Effective Care In Pregnancy and Childbirth: Table #2 ~ Forms of Care Likely to be Beneficial
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, DDU, FRCOG, FRANWOG,
Lelia Duley, MD, MSc(Epid), MRCOG, Ellen Hodnett, RN, PhD,
and G. Justus Hofmneyr, MBBCH, MRCOG
Third Edition ~ 2000
Table 2. Forms of Care Likely To Be Beneficial
The evidence in favor of these forms of care is strong,
although not established by randomized trials
Basic care
- Adequate access to care for all childbearing women
- Social support for childbearing women
- Financial Support for childbearing women in need
- Legislation on paid leave and income maintenance during maternity or parental leave
- Midwifery care for women with no serious risk factors
- Continuity of care for childbearing women
- Antenatal classes for women and their partners who want them
- Advice to avoid excessive alcohol consumption during pregnancy
- Avoidance of’ heavy physical work during pregnancy
Screening and diagnosis
- Ultrasound to resolve questions about fetal size, structure, or position
- Selective use of ultrasound to assess amniotic fluid volume
- Selective use of ultrasound to estimate gestational Age in first and early second trimester
- Ultrasound to determine whether the embryo is alive in threatened miscarriage
- Ultrasound to confirm suspected multiple pregnancy
- Ultrasound for placental location in suspected placenta previa
- Second trimester amniocentesis to identify chromosomal abnormalities in pregnancies at risk
- Transabominal instead of transcervical chorionic villus sampling
- Genetic counseling before prenatal diagnosis
- Clinical history to assess risk of pre~eclampsia
- Regular monitoring of blood pressure during pregnancy
- Testing for protcinuria during pregnancy
- Uric acid levels for following the course of pre-eclanipsia
- Fundal height measurements during pregnancy
Pregnancy problems
- Ultrasound to facilitate intrauterine interventions
- Antacids for heartburn of’ pregnancy if simple measures are ineffective
- Bulking agents for constipation if simple measures are ineffective
- Local metronidazole for symptomatic trichomonal vaginitis after the first trimester
- Antibiotics for symptomatic bacterial vagmosis
- Antiplatelet agents to prevent preeclampsia
- Antihypertensive agents to control serious hypertension in pregnancy
- Calcium to prevent pre‑eclampsia, for women at high risk or with low calcium in diet
- Balanced protein / energy supplementation for impaired fetal growth
- Ultrasound surveillance of fetal growth in multiple pregnancies
- Screening all pregnant women for blood group isoimmunization
- Anti-D immunization Rh‑negative women after any uterine bleeding, intrauterine procedure, or abdominal trauma during pregnancy
- Intra-uterine transfusion for a severely affected isoimmunization fetus
- Advice to not breastfeed for HIV‑infected women to prevent transmission to baby
- Routine screening for, and treatment of, syphilis in pregnancy
- Rubella vaccination of seronegative women postpartum
- Screening for. and treatment of’ chlamydlia in high prevalence populations
- Cesarean section for active herpes (with visible lesion) in labor with intact membranes
- Pre-pregnancy counselling for‑ women with diabetes
- Specialist care for‑ pregnant women with diabetes
- Home instead of hospital glucose monitoring for pregnant women with diabetes
- Ultrasound surveillance of’ fetal growth for pregnant women with diabetes
- Allowing pregnancy to continue to term in otherwise uncomplicated diabetic pregnancies
- Careful attention to insulin requirements postpartum
- Encouraging diabetic women to breastfeed
- Checking for clotting disorders with severe placental abruption
- Vaginal instead of’ cesarean delivery for placental abruption in the absence of fetal distress
- Vaginal instead of cesarean birth for a dead fetus after placental abruption
- Repeat ultrasound scanning of a low‑lying placenta in late pregnancy
- Delaying planned cesarean section for placenta previa until term
- Cesarean section for placenta previa covering any portion of the cervical os
- Ultrasound examination for vagina] bleeding of undetermined origin
- External cephalic version for transverse or oblique lie at term
- Tocolysis for external cephalic version of breech, particularly if unsuccessful otherwise
- External cephalic version for breech in early labor if’ the membranes are intact
- Corticosteroid administration after prelabor rupture of the membranes preterm
- Vaginal culture after prelabor rupture of the membranes preterm
- Antibiotics for prelabor rupture of the membranes with suspected intrauterine infection
- Not stopping spontaneous labor after prelabor rupture of the membranes preterm
- Elective delivery for prelabor rupture of the membranes preterm with signs of infection
- Amnioinfusion for fetal distress thought to be due to oligoliydraminios in labor
- Betamimetic tocolysis to allow effective preparation for preterm birth
- Short-term indomethacin to stop preterm labor
- Offering induction of labor as an option after fetal death
- Prostaglandin or prostaglandin analogy for induction of labor after fetal death
Childbirth
- Respecting women’s choice of companions during labor and birth
- Respecting women’s choice of place of birth
- Presence of a companion on admission to hospital
- Giving women as much information as they desire
- Freedom of’ movement and choice of position in labor
- Change of mother’s position for fetal distress in labor
- Intravenous betamimetics for fetal distress in labor to buy time
- Respecting women’s choice of position for the second stage of labor and giving birth
- Guarding the perineum versus watchful waiting during birth
- Intramyometrial prostaglandins for severe postpartum hemorrhage
Problems during childbirth
- Regular top-ups of epidural analgesia instead of top-ups on maternal demand
- Maternal movement and position changes to relieve pain in labor
- Counter-pressure to relieve pain in labor
- Superficial heat or cold to relieve pain in labor
- Touch and massage to relieve pain in labor
- Attention focusing and distraction to relieve pain in labor
- Music and audio-analglesia to relieve pain in labor
- Epidural instead of narcotic analgesia for preterm labor and birth
- Amniotomy to augment slow or prolonged labor
- Continuous subcuticular suture for perinea skin repair
- Primary rather than delayed repair of episiotomy breakdown
- Delivery of a very preterm baby in a center with adequate perinatal facilities
- Presence of a pediatrician at a very preterm birth
- Trial of’ labor after previous lower segment cesarean section
- Trial of labor after more than one previous lower segment cesarean section
- Use of oxytocic agents when indicated for labor after a previous cesarean section
- Use of epidural analgesia in labor. when needed after previous cesarean section
Techniques of induction and operative delivery
- Assessing the state of the cervix before induction of labor
- Transverse instead of vertical skin incision for cesarean section
- Low-dose heparin with cesarean section to prevent thrombo-embolism
- Transverse lower segment uterine incision or cesarean section
Care after birth
- Keeping newborn babies warm
- Prophylactic vitamin K to the baby to prevent hemorrhagic disease of the newborn
- Nasopharyngeal suctioning of infants who have passed meconium before birth
- Presence of someone skilled in neonatal resuscitation at birth of all infants likely to be at risk
- Oxygen for resuscitation of distressed newborn infants
- Cardiac massage for infants born with absent heart beat
- Naloxone for infants with respiratory depression due to narcotic administration before birth
- Encouraging early mother‑infant contact
- Allowing mothers access to their own supply of symptom‑relieving drugs in hospital
- Consistent advice to new mothers
- Offering choice in the length of’ hospital stay after childbirth
- Telephone service of advice and information after women go home from hospital after birth
- Psychological support for women depressed after childbirth
- Encouraging early breastfeeding when mother and baby are ready
- Skilled help with first breastfeed
- Flexibility in breastfeeding practices
- Antibiotics for infectious mastitis in breastfeeding women
- Breast binding and fluid restriction for suppression of lactation
- Support and care programs for bereaved parents
- Encouraging parental contact with a dying or dead baby
- Providing parents with prompt, accurate information about a severely ill baby
- Encouraging autopsy for a dead baby and discussing the results with the parents
- Help with funeral arrangements for a dead baby
- Self-help groups for bereaved parent
