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, MRCOGEDITOR'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 5. Forms of Care Unlikely To Be Beneficial
Evidence against these forms of care are not as firmly established as for those in Table 6 "This evidence should encourage ... the abandonment of those that are useless or harmful."
Editor's Note: forms of care in table 6 are evaluated as "ineffective or harm demonstrated by clear evidence" thus the forms of care listed on this table are highly likely to be either ineffective or harmful. Forms of care "likely to be ineffective or harmful" should be formally acknowledged as such by the caregiver and "informed consent" should be obtain before they are employed.
In particular, the difference between ineffective but beneign treatment (for instance the advise to drink extra water to stop preterm labor) should be distinquished from those interventions that have great harm associated with them (such as scheduled Cesarean because the physician is trying to prevent possible should dystocia with all the well-known hazards of cesarean surgery / subsequent VBAC status.
Basic care
Reliance on expert opinion instead of on good evidence for decisions about care
Routinely involving doctors in the care of all women during pregnancy and childbirth
Routinely involving obstetricians in the care of all women during pregnancy and childbirth
Not involving obstetricians in the care of women with serious risk factors
Fragmentation of care during pregnancy and childbirth
Social support for high-risk women to prevent preterm birth
Antenatal breast or nipple care for women who plan to breastfeed
Advice to restrict sexual activity during pregnancy
Prohibition of all alcohol intake during pregnancy
Imposing dietary restrictions during pregnancy
Routine vitamin supplementation in late pregnancy in well-nourished populations
Routine hematinic supplementation in pregnancy in well-nourished populations
High-protein dietary supplementation
Restriction of salt intake to prevent pre-eclampsiaScreening and diagnosis
Routine use of ultrasound for fetal measurement in late pregnancy
Reliance on edema to screen for pre-eclampsia
Angiotensin-sensitivity test to screen for pre-eclampsia
Cold-pressor test to screen for pre-eclampsia
Roll-over test to screen for pre-eclampsia
Isometric exercise test to screen for pre-eclampsia
Measuring uric acid as a diagnostic test for pre-eclampsia
Screening for gestational diabetes‑
Routine glucose challenge test during pregnancy
Routine measurement of blood glucose during pregnancy
Insulin plus diet treatment for "gestational diabetes"
Diet treatment for gestational diabetes
Routine fetal movement counting to improve perinatal outcome
Routine use of Doppler ultrasound screening in all pregnancies
Measurement of placental proteins or hormones (including estriol and human placental lactogen)
Routine cervical assessment for prevention of preterm birthPregnancy problems
Calcium supplementation for leg cramps
Screening for, and treatment of, vagina] candidal colonization without symptoms
Screening for, and treatment of, vaginal trichomonas colonization without symptoms
Screening for, and treatment of, bacterial vaginosis without symptoms
Bed-rest for threatened miscarriage
Inotherapy for recurrent miscarriage
Antithrombotic agents to prevent pre-eclampsia
Reducing salt intake to prevent pre-eclampsia
Diazoxide for pre-eclampsia or hypertension in pregnancy
Ketanserin for severe hypertension in pregnancy
Diuretics for pregnanc-induced hypertension
High protein dietary supplementation for impaired fetal growth
Hospitalization and bed-rest for uncomplicated twin pregnancy
Cervical cerclage for multiple pregnancy
Prophylactic betamimetics for multiple pregnancy
Routine cesarean section for multiple pregnancy
Routine screening for mycoplasmas during pregnancy
Screening for toxoplasmosis during pregnancy
Treatment of group B streptococcus colonization during pregnancy
Cesarean section for non-active herpes simplex before or at the onset of labor
Amniotomy in HIV-infected women
Elective delivery before term in women with otherwise uncomplicated diabetes
Elective cesarean section for pregnant women with diabetes
Discouraging breastfeeding in women with diabetes
Vaginal or rectal examination when placenta previa is suspected
Postural techniques for turning breech into cephalic presentation
External cephalic version before term to avoid breech presentation at birth
X-ray pelvimetry to diagnose cephalopelvic disproportion
Computer tomographic pelvimetry to predict cephalopelvic disproportion
Cesarean section for macrosomia without a trial of labor to prevent shoulder dystocia
Induction of' labor to prevent cephalopelvic disproportion
Amniocentesis for prelabor rupture of the membranes preterm
Prophylactic tocolytics with prelabor rupture of the membranes preterm
Regular leucocyte counts for surveillance in prelabor rupture of the membranes
Home uterine activity monitoring for prevention of preterm birth
Magnesium sulphate to stop preterm labor
Betamimetics for preterm labor in women with heart disease or diabetes
Hydration to arrest preterm labor
Diazoxide to stop preterm labor
Adding thyrotrophin releasing hormone (TRH) to corticosteroids to promote fetal maturationChildbirth
Withholding food and drink from women in labor
Routine intravenous infusion in labor
Routine measurement of intrauterine pressure during oxytocin administration
Wearing face masks during labor or for vaginal examinations
Frequent scheduled vaginal examinations in labor
Routine directed pushing during the second stage of labor
Pushing by sustained bearing down during the second stage of labor
Breath holding during the second stage of labor
Early bearing down during the second stage of labor
Arbitrary limitations of the duration of the second stage of labor
"Ironing out" or massaging the perineum during the second stage of labor
Routine manual exploration of the uterus after vaginal birth
Injectable prostaglandins in the third stage of labor
Encouraging early suckling to prevent postpartum hemorrhageProblems during childbirth
Injecting saline into the umbilical vein for retained placenta
Biofeedback to relieve pain in labor
Sedative and tranqullizers to relieve pain in labor
Caudal block to relieve pain in labor
Paracervical block to relieve pain in labor
X-ray to diagnose cephalopelvic disproportion
Diagnosing cephalopelvic disproportion without ensuring adequate uterine contractions
Relaxin for slow or prolonged labor
Hyaluronidase for slow or prolonged labor
Vitamin K to the mother to prevent intraventricular hemorrhage in the very preterm infant
Phenobarbitone to the mother to prevent intraventricular hemorrhage in the very preterm infant
Delivery of a very preterm infant without adequate facilities to care for a very preterm baby
Elective forceps delivery for preterm birth
Routine use of episiotomy for preterm birth
Trial of labor after previous classical cesarean section
Routine manual exploration of the uterus to assess a previous cesarean section scarTechniques of induction and operative delivery
Relaxin for cervical ripening before induction labor
Nipple stimulation for cervical ripening before induction of labor
Extra-amniotic instead of other prostaglandin regimens for cervical ripening
Instrumental vaginal delivery to shorten the second stage of labor
Routine exteriorization of the uterus for repair of the uterine incision at cesarean sectionCare after childbirth
Silver nitrate to prevent eye infection in newborn babies
Elective tracheal intubation for very low birthweight infants who are not depressed
Routine suctioning of newborn babies
Medicated bathing of babies to reduce infection
Wearing hospital gowns in newborn nurseries
Restricting siblings visits to babies in hospital
Routine measurements of temperature, pulse, blood pressure, and fundal height postpartum
Limiting use of women's own non-prescription drugs postpartum in hospital
Administering non-prescription symptom-relieving drugs at regularly set intervals
Prohibition of oral contraceptives for diabetic women
Nipple shields for breastfeeding mothers
Switching breasts before babies spontaneously terminate the feed
Oxytocin c for breast engorgement in breastfeeding mothers
Antibiotics for localized breast engorgement (milk stasis)
Discontinuing breastfeeding for localized breast engorgement (milk stasis)
Combinations of local anesthetics and topical steroids for relief of perineal pain**Relying on these tables without referring to the rest of the book**
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