The American College of Obstetricians and Gynecologists

Five Things Physicians and Patients Should Question

Released February 21, 2013

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1

Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks 0 days gestational age.

Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

2

Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.

Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

3

Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age.

In average risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems, and have appropriate screening with consideration of a pelvic examination.

4

Don’t treat patients who have mild dysplasia of less than two years in duration.

Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the human papillomavirus (HPV), which does not require treatment in average risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.

5

Don’t screen for ovarian cancer in asymptomatic women at average risk.

In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than it can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 56,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization.

For more information, visit www.acog.org.

How this list was created: As a national medical specialty society, the American College of Obstetricians and Gynecologists relies on the input of any number of its committees in the development of various documents. In the case of the items submitted for the Choosing Wisely® campaign, input from the following committees was solicited: the Committees on Patient Safety and Quality Improvement; Obstetric Practice; and Gynecologic Practice. A literature search was conducted related to the initial list of approximately ten items. We then sent this list to the College’s Executive Board and asked them to select five of the items based on their potential to improve quality and reduce cost. We explained to them that the items were written to avoid complex or clinical terminology, but not at the risk of reducing the value and credibility of the recommendations made. In the case of the first two items on our list – “Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks 0 days gestational age” and “Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable” – we collaborated with the American Academy of Family Physicians in developing the final language.

The College’s disclosure and conflict of interest policy can be found at www.acog.org.

Sources

1.

Elimination of non-medically indicated (elective) deliveries before 39 weeks gestational age. Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, Kowalewski L (California Maternal Quality Care Collaborative). California: March of Dimes; First edition July 2010. California Department of Public Health; Maternal, Child and Adolescent Health Division; Contract No: 08-85012.

2.

Guidelines for perinatal care. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. 7th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2012.

Induction of labor. ACOG Practice Bulletin No. 107. American College of Obstetricians and Gynecologists. Obstet Gynecol [Internet]. 2009 Aug;114(2 Part 1):386–97.

3.

Systematic review: The value of the periodic health evaluation. Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D. Ann Intern Med [Internet]. 2007 Feb 20;146(4):289-300.

Screening Guidelines for the prevention and early detection of cervical cancer. Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, Garcia FA, Moriarty AT, Waxman AG, Wilbur DC, Wentzensen N, Downs LS Jr, Spitzer M, Moscicki AB, Franco EL, Stoler MH, Schiffman M, Castle PE, Myers ER; ACS-ASCCP-ASCP Cervical Cancer Guideline Committee, American Cancer Society, American Society for Colpoloscopy and Cervical Pathology, and American Society for Clinical Pathology. CA Cancer J Clin [Internet]. 2012 May-Jun;62(3):147–72.

Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol [Internet]. 2012 Aug;120:421–4.

Screening for cervical cancer. Practice Bulletin No. 131. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012 Nov;120(5):1222-38.

4.

2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcionoma in situ. Wright TC, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D. Am J Obstet Gynecol. 2007;197:340-45.

Management of abnormal cervical cytology and histology. Practice Bulletin No. 99. American College of Obstetricians and Gynecologists. Obstet Gynecol [Internet]. 2008 Dec;112(6):1419–44.

5.

Screening for ovarian cancer: Recommendation statement. U.S. Preventive Services Task Force. Ann Fam Med [Internet]. 2004 May 1;2(3):260–62.

Screening for ovarian cancer: Evidence update for the U.S. Preventive Services Task Force reaffirmation recommendation statement. Barton MB, Lin K. [Internet]. Rockville (MD); 2012 Apr. Agency for Healthcare Research and Quality; AHRQ Publication No. 12-05165-EF3.

Results from four rounds of ovarian cancer screening in a randomized trial. Partridge E, Kreimer AR, Greenlee RT, Williams C, Xu JL, Church TR, Kessel B, Johnson CC, Weissfeld JL, Isaacs C, Andriole GL, Ogden S, Ragard LR, Buys SS; PLCO Project Team. Obstet Gynecol [Internet]. 2009 Apr;113(4):775–82.

The role of the obstetrician–gynecologist in the early detection of epithelial ovarian cancer. Committee Opinion No. 477. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. Obstet Gynecol 2011 Mar;117(3):742–6.