Professional Documents
Culture Documents
A Cog Today 0810
A Cog Today 0810
of obstetricians
and gynecologists TODAY
AUG 2010
New
VBAC
Guidelines:
What they mean
to you and your
patients
TODAY Message From the President
aug 2010 Volume 54, Issue 4
C
Ralph W. Hale, MD, FACOG
Director of Communications hildbirth is a joyous, safe Birth After Previous Cesarean Delivery,
Penelope Murphy, MS experience for most mothers in described on page six.
Editor the US, and ob-gyns play the Ob-gyns must keep moving ahead
Laura Humphrey leading role in delivering their care. Yet to tackle all factors contributing to the
Design and Production
the US lags behind other industrialized maternal mortality rate. While the re-
BonoTom Studio, Inc nations in healthy births, and we know cently enacted health care reform law
very little about why. The growing rate will expand access to prenatal care,
Permission to Photocopy/Reprint
Laura Humphrey, Editor of maternal deaths in this country is a research is critically needed to under-
email: lhumphrey@acog.org significant and deeply troubling prob- stand how our nation can drive down
lem. The US maternal mortality ratio has maternal and infant mortality and pre-
Address Changes
800-673-8444, ext 2427, doubled in the past 20 years, reversing Richard N. Waldman, MD, maturity rates. Effective research based
or 202-863-2427 years of progress. Increasing cesarean President on comprehensive data is the key to
Fax: 202-479-0054 deliveries, obesity, increasing maternal developing, testing, and implementing
email: membership@acog.org age, and changing population demographics each evidence-based actions. Other countries have devel-
Copyright 2010 by contribute to the trend. oped robust approaches to maternal mortality and
The American Congress of In 2008 the cesarean delivery rate reached another the US should follow their lead.
Obstetricians and Gynecologists record high—32.3% of all births. There is a community ACOG’s “Making Obstetrics and Maternity Safer”
409 12th Street, SW not far from my home in which 45% of the newborns (MOMS) initiative is a comprehensive, multi-pronged
Washington, DC 20024-2188 are delivered via an abdominal incision. Let me be very approach to this challenge. The goals of MOMS
(ISSN 0400-048X). honest. This increase in cesarean delivery rate grieves include understanding and reducing premature births,
Main phone: 800-673-8444 or me because it seems as if we are changing the culture improving data collection on maternal and infant health,
202-638-5577. of birth. While it is certainly true that a physician has and focusing on obesity research and prevention. ACOG
The American Congress of Obstetricians a contract with an individual patient, our specialty has Today will include more on MOMS next month.
and Gynecologists (ACOG) does not a covenant with our society. We are committed to leading this improvement as
endorse or make any representation or The College’s new guidelines for VBAC are expect- part of our imperative to make motherhood as safe as
warranty, express or implied, with respect ed to help address the rising cesarean rate, making possible. The US Congress and government have im-
to any of the products or services described trial of labor after cesarean an option for more wom- portant roles to play by helping fund major research to
herein. en. Our Committee on Practice Bulletins-Obstetrics understand and ensure safe births and healthy babies.
worked tirelessly to review data and evidence, in- I know each of you is committed to making every
ACOG Today’s mission is to keep members cluding the 2010 findings of the NIH Consensus birth healthy and safe in your practices, and I com-
apprised of activities of both The Development Conference on Vaginal Birth after Ce- mend you for the diligent work you do every day.
American Congress of Obstetricians and sarean, to develop our new Practice Bulletin, Vaginal Thank you.
Gynecologists and The American College
of Obstetricians and Gynecologists.
cover: INMAGINE
A
l l C ol l e ge a n d care. Another principle states
C o n g r e s s com- that, in general, no more than
Courses and coding workshops������ 12
mittee members are two members from the same dis-
appointed for one-year terms trict may serve on a committee.
beginning the day after the new For a 2011–2012 appointment,
president is inaugurated at the no committee member can have
spring Annual Clinical Meeting. a relationship with the phar-
A committee member may be maceutical or device industry
reappointed for a total of three except in relation to clinical in-
terms, and can serve for an ad- vestigations or studies conducted
ditional two years if the member in accordance with government
Ralph W. Hale, MD,
becomes committee chair. The Executive Vice President regulations.
Executive Boards of The Con- In an average year, we receive
gress and The College create, abolish, and more than 400 applications. With annual
define functions of their respective committees. openings limited to about 60 or 70, we regret
The process for appointment to a commit- that many very qualified individuals cannot
tee for the following year begins in the summer be appointed to a committee. Repeated ap-
Treasurers’
conference
after the ACM. Application forms for commit- plications improve your chances of being
tee service are placed on the ACOG website, appointed, but the most important factor is
www.acog.org, and must be completed and your involvement in district and section activ-
received at the national office in Washington, ities. District chair recommendations are very Current and incoming district treasurers and
DC, by early September. For 2010, the dead- influential and prior exposure to Congress new section treasurers are invited to the 13th
line date is September 10. and College activities is helpful in distinguish- Annual ACOG Treasurers Conference, January
Following receipt of the applications, staff ing you from another applicant. 15—16, 2011, in Orlando, FL. Other officers
review the requests and compile a list, by com- Committee members are responsible and administrators responsible for the finan-
mittee, from which the selections will be made for making critical decisions that affect our
cial management of their districts or sections
by the president elect. There are several prin- specialty and how we practice. We encour-
ciples that affect the appointments because age Fellows and Junior Fellows to consider are also invited. There is no registration fee.
many committees have special requirements. applying for a committee position to help The two-day educational meeting trains of-
To serve on an obstetric committee, for exam- The College and Congress develop the best ficers and administrators in the financial
ple, you must be actively providing obstetric positions we can. management of their districts or sections,
and updates them on new ACOG policies and
changes in tax laws. Presenters will include
! ACOG finance division staff, national and dis-
An Indepen
dent supple
ment by med
IAplAnet to
usA todAy
many changes
many months, on what really
trict officers, and outside investment manag-
breastfeedingmom’s and their An inside lookyour body
s
through each healthy
y wellnes
stay trendy babies stay
trimester
F r e e p r e g n a nc y g u id e
pregnAnc or scathcart@acog.org for information. The
Tips for having a healthy pregnancy, registration deadline is December 17.
including a message from ACOG
President Richard N. Waldman, MD
5
shutterstock
EP YO U
RE TO KE
WE ’RE HE LI FE TI ME
Y FO R A
HE ALTH
AN CONGR
ESS OF
www.ACOG.ORG AUGUS T 2 0 1 0 ACOG TODAY 3
ACOG
THE AMERIC OLOGISTS
NS AND GYNEC
OBSTETRICIA
A r e you r e g i st e r e d ?
annual district meetings 2010
Savannah, GA: District IV Key Biscayne, FL: Districts III and VI Cancun, Mexico: District V
October 1–3 October 8–10 October 20–23
“Enjoy our fun-filled Stump the Professors com- “The excellent scientific program includes an up- “We will gather in beautiful Cancun amidst lively
petition between residents and Fellows, outstand- date on the evaluation and treatment of cervical and leisurely attractions, wonderful shopping, and
ing speakers on current topics, and a taste of diseases, plus outstanding College postgraduate dining opportunities. In addition to the first class
some southern charm on the harbor lawn. Party training. The multi-district format allows members scientific program, attendees can visit nearby
at the Saturday night gala, and bring the family to of both districts to meet new Fellows and Junior Mayan sites or simply relax on The Ritz-Carlton’s
Oktoberfest on the River on historic River Street.” Fellows and enjoy old acquaintances.” white-sand beachfront.”
Alfred H. Moffett, Jr, MD, District IV chair Owen C. Montgomery, MD, District III chair Robert P. Lorenz, MD, District V chair
Bar Harbor, ME: District I Maui, HI: Districts VII, VIII, IX, and XI New York City: District II
October 8–10 October 14–16 October 29–31
“Bar Harbor has the ambiance of a small New “This year’s program, ‘Reawakening the Excitement “New York’s premier women’s health care event
England harbor town coupled with a nearby na- of Ob-Gyn,’ includes impressive faculty and is aug- of the year offers attendees the opportunity to roll
tional park, presenting magnificent views. The mented by excellent lectures, the Lonnie Burnett up their sleeves and practice laparoscopic tech-
meeting features an important clinical course Film Festival, and a fascinating patient safety niques. Have a total hands-on experience using
plus topics dealing with the business of medicine presentation by a physician pilot. Plus, enjoy the the most current technology available to the gy-
and personal growth.” ‘Whales and Reefs’ marine science program and necologic surgeon, including robotics. Take in a
Ronald T. Burkman, Jr, MD, District I chair the recently remodeled Grand Wailea Resort.” Broadway show, and historic landmarks.”
J. Joshua Kopelman, MD, District VIII chair Scott D. Hayworth, MD, District II chair
shutterstoCK
Junior Fellows, young physicians, and Fellows, MD. Dr. Tucker was incorrectly listed as the District VII member
in the July issue of ACOG Today. Visit www.acog.org and click on
and experience the best fajitas on the planet.” “National Officers Nominations Process” under “Membership” for
Christopher M. Zahn, MD, information on ACOG’s national elections.
Armed Forces District chair
cords, prescriptions, lab reports, reminders for Dr. Hayworth suggested that ob-gyn
follow-ups, and so on, is electronically,” said Dr. practices consider hiring mid-level
DeFrancesco. “Not having that capability will staff. “More patients being covered
limit your growth in the short term and will will be good for physicians if they
T
he rate of cesarean delivery in the US has increased dramati-
cally over the past four decades—from 5% in 1970 to 32.3% in 2008—and
a contributing factor behind this increase is a decline in the number of
vaginal births after cesareans (VBACs).
This decrease in VBACs is due to a number of factors, such as decisions by pa-
tients not to have VBACs, the restrictions that some hospitals and insurers have
placed on trial of labor after cesarean (TOLAC), and the medical liability environ-
ment in general. VBACs have been in steady decline since 1996 and fell to only
8.5% in 2006. Yet, it’s estimated that 60–80 percent of appropriate candidates who
attempt VBAC will be successful.
Earlier this year, the National Institutes of Health convened a Consensus Develop-
ment Conference to evaluate, discuss, and raise awareness about this complex topic.
After the conference, the conference panel offered a statement, “Vaginal Birth After
Cesarean: New Insights.” They acknowledged there are many “clinical uncertainties”
when it comes to VBACs, yet given the available evidence, they believe trial of la-
bor is a reasonable option for many pregnant women with one prior low transverse
uterine incision.
During his inaugural address at the Annual Clinical Meeting (ACM) in May,
ACOG President Richard N. Waldman, MD, said a new sense of urgency must be
placed on reducing the rate of cesarean deliveries and asked Fellows to “recommit to
do everything in our power to reduce the cesarean rate.”
Consistent with past recommendations, most women with one previous cesarean
delivery with a low-transverse incision are candidates for and should be counseled
about VBAC and offered a TOLAC. In addition, “The College guidelines state that
women with two previous low-transverse cesarean incisions and women carrying
providers not to
exist where Pap testing should begin earlier, age 21. The same recommendation is made
according to Cervical Cancer in Adolescents: for adolescents who have had a previous ab-
use unapproved
Screening, Evaluation, and Management, a normal Pap test followed by two subsequent
new College Committee Opinion published normal Pap test results.
IUDs
in the August issue of Obstetrics & Gyne- For adolescents who present low- to high-
cology. The Committee Opinion addresses grade cervical dysplasia, the Committee
these situations and continues to advise Opinion offers detailed recommendations.
against testing for the human papillomavi-
rus (HPV) in all adolescents.
A healthy adolescent immune system
will typically resolve an HPV infection, the
Generally, these conditions can be managed
through periodic observation. When screen-
ing results show regression of the abnormal
cells, rescreening can be delayed until age 21.
F ederal health officials warned
medical practitioners in July not
to use unapproved intrauterine devices
(IUDs). However, both The College and the
primary cause of cervical cancer, within two However, if cervical intraepithelial neoplasia Food and Drug Administration (FDA) em-
years. A compromised, weakened adolescent 3 is found, treatment is recommended. phasize that FDA-approved IUDs are safe,
immune system has more difficulty fending “This Committee Opinion is important effective methods of birth control that can
off viral infections and may not be able to because ob-gyns who do not follow The be used with confidence.
resolve HPV at all. Therefore, The College College’s recommendations can overtreat “We need to reassure our patients,” said
recommends that adolescents with HIV be patients,” Anna-Barbara Moscicki, MD, Hal C. Lawrence III, MD, vice president of
screened for cervical cancer twice in the first American Society for Colposcopy and Cer- Practice Activities for ACOG. “IUDs can
year after diagnosis and annually thereafter. vical Pathology liaison to the Committee on prevent pregnancy for years at a time, and
It also recommends that adolescents Adolescent Health Care, said. “The guidelines if more women used them, the unintended
with compromised immune systems, offered should decrease the number of young pregnancy rate in this country would be a
such as those who have received an organ women inappropriately referred to colposco- lot lower. IUDs are one of the most effective
transplant or those on long-term steroids, py and/or treated, and will allow ob-gyns to methods of reversible contraception.”
undergo screening after the onset of sexual focus more on STD screenings and repro- In a July 22 letter, the FDA reminded
activity. They should be screened six months ductive health care for adolescents.” health professionals that using unapproved
apart in the first year and receive annual IUDs raises concerns about effectiveness
screenings moving forward. Information: and safety, as well as the potential for fraud
Because some adolescents under the ■■ ACOG Practice Bulletin #109, Cervical and counterfeiting.
age of 21 may have received Pap tests Cytology Screening, www.acog.org/ “Federal law requires that IUD/IUSs (in-
before The College released its updated publications/educational_bulletins/ trauterine systems) be FDA-approved prior
screening guidelines in December 2009, pb109.cfm to marketing. This law is designed to protect
the Committee Opinion includes rec- ■■ “Guidelines for Prevention and Treatment patients,” said Theresa Toigo, FDA’s liaison
ommendations on how ob-gyns should of Opportunistic Infections in HIV- with health professionals. FDA is investigat-
proceed with screening for these pa- Infected Adults and Adolescents,” www. ing reported uses of non-approved IUDs.
tients. It recommends that any adolescent cdc.gov/mmwr/preview/mmwrhtml/ Links to the FDA communications and in-
rr5804a1.htm formation regarding the regulatory status of
■■ American Society for Colposcopy imported IUDs is available on The College’s
and Cervical Pathology “Practice Management and Managed
Consensus Guidelines, www.asccp. Care” webpage on www.acog.org. Click on
org/consensus.shtml “Importing IUDs.”
Information:
Clinical, coding, and other resources for long-
veer, vectorstock
P
hysicians have much needed skills in disaster relief, and ob-gyns are par-
ticularly valuable because the vulnerability of a woman’s health increases exponentially in
the wake of a disaster. Though many physicians may want to volunteer, they often do not Lisbet Hanson, MD, holding a six-year-old boy with
severe head trauma caused by the earthquake
know what to expect or where to begin.
A crucial first step for would-be “Haiti already had chronic prob-
volunteers is to connect with a rep- lems in women’s health care,” said
utable organization that has a track Dr. Hanson. “Now, with hospitals,
record in the affected country, ac- schools, and so many workers gone,
cording to Julie Taft, reproductive the country needs people who are
health advisor for International interested in working through the
Medical Corps. Ministry of Health to develop a new
“Coordination is vital to relief infrastructure and train nurses and
efforts,” Taft said. “Organizations physicians to take better care of
that are already familiar with patients.”
the country can ensure there is According to Taft, a relief or-
an appropriate allocation of re- ganization’s entry point is usually
sources for volunteers and can a disaster, but the organization im-
quickly prioritize the needs of mediately begins to lay groundwork
the country.” to rebuild the country’s health infra-
In a situation like this year’s structure and resources. While it’s
Haiti earthquake, volunteers who often a disaster that raises the most
jumped on planes and showed up Hector Tarraza, MD, caring for women and children injured in the 2010 Haiti earthquake attention, the ongoing provision of
to help often only added to the health services and the training of
chaos. recover in tents. Dr. Tarraza’s team of volunteers the country’s health care providers is critical
“Many people who came on their own had was the second to arrive. to mitigate damage in future disasters.
difficulty finding simple resources like food “Our purpose was to work with staff from the
and shelter,” said Taft. “If you can’t take care of hospital and set up primary care clinics,” said Dr. Getting involved
yourself, it’s hard to take care of other people.” Tarraza. “With so much need for the acutely in- Ob-gyns can register with International Medi-
jured, everything else can fall by the wayside. cal Corps (imcworldwide.org), Doctors without
On the ground And there were a lot of pregnant women with Borders (doctorswithoutborders.org), and others.
ACOG Fellow Hector Tarraza, MD, was very no place to go.” The ACOG website has information on the In-
familiar with Haiti when he traveled there just ternational Activities web page. Go to www.acog.
12 days after the earthquake with a team of Rebuilding what was lost org, and click on “Women’s Issues” and then “In-
volunteers. Dr. Tarraza is medical director of ACOG Fellow Lisbet Hanson, MD, has been ternational Activities.” You can register with the
Global Health Ministry (GHM), a non-profit volunteering in Haiti on and off for seven years. American Medical Association at ama-assn.org/
organization that has been sending volunteers She was working at a hospital 45 miles outside go/haiti-volunteer if you are specifically interest-
to Haiti since 1998 to promote women’s health. of Port-au-Prince with an outreach program for ed in Haiti.
The organization had been building a mater- the International Society of Ultrasound in Ob- To gain experience in disaster relief, start lo-
nity unit for the St. Francis De Sales Hospital in stetrics and Gynecology when the earthquake cally. Many local organizations and Red Cross
Port-au-Prince, and after the earthquake, it was hit. Dr. Hanson started her trip providing train- chapters hold disaster training courses through-
the only part of the hospital left standing. GHM’s ing and education in the use of ultrasound to out the year. To find your Red Cross chapter
first team of volunteers operated on patients in Haitians and ended it providing emergency care visit www.redcross.org and click on “Preparing
the maternity unit who were then sent outside to to earthquake victims. and Getting Trained.”
Do you know an extraordinary ob-gyn? Tell us about him or her in an email to lhumphrey@acog.org.
We will try to feature him or her in a future issue.
The
establish medical homes if they choose, but most medical homes are expected to be family
practice, internal medicine, or pediatric care providers.
medical
Can an ob-gyn practice support care costs are lower. At the same time, on a broad
a medical home model? level, funds are freed up, so medical homes pro-
The medical home concept was first intro- viding these services can be compensated.
home
duced in 1967 in the pediatric sector as a Two years ago, ACOG decided to look
way to better manage care for patients with more closely at the medical home model and
chronic conditions who require care from formed a working group to see if it might be
multiple sources. Through a medical home, of value for ob-gyns. Through this analysis,
these patients align with a single provider who says J. Craig Strafford, MD, committee mem-
An opportunity for coordinates all their care.
The goal is for the patient to get the compre-
ber and director of Clinical Research and staff
physician at Holzer Medical Center in Gallipo-
ob-gyn practices? hensive, preventive care he or she needs. In turn,
the patient has fewer acute or costly emergency
lis, OH, the group determined that a medical
home model could be of value as a care re-
room visits and stays healthier, and overall health source for women ages 15–55.
In a paper-based environment, the major- This resource can help practices assess their ■ October 13, Compliance
ity of costs to maintain a medical home interest in becoming a medical home, deter- ■ November 10, Opportunities
would lie in compensating staff to do the mine how significant the changes will be to
■ December 8, Non-Physician Providers
scheduling and follow-up with patients. their current practice, and make the required
But, for practices that have the right elec- changes. Visit www.acog.org/departments/ Log in to the members-only section of
tronic health record (EHR) system in place, dept_notice.cfm?recno=19&bulletin=5203 to www.acog.org with your username
it could be an opportunity. learn more and download the toolkit. and password and click on Health
“Properly designed EHR systems have Visit the Agency for Healthcare Re- Reform Center.
patient reminders built into them that can search and Quality’s new patient centered
medical home resource center at http://
.
do much of this work in a fraction of the
time it would take a staff person to do it,” pcmh.ahrq.gov/portal/server.pt/community/ Call 202-863-2509 with questions
Dr. Strafford said. “An EHR is not an official pcmh_home/1483.
“Given the evidence, we should reassure our pregnant patients and let them
know that it’s OK to have a cup of coffee.”
Committee Opinion #462, Moderate Caffeine Consumption During
Pregnancy, is published in the August 2010 issue of Obstetrics & Gynecology.
www.ACOG.ORG AUGUS T 2 0 1 0 ACOG TODAY 11
Presort
STANDARD
The American Congress of U.S. POSTAGE
Obstetricians and Gynecologists PAID
PO Box 70620 Permit No. 251
Washington, DC 20024-9998
Practice Updates
Excitement of Obstetrics and Gynecology,
In conjunction with the District I
Annual Meeting, Bar Harbor, ME
Committee Opinions
■■ October 8–10, Update on Cervical
■■ 463 Cervical Cancer in Adolescents: Screening, Evaluation, and Management
Diseases, In conjunction with District III and
■■ 462 Moderate Caffeine Consumption During Pregnancy
District VI Annual Meeting, Key Biscayne, FL
■■ 461 Tracking and Reminder Systems
■■ October 12, ACOG Webcast: Diagnosis
Practice Bulletin Coding for Obstetric Care Complications
■■ 115 Vaginal Birth after Previous Cesarean Section
■■ October 14–16, Reawakening the
These documents appear in the August issue of the Green Journal, and are online
Excitement of Obstetrics and Gynecology,
under Publications at www.acog.org
In conjunction with the Districts VII, VIII,
IX, and XI Annual Meeting, Maui, HI
■■ October 15–17, Coding
Workshop, San Antonio, TX
■■ November 9, ACOG Webcast: Cord
Blood Gases: From Delivery Room to
Courtroom
■■ November 19–21, Coding
Workshop, Chicago, IL