J Perinat Educ. 2007 Winter; 16(Suppl 1): 32S–64S. The Coalition for Improving Maternity Services: Step 6 of the Ten Steps of Mother-Friendly Care addresses two issues: 1) the routine use of interventions (shaving, enemas, intravenous drips, withholding food and fluids, early rupture of membranes, and continuous
electronic fetal monitoring; and 2) the optimal rates of induction, episiotomy, cesareans, and vaginal births after cesarean. Rationales for compliance and systematic reviews are presented. Keywords: labor preparation, perineal shaving, labor, enema, labor, intravenous drip, adverse effects, intravenous drip, labor, intravenous nutrition, labor, obstetric procedures, adverse effects, NPO, labor, nutrition, labor, oral intake, labor, amniotomy artificial rupture of
membranes, electronic fetal monitoring, intrapartum cardiotocography, elective induction, labor induction, labor induced, spontaneous labor rates, rates of induction, induction and adverse effects, maternal satisfaction and induction, episiotomy, adverse effects, episiotomy, median, episiotomy, mediolateral, episiotomy rate, cesarean, cesarean rate, cesarean, adverse effects, vaginal birth, adverse effects, obstetric birth, adverse effects, pelvic-floor dysfunction, urinary incontinence, anal
incontinence, vaginal birth after cesarean (VBAC), VBAC rates, elective repeat cesarean, VBAC and induction of labor Step 6: Does not routinely employ practices and procedures that are unsupported by scientific evidence, including, but not limited to, the following: shaving [for vaginal birth]; enemas; intravenous drips (IVs); withholding nourishment or water; early rupture of membranes; and [continuous] electronic fetal monitoring [intrapartum cardiotocography]. Limits interventions, as follows: induction rate of 10% or less; episiotomy rate of 20% or less, with a goal of 5% or less; total cesarean rate of
10% or less in community hospitals, and 15% or less in tertiary hospitals; and vaginal birth after cesarean (VBAC) rate of 60% or more, with a goal of 75% or more. Step 6: Does not routinely employ practices and procedures that are unsupported by scientific evidence, including, but not limited to, the following: shaving [for vaginal birth] Shaving for Vaginal Birth
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Step 6: Does not routinely employ practices and procedures that are unsupported by scientific evidence, including, but not limited to, the following:
Enemas
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Step 6: Does not routinely employ practices and procedures that are unsupported by scientific evidence, including, but not limited to, the following:
Intravenous Drips
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Step 6: Does not routinely employ practices and procedures that are unsupported by scientific evidence, including, but not limited to, the following:
Oral Intake
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Step 6: Does not routinely employ practices and procedures that are unsupported by scientific evidence, including, but not limited to, the following:
Amniotomy
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Step 6: Does not routinely employ practices and procedures that are unsupported by scientific evidence, including, but not limited to, the following:
Continuous Electronic Fetal Monitoring
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Step 6: Limits interventions, as follows:
For the purposes of this document, induced labors are defined as labors started by artificial means of whatever kind. They are associated with an increased incidence of adverse outcomes compared with labors of spontaneous onset; however, it is possible that, in some instances, this increase may result from medical complications that may have led to the use of induction. In order to determine adverse effects related to the procedure itself, this section is confined to studies of elective induction—that is, induction for nonmedical reasons such as convenience. Induction of Labor
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Step 6: Limits interventions, as follows:
The RCTs of liberal versus restricted use of episiotomy testify to the difficulties of changing entrenched practice. In most trials, sizeable percentages of women in the “restrict episiotomy” arm were given episiotomies. Of the seven RCTs conducted to date, the episiotomy rate in the restrictive arm was 10% or less in only two and exceeded 30% in four (Hartmann, 2005). Proper data analysis of an RCT demands that investigators keep participants with their assigned group (“intent to treat”) regardless of actual treatment. To do otherwise would defeat random allotment, the principal advantage of this study design. In trials where treatment depends little on clinician judgment, few protocol violations are likely to occur, and crossover between groups is rarely an issue. However, where this is not the case and where clinician opinion favors the intervention—as is the case with many clinicians and episiotomy—high crossover rates can occur, causing a serious problem with data interpretation. By commingling the treatments, a high degree of protocol violation decreases the power of the study to detect differences between groups. This can make it falsely appear that no difference exists between groups when, in fact, it does. For example, because many women in the “restrictive use of episiotomy” arm of the sole RCT of median episiotomy had episiotomies, an “intent to treat” analysis showed no difference between groups in the incidence of anal sphincter tears (Klein, 1992). In fact, an episiotomy preceded all but one of the 53 anal injuries. Clinician preference for performing episiotomy causes a secondary problem in establishing a goal episiotomy rate based on data from the RCTs. The 20% rate established in the Coalition for Improving Maternity Services's Mother-Friendly Childbirth Initiative came from the best available evidence at the time: the Cochrane systematic review. However, as can be seen below, much lower rates than this can be supported as upper limitations for performing this procedure. Episiotomy
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Step 6: Limits interventions, as follows:
Current arguments articulated in the March 2006 National Institutes of Health (NIH) State-of-the-Science Conference Statement against setting a goal cesarean rate rest on four premises (NIH, 2006):
As this portion of Step 6 makes clear, cesarean section significantly increases the risk of a long list of adverse outcomes in mothers and babies, some of them catastrophic. It is true that planned cesarean surgery reduces the risk of certain harms compared with unplanned surgery. Nonetheless, the woman still emerges with a uterine scar and substantial possibility of dense surgical adhesions, both of which can have long-term consequences for her future health and reproduction. As can be seen below, cesarean section offers little protection from urinary or anal incontinence in the childbearing years and none at all in older women. Even the minimal short-term benefits are reported in studies that did not take into account the effects of modifiable elements of conventional obstetric management in injuring and weakening the pelvic floor. Chief among these are both median and mediolateral episiotomy and vaginal instrumental delivery (MCA, 2004). Other flaws that make it difficult to determine the true excess risk, if any, of vaginal birth are (MCA, 2004):
Moreover, urinary incontinence can often be abated or cured by conservative measures, such as losing weight or engaging in a program of pelvic floor exercises (Groutz, 2004; MCA, 2004). Finally, the oft-cited 10–15% maximum cesarean rate first recommended in 1985 by the World Health Organization (WHO) after an international consensus conference was neither opinion-based nor artificially derived (WHO, 1985). In fact, it was founded upon the statistic that “[c]ountries with some of the lowest perinatal mortality rates in the world have caesarean section rates of less than 10%” (WHO, 1985, p. 437). As can be seen below as well, that maximum has since been confirmed by numerous studies demonstrating that cesarean rates can be 15% or less in unselected populations without any deleterious effect on maternal or perinatal outcomes. Indeed, women and babies are likely to be healthier because they have not been unnecessarily exposed to the harms of cesarean delivery. Cesarean
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Step 6: Limits interventions, as follows:
Several decades of research into the question of planned VBAC versus elective repeat cesarean have produced hundreds of studies involving tens of thousands of women and a large body of knowledge on the subject. Nonetheless, many of the prominent studies are beset by serious problems that make it difficult to gauge the true comparative risks of planned vaginal birth versus elective repeat cesarean—problems that, moreover, tend to bias the picture in favor of repeat cesarean. The problems include the following:
When the long-term view is taken, it becomes clear that maximizing VBAC rates among women who choose VBAC and minimizing the risk of scar rupture during planned vaginal births will produce the best maternal-child health and reproductive outcomes. This is because those goals reduce exposure to the potential harms of repeated cesarean surgeries, of VBAC labors, and to the excess morbidity attendant on unplanned cesarean sections. It also bears pointing out that the policies and procedures espoused in the Ten Steps of Mother-Friendly Care will best promote safer VBAC and higher VBAC rates. In furtherance of those twin goals, clinicians have the obligation to provide women with complete, unbiased, and evidence-based information on the comparative benefits and harms of planned vaginal birth versus planned repeat cesarean so that they may make an informed decision. Nonetheless, regardless of the care provider's opinion of the relative safety of the two options in any individual case, the choice rests solely in the hands of the pregnant woman, unless she chooses to cede her right to her care provider. VBAC denial, or instituting restrictions that amount to VBAC denial, constitutes coercion in that it forces women to consent to major surgery in order to obtain care. The American College of Obstetricians and Gynecologists (2000) guarantees women freedom from this violation of their rights, as the following passage makes clear:
Note that, although cesarean section is a “procedure” (something that requires a care provider to take positive action for it to occur), planned vaginal birth is not because labor is the inevitable end of pregnancy. Note too that the right to refuse is not predicated on the woman having what the clinician considers an acceptable reason. Some have claimed that the weaknesses of the studies cannot be overcome without a randomized controlled trial, and, indeed, one is currently underway in Australia.a As will be seen below, however, those weaknesses do not prevent arriving at an adequate understanding of the comparative benefits and harms of planned vaginal birth versus planned cesarean surgery, an understanding that is, moreover, unlikely to be improved by such a trial for the reasons listed above. VBAC
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FootnotesFor a description and discussion of the methods used to determine the evidence basis of the Ten Steps of Mother-Friendly Care, see this issue's “Methods” article by Henci Goer on pages 5S–9S. For more information on the Coalition for Improving Maternity Services (CIMS) and copies of the Mother-Friendly Childbirth Initiative and accompanying Ten Steps of Mother-Friendly Care, log on to the organization's Web site (www.motherfriendly.org) or call CIMS toll-free at 888-282-2467. Members of the CIMS Expert Work Group were:
Childbirth Connection's “Alert” document, NIH Cesarean Conference: Interpreting Meeting and Media Reports (updated October 2006), contains a cogent analysis of the flaws and weaknesses of the March 2006 NIH State-of-the-Science Conference. View Childbirth Connection's document online at http://www.childbirthconnection.org/article.asp?ck=10375 REFERENCES
Articles from The Journal of Perinatal Education are provided here courtesy of Lamaze International What are priority nursing interventions for postpartum hemorrhage?Deficient Fluid Volume Interventions. Massage uterus. Massaging of the uterus after delivery can promote contractions and prevent PPH. ... . Administer oxytocin. ... . Maintain bed rest. ... . Administer IV fluids. ... . Administer blood products. ... . Prepare for surgery.. What are the priority nursing interventions in an attempt to stop postpartum hemorrhage due to uterine atony?Nursing Interventions
Save all perineal pads used during bleeding and weigh them to determine the amount of blood loss. Place the woman in a side lying position to make sure that no blood is pooling underneath her. Assess lochia frequently to determine if the amount discharged is still within the normal limits.
What is the firstOxytocin is an effective first-line treatment for postpartum hemorrhage31; 10 international units (IU) should be injected intramuscularly, or 20 IU in 1 L of saline may be infused at a rate of 250 mL per hour. As much as 500 mL can be infused over 10 minutes without complications.
What is the nursing role for postpartum hemorrhage?The primary role of the nurse in caring for patients with postpartum hemorrhage is to assess and intervene early or during a hemorrhage to help the client regain her strength and prevent complications. Early recognition and treatment of PPH are critical to care management.
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