MCH Frequently Asked Questions
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Links to B FAQs
- Bacterial vaginosis, alternative therapy
- Barriers to contraception: None
- Beta strep prevention
- Biochemical Markers for Osteoporosis
- Biofeedback: strengthen the pelvic musculature to help control urinary incontinence. [12/01]
- Birthing center regulations
- Bloodless medicine in OB/GYN
- Bone loss: with Depo Provera (depot medroxyprogesterone acetate)
- Breakfast Tolerance Tests
- Breast cancer: See Cancer, breast below
- Breast Cancer risk assessment
- Bilateral tubal ligation: [Also see more info on this site's Family Planning page]
- Bilateral Tubal ligation: Benefits and Risks of Sterilization, A C O G
- Bilateral Tubal ligation: Reports of forced sterilization not substantiated
- Bilateral tubal ligation: Sterilization Electronic Code of Federal Regulations
- Consent: missing or untimely witness signature. [8/01]
- Consent: patient's age (#2). [8/01]
- Consent: patient in-hospital. [8/01]
- Consent: time interval, and ligation after delivery. [8/01]
- Consent: time interval, and patient's age. [8/01]
- Consent: timing and full term. [8/01]
- Consent: What is a 'premature delivery' on the BTL form?. [8/01]
- Essure, hysterscopic coil procedure
- Is the provider obligated to perform a BTL on a 21 y.o.?: Is the provider obligated? [8/01]
- Is there such a thing as post-tubal ligation syndrome? [10/01]
- Menstrual irregularities - are they caused by tubal ligations? [4-02]
- Ovarian cancer risk reduced with BTL
- Reversals: available in I.H.S./Tribal /Urban facilities? [11/01]
- Sterilization: Electronic Code of Federal Regulations
- Sterilization procedures for non-Native partners
- Breast exam, clinical
B FAQs
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. 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 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. (WORD 47k)
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. 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.
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.
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.
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
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.
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. 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. Does tubal ligation reduce the risk of ovarian cancer?
A. Yes, tubal ligation has reduced the risk of ovarian cancer in several case control studies. (WORD 39k)
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. 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. 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. My patient with bacterial vaginosis is allergic to metronidazole. What else can I use?
A. First make sure it is bacterial vaginosis, and then consider one of these other regimens. (WORD 86k)
Q. What does the Essure sterilization procedure entail?
A. A coil is placed in the fallopian tube / is 99.8 % effective. It needs a post-op HSG. See details (WORD 49k)
Q. Are birthing center regulations less restrictive than hospitals?
A. Birthing centers in Indian Country have the same regulations as Level I hospitals. (WORD 85k)
Q. Should I withhold contraception from a woman who is not ‘current’ on her pap? (WORD - 110K)
A. No, there should be no barriers to the use of FDA approved contraception
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