COVER PAGE
Philippine Obstetrical and Gynecological Society (POGS), Foundation, Inc.
November 2009
Task Force on Clinical Practice Guideline In the Management of Abnormal Labor and Delivery
Philippine Obstetrical and Gynecological Society (POGS), Foundation, Inc.
CLINICAL PRACTICE GUIDELINES on ABNORMAL LABOR and DELIVERY
November 2009
Task Force on Clinical Practice Guideline In the Management of Abnormal Labor and Delivery
FOREWORD
LOURDES B. CAPITO, MD
President Philippine Obstetrical Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2009
I have envisioned and have implemented to completion the publication of a series of Clinical Practice Guidelines on the major procedures and topics of Obstetrics and Gynecology. This is in consonance with the theme of my Presidency, “Babae, Kalusugan Mo, Katungkulan Natin”. This is the Clinical Practice Guidelines on Abnormal Labor and Delivery and is the First Edition of this Publication, 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. In the process of the formulation of the guideline/recommendation, the entire membership of the POGS was consulted. I take special effort to thank the AdHoc Committee on Clinical Clinical Practice Guidelines, Guidelines, headed by its Chair, Dr. Efren J. Domingo for the unceasing tireless effort to complete this publication. I also gratefully acknowledge the Chairs and Training Officers of the Residency Accredited Hospitals, the Technical Technical Working Working Group, and and the CME CME Committee. Committee. It becomes easy, dignified and scientific to conduct the practice of Obstetrics and Gynecology specifically on Abnormal Labor and Delivery. Now, the Clinical Practice Guidelines on Abnormal Labor and Delivery will hope to update and make the practice current and responsive to world-class standards and make the patients under our care deserving of the trust and confidence that we, Obstetricians, impart with utmost care and compassion.
LOURDES BLANCO-CAPITO, MD
INTRODUCTION
EFREN J. DOMINGO, MD, PhD
Chair, AdHoc Committee on the Clinical Clinical Practice Guidelines, 2009
The Clinical Practice Guidelines on Abnormal Labor and Delivery is the First Edition of this Publication, 2009. The Philippine Obstetrical and Gynecological Society, (Foundation), Inc. (POGS), through the AdHoc Committee on Clinical Practice Guidelines initiated and led to completion the publication of this manual in plenary consultation with the Residency Accredited Training Hospitals’ Chairs and Training Officers, The Regional Board of Directors, The Board of Trustees, The Task Force on the Management of Abnormal Labor and Delivery and the Committee on Continuing Continuing Medical Education. This publication represents the collective effort of the POGS in updating the clinical practice of Obstetrics and Gynecology, specifically on Abnormal Labor and Delivery, and making it responsive to the most current and acceptable standard in this procedure. A greater part of the inputs incorporated in this edition are the contributions originating from the day-to-day academic interactions from the faculty of the different Residency-Accredited Hospitals in Obstetrics and Gynecology in the country. This Clinical Practice Guideline on Abnormal Labor and Delivery is envisioned to become the handy companion of the Obstetrician-Gynecologist in his/her day-to-day rendition of quality care and decision making in managing the Obstetric patient. This is also envisioned to provide the academic institutions in the country and in Southeast Asia updated information and Abnormal Labor and Delivery treatments being practiced in the Philippines. Profound gratitude is extended to all the members of the POGS, the Chairs and Training Officers of the Residency-Training Accredited Institutions, the Regional Directors, The Task Force on the Management of Abnormal Labor and Delivery Reviewers/Contributors, The CME Committee members, and the 2009 POGS Board of Trustees.
EFREN J. DOMINGO, MD, PhD
BOARD OF TRUSTEES 2009 OFFICERS
Lourdes B. Capito, MD President Regta L. Pichay, MD Vice President Ma. Carmen H. Quevedo, MD Secretary Ditas Christina D. Decena, MD Treasurer 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
Efren J. Domingo, MD, PhD Chair 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 TECHNICAL STAFF ASSISTANTS Ms. Emiliana C. Enriquez Ms. Jhasmin G. De Guzman
TASK FORCE ON ABNORMAL LABOR AND DELIVERY
Rosendo R. Roque, MD Project D irector Mayumi S. Bismark, MD Lourdes B. Capito, MD Sylvia A. Carnero, MD Lyra Ruth Clemente-Chua, MD Jennifer T. Co, MD
Ditas Cristina D. Decena, MD Ruth V. Gutierrez, MD Marlene Javier, MD Milagros T. Jocson, MD Evelyn P. Palaypayon, MD
Susan Pelea-Nagtalon, MD Ma. Carmen H. Quevedo, MD Raul M. Quillamor, MD Ma. Socorro M. Solis, MD
TASK FORCE REVIEWERS AND PLENARY REVIEWERS
Rainerio S. Abad, MD Imelda O. Andres, MD Cecilia Joyce M. Bascarra, MD Ricardo R. Braganza, MD Virgilio B. Castro, MD Maria Lourdes B. Coloma, MD Godofreda V. Dalmacion, MD Santiago A. del Rosario, MD Rey H. Delos Reyes, MD Virginia R. de Jesus, MD Arcangel N. Diamante, MD Rommel Z. Dueñas, MD
Joseline A. Ferrolino, MD Ma. Corazon N. Gamilla, MD Erlinda G. Germar, MD Ma. Antonia E. Habana, MD Myrna R. Habaña, 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 D irectors irector s 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
Evelyn R. Lacson, MD (Region 6) Belinda N. Pañares, MD (Region 7) Realino G. Molina, MD (Region 8) Suzette S. Montuno, MD (Region 9) Jana Joy R. Tusalem, MD (Region 10) Amelia A. Vega, MD (Region 1
DISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY
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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 me mbership. 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 par t/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
I.
Electronic Fetal Monitoring During Abnormal Labor and Delivery Dr. Christia S. Padolina A. Electronic Fetal Monitoring: Definition of Terms ……………… B. Classification of Fetal Heart Rate Tracings …………………….. C. Clinical Consideration and Recommendations ………………….
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Dystocia Dr. Sylvia A. Carnero A. Definitions of Abnormal Patterns of Labor ……………………. B. Recommendations ………………………… ……………………………………………… ……………………
III.
Dystocia Secondary to Problems in Passenger Dr. Ma. Socorro M. Solis A. Breech Presentation …………………………… ……………………………………………. ………………. B. External Cephalic Version ……………………………………... ……………………………………... C. Persistent Occiput Posterior and Occiput Transverse …………. D. Brow Presentation P resentation ……………………………………………… ……………………………………………… E. Face Presentation ………………………… ……………………………………………… …………………….. F. Fetal Macrosomia ……………………………………………… ……………………………………………… G. Shoulder Dystocia ……………………………………………… ……………………………………………… H. Transverse/Oblique Lie L ie ………………………………………… I. Compound Presentation P resentation ………………………………………… …………………………………………
Appendix …………………………………………………… ……………………………………………………………………. ……………….
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I ELECTRONIC FETAL MONITORING DURING ABNORMAL LABOR AND DELIVERY Christia S. Padolina, MD, FPOGS
A. Electronic Fetal Monitoring Definition of Terms 1 Pattern Baseline
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 chan ges - 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 frequency. variability Variability is visually quantified as the amplitude of peak-to-trough in beats per minute. Absent – amplitude range undetectable Minimal – amplitude range detectable d etectable 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
At 32 weeks of gestation and beyond, an acceleration has a peak of 15 beats per p er minute or more above baseline, with duration of 15 seconds or more but less than 2 minutes from onset to return. 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 o nset 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 Visually apparent usually symmetrical gradual decrease and return of the deceleration 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 is FHR is calculated from the onset to the nadir of the
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 Late deceleration 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. Variable Visually apparent abrupt decrease in FHR deceleration 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 baseline Prolonged deceleration 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. chan ge. Visually apparent, smooth, sine wave-like undulating pattern in FHR Sinusoidal pattern baseline with a cycle frequency of 3-5 per minute which persists for 20 minutes or more.
B. Classification of FHR Tracings – Three Tiered System for the 2 Categorization of FHR Patterns Category I
FHR Tracings Normal
II
Indeterminate
III
Abnormal
Definition Definitio n 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 measure s 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.
C. Clinical Consideration and Recommendations #$
Fetal surveillance in labor, whether by intermittent auscultation (IA) or by electronic fetal monitoring (EFM), should be recommended to all women.3 (Level III, Grade C). 4 Frequency of intermittent auscultation is as follows : st nd For low risk patients - every 30 mins for 1 stage, then every 15 mins for the 2 stage st nd For high risk patients - every 15 mins for 1 stage, then every 5 mins for the 2 stage
2. Based on available data, there is no clear benefit for the use of EFM over IA. 3 Either option is acceptable in a patient without complications. (Level III, Grade C)
A meta-analysis synthesizing results of RCTs comparing modalities had the following 5 conclusions : (Level I, Grade A) •
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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 6-9 neonatal encephalopathy . (Level II-2 to III, Grade C) 4. Current evidence does not support the use of admission tocogram in low risk 10 pregnancy . (Level III, Grade C) 5. Based on careful review of available terminologies, a three-tiered three-tiered system of 1 categorization of FHR interpretation is recommended . (Level III, Grade C) Category Baseline FHR
Baseline variability
Decelerations
I II 110-160 beats Bradycardia not accompanied per minute by absent baseline variability or Tachycardia Moderate Minimal baseline variability Absent baseline variability with no recurrent decelerations Marked baseline variability Absent early, Recurrent variable decelerations late or accompanied by minimal or variable 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
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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 6-9 than 99%. (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, 11 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 12 evaluating fetal status. (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 1 continuous FHR monitoring. (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, 1 averaged over a 30-minute window). (Level III, Grade C)
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.15 (Level II-3, Grade B) Because vibroacoustic stimulation and digital scalp stimulation is less 16 invasive than the other two methods, they are the preferred methods. (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 • •
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Monitoring maternal blood pressure level for evidence of hypotension, especially in those with regional region al anesthesia (if present, treatment with volume expansion or with ephedrine or both or phenylephrine may be warranted) Assessment of patient patient for uterine tachysystole by evaluating uterine contraction frequency and duration
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 intrap artum 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 GD.tempora l and Demographic trends in celebral palsy-fack and fiction. Am J Obstet Gynecol 2003; 188: 628-33. 8. Hankins GD, Speer M. Defining 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, O’Sullivan F, Burton PR, et al. Antepartum risk factors for newborn encephalopathy: e ncephalopathy: 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 au scultation 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 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 T ocolytics 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 Disorder
Diagnostic Criteria Nulliparas Multiparas
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1. Prolonged Latent Phase
> 20 hrs
> 14 hrs
1. Protracted Active Phase Dilatation (Phase of maximum slope of dilatation)
< 1.2 cm/hr
< 1.5 cm/hr
2. Protracted Descent (maximum slope of descent during the pelvic division)
< 1.0 cm/hr
< 2 cm/hr
Protraction Disorders
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Arrest Disorders 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) 1 4. Failure of Descent (station 0)
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5. Prolonged Second Stage
> 3 hrs
> 1 hr
> 2 hrs
> 1 hr
Lack of expected descent during deceleration phase or second stage of labor > 3 hrs with
> 2 hrs with
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 3 established. (Level III, Grade C) Develop a plan to meet the woman’s needs either at home or in a non3 laboring hospital unit. (Level III, Grade C) Observation, rest and therapeutic analgesia/strong sedatives are favored 3 over a more active active approach of amniotomy and oxytocin oxytocin induction. (Level III, Grade C) 3, 2 Support and information from caregivers to provide coping strategies. strategies. (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 4 develop problems than gravidas with normal latent phases. (Level III, Grade C) A patient who has a latent phase longer than 20 hours should be expected 4 to evolve a normal subsequent dilatation and descent if allowed to do so. (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 4 time. (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 non4 reassuring fetal status. (Level III, Grade C) Friedman’s recommended approach is support and therapeutic rest by the 4 use of large doses of narcotic analgesics. (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 4 chorioamnionitis. (Level III, Grade C) •
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2. Protracted Active Phase Dilatation 2 Physical and emotional support (Level I, Grade A) •
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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) Amniotomy with early oxytocin augmentation shortens labor by as much as 2 hours compared to expectant care but has not been shown to change 7 cesarean delivery rates. (Level I, Grade A) Amniotomy may enhance progress in the active phase and negate the need 7 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 7 Montevideo units) before operative delivery is considered. (Level I, Grade B) High-dose oxytocin regimens result re sult in shorter labors than low dose 7 regimens without adverse effects to the fetus. (Level I, Grade B) 1 Rule out cephalopelvic disproportion (CPD) (Level III, Grade B) 1 If with CPD, do cesarean section. (Level III, Grade B)
3. Arrest Disorders Continuous support during labor from caregivers should be encouraged 2,5,6 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 8 have benefit, and therefore is not recommended. (Level I, Grade B) 1 Rule out CPD (Level III, Grade B) 1 If with CPD, do cesarean section (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 9 exceeds 200 Montevideo units for 2 hours without cervical change. (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 9 Montevideo units. (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 9 the contraction pattern could not be achieved. (Level III, Grade C) The protocol resulted in a high rate of vaginal delivery (92%) with no severe adverse maternal or fetal outcomes. •
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Extending the minimum period of oxytocin augmentation for active phase 9 arrest from 2 hours to 4 hours appears effective. (Level III, Grade C)
References nd
1. Friedman EA. Labor Clinical Evaluation and Management,2 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, th 4 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.
III. Dystocia secondary to Problems in Passenger Ma. Socorro Solis, MD, FPOGS
BREECH PRESENTATION Recommendations: •
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Planned cesarean section for babies in breech presentation has a reduced risk for perinatal or neonatal death and neonatal morbidity compared to planned vaginal 1 birth. (Level I, Grade A) Planned cesarean section for babies in breech presentation is associated with a 1 modest increase in short term maternal morbidity. (Level I, Grade A) 1 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 1 neurodevelopmental delay”. Maternal outcomes were also similar. (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 2,3 accreta). (Level III, Grade C) There is no evidence that the long term health of babies with a breech presentation 2,3 delivered at term is influenced by how the baby is born. (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 2,3 available, and the woman is informed of all possible risks. (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, 4 Caesarean section is recommended. (Level II, Grade A) Contraindications to labor include 3,4,5 a. Cord presentation (Level II, Grade A) 3,4,5 b. Fetal growth restriction or macrosomia (Level I, Grade A) c. Any presentation other than a frank or complete breech with a flexed or 3,4,5 neutral head attitude (Level III, Grade B) 3,4,5 d. Clinically inadequate maternal pelvis (Level III, Grade B) 3,4,5 e. Fetal anomaly incompatible with vaginal delivery (Level III, Grade B) Vaginal breech delivery can be offered when the estimated fetal weight is 3,4,5 between 2500 g and 4000 40 00 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 3,4,5 progress in labor is the best indicator of adequate fetal-pelvic proportions. (Level III, Grade B) Continuous electronic fetal heart monitoring is preferable in the first stage and 3,4,5 mandatory in the second stage of labor. (Level I, Grade A)
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When membranes rupture, immediate vaginal examination is recommended to 4 rule out prolapsed cord. (Level III, Grade B) 4 In the absence of adequate progress in labor, Caesarean section is advised. (Level II-1, Grade A) 4 Induction of labor is not recommended for breech presentation. (Level II, Grade B) Oxytocin augmentation is acceptable in the presence of hypotonic uterine 4 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, Caesarean section is 4 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 Caesarean section if 3,4,5 necessary. (Level III, Grade A) A health care professional skilled in neonatal resuscitation should be in 3,4,5 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.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 3,4,5 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 after-coming head or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can 3,4,5 be life saving. (Level III, Grade B) 4 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 4 encouraged. (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 3,4,5 to the level of the umbilicus. (Level III, Grade A) 3,4,5 Nuchal arms may be reduced by the Løvset maneuver. (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 3,4,5 forceps. (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 woman’s 4 choice of delivery mode should be respected. (Level III, Grade A) The consent discussion and chosen plan should be well documented and 4 communicated to labor-room staff. (Level III, Grade B)
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Hospitals offering a trial of labor should have a written protocol for eligibility and 4 intrapartum management. (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 4 providers for unexpected vaginal breech births. (Level III, Grade B) Not enough evidence to support the intervention of helping a breech baby to be 5 born in one pushing contraction following the birth of the baby’s umbilicus. (Level III, Grade B) 2 Epidural anesthesia is not routinely advised. (Level III, Grade C)
EXTERNAL CEPHALIC VERSION 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 •
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Women should be counseled that ECV reduces the chance of breech presentation 7,8 at delivery. (Level I, Grade A) 7,8 External version reduces the chances of having a cesarean section. (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 7, 9 rate. (Level I, Grade A) External cephalic version before 36 weeks is not associated with significant 7,10 reduction in noncephalic noncep halic births or cesarean section. (Level II, Grade B) There is insufficient evidence to support the use of postural management as a 7,11 method of promoting spontaneous version over external cephalic version. (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 7,12 version has not been required. (Level I, Grade B) Absolute contraindications for ECV that are likely to be associated with increased 7 mortality or morbidity: (Level III, Grade C)
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Where cesarean delivery is required Antepartum hemorrhage within the last 7 days Abnormal cardiotocograph Major uterine anomaly Ruptured membranes Multiple pregnancy (except delivery of second twin) 7
Relative contraindications where ECV might be more complicated (Level III, Grade C) Small for gestational age fetus with abnormal Doppler parameters o o Proteinuric pre-eclampsia o Oligohydramnios Major fetal anomalies o Scarred uterus o o Unstable lie
MALPRESENTATION (Persistent occiput posterior, occiput transverse) Definition Persistent occiput posterior is ______________ Recommendations •
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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 5,13,14,15,16 associated with persistent occiput posterior. (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 17 backache. (Level I, Grade A)
BROW PRESENTATION Recommendations •
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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.5,18 (Level II, Grade B) The use of forceps or manual conversion to convert a brow presentation to a more 5,18 favorable position is contraindicated. (Level II, Grade B)
FACE PRESENTATION Recommendations •
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Continuous electronic fetal heart rate monitoring is considered mandatory by many authors because of the increased incidence of abnormal fetal heart rate patterns and/or fetal compromise. Careful application of the electrode must be 5,19 ensured; the mentum is the recommended site of application. (Level III, Grade B) 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, 5,19 adequacy of the pelvis, and reassuring fetal heart tracing. (Level III, Grade B) 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.5,19 (Level III, Grade B) Forceps may be used if the mentum is anterior. Any typical forceps, including 5,19 Kielland forceps, can be used. (Level III, Grade B) The mechanisms of labor in the term infant can occur only if the mentum is 5,19 anterior. (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 •
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The diagnosis of fetal macrosomia is imprecise. For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than 20 that obtained with clinical palpation (Leopold's maneuvers). (Level I, Grade A) Suspected fetal macrosomia is not an indication for induction of labor, because 20,21,22,23 induction does not improve maternal or fetal outcomes. (Level II, Grade B)
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Labor and vaginal delivery is not contraindicated for women with estimated fetal 20,21,22,23 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.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 20,21,22,23 4,500 g in pregnant women with diabetes. (Level III, Grade C) Suspected fetal macrosomia is not a contraindication to attempted vaginal birth 20,21,22,23 after a previous cesarean delivery. (Level III, Grade C)
SHOULDER DYSTOCIA Recommendations •
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Risk assessments for the prediction of shoulder dystocia are insufficiently 22 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 22 or neonatal morbidity of shoulder dystocia. (Level I, Grade A) Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy with increasing birth weight, and an overall tendency to overestimate the birth weight.24 (Level II, Grade B) 22,25 Fundal pressure should not be employed. (Level III, Grade C) Episiotomy is not necessary for all cases, is reserved to facilitate maneuvers such 22,25 as delivery of posterior arm or internal rotation of shoulders. (Level III, Grade C) McRobert’s is the single most effective intervention and should be performed 22,25 first. (Level III, Grade C) Suprapubic pressure is useful.22,25 (Level III, Grade C) Suprapubic pressure can be employed together with McRobert’s maneuver to 22,25 improve success rates. (Level III, Grade C) Other maneuvers such as Rubin’s, Wood’s screw maneuver, Zavanelli, cleidotomy and symphysiotomy have been employed but no controlled trials have 5,22,25 been made. (Level III, Grade C)
TRANSVERSE LIE / OBLIQUE LIE Recommendation •
Transverse lie and oblique lie will benefit from a trial of version to cephalic presentation following the criteria and recommendations of external cephalic 5,26 version for breech presentations. (Level III, Grade C)
COMPOUND PRESENTATION Recommendations: •
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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 5 progressing normally. (Level III, Grade C) In contrast, if the hand or arm has prolapsed past the presenting part, abandoning 5 vaginal delivery and proceeding to cesarean delivery is wise. (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 Sy stematic 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 occipitoanterior 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 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.
