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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Post-term Pregnancy and Induction of Labor
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12 A.C.O.G. resources
What are the latest A.C.O.G. statements on this?
Summary of Recommendations*
(Induction of Labor ACOG Practice Bulletin NUMBER 10, NOVEMBER 1999
)
The following recommendations are based on good and consistent scientific evidence (Level A):
- Prostaglandin E analogues are effective in promoting cervical ripening and inducing labor.
- Women in whom induction of labor is indicated may be appropriately managed with either a low- or high-dose oxytocin regimen.
- Fetal heart rate and uterine activity should be continuously monitored from the time the PGE2 vaginal insert is placed until at least 15 minutes after it is removed.
- High-dose PGE2 vaginal suppositories may be used in the management of intrauterine fetal demise in the second trimester of pregnancy.
- Although the optimal dose and timing interval of misoprostol is unknown, lower doses (25 mcg every 3-6 hours) are effective for cervical ripening and induction of labor.
- With term premature rupture of membranes, labor may be induced with prostaglandins
The following recommendations are based on evidence that may be limited or inconsistent (Level B):
- Misoprostol use in women with prior cesarean birth should be avoided because of the possibility of uterine rupture.
- The use of higher doses of misoprostol (50 mcg every 6 hours) to induce labor may be appropriate in some situations, although there are reports of increased risk of complications, including uterine hyperstimulation.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- For women with third-trimester intrauterine fetal demise, intravaginal misoprostol can be used to induce labor.
- Fetal heart rate and uterine activity should be continuously monitored from 30 minutes to 2 hours after administration of PGE2 gel.
Summary of Recommendations*
(Antepartum Fetal Surveillance ACOG Practice Bulletin NUMBER 9, OCTOBER 1999
)
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Women with high-risk factors for stillbirth should undergo antepartum fetal surveillance using the NST, CST, BPP, or modified BPP.
- Initiating testing at 32-34 weeks of gestation is appropriate for most pregnancies at increased risk of stillbirth, although in pregnancies with multiple or particularly worrisome high-risk conditions, testing may be initiated as early as 26-28 weeks of gestation.
- When the clinical condition that has prompted testing persists, a reassuring test should be repeated periodically (either weekly or, depending on the test used and the presence of certain high-risk conditions, twice weekly) until delivery. Any significant deterioration in the maternal medical status or any acute diminution in fetal activity requires fetal reevaluation, regardless of the amount of time that has elapsed since the last test.
- An abnormal NST or modified BPP usually should be further evaluated by either a CST or a full BPP. Subsequent management should then be predicated on the results of the CST or BPP, the gestational age, the degree of oligohydramnios (if assessed), and the maternal condition.
- Oligohydramnios, defined as either no ultrasonographically measurable vertical pocket of amniotic fluid greater than 2 cm or an AFI of 5 cm or less, requires (depending on the degree of oligohydramnios, the gestational age, and the maternal clinical condition) either delivery or close maternal or fetal surveillance.
- In the absence of obstetric contraindications, delivery of the fetus with an abnormal test result often may be attempted by induction of labor with continuous monitoring of the fetal heart rate and contractions. If repetitive late decelerations are observed, cesarean delivery generally is indicated.
- Recent, normal antepartum fetal test results should not preclude the use of intrapartum fetal monitoring.
- Umbilical artery Doppler velocimetry has been found to be of benefit only in pregnancies complicated by intrauterine growth restriction. If used in this setting, decisions regarding timing of delivery should be made using a combination of information from the Doppler ultrasonography and other tests of fetal well-being, along with careful monitoring of maternal status.
- Middle cerebral artery Doppler velocimetry should be considered an investigational approach to antepartum fetal surveillance.
If you ARE an A.C.O.G. member, read this on-line.
Fetal Macrosomia
ACOG Practice Bulletin NUMBER 22, NOVEMBER 2000
Induction of Labor
ACOG Practice Bulletin NUMBER 10, NOVEMBER 1999
Antepartum Fetal Surveillance
ACOG Practice Bulletin NUMBER 9, OCTOBER 1999
Shoulder dystocia
ACOG Practice Bulletin NUMBER 40, NOVEMBER 2002
Operative Vaginal Delivery
ACOG Practice Bulletin NUMBER 17, JUNE 2000
Intrauterine Growth Restriction
ACOG Practice Bulletin NUMBER 12, JANUARY 2000
Induction of Labor for Vaginal Birth After Cesarean Delivery
ACOG Committee Opinion Number 271, April 2002
Response to Searle's Drug Warning on Misoprostol
ACOG Committee Opinion Number 248, December 2000
Induction of Labor with Misoprostol
ACOG Committee Opinion Number 228, November 1999
Monitoring During Induction of Labor with Dinoprostone
ACOG Committee Opinion Number 209, October 1998
* ACOG Evidence grading system
The MEDLINE database, the Cochrane Library, and ACOG's own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and October 2000. 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. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. 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.
- I I-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.
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.
