CLINICAL PRACTICE GUIDELINES ON

ABNORMAL LABOR AND DELIVERY

ELECTRONIC FETAL MONITORING
DURING ABNORMAL LABOR AND
DELIVERY
Definition of Terms:
A. Baseline
B. Baseline variability
C. Acceleration
D. Early deceleration
E. Late deceleration
F. Variable deceleration
G. Prolonged deceleration
H. 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 10-minute
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 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 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.
 The decrease in FHR is calculated from the
onset to the nadir of the deceleration.
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.
 The decrease in FHR is calculated from the onset
to the nadir of the deceleration.
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
Category FHR Definition
Tracings
I Normal • Category I FHR tracings 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 specific action is required.
Category FHR Definition
Tracings
II Indetermi- • not predictive of abnormal fetal acid-
nate base status, yet presently there is no
adequate evidence to classify these as
Category I or Category III.
• require evaluation and continued
surveillance and reevaluation, taking into
account the entire associated clinical
circumstances.
• In some circumstances, either ancillary
tests to ensure fetal well being or
intrauterine resuscitative measures may be
used with Category II tracings.
Category FHR Definition
Tracings
III Abnormal • associated with abnormal fetal acid-base
status at the time of observation.
• 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:
1. maternal oxygen
2. change in maternal position
3. discontinuation of labor stimulation
4. treatment of maternal hypotension
5. treatment of tachysystole with FHR
changes.
Category FHR Definition
Tracings
III Abnormal If category III 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.
(Level III, Grade C)
 Category I II III
Baseline 110-160 Bradycardia not Bradycardia
FHR beats per accompanied by
minute absent baseline
variability or
Tachycardia
Baseline Moderate Minimal baseline Absent
variability variability
Absent baseline
variability with no
recurrent
decelerations
Marked baseline
variability
Category I II III
Decelerations Absent Recurrent variable Recurrent
early, late or decelerations late
variable accompanied by decelerations
minimal or moderate Recurrent
baseline variability variable
Prolonged decelerations
deceleration more
than 2 minutes but
less than 10 minutes
Recurrent late
decelerations with
moderate baseline
variability
 Category I II III
Decelerations Absent Variable Recurrent
early, late or decelerations with late
variable other characteristics decelerations
such as slow return to Recurrent
baseline, overshoots, variable
or “shoulders” decelerations

Accelerations Present or Absence of induced Sinusoidal

Absent accelerations after pattern
fetal stimulation
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%.

(Level II-2 to III, Grade C)

 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.
(Level II-2 to III, Grade C)
 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.

(Level III, Grade C)

 There is high interobserver and intraobserver variability
in interpretation of FHR tracing.

(Level III, Grade C)

 Reinterpretation of the FHR tracing, especially if the

neonatal outcome is known, may not be reliable.

(Level III, Grade C)

 The use of EFM does not result in reduction of
cerebral palsy.

(Level III, Grade C)

 A three-tiered system for the categorization
of FHR patterns is recommended.

(Level III, Grade C)

 The labor of women with high-risk conditions
should be monitored with continuous FHR
monitoring.

(Level III, Grade C)

 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).

(Level III, Grade C)

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

(Level III, Grade C)

 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 Phase > 20 hrs > 14 hrs
Protraction Disorder
1. Protracted Active Phase < 1.2 cm/hr < 1.5 cm/hr
Dilation (Phase of maximum
slope of dilatation)
2. Protracted Descent < 1 cm/hr < 2cm/hr
(maximum slope of descent
during the pelvic division)
 LABOR PATTERN Diagnostic Criteria
Nulliparas Multiparas
Arrest Disorder
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 > 1 hr

descent stops during pelvic division
of labor, station + 1)
 LABOR PATTERN Diagnostic Criteria
Nulliparas Multiparas
4. Failure of Descent (station 0) Lack of expected descent during
deceleration phase or second
stage of labor

5. Prolonged Second Stage > 3 hrs with > 2 hrs with

regional regional
anesthesia or > anesthesia or >
2 hrs without 1 hr without
regional regional
anesthesia 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.
(Level III, Grade C)

• Develop a plan to meet the woman’s need

either at home or in a non-laboring hospital
unit.
(Level III, Grade C)
Prolonged Latent Phase

• Friedman (1972) reported that prolongation

of the latent phase did not adversely
influence fetal or maternal morbidity and
mortality. (Level III, Grade C)
• Data show that patients with prolonged latent
phase are no more prone to develop
problems than gravidas with normal latent
phase. (Level III, Grade C)
Prolonged Latent Phase

• Observation, rest and therapeutic

analgesia/strong sedatives are favored over a
more active approach of amniotomy and
oxytocin induction. (Level III, Grade C)

• Support and information from caregivers to

provide coping strategies. (Level III, Grade C)
Prolonged Latent Phase

• 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.
(Level III, Grade C)
Prolonged Latent Phase

- 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.
(Level III, Grade C)
Prolonged Latent Phase

 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).
(Level III, Grade C)
 Friedman’s recommended approach is support and
therapeutic rest by the use of large doses of
narcotic analgesics.
(Level III, Grade C)
Prolonged Latent Phase

 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.
(Level III, Grade C)
Recommendations

1. Prolonged Latent Phase

2. Protracted Active Phase Dilatation
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.

(Level III, Grade B)
Recommendations

1. Prolonged Latent Phase

2. Protracted Active Phase Dilatation
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
(Level III, Grade B)
Arrest Disorders

 If with CPD, do CS.

(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.
(Level III, Grade C)
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.

(Level III, Grade C)

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.
(Level III, Grade C)
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.

(Level III, Grade C)

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).
(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.
(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
(Level III, Grade B)

d) Clinically inadequate maternal pelvis (Level III, Grade B)

e) Fetal anomaly incompatible with vaginal delivery.
(Level III, Grade B)
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.
(Level III, Grade B)
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.
(Level III, Grade B)
• 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.
(Level III, Grade B)
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.
(Level III, Grade A)
Recommendations:

• The fetal head may deliver

spontaneously, with the
assistance of suprapubic
pressure, by Mauriceau-Smellie-
Veit maneuver, or with the
assistance of Piper forceps.
(Level III, Grade B)
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 woman’s choice
of delivery mode should be respected.
(Level III, Grade A)
Recommendations:
• The consent discussion and chosen plan should be well
documented and communicated to labor room staff.
(Level III, Grade B)

 Hospitals offering a trial of labor should have a

written protocol for eligibility and intrapartum
management.
(Level III, Grade B)
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.
(Level III, Grade A)
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
(Level III, Grade B)
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
baby’s umbilicus.
(Level III, Grade B)

 Epidural anesthesia is not routinely advised.

(Level III, Grade C)
EXTERNAL CEPHALIC VERSION
EXTERNAL CEPHALIC VERSION
 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

(Level III, Grade B)

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)

(Level III, Grade C)

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

(Level III, Grade C)

PERSISTENT OCCIPUT POSTERIOR,
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.
PERSISTENT OCCIPUT POSTERIOR,
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.
PERSISTENT OCCIPUT POSTERIOR,
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
(Level III, Grade B)
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 comfortable. 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.

(Level III, Grade B)

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.

(Level III, Grade B)

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.
(Level III, Grade B)
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
(Leopold’s 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.

(Level III, Grade C)

 Suspected fetal macrosomia is not contraindication
to attempted vaginal birth after a previous
cesarean delivery.

(Level III, Grade C)

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.

(Level III, Grade C)
Recommendations
 Episiotomy is not necessary for all cases, is
reserved to facilitate maneuvers such 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 first.

(Level III, Grade C)

Recommendations
 Suprapubic pressure is useful
(Level III, Grade C)

 Suprapubic pressure can be employed together

with McRobert’s maneuver to improve success rates.
(Level III, Grade C)
Recommendations
 Other maneuvers such as Rubin’s, Wood’s screw
maneuver, Zavanelli, cleidotomy and symphysiotomy
have been employed but no controlled trials have
been made.

(Level III, Grade C)

 Rubin Maneuver
 Wood’s screw maneuver
 Zavanelli maneuver
 Symphysiotomy
TRANSVERSE LIE/OBLIQUE LIE
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 ECV for breech presentations.

(Level III, Grade C)

 COMPOUND PRESENTATION
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.

(Level III, Grade C)

COMPOUND PRESENTATION

Recommendations
 In contrast, if the hand or arm has prolapsed past the
presenting part, abdominal vaginal delivery and
proceeding to cesarean delivery is wise.

(Level III, Grade C)

 Thank you