Diabetes & Pregnancy ICP

Departments of Obstetrics & Diabetes

Taunton & Somerset NHS Trust

ICP Number OBGYN-0001

Special Instructions
Standard issues
1. Strict control of diabetes is paramount at all times
2. Read letters and guidelines carefully
3. Always be alert to possibility of shoulder dystocia
4. Feel free to contact senior obstetricians & diabetologists
Issues specific to this patient
1.
2.
3.
4.

 Information on postpartum insulin therapy is in section 6.2 

Index of Contents
Abbreviations, reference to supporting guidelines & leaflets Page 3
Guidelines for care Page 4, 5 & 6
Obstetric plan sheet Page 7
Clinic visit spread sheet Pages 8 & 9
Diabetes plan sheet Page 10
Dietary report Page 11
Urinalysis results Page 12
Labour plan Page 13
Plan for puerperium and beyond Page 14
Free text continuation sheets Pages 15, 16, 17 & 19
 STRICTLY CONFIDENTIAL

Integrated Care Pathways (ICPs)

Integrated Care Pathways are documents which combine clinical notes with guidelines. They are intended for use by
all healthcare workers. Where an ICP exists, its use mandatory. ICP are used to prompt effective healthcare and
improve documentation but they cannot replace clinical judgment.

Free text areas are available at the end of the ICP for the extended documentation of more complex clinical issues.

● Add patient name and number to each sheet

● Date and sign front signature sheet at first use.
● Standard Trust sheets should be used for clinical observations, consent etc.
● Tick and initial each action as it is carried out
● If unable to complete an action fill in the variance section below the action

Introduction to Diabetes in Pregnancy ICP

This ICP is the main documentary record for women with diabetes in pregnancy. It runs from booking until
discharge after delivery though labour details are entered onto the standard partogram. Not all clinical scenarios can
be catered for within an ICP. You must feel free to contact senior help if you do not know how to deal with a
problem or the woman is unwell.

If a woman is admitted use the continuation sheets in the ICP.

If the details of an antenatal clinic visit are too great for the spreadsheet, overflow text should be written on the
special continuation sheet at the end of the ICP.
 Taunton & Somerset Foundation NHS Trust – Diabetes & pregnancy ICP (OBGYN0001 - Jun2008)

Woman’s name and number

1. List of ICP Specific/Unusual Abbreviations

Abbreviations Full text Abbreviations Full text
Abn Abnormal LSCS Lower segment caesarean
section
AC Abdominal circumference MSU Mid-stream urine specimen
AFI Amniotic fluid index N Normal
B Bedtime CBG NT Nuchal translucency
BMI Body mass index P Post prandial CBG
BP Blood pressure (HC Professional to state whether
taken at 1 or 2 hr)
C Continued at back TFTs Thyroid function tests
CBG (or SMBG or HMBG ) Capillary blood glucose TSH Thyroid stimulating hormone
(self/home-monitored blood glucose )
E Evening meal CBG U&Es Urea and electrolytes
fa Fasting CBG USS Ultrasound scan
FH(R) Fetal heart (rate) /40 Weeks of pregnancy
FM Fetal movement Add additional abbreviations used in document
FT4 Free thyroxine
GDM Gestational diabetes mellitus
HbA1C (GHB) Glycosylated haemoglobin
HC Head circumference
IFH Impaired fasting hyperglycaemia
L Lunchtime CBG
LFTS Liver function test
2. Stand-alone guidelines which accompany this ICP
Guideline title Guideline title
Glycaemic control of diabetes in labour Diabetic ketoacidosis (on intranet)
Diabetes in pregnancy Diabetic hypoglycaemia (on intranet)
Screening for GDM Shoulder dystocia
3. List of other medical record sheets which supplement ICP
Midwifery care plan Partogram
Diabetes specialist notes
4. List of leaflets to be routinely given to women
Diabetes & pregnancy leaflet
Diabetes & SCBU leaflet
Diabetes in pregnancy :Understanding NICE guidance

Page 3 of 17
Guidelines for Care of Women with Diabetes in Pregnancy

1. Pre-pregnancy care
Ideally all women with diabetes should be offered pre-pregnancy advice.
Aims of care:
1. Achieve optimal control of diabetes (HbA1C less than 7% for 3 months before conception, ideally <6.1%).
2. Consider use of teratogenic / problematic drugs (such as ACE inhibitors and statins).
3. Consider need for testing (TFTs, renal function, LFTs, 24 hour protein, ECG).
4. Advise on both maternal & fetal risk. Be explicit.
5. Prescribe folic acid (5mg daily by mouth); to take until 13w pregnant.
2. Booking visit – see as soon as possible
1. Full medical assessment according to proforma obstetric & diabetes sheets.
2. Stop teratogenic drugs (ACE inhibitors & statins).
3. MSU for bacteriology.
4. Urinalysis – if negative for protein send off Early Morning Urine for baseline ACR.
5. Thyroid function (TSH & FT4 measurement) for those with type I diabetes.
6. Renal & liver function tests.
7. Do dating USS only when 7 weeks’ gestation or more.
8. Start folic acid (5mg) if not already commenced. NB - not known to beneficial at this stage.
9. Emphasise need for tight control of diabetes consistently – explain reasons and emphasise support.
10. Do booking bloods if not already done.
3. Follow-up visits
1. If not significant complications of diabetes: obstetricians see 4w until 28 w, 2w until 36 week, 1w until delivery; diabetes
specialist team see fortnightly or as according to care requirements.
2. If significant complications, individualise care. Some women need seeing weekly or more.
3. Ensure routine FBC & Group & antibody screen performed at 28 and 34 weeks as necessary.
4. Prenatal diagnosis
1. Advise that triple less reliable in women with diabetes.
2. Offer nuchal translucency at St Michael’s in Bristol.
3. Offer detailed fetal scan @ about 20 weeks with marker on request to concentrate on fetal heart.
5. Persistent proteinuria in early pregnancy
1. If persistent proteinuria with reagent sticks and MSU bacteriology negative, request:
24h urine collection for protein loss
serum U+Es, creatinine
2. If significant proteinuria (>300 mg in 24 hours):
Consider aspirin therapy (75 mg daily from 14 weeks).
Request 24-hour urine collection monthly.
3. If gets, protein loss >5gm/24 hours, very high risk including thrombosis: see thromboprophylaxis.
4. Refer to nephrologist if Creatinine >120mcg/l or proteinurea >2g/ day in early pregnancy
6. Hypertension in pregnancy
1. Treat with anti-hypertensive if repeatedly greater than 150/ and/or 105 mmHg.
(NB - Use lower threshold for nephropathy - >135/ or /90).
2. First choice treatment is labetalol unless asthma or severe liver disease (100mg twice daily).
Do NOT use if asthma.
Second choice treatment is nifedipine (20mg bd of slow release formulation)
3. Target pressure = 140/80 mmHg.
4. Consider aspirin therapy (75mg daily from 14 weeks – see next section).
5. Consider calcium supplementation (calcichew) if poor dairy diet. Discuss with DM
7. Use of aspirin therapy
1. Consider in women with hypertension, persistent proteinuria, or history of pre-eclampsia.
2. Advise woman of possible benefit (NNT is about 50).
3. Advise woman of safety & risks; peptic ulceration, haemorrhage, exacerbation of asthma, and allergy.
4. Advise woman to stop if gets bleeding
5. Stop at 36 weeks’ gestation, if gets pre-eclampsia, or if gets severe hypertension (until controlled).
 Taunton & Somerset Foundation NHS Trust – Diabetes & pregnancy ICP (OBGYN0001 - Jun2008)

Woman’s name and number

8. Antenatal fetal monitoring (minimum)
1. Unless there are special indicators: first growth scan at 26 weeks to screen for early IUGR if high-risk
next scan at 28 weeks to screen for IUGR.
next scan at 32 weeks to screen for IUGR.
third scan at 36 weeks to look for macrosomia.
2. Do CTG weekly from 38 weeks onwards. Do more if IUGR.
3. The value of Doppler assessment for fetal blood velocities is uncertain. Use for IUGR only.
9. Delivery
1. In pregnancy uncomplicated by IUGR or pre-eclampsia, manage as usual for non-DM situation.
2. The optimal management of severe macrosomia is not known. We aim to get beyond 37 weeks and preferably to 38 completed
weeks – consultant input is essential.
3. NICE guidance is not explicit on management for uncomplicated DM pregnancy – we recommend getting to at least 39
completed weeks.
4. If estimated fetal weight is or will be >4.5kg – recommend caesarean section.
5. Discuss throughout pregnancy but have detailed discussion at 36 weeks.
10. Control & monitoring of diabetes (general)
1. For type 1 & type 2 DM use the same target glucose levels (mmol/l) which are:
Fasting average <5.5, range 3.5-5.9; pre-meal 3.5-5.9; 1h post prandial 7.8; 2h post prandial 7.0
These may alter according to the individual woman and will be discussed.
Advise to check before bedtime too.
2. Request HbA1C monthly (use stamp to override laboratory frequency guideline). Target <7%.This is a guide only as HbA1c
falls during pregnancy
3. In women with type 1 diabetes, consider need for ketonuria testing.
4. Aim to avoid both hyperglycaemia and hypoglycaemia.
5. Assess need for glucagon supply- routine in Type 1 diabetic women.
6. Explain to woman:
- The need for smooth and tight control with the avoidance of ketoacidosis.
- The reasons for tight control.
- The change in insulin requirements during pregnancy.
- To report vomiting.
- To report heavy ketonuria.
- To report persistent, severe hyperglycaemia (>13mmol/l, over 2-4 h)
- To report if rapidly increasing frequency of hypoglycaemia
11. Control & monitoring of diabetes (in-patient antenatal ward care)
1. Women will usually be responsible for administering their own insulin but it should be prescribed on the insulin prescribing
chart and all doses should be checked as being given on each ward round.
2. The women should be encouraged to check CBG up to 7 times daily and do urine testing for ketones on each sample of urine if
glucose is high (>13 mmol/l) or unwell.
3. The diabetes team should be informed of:
- Hyperglycaemia (action points defined below)
- Severe ketonuria even if normoglycaemic (3+ or 7.8mmol/l)
- Not eating properly (if fails to eat single meal)
- Vomiting repeatedly
- Not taking insulin
4. Hyperglycaemia definition:
a. Patient well & not ketotic – call if >13mmol/l on two occasions.
b. Patient unwell and/or ketotic – call if >13mmol/l on single occasion.
5. Type 1 diabetic women have 1 mg glucagon im prescribed prn on the drug chart.
12. Avoidance & management of hypoglycaemia (CBG <3.5mmol/l)
1. Hypoglycaemia and awareness are significant, frequent problems especially in the first trimester.
2. Severe hypoglycaemia (requiring a 3rd party for assistance) is more common during pregnancy.
3. Adjust insulin according to CBG values to avoid hypoglycaemia.
4. Advise women to have supply of Lucozade Energy Original to use for immediate hypoglycaemia treament
5. Prescribe glucagon (1mg intramuscular injection) for women with Type 1 diabetes. Teach partner how to recognise
hypoglycaemia, use of sugar drinks and how to administer glucagon.
6. See intranet guidance note for management of hypoglycaemia. Ensure women aware of treatment.
7. Women with recurrent severe hypoglycaemia may need to use an insulin pump during pregnancy.
Page 5 of 17
13. Prevention of ketoacidosis
1. Pregnant women can get accelerated ketosis that can turn to ketoacidosis within a few hours. This is potentially
2. life threatening, for the baby in particular but also for the mother.
3. Note – Ketoacidosis can develop in the absence of hyperglycaemia (euglycaemic ketoacidosis).
4. The key to prevention is:
- Tight control with careful monitoring and regular review
- A regular lifestyle
- Rapid action for acute events.
5. If woman develops vomiting or severe infection, cannot tolerate diet, or declines insulin, contact medical team (preferably a
diabetologist) and a senior obstetrician.
DO NOT STRUGGLE BY YOURSELF.
14. Diagnosis and management of ketoacidosis
1. Suspect if heavy ketonuria (>7.8 mmol/l or +++) with or without hyperglycaemia.
2. Check venous bicarbonate if appears well and arterial blood gases if appears unwell.
**Do not do testing on fetal scalp pH machine which is unreliable for this purpose. **
3. Screen for infection.
4. If bicarbonate <18mmol/l, ketoacidosis must be managed directly by the medical team (preferably a diabetologist) using the
Trust Guideline (available on the Intranet).
5. If bicarbonate >18 but < 24 mmol/l, get advice from diabetologist or on-call physician about using sliding scale insulin
regimen and i.v. fluids.
6. Remember: monitor viable fetus continuously with CTG if ketoacidosis develops.
7. Site of care:
If fetus pre-viable, manage on medical unit or HDU as appropriate.
If fetus viable and DKA moderate, manage on labour ward.
If fetus viable and DKA severe, manage on HDU with access to main theatres.
DO NOT STRUGGLE BY YOURSELF.
15. Use of corticosteroids to enhance fetal lung maturity
1. Single courses prevent RDS and consequent complications <36 weeks’ gestation.
2. They have not been shown to be effective in presence of maternal diabetes.
3. Corticosteroids cause severe disruption of glycaemic control with rising BG values and increased insulin requirements. Can
precipitate ketoacidosis. Avoid concomitant use of beta-mimetics.
4. If available, Dr Douek, Dr Watson &/ or Mr Fox will closely supervise increased insulin administration (50-100% increase in
each individual dose for 48 to 72 hours). If none of these three staff members are available, set up sliding scale insulin regimen
according to separate guideline.
5. Test urine for ketones every time urine passed and measure bicarbonate if >3+.
16. Tocolysis
Can be used in the usual way but avoid beta-mimetics such as ritodrine.
17. Retinal Screening
1. The diabetes team will contact the retinal screening centre to arrange eye photos in the first trimester (01823 287790/91).
2. The screening service will action if there is serious retinopathy. Otherwise this is repeated at 16-20 w if background retinopathy
present or at 28 w if normal.
3. Mr Gray or Mr Herbert are the consultant ophthalmolgists who care for women with diabetes.
18. Thromboprophylaxis – see separate AN and IP guidelines
1. Treat such women as special risk at LSCS.
2. Consider antenatal prophylaxis if multiple risk factors (morbid obesity, nephropathy (proteinurea >5g/d) , immobility etc).
Enoxaparin 40mg daily / 40mg twice daily if >90kgs. (see separate guidance for full details).
3. Avoid TED stockings if peripheral vascular disease present.
19. Influenza vaccination
1. Offer women vaccine in late Autumn to late February regardless of stage of pregnancy
2. Use inactivated virus that is thiomersal free
3. Contraindicated if egg allergy
4. Ask GP to prescribe – use formatted letter
5. Advise woman to use paracetamol if gets febrile reaction
Taunton & Somerset Foundation NHS Trust – Diabetes & pregnancy ICP (OBGYN0001 - Jun2008)

Woman’s name and number

1. OBSTETRIC BOOKING SHEET Likes to be called

Risk factors (list) Maternal age

Parity
Booking BP

Booking urinalysis

1.1 Dating of pregnancy  NICE advises all dating be done by ultrasound. Beware if admitted in
preterm labour. Gestation might be underestimated.
Obstetrician-defined EDD =

1.2 Prenatal diagnosis Discussed (initials & date) Decision (action/initials/date)

Nuchal translucency Scan: Yes / no / not sure

Given NT leaflet Yes N/A Date Facsimile sent:
Serum test Not valid test in women with diabetes

Discussed Yes N/A Wants IPND: Yes / no / not sure CVS / Amnio booked for:
Invasive Prenatal CVS / Amnio
Diagnosis
Detailed scan @ 20 weeks Scan: Yes / no / not sure Date card sent:
(with fetal echo @ MPH)
1.3 Standard blood/urine test Date Results / action undertaken
Antibody screen at booking
between 28-34 weeks
Blood group
Hep B status
HIV status
MSU for bacteruria screen
Rubella status
Haemoglobinbopathy status
Aspirin therapy commenced at weeks
Diabetes & pregnancy leaflet Yes
Diabetes & SCBU leaflet Yes
Diabetes in pregnancy: Understanding NICE guidance Yes
APEC leaflet Yes / NR
Contact tel no for emergency OOH diabetes care (01823-342059) Yes
Influenza vaccination discussed (see guidance at page 6) Yes
Discuss need for tight & consistent control with support Yes
1.4 Free text box for additional comments

Signed Date =
Grade Consultant / SpR / Specialist midwife

Page 7 of 17
 Write on single line only. If need more space, use cont. sheet at back of ICP

Maternity Care
Date Gestation FM Wt BP Urine Fundal ht Pres US Result Plan, Comments & initials
(c in box = continued at back)
1

10

11

12

13

14

15

16
Taunton & Somerset Foundation NHS Trust – Diabetes & pregnancy ICP (OBGYN0001 - Jun2008)

Woman’s name and number

Write on single line only. If need more space, use continuation sheet at back of ICP
Visit Comments / Initials Insulin changes SMBG values (ranges) HbA1C Appt
& (C = continued in notes)
Date
Type Br L T Bd fa P L P E P B (4 wkly)
1

10

11

12

13

14

15

16

Page 9 of 17
3. DIABETES BOOKING SHEET Likes to be called
(History taken at first appointment)
2.1 Diabetes History
Maternal age Pre-pregnancy
insulin treatment
Type of diabetes Pre-pregnancy
counselling
Year of diagnosis Height BMI @
booking
Recent control- HbA1c
(date)
2.2 Complications/ Medical Hx Action required
Hypoglycaemia Supplied glucagon: Yes / Not Applicable
Advise to have supply of Lucozade or alternative
Retinopathy Retinal screening programme or ophthalmologist f/u

Hypertension/ Renal assessment in last 12 m? Yes/ No

Nephropathy Refer to nephrologist if Creatinine >120mcg/l or
proteinurea >2g/ day in early pregnancy

Neuropathy

Other

2.3 Medical therapy / Lifestyle Mx

Insulin therapy Dietician referral
(type)
Injection sites Folic acid (dose and
when started)
Needles and devices Other drugs

Oral hypoglycaemic Alcohol Tobacco

agents
Aims of blood glucose management CBG readings: 3.5-5.9 mmol/l fasting av <5.5 mmol/l
3.5-5.9 mmol/l pre-meal
≤7.8 mmol/l 1 hour post meal
≤7.0 mmol/l 2 hours post meal
6-8 mmol/l bedtime
Avoiding hypoglycaemia and hyperglycaemia
HbA 1c 6% (ideally prior to conception)
2.4 Arrangements for diabetes care after delivery (section 6.3)

2.5 Free text box for additional comments

Signed
Grade Consultant / SpR / DNS
Date
Taunton & Somerset Foundation NHS Trust – Diabetes & pregnancy ICP (OBGYN0001 - Jun2008)

Woman’s name and number

Date Gestation FM Wt BP Urine Fundal ht Pres US Result Plan, Comments & initials
(c in box = continued at back)
17

18

19

20

21

22

23

Visit Comments / Initials Insulin changes SMBG values (ranges) HbA1C Appt
& (C = continued in notes)
Date
Type Br L T Bd fa P L P E P B (4 wkly)
17

18

19

20

21

22

23

Page 11 of 17
4. Sheet to stick urinalysis results onto (Visit number is in the boxes).
1 2 3 4

5 6 7 8

9 10 11 12

13 14 15 16

17 18 19 20
Taunton & Somerset Foundation NHS Trust – Diabetes & pregnancy ICP (OBGYN0001 - Jun2008)

Woman’s name and number

5. Later pregnancy tasks – at 36 weeks

Task Date & initials
Issue SCBU leaflet if not done already
Do growth scan at 36 - 38 weeks for macrosomia
Discuss delivery (final deciding often at 38 weeks)
Do CTGs weekly after 38 weeks
Discuss contraception & planning future pregnancy
Breast feeding is fine with Metformin and glibenclamide
5.2 Obstetric plan for labour & delivery

5.2.1 Mode & timing of delivery is usually decided quite late in pregnancy. The control of diabetes
needs to be taken into account together with the size of the fetus and other obstetric complications.

5.2.2 In general: otherwise healthy women with good diabetes control and normally sized and
proportioned babies should be offered induction of labour at 39 – 40 weeks (no systematic evidence,
concensus view only).

5.2.3 SIGN & RCOG advises estimated fetal weight of 4.5 kg is used to guide safety of vaginal
delivery.

5.2.4 Continuous electronic fetal monitoring is advised for all women with diabetes mellitus in labour.

5.2.5 If larger baby 4.0kg to 4.4kg and slow progress, consider possibility of shoulder dystocia.

5.2.6 Manage as high-risk category for thrombo-embolism.

5.3 Free text for specific obstetric instructions for delivery (sign and date entry)

5.4 Free text for specific diabetes instructions for delivery (sign and date entry)

NB – See diabetes protocol for precise details of glycaemic control in labour

NB – Use 10% dextrose if pre-eclampsia

Page 13 of 17
6. Obstetrics and Diabetes in-patient care after delivery

6.1.1. Continue sliding scale regimen until tolerating diet.

6.1.2. Women with established type 1 diabetes return immediately to their pre-pregnancy insulin doses.

6.1.3. Women with Type 2 diabetes may continue on insulin or have planned to restart oral
hypoglycaemic agents. If breast feeding only insulin, metformin & glibenclamide can be used.

6.1.4. Women should receive advice about contraception. Progestogen-only methods are particularly
favourable, most notably the Mirena device and Implanon.

6.2 Free text for special instructions (sign and date entries)

Contraception Discussed (date & initials)

6.3 Diabetes care after discharge
** This should have been organised earlier, unless the woman delivers unexpectedly,
please check:

6.3.1. Women with established type 1& type 2 diabetes and no serious complications are seen in a
consultant diabetes clinic at 2 months.

Dr Douek’s secretary 4986, Dr Watson’s secretary 4536

6.3.2. Women with established type 1 diabetes and serious complications such as nephropathy or
severe pre-existing hypertension will be seen earlier.

Date of appointment =

6.4 Free text area (Write in arrangements made. Sign and date entries)
Taunton & Somerset Foundation NHS Trust – Diabetes & pregnancy ICP (OBGYN0001 - Jun2008)

Woman’s name and number

Multidisciplinary Free Text Overflow Sheet for Diabetes & Pregnancy ICP

Date & Comments Initials &

Time FOR ALL ANTENATAL NOTES Profession

Page 15 of 17
Multidisciplinary Free Text Overflow Sheet for Diabetes & Pregnancy ICP

Date & Comments Initials &

Time FOR ALL ANTENATAL NOTES Profession
Taunton & Somerset Foundation NHS Trust – Diabetes & pregnancy ICP (OBGYN0001 - Jun2008)

Woman’s name and number

Administrative Details of ICP Document

Please note, this page does not need to be issued with each individual patient ICP. It should be attached to
library and ward reference copies:

1. ICP reference number OBGYN-0001

2. ICP version number 8 (Jun 2008)
3. Date of initial ratification 23.01.02
4. Next review date Dec 2009
5. Archiving details RF computer
6. Lead clinical author Robert Fox
Lead clinical authors (medicine) Joanne Watson/Isabelle Douek
Lead midwife author Katy Evans
Lead nurse author Ellie Parsons
Lead PAM author Roberta Winterson
7 Distribution list ANC @ MPH

After revision, the superseded document must be archived for medico-legal reference.

Bibliography

Databases explored: RCOG guideline database, Cochrane database of systematic reviews, Bandolier, SIGN, Clinical Evidence,
and Medline.

1. NICE CG063 (2008): Diabetes in Pregnancy. Management of diabetes and its complications from pre-conception to the postnatal
period.

2. Irion O et al. (2002). Induction of labour for suspected fetal macrosomia. Cochrane Database of Systematic Reviews.

3. Knight M et al. (2002). Antiplatelet agents for preventing and treating pre-eclampsia. Cochrane Database of Systematic
Reviews.

4. Boulvain M et al. (2002). Elective delivery in diabetic pregnant women. Cochrane Database of Systematic Reviews.

5. Abalos F et al Anti-hypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database of
Systematic Reviews.

6. Walkinshaw SA (2002). Dietary regulation for gestational diabetes. Cochrane Database of Systematic Reviews.

7. Walkinshaw SA (2002). Very tight vs tight control for diabetes in pregnancy. Cochrane Database of Systematic Reviews.

8. NICE (2001). The use of electronic fetal monitoring. NICE inherited clinical guideline C.

9. SIGN (2001). Management of diabetes (Section 8: diabetes in pregnancy). Scottish Intercollegiate Guidelines Network.

10 . RCOG (2004). Guidelines on thromboprophylaxis. Royal College of Obstetricians & Gynaecologists.

11. Chitty L et al. (1994). Fetal biometry charts. British Journal of Obstetrics and Gynaecology, 101; 35-43 & 125-131.

12. Magee LA et al. (1999). Management of hypertension in pregnancy. BMJ 318; 1332-1336.

13. RCOG (2005). Shoulder dystocia Green-top Guideline.

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