Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
November 2009
November 2009
LOURDES B. CAPITO, MD
President
Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2009
In the role of the POGS to provide its members with updates, current and
standard practice recommendations and guidelines, this publication will fulfill the
objective of continuing education and implementation of refinements in Obstetrics
and Gynecology. In keeping with the highest standards of care, the Level and
Grades of Clinical Practice/Recommendation have been adopted for every
recommendation that is completed and decided.
LOURDES BLANCO-CAPITO, MD
INTRODUCTION!
OFFICERS
Lourdes B. Capito, MD
President
Regta L. Pichay, MD
Vice President
Christia S. Padolina, MD
Public Relations Officer
BOARD OF TRUSTEES
Mayumi S. Bismarck, MD
Virgilio B. Castro, MD
Efren J. Domingo, MD, PhD
Gil S. Gonzales, MD
Diosdado V. Mariano, MD
Ma. Socorro M. Solis, MD
ADHOC COMMITTEE ON CLINICAL PRACTICE GUIDELINES ON
ABNORMAL LABOR AND DELIVERY
MEMBERS
Jennifer T. Co, MD Jericho Thaddeus P. Luna, MD
Josephine M. Lumitao, MD Lisa Teresa P. Jabson, MD
Noel E. Raymundo, MD Elisa O. Tiu, MD
FELLOWS
Rachelle U. delos Reyes, MD Ana Victoria V. Dy Echo, MD
May Nueva-Hipolito, MD Michelle R. Ong, MD
Renee Vina G. Sicam, MD
Rosendo R. Roque, MD
Project Director
Regional Directors
Ellen A. Manzano, MD (Region 1) Evelyn R. Lacson, MD (Region 6)
Melchor C. dela Cruz, MD (Region 2) Belinda N. Paares, MD (Region 7)
Concepcion P. Aronza, MD (Region 3) Realino G. Molina, MD (Region 8)
Ernesto S. Naval, MD (Region 4) Suzette S. Montuno, MD (Region 9)
Rowena M. Auxillos, MD (Region 4A) Jana Joy R. Tusalem, MD (Region 10)
Cecilia Valdes-Neptuno, MD (Region 5) Amelia A. Vega, MD (Region 1
DISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY
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.
CPG ON ABNORMAL LABOR AND DELIVERY
CONTENTS, AUTHOR/S
II. Dystocia
Dr. Sylvia A. Carnero
A. Definitions of Abnormal Patterns of Labor .
B. Recommendations
Appendix .
I
ELECTRONIC FETAL MONITORING
DURING ABNORMAL LABOR AND DELIVERY
Christia S. Padolina, MD, FPOGS
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)
A meta-analysis synthesizing results of RCTs comparing modalities had the following
conclusions5: (Level I, Grade A)
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, 0.59-
1.23)
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)
Category I II III
Baseline FHR 110-160 beats Bradycardia not accompanied Bradycardia
per minute by absent baseline variability or
Tachycardia
Baseline Moderate Minimal baseline variability Absent
variability Absent baseline variability with
no recurrent decelerations
Marked baseline variability
Decelerations Absent early, Recurrent variable decelerations Recurrent late
late or accompanied by minimal or decelerations
variable moderate baseline variability Recurrent
Prolonged deceleration more variable
than 2 minutes but less than 10 decelerations
minutes
Recurrent late decelerations
with moderate baseline
variability
Variable decelerations with
other characteristics such as
slow return to baseline,
overshoots, or shoulders
Accelerations Present or Absence of induced Sinusoidal
Absent accelerations after fetal pattern
stimulation
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)
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: 628-
36.
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
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 > 3 hrs with > 2 hrs with
regional anesthesia regional anesthesia
or > 2 hrs without or > 1 hr without
regional anesthesia regional anesthesia
B. Recommendations in Management
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.
Extending the minimum period of oxytocin augmentation for active phase
arrest from 2 hours to 4 hours appears effective. 9 (Level III, Grade C)
References
BREECH PRESENTATION
Recommendations:
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)
When membranes rupture, immediate vaginal examination is recommended to
rule out prolapsed cord.4 (Level III, Grade B)
In the absence of adequate progress in labor, Caesarean section is advised.4 (Level
II-1, Grade A)
Induction of labor is not recommended for breech presentation.4 (Level II, Grade
B)
Oxytocin augmentation is acceptable in the presence of hypotonic uterine
dysfunction.4 (Level II, Grade A)
A passive second stage without active pushing may last up to 90 minutes,
allowing the breech to descend well into the pelvis. Once active pushing
commences, if delivery is not imminent after 60 minutes, Caesarean section is
recommended.4 (Level I, Grade A)
The active second stage of labor should take place in or near an operating room
with equipment and personnel available to perform a timely Caesarean section if
necessary.3,4,5 (Level III, Grade A)
A health care professional skilled in neonatal resuscitation should be in
attendance at the time of delivery.3,4,5 (Level III, Grade A)
The health care provider for a planned vaginal breech delivery needs to possess
the requisite skills and experience.3,4,5 (Level II, Grade A)
An experienced obstetrician-gynaecologist comfortable in the performance of
vaginal breech delivery should be present at the delivery to supervise other health
care providers, including a trainee.3,4,5 (Level I, Grade A)
The health care provider should have rehearsed a plan of action and should be
prepared to act promptly in the rare circumstance of a trapped after-coming head
or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can
be life saving.3,4,5 (Level III, Grade B)
Total breech extraction is inappropriate for term singleton breech delivery.4
(Level II, Grade A)
Effective maternal pushing efforts are essential to safe delivery and should be
encouraged.4 (Level II, Grade A)
At the time of delivery of the after-coming head, an assistant should be present to
apply suprapubic pressure to favor flexion and engagement of the fetal head.3,4,5
(Level II, Grade B)
Spontaneous or assisted breech delivery is acceptable. Fetal traction should be
avoided, and fetal manipulation must be applied only after spontaneous delivery
to the level of the umbilicus.3,4,5 (Level III, Grade A)
Nuchal arms may be reduced by the Lvset maneuver.3,4,5 (Level III, Grade B)
The fetal head may deliver spontaneously, with the assistance of suprapubic
pressure, by Mauriceau-Smellie-Veit maneuver, or with the assistance of Piper
forceps.3,4,5 (Level III, Grade B)
In the absence of a contraindication to vaginal delivery, a woman with a breech
presentation should be informed of the risks and benefits of a trial of labor and
elective Caesarean section, and informed consent should be obtained. A womans
choice of delivery mode should be respected.4 (Level III, Grade A)
The consent discussion and chosen plan should be well documented and
communicated to labor-room staff.4 (Level III, Grade B)
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)
Definition
External cephalic version (ECV) is a procedure of manipulation of the fetus
through the maternal abdomen to a cephalic presentation. The rationale behind ECV is to
reduce the incidence of breech presentation at term and therefore the associated risks,
particularly of avoiding cesarean section.
Recommendations
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 Where cesarean delivery is required
o Antepartum hemorrhage within the last 7 days
o Abnormal cardiotocograph
o Major uterine anomaly
o Ruptured membranes
o Multiple pregnancy (except delivery of second twin)
Definition
Persistent occiput posterior is ______________
Recommendations
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
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
SHOULDER DYSTOCIA
Recommendations
Recommendation
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
9. Hofmeyr GJ, Gyte GML Interventions to help external cephalic version for breech
presentation at term. Cochrane Database of Systematic Reviews 2004
10. Huttona EK, Hofmeyr GJ. External cephalic version for breech presentation
before term. Cochrane Database of Systematic Reviews 2006
11. Hofmeyr GJ, Kulier R, Cephalic version by postural management for breech
presentation Cochrane Database Systematic Review 2000
12. Chan LY, Tang JL. Intrapartum cesarean delivery after successful ECV: a
metaanalysis. Obstet Gynecol 2004
13. Reichman O, Gdansky E. Digital rotation from occipito-posterior to occipito-
anterior decreases the need for cesarean section. Eur J Obstet Gynecol Reprod
Biol 2008
14. Le Ray C, Serres P. Manual rotation in occiput posterior or transverse positions:
risk factors and consequences on the cesarean delivery rate. Obstet Gynecol 2007
Oct
15. Shaffer BL, Cheng YW. Manual rotation of the fetal occiput: predictors of
success and delivery. Am J Obstet Gynecol 2006 May
16. Stitely ML, Gherman RB. Labor with abnormal presentation and postion. Obstet
Gynecol Clin North Am 2005
17. Hunter S, Hofmeyr GJ. Hands and knees posture in late pregnancy or labor for
fetal malposition (lateral or posterior). Cochrane Database Systematic Reviews
2007 Oct
18. Stitely ML, Gherman RB. Labor with abnormal presentation and position. Obstet
Gynecol Clin North Am. Jun 2005;32(2):165-79.
19. Shaffer BL, Cheng YW, Vargas JE, Laros RK Jr, Caughey AB. Face presentation:
predictors and delivery route. Am J Obstet Gynecol. 2006 May;194(5):e10-2.
Epub 2006 Apr 21
20. ACOG Practice bulletin No. 22. Clinical Guidelines on Fetal Macrosomia. Obstet
Gynecol November 2000
21. Irion O, Boulvain M. Induction of labor for suspected fetal macrosomia. Cochrane
Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000938. DOI:
10.1002/14651858.CD000938
22. Royal College of Obstetricians and Gynecologists. Greentop Guidelines No. 42.
Shoulder Dystocia. 2005
23. Sanchez-Ramos L, Bernstein S, Kaunitz A Expectant Management Versus Labor
Induction for Suspected Fetal Macrosomia: A Systematic Review. Obstetrics &
Gynecology 2002;100:997-1002
24. Gherman RB, Chauhan S. Shoulder dystocia: the unpreventable obstetric
emergency with empiric management guidelines. Am J Obstet Gynecol 2006 Sept
25. Gherman RB. Shoulder dystocia prevention and management. Obstet Gynecol
Clin North Am. 2005 Jun;32(2):297-305
26. Murray Enkin M,. Keirse JM, Crowther C, Duley L, Hodnett E, Hofmeyr J.
Suspected fetopelvic disproportion and abnormal lie, Guide to Effective Care in
Pregnancy and Childbirth (Oxford University Press, 2000)
APPENDIX
LEVEL DEFINITION
I Evidence obtained from at least one properly randomized controlled trial
Evidence obtained from well-designed controlled trials without
II-1
randomization
Evidence obtained from well-designed cohort or case-control analytic
II-2
studies, preferably from more than one center or research group
Evidence obtained from multiple time series with or without the
II-3
intervention.
Opinions of respected authorities, based on clinical experience; descriptive
III
studies and case reports or reports of expert committees.
GRADE DEFINITION
There is good evidence to support the recommendation of the practice in
A
abnormal uterine bleeding.
There is fair evidence to support the recommendation of the practice in
B
abnormal uterine bleeding.
There is insufficient evidence to recommend for or against the inclusion of
C
the practice in abnormal uterine bleeding.
There is fair evidence to support the recommendation that the practice be
D
excluded in abnormal uterine bleeding.
There is good evidence to support the recommendation that the practice be
E
excluded in abnormal uterine bleeding.
A good practice point (GPP) is a recommendation for best practice based
GPP
on the experience of the Technical Working Group.