Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + CESAREAN SECTION Download Section PDF Listen +++ +++ Population ++ Pregnant women with history of prior cesarean delivery. +++ Recommendations +++ AAFP 2014, ACOG 2017 ++ Attempting a vaginal birth after cesarean (VBAC) is safe and appropriate for most women. Encourage and facilitate planning for VBAC. If necessary, refer to a facility that offers trial of labor after cesarean (TOLAC). +++ Sources ++ AAFP. Clinical Recommendation: Vaginal Birth After Cesarean. 2014. Obstet Gynecol. 2017;130(5):1167-1169. +++ Comments ++ Provide counseling, encouragement, and facilitation for a planned vaginal birth after cesarean (PVBAC) so that women can make informed decisions. If PVBAC is not locally available, offer women who desire it referral to a facility or clinician who offers the service. Obtain informed consent for PVBAC, including risk to patient, fetus, future fertility, and the capabilities of local delivery setting. Develop facility guidelines to promote access to PVBAC and improve quality of care for women who elect TOLAC. Assess the likelihood of PVBAC as well as individual risks to determine who is an appropriate candidate for TOLAC. A calculator for probability for successful VBAC is available here: https://mfmunetwork.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html +++ Population ++ Women in labor. +++ Recommendations +++ ACOG 2012 ++ Induce labor only for medical indications. If induction is performed for nonmedical reasons, ensure that gestational age is >39 wk and cervix is favorable. Do not diagnose failed induction or arrest of labor until sufficient timea has passed. Consider intermittent auscultation rather than continuous fetal monitoring if heart rate is normal. +++ Source ++ Obstet Gynecol. 2012;120(5):1181. +++ WHO 2018 ++ Implement prenatal education programs including childbirth training, nurse-led relaxation, couple-based support, and psychoeducation. Consider mandatory second opinion for cesarean section decisions. Give timely feedback to health care professionals regarding cesarean section decision making. +++ Source ++ World Health Organization. WHO Recommendations Non-Clinical Interventions to Reduce Unnecessary Cesarean Sections. 2018. +++ Comments ++ If fetal heart rate variability is moderate, other factors have little association with fetal neurologic outcomes. Doctors who are salaried have lower cesarean rates than those paid fee-for-service. As part of informed consent for the first cesarean, discuss effect on future pregnancies including risks of uterine rupture and abnormal implantation of placenta. + ++ aFailed induction: inability to generate contractions every 3 min and cervical change after 24 h of oxytocin administration and rupture of membranes, if feasible. Arrest of labor, first stage: 6 cm dilation, membrane rupture, and 4 h of adequate contractions or 6 h of inadequate contractions without cervical change. Arrest of labor, second stage: no descent or rotation for 4 h (nulliparous woman with epidural), 3 h (nulliparous woman without epidural or multiparous woman with epidural), or 2 h (multiparous woman without epidural). + GROUP B STREPTOCOCCAL (GBS) INFECTION Download Section PDF Listen +++ +++ Population ++ Pregnant women. +++ Recommendations +++ ACOG 2019, AAP 2019 ++ Obtain vaginal-rectal swab specimen for GBS culture at 36 0/7–37 6/7 wk gestation. Intrapartum antibiotic prophylaxis (IAP) to prevent early-onset invasive GBS disease in newborns is indicated for high-risk pregnancies, including those with positive GBS culture, GBS bacteriuria during pregnancy, or history of previous GBS-infected newborn. If a woman presents in labor with unknown GBS colonization status this pregnancy, but has a history of GBS in a prior pregnancy, can offer IAP. Do not give IAP if a cesarean delivery is performed with intact membranes and before the onset of labor. +++ Sources ++ https://www.acog.org/GBS https://pediatrics.aappublications.org/content/144/2/e20191881 +++ Comments ++ Penicillin G is the agent of choice for IAP. Ampicillin is an acceptable alternative to penicillin G. Use cefazolin if the patient has a penicillin allergy that does not cause anaphylaxis, angioedema, urticaria, or respiratory distress. Use clindamycinb or vancomycin if the patient has a penicillin allergy that causes anaphylaxis, angioedema, urticaria, or respiratory distress. + ++ bUse clindamycin if isolate is sensitive to both clindamycin and erythromycin. If not, use vancomycin. + NEURAL TUBE DEFECTS Download Section PDF Listen +++ +++ Population ++ Women of childbearing age. +++ Recommendation +++ USPSTF 2016, AAFP 2016, ACOG 2017 ++ Women should take a daily supplement containing 400–800 µg of folic acid if planning or capable of pregnancy. +++ Sources ++ Obstet Gynecol. 2017;130:e279-e290. [lww.com] https://journals.lww.com/greenjournal/Fulltext/2017/12000/Practice_simplein_No__187___Neural_Tube_Defects.41.aspx JAMA. 2017;317(2):183-189. [uspstf] https://www.uspreventiveservices taskforce.org/Page/Document/RecommendationStatementFinal/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication AAFP. Clinical Recommendation. [aafp.org] https://www.aafp.org/patient-care/clinical-recommendations/all/neural-tube-defects.html + POSTPARTUM DEPRESSION Download Section PDF Listen +++ +++ Population ++ Pregnant women. +++ Recommendations +++ USPSTF 2019 ++ Refer those at increased risk of perinatal depression to counseling interventions. No accurate screening tool to identify those at risk. Consider providing counseling to women with 1 or more of the following risk factors: history of depression, current depressive symptoms, certain socioeconomic risk factors such as low income or adolescent or single parenthood, recent intimate partner violence, or mental health–related factors. +++ Source ++ https://jamanetwork.com/journals/jama/fullarticle/2724195 + POSTPARTUM HEMORRHAGE Download Section PDF Listen +++ +++ Population ++ Pregnant women. +++ Recommendations +++ ACOG 2017 ++ Give uterotonic medications to all women during the third stage of labor. Oxytocin 10 IU, IV, or IM is first choice. Methylergometrine or oral/rectal misoprostol is an alternative. Perform uterine massage. Use controlled cord traction to remove the placenta. +++ Source ++ Obstet Gynecol. 2017;183(130):e168-e186. +++ Comment ++ ACOG defines maternal hemorrhage as cumulative blood loss of ≥1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 h after birth. + PREECLAMPSIA Download Section PDF Listen +++ +++ Population ++ Pregnant women at increased risk of preeclampsia. +++ Recommendation +++ USPSTF 2014 ++ Use aspirin 81 mg/d after 12th wk of gestation if ≥1 major risk factor for preeclampsia. +++ Source ++ Ann Intern Med. 2014;161:819-826. +++ Comment ++ Major risk factors: personal history of preeclampsia, multifetal gestation, chronic hypertension, DM, renal disease, autoimmune disease. + PRETERM BIRTH Download Section PDF Listen +++ +++ Population ++ Pregnant women. +++ Recommendations +++ ACOG 2012 ++ Do not use maintenance tocolytics to prevent preterm birth. Do not give antibiotics for the purpose of prolonging gestation or improving neonatal outcome in preterm labor with intact membranes. In women with prior spontaneous preterm delivery, start progesterone therapy between 16 and 24 wk gestation. Consider cerclage placement to improve preterm birth outcomes in women with prior spontaneous preterm delivery <34 wk, current singleton pregnancy, short cervical length (<25 mm) before 24 wk gestation. +++ Source ++ Obstet Gynecol. 2012;120(4):964-973. +++ Comments ++ No evidence to support the use of prolonged tocolytics for women with preterm labor. No evidence to support strict bed rest for the prevention of preterm birth. The positive predictive value of a positive fetal fibronectin test or a short cervix for preterm birth is poor in isolation. + Rh ALLOIMMUNIZATION Download Section PDF Listen +++ +++ Population ++ Pregnant women. +++ Recommendations +++ ACOG 2018 ++ Screen ABO blood group and Rh-D type at first prenatal visit of each pregnancy. Repeat antibody screen before giving anti-D immune globulin (28 wk gestation, postpartum, and pregnancy events). +++ Source ++ Obstet Gynecol. 2018;131:e8. + SURGICAL SITE INFECTIONS (SSI) Download Section PDF Listen +++ +++ Population ++ Women undergoing abdominal procedures. +++ Recommendations +++ Cochrane Database of Systematic Reviews 2014, ACOG 2018 ++ Treat remote infections prior to elective operations. Do not shave incision site unless hair interferes with operation. If necessary, remove hair immediately before operation with clippers. Control serum blood glucose levels and avoid perioperative hyperglycemia. Patients should shower or bathe (full body) on at least the night before abdominal surgery. Prepare the surgical site preoperatively with an alcohol-based agent unless contraindicated. Use a vaginal preparation with povidone-iodine solution immediately prior to hysterectomy or vaginal surgery. Give prophylactic IV antibiotics preoperatively within 60 min of skin incision as opposed to administration after cord clamping. +++ Sources ++ Obstet Gynecol. 2018;131:e172-e189. http://www.cochrane.org/CD007892/PREG_vaginal-cleansing-before-cesarean-delivery-to-reduce-post-cesarean-infections +++ Comments ++ A vaginal prep prior to cesarean section reduces the incidence of postpartum endometritis. This benefit was especially true for women in active labor or with rupture membranes. The incidence of maternal infectious morbidity is decreased (RR 0.54) when prophylactic antibiotics are administered preoperatively as opposed to after cord clamping. + THROMBOEMBOLISM IN PREGNANCY Download Section PDF Listen +++ +++ Population ++ Pregnant women. +++ Recommendations +++ ACOG 2018 ++ Consider thromboprophylaxis for patients at increased risk of thromboembolism. There is not sufficient evidence for routine prophylaxis in pregnancy. No risk assessment tool has been sufficiently validated, but risk factors include: personal history of thrombosis, thrombophilia, cesarean delivery, obesity, hypertension, autoimmune disease, heart disease, sickle cell disease, multiple gestations, preeclampsia. + TOBACCO USE Download Section PDF Listen +++ +++ Population ++ Pregnant women. +++ Recommendation +++ AAFP 2015, USPSTF 2015, ICSI 2014 ++ Screen all pregnant women for tobacco use and provide pregnancy-directed counseling and literature for those who smoke. +++ Sources ++ AAFP. Clinical Preventive Service Recommendation: Tobacco Use. 2015. USPSTF. Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. 2015. ICSI. Preventive Services for Adults. 20th ed. 2014. +++ Comment ++ The “5-A” framework is helpful for smoking cessation counseling: Ask about tobacco use. Advise to quit through clear, individualized messages. Assess willingness to quit. Assist in quitting. Arrange follow-up and support sessions. +++ Population ++ School-aged children and adolescents. +++ Recommendation +++ AAFP/USPSTF 2013 ++ Recommend that primary care clinicians provide interventions including education or brief counseling to prevent the initiation of tobacco use. +++ Comment ++ The efficacy of counseling to prevent tobacco use in children and adolescents is uncertain. +++ Source ++ USPSTF. Tobacco Use in Children and Adolescents: Primary Care Interventions. 2013.