ACOG GUIDELINES Induction of Labor ACOG Practice Bulletin Number 107 August 2009 More than 22% of all

gravid women undergo induction of labor in the United States, and the overall rate of induction of labor in the United States has more than doubled since 1990 to 225 per 1,000 live births in 2006. The goal of induction of labor is to achieve vaginal delivery by stimulating uterine contractions before the spontaneous onset of labor. Generally, induction of labor has merit as a therapeutic option when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure. The purpose of this document is to review current methods for cervical ripening and induction of labor and to summarize the effectiveness of these approaches based on appropriately conducted outcomes-based research. These practice guidelines classify the indications for and contraindications to induction of labor, describe the various agents used for cervical ripening, cite methods used to induce labor, and outline the requirements for the safe clinical use of the various methods of inducing labor. The following recommendations and conclusions are based on good and consistent scientific evidence (Level A): Prostaglandin E analogues are effective for cervical ripening and inducing labor. Low- or high-dose oxytocin regimens are appropriate for women in whom induction of labor is indicated. Before 28 weeks of gestation, vaginal misoprostol appears to be the most efficient method of labor induction regardless of Bishop score, although high dose oxytocin infusion also is an acceptable choice. Approximately 25 mcg of misoprostol should be considered as the initial dose for cervical ripening and labor induction. The frequency of administration should not be more than every 36 hours. Intravaginal PGE2 for induction of labor in women with premature rupture of membranes appears to be safe and effective. The use of misoprostol in women with prior cesarean delivery or major uterine surgery has been associated with an increase in uterine rupture and, therefore, should be avoided in the third trimester. The Foley catheter is a reasonable and effective alternative for cervical ripening and inducing labor. The following recommendation is based on evidence that may be limited or inconsistent (Level B): Misoprostol (50 mcg every 6 hours) to induce labor may be appropriate in some situations, although higher doses are associated with an increased risk of complications, including uterine tachysystole with FHR decelerations. Proposed Performance Measure: Percentage of patients in whom gestational age is established by clinical criteria when labor is being induced for logistic or psychosocial indications.

Induction of labor. ACOG Practice Bulletin No. 107. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:38697. Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles ACOG Practice Bulletin Number 106 July 2009 In the most recent year for which data are available, approximately 3.4 million fetuses (85% of approximately 4 million live births) in the United States were assessed with electronic fetal monitoring (EFM), making it the most common obstetric procedure. Despite its widespread use, there is controversy about the efficacy of EFM, interobserver and intraobserver variability, nomenclature, systems for interpretation, and management algorithms. Moreover, there is evidence that the use of EFM increases the rate of cesarean deliveries and operative vaginal deliveries. The purpose of this document is to review nomenclature for fetal heart rate assessment, review the data on the efficacy of EFM, delineate the strengths and shortcomings of EFM, and describe a system for EFM classification. The following recommendations and conclusions are based on good and consistent scientific evidence (Level A): The false-positive rate of EFM for predicting cerebral palsy is high, at greater than 99%. The use of EFM is associated with an increased rate of both vacuum and forceps operative vaginal delivery, and cesarean delivery for abnormal FHR patterns or acidosis or both. When the FHR tracing includes recurrent variable decelerations, amnioinfusion to relieve umbilical cord compression should be considered. Pulse oximetry has not been demonstrated to be a clinically useful test in evaluating fetal status. The following conclusions are based on limited or inconsistent scientific evidence (Level B): There is high interobserver and intraobserver variability in interpretation of FHR tracing. Reinterpretation of the FHR tracing, especially if the neonatal outcome is known, may not be reliable. The use of EFM does not result in a reduction of cerebral palsy. The following recommendations are based on expert opinion (Level C): A three-tiered system for the categorization of FHR patterns is recommended. The labor of women with high-risk conditions should be monitored with continuous FHR monitoring. The terms hyperstimulation and hypercontractility should be abandoned. Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. ACOG Practice Bulletin No. 106. American College of

Obstetricians and Gynecologists. Obstet Gynecol 2009;114:192202.

http://www.ncbi.nlm.nih.gov/pubmed/19546798

Bariatric Surgery and Pregnancy ACOG Practice Bulletin Number 105 June 2009 As the rate of obesity increases, it is becoming more common for providers of womens health care to encounter patients who are either contemplating or have had operative procedures for weight loss, also known as bariatric surgery. The counseling and management of patients who become pregnant after bariatric surgery can be complex. Although pregnancy outcomes generally have been favorable after bariatric surgery, nutritional and surgical complications can occur and some of these complications can result in adverse perinatal outcomes. The purpose of this Practice Bulletin is to provide a summary of the risks of obesity in pregnancy, review the available literature regarding outcomes of pregnancy after bariatric surgery, and provide recommendations for the care of the patient during her pregnancy and delivery after bariatric surgery. The following conclusions and recommendations are based on limited or inconsistent scientific evidence (Level B:) Contraceptive counseling is important for adolescents because pregnancy rates after bariatric surgery are double the rate in the general adolescent population. Because there is an increased risk of oral contraception failure after bariatric surgery with a significant malabsorption component, nonoral administration of hormonal contraception should be considered in these patients. In using medications in which a therapeutic drug level is critical, testing drug levels may be necessary to ensure a therapeutic effect. The following conclusions and recommendations are based primarily on consensus and expert opinion (Level C): There should be a high index of suspicion for gastro-intestinal surgical complications when pregnant women who have had these procedures present with significant abdominal symptoms. Bariatric surgery should not be considered a treatment for infertility. Bariatric surgery should not be considered an indication for cesarean delivery. There is no consensus on the management of patients during pregnancy who have had an adjustable gastric banding procedure, but early consultation with a bariatric surgeon is recommended. Alternative testing for gestational diabetes should be considered for those patients with a malabsorptive-type surgery. Consultation with a nutritionist after conception may help the patient adhere to dietary regimens and cope with the physiologic changes of pregnancy. A broad evaluation for micronutrient deficiencies at the beginning of pregnancy for women who have had bariatric surgery should be considered. Proposed Performance Measure: Documentation of counseling about weight gain and nutrition in pregnancy

Bariatric Surgery and Pregnancy. ACOG Practice Bulletin No. 105. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:140513.
http://www.ncbi.nlm.nih.gov/pubmed/19461456

Antibiotic Prophylaxis for Gynecologic Procedures ACOG Practice Bulletin Number 104 May 2009 Surgical site infection remains the most common surgical complication. Up to 5% of patients undergoing operative procedures will develop a surgical site infection leading to a longer hospital stay and increased cost (1). One of the advances in infection control practices has been the selective use of antibiotic prophylaxis. However, indiscriminate antibiotic use has been associated with the selection of antibiotic-resistant bacteria, which have acknowledged consequences for institutions as well as for individual patients. It is important for clinicians to understand when antibiotic prophylaxis is indicated and when it is inappropriate. The purpose of this document is to review the evidence for surgical site infection prevention and appropriate antibiotic prophylaxis for gynecologic procedures. The following recommendations and conclusions are based on good and consistent scientific evidence (Level A): Patients undergoing hysterectomy should receive single-dose antimicrobial prophylaxis preoperatively. Pelvic inflammatory disease occurs uncommonly with or without the use of antibiotic prophylaxis and so prophylaxis is not indicated at the time of IUD insertion. Antibiotic prophylaxis is indicated for elective suction curettage abortion. Antibiotic prophylaxis is not recommended in patients undergoing diagnostic laparoscopy. The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B): In patients with no history of pelvic infection, HSG can be performed without prophylactic antibiotics. If HSG demonstrates dilated fallopian tubes, antibiotic prophylaxis should be given to reduce the incidence of post-HSG PID. Routine antibiotic prophylaxis is not recommended for the general patient population undergoing Hysteroscopic surgery. Cephalosporin prophylaxis is acceptable in those patients with a history of penicillin allergy not felt to be immunoglobulin E mediated (immediate hypersensitivity). Patients found to have preoperative bacterial vaginosis should be treated before hysterectomy. The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C): Antibiotic prophylaxis is not recommended in patients undergoing exploratory laparotomy.

For transcervical procedures such as HSG, chromotubation, and hysteroscopy, prophylaxis may be considered in those patients with a history of PID or tubal damage noted at the time of the procedure. Patients with a history of an immediate hypersensitivity reaction to penicillin should not receive cephalosporin antibiotics. Pretest screening for bacteriuria or urinary tract infection by urine culture or urinalysis, or both, is recommended in women undergoing urodynamic testing. Those with positive test results should be given antibiotic treatment.

Proposed Performance Measure: The percentage of women undergoing hysterectomy who received preoperative antibiotic prophylaxis. American College of Obstetricians and Gynecologists. Antibiotic prophylaxis for gynecologic procedures. ACOG Practice Bulletin No. 104. Obstet Gynecol 2009;113:11809.
http://www.ncbi.nlm.nih.gov/pubmed/19384149

Hereditary Breast and Ovarian Cancer Syndrome ACOG Practice Bulletin Number 103 April 2009 Hereditary breast and ovarian cancer syndrome is an inherited cancer-susceptibility syndrome. The hallmarks of this syndrome are multiple family members with breast cancer or ovarian cancer or both, the presence of both breast cancer and ovarian cancer in a single individual, and early age of breast cancer onset. Clinical genetic testing for gene mutations allows physicians to more precisely identify women who are at substantial risk of breast cancer and ovarian cancer. For these individuals, screening and prevention strategies can be instituted to reduce their risks. Obstetricians and gynecologists play an important role in the identification and management of women with hereditary breast and ovarian cancer syndrome. The following recommendations are based on good and consistent scientific evidence (Level A): Women with BRCA1 or BRCA2 mutations should be offered risk-reducing salpingo-oophorectomy by age 40 years or when child-bearing is complete. For a risk-reducing bilateral salpingo-oophorectomy, all tissue from the ovaries and fallopian tubes should be removed. Thorough visualization of the peritoneal surfaces with pelvic washings should be performed. Complete, serial sectioning of the ovaries and fallopian tubes is necessary, with microscopic examination for occult cancer. A genetic risk assessment is recommended for patients with a greater than an approximate 2025% chance of having an inherited predisposition to breast cancer and ovarian cancer. Proposed Performance Measure:

Percentage of patients identified as having greater than a 2025% risk of having a BRCA mutation (high risk) who are referred for genetic counseling American College of Obstetricians and Gynecologists. Hereditary breast and ovarian cancer syndrome. ACOG Practice Bulletin No. 103. Obstet Gynecol 2009;113:95766.
http://www.ncbi.nlm.nih.gov/pubmed/19305347

Management of Stillbirth ACOG Practice Bulletin Number 102 March 2009 Stillbirth is one of the most common adverse pregnancy outcomes, complicating 1 in 160 deliveries in the United States. Approximately 25,000 stillbirths at 20 weeks or greater of gestation are reported annually (1). The purpose of this bulletin is to review the current information on stillbirth, including definitions and management, the evaluation of a stillbirth, and strategies for prevention. The following recommendations and conclusions are based on good and consistent scientific evidence. (Level A) In low-risk women with unexplained stillbirth the risk of recurrence stillbirth after 20 weeks of gestation is estimated at 7.810.5/1,000 with most of this risk occurring before 37 weeks of gestation. The most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, and obesity (Table 1). The risk of subsequent still birth is twice as high for women with a prior live born, growth restricted infant delivered before 32 weeks of gestation than for women with a prior stillbirth. Amniocentesis for fetal karyotyping has the highest yield and is particularly valuable if delivery is not expected imminently. The following recommendations and conclusions are based primarily on limited or inconsistent scientific evidence (Level B): In the second trimester, dilation and evacuation can be offered. Labor induction also is appropriate at later gestational ages, if second trimester dilation and evacuation is unavailable, or based on patient preference. Induction of labor with vaginal misoprostol is safe and effective in patients with a prior cesarean delivery with a low transverse uterine scar before 28 weeks of gestation. The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C): The most important tests in the evaluation of a stillbirth are fetal autopsy; examination of the placenta, cord, and membranes; and karyotype evaluation. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, religious leader, peer support group, or mental health professional may be advisable for management of grief and depression.

Performance Measure: The percentage of stillbirths for which placental evaluation was performed and autopsy was offered Management of Stillbirth. ACOG Practice Bulletin No. 98. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 113:74861.
http://www.ncbi.nlm.nih.gov/pubmed/19300347

Ultrasonography in Pregnancy ACOG Practice Bulletin Number 101 February 2009 Most women have at least one ultrasound examination during pregnancy. The purpose of this document is to present evidence regarding the methodology of, indications for, benefits of, and risks associated with obstetric ultrasonography in specific clinical situations. Portions of this document were developed collaboratively with the American College of Radiology and the American Institute of Ultrasound in Medicine. The sections that address physician qualifications and responsibilities, documentation, quality control, infection control, and patient safety contain recommendations from the American College of Obstetricians and Gynecologists. The following conclusions are based on good and consistent evidence (Level A): Ultrasound examination is an accurate method of determining gestational age, fetal number, viability, and placental location. Gestational age is most accurately determined in the first half of pregnancy. Ultrasonography can be used in the diagnosis of many major fetal anomalies. Ultrasonography is safe for the fetus when used appropriately. The following conclusions are based on limited or inconsistent evidence (Level B): Ultrasonography is helpful in detecting fetal growth disturbances. Ultrasonography can detect abnormalities in amniotic fluid volume. The following conclusion and recommendation are based primarily on consensus and expert opinion (Level C): The optimal timing for a single ultrasound examination in the absence of specific indications for a first-trimester examination is at 18 20 weeks of gestation. The benefits and limitations of ultrasonography should be discussed with all patients. Proposed Performance Measure: Documentation of the discussion of the benefits and limitations of ultrasonography. Ultrasonography in Pregnancy. ACOG Practice Bulletin No. 101. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113: 45161.
http://www.ncbi.nlm.nih.gov/pubmed/19155920

Critical Care in Pregnancy ACOG Practice Bulletin Number 100 February 2009 Critical care in pregnancy is a field that remains unevenly researched. Although there is a body of evidence to guide many recommendations in critical care, limited research specifically addresses obstetric critical care. The purpose of this document is to review the available evidence, propose strategies for care, and highlight the need for additional research. Much of the review will, of necessity, focus on general principles of critical care, extrapolating where possible to obstetric critical care. The following conclusions are based on good and consistent scientific evidence (Level A): Pregnancy changes normal laboratory values and physiologic parameters. Approximately 75% of obstetric ICU patients are admitted to the unit postpartum. Hemorrhage and hypertension are the most common causes of admission from obstetric services to intensive care. The following recommendations are based on limited or inconsistent scientific evidence (Level B): Cesarean delivery in the ICU should be restricted to cases in which transport to the operating room or delivery room cannot be achieved safely or expeditiously, or to a perimortem procedure. Treatment of sepsis should not await admission to an ICU but should begin as soon as septic shock is diagnosed. The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C): High-intensity ICU physician staffing is associated with lower ICU mortality rates, lower hospital mortality rates, and decreased length of stay in both the ICU and a hospital, compared with models in which intensivist consultation is optional. Decisions about care for a pregnant patient in the ICU should be made collaboratively with the intensivist, obstetrician, specialty nurses, and neonatologist. The care of any pregnant woman requiring ICU services should be managed in a facility with obstetric adult ICU and neonatal ICU capability. Necessary medications should not be withheld from a pregnant woman because of fetal concerns. Necessary imaging studies should not be withheld out of potential concern for fetal status, although attempts should be made to limit fetal radiation exposure during diagnostic testing. Proposed Performance Measure: Percentage of pregnant or postpartum patients in the ICU who have documented involvement of an obstetrician gynecologist. Critical Care in Pregnancy. ACOG Practice Bulletin No. 100. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113: 43350.
http://www.ncbi.nlm.nih.gov/pubmed/19155919

The Role of Transvaginal Ultrasonography in the Evaluation of Postmenopausal Bleeding ACOG Committee Opinion Number 440 August 2009 ABSTRACT: The clinical approach to postmenopausal bleeding requires prompt and efficient evaluation to exclude or diagnose carcinoma. Women with postmenopausal bleeding may be assessed initially with either endometrial biopsy or transvaginal ultrasonography; this initial evaluation does not require performance of both tests. Transvaginal ultrasonography can be useful in the triage of patients in whom endometrial sampling was performed but tissue was insufficient for diagnosis. When transvaginal ultrasonography is performed for patients with postmenopausal bleeding and an endometrial thickness of less than or equal to 4 mm is found, endometrial sampling is not required. Meaningful assessment of the endometrium by ultrasonography is not possible in all patients. In such cases, alternative assessment should be completed. When bleeding persists despite negative initial evaluations, additional assessment usually is indicated. The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. ACOG Committee Opinion No. 440. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:40911. Informed Consent ACOG Committee Opinion Number 439 August 2009 ABSTRACT: Obtaining informed consent for medical treatment, for participation in medical research, and for participation in teaching exercises involving students and residents is an ethical requirement that is partially reflected in legal doctrines and requirements. As an ethical doctrine, informed consent is a process of communication whereby a patient is enabled to make an informed and voluntary decision about accepting or declining medical care. In this Committee Opinion, the American College of Obstetricians and Gynecologists Committee on Ethics describes the history, ethical basis, and purpose of informed consent and identifies special ethical questions pertinent to the practice of obstetrics and gynecology. Two major elements in the ethical concept of informed consent, comprehension (or understanding) and free consent, are reviewed. Limits to informed consent are addressed. Informed consent. ACOG Committee Opinion No. 439. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:4018. Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination ACOG Committee Opinion Number 438 August 2009 ABSTRACT: To provide optimal protection for the pregnant woman and her neonate, preconception immunization is preferred to vaccination during pregnancy. However, when indicated, the benefits of immunization to the pregnant woman and her neonate usually outweigh the theoretic risks of adverse effects. To add protection against pertussis or for

pregnant women who need tetanus or diphtheria protection during pregnancy, immunization with the diphtheria and reduced tetanus toxoids and acellular pertussis vaccine (Tdap) instead of the tetanus and diphtheria toxoids (Td) vaccine may be considered in the second or third trimester. Pregnant women (including women who are breastfeeding) who have not received a dose of Tdap previously, should receive it after delivery and before discharge from the hospital if 2 years or more have elapsed since the most recent Td vaccination. Current information on the safety of vaccines given during pregnancy is frequently updated and may be verified from the Centers for Disease Control and Prevention web site at www.cdc.gov/vaccines. Update on immunization and pregnancy: tetanus, diphtheria, and pertussis vaccination. ACOG Committee Opinion No. 438. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:398400. Community Involvement and Volunteerism ACOG Committee Opinion Number 437 July 2009 ABSTRACT: As professional and community leaders, obstetriciangynecologists have unlimited opportunities to become involved in and have a positive impact on local, national, and international communities and organizations. Volunteering outside of daily work routines often revitalizes a commitment to medicine while serving as a much needed resource to the community. Community Involvement and Volunteerism. ACOG Committee Opinion No. 437. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009:114:2034.
http://www.ncbi.nlm.nih.gov/pubmed/19546799

Evaluation and Management of Abnormal Cervical Cytology and Histology in Adolescents ACOG Committee Opinion Number 436 July 2009 ABSTRACT: The management of abnormal cervical cytology in adolescents differs from that of the adult population. Cervical cancer is almost nonexistent in adolescents, yet human papillomavirus (HPV) infection is very common in this population. In the past 5 years there has been significant advancement in the management of HPV-related diseases in adolescents. The publication of the American Society of Colposcopy and Cervical Pathology 2006 consensus guidelines has led to major changes in the prevention and management of cervical disease in adolescents. With the availability of the HPV vaccination (since 2006), it is expected that these guidelines will continue to change. The American Society of Colposcopy and Cervical Pathology guidelines now advise against HPV testing and recommend against treatment of low grade squamous intraepithelial lesions or cervical intraepithelial neoplasia 1. In addition, among adherent adolescents, treatment of cervical intraepithelial neoplasia 2 also should be deferred. These new guidelines were established to minimize the potential negative impact that treatment can have on future pregnancy outcomes, while taking advantage of the natural history of HPV in young women.

Evaluation and Management of Abnormal Cervical Cytology and Histology in Adolescents. ACOG Committee Opinion No. 436. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 113:14225. http://www.ncbi.nlm.nih.gov/pubmed/19461460 Postpartum Screening for Abnormal Glucose Tolerance in Women Who Had Gestational Diabetes Mellitus ACOG Committee Opinion Number 435 June 2009 ABSTRACT: Establishing the diagnosis of gestational diabetes mellitus offers an opportunity not only to improve pregnancy outcome, but also to decrease risk factors associated with the subsequent development of type 2 diabetes. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice recommends that all women with gestational diabetes mellitus be screened at 6 to 12 weeks postpartum and managed appropriately. Postpartum Screening for Abnormal Glucose Tolerance in Women Who Had Gestational Diabetes Mellitus. ACOG Committee Opinion No. 435. American College of Obstetricians. Obstet Gynecol 2009;113:1419 21. http://www.ncbi.nlm.nih.gov/pubmed/19461459 Induced Abortion and Breast Cancer Risk ACOG Committee Opinion Number 434 June 2009 ABSTRACT: The relationship between induced abortion and the subsequent development of breast cancer has been the subject of a substantial amount of epidemiologic study. Early studies of the relationship between prior induced abortion and breast cancer risk were methodologically flawed. More rigorous recent studies demonstrate no causal relationship between induced abortion and a subsequent increase in breast cancer risk. Induced Abortion and Breast Cancer Risk. ACOG Committee Opinion No. 434. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:14178.
http://www.ncbi.nlm.nih.gov/pubmed/19461458

Optimal Goals for Anesthesia Care in Obstetrics ACOG Committee Opinion Number 433 May 2009 ABSTRACT: A joint statement from the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists was developed to address issues of concern to both specialties. Good obstetric care requires the availability of qualified personnel and equipment to administer general or regional anesthesia both electively and emergently. The extent and degree to which anesthesia services are available varies widely among hospitals. However, for hospitals providing obstetric care, certain optimal anesthesia goals should be sought. Optimal goals for anesthesia care in obstetrics. ACOG Committee Opinion No. 433. American College of Obstetricians and Gynecologists and American Society of Anesthesiologists. Obstet Gynecol 2009;113:11979. http://www.ncbi.nlm.nih.gov/pubmed/19384152

Spinal Muscular Atrophy ACOG Committee Opinion Number 432 May 2009 ABSTRACT: Spinal muscular atrophy (SMA) is an autosomal recessive neurodegenerative disease that results from degeneration of spinal cord motor neurons leading to atrophy of skeletal muscle and overall weakness. In current practice, patients with a family history of SMA are being offered carrier screening for the survival motor neuron gene (SMN1) deletion mutations. Recent marketing and public awareness campaigns by laboratories and advocacy organizations are promoting widespread population-based carrier screening for SMA in the prenatal or preconception setting, regardless of family history. However, the American College of Obstetricians and Gynecologists Committee on Genetics agrees that preconception and prenatal screening for SMA is not recommended in the general population at this time. Spinal muscular atrophy. ACOG Committee Opinion No. 432. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:11946.
http://www.ncbi.nlm.nih.gov/pubmed/19384151

Routine Pelvic Examination and Cervical Cytology Screening ACOG Committee Opinion Number 431 ABSTRACT: The American College of Obstetricians and Gynecologists provides recommendations on when to start screening, how often to continue screening, and when to stop routine pelvic examination and cervical cytology. The pelvic examination serves multiple purposes, including the assessment of the vulva, vagina, cervix, uterus, and adnexa. Annual pelvic examination is a routine part of preventive care for all women 21 years of age and older even if they do not need cervical cytology screening. Pelvic examination is not a routine part of the annual assessment in females aged 1318 years, unless medically indicated. Evidence is inconclusive to establish an upper age limit for cervical cancer screening. Because cervical cancer develops slowly and risk factors decrease with age, it is reasonable to discontinue cervical cancer screening at either 65 years or 70 years of age in women who have had three or more normal cytology test results in a row and no abnormal test results in the past 10 years. Routine pelvic examination and cervical cytology screening. ACOG Committee Opinion No. 431. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:11903.
http://www.ncbi.nlm.nih.gov/pubmed/19384150

Preimplantation Genetic Screening for Aneuploidy ACOG Committee Opinion Number 430 March 2009 ABSTRACT: Preimplantation genetic screening differs from preimplantation genetic diagnosis for single gene disorders and was introduced for the detection of chromosomal aneuploidy. Current data does not support a recommendation for preimplantation genetic screening for aneuploidy using fluorescence in situ hybridization solely because of maternal age. Also, preimplantation genetic screening for aneuploidy does not improve in vitro fertilization success rates and may be detrimental. At this time there are no data to support preimplantation genetic screening for recurrent unexplained miscarriage and

recurrent implantation failures; its use for these indications should be restricted to research studies with appropriate informed consent. Preimplantation Genetic Screening for Aneuploidy. ACOG Committee Opinion No.430. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:7667.
http://www.ncbi.nlm.nih.gov/pubmed/19300349

Health Disparities for Rural Women ACOG Committee Opinion Number 429 March 2009 ABSTRACT: Significant health disparities exist for rural women in all categories of womens health, including obstetric and gynecologic outcomes and access to care. Minority women living in rural areas may face even greater risks based on their combined characteristics. Many rural areas have limited numbers of health care providers, particularly those who provide obstetric and gynecologic care. Generalizations regarding rural America are difficult because of the heterogeneity of rural areas within the United States and even within the borders of a single state. Health professionals are encouraged to engage in activities to diminish health disparities for rural women. Health Disparities for Rural Women. ACOG Committee Opinion No.429. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:7625.
http://www.ncbi.nlm.nih.gov/pubmed/19300348

Legal Status: Health Impact for Lesbian Couples ACOG Committee Opinion Number 428 February 2009 ABSTRACT: Women in same-sex relationships encounter barriers to health care that include concerns about confidentiality and disclosure, discriminatory attitudes and treatment, limited access to health care and health insurance, and often a limited understanding as to what their health risks may be. Lesbians and their families also are adversely affected by the lack of legal recognition of their relationships. Tangible harm comes from the lack of financial and health care protections that are granted to legal spouses, and children are harmed by the lack of protections afforded married families. The American College of Obstetricians and Gynecologists endorses equitable treatment for lesbians and their families, not only for direct health care needs but also for indirect health care issues; this should include the same legal protections afforded married couples. Legal Status: Health Impact for Lesbian Couples. ACOG Committee Opinion No.428. American College of Obstetricians and Gynecologists. Obstet Gynecol;113:469-72
http://www.ncbi.nlm.nih.gov/pubmed/19155923

Misoprostol for Postabortion Care ACOG Committee Opinion Number 427 February 2009 ABSTRACT: The World Health Organization estimates that 67,000 women, mostly in developing countries, die each year from untreated or inadequately treated abortion complications. Postabortion care, a term commonly used by the international reproductive

health community, refers to a specific set of services for women experiencing problems from all types of spontaneous or induced abortion. There is increasing evidence that misoprostol is a safe, effective, and acceptable method to achieve uterine evacuation for women needing postabortion care. To reduce maternal mortality, availability of postabortion care services must be increased. Misoprostol must be readily available especially for women who do not otherwise have access to postabortion care. Nurses and midwives can safely provide first-line postabortion care services, including in outpatient settings, provided they receive appropriate training and support. Access to contraception and safe abortion services prevents complications from unsafe abortion and decreases the need for postabortion care. It is much less expensive and far better for women's health to prevent the problem of unsafe abortion rather than to treat resulting complications. Misoprostol for Postabortion Care. ACOG Committee Opinion No.427. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:465-8.
http://www.ncbi.nlm.nih.gov/pubmed/19155922

Health Care for Undocumented Immigrants ACOG Committee Opinion Number 425 January 2009 ABSTRACT: Undocumented immigrants are less likely than other residents of the United States to have health insurance. Their access to publicly funded health programs has become increasingly limited since the passage of welfare reform in 1996 and varies from state to state. This is reflected in less preventive health care, including prenatal care, and poorer health outcomes, including those associated with childbirth. The U.S.-born children of undocumented immigrant women are U.S. citizens, and the nation's public health is enhanced by assuring that all who reside in the United States, including undocumented immigrants, have access to quality health care. Health Care for Undocumented Immigrants. ACOG Committee Opinion No.425. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:2514.
http://www.ncbi.nlm.nih.gov/pubmed/19104393

Abortion Access and Training ACOG Committee Opinion Number 424 January 2009 ABSTRACT: Despite a decrease in abortion rates over the past decade, numerous political, social, and provider barriers limit access to abortion services. Barriers include state restrictions and mandates limiting access, lack of public funding for abortion services, and the decrease in abortion providers. Abortion education and training are limited in medical schools and in residency programs. The American College of Obstetricians and Gynecologists supports education in family planning and abortion for both medical students and residents and abortion training among residents. In addition, the American College of Obstetricians and Gynecologists supports availability of reproductive health services for all women, including strategies to reduce unintended pregnancy and to improve access to safe abortion services.

Abortion Access and Training. ACOG Committee Opinion No.424. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:24750.
http://www.ncbi.nlm.nih.gov/pubmed/19104392

Motivational Interviewing: A Tool for Behavior Change ACOG Committee Opinion Number 423 January 2009 ABSTRACT: Applying the principles of motivational interviewing to everyday patient interactions has been proved effective in eliciting "behavior change" that contributes to positive health outcomes and improved patientphysician communication. Current Procedural Terminology codes are available to aid in obtaining reimbursement for time spent engaging patients in motivational interviewing for some conditions. Motivational Interviewing: A Tool for Behavior Change. ACOG Committee Opinion No.423. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:2436.
http://www.ncbi.nlm.nih.gov/pubmed/19104391