The following is taken from the World Health Organization’s report on Safe Motherhood, Care in Normal Birth: a practical guide. There are a couple of introductory pages and about fifteen pages of references, and the remainder of the 57 pages of this pdf file are devoted to a discussion of the typical practices in birth around the world, finally dividing them into one of four categories: 1) practices which are demonstrably useful; 2) practices which are clearly harmful; 3) practices for which insufficient evidence exists; and 4) practices which are frequently used inappropriately. They arrived at these conclusions from studying birth practices around the world (from the high-tech U.S. to the impoverished third-world countries), citing a plethora of published research along the way. This document is pretty “meaty” or “heavy” reading, but quite understandable. Some of the practices (like using sterile instruments) are obviously always done in the U.S., but other countries need to improve on them. I would encourage you to read the full document, especially to see how they arrive at some of the following conclusions (the numbers at the end of each point correspond to the discussion sections in the document, and they are in chronological order–pregnancy, first stage of labor, second stage of labor, etc.). This discussion is for normal labor with normal women; there are things that could make a woman high-risk during pregnancy, or things that happen during labor that would change the “risk category”. But this is for most of the women in the world. (I will put italicized explanatory notes on some of these.) This is part three.
6.3Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue
[This section deals with things that have insufficient studies, or conflicting studies, to determine their effectiveness and/or the balance of risk and benefits. Elsewhere in the WHO document, the authors stress the importance of not interfering with the natural process of labor and birth unless clearly beneficial. I strongly encourage you to read the appropriate sections on these points in the full document, to see the potential benefits and risks of these methods. Just because it’s listed below does not mean it’s dangerous (most obviously would be the last point–nipple stimulation in the immediate postpartum–i.e., nursing); but some of these things are clearly not “physiological” and these should be used with caution; others probably have little or no risk at all, but they’re just not well-studied.]
1. Non-pharmacological methods of pain relief during labour, such as herbs, immersion in water and nerve stimulation (2.6). [Not typically available in U.S. hospitals, but may be beneficial. Most of these pain relief methods have not been studied, or the studies have been small or not duplicated. It does not mean that these non-drug pain relief measures are risky….just unknown effectiveness. These methods are well-used in home-births, but this would be considered “anecdotal” evidence since it wasn’t observed in a scientific study.]
2. Routine early amniotomy in the first stage of labour (3.5). [Also known as AROM, “artificial rupture of membranes,” or artificially “breaking the water,” and is typically done in U.S. hospitals. The WHO document cites research that while it may shorten labor, there was an increase in fetal heart-rate decelerations. So it concludes, “Therefore, in normal labour there should be a valid reason to interfere with the spontaneous timing of the rupture of the membranes.” I’ve read that there have been some recent studies that do not show a shorter labor at all. I’ve also heard several stories (including one of my sisters-in-law) who found that the pain from contractions increased dramatically after this procedure.]
3. Fundal pressure during labour (4.4). [Pressing on the top of the uterus–not typically done in the U.S. Update — the Science and Sensibility blog delves into this topic, saying that 17% of the women who answered the “Listening to Mothers Survey II” reported having fundal pressure during pushing. I did not realize it was that common (not “typical” perhaps, but far too common for a practice that does not have a sound basis in science), so am including the link so you can read the studies about it.]
4. Manoeuvres related to protecting the perineum and the management of the fetal head at the moment of birth (4.7).
5. Active manipulation of the fetus at the moment of birth (4.7).
6. Routine oxytocin, controlled cord traction, or combination of the two during the third stage of labour (5.2, 5.3, 5.4). [There may be decreased maternal blood loss if using these things routinely, but oxytocin may increase the rate of retained placenta, and may rarely cause serious maternal side effects; and pulling on the umbilical cord may possibly rupture it, or pull the uterus partially out (called “inversion”).]
7. Early clamping of the umbilical cord (5.5). [From the WHO document, “Late clamping (or not clamping at all) is the physicological way of treating the cord, and early clamping is an intervention that needs justification.”]
8. Nipple stimulation to increase uterine contractions during the third stage of labour (5.6). [This is thought to reduce blood loss, but has not been proven. Typically, a normal newborn (including one who has not been drugged prenatally) will start nursing within the first hour, perhaps even immediately. Nursing does cause uterine contractions (ask any mother who has felt “after-birth pains” when nursing her baby who is a few days old!); but whether or not this decreases total blood loss needs further study.]
Filed under: birth choices, labor support, safe motherhood, umbilical cord | Tagged: amniotomy, AROM, birth choices, childbirth, childbirth education, health, home birth, homebirth, hospital birth, L&D, labor and birth, labor support, nursing, oxytocin, pitocin, postpartum, umbilical cord, water birth, WHO, world health organization |