Help Prevent Group B Strep this Month

July is International Group B Strep Awareness Month. Group B Strep (GBS), found in 10–30% of pregnant women, is the leading cause of sepsis and meningitis in newborns, according to the US Centers for Disease Control and Prevention (CDC).

Ob-gyns have long been aware that preventing GBS is a key part of our commitment to protecting the health of newborns. Now we have the tools at our fingertips—literally—to be more effective.

Ingbsapp 2010, the CDC released new guidelines for GBS prevention. To help clinicians better implement them, the CDC worked with ACOG, the American Academy of Pediatrics, the American College of Nurse-Midwives, and the American Academy of Family Physicians to develop an app called “Prevent Group B Strep.”

The app debuted in September 2013. It is designed specifically for obstetricians and other health care professionals who provide obstetric or neonatal care. It creates customized guidelines based on your patient’s characteristics. “Prevent Group B Strep” is free and available for Apple and Android devices.

If you haven’t already, download the app and implement it in your practice in this month. You can also help to educate your patients about the importance of GBS prevention by sharing ACOG’s patient education FAQ: Group B Strep and Pregnancy.

Spread the word about Group B Strep this month. Your efforts can help save more babies.

Our Patients Deserve Our Patience

Recent reports of rising cesarean delivery rates in the United States are a significant concern, both to the public and to those of us who are practicing obstetrics. Cesarean delivery rates vary dramatically across geographic areas of the country but also from one neighboring hospital to the next.

Certainly the variations in cesarean delivery rates are multi-factorial. It is easy to understand if a tertiary care hospital receiving high-risk pregnancies from a broad referral area would have an elevated cesarean delivery rate. However, it is disturbing to see that some hospitals with a high percentage of low-risk deliveries have higher cesarean delivery rates than the tertiary care hospitals in their referral area.

ACOG and the Society for Maternal-Fetal Medicine released a consensus statement in March on Safe Prevention of the Primary Cesarean Delivery. The statement addresses multiple modifiable considerations to reduce the cesarean delivery rate. I suggest that every obstetrician carefully read this document, paying particular attention to the discussion of labor dystocia and labor arrest as the most common cause of primary cesarean delivery.

Simply stated, current evidence according to the Consortium on Safe Labor indicates the diagnosis of labor arrest should not strongly be considered until the cervix has reached 6 centimeters dilated in both primiparous and multiparous women. This is in contrast to the standards proposed by the Friedman curve that have been operational in most labor and delivery units.

Waiting, observing, having another cup of coffee, and even pacing the floor until the cervix reaches 6 cm dilated can make the difference between a vaginal delivery and a cesarean delivery. Normal labor can be a relatively slow process, but our patients do deserve our patience.

Guest Blog: The Value of Education and Outreach to Improve Global Women’s Health

Taraneh Shirazian, MD

Millions of women around the globe lack basic rights—rights to health care, rights to family planning services, and the right to lead long, healthy lives. Pregnancy and childbirth are major threats to women in underserved areas of the world with over 300,000 women dying yearly from their associated complications, unattended by trained medical professionals. While most of these deaths are preventable, these women need a voice to bring the world’s attention to what is truly a global crisis in women’s health.

As ob-gyns, awareness of the scope of issues faced by women internationally should be integral to our education. Only with this foundation can we prepare ourselves for the monumental challenges of global health care delivery. Ultimately, it is our collective responsibility as women’s health care providers to give voice to and promote care for these women, whether or not we choose to work at home or abroad.

It has been my work and passion over the last seven years to develop educational resources for health care providers interested in global women’s health, including a new online course. Preparing for cultural and ethical aspects of health care delivery abroad is critical and just as essential as our medical knowledge. These skills can also allow us to take better care of women here in the US.

All women’s health providers should educate themselves on these global women’s health topics, including maternal mortality, obstetric fistula, family planning, and female genital cutting.

I encourage you to be part of a global voice for women.

Taraneh Shirazian, MD, is assistant professor and director of Global Health in the department of ob/gyn and reproductive sciences at Mount Sinai School of Medicine in New York.

No Sushi during Pregnancy…and Other Hard-to-Swallow Rules

I love sushi—living in California this is no surprise. Lucky for me my office is across the street from one of the best local sushi restaurants in town. It’s a favorite destination for me, my staff, and my patients. I recommend it to everyone—EXCEPT my pregnant patients. Why? Because I am inherently cautious.

We know raw fish is more likely to contain parasites or bacteria than cooked fish is. Sushi-related infections are rare, but this doesn’t erase my concern about the risk of adverse outcomes, mercury exposure, and the potential complications of treating an infection should one occur. As an ob-gyn, this is my job. It’s my business to consider potential problems, make my patients aware of them, and advise them to avoid unnecessary risks. If you really want to have some sushi, it’s a good idea to eat only cooked or vegetable sushi.

My goal is not to worry or alarm my patients, but to make suggestions based on solid, high-quality research. I use evidence to guide my recommendations, support my practice, and help my patients make healthy decisions for themselves and their fetuses. That’s why a recent essay by an economist and mom, who asserts that many common pregnancy recommendations are not fully supported by evidence, caught my attention.

Ob-gyns understand there’s often conflicting data and that the changes we suggest during pregnancy can sometimes be overwhelming: nine months can seem like an eternity when you have to give up your favorite things. Sometimes we even look back and realize our advice missed the mark. I remember a time when bed rest was prescribed for many patients with preterm labor, which we now realize accomplished little. But as doctors, we’re continuously learning. Advising patients to avoid things that we KNOW can cause harm is a good practice. Why take the risk of drinking alcohol when you know it could cause a problem? Given the risks, most patients don’t want to use their own child as a test subject.

In other areas, the evidence is very clear. For example, obesity and its impact on pregnancy, the fetus, and a woman’s long term health. Research has shown that excess weight gain increases the risk of maternal and neonatal complications. Obese women have a higher risk of having children born with birth defects. Excess pregnancy weight also increases the risk of maternal obesity eight to 10 years after delivery, especially if women do not lose their pregnancy weight within six months. I would argue that we have not focused enough on weight gain. Ob-gyns could go even further to support women on appropriate weight gain and exercise during pregnancy and healthy weight loss and exercise after delivery.

Certainly it is up to women to make their own decisions during their pregnancy. It’s also important for ob-gyns to remember not to lecture patients, but to partner with them to help them achieve the healthiest pregnancy possible. We must stay tuned in to the recommendations put forth by ACOG and the dedicated practicing physicians who spend countless hours reviewing the latest literature and developing guidance and best practices for ob-gyn care. And it’s also OK to listen to that precautionary voice in the back of your head. Evidence first, but better safe than sorry.

Listen to Dr. Conry’s NPR interview: The Facts Behind Pregnancy Rules

Subscribe to the ACOG President’s Blog to receive an email alert every time a new blog is posted.

Oral Health and Pregnancy: Tell Your Patients to Say “Cheese”

A healthy smile is more than a way to make a good first impression. It can be a strong health indicator, too. Poor dental health has been linked to heart disease, diabetes, and respiratory infections. Maintaining good oral health through the years is extremely important and pregnancy is no exception.

Pregnancy can cause changes in the gums and teeth and roughly 40% of pregnant women have some form of periodontal disease such as gingivitis (inflammation of the gums), cavities (tooth decay), and periodontitis (inflammation of ligaments and bones that support the teeth). Despite this, 56% of pregnant women report that they have not been to the dentist during pregnancy.

Dental care during pregnancy has been a source of confusion for women, their doctors, and dentists. Some people mistakenly think that pregnant women cannot be treated for oral health problems. However, the opposite is true. Pregnancy is an excellent time to discuss dental health with women, and ob-gyns can play a major role.

In a new Committee Opinion, ACOG urges ob-gyns to support good dental hygiene among pregnant patients by performing routine oral health assessments at the first prenatal visit and encouraging women to see a dentist. This can also help us reassure our patients that common treatments and procedures, such as teeth cleaning, dental X-rays, and root canals, are safe during pregnancy.

We can also reiterate important healthy mouth basics:
• Limit sugary foods and drinks
• Brush teeth twice daily with a fluoridated toothpaste
• Floss once daily
• Visit the dentist twice a year

With just a few questions and suggestions, we can help patients—some of whom may not have seen a dentist in years—take a step toward a healthier mouth. And, the benefits may reach beyond mom. Studies show that women with good dental hygiene are also less likely to pass cavity-causing bacteria on to their babies—two for one protection. By performing oral health screenings, ob-gyns can help ensure a healthier smile for women and their babies. So check in with your patients about their dental health and make sure they’re smiling for all the right reasons.

Subscribe to the ACOG President’s Blog to receive an email alert every time a new blog is posted.

Teaming Up with Our Nurse-Midwife Friends

Earlier this month, I had the good fortune to attend the American College of Nurse Midwives (ACNM) annual meeting in Nashville, TN. What a fabulous meeting in a great location. The meeting program was diverse and holistic, with an emphasis on the same issues ob-gyns are struggling with: improving safety in our birthing centers, improving global women’s health, and changing the delivery of care right here at home so that we see healthier moms and babies.

An ACOG delegation—including myself, Executive Vice President Dr. Hal Lawrence, Past President Dr. Richard Waldman, and President Elect Dr. John Jennings—attended the opening ceremonies and were greeted with a thunder of applause, an acknowledgment that collaboration in improving women’s health and access to care is a shared goal of our organizations. ACNM also gave ACOG a very special award: the Organizational Partner Award for aiding in the development and practice of midwifery. This award was very meaningful to us. It was recognition that ob-gyns and nurse-midwives do collaborate, share delivery services, and very much depend on one another. The changing face of health care ensures that our professions will continue to interact, innovate, and work together.

Change is tough, because often it means separation from our comfort zone and having to adopt different behaviors or different approaches. Some physician practices have quickly incorporated midwives, and others have not. According to trends in the ob-gyn workforce, we do not have enough physicians in our specialty to meet the challenges ahead. The reality as we look toward the future? It is likely that many models of collaborative practice will be adopted by more and more physicians, both out of necessity and because it just makes sense. Expanding our access to patients with physician assistants, nurse-midwives, and nurse practitioners when possible both serves our patients and allows ob-gyns an opportunity to focus on the work that specifically requires our special skill set. We will need to look closely at how we provide care, and particularly on how we collaborate on the delivery of care, over the next decade. I’m personally looking forward to sharing more information on successful strategies to provide our patients with the best coordinated care we can.

Subscribe to the ACOG President’s Blog to receive an email alert every time a new blog is posted.

Smoking Cessation Front and Center with “Talk With Your Doctor” Initiative

As “Physician to the United States,” the US surgeon general speaks with a strong voice about a variety of health concerns, with a focus on prevention and wellness. January 2014 will mark the 50th anniversary of the first surgeon general’s report to conclude that smoking cigarettes causes lung cancer. Five decades later, 43 million American adults continue to smoke, and cigarette smoking kills an estimated 440,000 Americans each year.

I was happy to represent ACOG last week, standing with Surgeon General Regina Benjamin, MD, the Centers for Disease Control and Prevention, and our colleagues at other physician organizations to launch “Talk With Your Doctor,” a campaign to encourage patients to come to us, their physicians, and learn how to succeed with smoking cessation. As ob-gyns, we need a strong voice here. We see the short- and long-term impact of smoking on women and on their families. It is imperative that we assist all of our patients in their efforts to quit smoking, especially our pregnant patients.

A woman who stops smoking at the start of a pregnancy can reduce her risk of pregnancy complications. We ob-gyns need to help our pregnant patients understand that smoking cessation brings immediate results and immediate successes.

The most important step is to ask, and then to respond. We need to treat smoking the same way we have treated vital signs—as a measure that we routinely screen for and assess—and be prepared to support patients who are ready to kick the habit. Surveys have shown that most of us ASK about smoking, yet only one-third provide assistance or a program. Cessation programs are most effective in helping people quit smoking.

When we see our patients, we all need to remember the FIVE A’s:

• Ask about tobacco use.
• Advise to quit.
• Assess willingness to make a quit attempt.
• Assist in quit attempt.
• Arrange follow-up.

ACOG has developed a smoking cessation during pregnancy guide for clinicians to help pregnant patients kick the habit. Check out this helpful resource and be ready when a patient says “I was told to ‘Talk With My Doctor.’”

Dr. Conry and "Talk With Your Doctor" Panel

Dr. Conry and “Talk With Your Doctor” Panel

Subscribe to the ACOG President’s Blog to receive an email alert every time a new blog is posted.

With Delivery Times, Defer to Mother Nature

“Let nature take its course.” Over the years, I’ve found this saying particularly applies to the process of giving birth. My personal experience as an ob-gyn and reams of scientific research demonstrate that Mother Nature knows best when a child is ready to be born. The start of natural labor is the main sign, but we’re not always patient enough to wait for it.

Today, one in three babies in the US are born by cesarean—the delivery of a baby through an incision in the mother’s abdomen and uterus. The rate of labor induction is also at an all-time high. Unfortunately, many of these births occur before the pregnancy is considered “term” at 39 weeks. These upward trends have long been a source of concern in the medical community, especially considering the increased risks to a baby who may not be fully developed at delivery.

Among cesarean deliveries, an estimated 2.5% (more than 100,000 births each year) are scheduled on a designated date by the mother and her doctor. Some women cite reasons such as a lower risk of future incontinence, better sexual functioning after childbirth, and fear of pain as motivations to schedule cesareans. Inevitably, some cesareans (and labor inductions, too) are scheduled before a pregnancy is full term, increasing the risk of negative outcomes for the newborn, including respiratory problems and time spent in the neonatal intensive care unit. The fact remains that due dates are estimates, and you can never be sure that the infant will have reached optimal maturity at the time of a scheduled delivery.

Women should keep in mind that cesarean delivery is no walk in the park. While it’s a safe option, cesarean delivery is a major surgery and comes with a number of risks, such as placental complications in future pregnancies, problems with anesthesia, infection, and longer recovery times.

Certain urgent situations—such as preeclampsia, eclampsia, multiple fetuses, fetal growth restriction, and poorly controlled diabetes—may make it necessary to deliver the baby before the onset of natural labor. However, newly issued guidelines from ACOG remind women and ob-gyns that in uncomplicated pregnancies, a vaginal birth that occurs after the natural onset of labor is ideal. Additional new ACOG guidelines reaffirm that cesareans and labor inductions should only be performed when medically-necessary.

Delaying delivery until labor starts naturally may not make ob-gyns too popular with a patient who’s uncomfortable and near the end of her pregnancy, but it’s a decision that will pay dividends by giving the baby the extra time it needs to face the world.

Big HIV News and An Important Reminder

Earlier this week it was reported that a Mississippi toddler born with human immunodeficiency virus (HIV) apparently cleared her HIV infection and is now disease-free. The story of her innovative medical treatment and remarkable results is truly exciting. However, as an ob-gyn, I can’t help but think that this entire situation could have been avoided.

Today in the US, mother-to-child transmission of HIV is a rare occurrence. HIV-positive women have roughly a 2% chance of passing along the virus to their babies. This is due in large part to increased HIV screening among pregnant women. Those who test positive for HIV during pregnancy can begin treatment with antiretroviral medications before they give birth. These medications significantly reduce the risk that a child will be born with HIV. The earlier the medication is given during pregnancy, the better, but it can still have a positive effect when administered just 24–48 hours before delivery and/or to the newborn within the first two days of life.

ACOG recommends that all pregnant women be screened for HIV as a part of routine prenatal care. Repeat third-trimester testing is also recommended for pregnant women in areas with high HIV prevalence. Not all women receive prenatal care, and it’s not uncommon for ob-gyns to see women for the first time when they come to the hospital to deliver. In this case, rapid HIV testing can confirm a woman’s HIV status. If she tests positive, she may still be able to receive medication in time to protect her baby from infection.

I cannot stress enough the importance of knowing your HIV status. Screening is the best method we have to both head off HIV transmission to infants and stop the spread of the disease to people of all ages. In addition to the screening recommendations for pregnant women, ACOG also recommends that all women ages 19–64 be routinely screened for HIV, regardless of individual risk factors.

Subscribe to the ACOG President’s Blog to receive an email alert every time a new blog is posted.

A Healthy Weight for Pregnancy

It’s no secret that the US has a weight problem. Roughly two-thirds of us could stand to lose a few (or more) pounds. Today, more than half of all pregnant women in the US are overweight or obese. Maintaining a healthy weight is always important to overall health, but it becomes an even more important vital sign when a woman is pregnant or planning a pregnancy.

Carrying too much weight can throw a wrench in a woman’s reproductive works. Not only can it interfere with getting pregnant, but it can also make pregnancy more difficult once achieved. Overweight and obese women are at increased risk of a number of complications during and after pregnancy, such as high blood pressure, preeclampsia, gestational diabetes, and cesarean delivery. They are at a higher risk of problems related to cesarean delivery—including complications with anesthesia, excessive blood loss, blood clots, and infection. Overweight and obese women also have increased odds of miscarriage, stillbirth, premature birth, or having a baby with a birth defect.

So what’s a woman struggling with weight to do if she wants to achieve the best pregnancy outcome? Losing weight before becoming pregnant is ideal, but that doesn’t always happen. According to new ACOG recommendations on weight gain and obesity during pregnancy, some overweight and obese women may be cleared to gain less weight than typically recommended to reduce risk factors. Gaining less weight during pregnancy may also help with losing extra pounds post-delivery.

If you’re considering getting pregnant in 2013 and are currently outside of a healthy BMI range, it’s not too late to make a New Year’s resolution to lose weight. There are many resources and articles focused on eating right and getting fit at this time of year, so investigate and develop your plan of attack. If you’re already pregnant, be sure to ask your doctor about a healthy amount of weight gain and an exercise plan to help you stay active.