Download - 02 Changing midwifery practices
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.