What is Evidence Based Medicine?
In a world where information can be achieved with a click of a button and yet can be disorganized and unvalidated, Dr. David Sackett in 1996 introduced the concept of Evidence Based Medicine. Defined as a conscientious, explicit, judicious use of current best evidence in making decisions about the care of individual patient, Dr. Sackett described it as a means of integrating individual clinical expertise with the best available external clinical evidence from systematic research. It was created so that as physicians, we can be up to date with the latest modalities, whether diagnostic, treatment or clinical practice guidelines, but more importantly for better quality of care and utilization of resources.
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Dr. Jessamine Sareno giving our GenSan audience a crash course in evidence based medicine |
In their book “Painless Evidence-Based Medicine”, Drs. Antonio Dans, Leonila Dans and Maria Asuncion Silvestre set forth this definition "EBM is a systematic approach to the acquisition, appraisal and application of research evidence to guide healthcare decisions." [1]
The EINC Bulletin will look at the respective studies behind the EINC practices, dissect them and provide a short assessment that are sound and evidence - based. But in the end we should always emphasize that you are still the attending physician. After all it is the triad of individual clinical expertise, best external evidence and patient values and expectations that forms the backbone of evidence based medicine.
The EINC Bulletin will look at the respective studies behind the EINC practices, dissect them and provide a short assessment that are sound and evidence - based. But in the end we should always emphasize that you are still the attending physician. After all it is the triad of individual clinical expertise, best external evidence and patient values and expectations that forms the backbone of evidence based medicine.
Evidence-based Practices for Intrapartum and Newborn Care
Enemas During Labor
The use of enemas during labor is common practice among attending physicians. However, enemas can also cause discomfort for women and increase the cost of delivery. The Systematic Review, which made use of the Cochrane Pregnancy and Childbirth Group trials register, Database of Abstracts of Reviews of Effectiveness, and Medline dated from 1966 to December 2006, by Cuervo et. al in the Clinical Epidemiology unit of the Universidad de Javeriana in Columbia, showed that there were no significant differences in the incidence of lower and respiratory tract tract infections among those who used enema during labor after one month of follow up (2 RCTs; 594 women; relative risk (RR) 0.66, 95% CI 0.42 to 1.04) or newborn children (1 RCT; 370 newborns; RR 1.12, 95% CI 0.76 to 1.67). The authors further concluded that there is not enough evidence to evaluate the use of routine enemas during the first stage of labor. Enemas therefore should only be on a per request basis and not routine.
Perineal Shaving
It is common practice to perform pubic or perineal shaving before birth in order to lessen the risk of infection especially if there is a spontaneous perineal tear. However in a Systematic Review done by Calibri et al. in Centro Interaziendale in Italy, comparing perineal shaving with that of no perineal shaving, the differences were not significant (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.75, 2.12) with regards to post partum maternal febrile morbidity and perineal wound infection. However in one study from the same review, they found that fewer women who had not been shaved had gram negative bacterial colonization compared with women who had been shaved (OR 0.43, 95% CI 0.20, 0.92). How then can we reconcile this single study from the conclusion of the authors? Surrogate outcomes are those that come from laboratory tests while clinical outcomes are those that are well, clinical. So in effect although the gram negative bacterial colonization is indeed significant, there is still no sufficient Clinical Evidence that it can cause perineal wound infection or post partum febrile morbidity.
1Sacket dl., et al. Evidence-based medicine: what is and what isn’t. BMJ 1996 January 13; (31217023): 71-2
2 Fr. Dans, Al, Dans LF and Silvestre MA. In Chapter 1. Introduction. Dans, AL, Dans LF and Silvestre MS. Painless Evidence Based Medicine. John D. Wiley and Sons, United Kingdom. 2008.
Enemas During Labor
The use of enemas during labor is common practice among attending physicians. However, enemas can also cause discomfort for women and increase the cost of delivery. The Systematic Review, which made use of the Cochrane Pregnancy and Childbirth Group trials register, Database of Abstracts of Reviews of Effectiveness, and Medline dated from 1966 to December 2006, by Cuervo et. al in the Clinical Epidemiology unit of the Universidad de Javeriana in Columbia, showed that there were no significant differences in the incidence of lower and respiratory tract tract infections among those who used enema during labor after one month of follow up (2 RCTs; 594 women; relative risk (RR) 0.66, 95% CI 0.42 to 1.04) or newborn children (1 RCT; 370 newborns; RR 1.12, 95% CI 0.76 to 1.67). The authors further concluded that there is not enough evidence to evaluate the use of routine enemas during the first stage of labor. Enemas therefore should only be on a per request basis and not routine.
Perineal Shaving
It is common practice to perform pubic or perineal shaving before birth in order to lessen the risk of infection especially if there is a spontaneous perineal tear. However in a Systematic Review done by Calibri et al. in Centro Interaziendale in Italy, comparing perineal shaving with that of no perineal shaving, the differences were not significant (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.75, 2.12) with regards to post partum maternal febrile morbidity and perineal wound infection. However in one study from the same review, they found that fewer women who had not been shaved had gram negative bacterial colonization compared with women who had been shaved (OR 0.43, 95% CI 0.20, 0.92). How then can we reconcile this single study from the conclusion of the authors? Surrogate outcomes are those that come from laboratory tests while clinical outcomes are those that are well, clinical. So in effect although the gram negative bacterial colonization is indeed significant, there is still no sufficient Clinical Evidence that it can cause perineal wound infection or post partum febrile morbidity.
1Sacket dl., et al. Evidence-based medicine: what is and what isn’t. BMJ 1996 January 13; (31217023): 71-2
2 Fr. Dans, Al, Dans LF and Silvestre MA. In Chapter 1. Introduction. Dans, AL, Dans LF and Silvestre MS. Painless Evidence Based Medicine. John D. Wiley and Sons, United Kingdom. 2008.
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