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.
Table
2. Forms of Care Likely To Be Beneficial
The
evidence in favor of
these forms of care is strong, although not established by randomized
trials
Basic
care
Adequate
access to care for all childbearing women
Social
support for childbearing women
Financial Support for childbearing women in need
Legislation
on paid leave and income maintenance during maternity or parental leave
Midwifery
care for women with no serious risk factors
Continuity of care for childbearing women
Antenatal classes for women and their partners who want them
Advice to avoid excessive alcohol consumption during pregnancy
Avoidance
of' heavy physical work during pregnancy
Screening
and diagnosis
Ultrasound
to resolve questions about fetal size, structure, or position
Selective
use of ultrasound to assess amniotic fluid volume
Selective use of ultrasound to estimate gestational Age in first and early
second trimester
Ultrasound to determine whether the embryo is alive in threatened miscarriage
Ultrasound
to confirm suspected multiple pregnancy
Ultrasound for placental location in suspected placenta previa
Second
trimester amniocentesis to identify chromosomal abnormalities in pregnancies at
risk
Transabominal instead of transcervical chorionic villus sampling
Genetic counseling before prenatal diagnosis
Clinical
history to assess risk of pre~eclampsia
Regular
monitoring of blood pressure (luring pregnancy
Testing for prolcinuria during pregnancy
Uric
acid levels for following the course of pre-eclanipsia
Fundal
height measurements during pregnancy
Pregnancy
problems
Ultrasound
to facilitate intrauterine interventions
Antacids for heartburn of' pregnancy if simple measures are ineffective
Bulking agents for constipation if simple measures are ineffective
Local metronidazole for symptomatic trichomonal vaginitis after the first
trimester
Antibiotics
['or symptomatic bacterial vagmosis
Antiplatelet agents to prevent preeclampsia
Antihypertensive agents to control serious hypertension in pregnancy
Calcium to prevent pre‑eclampsia, for women at high risk or with
low calcium in diet
Balanced protein / energy supplementation for impaired fetal g, growth
Ultrasound surveillance of fetal growth in multiple pregnancies
Screening all pregnant women for blood group isoimmunization
Anti-D immunization Rh‑negative women after any uterine bleeding,
intrauterine procedure, or abdominal trauma during pregnancy
Intra-uterine transfusion for a severely affected isoimmunization fetus
Advice
to riot breastfeed for HIV‑infected women to prevent transmission to baby
Routine screening for, and treatment of, syphilis in pregnancy
Rubella
vaccination of seronegative women postpartum
Screening for. and treatment of' chlamydlia in high prevalence
populations
Cesarean section for active herpes (with visible lesion) in labor with intact
membranes
Pre-pregnancy counselling for‑ women with diabetes
Specialist care for‑ pregnant women with diabetes
Home instead of
hospital
glucose monitoring for pregnant women with diabetes
Ultrasound surveillance of' fetal growth for pregnant women with diabetes
Allowing pregnancy to continue to term in otherwise uncomplicated diabetic
pregnancies
Careful attention to insulin requirements postpartum
Encouraging diabetic women to breastfeed
Checking for clotting disorders with severe placental abruption
Vaginal instead of' cesarean delivery for placental abruption in the absence of
fetal distress
Vaginal instead of cesarean birth for a dead fetus after placental abruption
Repeat ultrasound scanning of a low‑lying placenta in late pregnancy
Delaying planned cesarean section for placenta previa until term
Cesarean section for placenta previa covering any portion of the cervical os
Ultrasound examination for vagina] bleeding of undetermined origin
External cephalic version for transverse or oblique lie at term
Tocolysis for external cephalic version of breech, particularly if unsuccessful
otherwise
External cephalic version for breech in early labor if' the membranes are intact
Corticosteroid administration after prelabor rupture of the membranes preterm
Vaginal culture after prelabor rupture of the membranes preterm
Antibiotics for prelabor rupture of the membranes with suspected intrauterine
infection
Not stopping spontaneous labor after prelabor rupture of the membranes preterm
Elective delivery for prelabor rupture of
the
membranes preterm with signs of infection
Amnioinfusion for fetal distress thought to be due to oligoliydraminios in labor
Betamimetic tocolysis to allow effective preparation for preterm birth
Short-term indomethacin to stop preterm labor
Offering induction of labor as an option after fetal death
Prostaglandin or prostaglandin analogy for induction of labor after fetal death
Childbirth
Respecting
women's choice of companions during labor and birth
Respecting women's choice of place of birth
Presence of a companion on admission to hospital
Giving women as much information as they desire
Freedom of' movement and choice of position in labor
Change of mother's position for fetal distress in labor
Intravenous betamimetics for fetal distress in labor to buy time
Respecting women's choice of position for the second stage of labor and giving
birth
Guarding the perineum versus watchful waiting during birth
Intramyometrial prostaglandins for severe postpartum hemorrhage
Problems
during childbirth
Regular
top-ups of epidural analgesia instead of top-ups on maternal demand
Maternal movement and position changes to relieve pain in labor
Counter-pressure to relieve pain in labor
Superficial heat or cold to relieve pain in labor
Touch and
massage to relieve pain in labor
Attention focusing and distraction to relieve pain in labor
Music and audio-analglesia to relieve pain in labor
Epidural instead of narcotic analgesia for preterm labor and birth
Amniotomy to augment slow or prolonged labor
Continuous subcuticular suture for perinea] skin repair
Primary rather than delayed repair of episiotomy breakdown
Delivery of a very preterm baby in a center with adequate perinatal facilities
Presence of a pediatrician at a very preterm birth
Trial of' labor after previous lower segment cesarean section
Trial of labor after more than one previous lower segment cesarean section
Use of oxytocic agents when indicated for labor after a previous cesarean
section
Use of epidural analgesia in labor. when needed after previous cesarean section
Techniques of induction and operative delivery
Assessing the state of the cervix before induction of
labor
Transverse instead of vertical skin incision for cesarean section
Low-dose heparin with cesarean section to prevent thrombo-embolism
Transverse lower segment uterine incision or cesarean section
Care after
birth
Keeping newborn babies warm
Prophylactic vitamin K to the baby to prevent hemorrhagic disease of the
newborn
Nasopharyngeal suctioning of infants who have passed meconium before birth
Presence of someone skilled in neonatal resuscitation at birth of all infants
likely to be at risk
Oxygen for resuscitation of distressed newborn infants
Cardiac massage for infants born with absent heart beat
Naloxone for infants with respiratory depression due to narcotic
administration before birth
Encouraging early mother‑infant contact
Allowing mothers access to their own supply of symptom‑relieving drugs
in hospital
Consistent advice to new mothers
Offering choice in the length of' hospital stay after childbirth
Telephone service of advice and information after women go home from hospital
after birth
Psychological support for women depressed after childbirth
Encouraging early breastfeeding when mother and baby are ready
Skilled help with first breastfeed
Flexibility in breastfeeding practices
Antibiotics for infectious mastitis in breastfeeding
women
Breast binding and fluid restriction for suppression of
lactation
Support and care programs for bereaved parents
Encouraging parental contact with a dying or dead baby
Providing parents with prompt, accurate information
about a severely ill baby
Encouraging autopsy for a dead baby and discussing the
results with the parents
Help with funeral arrangements for a dead baby
Self-help groups for bereaved parent
Contine
on to Table No. 3
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