Thursday, December 11, 2008

Evidence-based labor and delivery management

There is a new study providing guidance for management decisions during labor and birth. Published in the November 2008 issue of the American Journal of Obstetrics & Gynecology, the autheors performed searches on MEDLINE, PubMed and Cochrane.

Evidence based good quality data favors hospital births, delayed admission, support by doulas (stating it was one of the most effective interventions, training birth assistants in developing countries, perineal massage from 34 weeks on (fewer epis or tears), perineal massage & warm packs during second stage and upright position in second stage.

The data did not seem to favor home-like births (stated there were no trials available), enemas, shaving, routine vaginal irrigation, amniotomy (increased cesarean delivery), "hands on" method (described by Ritgen in 1855 and involving pressure on the infant's head on crowning results in more epis and 3rd degree lacerations) , fundal pressure (less satisfaction by mothers) and episiotomy ("should be avoided if at all possible"). An astounding statement is made about oxytocin (well, it is technically Pitocin) augmentation: "Oxytocin augmentation has not been studied as a primary isolated intervention for human labor. In fact, dozens of different doses have been used in different studies, without direct comparison in a randomized trial. Therefore,there is insufficient evidence to assess the effect of any specific regimen for oxytocin use in labor." There you have it, straight from the horses' mouth.

The data was not current or was insufficient on restriction of food/fluids during labor, the use of IUPCs, or aromatherapy.

I applaud any policy changes that come as a result of this study particularly about doulas, perineal massage, upright/gravity positive positioning for second stage, episiotomies etc. However, it is disturbing to see that the data they found did not favor home-like births especially since there is a myriad of data suggesting otherwise.

Perhaps we ARE making small steps. Perhaps things ARE changing. Perhaps one day we will see evidence-based maternity care. After all, we have been talking and writing about it for nearly five decades.

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