Dear Denis,

To mention two Dutch studies that showed no evidence for two commonly used interventions: the use of internal monitoring of the strength of contractions and induction for suspected growth restriction at term (see references below). Interestingly, in Boers’ study they found no difference between induction and expectant management.  Hence, you would expect the conclusion to be in favour of expectant management (‘primum non nocere’ or ‘first do no harm’) but the conclusion in the abstract reads: Patients who are keen on non-intervention can safely choose expectant management with intensive maternal and fetal monitoring; however, it is rational to choose induction to prevent possible neonatal morbidity and stillbirth.

Considering the potential side effects of induction compared to sterile water injections (let alone the difference in effects) it is difficult to understand the strong belief in induction and the highly emotional rejection of sterile water injections. Beliefs are much stronger than evidence….

Before we start ‘blaming’ medics for these attitudes, midwives have them too. As you know very well and have published about – many more women end up lying on their back for labour than would naturally choose to do so (also with midwives attending the birth) … In spite of tonnes of evidence of advantages of giving them more choices in positions.

Best wishes, Ank.

  (1)    Bakker JJ, Verhoeven CJ, Janssen PF, van Lith JM, van Oudgaarden ED, Bloemenkamp KW et al. Outcomes after internal versus external tocodynamometry for monitoring labor. N Engl J Med 2010; 362(4):306-313.

  (2)    Boers KE, Vijgen SM, Bijlenga D, van der Post JA, Bekedam DJ, Kwee A et al. Induction versus expectant monitoring for intrauterine growth restriction at term: randomised equivalence trial (DIGITAT). BMJ 2010; 341:c7087.

Van: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] Namens Denis Walsh
Verzonden: maandag 31 maart 2014 17:23
Aan: [log in to unmask]
Onderwerp: are intrapartum guidelines evidence based

Does anyone know of papers that have estimated how much of routine intrapartum practice is evidence-based? The query stems from anaesthetists not accepting the introduction of water injections for back pain in an alongside midwifery unit unless a Cochrane review unequivocally  shows benefit and recommends it (setting aside the issue of one professional group having the right of veto over another groups sphere of practice). We are looking for papers that summarise a cluster of therapies/interventions that are common practice with less of an evidence base than a robust Cochrane review and that the  judgement about what therapies/interventions pass the test of robust evidence may be influenced by prior beliefs/preferences. There may also be literature that the decision of what is ‘approved’ for practice is related to the most powerful voices locally.

Many thanks.

Best wishes,

Denis

Dr Denis Walsh

Associate Professor in Midwifery

Postgraduate Director of Research & Knowledge Transfer

Academic Division of Midwifery

University of Nottingham

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Medical School

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