02 changing midwifery practices


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02 changing midwifery practices

  1. 1. Changing Obstetric Practices
  2. 2. Changing Established Practices <ul><li>Experience </li></ul><ul><li>Expert opinion </li></ul><ul><li>Evidence </li></ul><ul><li>Expectation </li></ul>Obstetric and Midwifery Practice
  3. 3. Evidence-Based Medicine <ul><li>Systematic, scientific and explicit use of current best evidence in making decisions about the care of individual patients </li></ul>Obstetric and Midwifery Practice
  4. 4. So What Has Changed? <ul><li>Developments in clinical research </li></ul><ul><li>Developments in methodology </li></ul><ul><ul><li>Meta-analysis </li></ul></ul><ul><ul><li>Recognition of bias in traditional reviews and expert opinions </li></ul></ul><ul><li>Explosion in medical literature </li></ul><ul><ul><li>Methodological papers </li></ul></ul><ul><ul><li>Electronic databases </li></ul></ul>Obstetric and Midwifery Practice
  5. 5. Beneficial Forms of Care <ul><li>Active management of the third stage of labor (decreases blood loss after childbirth) </li></ul><ul><li>Antibiotic treatment of asymptomatic bacteriuria in pregnancy (prevents pyelonephritis and reduces the incidence of preterm childbirth) </li></ul><ul><li>Antibiotic prophylaxis for women undergoing cesarean section (reduces postoperative infectious morbidity) </li></ul>Obstetric and Midwifery Practice
  6. 6. Beneficial Forms of Care (continued) <ul><li>External cephalic version at term (decreases incidence of breech delivery and reduces cesarean section rates) </li></ul><ul><li>Magnesium sulfate therapy for women with eclampsia (more effective than diazepam, etc.) for the control of convulsions </li></ul><ul><li>Population-based iodine supplementation in severely iodine deficient areas (prevents cretinism and infant deaths due to iodine deficiency) </li></ul><ul><li>Routine iron and folic acid supplementation (reduces the incidence of maternal anemia at childbirth or at 6 weeks postpartum) </li></ul>Obstetric and Midwifery Practice
  7. 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. 8. Forms of Care of Unknown Effectiveness <ul><li>Antibiotic prophylaxis for uncomplicated incomplete abortion to reduce postabortion complications </li></ul><ul><li>Anticonvulsant therapy to women with pre-eclampsia, the prevention of eclampsia </li></ul><ul><li>Routine symphysio-fundal height measurements during pregnancy to help detect IUGR </li></ul><ul><li>Routine topical antiseptic or antibiotic application to the umbilical cord to prevent sepsis and other illness in the neonate </li></ul>Obstetric and Midwifery Practice
  9. 9. Forms of Care Likely to Be Ineffective <ul><li>Use of antibiotics in preterm labor with intact membranes in order to prolong pregnancy and reduce preterm birth </li></ul><ul><li>Early amniotomy during labor to reduce cesarean section rates </li></ul><ul><li>External cephalic version before term to reduce incidence of breech delivery </li></ul><ul><li>Routine early pregnancy ultrasound to decrease perinatal mortality </li></ul>Obstetric and Midwifery Practice
  10. 10. Forms of Care Likely to Be Harmful <ul><li>Routine episiotomy (compared to restricted use of episiotomy) to prevent perineal/vaginal tears </li></ul><ul><li>Diazoxide for rapid lowering of blood pressure during pregnancy (associated with severe hypotension) </li></ul><ul><li>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 </li></ul><ul><li>Using diazepam or phenytoin to prevent further fits in women with eclampsia when magnesium sulfate is available </li></ul>Obstetric and Midwifery Practice
  11. 11. Antenatal Care Practices <ul><li>Practices not recommended </li></ul><ul><li>High risk approach </li></ul><ul><li>Routine antenatal measurement </li></ul><ul><ul><li>Maternal height to screen for cephalopelvic disproportion </li></ul></ul><ul><ul><li>Determining fetal position before 36 weeks </li></ul></ul><ul><ul><li>Testing for ankle edema to detect pre-eclampsia </li></ul></ul><ul><li>Bed rest for threatened abortion, uncomplicated twins, mild pre-eclampsia </li></ul><ul><li>External cephalic version before 37 weeks </li></ul><ul><li>Recommended practices </li></ul><ul><li>Birth preparedness counseling </li></ul><ul><li>Complication readiness planning </li></ul><ul><li>Iron and folate supplementation </li></ul><ul><li>Tetanus immunization </li></ul><ul><li>Reduced frequency of antenatal visits by skilled provider to maintain normal health and detect complications </li></ul><ul><li>In selected populations </li></ul><ul><ul><li>Iodine supplementation in severely iodine deficient areas </li></ul></ul><ul><ul><li>Intermittent presumptive treatment for malaria </li></ul></ul><ul><li>External cephalic version at term </li></ul>Obstetric and Midwifery Practice
  12. 12. Essential Care Series Obstetric and Midwifery Practice
  13. 13. Promoting a Culture of Quality Care <ul><li>Good quality care saves time and money </li></ul><ul><ul><li>Partograph </li></ul></ul><ul><ul><li>Manual vacuum aspiration/postabortion care </li></ul></ul><ul><ul><li>Active management of third stage </li></ul></ul><ul><li>Team responsibility: </li></ul><ul><ul><li>Providers </li></ul></ul><ul><ul><li>Supervisors </li></ul></ul><ul><ul><li>Community </li></ul></ul>Obstetric and Midwifery Practice
  14. 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. 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.
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