OBG Management

Cervical cancer screening represents one of the great public health successes of the 20th Century. Two physician-scientists, George Papanicolaou, MD, PhD (1883–1962), and Harald zur Hausen, MD (1936–), made extraordinary contributions to the evolution of effective cervical cancer screening programs. Dr. Papanicolaou led development of the iconic Pap smear, creating techniques for collecting specimens and using cytologic techniques to identify cervical cancer and its precursors, and Dr. zur Hausen discovered the association of human papillomavirus (HPV) infection with cervical cancer.^1,2

Although it is but a distant memory, in the 1930s cervical and uterine cancer caused more deaths among women than breast, lung, or ovarian cancer. The successful deployment of Pap smear screening resulted in a decrease in cervical cancer rates in developed countries. Cervical cancer deaths remain common in many parts of the world, however. Cervical cancer screening programs can reduce cervical cancer incidence by greater than 80%.³ In the United States between 1973 and 2006, the invasive cervical cancer age-adjusted incidence rates dropped from 10.28 to 3.97 per 100,000 women.⁴

HPV causes cervical cancer

Dr. zur Hausen dedicated his career to identifying viral causes of human cancer. In his Nobel Laureate autobiography, he reported that during his 2-year rotating residency, he loved his obstetrics and gynecology experience, but found it “physically highly demanding” and decided to focus his career in microbiology and immunology.⁵ After proving that herpes simplex virus did not cause cervical cancer he began to explore the role of HPV in the disease process. He first identified HPV types 6 and 11 and showed that these agents caused genital warts. He then used low-stringency hybridization techniques to identify HPV types 16 and 18 in specimens of cervical cancer. Later, he and his colleagues proved that two HPV proteins, E6 and E7, interfere with the function of cell cycle control proteins p53 and retinoblastoma protein, resulting in dysregulated cell growth and cancer.² These findings permitted the development of both HPV vaccines and nucleic acid–based tests to identify high-risk oncogenic HPV (hrHPV) in cells and tissue specimens.

HPV vaccination

Dr. zur Hausen was an energetic and vocal advocate for the development and widescale deployment of HPV vaccines, including vaccination of males and females.⁶ Initially his ideas were rejected by the pharmaceutical industry, but eventually, with advances in virology and vaccine development, multiple companies pursued the development of HPV vaccines, the first cancer prevention vaccines. The best approach to cervical cancer prevention is intensive population-wide HPV vaccination of both boys and girls before exposure to the HPV virus. Beyond its beneficial effect on the incidence of cervical cancer, HPV vaccination also reduces the population incidence of anal, vulvar, and oropharyngeal cancer.⁷ Prevention of oropharyngeal cancer is especially important for men, supporting the recommendation for vaccination of all boys.⁸

Population-wide HPV vaccination will result in a lower prevalence of cervical cancer precursors and reduce the sensitivity of cytology, thereby making primary HPV screening more attractive.⁹ Based on one modelling study, universal HPV vaccination can reduce cervical cancer rates by greater than 50% over current levels, and introduction of primary HPV screening will reduce cervical cancer rates by an additional 20%.¹⁰ In an era of widespread vaccination for HPV, screening for cervical cancer should be intensified for nonvaccinated women.¹⁰

Read about Primary cervical cancer screening with cytology

Primary cervical cancer screening with cytology

Primary screening with cervical cytology alone remains an option supported by many authorities and professional society guidelines.¹¹ Most studies report that HPV testing has greater sensitivity than cervical cytology alone, especially for the detection of adenocarcinoma of the cervix.¹² In one Canadian study, 10,154 women were randomly assigned to HPV or cervical cytology testing. The sensitivity of HPV testing and cervical cytology for detecting cervical intraepithelial neoplasia grade 2 or 3 was 95% and 55%, respectively, with a specificity of 94% and 97%, respectively.¹³ When used together the sensitivity and specificity of cotesting was 100% and 93%, respectively, but resulted in an increased number of colposcopies, which may be costly and add stress for the patient. Many countries are beginning to move away from cervical cancer screening with cytology or cotesting to programs built upon a foundation of primary HPV testing.

Primary cervical cancer screening with HPV testing

The knowledge that hrHPV is a more sensitive test for cervical cancer and its precursors, as well as the relatively lower sensitivity of cytology, is the foundation for transitioning from primary screening with cervical cytology to primary screening with HPV testing. In the Netherlands¹⁴ and Australia^15,16 HPV testing with reflex cytology is the nationwide approach to cervical cancer screening. The basic components of the Dutch primary HPV screening program, as explained by Dr. Lai van Zulyan Mandres, are¹⁴:

1. Samples are collected by a general practitioner and sent to one of 5 central testing facilities for DNA testing for hrHPV.
2. If all previous samples tested negative, the screening occurs at ages 30, 35, 40, 50, and 60 years, a minimum of 5 screens per woman.
3. If there is a history of a previously positive hrHPV, the screening is intensified, with additional specimens collected at ages 45, 55, and 60 years.
4. If the sample is hrHPV negative, the patient continues screening at the standard intervals. No cytology testing is performed.
5. If the sample is hrHPV positive, reflex cytology is performed using the original collected sample. If the cytology shows no intraepithelial lesion or malignancy (NILM), another specimen is obtained for cytology within 6 months. If the second cytology specimen shows atypical squamous cells of undetermined significance (ASCUS) or a more worrisome cytology finding, the patient is sent for colposcopy. If two NILM cytology specimens have been obtained, the patient resumes primary hrHPV screening every 5 years.
6. If the specimen is hrHPV positive and cytology is ASCUS or more worrisome the patient is referred for colposcopy (FIGURE).¹⁴ The Dutch estimate that primary hrHPV screening will reduce the number of cervical cytology specimens by 90% annually.

Australia also has implemented nationwide primary HPV testing for cervical cancer screening. This change was implemented following a 10-year program of universal school-based vaccination of girls and boys, and biennial cytology screening for all women. The Australian screening program initiates hrHPV testing at age 25 years and thereafter every 5 years until age 74. If the hrHPV test is positive, reflex testing for HPV types 16 and 18 are performed on the original specimen along with cervical cytology. Women who test positive for HPV 16 or 18 are immediately referred for colposcopy. If the hrHPV test is positive and reflex testing for HPV 16 and 18 is negative, cervical cytology demonstrating ASCUS, low- or high-grade squamous intraepithelial lesions, or more worrisome results trigger a referral for colposcopy. The Australian program supports testing of self-collected vaginal samples for women who are underscreened or have never been screened.^15,16

Read about Pros and cons of switching approaches

Pros and cons of switching approaches

Deployment of new technology often yields benefits and challenges. A putative benefit of primary HPV screening is a reduction in health care costs without an increase in cervical cancer deaths. Another benefit of primary HPV screening is that it may enable self-collection of specimens for analysis, thereby increasing access to cervical cancer screening for underserved and marginalized populations of women who are not currently participating in cervical cancer screening programs.¹⁷ One challenge is that many women are unaware that hrHPV is the cause of most invasive cervical cancers. The detection of hrHPV in a woman in a long-term relationship who was previously negative for hrHPV may cause the emotions of surprise, fear, anxiety, and anger, thereby stressing the relationship.¹⁸

Another concern is that many women are worried about no longer receiving the familiar “Pap smear” cancer screening test in which they have tremendous faith. When Australia transitioned to primary HPV screening, more than 70,000 women signed a petition to “save women’s lives” by permitting continued access to the cervical cytology testing.¹⁹ Primary HPV testing may result in a transient increase in the number of women referred for colposcopy, potentially overwhelming the capacity of the health care system to deliver this vital service.^20,21 The HPV types that most often cause cervical cancer may vary among countries. For example, in Thailand, HPV 52 and 58 are frequently detected in women with high-grade squamous lesions, and including these subtypes in reflex genotyping may be of regional benefit.²²

Primary cervical cancer screening with HPV testing: When will it be used widely in the United States?

In contrast to the United States, the Netherlands is a small, densely populated country that has a highly integrated health system with centralized laboratory centers, a nationwide electronic health record, and clinicians organized to perform as an integrated team. These features ensure that all lifetime tests results are available in one record, that HPV testing is highly standardized, and that clinicians will follow a prescribed care pathway. The Netherlands’ health system is organized to support the successful transition, in a single step, to primary HPV testing. The United States is the third most populous country in the world, following China and India, with a diverse approach to health care, a highly mobile population, no single interoperable electronic health record, and minimal central control of clinical practice. The United States is not organized to make a “big bang” transition to primary HPV cervical cancer screening. It is likely that the introduction of primary HPV screening will occur first in highly integrated health systems that control the clinical, laboratory, and electronic records of a large population.

The results of the ATHENA study provide a clear clinical algorithm for implementing a primary HPV screening program for cervical cancer in the United States.^23–25 Samples are collected for hrHPV testing at a specified interval, 3 or 5 years, beginning at age 25 years. Women younger than age 25 years should be screened with cytology alone. Detection of hrHPV results in reflex viral typing for HPV 16 and 18. Women with samples positive for HPV 16 and 18 are immediately referred for colposcopy. Samples positive for hrHPV and negative for HPV 16 and 18 have reflex cytology testing performed on the original HPV specimen. If cytology testing reports NILM, repeat cotesting is performed in one year. If cytology testing reports ASCUS or a more concerning result, the woman is referred for colposcopy.

Malcolm Gladwell, in his book The Tipping Point, identified 3 processes that help push an innovative new approach from obscurity into widespread use.²⁶ First, authoritative voices that can catalyze change need to consistently communicate their shared vision for the future. Second, there must be a clear message that galvanizes the many to change their approach. Third, the historical context must be supportive of the change. Over the next decade we are likely to hit a tipping point and transition from cervical cancer screening that relies on cervical cytology to an approach that prioritizes hrHPV testing. When that change will occur in the United States is unclear. But our colleagues in other countries already have transitioned to primary hrHPV testing for cervical cancer screening.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Cervical cancer screening represents one of the great public health successes of the 20th Century. Two physician-scientists, George Papanicolaou, MD, PhD (1883–1962), and Harald zur Hausen, MD (1936–), made extraordinary contributions to the evolution of effective cervical cancer screening programs. Dr. Papanicolaou led development of the iconic Pap smear, creating techniques for collecting specimens and using cytologic techniques to identify cervical cancer and its precursors, and Dr. zur Hausen discovered the association of human papillomavirus (HPV) infection with cervical cancer.^1,2

Although it is but a distant memory, in the 1930s cervical and uterine cancer caused more deaths among women than breast, lung, or ovarian cancer. The successful deployment of Pap smear screening resulted in a decrease in cervical cancer rates in developed countries. Cervical cancer deaths remain common in many parts of the world, however. Cervical cancer screening programs can reduce cervical cancer incidence by greater than 80%.³ In the United States between 1973 and 2006, the invasive cervical cancer age-adjusted incidence rates dropped from 10.28 to 3.97 per 100,000 women.⁴

HPV causes cervical cancer

Dr. zur Hausen dedicated his career to identifying viral causes of human cancer. In his Nobel Laureate autobiography, he reported that during his 2-year rotating residency, he loved his obstetrics and gynecology experience, but found it “physically highly demanding” and decided to focus his career in microbiology and immunology.⁵ After proving that herpes simplex virus did not cause cervical cancer he began to explore the role of HPV in the disease process. He first identified HPV types 6 and 11 and showed that these agents caused genital warts. He then used low-stringency hybridization techniques to identify HPV types 16 and 18 in specimens of cervical cancer. Later, he and his colleagues proved that two HPV proteins, E6 and E7, interfere with the function of cell cycle control proteins p53 and retinoblastoma protein, resulting in dysregulated cell growth and cancer.² These findings permitted the development of both HPV vaccines and nucleic acid–based tests to identify high-risk oncogenic HPV (hrHPV) in cells and tissue specimens.

HPV vaccination

Dr. zur Hausen was an energetic and vocal advocate for the development and widescale deployment of HPV vaccines, including vaccination of males and females.⁶ Initially his ideas were rejected by the pharmaceutical industry, but eventually, with advances in virology and vaccine development, multiple companies pursued the development of HPV vaccines, the first cancer prevention vaccines. The best approach to cervical cancer prevention is intensive population-wide HPV vaccination of both boys and girls before exposure to the HPV virus. Beyond its beneficial effect on the incidence of cervical cancer, HPV vaccination also reduces the population incidence of anal, vulvar, and oropharyngeal cancer.⁷ Prevention of oropharyngeal cancer is especially important for men, supporting the recommendation for vaccination of all boys.⁸

Population-wide HPV vaccination will result in a lower prevalence of cervical cancer precursors and reduce the sensitivity of cytology, thereby making primary HPV screening more attractive.⁹ Based on one modelling study, universal HPV vaccination can reduce cervical cancer rates by greater than 50% over current levels, and introduction of primary HPV screening will reduce cervical cancer rates by an additional 20%.¹⁰ In an era of widespread vaccination for HPV, screening for cervical cancer should be intensified for nonvaccinated women.¹⁰

Read about Primary cervical cancer screening with cytology

Primary cervical cancer screening with cytology

Primary screening with cervical cytology alone remains an option supported by many authorities and professional society guidelines.¹¹ Most studies report that HPV testing has greater sensitivity than cervical cytology alone, especially for the detection of adenocarcinoma of the cervix.¹² In one Canadian study, 10,154 women were randomly assigned to HPV or cervical cytology testing. The sensitivity of HPV testing and cervical cytology for detecting cervical intraepithelial neoplasia grade 2 or 3 was 95% and 55%, respectively, with a specificity of 94% and 97%, respectively.¹³ When used together the sensitivity and specificity of cotesting was 100% and 93%, respectively, but resulted in an increased number of colposcopies, which may be costly and add stress for the patient. Many countries are beginning to move away from cervical cancer screening with cytology or cotesting to programs built upon a foundation of primary HPV testing.

Primary cervical cancer screening with HPV testing

The knowledge that hrHPV is a more sensitive test for cervical cancer and its precursors, as well as the relatively lower sensitivity of cytology, is the foundation for transitioning from primary screening with cervical cytology to primary screening with HPV testing. In the Netherlands¹⁴ and Australia^15,16 HPV testing with reflex cytology is the nationwide approach to cervical cancer screening. The basic components of the Dutch primary HPV screening program, as explained by Dr. Lai van Zulyan Mandres, are¹⁴:

1. Samples are collected by a general practitioner and sent to one of 5 central testing facilities for DNA testing for hrHPV.
2. If all previous samples tested negative, the screening occurs at ages 30, 35, 40, 50, and 60 years, a minimum of 5 screens per woman.
3. If there is a history of a previously positive hrHPV, the screening is intensified, with additional specimens collected at ages 45, 55, and 60 years.
4. If the sample is hrHPV negative, the patient continues screening at the standard intervals. No cytology testing is performed.
5. If the sample is hrHPV positive, reflex cytology is performed using the original collected sample. If the cytology shows no intraepithelial lesion or malignancy (NILM), another specimen is obtained for cytology within 6 months. If the second cytology specimen shows atypical squamous cells of undetermined significance (ASCUS) or a more worrisome cytology finding, the patient is sent for colposcopy. If two NILM cytology specimens have been obtained, the patient resumes primary hrHPV screening every 5 years.
6. If the specimen is hrHPV positive and cytology is ASCUS or more worrisome the patient is referred for colposcopy (FIGURE).¹⁴ The Dutch estimate that primary hrHPV screening will reduce the number of cervical cytology specimens by 90% annually.

Australia also has implemented nationwide primary HPV testing for cervical cancer screening. This change was implemented following a 10-year program of universal school-based vaccination of girls and boys, and biennial cytology screening for all women. The Australian screening program initiates hrHPV testing at age 25 years and thereafter every 5 years until age 74. If the hrHPV test is positive, reflex testing for HPV types 16 and 18 are performed on the original specimen along with cervical cytology. Women who test positive for HPV 16 or 18 are immediately referred for colposcopy. If the hrHPV test is positive and reflex testing for HPV 16 and 18 is negative, cervical cytology demonstrating ASCUS, low- or high-grade squamous intraepithelial lesions, or more worrisome results trigger a referral for colposcopy. The Australian program supports testing of self-collected vaginal samples for women who are underscreened or have never been screened.^15,16

Read about Pros and cons of switching approaches

Pros and cons of switching approaches

Deployment of new technology often yields benefits and challenges. A putative benefit of primary HPV screening is a reduction in health care costs without an increase in cervical cancer deaths. Another benefit of primary HPV screening is that it may enable self-collection of specimens for analysis, thereby increasing access to cervical cancer screening for underserved and marginalized populations of women who are not currently participating in cervical cancer screening programs.¹⁷ One challenge is that many women are unaware that hrHPV is the cause of most invasive cervical cancers. The detection of hrHPV in a woman in a long-term relationship who was previously negative for hrHPV may cause the emotions of surprise, fear, anxiety, and anger, thereby stressing the relationship.¹⁸

Another concern is that many women are worried about no longer receiving the familiar “Pap smear” cancer screening test in which they have tremendous faith. When Australia transitioned to primary HPV screening, more than 70,000 women signed a petition to “save women’s lives” by permitting continued access to the cervical cytology testing.¹⁹ Primary HPV testing may result in a transient increase in the number of women referred for colposcopy, potentially overwhelming the capacity of the health care system to deliver this vital service.^20,21 The HPV types that most often cause cervical cancer may vary among countries. For example, in Thailand, HPV 52 and 58 are frequently detected in women with high-grade squamous lesions, and including these subtypes in reflex genotyping may be of regional benefit.²²

Primary cervical cancer screening with HPV testing: When will it be used widely in the United States?

In contrast to the United States, the Netherlands is a small, densely populated country that has a highly integrated health system with centralized laboratory centers, a nationwide electronic health record, and clinicians organized to perform as an integrated team. These features ensure that all lifetime tests results are available in one record, that HPV testing is highly standardized, and that clinicians will follow a prescribed care pathway. The Netherlands’ health system is organized to support the successful transition, in a single step, to primary HPV testing. The United States is the third most populous country in the world, following China and India, with a diverse approach to health care, a highly mobile population, no single interoperable electronic health record, and minimal central control of clinical practice. The United States is not organized to make a “big bang” transition to primary HPV cervical cancer screening. It is likely that the introduction of primary HPV screening will occur first in highly integrated health systems that control the clinical, laboratory, and electronic records of a large population.

The results of the ATHENA study provide a clear clinical algorithm for implementing a primary HPV screening program for cervical cancer in the United States.^23–25 Samples are collected for hrHPV testing at a specified interval, 3 or 5 years, beginning at age 25 years. Women younger than age 25 years should be screened with cytology alone. Detection of hrHPV results in reflex viral typing for HPV 16 and 18. Women with samples positive for HPV 16 and 18 are immediately referred for colposcopy. Samples positive for hrHPV and negative for HPV 16 and 18 have reflex cytology testing performed on the original HPV specimen. If cytology testing reports NILM, repeat cotesting is performed in one year. If cytology testing reports ASCUS or a more concerning result, the woman is referred for colposcopy.

Malcolm Gladwell, in his book The Tipping Point, identified 3 processes that help push an innovative new approach from obscurity into widespread use.²⁶ First, authoritative voices that can catalyze change need to consistently communicate their shared vision for the future. Second, there must be a clear message that galvanizes the many to change their approach. Third, the historical context must be supportive of the change. Over the next decade we are likely to hit a tipping point and transition from cervical cancer screening that relies on cervical cytology to an approach that prioritizes hrHPV testing. When that change will occur in the United States is unclear. But our colleagues in other countries already have transitioned to primary hrHPV testing for cervical cancer screening.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Cervical cancer screening represents one of the great public health successes of the 20th Century. Two physician-scientists, George Papanicolaou, MD, PhD (1883–1962), and Harald zur Hausen, MD (1936–), made extraordinary contributions to the evolution of effective cervical cancer screening programs. Dr. Papanicolaou led development of the iconic Pap smear, creating techniques for collecting specimens and using cytologic techniques to identify cervical cancer and its precursors, and Dr. zur Hausen discovered the association of human papillomavirus (HPV) infection with cervical cancer.^1,2

Although it is but a distant memory, in the 1930s cervical and uterine cancer caused more deaths among women than breast, lung, or ovarian cancer. The successful deployment of Pap smear screening resulted in a decrease in cervical cancer rates in developed countries. Cervical cancer deaths remain common in many parts of the world, however. Cervical cancer screening programs can reduce cervical cancer incidence by greater than 80%.³ In the United States between 1973 and 2006, the invasive cervical cancer age-adjusted incidence rates dropped from 10.28 to 3.97 per 100,000 women.⁴

HPV causes cervical cancer

Dr. zur Hausen dedicated his career to identifying viral causes of human cancer. In his Nobel Laureate autobiography, he reported that during his 2-year rotating residency, he loved his obstetrics and gynecology experience, but found it “physically highly demanding” and decided to focus his career in microbiology and immunology.⁵ After proving that herpes simplex virus did not cause cervical cancer he began to explore the role of HPV in the disease process. He first identified HPV types 6 and 11 and showed that these agents caused genital warts. He then used low-stringency hybridization techniques to identify HPV types 16 and 18 in specimens of cervical cancer. Later, he and his colleagues proved that two HPV proteins, E6 and E7, interfere with the function of cell cycle control proteins p53 and retinoblastoma protein, resulting in dysregulated cell growth and cancer.² These findings permitted the development of both HPV vaccines and nucleic acid–based tests to identify high-risk oncogenic HPV (hrHPV) in cells and tissue specimens.

HPV vaccination

Dr. zur Hausen was an energetic and vocal advocate for the development and widescale deployment of HPV vaccines, including vaccination of males and females.⁶ Initially his ideas were rejected by the pharmaceutical industry, but eventually, with advances in virology and vaccine development, multiple companies pursued the development of HPV vaccines, the first cancer prevention vaccines. The best approach to cervical cancer prevention is intensive population-wide HPV vaccination of both boys and girls before exposure to the HPV virus. Beyond its beneficial effect on the incidence of cervical cancer, HPV vaccination also reduces the population incidence of anal, vulvar, and oropharyngeal cancer.⁷ Prevention of oropharyngeal cancer is especially important for men, supporting the recommendation for vaccination of all boys.⁸

Population-wide HPV vaccination will result in a lower prevalence of cervical cancer precursors and reduce the sensitivity of cytology, thereby making primary HPV screening more attractive.⁹ Based on one modelling study, universal HPV vaccination can reduce cervical cancer rates by greater than 50% over current levels, and introduction of primary HPV screening will reduce cervical cancer rates by an additional 20%.¹⁰ In an era of widespread vaccination for HPV, screening for cervical cancer should be intensified for nonvaccinated women.¹⁰

Read about Primary cervical cancer screening with cytology

Primary cervical cancer screening with cytology

Primary screening with cervical cytology alone remains an option supported by many authorities and professional society guidelines.¹¹ Most studies report that HPV testing has greater sensitivity than cervical cytology alone, especially for the detection of adenocarcinoma of the cervix.¹² In one Canadian study, 10,154 women were randomly assigned to HPV or cervical cytology testing. The sensitivity of HPV testing and cervical cytology for detecting cervical intraepithelial neoplasia grade 2 or 3 was 95% and 55%, respectively, with a specificity of 94% and 97%, respectively.¹³ When used together the sensitivity and specificity of cotesting was 100% and 93%, respectively, but resulted in an increased number of colposcopies, which may be costly and add stress for the patient. Many countries are beginning to move away from cervical cancer screening with cytology or cotesting to programs built upon a foundation of primary HPV testing.

Primary cervical cancer screening with HPV testing

The knowledge that hrHPV is a more sensitive test for cervical cancer and its precursors, as well as the relatively lower sensitivity of cytology, is the foundation for transitioning from primary screening with cervical cytology to primary screening with HPV testing. In the Netherlands¹⁴ and Australia^15,16 HPV testing with reflex cytology is the nationwide approach to cervical cancer screening. The basic components of the Dutch primary HPV screening program, as explained by Dr. Lai van Zulyan Mandres, are¹⁴:

1. Samples are collected by a general practitioner and sent to one of 5 central testing facilities for DNA testing for hrHPV.
2. If all previous samples tested negative, the screening occurs at ages 30, 35, 40, 50, and 60 years, a minimum of 5 screens per woman.
3. If there is a history of a previously positive hrHPV, the screening is intensified, with additional specimens collected at ages 45, 55, and 60 years.
4. If the sample is hrHPV negative, the patient continues screening at the standard intervals. No cytology testing is performed.
5. If the sample is hrHPV positive, reflex cytology is performed using the original collected sample. If the cytology shows no intraepithelial lesion or malignancy (NILM), another specimen is obtained for cytology within 6 months. If the second cytology specimen shows atypical squamous cells of undetermined significance (ASCUS) or a more worrisome cytology finding, the patient is sent for colposcopy. If two NILM cytology specimens have been obtained, the patient resumes primary hrHPV screening every 5 years.
6. If the specimen is hrHPV positive and cytology is ASCUS or more worrisome the patient is referred for colposcopy (FIGURE).¹⁴ The Dutch estimate that primary hrHPV screening will reduce the number of cervical cytology specimens by 90% annually.

Australia also has implemented nationwide primary HPV testing for cervical cancer screening. This change was implemented following a 10-year program of universal school-based vaccination of girls and boys, and biennial cytology screening for all women. The Australian screening program initiates hrHPV testing at age 25 years and thereafter every 5 years until age 74. If the hrHPV test is positive, reflex testing for HPV types 16 and 18 are performed on the original specimen along with cervical cytology. Women who test positive for HPV 16 or 18 are immediately referred for colposcopy. If the hrHPV test is positive and reflex testing for HPV 16 and 18 is negative, cervical cytology demonstrating ASCUS, low- or high-grade squamous intraepithelial lesions, or more worrisome results trigger a referral for colposcopy. The Australian program supports testing of self-collected vaginal samples for women who are underscreened or have never been screened.^15,16

Read about Pros and cons of switching approaches

Pros and cons of switching approaches

Deployment of new technology often yields benefits and challenges. A putative benefit of primary HPV screening is a reduction in health care costs without an increase in cervical cancer deaths. Another benefit of primary HPV screening is that it may enable self-collection of specimens for analysis, thereby increasing access to cervical cancer screening for underserved and marginalized populations of women who are not currently participating in cervical cancer screening programs.¹⁷ One challenge is that many women are unaware that hrHPV is the cause of most invasive cervical cancers. The detection of hrHPV in a woman in a long-term relationship who was previously negative for hrHPV may cause the emotions of surprise, fear, anxiety, and anger, thereby stressing the relationship.¹⁸

Another concern is that many women are worried about no longer receiving the familiar “Pap smear” cancer screening test in which they have tremendous faith. When Australia transitioned to primary HPV screening, more than 70,000 women signed a petition to “save women’s lives” by permitting continued access to the cervical cytology testing.¹⁹ Primary HPV testing may result in a transient increase in the number of women referred for colposcopy, potentially overwhelming the capacity of the health care system to deliver this vital service.^20,21 The HPV types that most often cause cervical cancer may vary among countries. For example, in Thailand, HPV 52 and 58 are frequently detected in women with high-grade squamous lesions, and including these subtypes in reflex genotyping may be of regional benefit.²²

Primary cervical cancer screening with HPV testing: When will it be used widely in the United States?

In contrast to the United States, the Netherlands is a small, densely populated country that has a highly integrated health system with centralized laboratory centers, a nationwide electronic health record, and clinicians organized to perform as an integrated team. These features ensure that all lifetime tests results are available in one record, that HPV testing is highly standardized, and that clinicians will follow a prescribed care pathway. The Netherlands’ health system is organized to support the successful transition, in a single step, to primary HPV testing. The United States is the third most populous country in the world, following China and India, with a diverse approach to health care, a highly mobile population, no single interoperable electronic health record, and minimal central control of clinical practice. The United States is not organized to make a “big bang” transition to primary HPV cervical cancer screening. It is likely that the introduction of primary HPV screening will occur first in highly integrated health systems that control the clinical, laboratory, and electronic records of a large population.

The results of the ATHENA study provide a clear clinical algorithm for implementing a primary HPV screening program for cervical cancer in the United States.^23–25 Samples are collected for hrHPV testing at a specified interval, 3 or 5 years, beginning at age 25 years. Women younger than age 25 years should be screened with cytology alone. Detection of hrHPV results in reflex viral typing for HPV 16 and 18. Women with samples positive for HPV 16 and 18 are immediately referred for colposcopy. Samples positive for hrHPV and negative for HPV 16 and 18 have reflex cytology testing performed on the original HPV specimen. If cytology testing reports NILM, repeat cotesting is performed in one year. If cytology testing reports ASCUS or a more concerning result, the woman is referred for colposcopy.

Malcolm Gladwell, in his book The Tipping Point, identified 3 processes that help push an innovative new approach from obscurity into widespread use.²⁶ First, authoritative voices that can catalyze change need to consistently communicate their shared vision for the future. Second, there must be a clear message that galvanizes the many to change their approach. Third, the historical context must be supportive of the change. Over the next decade we are likely to hit a tipping point and transition from cervical cancer screening that relies on cervical cytology to an approach that prioritizes hrHPV testing. When that change will occur in the United States is unclear. But our colleagues in other countries already have transitioned to primary hrHPV testing for cervical cancer screening.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Citation: Middleton P, Shepherd E, Crowther CA. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev. 2018;5:CD004945.

Citation: Middleton P, Shepherd E, Crowther CA. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev. 2018;5:CD004945.

Citation: Middleton P, Shepherd E, Crowther CA. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev. 2018;5:CD004945.

Click Here to Read Supplement.

Bacterial vaginosis (BV) affects women worldwide and recurrent BV can be a frustrating condition for both patients and providers. In this new supplement, expert Khady Diouf, MD, discusses her treatment approach and suggested counseling for patients with recurrent BV.

Click Here to Read the Supplement. 

Click Here to Read Supplement.

Bacterial vaginosis (BV) affects women worldwide and recurrent BV can be a frustrating condition for both patients and providers. In this new supplement, expert Khady Diouf, MD, discusses her treatment approach and suggested counseling for patients with recurrent BV.

Click Here to Read the Supplement. 

Click Here to Read Supplement.

Bacterial vaginosis (BV) affects women worldwide and recurrent BV can be a frustrating condition for both patients and providers. In this new supplement, expert Khady Diouf, MD, discusses her treatment approach and suggested counseling for patients with recurrent BV.

Click Here to Read the Supplement. 

St. Joseph Hospital in Orange, California, like most institutions performing deliveries in 2016, started releasing metrics internally before subsequently releasing them to the public. Data for the first 9 months of 2016 were released. As I am often an outlier, I was gratified to see that I ranked 1st in the vaginal birth after cesarean delivery (VBAC) rate at 36.8% and 4th at 15.9% for my cesarean delivery (CD) rate in the low-risk nulliparous term singleton vertex (NTSV) population.

I have been an avid proponent of VBAC since 1984 when one of the fathers of modern obstetric care, Edward J. Quilligan, MD, presented the benefits and safety of VBAC at our institution.

Experiences that may alter a reported rate

I list here a few circumstances of a CD on maternal request:

• A primagravida with a 10-cm nonphysiologic, nonmalignant ovarian cyst at term elects a primary CD with ovarian cystectomy.
• A woman who is concerned about pelvic organ prolapse and urinary incontinence later in life requests a CD. After all, normal babies do not weigh 5 and 6 lb anymore.
• An elderly primagravida with an in vitro fertilization pregnancy requests a CD.

Should these experiences adversely affect a physician’s statistics? Personally, I don’t think so. Is the morbidity and mortality from a CD really all that much higher than a normal spontaneous vaginal delivery (NSVD)? Granted, the cost is more. But are we really helping all our patients by insisting on a NSVD? Thousands of people have medically indicated and elective surgery in the United States each day.

Of course, these data points depend on the denominator (the number of deliveries attributed to each ObGyn). Those with a contradictory opinion will say that this evens out over time. I dispute that claim. This might be closer to being true for the ObGyn with the highest number, say, 134 in the NTSV denominator versus someone with a low number, such as 4. For VBAC, the denominator range at our institution was 1 to 115 cases.

Rethinking my position

Two recent cases have caused me to rethink my position on using VBAC and CD rates to evaluate ObGyns.

Uterine rupture

A 31-year-old G3P1 woman at 39 6/7 weeks’ gestation was admitted in early labor for a VBAC. She had undergone a CD with her first baby because of fetal intolerance to labor. Her prenatal course was complicated by white-coat hypertension, but I monitored her blood pressure at home and it had been normal. She took aspirin 81 mg during the pregnancy. The fetus was not reactive to a nonstress test on the day of admission.

That evening, amniotomy results showed clear fluid. I placed an intrauterine pressure catheter. The patient’s labor progressed well during the night, she received an epidural anesthetic, and labor was augmented with intravenous oxytocin. She progressed to complete dilation. I was notified of severe, prolonged, variable fetal heart-rate decelerations.

The Laborist who evaluated the patient recommended an emergency CD. I came immediately to Labor and Delivery and performed a CD with delivery of a 7 lb 4 oz infant whose Apgars were 2, 5, and 8 at 1, 5, and 10 minutes, respectively. Arterial cord blood gas tests revealed: pH, 6.94; pCO₂, 95 mm Hg; pO₂, 19.9 mm Hg; HCO₃, 19.9 mmol/L; and base excess (BE), –14.4 mmol/L. Venous cord blood gas tests revealed: pH, 7.25; pCO₂, 45 mm Hg; pO₂, 35 mm Hg; HCO₃, 19.2 mmol/L; BE, −8.0 mmol/L. The cord blood gases revealed that the baby was becoming compromised, but was delivered in time to avoid complications.

After advocating and performing many successful VBACs for 33 years, this was my first uterine rupture.

The uterus had ruptured in the lower segment from the mid-portion extending inferolaterally on the right side and was hemorrhaging. I successfully repaired the rupture. Maternal quantitative blood loss was 1,020 mL.

The baby initially was apneic and was limp. He required continuous positive airway pressure (CPAP) and positive pressure ventilation in the operating room. The baby was transferred to the neonatal intensive care unit (NICU), recovered well, and was discharged home with the mother on the 4th day of life.

Commentary: Why should this necessary, emergency CD count against me on my core measure rate? Although I have advocated for VBACs for 33 years, perhaps they aren’t so safe. After this experience, I do not ever want to have to deal with a ruptured uterus, a compromised baby, and maternal hemorrhage again.

Read Dr. Kanofsky’s solution to using this metric.

Depressed baby

A 24-year-old G1P0 woman at 39 weeks’ gestation was admitted for induction of labor because of mild pregnancy-induced hypertension. Her prenatal course was complicated by Class A1 gestational diabetes mellitus, which was untreated due to compliance issues, Group B streptococcus, and cholelithiasis. Clinically, I suspected she was going to have a large (9 lb) baby. An ultrasound to estimate fetal weight at 37 2/7 weeks’ gestation showed the fetus at 3.937 kg. I was concerned, but, because the mother was 5 ft 5 in tall and weighed 282 lbs, I thought it was reasonable for her to attempt a NSVD.

Induction and labor progressed normally. Her labor curve decelerated at an anterior lip, but subsequently stage 2 progressed normally and lasted 2 hrs. Her temperature was elevated in stage 2 to 100.0⁰F. The fetal heart rate tracings were reassuring.

Immediately after delivery of the fetal vertex, a turtleneck sign was seen and shoulder dystocia occurred. A Wood’s maneuver was performed in both directions, the nurse applied suprapubic pressure, and the infant was delivered. A loose nuchal cord x2 was reduced. The infant was apneic and had no tone. She was taken to the warmer, given oxygen, suctioned, and stimulated until the NICU team arrived. Her Apgar scores were 2, 5, and 9 at 1, 5, and 10 minutes, respectively. The birthweight was 9 lb 0 oz.

A depressed baby of this magnitude was certainly not expected from the FHR tracing or the shoulder dystocia. Venous cord gas evaluation revealed pH, 7.16; pCO₂, 57 mm Hg; pO₂, 17 mm Hg; HCO₃, 20.2 mmol/L; and BE, –19.1 mmol/L.

The baby recovered quickly in the labor and delivery recovery room, went to the NICU on CPAP, subsequently transitioned to room air, and was discharged on the 4th day of life with her mother.

Commentary: Did I do the best I could for this mother and baby? In hindsight, I should have performed a CD because of my concerns for a large fetus. The “retrospectoscope” always makes cases more clear! Note that, if I had performed an elective CD for fetal macrosomia, it would have counted against me on this metric. Prior to labor, if I thought an elective CD was the right approach to this patient, and was providing the best care I could for this mother and fetus, why should it count against me?

Is there a solution?

With my newfound concerns, it is my opinion that VBAC and CD/NTSV rates may not be the correct things to use as quality metric measures without some additional qualifying information.

Better metrics of quality and safety that might be more helpful to measure include:

• Prophylactic oxytocin after delivery of the baby’s anterior shoulder
• Since “6 is the new 4,” in order to increase the NTSV rate, we could measure¹:
  • patients admitted before active labor
  • patients receiving an epidural before active labor.
• Since NTSV is a goal, measure the number of patients in an advanced stage of labor whose labor pattern has become dysfunctional, no interventions are taken, and who subsequently deliver by primary CD.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

St. Joseph Hospital in Orange, California, like most institutions performing deliveries in 2016, started releasing metrics internally before subsequently releasing them to the public. Data for the first 9 months of 2016 were released. As I am often an outlier, I was gratified to see that I ranked 1st in the vaginal birth after cesarean delivery (VBAC) rate at 36.8% and 4th at 15.9% for my cesarean delivery (CD) rate in the low-risk nulliparous term singleton vertex (NTSV) population.

I have been an avid proponent of VBAC since 1984 when one of the fathers of modern obstetric care, Edward J. Quilligan, MD, presented the benefits and safety of VBAC at our institution.

Experiences that may alter a reported rate

I list here a few circumstances of a CD on maternal request:

• A primagravida with a 10-cm nonphysiologic, nonmalignant ovarian cyst at term elects a primary CD with ovarian cystectomy.
• A woman who is concerned about pelvic organ prolapse and urinary incontinence later in life requests a CD. After all, normal babies do not weigh 5 and 6 lb anymore.
• An elderly primagravida with an in vitro fertilization pregnancy requests a CD.

Should these experiences adversely affect a physician’s statistics? Personally, I don’t think so. Is the morbidity and mortality from a CD really all that much higher than a normal spontaneous vaginal delivery (NSVD)? Granted, the cost is more. But are we really helping all our patients by insisting on a NSVD? Thousands of people have medically indicated and elective surgery in the United States each day.

Of course, these data points depend on the denominator (the number of deliveries attributed to each ObGyn). Those with a contradictory opinion will say that this evens out over time. I dispute that claim. This might be closer to being true for the ObGyn with the highest number, say, 134 in the NTSV denominator versus someone with a low number, such as 4. For VBAC, the denominator range at our institution was 1 to 115 cases.

Rethinking my position

Two recent cases have caused me to rethink my position on using VBAC and CD rates to evaluate ObGyns.

Uterine rupture

A 31-year-old G3P1 woman at 39 6/7 weeks’ gestation was admitted in early labor for a VBAC. She had undergone a CD with her first baby because of fetal intolerance to labor. Her prenatal course was complicated by white-coat hypertension, but I monitored her blood pressure at home and it had been normal. She took aspirin 81 mg during the pregnancy. The fetus was not reactive to a nonstress test on the day of admission.

That evening, amniotomy results showed clear fluid. I placed an intrauterine pressure catheter. The patient’s labor progressed well during the night, she received an epidural anesthetic, and labor was augmented with intravenous oxytocin. She progressed to complete dilation. I was notified of severe, prolonged, variable fetal heart-rate decelerations.

The Laborist who evaluated the patient recommended an emergency CD. I came immediately to Labor and Delivery and performed a CD with delivery of a 7 lb 4 oz infant whose Apgars were 2, 5, and 8 at 1, 5, and 10 minutes, respectively. Arterial cord blood gas tests revealed: pH, 6.94; pCO₂, 95 mm Hg; pO₂, 19.9 mm Hg; HCO₃, 19.9 mmol/L; and base excess (BE), –14.4 mmol/L. Venous cord blood gas tests revealed: pH, 7.25; pCO₂, 45 mm Hg; pO₂, 35 mm Hg; HCO₃, 19.2 mmol/L; BE, −8.0 mmol/L. The cord blood gases revealed that the baby was becoming compromised, but was delivered in time to avoid complications.

After advocating and performing many successful VBACs for 33 years, this was my first uterine rupture.

The uterus had ruptured in the lower segment from the mid-portion extending inferolaterally on the right side and was hemorrhaging. I successfully repaired the rupture. Maternal quantitative blood loss was 1,020 mL.

The baby initially was apneic and was limp. He required continuous positive airway pressure (CPAP) and positive pressure ventilation in the operating room. The baby was transferred to the neonatal intensive care unit (NICU), recovered well, and was discharged home with the mother on the 4th day of life.

Commentary: Why should this necessary, emergency CD count against me on my core measure rate? Although I have advocated for VBACs for 33 years, perhaps they aren’t so safe. After this experience, I do not ever want to have to deal with a ruptured uterus, a compromised baby, and maternal hemorrhage again.

Read Dr. Kanofsky’s solution to using this metric.

Depressed baby

A 24-year-old G1P0 woman at 39 weeks’ gestation was admitted for induction of labor because of mild pregnancy-induced hypertension. Her prenatal course was complicated by Class A1 gestational diabetes mellitus, which was untreated due to compliance issues, Group B streptococcus, and cholelithiasis. Clinically, I suspected she was going to have a large (9 lb) baby. An ultrasound to estimate fetal weight at 37 2/7 weeks’ gestation showed the fetus at 3.937 kg. I was concerned, but, because the mother was 5 ft 5 in tall and weighed 282 lbs, I thought it was reasonable for her to attempt a NSVD.

Induction and labor progressed normally. Her labor curve decelerated at an anterior lip, but subsequently stage 2 progressed normally and lasted 2 hrs. Her temperature was elevated in stage 2 to 100.0⁰F. The fetal heart rate tracings were reassuring.

Immediately after delivery of the fetal vertex, a turtleneck sign was seen and shoulder dystocia occurred. A Wood’s maneuver was performed in both directions, the nurse applied suprapubic pressure, and the infant was delivered. A loose nuchal cord x2 was reduced. The infant was apneic and had no tone. She was taken to the warmer, given oxygen, suctioned, and stimulated until the NICU team arrived. Her Apgar scores were 2, 5, and 9 at 1, 5, and 10 minutes, respectively. The birthweight was 9 lb 0 oz.

A depressed baby of this magnitude was certainly not expected from the FHR tracing or the shoulder dystocia. Venous cord gas evaluation revealed pH, 7.16; pCO₂, 57 mm Hg; pO₂, 17 mm Hg; HCO₃, 20.2 mmol/L; and BE, –19.1 mmol/L.

The baby recovered quickly in the labor and delivery recovery room, went to the NICU on CPAP, subsequently transitioned to room air, and was discharged on the 4th day of life with her mother.

Commentary: Did I do the best I could for this mother and baby? In hindsight, I should have performed a CD because of my concerns for a large fetus. The “retrospectoscope” always makes cases more clear! Note that, if I had performed an elective CD for fetal macrosomia, it would have counted against me on this metric. Prior to labor, if I thought an elective CD was the right approach to this patient, and was providing the best care I could for this mother and fetus, why should it count against me?

Is there a solution?

With my newfound concerns, it is my opinion that VBAC and CD/NTSV rates may not be the correct things to use as quality metric measures without some additional qualifying information.

Better metrics of quality and safety that might be more helpful to measure include:

• Prophylactic oxytocin after delivery of the baby’s anterior shoulder
• Since “6 is the new 4,” in order to increase the NTSV rate, we could measure¹:
  • patients admitted before active labor
  • patients receiving an epidural before active labor.
• Since NTSV is a goal, measure the number of patients in an advanced stage of labor whose labor pattern has become dysfunctional, no interventions are taken, and who subsequently deliver by primary CD.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

St. Joseph Hospital in Orange, California, like most institutions performing deliveries in 2016, started releasing metrics internally before subsequently releasing them to the public. Data for the first 9 months of 2016 were released. As I am often an outlier, I was gratified to see that I ranked 1st in the vaginal birth after cesarean delivery (VBAC) rate at 36.8% and 4th at 15.9% for my cesarean delivery (CD) rate in the low-risk nulliparous term singleton vertex (NTSV) population.

I have been an avid proponent of VBAC since 1984 when one of the fathers of modern obstetric care, Edward J. Quilligan, MD, presented the benefits and safety of VBAC at our institution.

Experiences that may alter a reported rate

I list here a few circumstances of a CD on maternal request:

• A primagravida with a 10-cm nonphysiologic, nonmalignant ovarian cyst at term elects a primary CD with ovarian cystectomy.
• A woman who is concerned about pelvic organ prolapse and urinary incontinence later in life requests a CD. After all, normal babies do not weigh 5 and 6 lb anymore.
• An elderly primagravida with an in vitro fertilization pregnancy requests a CD.

Should these experiences adversely affect a physician’s statistics? Personally, I don’t think so. Is the morbidity and mortality from a CD really all that much higher than a normal spontaneous vaginal delivery (NSVD)? Granted, the cost is more. But are we really helping all our patients by insisting on a NSVD? Thousands of people have medically indicated and elective surgery in the United States each day.

Of course, these data points depend on the denominator (the number of deliveries attributed to each ObGyn). Those with a contradictory opinion will say that this evens out over time. I dispute that claim. This might be closer to being true for the ObGyn with the highest number, say, 134 in the NTSV denominator versus someone with a low number, such as 4. For VBAC, the denominator range at our institution was 1 to 115 cases.

Rethinking my position

Two recent cases have caused me to rethink my position on using VBAC and CD rates to evaluate ObGyns.

Uterine rupture

A 31-year-old G3P1 woman at 39 6/7 weeks’ gestation was admitted in early labor for a VBAC. She had undergone a CD with her first baby because of fetal intolerance to labor. Her prenatal course was complicated by white-coat hypertension, but I monitored her blood pressure at home and it had been normal. She took aspirin 81 mg during the pregnancy. The fetus was not reactive to a nonstress test on the day of admission.

That evening, amniotomy results showed clear fluid. I placed an intrauterine pressure catheter. The patient’s labor progressed well during the night, she received an epidural anesthetic, and labor was augmented with intravenous oxytocin. She progressed to complete dilation. I was notified of severe, prolonged, variable fetal heart-rate decelerations.

The Laborist who evaluated the patient recommended an emergency CD. I came immediately to Labor and Delivery and performed a CD with delivery of a 7 lb 4 oz infant whose Apgars were 2, 5, and 8 at 1, 5, and 10 minutes, respectively. Arterial cord blood gas tests revealed: pH, 6.94; pCO₂, 95 mm Hg; pO₂, 19.9 mm Hg; HCO₃, 19.9 mmol/L; and base excess (BE), –14.4 mmol/L. Venous cord blood gas tests revealed: pH, 7.25; pCO₂, 45 mm Hg; pO₂, 35 mm Hg; HCO₃, 19.2 mmol/L; BE, −8.0 mmol/L. The cord blood gases revealed that the baby was becoming compromised, but was delivered in time to avoid complications.

After advocating and performing many successful VBACs for 33 years, this was my first uterine rupture.

The uterus had ruptured in the lower segment from the mid-portion extending inferolaterally on the right side and was hemorrhaging. I successfully repaired the rupture. Maternal quantitative blood loss was 1,020 mL.

The baby initially was apneic and was limp. He required continuous positive airway pressure (CPAP) and positive pressure ventilation in the operating room. The baby was transferred to the neonatal intensive care unit (NICU), recovered well, and was discharged home with the mother on the 4th day of life.

Commentary: Why should this necessary, emergency CD count against me on my core measure rate? Although I have advocated for VBACs for 33 years, perhaps they aren’t so safe. After this experience, I do not ever want to have to deal with a ruptured uterus, a compromised baby, and maternal hemorrhage again.

Read Dr. Kanofsky’s solution to using this metric.

Depressed baby

A 24-year-old G1P0 woman at 39 weeks’ gestation was admitted for induction of labor because of mild pregnancy-induced hypertension. Her prenatal course was complicated by Class A1 gestational diabetes mellitus, which was untreated due to compliance issues, Group B streptococcus, and cholelithiasis. Clinically, I suspected she was going to have a large (9 lb) baby. An ultrasound to estimate fetal weight at 37 2/7 weeks’ gestation showed the fetus at 3.937 kg. I was concerned, but, because the mother was 5 ft 5 in tall and weighed 282 lbs, I thought it was reasonable for her to attempt a NSVD.

Induction and labor progressed normally. Her labor curve decelerated at an anterior lip, but subsequently stage 2 progressed normally and lasted 2 hrs. Her temperature was elevated in stage 2 to 100.0⁰F. The fetal heart rate tracings were reassuring.

Immediately after delivery of the fetal vertex, a turtleneck sign was seen and shoulder dystocia occurred. A Wood’s maneuver was performed in both directions, the nurse applied suprapubic pressure, and the infant was delivered. A loose nuchal cord x2 was reduced. The infant was apneic and had no tone. She was taken to the warmer, given oxygen, suctioned, and stimulated until the NICU team arrived. Her Apgar scores were 2, 5, and 9 at 1, 5, and 10 minutes, respectively. The birthweight was 9 lb 0 oz.

A depressed baby of this magnitude was certainly not expected from the FHR tracing or the shoulder dystocia. Venous cord gas evaluation revealed pH, 7.16; pCO₂, 57 mm Hg; pO₂, 17 mm Hg; HCO₃, 20.2 mmol/L; and BE, –19.1 mmol/L.

The baby recovered quickly in the labor and delivery recovery room, went to the NICU on CPAP, subsequently transitioned to room air, and was discharged on the 4th day of life with her mother.

Commentary: Did I do the best I could for this mother and baby? In hindsight, I should have performed a CD because of my concerns for a large fetus. The “retrospectoscope” always makes cases more clear! Note that, if I had performed an elective CD for fetal macrosomia, it would have counted against me on this metric. Prior to labor, if I thought an elective CD was the right approach to this patient, and was providing the best care I could for this mother and fetus, why should it count against me?

Is there a solution?

With my newfound concerns, it is my opinion that VBAC and CD/NTSV rates may not be the correct things to use as quality metric measures without some additional qualifying information.

Better metrics of quality and safety that might be more helpful to measure include:

• Prophylactic oxytocin after delivery of the baby’s anterior shoulder
• Since “6 is the new 4,” in order to increase the NTSV rate, we could measure¹:
  • patients admitted before active labor
  • patients receiving an epidural before active labor.
• Since NTSV is a goal, measure the number of patients in an advanced stage of labor whose labor pattern has become dysfunctional, no interventions are taken, and who subsequently deliver by primary CD.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

On March 20, 2018, the United States Supreme Court heard arguments in National Institute of Family and Life Advocates (NIFLA) v Becerra. The Court is expected to issue its decision in June and the results could shape legislation around the country. Here is what you need to know.

The background

There are more than 4,000 Crisis Pregnancy Centers (CPCs) around the country, vastly out numbering abortion clinics.¹ The services offered and the make-up of the staff who work in CPCs can vary. CPCs can be licensed to provide medical services, including urine pregnancy tests and ultrasounds, and may have clinicians on staff. Alternatively, other CPCs may be volunteer-run and provide counseling as well as supplies for women, including diapers and baby formula. Within CPCs, however, women are often given misleading and medically inaccurate information about abortion and contraception and are not provided with appropriate or timely referrals if they seek abortion care.

To ensure women have access to comprehensive reproductive health services, California passed the Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act in 2015. This act requires licensed clinics — which may include some CPCs — to notify patients that they may access state-funded prenatal care, family planning, and abortion services through a county health department phone number. Additionally, facilities that provide pregnancy testing and ultrasounds are required to notify clients if they do not employ a licensed medical professional.

In response, NIFLA sued the state of California, alleging that the law violated their freedom of speech by forcing them to communicate about abortion with women who visited their centers.

The case

NIFLA argues that California is violating CPCs’ freedom of speech by requiring them to post statements about medications and medical procedures they strongly oppose. According to NIFLA, if California wants to promote state-funded options, they should publicize that information and not require the CPCs to post it.

The State of California enacted the law to ensure that California women have timely access to all available health care services, including contraception and abortion, and are made aware that the clinic they visit does not offer licensed medical care. Women may not know of their publicly funded options and, without this law, CPCs could withhold that information or provide misleading information, delaying or preventing women from accessing care.

Possible outcomes

If the Supreme Court strikes down California’s FACT Act as a violation of the First Amendment, CPCs in that state would not be required to provide information about free or low-cost prenatal care, contraception, and abortion services or post, if appropriate, that they were an unlicensed facility. However, such a ruling could call into question laws in 18 other states that require doctors to give women false information about possible side effects and complications of abortion during the consent process. This case could provide precedent for physicians to assert that such requirements violate their freedom of speech.

If the Supreme Court upholds California’s FACT Act, this would likely lead to similar laws around the country requiring CPCs to disclose the availability of affordable contraception and abortion services in their state and the lack of licensed medical providers.

For more information, check out https://www.supremecourt.gov/

Acknowledgement
Special thanks to Sara Needleman Kline, Esq, Chief Legal Officer, American College of Obstetricians and Gynecologists, for aid with this article.

‌

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

On March 20, 2018, the United States Supreme Court heard arguments in National Institute of Family and Life Advocates (NIFLA) v Becerra. The Court is expected to issue its decision in June and the results could shape legislation around the country. Here is what you need to know.

The background

There are more than 4,000 Crisis Pregnancy Centers (CPCs) around the country, vastly out numbering abortion clinics.¹ The services offered and the make-up of the staff who work in CPCs can vary. CPCs can be licensed to provide medical services, including urine pregnancy tests and ultrasounds, and may have clinicians on staff. Alternatively, other CPCs may be volunteer-run and provide counseling as well as supplies for women, including diapers and baby formula. Within CPCs, however, women are often given misleading and medically inaccurate information about abortion and contraception and are not provided with appropriate or timely referrals if they seek abortion care.

To ensure women have access to comprehensive reproductive health services, California passed the Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act in 2015. This act requires licensed clinics — which may include some CPCs — to notify patients that they may access state-funded prenatal care, family planning, and abortion services through a county health department phone number. Additionally, facilities that provide pregnancy testing and ultrasounds are required to notify clients if they do not employ a licensed medical professional.

In response, NIFLA sued the state of California, alleging that the law violated their freedom of speech by forcing them to communicate about abortion with women who visited their centers.

The case

NIFLA argues that California is violating CPCs’ freedom of speech by requiring them to post statements about medications and medical procedures they strongly oppose. According to NIFLA, if California wants to promote state-funded options, they should publicize that information and not require the CPCs to post it.

The State of California enacted the law to ensure that California women have timely access to all available health care services, including contraception and abortion, and are made aware that the clinic they visit does not offer licensed medical care. Women may not know of their publicly funded options and, without this law, CPCs could withhold that information or provide misleading information, delaying or preventing women from accessing care.

Possible outcomes

If the Supreme Court strikes down California’s FACT Act as a violation of the First Amendment, CPCs in that state would not be required to provide information about free or low-cost prenatal care, contraception, and abortion services or post, if appropriate, that they were an unlicensed facility. However, such a ruling could call into question laws in 18 other states that require doctors to give women false information about possible side effects and complications of abortion during the consent process. This case could provide precedent for physicians to assert that such requirements violate their freedom of speech.

If the Supreme Court upholds California’s FACT Act, this would likely lead to similar laws around the country requiring CPCs to disclose the availability of affordable contraception and abortion services in their state and the lack of licensed medical providers.

For more information, check out https://www.supremecourt.gov/

Acknowledgement
Special thanks to Sara Needleman Kline, Esq, Chief Legal Officer, American College of Obstetricians and Gynecologists, for aid with this article.

‌

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

On March 20, 2018, the United States Supreme Court heard arguments in National Institute of Family and Life Advocates (NIFLA) v Becerra. The Court is expected to issue its decision in June and the results could shape legislation around the country. Here is what you need to know.

The background

There are more than 4,000 Crisis Pregnancy Centers (CPCs) around the country, vastly out numbering abortion clinics.¹ The services offered and the make-up of the staff who work in CPCs can vary. CPCs can be licensed to provide medical services, including urine pregnancy tests and ultrasounds, and may have clinicians on staff. Alternatively, other CPCs may be volunteer-run and provide counseling as well as supplies for women, including diapers and baby formula. Within CPCs, however, women are often given misleading and medically inaccurate information about abortion and contraception and are not provided with appropriate or timely referrals if they seek abortion care.

To ensure women have access to comprehensive reproductive health services, California passed the Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act in 2015. This act requires licensed clinics — which may include some CPCs — to notify patients that they may access state-funded prenatal care, family planning, and abortion services through a county health department phone number. Additionally, facilities that provide pregnancy testing and ultrasounds are required to notify clients if they do not employ a licensed medical professional.

In response, NIFLA sued the state of California, alleging that the law violated their freedom of speech by forcing them to communicate about abortion with women who visited their centers.

The case

NIFLA argues that California is violating CPCs’ freedom of speech by requiring them to post statements about medications and medical procedures they strongly oppose. According to NIFLA, if California wants to promote state-funded options, they should publicize that information and not require the CPCs to post it.

The State of California enacted the law to ensure that California women have timely access to all available health care services, including contraception and abortion, and are made aware that the clinic they visit does not offer licensed medical care. Women may not know of their publicly funded options and, without this law, CPCs could withhold that information or provide misleading information, delaying or preventing women from accessing care.

Possible outcomes

If the Supreme Court strikes down California’s FACT Act as a violation of the First Amendment, CPCs in that state would not be required to provide information about free or low-cost prenatal care, contraception, and abortion services or post, if appropriate, that they were an unlicensed facility. However, such a ruling could call into question laws in 18 other states that require doctors to give women false information about possible side effects and complications of abortion during the consent process. This case could provide precedent for physicians to assert that such requirements violate their freedom of speech.

If the Supreme Court upholds California’s FACT Act, this would likely lead to similar laws around the country requiring CPCs to disclose the availability of affordable contraception and abortion services in their state and the lack of licensed medical providers.

For more information, check out https://www.supremecourt.gov/

Acknowledgement
Special thanks to Sara Needleman Kline, Esq, Chief Legal Officer, American College of Obstetricians and Gynecologists, for aid with this article.

‌

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Citation: Fejzo MS, Sazonova OV, Fah Sathirapongsasuti J, et al. Placenta and appetite genes GDF15 and IGFBP7 are associated with hyperemesis gravidarum. Nature Communications. 2018;9:1178.

Citation: Fejzo MS, Sazonova OV, Fah Sathirapongsasuti J, et al. Placenta and appetite genes GDF15 and IGFBP7 are associated with hyperemesis gravidarum. Nature Communications. 2018;9:1178.

Citation: Fejzo MS, Sazonova OV, Fah Sathirapongsasuti J, et al. Placenta and appetite genes GDF15 and IGFBP7 are associated with hyperemesis gravidarum. Nature Communications. 2018;9:1178.