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,
DDU, FRCOG, FRANWOG,
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 4. Forms of Care of Unknown Effectiveness

There are insufficient or inadequate quality data upon which 
to base a recommendation for practice  "
Table 4 should usually be avoided except in the context of trials to better evaluate their effects."

Basic care

Formal preconceptional care for all women
Fish oil supplementation to improve pregnancy outcome
Prostaglandin precursors to improve pregnancy outcome
Calcium supplementation to improve pregnancy outcome
Magnesium supplementation to improve pregnancy outcome
Zinc supplementation to improve pregnancy outcome
Antigen-avoidance diets to reduce risk of an atopic child

Screening and diagnosis

Placental grading by ultrasound to improve perinatal outcome
Measuring placental proteins for pre-eclampsia
Doppler ultrasound of' uterine artery for pre-eclampsia
Measuring hematocrit and platelets for following the course of pre-eclampsia
Fetal biophysical profile for fetal surveillance

Pregnancy problems

Acupressure for nausea and vomiting of pregnancy if simple measures are ineffective
Vitamin 136 for nausea and vomiting of pregnancy if simple measures are ineffective
Ginger for nausea and vomiting of' pregnancy
Acid-suppressing drugs for heartburn
Ritiosides for hemorrhoids
Rutosides for varicose veins
Exercise and education programs for backache
Increased salt intake for leg cramps
Oral magnesium for leg cramps
Progestogens for threatened miscarriage with a live fetus
Human chorionic gonadotrophin (HCG) for threatened miscarriage with a live fetus
Steroids for women with auto‑antibodies and recurrent miscarriage
Evacuation (of uterine contents) versus “wait and see” following spontaneous miscarriage
Medical versus surgical evacuation following spontaneous miscarriage
Hospitalization for women with pregnancy-induced hypertension
Bed-rest for women with pre-eclampsia
Antihypertensive drugs for mild to moderate hypertension
Antioxidant vitamins C and E to prevent pre-eclampsia
Magnesium sulphate for pre-eclampsia
Interventionist versus expectant management for severe early onset pre‑eclampsia
Plasma volume expansion for pre-eclampsia
Hospitalization and bed‑rest for impaired fetal growth
Abdominal decompression for impaired fetal growth
Betamimetics for impaired fetal growth
Oxygen treatment for impaired fetal growth
Hormone treatment for impaired fetal growth
Calcium channel blockers for impaired fetal growth
Plasma volume expanders for impaired fetal growth
Hospitalization and bed-rest for triplet and higher order pregnancy
Antiviral agents for women with a history of recurrent genital herpes
Prophylactic antibiotics for prelabor rupture of membranes at term or preterm
Postpartum prophylactic antibiotics after prelabor rupture of membranes
Bed‑rest to prevent preterm birth
Progestogens to prevent preterm birth
Calcium antagonists to stop preterm labor
Antibiotic treatment in preterm labor
Oxytocin antagonists to stop preterm labor
Sweeping of the membranes to prevent post‑term pregnancy 
Nipple stimulation to prevent post‑term pregnancy  

Childbirth

Pre-admission assessment to determine if labor is in the active phase 
Routine amnioscopy to detect meconium‑stained amniotic fluid in labor  
Routine artificial rupture of membranes to detect meconium-stained amniotic fluid in labor
Short periods of electronic fetal monitoring as a screening test on admission in labor   
Fetal stimulation tests for fetal assessment in labor   
Maternal oxygen administration for fetal distress in labor   
Institutional routines for repeating blood pressure measurements in labor  
Nipple stimulation to prevent postpartum haemorrhage   
Misoprostol in the third stage of labor to prevent postparturm hermorrhage    
Early versus, late clamping of the umbilical cord at birth   
Method for delivery of the placenta in the third stage of labor   
Injecting oxytocin in the umbilical vein in the third stage of labor    
Injecting oxytocin in the umbilical vein for retained placenta    

Problems during childbirth

Abdominal decompression to relieve pain in labor  
Immersion in water to relieve pain in labor   
Acupuncture to relieve pain in labor  
Acupuncture to relieve pain in labor  
Transcutancous electrical nerve stimulation to relieve pain in labor   
Intradermal injection of sterile water to relieve pain in labor  
Aromatherapy to relieve pain in labor   
Hypnosis to relieve pain in labor 
Continuous infusion versus intermittent top-ups for epidural analgesia    
Free mobility during labor to augment slow labor   
Early use of oxytocin to augment slow or prolonged labor   
"Active management" of labor  
Cervical vibration for slow or prolonged labor   
Histoacryl tissue adhesive for perineal skin repair    
Cesarean section for very preterm delivery   
Cesarean section for preterm breech delivery   
Immediate versus delayed clamping of' the umbilical cord of preterm infants  

Techniques of induction and operative delivery

Oxytocin by automatic-infusion systems versus "standard regimens" for induction of' labor  
Misoprostol orally or vaginally for induction of labor   
Use of hemostatic stapler for the uterine incision at cesarean section  
Single versus two layer closure of the uterine incision at cesarean section    
Systemic versus intraperitoneal prophylactic antibiotics at cesarean section

Care after childbirth

Tracheal suctioning for meconium in babies without respiratory depression 
Routine use of antiseptics on the umbilical cord stump  
Oral protcolytic enzymes, for breast engorgement in breastfeeding mothers  
Cabbage leaves for breast engorgement in breastfeeding mothers 
Dopamine agonists to improve milk supply in breastfeeding mothers  
Oxytocin nasal spray to improve milk supply in breastfeeding mothers 
Oral protcolytic enzymes for perineal pain postpartum  
Ultrasound and pulsed electromagnetic energy for perineal pain 
Rubber rings and similar devices to prevent pressure for perineal pain   
Cabergoline versus physical methods of suppressing lactation 

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