Guideline Title
Dystocia and augmentation of labor.
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.
The American College of Obstetricians and Gynecologists (ACOG) reaffirmed the currency of the guideline in 2009.
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Disease/Condition(s)
*Dystocia: defined as abnormal labor that results from what have been categorized classically as abnormalities of the power (uterine contractions or maternal expulsive forces), the passenger (position, size, or presentation of the fetus), or the passage (pelvis or soft tissues).
Guideline Category
Diagnosis
Management
Treatment
Clinical Specialty
Obstetrics and Gynecology
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
- Uterine activity monitoring (external tocotransducers, intrauterine catheters)
- Ambulation
- X-ray pelvimetry
- Magnetic resonance imaging (MRI) (investigational)
- Continuous caregiver support during labor
- Intravenous fluids
- 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
- Low-dose versus high-dose oxytocin
- Amniotomy
- 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
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Methods Used to Collect/Select the 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.
2009 Reaffirmation
For reaffirmation of a current Practice Bulletin, MEDLINE and Cochrane are searched for new literature. At the discretion of the review committee, additional databases may be searched for particular topics as warranted. In addition, committee members identify relevant literature for review.
Number of Source Documents
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
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.
2009 Reaffirmation
Each American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin is reviewed every 18-24 months by a member of the Practice Bulletins Committee. The reviewer presents the practice bulletin and any new literature at a full committee hearing. The committee then reaches a consensus on whether to reaffirm or withdraw the practice bulletin.
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.
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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.
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Evidence Supporting the Recommendations
Type of Evidence Supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
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Benefits/Harms of Implementing the Guideline Recommendations
Potential Benefits
Appropriate management of labor complicated by dystocia
Potential Harms
Amniotomy may increase the risk of maternal fever and chorioamnionitis.
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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.
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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.
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Implementation of the Guideline
Description of Implementation Strategy
An implementation strategy was not provided.
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Institute of Medicine (IOM) National Healthcare Quality Report Categories
IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
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Identifying Information and Availability
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.
Date Released
2003 Dec (reaffirmed 2009)
Guideline Developer(s)
American College of Obstetricians and Gynecologists - Medical Specialty Society
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
Financial Disclosures/Conflicts of Interest
Guideline Status
This is the current release of the guideline.
The American College of Obstetricians and Gynecologists (ACOG) reaffirmed the currency of the guideline in 2009.
Guideline Availability
Electronic copies: None available
Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; 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
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. The information was reaffirmed by the guideline developer in 2009 and updated by ECRI Institute on February 9, 2010.
Copyright Statement
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
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