Obstetrics and Gynaecology

Twelve Tests and Treatments to Question

by
Society of Obstetricians and Gynaecologists of Canada
Last updated: August 2021

Don’t do routine episiotomy in spontaneous or instrumented vaginal births.
1

Routine episiotomy has been shown to cause more harm than good. Studies demonstrate that restrictive episiotomy policies are associated with less posterior perineal trauma, less suturing, and fewer complications, with no difference for most pain measures or severe vaginal and/or perineal trauma. When the perineum is preventing delivery, particularly if the fetal heart rate is abnormal, an episiotomy may expedite a vaginal birth.

Sources:

Carroli G, et al. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2000;(2):CD000081. PMID: 10796120.

Lee L, et al. Management of Spontaneous Labour at Term in Healthy Women. J Obstet Gynaecol Can. 2016 Sep;38(9):843-865. PMID: 27670710.
Don’t do electronic fetal monitoring for low risk women in labour; use intermittent auscultation.
2

Continuous electronic fetal monitoring (EFM) leads to significantly greater rates of caesareans and operative vaginal deliveries in low risk patients compared to those monitored with intermittent auscultation. Intermittent auscultation results in no significant difference in the number of infant deaths during and shortly after labour, cerebral palsy rates, use of drugs for pain relief, and cord blood acidosis in low risk patients. Further, EFM restricts movement and positioning, excludes the option of using a birthing pool, and requires greater resource use to continuously interpret fetal heart rate tracings. EFM therefore increases risk of intervention and decreases choice without providing meaningful benefit to patient or neonatal outcomes in low risk patients.

Sources:

Alfirevic Z, et al. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2017 Feb 3;2:CD006066. PMID: 28157275.

Leveno KJ, et al. A Prospective Comparison of Selective and Universal EFM in 34,995 Pregnancies. N Engl J Med. 1986 Sep 4;315(10):615-9. PMID: 3736600.

Liston R, et al. Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline: Fetal Health Surveillance in Labour [Internet]. J Obstet Gynaecol Can. 2007 Sep [cited 2017 May 29];29(9):S27.

Mires G, et al. Randomised controlled trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labour in low risk obstetric population. BMJ. 2001 Jun 16;322(7300):1457-60; discussion 1460-2. PMID: 11408301.
Don’t perform routine urinalysis (protein, glucose) at every antenatal visit (in low risk normotensive women).
3

Routine urinalysis (for glucose and protein) in low-risk pregnancies is not recommended. For screening of healthy pregnant women, urinalysis for glucose to assess the risk of developing gestational diabetes is not recommended due to low sensitivity. For assessing the potential development of preeclampsia in pregnant women, routine urine dipstick or urinalysis are not recommended as the test for albumin levels is unreliable. Do not rely on proteinuria to screen for gestational hypertension; periodically check the blood pressure.

Sources:

Akkerman D, et al. Routine prenatal care [Internet]. 2012 Jul [cited 2017 May 29]. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI).

Atacag T, et al. Asymptomatic bacteriuria screened by catheterized samples at pregnancy term in women undergoing cesarean delivery. Clin Exp Obstet Gynecol. 2015;42(5):590-4. PMID: 26524804.

Committee on Obstetric Practice, The American College of Obstetricians and Gynecologists. Committee Opinion No. 692: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol. 2017 Apr;129(4):e90-e95. PMID: 28333820.

National Institute for Health and Care Excellence. Diabetes in pregnancy: Management of diabetes from preconception to the postnatal period [Internet]. 2015 Feb [cited 2017 May 29].

Sperling JD, et al. Screening for Preeclampsia and the USPSTF Recommendations. JAMA. 2017 Apr 25;317(16):1629-1630. PMID: 28444259.

US Preventive Services Task Force, et al. Screening for Preeclampsia: US Preventive Services Task Force Recommendation Statement. JAMA. 2017 Apr 25;317(16):1661-1667. PMID: 28444286.
Don’t perform umbilical artery Doppler studies as a routine screening test in uncomplicated pregnancies with normal fetal growth.
4

Placental integrity, specifically vascular resistance, may be assessed by evaluating flow in the umbilical arteries using Doppler ultrasound. When this is done with high risk pregnancies the perinatal death rate is reduced and interventions may be appropriately timed or withheld. “High risk” in these investigations were principally related to intrauterine growth restriction and maternal hypertension. When Doppler studies were extended to low-risk pregnancies however there was no improvement in outcome and abnormal results were more likely to be false positives.

Sources:

Alfirevic Z, et al. Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane Database Syst Rev. 2013 Nov 12;(11):CD007529. PMID: 24222334.

Alfirevic Z, et al. Fetal and umbilical Doppler ultrasound in normal pregnancy. Cochrane Database Syst Rev. 2015 Apr 15;(4):CD001450. PMID: 25874722.
Don’t routinely screen with Pap smears if under 21 years of age or over 69 years of age.
5

Screening should be initiated at 21 years of age for those who are asymptomatic and immunocompetent. Studies have shown the largest number of false positive test results occurring in adolescents younger than 21 years and have the lowest incidence of cervical cancer. There is no protective effect in screening those younger than 21 years. There are few studies that address the age of cessation. Modelling studies have not shown increase in protective effect when screening those greater than 70 years who have had prior routine screening.

Sources:

Kulasingam SL, et al. Screening for Cervical Cancer: A Decision Analysis for the US Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 May. Report No.: 11-05157-EF-1. PMID: 22553886.

Miller AB, et al. Report of a National Workshop on Screening for Cancer of the Cervix. CMAJ. 1991 Nov 15;145(10):1301-25. PMID: 1933712.

Moyer VA, et al. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Jun 19;156(12):880-91, W312. PMID: 22711081.

Murphy J, et al. Cervical Screening: A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO) [Internet]. 2001 Oct 5 [cited 2017 May 29].

Sasieni P, et al. Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data. BMJ. 2009 Jul 28;339:b2968. PMID: 19638651.

Related Resources:

Patient Pamphlet: Pap Tests: When you need them and when you don’t
Don’t routinely order hormone levels including estradiol, progesterone, follicle-stimulating hormone and luteinizing hormone in postmenopausal women or after a hysterectomy, either to diagnose menopause or to manage hormone therapy.
6

The frequency and severity of menopausal symptoms do not correlate to the levels of either follicle-stimulating hormone (FSH) or serum estradiol. Reproductive estrogen levels are typically much higher than required to reduce symptoms. Management with hormone therapy is based on using the lowest effective dose to reduce symptoms to an acceptable level. Relying on elevated FSH to make a diagnosis may result in women being denied effective therapy for disruptive symptoms; use of an unreliable test may in this way contribute to less than optimal care. Using blood levels to adjust hormone therapy may result in higher doses of hormone therapy than are needed to reduce and manage symptoms.

Sources:

Harlow SD, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. J Clin Endocrinol Metab. 2012 Apr;97(4):1159-68. PMID: 22344196.

National Institute for Health and Care Excellence. Menopause: diagnosis and management [Internet]. 2015 Nov [cited 2017 May 29].

Reid R, et al. Managing menopause. J Obstet Gynaecol Can. 2014 Sep;36(9):830-833. PMID: 25222364.
Don’t screen for ovarian cancer in asymptomatic women at average risk.
7

Screening for ovarian cancer does not improve clinical outcomes in asymptomatic women without a family history of the disease. Screening does not decrease all-cause mortality, ovarian cancer mortality or the risk of diagnoses of advanced stage ovarian cancer. There is no demonstrable benefit on mortality following transvaginal ultrasonography or routine pelvic screening examinations and the use of CA125 or other biomarkers for ovarian cancer but such screening resulted in false-positive tests, overdiagnosis, and overtreatment with inevitable complications.

Sources:

Buhling KJ, et al. The role of transvaginal ultrasonography for detecting ovarian cancer in an asymptomatic screening population: a systematic review. Arch Gynecol Obstet. 2017 May;295(5):1259-1268. PMID: 2835755.

Guirguis-Blake JM, et al. Periodic Screening Pelvic Examination: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2017 Mar 7;317(9):954-966. PMID: 28267861.

Luzak A, et al. Clinical effectiveness of cancer screening biomarker tests offered as self-pay health service: a systematic review. Eur J Public Health. 2016 Jun;26(3):498-505. PMID: 26733629.

Pinsky PF, et al. Extended mortality results for ovarian cancer screening in the PLCO trial with median 15years follow-up. Gynecol Oncol. 2016 Nov;143(2):270-275. PMID: 27615399.

Reade CJ, et al. Risks and benefits of screening asymptomatic women for ovarian cancer: a systematic review and meta-analysis. Gynecol Oncol. 2013 Sep;130(3):674-81. PMID: 23822892.

US Preventive Services Task Force, et al. Screening for Gynecologic Conditions With Pelvic Examination: US Preventive Services Task Force Recommendation Statement. JAMA. 2017 Mar 7;317(9):947-953. PMID: 28267862.
Don’t offer hysterectomy to women with asymptomatic fibroids on the basis of risk malignancy.
8

Rapid growth of a fibroid is not a predictor of leiomyosarcoma. In women undergoing surgery for fibroids approximately 1 in 400 (0.25%) is at risk of having a leiomyosarcoma. However, growth and/or new onset of symptoms post-menopause should carry a higher index of suspicion for malignancy. Incidental uterine leiomyosarcomas have been encountered during routine resectoscopic myomectomy, though their incidence appears to be lower than that reported following hysterectomy (0.13%). Leiomyomas and leiomyosarcomas cannot reliably be distinguished clinically or by any imaging technique.

Sources:

Knight J, et al. Tissue extraction by morcellation: a clinical dilemma. J Minim Invasive Gynecol. 2014 May-Jun;21(3):319-20. PMID: 24646445.

Parker WH, et al. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol. 1994 Mar;83(3):414-8. PMID: 8127535.

Vilos GA, et al. Miscellaneous uterine malignant neoplasms detected during hysteroscopic surgery. J Minim Invasive Gynecol. 2009 May-Jun;16(3):318-25. PMID: 19423062.

Vilos GA, et al. The management of uterine leiomyomas. J Obstet Gynaecol Can. 2015 Feb;37(2):157-178. PMID: 25767949.
Don’t do any surgical intervention, including ablation, for abnormal uterine bleeding until medical management (including the progesterone intra-uterine system) has been offered and either declined or found unsuccessful.
9

There are several non-hormonal and hormonal agents that have proven to be effective in the treatment of abnormal uterine bleeding. Some of these may have the added benefit of providing symptom relief for dysmenorrhoea and offer contraceptive coverage. These agents may help stabilize anaemia and provide symptom relief alone, or may be utilized prior to surgical management of heavy menstrual bleeding. Medical management allows for early initiation of treatment in a primary care setting whereas surgical intervention may be limited by access to specialist consultation and operating facilities. All potential treatment options for abnormal uterine bleeding should be discussed with the patient and their side-effects, relative effectiveness, risks, costs and impact on fertility outlined so that an informed shared treatment decision can be made and a treatment plan instituted.

Sources:

Health Quality Ontario. Heavy Menstrual Bleeding: Care for Adults and Adolescents of Reproductive Age [Internet]. 2017 [cited 2017 May 29].

Laberge P, et al. SOGC clinical practice guideline: endometrial ablation in the management of abnormal uterine bleeding [Internet]. J Obstet Gynaecol Can. 2015 Apr [cited 2017 May 29];322:362-76.

Munro MG, et al. Acute uterine bleeding unrelated to pregnancy: a Southern California Permanente Medical Group practice guideline [Internet]. Perm J. 2013 [cited 2017 May 29]:17(3):43-56.

National Collaborating Centre for Women’s and Children’s Health (UK). Heavy menstrual bleeding. London: RCOG Press; 2007 Jan. PMID: 21938862.

Sukhbir S, et al. Abnormal uterine bleeding in pre-menopausal women [Internet]. J Obstet Gynaecol Can. 2013 May [cited 2017 May 29]:35(5);473-9.

Vilos GA, et al. SOCG clinical practice guideline: the management of uterine leiomyomas [Internet]. J Obstet Gynaecol Can. 2015 Feb [cited 2017 May 29]:318:157-81.
Don’t remove ovaries in premenopausal women without strong clinical indications.
10

Large US population-based databases have estimated the rate of bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy for benign indications to be 46.4%. When stratified by age, the rates of oophorectomy in women 45-49 years is approximately 60%, and in women >55 years is 65-75%. Studies have shown increase in all-cause mortality, coronary heart disease and cardiovascular death in women with BSO <50 years. These risks may be modified with hormone therapy. BSO has also been shown to increase risk of cognitive impairment and dementia, as well as increase long-term risks of depressive and anxiety symptoms. While BSO has been shown to reduce incidence of ovarian and breast cancer, there are conflicting studies on the impact of BSO on colorectal and lung cancer. Clinical indications for BSO in premenopausal women include women with increased genetic risk for ovarian cancer (BRCA 1, BRCA 2, and Lynch Syndrome) and endometriosis.

Sources

Adelman MR, Sharp HT. Ovarian conservation vs removal at the time of benign hysterectomy. Am J Obstet Gynecol. 2018;218(3):269-279. PMID: 28784419.

Evans EC, Matteson KA, Orejuela FJ, et al. Salpingo-oophorectomy at the Time of Benign Hysterectomy: A Systematic Review. Obstet Gynecol. 2016;128(3):476-485. PMID: 27500347.

Jacoby VL, Grady D, Wactawski-Wende J, et al. Oophorectomy vs ovarian conservation with hysterectomy: cardiovascular disease, hip fracture, and cancer in the Women’s Health Initiative Observational Study. Arch Intern Med. 2011;171(8):760-768. PMID: 21518944.

Parker WH, Broder MS, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses’ health study. Obstet Gynecol. 2009;113(5):1027-1037. PMID: 19384117.

Parker WH, Feskanich D, Broder MS, et al. Long-term mortality associated with oophorectomy compared with ovarian conservation in the nurses’ health study. Obstet Gynecol. 2013;121(4):709-716. PMID: 23635669.

Perera HK, Ananth CV, Richards CA, et al. Variation in ovarian conservation in women undergoing hysterectomy for benign indications. Obstet Gynecol. 2013;121(4):717-726. PMID: 23635670.

Rocca WA, Bower JH, Maraganore DM, et al. Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause. Neurology. 2007;69(11):1074-1083. PMID: 17761551.

Rocca WA, Grossardt BR, Geda YE, et al. Long-term risk of depressive and anxiety symptoms after early bilateral oophorectomy. Menopause. 2018;25(11):1275-1285.
Don’t do a caesarean delivery for the sole indication of failure of progress in labour in the latent phase of labour for a woman at term with a singleton fetus and cephalic presentation.
11

Women who do not make progress in cervical dilatation at less than 4 cm can be managed expectantly, with analgesia and rest as needed. They generally have good outcomes and can often deliver vaginally with no further complications, similar to women who did not have a prolongation of the latent phase of labour. According to the SOGC Clinical Practice Guideline on Management of Labour, “Dystocia cannot be diagnosed prior to the onset of labour or during the latent phase of labour; caesarean section carried out at this time for an indication of dystocia is inappropriate.” The end of the latent phase is subject to reassessment, the transition to an active phase is easier to diagnose retrospectively. A description of labour curves suggest that the end of the latent phase may be at 6 cm, rather than 4 cm and that overall progress is slower than that originally described. Each obstetrical unit must decide the definition of entry into the active phase of the first stage of labour. Regardless, intervention for a diagnosis of presumed dystocia is inappropriate in whatever may be considered the latent phase. Women should be allowed the opportunity to advance in labour, which many will do if given time, and achieve a vaginal delivery and avoid a caesarean delivery.

Sources

American College of Obstetricians and Gynecologists. Safe prevention of the primary Cesarean delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93. PMID: 24565430.

Boyle A, Reddy UM, Landy HJ et al. Primary Cesarean Delivery in the United States. Obstet Gynecol 2013; 122:33 – 40.

Friedman EA. Labour: clinical evaluation and management. Second edition. New York: Appleton Century Croft; 1978

Lee L, Dy J, Azzam H. Management of Spontaneous Labour at Term in Healthy Women. J Obstet Gynaecol Can 2016; 38:843 – 865. PMID: 27670710.

Zhang J, Troendle JF, Yancey, MK. Reassessing the labour curve in nulliparous women. Am J Obstet 2002; 187:824 – 28. PMID: 12388957.
Don’t give antenatal corticosteroid therapy unless the pregnant woman meets the gestational age criteria and the risk of delivery within the next 7 days is very high.
12

The likelihood of preterm delivery and also the gestational age need to be carefully considered when contemplating the use of antenatal corticosteroid therapy among pregnant women. The efficacy of such therapy is highest when the course is given 24 hours to 7 days prior to delivery. Administration more than 7 days before delivery leads to reduced benefit and potentially unnecessary adverse effects . Trials enrolling pregnant women from 24 + 0 to 34 + 6 weeks gestation at high risk of preterm birth show that antenatal corticosteroid therapy significantly reduces perinatal death, respiratory distress syndrome, and intraventricular hemorrhage in the infants who in fact delivered pre-term. Evidence from cohort studies shows a significant reduction in perinatal mortality among infants exposed to antenatal corticosteroid therapy at less than 24 weeks gestation. Women between 22 + 0 weeks and 23 + 6 weeks gestation at high risk of preterm birth within the next 7 days should be provided with a multidisciplinary consultation regarding the high likelihood for severe perinatal morbidity and mortality, and associated maternal morbidity. Steroids should be given if intensive care for the baby is planned.

Sources

Asztalos E, Willan A, Murphy K, et al. Association between gestational age at birth, antenatal corticosteroids, and outcomes at 5 years: multiple courses of antenatal corticosteroids for preterm birth study at 5 years of age (MACS-5). BMC Pregnancy Childbirth 2014;14:272. PMID: 25123162.

Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2006;(3):CD004454. PMID: 16856047.

Skoll A, Boutin A, Bujold E, Burrows J, Crane J, Geary M, Jain V, Lacaze-Masmonteil T, Liauw J, Mundle W, Murphy K, Wong S, Joseph KS. No. 364-Antenatal Corticosteroid Therapy for Improving Neonatal Outcomes. J Obstet Gynaecol Can 2018;40(9):1219-1239. PMID: 30268316.
How the list was created

The Society of Obstetricians and Gynaecologists of Canada (SOGC) struck a small working group to oversee the Choosing Wisely Canada list development process. An initial list of recommendations was compiled from all published SOGC guidelines. The list was reviewed by the Choosing Wisely committee, who provided input and guidance. A long list was then created from four sources: SOGC guidelines, Choosing Wisely recommendations published by American societies (notably the American College of Obstetricians and Gynaecologists), Canadian Choosing Wisely recommendations relevant to Ob/Gyn, and other proposals from SOGC members. The refined list was circulated to all members of the Clinical Practice – Obstetrics and Gynaecology committees then further refined by the Board of Directors. A list consisting of 24 recommendations (sorted based on specialty: obstetrics; gynaecology and generalist) was generated and circulated to the wider SOGC membership to obtain the final list.