hannah dahlen evidence-based-midwifery-practice-mooc
TRANSCRIPT
From Old Wives Tale to Level One
Evidence: A journey of imagination,
intuition and scientific rigour
Lost in antiquity…
“… drench warm pieces of cloth with warm, sweet olive oil and put them over the abdomen as well as the labia and keep them saturated with the warm oil for some time, and one must also place bladders filled with warm oil alongside” (Soranus 98-138 AD cited in Temkin, 1956 p. 72)
Perineal ‘Warm Pack Trial’
Perineal preservation and maternal
comfort related to the application of
warmth to the perineum in the second
stage of labour
A randomised controlled
trial
Flow diagram of women’s progress through
the phases of the RCT
Consented (n=1047)
Randomised (n=717)
Not randomised (n=330)
Warm pack group (n=360) Normal care group (n=357)
Six week follow up 77%
Six week follow up 78%
Three month follow up 74%
Three month follow up 74%
Maternal questionnaire 87%
Midwives Questionnaire 89%
Perineal outcomes
Perineal outcomes Warm Pack Normal Care OR (95% CI)
Sutured
Not sutured
81%
19%
81%
19%
1.00 (0.67-1.48)
Minor trauma
Major trauma
41%
59%
40%
60%
0.98 (0.72-1.34)
3rd & 4th degree
Other
4% (n=15)
96%
9%(n=31)
91%
*2.16 (1.15-4.10)
Episiotomy
No episiotomy
11%
89%
12%
88%
1.07 (0.65-1.74)
Pain Scores giving birth
1) Warm Pack Group (272/360)
• No pain (4%)
• Some pain (13%)
• Moderate pain (25%)
• Bad pain (25%)
• The worst pain in my life (34%)
2) Normal Care Group (290/357)
• No pain (0.3%)
• Some pain (3%)
• Moderate pain (15%)
• Bad pain (31%)
• The worst pain in my life (51%)
Perineal techniques during the second stage of labour for
reducing perineal trauma (Asheim et al. 2012)
Eight trials (n=11,651)
• Warm packs
• Intrapartum massage
• Hands off or poised
• Ritgen’s manoeuvre
24Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of
Systematic Reviews 2011, Issue 12. Art. No.: CD006672. DOI: 10.1002/14651858.CD006672.pub2.
Authors recommendations
“The use of warm compresses on the perineum
is associated with a decreased occurrence of
perineal trauma. The procedure has shown to
be acceptable to women and midwives. This
procedure may therefore be offered to
women.”
26
Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of
labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2011, Issue 12.
Art. No.: CD006672. DOI: 10.1002/14651858.CD006672.pub2.
Critiquing Cochrane
Dahlen H. (2012). Perineal warm compress reduces risk of third- and fourth- degree tears and should be part of second stage care. Evidence Based Nursing 15(4), 103-104.
“The RCT regarding application of warm compress examined two hypotheses: (1) perineal suturing and (2) comfort during and after birth.5 Reduction in second stage and postpartum pain was the most significant part of this trial, along with the high acceptability to women and midwives. This did not form part of the meta-analysis, most likely because it was not examined in other primary RCTs.”
Now what?
• PhD and Masters HonsStudents
• Engagement with industry
• Publications
• Text book chapters
• Translation into practice
• Take to the streets and tweet!