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	Q.		What do you use to treat pregnant women with migraines?
	A.		First of all make sure these are migraine headaches, then treat appropriately. See below. (WORD 76k)
	Q.		When should antenatal testing start after an IUFD? 34 weeks? or prior to the gestational age of the IUFD?
	A.		Probably neither, unless you know the exact etiology of the prior IUFD, but there is more. (WORD 40k)
	Q.		Should we perform routine urine dipstick protein screening in our prenatal clinic?
	A.		No, the urine dipstick tests are not sensitive, nor specific enough for routine screening for pre-eclampsia. There is more to the story, though. See below. (WORD 71k)
	Q.		Do we have an Indian Health policy on positive skin tests in pregnancy for TB--and treatment?
	A.		Yes, here is a discussion on screening and treatment during pregnancy and lactation. (WORD 85k)
	Q.		What are the latest screening and treatment guidelines from the CDC?
	A.		The HHS AIDS info site has the updated HIV information.
	Q.		Is there data to support combined visual inspection of the cervix with acetic acid wash (VIA) in low resource settings?
	A.		Yes, there is a significant body of literature to support VIA (WORD 41k)
	Q.		Do all hospitals need cesarean delivery capacity?
	A.		Here is an example in which careful triage leads to excellent outcomes. (WORD 42k)
	Q.		What is the latest on Congenital Toxoplasmosis
	A.		The AFP presents a review of the topic.
	Q.		What are some methods of cervical ripening and Induction of Labor?
	A.		The AFP presents a review of the topic.
	Q.		Should Active Management of the Third Stage of Labor Be Routine?
	A.		AFP presents a review of the Cochrane Library.
	Q.		Is percutaneous drainage of tubo-ovarian abscess standard of care?
	A.		Yes, especially in women who have not completed their child-bearing. (WORD 43k)
	Q.		Is membrane stripping associated with abruption placenta?
	A.		No, in addition, there was no increased risk of maternal or neonatal infection, but minor maternal discomforts were common. (WORD 31k)
	Q.		How can my department tell if we providing effective urinary incontinence procedures?
	A.		Two good benchmark times to re-evaluate are at 1 and 5 years post operatively. (WORD 42k)
	Q.		Are there medical student rotations available?
	A.		Yes, Medical Students seeking a medical rotation/clerkship in an IHS facility should contact the appropriate person on the Medical Student Clerkship Contacts List.
	Q.		Are there 4th Medical student rotations available in OB/GYN?
	A.		Yes,Sub Internships in OB/GYN are available for clinical supervised patient contact in all areas of women's health care. (WORD 32k)
	Q.		What should I do about a patient at 4-6 weeks gestation with a varicella like rash?
	A.		Rapid treatment may ameilorate maternal symptoms, but have little benefit for the fetus. (WORD 35k)
	Q.		What is the cost effectiveness for the use of cytotec or any other induction agents?
	A.		Misoprostol is more cost-effective than the comparable commercial agents. (WORD 35k)
	Q.		What issues do patients and providers need to know about smallpox?
	A.		CDC answers many of the common questions
	Q.		Should pregnant women wear seat belts?
	A.		Yes. Take a look at what the National Highway Traffic Safety Administration says
	Q.		What is the risk of developing breast cancer
	A.		Here is a site with the Gail model of breast cancer risk assessment. Just plug in the risk factors and get the risk score.
	Q.		Did thousands of American Indian women undergo forced sterilization in the 1970s?
	A.		The following resources discuss evidence that refutes that hypothesis Straight Dope 3/22/02 Comptroller General Report to Senator Abourezk 11/4/76, 38 pages GAO Report 2/27/78, 11 pages GAO 4/14/78 Letter to Representative Robert Young, 2 pages National Wombs: Sterilization of American Indian Women in the 1970s
	Q.		How effective a screening test is the clinical breast exam?
	A.		Clinical breast exam has a limited role, but mammography is the test of choice. [WORD 89k]
	Q.		What are the differences between the 2002 CDC GBS Recommendations and the 1996 CDC guidelines?
	A.		The main difference is the recommendation for universal screening at 35-37 week, but here are several others.
	Q.		What is the evidence behind the 2002 CDC GBS Recommendations?
	A.		The recommendation for universal screening at 35-37 week is level A-2, but here are the others recommendations, too
	Q.		What are some guidelines to use for the care of diabetes in pregnancy?
	A.		Here are some guidelines and other resources.
	Q.		Is H.I.V. testing recommended for all pregnant women?
	A.		A.C.O.G. recommends: H.I.V. Tests Urged for All Pregnant Women with Patient Notification and Right of Refusal. Non-A.C.O.G. members | A.C.O.G. members.
	Q.		Is antibiotic prophylaxis recommended with all hysterectomies? [12/01]
	A.		Yes, A.C.O.G. practice Bulletin #23 gives an 'A' Recommendation to antibiotic prophylaxis for BOTH abdominal and vaginal hysterectomy. (Link for A.C.O.G. members only.)
	Q.		Is antibiotic prophylaxis recommended for all I.U.D. insertions? [12/01]
	A.		No. The cost effectiveness of screening for gonorrhea and chlamydia before I.U.D. insertion is unclear; in women screened and found to be negative, prophylactic antibiotics appears to provide no benefit. A.C.O.G. Practice Bulletin #23, 'A' Recommendation. (Link for A.C.O.G. members only.)
	Q.		Is antibiotic prophylaxis recommended with all hysterosalpingograms (H.S.G.)?
	A.		No, but if you find dilated tubes, then prophylaxis should be given to reduce post H.S.G. P.I.D. From: A.C.O.G. Practice Bulletin #23, 'B' Recommendation. (Link for A.C.O.G. members only.)
	Q.		Can misoprostol be used for cervical ripening?
	A.		Misoprostol is appropriate to use for cervical ripening. The exact dosing should be individualized. ACOG Supports Use of Misoprostol for Labor Induction. Non-A.C.O.G. members | A.C.O.G. members.
	Q.		What kind of surgical availability is necessary for vaginal birth after cesarean (V.B.A.C.)?
	A.		V.B.A.C. should be attempted in institutions equipped to respond with physicians immediately available to provide emergency delivery. (WORD 37k)
	Q.		What is the CDC's response to the Cochrane review about reconsidering use of mammography? [2/02]
	A.		See this downloadable file: MS Word (.DOC) 40K | Acrobat Reader {.PDF) 20K.
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	Q.		What reproductive rights do minors have in my state? [12/01]
	A.		The Alan Guttmacher Institute gives an update on a state by state basis. Downloadable Acrobat Reader (.PDF) files: Minors' access to contraceptive services; Minors' access to prenatal care; Minors' access to STD care; Minors' rights as parents; Minors' abortions - parental involvement; State sexuality education policy.
	Q.		How are adolescent reproductive rights handled in I/T/U Areas? (Note: two answers below.)
	A.		Here is an example of how one I/T/U Area has grappled with some difficult adolescent issues. Downloadable file: MS Word (.DOC) 32K | Acrobat Reader (.PDF) 8K.
	A.		But you should consult your state's most recent policies (just above).
	Q.		What is the status of reproductive health and rights in my state?
	A.		The Alan Guttmacher Institute provides monthly State Policies in Brief.
	Q.		What evidence based prevention strategies actually work? [12/01]
	A.		The A.H.R.Q. offers these evidence based prevention strategies and guide.
	Q.		What resources are available for child sexual assault training?
	A.		A provider at an I/T/U site asked the above question. I posed it to members of the MCH listserv and found that there are several resources available. Downloadable file: MS Word (.DOC) 32K | Acrobat Reader {.PDF) 12K.
	Q.		Should all women be screened for chlamydia?
	A.		U.S.P.S.T.F. strongly recommends ('A' recommendation) routine screening for:
			All sexually active women ages 25 and younger. Other asymptomatic women at increased risk for infection.
	Q.		What are the latest recommendations on chlamydia screening?
	A.		Here are the National Guideline Clearinghouse's latest recommendations.
	Q.		What is a safe amount of fish to eat during pregnancy? [12/01]
	A.		The FDA recommends women can safely eat 12 ounces per week of cooked fish including shellfish, canned fish, smaller ocean fish or farm-raised fish.
	A.		The E.P.A. recommends one meal a week (8 oz. for adults and 3 oz. for young children). The E.P.A. National Advice answers several questions about fish consumption for women and children. E.P.A.: Protecting residents from the health risks of consuming contaminated non-commercial fish and wildlife.
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	Q.		How should I follow patients with ovarian cancer? [2/02]
	A.		Here is how one service unit approached that problem. Downloadable file: MS Word (.DOC) 28K | Acrobat Reader {.PDF) 12K.
	Q.		How should I follow patients with cervical cancer? [2/02]
	A.		Here is how one service unit approached that problem. Downloadable file: MS Word (.DOC) 28K | Acrobat Reader {.PDF) 12K.
	Q.		How should I follow patients with endometrial cancer? [2/02]
	A.		Here is how one service unit approached that problem. Downloadable file: MS Word (.DOC) 28K | Acrobat Reader {.PDF) 8K.
	Q.		Are there are any good sites to learn more about female anatomy? [2/02]
	A.		Yes, try Visible Woman or Anatomy In Vivo.
	Q.		What is hirsuitism (excess hair) and what can I do about it? [2/02]
A.		See The Endocrine Society and The American Academy of Family Physicians.
Q.		What is the polycystic ovarian syndrome (P.C.O.S.) and what can I do about it? [2/02]
A.		See The Endocrine Society, the P.C.O.S. Association, and PCOSupport Chapters.
Q.		How can physical therapy help with urinary incontinence? [12/01]
A.		Irene Boyd, BS, MPT has developed a unique physical therapy program to strengthen the female pelvic musculature through exercise, biofeedback, and pelvic muscle electrical stimulation. Downloadable files: a) Biofeedback - MS Word (.DOC) 28K | Acrobat Reader (.PDF) 12K, b) Electrical muscle stimulation - MS Word (.DOC) 28K | Acrobat Reader (.PDF) 12K, c) Product list - MS Word (.DOC) 36K | Acrobat Reader (.PDF) 20K. Many more links on pelvic relaxation, pain and related issues, downloadable file: MS Excel (.XLS) 20K | Acrobat Reader (.PDF) 8K.
Q.		How can Listeriosis affect pregnancy? [12/01]
A.		Look at C.D.C.'s Listeriosis - Frequently Asked Questions.
Q.		How can I diagnose and manage food borne illnesses in pregnancy? [12/01]
A.		C.D.C.'s primer Diagnosis and Management of Food borne Illnesses. You can also get 3.0 hours of C.M.E.
Q.		What does the N.I.H. Consensus say about repeat courses of antenatal corticosteroids? [12/01]
A.		The current benefit and risk data are insufficient to support routine use of repeat or rescue courses of antenatal corticosteroids in clinical practice.
Q.		Should I offer DNA screening for cystic fibrosis in preconception and prenatal care? (Note: 5 answers below.) [12/01]
A.		A.C.O.G. recommends that Ob-Gyns make screening for cystic fibrosis available to all couples seeking care.
A.		Cystic Fibrosis Carrier Testing: The Decision is Yours. A.C.O.G. Patient education brochure.
A.		Cystic Fibrosis Testing: What Happens If Both My Partner and I Are Carriers? A.C.O.G. Patient education brochure.
A.		Also see: Preconception and Prenatal Carrier Screening for Cystic Fibrosis (publication at A.C.O.G. store).
A.		Cystic Fibrosis Foundation publications.
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	Q.		How should I manage a fetal demise? [8/01]
	A.		This I.H.S. Primary Provider article discusses the need for investigation of every loss of pregnancy (intrauterine fetal demise [IUFD], or spontaneous abortion), risk factors, possibly early warning signs, aspects of counseling and emotional support, and criteria for protocols. April 1993. Acrobat reader (.PDF) 324K
	Q.		Can we prescribe 'emergency contraception' or the 'morning after pill' in the Indian Health Service / Tribal / Urban facilities? [8/01]
	A.		Yes, we provide a full range of FDA approved contraceptive options to our patients, including the so called 'emergency contraception', a.k.a. "the morning after pill."
			We provide this service as well as proper patient education, and appropriate follow-up as outlined in Maternal Child Health, Chapter 13 3-13.12 F.2 of the Indian Health Service Manual (1992 edition).
			While research suggests that emergency contraception acts via interruption of ovulation or tubal function, some providers have construed emergency contraception to be an abortifecient. Consequently some have refused to prescribe or to dispense the prescription after it has been prescribed by a provider. While it the right of providers and health care workers to work within their conscience, those health care personnel are also obliged to refer the patient to a provider or facility that is able to meet their needs at minimum of inconvenience.
			Toward that end any provider licensed to write prescriptions, can dispense medications. As a practical matter some women's clinics have kept a supply of bottles of 8 Lo-ovral attached to bottles of 2 Compazine with instructions in the women's clinic. These were kept in a locked cabinet. The physicians and midwives would hand the meds to the patients with instructions prn. Please note this should only be an interim solution while the health care facility makes appropriate arrangements to fulfill its obligation above. Please consult the ACOG/IHS Postgraduate OB/GYN PEDs Manual for further prescriptive information.
			If there are questions about this or other similar issues one may also want to consult the Federal Register Vol. 47, No. 18 Wed. January 27, 1982. DHHS, PHS 42 CFR Part 36 Subpart F, Abortions and Related Medical Services in Indian Health Service Facilities and Indian Health Service Programs. Paragraph 36.55: Drugs and devices and termination of ectopic pregnancies. "Federal funds are available for drugs or devices to prevent implantation of the fertilized ovum, and for medical procedures necessary for the termination of an ectopic pregnancy."
			Find more info on this and other FDA approved agents: On-line: Plan B and the Not-2-Late site.
	Q.		Are there any advantages to the new progesterone-containing IUDs? [10/01]
	A.		There may be advantages to the new progesterone-containing IUDs related to less bleeding. Download a document that explores many of the issues: MS Word (.DOC) 32K | Acrobat Reader (.PDF) 24K.
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	Q.		Is Depo Provera associated with weight gain or diabetes in American Indians and Alaska Natives? [8/01]
	A.		Use of depot medroxyprogesterone acetate (DMPA) has commonly been associated with weight gain. A recent cohort study among Navajo women demonstrated weight gain among DMPA users that was a mean of six pounds greater than in comparison group after one year and a mean of 11 lbs. greater after two years of use. The difference remained statistically significant after controlling for age, parity, and initial weight(1).
			A recent case-control study among Navajo women demonstrated that women who developed type II diabetes were more than tree times as likely to have used DMPA as those who maintained normal glucose tolerance(2). This association persisted after controlling for body mass index. A study of Latina woman with gestational diabetes showed a three-fold increase in progression to overt diabetes among those who took a progestin-only oral contraceptive as opposed to refraining from hormonal contraceptive use(3).
			These facts raise several questions. Is exposure to progestins a risk factor for subsequent development of diabetes in Native American women? If so is this effect truly independent of weight gain, a recognized risk factor in populations with relatively high frequency of insulin resistance?
			The National Epidemiology Program, in cooperation with several service units around the country, is undertaking a retrospective cohort study to address these issues.
	Contact for the study: Richard Leman, 505-258-4234.
			(1) Espey El, Steinhart J, et al. Depo-Provera associated with weight gain in Navajo women. Contraception. 2000; 62: 55-58.
			(2) Kim C, Seidel K, et al. Diabetes and depot medroxyprogesterone acetate contraception in Navajo women. In press.
			(3) Kjos S. Peters R, et al. Contraception and the risk of type 2 diabetes mellitus in Latina women with prior gestational diabetes mellitus. JAMA. 1998; 280: 533-538.
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	Q.		What are the risks of the breast cancer with silicone breast implants? [10/01]
	A.		Download the Q&A document on this topic from our sister site, Women's Health: MS Word (.DOC), 68k | Acrobat Reader (.PDF) 84K
	Q.		What is the final Bethesda System 2001 terminology? [4/02]
	A.		Here is the Bethesda System 2001 final terminology.
	Q.		Where can I find more discussion about the final Bethesda System 2001? [4/02]
	A.		Try this page and/or the many other options that NCI offers.
	Q.		What is the evidence that supports one pap smear interval versus another - for instance, every year versus every 3 years? [9/01]
	A.		The Agency for Healthcare Quality and Research provides this evidence-based background: On-line.
	Q.		What is the proper pap smear interval? [9/01]
	A.		One I.H.S. Area wrestled with that question and came up with this answer for their Area:
	Download file: MS Word (.DOC) 40K | Acrobat Reader (.PDF) 28K
	Q.		Should we switch to the new cervical cancer screening technologies? Two answers:
	A.		Dr. Alan Waxman on liquid-based technologies. Downloadable file: MS Word (.DOC) 28K | Acrobat Reader (.PDF) 8K. [4/02]
	A.		Don't believe everything you hear quite yet. Many clinical laboratories are pressuring providers to change to the more profitable new cervical cancer screening technologies. A.H.R.Q. presents evidence that suggests that clinical outcomes have not been improved. A.H.R.Q. info - on-line. [9/01]
	Q.		What are the 20 latest evidence-based cervical cancer screening guidelines? [9/01]
	A.		The following link will initiate a search at www.guideline.gov that pulls up links to the 20 guidelines that site offered as of 9/1/01. Results take a moment or two to appear - be patient. On-line search.
	Q.		What is the latest evidence on colon cancer screening? [8/01]
	A.		A.H.R.Q. offers the latest evidence on colon cancer screening: Summary | Technical review
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	Q.		What patient education material can I offer my patients about common uterine conditions? [8/01]
	A.		The A.H.R.Q. offers some pertinent information for patients.
	Q.		What is the latest evidence on management of uterine fibroids? [8/01]
	A.		The AHRQ offers this information on the management of uterine fibroids: On-line summary | Downloadable files - MS Word (.DOC) 64K, Acrobat Reader (.PDF) 36K.
	Q.		What is the evidence for the management of preterm labor? [8/01]
	A.		The AHRQ offers the latest evidence of what works and what doesn't: Summary | Full report
	Q.		How should I manage chronic hypertension in pregnancy? [8/01]
	A.		AHRQ offers the latest evidence based information. On-line: Summary | Full report. Download summary: MS Word (.DOC) 52K, Acrobat Reader (.PDF) 32K. Downloadable, zipped file collection: Word Perfect, 520K
	Q.		What is the latest evidence on the diagnosis and treatment of postmenopausal osteoporosis? [8/01]
	A.		The A.H.R.Q. offers the latest evidence based information on the diagnosis and treatment of postmenopausal osteoporosis: Summary.
Q.		What is known about osteoporosis in American Indians and Alaska Natives (A.I./A.N.)? [10/01]
A.		Very little is known about osteoporosis in A.I./A.N.. Here is a brief summary of an article about osteoporosis in Alaska Natives, plus the citations and conclusions to 8 articles on the topic from PubMed. Downloadable file: MS Word (.DOC) 32K | Acrobat Reader (.PDF) 16K.
Q.		How long a shift can I work safely? What patient safety practices actually work? [8/01]
A.		The AHRQ offers an evaluation of a wide variety of patient safety practices. On-line: Summary | Full report. Download summary: MS Word (.DOC) 56K, Acrobat Reader (.PDF) 32K. Downloadable, zipped file of the full report: MS Word, 954K.
Q.		How do you assess osteoporosis risk?
A.		Counsel all women on the risk factors for osteoporosis. Osteoporosis is a "silent" risk factor for fracture just as hypertension is for stroke; one out of two white women will experience an osteoporotic fracture at some point in her lifetime.
Q.		How do you diagnose osteoporosis?
A.		Consider the possibility of osteoporosis and fracture risk in all postmenopausal women, based on the presence of the risk factors in the question outlined above. Be alert to secondary causes of osteoporosis, which include a broad range of disease states and therapeutic drug.
Q.		How do you treat osteoporosis?
A.		Some interventions to maximize and preserve bone mass have multiple health benefits and are sufficiently cost-effective that they can be recommended to the general population.
Q.		What medications can you use?
A.		The decision to treat osteoporosis with a pharmacologic agent should be based on strong evidence that an intervention effectively prevents fractures and their consequences, that its expected benefits outweigh any potential adverse effects or risks, and that it represents a reasonable use of resources.
Q.		What exercises could I suggest?
A.		Physical medicine and rehabilitation can be effective strategies in treating patients after fracture, significantly improving functioning and reducing disability. For patients with hip fractures, rehabilitation is thought to be especially important.
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Q.		Should we routinely test prenatal patients for Hepatitis C (HCV)? [9/01]
A.		No, but providers should take histories from their patients designed to determine the need for testing and prevention measures, and those health care workers should be knowledgeable regarding HCV counseling, testing, and medical follow-up. Umbilical cord blood should not be for diagnosis of perinatal HCV infection because cord blood can be contaminated by maternal blood. For more information: downloadable Acrobat Reader (.PDF) file, 489K. Also available: online version (H.T.M.L.).
Q.		Should children born to HCV positive women be routinely tested? [9/01]
A.		Yes. Testing should not be performed before 12 months of age, when passively transferred maternal anti-HCV declines below detectable levels. IG and antiviral agents are not recommended for post exposure prophylaxis of infants born to HCV positive women. If earlier diagnosis is desired, RT-PCR for HCV RNA may be performed at or after the infant's first well-child visit at age 1-2 months. Umbilical cord blood should not be for diagnosis of perinatal HCV infection because cord blood can be contaminated by maternal blood. If positive for either anti-HCV or HCV RNA, children should be evaluated for the presence or development of liver disease, and those children with persistently elevated ALT levels should be referred to a specialist for medical management. For more information: downloadable Acrobat Reader (.PDF) file, 489K. Also available: online version (H.T.M.L.).
Q.		Should long-term steady sex partners of HCV Positive Persons be routinely tested? [9/01]
A.		This is uncertain. HCV positive persons with long-term steady sex partners do not need to change their sexual practices. Persons with HCV infection should discuss with their partner the need for counseling and testing. If the partner is negative the couple should be informed of available data regarding risk for HCV transmission by sexual activity to assist them in making decisions about precautions. If the partner tests positive, appropriate counseling and evaluation for the presence or development of liver disease should be provided. For more information: downloadable Acrobat Reader (.PDF) file, 489K. Also available: online version (H.T.M.L.).
Q.		Can we test pregnant patients that have clinical indications for drug testing? Can we screen pregnant patients? [10-01]
A.		This is a very complex issue that determined in large part by local laws and regulations. Here is how one Area has approached the problem. Downloadable file: MS Word (.DOC) 36K | Acrobat Reader (.PDF) 24K.
Q.		Should we offer preconception folic acid? To patients with a previously diagnosed neural tube defect? To patients without a previously diagnosed neural tube defect? [10-01]
A.		YES. YES. YES. More info in downloadable file: MS Word (.DOC) 32K | Acrobat Reader (.PDF) 20K.
Q.		What are some good online sources for how to quit smoking? [11/01]
A.		1. Quitnet: Quit altogether.
		2. University of Arizona's Smoker's Self-Help line. Learn to quit tobacco in the privacy of your home.
		3. American Lung Association.
		4. C.D.C.'s T.I.P.S.: Tobacco information and prevention source.

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	Q.		A 37-year-old patient (G 7, P 6-0-0-6) presents in labor at 37 1/7 weeks gestation (dates=examination=ultrasound) from a isolated service unit. She has her federal tubal consent form with her, which she signed, one week previously, at 36 1/7 week gestation. Can a BTL be performed following her delivery? [8/01]
	A.		Unfortunately, a tubal ligation can not be performed, because, when pregnant, the tubal papers must be signed 30 days before the documented EDC, but no earlier than 180 days prior to the EDC. If a BTL was performed, a federal infraction form must be completed with possible penalties for the operating physician.
			In rare cases, with special circumstances, the sterilization coordinator will intervene, assuming responsibility for the infraction. In this case, the sterilization coordinator will personally interview the patient. Considering the age, gravity, and isolated circumstances, the sterilization coordinator may approve the sterilization if documentation can be shown (or patient states) that this has been a recurrent request, and she fully understands that she will not be able to have further children. The sterilization coordinator will fill out the violation form documenting that a patient should not be penalized for 29 day verses 30 day period. This will also be well documented within the patient's medical record.
			But, in the vast majority of circumstances, it will be explained to the patient that she will have to return in the postpartum to have the BTL performed.
			The federal sterilization rules are extremely important to:
			Ascertain the woman is fully informed of the procedure and inability to become pregnant again. Ascertain that the woman has an adequate time and opportunity to think about having the procedure. Avoid any possibility of the women feeling that there was any coercion in signing the consent.
			As obstetrical care providers, it is extremely important to offer and sign all federal consent forms between 20 and 35 weeks gestation. At the time of signing the consent, the patient must be informed than she can change her mind at any time prior to being given anesthesia. At the time, the BTL is performed, the federal consent must also be resigned as well as the regular operative permit.
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	Q.		A 21-year-old patient (G 2, P 1-0-0-1) presents in labor at 37 1/7 weeks gestation (dates=examination=ultrasound). She has her federal sterilization consent form with her that she signed at 35 2/7 weeks gestation. The attending physician is especially concerned about this person's age. Can/should a BTL be performed following her delivery? [8/01]
	A.		Yes, a tubal ligation can be performed. This patient is of legal age and signed the federal consent over 30 days prior to her EDC. In pregnancy, the federal consent form must be signed 30 days before the documented EDC, but no earlier than 180 days prior to the EDC.
			In this case, the concerns of the attending is appreciated. It has been well documented in studies that many women, having a BTL done prior to 30 years of age, have regrets and request reanastomosis at a later time. This woman is of legal age and, if, insistent, must have her wishes respected.
			In this case, it is suggested that extra time be spent with this patient and concerns about having a BTL at such an early age be openly stated with a request that the patient uses another method. At the time of the original/first signing, it is especially important to fully counsel this patient regarding the above as well as the risks and ineffectiveness of having this procedure reversed. This patient should be thoroughly counseled that there are multiple other family spacing methods available which are highly effective and acceptable which do not take away the ability to have further children. If the patient is insistent, this counseling should be documented upon a single PCC with the patient signing that she has been so advised.
			The federal sterilization rules are extremely important to:
			Ascertain the woman is fully informed of the procedure and inability to become pregnant again. Ascertain that the woman has an adequate time and opportunity to think about having the procedure. Avoid any possibility of the women feeling that there was any coercion in signing the consent.
			In this specific case, the federal guidelines are exceeded because of the high rate of regret in patients having the procedure done at such a early age. It is a very possible that this patient will return stating she was coerced and did not fully understand the implications of having a BTL performed.
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	Q.		A 20-year-old patient (G 5, P 4-0-0-4) presents for prenatal care at 10 weeks gestation and repeatedly requests that a BTL be done following delivery. Can a BTL be performed following her delivery? [8/01]
	A.		No, a tubal ligation can not be performed. The federal consent rules are very clear that a patient must be at least 21 years of age at the time of delivery in order to perform a BTL. If insistent, the procedure can be provided when she reaches 21.
			It is appreciated that 5 children may be considered enough for many families. But, again, it has been well documented in studies that many women, having a BTL done prior to 30 years of age, have regrets and request reanastomosis at a later time. In this case, it is suggested that extra time be spent with this patient and concerns about having a BTL at such an early age be openly stated with a request that the patient uses another method. This patient should be thoroughly counseled that there are multiple other family spacing methods available which are highly effective and acceptable which do not take away the ability to have further children. If at age 21, the patient is insistent, this counseling should be documented upon a single PCC with the patient signing that she has been so advised.
			The federal sterilization rules are extremely important to:
			Ascertain the woman is fully informed of the procedure and inability to become pregnant again. Ascertain that the woman has an adequate time and opportunity to think about having the procedure. Avoid any possibility of the women feeling that there was any coercion in signing the consent.
			In this specific case, the federal guidelines must be followed with the procedure not being offered and/or provided.
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	Q.		The staff say I can't obtain a valid BTL consent while the patient is in the hospital. Is that correct? [8/01]
	A.		You can obtain a valid BTL consent in the hospital as long as the patient wasn't coerced, e.g., in labor, under the influence of psychoactive agents, or under mental health care when she was counseled and signed the form.
			The regulations state, 3-13.12.5(3) that sterilization is prohibited when the individual is..."Institutionalized in a correctional, mental, or other facility..."
			The above example may reflect an interpretation that "institutionalized in (an)other facility" includes an acute care hospital. The federal register 42 CFR50.202 defines "institutionalized individual" to include those who are "involuntarily confined or detained under a civil or criminal stature in a correctional or rehabilitative facility including a mental hospital or other facility for the care and treatment of mental illness, or (2) confined under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness."
			In the Department's response to public comments, they add to the list, facilities such as reform schools or halfway houses where confinement is involuntary but "not as restrictive as a prison." They then go on to state, "The definition does not cover health care institutions such as acute care hospitals, which are not primarily residential and which provide medical services."
			Here's an example:
			My patient was a 26 yo G5 P3113 in preterm labor at 26 weeks with a cerclage in place and I had just started the MgS04. She had had a previous low vertical cesarean delivery of a previous 24 week gestation. She had sustained significant cervical and vaginal lacerations during that surgery at another facility.
			Her primary care provider then came out and said the patient announced she finally decided she now wanted to sign a tubal ligation consent form. The common folklore I had been told was that the patient couldn't sign the form while 'in the hospital'. In this past we tried many different strategies to get around that 'policy', e.g., bundle the patient up for our 10 F weather and wheel her across the street to the clinic to get counseled and sign her form 'outside the hospital'. Just as frequently that wheelchair trip didn't happen for some logistical reason, and the patient would end up with another very high-risk pregnancy.
			What I did this time instead was consult the new Maternal Child Health page on the IHS website because the current IHS Policy Manual Chapter 13 for MCH is posted there. As it turns out this was actually published in the Federal Register November 6, 1978.
			I found that there are exceptions to getting the tubal ligation consent form, but none are that the patient can't be in a hospital. The exceptions to obtaining a tubal ligation consent form are listed under 3-13.12F.5.a(4)b on page 82:
			the patient is in labor or childbirth seeking to obtain or obtaining an abortion under the influence of alcohol or the substances that affect the individual's state of awareness
			The IHS Policy Manual then goes through several pages of audits and significant penalties if you facility doesn't perform according to this policy.
			In this case I can't obtain the consent now for two reasons 1.) the patient is in preterm labor and 2.) on MgS04, which can affect her state of awareness.
			I can obtain the consent once she gets off MgS04 and goes out to the regular floor in stable condition. At that time it would be wise to write a short note in the chart to the effect that she:
			Has expressed a desire to seek sterilization, Is not in labor and, Is not on any other substances that affects her state of awareness.
			At that point she could receive a tubal ligation as soon as 72 hours after she signed the form.
			Resources:
			MCH page on IHS web site Chapter 13 on MCH page on IHS web site IHS web site
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	Q.		A patient comes in at 37 weeks wants a tubal. Provider goes ahead and has the patient sign the BTL consent under the likelihood that the patient could go 7 days beyond her due date and hence qualify for her 30 days of having the form signed. [8/01]
	A.		As a provider you would go ahead and sign the consent and explain to the patient that if she does not deliver a week overdue, the sterilization can not be done. The slippery slope to avoid is the 72 hour rule. If she goes into labor at 39 weeks, the 72 hour rule does not apply, because the consent is invalid. If a sterilization is performed before 41 weeks, it is an infraction. Hence, the need to state up front to patients that if they wish to consider a sterilization they must sign the permit before 36 weeks. They can always rescind their consent.
	Q.		What if the patient signs her consent in a timely fashion, but it isn't witnessed or at least the witness forgets to write their name on the witness line? The patient has expressed the intent for the BTL and that she understands the risks and benefits, it's just that the provider didn't put their signature down. [8/01]
	A.		Sterilization consents must be taken seriously. Anyone who obtains the consent can sign as a witness. You could go back in the record to confirm who obtained the original consent, and request that they sign and postdate the signature with documentation within the patient's record of their original witness.
			If the provider wrote, "tubal papers signed" or some other documentation, I'd find that provider and ask him/her to fill in the witness part of the note to be appended to the consent, to the effect that he/she witnessed the original signature - see progress note - but is delayed in documenting it. If there is no such note, and the patient doesn't remember who originally obtained the consent, she's out of luck.
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	Q.		Is there such a condition as the post tubal ligation syndrome? [10/01]
	A.		No. Look at this synopsis of the CREST study to find out why.
	Q.		Do tubal ligations cause menstrual irregularities or post-tubal ligation syndrome?
	A.		No. The CREST study provides evidence against any "syndrome" of menstrual abnormalities following tubal sterilization. See the many questions / answers addressed.
	Q.		What is a 'premature delivery' on the BTL consent form? [8/01]
	A.		Any date before the stated date of delivery. Here is a quote from the Federal Register, November 8, 1978:
			"An individual may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery, if at least 72 hours have passed since he or she gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery."
			If you invoke the premature delivery clause you may want to document your rationale in a legible note on the sterilization or in a progress note. The due date should be assigned in good faith, i.e. 30 days before a due date based on reasonable evidence available at the time. This definition of prematurity is different from the perinatalogist's definition of < 37 weeks.
	Q.		A 21-y.o. patient wants a BTL. I know the rate of requested reversal is very high in that scenario. Am I required to perform the BTL if I don't believe it is the best long term interest of the patient? [8/01]
	A.		No, you are not required to perform the tubal, but if, after thoroughly counseling the patient with extensive documentation, you choose not to, then you should refer the patient to another provider who is able to perform tubals with a minimum of inconvenience.
		The law gives a 21-y.o. the legal right to have a tubal ligation. If tubals are available to other women receiving care at a facility (direct or contract), they should be available to all women who are legally entitled to them. If the surgeon at the facility does not feel that he/she can, in good conscience, sterilize one so young, arrangements must be made for the woman to have the procedure done elsewhere, with a minimum of inconvenience.
		As a practical matter, it is OK to bring such a young woman back more than one time to ascertain her seriousness about the procedure. Many women are very sure they wish the procedure during pregnancy/before delivery, but change their mind even 6-8 weeks following delivery.
Q.		Can tubal reversals be offered in the Indian Health Service / Tribal / Urban (I/T/U) facilities? [11/01]
A.		Yes, tubal ligation reversals can be offered in the I/T/U facilities. Reversals have been offered at various facilities, including Gallup Indian Medical Center and Alaska Native Medical Center, depending on available personnel and other resource issues. Tubal reversals have been discussed in other areas, e.g., Phoenix, but were not felt to be within the scope of their care priorities at that time.
		At this point no I/T/U facilities are actively performing tubal reversals. In the past this service was performed at certain Service Units, but only for women from their service area who have met a pre-determined set of criteria
Q.		What can I do about urinary leakage or the sudden loss of urine? [10/01]
A.		There are many strategies on how to manage that problem. Some are very simple. Take a look.
Q.		How does Rh isoimmunization affect a fetus and a newborn? [4/02]
A.		John T. Queenan, MD from Contemporary OB/GYN presents many answers to the issue of isoimmunization
Q.		What are some of the practical issues on pregnancy-related HIV infection? [4/02]
A.		Mara J. Dinsmoor, MD from Contemporary OB/GYN presents many answers to the issues of pregnancy-related HIV infection.
Q.		What are some of the issues with Antepartum fetal evaluation? [4/02]
A.		Roger K. Freeman MD, from Contemporary OB/GYN presents some practical issues of antepartum fetal evaluation.
Q.		What are some of the practical issues of medical drug use in pregnancy? [4/02]
A.		Jennifer R. Niebyl, MD from Contemporary OB/GYN presents some of the practical issues of medical drug use in pregnancy.
Q.		What are some of the practical aspects of amnioinfusion? [4/02]
A.		Catherine Y. Spong, MD from Contemporary OB/GYN answers some of the practical questions about amnioinfusion.
Q.		What are some of the practical aspects of managing multiple pregnancy? [4/02]
A.		Mary E. D'Alton, from Contemporary OB/GYN presents some of the practical aspects of managing multiple pregnancy.
Q.		What are some of the practical aspects of managing antiphospholipid antibodies? [4/02]
A.		Charles J. Lockwood, MD from Contemporary OB/GYN presents some the practical aspects of managing antiphospholipid antibodies.
Q.		Is there potential liability risk in tribal courts when rendering care to American Indians and Alaska Natives (AI/AN)? [11/01]
A.		This is a very complex topic. You can download this article from A.C.O.G. Today, reproduced with their permission: MS Word (.DOC) 32K | Acrobat Reader (.PDF) 24K.
Q.		Is intermittent auscultation adequate for monitoring of fetal well being? [11/01]
A.		Yes, intermittent auscultative monitoring is an acceptable monitoring method in low risk pregnancies. This downloadable file reviews a number or references on the subject: MS Word (.DOC) 28K | Acrobat Reader (.PDF) 20K.
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	Q.		In various frustrating situations, how many times have you heard,"It's I.H.S. policy."? [8/01]
	A.		Well, here is the actual I.H.S. M.C.H. policy chapter...
			I.H.S. Manual Chapter 13: Maternal Child Health, 1992 Revision (current version; update due)
			This on-line resource contains information on: Maternal and Neonatal Services, Obstetric Anesthesia Services, Nurse Midwifery, Perinatal and Infant Mortality Reviews, Care of the Infant and Child, Child Abuse and Neglect, Sexual Abuse, School Health, Care of the Adolescent, Preventive Health Services for Women, Family Planning Services, Hysterectomies Resulting in Sterilization, Abortion Services. View on the I.H.S. Web site in Acrobat Reader format (.PDF)
	Q.		Is oral sex safe?
	A.		Oral sex is not considered safer sex. See the many questions answered: downloadable Acrobat Reader (.PDF) file, 24K.
	Q.		I am a Fellow of A.C.O.G. How can I sign up to work in an Indian Hospital? [12/01]
	A.		Contact Yvonne Malloy or Elaine Locke: 202-863-2580. For more I.H.S. OB/GYN information. For I.H.S. Job Opportunities. For the A.C.O.G. main page.
	Q.		Where can I get more information on common questions regarding women's health? [11/01]
	A.		The National Women's Health Information Center (N.W.H.I.C.) has offered resources on hundreds of common questions for your patients and resources for further information for providers. You can search N.W.H.I.C.'s F.A.Q.'s by category, or you can also browse all F.A.Q. titles in alphabetical order.
	Q.		What kind of information does Dr. Attico's page offer? [11/01]
	A.		Dr. Attico has collated material from A.C.O.G., C.D.C., A.M.A., A.C.O.E.M., A.A.P., N.I.H., and other sites to provide material on many maternal child health issues. His F.A.Q.s begin about one screen down on his main page.
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	Q.		Who should not get the smallpox vaccine?
	A.		The CDC suggests pregnant women should not get smallpox vaccine
	Q.		Smallpox Vaccination and Adverse Reactions
	A.		CDC Guidance for clinicians
	Q.		Are there rotations available for residents in the Indian Health Service/ Tribal / Urban (I/T/U) facilities that have OB/GYN physicians?
	A.		Yes, there are rotations available to OB/GYN and Family Practice residents. This is a list of centers that have OB/GYNs as of 8/8/02. (see also Medical Student rotations and contact lists) Also see the Data Tally to get an idea of the type of practice each center has. Some of the positions may be unfilled.
			OB/ GYN Rotations in I/T/Us (3rd and 4th year):
			Alaska Area Contact Alaska Native Medical Center (8 OB/GYNs, 1 Perinatologist) Daniel Szekely, 907-729-3188
			Billings Area Diane Jeanotte Browning (1.7 OB/GYNs) Crow (1 OB/GYN)
			Navajo Area Chinle (3.5 OB/GYNs) Jean Howe, 928-674-7018 Gallup Indian Medical Center (6 OB/GYNs) Martha Morgan 505 722 1000 Ft. Defiance (3 OB/GYNs) Shiprock, New Mexico (NNMC) (4 OB/GYNs) Jonathan Steinhart Tuba City (5 OB/GYNs) Amanda Lieb
			Phoenix Area Phoenix Indian Medical Centers Roy Teramoto
			*Other sites to contact include those listed below. Please note this list of I/T/U sites with OB/GYN positions includes an 'informal' list of OB/GYN total staff positions as of July 2000. Actual positions may vary.
			ANMC - 8 Sitka - 1 Pine Ridge - 1 Sante Fe - 1.5 Browning - 1.7 Crow - 1 Chinle - 2 Ft. Defiance - 2 GIMC - 6 Shiprock - 4.5 Tuba City - 5 Ada - 4 Claremore - 4 Lawton - 1 Talequah - 6 Talihina - 3 PIMC - 7 USUHS - 0 Belcourt - 0 Oklahoma City - 0 Harlem, MT - 0 Total - 59
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	Q.		Are there risk factors that suggest a provider should automatically move to treatment modalities to prevent postpartum hemorrhage?
	A.		There is not Level I data to support the automatic use of treatment modalities, other than the active management of labor, for a particular risk factor.
	Q.		Is rectal misoprostol the first line agent for treating postpartum hemorrhage, now?
	A.		No, rectal misoprostol is not the first agent for treating PPH, but there is more to the story.
	Q.		What are some of the issues with Latex Exposure in Pregancy?
	A.		Here is a review of the literature about Latex Exposure in Pregancy
	Q.		What is a sample set of Guidelines for Latex Exposure that could apply to Women's Health?
	A.		Here is a sample set of hospital-wide Guidelines for Latex Exposure that could apply to Women's Health.
	Q.		Are pharmacologic agents safe to use for smoking cessation in pregnancy?
	A.		Pharmacologic intervention should be the third choice after exhausting all behavioral approaches. See below. (WORD 270k)
	Q.		To what extent are IHS and tribal facilities Indian Health, Tribal, or urban (ITU) providing sterilization procedures in non-Native women with Native Partners?
	A.		Yes, non-Native partners can receive limited care in Indian Health System facilities
	Q.		What are the Benefits and Risks of Sterilization?
	A.		Please see the ACOG statement on the Benefits and Risks of Sterilization (WORD 28k)
	Q.		Have you ever wondered why your GDM or DM patient's blood sugars go really high only after certain meals?
	A.		Yes portion size is an issue, but it may have a lot to do with the Glycemic Index of the foods in that meal. (WORD 25k)
	Q.		What is the clinical significance of endometrial cells found on Pap smears?
	A.		It is only significant in women 40 years of age and then an endometrial biopsy should be performed. (WORD 33k)
	Q.		What resources are available to manage and/or prevent teenage pregnancy in the Indian Health system?
	A.		Here some examples from Alaska, (WORD 37k) Phoenix / Sells / and several other resources) (WORD 31k)
	Q.		Is a cesarean delivery indicated after a prior fourth degree laceration?
	A.		Yes, a decision analysis concluded only two to three elective cesarean deliveries would need to be performed to prevent one case of fecal incontinence (WORD 30k)
	Q.		Can we use Lispro in pregnancy?
	A.		Yes, we can use lispro in pregnancy. (WORD 30k)
	Q.		What medical services are available to American Indians and Alaska Natives, including eligibility, and services to members of federally recognized Indian tribes who may live near an Indian Health Service facility but are not enrolled in the tribe where the services are provided?
	A.		There are many requirements to qualify for those potential services. (WORD 34k)
	Note: nature and uses of material on this page
		The answers given on this Frequently Asked Questions page are prepared with the advice of the IHS OB/GYN Chief Clinical Consultant and her/his clinical Advisory Panel. Material for each topic has been developed by this Advisory Panel based on that person's clinical judgment and experience as an expert in that field. The answers to the Frequently Asked Questions do not represent official policy or recommendations of the Indian Health Service. Their publication should not be construed as excluding other acceptable methods of handling similar problems.

Feedback: Content coordinator Neil Murphy, MD

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This file last modified:   Thursday October 28, 2004  8:40 AM