02 changing midwifery practices
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The document discusses changing practices in obstetrics and midwifery care based on evidence from clinical research and methodology developments. It provides examples of beneficial practices that are evidence-based, such as active management of the third stage of labor, as well as practices of unknown effectiveness or practices likely to be ineffective or harmful. The document advocates for promoting quality care using evidence-based guidelines and recommendations.
02 changing midwifery practices
- 2. Changing Established Practices Experience Expert opinion Evidence Expectation Obstetric and Midwifery Practice
- 3. Evidence-Based Medicine Systematic, scientific and explicit use of current best evidence in making decisions about the care of individual patients Obstetric and Midwifery Practice
- 4. So What Has Changed? Developments in clinical research Developments in methodology Meta-analysis Recognition of bias in traditional reviews and expert opinions Explosion in medical literature Methodological papers Electronic databases Obstetric and Midwifery Practice
- 5. Beneficial Forms of Care Active management of the third stage of labor (decreases blood loss after childbirth) Antibiotic treatment of asymptomatic bacteriuria in pregnancy (prevents pyelonephritis and reduces the incidence of preterm childbirth) Antibiotic prophylaxis for women undergoing cesarean section (reduces postoperative infectious morbidity) Obstetric and Midwifery Practice
- 6. Beneficial Forms of Care (continued) External cephalic version at term (decreases incidence of breech delivery and reduces cesarean section rates) Magnesium sulfate therapy for women with eclampsia (more effective than diazepam, etc.) for the control of convulsions Population-based iodine supplementation in severely iodine deficient areas (prevents cretinism and infant deaths due to iodine deficiency) Routine iron and folic acid supplementation (reduces the incidence of maternal anemia at childbirth or at 6 weeks postpartum) Obstetric and Midwifery Practice
- 7. Active vs. Physiological Management: Postpartum Hemorrhage Obstetric and Midwifery Practice Prendiville et al 1988, Rogers et al 1998. Active Management Physiologic Management OR and 95% CI Bristol Trial 50/846 (5.9%) 152/849 (17.9%) 3.13 (2.3 – 4.2) Hinchingbrooke Trial 51/748 (6.8%) 126/764 (16.5%) 2.42 (1.78 – 3.3)
- 8. Forms of Care of Unknown Effectiveness Antibiotic prophylaxis for uncomplicated incomplete abortion to reduce postabortion complications Anticonvulsant therapy to women with pre-eclampsia, the prevention of eclampsia Routine symphysio-fundal height measurements during pregnancy to help detect IUGR Routine topical antiseptic or antibiotic application to the umbilical cord to prevent sepsis and other illness in the neonate Obstetric and Midwifery Practice
- 9. Forms of Care Likely to Be Ineffective Use of antibiotics in preterm labor with intact membranes in order to prolong pregnancy and reduce preterm birth Early amniotomy during labor to reduce cesarean section rates External cephalic version before term to reduce incidence of breech delivery Routine early pregnancy ultrasound to decrease perinatal mortality Obstetric and Midwifery Practice
- 10. Forms of Care Likely to Be Harmful Routine episiotomy (compared to restricted use of episiotomy) to prevent perineal/vaginal tears Diazoxide for rapid lowering of blood pressure during pregnancy (associated with severe hypotension) Forceps extraction instead of vacuum extraction for assisted vaginal delivery when both are applicable. Forceps delivery is associated with increased incidence of maternal genital tract trauma Using diazepam or phenytoin to prevent further fits in women with eclampsia when magnesium sulfate is available Obstetric and Midwifery Practice
- 11. Antenatal Care Practices Practices not recommended High risk approach Routine antenatal measurement Maternal height to screen for cephalopelvic disproportion Determining fetal position before 36 weeks Testing for ankle edema to detect pre-eclampsia Bed rest for threatened abortion, uncomplicated twins, mild pre-eclampsia External cephalic version before 37 weeks Recommended practices Birth preparedness counseling Complication readiness planning Iron and folate supplementation Tetanus immunization Reduced frequency of antenatal visits by skilled provider to maintain normal health and detect complications In selected populations Iodine supplementation in severely iodine deficient areas Intermittent presumptive treatment for malaria External cephalic version at term Obstetric and Midwifery Practice
- 12. Essential Care Series Obstetric and Midwifery Practice
- 13. Promoting a Culture of Quality Care Good quality care saves time and money Partograph Manual vacuum aspiration/postabortion care Active management of third stage Team responsibility: Providers Supervisors Community Obstetric and Midwifery Practice
- 14. References Obstetric and Midwifery Practice AbouZahr C and T Wardlaw. 2001. Maternal Mortality in 1995: Estimates Developed by WHO, UNICEF, UNFPA . World Health Organization (WHO): Geneva. Duley L and D Henderson-Smart. 2000. Magnesium sulphate versus diazepam for eclampsia (Cochrane Review), in The Cochrane Library . Issue 4. Update Software: Oxford. Maine D. 1999. What's So Special about Maternal Mortality?, in Safe Motherhood Initiatives: Critical Issues . Berer M et al (eds). Blackwell Science Limited: London. Prendiville et al. 1988. The Bristol third stage trial: Active versus physiological management of the third stage of labor. BMJ 297: 1295–1300.
- 15. References (continued) Obstetric and Midwifery Practice Rogers J et al. 1998. Active versus expectant management of third stage of labour: The Hinchingbrooke randomised controlled trial. Lancet 351 (9104): 693–699. Sadik N. 1997. Reproductive health/family planning and the health of infants, girls and women. Indian J Pediatr 64(6): 739 – 744. WHO. 1999. Care in Normal Birth: A Practical Guide . Report of a Technical Working Group. WHO: Geneva. WHO 1998. Pospartum Care of the Mother and Newborn: A Practical Guide . Report of a Technical Working Group. WHO: Geneva.