch of the NIKE Air Native N7 Shoes

Michael Berryhill

OB/GYN offering services at greatly reduced salary

Scott Giberson

USCA to Honor Native AI/AN at Opening Plenary and "Celebration of Life"
Event

**Amy Groom**

Let's clear up any confusion over the availability of the HPV vaccine

**Elaine Locke**

State Maternal Mortality Review: Accomplishments of Nine States: Now
Available

**Alan Waxman**

Mark your calendar! Ask for leave! Thnk snow! Telluride Conference -
February 8-10, 2008

#### Hot Topics {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics page 10

-SBE prophylaxis not recommended for cesarean delivery or other
genitourinary tract procedures

-A preventive approach to lower the cesarean delivery rate in a rural
hospital

-1 of every 6 women studied had filled a class D or X prescription

-Risk of uterine rupture with a prior cesarean delivery much lower than
expected: 0.3%

-Women who quit smoking before pregnancy benefit from reduced risk of
abruption

....and more

**Gynecology page 13**

-2006 ASCCP consensus guidelines for abnormal cervical cancer screening,
CIN, AIS

-Effectiveness of two tinidazole regimens in treatment of bacterial
vaginosis: RCT

-Minimally invasive strategy for large cysts: Laparoscopically guided
minilaparotomy

-Tailored mesh significantly reduced the rate of recurrence of anterior
vaginal wall prolapse

-Botulinum toxin injections for adults with overactive bladder syndrome

....and more

**Child Health page 17**

-Traumatic events and alcohol use disorders among American Indian
adolescents

-Viracept Use Should Be Limited in Children and Pregnant Women

-Statement Updated for Screening and Treatment of Teens at Risk for
Suicide 

-Medication errors made during half of care for children seen at
emergency departments

# -Maternal Weight Tied to Child\'s Body Composition at Age 9

**Chronic Illness and Disease page 18**

-Aging and prevalence of CVD risk factors in American Indians: the
Strong Heart Study

-Both coping and communication-enhancing and supportive counseling work
after cancer

-Opioid Analgesia During Evaluation of Acute Abdominal Pain

#### -Does Screening Mammography Benefit Women in Their 40s? {#does-screening-mammography-benefit-women-in-their-40s .Style-Heading-4-+-Arial-14-pt-Underline}

-CDC Updates Guidelines for Use of Influenza Vaccine and Antiviral
Agents

....and more

#### Features {#features-1 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists page 21

-Viral Hepatitis in Pregnancy

-Disclosure and Discussion of Adverse Events

-Routine Thyroid Screening Not Recommended for Pregnant Women

-Fetal Monitoring Prior to Scheduled Cesarean Delivery

-Evaluation of Stillbirths and Neonatal Deaths

##### American Family Physician

-Repeat Cesarean Delivery vs. Planned Induction of Labor: Cochrane
Briefs

-Hyperthyroidism

-Bell\'s Palsy: Diagnosis and Management

-Peptic Ulcer Disease

-Respiratory Distress in the Newborn

**Agency for Healthcare Research and Quality**

-Childbirth preferences after prior cesarean delivery: Information
affects future choices

-Colorectal cancer screening is not just for symptoms: Primary care
providers should clarify

-Three characteristics double risk of hysterectomy for women with common
pelvic conditions

-Three-fourths of low-income women dissatisfied with their body size 6
months after giving birth

-Women receive worse care than men for cardiovascular disease and
diabetes

**Ask a Librarian**

In Search of a Research Article?

**Breastfeeding**

-Breastfeeding Promotion: Good Public Health Policy

-Early skin-to-skin contact for mothers and their newborn infants
improves outcomes

-Breast milk: Greater mental development and fewer re-hospitalizations

**CCC Corner Digest**

\-[Group Prenatal Care Improves Pregnancy Outcomes at No Additional
Cost](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_AOM.cfm)

\-[Rebuilding Iraq one patient at a time: You can be part of the
solution](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Coll.cfm)

\-[Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum
Outcomes?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#ob)

\-[Cervical cancer differences disappear in rural women after
controlling for poverty and
race](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#gyn)

\-[How to improve psychosocial problems at well child care
visits?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#child)

\-[Why Hasn\'t This Patient Been Screened for Colon
Cancer?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#chrIll)

\-[Management of Delivery of a Newborn With Meconium-Stained Amniotic
Fluid](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#acog)

\-[In Search of a Research
Article?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#AskLib)

\-[A pacifier by any other
name....](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#breast)

\-[October is Domestic Violence Awareness
Month](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#dv):
Materials available

\-[Advance Provision for Emergency Oral Contraception Reduces Post
Coital
Interval](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#fp)

\-[What\'s the first course of action for this couple that\'s trying to
conceive?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#faq)

\-[Bar code medication administration changes nurses\'
work](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#it)

\-[Prevention of Mother-to-Child HIV Transmission: An Innovative Program
in
Cameroon](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#ih)

\-[AI / AN researchers on perinatal depression requesting names of
interested
individuals](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#headlines)

\-[Endometriosis: Where is the real
truth?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#mmtour)

\-[Estrogen Protects Women's Brains Prior to
Menopause](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#menopause)

\-[Piercing the veil: the marginalization of midwives in the United
States](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#MidWives)

\-[Evaluation of the pregnant patient for non-obstetric
surgery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907_Feat.cfm#navajo)

\-[Memories, As a Public Health Nurse on the
Navajo](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#nurseCorner)\*

\-[Common Questions about HPV and Cervical Cancer: For Women Who Have
HPV](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#owh)

\-[Fracture Outcomes in Women Discontinuing
Alendronate](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#oste)

\-[Procedure-related complications of amniocentesis and CVS are
small](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#periPicks)

\-[Chronic Renal Disease is Part of Primary
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907_Feat.cfm#pcfhttp://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm)

\-[Call for re-evaluation of gestational diabetes diagnosis and
treatment
criteria](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#stillW)

\- [Ovarian Cancer: Pinn Point on Women's
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#wheadlines)

**Domestic Violence**

-Coaching Boys into Men, AI/AN poster

-Aberdeen requesting DV and sexual assault pamphlets or CD-ROM resources

-Patient Self-Administered Report Effective to Screen for Domestic
Violence 

-DV victims have higher health care use and costs, even long after the
abuse has ended

**Elder Care News**

-Moderate- and High-Intensity Resistance Training Improves Cognitive
Function in Elderly

-Fall Injury Episodes Among Non-institutionalized Older Adults: United
States, 2001--2003

-Maintenance Antidepressant Treatment Improves Well-Being in Late-Life
Depression

\-[The Last Hours of Living: Practical Advice for
Clinicians](http://www.medscape.com/viewprogram/5808)

\-[Principles of Effective Pain Management at the End of
Life](http://www.medscape.com/viewprogram/6079)

**Family Planning**

-Transdermal hormonal contraception: benefits and risks

#### -Oral Contraceptive Use Linked to Cancer Risk {#oral-contraceptive-use-linked-to-cancer-risk .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

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

**Frequently asked questions**

How can we best manage Jehovah's Witnesses during pregnancy?

**Indian Child Health Notes**

-Challenges in Pediatric Rheumatic Disease: Special Issues with Native
Children

-Study of Virus Etiologies of Respiratory Hospitalizations in Alaska
Native children

-Native American genetic resources and the concept of cultural harm

-Widening socioeconomic disparities in US childhood mortality, 1969-2000

**Information Technology**

-National Release - RPMS Electronic Health Record, Version 1.1

-National Release - BI Immunization System, Version 8.2

International Health

-Treating schizophrenia in poorer countries: Old dilemmas and new
directions

#### MCH Alert

-Having more family meals during adolescence is associated with improved
diet quality

-Telemedicine Meeting the Health Care Needs of Children

-Challenges in the prevention of mother to child HIV transmission

-Supplement examines influences on obesity and healthy adolescent
behavior

#### MCH Headlines

-Child passengers are exposed to secondhand smoke

-26th Annual "Protecting Our Children"

-Child Poverty in Nonmetropolitan Areas by State including New Mexico 

-Substance Use Treatment Among Women of Childrearing Age

-Number one killer of youth: MVAs - Great set of slides to pick and
choose from

....and more

#### Medical Mystery Tour

#### Endometriosis: Where is the real truth? (Answers to last month's quiz) {#endometriosis-where-is-the-real-truth-answers-to-last-months-quiz .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

#### -Prevention of Influenza in a Family Setting to Reduce Transmission to Individuals at Risk {#prevention-of-influenza-in-a-family-setting-to-reduce-transmission-to-individuals-at-risk .Style-Heading-4-+-Arial-14-pt-Underline}

#### -78-year-old woman, is seen in consultation for chronic neck pain {#year-old-woman-is-seen-in-consultation-for-chronic-neck-pain .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Epidemiology and Prevalence of Breast Cancer in the US {#epidemiology-and-prevalence-of-breast-cancer-in-the-us .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Important Considerations for Treating Epilepsy in a Woman of Middle Age  {#important-considerations-for-treating-epilepsy-in-a-woman-of-middle-age .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Individualized Preventive Management of Hereditary Breast Ovarian Cancer Syndrome {#individualized-preventive-management-of-hereditary-breast-ovarian-cancer-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

....and more

**Menopause Management**

-Hormone therapy has no effect on memory but increases sexual interest

-Continuous HRT combined therapy vs sequential therapy and endometrial
cancer risk

#### -There are benefits to the introduction of hormone therapy on exercise {#there-are-benefits-to-the-introduction-of-hormone-therapy-on-exercise .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Strength Training Helps Prevent Fat Gain in Overweight, Obese Premenopausal Women {#strength-training-helps-prevent-fat-gain-in-overweight-obese-premenopausal-women .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-If you gotta use something, nitrous oxide might be better than
narcotics and epidurals

-Repeat HIV testing in pregnancy identifies opportunities for
antiretroviral prophylaxis

-Nei-Guan point acupressure is a useful treatment for relieving
hyperemesis gravidarum

-One in Seven Women are Depressed Before, During, or After Pregnancy

**Navajo News**

Acute Appendicitis and Pregnancy

**Nurses Corner**

Nurses and physicians have different perspectives in medical decisions

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

Church-Based Breast Cancer Screening Education: Impact of Two Approaches

**Oklahoma Perspective**

Training for Shoulder Dystocia

Osteoporosis

-Ordinary Doses of Vitamin D Linked to Lower Mortality

-Home health care following hip fracture limits osteoporosis progression

Patient Education

-Unsafe drugs during pregnancy: Frequency of birth control services with
prescriptions

-Improved health literacy should address literacy, language, and
cultural barriers

-Health literacy is not associated with how minorities perceive their
physical or mental health

#### -Bell\'s Palsy: What You Should Know {#bells-palsy-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Peptic Ulcers: What You Should Know {#peptic-ulcers-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-The Dating Game (No, I don't mean TV show the Dating Game)

-Prevention is the most effective evidence-based management to avoid
recurrence of FGR

-3 criteria of oligohydramnios in identifying peripartum complications

-Oxytocin agonists for preventing postpartum haemorrhage

-Features of metabolic syndrome increase risk of a child with a NTD

....and more

Primary Care Discussion Forum

Chronic Kidney Disease: CKD is Part of Primary Care!

STD Corner

-American Indian women, HIV/AIDS, and health disparity

# -Adolescents' Discussions About Contraception Or STDs with Partners Before First Sex 

-Using clinical classifcation trees to identify risk of STDs during
pregnancy

-Exam room reminders / provider feedback can improve screening for
chlamydia in young women

#### -Genital Herpes: Framing the Problem, Diagnosing the Disease {#genital-herpes-framing-the-problem-diagnosing-the-disease .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Magic Pill Improves Glycemic Control and Decreases Death by 25% for
Type 2\'s

-Laugh Your Way to Normal Blood Sugars

-Maternal Weight Gain Series (Six articles)

-True or False:  The largest at-risk group for sleep-related crashes is
commercial drivers

-PRESENT Diabetes, an Online Clinical Conference any time day or night

....and more

**Women's Health Headlines**

-Planning Group - conference on midwifery models of care

-Are women being scared away from math, science, and engineering fields?

###### Save the Dates: Upcoming events of interest page 63

#### What's new on the ITU MCH web pages page 64

**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>

11/21/07njm