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Association of Radical Midwives

In Midwifery Matters, Issue No. 81, Summer 1999

EVIDENCE BASED MIDWIFERY PRACTICE GUIDELINES - Part of a process?

Jane Munro

I HAVE RECENTLY been involved in developing, implementing and evaluating a set of evidence based guidelines for midwifery led care in labour, in support of our unit moving towards such care. It is now a year since the introduction of these guidelines and the process of review and update is about to take place. I therefore thought it would be interesting to share with the readers of Midwifery Matters some of what those guidelines looked like and ask for comment. As I have said, there was a programme of implementation to support the change inherent in some of the recommended practice and I shall be writing about this long process shortly, in another context. I would simply like to present here some of the guidelines which caused most excitement and contention. As I am still very much immersed in this document and its practical application, I am very interested in comments from those outside our unit as to what it all looks like and on the quality of what it contains. I also hoped that some of the work shown here might be useful to others.

I will briefly describe the methodology of the literature search, so that you can understand some of the context and allow for some of the weaknesses, many of which appear glaringly to me now!

Methodology

The guidelines presented here are from a literature search carried out in limited time by one researcher.

The methodology for the search was:

• looking at the electronic databases (COCHRANE, MEDLINE, CINAHL, MIDIRS).
• hand searching key journals and looking for frequently cited literature.
• local midwife researchers were consulted about what they considered important references as the project developed it was peer reviewed by another midwife researcher
• Literature covering three perspectives was sought:
• the prospective randomised controlled trial.
• midwives' research and reviews
• women's views.

In line with the directive of midwifery led care, particular weight was given to finding women's views, despite this being such an under-researched area.

The subjects to be investigated were determined during group discussion with midwives in the unit. A pocket-sized set of the guidelines was drawn up, the design and format were very much influenced by one produced by the Leicester Royal Infirmary NHS Trust. The guidelines were given personally to each midwife working in the unit and copies of a larger document, consisting of reviews from which the recommendations were drawn, were distributed around the wards. I have to tell you here, that very few midwives have looked at this larger document. There were twelve sets of guidelines in the book. I am just presenting just five of them here. These were the ones received with most enthusiasm or resistance, as they recommended practice that, for most midwives, was different from the traditional practice in our unit.

1. Vaginal Examinations

• Many women find vaginal examinations painful and sometimes traumatic (Menage 1996); sensitivity to this issue, privacy and continuity of midwife will make them less so.
• Vaginal examinations measure of the progress of labour imprecisely when performed by different examiners (Clement 1994). Where possible therefore, they should be carried out by the same midwife.
• Examinations should not be routine or prescriptive but carried out only where there is clinical necessity and after discussion with the woman.
• Midwives should give weight to their other skills in determining the progress of labour (McKay and Roberts 1990).
• "Repeated vaginal examinations are an invasive intervention of as yet unproven value" (Enkin 1992).

2.Fetal Heart Rate Monitoring

• The decision about fetal monitoring should be made antenatally in joint discussion between the woman and her midwife (Thacker et al 1997) when all options have been offered and preferences considered (DoH, 1993). Midwives should be able to offer the information contained in the Informed Choice Leaflets (MIDlRS 1996)
• If this discussion has not taken place by the time that woman goes into labour, it should form part of the initial birth planning.
• Because of the high level of intervention associated with electronic fetal monitoring, intermittent auscultation with a hand held instrument is the recommended method for normal labours (RCOG 1993). This consists of measuring the fetal heart at the following times:

• All values should be recorded (RCOG 1993)
• The hand-held Doppler is considered to be more accurate than any type of stethoscope (MIDIRS 1996), it can be more comfortable for the woman and does not restrain movement or position.
• Every midwife must take personal responsibility for being trained and regularly updated in all methods of fetal monitoring (RCOG 1993, MIDIRS 1996). The interpretation of fetal heart rate patterns and appropriate response should be informed by good unit guidelines (CESDI, 1994-1995).
• The admission trace has not been properly evaluated. It should not be used routinely until such time as reliable research has shown it to be of benefit (MIDIRS, 1996).

3. Rupturing Membranes

Practice Recommendations

• Amniotomy is not part of normal physiological labour (RCM 1997). It should be reserved for women with abnormal labour progress (Fraser et al 1997).
• The intervention can cause an increase in pain which makes labour unmanageable (Fraser 1993; NCT 1989; Inch 1985). Any intervention that interferes with a woman's ability to cope in labour can have long term implications for her own wellbeing and her relationship with her baby ( Robson and Kumar 1980; Oakley 1979).
• Amniotomy is associated with a reduction in labour duration of between 60 and 120 minutes. However, one intervention often leads to another (Donald, 1979), in this case the most obvious is the need for analgesia.
• The midwife's role in explaining and obtaining agreement to any intervention is paramount. Discussion about amniotomy should form part of the birth plan and not take place just before or during a vaginal examination.

4. Second Stage of Labour

Practice Recommendations

• There is no good evidence to justify arbitrary time limits on the length of the second stage. While maternal and fetal conditions are satisfactory and there is clear progress with the descent of the presenting part, there are no grounds for intervention (Paterson, Saunders and Wadsworth 1992; Watson 1994). Saunders et al (1992), however, highlight an association between maternal morbidity and a second stage of three hours. This increase in risk needs to be weighed against the risk of instrumental delivery.
• There is no evidence to suggest that women need to be taught when and how to push (Sleep, 1990) and the practice of sustained breath holding in directed pushing may be harmful (Thomson, 1993). Women should therefore be given confidence in following their own urge to push.
• The recumbent position tends to lengthen labour (MIDIRS, 1996) to reduce the incidence of spontaneous birth and increase the incidence of abnormal fetal heart rate patterns (Enkin et al 1995). Women should be encouraged to combine spontaneous pushing with upright positions.

Care of the perineum

• There is no evidence to support the practices of guarding, `ironing out' or massaging the perineum (Enkin et al, 1995). Traditional practices such as flexion and extension of the head, have recently been challenged (Myrfield, Brook and Creedy, 1997).
• The Hands On Technique and The Hands Poised Technique are currently being evaluated (McCandlish 1996). The use of either should therefore reflect the midwife's skill and confidence.*
• There is no evidence of short term or long term maternal benefit to support the use of liberal episiotomy (Carroli et al, 1997). Like any surgical procedure, episiotomy carries a number of risks (Enkin et al, 1995). Women report increased pain and discomfort after episiotomy that interferes with the experience of early motherhood (Kitzinger and Walters, 1981). The practice should therefore be restricted mainly to fetal indications (Sleep, 1990).

5. Third Stage of Labour

Practice recommendations

• Midwives should feel competent in both active and physiological management:

• Active management is superior to physiological in terms of blood loss (Prendiville et al, 1997). Adverse effects of active management are increase in nausea, vomiting, headache and hypertension (Prendiville et al, 1997). There is also a higher incidence of manual removal of the placenta and after pains requiring IM analgesia (Begley, 1990).
• Oxytocin (10 units) alone is as effective as the oxytocin plus ergometrine (Syntometrine) and is associated with a significantly lower rate of unpleasant maternal side effects (Soriano et al, 1996).
• Physiological management is appropriate only for women at low risk of postpartum haemorrhage and who have had a normal physiological labour. Any circumstances which may inhibit the uterus to function normally such as Syn-tocinon, large doses of narcotics, epidurals and early clamping and cutting of the cord should be seen as contraindications to a physiological third stage (Inch, 1988).
• If physiological management is attempted but intervention is needed, then management must proceed actively. If the placenta is retained after one hour, active management should be considered (Prendiville et al, 1988).
• Midwives need to help women consider the normal phys-iology of the third stage when they are making their choice about management. Physiological management is the logical ending to a normal physiological labour (RCM 1997).

Conclusion

I am very interested in any discussion about the details here or about what people might, overall, consider the value of such documents to be. I am very excited about the movement towards evidence based practice, as I think it has given us an opportunity to defend and define the parameters of midwifery, and works as a great resource with which to challenge practices which interfere with normal birth. However, I am also aware of the dangers of producing yet another model of prescriptive practice. Any comments on this debate could be sent either to Midwifery Matters or to me at: 219 Cemetery Road Sheffield S11 8FQ (Email: stephen.may2@virgin.net)

Responses

From Dr John Stevenson

REFERENCES

Begley C (1990). `A comparison of `active' and `physiological' management of the third stage of labour Midwifery, 6, 3-17.

Clement S (1994). `Unwanted vaginal examinations', British Journal of Midwifery, 2, 8, 368-370.

Chalmers I, Enkin M, Keirse M (eds) (1989). Effective Care in Pregnancy and Childbirth, Oxford University Press, Oxford.

DoH, Expert Maternity Group (1993). Changing Childbirth, HMSO, London.

Donald I (1979). Practical Obstetric Problems, 5th edition, Lloyd Luke, London.

Enkin M (1992). Commentary: `Do I do that? Do I really do that? Like that?' Birth, 19, 19-20.

Enkin M, Keirse M J N C, Renfrew M and Neilson J (1995). A Guide to Effective Care in Pregnancy and Childbirth, Oxford University Press, Oxford.

Fraser W D, Krauss I, Brisson-Carrol G, Thornton J, Breart G (1997). `Amniotomy to shorten spontaneous labour', in Neilson J P, Crowther C A, Hodnett E D, Hofmeyr G J, Keirse M J N C, (eds) Pregnancy and Childbirth Module of the Cochrane Database of Systematic Reviews, (updated June 1997). Available in the Cochrane Library (database on disk and CDROM) The Cochrane Collaboration, issue 3. Update Software, Oxford.

Fraser W F, (1993). `Methodological issues in assessing the active management of labour', Birth, 20, 155-156.

Gyte G (1994). `Evaluation of the meta-analyses on the effects on both mother and baby of the various components of `active' management of the third stage of labour', Midwifery, 10,183-199.

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Inch S (1985). Birth Rights, Hutchinson, London.

Inch S (1988). `Physiology of third stage of labour', Midwives Chronicle and Nursing Notes.

McKay S and Roberts J (1990). `Obstetrics by ear - Maternal and caregivers' perceptions of the meaning of maternal sounds during second stage of labour', Journal of Nurse Midwifery, 35, 5, 266-273.

Menage J (1993). `Women's perception of obstetric and gynaecological examinations', (correspondence) British Medical Joumal, 306, 1127-1128.

Menage J (1996). `Post-traumatic stress disorder following obstetric/gynaecological procedures', British Joumal of Midwifery, 4, 10, 532-533.

MIDIRS (1996). Positions in labour and delivery, Informed Choice for Professionals leaflet.

MIDIRS(1996). Fetal Heart Rate Monitoring in Labour in MIDIRS and the NHS Centre for Reviews and Dissemination, Informed Choice for Professionals leaflet.

Myrfield K, Brook S, Creedy D (1997). `Reducing perineal trauma: implications of flexion and extension of the fetal head during birth', Midwifery, 13, 197-201.

National Childbirth Trust (1989). Rupture of the Membranes in Labour, National Childbirth Trust, London.

Oakley, A (1979). From Here to Maternity, Penguin, London.

Olah K and Gee H (1996). `The active mismanagement of labour', British Joumal of Obstetrics and Gynaecology, 103, 729-731.

Prendiville W J, Elbourne D, Mcdonald S. (1997). `Active versus expectant management of the third stage of labour', in Neilson J P, Crowther C A, Hodnett E D, Hofmeyr G J, Keirse M J N C (eds) Pregnancy and Childbirth Module of the Cochrane Database of Systematic Reviews (updated June 1997) available in the Cochrane library (database on disk and CDROM). The Cochrane Collaboration; issue 3. Update Software, Oxford.

Prendiville W J, Harding J E, Elbourne D R, Stirrat G M (1988). `The Bristol third stage trial: active versus physiological management of third stage labour', British Medical Joumal, 297, 1295-1300.

RCOG 26th Study Group (1993). `Intrapartum Fetal Surveillance', in Spencer J A D, Ward R H T, (eds) Intrapartum Fetal Surveillance, (pp 387-393), RCOG Press, London.

Robson K M and Kumar R (1980). `Delayed onset of maternal affection after childbirth', British Joumal of Psychiatry, 136, 247-353.

Rosen M G and Peisner D B (1987). `Effect of amniotic membrane rupture on length of labor', Obstetrics and Gynecology, 70, 4, 604-607.

Royal College of Midwives (1997). Debating Midwifery: Normality in Midwifery, Royal College of Midwives, London.

Soriano D, Dulitzki M, Schiff E, Barkai G, Mashiach S, Seidman D S (1996). `A prospective cohort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage', British Journal of Obstetrics and Gynaecology, vol pp

Steele R (1995). `Midwifery care in the first stage of labour', in Alexander J, Levy V, Roch S (eds) Aspects of Midwifery Practice: A research based approach, Macmillan, Basingstoke.

Thacker S B, Stroup DF, Peterson H B (1997). `Continuous fetal heart monitoring during labour', in: Neilson J P, Crowther C A, Hodnett E D, Hofmeyr G J, Keirse M J N C (eds) Pregnancy and Childbirth Module of the Cochrane Database of Systematic Reviews, (updated June 1997). Available in the Cochrane Library (database on disk and CDROM) The Cochrane Collaboration; issue 3. Update Software, Oxford.

Thomson A (1994). `Research into some aspects of care in labour', in: Robinson S and Thomson A (eds) Midwives, Research and Childbirth, (vol 3) (293-300), Chapman & Hall, London.

Trent Region CESDI Report 1994-1995.

Watson V (1994). `The duration of the second stage of labour', Modern Midwife, 4, 6, 21-24.

Ed. IK 14^th June 1999

AH updated 16 September 1999

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