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Home Books CURRENT Practice Guidelines in Primary Care 2019

Chapter 24: Special Population: Pregnant Women

CESAREAN SECTION

Population

–Pregnant women with history of prior cesarean delivery.

Recommendations

AAFP 2014, ACOG 2017

  • –Attempting a vaginal birth after cesarean (VBAC) is safe and appropriate for most women.

  • –Encourage and facilitate planning for VBAC. If necessary, refer to a facility that offers trial of labor after cesarean (TOLAC).

Sources

  • –AAFP. Clinical Recommendation: Vaginal Birth After Cesarean. 2014.

  • –Obstet Gynecol. 2017;130(5):1167-1169.

Comments

  1. Provide counseling, encouragement, and facilitation for a planned vaginal birth after cesarean (PVBAC) so that women can make informed decisions. If PVBAC is not locally available, offer women who desire it referral to a facility or clinician who offers the service.

  2. Obtain informed consent for PVBAC, including risk to patient, fetus, future fertility, and the capabilities of local delivery setting.

  3. Develop facility guidelines to promote access to PVBAC and improve quality of care for women who elect TOLAC.

  4. Assess the likelihood of PVBAC as well as individual risks to determine who is an appropriate candidate for TOLAC.

  5. A calculator for probability for successful VBAC is available here: https://mfmunetwork.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html

Population

  • –Women in labor.

Recommendations

ACOG 2012

  • –Induce labor only for medical indications. If induction performed for nonmedical reasons, ensure that gestational age is >39 wk and cervix is favorable.

  • –Do not diagnose failed induction or arrest of labor until sufficient timea has passed.

  • –Consider intermittent auscultation rather than continuous fetal monitoring if heart rate is normal.

Source

  • –Obstet Gynecol. 2012;120(5):1181.

Comments

  1. If fetal heart rate variability is moderate, other factors have little association with fetal neurologic outcomes.

  2. Doctors who are salaried have lower cesarean rates than those paid fee-for-service.

  3. As part of informed consent for the first cesarean, discuss effect on future pregnancies including risks of uterine rupture and abnormal implantation of placenta.

aFailed induction: inability to generate contractions every 3 min and cervical change after 24 h of oxytocin administration and rupture of membranes, if feasible. Arrest of labor, first stage: 6 cm dilation, membrane rupture, and 4 h of adequate contractions or 6 h of inadequate contractions without cervical change. Arrest of labor, second stage: no descent or rotation for 4 h (nulliparous woman with epidural), 3 h (nulliparous woman without epidural or multiparous woman with epidural), or 2 h (multiparous woman without epidural).

GROUP B STREPTOCOCCAL (GBS) INFECTION

Population

  • –Pregnant women.

Recommendations

CDC 2010/ACOG 2011

  • –Obtain vaginal-rectal swab specimen for GBS culture at 35–37 wk gestation.

  • –Intrapartum antibiotic ...

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