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.

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


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

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