Evidence-based Birth Practices
1.) Evidence-based intrapartum care.
Hofmeyr GJ. Best Pract Res Clin Obstet Gynaecol. 2005 Feb;19(1):103-15. Epub 2004 Dec 13.
Routine care in normal labour may range from supportive care at home to intensive monitoring and multiple interventions in hospital. Good evidence of effectiveness is necessary to justify interventions in the normal process of labour. Inadequate evidence is available to support perineal shaving, routine enemas, starvation in labour and excluding the choice for home births. Evidence supports continuity of care led by midwives, companionship in labour, restricting the use of episiotomy, and active management of the third stage of labour, including routine use of 10 units of oxytocin. Both benefits and risks are associated with routine amniotomy, continuous electronic fetal heart rate monitoring, epidural analgesia, and oxytocin-ergometrine to prevent postpartum haemorrhage. More evidence is needed regarding the emotional consequences of labour interventions, home births, vaginal cleansing, opioid use, the partograph, second-stage labour techniques, misoprostol for primary prevention of postpartum haemorrhage, and strategies to promote evidence-based care in labour.
2.) Interventions during labor for reducing instrumental deliveries.
Schmitz, T et al. Source J Gynecol Obstet Biol Reprod (Paris). 2008 Dec;37 Suppl 8:S179-87.
Several interventions have been demonstrated, with high evidence levels (EL), to be associated with reduced instrumental deliveries and should therefore be undertaken during labor for increasing spontaneous vaginal deliveries. Using a partogram (EL1) and continuous support during labor and childbirth (EL1) lead to fewer operative vaginal deliveries. Systematic early amniotomy increases the frequency of fetal heart rate abnormalities (EL2) without decreasing the incidence of instrumental deliveries (EL1) and should thus be avoided. Early oxytocin in dysfunctional labor (EL2) and manual rotation of posterior and transverse presentations (EL3) may reduce operative vaginal deliveries. Even without epidural analgesia, any upright or lateral positions compared to supine or lithotomy positions do not reduce instrumental deliveries (EL2). Epidural analgesia alters significantly instrumental delivery rates and therefore patient management in the labor ward. Indeed, when used with high concentration of local anesthetic, epidural analgesia is associated with increased operative vaginal deliveries (EL1), at least in part because of increased posterior presentations (EL2). However, the effect of epidural analgesia on instrumental delivery rates closely depends from the type of anesthetic and concentrations used. This effect is reduced when low concentrations of local anesthetic are used in combination with fat-soluble morphinated agent (EL1). Finally, for nulliparous women with continuous epidural analgesia, unless irresistible urge to push or medical indication to shorten second stage of labor, delayed pushing is associated with reduced difficult instrumental deliveries (EL1). Fundal pressure maneuvers should be prohibited because of their inefficiency (EL2) and dangerousness (EL4).