What is your primary guideline for managing obstetrics and gynecology (OB/GYN) cases?

Primary Guidelines for Obstetrics and Gynecology Management

The American College of Obstetricians and Gynecologists (ACOG) serves as the primary guideline authority for managing obstetrics and gynecology cases, with their clinical guidance accessible through www.acog.org or by contacting the ACOG Resource Center. 1

Accessing ACOG Guidelines

ACOG provides comprehensive clinical guidance through multiple document formats including practice bulletins, committee opinions, and obstetric care consensus statements. 1 These guidelines are regularly reviewed and updated, with the most current versions available on their official website. 1

Digital access options include mobile-friendly formats for smartphones and tablets, allowing offline reading, content bookmarking, and real-time updates. 1 Always verify you are using the most recent guideline version, as ACOG frequently updates recommendations based on emerging evidence. 1

Core Clinical Areas Covered by ACOG Guidelines

Obstetric Anesthesia Management

For obstetric anesthesia, the American Society of Anesthesiologists (ASA) provides complementary guidelines that work alongside ACOG recommendations. 2

Key pre-anesthetic requirements include:

• Focused history examining maternal health, anesthetic history, obstetric history, baseline blood pressure, and airway/heart/lung examination 2
• Back examination when neuraxial anesthesia is planned 2
• Fasting for solids: 6-8 hours for elective cesarean delivery depending on fat content 2
• Laboring patients with aspiration risk factors (morbid obesity, diabetes, difficult airway) or those at increased operative delivery risk should avoid solid foods entirely 2

Blood work requirements:

• Routine blood cross-match is unnecessary for healthy, uncomplicated parturients 2
• Blood type and screen decisions should be based on maternal history and anticipated hemorrhagic complications (e.g., placenta accreta with placenta previa and previous uterine surgery) 2
• Platelet count ordering should be individualized based on patient history (e.g., preeclampsia with severe features), physical examination, and clinical signs 2

Cesarean Delivery Guidelines

The Enhanced Recovery After Surgery (ERAS) Society provides specific intraoperative care recommendations for cesarean delivery. 2

Neonatal management at delivery:

• Delayed cord clamping for at least 1 minute at term delivery (strong recommendation) 2
• Delayed cord clamping for at least 30 seconds at preterm delivery (strong recommendation) 2
• Maintain neonatal body temperature between 36.5°C and 37.5°C after birth through admission and stabilization 2
• Avoid routine airway suctioning or gastric aspiration; use only for obstructive airway symptoms 2
• Use room air for neonatal supplementation rather than oxygen, which may cause harm 2
• Immediate neonatal resuscitation capacity is mandatory in all cesarean delivery settings 2

Airway Management in Obstetrics

The Obstetric Anaesthetists' Association and Difficult Airway Society provide specific guidance for difficult and failed intubation. 2

Pre-theatre preparation essentials:

• Every woman undergoing obstetric surgery requires documented airway assessment predicting difficulty with tracheal intubation, mask ventilation, supraglottic airway device insertion, and front-of-neck access 2
• Remove oral piercings before any anesthesia to prevent trauma, bleeding, and aspiration risk 2
• Women with predicted significant airway difficulties requiring alternatives to rapid sequence induction need antenatal referral for specific anesthetic and obstetric management planning 2

Gastric preparation protocols:

• Elective cesarean: H2-receptor antagonist the night before and two hours before anesthesia, with or without prokinetic drug, plus sodium citrate immediately before induction 2
• During labor: High-risk women should receive oral H2-receptor antagonists every 6 hours, avoid eating but may have clear isotonic drinks 2
• If anesthesia required for delivery: Administer IV H2-receptor antagonist if not already given, plus sodium citrate 2

Intrauterine fetal resuscitation should be employed before emergency operative delivery, with urgency re-evaluated after operating theatre transfer. 2

Reproductive Health Management

The American College of Rheumatology 2020 guideline addresses reproductive health in patients with rheumatic and musculoskeletal diseases, but principles apply broadly. 2

Guiding principles include:

• Use safe and effective contraception to prevent unplanned pregnancy 2
• Pre-pregnancy counseling encouraging conception during disease quiescence while receiving pregnancy-compatible medications 2
• Ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues 2

Abnormal Uterine Bleeding Management

The levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/day) is the most effective first-line treatment for abnormal uterine bleeding, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 3

Treatment algorithms by clinical scenario:

• Acute heavy bleeding: Low-dose combined oral contraceptives for 10-20 days provide rapid control 3
• Acute heavy bleeding adjunct: NSAIDs for 5-7 days reduce bleeding volume and can be combined with hormonal methods 3
• Chronic heavy menstrual bleeding: LNG-IUD remains superior to all oral options 3
• NSAIDs alone reduce menstrual bleeding by 30-50% and are effective for both unscheduled spotting and heavy bleeding 3

Mandatory pre-treatment evaluation:

• Rule out pregnancy (beta-hCG test required) 3
• Exclude structural pathology (fibroids, polyps, adenomyosis) 3
• Assess for endometrial hyperplasia or malignancy (endometrial biopsy if indicated) 3
• Check thyroid disease (TSH measurement) and hyperprolactinemia (prolactin level) 3
• Evaluate for coagulopathy, medication interactions, and sexually transmitted infections 3
• Use PALM-COEIN classification system to systematically identify structural versus nonstructural causes 3

If bleeding persists after initial hormonal treatment, further investigation with imaging or hysteroscopy is mandatory. 3 Endometrial biopsy is preferred over dilation and curettage due to being less invasive, safer, and lower cost. 3

Patient Safety Framework

ACOG has maintained a long-standing commitment to quality and patient safety, codifying objectives that should be adopted by obstetrician-gynecologists in their practices. 4 The discipline has been a leader in quality and safety for decades, with obstetrics representing the leading cause for hospital admissions (over 4 million births annually). 5

Key safety initiatives include:

• Development of reliable and reproducible quality control measures with tracking systems 6
• National closed claim reviews to understand and address the most important safety and liability areas 6
• Creation of a culture of safety by incorporating safety education into all training levels 6
• Effective communication between clinical staff, patients, and social support providers to reduce preventable adverse events 7

Common Pitfalls to Avoid

• Missing supplementary materials available only online and not in print versions of ACOG guidelines 1
• Failing to check for the most recent guideline version, as ACOG regularly updates recommendations 1
• Subdermal contraceptive implants may cause irregular bleeding, especially during the first year; enhanced counseling about expected bleeding patterns reduces discontinuation 3
• Always alert pathologists when submitting specimens from patients treated with selective progesterone receptor modulators due to progesterone-associated endometrial changes 3
• Underestimating physiological changes of pregnancy that complicate airway management 8
• Delaying anesthesia consultation until an emergency arises, which limits options and increases risks 8