In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
Can Shoulder Dystocia Be Predicted?
D - Clinicians should be aware of existing risk factors in labouring women and must always be alert to the possibility of shoulder dystocia.
C - Risk assessments for the prediction of shoulder dystocia are insufficiently predictive to allow prevention of the large majority of cases.
Prevention of Shoulder Dystocia
Management of Suspected Fetal Macrosomia
Does Induction of Labour Prevent Shoulder Dystocia?
D - Induction of labour does not prevent shoulder dystocia in non-diabetic women with a suspected macrosomic fetus.
B - Induction of labour at term can reduce the incidence of shoulder dystocia in women with gestational diabetes.
Should Elective Caesarean Section Be Recommended for Suspected Fetal Macrosomia to Prevent Brachial Plexus Injury?
D - Elective caesarean section should be considered to reduce the potential morbidity for pregnancies complicated by pre-existing or gestational diabetes, regardless of treatment, with an estimated fetal weight of greater than 4.5 kg.
What Are the Recommendations for Future Pregnancy?
What Is the Appropriate Mode of Delivery for the Woman with a Previous Episode of Shoulder Dystocia?
D - Either caesarean section or vaginal delivery can be appropriate after a previous shoulder dystocia. The decision should be made jointly by the woman and her carers.
Management of Shoulder Dystocia
How Is Shoulder Dystocia Diagnosed?
D - Routine traction in an axial direction can be used to diagnose shoulder dystocia but any other traction should be avoided.
How Should Shoulder Dystocia Be Managed?
D - Fundal pressure should not be used.
D - McRoberts' manoeuvre is a simple, rapid and effective intervention and should be performed first.
D - Suprapubic pressure should be used to improve the effectiveness of the McRoberts' manoeuvre.
D - An episiotomy is not always necessary.
What Are the Recommendations for Training?
D - All maternity staff should participate in should dystocia training at least annually.
Grades of Recommendations
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++, and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results
B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Classification of Evidence Levels
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1- Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal
2- Case–control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal
3 Non-analytical studies; e.g., case reports, case series
4 Expert opinion