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Official recommendations

06 May

Here’s a bit of research I have undertaken to find out what the official guidelines are on these potentially contentious issues. Long Pregnancies, PROM, Electronic Fetal Monitoring, Breech Birth and VBAC.  I wanted to find more official guidelines on different topics, but I couldn’t think of more topics to look up!  It’s always good to know what the professional organisations recommend, compared to what your doctor is recommending.
 

ACOG (American College of Obstetricians & Gynecologists) on
Long pregnancies
2006
http://www.acog.org/publications/patient_education/bp069.cfm

Most women give birth between 38 and 42 weeks of pregnancy. But very few babies are born on their due dates. It is normal to give birth as much as 3 weeks before or 2 weeks after your due date.

A postterm pregnancy is one that lasts 42 weeks or longer.

Problems occur in only a small portion of postterm pregnancies. Most women who give birth after the due date have healthy newborns.

ACOG on PROM (Premature Rupture of the Membranes – Waters breaking)
http://www.acog.org/acog_districts/dist8/jfprom.pdf

Without treatment:
– 50% will deliver within 48 hours 50% will deliver within 48 hours
– 80% will deliver within 1 week 80% will deliver within 1 week

Initial Evaluation
• DO NOT TOUCH!! Cervical examination decreases latency and increases infectious decreases latency and increases infectious morbidity

Watch out for…
• Maternal fever
• Maternal or fetal tachycardia
• Uterine tendernes
• Vaginal discharge
• Flank pain

ACOG  on Electronic Fetal Monitoring 2009
http://www.acog.org/from_home/publications/press_releases/nr06-22-09-2.cfm

“Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,” says George A. Macones, MD, who headed the development of the ACOG document. “Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.”

One of the problems with FHR tracings is the variability in how they’re interpreted by different people. The ACOG guidelines highlight a case in which four obstetricians examined 50 FHR tracings; they agreed in only 22% of the cases. Two months later, these four physicians reevaluated the same 50 FHR tracings, and they changed their interpretations on nearly one out of every five tracings.

ACOG on Breech birth 2006
http://www.ncbi.nlm.nih.gov/pubmed/16816088

In light of recent studies that further clarify the long-term risks of vaginal breech delivery, the American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode for most physicians because of the diminish-ing expertise in vaginal breech delivery. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. Before a vaginal breech delivery is planned, women should be informed that the risk of peri-natal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient’s informed con-sent should be documented.

SOGC (Society of Obstetricians and Gynocologists of Canada) on
Breech birth 2009
http://www.sogc.org/guidelines/documents/gui226CPG0906.pdf

Vaginal Delivery of Breech Presentation Outcomes: Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality.

Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus.

Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care.

There was no difference in perinatal mortality (0.08% vs. 0.15%) or serious neonatal morbidity (1.6% vs. 1.45%) between a TOL and planned CS. The only difference in outcome was a 0.16% incidence of five-minute Apgar score < 4 in the TOL group versus 0.02% in the planned CS group.

Induction of labour is not recommended for breech presentation. Oxytocin augmentation is acceptable in the presence of uterine dystocia.

In light of recent publications that further clarify the lack of long-term newborn risk of vaginal breech delivery and the many cohort reports noting excellent neonatal outcomes in settings with specific protocols, it is acceptable for hospitals to offer vaginal breech delivery.

ACOG on VBAC (vaginal birth after cesarean) and
VBAMC (VBAmultipleC) 2010
http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm

Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans, according to guidelines

“The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC,” [Trial Of Labour After Cesarean]

A VBAC avoids major abdominal surgery, lowers a woman’s risk of hemorrhage and infection, and shortens postpartum recovery. It may also help women avoid the possible future risks of having multiple cesareans such as hysterectomy, bowel and bladder injury, transfusion, infection, and abnormal placenta conditions (placenta previa and placenta accreta).

Both repeat cesarean and a TOLAC carry risks including maternal hemorrhage, infection, operative injury, blood clots, hysterectomy, and death. Most maternal injury that occurs during a TOLAC happens when a repeat cesarean becomes necessary after the TOLAC fails.

The risk of uterine rupture during a TOLAC is low—between 0.5% and 0.9%


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