Bibliographic Source(s)

• American College of Obstetricians and Gynecologists (ACOG). Dystocia and augmentation of labor. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2003 Dec. 10 p. (ACOG practice bulletin; no. 49). [61 references]

Guideline Status

This is the current release of the guideline.

Guideline Category

Diagnosis
Management
Treatment

Intended Users

Advanced Practice Nurses
Physicians

Guideline Objective(s)

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To provide a review of the definition of dystocia risk factors associated with dystocia the criteria that require delivery and approaches to clinical management of labor complicated by dystocia

Target Population

Pregnant women experiencing dystocia during labor

Interventions and Practices Considered

1. Uterine activity monitoring (external tocotransducers intrauterine catheters)
2. Ambulation
3. X-ray pelvimetry
4. Magnetic resonance imaging (MRI) (investigational)
5. Continuous caregiver support during labor
6. Intravenous fluids
7. Active labor management:
   • Patient education
   • Strict criteria for diagnosis abnormal progress and fetal compromise
   • High-dose oxytocin infusion
   • One-to-one nursing support
   • Peer review of operative deliveries
8. Low-dose versus high-dose oxytocin
9. Amniotomy
10. Electronic fetal monitoring versus intermittent ascultation

Major Outcomes Considered

• Time to delivery
• Rate of cesarean delivery
• Rate of forceps-assisted delivery
• Incidence of maternal and fetal complications
• Predictive value of risk factors

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

The MEDLINE database the Cochrane Library and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and August 2003. 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.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

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.

II-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.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Rating Scheme for the Strength of the Recommendations

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.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

Major Recommendations

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations are based on good and consistent scientific evidence (Level A):

• Patients should be counseled that walking during labor does not enhance or improve progress in labor nor is it harmful.
• Continuous support during labor from caregivers should be encouraged because it is beneficial for women and their newborns.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

• Active management of labor may shorten labor in nulliparous women although it has not consistently been shown to reduce the rate of cesarean delivery.
• Amniotomy may be used to enhance progress in active labor but may increase the risk of maternal fever.
• X-ray pelvimetry alone as a predictor of dystocia has not been shown to have benefit and therefore is not recommended.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• Intrauterine pressure catheters may be helpful in the management of dystocia in selected patients such as those who are obese.
• Women with twin gestations may undergo augmentation of labor.

Definitions:

Grades of Evidence

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.

II-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.

Levels of Recommendations

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.

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Potential Benefits

Appropriate management of labor complicated by dystocia

Potential Harms

Amniotomy may increase the risk of maternal fever and chorioamnionitis.

Contraindications

Contraindications to augmentation are similar to those for labor induction and may include placenta or vasa previa umbilical cord presentation prior classical uterine incision active genital herpes infection pelvic structural deformities or invasive cervical cancer.

Qualifying Statements

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient resources and limitations unique to the institution or type of practice.

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

• American College of Obstetricians and Gynecologists (ACOG). Dystocia and augmentation of labor. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2003 Dec. 10 p. (ACOG practice bulletin; no. 49). [61 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American College of Obstetricians and Gynecologists (ACOG)

Guideline Committee

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics

Composition of Group that Authored the Guideline

Not stated

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: None available

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center PO Box 4500 Kearneysville WV 25430-4500; telephone 800-762-2264 ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site.

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on October 12 2007. The information was verified by the guideline developer on December 3 2007.

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This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.

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