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 6. Forms of Care Likely to be Ineffective or Harmful 

Ineffective or harm demonstrated by clear evidence 

"This evidence should encourage ... the abandonment of those that are useless or harmful."

Editor's Note:  The status of these forms of care has been established as "ineffective or harmful" - a fact that should be formally acknowledged by the caregiver. Informed consent should be obtain before any of these forms of care are employed. 

In particular, the difference between ineffective but beneign treatment (such as nipple creams or ointments for breastfeeding mothers) should be distinguished from interventions that have great harm associated with them (such as scheduled Cesarean to prevent possible should dystocia, with all the well-known hazards of cesarean surgery / VBAC status resulting from this massive intervention). 

Basic care

Dietary restrictions to prevent pre-eclampsia    

Screening and diagnosis 

Contraction stress cardiotocography to improve perinatal outcome
Nipple simulation test cardiotocography to improve perinatal outcome 
Non-selective use of non-stress cardiotocography to improve perinatal outcome 

Pregnancy problems

Adrenocorticotrophic hormone (ACTH) for severe vomiting of pregnancy   
Saline cathartics for constipation   
Lubricant oils for Constipation
Diethylstilbestrol during pregnancy  
Elective delivery for prelabor rupture of the membranes preterm
Ethanol to stop preterm labor 
Progestogens to stop preterm labor   

Childbirth       

Routine enema in labor
Routine pubic shaving in preparation for childbirth   
Electronic fetal monitoring without access to fetal scalp sampling during labor     
Prophylactic intrapartum amnioinfusion for oligohydrammos
Rectal examinations to assess labor progress  
Requiring' a supine (flat on back) position in the second stage of labor
Routine use of the lithotomy position for the second stage of labor
Routine or liberal episiotomy for birth
Ergometrine instead of oxytocin prophylaxis in the third stage of' labor

Problems in childbirth

Glycero-impregnated catgut for repair of perineal trauma   

Techniques of induction and operative delivery

Oral prostaglandins for cervical ripening   
Estrogens for cervical ripening or for induction of labor   
Oxytocin for cervical ripening before induction of labor   

Care after childbirth

Sodium bicarbonate for asphyxiated babies    
Routine restriction of mother-infant contact     
Routine nursery care for babies in hospital 
Antenatal Hoffman's exercises for inverted or flat nipples   
Antenatal breast shells for inverted or flat nipples  
Limitation of suckling time during breastfeeding    
Nipple creams or ointments for breastfeeding mothers   
Routine supplements of water or formula for breastfed babies    
Samples of formula for breastfeeding mothers    
Encouraging fluid intake beyond demands of thirst for breastfeeding mothers    
Combined estrogen-progesterone oral contraceptives for breastfeeding mothers   
Test weighing of breastfed infants   
Witchhazel for relief of perineal pain  
Adding salt to bath water for treating perineal pain  
Antiseptic solutions added to bath water for perineal pain  
Hormones for relief of breast symptoms in non-breastfeeding mothers  
Bromocriptine for relief of breast symptoms in non-breastfeeding mothers

Continue on to "Synopsis of Second Stage Labor Manegement"

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