UM Guidelines

	Deleted from: Clinical Indications
	Milliman Care Guidelines Clinical Indications were deleted.

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	Added to: Clinical Indications
	Cesarean Section, Primary Failed trial of labor, non-reassuring fetal status, or other obstetric indication. 1Dystocia, protraction disorder or arrest disorder, with adequate contractions (See below.) Fetal malposition (e.g., breech, brow, transverse lie) Multiple intrauterine pregnancy (i.e., Twins, Triplets, Quads) Non-reassuring fetal status, 2fetal distress (e.g., fetal acidosis) Cord prolapse, placenta previa, or placenta abruption Previous myomectomy or uterine reconstruction, which is full thickness or enters uterine cavity Previous intra-uterine fetal surgery HIV, active herpes Medical or Obstetrical complications precluding vaginal delivery Suspected macrosomia by sonographic estimated fetal weight greater than 4250 grams in diabetic individuals 1See ACOG Technical Bulletin # 218 definition of dystocia 2See ACOG Committee Opinion #197 definition of fetal distress Cesarean Section, Repeat, Planned Previous C-section* Clinical indications listed above for primary cesarean section would apply to repeat or planned cesarean section. Previous low vertical uterine incision or classical C-section Previous T-shaped extension of lower transverse uterine incision Unknown type of uterine scar (i.e., cannot be determined) Documented choice of patient to forgo a trial of labor in favor of a scheduled repeat C-section Abnormal lie with failure or refusal of version Contraindication to vaginal birth: Clinically inadequate pelvis Previous rupture Placenta previa Limited emergency facilities (physician, anesthesia, personnel, facility) *There is a growing concern as to whether a trial of labor is appropriate for most women who have had a previous low transverse cesarean delivery, because increased experience with VBAC indicates there are several potential problems. However, there are few absolute contraindications to a trial of labor and few reliable predictors of success or failure of a trial of labor. References: American College of Obstetricians and Gynecologists. Vaginal delivery after previous cesarean birth. ACOG Practice Patterns 1. Washington, DC: ACOG, 1995. American College of Obstetricians and Gynecologists. Cesarean section. ACOG Precis V. Washington, DC: ACOG, 1994. American College of Obstetricians and Gynecologists. Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin. Washington, DC: ACOG, 1998. BlueCross BlueShield of Tennessee network physicians. April - June 2008. McManon MJ. Vaginal birth after cesarean. In: Dolan MS, editor. Evidence Based Medicine: Clinical Applications in Clinical Obstetrics and Gynecology, 2nd ed. Philadelphia: Lippincott-Raven Publishers; 1998;41:369-81. Read JS et al. The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1-a meta-analysis of 15 prospective cohort studies. New England Journal of Medicine, 1999;340:977-87. Riley LE, Greene MF. Elective cesarean delivery to reduce the transmission of HIV. New England Journal of Medicine, 1999;340:1032-3. Dystocia Defined ACOG Technical Bulletin # 218 states the following: "The term cephalopelvic disproportion has been used to describe a disparity between the size of the maternal pelvis and the fetal head that precludes vaginal delivery. This condition can rarely be diagnosed with certainty; in fact, it is often given as an indication for operative delivery when the true abnormality is malposition of the fetal head (ie, asynclitism or extension of the fetal head that presents bony diameters too great to allow passage through the maternal pelvis). Similarly, the term failure to progress is imprecise and has been used to include lack of progressive cervical dilation or lack of descent of the fetal head or both. Often, the diagnosis of failure to progress is made before the active phase of labor and before an adequate trial of labor has been achieved. A more practical classification is to categorize labor abnormalities as either slower-than-normal (protraction disorders) or complete cessation of progress (arrest disorder). These disorders require the parturient to have entered the active phase of labor. A prolonged latent phase of labor is not indicative of dystocia as this diagnosis cannot be made in the latent phase of labor." Labor Pattern Nulligravida Multipara Protraction Disorders Dilation < 1.2 cm/hr < 1.5 c/hr Descent < 1.2 cm/hr < 1.5 c/hr Arrest Disorders Dilation > 2 hrs > 2 hrs Descent > 1 hr > 1 hr Fetal Distress Defined ACOG Committee Opinion #197 definition of fetal distress Committee Opinion ---------------------------------------------- Number 197, February 1998 --------------------------------------------- Inappropriate Use of the Terms Fetal Distress and Birth Asphyxia The Committee on Obstetric Practice is concerned about the continued use of the terms fetal distress as an antepartum or intrapartum diagnosis and birth asphyxia as a neonatal diagnosis. The Committee reaffirms that the term fetal distress is imprecise and nonspecific. The term has a low positive predictive value even in high-risk populations and is often associated with an infant who is in good condition at birth as determined by the Apgar score or umbilical cord blood gas analysis or both. The communication between clinicians caring for the woman and those caring for her neonate is best served by replacing the term fetal distress with nonreassuring fetal status, followed by a further description of findings (eg, repetitive variable decelerations, fetal bradycardia, and biophysical profile score of 2). Whereas fetal distress implies an ill fetus, nonreassuring fetal status describes the clinician's interpretation of data regarding fetal status (ie, the clinician is not reassured by the findings). This acknowledges the imprecision inherent in the interpretation of the data. Accordingly, the term nonreassuring fetal status is consistent with the delivery of a vigorous infant, and a good outcome does not have to be justified. Because of the limitations of the term fetal distress, its use may result in inappropriate actions, such as an unnecessarily urgent delivery under general anesthesia. Fetal heart rate patterns or auscultatory findings should be considered when the degree of urgency, mode of delivery, and type of anesthesia to be given are determined. Performing a cesarean delivery for a nonreassuring fetal heart rate pattern does not necessarily preclude the use of regional anesthesia. Effective October 1, 1998, all inclusion terms except metabolic acidemia will be removed from the current International Classification of Diseases (ICD) code for fetal distress. All other terms will be indexed to a new code to indicate an abnormality of the heart rate or rhythm, or they will be referenced to other more appropriate codes. A similar revision will be made to the perinatal ICD codes used by pediatricians. These changes have been made because of the waning use of fetal distress in clinical practice. The term asphyxia should be reserved for the clinical context of damaging acidemia, hypoxia, and metabolic acidosis. The Committee strongly supports the concept that a neonate who has had hypoxia proximate to delivery severe enough to result in hypoxic encephalopathy will show other signs of hypoxic damage, including all of the following: Profound metabolic or mixed acidemia (pH <7.00) on an umbilical cord arterial blood sample, if obtained Persistent Apgar score of 0-3 for longer than 5 minutes Evidence of neonatal neurologic sequelae (eg, seizures, coma, hypotonia, and one or more of the following: cardiovascular, gastrointestinal, hematologic, pulmonary, or renal system dysfunction)