Hannah dahlen evidence-based-midwifery-practice-mooc

From Old Wives Tale to Level One

Evidence: A journey of imagination,

intuition and scientific rigour

The birth of a midwife

Imagination!

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)

Returning to Australia

Meanwhile…

Intuition…

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

Begging for money

Falling into a PhD

Very short term view

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%

Method

Application of warm packs

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%)

Getting a PhD

So do all women now get advised

about the benefits from warm packs in

second stage?

Resisting change

Meanwhile…2008

Finally Level One evidence in 2012

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.

Perineal warm compresses and SPT

Albers et al. 2005; Dahlen et al. 2007 (n=1525)

25

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.”

Meanwhile…

Now what?

• PhD and Masters HonsStudents

• Engagement with industry

• Publications

• Text book chapters

• Translation into practice

• Take to the streets and tweet!

Have fun and believe in what you do