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 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-eclampsia     

Screening 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 birth       

Pregnancy 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 maturation   


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 hemorrhage    

Problems 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 scar  

Techniques 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 section 

Care 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**

Continue on to Table No. 6                        Return to College of Midwives.org Home Page