Evidence_based_practices_in_Obstetrics.pptx

evidence based scientifically proved practices helps make decisions about patient care.

1. EVIDENCE BASED PRACTICES IN OBSTETRICS Presented by: Archita Sharma M.Sc.(N) 1 st year

2. 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).

3. CONT… 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 healthcare.

4. CONT… Evidence based maternity care uses the best available research on the safety and effectiveness of specific practices to help guide maternity care decisions 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.

5. 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.

6. CONT… Research : Research is defined as the creation of new knowledge and/or the use of existing knowledge in a new and creative way so as to generate new concepts, methodologies and understandings . Practice: A repeated exercise in an activity requiring the development of skill.

7. 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 decisions about the care of individual patients.

8. CONT… Evidence based nursing : Evidence based nursing is a process of identifying the solid research findings and implementing them in 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.

9. CONT… Evidence based decision maker : Evidence-based decision making is a continuous interactive process involving the explicit, conscientious and judicious consideration of the best available evidence to provide care.

10. CONT… 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, labour, birth and the post-natal period and in collaboration with other health care professionals when required. 

11. Episiotomy

12. 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

13. Indications Maternal indication Prior to most instrumental vaginal delivery Prolonged second stage due to rigid perineum Old perineal scar about to rupture Fetal indication Large sized baby Preterm baby Breech delivery Shoulder dystocia

14. 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 )

15. CONT…. Median -Commences from the centre of fourchette and extends posteriorly along the midline for about 2.5 cm.

16. CONT… Lateral -Condemned J shaped - Not done widely

17. Procedure Anasthesia 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.

18. Procedure 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.

19. Procedure 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

20. Episiotomy repair 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 )

21. Evidence 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

22. 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)

23. PERINEAL SHAVING IN LABOUR

24. 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

25. Other evidences 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

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

27. ENEMAS DURING LABOUR

28. Practice of enemas in 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

29. 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

30. Recommendations 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 .

31. Recommendations 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.

32. USE OF PARTOGRAMS IN LABOUR

33. 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

34. Patient details Identification data Name Age Parity Date and time of admission Registration number Time of rupture of membranes

35. 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

36. Amniotic Fluid and Membranes 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’)

37. 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

38. 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.

39. Uterine contraction Chart the contractions every half an hour Number of contractions in 10 mins Duration in seconds Less than 20 seconds Between 20 and 40 seconds //// More than 40 seconds

40. 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

41. Interventions Interventions Mention dose Route Time of administration of any drug

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

43. Recommendations 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)

44. USE OF ANTIBIOTICS DURING LABOUR

45. Practice of antibiotic 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

46. Practice of antibiotic use in labour Infections are more common with preterm and low birth weight neonates, prolonged rupture of membranes, prolonged labour and in maternal diabetes .

47. 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.

48. Evidence 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)

49. 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.

50. Recommendation 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.

51. CONCLUSION Evidence based nursing started in 1800s with Florence nightingale. EBN is a problem-solving approach to clinical decision making. EBN integrates providers clinical expertise and 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.