• American College of Obstetricians and Gynecologists (ACOG). Dystocia and augmentation of labor. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2003 Dec. 10 p. (ACOG practice bulletin; no. 49). [61 references]

This is the current release of the guideline.

• Dystocia*
• Pregnancy

*Dystocia: defined as abnormal labor that results from what have been categorized classically as abnormalities of the power (uterine contractions or maternal expulsive forces), the passenger (position, size, or presentation of the fetus), or the passage (pelvis or soft tissues).

Diagnosis
Management
Treatment

Obstetrics and Gynecology

Advanced Practice Nurses
Physicians

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To provide a review of the definition of dystocia, risk factors associated with dystocia, the criteria that require delivery, and approaches to clinical management of labor complicated by dystocia

Pregnant women experiencing dystocia during labor

1. Uterine activity monitoring (external tocotransducers, intrauterine catheters)
2. Ambulation
3. X-ray pelvimetry
4. Magnetic resonance imaging (MRI) (investigational)
5. Continuous caregiver support during labor
6. Intravenous fluids
7. Active labor management:
   • Patient education
   • Strict criteria for diagnosis, abnormal progress, and fetal compromise
   • High-dose oxytocin infusion
   • One-to-one nursing support
   • Peer review of operative deliveries
8. Low-dose versus high-dose oxytocin
9. Amniotomy
10. Electronic fetal monitoring versus intermittent ascultation

• Time to delivery
• Rate of cesarean delivery
• Rate of forceps-assisted delivery
• Incidence of maternal and fetal complications
• Predictive value of risk factors

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and August 2003. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations are based on good and consistent scientific evidence (Level A):

• Patients should be counseled that walking during labor does not enhance or improve progress in labor nor is it harmful.
• Continuous support during labor from caregivers should be encouraged because it is beneficial for women and their newborns.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

• Active management of labor may shorten labor in nulliparous women, although it has not consistently been shown to reduce the rate of cesarean delivery.
• Amniotomy may be used to enhance progress in active labor, but may increase the risk of maternal fever.
• X-ray pelvimetry alone as a predictor of dystocia has not been shown to have benefit, and, therefore, is not recommended.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• Intrauterine pressure catheters may be helpful in the management of dystocia in selected patients, such as those who are obese.
• Women with twin gestations may undergo augmentation of labor.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Appropriate management of labor complicated by dystocia

Amniotomy may increase the risk of maternal fever and chorioamnionitis.

Contraindications to augmentation are similar to those for labor induction and may include placenta or vasa previa, umbilical cord presentation, prior classical uterine incision, active genital herpes infection, pelvic structural deformities, or invasive cervical cancer.

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Staying Healthy

Effectiveness
Patient-centeredness

• American College of Obstetricians and Gynecologists (ACOG). Dystocia and augmentation of labor. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2003 Dec. 10 p. (ACOG practice bulletin; no. 49). [61 references]

Not applicable: The guideline was not adapted from another source.

2003 Dec

American College of Obstetricians and Gynecologists - Medical Specialty Society

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics

Not stated

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on October 12, 2007. The information was verified by the guideline developer on December 3, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.