Management of pregnancy - VA/DoD Clinical Practice Guidelines ...
Management of pregnancy - VA/DoD Clinical Practice Guidelines ...
Management of pregnancy - VA/DoD Clinical Practice Guidelines ...
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<strong>VA</strong>/<strong>DoD</strong> <strong>Clinical</strong> <strong>Practice</strong> Guideline<br />
For Pregnancy <strong>Management</strong><br />
I 47. Assessment <strong>of</strong> Fetal Presentation: Weeks 36, 3841<br />
BACKGROUND<br />
Fetal non-cephalic presentation at term can result in cesarean section delivery. Examination at 36 weeks can<br />
identify non-cephalic presentation. External version <strong>of</strong> the fetus to the vertex position can allow a trial <strong>of</strong> labor for<br />
vaginal delivery. Vaginal delivery is associated with less morbidity and mortality than cesarean section delivery.<br />
RECOMMENDATIONS<br />
1. Recommend screening for non-cephalic presentation for all patients at 36 weeks’ gestation. [B]<br />
2. There is insufficient evidence to recommend for or against Leopolds versus cervical exam as the best screening<br />
method to determine fetal presentation. [I]<br />
3.<br />
4.<br />
Recommend ultrasound for confirmation, if non-cephalic presentation is suspected. [B]<br />
If non-cephalic presentation is confirmed and there are no contraindications, recommend external cephalic<br />
version at 37 weeks or beyond and referral to an advanced prenatal care provider. [B]<br />
DISCUSSION<br />
No systematic reviews or RCTs comparing Leopold's maneuvers to other manipulations were found. Two<br />
nonrandomized trials were found that evaluated Leopold's maneuvers as a screening test for fetal malpresentation,<br />
but did not assess the effect on maternal morbidity/mortality or infant mortality. The studies were <strong>of</strong> fair quality and<br />
suggest that the specificity for Leopold's to predict fetal malposition is high, but its sensitivity is only modest<br />
(Lydon-Rochelle et al., 1993; Thorp et al., 1991).<br />
External cephalic version for breech presentation at term is associated with a significant reduction in non-cephalic<br />
births and cesarean sections, without significant effects on perinatal mortality (H<strong>of</strong>meyr & Kulier, 2001b). External<br />
cephalic version for breech presentation prior to term does not reduce the number <strong>of</strong> non-cephalic births nor does it<br />
improve <strong>pregnancy</strong> outcomes (H<strong>of</strong>meyr, 2001). There is no evidence to support the use <strong>of</strong> postural management for<br />
breech presentation (H<strong>of</strong>meyr & Kulier, 2001c). If external cephalic version for breech presentation cannot be<br />
accomplished, planned cesarean delivery for term breech decreases perinatal and neonatal death and neonatal<br />
morbidity. There is a modest increase in maternal morbidity but no effect on maternal mortality (Hannah et al.,<br />
2000; H<strong>of</strong>meyer & Hannah, 2001).<br />
EVIDENCE<br />
Recommendations Sources <strong>of</strong> Evidence LE QE SR<br />
1 Screening for non-cephalic<br />
presentation at 36 weeks’ gestation<br />
H<strong>of</strong>meyr, 2001a II-2 Fair B<br />
2 Leopolds versus cervical exam for<br />
determining fetal presentation<br />
Lydon-Rochelle et al., 1993<br />
Thorp et al., 1991<br />
II-2 Fair I<br />
3 Ultrasound for presentation<br />
confirmation<br />
Thorp et al., 1991 II-2 Good B<br />
4 External cephalic version at 37 weeks<br />
or beyond, if there are no<br />
contraindications<br />
H<strong>of</strong>meyr & Kulier, 2001a &<br />
2001b<br />
I Good B<br />
LE = Level <strong>of</strong> Evidence; QE = Quality <strong>of</strong> Evidence; SR = Strength <strong>of</strong> Recommendation (See Appendix A)<br />
Interventions Page - 93