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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Shoulder Dystocia
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13. A.C.O.G. Resources (American College of Obstetricians and Gynecologists)
Shoulder dystocia. ACOG Practice Bulletin No. 40. American College of Obstetricians and Gynecologists. Obstet Gynecol 2002;100:1045–50.
Summary of Recommendations
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Shoulder dystocia cannot be predicted or prevented because accurate methods for identifying which fetuses will experience this complication do not exist.
- Elective induction of labor or elective cesarean delivery for all women suspected of carrying a fetus with macrosomia is not appropriate.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- In patients with a history of shoulder dystocia, estimated fetal weight, gestational age, maternal glucose intolerance, and the severity of the prior neonatal injury should be evaluated and the risks and benefits of cesarean delivery discussed with the patient.
- Planned cesarean delivery to prevent shoulder dystocia may be considered for suspected fetal macrosomia with estimated fetal weights exceeding 5,000 g in women without diabetes and 4,500 g in women with diabetes.
- There is no evidence that any one maneuver is superior to another in releasing an impacted shoulder or reducing the chance of injury. However, performance of the McRoberts maneuver is a reasonable initial approach.
Non-ACOG Members
ACOG Members
Fetal Macrosomia. ACOG Practice Bulletin No. 22. American College of Obstetricians and Gynecologists. November 2000.
Summary
The following recommendation is based on good and consistent scientific evidence (Level A):
- The diagnosis of fetal macrosomia is imprecise. For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold's maneuvers).
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.
- Labor and vaginal delivery are not contraindicated for women with estimated fetal weights up to 5,000 g in the absence of maternal diabetes.
- With an estimated fetal weight greater than 4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights greater than 5,000 g in women without diabetes and greater than 4,500 g in women with diabetes.
- Suspected fetal macrosomia is not a contraindication to attempted vaginal birth after a previous cesarean delivery.
Non-ACOG Members
ACOG Members
* 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.
