Changing Obstetric Practices

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Changing Established Practices

Experience Expert opinion Evidence Expectation

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Evidence-Based Medicine

Systematic, scientific and explicit use of current best evidence in making decisions about the care of individual patients

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So What Has Changed?

Developments in clinical research Developments in methodology

Meta-analysis Recognition of bias in traditional reviews and expert opinions

Explosion in medical literature Methodological papers Electronic databases

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Beneficial Forms of Care

Active management of the third stage of labor (decreases blood loss after childbirth)

Antibiotic treatment of asymptomatic bacteriuria in pregnancy (prevents pyelonephritis and reduces the incidence of preterm childbirth)

Antibiotic prophylaxis for women undergoing cesarean section (reduces postoperative infectious morbidity)

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Beneficial Forms of Care (continued)

External cephalic version at term (decreases incidence of breech delivery and reduces cesarean section rates)

Magnesium sulfate therapy for women with eclampsia (more effective than diazepam, etc.) for the control of convulsions

Population-based iodine supplementation in severely iodine deficient areas (prevents cretinism and infant deaths due to iodine deficiency)

Routine iron and folic acid supplementation (reduces the incidence of maternal anemia at childbirth or at 6 weeks postpartum)

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Active vs. Physiological Management: Postpartum Hemorrhage

Active Management

Physiologic Management

OR and 95% CI

Bristol Trial 50/846 (5.9%) 152/849 (17.9%) 3.13 (2.3–4.2)

Hinchingbrooke Trial 51/748 (6.8%) 126/764 (16.5%) 2.42 (1.78–3.3)

Prendiville et al 1988, Rogers et al 1998.

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Forms of Care of Unknown Effectiveness

Antibiotic prophylaxis for uncomplicated incomplete abortion to reduce postabortion complications

Anticonvulsant therapy to women with pre-eclampsia, the prevention of eclampsia

Routine symphysio-fundal height measurements during pregnancy to help detect IUGR

Routine topical antiseptic or antibiotic application to the umbilical cord to prevent sepsis and other illness in the neonate

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Forms of Care Likely to Be Ineffective

Use of antibiotics in preterm labor with intact membranes in order to prolong pregnancy and reduce preterm birth

Early amniotomy during labor to reduce cesarean section rates External cephalic version before term to reduce incidence of breech

delivery Routine early pregnancy ultrasound to decrease perinatal mortality

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Forms of Care Likely to Be Harmful

Routine episiotomy (compared to restricted use of episiotomy) to prevent perineal/vaginal tears

Diazoxide for rapid lowering of blood pressure during pregnancy (associated with severe hypotension)

Forceps extraction instead of vacuum extraction for assisted vaginal delivery when both are applicable. Forceps delivery is associated with increased incidence of maternal genital tract trauma

Using diazepam or phenytoin to prevent further fits in women with eclampsia when magnesium sulfate is available

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Antenatal Care Practices

Practices not recommended High risk approach Routine antenatal measurement

Maternal height to screen for cephalopelvic disproportion

Determining fetal position before 36 weeks

Testing for ankle edema to detect pre-eclampsia

Bed rest for threatened abortion, uncomplicated twins, mild pre-eclampsia

External cephalic version before 37 weeks

Recommended practices Birth preparedness counseling Complication readiness planning Iron and folate supplementation Tetanus immunization Reduced frequency of antenatal visits by

skilled provider to maintain normal health and detect complications

In selected populations Iodine supplementation in severely

iodine deficient areas Intermittent presumptive treatment

for malaria External cephalic version at term

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Essential Care Series

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Promoting a Culture of Quality Care

Good quality care saves time and money Partograph Manual vacuum aspiration/postabortion care Active management of third stage

Team responsibility: Providers Supervisors Community

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References

AbouZahr C and T Wardlaw. 2001. Maternal Mortality in 1995: Estimates Developed by WHO, UNICEF, UNFPA. World Health Organization (WHO): Geneva.

Duley L and D Henderson-Smart. 2000. Magnesium sulphate versus diazepam for eclampsia (Cochrane Review), in The Cochrane Library. Issue 4. Update Software: Oxford.

Maine D. 1999. What's So Special about Maternal Mortality?, in Safe Motherhood Initiatives: Critical Issues. Berer M et al (eds). Blackwell Science Limited: London.

Prendiville et al. 1988. The Bristol third stage trial: Active versus physiological management of the third stage of labor. BMJ 297: 1295–1300.

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References (continued)

Rogers J et al. 1998. Active versus expectant management of third stage of labour: The Hinchingbrooke randomised controlled trial. Lancet 351 (9104): 693–699.

Sadik N. 1997. Reproductive health/family planning and the health of infants, girls and women. Indian J Pediatr 64(6): 739–744.

WHO. 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva.

WHO 1998. Pospartum Care of the Mother and Newborn: A Practical Guide. Report of a Technical Working Group. WHO: Geneva.