Richard Johanson

Has the medicalisation of childbirth gone too far

Over the past few centuries childbirth has become increasingly influenced by medical technology, and now medical intervention is the norm in most Western countries. Richard Johanson and colleagues argue here that perhaps normal birth has become too “medicalised” and that higher rates of normal birth are in fact associated with beliefs about birth, implementation of evidence based practice, and team working Until the 17th century, birth in most parts of the world was firmly in the exclusively female domestic arena, and hospital birth was uncommon before the 20th century, except in a few major cities. 1 2 Before the invention of forceps, men had been involved only in difficult deliveries, using destructive instruments with the result that babies were invariably not born alive and the mother too would often die. Instrumental delivery with forceps became the hallmark of the obstetric era. In the 19th and 20th centuries, medical influence was extended further by the development of new forms of analgesia, anaesthesia, caesarean section, and safe blood transfusion. The introduction first of antiseptic and aseptic techniques and later of sulphonamides, coupled with changes in the severity of puerperal sepsis, lowered the maternal mortality that had made hospitals dangerous places in which to give birth.3 #### Summary points Obstetricians play an important role in preserving lives when there are complications of pregnancy or labour In developed countries, however, obstetrician involvement and medical interventions have become routine in normal childbirth, without evidence of effectiveness Factors associated with increased obstetric intervention seem to include private practice, medicolegal pressures, and not involving women fully in decision making Emerging evidence suggests that higher rates of normal births are linked to beliefs about birth, implementation of evidence based practice, and team working Maternal mortality in the West fell substantially during the 20th century. The World Health Organization and Unicef …

A randomised prospective study comparing the new vacuum extractor policy with forceps delivery

Objective To compare assisted vaginal delivery by forceps with delivery by vacuum extractor, where a new vacuum extractor policy was employed which dictated the cup to be used in specific situations.

A randomised controlled trial of epidural compared with non-epidural analgesia in labour

Objectives To investigate possible short and long term side effects of epidural analgesia, compared with non‐epidural analgesia for pain relief in labour.

Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial

BACKGROUND Trauma to the perineum is a serious and frequent problem after childbirth, with about 350000 women each year in the UK needing sutures for perineal injury after spontaneous vaginal delivery, and many millions more worldwide. We compared the continuous technique of perineal repair with the interrupted method, and the more rapidly absorbed polyglactin 910 suture material with the standard polyglactin 910 material. METHODS 1542 women who had a spontaneous vaginal delivery with a second-degree perineal tear or episiotomy were randomly allocated to either the continuous (n=771) or interrupted (771) suturing method, and to either the more rapidly absorbed polyglactin 910 suture material (772) or standard polyglactin 910 material (770). Primary outcomes were pain 10 days after delivery and superficial dyspareunia 3 months postpartum. Analysis was by intention to treat. FINDINGS At day 10, three women had dropped out of the study. Significantly fewer women reported pain at 10 days with the continuous technique than with the interrupted method (204/770 [26.5%] vs 338/769 [44.0%], odds ratio 0.47, 95% CI 0.38-0.58, p<0.0001). Occurrence of pain did not differ significantly between groups assigned the more rapidly absorbed material or standard material (256/769 [33.3%] vs 286/770 [37.1%], 0.84, 0.68-1.04, p=0.10). Women reported no difference in superficial dyspareunia at 3 months for the continuous vs the interrupted method (98/581 [16.9%] vs 102/593 [17.2%], 0.98, 0.72-1.33, p=0.88) or the more rapidly absorbed versus standard material (105/586 [17.9%] vs 95/588 [16.2%], 1.13, 0.84-1.54, p=0.42). Suture removal was done less with the more rapidly absorbed material than with standard suture material (22/769 [3%] vs 98/770 [13%], p<0.0001), and with the continuous versus interrupted method (24/770 [3%] vs 96/769 [12%], p<0.0001). INTERPRETATION A simple and widely practicable continuous repair technique can prevent one woman in six from having pain at 10 days. Also, the more rapidly absorbed polyglactin 910 material obviates need for suture removal up to 3 months postpartum for one in ten women sutured.

Randomised trial of educational visits to enhance use of systematic reviews in 25 obstetric units.

Abstract Objective To evaluate the effectiveness of an educational visit to help obstetricians and midwives select and use evidence from a Cochrane database containing 600 systematic reviews. Design Randomised single blind controlled trial with obstetric units allocated to an educational visit or control group. Setting 25 of the 26 district general obstetric units in two former NHS regions. Subjects The senior obstetrician and midwife from each intervention unit participated in educational visits. Clinical practices of all staff were assessed in 4508 pregnancies. Intervention Single informal educational visit by a respected obstetrician including discussion of evidence based obstetrics, guidance on implementation, and donation of Cochrane database and other materials. Main outcome measures Rates of perineal suturing with polyglycolic acid, ventouse delivery, prophylactic antibiotics in caesarean section, and steroids in preterm delivery, before and 9 months after visits, and concordance of guidelines with review evidence for same marker practices before and after visits. Results Rates varied greatly, but the overall baseline mean of 43% (986/2312) increased to 54% (1189/2196) 9 months later. Rates of ventouse delivery increased significantly in intervention units but not in control units; there was no difference between the two types of units in uptake of other practices. Pooling rates from all 25 units, use of antibiotics in caesarean section and use of polyglycolic acid sutures increased significantly over the period, but use of steroids in preterm delivery was unchanged. Labour ward guidelines seldom agreed with evidence at baseline; this hardly improved after visits. Educational visits cost 860

North Staffordshire/Wigan assisted delivery trial

each (at 1995 prices). Conclusions There was considerable uptake of evidence into practice in both control and intervention units between 1994 and 1995. Our educational visits added little to this, despite the informal setting, targeting of senior staff from two disciplines, and donation of educational materials. Further work is needed to define cost effective methods to enhance the uptake of evidence from systematic reviews and to clarify leadership and roles of senior obstetric staff in implementing the evidence.

Occult anal sphincter trauma following randomized forceps and vacuum delivery

Summary. In a trial conducted at the North Staffordshire and Billinge Maternity Hospitals (NSMH and BMH) a total of 264 women who required an assisted delivery in the second stage of labour were randomly assigned to be delivered either by Kobayashi silicone cup ventouse or by forceps. A larger proportion (90%) of those assigned to the forceps group were actually delivered by the allocated instrument compared to those in the silicone cup group (73%). However, there was a significantly higher rate of maternal morbidity in terms of perineal trauma and discomfort in the forceps group. No differences in neonatal morbidity were detected.

Randomised study of long term outcome after epidural versus non-epidural analgesia during labour

Objective: To determine the prevalence of occult anal sphincter trauma 5 years after randomization to forceps and vacuum delivery. Method: Anal endosonography and manometry was performed in 44 of 313 women who had originally participated in one center of the Keele University Multicenter Assisted Delivery Trial at the North Staffordshire Maternity Hospital between September 1989 and May 1990. Results: 50% admitted to defecatory symptoms and anal sphincter defects were identified in 61%. On the basis of intention to treat, 82% of forceps (n=17) and 48% of vacuum deliveries (n=27) had occult sphincter defects (P=0.03). In four women, both instruments were used. However, the preponderance of defects in the forceps group persisted even when analysis was performed according to the final mode of delivery as well as in the group where only one instrument was used (n=40). There was a significant fall in maximum squeeze anal pressure in the forceps group compared to the vacuum group (56 vs. 36 mmHg; P=0.0007). Although twice as many in the forceps group suffered anal incontinence (32% vs. 16%) significance was not reached. Conclusions: Vacuum delivery appears to be associated with less occult anal sphincter trauma than forceps delivery. A large prospective randomized study is required to address the impact of specific situations, such as failed instrumentation with use of a second instrument and rotational delivery.

Nifedipine in pregnancy

Abstract Objective: To determine whether epidural analgesia during labour is associated with long term backache. Design: Follow up after randomised controlled trial. Analysis by intention to treat Setting: Department of obstetrics and gynaecology at one NHS trust Participants: 369 women: 184 randomised to epidural group (treatment as allocated received by 123) and 185 randomised to non-epidural group (treatment as allocated received by 133). In the follow up study 151 women were from the epidural group and 155 from the non-epidural group Main outcome measures: Self reported low back pain, disability, and limitation of movement assessed through one to one interviews with physiotherapist, questionnaire on back pain and disability, physical measurements of spinal mobility Results: There were no significant differences between groups in demographic details or other key characteristics. The mean time interval from delivery to interview was 26 months. There were no significant differences in the onset or duration of low back pain, with nearly a third of women in each group reporting pain in the week before interview. There were no differences in self reported measures of disability in activities of daily living and no significant differences in measurements of spinal mobility Conclusions: After childbirth there are no differences in the incidence of long term low back pain, disability, or movement restriction between women who receive epidural pain relief and women who receive other forms of pain relief

Reducing risk by improving standards of intrapartum fetal care

Nifedipine is a dihydropyridine calcium channel blocker that is widely used for the treatment of cardiovascular disorders in nonpregnant individuals. Over the last 15 years its favourable pharmacologic characteristics have resulted in its efficacy and safety being assessed in pregnancy. Its application both as a treatment for acute severe hypertension, as well as for long term use for hypertension in pregnancy, have been explored. The drug has been shown to have a tocolytic effect on uterine smooth muscle and hence its use in the prevention of preterm delivery has been investigated. In this article, the mechanism of action of the drug, as well as the current understanding of its metabolism and pharmacokinetics in pregnancy, is reviewed, including assessment of the literature on the use of nifedipine in the management of hypertension in pregnancy and its use in suppressing preterm labour. A literature search of MEDLINE and the Cochrane Library was conducted for the years 1975 to September 1997 concerning the use of nifedipine in pregnancy, both for the treatment of hypertension and for tocolysis. The keywords used were: nifedipine, calcium channel blockers, pregnancy, hypertension, pre-eclampsia, umbilical artery blood flow, uteroplacental blood flow, teratogenicity, tocolysis, preterm labour; preterm delivery. The reference lists of all identified articles were examined to find additional relevant studies.