Intervention rates in maternity practices vary considerably across Canadian provinces and territories. This paper compares the use of interventions and practices in labor and birth as reported by a random sample of Canadian women who participated in the Maternity Experiences Survey with guidelines for care recommended by the Cochrane systematic reviews of evidence-based practice and Canadian and international guidelines for practice.
The Cochrane Collaboration is the largest organization in the world engaged in the production and maintenance of systematic reviews. It is the most comprehensive, single source of reliable evidence about the effects of health care (1). In Canada, the Society of Obstetricians and Gynaecologists’ national clinical practice guidelines, based on the foremost scientific knowledge in obstetrics and gynecology, advance these practices and promote informed choices for women (2). From time to time, the federal government convenes a group of key stakeholders and produces national guidelines, which are widely circulated to all professionals and hospitals providing maternity services (3). Internationally, the World Health Organization undertakes an international process of review and prepares programs and documents such as the Integrated Management of Pregnancy and Childbirth program (4), based on similar standards.
We examined the rates of use of electronic fetal monitoring, attempts to start or induce labor or to speed it up, epidural anesthesia, episiotomy, shaving, enemas, pushing on the top of the abdomen, forceps and vacuum use, and position adopted for birth as reported by women surveyed in the Maternity Experiences Survey who had vaginal or attempted vaginal births in relation to these guidelines.
Table 1 summarizes the evidence emerging from a systematic review of randomized controlled trials of these interventions and recommendations about their use by the existing Society of Obstetricians and Gynaecologists of Canada, Health Canada, and World Health Organization–Regional Office for Europe.
|Intervention||Cochrane Review||Society of Obstetricians and Gynaecologists of Canada||Health Canada||World Health Organization Regional Office for Europe|
|EFM on admission/continuous||Except for a reduction in neonatal seizures meta-analysis (5) of randomized control trials evaluating EFM vs intermittent auscultation has not found any benefit for the newborn in terms of mortality or substantive long-term morbidity such as cerebral palsy. An important concern is an increase in interventions such as cesarean section, operative vaginal birth, and the use of anesthesia. No evidence is available supporting use of the labor admission test for normal labor (6)||Continuous EFM is the least preferred method of fetal monitoring (7). Move away from routine EFM for normal, uncomplicated labor (7). Intermittent auscultation of the fetal heart is the method of choice (7)||Intermittent auscultation usually with doptone methods is preferred. Continuous EFM is the least preferred method of fetal monitoring (3)||Use a fetal stethoscope for monitoring the fetal heart in preference to all other methods (8)|
|Starting or speeding up labor||Labor induction has been associated with increased risk of operative vaginal deliveries, abnormal fetal heart rate patterns, uterine hyperstimulation, uterine rupture, and cesarean section (9). A systematic review by Gulmezoglu et al (10) found that a policy of induction at 41 completed weeks or beyond was associated with fewer perinatal deaths and no difference in the risk of cesarean section||Approaches to the management of slow progress in labor include: continuous professional support, upright postures in the first stage, cervical ripening before induction of labor, the use of low-dose epidurals and oxytocin and amniotomy||Induction is often associated with a cascade of problems and interventions. The decision to induce labor should only be made when the risk associated with continuing pregnancy is greater than the risk associated with induction (7)||An induction of labor can be dangerous for a mother or baby, or both. An induction of labor must have an indication (11)|
|Epidural||A meta-analysis comparing epidural anesthesia with opiates indicated that epidural anesthesia offered better pain relief than nonepidural anesthesia, but women having epidurals were more likely to have instrumental vaginal births, a longer second stage, augmentation, very low blood pressure, fever, and difficulty voiding (12)||Although the safety of epidural anesthesia has been well documented, it is important to recognize the effect it has on slowing the progress of labor. Women requesting epidurals should be partners in a thorough discussion of the procedure, its risks and benefits, and the expected outcome (7)||Epidural anesthesia should not be used as a first-line approach to pain relief during vaginal birth but should be reserved for use when other measures prove ineffective (3)||Avoid the use of epidural anesthesia as a routine method of pain management (8)|
|Episiotomy||A systematic review revealed no beneficial outcomes and a potential for harm from routine vs restricted use of episiotomy (13)||Episiotomy should be used only to expedite delivery in the case of fetal compromise or maternal distress and lack of progress (7)||The practice of routine episiotomy should be abandoned (3). Both routine mediolateral and median episiotomies are associated with increased maternal morbidity without demonstrable maternal or fetal benefit (3)||Do not routinely perform an episiotomy (8).|
|Shaving||A systematic review indicates that there is no evidence to support the claim that perineal shaving reduces the risk of infection in case of tears or episiotomies (14)||No evidence is available to support the routine use of shave preparations (7)||Shaving should be abandoned (3)||Abandon the use of shaving (8)|
|Enema||No evidence is available to indicate that enemas lead to reduction in length of labor or reduced infection rates (15)||No evidence to support the routine use of enemas is available (7)||Enemas should be abandoned (3)||Abandon the use of enemas (8)|
|Pushing on abdomen||—||—||—||Absence of augmentation including absence of external pressure on the fundus during labor is regarded as evidence of effective management of normal labor (16)|
|Forceps/vacuum||Vacuum extraction reduces maternal morbidity and use of forceps reduces cephalhematoma and retinal hemorrhages (17,18)|
|Supine position for birth||Second-stage bearing down is more efficient in upright positions (19). The supine position is a form of care that is ineffective or harmful (20)||Clear evidence is available that adopting an upright or semisitting position for delivery is advantageous from fetal and maternal points of view (7). Strapping women’s legs in restrictive stirrups in the supine position is to be avoided (7)||Upright positions are associated with less pain and less narcotic and epidural use but more labial lacerations and postpartum blood loss. Women should choose their most comfortable position for delivery (3)||An upright position of the women’s choice is preferred (8). Avoid the use of a supine position and particularly the use of stirrups (8). An upright position is included in the Bologna Score (16) of appropriate management of normal labor|