Professional Documents
Culture Documents
November 2009
November 2009
FOREWORD!
LOURDES B. CAPITO, MD
President
Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2009
LOURDES BLANCO-CAPITO, MD
INTRODUCTION!
Susan Pelea-Nagtalon, MD
Ma. Carmen H. Quevedo, MD
Raul M. Quillamor, MD
Ma. Socorro M. Solis, MD
Joseline A. Ferrolino, MD
Ma. Corazon N. Gamilla, MD
Erlinda G. Germar, MD
Ma. Antonia E. Habana, MD
Myrna R. Habaa, MD
Bernardita B. Javier, MD
Genara M. Limson, MD
Lilia P. Luna, MD
Augusto M. Manalo, MD
Diosdado V. Mariano, MD
Jocelyn Z. Mariano, MD
Christia S. Padolina, MD
Mildred N. Pareja, MD
Regional Directors
Ellen A. Manzano, MD (Region 1)
Melchor C. dela Cruz, MD (Region 2)
Concepcion P. Aronza, MD (Region 3)
Ernesto S. Naval, MD (Region 4)
Rowena M. Auxillos, MD (Region 4A)
Cecilia Valdes-Neptuno, MD (Region 5)
Wilhelmina Pineda, MD
Patria P. Punsalan, MD
Rebecca M. Ramos, MD
Cristina C. Raymundo, MD
Marilyn D. Ruaro, MD
Sherri Ann L. Suplido, MD
Walfrido W. Sumpaico, MD
Carmencita B. Tongco, MD
Ma. Victoria Torres, MD
Milagros P. Torres, MD
Ma. Trinidad R. Vera, MD
Ma. Guadalupe N. Villanueva, MD
This is the Clinical Practice Guidelines (CPG) on Abnormal Labor and Delivery, First
Edition, November 2009.
This is the publication of the Philippine Obstetrical and Gynecological Society,
(Foundation), Inc. (POGS).
This is the ownership of the POGS, its officers, and its entire membership.
The obstetrician gynecologist, the general practitioner, the patient, the student, the
allied medical practitioner, or for that matter, any capacity of the person or individual
who may read, quote, cite, refer to, or acknowledge, any, or part, or the entirety of
any topic, subject matter, diagnostic condition or idea/s willfully release and waive all
the liabilities and responsibilities of the POGS, its officers and general membership,
as well as the AdHoc Commiittee on the Clinical Practice Guidelines and its Editorial
Staff in any or all clinical or other disputes, disagreements, conference
audits/controversies, case discussions/critiquing.
The reader is encouraged to deal with each clinical case as a distinct and unique
clinical condition which will never fit into an exact location if reference is made into
any or all part/s of this CPG.
The intention and objective of this CPG is to serve as a guide, to clarify, to make
clear the distinction. It is not the intention or objective of this CPG to serve as the
exact and precise answer, solution and treatment for clinical conditions and situations.
It is always encouraged to refer to the individual clinical case as the one and only
answer to the case in question, not this CPG.
It is hoped that with the CPG at hand, the clinician will find a handy guide that leads
to the a clue, to a valuable pathway that leads to the discovery of clinical tests leading
to clinical treatments and eventually recovery.
In behalf of the POGS, its Board of Trustees, the AdHoc Committee on The Clinical
Practice Guidelines, 2009, this CPG is meant to make each one of us a perfect image
of Christ, the Healer.
II.
Dystocia
Dr. Sylvia A. Carnero
A. Definitions of Abnormal Patterns of Labor .
B. Recommendations
III.
Appendix .
I
ELECTRONIC FETAL MONITORING
DURING ABNORMAL LABOR AND DELIVERY
Christia S. Padolina, MD, FPOGS
Definition
The mean fetal heart rate (FHR) rounded to increments of 5 beats per
minute during a 10-minute segment, excluding:
- Periodic or episodic changes
- Periods of marked FHR variability
- Segments of baseline that defer by more than 25 beats per min
The baseline must be for a minimum of 2 minutes in any 10-minute
segment, or the baseline for that time period is indeterminate. In this case,
one may refer to the prior 10-minute window for determination of
baseline.
Normal FHR baseline: 110-160 beats per minute
Tachycardia: FHR baseline is greater than 160 beats per minute
Bradycardia: FHR baseline is less than 110 beats per minute
Baseline
Fluctuations in the baseline FHR that are irregular in amplitude and
variability
frequency.
Variability is visually quantified as the amplitude of peak-to-trough in
beats per minute.
" Absent amplitude range undetectable
" Minimal amplitude range detectable but 5 beats per minute or fewer
" Moderate (Normal) amplitude range 6-25 beats per minute
" Marked amplitude range greater than 25 beats per minute
Acceleration A visually apparent abrupt increase (onset to peak in less than 30
seconds) in the FHR
Early
deceleration
Late
deceleration
Variable
deceleration
Prolonged
deceleration
Sinusoidal
pattern
deceleration.
The nadir of the deceleration occurs at the same time as the peak of the
contraction.
In most cases the onset, nadir, and recovery of the deceleration are
coincident with the beginning, peak, and ending of the contraction,
respectively.
Visually apparent usually symmetrical gradual decrease and return of the
FHR associated with a uterine contraction.
A gradual FHR decrease is defined as from the onset to the FHR nadir of
30 seconds or more.
The decrease in FHR is calculated from the onset to the nadir of the
deceleration.
The deceleration is delayed in timing, with the nadir of the deceleration
occurring after the peak of the contraction.
In most cases, the onset, nadir, and recovery of the deceleration occur
after the beginning, peak, and ending of the contraction, respectively.
Visually apparent abrupt decrease in FHR
An abrupt FHR decrease is defined as from the onset of the deceleration
to the beginning of the FHR nadir less than 30 seconds.
The decrease in FHR is calculated from the onset to the nadir of the
deceleration.
The decrease in FHR is 15 beats per minute or greater, lasting 15 seconds
or greater, and less than 2 minutes in duration.
When variable decelerations are associated with uterine contractions,
their onset, depth, and duration commonly vary with successive uterine
contractions.
Visually apparent decrease in the FHR below the baseline
Decrease in FHR from the baseline that is 15 beats per minute or more,
lasting 2 minutes or more but less than 10 minutes in duration.
If a deceleration lasts 10 minutes or longer, it is a baseline change.
Visually apparent, smooth, sine wave-like undulating pattern in FHR
baseline with a cycle frequency of 3-5 per minute which persists for 20
minutes or more.
FHR Tracings
Normal
II
Indeterminate
III
Abnormal
Definition
Category 1 FHR tracings are strongly predictive of
normal fetal acid-base status at the time of observation.
Category 1 FHR tracings may be monitored in a routine
manner, and no specific action is required.
Category II FHR tracings are not predictive of abnormal
fetal acid-base status, yet presently there is not adequate
evidence to classify these as Category I or category III.
Category II FHR tracings require evaluation and
continued surveillance and reevaluation, taking into
account the entire associated clinical circumstances.
In some circumstances, either ancillary tests to ensure
fetal well being or intrauterine resuscitative measures
may be used with Category II tracings.
Category III tracings are associated with abnormal fetal
acid-base status at the time of observation.
Category III FHR tracings require clinical evaluation.
Depending on the clinical situation, efforts to
expeditiously resolve the abnormal FHR pattern may
include but are not limited to provision of maternal
oxygen, change in maternal position, discontinuation of
labor stimulation, treatment of maternal hypotension, and
treatment of tachysystole with FHR changes.
If category III tracing does not resolve with these
measures, delivery should be undertaken.
2. Based on available data, there is no clear benefit for the use of EFM over IA.
Either option is acceptable in a patient without complications.3 (Level III, Grade
C)
The use of EFM compared with IA increased the overall cesarean delivery
rate (RR, 1.66; 95% CI, 1.30-2.13) and the cesarean delivery rate for
abnormal FHR or acidosis or both (RR, 2.37; 95% CI, 1.88-3.00).
The use of EFM increased the risk of both vacuum and forceps operative
vaginal delivery (RR, 1.16; 95% CI, 1.01-1.32).
The use of EFM did not reduce prenatal mortality (RR, 0.85; 95% CI, 0.591.23)
The use of EFM reduced the risk of neonatal seizures (RR, 0.50; 95% CI,
0.31-0.80).
The use of EFM did not reduce the risk of cerebral palsy (RR, 1.74; 95% CI,
0.97-3.11).
3. In ideal settings, continuous EFM should be offered and is recommended for high
risk pregnancies where there is increased risk of perinatal dealth, cerebral palsy or
neonatal encephalopathy6-9. (Level II-2 to III, Grade C)
4. Current evidence does not support the use of admission tocogram in low risk
pregnancy10. (Level III, Grade C)
5. Based on careful review of available terminologies, a three-tiered system of
categorization of FHR interpretation is recommended1. (Level III, Grade C)
Category
Baseline FHR
I
110-160 beats
per minute
Baseline
variability
Moderate
Decelerations
Absent early,
late or
variable
II
Bradycardia not accompanied
by absent baseline variability or
Tachycardia
Minimal baseline variability
Absent baseline variability with
no recurrent decelerations
Marked baseline variability
Recurrent variable decelerations
accompanied by minimal or
moderate baseline variability
Prolonged deceleration more
than 2 minutes but less than 10
minutes
Recurrent late decelerations
with moderate baseline
variability
Variable decelerations with
other characteristics such as
slow return to baseline,
overshoots, or shoulders
III
Bradycardia
Absent
Recurrent late
decelerations
Recurrent
variable
decelerations
Accelerations
Present or
Absent
Absence of induced
accelerations after fetal
stimulation
Sinusoidal
pattern
The false-positive rate of EFM for predicting cerebral palsy is high, at greater
than 99%.6-9 (Level II-2 to III, Grade C)
The use of EFM is associated with an increased rate of both vacuum and
forceps operative vaginal delivery, and caesarean delivery for abnormal FHR
patterns or acidosis or both. 6-9 (Level II-2 to III, Grade C)
When the FHR tracing includes recurrent variable decelerations,
amnioinfusion to relieve umbilical cord compression should be considered.11
(Level II-1, Grade B)
Pulse oximetry has not been demonstrated to be a clinically useful test in
evaluating fetal status.12 (Level III, Grade C)
There is high interobserver and intraobserver variability in interpretation of
FHR tracing. 13-14 (Level III, Grade C)
Reinterpretation of the FHR tracing, especially if the neonatal outcome is
known, may not be reliable. 13-14 (Level III, Grade C)
The use of EFM does not result in a reduction of cerebral palsy. 13-14 (Level
III, Grade C)
A three-tiered system for the categorization of FHR patterns is recommended.
1
(Level III, Grade C)
The labor of women with high-risk conditions should be monitored with
continuous FHR monitoring. 1 (Level III, Grade C)
The terms hyperstimulation and hypercontractility should be abandoned. It is
now called uterine tachysystole (i.e. more than 5 contractions in 10 minutes,
averaged over a 30-minute window). 1 (Level III, Grade C)
Category III fetal heart tracings include fetal scalp pH sampling, Allis clamp
stimulation, vibroacoustic stimulation and digital scalp stimulation.15 (Level II-3,
Grade B)!
Because vibroacoustic stimulation and digital scalp stimulation is less
invasive than the other two methods, they are the preferred methods. 16 (Level
I, Grade A).
7. A Category II or Category III FHR tracing requires initial evaluation and
treatment may include the following17 (Level III, Grade C):
Discontinuation of any labor stimulating agent
Cervical examination to determine umbilical cord prolapse, rapid cervical
dilatation, or descent of the fetal head.
Changing maternal position to left or right lateral recumbent position,
reducing compression of the vena cava and improving uteroplacental blood
flow
References
1. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National
Institute of Child Health and Human Development workshop report on
electronic fetal monitoring: update on definitions, interpretation, and research
guidelines. Obstet Gynecol 2008; 112:661-6.
2. Reference for the Classification of FHR Tracings Three Tiered System for the
Categorization of FHR Patterns???
3. Freeman RK. Problems with intrapartum fetal heart rate monitoring interpretation
and patient management. Obstet Gynecol 2002;100:813-26.
4. NICE Guidelines for the Frequency of Intermittent Auscultation??
5. Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a
form of electronic fetal monitoring (EFM) for fetal assessment during labour.
Cochrane Database of Systemic Reviews 2006, Issue 3. Art. No.: CD006066.
DOI: 10.1002/14651858.CD006066.
6. Nelson KB, Dambrosia JM, Ting TY, Grether JK. Uncertain value of electronic
fetal monitoring in predicting cerebral palsy. N Engl J Med 1996; 334:613-8.
7. Clark St. Hankins GD.temporal and Demographic trends in celebral palsy-fack
and fiction. Am J Obstet Gynecol 2003; 188: 628-33.
8. Hankins GD, Speer M. Defining the pathogenesis and pathophysiology of
neonatal encephalopathy and celebral palsy. Obstet Gynecol 2005;102: 62836.
9. Badawi N. Kurinczuk JJ. Keogh JM, Alessandri LM, OSullivan F, Burton PR, et
al. Antepartum risk factors for newborn encephalopathy: the Western
Australian case control study. BMJ 1998; 317;1549-53.
10. Morrison JC, Chez BF, Davis ID, Martin RW, Roberts WE, Martin JN Jr, et al.
Intrapartum fetal heart rate assessment: monitoring by auscultation or
electronic means. Am J Obstet Gynecol 1993; 168:63-6.
11. Vintzileos AM, Nochimson DJ. Antsaklis A. Varvarigos I. Gusman ER, Knuppel
RA. Comparison of intrapartum electronic fetal heart rate monitoring versus
intermittent auscultation in detecting fetal academia at birth. Am J Obstet
Gynecol 1995; 173:1021-4.
12. Nielsen PV. Stigsby B. Nickelsen C. Nim J. Intra-and inter-observer variability in
the assessment of intrapatum cardiotocogram. Acta Obstet Gynecol Scand
1987;66:421-4.
13. Bliz E, Sviggum O, Koss KS, Oian P. Inter-observer variation in assessment of
845 labour admission tests: comparison between midwives and obstetricians
in the clinical setting and two experts. BJOG 2003;110:1-5.
14. Zain HA, Wright JW, Parish GE, Diehl SJ. Interpreting the fetal heart rate tracing.
Effect of knowledge of neonatal outcome. J Reprod Med 1998;43:367-70.
15. Goodwin TM, Milner-Masterson L, Paul RH. Elimination of fetal scalp blood
sampling on a large clinical service. Obstet Gynecol 1994;83:971-4.
16. Skupski DW, Rosenberg CR, Erlinton GS. Intrapartum fetal stimulation tests: a
meta-analysis Obstet Gynecol 2002;99:129-34.
17. Kulier R, Hofmeyr GJ. Tocolytics for suspected intrapartum fetal distress.
Cochrane Database of Systematic Reviews 1998, Issue 2.
Art.No.:CD000035.DOI:10.1002/14651858.CD000035.
II. Dystocia
Sylvia A. Carnero, MD, FPOGS
A. Definitions of Abnormal Patterns of Labor
Labor Pattern
Prolongation Disorder1
1. Prolonged Latent Phase
Diagnostic Criteria
Nulliparas
Multiparas
> 20 hrs
> 14 hrs
< 2 cm/hr
Protraction Disorders
Arrest Disorders1
1. Prolonged Deceleration Phase
> 3 hrs
> 1 hr
(cervical dilatation arrested at 8 to 9
cm)
2. Secondary Arrest of Dilatation
> 2 hrs
(progressive cervical dilatation stops at
the phase of maximum slope)
3. Arrest of Descent (progressive descent
> 1 hr
stops during pelvic division of labor,
station +1)
4. Failure of Descent1 (station 0)
Lack of expected descent during
deceleration phase or second stage of
labor
5. Prolonged Second Stage4
regional anesthesia
or > 2 hrs without
regional anesthesia
regional anesthesia
or > 1 hr without
regional anesthesia
B. Recommendations in Management
1. Prolonged Latent Phase.
Avoid admission to the labor and delivery area until active labor is
established.3 (Level III, Grade C)
Develop a plan to meet the womans needs either at home or in a nonlaboring hospital unit.3 (Level III, Grade C)
Observation, rest and therapeutic analgesia/strong sedatives are favored
over a more active approach of amniotomy and oxytocin induction.3
(Level III, Grade C)
Support and information from caregivers to provide coping strategies.3, 2
(Level III, Grade C)
Friedman (1972) reported that prolongation of the latent phase did not
adversely influence fetal or maternal morbidity and mortality.4 (Level III,
Grade C)
Data show that patients with prolonged latent phase are no more prone to
develop problems than gravidas with normal latent phases.4 (Level III,
Grade C)
A patient who has a latent phase longer than 20 hours should be expected
to evolve a normal subsequent dilatation and descent if allowed to do so.4
(Level III, Grade C)
It cannot be too strongly stated that patients who are delivered by cesarean
section during the latent phase for no other reason than their lack of
progress are being subjected to this operation unnecessarily most of the
time.4 (Level III, Grade C)
Cesarean section has no place as a method of treatment for prolonged
latent phase without other clear indications like documented CPD or nonreassuring fetal status.4 (Level III, Grade C)
Friedmans recommended approach is support and therapeutic rest by the
use of large doses of narcotic analgesics.4 (Level III, Grade C)
Exceptionally, oxytocin may be undertaken directly if additional 6 to 10
hours delay by rest would be clinically unacceptable as in the presence of
chorioamnionitis.4 (Level III, Grade C)
2. Protracted Active Phase Dilatation
Physical and emotional support2 (Level I, Grade A)
3. Arrest Disorders
Continuous support during labor from caregivers should be encouraged
because it is beneficial for women and their newborns. 2,5,6 (Level I, Grade
A)
X-ray pelvimetry alone as a predictor of dystocia has not been shown to
have benefit, and therefore is not recommended.8 (Level I, Grade B)
Rule out CPD1 (Level III, Grade B)
If with CPD, do cesarean section1 (Level III, Grade B)
Before an arrest disorder can be diagnosed in the first stage of labor, the
latent phase should be completed, and the uterine contraction pattern
exceeds 200 Montevideo units for 2 hours without cervical change. 9(Level
III, Grade C)
The 2-hour rule for the diagnosis of arrest in active labor has been
challenged. In a clinical trial, 542 women were managed by a protocol in
which, after active phase arrest was diagnosed, oxytocin was initiated with
the intent to achieve a sustained uterine contraction pattern of greater 200
Montevideo units.9 (Level III, Grade C)
Cesarean delivery is not performed for labor arrest until there were at least
4 hours of a sustained uterine contraction pattern of greater than 200
Montevideo units, or a minimum of 6 hours of oxytocin augmentation if
the contraction pattern could not be achieved. 9 (Level III, Grade C)
The protocol resulted in a high rate of vaginal delivery (92%) with no
severe adverse maternal or fetal outcomes.
References
1. Friedman EA. Labor Clinical Evaluation and Management,2nd Ed, 1978,
Appleton-Century-Crofts.
2. Rouse DJ, McCullough C, Wren AL, Owen J, Hauth JC. Active-phase labor
arrest: A randomized control trial of chorioamnion management. Obstet
Gynecol 1994; 83:937-40.
3. ACOG Practice Bulletin, Dystocia and Augmentation of Labor, Clinical
Management Guidelines For Obstetrician Gynecologists, Number 49,
December 2003.
4. Alarm International Program, Management of Labor and Obstructed Labor,
4th Ed. 2006 4:1-34.
5. Gagnon AJ, Waghorn K, Covell C. A randomized trial of one-to-one nurse
support of women in labor. Birt5h 1997; 24:71-7.
6. Hodnett ED, Gates S, Hofmeyer GJ Sakala C. Continuous support for womrn
during childbirth(Cochrane Review). In: Cochrane Library, Issue 3,2003.
Oxford: Update Software. (Metaanalysis).
7. Xenakis EM, Langer O, Piper JM, Conway D, Berkus MD. Low-dose versus
high-dose oxytocin augmentation of labor a randomized trial. Am J Obstet
Gynecol 1995; 173:1874-8.
8. PATTINSON rc. Pelvimetry for fetal cephalic presentation at term (Cochrane
Review). In The Cochrane Library Issue 3, 2003. Oxford; Update Software
(Metaanalysis).
9. Rouse DJ, Owen J, Hauth JC. Active phase labor arrest: oxytocin
augmentation for at least 4 hrs. Obstet Gynecol. 1999, 93(3):323-328.
Planned cesarean section for babies in breech presentation has a reduced risk for
perinatal or neonatal death and neonatal morbidity compared to planned vaginal
birth.1 (Level I, Grade A)
Planned cesarean section for babies in breech presentation is associated with a
modest increase in short term maternal morbidity.1 (Level I, Grade A)
Information is limited about the potential for problems with future pregnancies.1
(Level I, Grade C)
After two years, there were no differences in the combined outcome death or
neurodevelopmental delay. Maternal outcomes were also similar.1 (Level I,
Grade A)
There is no data to quantify risks of cesarean section to the mother (scar
dehiscence in a subsequent pregnancy, increased risk of repeat CS, placenta
accreta).2,3 (Level III, Grade C)
There is no evidence that the long term health of babies with a breech presentation
delivered at term is influenced by how the baby is born.2,3 (Level I, Grade A)
Planned vaginal breech delivery remains a viable option, provided the criteria are
met, a skilled obstetrician and facilities for cesarean section are immediately
available, and the woman is informed of all possible risks.2,3 (Level I, Grade B)
For a woman with suspected breech presentation, pre- or early labor ultrasound
should be performed to assess type of breech presentation, fetal growth and
estimated weight, and attitude of fetal head. If ultrasound is not available,
Caesarean section is recommended.4 (Level II, Grade A)
Contraindications to labor include
a. Cord presentation3,4,5 (Level II, Grade A)
b. Fetal growth restriction or macrosomia3,4,5 (Level I, Grade A)
c. Any presentation other than a frank or complete breech with a flexed or
neutral head attitude3,4,5 (Level III, Grade B)
d. Clinically inadequate maternal pelvis3,4,5 (Level III, Grade B)
e. Fetal anomaly incompatible with vaginal delivery3,4,5 (Level III, Grade B)
Vaginal breech delivery can be offered when the estimated fetal weight is
between 2500 g and 4000 g.3,4,5 (Level II, Grade B)
Clinical pelvic examination should be performed to rule out pathological pelvic
contraction. Radiologic pelvimetry is not necessary for a safe trial of labor; good
progress in labor is the best indicator of adequate fetal-pelvic proportions.3,4,5
(Level III, Grade B)
Continuous electronic fetal heart monitoring is preferable in the first stage and
mandatory in the second stage of labor.3,4,5 (Level I, Grade A)
Hospitals offering a trial of labor should have a written protocol for eligibility and
intrapartum management.4 (Level III, Grade B)
Women with a contraindication to a trial of labor should be advised to have a
Caesarean section. Women choosing to labor despite this recommendation have a
right to do so and should not be abandoned. They should be provided the best
possible in-hospital care.4 (Level III, Grade A)
Add a statement regarding physician autonomy his/her right to refuse a px and
to refer that px to another doctor
Theoretical and hands-on breech birth training simulation should be part of basic
obstetrical skills training programs such as ALARM, to prepare health care
providers for unexpected vaginal breech births.4 (Level III, Grade B)
Not enough evidence to support the intervention of helping a breech baby to be
born in one pushing contraction following the birth of the babys umbilicus.5
(Level III, Grade B)
Epidural anesthesia is not routinely advised.2 (Level III, Grade C)
Women should be counseled that ECV reduces the chance of breech presentation
at delivery.7,8 (Level I, Grade A)
External version reduces the chances of having a cesarean section.7,8 (Level I,
Grade A)
With a trained operator about 50% of ECV attempts will be successful.7,8 (Level
III, Grade B)
The use of tocolysis with beta sympathomimetic drugs may be offered to women
undergoing external cephalic version as it has been shown to increase the success
rate. 7, 9 (Level I, Grade A)
External cephalic version before 36 weeks is not associated with significant
reduction in noncephalic births or cesarean section.7,10 (Level II, Grade B)
There is insufficient evidence to support the use of postural management as a
method of promoting spontaneous version over external cephalic version.7,11
(Level I, Grade A)
Labor with a cephalic presentation following external cephalic version is
associated with a higher rate of obstetric intervention than when external cephalic
version has not been required.7,12 (Level I, Grade B)
Absolute contraindications for ECV that are likely to be associated with increased
mortality or morbidity:7 (Level III, Grade C)
o
o
o
o
o
o
Digital rotation should be considered when managing the labor of a fetus in the
occipitoposterior position. This maneuver successfully rotates the fetus reducing
the need for cesarean section, instrumental delivery, and other complications
associated with persistent occiput posterior.5,13,14,15,16 (Level III, Grade B)
Use of hands and knees position for ten minutes twice daily in late pregnancy or
during labor to correct occipito-posterior position cannot be recommended as an
intervention. This is not to suggest that women should not adopt this position if
they found it comfortable. The use of this position was associated with reduced
backache.17 (Level I, Grade A)
BROW PRESENTATION
Recommendations
FACE PRESENTATION
Recommendations
Oxytocin can be used to augment labor using the same precautions as in a vertex
presentation and using the same criteria of assessment of uterine activity,
adequacy of the pelvis, and reassuring fetal heart tracing.5,19 (Level III, Grade B)
Forceps may be used if the mentum is anterior. Any typical forceps, including
Kielland forceps, can be used.5,19 (Level III, Grade B)
The mechanisms of labor in the term infant can occur only if the mentum is
anterior.5,19 (Level III, Grade B)
MACROSOMIA
Definition
The term fetal macrosomia implies fetal growth beyond a specific weight, usually
4000 gm (8 lb 13 oz) or 4500 gm (9 lb 4 oz) regardless of the fetal gestational age.
Recommendations
Labor and vaginal delivery is not contraindicated for women with estimated fetal
weights up to 5,000 g in the absence of maternal diabetes.20,21,22,23 (Level II,
Grade B)
With an estimated fetal weight more than 4,500 g, a prolonged second stage of
labor or arrest of descent in the second stage is an indication for cesarean
delivery.20,21,22,23 (Level II, Grade B)
Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean
delivery may be considered for suspected fetal macrosomia with estimated fetal
weights of more than 5,000 g in pregnant women without diabetes and more than
4,500 g in pregnant women with diabetes.20,21,22,23 (Level III, Grade C)
Suspected fetal macrosomia is not a contraindication to attempted vaginal birth
after a previous cesarean delivery.20,21,22,23 (Level III, Grade C)
SHOULDER DYSTOCIA
Recommendations
Transverse lie and oblique lie will benefit from a trial of version to cephalic
presentation following the criteria and recommendations of external cephalic
version for breech presentations.5,26 (Level III, Grade C)
COMPOUND PRESENTATION
Recommendations:
If the hand has not prolapsed beyond the presenting part, causing the hand to
retract often is accomplished, if necessary. It can be ignored as long as labor is
progressing normally.5 (Level III, Grade C)
In contrast, if the hand or arm has prolapsed past the presenting part, abandoning
vaginal delivery and proceeding to cesarean delivery is wise.5 (Level III, Grade C)
References
1. Hofmeyr GJ, Hannah ME. Planned cesarean section for term breech delivery.
Cochrane Database of Systematic Reviews 2004 Issue 4
2. Royal College of Obstetricians and Gynecologists Greentop Guidelines No. 20b.
The management of breech presentation December 2006
3. ACOG Committee Opinion 340. Mode of Term Singleton Breech Delivery.
Obstet Gynecol July 2006
4. SOGC Clinical Practice Guidelines No. 226. Vaginal Delivery of Breech
Presentation. JOGC June 2009 : 557-566
5. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap L, Wenstrom KD.
Williams Obstetrics. 22nd ed. McGraw-Hill; 2005
6. Hofmeyr GJ, Kulier R. Expedited versus conservative approaches for vaginal
delivery in breech presentation. Cochrane Database of Systematic Review 2007
7. Royal College of Obstetricians and Gynecologists Greentop Guideline No. 20a.
External cephalic version and reducing the incidence of breech presentation.
December 2006
8. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term.
Cochrane Database of Systematic Reviews 2009 Issue No. 3
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APPENDIX
LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION
LEVEL
I
II-1
II-2
II-3
III
GRADE
A
B
C
D
E
GPP
DEFINITION
Evidence obtained from at least one properly randomized controlled trial
Evidence obtained from well-designed controlled trials without
randomization
Evidence obtained from well-designed cohort or case-control analytic
studies, preferably from more than one center or research group
Evidence obtained from multiple time series with or without the
intervention.
Opinions of respected authorities, based on clinical experience; descriptive
studies and case reports or reports of expert committees.
DEFINITION
There is good evidence to support the recommendation of the practice in
abnormal uterine bleeding.
There is fair evidence to support the recommendation of the practice in
abnormal uterine bleeding.
There is insufficient evidence to recommend for or against the inclusion of
the practice in abnormal uterine bleeding.
There is fair evidence to support the recommendation that the practice be
excluded in abnormal uterine bleeding.
There is good evidence to support the recommendation that the practice be
excluded in abnormal uterine bleeding.
A good practice point (GPP) is a recommendation for best practice based
on the experience of the Technical Working Group.