Gynecologists Practice Bulletin Research Articles

(065) Let’s Talk about Sex: Resident Run Didactic Curriculum

Abstract Introduction The Council on Resident Education in Obstetrics and Gynecology (CREOG) includes sexual health learning objectives as part of the core education for Ob/Gyn training. Residents are expected to gain understanding of normal sexual function as well as common areas of sexual dysfunction. Unfortunately, several studies have demonstrated a lack of knowledge in this area by Ob/Gyn residents and that educational didactic programs are not standardized on this topic. In 2010, over 90% of post graduate year (PGY)3 and PGY4 residents reported attending fewer than 5 didactic activities on sexual function/dysfunction, with only 50% feeling able to perform a targeted physical exam. Over the past decade, there has not been substantial improvement in this subject matter. In a 2021 survey evaluating the sexual health CREOG objectives showed that more than half of Ob/Gyn residents were not able to describe the disorders of sexual function or list common medications that effect sexual function. This is not isolated to the US, with studies in other countries including Singapore and Brazil, showing residents lack formal training and residents want increased didactic time focused on sexual health. Objective Our hypothesis was that at our institution the baseline knowledge of sexual dysfunction among Ob/Gyn residents would be low. The primary objective was formulating a needs assessment through implementation of a pre/post survey with a curriculum component. The secondary objective was to determine what areas of sexual medicine are most commonly areas of confusion or where residents lack comfort in regard to patient care. Methods The resident-designed curriculum was built with collaboration from a pelvic floor physical therapist. The journal club format was based on American College of Obstetricians and Gynecologists (ACOG) Practice Bulletins, the International Society for the Study of Women’s Sexual Health (ISSWSH) clinical pearls, and the North American Menopausal Society (NAMS) position statements. The pelvic floor physical therapy component focused on pelvic pain, perinatal considerations, and incontinence. The WCG IRB deemed this study exempt. After the pre-curriculum assessment was used to identify knowledge gaps, a month of one-hour weekly sexual health sessions were implemented followed by a post-curriculum survey. Results Due to small sample size, (N=14) there was no way to establish significance in our results. In general, areas that residents were weak and the curriculum focused on were: 1) Pelvic floor/vulvar/vestibular disorders. 2) Genitourinary syndrome of menopause and vasomotor symptoms of menopause. 3) Sexual medicine disorders (hypoactive sexual desire disorder, female sexual arousal disorder, persistent genital arousal disorder, female orgasm disorders, genitopelvic pain penetration dysfunction). Conclusions The baseline knowledge of sexual dysfunction and menopausal concerns among Ob/Gyn residents was low. However, implementation of a structured curriculum after a formal needs assessment improved comfort with these topics. Now that the baseline curriculum is designed it is imperative to expand to further residency programs (in Ob/Gyn as well as other specialties) to disseminate the knowledge to providers in training who require competency in sexual health concerns. Disclosure No

Trends in Apical Suspension at the Time of Hysterectomy for Pelvic Organ Prolapse: Impact of American College of Obstetricians and Gynecologists Recommendations.

The aim of the study was to compare national surgical practice patterns of performing apical suspension procedures (ASPs) at the time of hysterectomy for pelvic organ prolapse (POP) before and after the publication of the American College of Obstetricians and Gynecologists (ACOG) 2017 Practice Bulletin on POP. The American College of Surgeons National Surgical Quality Improvement Program database was queried for hysterectomy cases performed for POP indications for the years 2015-2016 and 2018-2019. The primary outcome was the use of ASP at the time of hysterectomy for POP. Secondary outcomes included the use of anterior, posterior, and paravaginal prolapse repair procedures. Multivariable regression analysis was performed to identify factors associated with performing a hysterectomy without an ASP. A total of 11,336 cases were included, and apical prolapse was the primary POP diagnosis in 86.3% of these cases. There was no statistically significant change in the utilization of ASPs in 2018-2019 compared with 2015-2016 (51.4% vs 49.8%, P = 0.081). Urogynecologists were significantly more likely than general gynecologists to perform ASPs (65.6% vs 37.5%, P < 0.001), which was confirmed on multivariable logistic regression analysis (adjusted odds ratio, 3.257; P < 0.001). The use of concomitant anterior repairs (44.1% vs 39.5%, P < 0.001) and posterior repairs (47.5% vs 41.3%, P < 0.001) increased in the 2018-2019 cohort. There was no overall increase in the utilization of concomitant ASPs at the time of hysterectomy done for POP indications despite the 2017 American College of Obstetricians and Gynecologists practice bulletin. Urogynecologists were more likely to perform ASPs than general gynecologists.

Changes in Performance of Apical Suspension at the Time of Surgery for Prolapse: Assessment of the Influence of the American Urogynecologic Society and American College of Obstetricians and Gynecologists Practice Bulletin.

To assess the association of publication of the American Urogynecologic Society (AUGS)/American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin on pelvic organ prolapse and performance of an apical suspension at the time of surgery for pelvic organ prolapse. Surgical procedures performed with a primary diagnosis of uterovaginal or female genital prolapse, cystocele, or enterocele were isolated from the 2011 to 2019 American College of Surgeons National Surgical Quality Improvement Program Database. An autoregressive interrupted time series regression estimated the overall temporal trend in performance of an apical suspension and assessed for a change in trend associated with publication of the AUGS/ACOG Practice Bulletin in April 2017. A stratified analysis was also performed depending on performance of a concomitant hysterectomy, and sensitivity analysis was performed using only diagnoses of uterovaginal or vaginal vault prolapse. There were 72,194 individuals identified; 83.4% had a diagnosis of uterovaginal or female genital prolapse, 15.2% cystocele and 1.4% enterocele. Only 36.6% of cases had an apical suspension. Prior to the practice bulletin publication, performance of an apical suspension grew at 0.19% per quarter (95% confidence interval [CI], 0.07-0.31), with a trend toward increased utilization (+0.12%; 95% CI, -0.06 to 0.30) after publication. The increase was greater among cases with a concomitant hysterectomy (+0.35%; 95% CI, 0.08-0.62). Sensitivity analyses found similar changes in trend. Performance of apical suspensions during surgery for prolapse remains low and is increasing at less than 1% per year. The AUGS/ACOG practice guidelines were associated with minimal changes in this pattern. Incentives or other strategies may be needed to further encourage standard of care management of prolapse.

Makrozomik Fetuslar 38. Gebelik Haftasında Doğurtulabilir Mi?

Objective: Numerous articles have been written on macrosomic fetuses, including the American College of Obstetricians and Gynecologists practice bulletin. However, there is no clear consensus about the time of birth. The aim of this study was to compare the maternal and fetal outcomes of women giving birth at 38+0-38+6 weeks and those with deliveries at ≥39 weeks in pregnancies complicated by fetal macrosomia, and to determine the effect on morbidity and mortality of delivery in the 38th gestational week.Material and Methods: Data of women and their infants born in Kayseri Training and Research Hospital between 01 May 2018 and 31 March 2020 were analyzed retrospectively. The patients included were those with a singleton pregnancy delivered at ≥38 weeks with a birthweight of ≥4000 gr. Demographic data and medical history and birth outcomes of the patients were recorded from the hospital data system. Multiple pregnancies, those with fetal anomalies and births &amp;lt;38 weeks were excluded from the study. The patients were separated into two groups as those who gave birth at 38+0-38+6 gestational weeks (Group 1) and those who gave birth at ≥39 weeks (Group 2).Results: Maternal and/or fetal trauma was found to be statistically significantly higher in nulliparous women with vaginal delivery ≥39 weeks compared to those with vaginal delivery at 38+0-38+6 weeks (p=0.017). No significant difference was observed between the groups in respect of fetal morbidity and mortality.Conclusion: When fetal macrosomia is determined antenatally, rates of fetal and/or maternal trauma can be reduced with delivery planned for the 38th week without increasing fetal morbidity and mortality.

Antibiotic overuse in obstetric and gynecologic procedures at Zagazig university hospitals: A prospective observational study

Surgical site infection (SSI) constitutes a major problem in healthcare in terms of healthcare cost, morbidity and mortality. Surgical antibiotic prophylaxis (SAP) is one of the effective strategies for SSI prevention. Poor adherence to SAP guidelines across different countries has been observed. Misuse of prophylactic antibiotics threatens patient safety and leads to an increase in the acquisition of antibiotic resistance. The aim of this study was to assess the utilization of SAP in obstetric and gynecologic procedures in terms of indication for prophylaxis, antibiotic selection, timing of administration and prophylaxis duration. A prospective observational study was conducted at the obstetrics and gynecology department of Zagazig University Hospital during the period from January 2020 to June 2020. Medical records of 264 women were recorded and evaluated. The American Society of Health-System Pharmacists (ASHP) therapeutic guidelines, World Health Organization (WHO) recommendations and The American College of Obstetricians and Gynecologists (ACOG) practice bulletin were used for data evaluation and hence women were stratified into two groups. For women who underwent procedures in which guidelines recommended the use of SAP (200 patients; 75.75%), 198 women (99%) received preoperative prophylaxis. None of women (0%) received the recommended first line antibiotic by guidelines while the most commonly used prophylactic antibiotics were Cefotaxime (86 patients; 43.43%) and Ampicillin-sulbactam (62 patients; 31.31%). Preoperative antibiotic prophylaxis timing was 0-60 minutes before skin incision. All women received postoperative prophylaxis that extended to an average of 7 days. Regarding the other group who underwent procedures in which prophylactic antibiotics weren’t recommended by guidelines (64 patients; 24.24%), 37 women (57.81%) followed the guidelines and didn’t receive SAP while 27 women (42.18%) received SAP. Poor adherence to guidelines recommendations regarding prophylactic antibiotic selection and prophylaxis duration was observed. High utilization rate of prophylactic antibiotics in procedures that didn’t require their use was reported..

Commentary: No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond

Author(s): Raymond, Elizabeth; Grossman, Daniel; Mark, Alice; Upadhyay, Ushma; Dean, Gillian; Creinin, Mitchell; Coplon, Leah; Perritt, Jamila; Atrio, Jessica; Taylor, DeShawn; Gold, Marji | Abstract: No abstract

528: Evaluation of early screening for Gestational Diabetes Mellitus (GDM) with standard HbA1c

Diabetes mellitus (DM) is associated with adverse pregnancy outcomes and early detection allows for timely management of the disease. Early DM screening is currently recommended for pregnant women who are considered high risk via a 1-hour glucose challenge test (1h GCT). This test is often bothersome for women as it is time-consuming and may induce gastrointestinal distress. Hemoglobin A1c (A1c) is a fast and reliable method of assessing long term glycemic control. We sought to examine the correlation between hemoglobin A1c (A1c) and 1h GCT for DM screening in early pregnancy This was a retrospective cohort study of pregnant women who were high-risk for DM that underwent early A1c and 1h GCT between October 2017 and July 2019. We defined ‘high-risk’ as women that met the criteria for early testing based on the screening strategy in American College of Obstetricians and Gynecologists practice bulletin # 180. Three-hour glucose tolerance test (3h GTT) data was also collected if the 1h GCT was abnormal (>135 mg/dL). DM was diagnosed if the A1c was 6.5% or higher. Pearson correlation coefficient was calculated to investigate the relationship between early A1c and 1h GCT A total of 115 patients were included with mean age of 30.4 and mean BMI of 36.8 kg/m2. Median gestational age was 8.9 weeks at A1c draw and 13.8 weeks at 1h GCT draw. Two (1.7%) women were diagnosed with DM based on an early A1c. Four of 20 women (20.0%) with early A1c of 5.7-6.4% and 2 of 93 (2.2%) with A1c< 5.7% had an early diagnosis of DM. A significant positive correlation between A1c and early 1h GCT result was detected (Pearson correlation coefficient=0.55, P< 0.01). A1c significantly predicts the risk of early 1h GCT with AUC=0.75 (95%CI: 0.63,0.86) and the risk of DM with AUC=0.91 (95%CI: 0.83,0.99). An early A1c of 5.3% or less (61.7% of patients) had a 100% negative predictive value for DM A1c correlates with 1h GCT for the early screening of gestational DM. Our findings suggest that women with an early A1c ≤ 5.3% in a similar-risk population could potentially forego further testingView Large Image Figure ViewerDownload Hi-res image Download (PPT)

AIUM Practice Parameter for the Performance of Fetal Echocardiography.

AIUM Practice Parameter for the Performance of Fetal Echocardiography.

Miscarriage information available on the internet: a content analysis of leading consumer websites

ObjectiveThe objective of this content analysis was to explore the accuracy and completeness of information provided about miscarriage on consumer-facing websites. Study designWe identified the most popular consumer websites for health information and the leading medical and nursing professional association websites. We reviewed each website for content on miscarriage aimed at consumers and compared the website content to the information contained in the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin on Early Pregnancy Loss. We used a simple scoring method to compare the accuracy and completeness of the content on each website with the ACOG Practice Bulletin. ResultsSixty percent (n = 9) of the top 15 consumer websites for health information had dedicated webpages on miscarriage. Of the nine leading professional association websites, two had dedicated pages on miscarriage. On average, each site provided information on 64% of the key messages from the ACOG Practice Bulletin. Sites commonly emphasized and provided overall accurate and complete information on risk factors of miscarriage. The key messages with the most limited or inaccurate information pertained to diagnosis of miscarriage; treatment, including medical management with mifepristone and misoprostol; instructions postmiscarriage and prevention of miscarriage. ConclusionsThe majority of popular health websites include consumer-facing content on miscarriage, and the information presented is a mostly complete and accurate representation of the ACOG Practice Bulletin. The lack of information on treatment options may affect patients' ability to make informed choices about their care. The missing information points to areas that patients may feel underprepared to discuss with healthcare providers. ImplicationsMore effort is needed to ensure that internet-based consumer information about miscarriage reflects the best scientific evidence.

CommentaryACOG Practice Bulletin July 2017: Breast Cancer Risk Assessment andScreening in Average-Risk Women.

Screening mammography reduces breast cancer mortality in average-risk women. However, adverse consequences include false-positive findings possibly leading to benign breast biopsies and patient anxiety. There is also potential for overdiagnosis and overtreatment. Differences in how to balance benefits and harms have led to varying recommendations by the U.S. Preventive Services Task Force, the American Cancer Society, the National Comprehensive Cancer Network and the American College of Radiology/Society of Breast Imaging. These recommendations differ with respect to what age to start, what age to stop, and frequency of screening in average-risk women. Most recently, the American College of Obstetricians and Gynecologists have issued updated clinical management guidelines for breast cancer risk assessment and screening in average-risk women that aim to maximize the benefits of screening while keeping in mind the potential harms of false-positive results. This commentary summarizes the clinical management guidelines of the American College of Obstetricians and Gynecologists Practice Bulletin July 2017 for breast cancer risk assessment and screening in average-risk women. We review evidence of the benefits and adverse consequences of screening mammography and briefly discuss new advances in breast cancer screening with recent technologies such digital breast tomosynthesis and risk-adapted screening.

Pharmacological treatment of gestational diabetes mellitus: point/counterpoint

Controversies persist over the most efficacious pharmacologic treatment for gestational diabetes mellitus. For purposes of accuracy in this article, the individual American College of Obstetricians and Gynecologists Practice Bulletin and American Diabetes Association Standards of Medical Care positions on each issue are quoted and then deliberated with evidence of counter claims presented in point/counterpoint. This is a review of all the relevant evidence for the most holistic picture possible. The main issues are (1) which diabetic drugs cross the placenta, (2) the quality of evidence and data source validity, (3) the rationale for the designation of glucose control as the primary outcome in gestational diabetes mellitus, and (4) which drugs (metformin, glyburide, or insulin) are most effective in improving secondary outcomes. The concept that 1 drug fits all, whether it be insulin, glyburide, or metformin, is a fallacy. Different drugs provide certain benefits but not all the benefits and not to all patients. In addition, the steps in the gestational diabetes mellitus management decision path and the current cost of the use of insulin, glyburide, or metformin are addressed. In the future, we must consider studying the potential of diabetic drugs that currently are used in nonpregnancy and incorporating the concept of precision medicine in the decision tree to maximize pregnancy outcomes.

The Effect of Maternal Low Flow Oxygen Administration During the Second Stage of Labour on Umbilical Cord Artery pH: A Randomized Controlled Trial

(BJOG. 2017;124:678–685) Oxygen is routinely used in the United States for intrauterine resuscitation when fetal heart rate (FHR) abnormalities are present. In fact, an American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin recommended its use as a component of intrauterine resuscitation. It is also commonly used by obstetricians prophylactically during the second stage of labor. However, its efficacy has been debated. Some studies have shown increased maternal oxygen levels with no increase in fetal levels while other studies did report an increase in fetal oxygen saturation when maternal oxygen supplementation was administered. No randomized controlled trials have looked at the effects of supplemental maternal oxygen on nonreassuring FHR and just 2 small trials investigated the effect of prophylactic oxygen administration during the second stage of labor. Finally, hyperoxia has been shown to cause vasoconstriction, including vessels of the placenta and umbilical cord, which could lead to the conclusion that oxygen administration during intrauterine resuscitation may be harmful. This randomized, controlled study evaluated the effects on umbilical artery pH of low flow maternal oxygen administration during the second stage of labor.

Cerclage Use: A Review of 3 National Guidelines.

Preterm birth is a major contributor to perinatal morbidity and mortality. The most common intervention performed to improve perinatal outcomes for a woman experiencing cervical dilation in the second trimester without signs or symptoms of preterm labor is the cerclage. We sought to review and compare available national guidelines on cerclage use. We performed a descriptive review of 3 national guidelines on cerclage: The American Congress of Obstetricians and Gynecologists Practice Bulletin on "Cerclage for the Management of Cervical Insufficiency," Green-top Guideline from the Royal College of Obstetricians and Gynaecologists entitled "Cervical Cerclage," and the Society of Obstetricians and Gynaecologists of Canada Clinical Practice Bulletin entitled "Cervical Insufficiency and Cervical Cerclage." Guidelines were compared, and the following aspects of cerclage use for prevention of preterm delivery were summarized: indications and contraindications, risk factors for cervical insufficiency, perioperative considerations, and timing of removal. Recommendations and strength of evidence were reviewed based on each guideline's method of reporting. The references were compared with regard to the total number of randomized control trials, Cochrane Reviews, and systematic reviews/meta-analyses cited. The variations highlighted in the guidelines reflect the heterogeneity of the literature contributing to guidelines and the challenges of diagnosing and managing cervical insufficiency. A cohesive international guideline may improve safety and quality and optimize patient outcomes. Obstetricians and gynecologists, family physicians. After completing this activity, the learner should be better able to outline variations in indications and contraindications for cervical cerclage use by international guideline, identify variation in perioperative considerations for cervical cerclage use by international guideline, and recognize variation in timing of removal by international guideline.

False Alarms, Pseudoepidemics, and Reality: A Case Study with American College of Obstetricians and Gynecologists Practice Bulletins (Podcast)

False Alarms, Pseudoepidemics, and Reality: A Case Study with American College of Obstetricians and Gynecologists Practice Bulletins (Podcast)

False Alarms, Pseudoepidemics, and Reality: A Case Study with American College of Obstetricians and Gynecologists Practice Bulletins.

The objectives of this review are to (1) ascertain the frequency with which odd ratio (OR) and relative risk (RR) are in the zone of potential bias or interest in the American College of Obstetricians and Gynecologists (ACOG) practice bulletins (PB); (2) the likelihood that false alarms have been linked to recommendations; and (3) if there are differences in obstetric versus gynecological PB, vis-à-vis OR and RR in the zone of bias or interest. We reviewed all ACOG PBs published between May 1999 and March 2014. Documents were searched for statements with mention of OR and RR. When the reported ORs fell between 0.33 and 3.0, it was categorized as "zone of potential bias"; if ORs fell outside the interval 0.25 to 4.0, it was "zone of potential interest." With RRs, the zones of bias and interest were 0.5 to 2.0 and 0.33 to 3.0, respectively. Of the 79 PBs reviewed, 22% (n = 17) had 44 statements with OR, with 41% (n = 18) of the ORs being in the zone of bias and 54% (n = 24) in the zone of potential interest. Overall, 84% of the ORs did not lead to an actual recommendation by ACOG. In 28% (n = 22) of PBs, there were 67 statements with RRs, with 58% (n = 39) of them being in the zone of bias and 28% (n = 19) were in the zone of interest. In 73% of the PBs the RR citations did not lead to any recommendations. Across the 79 PBs, ACOG made 733 recommendations, and among them only 1 and 2% were linked with ORs and RRs, respectively. Over 70% of ACOGPBs did not cite OR and RR. To better understand the evidence, ACOG should increase citation of OR and RR; whenever applicable OR and RR should be part of graded recommendations. Level C. Less than a third of ACOG practice bulletins mention odds ratios or relative risks and over 95% of recommendations in them remain unsubstantiated.

Use of the Combined First-Trimester Screen in High- and Low-Risk Patient Populations After Introduction of Noninvasive Prenatal Testing.

To report changes in the use of the combined first-trimester screen (FTS) in patients classified as high and low risk for fetal aneuploidy, including after introduction of noninvasive prenatal testing (NIPT). A prospectively collected database was reviewed to investigate changes in FTS use before and after American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 77 (Obstet Gynecol 2007; 109:217-227), which recommended that all patients be offered aneuploidy screening, and after NIPT introduction. High-risk patients were classified as 35 years or older at the estimated time of delivery or those with an abnormal prior screen, abnormal ultrasound findings, or family history of aneuploidy. Data were normalized per 100 morphologic ultrasound examinations to account for changes in patient number over time. Statistical significance was defined as P < .05. A total of 10,125 FTSs were recorded during the 88-month study period, including 2962 in high-risk patients and 7163 in low-risk patients. The total number of FTSs performed per 100 morphologic ultrasound examinations significantly increased after ACOG Practice Bulletin No. 77 and significantly decreased after NIPT introduction. In high-risk patients, the total number of FTSs performed per 100 morphologic ultrasound examinations significantly increased after ACOG Practice Bulletin No. 77 but significantly decreased after NIPT introduction. In contrast, in low-risk patients, the total number of FTSs performed per 100 morphologic ultrasound examinations significantly increased after ACOG Practice Bulletin No.77 but was not statistically different after NIPT introduction. American College of Obstetricians and Gynecologists Practice Bulletin No. 77 significantly increased patient use of FTS. The introduction of NIPT significantly decreased FTS use in the high-risk population but not in the low-risk population.

Obstetric Recommendations in American Congress of Obstetricians and Gynecologists Practice Bulletins versus UpToDate: A Comparison (Podcast)

Comment on: Obstetric Recommendations in American Congress of Obstetricians and Gynecologists Practice Bulletins versus UpToDate: A ComparisonAm J Perinatol 2015; 32(05): 427-444DOI: 10.1055/s-0034-1396684

Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines

The purpose of this study was to compare 4 national guidelines for the prevention and management of postpartum hemorrhage (PPH). We performed a descriptive analysis of guidelines from the American College of Obstetrician and Gynecologists practice bulletin, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Royal College of Obstetrician and Gynaecologists (RCOG), and the Society of Obstetricians and Gynaecologists of Canada on PPH to determine differences, if any, with regard to definitions, risk factors, prevention, treatment, and resuscitation. PPH was defined differently in all 4 guidelines. Risk factors that were emphasized in the guidelines conferred a high risk of catastrophic bleeding (eg, previous cesarean delivery and placenta previa). All organizations, except the American College of Obstetrician and Gynecologists, recommended active management of the third stage of labor for primary prevention of PPH in all vaginal deliveries. Oxytocin was recommended universally as the medication of choice for PPH prevention in vaginal deliveries. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists and RCOG recommended development of a massive transfusion protocol to manage PPH resuscitation. Recommendations for nonsurgical treatment strategies such as uterine packing and balloon tamponade varied across all guidelines. All organizations recommended transfer to a tertiary care facility for suspicion of abnormal placentation. Specific indications for hysterectomy were not available in any guideline, with RCOG recommending hysterectomy "sooner rather than later" with the assistance of a second consultant. Substantial variation exists in PPH prevention and management guidelines among 4 national organizations that highlights the need for better evidence and more consistent synthesis of the available evidence with regard to a leading cause of maternal death.

Obstetric Recommendations in American Congress of Obstetricians and Gynecologists Practice Bulletins versus UpToDate: A Comparison

To compare the obstetric recommendations in American Congress of Obstetricians and Gynecologists (ACOG) practice bulletins (PB) with similar topics in UpToDate (UTD). We accessed all obstetric PB and cross-searched UTD (May 1999-May 2013). We analyzed only the PB which had corresponding UTD chapter with graded recommendations (level A-C). To assess comparability of recommendations for each obstetric topic, two maternal-fetal medicine (MFM) subspecialists categorized the statement as similar, dissimilar, or incomparable. Simple and weighted kappa statistics were calculated to assess agreement between the two raters. We identified 46 ACOG obstetric PB and 86 UTD chapters. There were 50% fewer recommendations in UTD than in PB (181 vs. 365). The recommendations being categorized as level A, B, or C was significantly different (p < 0.001) for the two guidelines. While the overall concordance rate between the two MFM subspecialists was 83% regarding the recommendations for the same topic as similar, dissimilar, or incomparable, the agreement was moderate (kappa, 0.56; 95% confidence intervals, 0.48-0.65). Though obstetricians have two sources for graded recommendations, incongruity among them may be a source of consternation. Congruent recommendations from ACOG and UTD could enhance compliance and potentially optimize outcomes.

Shoulder dystocia: Definitions and incidence

Though subjective in nature, both the American College of Obstetricians and Gynecologists practice bulletin and the Royal College of Obstetricians and Gynaecologists green guideline are in agreement on the descriptor of shoulder dystocia: requirement of additional obstetric maneuvers when gentle downward traction has failed to affect the delivery of the shoulders. The rate of shoulder dystocia is about 1.4% of all deliveries and 0.7% for vaginal births. Compared to non-diabetics (0.6%), among diabetics, the rate of impacted shoulders is 201% higher (1.9%); newborns delivered by vacuum or forceps have 254% higher likelihood of shoulder dystocia than those born spontaneously (2.0% vs. 0.6%, respectively). When the birthweight is categorized as <4000, 4000–4449, and >4500g, the likelihood of shoulder dystocia in the US vs. other countries varies significantly. Future studies should focus on lowering the rate of shoulder dystocia and its associated morbidities, without concomitantly increasing the rate of cesarean delivery.