Abnormal Labor and Delivery

CLINICAL PRACTICE GUIDELINES ON
ABNORMAL LABOR AND DELIVERY
Jo-An Marie G. Aguedan, M.D.
ELECTRONIC FETAL MONITORING

DURING ABNORMAL LABOR AND
DELIVERY
Definition of Terms:
A.
B.
C.
D.
E.
F.
G.
H.
Baseline
Baseline variability
Acceleration
Early deceleration
Late deceleration
Variable deceleration
Prolonged deceleration
Sinusoidal pattern
BASELINE
The mean fetal heart rate (FHR) rounded
to increments of 5 beats per minute
during a 10-minute segment, excluding:
Periodic or episodic changes
Periodic of marked FHR variability
Segments of baseline that defer by more than
25 beats per minute
BASELINE
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 10minute window for determination of
baseline.
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 VARIABILITY
Fluctuations in the baseline FHR that are
irregular in amplitude and frequency.
Variability is visually quantified as the
amplitude of peak-to-trough in beats per
minute.
BASELINE VARIABILITY
Absent amplitude range undetectable
Minimal amplitude range detectable but
5 beats per minute or fewer
Moderate (Normal) amplitude range 625 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.
At more than or equal to 32 weeks of
gestation, acceleration has a peak of 15
beats per minute or more above baseline,
with duration of 15 seconds or more but
less than 2 minutes from onset to return.
ACCELERATION
Before 32 weeks of gestation, an
acceleration has a peak of 10 beats per
minute or more above baseline, with a
duration of 10 seconds or more but less
than 2 minutes from onset to return.
Prolonged acceleration lasts 2 minutes or
more but less than 10 minutes in duration.
If an acceleration lasts 10 minutes or
longer, it is a baseline change.
EARLY DECELERATION
Visually apparent usually symmetrical
gradual decrease and return of the FHR
associated with a uterine contraction.
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.
EARLY 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.
LATE DECELERATION
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.
LATE 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
VARIABLE DECELERATION
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.
VARIABLE 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
PROLONGED DECELERATION
Visually apparent decrease in 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.
SINUSOIDAL PATTERN
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.
Classification of FHR
Tracings Three
Tiered System for the
Categorization of FHR
Patterns
Categ FHR
ory
Tracin
gs
Definition
Norm Category I FHR tracings

al
are strongly predictive of
normal fetal acid-base
status at the time of
observation.
Category I FHR tracings
may be monitored in a
routine manner, and no
Catego
FHR
ry
Tracings
II
Definition
not predictive of abnormal fetal

Indeter acid-base status, yet presently
mi-nate there is no adequate evidence to
classify these as Category I or
Category III.
require
evaluation
and
continued
surveilance
and
reevaluation, taking into account
the entire associated clinical
circumstances.
In some circumstances, either
ancillary tests to ensure fetal well
being
or
intrauterine
Catego
FHR
Definition
ry
Tracings
III
Abnorm associated with abnormal fetal
al
acid-base status at the time of
observation.
require clinical evaluation
on
the
clinical
Depending
situation, efforts to expeditiously
resolve the abnormal FHR pattern
may include but are not limited
to provision of:
1.maternal oxygen
2.change in maternal position
3.
discontinuation
of
labor
stimulation
4.treatment
of
maternal
Categ
ory
III
FHR
Tracings
Definition
Abnor If
category
III
mal tracing does not
resolve with these
measures, delivery
should
be
undertaken.
Clinical Consideration and

Recommendations
1. Fetal surveillance in labor, whether by
intermittent auscultation (IA) or by EFM
should be recommended to all women.
(Level III, Grade C)
Frequency of IA is as follows:
For low risk patients every 30 minutes for 1st

stage, then every 15 minutes for the 2nd stage
For high risk patients every 15 minutes for 1st

stage, then every 5 minutes for the 2nd stage
2. Based on available data, there is no clear

benefit for the use of EFM over IA. Either
option is acceptable in patients without
complications.
A meta-analysis synthesizing results of

randomized
control trials (RCTs) comparing modalities
had the
following conclusions: (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 perinatal

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 0.310.80).
The use of EFM did not reduce the risk of
cerebral palsy (RR 1.74, 95% CI 0.973.11).
3. In ideal settings, continuous EFM should

be offered and is recommended for high
risk pregnancies where there is increased
risk of perinatal death, cerebral palsy or
neonatal encephalopathy.
(Level II-2 to III, Grade C)
4. Current evidence does not support the use

of admission tocogram in low risk
pregnancy.
5. Based on careful review of available

terminologies, a three-tiered system of
categorization of FHR interpretation is
recommended.
Category
II
Baseline 110-160 Bradycardia not

FHR
beats per accompanied by
minute
absent baseline
variability or
Tachycardia
III
Bradycar
dia
Baseline Moderate Minimal baseline Absent

variabilit
variability
y
Absent baseline
variability with no
recurrent
decelerations
Marked baseline
variability
Category
Decelerati Absent
ons
early, late
or
variable
II
Recurrent
variable
decelerations
accompanied by
minimal or
moderate
baseline
variability
Prolonged
deceleration
more than 2
minutes but less
than 10 minutes
Recurrent late
III
Recurrent
late
deceleratio
ns
Recurrent
variable
deceleratio
ns
Category
Decelerat Absent
ions
early,
late
or
variable
II
III
Variable
decelerations with
other
characteristics such
as slow return to
baseline,
overshoots, or
shoulders
Recurrent
late
decelerati
ons
Recurrent
variable
decelerati
ons
Accelerati Present
Absence of
ons
or Absent induced
accelerations
after fetal
Sinusoidal
pattern
Based on careful review of available

terminologies, a three-tiered system of
categorization of FHR interpretation is
recommended. (Level III, Grade C)
The false-positive rate of EFM for
predicting cerebral palsy is high, at
greater than 99%.
The use if EFM is associated with an

increased rate of both vacuum and
forceps operative vaginal delivery, and
cesarean delivery for abnormal FHR
patterns or acidosis or both.
When the FHR tracing includes recurrent

variable decelerations, amnioinfusion to
relieve umbilical cord compression should
be considered.
(Level II-1, Grade B)
Pulse oximetry has not been demonstrated

to be a clinically useful test in evaluating
fetal status.
There is high interobserver and intraobserver

variability in interpretation of FHR tracing.
Reinterpretation of the FHR tracing, especially

if the neonatal outcome is known, may not be
reliable.
The use of EFM does not result in

reduction of cerebral palsy.
A three-tiered system for the

categorization of FHR patterns is
recommended.
The labor of women with high-risk

conditions should be monitored with
continuous FHR monitoring.
The terms hyperstimulation and

hypercontractiliy should be abandonded. It
is now calles uterine tachysystole (i.e. more
than 5 contractions in 10 minutes, averaged
over a 30-minute window).
Clinical Consideration and

Recommendations
6. Ancillary tests available that can aid in the
management of Category II or Category III
fetal heart tracings include fetal scalp pH
sampling, Allis clamp stimulation,
vibroacoustic stimulation and digital scalp
stimulation.
(Level II-3, Grade B)
Because vibroacoustic stimulation and

digital scalp stimulation is less invasive
than the other two methods, they are
preferred methods.
(Level I, Grade A)
7. A Category II or Category III FHR Tracing

requires initial evaluation and treatment
may include the following:
a. Discontinuation of any labor stimulating
agent
b. Cervical examination to determine
umbilical cord prolapsed, 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.
Monitoring maternal for evidence of

hypotension, especially in those with
regional anesthesia (if present, treatment
with volume expansion or with ephedrine
or both or phenylephrine may be
warranted).
DYSTOCIA
Definition of Abnormal Patterns of Labor

LABOR PATTERN
Diagnostic Criteria
Nulliparas Multiparas
Prolongaton Disorder
1. Prolonged Latent
> 20 hrs
Phase
Protraction Disorder
1. Protracted Active
< 1.2 cm/hr
Phase Dilation (Phase
of maximum slope of
dilatation)
2. Protracted Descent
< 1 cm/hr
(maximum slope of
descent during the pelvic
> 14 hrs
< 1.5 cm/hr
< 2cm/hr
LABOR PATTERN
Arrest Disorder
1.
Prolonged
Deceleration
Phase
(cervical dilatation arrested
at 8 to 9 cm)
2. Secondary Arrest of
Dilatation
(progressive
cervical dilatation stops at
the phase of maximum
slope)
3. Arrest of Descent
(progressive descent stops
during pelvic division of
labor, station + 1)
Diagnostic Criteria
> 3 hrs
> 1 hr
> 2 hrs
> 1 hr
LABOR PATTERN
Diagnostic Criteria
4. Failure of Descent Lack of expected descent

(station 0)
during deceleration phase
or second stage of labor
5. Prolonged
Stage
Second > 3 hrs with > 2 hrs with

regional
regional
anesthesia or anesthesia or
> 2 hrs
without
regional
anesthesia
> 1 hr
without
regional
anesthesia
Recommendations
1. Prolonged Latent Phase
2. Protracted Active Phase Dilatation
3. Arrest Disorders
Prolonged Latent Phase

Avoid admission to the labor and
delivery area until active labor is
established.
Develop a plan to meet the womans

need either at home or in a nonlaboring hospital unit.

Friedman (1972) reported that
prolongation of the latent phase did not
adversely influence fetal or maternal
morbidity and mortality.
Data show that patients with prolonged

latent phase are no more prone to
develop problems than gravidas with
normal latent phase.

Observation, rest and therapeutic
analgesia/strong sedatives are
favored over a more active approach
of amniotomy and oxytocin induction.
Support and information from

caregivers to provide coping
strategies.

A patient who has a latent
phase longer than 20 hrs
should be expected to evolve a
normal subsequent dilatation
and descent if allowed to do
so.

- It cannot be too strongly stated that
patients who are delivered by
cesarean section (CS) during the
latent phase for no other reason than
their lack of progress are being
subjected to this operation
unnecessarily most of the time.

CS has no place as a method of
treatment for prolonged latent phase
without other clear indications like
documented cephalopelvic disproportion
(CPD) or abnormal FHR pattern (category
III).
Friedmans recommended approach is

support and therapeutic rest by the use of
large doses of narcotic analgesics.

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.
Recommendations
3. Arrest Disorders
Protracted Active Phase

Dilatation
Physical and emotional support.
(Level I, Grade A)
Continuous support during labor from

caregivers should be encouraged because it is
beneficial for women and their newborns.
(Level I, Grade A)
Amniotomy with early oxytocin

augmentation shortens labor by as much
as 2 hours compared to expectant care but
has not been shown to change cesarean
delivery rates.
(Level I, Grade A)
Protracted Active Phase

Dilatation
Amniotomy may enhance progress in the
active phase and negate the need for oxytocin
augmentation but may increase the risk of
chorioamnionitis.
(Level I, Grade A)
Oxytocin should be used to achieve adequate

contractions (at least 200 Montevideo units)
before operative delivery is considered.
(Level I, Grade B)
High-dose oxytocin regimens result in

shorter labors than low dose regimens
without adverse effects to the fetus.
(Level I, Grade B)
Rule out CPD.

(Level III, Grade B)
If with CPD, do CS.

Recommendations
3. Arrest Disorders
Arrest Disorders
Continuous support during labor from
caregivers should be encouraged because it
is beneficial for women and their newborns.
(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.
(Level I, Grade B)
Rule out CPD

Arrest Disorders
If with CPD, do CS.
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.
Arrest Disorders
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 than 200
Montevideo units.
Arrest Disorders
Cesarean delivery is not performed for
labor arrest until there were at least 4
hours of 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.
Arrest Disorders
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 appears effective.
DYSTOCIA SECONDARY TO
PROBLEMS IN PASSENGER
BREECH PRESENTATION
EXTERNAL CEPHALIC VERSION
PERSISTENT OCCIPUT POSTERIOR,
OCCIPUT TRANSVERSE
BROW PRESENTATION
FACE PRESENTATION
FETAL MACROSOMIA
SHOULDER DYSTOCIA
TRANSVERSE LIE/OBLIQUE LIE
COMPOUND PRESENTATION
BREECH PRESENTATION
BREECH PRESENTATION
Recommendations:
Planned cesarean section (CS) for babies in
breech presentation has a reduced risk for
perinatal death and neonatal morbidity
compared to planned vaginal birth.
(Level I, Grade A)
Planned CS for babies in breech presentation

is associated with a modest increase in short
term maternal morbidity
(Level I, Grade A)
Recommendations:
Information is limited about the potential for
problems with future pregnancies.
(Level I, Grade C)
After two years, there were no differences in

the combined outcome death or
neurodevelopmental delay. Maternal
outcomes were also similar.
(Level I, Grade A)
Recommendations:
There is no data to quantify risks of CS to
the mother (scar dehiscence in a
subsequent pregnancy, increased risk to
repeat CS, placenta accreta).
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.
(Level I, Grade A)
Recommendations:
Planned vaginal breech delivery remains a
viable option, provided the criteria are met,
a skilled obstetrician and facilities for CS
are immediately available, and the women
is informed of all possible risks.
(Level I, Grade B)
Recommendations:
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, CS is
recommended.
(Level II, Grade A)
Recommendations:
Contraindications to labor
include:
a) Cord presentation. (Level II, Grade A)
b) Fetal growth restriction or macrosomia
(Level I, Grade A)
c) Any presentation other than a frank or

complete breech with a flexed or
neutral head attitude
Recommendations:
Contraindications to labor
include:
d)Clinically inadequate maternal pelvis
(Level
III, Grade B)
e)Fetal anomaly incompatible with vaginal

delivery.
Recommendations:
Vaginal breech delivery can be offered when the
estimated fetal weight is between 2500 g and
4000 g.
(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.
Recommendations:
Continuous electronic fetal heart monitoring (EFM)
is preferable in the first stage and mandatory in
the second stage of labor.
(Level I, Grade A)
When membrane rupture, immediate vaginal

examination is recommended to rule out
prolapsed cord.
In the absence of adequate progress in labor, CS

is advised.
(Level II-1, Grade A)
Recommendations:
Induction of labor is not recommended for breech

presentation.
(Level II, Grade B)
Oxytocin augmentation is acceptable in the

presence of hypotonic uterine dysfunction.
(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, CS is recommended.
(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 CS section
if necessary.
(Level I, Grade A)
Recommendations:
A health care professional skilled in neonatal
resuscitation should be in attendance at the time of
delivery.
(Level III, Grade A)
The health care provider for a planned vaginal

breech delivery needs to possess the requisite
skills and experience.
(Level II, Grade A)
Recommendations:
An experienced obstetrician-gynecologist comfortable
in the performance of vaginal breech delivery should be
present at the delivery to supervise other health care
providers, including a trainee.
(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 aftercoming head or
irreducible nuchal arms: symphysiotomy or emergency
abdominal rescue can be life saving.
Recommendations:
Total breech extraction is inappropriate for term
singleton breech delivery
(Level II, Grade A)
Effective maternal pushing efforts are essential to

safe delivery and should be encouraged.
(Level II, Grade A)
At the time of delivery of the aftercoming head, an

assistant should be present to apply suprapubic
pressure to favor flexion and engagement of the
fetal head.
(Level II, Grade B)
Recommendations:
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.
Nuchal arms may be reduced by

Lovset maneuver.
Recommendations:
The fetal head may deliver spontaneously, with the
assistance of suprapubic pressure, by MauriceauSmellie-Veit maneuver, or with the assistance of
Piper forceps.
Recommendations:
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 CS, and
informed consent should be
obtained. A womans choice of
delivery mode should be respected.
Recommendations:
The consent discussion and chosen plan
should be well documented and
communicated to labor room staff.
Hospitals offering a trial of labor should

have a written protocol for eligibility and
intrapartum management.
Recommendations:
Women with a contraindication to a trial

of labor should be advised to have a
CS. Women choosing to labor despite
this recommendation have right to do
so and should not be abandoned. They
should be provided the best possible
in-hospital care.
Recommendations:
A physician is free to choose whom he will serve.
He may refuse calls, or other medical services for
reasons satisfactory to his professional
conscience.
He should, however, always respond to any

request for his assistance in an emergency. Once
he undertakes a case, he should not abandon nor
neglect it.
If for any reason he wants to be released from it,

he should announce his desire previously, giving
sufficient time or opportunity to the patient or his
family to receive another medical attendant.
Recommendations:
Theoretical and hands-on breech birth

training simulation should be part of
basic obstetrical skills taining programs
such as ALARM, to prepare health care
providers for unexpected vaginal breech
births
Recommendations:
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.
Epidural anesthesia is not routinely

advised.

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 CS.
Recommendations
Women should be counseled that ECV
reduces the chance of breech presentation at
delivery.
(Level I, Grade A)
ECV reduces the chances of having a CS.

(Level I, Grade A)
With a trained operator about 50% of ECV

attempts will be successful
Recommendations
The use of tocolysis with beta
sympathomimetic drugs may be offered to
women undergoing ECV as it has been
shown to increase the success rate.
(Level I, Grade A)
ECV before 36 weeks is not associated

with significant reduction in noncephalic
births or CS.
(Level II, Grade B)
Recommendations
There is insufficient evidence to support
the use of postural management as a
method of promoting spontaneous version
over ECV.
(Level I, Grade A)
Labor with a cephalic presentation

following ECV is associated with a higher
rate of obstetric intervention than when
ECV has not been required.
(Level I, Grade B)
Recommendations
Absolute contraindications for ECV
that are likely to be associated with
increased mortality or morbidity:
Where cesarean delivery is required

Antepartum hemorrhafe within the last 7 days
Abnormal cardiotocograph
Major uterine anomaly
Ruptured membranes
Multiple pregnancy (except delivery of
second twin)
Recommendations
Relative contraindications where ECV
might be more complicated:
Small for gestational age fetus with abnormal
Doppler parameters
Proteinuric pre-eclapmsia
Oligohydramnios
Major fetal anomalies
Scarred uterus
Unstable lie

OCCIPUT TRANSVERSE

OCCIPUT TRANSVERSE
Definition
With effective contractions, adequate
flexion of the head, and a fetus of average
size, most posteriorly positioned occiputs
route promptly as soon as they reach the
pelvic floor.

OCCIPUT TRANSVERSE
Poor contractions, faulty flexion of the
head, or epidural analgesia, which
diminishes abdominal muscular pushing
and relaxes the muscles of the pelvic floor
may predispose to incomplete rotation.

OCCIPUT TRANSVERSE
If rotation is incomplete, transverse arrest
may result.
If no rotation toward the symphysis takes
place.
The occiput may remain in the direct
occiput posterior position, a condition
known as persistent occiput posterior.
Recommendations
Digital rotation should be considered when
managing the labor of a fetus in the
occipito-posterior position. This maneuver
successfully rotates the fetus reducing the
need for CS, instrumental delivery, and
other complications associated with
persistent occiput posterior
Recommendations
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 confortable. The use of this position
was associated with reduced backache.
(Level I, Grade A)
BROW PRESENTATION
BROW PRESENTATION
Recommendations:
Expectant management is reasonable as
long as the fetal heart tracing remains
reassuring and dilation and descent are
progressing normally because
spontaneous conversion to vertex or face
may occur.
(Level II, Grade B)
Recommendations
The use of forceps or manual conversion
to convert a brow presentation to a more
favorable position is contraindicated.
(Level II, Grade B)
FACE PRESENTATION
FACE PRESENTATION
Recommendations
Continuous EFM is considered mandatory
by many authors because of the increased
incidence of abnormal FHR patterns
and/or fetal compromise. Careful
application of the electrode must be
ensured; the mentum is recommended site
of application.
Recommendations
Oxytocin can be used to augment labor
using the same precaution as in a vertex
presentation and using the same criteria of
assessment of uterine activity, adequacy of
the pelvis, and reassuring fetal hear
tracing.
Recommendations
Attempts to manually convert the face to
vertex (Thom maneuver) or to rotate a
posterior position to a more favorable anterior
mentum position are rarely successful and are
associated with high perinatal mortality and
maternal morbidity.
Internal podalic version and breech extraction
are no longer recommended in the modern
management of the face presentation.
Recommendations
Forceps may be used if the mentum is anterior.
Any typical forceps including Keilland forceps,
can be used.
The mechanisms of labor in the term infant can

occur only if the mentum is anterior.
FETAL MACROSOMIA
FETAL MACROSOMIA
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
The diagnosis of fetal macrosomia is
imprecise. For suspected fetal
macrosomia, the accuracy is estimated
fetal weight using ultrasound biometry is
no better than that obtained with clinical
palpation (Leopolds maneuvers).
(Level I, Grade A)
Suspected fetal macrosomia is not an

indication for induction of labor because
induction does not improve maternal or fetal
outcomes.
(Level II, Grade B)
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.
(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.
(Level II, Grade B)
Recommendations
Although the diagnosis of fetal
macrosomia is imprecise, prophylactic
cesarean delivery may be considered for
suspected fetal macrosomia with
estimated fetal weights more than 5,000 g
in pregnant women without diabetes and
more than 4,500 g in pregnant women with
diabetes.
Suspected fetal macrosomia is not

contraindication to attempted vaginal birth
after a previous cesarean delivery.
SHOULDER DYSTOCIA
SHOULDER DYSTOCIA
Recommendations
Risk assessments for the prediction of
shoulder dystocia are insufficiently
predictive to allow prevention of the large
majority of cases.
(Level II, Grade B)
Induction of labor in women with diabetes

mellitus does not reduce the maternal or
neonatal morbidity of shoulder dystocia.
(Level I, Grade A)
Recommendations
Late pregnancy ultrasound likewise displays
low sensitivity, decreasing accuracy with
increasing birth weight, and an overall
tendency to overestimate the birth weight.
(Level II, Grade B)
Fundal pressure should not be employed.
Recommendations
Episiotomy is not necessary for all cases,
is reserved to facilitate maneuvers such as
delivery of posterior arm or internal
rotation of shoulders.
McRoberts is the single most effective

intervention and should be performed first.
Recommendations
Suprapubic pressure is useful
Suprapubic pressure can be employed

together with McRoberts maneuver to
improve success rates.
Recommendations
Other maneuvers such as Rubins, Woods
screw maneuver, Zavanelli, cleidotomy
and symphysiotomy have been employed
but no controlled trials have been made.
Rubin Maneuver
Woods screw maneuver
Zavanelli maneuver
Symphysiotomy

Recommendation
Transverse lie and oblique lie will benefit
from a trial of version to cephalic
presentation following the criteria and
recommendations of ECV for breech
presentations.
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.
Recommendations
In contrast, if the hand or arm has
prolapsed past the presenting part,
abdominal vaginal delivery and proceeding
to cesarean delivery is wise.
Thank you

Abnormal Labor and Delivery - Jo An

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CLINICAL PRACTICE GUIDELINES ON

Jo-An Marie G. Aguedan, M.D.

ELECTRONIC FETAL MONITORING

The decrease in FHR is 15 beats per

Norm Category I FHR tracings

not predictive of abnormal fetal

Clinical Consideration and

(Level III, Grade C)

For low risk patients every 30 minutes for 1st

For high risk patients every 15 minutes for 1st

2. Based on available data, there is no clear

(Level III, Grade C)

A meta-analysis synthesizing results of

The use of EFM did not reduce perinatal

3. In ideal settings, continuous EFM should

4. Current evidence does not support the use

5. Based on careful review of available

(Level III, Grade C)

Baseline 110-160 Bradycardia not

Baseline Moderate Minimal baseline Absent

Based on careful review of available

The use if EFM is associated with an

When the FHR tracing includes recurrent

Pulse oximetry has not been demonstrated

There is high interobserver and intraobserver

Reinterpretation of the FHR tracing, especially

(Level III, Grade C)

The use of EFM does not result in

A three-tiered system for the

The labor of women with high-risk

The terms hyperstimulation and

(Level III, Grade C)

Clinical Consideration and

(Level II-3, Grade B)

Because vibroacoustic stimulation and

7. A Category II or Category III FHR Tracing

Changing maternal position to left or right

Monitoring maternal for evidence of

Definition of Abnormal Patterns of Labor

< 1.5 cm/hr

4. Failure of Descent Lack of expected descent

Second > 3 hrs with > 2 hrs with

Prolonged Latent Phase

Develop a plan to meet the womans

Prolonged Latent Phase

Data show that patients with prolonged

Prolonged Latent Phase

Support and information from

Prolonged Latent Phase

Prolonged Latent Phase

Prolonged Latent Phase

(Level III, Grade C)

Friedmans recommended approach is

(Level III, Grade C)

Prolonged Latent Phase

(Level III, Grade C)

Protracted Active Phase

Continuous support during labor from

Amniotomy with early oxytocin

Protracted Active Phase

Oxytocin should be used to achieve adequate