DEFINITION

EBP is a process used to review, analyze, and translate the latest scientific evidence. The goal
is to quickly incorporate the best available research, along with clinical experience and
patient preference, into clinical practice, so nurses can make informed patient-care decisions

MEANING BY EVIDENCE PRACTICE

Evidence-based practice is defined as a problem-solving and decision making approach in
practice that involves the conscientious use of current best (research) evidence, clinical
expertise, & patient preferences. Evidence-based practice involves critical appraisal of
information used to answer a clinical question.

EXAMPLE OF EVIDENCE BASED PRACTICE

Through evidence-based practice, nurses have improved the care they deliver to patients. Key
examples of evidence-based practice in nursing include: Giving oxygen to patients with
COPD: Drawing on evidence to understand how to properly give oxygen to patients with
chronic obstructive pulmonary disease

3 COMPONENTS OF EVIDENCE BASED PRACTICE

Components of Evidence-Based Practice
 Best Available Evidence. ...
 Clinician's Knowledge and Skills. ...
 Patient's Wants and Needs.

8 PRINCIPLES OF EVIDENCE-BASED PRACTICE

Eight Evidence-Based Principles for Effective Interventions.
 1) Assess Actuarial Risk/Needs.
 2) Enhance Intrinsic Motivation.
 3) Target Interventions.
 a) Risk Principle.
 b) Criminogenic Need Principle.
 c) Responsivity Principle.
 e) Treatment Principle.
 4 Pillars Of Evidence-Based Practice
 Abstract. Rationale, aims and objectives: Four pillars of evidence underpin evidence-
based behavioural practice: research evidence, practice evidence, patient evidence and
contextual evidence.

5 STEPS OF EVIDENCE BASED PRACTICE

5 steps of Evidence Based Practice

 Ask a question. ...
 Find information/evidence to answer question. ...
 Critically appraise the information/evidence. ...
 Integrate appraised evidence with own clinical expertise and patient's preferences. ...
 Evaluate.

EVIDENCE BASED PRACTICES IN OBSTETRICS

• What is Evidence-based medicine-

It is the process of systemically reviewing, appraising and

using clinical research findings to aid the delivery of optimum

clinical care to patients.

• THE IMPACT OF EBM-

The basic principle of EBM is that we should treat when there is evidence of
benefit and not treat if evidence shows no benefit

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
INDICATIONS

MATERNAL INDICATION

1. Prior to most instrumental vaginal delivery

2. Prolonged second stage due to rigid perineum

3. Old perineal scar about to rupture

FETAL INDICATION

1. Large sized baby

2. Preterm baby

3. Breech delivery

4. Shoulder dystocia

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)

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

• Lateral-Condemned

• J shaped- Not done widely

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.

• 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 [Link] incision is usually 3-5 cm in length including post
vaginal wall,fourchette, perineal muscle and perineal skin.

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

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 )

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

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)

Perineal shaving in labour

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

DISADVANTAGES OF PERINEAL SHAVING

• Shaving causes lacerations of perineal skin that leads to colonization of micro-

organisms (Briggs 1997)

• Disliked by many women (Oakley 1979)

• Cause perineal discomfort during regrowth (Kantor 1965)

• Embarassing for the woman (Romney 1980)

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

RECOMMENDATIONS

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

Enemas during labour

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

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
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.

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.

USE OF PARTOGRAMS IN LABOUR

• 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

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

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

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)

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.

• 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.

BIBLIOGRAPHY:-

1. EBP Process. Accessed at [Link]

resource/practitioners-students-teachers/ebp-process-0 on 25 March 2015
2. ↑ Bernadette Mazurek Melnyk, Ellen Fineout-Overholt, Susan B. Stillwell,
Kathleen [Link]. The Seven Steps of Evidence-Based Practice. AJN,
2010,110(1)
3. ↑ Trisha Greenhalgh, Jeremy Howick, and Neal Maskrey. Evidence based
medicine: a movement in crisis? BMJ. 2014; 348: g3725.
 VIVEKANAND COLLEGE OF
NURSING

ASSIGNMENT
ON
EVEDENCED BASED
PRACTICES IN OBG

SUBMITTED TO SUBMITTED BY
MRS. Bhavana rawat Ms. RUCHI
Asst prof ( OBG) [Link]. NURSING
VCON VCON