The ALSO article series

Author: Mark Deutchman, Barbara Apgar
Date: April 1, 2004

In this issue of American Family Physician, we begin an article series based on the Advanced Life Support in Obstetrics (ALSO[R]) course with an article on shoulder dystocia by Baxley and Gobbo. (1) The ALSO program was developed initially at the University of Wisconsin by two family physicians, James R. Damos, M.D., who originated the concept, and John W. Beasley, M.D. (2) They thought that clinicians providing maternity care could enhance their confidence and competence by preparing for the urgent problems that can arise during prenatal care and delivery.

A group of family physicians, obstetricians, and nurses wrote the original ALSO materials in 1991. The demand for the course was so great that it required a national organizational structure, and the American Academy of Family Physicians acquired the program in 1993. Over the years, the ALSO concept evolved into an evidence-based approach to obstetric emergency management. This evolution is realized in the current fourth edition, which is noteworthy for its evidence-based structure and documentation. (2)

The wide appeal of the ALSO program stems from its ability to fine-tune skills that clinicians do not want to have to think about during an emergency. As with the advanced cardiac life support protocols, the steps of obstetric emergency management should be so routine that a physician can move automatically into them. The course is a compact review of the knowledge and skills necessary to cope with situations such as preeclampsia, preterm labor, assisted vaginal delivery, and shoulder dystocia (see accompanying table on page 1610). (2) Because an emergency is no time to attempt the unfamiliar, the course allows clinicians to practice without the stress of a real emergency. A unique aspect is the inclusion of several mnemonics that help students perform technical procedures and interpret electronic fetal monitors. For those who deliver without immediate surgical back-up, ALSO training assists in building management strategies to use until back-up arrives or the patient can be transported to another facility.

More than 30,000 physicians have taken the ALSO course since its inception. Most attendees have been family physicians in the United States and Canada, but increasing numbers of nurses, midwives, and obstetricians are taking the course as well. The majority of courses are conducted within family medicine residency settings, and many courses include community physicians, who serve as role models for providing maternity care. When nurses attend the course, the team approach to labor and delivery management can be modeled.

ALSO has undergone significant international expansion in the past several years, with licensed affiliates in Canada, the United Kingdom, Brazil, Haiti, Australia, New Zealand and the Pacific Islands, Scandinavia, Hong Kong, Greece, United Arab Emirates, Pakistan, Kenya, Qatar, Sudan, Gaza/West Bank, and the People's Republic of China. Courses also have been held in Uzbekistan, Ecuador, Nepal, Kyrgyzstan, Iraq, Bangladesh, and Zambia. ALSO has been adopted widely in the United Kingdom by the obstetrics and midwifery communities for use with their trainees and active practitioners.

The results of studies show that ALSO training increases short- and long-term confidence in handling obstetric emergencies. (3-5) Other benefits are anecdotal but common. For example, residents appreciate having evidence-based information assembled in an organized fashion. Practicing physicians appreciate the review of factual information and the chance to rehearse manual skills they may not have had the chance to employ since residency. Furthermore, the program is cited commonly as being a catalyst for positive changes in hospital policy and procedure; some hospitals and insurers recommend or require the course.

This article series allows AFP to present useful articles about obstetric emergencies; in addition, it allows the ALSO course to take its proper place in the medical literature. Although more than 30,000 practitioners have taken the course, there are few references to it in print. Granted, the article series will not (and should not) take the place of participation in an ALSO course. However, it can serve as a readily available reference for health care professionals who want to keep current about problems that may arise during delivery.

When clinicians, residents, and students search for a review on shoulder dystocia or a similar topic, we hope these articles will be regarded as an authoritative and reliable resource. ALSO can empower trainees with the knowledge, skill, and confidence to provide maternity care and can encourage existing practitioners to continue providing maternity care. For our specialty, these goals are more important than ever. Harry A. Taylor, M.D., of Middletown, R.I., is the ALSO managing editor who will be overseeing the article series. ALSO is a registered trademark of the American Academy of Family Physicians.

ALSO ChaptersChapter topic Lecture or Required workshop or optionalFirst-trimester complications Lecture RequiredMedical complications of pregnancy Lecture RequiredVaginal bleeding in late pregnancy Lecture RequiredPreterm labor and premature rupture of Lecture Required membranesIntrapartum fetal surveillance Workshop RequiredLabor dystocia Lecture RequiredMalpresentations, malpositions, and multiple Workshop Required gestationAssisted vaginal delivery Workshop RequiredShoulder dystocia Workshop RequiredPostpartum hemorrhage Lecture RequiredMaternal resuscitation and trauma Lecture RequiredSafety in maternity care Lecture RequiredObstetric cases Workshop RequiredThird- and fourth-degree perineal Workshop Optional lacerationsDiagnostic ultrasonography in labor and Workshop Optional deliveryNeonatal resuscitation Workshop OptionalCesarean delivery Workshop OptionalBirth crisis Workshop OptionalNOTE: Information about the ALSO program and a listing of availablecourses are provided at: from ALSO: Advanced Life Support in Obstetrics providercourse syllabus. 4th ed. Leawood, Kan.: American Academy of FamilyPhysicians, 2000.


(1.) Baxley EG, Gobbo RW. Shoulder dystocia. Am Fam Physician 2004;69:1707-14.

(2.) ALSO: Advanced Life Support in Obstetrics provider course syllabus. 4th ed. Leawood, Kan.: American Academy of Family Physicians, 2000.

(3.) Beasley JW, Damos JR, Roberts RG, Nesbitt TS. The advanced life support in obstetrics course. A national program to enhance obstetric emergency skills and to support maternity care practice [published correction in Arch Fam Med 1995;4:206]. Arch Fam Med 1994;3:1037-41.

(4.) Bower DJ, Wolkomir MS, Schubot DB. The effects of the ALSO course as an educational intervention for residents. Advanced Life Support in Obstetrics. Fam Med 1997;29:187-93.

(5.) Taylor HA, Kiser WR. Reported comfort with obstetrical emergencies before and after participation in the advanced life support in obstetrics course. Fam Med Feb 1998;30:103-7.

MARK DEUTCHMAN, M.D. University of Colorado Health Sciences Center Denver, Colorado

Mark Deutchman, M.D., is professor in the Department of Family Medicine and director of the Family Medicine Perinatal Service and Advanced Training Track, University of Colorado Health Sciences Center, Denver.

CHARLES J. CARTER, M.D. Atlanta Medical Center Family Medicine Residency Morrow, Georgia

Charles J. Carter, M.D., is a faculty member at Atlanta Medical Center Family Medicine Residency, Morrow, Ga. He is also a contributing editor with AFP.

BARBARA APGAR, M.D., M.S. University of Michigan Medical Center Ann Arbor, Michigan

Barbara Apgar, M.D., M.S., is clinical professor of Family Medicine, University of Michigan Medical Center, Ann Arbor. She is also an associate editor with AFP. Address correspondence to Charles J. Carter, M.D., Atlanta Medical Center Family Medicine Residency Program, 1000 Corporate Center Dr., Suite 200, Morrow, GA 30260. Reprints are not available from the authors.

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