Sherry Boschert

SAN FRANCISCO — Selectively screening patients for substance abuse in pregnancy is ineffective, Dr. Allison S. Bryant said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

“Everyone should be screened. If you don't want to be screening everybody, then you probably should be screening no one,” said Dr. Bryant, a perinatologist who is also an assistant adjunct professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences.

Universal screening doesn't take much time—perhaps 30 seconds for a woman who is not using alcohol or drugs during pregnancy or 5–10 minutes for patients who are actively using substances, she said.

The first step in screening is to ask every patient about substance use. “It provides an opportunity for a conversation with every patient,” Dr. Bryant said.

Think of potential substance abuse when you see a medical history of frequent hospitalizations, unusual trauma or infections, frequent falls or bruises, chronic mental illness, or diabetes, cirrhosis, hepatitis, or pancreatitis, Dr. Bryant advised.

“I can't tell you how many times during my fellowship I did consults on patients admitted with raging pancreatitis in pregnancy, and they'd had million-dollar work-ups, and nowhere in the medical charts was there documentation about whether they reported using alcohol during pregnancy,” she added.

Some patient behaviors may flag the need for more aggressive screening—behaviors like slurred speech and/or unsteady gait, agitation, disorientation, an appearance of euphoria, or prescription drug-seeking.

Physical clues that should trigger more aggressive screening include tremors, multiple needle marks, inflamed or eroded nasal mucosa, alterations in vital signs, and the dilated or constricted pupils typical of heroin or amphetamine use.

More aggressive screening usually means administering a urine toxicology test, best used after a positive interview screen.

Under most state laws, physicians must obtain consent for a maternal toxicology screen, whereas toxicology screening of infants can be performed without maternal consent.

“Sometimes I see patients who had screening due to acute labor or partial premature rupture of membranes. In our particular setting, I don't think that's warranted,” she said.

“Patients who present with an abruption, on the other hand, probably all should be consented for a tox screen for cocaine use.”

Among pregnant women, approximately 15% abuse alcohol, 20% smoke cigarettes, 2% abuse marijuana, 0.3% abuse cocaine, and 0.7% use other illicit drugs, according to a national survey from 1996 to 1998.

Studies suggest that treatment of substance abuse is as effective as treating other chronic diseases, Dr. Bryant said.

Studies suggest that treatment of substance abuse is as effective as treating other chronic diseases. DR. BRYANT

SAN FRANCISCO — Selectively screening patients for substance abuse in pregnancy is ineffective, Dr. Allison S. Bryant said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

“Everyone should be screened. If you don't want to be screening everybody, then you probably should be screening no one,” said Dr. Bryant, a perinatologist who is also an assistant adjunct professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences.

Universal screening doesn't take much time—perhaps 30 seconds for a woman who is not using alcohol or drugs during pregnancy or 5–10 minutes for patients who are actively using substances, she said.

The first step in screening is to ask every patient about substance use. “It provides an opportunity for a conversation with every patient,” Dr. Bryant said.

Think of potential substance abuse when you see a medical history of frequent hospitalizations, unusual trauma or infections, frequent falls or bruises, chronic mental illness, or diabetes, cirrhosis, hepatitis, or pancreatitis, Dr. Bryant advised.

“I can't tell you how many times during my fellowship I did consults on patients admitted with raging pancreatitis in pregnancy, and they'd had million-dollar work-ups, and nowhere in the medical charts was there documentation about whether they reported using alcohol during pregnancy,” she added.

Some patient behaviors may flag the need for more aggressive screening—behaviors like slurred speech and/or unsteady gait, agitation, disorientation, an appearance of euphoria, or prescription drug-seeking.

Physical clues that should trigger more aggressive screening include tremors, multiple needle marks, inflamed or eroded nasal mucosa, alterations in vital signs, and the dilated or constricted pupils typical of heroin or amphetamine use.

More aggressive screening usually means administering a urine toxicology test, best used after a positive interview screen.

Under most state laws, physicians must obtain consent for a maternal toxicology screen, whereas toxicology screening of infants can be performed without maternal consent.

“Sometimes I see patients who had screening due to acute labor or partial premature rupture of membranes. In our particular setting, I don't think that's warranted,” she said.

“Patients who present with an abruption, on the other hand, probably all should be consented for a tox screen for cocaine use.”

Among pregnant women, approximately 15% abuse alcohol, 20% smoke cigarettes, 2% abuse marijuana, 0.3% abuse cocaine, and 0.7% use other illicit drugs, according to a national survey from 1996 to 1998.

Studies suggest that treatment of substance abuse is as effective as treating other chronic diseases, Dr. Bryant said.

Studies suggest that treatment of substance abuse is as effective as treating other chronic diseases. DR. BRYANT

SAN FRANCISCO — Selectively screening patients for substance abuse in pregnancy is ineffective, Dr. Allison S. Bryant said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

“Everyone should be screened. If you don't want to be screening everybody, then you probably should be screening no one,” said Dr. Bryant, a perinatologist who is also an assistant adjunct professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences.

Universal screening doesn't take much time—perhaps 30 seconds for a woman who is not using alcohol or drugs during pregnancy or 5–10 minutes for patients who are actively using substances, she said.

The first step in screening is to ask every patient about substance use. “It provides an opportunity for a conversation with every patient,” Dr. Bryant said.

Think of potential substance abuse when you see a medical history of frequent hospitalizations, unusual trauma or infections, frequent falls or bruises, chronic mental illness, or diabetes, cirrhosis, hepatitis, or pancreatitis, Dr. Bryant advised.

“I can't tell you how many times during my fellowship I did consults on patients admitted with raging pancreatitis in pregnancy, and they'd had million-dollar work-ups, and nowhere in the medical charts was there documentation about whether they reported using alcohol during pregnancy,” she added.

Some patient behaviors may flag the need for more aggressive screening—behaviors like slurred speech and/or unsteady gait, agitation, disorientation, an appearance of euphoria, or prescription drug-seeking.

Physical clues that should trigger more aggressive screening include tremors, multiple needle marks, inflamed or eroded nasal mucosa, alterations in vital signs, and the dilated or constricted pupils typical of heroin or amphetamine use.

More aggressive screening usually means administering a urine toxicology test, best used after a positive interview screen.

Under most state laws, physicians must obtain consent for a maternal toxicology screen, whereas toxicology screening of infants can be performed without maternal consent.

“Sometimes I see patients who had screening due to acute labor or partial premature rupture of membranes. In our particular setting, I don't think that's warranted,” she said.

“Patients who present with an abruption, on the other hand, probably all should be consented for a tox screen for cocaine use.”

Among pregnant women, approximately 15% abuse alcohol, 20% smoke cigarettes, 2% abuse marijuana, 0.3% abuse cocaine, and 0.7% use other illicit drugs, according to a national survey from 1996 to 1998.

Studies suggest that treatment of substance abuse is as effective as treating other chronic diseases, Dr. Bryant said.

Studies suggest that treatment of substance abuse is as effective as treating other chronic diseases. DR. BRYANT

SAN FRANCISCO — When it comes to relieving labor pain, there's nothing like an epidural.

Beyond that, however, some nonpharmacologic strategies compete well with opioids, the next most common pharmacologic option for treating labor pain, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Nonpharmacologic techniques should be considered for women who arrive at the labor-and-delivery room too late to get an epidural, women who want to try an unmedicated birth, or women who want to incorporate nonpharmacologic options as stepping-stones to possible use of pain-relieving medications later in labor, she said.

Epidurals or spinal analgesia were received by 76% of 1,573 women who were delivering singletons in U.S. hospitals and who were surveyed for the 2006 Listening to Mothers II Survey Report.

Among those who received epidurals or spinal analgesia, 81% said that they were very helpful, according to the report compiled for the nonprofit organization Childbirth Connection by Eugene R. Declerq, Ph.D., professor of maternal and child health at Boston University, and associates.

Besides epidurals, “the interesting thing is that immersion in a tub or hands-on techniques came up a little bit above the effectiveness of narcotics” for relieving labor pain, although they were less often used than narcotics, said Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the University of California.

“Many of the other nonpharmacologic techniques are not far behind” in effectiveness, she added. (See box.)

Overall, 69% of women used one or more nonpharmacologic techniques to relieve discomfort in labor.

Ms. Bishop reviewed the evidence for some nonpharmacologic strategies that had been identified as effective by one or more of three published reviews of the literature.

▸ Continuous labor support. This category is a catchall of steps taken usually by a doula, midwife, or nurse.

Continuous labor support typically includes touch, massage, application of cold or heat, and other strategies for physical comfort plus emotional support, a steady flow of information to the mother, and facilitation of communication between the mother and the health care providers.

A 2003 Cochrane meta-analysis of 15 randomized, controlled studies with 12,791 women found significant decreases in use of regional analgesia, forceps, or cesarean births and increased likelihood of vaginal birth with continuous labor support.

Women reported 33% less dissatisfaction with labor regardless of pain, compared with unsupported control groups.

A separate 2003 review of studies found less striking results, but concluded that all women should have support during labor and that starting support earlier in labor rather than later maximizes the benefits.

▸ Water immersion. Putting a laboring woman in a warm bath was associated with decreased pain (particularly during the first 30 minutes) and decreased use of epidurals, according to a 2004 Cochrane meta-analysis of eight randomized, controlled trials with 2,939 women.

Two studies found that tub immersion during early labor (before 5-cm dilation) may prolong labor. Individual studies found fewer fetal malpositions in tub-immersed women and no increased rate of infection in those who rupture membranes while in the tub.

“There should be no barriers to women getting into a tub due to misconceptions regarding infection” risk, Ms. Bishop said.

▸ Hypnosis. A very old strategy recently repackaged under the term “hypnobirthing,” hypnotic pain relief techniques carry the disadvantages of time and costs needed for training, and the lengthy time needed to implement this into practice, she said.

A 2006 Cochrane review of five trials with 749 women found suggestions of effectiveness in decreasing the need for pharmacologic pain relief and increasing vaginal deliveries and patient satisfaction with pain relief. No adverse outcomes were seen, but hypnosis generally is contraindicated in women with a history of psychosis, she added.

▸ Intradermal water injections. Four randomized, controlled studies found significant reductions in severe back pain for 45–90 minutes but no decrease in requests for medication for abdominal pain using this strategy.

Intradermal water injections involve injecting 0.05–0.1 mL of sterile water into four locations on the lower back—two over each posterior superior iliac spine, and two located 3 cm below and 1 cm medial to the posterior superior iliac spine.

Injections seem to be more effective earlier rather than later in labor. The injections are painful for 20–30 seconds, and the counterirritation of the injection pain may be a mechanism of action for relieving the back pain, she speculated.

▸ Acupuncture. Although the overall evidence that acupuncture can reduce labor pain is encouraging, “it's really difficult to find an acupuncturist willing to be on call to come into labor” rooms, Ms. Bishop said. Midwives in some European countries can take a course to provide acupuncture to patients, something that should be tried in the United States, she added.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — When it comes to relieving labor pain, there's nothing like an epidural.

Beyond that, however, some nonpharmacologic strategies compete well with opioids, the next most common pharmacologic option for treating labor pain, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Nonpharmacologic techniques should be considered for women who arrive at the labor-and-delivery room too late to get an epidural, women who want to try an unmedicated birth, or women who want to incorporate nonpharmacologic options as stepping-stones to possible use of pain-relieving medications later in labor, she said.

Epidurals or spinal analgesia were received by 76% of 1,573 women who were delivering singletons in U.S. hospitals and who were surveyed for the 2006 Listening to Mothers II Survey Report.

Among those who received epidurals or spinal analgesia, 81% said that they were very helpful, according to the report compiled for the nonprofit organization Childbirth Connection by Eugene R. Declerq, Ph.D., professor of maternal and child health at Boston University, and associates.

Besides epidurals, “the interesting thing is that immersion in a tub or hands-on techniques came up a little bit above the effectiveness of narcotics” for relieving labor pain, although they were less often used than narcotics, said Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the University of California.

“Many of the other nonpharmacologic techniques are not far behind” in effectiveness, she added. (See box.)

Overall, 69% of women used one or more nonpharmacologic techniques to relieve discomfort in labor.

Ms. Bishop reviewed the evidence for some nonpharmacologic strategies that had been identified as effective by one or more of three published reviews of the literature.

▸ Continuous labor support. This category is a catchall of steps taken usually by a doula, midwife, or nurse.

Continuous labor support typically includes touch, massage, application of cold or heat, and other strategies for physical comfort plus emotional support, a steady flow of information to the mother, and facilitation of communication between the mother and the health care providers.

A 2003 Cochrane meta-analysis of 15 randomized, controlled studies with 12,791 women found significant decreases in use of regional analgesia, forceps, or cesarean births and increased likelihood of vaginal birth with continuous labor support.

Women reported 33% less dissatisfaction with labor regardless of pain, compared with unsupported control groups.

A separate 2003 review of studies found less striking results, but concluded that all women should have support during labor and that starting support earlier in labor rather than later maximizes the benefits.

▸ Water immersion. Putting a laboring woman in a warm bath was associated with decreased pain (particularly during the first 30 minutes) and decreased use of epidurals, according to a 2004 Cochrane meta-analysis of eight randomized, controlled trials with 2,939 women.

Two studies found that tub immersion during early labor (before 5-cm dilation) may prolong labor. Individual studies found fewer fetal malpositions in tub-immersed women and no increased rate of infection in those who rupture membranes while in the tub.

“There should be no barriers to women getting into a tub due to misconceptions regarding infection” risk, Ms. Bishop said.

▸ Hypnosis. A very old strategy recently repackaged under the term “hypnobirthing,” hypnotic pain relief techniques carry the disadvantages of time and costs needed for training, and the lengthy time needed to implement this into practice, she said.

A 2006 Cochrane review of five trials with 749 women found suggestions of effectiveness in decreasing the need for pharmacologic pain relief and increasing vaginal deliveries and patient satisfaction with pain relief. No adverse outcomes were seen, but hypnosis generally is contraindicated in women with a history of psychosis, she added.

▸ Intradermal water injections. Four randomized, controlled studies found significant reductions in severe back pain for 45–90 minutes but no decrease in requests for medication for abdominal pain using this strategy.

Intradermal water injections involve injecting 0.05–0.1 mL of sterile water into four locations on the lower back—two over each posterior superior iliac spine, and two located 3 cm below and 1 cm medial to the posterior superior iliac spine.

Injections seem to be more effective earlier rather than later in labor. The injections are painful for 20–30 seconds, and the counterirritation of the injection pain may be a mechanism of action for relieving the back pain, she speculated.

▸ Acupuncture. Although the overall evidence that acupuncture can reduce labor pain is encouraging, “it's really difficult to find an acupuncturist willing to be on call to come into labor” rooms, Ms. Bishop said. Midwives in some European countries can take a course to provide acupuncture to patients, something that should be tried in the United States, she added.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — When it comes to relieving labor pain, there's nothing like an epidural.

Beyond that, however, some nonpharmacologic strategies compete well with opioids, the next most common pharmacologic option for treating labor pain, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Nonpharmacologic techniques should be considered for women who arrive at the labor-and-delivery room too late to get an epidural, women who want to try an unmedicated birth, or women who want to incorporate nonpharmacologic options as stepping-stones to possible use of pain-relieving medications later in labor, she said.

Epidurals or spinal analgesia were received by 76% of 1,573 women who were delivering singletons in U.S. hospitals and who were surveyed for the 2006 Listening to Mothers II Survey Report.

Among those who received epidurals or spinal analgesia, 81% said that they were very helpful, according to the report compiled for the nonprofit organization Childbirth Connection by Eugene R. Declerq, Ph.D., professor of maternal and child health at Boston University, and associates.

Besides epidurals, “the interesting thing is that immersion in a tub or hands-on techniques came up a little bit above the effectiveness of narcotics” for relieving labor pain, although they were less often used than narcotics, said Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the University of California.

“Many of the other nonpharmacologic techniques are not far behind” in effectiveness, she added. (See box.)

Overall, 69% of women used one or more nonpharmacologic techniques to relieve discomfort in labor.

Ms. Bishop reviewed the evidence for some nonpharmacologic strategies that had been identified as effective by one or more of three published reviews of the literature.

▸ Continuous labor support. This category is a catchall of steps taken usually by a doula, midwife, or nurse.

Continuous labor support typically includes touch, massage, application of cold or heat, and other strategies for physical comfort plus emotional support, a steady flow of information to the mother, and facilitation of communication between the mother and the health care providers.

A 2003 Cochrane meta-analysis of 15 randomized, controlled studies with 12,791 women found significant decreases in use of regional analgesia, forceps, or cesarean births and increased likelihood of vaginal birth with continuous labor support.

Women reported 33% less dissatisfaction with labor regardless of pain, compared with unsupported control groups.

A separate 2003 review of studies found less striking results, but concluded that all women should have support during labor and that starting support earlier in labor rather than later maximizes the benefits.

▸ Water immersion. Putting a laboring woman in a warm bath was associated with decreased pain (particularly during the first 30 minutes) and decreased use of epidurals, according to a 2004 Cochrane meta-analysis of eight randomized, controlled trials with 2,939 women.

Two studies found that tub immersion during early labor (before 5-cm dilation) may prolong labor. Individual studies found fewer fetal malpositions in tub-immersed women and no increased rate of infection in those who rupture membranes while in the tub.

“There should be no barriers to women getting into a tub due to misconceptions regarding infection” risk, Ms. Bishop said.

▸ Hypnosis. A very old strategy recently repackaged under the term “hypnobirthing,” hypnotic pain relief techniques carry the disadvantages of time and costs needed for training, and the lengthy time needed to implement this into practice, she said.

A 2006 Cochrane review of five trials with 749 women found suggestions of effectiveness in decreasing the need for pharmacologic pain relief and increasing vaginal deliveries and patient satisfaction with pain relief. No adverse outcomes were seen, but hypnosis generally is contraindicated in women with a history of psychosis, she added.

▸ Intradermal water injections. Four randomized, controlled studies found significant reductions in severe back pain for 45–90 minutes but no decrease in requests for medication for abdominal pain using this strategy.

Intradermal water injections involve injecting 0.05–0.1 mL of sterile water into four locations on the lower back—two over each posterior superior iliac spine, and two located 3 cm below and 1 cm medial to the posterior superior iliac spine.

Injections seem to be more effective earlier rather than later in labor. The injections are painful for 20–30 seconds, and the counterirritation of the injection pain may be a mechanism of action for relieving the back pain, she speculated.

▸ Acupuncture. Although the overall evidence that acupuncture can reduce labor pain is encouraging, “it's really difficult to find an acupuncturist willing to be on call to come into labor” rooms, Ms. Bishop said. Midwives in some European countries can take a course to provide acupuncture to patients, something that should be tried in the United States, she added.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — When it comes to relieving labor pain, there's nothing like an epidural.

Beyond that, however, some nonpharmacologic strategies compete well with opioids, the next most common pharmacologic option for treating labor pain, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Nonpharmacologic techniques should be considered for women who arrive at the labor and delivery room too late to get an epidural, women who want to try an unmedicated birth, or women who want to incorporate nonpharmacologic options as stepping-stones to possible use of pain-relieving medications later in labor, she said.

Epidurals or spinal analgesia were used by 76% of 1,573 women delivering singletons in U.S. hospitals who were surveyed for the 2006 Listening to Mothers II Survey Report. Among those who received epidurals or spinal analgesia, 81% said that they were very helpful, according to the report compiled for the nonprofit organization Childbirth Connection by Eugene R. Declerq, Ph.D., professor of maternal and child health at Boston University, and associates.

Besides epidurals, “immersion in a tub or hands-on techniques came up a little bit above the effectiveness of narcotics” for relieving labor pain, although they were used less often than narcotics, said Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the University of California. “Many of the other nonpharmacologic techniques are not far behind” in effectiveness. (See box.)

Overall, 69% of women used one or more nonpharmacologic techniques to relieve discomfort in labor. Ms. Bishop reviewed the evidence for some nonpharmacologic strategies identified as effective by one of three published reviews of the literature:

▸ Continuous labor support. This category is a catchall of steps taken usually by a doula, midwife, or nurse. It typically includes touch, massage, application of cold or heat, and other strategies for physical comfort plus emotional support, a steady flow of information to the mother, and facilitation of communication between the mother and the health care providers.

A 2003 Cochrane meta-analysis of 15 randomized, controlled studies with 12,791 women found significant decreases in use of regional analgesia, forceps, or cesarean births and increased likelihood of vaginal birth with continuous labor support. Women reported 33% less dissatisfaction with labor regardless of pain, compared with unsupported control groups.

▸ Water immersion. Putting a laboring woman in a bath of warm water was associated with decreased pain (particularly during the first 30 minutes) and decreased use of epidurals, according to a 2004 Cochrane meta-analysis of eight randomized, controlled trials with 2,939 women. Two studies found that tub immersion during early labor (before 5-cm dilation) may prolong labor. Individual studies found fewer fetal malpositions in tub-immersed women and no increased rate of infection in those who rupture membranes while in the tub.

▸ Hypnosis. Hypnotic pain relief techniques, or “hypnobirthing,” carry the disadvantages of time and costs needed for training, and the lengthy time needed to implement this practice. A 2006 Cochrane review of five trials with 749 women found suggestions of effectiveness in decreasing the need for pharmacologic pain relief and increasing vaginal deliveries and patient satisfaction with pain relief. No adverse outcomes were seen, but hypnosis generally is contraindicated in women with a history of psychosis, she added.

▸ Intradermal water injections. Four randomized, controlled studies found significant reductions in severe back pain for 45–90 minutes, but no decrease in requests for medication for abdominal pain using this strategy. Intradermal water injections involve injecting 0.05–0.1 mL of sterile water into four locations on the lower back—two over each posterior superior iliac spine, and two located 3 cm below and 1 cm medial to the posterior superior iliac spine. Injections seem to be more effective earlier rather than later in labor.

▸ Acupuncture. Although the overall evidence that acupuncture can reduce labor pain is encouraging, “it is difficult to find an acupuncturist willing to be on call to come into labor” rooms, Ms. Bishop said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — When it comes to relieving labor pain, there's nothing like an epidural.

Beyond that, however, some nonpharmacologic strategies compete well with opioids, the next most common pharmacologic option for treating labor pain, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Nonpharmacologic techniques should be considered for women who arrive at the labor and delivery room too late to get an epidural, women who want to try an unmedicated birth, or women who want to incorporate nonpharmacologic options as stepping-stones to possible use of pain-relieving medications later in labor, she said.

Epidurals or spinal analgesia were used by 76% of 1,573 women delivering singletons in U.S. hospitals who were surveyed for the 2006 Listening to Mothers II Survey Report. Among those who received epidurals or spinal analgesia, 81% said that they were very helpful, according to the report compiled for the nonprofit organization Childbirth Connection by Eugene R. Declerq, Ph.D., professor of maternal and child health at Boston University, and associates.

Besides epidurals, “immersion in a tub or hands-on techniques came up a little bit above the effectiveness of narcotics” for relieving labor pain, although they were used less often than narcotics, said Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the University of California. “Many of the other nonpharmacologic techniques are not far behind” in effectiveness. (See box.)

Overall, 69% of women used one or more nonpharmacologic techniques to relieve discomfort in labor. Ms. Bishop reviewed the evidence for some nonpharmacologic strategies identified as effective by one of three published reviews of the literature:

▸ Continuous labor support. This category is a catchall of steps taken usually by a doula, midwife, or nurse. It typically includes touch, massage, application of cold or heat, and other strategies for physical comfort plus emotional support, a steady flow of information to the mother, and facilitation of communication between the mother and the health care providers.

A 2003 Cochrane meta-analysis of 15 randomized, controlled studies with 12,791 women found significant decreases in use of regional analgesia, forceps, or cesarean births and increased likelihood of vaginal birth with continuous labor support. Women reported 33% less dissatisfaction with labor regardless of pain, compared with unsupported control groups.

▸ Water immersion. Putting a laboring woman in a bath of warm water was associated with decreased pain (particularly during the first 30 minutes) and decreased use of epidurals, according to a 2004 Cochrane meta-analysis of eight randomized, controlled trials with 2,939 women. Two studies found that tub immersion during early labor (before 5-cm dilation) may prolong labor. Individual studies found fewer fetal malpositions in tub-immersed women and no increased rate of infection in those who rupture membranes while in the tub.

▸ Hypnosis. Hypnotic pain relief techniques, or “hypnobirthing,” carry the disadvantages of time and costs needed for training, and the lengthy time needed to implement this practice. A 2006 Cochrane review of five trials with 749 women found suggestions of effectiveness in decreasing the need for pharmacologic pain relief and increasing vaginal deliveries and patient satisfaction with pain relief. No adverse outcomes were seen, but hypnosis generally is contraindicated in women with a history of psychosis, she added.

▸ Intradermal water injections. Four randomized, controlled studies found significant reductions in severe back pain for 45–90 minutes, but no decrease in requests for medication for abdominal pain using this strategy. Intradermal water injections involve injecting 0.05–0.1 mL of sterile water into four locations on the lower back—two over each posterior superior iliac spine, and two located 3 cm below and 1 cm medial to the posterior superior iliac spine. Injections seem to be more effective earlier rather than later in labor.

▸ Acupuncture. Although the overall evidence that acupuncture can reduce labor pain is encouraging, “it is difficult to find an acupuncturist willing to be on call to come into labor” rooms, Ms. Bishop said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — When it comes to relieving labor pain, there's nothing like an epidural.

Beyond that, however, some nonpharmacologic strategies compete well with opioids, the next most common pharmacologic option for treating labor pain, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Nonpharmacologic techniques should be considered for women who arrive at the labor and delivery room too late to get an epidural, women who want to try an unmedicated birth, or women who want to incorporate nonpharmacologic options as stepping-stones to possible use of pain-relieving medications later in labor, she said.

Epidurals or spinal analgesia were used by 76% of 1,573 women delivering singletons in U.S. hospitals who were surveyed for the 2006 Listening to Mothers II Survey Report. Among those who received epidurals or spinal analgesia, 81% said that they were very helpful, according to the report compiled for the nonprofit organization Childbirth Connection by Eugene R. Declerq, Ph.D., professor of maternal and child health at Boston University, and associates.

Besides epidurals, “immersion in a tub or hands-on techniques came up a little bit above the effectiveness of narcotics” for relieving labor pain, although they were used less often than narcotics, said Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the University of California. “Many of the other nonpharmacologic techniques are not far behind” in effectiveness. (See box.)

Overall, 69% of women used one or more nonpharmacologic techniques to relieve discomfort in labor. Ms. Bishop reviewed the evidence for some nonpharmacologic strategies identified as effective by one of three published reviews of the literature:

▸ Continuous labor support. This category is a catchall of steps taken usually by a doula, midwife, or nurse. It typically includes touch, massage, application of cold or heat, and other strategies for physical comfort plus emotional support, a steady flow of information to the mother, and facilitation of communication between the mother and the health care providers.

A 2003 Cochrane meta-analysis of 15 randomized, controlled studies with 12,791 women found significant decreases in use of regional analgesia, forceps, or cesarean births and increased likelihood of vaginal birth with continuous labor support. Women reported 33% less dissatisfaction with labor regardless of pain, compared with unsupported control groups.

▸ Water immersion. Putting a laboring woman in a bath of warm water was associated with decreased pain (particularly during the first 30 minutes) and decreased use of epidurals, according to a 2004 Cochrane meta-analysis of eight randomized, controlled trials with 2,939 women. Two studies found that tub immersion during early labor (before 5-cm dilation) may prolong labor. Individual studies found fewer fetal malpositions in tub-immersed women and no increased rate of infection in those who rupture membranes while in the tub.

▸ Hypnosis. Hypnotic pain relief techniques, or “hypnobirthing,” carry the disadvantages of time and costs needed for training, and the lengthy time needed to implement this practice. A 2006 Cochrane review of five trials with 749 women found suggestions of effectiveness in decreasing the need for pharmacologic pain relief and increasing vaginal deliveries and patient satisfaction with pain relief. No adverse outcomes were seen, but hypnosis generally is contraindicated in women with a history of psychosis, she added.

▸ Intradermal water injections. Four randomized, controlled studies found significant reductions in severe back pain for 45–90 minutes, but no decrease in requests for medication for abdominal pain using this strategy. Intradermal water injections involve injecting 0.05–0.1 mL of sterile water into four locations on the lower back—two over each posterior superior iliac spine, and two located 3 cm below and 1 cm medial to the posterior superior iliac spine. Injections seem to be more effective earlier rather than later in labor.

▸ Acupuncture. Although the overall evidence that acupuncture can reduce labor pain is encouraging, “it is difficult to find an acupuncturist willing to be on call to come into labor” rooms, Ms. Bishop said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Bullying that was experienced or witnessed by 185 high school students went beyond the more commonly acknowledged forms of bullying to include racial/ethnic harassment, sexual harassment, and homophobic epithets, Sandra Cortina, Ph.D., reported in a poster presentation at the annual meeting of the American Psychological Association.

The high school students' ideas for ways to alleviate bullying indicated that a multisystem approach is needed to increase school monitoring, prosocial peer behavior, and attention to diversity-related bullying, said Dr. Cortina, formerly of the University of Iowa, Iowa City, where the study was based, and now a psychology fellow at Cincinnati Children's Hospital.

During educational presentations on school bullying at two rural Midwestern high schools, the investigators divided students into groups of three or four, gave them a one-page handout on commonly researched forms of bullying, and asked each student to write three to five examples of bullying at their school and two or three suggestions for improving the problem.

Physical and verbal harassment were the most common forms of bullying. Harassment based on race or ethnicity, sex, or sexual orientation were prevalent, Dr. Cortina reported.

The students were clear that increased involvement from both peers and staff would be essential to prevent and intervene in bullying.

Recent separate research suggests that some school staff still consider student peer aggression to be developmentally normative, or they fail to recognize specific behaviors as bullying, she noted.

Little previous research has looked at student perceptions of what constitutes bullying.

Among verbal bullying, name calling focused on physical attributes or appearance in 18% of cases, on race or ethnicity 16% of the time, on the students' beliefs (like religion or politics) in 5% of cases, and on their intellect in 5% of incidents. Verbal harassment was described in nonspecific forms in 43% of cases, with 12% involving name calling on miscellaneous topics. (Percentages were rounded.)

Physical bullying was nonsexual in nature 77% of the time and included kicking, hitting, fighting, choking, shoving, tripping, and more. Stealing accounted for 7% of cases of physical bullying, and 16% of cases were physical threats or intimidation.

Sexual harassment was verbal in 55% of cases, physical in 27% of cases, and nonspecific 18% of the time. Social bullying included spreading rumors and gossip (63%), excluding or ignoring people (25%), and public humiliation (8%).

SAN FRANCISCO – Bullying that was experienced or witnessed by 185 high school students went beyond the more commonly acknowledged forms of bullying to include racial/ethnic harassment, sexual harassment, and homophobic epithets, Sandra Cortina, Ph.D., reported in a poster presentation at the annual meeting of the American Psychological Association.

The high school students' ideas for ways to alleviate bullying indicated that a multisystem approach is needed to increase school monitoring, prosocial peer behavior, and attention to diversity-related bullying, said Dr. Cortina, formerly of the University of Iowa, Iowa City, where the study was based, and now a psychology fellow at Cincinnati Children's Hospital.

During educational presentations on school bullying at two rural Midwestern high schools, the investigators divided students into groups of three or four, gave them a one-page handout on commonly researched forms of bullying, and asked each student to write three to five examples of bullying at their school and two or three suggestions for improving the problem.

Physical and verbal harassment were the most common forms of bullying. Harassment based on race or ethnicity, sex, or sexual orientation were prevalent, Dr. Cortina reported.

The students were clear that increased involvement from both peers and staff would be essential to prevent and intervene in bullying.

Recent separate research suggests that some school staff still consider student peer aggression to be developmentally normative, or they fail to recognize specific behaviors as bullying, she noted.

Little previous research has looked at student perceptions of what constitutes bullying.

Among verbal bullying, name calling focused on physical attributes or appearance in 18% of cases, on race or ethnicity 16% of the time, on the students' beliefs (like religion or politics) in 5% of cases, and on their intellect in 5% of incidents. Verbal harassment was described in nonspecific forms in 43% of cases, with 12% involving name calling on miscellaneous topics. (Percentages were rounded.)

Physical bullying was nonsexual in nature 77% of the time and included kicking, hitting, fighting, choking, shoving, tripping, and more. Stealing accounted for 7% of cases of physical bullying, and 16% of cases were physical threats or intimidation.

Sexual harassment was verbal in 55% of cases, physical in 27% of cases, and nonspecific 18% of the time. Social bullying included spreading rumors and gossip (63%), excluding or ignoring people (25%), and public humiliation (8%).

SAN FRANCISCO – Bullying that was experienced or witnessed by 185 high school students went beyond the more commonly acknowledged forms of bullying to include racial/ethnic harassment, sexual harassment, and homophobic epithets, Sandra Cortina, Ph.D., reported in a poster presentation at the annual meeting of the American Psychological Association.

The high school students' ideas for ways to alleviate bullying indicated that a multisystem approach is needed to increase school monitoring, prosocial peer behavior, and attention to diversity-related bullying, said Dr. Cortina, formerly of the University of Iowa, Iowa City, where the study was based, and now a psychology fellow at Cincinnati Children's Hospital.

During educational presentations on school bullying at two rural Midwestern high schools, the investigators divided students into groups of three or four, gave them a one-page handout on commonly researched forms of bullying, and asked each student to write three to five examples of bullying at their school and two or three suggestions for improving the problem.

Physical and verbal harassment were the most common forms of bullying. Harassment based on race or ethnicity, sex, or sexual orientation were prevalent, Dr. Cortina reported.

The students were clear that increased involvement from both peers and staff would be essential to prevent and intervene in bullying.

Recent separate research suggests that some school staff still consider student peer aggression to be developmentally normative, or they fail to recognize specific behaviors as bullying, she noted.

Little previous research has looked at student perceptions of what constitutes bullying.

Among verbal bullying, name calling focused on physical attributes or appearance in 18% of cases, on race or ethnicity 16% of the time, on the students' beliefs (like religion or politics) in 5% of cases, and on their intellect in 5% of incidents. Verbal harassment was described in nonspecific forms in 43% of cases, with 12% involving name calling on miscellaneous topics. (Percentages were rounded.)

Physical bullying was nonsexual in nature 77% of the time and included kicking, hitting, fighting, choking, shoving, tripping, and more. Stealing accounted for 7% of cases of physical bullying, and 16% of cases were physical threats or intimidation.

Sexual harassment was verbal in 55% of cases, physical in 27% of cases, and nonspecific 18% of the time. Social bullying included spreading rumors and gossip (63%), excluding or ignoring people (25%), and public humiliation (8%).

When Dr. Joseph C. Kvedar founded a program in telemedicine at Massachusetts General Hospital in 1995, his first digital camera cost around $1,200 and had about as much sophistication as today's average cell phone camera.

That early technology led to an epiphany, however, about the potential roles for consumer-ready technologies in health care—using tools such as cellular phones, the Internet, and digital cameras.

An early study compared two groups of dermatologists who were asked to diagnose skin lesions, with one group seeing the patients and the other seeing photographs of the lesions, to assess the accuracy of diagnoses using digital photos. The photography group breezed through evaluations of 37 cases in a 3-hour period.

"That's when I realized it was an efficiency tool" as well as a diagnostic tool, said Dr. Kvedar, a dermatologist and director of the Center for Connected Health, Boston. The center, which was called Partners Telemedicine until this year, is a division of Partners HealthCare, the integrated health system comprising Massachusetts General Hospital, Brigham and Women's Hospital, and many providers throughout eastern Massachusetts.

The center grew from a facility requiring Dr. Kvedar's half-time attention to one with eight staff members who have coordinated studies and implemented programs to improve management of acne, wound care, hypertension, heart failure, psoriasis, and more. Compelling trends in the delivery of medical services fuel the center's expansion.

"We're facing an enormous challenge in terms of capacity" to provide health care in the United States, he said. "It's so much more acute now." A massive growth in the prevalence of chronic illness combined with cost constraints and a shortage of dermatologists, other specialists, and nurses make greater efficiency imperative, he said.

"In the last month, I've seen four articles in the lay press about the primary care workforce shortage," he noted. "It's disturbing." A suburb of Boston recently had to choose between paying for health insurance for the town's employees or funding high school sports. The students lost their sports programs.

"This is going to hit all of us. Our towns are going to have to make choices like this" that will drive demand for greater efficiencies to help decrease the costs of health care, he said.

Efficiency is only part of the equation. Connected care can improve efficacy as well. Detaching some patient-provider interactions from the old paradigm of scheduled in-person visits can help give patients care when and where they need it. Using technology to give patients the feedback of physiologic data gets them more engaged in their health care.

"There's all kinds of magic that happens when you're able to take the care to the patient," he said.

The center's first big success was a study of 85 housebound patients with heart failure who were followed for 2 months after hospital discharge. The patients were given equipment to measure their weight, blood pressure, and oxygen saturation plus a tabletop device to answer disease management questions and to transmit daily measurements to telemonitoring nurses, who triaged follow-up care. These patients required 40% fewer home visits by a nurse and were hospitalized 25% less often, compared with a group receiving usual care.

Patients also reported improved quality of life and appreciated taking a more active role in their health. "We inadvertently learned that patients get very involved in their care," Dr. Kvedar said.

The Partners hospitals discharge 2,300 heart-failure patients per year. The Connected Cardiac Care program is expanding to enroll as many of these patients as possible, housebound or not. Next, a similar study of diabetic patients is being planned.

Mistakes along the way inform the next steps in an iterative process. The heart failure study initially tried to get patients to send daily information through cell phones instead of a tabletop device. That "was a miserable failure because the over-65 set couldn't tolerate the small screen and buttons" or other cell-phone features. After enrolling just 30 patients, the study was redesigned.

The center's programs include:

▸ Wound Care. Home-care nurses uploaded digital photos of wounds on 34 homebound patients to wound care specialists, which reduced the average time for assessment by 2.5 hours per patient, a study found. The trial also showed that specialists provided different diagnoses and treatment plans than did the home-care nurses in many cases.

The Wound Telehealth Consultation System is being expanded to cover all wounds that require daily care, including stasis dermatitis, diabetic ulcers, and pressure sores. A new study will look at the feasibility of using cell phone camera photos for wound care assessment.

▸ Acne. Electronic follow-up visits for mild to moderate acne were a hit with patients and dermatologists in preliminary results from the first 60 patients of an ongoing study. Patients received digital cameras and uploaded facial photos for evaluation, trimming the average time spent by patients to about 20 minutes instead of over 2 hours for travel and clinic time. Blue Cross/Blue Shield reimbursed dermatologists for e-visits at the same rate as a follow-up visit in the clinic. "We see it extending to psoriasis and other skin conditions that don't vary too much between visits," Dr. Kvedar said.

▸ Hypertension. To increase adherence to hypertension therapy, 70 patients are being given "smart" pill bottles that transmit a signal when a scheduled medication dose has been taken or missed. They'll also get a palm-size globe that glows red when a dose is overdue and green when the medication is taken.

A separate study brings the center together for the first time with employees of a large company, EMC Corp. of Hopkinton, Mass. The company recruited 400 employees with high blood pressure to be randomized to usual care or to a group that is asked to measure their blood pressures at least twice weekly with special home blood pressure cuffs that transmit readings to a central computer. Patients will get individualized feedback and advice weekly on a Web site; those whose blood pressure readings climb particularly high will be contacted via e-mail or phone by a clinician.

If these technological self-management strategies succeed in keeping blood pressures down, it's a win for patients, the company, and clinicians. Trends toward basing clinician reimbursements on quality care through "pay for performance" and similar strategies will help push demand for better, more efficient care, Dr. Kvedar said.

When physicians in a system don't get a bonus unless they keep the average hemoglobin A_1c levels of diabetic patients under a certain level, a Center for Connected Health program to help them attain one is "music to people's ears," he said. "Things are starting to line up in a very exciting way on the reimbursement side. You'll see that in the next few years."

When Dr. Joseph C. Kvedar founded a program in telemedicine at Massachusetts General Hospital in 1995, his first digital camera cost around $1,200 and had about as much sophistication as today's average cell phone camera.

That early technology led to an epiphany, however, about the potential roles for consumer-ready technologies in health care—using tools such as cellular phones, the Internet, and digital cameras.

An early study compared two groups of dermatologists who were asked to diagnose skin lesions, with one group seeing the patients and the other seeing photographs of the lesions, to assess the accuracy of diagnoses using digital photos. The photography group breezed through evaluations of 37 cases in a 3-hour period.

"That's when I realized it was an efficiency tool" as well as a diagnostic tool, said Dr. Kvedar, a dermatologist and director of the Center for Connected Health, Boston. The center, which was called Partners Telemedicine until this year, is a division of Partners HealthCare, the integrated health system comprising Massachusetts General Hospital, Brigham and Women's Hospital, and many providers throughout eastern Massachusetts.

The center grew from a facility requiring Dr. Kvedar's half-time attention to one with eight staff members who have coordinated studies and implemented programs to improve management of acne, wound care, hypertension, heart failure, psoriasis, and more. Compelling trends in the delivery of medical services fuel the center's expansion.

"We're facing an enormous challenge in terms of capacity" to provide health care in the United States, he said. "It's so much more acute now." A massive growth in the prevalence of chronic illness combined with cost constraints and a shortage of dermatologists, other specialists, and nurses make greater efficiency imperative, he said.

"In the last month, I've seen four articles in the lay press about the primary care workforce shortage," he noted. "It's disturbing." A suburb of Boston recently had to choose between paying for health insurance for the town's employees or funding high school sports. The students lost their sports programs.

"This is going to hit all of us. Our towns are going to have to make choices like this" that will drive demand for greater efficiencies to help decrease the costs of health care, he said.

Efficiency is only part of the equation. Connected care can improve efficacy as well. Detaching some patient-provider interactions from the old paradigm of scheduled in-person visits can help give patients care when and where they need it. Using technology to give patients the feedback of physiologic data gets them more engaged in their health care.

"There's all kinds of magic that happens when you're able to take the care to the patient," he said.

The center's first big success was a study of 85 housebound patients with heart failure who were followed for 2 months after hospital discharge. The patients were given equipment to measure their weight, blood pressure, and oxygen saturation plus a tabletop device to answer disease management questions and to transmit daily measurements to telemonitoring nurses, who triaged follow-up care. These patients required 40% fewer home visits by a nurse and were hospitalized 25% less often, compared with a group receiving usual care.

Patients also reported improved quality of life and appreciated taking a more active role in their health. "We inadvertently learned that patients get very involved in their care," Dr. Kvedar said.

The Partners hospitals discharge 2,300 heart-failure patients per year. The Connected Cardiac Care program is expanding to enroll as many of these patients as possible, housebound or not. Next, a similar study of diabetic patients is being planned.

Mistakes along the way inform the next steps in an iterative process. The heart failure study initially tried to get patients to send daily information through cell phones instead of a tabletop device. That "was a miserable failure because the over-65 set couldn't tolerate the small screen and buttons" or other cell-phone features. After enrolling just 30 patients, the study was redesigned.

The center's programs include:

▸ Wound Care. Home-care nurses uploaded digital photos of wounds on 34 homebound patients to wound care specialists, which reduced the average time for assessment by 2.5 hours per patient, a study found. The trial also showed that specialists provided different diagnoses and treatment plans than did the home-care nurses in many cases.

The Wound Telehealth Consultation System is being expanded to cover all wounds that require daily care, including stasis dermatitis, diabetic ulcers, and pressure sores. A new study will look at the feasibility of using cell phone camera photos for wound care assessment.

▸ Acne. Electronic follow-up visits for mild to moderate acne were a hit with patients and dermatologists in preliminary results from the first 60 patients of an ongoing study. Patients received digital cameras and uploaded facial photos for evaluation, trimming the average time spent by patients to about 20 minutes instead of over 2 hours for travel and clinic time. Blue Cross/Blue Shield reimbursed dermatologists for e-visits at the same rate as a follow-up visit in the clinic. "We see it extending to psoriasis and other skin conditions that don't vary too much between visits," Dr. Kvedar said.

▸ Hypertension. To increase adherence to hypertension therapy, 70 patients are being given "smart" pill bottles that transmit a signal when a scheduled medication dose has been taken or missed. They'll also get a palm-size globe that glows red when a dose is overdue and green when the medication is taken.

A separate study brings the center together for the first time with employees of a large company, EMC Corp. of Hopkinton, Mass. The company recruited 400 employees with high blood pressure to be randomized to usual care or to a group that is asked to measure their blood pressures at least twice weekly with special home blood pressure cuffs that transmit readings to a central computer. Patients will get individualized feedback and advice weekly on a Web site; those whose blood pressure readings climb particularly high will be contacted via e-mail or phone by a clinician.

If these technological self-management strategies succeed in keeping blood pressures down, it's a win for patients, the company, and clinicians. Trends toward basing clinician reimbursements on quality care through "pay for performance" and similar strategies will help push demand for better, more efficient care, Dr. Kvedar said.

When physicians in a system don't get a bonus unless they keep the average hemoglobin A_1c levels of diabetic patients under a certain level, a Center for Connected Health program to help them attain one is "music to people's ears," he said. "Things are starting to line up in a very exciting way on the reimbursement side. You'll see that in the next few years."

When Dr. Joseph C. Kvedar founded a program in telemedicine at Massachusetts General Hospital in 1995, his first digital camera cost around $1,200 and had about as much sophistication as today's average cell phone camera.

That early technology led to an epiphany, however, about the potential roles for consumer-ready technologies in health care—using tools such as cellular phones, the Internet, and digital cameras.

An early study compared two groups of dermatologists who were asked to diagnose skin lesions, with one group seeing the patients and the other seeing photographs of the lesions, to assess the accuracy of diagnoses using digital photos. The photography group breezed through evaluations of 37 cases in a 3-hour period.

"That's when I realized it was an efficiency tool" as well as a diagnostic tool, said Dr. Kvedar, a dermatologist and director of the Center for Connected Health, Boston. The center, which was called Partners Telemedicine until this year, is a division of Partners HealthCare, the integrated health system comprising Massachusetts General Hospital, Brigham and Women's Hospital, and many providers throughout eastern Massachusetts.

The center grew from a facility requiring Dr. Kvedar's half-time attention to one with eight staff members who have coordinated studies and implemented programs to improve management of acne, wound care, hypertension, heart failure, psoriasis, and more. Compelling trends in the delivery of medical services fuel the center's expansion.

"We're facing an enormous challenge in terms of capacity" to provide health care in the United States, he said. "It's so much more acute now." A massive growth in the prevalence of chronic illness combined with cost constraints and a shortage of dermatologists, other specialists, and nurses make greater efficiency imperative, he said.

"In the last month, I've seen four articles in the lay press about the primary care workforce shortage," he noted. "It's disturbing." A suburb of Boston recently had to choose between paying for health insurance for the town's employees or funding high school sports. The students lost their sports programs.

"This is going to hit all of us. Our towns are going to have to make choices like this" that will drive demand for greater efficiencies to help decrease the costs of health care, he said.

Efficiency is only part of the equation. Connected care can improve efficacy as well. Detaching some patient-provider interactions from the old paradigm of scheduled in-person visits can help give patients care when and where they need it. Using technology to give patients the feedback of physiologic data gets them more engaged in their health care.

"There's all kinds of magic that happens when you're able to take the care to the patient," he said.

The center's first big success was a study of 85 housebound patients with heart failure who were followed for 2 months after hospital discharge. The patients were given equipment to measure their weight, blood pressure, and oxygen saturation plus a tabletop device to answer disease management questions and to transmit daily measurements to telemonitoring nurses, who triaged follow-up care. These patients required 40% fewer home visits by a nurse and were hospitalized 25% less often, compared with a group receiving usual care.

Patients also reported improved quality of life and appreciated taking a more active role in their health. "We inadvertently learned that patients get very involved in their care," Dr. Kvedar said.

The Partners hospitals discharge 2,300 heart-failure patients per year. The Connected Cardiac Care program is expanding to enroll as many of these patients as possible, housebound or not. Next, a similar study of diabetic patients is being planned.

Mistakes along the way inform the next steps in an iterative process. The heart failure study initially tried to get patients to send daily information through cell phones instead of a tabletop device. That "was a miserable failure because the over-65 set couldn't tolerate the small screen and buttons" or other cell-phone features. After enrolling just 30 patients, the study was redesigned.

The center's programs include:

▸ Wound Care. Home-care nurses uploaded digital photos of wounds on 34 homebound patients to wound care specialists, which reduced the average time for assessment by 2.5 hours per patient, a study found. The trial also showed that specialists provided different diagnoses and treatment plans than did the home-care nurses in many cases.

The Wound Telehealth Consultation System is being expanded to cover all wounds that require daily care, including stasis dermatitis, diabetic ulcers, and pressure sores. A new study will look at the feasibility of using cell phone camera photos for wound care assessment.

▸ Acne. Electronic follow-up visits for mild to moderate acne were a hit with patients and dermatologists in preliminary results from the first 60 patients of an ongoing study. Patients received digital cameras and uploaded facial photos for evaluation, trimming the average time spent by patients to about 20 minutes instead of over 2 hours for travel and clinic time. Blue Cross/Blue Shield reimbursed dermatologists for e-visits at the same rate as a follow-up visit in the clinic. "We see it extending to psoriasis and other skin conditions that don't vary too much between visits," Dr. Kvedar said.

▸ Hypertension. To increase adherence to hypertension therapy, 70 patients are being given "smart" pill bottles that transmit a signal when a scheduled medication dose has been taken or missed. They'll also get a palm-size globe that glows red when a dose is overdue and green when the medication is taken.

A separate study brings the center together for the first time with employees of a large company, EMC Corp. of Hopkinton, Mass. The company recruited 400 employees with high blood pressure to be randomized to usual care or to a group that is asked to measure their blood pressures at least twice weekly with special home blood pressure cuffs that transmit readings to a central computer. Patients will get individualized feedback and advice weekly on a Web site; those whose blood pressure readings climb particularly high will be contacted via e-mail or phone by a clinician.

If these technological self-management strategies succeed in keeping blood pressures down, it's a win for patients, the company, and clinicians. Trends toward basing clinician reimbursements on quality care through "pay for performance" and similar strategies will help push demand for better, more efficient care, Dr. Kvedar said.

When physicians in a system don't get a bonus unless they keep the average hemoglobin A_1c levels of diabetic patients under a certain level, a Center for Connected Health program to help them attain one is "music to people's ears," he said. "Things are starting to line up in a very exciting way on the reimbursement side. You'll see that in the next few years."

LOS ANGELES — The proportion of skin excisions for malignant lesions relative to benign lesions increased between 1993 and 2002, Dr. Marta J. Van Beek said at the annual meeting of the Society for Investigational Dermatology.

That finding "is something that we weren't really expecting to see," said Dr. Van Beek of the University of Iowa, Iowa City.

She and her associates studied CPT data between 1993 and 2002 from a random sample of 5% of Medicare recipients living in nine regions covered by the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database.

They weren't surprised to find increasing numbers over time for skin biopsies, shave removals, excisions, and other dermatologic procedures, given the rising incidence of skin cancer. In clinical practice, however, a certain number of benign lesions are biopsied over time to ensure complete ascertainment of malignancies. If clinical thresholds for a skin biopsy remain constant, it would be reasonable to expect a constant ratio of benign to malignant episodes of care over time, even in the setting of an increasing incidence of skin cancer, she explained.

Instead, the rate of benign excisions decreased from 45 per 1,000 Medicare beneficiaries in 1993 to 30/1,000 in 2002, Dr. Van Beek said. Malignant excisions increased from 25/1,000 to 27/1,000 in that period.

Skin biopsies increased from 55/1,000 to 90/1,000 beneficiaries, shave removals increased from 22/1,000 to 38/1,000, and Mohs procedures jumped from 5/1,000 to 11/1,000 beneficiaries.

Since some biopsies or lesion removals are performed not because of suspected cancer but for diagnosis of inflammatory eruptions, or because patients find lesions irritating or unsightly, Dr. Van Beek and her associates created categories that they called malignant, benign, or unknown "episodes of care." The ratio of malignant to benign episodes of care increased from 1.4 in 1993 to 2.2 in 2002, indicating a surge in malignant episodes of care.

Besides the rising incidence of cancer, factors that may have influenced these trends in health care utilization include access to specialist care and changes in coding and billing practices.

LOS ANGELES — The proportion of skin excisions for malignant lesions relative to benign lesions increased between 1993 and 2002, Dr. Marta J. Van Beek said at the annual meeting of the Society for Investigational Dermatology.

That finding "is something that we weren't really expecting to see," said Dr. Van Beek of the University of Iowa, Iowa City.

She and her associates studied CPT data between 1993 and 2002 from a random sample of 5% of Medicare recipients living in nine regions covered by the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database.

They weren't surprised to find increasing numbers over time for skin biopsies, shave removals, excisions, and other dermatologic procedures, given the rising incidence of skin cancer. In clinical practice, however, a certain number of benign lesions are biopsied over time to ensure complete ascertainment of malignancies. If clinical thresholds for a skin biopsy remain constant, it would be reasonable to expect a constant ratio of benign to malignant episodes of care over time, even in the setting of an increasing incidence of skin cancer, she explained.

Instead, the rate of benign excisions decreased from 45 per 1,000 Medicare beneficiaries in 1993 to 30/1,000 in 2002, Dr. Van Beek said. Malignant excisions increased from 25/1,000 to 27/1,000 in that period.

Skin biopsies increased from 55/1,000 to 90/1,000 beneficiaries, shave removals increased from 22/1,000 to 38/1,000, and Mohs procedures jumped from 5/1,000 to 11/1,000 beneficiaries.

Since some biopsies or lesion removals are performed not because of suspected cancer but for diagnosis of inflammatory eruptions, or because patients find lesions irritating or unsightly, Dr. Van Beek and her associates created categories that they called malignant, benign, or unknown "episodes of care." The ratio of malignant to benign episodes of care increased from 1.4 in 1993 to 2.2 in 2002, indicating a surge in malignant episodes of care.

Besides the rising incidence of cancer, factors that may have influenced these trends in health care utilization include access to specialist care and changes in coding and billing practices.

LOS ANGELES — The proportion of skin excisions for malignant lesions relative to benign lesions increased between 1993 and 2002, Dr. Marta J. Van Beek said at the annual meeting of the Society for Investigational Dermatology.

That finding "is something that we weren't really expecting to see," said Dr. Van Beek of the University of Iowa, Iowa City.

She and her associates studied CPT data between 1993 and 2002 from a random sample of 5% of Medicare recipients living in nine regions covered by the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database.

They weren't surprised to find increasing numbers over time for skin biopsies, shave removals, excisions, and other dermatologic procedures, given the rising incidence of skin cancer. In clinical practice, however, a certain number of benign lesions are biopsied over time to ensure complete ascertainment of malignancies. If clinical thresholds for a skin biopsy remain constant, it would be reasonable to expect a constant ratio of benign to malignant episodes of care over time, even in the setting of an increasing incidence of skin cancer, she explained.

Instead, the rate of benign excisions decreased from 45 per 1,000 Medicare beneficiaries in 1993 to 30/1,000 in 2002, Dr. Van Beek said. Malignant excisions increased from 25/1,000 to 27/1,000 in that period.

Skin biopsies increased from 55/1,000 to 90/1,000 beneficiaries, shave removals increased from 22/1,000 to 38/1,000, and Mohs procedures jumped from 5/1,000 to 11/1,000 beneficiaries.

Since some biopsies or lesion removals are performed not because of suspected cancer but for diagnosis of inflammatory eruptions, or because patients find lesions irritating or unsightly, Dr. Van Beek and her associates created categories that they called malignant, benign, or unknown "episodes of care." The ratio of malignant to benign episodes of care increased from 1.4 in 1993 to 2.2 in 2002, indicating a surge in malignant episodes of care.

Besides the rising incidence of cancer, factors that may have influenced these trends in health care utilization include access to specialist care and changes in coding and billing practices.

SAN FRANCISCO — Physicians should demand that first-trimester ultrasounds of twins document whether they share a placenta or have separate placentas, Dr. Vickie E. Feldstein said at a meeting on antepartum and intrapartum management.

Monochorionic twins, who share a placenta, face higher risks than dichorionic twins, and management differs based on chorionicity. It's much easier to determine chorionicity in the first trimester than in the second, she said at the meeting sponsored by the University of California, San Francisco.

“Most of the women with twins that I see in the second trimester were picked up as having twins sometime in their first trimester by somebody, and often all they've been told is there are “two sacs.' Sometimes that's all the information that's been recorded” in the patient's record, said Dr. Feldstein, professor of clinical radiology and ob.gyn. at the university. “Two sacs” does not differentiate between dichorionic twins or higher-risk monochorionic, diamniotic twins.

The first essential step is to look for twins during that first-trimester ultrasound, Dr. Mary E. Norton added in a joint presentation with Dr. Feldstein.

“It's really important any time you put the transducer down on your patients in pregnancy to make a conscious effort to think about how many embryos or fetuses are there,” said Dr. Norton, director of perinatal medicine and genetics and professor of ob.gyn. at the university. “It's an embarrassing mistake for anyone to make to miss an entire fetus, but it happens a lot.”

If you see one fetus, don't be distracted by looking at it. Remember to sweep the ultrasound transducer up, down, forward and backward to image the whole uterus, and consciously think about counting how many fetuses are there, she advised. For twins, look for the number of placentas, take a picture, and document it.

Monochorionic twins necessarily are monozygotic or so-called “identical” twins. Dichorionic twins can be monozygotic or dizygotic twins.

Monochorionic twins are at greater risk for discordant growth, anomalies, preterm labor, and death. Only monochorionic twins can develop twin-twin transfusion syndrome. If one twin dies in utero, that greatly increases the risks for the other twin in monochorionic but not in dichorionic pregnancies.

Be sure to look for twins after in vitro fertilization, Dr. Norton said. “Monozygotic twinning is more common than one might think after IVF.” Approximately 2% of embryos split into twins after conventional IVF, or up to 5%–10% after blastocyst transfer. “Just because someone had two embryos implanted by IVF does not mean that they have to be dichorionic twins” if twins are present, she said.

Monochorionic twins get followed at her institution every 2–3 weeks in the second trimester to watch for amniotic fluid discordance or evidence of twin-twin transfusion syndrome. Dichorionic twins that are growing appropriately are seen every 6 weeks. Chorionicity can be difficult to determine in the second trimester if all that's seen on ultrasound is a single placental mass, which could be a fused dichorionic pregnancy or a monochorionic pregnancy. There are clues that can help, if a patient's record doesn't include a placenta count, Dr. Feldstein said.

Ask the patient if she has a first-trimester ultrasound—she may pull one out of her pocketbook, in Dr. Feldstein's experience. If two fetuses are of the opposite sex, they must have two placentas, she said. If they're the same sex, this could be either a monochorionic or dichorionic pregnancy.

A “twin peak” sign and thicker membrane on ultrasound suggest two placentas fused together. If you don't see the twin peak sign and only a thin membrane, it's likely a monochorionic pregnancy. A thin membrane can be hard to visualize.

If you can find the two umbilical cord insertion sites and turn on color Doppler, look for an artery-to-artery connection—a telltale sign of a shared placenta.

SAN FRANCISCO — Physicians should demand that first-trimester ultrasounds of twins document whether they share a placenta or have separate placentas, Dr. Vickie E. Feldstein said at a meeting on antepartum and intrapartum management.

Monochorionic twins, who share a placenta, face higher risks than dichorionic twins, and management differs based on chorionicity. It's much easier to determine chorionicity in the first trimester than in the second, she said at the meeting sponsored by the University of California, San Francisco.

“Most of the women with twins that I see in the second trimester were picked up as having twins sometime in their first trimester by somebody, and often all they've been told is there are “two sacs.' Sometimes that's all the information that's been recorded” in the patient's record, said Dr. Feldstein, professor of clinical radiology and ob.gyn. at the university. “Two sacs” does not differentiate between dichorionic twins or higher-risk monochorionic, diamniotic twins.

The first essential step is to look for twins during that first-trimester ultrasound, Dr. Mary E. Norton added in a joint presentation with Dr. Feldstein.

“It's really important any time you put the transducer down on your patients in pregnancy to make a conscious effort to think about how many embryos or fetuses are there,” said Dr. Norton, director of perinatal medicine and genetics and professor of ob.gyn. at the university. “It's an embarrassing mistake for anyone to make to miss an entire fetus, but it happens a lot.”

If you see one fetus, don't be distracted by looking at it. Remember to sweep the ultrasound transducer up, down, forward and backward to image the whole uterus, and consciously think about counting how many fetuses are there, she advised. For twins, look for the number of placentas, take a picture, and document it.

Monochorionic twins necessarily are monozygotic or so-called “identical” twins. Dichorionic twins can be monozygotic or dizygotic twins.

Monochorionic twins are at greater risk for discordant growth, anomalies, preterm labor, and death. Only monochorionic twins can develop twin-twin transfusion syndrome. If one twin dies in utero, that greatly increases the risks for the other twin in monochorionic but not in dichorionic pregnancies.

Be sure to look for twins after in vitro fertilization, Dr. Norton said. “Monozygotic twinning is more common than one might think after IVF.” Approximately 2% of embryos split into twins after conventional IVF, or up to 5%–10% after blastocyst transfer. “Just because someone had two embryos implanted by IVF does not mean that they have to be dichorionic twins” if twins are present, she said.

Monochorionic twins get followed at her institution every 2–3 weeks in the second trimester to watch for amniotic fluid discordance or evidence of twin-twin transfusion syndrome. Dichorionic twins that are growing appropriately are seen every 6 weeks. Chorionicity can be difficult to determine in the second trimester if all that's seen on ultrasound is a single placental mass, which could be a fused dichorionic pregnancy or a monochorionic pregnancy. There are clues that can help, if a patient's record doesn't include a placenta count, Dr. Feldstein said.

Ask the patient if she has a first-trimester ultrasound—she may pull one out of her pocketbook, in Dr. Feldstein's experience. If two fetuses are of the opposite sex, they must have two placentas, she said. If they're the same sex, this could be either a monochorionic or dichorionic pregnancy.

A “twin peak” sign and thicker membrane on ultrasound suggest two placentas fused together. If you don't see the twin peak sign and only a thin membrane, it's likely a monochorionic pregnancy. A thin membrane can be hard to visualize.

If you can find the two umbilical cord insertion sites and turn on color Doppler, look for an artery-to-artery connection—a telltale sign of a shared placenta.

SAN FRANCISCO — Physicians should demand that first-trimester ultrasounds of twins document whether they share a placenta or have separate placentas, Dr. Vickie E. Feldstein said at a meeting on antepartum and intrapartum management.

Monochorionic twins, who share a placenta, face higher risks than dichorionic twins, and management differs based on chorionicity. It's much easier to determine chorionicity in the first trimester than in the second, she said at the meeting sponsored by the University of California, San Francisco.

“Most of the women with twins that I see in the second trimester were picked up as having twins sometime in their first trimester by somebody, and often all they've been told is there are “two sacs.' Sometimes that's all the information that's been recorded” in the patient's record, said Dr. Feldstein, professor of clinical radiology and ob.gyn. at the university. “Two sacs” does not differentiate between dichorionic twins or higher-risk monochorionic, diamniotic twins.

The first essential step is to look for twins during that first-trimester ultrasound, Dr. Mary E. Norton added in a joint presentation with Dr. Feldstein.

“It's really important any time you put the transducer down on your patients in pregnancy to make a conscious effort to think about how many embryos or fetuses are there,” said Dr. Norton, director of perinatal medicine and genetics and professor of ob.gyn. at the university. “It's an embarrassing mistake for anyone to make to miss an entire fetus, but it happens a lot.”

If you see one fetus, don't be distracted by looking at it. Remember to sweep the ultrasound transducer up, down, forward and backward to image the whole uterus, and consciously think about counting how many fetuses are there, she advised. For twins, look for the number of placentas, take a picture, and document it.

Monochorionic twins necessarily are monozygotic or so-called “identical” twins. Dichorionic twins can be monozygotic or dizygotic twins.

Monochorionic twins are at greater risk for discordant growth, anomalies, preterm labor, and death. Only monochorionic twins can develop twin-twin transfusion syndrome. If one twin dies in utero, that greatly increases the risks for the other twin in monochorionic but not in dichorionic pregnancies.

Be sure to look for twins after in vitro fertilization, Dr. Norton said. “Monozygotic twinning is more common than one might think after IVF.” Approximately 2% of embryos split into twins after conventional IVF, or up to 5%–10% after blastocyst transfer. “Just because someone had two embryos implanted by IVF does not mean that they have to be dichorionic twins” if twins are present, she said.

Monochorionic twins get followed at her institution every 2–3 weeks in the second trimester to watch for amniotic fluid discordance or evidence of twin-twin transfusion syndrome. Dichorionic twins that are growing appropriately are seen every 6 weeks. Chorionicity can be difficult to determine in the second trimester if all that's seen on ultrasound is a single placental mass, which could be a fused dichorionic pregnancy or a monochorionic pregnancy. There are clues that can help, if a patient's record doesn't include a placenta count, Dr. Feldstein said.

Ask the patient if she has a first-trimester ultrasound—she may pull one out of her pocketbook, in Dr. Feldstein's experience. If two fetuses are of the opposite sex, they must have two placentas, she said. If they're the same sex, this could be either a monochorionic or dichorionic pregnancy.

A “twin peak” sign and thicker membrane on ultrasound suggest two placentas fused together. If you don't see the twin peak sign and only a thin membrane, it's likely a monochorionic pregnancy. A thin membrane can be hard to visualize.

If you can find the two umbilical cord insertion sites and turn on color Doppler, look for an artery-to-artery connection—a telltale sign of a shared placenta.

SAN FRANCISCO — With only a handful of case reports in the medical literature, Raynaud's phenomenon of the nipples isn't the first thing that physicians think of when a breast-feeding mother complains of nipple pain.

If there are no signs of infection and no cracks or fissures on the nipples, one should consider this rare cause of nipple pain, especially if the woman has a history of Raynaud's syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and has a spasm-like throb. The nipple usually turns white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Of 12 women in a 2004 case report who were diagnosed with Raynaud's phenomenon of the nipples, 8 had been treated for candidiasis of the breast.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud's syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. It's a quick acting vasodilator, she said. “[Those] I have treated have responded very well and didn't need a repeat of the prescription.” In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of cases.

Raynaud's phenomenon of the nipples has been associated with rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

SAN FRANCISCO — With only a handful of case reports in the medical literature, Raynaud's phenomenon of the nipples isn't the first thing that physicians think of when a breast-feeding mother complains of nipple pain.

If there are no signs of infection and no cracks or fissures on the nipples, one should consider this rare cause of nipple pain, especially if the woman has a history of Raynaud's syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and has a spasm-like throb. The nipple usually turns white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Of 12 women in a 2004 case report who were diagnosed with Raynaud's phenomenon of the nipples, 8 had been treated for candidiasis of the breast.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud's syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. It's a quick acting vasodilator, she said. “[Those] I have treated have responded very well and didn't need a repeat of the prescription.” In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of cases.

Raynaud's phenomenon of the nipples has been associated with rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

SAN FRANCISCO — With only a handful of case reports in the medical literature, Raynaud's phenomenon of the nipples isn't the first thing that physicians think of when a breast-feeding mother complains of nipple pain.

If there are no signs of infection and no cracks or fissures on the nipples, one should consider this rare cause of nipple pain, especially if the woman has a history of Raynaud's syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and has a spasm-like throb. The nipple usually turns white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Of 12 women in a 2004 case report who were diagnosed with Raynaud's phenomenon of the nipples, 8 had been treated for candidiasis of the breast.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud's syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. It's a quick acting vasodilator, she said. “[Those] I have treated have responded very well and didn't need a repeat of the prescription.” In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of cases.

Raynaud's phenomenon of the nipples has been associated with rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

SAN FRANCISCO — Many new mothers are leery of taking antibiotics while breast-feeding, but their fears are unfounded, Dr. Natali Aziz said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Most of the commonly used antimicrobials are safe in breast-feeding and very few are controversial or contraindicated.

Take the time to review the risks and benefits of antibiotics for a new mother who needs the medicine. “Many times we can dispel the fears and rumors that patients might have heard,” said Dr. Aziz of the university.

Penicillins, cephalosporins, macrolides, and aminoglycosides all are safe in breast-feeding. The only potential side effects observed in infants who breast-feed from mothers taking these antibiotics are changes in intestinal flora that may cause loose stools or diarrhea.

Some controversy around whether to take quinolones or metronidazole while breast-feeding has been resolved in favor of the drugs' safety.

The quinolone ofloxacin raised concerns after it was associated with arthropathy in juvenile animals, but the risk of arthropathy in infants breast-feeding from mothers on short courses of the medication is extremely low, she said. In a review of more than 7,000 children on chronic quinolone therapy, only 10 developed an arthropathy-like syndrome.

The American Academy of Pediatrics has declared ofloxacin safe for breast-feeding, she added.

Metronidazole has been associated with carcinogenesis in rodents, but the drug does not increase the rate of adverse events in breast-fed infants and no studies have found cancer to be associated with breast-feeding in humans. The worst the data show is a statistical trend toward relatively benign side effects—loose stools or candidal colonization may develop in infants breast-feeding from women on metronidazole.

The American Academy of Pediatrics rates metronidazole safe while breast-feeding, with one caveat. Because a large percentage of the metronidazole ends up in a woman's breast milk, she should consider discarding some milk after a dose.

“So women who are taking a 2-gram dose, for example for trichomonas treatment, should express and discard milk for up to 24 hours” before resuming breast-feeding, Dr. Aziz said.

Chloramphenicol is one of the rare antibiotics contraindicated during breast-feeding because it may cause bone marrow suppression. In addition, the drug can induce “gray-baby syndrome”—a decrease in hepatic enzyme function leading to hypotension, cyanosis, and even death.

Chronic use of tetracyclines is not recommended because this can stain the immature teeth of infants. Short-term use, however, is approved by numerous organizations, Dr. Aziz said.

Women taking a 2-gram dose of metronidazole should express and discard milk for up to 24 hours. DR. AZIZ

Safe Drugs During Breast-Feeding

Acyclovir

Amoxicillin

Aztreonam

Cefazolin

Cefotaxime

Cefoxitin

Cefprozil

Ceftazidime

Ceftriaxone

Chloroquine

Ciprofloxacin

Clindamycin

Dapsone

Erythromycin

Ethambutol

Fluconazole

Gentamicin

Isoniazid

Kanamycin

Nitrofurantoin

Ofloxacin

Quinidine

Quinine

Rifampin

Streptomycin

Sulbactam

Sulfadiazine

Sulfisoxazole

Tetracycline

Trimethoprim-sulfamethoxazole

Source: American Academy of Pediatrics Committee on Drugs, 2001

SAN FRANCISCO — Many new mothers are leery of taking antibiotics while breast-feeding, but their fears are unfounded, Dr. Natali Aziz said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Most of the commonly used antimicrobials are safe in breast-feeding and very few are controversial or contraindicated.

Take the time to review the risks and benefits of antibiotics for a new mother who needs the medicine. “Many times we can dispel the fears and rumors that patients might have heard,” said Dr. Aziz of the university.

Penicillins, cephalosporins, macrolides, and aminoglycosides all are safe in breast-feeding. The only potential side effects observed in infants who breast-feed from mothers taking these antibiotics are changes in intestinal flora that may cause loose stools or diarrhea.

Some controversy around whether to take quinolones or metronidazole while breast-feeding has been resolved in favor of the drugs' safety.

The quinolone ofloxacin raised concerns after it was associated with arthropathy in juvenile animals, but the risk of arthropathy in infants breast-feeding from mothers on short courses of the medication is extremely low, she said. In a review of more than 7,000 children on chronic quinolone therapy, only 10 developed an arthropathy-like syndrome.

The American Academy of Pediatrics has declared ofloxacin safe for breast-feeding, she added.

Metronidazole has been associated with carcinogenesis in rodents, but the drug does not increase the rate of adverse events in breast-fed infants and no studies have found cancer to be associated with breast-feeding in humans. The worst the data show is a statistical trend toward relatively benign side effects—loose stools or candidal colonization may develop in infants breast-feeding from women on metronidazole.

The American Academy of Pediatrics rates metronidazole safe while breast-feeding, with one caveat. Because a large percentage of the metronidazole ends up in a woman's breast milk, she should consider discarding some milk after a dose.

“So women who are taking a 2-gram dose, for example for trichomonas treatment, should express and discard milk for up to 24 hours” before resuming breast-feeding, Dr. Aziz said.

Chloramphenicol is one of the rare antibiotics contraindicated during breast-feeding because it may cause bone marrow suppression. In addition, the drug can induce “gray-baby syndrome”—a decrease in hepatic enzyme function leading to hypotension, cyanosis, and even death.

Chronic use of tetracyclines is not recommended because this can stain the immature teeth of infants. Short-term use, however, is approved by numerous organizations, Dr. Aziz said.

Women taking a 2-gram dose of metronidazole should express and discard milk for up to 24 hours. DR. AZIZ

Safe Drugs During Breast-Feeding

Acyclovir

Amoxicillin

Aztreonam

Cefazolin

Cefotaxime

Cefoxitin

Cefprozil

Ceftazidime

Ceftriaxone

Chloroquine

Ciprofloxacin

Clindamycin

Dapsone

Erythromycin

Ethambutol

Fluconazole

Gentamicin

Isoniazid

Kanamycin

Nitrofurantoin

Ofloxacin

Quinidine

Quinine

Rifampin

Streptomycin

Sulbactam

Sulfadiazine

Sulfisoxazole

Tetracycline

Trimethoprim-sulfamethoxazole

Source: American Academy of Pediatrics Committee on Drugs, 2001

SAN FRANCISCO — Many new mothers are leery of taking antibiotics while breast-feeding, but their fears are unfounded, Dr. Natali Aziz said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Most of the commonly used antimicrobials are safe in breast-feeding and very few are controversial or contraindicated.

Take the time to review the risks and benefits of antibiotics for a new mother who needs the medicine. “Many times we can dispel the fears and rumors that patients might have heard,” said Dr. Aziz of the university.

Penicillins, cephalosporins, macrolides, and aminoglycosides all are safe in breast-feeding. The only potential side effects observed in infants who breast-feed from mothers taking these antibiotics are changes in intestinal flora that may cause loose stools or diarrhea.

Some controversy around whether to take quinolones or metronidazole while breast-feeding has been resolved in favor of the drugs' safety.

The quinolone ofloxacin raised concerns after it was associated with arthropathy in juvenile animals, but the risk of arthropathy in infants breast-feeding from mothers on short courses of the medication is extremely low, she said. In a review of more than 7,000 children on chronic quinolone therapy, only 10 developed an arthropathy-like syndrome.

The American Academy of Pediatrics has declared ofloxacin safe for breast-feeding, she added.

Metronidazole has been associated with carcinogenesis in rodents, but the drug does not increase the rate of adverse events in breast-fed infants and no studies have found cancer to be associated with breast-feeding in humans. The worst the data show is a statistical trend toward relatively benign side effects—loose stools or candidal colonization may develop in infants breast-feeding from women on metronidazole.

The American Academy of Pediatrics rates metronidazole safe while breast-feeding, with one caveat. Because a large percentage of the metronidazole ends up in a woman's breast milk, she should consider discarding some milk after a dose.

“So women who are taking a 2-gram dose, for example for trichomonas treatment, should express and discard milk for up to 24 hours” before resuming breast-feeding, Dr. Aziz said.

Chloramphenicol is one of the rare antibiotics contraindicated during breast-feeding because it may cause bone marrow suppression. In addition, the drug can induce “gray-baby syndrome”—a decrease in hepatic enzyme function leading to hypotension, cyanosis, and even death.

Chronic use of tetracyclines is not recommended because this can stain the immature teeth of infants. Short-term use, however, is approved by numerous organizations, Dr. Aziz said.

Women taking a 2-gram dose of metronidazole should express and discard milk for up to 24 hours. DR. AZIZ

Safe Drugs During Breast-Feeding

Acyclovir

Amoxicillin

Aztreonam

Cefazolin

Cefotaxime

Cefoxitin

Cefprozil

Ceftazidime

Ceftriaxone

Chloroquine

Ciprofloxacin

Clindamycin

Dapsone

Erythromycin

Ethambutol

Fluconazole

Gentamicin

Isoniazid

Kanamycin

Nitrofurantoin

Ofloxacin

Quinidine

Quinine

Rifampin

Streptomycin

Sulbactam

Sulfadiazine

Sulfisoxazole

Tetracycline

Trimethoprim-sulfamethoxazole

Source: American Academy of Pediatrics Committee on Drugs, 2001

SAN FRANCISCO — A simple technique to help manage labor pain is used commonly in the United Kingdom, Scandinavia, and Canada, but is offered to few U.S. women—nitrous oxide, or so-called “laughing gas.”

Administered as a 50/50 blend of oxygen and nitrous oxide, the gas has proved safe for mothers, their babies, and health care personnel in the vicinity of use, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

It's relatively weak as an analgesic, yet useful. One woman who delivered at the university described how it felt to use nitrous oxide during labor by saying, “It still hurts, but I don't care,” recalled Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the university.

“I've heard that more than once. It's not too dissimilar from some reports from women who are using nonpharmacologic methods,” she noted. “They may have rated their pain somewhat highly, but their satisfaction and their ability to cope was improved.”

Her institution has large holding tanks of oxygen and nitrous oxide that get piped into every labor and delivery room. Three cables control the flow—one for each gas, and one to scavenge the gas from the environment and remove it from the room.

The mother controls the application of the gas. She's given a mask and some instructions on its use by the anesthesiologist, midwife, or obstetrician, with ongoing supervision by a nurse. The full effect of nitrous oxide can be felt in 50 seconds.

Because it's simple and fast to start or stop, nitrous oxide is particularly useful through the second stage of labor for multiparous women who arrive in time to deliver but too late to get an epidural, she said. Nitrous oxide also can be used during perineal repair of women who didn't get an epidural.

Very few U.S. medical centers offer nitrous oxide during labor, for reasons that are unclear. “Many, many places are asking us for information about nitrous oxide. We have a protocol for nurses and certified nurse-midwives to administer” nitrous oxide, Ms. Bishop said. The University of Washington is the only other medical center that she knows of that offers nitrous oxide for labor pain.

Dr. Mark A. Rosen, director of obstetric anesthesia at the university and author of a review of nitrous oxide during labor, said in an interview that he has taken informal polls while lecturing at other institutions and conferences. When he asks how many physicians have nitrous oxide available during deliveries at their hospitals, he said, very few raise their hands.

His systematic review of 11 randomized controlled trials of nitrous oxide for labor pain reported that more than half of laboring women in the United Kingdom and Finland use nitrous oxide, which is widely employed and considered safe in Canada, Australia, New Zealand, and many other parts of the world when supervised by physicians, nurses, or midwives (Am. J. Obstet. Gynecol. 2002;186:S110-26).

He also assessed eight controlled trials and eight observational studies for potential adverse outcomes and performed a nonsystematic review of studies on occupational exposure. Potential side effects from nitrous oxide include maternal nausea, vomiting, or poor recall of labor, but it does not seem to affect the fetus, as seen with narcotics.

“Nitrous oxide is not a potent labor analgesic, but it is safe for parturient women, their newborns, and health care workers in attendance during its administration. It appears to provide adequately effective analgesia for many women,” he concluded.

An estimated 6% of U.S. women in labor used nitrous oxide in the decade leading up to 1986, but by the 1990s the use of nitrous oxide in labor had nearly disappeared in the United States, his report noted. “I really don't understand why this simple but weakly effective analgesic doesn't have more use in the United States,” Dr. Rosen said.

Ms. Bishop suggested that habit and tradition have more to do with its use than science. “We develop our own routines within practices, institutions, and countries. It is really not in most cases about what's 'right' or 'best,' just what the decision-makers decide,” she said.

Before she and Dr. Rosen arrived at the university, the director of obstetric anesthesia was an Englishman.

“I imagine he had good experience with nitrous oxide and was comfortable with it,” she speculated. Dr. Rosen trained under his predecessor and also spent some time in England.

A midwife colleague at the University of Michigan told Ms. Bishop that use of nitrous oxide for labor started in Michigan in 1978 when a British physician became chair of obstetric anesthesia. “Its use became quite popular,” but the chair's successor in 1995 removed it as an option, she said.

“We tend in the United States to go with the higher-tech approach to health care—doctors, not midwives, and epidurals, not nitrous oxide—dropping off lower-tech options even though they may still serve a purpose,” Ms. Bishop noted.

Market forces also may play a role in the demise of U.S. use of nitrous oxide for labor, midwife and epidemiologist Judith Rooks suggested in a recent editorial (Birth 2007;34:3-5). “Obstetric use of nitrous oxide in America is similar to that of any older, inexpensive, off-patent, unglamorous, safe and reasonably effective but not highly potent drug. Nitrous oxide is like an 'orphan' drug—little known outside of dentistry, lacking elan and pizzazz, with no companies or influential professional groups that stand to profit by its greater use,” she wrote.

“There is no 'nitrous lobby,'” Ms. Bishop added.

SAN FRANCISCO — A simple technique to help manage labor pain is used commonly in the United Kingdom, Scandinavia, and Canada, but is offered to few U.S. women—nitrous oxide, or so-called “laughing gas.”

Administered as a 50/50 blend of oxygen and nitrous oxide, the gas has proved safe for mothers, their babies, and health care personnel in the vicinity of use, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

It's relatively weak as an analgesic, yet useful. One woman who delivered at the university described how it felt to use nitrous oxide during labor by saying, “It still hurts, but I don't care,” recalled Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the university.

“I've heard that more than once. It's not too dissimilar from some reports from women who are using nonpharmacologic methods,” she noted. “They may have rated their pain somewhat highly, but their satisfaction and their ability to cope was improved.”

Her institution has large holding tanks of oxygen and nitrous oxide that get piped into every labor and delivery room. Three cables control the flow—one for each gas, and one to scavenge the gas from the environment and remove it from the room.

The mother controls the application of the gas. She's given a mask and some instructions on its use by the anesthesiologist, midwife, or obstetrician, with ongoing supervision by a nurse. The full effect of nitrous oxide can be felt in 50 seconds.

Because it's simple and fast to start or stop, nitrous oxide is particularly useful through the second stage of labor for multiparous women who arrive in time to deliver but too late to get an epidural, she said. Nitrous oxide also can be used during perineal repair of women who didn't get an epidural.

Very few U.S. medical centers offer nitrous oxide during labor, for reasons that are unclear. “Many, many places are asking us for information about nitrous oxide. We have a protocol for nurses and certified nurse-midwives to administer” nitrous oxide, Ms. Bishop said. The University of Washington is the only other medical center that she knows of that offers nitrous oxide for labor pain.

Dr. Mark A. Rosen, director of obstetric anesthesia at the university and author of a review of nitrous oxide during labor, said in an interview that he has taken informal polls while lecturing at other institutions and conferences. When he asks how many physicians have nitrous oxide available during deliveries at their hospitals, he said, very few raise their hands.

His systematic review of 11 randomized controlled trials of nitrous oxide for labor pain reported that more than half of laboring women in the United Kingdom and Finland use nitrous oxide, which is widely employed and considered safe in Canada, Australia, New Zealand, and many other parts of the world when supervised by physicians, nurses, or midwives (Am. J. Obstet. Gynecol. 2002;186:S110-26).

He also assessed eight controlled trials and eight observational studies for potential adverse outcomes and performed a nonsystematic review of studies on occupational exposure. Potential side effects from nitrous oxide include maternal nausea, vomiting, or poor recall of labor, but it does not seem to affect the fetus, as seen with narcotics.

“Nitrous oxide is not a potent labor analgesic, but it is safe for parturient women, their newborns, and health care workers in attendance during its administration. It appears to provide adequately effective analgesia for many women,” he concluded.

An estimated 6% of U.S. women in labor used nitrous oxide in the decade leading up to 1986, but by the 1990s the use of nitrous oxide in labor had nearly disappeared in the United States, his report noted. “I really don't understand why this simple but weakly effective analgesic doesn't have more use in the United States,” Dr. Rosen said.

Ms. Bishop suggested that habit and tradition have more to do with its use than science. “We develop our own routines within practices, institutions, and countries. It is really not in most cases about what's 'right' or 'best,' just what the decision-makers decide,” she said.

Before she and Dr. Rosen arrived at the university, the director of obstetric anesthesia was an Englishman.

“I imagine he had good experience with nitrous oxide and was comfortable with it,” she speculated. Dr. Rosen trained under his predecessor and also spent some time in England.

A midwife colleague at the University of Michigan told Ms. Bishop that use of nitrous oxide for labor started in Michigan in 1978 when a British physician became chair of obstetric anesthesia. “Its use became quite popular,” but the chair's successor in 1995 removed it as an option, she said.

“We tend in the United States to go with the higher-tech approach to health care—doctors, not midwives, and epidurals, not nitrous oxide—dropping off lower-tech options even though they may still serve a purpose,” Ms. Bishop noted.

Market forces also may play a role in the demise of U.S. use of nitrous oxide for labor, midwife and epidemiologist Judith Rooks suggested in a recent editorial (Birth 2007;34:3-5). “Obstetric use of nitrous oxide in America is similar to that of any older, inexpensive, off-patent, unglamorous, safe and reasonably effective but not highly potent drug. Nitrous oxide is like an 'orphan' drug—little known outside of dentistry, lacking elan and pizzazz, with no companies or influential professional groups that stand to profit by its greater use,” she wrote.

“There is no 'nitrous lobby,'” Ms. Bishop added.

SAN FRANCISCO — A simple technique to help manage labor pain is used commonly in the United Kingdom, Scandinavia, and Canada, but is offered to few U.S. women—nitrous oxide, or so-called “laughing gas.”

Administered as a 50/50 blend of oxygen and nitrous oxide, the gas has proved safe for mothers, their babies, and health care personnel in the vicinity of use, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

It's relatively weak as an analgesic, yet useful. One woman who delivered at the university described how it felt to use nitrous oxide during labor by saying, “It still hurts, but I don't care,” recalled Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the university.

“I've heard that more than once. It's not too dissimilar from some reports from women who are using nonpharmacologic methods,” she noted. “They may have rated their pain somewhat highly, but their satisfaction and their ability to cope was improved.”

Her institution has large holding tanks of oxygen and nitrous oxide that get piped into every labor and delivery room. Three cables control the flow—one for each gas, and one to scavenge the gas from the environment and remove it from the room.

The mother controls the application of the gas. She's given a mask and some instructions on its use by the anesthesiologist, midwife, or obstetrician, with ongoing supervision by a nurse. The full effect of nitrous oxide can be felt in 50 seconds.

Because it's simple and fast to start or stop, nitrous oxide is particularly useful through the second stage of labor for multiparous women who arrive in time to deliver but too late to get an epidural, she said. Nitrous oxide also can be used during perineal repair of women who didn't get an epidural.

Very few U.S. medical centers offer nitrous oxide during labor, for reasons that are unclear. “Many, many places are asking us for information about nitrous oxide. We have a protocol for nurses and certified nurse-midwives to administer” nitrous oxide, Ms. Bishop said. The University of Washington is the only other medical center that she knows of that offers nitrous oxide for labor pain.

Dr. Mark A. Rosen, director of obstetric anesthesia at the university and author of a review of nitrous oxide during labor, said in an interview that he has taken informal polls while lecturing at other institutions and conferences. When he asks how many physicians have nitrous oxide available during deliveries at their hospitals, he said, very few raise their hands.

His systematic review of 11 randomized controlled trials of nitrous oxide for labor pain reported that more than half of laboring women in the United Kingdom and Finland use nitrous oxide, which is widely employed and considered safe in Canada, Australia, New Zealand, and many other parts of the world when supervised by physicians, nurses, or midwives (Am. J. Obstet. Gynecol. 2002;186:S110-26).

He also assessed eight controlled trials and eight observational studies for potential adverse outcomes and performed a nonsystematic review of studies on occupational exposure. Potential side effects from nitrous oxide include maternal nausea, vomiting, or poor recall of labor, but it does not seem to affect the fetus, as seen with narcotics.

“Nitrous oxide is not a potent labor analgesic, but it is safe for parturient women, their newborns, and health care workers in attendance during its administration. It appears to provide adequately effective analgesia for many women,” he concluded.

An estimated 6% of U.S. women in labor used nitrous oxide in the decade leading up to 1986, but by the 1990s the use of nitrous oxide in labor had nearly disappeared in the United States, his report noted. “I really don't understand why this simple but weakly effective analgesic doesn't have more use in the United States,” Dr. Rosen said.

Ms. Bishop suggested that habit and tradition have more to do with its use than science. “We develop our own routines within practices, institutions, and countries. It is really not in most cases about what's 'right' or 'best,' just what the decision-makers decide,” she said.

Before she and Dr. Rosen arrived at the university, the director of obstetric anesthesia was an Englishman.

“I imagine he had good experience with nitrous oxide and was comfortable with it,” she speculated. Dr. Rosen trained under his predecessor and also spent some time in England.

A midwife colleague at the University of Michigan told Ms. Bishop that use of nitrous oxide for labor started in Michigan in 1978 when a British physician became chair of obstetric anesthesia. “Its use became quite popular,” but the chair's successor in 1995 removed it as an option, she said.

“We tend in the United States to go with the higher-tech approach to health care—doctors, not midwives, and epidurals, not nitrous oxide—dropping off lower-tech options even though they may still serve a purpose,” Ms. Bishop noted.

Market forces also may play a role in the demise of U.S. use of nitrous oxide for labor, midwife and epidemiologist Judith Rooks suggested in a recent editorial (Birth 2007;34:3-5). “Obstetric use of nitrous oxide in America is similar to that of any older, inexpensive, off-patent, unglamorous, safe and reasonably effective but not highly potent drug. Nitrous oxide is like an 'orphan' drug—little known outside of dentistry, lacking elan and pizzazz, with no companies or influential professional groups that stand to profit by its greater use,” she wrote.

“There is no 'nitrous lobby,'” Ms. Bishop added.