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.

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 3. Forms of Care with a Trade-off Between Beneficial and Adverse Effects

Women and caregivers should weigh these effects according 
to circumstances, priorities, and preferences

Basic care

Continuity of caregiver for childbearing women
Legislation restricting type of employment for pregnant women

Screening and diagnosis

Formal systems of risk scoring
Routine ultrasound in early pregnancy
Chorionic villus sampling versus amniocentesis for diagnosis of chromosomal abnormalities
Scrum alpha‑fetoprotein screening for neural tube defects
Triple‑test screening for Down syndrome and neural tube defects

Pregnancy problems

Corticosteroids, to promote fetal maturity before preterm birth in diabetic pregnancy
Routine elective cesarean for breech presentation
Induction of labor for prelabor rupture of the membranes at term
Oral betamimetics to maintain uterine quiescence after arrest of preterm labor
Cervical cerclage for women at risk of preterm birth
Betamimetic drugs to stop preterm labor
Induction instead of surveillance for pregnancy after 41 weeks gestation
Expectant care versus induction of labor after fetal death


Continuous electronic monitoring (with scalp sampling) versus intermittent auscultation during labor
Milling versus mediolateral episiotomy, when episiotomy is necessary
Prophylactic ergometrine /oxytocin (syntometrine) versus oxytocin alone in the third stage of labor

Problems during childbirth

Routine preloading with intravenous fluids before epidural analgesia 
Narcotics to relieve pain in labor  
Inhalation analgesia to relieve pain in labor  
Epidural analgesia to relieve pain in labor   
Epidural administration of opiates to relieve pain in labor  
Early amniotomy in spontaneous labor  

Techniques of induction and operative delivery

Mechanical methods for cervical ripening or induction of labor  
Endocervical versus vaginal prostaglandin for cervical ripening before induction of labor
Oral prostaglandin L, for induction of labor with a ripe cervix  
Natural prostaglandins versus oxytocin for induction of labor   
Soft versus rigid vacuum extractor cups   
Regional Versus general anaesthesia for cesarean section  
Epidural versus spinal anesthesia for cesarean section   
Ampicillin versus broader spectrum antibiotics for cesarean section   

Care after childbirth

Prophylactic antibiotic eye ointments to prevent eye infection in the newborn     
Prophylactic versus "rescue" surfactant for very preterm infants    

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