Management of pregnancy - VA/DoD Clinical Practice Guidelines ...

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VA/DoD Clinical Practice Guideline For Pregnancy Management I 47. Assessment of Fetal Presentation: Weeks 36, 3841 BACKGROUND Fetal non-cephalic presentation at term can result in cesarean section delivery. Examination at 36 weeks can identify non-cephalic presentation. External version of the fetus to the vertex position can allow a trial of labor for vaginal delivery. Vaginal delivery is associated with less morbidity and mortality than cesarean section delivery. RECOMMENDATIONS 1. Recommend screening for non-cephalic presentation for all patients at 36 weeks’ gestation. [B] 2. There is insufficient evidence to recommend for or against Leopolds versus cervical exam as the best screening method to determine fetal presentation. [I] 3. 4. Recommend ultrasound for confirmation, if non-cephalic presentation is suspected. [B] If non-cephalic presentation is confirmed and there are no contraindications, recommend external cephalic version at 37 weeks or beyond and referral to an advanced prenatal care provider. [B] DISCUSSION No systematic reviews or RCTs comparing Leopold's maneuvers to other manipulations were found. Two nonrandomized trials were found that evaluated Leopold's maneuvers as a screening test for fetal malpresentation, but did not assess the effect on maternal morbidity/mortality or infant mortality. The studies were of fair quality and suggest that the specificity for Leopold's to predict fetal malposition is high, but its sensitivity is only modest (Lydon-Rochelle et al., 1993; Thorp et al., 1991). External cephalic version for breech presentation at term is associated with a significant reduction in non-cephalic births and cesarean sections, without significant effects on perinatal mortality (Hofmeyr & Kulier, 2001b). External cephalic version for breech presentation prior to term does not reduce the number of non-cephalic births nor does it improve pregnancy outcomes (Hofmeyr, 2001). There is no evidence to support the use of postural management for breech presentation (Hofmeyr & Kulier, 2001c). If external cephalic version for breech presentation cannot be accomplished, planned cesarean delivery for term breech decreases perinatal and neonatal death and neonatal morbidity. There is a modest increase in maternal morbidity but no effect on maternal mortality (Hannah et al., 2000; Hofmeyer & Hannah, 2001). EVIDENCE Recommendations Sources of Evidence LE QE SR 1 Screening for non-cephalic presentation at 36 weeks’ gestation Hofmeyr, 2001a II-2 Fair B 2 Leopolds versus cervical exam for determining fetal presentation Lydon-Rochelle et al., 1993 Thorp et al., 1991 II-2 Fair I 3 Ultrasound for presentation confirmation Thorp et al., 1991 II-2 Good B 4 External cephalic version at 37 weeks or beyond, if there are no contraindications Hofmeyr & Kulier, 2001a & 2001b I Good B LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A) Interventions Page - 93
VA/DoD Clinical Practice Guideline For Pregnancy Management Visits During Weeks: 3841 I 48. Consider Weekly Cervical Check/stripping (sweeping): Weeks 3841 BACKGROUND Post-dates pregnancies (over 42 weeks) occur in 10 percent of uncomplicated pregnant women. Post-dates pregnancies have a higher incidence of induction of labor, operative delivery, post-partum hemorrhage and shoulder dystocia. Routine membrane stripping, in low-risk pregnant women with accurate dating criteria, has been proposed as a method of encouraging earlier delivery to prevent post-dates pregnancy. RECOMMENDATIONS 1. Consider offering routine membrane sweeping to all pregnant women every visit beginning at 38 weeks. [C] 2. There is insufficient data to encourage or discourage this practice in women known to be GBS-colonized. [I] DISCUSSION Membrane sweeping lessens the incidence of post-dates pregnancies and the need for medical inductions (NNT = 8) (Boulvain et al., 2005). A well-done meta-analysis of randomized trials found no harm regarding neonatal morbidity/mortality if women undergo routine weekly “membrane stripping” beginning at 38 weeks’ gestation (Boulvain et al., 1999 & 2001, 2005). No “serious maternal morbidity/mortality,” increased cesarean-sections, instrumental delivery rates, or maternal infection was found. ACOG (2002) states that the risks of membrane stripping in women colonized with GBS “have not been investigated in well-designed prospective studies. Therefore data are insufficient to encourage or discourage this practice in women known to be GBS-colonized.” Membrane sweeping in women who are positive GBS carriers may increase susceptibility to litigation in the event of a GBS-related adverse fetal/neonatal outcome despite the fact that randomized trials found no harm regarding increased neonatal or maternal morbidity/mortality (Cohen & Goldberg, 2006). EVIDENCE TABLE Recommendations Sources of Evidence LE QE SR 1 Membrane stripping at each visit Boulvain et al., 2005 I Fair C beginning at 38 weeks LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A) I 49. Term Management: Weeks 3841 BACKGROUND Intrapartum fetal distress, meconium staining, postmaturity syndrome and primary cesarean section rates all increase after the 40 th week of gestation (Devoe, 1983). Pregnancies continuing past the 41 st week carry additional risk of oligohydramnios, perinatal morbidity and mortality (Sims & Walther, 1989). The goal of antepartum fetal testing is to prevent adverse fetal and maternal outcomes, to include fetal death. The success of antenatal fetal testing at predicting these outcomes, as well as the appropriate time to initiate antenatal fetal testing, have both been topics of debate in the medical community. RECOMMENDATIONS 1. In the absence of contraindications, labor induction should be offered to women who reach 41 and 0/7 weeks undelivered. [A] Interventions Page - 94
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