MATERNAL AND EARLY CHILD HEALTH

Health Evidence Bulletins - Wales

Date of completion: 9.1.98

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available


12. Interventions in labour

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

12.1 INDUCTION of LABOUR
Avoiding unnecessary interventions should result in a reduction in complications of the intervention and less use of resources. The problem comes in deciding at which point the desires of the mother conflict with any risk to mother and child. Where an intervention may be indicated, the options must be fully discussed with the parents. Both discussion and procedure should be carried out by staff with appropriate expertisei.
i. Internal Review Group (Type V evidence - expert opinion. See Contributors)
The Statements The Evidence
12.1a. There is little controlled research on the indications for elective delivery (by induction or Caesarean Section) which range from the lifesaving to the trivial. The most important decision is whether induction is justified rather than how it may be achieved. The place of elective delivery in association with severe haemorrhage, severe pre-eclampsia, diabetes or preterm prelabour rupture of membranes are discussed in the appropriate section(i).
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
i. Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press, 1995. pp 297

(Type V evidence - expert opinion)

12.1b. Following intrauterine fetal death many women prefer induction and early delivery. Others may prefer to wait for the spontaneous onset of labour and there is little disadvantage other than a small risk of disturbance of blood coagulation (if labour is delayed for 4 weeks or more) and the risk of fetal maceration affecting postmortem findings (i).
(Health gain notation - 2 "likely to be beneficial")
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1119-1120
(Type V evidence - expert opinion. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 184-187)

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12.1c. Perinatal mortality is increased in post-term pregnancy and reduced by induction at or after 41 weeks (at 42 weeks: NNT = 500 inductions to prevent one death). There is, however, no clear evidence on optimum management. There is a need for a well planned randomised controlled trial dealing with management at either 41 or 42 weeks (following accurate ultrasonic dating of pregnancy, which reduces the chance of unnecessary intervention)(i,ii).
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
i. Managing post-term pregnancy. Drug and Therapeutics Bulletin 1997; 35(3): 17-18
(Type I evidence - systematic review);
ii. Grant JM. Induction of labour confers benefit in prolonged pregnancy British Journal of Obstetrics and Gynaecology. 1994; 101: 99-102
(Type I evidence - systematic review)
12.1d. There is no increase of either epidural usage or Caesarean section following induction for postmaturity(i).

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 781-790
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 180-181)
12.1e. The principle determinant of the progress of labour following induction is the state of the cervix at the time that induction is attempted (i).

(Health gain notation - 1" beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 988-1056
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 297-298)
12.1f. Preliminary ripening of an unfavourable cervix with prostaglandin (Dinoprostone) is effective with vaginal PGE2 gel being the method of choice(i,ii).

(Health gain notation - 1" beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1043-1053
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 298-302);
ii. British National Formulary March 1997. p.333
(Type V evidence - expert opinion)

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12.1g. Oxytocin combined with amniotomy remains widely used for induction but is associated with more painful contractions, a risk of intrauterine infection and fetal heart irregularities, although severe complications are rare (i,ii).
(Health gain notation - 4 " unknown")

caveat: If oxytocin is used (having excluded other causes for delay in labour) the dose should be the smallest possible, controlled in the most effective manner.

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1058-1063
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 305-306);
ii. Reichler A, Romem Y, Divon MY. Induction of labour. Current Opinion in Obstetrics and Gynecology. 1995; 7: 432-436
(Type I evidence - review of the literature including a meta-analysis)
12.1h. Prostaglandin has been shown to be more effective than oxytocin in the induction of labour with the option of retaining intact membranes (i).
(Health gain notation - 2 " likely to be beneficial")
caveat: Side effects include gastrointestinal problems and pyrexia.
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1080-1111
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 308-312)
12.1i. Where oxytocin is used, automated versus standard methods have been subjected to only limited review (i).

(Health gain notation - 4 " unknown")

Methods and risks of automated systems should be more thoroughly evaluated

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1063-1066
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 307)
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12.2 AUGMENTATION of LABOUR
Avoiding unnecessary interventions should result in a reduction in complications of the intervention and less use of resources. The problem comes in deciding at which point the desires of the mother conflict with any risk to mother and child. Where an intervention may be indicated, the options must be fully discussed with the parents. Both discussion and procedure should be carried out by staff with appropriate expertise(i). The precise time of the onset of labour (defined as the start of the latent phase) is often difficult to determine as is the differentiation between a prolonged latent phase and a 'false labour' These problems make any decision to augment labour more difficult (i).
i. Internal Review Group (Type V evidence - expert opinion. See Contributors);
ii. Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press, 1995. pp. 262-263 (Type V evidence - expert opinion)
The Statements The Evidence
12.2a. Augmentation of the first stage of labour, including amniotomy, is likely to be required less often if women are allowed to move about as they please, have continuity of care and friendly support(i).
(Health gain notation - 1 "beneficial")
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 952
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 262)
12.2b. A policy of early amniotomy in normal spontaneous labour reduces the length of labour (by an average of 1-2 hours) and is associated with less use of oxytocin but has no effect on the use of analgesia, forceps or Caesarean section (i,ii).

(Health gain notation - 2 "likely to be beneficial")

caveat: One more recent trial has suggested a minimal increase in the Caesarean section rateiii.

i. Brisson-Carroll G, Fraser W, Breart G, Krauss I, Thornton J. The effect of routine early amniotomy on spontaneous labour: a meta-analysis. Obstetrics and Gynecology.1996; 87:891-896
(Type I evidence - meta-analysis);
ii. Fraser WD, Krauss I, Brisson-Carrol G, Thornton J, Breart G. Amniotomy to shorten spontaneous labour. Cochrane Database of Systematic Reviews. Cochrane Library 1997 Issue 4.
(Type I evidence - systematic review);
iii. Johnson N, Lilford R, Guthrie K et al. Randomised trial comparing a policy of early with selective amniotomy in uncomplicated labour at term. British Journal of Obstetrics and Gynaecology. 1997; 104: 340-346
(Type II evidence - randomised controlled trial with some flaws of 1132 women)

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12.2c. There is no direct evidence that amniotomy to augment slow or prolonged labour is beneficial although given the evidence from controlled trials in normal labour and from data on induction, it is highly likely that amniotomy would enhance the progress of prolonged labour(i).
(Health gain notation - 2 "likely to be beneficial")
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 955-956
(Type V evidence - expert opinion. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 265)
12.2d. While there is no evidence that early amniotomy affects the mothers' view of management a review showed a reduction in the percentage of women reporting severe pain in labour (i).
(Health gain notation - 2 "likely to be beneficial")
i. Fraser WD, Krauss I, Brisson-Carrol G, Thornton J, Breart G. Amniotomy to shorthen spontaneous labour.  Cochrane Database of Systematic Reviews. Cochrane Library 1997, Issue 4.
(Type I evidence - systematic review)
12.2e. Active management of labour by the liberal use of both amniotomy and oxytocin may be instrumental in reducing Caesarean section rates(i,ii).
(Health gain notation - 4 "unknown")

caveat: The management was based on largely uncontrolled studies and the intervention in otherwise normal labours is unacceptable to many professionals and pregnant women

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 958
(Type I evidence - systematic review of 4 small trials. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 266-267);
ii. O’Driscoll K, Strong J, Minogue M. Active management of labour. British Medical Journal 1973; 3: 135-137
(Type IV evidence - prospective study of 1000 consecutive primigravidae)
12.2f. Despite little evidence of benefit intravenous oxytocin is widely used to expedite labour. Expert opinion would recommend its use in selected cases of inadequate uterine action(i).
(Health gain notation - 4 "unknown")
caveat: If oxytocin is used (having excluded other causes for delay in labour) the dose should be the smallest possible, controlled in the most effective manner
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 956-960
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 265-266)
12.2g. Management following spontaneous rupture of membranes is discussed in Chapter 13: ‘Premature labour’.  
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12.3 FORCEPS/VENTOUSE DELIVERY
Avoiding unnecessary interventions should result in a reduction in complications of the intervention and less use of resources. The problem comes in deciding at which point the desires of the mother conflict with any risk to mother and child. Where an intervention may be indicated, the options must be fully discussed with the parents. Both discussion and procedure should be carried out by staff with appropriate expertise.
Curtailing the length of the 2nd stage of labour should be based on evidence of fetal or maternal distress or lack of progress of labour. With epidural analgesia, where a prolonged 2nd stage is a recognised association, there is a dearth of trials of expectant as against assisted vaginal delivery(i).
i. Internal Review Group (Type V evidence - expert opinion. See Contributors)
The Statements The Evidence
12.3a. In most circumstances when operative vaginal delivery is required it is preferable to use vacuum extraction rather than forceps (i).
(Health gain notation - 1 "beneficial")
While the two procedures are largely interchangeable and both have known complications(ii), the use of forceps is associated with more maternal injury and requires more extensive analgesia.
 i. Johanson RB, Menon VJ. Vacuum extraction vs forceps delivery. Cochrane Database of Systematic Reviews. Cochrane Library. 1997 Issue 4.
(Type I evidence - systematic review)
ii.Drife JO. Choice and instrumental delivery. British Journal of Obstetrics and Gynaecology. 1996; 103: 608-611
(Type V evidence - expert commentary)
12.3b. There is no convincing evidence that elective forceps for preterm delivery confers any benefit (i).

(Health gain notation - 4 "unknown")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1283-1284
(Type III-IV evidence - non-randomised trials and observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 281)
12.3c. Direct comparison suggests that soft (Silastic) cups compared with traditional metal cups are less likely to achieve vaginal delivery although with less neonatal trauma (i).

(Health gain notation - 3 "trade-off between beneficial and adverse effects")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1221-1226
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 316);
ii. Kuit JA, Eppinga HG, Wallenburg HCS, Huikeshoven JM. A randomized comparison of vacuum extraction delivery with a rigid and a pliable cup. Obstetrics and Gynecology. 1993; 82(2): 280-284
(Type II evidence - randomised controlled trial of 100 women)
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12.4 MANAGEMENT of BREECH PRESENTATION  
Avoiding unnecessary interventions should result in a reduction in complications of the intervention and less use of resources. The problem comes in deciding at which point the desires of the mother conflict with any risk to mother and child. Where an intervention may be indicated, the options must be fully discussed with the parents(i). The prevalence of breech presentation decreases as pregnancy progresses from about 15% at 29 weeks to 3-4% at term. The risk associated with breech presentation are primarily those of the hazards of the breech delivery (if congenital anomaly and postural deformities are excluded)(ii).
i. Internal Review Group (Type V evidence - expert opinion. See Contributors);
ii. MIDIRS. Breech presentation - options for care. Informed choice for professionals. Leaflet No.9. MIDIRS, January 1997 (Type I evidence - systematic review)
The Statements The Evidence
12.4a. The value of Caesarean section for breech delivery depends primarily on gestation. The place of elective Caesarean section for breech presentation at term is unclear although 85% or more of breech presentations are now delivered by Caesarean section. Key factors are the experience of the attendant, absence of disproportion and maternal choice(i).
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
Expert recommendation is for Caesarean section where there is any risk of disproportion. The place of x-ray pelvimetry is not established(ii).
i. Hofmeyr GJ. Planned elective Caesarean section for term breech. Cochrane database of systematic reviews. Cochrane Library 1997, Issue 4.
(Type I evidence - systematic review);
ii. Internal Review Group (See Contributors)
(Type V evidence - expert opinion)
12.4b. The value of routine elective Caesarean section for preterm breech delivery is unknown. While observational studies have usually found higher survival after Caesarean section, all studies are affected by confusing variables. A trial designed to overcome these biases was discontinued because of difficulties in recruitment(i,ii).

(Health gain notation - 4 "unknown")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1280-1282
(Type III evidence - non-randomised trials. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 279)
ii. Penn ZJ, Steer PJ, Grant A. A multicentre randomised controlled trial comparing elective and selective caesarean section for the delivery of the preterm breech infant. British Journal of Obstetrics and Gynaecology. 1996; 103(7): 684-689
(Type II evidence - randomised controlled trial, discontinued)
12.4c. External cephalic version at term (after 36 weeks gestation), by a practitioner experienced in the technique, is good practice since it reduces the incidence of breech delivery of Caesarean section, provided fetal wellbeing is first confirmed and monitored (and anti-D given if appropriate) (i,ii).
(Health gain notation - 1 "beneficial")
Following version, 67% of babies will proceed to a cephalic birth compared to 22% who turn spontaneously before delivery (ii).
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 655-658
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 145);
ii. Zhang J, Bowes WA, Fortney JA. Efficacy of external cephalic version: a review. Obstetrics and Gynaecology. 1993; 82(2): 306-312.
(Type II evidence - review of clinical trials included in the Medline database)
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12.5 CAESAREAN SECTION  
Avoiding unnecessary interventions should result in a reduction in complications of the intervention and less use of resources. The problem comes in deciding at which point the desires of the mother conflict with any risk to mother and child. Where an intervention may be indicated, the options must be fully discussed with the parents(i).
There is considerable debate about the optimum rate for Caesarean Section. Inevitably unit rates will vary according to referral patterns and there is a need for population based denominator data. The four commonest indications for performing a Caesarean section are: breech presentation (see ‘management of breech presentation’ in this Chapter); failure to progress in labour (see ‘augmentation’ in this chapter); suspected fetal compromise(see Chapter 14); and a previous Caesarean section (see below)(ii,iii).
i. Internal Review Group (Type V evidence - expert opinion. See Contributors);
ii. National Childbirth Trust, Savage W, Churchill H, Francome C. Caesarean birth in Britain. London, Middlesex University Press, 1993 and 1994 supplement (Type V evidence - expert opinion);
iii. Patel N, Chamberlain G (eds.) The future of the maternity services. London: Royal College of Obstetricians and Gynaecologists Press, 1994 (Type V evidence - expert opinion)
The Statements The Evidence
12.5a. The use of Caesarean section for potential 'fetal compromise' is dependent on accurate
diagnosis of that condition. There is no strong evidence of improvement in outcome with extensive use of electronic fetal monitoring. Whether this is due to wrong hypothesis or currently less than optimum monitoring methods is unclear. There is need for controlled trials to determine both indications for and extent to which labour should be monitored (i).
(Health gain notation - 4 "unknown" - see also Chapter 14 ‘Suspected fetal compromise in pregnancy and labour)
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1186-1189

(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 214)

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12.5b. The use of Caesarean Section following a previous Caesarean section has been subject to much review but little controlled trial. Most expert opinion would support a woman’s wish for a trial of vaginal delivery provided the first Caesarean section had not been for gross disproportion.
There are also some women who choose delivery by Caesarean section if previous experience has been of a difficult labour or delivery (i,ii).

(Health gain notation - 4 "unknown")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1189, 1204-1215
(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 284-293);
ii. Roberts LJ, Beardsworth SA, Trew G. Labour following Caesarean section in the United Kingdom. British Journal of Obstetrics and Gynaecology. 1994; 101: 153-155
(Type IV evidence - study by questionnaire of 741 Consultants: 71.7% response rate)
12.5c. The following are good practice when carrying out Caesarean sectioni :
  • the use of low dose heparin to prevent thromboembolism in moderate or high risk patients;(i)
  • antibiotic prophylaxis (ii)
  • a transverse lower segment uterine incision (iii)

(Health gain notation - 1 "beneficial")

i. Report of the RCOG Working Party on prophylaxis (and management) against Thromboembolism in Gynaecology and Obstetrics. London: Royal College of Obstetricians and Gynaecologists, 1995
(Type V evidence - expert opinion)
ii. Department of Health and Others. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1991-1993. London: HMSO, 1996. p.83
(Type V evidence - expert opinion)
iii. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1239-1241
(Type V evidence - expert opinion)

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12.5d. The small amount of information available suggests that routine manual removal of the placenta at Caesarean section does more harm than good (i).
(Health gain notation - 5 "unlikely to be beneficial")
i. Enkin MW, Wilkinson C. Manual removal of placenta at Caesarean section. Cochrane Database of Systematic Reviews. Cochrane Library 1997, Issue 4 (Type I evidence - systematic review)
12.5e. The type of anaesthesia for Caesarean section is dictated mainly by availability and maternal choice, rarely for reasons of extreme haste or coagulation disorder. Regional anaesthesia has the advantage over general anaesthesia of avoiding aspiration of stomach contents and allowing earlier contact between mother and child (i).
(Health gain notation - 2 "likely to be beneficial")
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1235-1239
(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 319)
12.5f. When general anaesthesia is used for Caesarean section, cricoid pressure, restriction of food and drink and the use of antacids or H2-receptor antagonists (eg Ranitidine) are only partially effective in prevention of gastric aspiration(i).
(Health gain notation - 2 "likely to be beneficial")
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1237-1238
(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 320)
12.5g. On limited data, there are only minor differences between spinal and epidural block(i)i. The technique of combined spinal epidural offers the advantages of both methods.
(Health gain notation - 4 "unknown")
i. Expert anaesthetic opinion to the Internal Review Group (See Contributors)
(Type V evidence - expert opinion)

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12.5h. On the basis of good observational evidence, lateral tilt should always be used in Caesarean section to prevent vena caval compression (i) and intravenous pre-loading should also be carried out for the prevention of hypotension(ii).

(Health gain notation - 1 "beneficial")

i. Enkin MW, Wilkinson C. Effect of lateral tilt during Caesarean section. Cochrane Database of Systematic Reviews. Cochrane Library 1997, Issue 4. (Type I evidence - systematic review)
ii. Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press, 1995. p. 258 (Type V evidence - expert opinion)
12.5i. The value of routine exteriorization of the uterus versus intraperitoneal repair at Caesarean section is unknown (i).

(Health gain notation - 4 "unknown")

i. Enkin MW, Wilkinson C. Uterine exteriorization vs intraperitoneal repair at Caesarean section. Cochrane Database of Systematic Reviews. Cochrane Library 1997, Issue 4
(Type I evidence - systematic review)
12.5j. Preliminary evidence suggests that non-closure of the parietal peritoneum at Caesarean section should be considered, in that it saves 5-8 minutes of operating time with no significant difference in post operative morbidity and length of hospital stay(i,ii)i.

(Health gain notation - 4 "unknown")

i. Enkin MW, Wilkinson C. Peritoneal non-closure at Caesarean section. Cochrane Database of Systematic Reviews. Cochrane Library 1996, Issue 3. (Type I evidence - systematic review);
ii. deZerega GS, Duffy DM. Is peritoneal closure necessary? PACE review No. 96/02. London: Royal College of Obstetricians and Gynaecologists, 1996.
(Type II evidence - review of randomised controlled trials)
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12.6 EPISIOTOMY/PERINEAL TRAUMA  
Avoiding unnecessary interventions should result in a reduction in complications of the intervention and less use of resources. The problem comes in deciding at which point the desires of the mother conflict with any risk to mother and child. Where an intervention may be indicated, the options must be fully discussed with the parents(i).
i. Internal Review Group (Type V evidence - expert opinion. See Contributors);
The Statements The Evidence
12.6a. There is a trade-off between the beneficial and adverse effects of episiotomy(i)

(Health gain notation - 3)

and its routine use in spontaneous delivery should be strongly discouraged(i,ii,iii).

(Health gain notation - 6 "likely to be ineffective or harmful")

i. Carroli G, Belizan J, Stamp G. Episiotomy policies in vaginal births. Cochrane database of systematic reviews. Cochrane Library 1997 Issue 4.
(Type I evidence - systematic review);
ii. Thompson DJ. No episiotomy?! Australian and New Zealand Journal of Obstetrics and Gynaecology1987;27:18-20
(Type V evidence - expert opinion);
iii. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1136-1141
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 232-233)
12.6b. In assisted delivery by ventouse, and in the delivery of the premature infant there is no evidence of the benefit of routine episiotomy(i)i.

(Health gain notation - 5 "unlikely to be beneficial"

i. The T G. Is routine episiotomy beneficial in the low birth weight delivery? International Journal of Gynecology and Obstetrics 1990;31:135-40
(Type IV evidence - case note study of 439 singleton deliveries of babies of <2500g)
ii. Lobb MO, Duthie SJ, Cooke RWI. The influence of episiotomy on the neonatal survival and incidence of periventricular haemorrhage in very low birth weight infants. European Journal of Obstetrics and Gynecology. Reproductive Biology. 1986;22:17-21
(Type IV evidence - retrospective study of 94 babies of <1500g);
12.6c. In the delivery of mature breech babies, or in the use of Kielland's or other rotational forceps, the use of episiotomy is recommended(i,ii).
(Health gain notation -2"likely to be beneficial")
i. Internal Review Group (See Contributors)
(Type V evidence - expert opinion)

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12.6d. There have been numerous trials regarding optimum technique for repair of either episiotomy or a perineal tear but there is still the need for trials where operator skill, type of skin suture and degree of tightness of repair are controlled(i). i. Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press, 1995 pp. 269-273
12.6e. Absorbable instead of non-absorbable sutures are beneficial for skin repair. They are associated with less short term pain but more irritation sufficient to lead to removal in an important minority. The findings in favour of absorbable sutures may only reflect differences in tightness of suture rather than suture material(i).
(Health gain notation - 2 "likely to be beneficial")
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1173-1181
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 270-271)
12.6f. Where absorbable skin sutures are used the following are likely to be beneficial(i)i:
(Health gain notation - 2 "likely to be beneficial")
  • polyglycolic acid sutures instead of chromic catgut.
  • continuous subcuticular suture
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1171-1181
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 270-271)
12.6g. Glycerol impregnated catgut for repair of perineal trauma is likely to be harmful (i).

(Health gain notation - 6 "likely to be harmful")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1173-1181
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 270-271)
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12.7 ANALGESIA FOR PERINEAL PAIN  
Avoiding unnecessary interventions should result in a reduction in complications of the intervention and less use of resources. The problem comes in deciding at which point the desires of the mother conflict with any risk to mother and child. Where an intervention may be indicated, the options must be fully discussed with the parents. Much of the discomfort from perineal pain can be relieved by the use of sympathy and mild analgesia while avoiding constipation(i).
i. Internal Review Group
(Type V evidence - expert opinion. See Contributors);
The Statements The Evidence
12.7a. The use of crushed ice or warm water gives short-term symptomatic relief from perineal pain and discomfort(i)i:

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1347-1349
(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 364)
12.7b. The choice of oral analgesia is a balance between effectiveness and unwanted side effects. Paracetamol is probably the drug of choice for mild perineal pain with ibuprofen among the non-steoidal anti-inflammatories having few side-effects, with little excreted in breast milk(i,ii).

(Health gain notation - 3 "trade-off between beneficial and adverse effects)

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1355-1356
(Type V evidence - expert opinion. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 369);
ii. British National Formulary March 1997 p.414 (Type V evidence - expert opinion)
12.7c. There is a trade-off between beneficial and adverse effects for locally applied anaesthetics such as aqueous 5% lignocaine spray or lignocaine gel but their effect may last longer than ice or tap water(i).
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
caveat: Potential allergic reactions.
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 1351
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 366)

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12.7d. The value of the following treatments for reducing perineal pain is unknown(i).
(Health gain notation - 4 "unknown"):
  • Oral proteolytic enzymes;
  • Ultrasound and pulsed electromagnetic energy
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1351-1354
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 364-371)
12.7e. The following are unlikely to be beneficial for the treatment of perineal pain(i).
(Health gain notation - 5 "unlikely to be beneficial")
  • Witchhazel;
  • Adding salt to bathwater;
  • Antiseptic solutions added to bathwater
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1347-1350
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 364-371)
12.7f. Combinations of local anaesthetics and topical steroids for the relief of perineal pain are unlikely to be beneficial and may be harmful(i,ii).

(Health gain notation - 6 "likely to be ineffective or harmful")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 1351
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 364-371);
ii. British National Formulary March 1997 p.539 (Type V evidence - expert opinion)
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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk