In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Levels of evidence (Ia-IV) and grading of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
Prediction
Can Shoulder Dystocia be Predicted?
B - Risk assessments for the prediction of shoulder dystocia are insufficiently predictive to allow prevention of the large majority of cases.
Prevention
Management of Suspected Fetal Macrosomia
Does Induction of Labour Prevent Shoulder Dystocia?
A - There is no evidence to support induction of labour in women without diabetes at term where the fetus is thought to be macrosomic.
A - Induction of labour in women with diabetes mellitus does not reduce the maternal or neonatal morbidity of shoulder dystocia.
Should Elective Caesarean Section be Recommended for Suspected Fetal Macrosomia?
C - Elective caesarean section is not recommended to reduce the potential morbidity for pregnancies complicated by suspected fetal macrosomia without maternal diabetes mellitus.
C - Elective caesarean section should be considered to reduce the potential morbidity for pregnancies complicated by suspected fetal macrosomia associated with maternal diabetes mellitus.
Management
Delivery
How Should Shoulder Dystocia be Managed?
C - Fundal pressure should not be employed.
B - Episiotomy is not necessary for all cases.
The Managing Obstetric Emergencies and Trauma (MOET) Group suggests a selective approach, reserving episiotomy to facilitate manoeuvres such as delivery of the posterior arm or internal rotation of the shoulders. An episiotomy should therefore be considered but it is not mandatory. (Evidence level III)
B - McRoberts' manoeuvre is the single most effective intervention and should be performed first.
C - Suprapubic pressure is useful.
Suprapubic pressure can be employed together with McRoberts' manoeuvre to improve success rates. (Evidence level IV)
Definitions:
Grading of Recommendations
Grade A - Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence levels Ia, Ib)
Grade B - Requires the availability of well-conducted clinical studies but no randomised clinical trials on the topic of recommendations (evidence levels IIa, IIb, III)
Grade C - Requires evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates an absence of directly applicable clinical studies of good quality (evidence level IV)
Levels of Evidence
Ia: Evidence obtained from meta-analysis of randomised controlled trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
