Royal College of Obstetricians and Gynaecologists guidelines: How evidence-based are they?

Figures & data

Table I. The Green-top Guidelines analysed.

	Guideline number	Date published
Amniocentesis and Chorionic Villus Sampling	8	Jun 2010
Antenatal Corticosteroids to Reduce Neonatal Morbidity	7	Oct 2010
Antepartum Haemorrhage	68	Dec 2011
Birth After Previous Caesarean Birth	45	Feb 2007
Blood Transfusions in Obstetrics	47	Dec 2007
Breast Cancer and Pregnancy	12	Apr 2011
Breech Presentation, Management	20b	Dec 2006
Cervical Cerclage	60	May 2011
Chickenpox in Pregnancy	1	Sep 2007
Chronic Pelvic Pain, Initial Management	41	Apr 2005
Early Pregnancy Loss, Management	25	Oct 2006
Endometriosis, Investigation and Management	24	Oct 2006
External Cephalic Version (ECV) and Reducing the Incidence of Breech Presentation	20a	Dec 2006
Female Genital Mutilation Management	53	May 2009
Genital Herpes in Pregnancy, Management	30	Sep 2007
Gestational Trophoblastic Disease	38	Feb 2010
Group B Streptococcal Disease, Early Onset	36	Nov 2003
HIV in Pregnancy, Management	39	Jun 2010
Hormone Replacement Therapy and Venous Thromboembolism	19	May 2011
Hysteroscopy, Best Practice in Outpatient	59	Apr 2011
Laparoscopic Injuries	49	May 2008
Late Intrauterine Fetal Death and Stillbirth	55	Nov 2010
Malaria in Pregnancy Diagnosis and Treatment	54b	Apr 2010
Malaria in Pregnancy Prevention	54a	Apr 2010
Maternal Collapse in Pregnancy and the Puerperium	56	Feb 2011
Monochorionic Twin Pregnancy, Management	51	Dec 2008
Obstetric Cholestasis	43	Apr 2011
Operative Vaginal Delivery	26	Feb 2011
Ovarian Cysts in Postmenopausal Women	34	Oct 2003
Ovarian Hyperstimulation Syndrome, Management	5	Sep 2006
Ovarian Masses in Premenopausal Women: Management of Suspected	62	Dec 2011
Pelvic Inflammatory Disease	32	Nov 2008
Placenta Praevia and Placenta Praevia Accreta: Diagnosis and Management	27	Jan 2011
Polycystic Ovary Syndrome, Long-Term Consequences	33	Dec 2007
Postpartum Haemorrhage, Prevention and Management	52	May 2009
Premenstrual Syndrome, Management	48	Dec 2007
Preterm Labour, Tocolytic Drugs	1b	Feb 2011
Preterm Prelabour Rupture of Membranes	44	Nov 2006
Recurrent Miscarriage, Investigation and Treatment of Couples	17	Apr 2011
Reduced Fetal Movements	57	Feb 2011
Rh Prophylaxis, Anti-D Immunoglobulin	22	Mar 2011
Shoulder dystocia	42	Mar 2012
Sickle Cell Disease in Pregnancy, Management	61	Aug 2011
Third- and Fourth-degree Perineal Tears, Management	29	Mar 2007
Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management	37b	Feb 2007
Thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the Risk	37a	Nov 2009
Tubal Pregnancy, Management	21	May 2004
Umbilical Cord Prolapse	50	Apr 2008
Vaginal Vault Prolapse	46	Oct 2007
Venous Thromboembolism and Hormonal Contraception	40	Sep 2010
Venous Thromboembolism and Hormone Replacement Therapy	19	May 2011
Vulval Skin Disorders, Management	58	Feb 2011

Table II. The classification scheme for the recommendations by the Royal College of Obstetricians and Gynaecologists.

	Classification scheme for recommendations by the Royal College of Obstetricians and Gynaecologists
Pre-December 2007
A	At least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation.
B	Requires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations.
C	Requires evidence obtained from expert committee reports or opinions and/or clinical experiences or respected authorities. Indicates an absence of directly applicable clinical studies of good quality.
D	Recommended best practice based on the clinical experience of the guideline development group.
Post-December 2007
A	At least one meta-analysis, systematic review or randomised controlled trial rated as 1++ directly applicable to the target population and demonstrating overall consistency of results. 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. 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. Extrapolated evidence from studies rated as 2++.
D	Evidence level 3 or 4. Extrapolated evidence from studies rated as 2+.
E	Recommended best practice based on the clinical experience of the guideline development group.

Table III. The classification scheme for the stratification of guidelines into topics.

	Classification scheme for the stratification of guidelines into topics
Guideline specialty grouping
Obstetrics
Gynaecology	General Gynaecology
	Oncology
	Fertility
	Endoscopy
Guideline classification scheme
Diagnosis and treatment	Recommendations for the diagnostic evaluation in patients without a known abnormal condition, and for the specific interventions for the diagnosed condition.
Evaluation	Recommendation for evaluation, monitoring, and follow-up of patients with a known abnormal condition.
Mode of delivery	Recommendations specifically tailored to directing for a particular mode of delivery (obstetrics guidelines only).

Figure 1. Classification of evidence levels underlying RCOG guidelines published (a) before and (b) after December 2007.

Figure 2. Classification of evidence underlying Obstetrics guidelines published (a) before and (b) after December 2007.

Figure 3. Classification of evidence underlying Gynaecology guidelines published (a) before and (b) after December 2007.

Figure 4. Distribution of quality of evidence underlying obstetric recommendations stratified by the type of guideline, published (a) before and (b) after December 2007.

Figure 5. Distribution of quality of evidence underlying gynaecology recommendations stratified by the type of guideline, published (a) before and (b) after December 2007.

Figure 6. Quality of evidence underlying gynaecological subspecialty guidelines, published (a) before and (b) after December 2007.