Effective Care In Pregnancy and Childbirth: A Synopsis

Murray  Enkin, MD, FRCS(C), L L D, Marc J. N. C Keirse, MD, DPhil, DPH, FRA NWOG, FRCOG
James Neilson, BSc, MD, FRCOG, Caroline Crowther, MD, DCH,
Lelia Duley, MD, MSc(Epid), MRCOG, Ellen Hodnett, RN, PhD,
and G. Justus Hofmneyr, MBBCH, MRCOG

EDITOR'S NOTE: This article is the text and six tables from the final chapter (Chapter 50) of the new third edition of A Guide to Effective Care in Pregnancy and Childbirth. It summarizes the authors' conclusions and recommendations, based on the information they have compiled in the book about the beneficial or harmful effects of the various elements of care used during pregnancy, and childbirth. 

The underlying thesis of this book is that evidence from well-controlled comparisons provides the best basis, for choosing among alternative forms of care in pregnancy and childbirth. This evidence should encourage the adoption of useful measures and the abandonment of those that are useless or harmful.

The inclusion of a particular forms of care in Tables 1 or 2 does not imply that it should always be adopted in practice. Research based on the study of groups may riot always apply to individuals, although it should be relevant to guide broad policies of care. Forms of care listed in Tables, 5 and 6 may still be useful in particular circumstances, although, once again, they should be discouraged as a matter of policy. Practices listed in Table 3 will require careful consideration by the individuals concerned, while those in Table 4 should usually be avoided except in the context of trials to better evaluate their effects.

Some of the conclusions that we have reached will be controversial, but they must be judged in the light of the methods we used to assemble and review the evidence on which they are based. While we have made great efforts to ensure that the data presented are comprehensive and accurate, it is possible that errors and misinterpretations have crept in. We conclude by reiterating the invitation extended to readers in our first edition to bring omissions and mistakes to our attention for inclusion and correction in the Cochrane Library and in later editions of this book. Correspondence should be addressed to the Cochrane Pregnancy and Childbirth Group, Liverpool Women's Hospital NHS Trust, Crown Street, Liverpool, UK L8 7SS.

Table 1. Beneficial Forms of Care

Demonstrated by Clear evidence from controlled trials

Basic care

Women carrying their pregnancy record to enhance their feeling of being in control
Pre and peri-conceptional folic acid supplementation to prevent recurrent neural tube defects
Folic acid supplementation (or high folate diet) for all women envisaging pregnancy
Assistance (especially behavioural strategies) to stop smoking during pregnancy
Balanced energy and protein supplementation when dietary supplementation is required
Vitamin D supplementation for women with inadequate exposure to sunlight iodine supplementation in populations with a high incidence of endemic cretinism 

Screening and diagnosis

Doppler ultrasound in pregnancies at high risk of fetal compromise

Pregnancy problems

Antihistamines for nausea and vomiting of pregnancy that is resistant to simple measures
Local imidazoles for vaginal candida infection (thrush)
Local imidaxoles instead of nystatin for vagina] candida infection (thrush)
Magnesium Sulphate rather than other anticonvulsants for treatment of eclampsia
Administration of anti-D immunoglobulin to Rh-negative women whose newborn baby is not Rh-negative
Administration of anti-D immunoglobulin to Rh-negative women at 28 weeks of pregnancy
Antirotroviral treatment
of HIV-inflected pregnant women to prevent transmission to fetus
Antibiotic treatment of asymptomatic bacteriuria
Antibiotics during labor for women known to be colonized with group B streptococcus
Tight as opposed to too strict or loose control of blood sugar levels in pregnant diabetic women
External cephalic version at term to avoid breech birth
Corticosteroids to promote fetal maturity before preterm birth
Offering induction
of labor after 41 completed weeks of gestation


Physical, emotional, and psychological support during labor and birth 
Continuous Support for women during labor and childbirth agents to reduce acidity of' stomach contents before general anaesthesia Complementing fetal heart rate monitoring in labor with fetal acid‑base assessment 
Oxytocics to treat postpartum hemorrhage
Prophylactic oxytocics in the third stage of labor
Active versus expectant management of' third stage of labor

Problems during childbirth

Absorbable instead of non‑absorbable sutures for skin repair of' perineal trauma
Polylycolic acid Sutures instead of chromic catgut for repair of' perineal trauma

Techniques of induction and operative delivery

Prostaglandins to increase cervical readiness for induction of labor
Aniniotomy plus, oxytocin for induction of labor instead of either amniotomy alone or oxytocin alone
Vacuum extraction instead of forceps when operative vaginal delivery is required
Antibiotic prophylaxis (short course or intraperitoncal lavage with cesarean section                                                             

Care after childbirth

Use of surfactant for very preterm infants, to prevent respiratory distress syndrome
Support for socially disadvantaged mothers to improve parenting
Consistent support for breastfeeding mothers
Personal support from a knowledgeable individual for breastfeeding mothers
Unrestricted breastfeeding
Local anesthetic sprays for relief of perineal pain postpartum
Cabergoline instead of' bromocriptine for relief of breast symptoms in non-breastfeeding mothers  

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