EVIDENCED BASED MIDWIFERY PRACTICE

INTRODUCTION:
Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that
integrates the best evidence from studies and patient care data with clinician expertise and patient
preferences and values. (Fineout-Overholt E, 2010).

Health care that is evidence-based and conducted in a caring context leads to better clinical
decisions and patient outcomes. Gaining knowledge and skills in the EBP process provides
nurses and other clinicians the tools needed to take ownership of their practices and transform
health 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. Although the field of pregnancy and childbirth pioneered
evidence-based practice, resulting in a wealth of clear guidance for evidence-based maternity
care, there remains a widespread and continuing underuse of beneficial practices, overuse of
harmful or ineffective practices, and uncertainty about effects of inadequately assessed practices.
Effective maternity care with least harm is optimal for childbearing women and newborns.

TERMINOLOGY
Evidence:

 ‘Knowledge derived from a variety of sources that has been found to be credible’ (Higgs
& Jones 2000)
 Evidence refers to a particular form of research

Research:

 Research is defined as a systematic and objective analysis and recording of controlled

observation that may lead to the development of generalization of principles, theories,
resulting in prediction and possible ultimate control of events (J.W. Best).
 Research in its broadest sense is an attempt to gain solutions to problems; more precisely
it is the collection of data in a rigorously- controlled situation for the purpose of
prediction or explanation (Treece & Treece).

Nursing:

 ICN defines nursing as the unique function of nurse that is to assist the individual sick or
well in the performance of those activities contributing to health or its recovery (peaceful
death) that he would perform if he had the necessary strength, will or knowledge.
  Professional nursing is a devoted occupation with ethical components that are devoted to
the promotion of human and social welfare. The services are based on specialized
knowledge and skills that have been developed in a scientific manner (Sr. Stephaine).

Nursing research:

 Nursing research refers to the use of systematic, controlled, empirical, and critical
investigation in attempting to discover or confirm facts that relate to specific problem or
question about the practice of nursing (Walls & Bauzell, 1981).
 Nursing research is a way to identify new knowledge, improve professional education and
practices and use of resources effectively (International council of nurses, 1986).

Practice:

 A repeated exercise in an activity requiring the development of skill (oxford dictionary).

Decision:

 A conclusion or resolution reached after consideration (oxford dictionary).

DEFINITION
Evidence based medicine:

The practice of evidence based medicine means integrating individual clinical expertise with the
best available external clinical evidence from systematic research. It is conscientious, explicit and
judicious use of current evidence in making decision about the care of individual patients.

Evidence based nursing:

Sharma (2011) defines evidence based nursing as a process of identifying the solid research
findings and implementing them in nursing practice, in order to increase the quality of patient
care.

Evidence based nursing is a type of evidence based practice in nursing. It involves identifying
solid research findings and implementing them in nursing practices, in order to increase the
quality of patient care.

Evidence based practice: Sackett etal (1996) define EBP as ‘the conscientious, explicit and
judicious use of current best evidence in making nursing decisions about the care of individual
patients.’

Evidence based decision making:

"Evidence-based decision-making is a continuous interactive process involving the explicit,
conscientious and judicious consideration of the best available evidence to provide care."-
Position Statement by Canadian Nurses'.

Midwifery practice-

Midwifery practice is underpinned by values that guide the way in which midwives provide

care.  Midwives are the most appropriate care providers to attend women during pregnancy,
labor, birth and the post-natal period and in collaboration with other health care professionals
when required.

Evidenced based practice in midwifery

EPISIOTOMY:

 Episiotomy is a surgically planned incision on the perineum and posterior vaginal wall
during the second stage of labor to assist in vaginal delivery of the fetus
 Also assists in instrumental vaginal deliveries (vacuum, forceps)
 Increases room for obstetric manoeuvres in shoulder dystocia, breech deliveries, internal
podalic versions of second twin.
Indication
Maternal indication
1. Prior to most instrumental vaginal delivery
2. Prolonged second stage due to rigid perineum
3. Old perineal scar about to rupture
Fetal indication
1. Large sized baby
2. Preterm baby
3. Breech delivery
4. Shoulder dystocia
Types of episiotomy:
• Medio-lateral-Incision is made downwards and outward from the midpoint of fourchette
either to the right or left .It is directed diagonally in a straight line which runs about 2.5
cm away from the anus(midpoint between anus and Ischial tuberocity)
• Median-Commences from the centre of fourchette and extends posteriorly along the
midline for about 2.5 cm.
• Lateral-Condemned
• J shaped- Not done widely
 Method

Procedure

Anesthesia

Local infiltration(10 ml of 1% lignocaine in the line of proposed incision with plunger

withdrawal and syringe withdrawal technique)

Pudendal nerve block

Timing of Episiotomy

• Bulging thinned perineum when the head is visible during a contraction to a diameter of
3to 4cm.

• When used in conjunction with forceps delivery it is given after application of the blades.

• Incision- The index and middle finger of one hand is introduced between the presenting
part and proposed site of incision to protect the presenting part and support the tissue that
will be incised.the incision is usually 3-5 cm in length including post vaginal
wall,fourchette, perineal muscle and perineal skin.

Episiotomy repair-

• The woman is placed in lithotomy position

• Good light source from behind is needed

 • The patient is draped properly and repair should be done under strict aseptic precaution

• If the repair field is obscured by oozing of blood from above, a vaginal pack is inserted

• Do not forget to remove the pack after the repair is completed

Repair is done in three layers

• Vaginal mucosa and submucosa

• The first suture is placed 1 cm above apex

• Vaginal mucosa and sub mucosa is closed with a continuous locking suture of 2-0
chromic catgut or 2-0 synthetic delayed absorbable suture (polyglycolic acid or vicryl) or
polyglactin 910 (vicryl Rapid )

Evidenced regarding episiotomy

• Episiotomy is associated with posterior perineal trauma, healing complications, painful

intercourse (Carroli G 1999; Hartmann K et al 2005)

• Routine episiotomy is associated with increased incidence of anal sphincter and rectal
tears (Rodriguez 2008)

• ACOG 2006- restricted use of episiotomy to be preferred then routine use

Recommendation

• ACOG 2008- Evidence based labour and delivery management-

• Episiotomy should be avoided if at all possible, but if used, it is unknown which

episiotomy technique provides the best outcome (Recommendation D: ineffective or
harms outweigh benefits; Quality of evidence: Good)

PERINEAL SHAVING IN LABOUR

Practice of perineal shaving

• Preparation for childbirth includes practice of pubic hair removal

• Believed to lessen infections caused by perineal tears and episiotomies

• Clean site for surgical repair of episiotomy or perineal tear

• Other methods of hair removal include clipping of perineal hairs and use of depilatory
creams

Other evidence
 • Kovavisarach 2005- found no difference in women with and without perineal shaving
with respect to perineal wound infection and dehiscence, pueperal morbidity and infection
and maternal satisfaction

• Tanner 2011- Shaving resulted in more surgical site infections when compared with
clipping or use of depilatory creams

Recommendation

• Cochrane 2014- There is insufficient evidence to suggest that perineal shaving confers
any benefit to women on admission in labor.

Enema during labour

Practice of enema during labour

• Believed to expedite the process of labour

• Cause uterine stimulation due to distension of rectum stimulating the nerve supply to
these organs

• Emptying of rectum of fecal matter prevents soiling of perineum and decreases chances
of perineal infection in the mother and neonatal infections.

Evidences

• No differences in duration of labour, maternal and neonatal outcomes for enema in first
stage of labour (Cuervo 2007)

• Lower infection rates in newborn and mother in women where no enema was given.

Recommendation

• Cochrane 2007- Enemas did not improve puerperal or neonatal infection rates, episiotomy
dehiscence rates or maternal satisfaction.

• Therefore, their use is unlikely to benefit women or newborn children and there is no
reliable scientific basis to recommend their routine use.

• These findings discourage the routine use of enemas during labour.

• National Health Survey 2010- Use of enemas during labour is not effective. There is no
significant difference in infection rate in puerperal women or neonate,

• No overall effect on length of labour and no clear improvement in maternal satisfaction

between groups of mothers given or not given enemas.

USE OF PARTOGRAMS IN LABOUR

Partogram
 • Partogram is a visual/graphical representation of related values or events over the course
of labor.

• Tool to identify complications of labor and make timely referrals

Patient details

Identification data

• Name

• Age

• Parity

• Date and time of admission

• Registration number

• Time of rupture of membranes

Fetal condition

– Count fetal heart rate every half hour

– Count for one full minute, immediately following a uterine contraction

– Fetal distress:

FHR <120 beats/minute or >160 beats/minute

 Manage

Amniotic fluid and membrances

 Record status of membranes and amniotic fluid in Partograph:

– Membranes intact (mark ‘I’)

– Membranes ruptured (mark ‘R’)

– Clear liquor (mark ‘C’)

 – Meconium stained liquor (mark ‘M’)

Cervical dilatation

• Begin plotting in active labor

• Cervical dilatation > 4 cms

• Plot the initial finding

• Note the time

• Repeat P/V after 4 hours and plot the cervical dilatation

Descent of head

• In fifths per abdomen

• Engagement at 2/5 and less

• If 3/5 or more than CPD [absolute or relative] is present

• Vaginal assessment in relation to ischial spines not useful to define engagement since
position of spines dependant on type of pelvis.

Uterine contraction

• In fifths per abdomen

• Engagement at 2/5 and less

• If 3/5 or more than CPD [absolute or relative] is present

• Vaginal assessment in relation to ischial spines not useful to define engagement since
position of spines dependant on type of pelvis.

Maternal condition

• Record maternal pulse every half hour and mark with a dot ( . )

• Record maternal BP every 4 hours using a vertical arrow, with upper end
signifying systolic BP and lower end diastolic BP

• Record the temperature every 4 hours and note on temperature graph

Interventions

• Mention dose

• Route

• Time of administration of any drug

Evidence

Similar incidence of interventions and Cesarean deliveries in labour monitored with or without
partograms (Windrim R 2007)

Recommendation

• Evidence based labour and delivery management ACOG 2008- There is insufficient
evidence to recommend the routine use of Partogram (Level C recommendation; Fair
quality evidence)

• WHO recommendations for augmentation of labour 2014- Active phase partograph with a
4 hour action line is recommended for monitoring the progress of labour (Strong
recommendation; very low quality of evidence)

Use of Antibiotics during labour

Practice of antibiotics use in labour

• Group B streptococcus are common inhabitants of GIT, urethra and vagina

• The baby contacts this organism from the mother during the birthing process as it passes
through the birth canal (vertical transmission)

• Common infections in the neonate are respiratory infections, meningitis and sepsis

• Antibiotics administered to the mother during labour can prevent development of these
infections by decreasing the bacterial load

• Infections are more common with preterm and low birth weight neonates, prolonged
rupture of membranes, prolonged labour and in maternal diabetes

Evidence

 Cochrane 2014- Intrapartum antibiotic prophylaxis appears to reduce early onset group B
streptococcal disease but results may be biased.
 Three trials showed antibiotics did not significantly reduce mortality or morbidity from
GBS/ non GBS
 Another trial showed no added benefit with ampicillin on maternal or neonatal outcomes
 High degree of bias in trials included
 If a mother who carries GBS is not treated with antibiotics during labor, the baby’s risk of
becoming colonized with GBS is approximately 50% and the risk of developing a serious,
life-threatening GBS infection is 1 to 2% (Boyer and Gotoff 1985; CDC 2010; Feigin,
Cherry et al. 2009)
 • If a woman with GBS is treated with antibiotics during labor, the risk of her infant
developing an early GBS infection drops by 80%. So for example, her risk could drop
from 1% down to 0.2%. (Ohlsson 2013)

Recommendation

• ACOG- The following recommendations are based on good and consistent scientific
evidence (Level A):

• Antimicrobial prophylaxis is recommended for all cesarean deliveries unless the patient is
already receiving appropriate antibiotics (e.g., for chorioamnionitis)

• That prophylaxis should be administered within 60 minutes before the start of the
cesarean delivery.

• For cesarean delivery prophylaxis, a single dose of a targeted antibiotic, such as a first-
generation cephalosporin, is the first-line antibiotic of choice, unless significant drug
allergies are present.

• Antibiotic prophylaxis is indicated for patients with preterm premature rupture of

membranes (PROM) to prolong the latency period between membrane rupture and
delivery.

• Antibiotic prophylaxis should not be used for pregnancy prolongation in women with
preterm labour and intact membranes.

• This recommendation is distinct from recommendations for antibiotic use for preterm
PROM and group B streptococci (GBS) carrier status.
SUMMARY
Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that
integrates the best evidence from studies and patient care data with clinician expertise and patient
preferences and values. Midwifery is defined in the series as: “Skilled, knowledgeable and
compassionate care for childbearing women, newborn infants and families across the continuum
throughout pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life.

Conclusion

Evidence based nursing started in the 1800s with Florence Nightingale. EBN is a problem
solving approach to clinical decision making. EBN integrates providers' clinical expertise
with the best external clinical evidence. EBN is the process of integrating Clinical
knowledge Judgment Proficiency skills with the best available clinical evidence, such as
nursing practice in to patient care.
Nursing abstract

CNM
ABSTRACT
The purpose of this study was to
describe the lived experience of
midwifery clients throughout the life
span. A qualitative study using a
phenomenological approach was
employed. In-depth interviews were
conducted with a purposive sample
of 12 midwifery clients. The research
question was: What has been
your experience with midwifery
care? Interviews were audio-
recorded and transcribed verbatim.
Data
saturation was achieved and
analysisprocedures from Colaizzi
were used. Five themes emerged
from the
data: 1) decision to seek midwifery
care; 2) working together in a
therapeutic alliance; 3) formulating
a birth plan; 4) childbirth education;
and 5) nurse-midwives as primary
health-care providers through-
out the life span. There is much to
learn from listening to the voices of
midwifery clients
CNM
ABSTRACT
The purpose of this study was to
describe the lived experience of
midwifery clients throughout the life
span. A qualitative study using a
phenomenological approach was
employed. In-depth interviews were
conducted with a purposive sample
of 12 midwifery clients. The research
question was: What has been
your experience with midwifery
care? Interviews were audio-
recorded and transcribed verbatim.
Data
saturation was achieved and
analysisprocedures from Colaizzi
were used. Five themes emerged
from the
data: 1) decision to seek midwifery
care; 2) working together in a
therapeutic alliance; 3) formulating
a birth plan; 4) childbirth education;
and 5) nurse-midwives as primary
health-care providers through-
out the life span. There is much to
learn from listening to the voices of
midwifery clients
CNM
ABSTRACT
The purpose of this study was to
describe the lived experience of
midwifery clients throughout the life
span. A qualitative study using a
phenomenological approach was
employed. In-depth interviews were
conducted with a purposive sample
of 12 midwifery clients. The research
question was: What has been
your experience with midwifery
care? Interviews were audio-
recorded and transcribed verbatim.
Data
saturation was achieved and
analysisprocedures from Colaizzi
were used. Five themes emerged
from the
data: 1) decision to seek midwifery
care; 2) working together in a
therapeutic alliance; 3) formulating
a birth plan; 4) childbirth education;
and 5) nurse-midwives as primary
health-care providers through-
out the life span. There is much to
learn from listening to the voices of
midwifery clients
The purpose of this study was to
describe the lived experience of
midwifery clients throughout the life
span. A qualitative study using a
phenomenological approach was
employed. In-depth interviews were
conducted with a purposive sample
of 12 midwifery clients. The research
question was: What has been
your experience with midwifery
care? Interviews were audio-
recorded and transcribed verbatim.
Data
saturation was achieved and
analysisprocedures from Colaizzi
were used. Five themes emerged
from the
data: 1) decision to seek midwifery
care; 2) working together in a
therapeutic alliance; 3) formulating
a birth plan; 4) childbirth education;
and 5) nurse-midwives as primary
health-care providers through-
out the life span. There is much to
learn from listening to the voices of
midwifery clients.
The purpose of this study was to
describe the lived experience of
midwifery clients throughout the life
span. A qualitative study using a
phenomenological approach was
employed. In-depth interviews were
conducted with a purposive sample
of 12 midwifery clients. The research
question was: What has been
your experience with midwifery
care? Interviews were audio-
recorded and transcribed verbatim.
Data
saturation was achieved and
analysisprocedures from Colaizzi
were used. Five themes emerged
from the
data: 1) decision to seek midwifery
care; 2) working together in a
therapeutic alliance; 3) formulating
a birth plan; 4) childbirth education;
and 5) nurse-midwives as primary
health-care providers through-
out the life span. There is much to
learn from listening to the voices of
midwifery clients.
Aim To establish self-reported skill levels, behaviours and barriers in relation to evidence-
based practice (EBP) among a representative sample of regional Australian nurses and
midwives in senior roles. Background It has been widely established that nurses and
midwives continue to face challenges in relation to putting evidence into practice on the
clinical floor. Prior to conducting an EBP capacity building activity in a regional Australian
Local Health District, a survey assessing needs and skill and barrier areas was conducted.
Methods A quantitative descriptive survey which utilised the ‘Developing Evidence Based
Practice Questionnaire’ (DEBPQ) was conducted in early 2012 among senior nurses and
midwives of a regional New South Wales Local Health District (LHD). The survey results
were contrasted with reported DEBPQ results from a sample of UK metropolitan nurses and a
sample of Australian general practice nurses (GPNs). Results One hundred and sixty nine
nurses completed the survey (response rate 42%). Survey respondents’ reliance on accepted
evidentiary knowledge sources was found to be low. Research literature-related knowledge
sources were ranked outside of the top 10 sources, compared with numerous personalised and
subjective sources, which ranked within the top 10. Access to and understanding of research
material was a primary barrier to reviewing evidence in the study sample. Time-related
barriers to changing practice on the basis of evidence figured prominently in the study sample
and the UK and Australian GPN samples. The study sample rated their EBP skill levels
significantly higher than both their UK counterparts and the Australian GPN sample (P <
0.0001). Conclusion Capacity building interventions are needed among senior nurses and
midwives in Australian regional LHDs, as the most prominent knowledge sources reported
are non-evidentiary in nature and barriers to finding and reviewing evidence, along with
barriers to making practice change, remain significant.

BIBLIOGRAPHY
 Myles. “Textbook for Midwives”. Fifteenth Edition. Elsevier publications;
2009.
 .www.medscape.com
 http://www.ncbi.nlm.gov
 http://www.scribd.com