EVIDENCE BASED PRACTICE IN OBSTETRICS

Introduction

Over the past decades, nurses have been part of a movement that reflects

perhaps more changes than any two decades combined. Only in mid -1990s did it

become clear that producing new knowledge was not enough .To affected better patient

outcomes, new knowledge must be transformed in to clinically useful forms.

Effective maternity care with least optimal for childbearing women and newborns.

High quality systemic reviews of the best available research provide the most

trustworthy knowledge about beneficial and harmful effects of health interventions.

Practices that are disproved or appropriate for mothers and babies in limited

circumstances are in wide use, and beneficial practices are underused.

The early origins of evidence based nursing

Nursing research is associated with the founder of nursing; Florence Nightingale.

Her belief was that through observation, a nurse could determine the best care for a

patient. Evidence based nursing can date back to the 1800s if one considers

Nightingale’s first steps forward. Her “Notes on Nursing” was first published in 1859 in

England and in 1860 in America (Evidence-Based Nursing, 2012). At that time,

Nightingale was spreading the word of the importance of sanitation in nursing care. Her

observations indicated that patients healed faster if the materials used to treat them

were clean and if physicians washed their hands.

"What you want are facts, not opinions.

Definitions

Evidence based medicine

The integration of best research evidence with clinical expertise and patient value

- sackett et al

Evidence Based Practice

Conscientious, explicit, and judicious use of theory-driven, research-based

information in making decisions about care delivery to individuals or a group of patients,

and in consideration of individual needs and preferences (Ingersoll, 2000).

Research utilization

This process involved critical analysis and evaluation of research findings and

then determining how they fit into clinical practice.

Quality improvement

Process that utilizes a system to monitor and evaluate the quality and

appropriateness of care based on evidence-based practice and research. Identify the

evidence-based practice and quality improvement as 2 core competencies.

Why is EBP important to nursing practice?

 It keeps practice current and relevant practices

 It increases confidence in decision making

 Policies and procedures are current and include the latest research

 Integration of EBP into nursing practice is essential for high-quality patient care

and achievement.

Levels Evidence Based Practice

• I Evidence - Systematic reviews, meta-analysis RCTs, EB clinical practice

guidelines based on RCTs

• II Evidence - One well designed RCT

• III Evidence - CTs without randomization

• IV Evidence - Well-designed case control or cohort studies

• V Evidence - Systematic reviews of descriptive or qualitative studies

• VI Evidence - Single descriptive or qualitative study

• VII Evidence – Opinions of authorities, reports of experts

Meta-Analysis: A systematic review that uses quantitative methods to summarize the

results.

Systematic Review: Authors have systematically searched for, appraised, and

summarized all of the medical literature for a specific topic.

Critically Appraised Topic: Authors evaluate and synthesize multiple research

studies.
Critically Appraised Articles: Authors evaluate and synopsize individual research

studies.

Randomized Controlled Trials: Include a randomized group of patients in an

experimental group and a control group. These groups are followed up for the

variables/outcomes of interest.

Cohort Study: Identifies two groups (cohorts) of patients, one which did receive the

exposure of interest, and one which did not.

Case-Control Study: Identifies patients who have the outcome of interest (cases) and

control patients without the same outcome.

Background Information/Expert Opinion: Handbooks, encyclopedias, and textbooks

often provide a good foundation or introduction and often include generalized

information about a condition. 

Animal Research/Lab Studies: This is where ideas and laboratory research takes

place. Ideas turn into therapies and diagnostic tools, which then are tested with lab

models and animals.

Five steps of Evidence Based Practices

• Ask the burning clinical question (Picot format)

P – Who or what is your patient or population group?

I - what is your intervention or indicator?

C – What is your comparison or control?

O – What outcome are you looking for?

T - Time

• Search for and collect the most relevant and best evidence
• Critically appraise the evidence

• Integrate all evidence with one’s clinical expertise, patient preferences and

values in making a practice decision or change

• Evaluate the practice decision or change

• (Disseminate)

Models of Evidence Based Practice

 ACE star model

 Lowa model of Evidence Based Practice to promote quality care

 Stetler model

a) ACE Star model

• This model is having 5 major stages of knowledge in a relative sequence as

research evidence is moved through several cycles, combined with other

knowledge and integrated into practice

• Converting knowledge into practice

• Provides a framework for systematically putting evidence-based practice

processes .

b) Lowa model of Evidence Based Practice to promote quality care

• Nurses have a strong commitment to EBP and can benefit by the direction

provided by the LOWA MODEL to expand their practice that is based on

research.

• This EBP model was initially developed by Titler and colleagues in 1994 and

revised in 2001.
• In a health care agency, there are triggers that initiate the need for change, which

is best made based on research evidence. These triggers can be problem

focused and evolve from risk management data, process improvement data,

benchmarking data, financial data, and clinical problems.

c) Stetler model

• This is a model of research utilization to facilitate Evidence Based Practice

( EBP)

• The model formulated a series of critical thinking and decision making steps

designed to facilitate safe and effective use of research findings.

Information sources

ACPonline (formerly PIER (Physician Information & Education Resource),

designed by the American College of Physician's for the rapid diagnosis and treatment

of diseases which provide you with information of a series of succinct guidance

statements and practice recommendations,

DYNAMed: clinically-organized summaries for nearly 3,000 topics; updated daily and

monitors the content of over 500 medical journals.

UpToDate: designed to provide physicians access to current clinical information. It

addresses specific clinical issues in the form of topic reviews. Covers primarily internal

medicine.

HSTAT: (Health Services/Technology Assessment) is a free, Web-based resource of

full-text documents that provide health information and support health care.

Joanna Briggs Institute. EBP Database:  Collection of evidence-based publications

from the JBI.

• The Cochrane Library

• NHS evidence

• Trip Database

• The virtual health library

• Health system evidence

• Pub Med health

Evidence Based Maternity Care

Evidence – based maternity care uses the best available research on the safety

and effectiveness of specific practices to help guide maternity care decisions and to

facilitate optimal outcomes in mothers and newborns..

Overused maternity practices

Many maternity practices that were originally developed to address specific

problems have come to used liberally and even routinely in healthy women. This over

use exposes many mothers and babies to risk of harm with marginal medical benefits or

none at all which is not recommended by the evidence.

The following practices, include

1) Labour induction:

Labor induction is the use of drugs and/or techniques to cause labor to start, as

opposed to waiting for labor to begin on its own through a complex interplay of maternal

and fetal factors. Induction for convenience that is not supported by evidence except the

following condition:

 Caregiver’s concern that the baby was overdue

 Mother’s desire to end the pregnancy

 Caregiver’s concern about the size of the baby

Less common reasons included

 Concern about infection with ruptured (broken) membranes 

 Concern about baby’s health

 Mother’s interest in controlling timing

 Mother’s interest in giving birth with a specific provider

Instead expose mothers and babies to induction agents and techniques and

shorter gestation without sound evidence that the health benefits outweigh harms?

Several examples and other possible impacts suggested that:

 Synthetic oxytocin, which is widely used to induce labor, interferes with the

functioning of a woman’s own oxytocin receptors.

 This may adversely affect other important functions of a mother’s natural oxytocin

release, such as reducing postpartum hemorrhage and contributing to

attachment and the establishment of breastfeeding.

2) Epidural Analgesia

Epidural analgesia, a regional form of pain medication administered into the epidural

space of the spinal cord, is the most effective form of pain relief commonly available for

use during labor.

The evidence strongly saying that using epidurals for reducing labour pain alter

the physiology of labor and increase risk for numerous adverse effects on maternal

and fetal health. That effects are includes:

 Immobility

 voiding difficulty

 sedation

 fever

 hypotension

 itching

 longer length of the pushing phase of labor

 Serious perineal tears.

Fetal/newborn risks include

 Rapid fetal heart rate

 Hyper bilirubinemia

 increased risk for sepsis and administration of antibiotics 

Women with an epidural are also more likely to experience bladder catheterization,

synthetic oxytocin, medication for hypotension, vacuum extraction or forceps, and

episiotomy. The evidence-based framework suggests that optimal outcomes in mothers

and babies and best value for using safer, less invasive methods for comfort and labor

pain relief.

3) Cesarean Section

Delivery by cesarean section is a clearly beneficial and even life-saving

procedure for mother and/or baby in selected circumstances. The evidence

supporting cesarean section following absolute conditions only:

 Prolapsed umbilical cord
 Placenta previa

 Placental abruption

 Persistent transverse lie 

When babies are undergone cesarean section instead of normal delivery :

 They fail to benefit from physiologic changes that precede spontaneous onset of

labor to help clear fluid from their lungs.

 Passage through the vagina increases the newborn intestines will be colonized

with beneficial bacteria.

 Estimating fetal gestational age are imprecise, planned cesareans 

may inadvertently lead to iatrogenic prematurity.

 Delivery by elective cesarean is consistently associated with increased risk of

respiratory morbidity in near-term newborns and full-term newborns.

The effects of cesarean section on mother and newborn includes:

Short – term harms to mothers with cesarean section:

 Maternal death 

 Emergency hysterectomy 

 Blood clots and stroke 

 Surgical injury 

 Longer hospitalization and more likely rehospitalization 

 Infection 

 Poor birth experience 

 Less early contact with babies 

 Intense and prolonged postpartum pain 

 Poor overall functioning 

4) Continuous Electronic Fetal Monitoring

It is important during labor to periodically monitor the fetal heart rate as a way to

check on the baby’s well-being. Continuous EFM did not reduce of perinatal death or

cerebral palsy, but increased the cesarean section and vaginal birth assisted with

vacuum extraction or forceps.

Other adverse effects of continuous EFM were impairment of mobility, increased

discomfort, and focus on the machine rather than the woman.

5) Rapture of Membranes

Breaking the membranes containing the fetus, amniotic fluid, and umbilical cord with

a tool similar to a crochet hook (amniotomy) is a common procedure for inducing labor

and after labor has begun.

The researchers found a possible increase in cesarean section with this procedure

and identified concerns about adverse effects on the fetal heart rate and the serious

problem of umbilical cord prolapse and compression.

6) Episiotomy

Episiotomy is a cut made to enlarge the vaginal opening just before birth. The routine or

liberal use of this practice does not confer benefits and rather exposes women to risk of

harm.

Depending on circumstances, the evidence found that routine episiotomy was

associated with an increase risk in the following conditions:

 Perineal injury
 Need for stitches

 Experience of pain and tenderness

 Healing period

 Likelihood of leaking stool or gas

 Pain with intercourse.

Underused intervention

They are some effective and noninvasive forms of care with least or no harm to

the childbearing women and newborns. The effective interventions could offer many

benefits to a childbearing women which is not using frequently by health care

personals are discussed below:

a) Prenatal multivitamins for preventing congenital anomalies

Prenatal folic acid and multivitamins were protective against congenital

anomalies. Use of the multivitamin supplements was consistently protective against

neural tube defects, cardiovascular defects, and limb defects.

b) Smoking cessation interventions for pregnant women

Short- and longer-term hazards of smoking in pregnancy are well established.

Smoking cessation programs for pregnant women have been shown to reduce

smoking and prematurity and to increase birth weight.

Interventions to reducing smoking in pregnant women:

 Advice from caregivers

 Group sessions

 Behavioral therapy with self-help manuals.

pregnant participants.

c) Ginger for nausea and vomiting in pregnancy

A growing body of evidence finds ginger (Zingiber officinale) to be helpful for nausea

and vomiting in pregnancy, and no side effects have been identified to date.

d) External version to turn breech babies at end of pregnancy:

Using hands-to-belly maneuvers to try to turn babies to a head-first position (external

version) at the end of pregnancy succeeds in many instances and reduces the

cesarean section.

e) Continuous labour support:

Presence of a labor companion who has an exclusive focus on providing

emotional in comparison with usual care. A friend, family member, or doula can assist

women in this way. Benefits include reduced l of the following:

 Less medications

 Cesarean section

 Assisted delivery with vacuum extraction or forceps

 Dissatisfaction with the childbirth experience.

No adverse effects were identified with the continual presence of a labor

companion

f) Measures to relieve pain, bring comfort, and/or promote progress during

labour
Mothers gave birth without the use of pain medications. Many women find

several noninvasive methods of pain relief helpful during labor, including immersion in

water, hypnosis, acupuncture, and intradermal sterile water injections for low back pain.

Initial evidence also suggests that a hands-and-knees position helps reduce pain

among women with “posterior” babies (forward-facing position that is less common,

more painful, and associated with more difficult labor)

g) Delayed and spontaneous pushing:

Very frequently, hospital staff coach women to push their babies out and direct them

in forceful, sustained pushing as soon as a cervical dilation of ten centimeters. Women

with epidural analgesia who delay pushing for some period of time (from up to one hour

to up to three hours) have the opportunity for spontaneous descent of the baby,

spontaneous rotation of the baby’s head through the pelvic passage.

h) Nonsupine positions for giving birth:

Most women who give birth vaginally in lie on their backs while pushing their babies

out. However, women without epidurals, upright and side- lying positions are associated

with less severe pain for mothers, less use of episiotomy, less use of vacuum extraction

or forceps, fewer heartbeat abnormalities in babies, and a shorter pushing phase  of

labor.

i) Delayed cord clamping in full-term and preterm newborns:

Immediate cord clamping is standard procedure in hospitals at present. However, in

term newborns, delaying cord clamping for a minimum of two minutes was associated

with improved hematologic status, iron status, and iron stores, as well as reduced
anemia, with benefits measured from two to six months after birth. Delayed clamping

also offers benefits to preterm babies.

j) Early skin – to – skin contact:

Skin-to-skin contact between mothers and babies right after birth and during the first

twenty- four hours postpartum, in comparison with usual hospital care, was associated

with improved breastfeeding status and duration, improved newborn

temperature regulation, reduced newborn crying, and more affectionate maternal

behaviors, with some evidence of long-term effects, and no evidence of harm.

k) Interventions to reduce newborn procedure pain:

Blood sampling and other routine and less common procedures can be painful to

newborns. Infants who were breastfed during these procedures, in comparison with

swaddling, pacifiers, and other measures, had better scores on several measures of

pain experience. Babies with blood drawn from veins similarly appeared to experience

less pain than babies with blood drawn by heel lance.

l) Psychosocial and psychological interventions for postpartum depression:

Best current evidence suggests that both psychosocial interventions (such as peer

support and nondirective counseling) and psychological interventions (such as cognitive

behavioral therapy and interpersonal psychotherapy) reduce the depressive symptoms

among new mothers with depression.

m) Vaginal birth after cesarean ( VABC ):

For much of the 20th century, most people believed that a woman who had

previously undergone a cesarean delivery (previously termed a C-section) would require

vaginal delivery after Cesarean Section. It includes:

 Shorter length of hospital stay and postpartum recovery (in most cases)

 Fewer complications, such as postpartum fever, wound or uterine infection,

thromboembolism (blood clots in the leg or lung), need for blood transfusion

 Fewer neonatal breathing problems

Risk of vaginal birth after cesarean section:

 Risk of failed trial of labor after cesarean (TOLAC) without a vaginal birth after

cesarean (VBAC) resulting in repeat cesarean delivery (RCD) in about 20 to 40

percent of women who attempt VBAC.

 Risk of rupture of uterus resulting in an emergency cesarean delivery.

Barriers to the Evidence Based Practice

• Overwhelming patient workloads

• Misperceptions about EBP and research

• Lack of time and resources to search for and appraise evidence

• Organizational constraints – lack of support

• Peer pressure to continue with practices that are stepped in tradition – “we’ve

always done it this way and we are not changing now”.

Overcome to those barriers

 Devote 15 minutes a day to reading evidence related to a clinical problem

 Search for already established clinical evidences

this list for discussions with colleagues

 When disagreement arise about protocol, find an article that supports your

position and share it with others.

 Link measurement of quality indicators to EBP

 Attend a continuing education offering on EBP

 Consult with advance practice nurse

 Learn to use bookmark website that are sources of clinical guidelines

 Write a proposal for funds to support the care

 Write down questions about your clinical problems and share them with nurse

researchers.

Conclusion

Maternity care decisions should be guided by the best available evidence and the

effective care with least harm, rather than by unsupported beliefs about appropriate

care, convenience, or other extrinsic factor. This power point teaching will explain the

importance and use of Evidence Based Practice for midwifes and the skills that

midwifes need to incorporate it into their practice. These gaps between the actual

practice and lessons from the best evidence will improve the practices and outcomes of

maternity care for women and babies and to obtain greater value.