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Philippine Obstetrical and

Gynecological Society (POGS), Foundation, Inc.



November 2009

Task Force on Clinical Practice Guideline

In the Management of
Abnormal Labor and Delivery

Philippine Obstetrical and

Gynecological Society (POGS),
Foundation, Inc.



November 2009

Task Force on Clinical Practice Guideline

In the Management of
Abnormal Labor and Delivery


Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2009

I have envisioned and have implemented to completion the publication of

a series of Clinical Practice Guidelines on the major procedures and topics of
Obstetrics and Gynecology. This is in consonance with the theme of my
Presidency, Babae, Kalusugan Mo, Katungkulan Natin. This is the Clinical
Practice Guidelines on Abnormal Labor and Delivery and is the First Edition of
this Publication, 2009.
In the role of the POGS to provide its members with updates, current and
standard practice recommendations and guidelines, this publication will fulfill the
objective of continuing education and implementation of refinements in Obstetrics
and Gynecology. In keeping with the highest standards of care, the Level and
Grades of Clinical Practice/Recommendation have been adopted for every
recommendation that is completed and decided.
In the process of the formulation of the guideline/recommendation, the
entire membership of the POGS was consulted. I take special effort to thank the
AdHoc Committee on Clinical Practice Guidelines, headed by its Chair, Dr. Efren
J. Domingo for the unceasing tireless effort to complete this publication. I also
gratefully acknowledge the Chairs and Training Officers of the ResidencyAccredited Hospitals, the Technical Working Group, and the CME Committee.
It becomes easy, dignified and scientific to conduct the practice of
Obstetrics and Gynecology specifically on Abnormal Labor and Delivery. Now,
the Clinical Practice Guidelines on Abnormal Labor and Delivery will hope to
update and make the practice current and responsive to world-class standards
and make the patients under our care deserving of the trust and confidence that
we, Obstetricians, impart with utmost care and compassion.




Chair, AdHoc Committee on the Clinical Practice Guidelines, 2009

The Clinical Practice Guidelines on Abnormal Labor and Delivery is the

First Edition of this Publication, 2009. The Philippine Obstetrical and
Gynecological Society, (Foundation), Inc. (POGS), through the AdHoc
Committee on Clinical Practice Guidelines initiated and led to completion the
publication of this manual in plenary consultation with the Residency Accredited
Training Hospitals Chairs and Training Officers, The Regional Board of
Directors, The Board of Trustees, The Task Force on the Management of
Abnormal Labor and Delivery and the Committee on Continuing Medical
This publication represents the collective effort of the POGS in updating
the clinical practice of Obstetrics and Gynecology, specifically on Abnormal
Labor and Delivery, and making it responsive to the most current and acceptable
standard in this procedure. A greater part of the inputs incorporated in this edition
are the contributions originating from the day-to-day academic interactions from
the faculty of the different Residency-Accredited Hospitals in Obstetrics and
Gynecology in the country.
This Clinical Practice Guideline on Abnormal Labor and Delivery is
envisioned to become the handy companion of the Obstetrician-Gynecologist in
his/her day-to-day rendition of quality care and decision making in managing the
Obstetric patient. This is also envisioned to provide the academic institutions in
the country and in Southeast Asia updated information and Abnormal Labor and
Delivery treatments being practiced in the Philippines.
Profound gratitude is extended to all the members of the POGS, the
Chairs and Training Officers of the Residency-Training Accredited Institutions,
the Regional Directors, The Task Force on the Management of Abnormal Labor
and Delivery Reviewers/Contributors, The CME Committee members, and the
2009 POGS Board of Trustees.


Lourdes B. Capito, MD
Regta L. Pichay, MD
Vice President
Ma. Carmen H. Quevedo, MD
Ditas Christina D. Decena, MD
Christia S. Padolina, MD
Public Relations Officer
Mayumi S. Bismarck, MD
Virgilio B. Castro, MD
Efren J. Domingo, MD, PhD
Gil S. Gonzales, MD
Diosdado V. Mariano, MD
Ma. Socorro M. Solis, MD


Efren J. Domingo, MD, PhD
Jennifer T. Co, MD
Jericho Thaddeus P. Luna, MD
Josephine M. Lumitao, MD
Lisa Teresa P. Jabson, MD
Noel E. Raymundo, MD
Elisa O. Tiu, MD
Rachelle U. delos Reyes, MD
Ana Victoria V. Dy Echo, MD
May Nueva-Hipolito, MD
Michelle R. Ong, MD
Renee Vina G. Sicam, MD
Ms. Emiliana C. Enriquez
Ms. Jhasmin G. De Guzman
Rosendo R. Roque, MD
Project Director
Mayumi S. Bismark, MD
Lourdes B. Capito, MD
Sylvia A. Carnero, MD
Lyra Ruth Clemente-Chua, MD
Jennifer T. Co, MD

Ditas Cristina D. Decena, MD

Ruth V. Gutierrez, MD
Marlene Javier, MD
Milagros T. Jocson, MD
Evelyn P. Palaypayon, MD

Susan Pelea-Nagtalon, MD
Ma. Carmen H. Quevedo, MD
Raul M. Quillamor, MD
Ma. Socorro M. Solis, MD


Rainerio S. Abad, MD
Imelda O. Andres, MD
Cecilia Joyce M. Bascarra, MD
Ricardo R. Braganza, MD
Virgilio B. Castro, MD
Maria Lourdes B. Coloma, MD
Godofreda V. Dalmacion, MD
Santiago A. del Rosario, MD
Rey H. Delos Reyes, MD
Virginia R. de Jesus, MD
Arcangel N. Diamante, MD
Rommel Z. Dueas, MD

Joseline A. Ferrolino, MD
Ma. Corazon N. Gamilla, MD
Erlinda G. Germar, MD
Ma. Antonia E. Habana, MD
Myrna R. Habaa, MD
Bernardita B. Javier, MD
Genara M. Limson, MD
Lilia P. Luna, MD
Augusto M. Manalo, MD
Diosdado V. Mariano, MD
Jocelyn Z. Mariano, MD
Christia S. Padolina, MD
Mildred N. Pareja, MD

Regional Directors
Ellen A. Manzano, MD (Region 1)
Melchor C. dela Cruz, MD (Region 2)
Concepcion P. Aronza, MD (Region 3)
Ernesto S. Naval, MD (Region 4)
Rowena M. Auxillos, MD (Region 4A)
Cecilia Valdes-Neptuno, MD (Region 5)

Wilhelmina Pineda, MD
Patria P. Punsalan, MD
Rebecca M. Ramos, MD
Cristina C. Raymundo, MD
Marilyn D. Ruaro, MD
Sherri Ann L. Suplido, MD
Walfrido W. Sumpaico, MD
Carmencita B. Tongco, MD
Ma. Victoria Torres, MD
Milagros P. Torres, MD
Ma. Trinidad R. Vera, MD
Ma. Guadalupe N. Villanueva, MD

Evelyn R. Lacson, MD (Region 6)

Belinda N. Paares, MD (Region 7)
Realino G. Molina, MD (Region 8)
Suzette S. Montuno, MD (Region 9)
Jana Joy R. Tusalem, MD (Region 10)
Amelia A. Vega, MD (Region 1


This is the Clinical Practice Guidelines (CPG) on Abnormal Labor and Delivery, First
Edition, November 2009.
This is the publication of the Philippine Obstetrical and Gynecological Society,
(Foundation), Inc. (POGS).
This is the ownership of the POGS, its officers, and its entire membership.
The obstetrician gynecologist, the general practitioner, the patient, the student, the
allied medical practitioner, or for that matter, any capacity of the person or individual
who may read, quote, cite, refer to, or acknowledge, any, or part, or the entirety of
any topic, subject matter, diagnostic condition or idea/s willfully release and waive all
the liabilities and responsibilities of the POGS, its officers and general membership,
as well as the AdHoc Commiittee on the Clinical Practice Guidelines and its Editorial
Staff in any or all clinical or other disputes, disagreements, conference
audits/controversies, case discussions/critiquing.
The reader is encouraged to deal with each clinical case as a distinct and unique
clinical condition which will never fit into an exact location if reference is made into
any or all part/s of this CPG.
The intention and objective of this CPG is to serve as a guide, to clarify, to make
clear the distinction. It is not the intention or objective of this CPG to serve as the
exact and precise answer, solution and treatment for clinical conditions and situations.
It is always encouraged to refer to the individual clinical case as the one and only
answer to the case in question, not this CPG.
It is hoped that with the CPG at hand, the clinician will find a handy guide that leads
to the a clue, to a valuable pathway that leads to the discovery of clinical tests leading
to clinical treatments and eventually recovery.
In behalf of the POGS, its Board of Trustees, the AdHoc Committee on The Clinical
Practice Guidelines, 2009, this CPG is meant to make each one of us a perfect image
of Christ, the Healer.



Electronic Fetal Monitoring During Abnormal Labor and Delivery

Dr. Christia S. Padolina
A. Electronic Fetal Monitoring: Definition of Terms
B. Classification of Fetal Heart Rate Tracings ..
C. Clinical Consideration and Recommendations .


Dr. Sylvia A. Carnero
A. Definitions of Abnormal Patterns of Labor .
B. Recommendations


Dystocia Secondary to Problems in Passenger

Dr. Ma. Socorro M. Solis
A. Breech Presentation .
B. External Cephalic Version ...
C. Persistent Occiput Posterior and Occiput Transverse .
D. Brow Presentation
E. Face Presentation .
F. Fetal Macrosomia
G. Shoulder Dystocia
H. Transverse/Oblique Lie
I. Compound Presentation

Appendix .

Christia S. Padolina, MD, FPOGS

A. Electronic Fetal Monitoring Definition of Terms1


The mean fetal heart rate (FHR) rounded to increments of 5 beats per
minute during a 10-minute segment, excluding:
- Periodic or episodic changes
- Periods of marked FHR variability
- Segments of baseline that defer by more than 25 beats per min
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
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
Fluctuations in the baseline FHR that are irregular in amplitude and
Variability is visually quantified as the amplitude of peak-to-trough in
beats per minute.
" 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 32 weeks of gestation and beyond, an 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.
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.
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 is FHR is calculated from the onset to the nadir of the




The nadir of the deceleration occurs at the same time as the peak of the
In most cases the onset, nadir, and recovery of the deceleration are
coincident with the beginning, peak, and ending of the contraction,
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
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.
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
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
Visually apparent decrease in the 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.
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.

B. Classification of FHR Tracings Three Tiered System for the

Categorization of FHR Patterns2

FHR Tracings





Category 1 FHR tracings are strongly predictive of
normal fetal acid-base status at the time of observation.
Category 1 FHR tracings may be monitored in a routine
manner, and no specific action is required.
Category II FHR tracings are not predictive of abnormal
fetal acid-base status, yet presently there is not adequate
evidence to classify these as Category I or category III.
Category II FHR tracings 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 III tracings are associated with abnormal fetal
acid-base status at the time of observation.
Category III FHR tracings 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 maternal
oxygen, change in maternal position, discontinuation of
labor stimulation, treatment of maternal hypotension, and
treatment of tachysystole with FHR changes.
If category III tracing does not resolve with these
measures, delivery should be undertaken.

C. Clinical Consideration and Recommendations

#$ Fetal surveillance in labor, whether by intermittent auscultation (IA) or by

electronic fetal monitoring (EFM), should be recommended to all women.3 (Level

III, Grade C). !
Frequency of intermittent auscultation is as follows4:
For low risk patients - every 30 mins for 1st stage, then every 15 mins for the 2nd
For high risk patients - every 15 mins for 1st stage, then every 5 mins for the 2nd

2. Based on available data, there is no clear benefit for the use of EFM over IA.
Either option is acceptable in a patient without complications.3 (Level III, Grade

A meta-analysis synthesizing results of RCTs comparing modalities had the following

conclusions5: (Level I, Grade A)

The use of EFM compared with IA increased the overall cesarean delivery
rate (RR, 1.66; 95% CI, 1.30-2.13) and the cesarean delivery rate for
abnormal FHR or acidosis or both (RR, 2.37; 95% CI, 1.88-3.00).
The use of EFM increased the risk of both vacuum and forceps operative
vaginal delivery (RR, 1.16; 95% CI, 1.01-1.32).
The use of EFM did not reduce prenatal mortality (RR, 0.85; 95% CI, 0.591.23)
The use of EFM reduced the risk of neonatal seizures (RR, 0.50; 95% CI,
The use of EFM did not reduce the risk of cerebral palsy (RR, 1.74; 95% CI,

3. In ideal settings, continuous EFM should be offered and is recommended for high
risk pregnancies where there is increased risk of perinatal dealth, cerebral palsy or
neonatal encephalopathy6-9. (Level II-2 to III, Grade C)
4. Current evidence does not support the use of admission tocogram in low risk
pregnancy10. (Level III, Grade C)
5. Based on careful review of available terminologies, a three-tiered system of
categorization of FHR interpretation is recommended1. (Level III, Grade C)
Baseline FHR

110-160 beats
per minute




Absent early,
late or

Bradycardia not accompanied
by absent baseline variability or
Minimal baseline variability
Absent baseline variability with
no recurrent decelerations
Marked baseline variability
Recurrent variable decelerations
accompanied by minimal or
moderate baseline variability
Prolonged deceleration more
than 2 minutes but less than 10
Recurrent late decelerations
with moderate baseline
Variable decelerations with
other characteristics such as
slow return to baseline,
overshoots, or shoulders


Recurrent late


Present or

Absence of induced
accelerations after fetal


The false-positive rate of EFM for predicting cerebral palsy is high, at greater
than 99%.6-9 (Level II-2 to III, Grade C)
The use of EFM is associated with an increased rate of both vacuum and
forceps operative vaginal delivery, and caesarean delivery for abnormal FHR
patterns or acidosis or both. 6-9 (Level II-2 to III, Grade C)
When the FHR tracing includes recurrent variable decelerations,
amnioinfusion to relieve umbilical cord compression should be considered.11
(Level II-1, Grade B)
Pulse oximetry has not been demonstrated to be a clinically useful test in
evaluating fetal status.12 (Level III, Grade C)
There is high interobserver and intraobserver variability in interpretation of
FHR tracing. 13-14 (Level III, Grade C)
Reinterpretation of the FHR tracing, especially if the neonatal outcome is
known, may not be reliable. 13-14 (Level III, Grade C)
The use of EFM does not result in a reduction of cerebral palsy. 13-14 (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. 1 (Level III, Grade C)
The terms hyperstimulation and hypercontractility should be abandoned. It is
now called uterine tachysystole (i.e. more than 5 contractions in 10 minutes,
averaged over a 30-minute window). 1 (Level III, Grade C)

%$ 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.15 (Level II-3,
Grade B)!
Because vibroacoustic stimulation and digital scalp stimulation is less
invasive than the other two methods, they are the preferred methods. 16 (Level
I, Grade A).
7. A Category II or Category III FHR tracing requires initial evaluation and
treatment may include the following17 (Level III, Grade C):
Discontinuation of any labor stimulating agent
Cervical examination to determine umbilical cord prolapse, rapid cervical
dilatation, or descent of the fetal head.
Changing maternal position to left or right lateral recumbent position,
reducing compression of the vena cava and improving uteroplacental blood

Monitoring maternal blood pressure level 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)
Assessment of patient for uterine tachysystole by evaluating uterine
contraction frequency and duration

1. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National
Institute of Child Health and Human Development workshop report on
electronic fetal monitoring: update on definitions, interpretation, and research
guidelines. Obstet Gynecol 2008; 112:661-6.
2. Reference for the Classification of FHR Tracings Three Tiered System for the
Categorization of FHR Patterns???
3. Freeman RK. Problems with intrapartum fetal heart rate monitoring interpretation
and patient management. Obstet Gynecol 2002;100:813-26.
4. NICE Guidelines for the Frequency of Intermittent Auscultation??
5. Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a
form of electronic fetal monitoring (EFM) for fetal assessment during labour.
Cochrane Database of Systemic Reviews 2006, Issue 3. Art. No.: CD006066.
DOI: 10.1002/14651858.CD006066.
6. Nelson KB, Dambrosia JM, Ting TY, Grether JK. Uncertain value of electronic
fetal monitoring in predicting cerebral palsy. N Engl J Med 1996; 334:613-8.
7. Clark St. Hankins GD.temporal and Demographic trends in celebral palsy-fack
and fiction. Am J Obstet Gynecol 2003; 188: 628-33.
8. Hankins GD, Speer M. Defining the pathogenesis and pathophysiology of
neonatal encephalopathy and celebral palsy. Obstet Gynecol 2005;102: 62836.
9. Badawi N. Kurinczuk JJ. Keogh JM, Alessandri LM, OSullivan F, Burton PR, et
al. Antepartum risk factors for newborn encephalopathy: the Western
Australian case control study. BMJ 1998; 317;1549-53.
10. Morrison JC, Chez BF, Davis ID, Martin RW, Roberts WE, Martin JN Jr, et al.
Intrapartum fetal heart rate assessment: monitoring by auscultation or
electronic means. Am J Obstet Gynecol 1993; 168:63-6.
11. Vintzileos AM, Nochimson DJ. Antsaklis A. Varvarigos I. Gusman ER, Knuppel
RA. Comparison of intrapartum electronic fetal heart rate monitoring versus
intermittent auscultation in detecting fetal academia at birth. Am J Obstet
Gynecol 1995; 173:1021-4.
12. Nielsen PV. Stigsby B. Nickelsen C. Nim J. Intra-and inter-observer variability in
the assessment of intrapatum cardiotocogram. Acta Obstet Gynecol Scand
13. Bliz E, Sviggum O, Koss KS, Oian P. Inter-observer variation in assessment of
845 labour admission tests: comparison between midwives and obstetricians
in the clinical setting and two experts. BJOG 2003;110:1-5.
14. Zain HA, Wright JW, Parish GE, Diehl SJ. Interpreting the fetal heart rate tracing.
Effect of knowledge of neonatal outcome. J Reprod Med 1998;43:367-70.

15. Goodwin TM, Milner-Masterson L, Paul RH. Elimination of fetal scalp blood
sampling on a large clinical service. Obstet Gynecol 1994;83:971-4.
16. Skupski DW, Rosenberg CR, Erlinton GS. Intrapartum fetal stimulation tests: a
meta-analysis Obstet Gynecol 2002;99:129-34.
17. Kulier R, Hofmeyr GJ. Tocolytics for suspected intrapartum fetal distress.
Cochrane Database of Systematic Reviews 1998, Issue 2.

II. Dystocia
Sylvia A. Carnero, MD, FPOGS
A. Definitions of Abnormal Patterns of Labor
Labor Pattern
Prolongation Disorder1
1. Prolonged Latent Phase

Diagnostic Criteria
> 20 hrs

> 14 hrs

1. Protracted Active Phase Dilatation

(Phase of maximum slope of

< 1.2 cm/hr

< 1.5 cm/hr

2. Protracted Descent (maximum slope of

descent during the pelvic division)

< 1.0 cm/hr

< 2 cm/hr

Protraction Disorders

Arrest Disorders1
1. Prolonged Deceleration Phase
> 3 hrs
> 1 hr
(cervical dilatation arrested at 8 to 9
2. Secondary Arrest of Dilatation
> 2 hrs
(progressive cervical dilatation stops at
the phase of maximum slope)
3. Arrest of Descent (progressive descent
> 1 hr
stops during pelvic division of labor,
station +1)
4. Failure of Descent1 (station 0)
Lack of expected descent during
deceleration phase or second stage of
5. Prolonged Second Stage4

> 3 hrs with

> 2 hrs with

regional anesthesia
or > 2 hrs without
regional anesthesia

regional anesthesia
or > 1 hr without
regional anesthesia

B. Recommendations in Management
1. Prolonged Latent Phase.
Avoid admission to the labor and delivery area until active labor is
established.3 (Level III, Grade C)
Develop a plan to meet the womans needs either at home or in a nonlaboring hospital unit.3 (Level III, Grade C)
Observation, rest and therapeutic analgesia/strong sedatives are favored
over a more active approach of amniotomy and oxytocin induction.3
(Level III, Grade C)
Support and information from caregivers to provide coping strategies.3, 2
(Level III, Grade C)
Friedman (1972) reported that prolongation of the latent phase did not
adversely influence fetal or maternal morbidity and mortality.4 (Level III,
Grade C)
Data show that patients with prolonged latent phase are no more prone to
develop problems than gravidas with normal latent phases.4 (Level III,
Grade C)
A patient who has a latent phase longer than 20 hours should be expected
to evolve a normal subsequent dilatation and descent if allowed to do so.4
(Level III, Grade C)
It cannot be too strongly stated that patients who are delivered by cesarean
section during the latent phase for no other reason than their lack of
progress are being subjected to this operation unnecessarily most of the
time.4 (Level III, Grade C)
Cesarean section has no place as a method of treatment for prolonged
latent phase without other clear indications like documented CPD or nonreassuring fetal status.4 (Level III, Grade C)
Friedmans recommended approach is support and therapeutic rest by the
use of large doses of narcotic analgesics.4 (Level III, Grade C)
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.4 (Level III, Grade C)
2. Protracted Active Phase Dilatation
Physical and emotional support2 (Level I, Grade A)

Continuous support during labor from caregivers should be encouraged

because it is beneficial for women and their newborns.2,5,6 (Level I, Grade
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.7 (Level I, Grade A)
Amniotomy may enhance progress in the active phase and negate the need
for oxytocin augmentation but may increase the risk of chorioamnionitis.7
(Level I, Grade A)
Oxytocin should be used to achieve adequate contractions (at least 200
Montevideo units) before operative delivery is considered.7 (Level I,
Grade B)
High-dose oxytocin regimens result in shorter labors than low dose
regimens without adverse effects to the fetus. 7 (Level I, Grade B)
Rule out cephalopelvic disproportion (CPD) 1 (Level III, Grade B)
If with CPD, do cesarean section.1 (Level III, Grade B)

3. Arrest Disorders
Continuous support during labor from caregivers should be encouraged
because it is beneficial for women and their newborns. 2,5,6 (Level I, Grade
X-ray pelvimetry alone as a predictor of dystocia has not been shown to
have benefit, and therefore is not recommended.8 (Level I, Grade B)
Rule out CPD1 (Level III, Grade B)
If with CPD, do cesarean section1 (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. 9(Level
III, Grade C)
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 200
Montevideo units.9 (Level III, Grade C)
Cesarean delivery is not performed for labor arrest until there were at least
4 hours of a 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. 9 (Level III, Grade C)
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 to 4 hours appears effective. 9 (Level III, Grade C)

1. Friedman EA. Labor Clinical Evaluation and Management,2nd Ed, 1978,
2. Rouse DJ, McCullough C, Wren AL, Owen J, Hauth JC. Active-phase labor
arrest: A randomized control trial of chorioamnion management. Obstet
Gynecol 1994; 83:937-40.
3. ACOG Practice Bulletin, Dystocia and Augmentation of Labor, Clinical
Management Guidelines For Obstetrician Gynecologists, Number 49,
December 2003.
4. Alarm International Program, Management of Labor and Obstructed Labor,
4th Ed. 2006 4:1-34.
5. Gagnon AJ, Waghorn K, Covell C. A randomized trial of one-to-one nurse
support of women in labor. Birt5h 1997; 24:71-7.
6. Hodnett ED, Gates S, Hofmeyer GJ Sakala C. Continuous support for womrn
during childbirth(Cochrane Review). In: Cochrane Library, Issue 3,2003.
Oxford: Update Software. (Metaanalysis).
7. Xenakis EM, Langer O, Piper JM, Conway D, Berkus MD. Low-dose versus
high-dose oxytocin augmentation of labor a randomized trial. Am J Obstet
Gynecol 1995; 173:1874-8.
8. PATTINSON rc. Pelvimetry for fetal cephalic presentation at term (Cochrane
Review). In The Cochrane Library Issue 3, 2003. Oxford; Update Software
9. Rouse DJ, Owen J, Hauth JC. Active phase labor arrest: oxytocin
augmentation for at least 4 hrs. Obstet Gynecol. 1999, 93(3):323-328.

III. Dystocia secondary to Problems in Passenger

Ma. Socorro Solis, MD, FPOGS

Planned cesarean section for babies in breech presentation has a reduced risk for
perinatal or neonatal death and neonatal morbidity compared to planned vaginal
birth.1 (Level I, Grade A)
Planned cesarean section for babies in breech presentation is associated with a
modest increase in short term maternal morbidity.1 (Level I, Grade A)
Information is limited about the potential for problems with future pregnancies.1
(Level I, Grade C)
After two years, there were no differences in the combined outcome death or
neurodevelopmental delay. Maternal outcomes were also similar.1 (Level I,
Grade A)
There is no data to quantify risks of cesarean section to the mother (scar
dehiscence in a subsequent pregnancy, increased risk of repeat CS, placenta
accreta).2,3 (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.2,3 (Level I, Grade A)
Planned vaginal breech delivery remains a viable option, provided the criteria are
met, a skilled obstetrician and facilities for cesarean section are immediately
available, and the woman is informed of all possible risks.2,3 (Level I, Grade B)
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,
Caesarean section is recommended.4 (Level II, Grade A)
Contraindications to labor include
a. Cord presentation3,4,5 (Level II, Grade A)
b. Fetal growth restriction or macrosomia3,4,5 (Level I, Grade A)
c. Any presentation other than a frank or complete breech with a flexed or
neutral head attitude3,4,5 (Level III, Grade B)
d. Clinically inadequate maternal pelvis3,4,5 (Level III, Grade B)
e. Fetal anomaly incompatible with vaginal delivery3,4,5 (Level III, Grade B)
Vaginal breech delivery can be offered when the estimated fetal weight is
between 2500 g and 4000 g.3,4,5 (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.3,4,5
(Level III, Grade B)
Continuous electronic fetal heart monitoring is preferable in the first stage and
mandatory in the second stage of labor.3,4,5 (Level I, Grade A)

When membranes rupture, immediate vaginal examination is recommended to

rule out prolapsed cord.4 (Level III, Grade B)
In the absence of adequate progress in labor, Caesarean section is advised.4 (Level
II-1, Grade A)
Induction of labor is not recommended for breech presentation.4 (Level II, Grade
Oxytocin augmentation is acceptable in the presence of hypotonic uterine
dysfunction.4 (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, Caesarean section is
recommended.4 (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 Caesarean section if
necessary.3,4,5 (Level III, Grade A)
A health care professional skilled in neonatal resuscitation should be in
attendance at the time of delivery.3,4,5 (Level III, Grade A)
The health care provider for a planned vaginal breech delivery needs to possess
the requisite skills and experience.3,4,5 (Level II, Grade A)
An experienced obstetrician-gynaecologist comfortable in the performance of
vaginal breech delivery should be present at the delivery to supervise other health
care providers, including a trainee.3,4,5 (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 after-coming head
or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can
be life saving.3,4,5 (Level III, Grade B)
Total breech extraction is inappropriate for term singleton breech delivery.4
(Level II, Grade A)
Effective maternal pushing efforts are essential to safe delivery and should be
encouraged.4 (Level II, Grade A)
At the time of delivery of the after-coming head, an assistant should be present to
apply suprapubic pressure to favor flexion and engagement of the fetal head.3,4,5
(Level II, Grade B)
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.3,4,5 (Level III, Grade A)
Nuchal arms may be reduced by the Lvset maneuver.3,4,5 (Level III, Grade B)
The fetal head may deliver spontaneously, with the assistance of suprapubic
pressure, by Mauriceau-Smellie-Veit maneuver, or with the assistance of Piper
forceps.3,4,5 (Level III, Grade B)
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 Caesarean section, and informed consent should be obtained. A womans
choice of delivery mode should be respected.4 (Level III, Grade A)
The consent discussion and chosen plan should be well documented and
communicated to labor-room staff.4 (Level III, Grade B)

Hospitals offering a trial of labor should have a written protocol for eligibility and
intrapartum management.4 (Level III, Grade B)
Women with a contraindication to a trial of labor should be advised to have a
Caesarean section. Women choosing to labor despite this recommendation have a
right to do so and should not be abandoned. They should be provided the best
possible in-hospital care.4 (Level III, Grade A)
Add a statement regarding physician autonomy his/her right to refuse a px and
to refer that px to another doctor
Theoretical and hands-on breech birth training simulation should be part of basic
obstetrical skills training programs such as ALARM, to prepare health care
providers for unexpected vaginal breech births.4 (Level III, Grade B)
Not enough evidence to support the intervention of helping a breech baby to be
born in one pushing contraction following the birth of the babys umbilicus.5
(Level III, Grade B)
Epidural anesthesia is not routinely advised.2 (Level III, Grade C)


External cephalic version (ECV) 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 cesarean section.

Women should be counseled that ECV reduces the chance of breech presentation
at delivery.7,8 (Level I, Grade A)
External version reduces the chances of having a cesarean section.7,8 (Level I,
Grade A)
With a trained operator about 50% of ECV attempts will be successful.7,8 (Level
III, Grade B)
The use of tocolysis with beta sympathomimetic drugs may be offered to women
undergoing external cephalic version as it has been shown to increase the success
rate. 7, 9 (Level I, Grade A)
External cephalic version before 36 weeks is not associated with significant
reduction in noncephalic births or cesarean section.7,10 (Level II, Grade B)
There is insufficient evidence to support the use of postural management as a
method of promoting spontaneous version over external cephalic version.7,11
(Level I, Grade A)
Labor with a cephalic presentation following external cephalic version is
associated with a higher rate of obstetric intervention than when external cephalic
version has not been required.7,12 (Level I, Grade B)
Absolute contraindications for ECV that are likely to be associated with increased
mortality or morbidity:7 (Level III, Grade C)


Where cesarean delivery is required

Antepartum hemorrhage within the last 7 days
Abnormal cardiotocograph
Major uterine anomaly
Ruptured membranes
Multiple pregnancy (except delivery of second twin)

Relative contraindications where ECV might be more complicated7 (Level III,

Grade C)
o Small for gestational age fetus with abnormal Doppler parameters
o Proteinuric pre-eclampsia
o Oligohydramnios
o Major fetal anomalies
o Scarred uterus
o Unstable lie

MALPRESENTATION (Persistent occiput posterior, occiput transverse)

Persistent occiput posterior is ______________

Digital rotation should be considered when managing the labor of a fetus in the
occipitoposterior position. This maneuver successfully rotates the fetus reducing
the need for cesarean section, instrumental delivery, and other complications
associated with persistent occiput posterior.5,13,14,15,16 (Level III, Grade B)
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.17 (Level I, Grade A)


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.5,18 (Level II, Grade B)
The use of forceps or manual conversion to convert a brow presentation to a more
favorable position is contraindicated.5,18 (Level II, Grade B)


Continuous electronic fetal heart rate monitoring is considered mandatory by

many authors because of the increased incidence of abnormal fetal heart rate
patterns and/or fetal compromise. Careful application of the electrode must be
ensured; the mentum is the recommended site of application.5,19 (Level III, Grade

Oxytocin can be used to augment labor using the same precautions as in a vertex
presentation and using the same criteria of assessment of uterine activity,
adequacy of the pelvis, and reassuring fetal heart tracing.5,19 (Level III, Grade B)

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.5,19 (Level III,
Grade B)

Forceps may be used if the mentum is anterior. Any typical forceps, including
Kielland forceps, can be used.5,19 (Level III, Grade B)

The mechanisms of labor in the term infant can occur only if the mentum is
anterior.5,19 (Level III, Grade B)

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.

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).20 (Level I, Grade A)
Suspected fetal macrosomia is not an indication for induction of labor, because
induction does not improve maternal or fetal outcomes.20,21,22,23 (Level II, Grade

Labor and vaginal delivery is not contraindicated for women with estimated fetal
weights up to 5,000 g in the absence of maternal diabetes.20,21,22,23 (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.20,21,22,23 (Level II, Grade B)
Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean
delivery may be considered for suspected fetal macrosomia with estimated fetal
weights of more than 5,000 g in pregnant women without diabetes and more than
4,500 g in pregnant women with diabetes.20,21,22,23 (Level III, Grade C)
Suspected fetal macrosomia is not a contraindication to attempted vaginal birth
after a previous cesarean delivery.20,21,22,23 (Level III, Grade C)


Risk assessments for the prediction of shoulder dystocia are insufficiently

predictive to allow prevention of the large majority of cases.22 (Level II, Grade B)
Induction of labor in women with diabetes mellitus does not reduce the maternal
or neonatal morbidity of shoulder dystocia.22 (Level I, Grade A)
Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy
with increasing birth weight, and an overall tendency to overestimate the birth
weight.24 (Level II, Grade B)
Fundal pressure should not be employed.22,25 (Level III, Grade C)
Episiotomy is not necessary for all cases, is reserved to facilitate maneuvers such
as delivery of posterior arm or internal rotation of shoulders.22,25 (Level III, Grade
McRoberts is the single most effective intervention and should be performed
first.22,25 (Level III, Grade C)
Suprapubic pressure is useful.22,25 (Level III, Grade C)
Suprapubic pressure can be employed together with McRoberts maneuver to
improve success rates.22,25 (Level III, Grade C)
Other maneuvers such as Rubins, Woods screw maneuver, Zavanelli,
cleidotomy and symphysiotomy have been employed but no controlled trials have
been made.5,22,25 (Level III, Grade C)



Transverse lie and oblique lie will benefit from a trial of version to cephalic
presentation following the criteria and recommendations of external cephalic
version for breech presentations.5,26 (Level III, Grade C)


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.5 (Level III, Grade C)

In contrast, if the hand or arm has prolapsed past the presenting part, abandoning
vaginal delivery and proceeding to cesarean delivery is wise.5 (Level III, Grade C)

1. Hofmeyr GJ, Hannah ME. Planned cesarean section for term breech delivery.
Cochrane Database of Systematic Reviews 2004 Issue 4
2. Royal College of Obstetricians and Gynecologists Greentop Guidelines No. 20b.
The management of breech presentation December 2006
3. ACOG Committee Opinion 340. Mode of Term Singleton Breech Delivery.
Obstet Gynecol July 2006
4. SOGC Clinical Practice Guidelines No. 226. Vaginal Delivery of Breech
Presentation. JOGC June 2009 : 557-566
5. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap L, Wenstrom KD.
Williams Obstetrics. 22nd ed. McGraw-Hill; 2005
6. Hofmeyr GJ, Kulier R. Expedited versus conservative approaches for vaginal
delivery in breech presentation. Cochrane Database of Systematic Review 2007
7. Royal College of Obstetricians and Gynecologists Greentop Guideline No. 20a.
External cephalic version and reducing the incidence of breech presentation.
December 2006
8. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term.
Cochrane Database of Systematic Reviews 2009 Issue No. 3
9. Hofmeyr GJ, Gyte GML Interventions to help external cephalic version for breech
presentation at term. Cochrane Database of Systematic Reviews 2004
10. Huttona EK, Hofmeyr GJ. External cephalic version for breech presentation
before term. Cochrane Database of Systematic Reviews 2006
11. Hofmeyr GJ, Kulier R, Cephalic version by postural management for breech
presentation Cochrane Database Systematic Review 2000
12. Chan LY, Tang JL. Intrapartum cesarean delivery after successful ECV: a
metaanalysis. Obstet Gynecol 2004
13. Reichman O, Gdansky E. Digital rotation from occipito-posterior to occipitoanterior decreases the need for cesarean section. Eur J Obstet Gynecol Reprod
Biol 2008
14. Le Ray C, Serres P. Manual rotation in occiput posterior or transverse positions:
risk factors and consequences on the cesarean delivery rate. Obstet Gynecol 2007

15. Shaffer BL, Cheng YW. Manual rotation of the fetal occiput: predictors of
success and delivery. Am J Obstet Gynecol 2006 May
16. Stitely ML, Gherman RB. Labor with abnormal presentation and postion. Obstet
Gynecol Clin North Am 2005
17. Hunter S, Hofmeyr GJ. Hands and knees posture in late pregnancy or labor for
fetal malposition (lateral or posterior). Cochrane Database Systematic Reviews
2007 Oct
18. Stitely ML, Gherman RB. Labor with abnormal presentation and position. Obstet
Gynecol Clin North Am. Jun 2005;32(2):165-79.
19. Shaffer BL, Cheng YW, Vargas JE, Laros RK Jr, Caughey AB. Face presentation:
predictors and delivery route. Am J Obstet Gynecol. 2006 May;194(5):e10-2.
Epub 2006 Apr 21
20. ACOG Practice bulletin No. 22. Clinical Guidelines on Fetal Macrosomia. Obstet
Gynecol November 2000
21. Irion O, Boulvain M. Induction of labor for suspected fetal macrosomia. Cochrane
Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000938. DOI:
22. Royal College of Obstetricians and Gynecologists. Greentop Guidelines No. 42.
Shoulder Dystocia. 2005
23. Sanchez-Ramos L, Bernstein S, Kaunitz A Expectant Management Versus Labor
Induction for Suspected Fetal Macrosomia: A Systematic Review. Obstetrics &
Gynecology 2002;100:997-1002
24. Gherman RB, Chauhan S. Shoulder dystocia: the unpreventable obstetric
emergency with empiric management guidelines. Am J Obstet Gynecol 2006 Sept
25. Gherman RB. Shoulder dystocia prevention and management. Obstet Gynecol
Clin North Am. 2005 Jun;32(2):297-305
26. Murray Enkin M,. Keirse JM, Crowther C, Duley L, Hodnett E, Hofmeyr J.
Suspected fetopelvic disproportion and abnormal lie, Guide to Effective Care in
Pregnancy and Childbirth (Oxford University Press, 2000)


Evidence obtained from at least one properly randomized controlled trial
Evidence obtained from well-designed controlled trials without
Evidence obtained from well-designed cohort or case-control analytic
studies, preferably from more than one center or research group
Evidence obtained from multiple time series with or without the
Opinions of respected authorities, based on clinical experience; descriptive
studies and case reports or reports of expert committees.
There is good evidence to support the recommendation of the practice in
abnormal uterine bleeding.
There is fair evidence to support the recommendation of the practice in
abnormal uterine bleeding.
There is insufficient evidence to recommend for or against the inclusion of
the practice in abnormal uterine bleeding.
There is fair evidence to support the recommendation that the practice be
excluded in abnormal uterine bleeding.
There is good evidence to support the recommendation that the practice be
excluded in abnormal uterine bleeding.
A good practice point (GPP) is a recommendation for best practice based
on the experience of the Technical Working Group.