What are the latest evidence-based practices in midwifery for improving outcomes during labor, delivery, and postpartum care?

Latest Evidence-Based Practices in Midwifery for Labor, Delivery, and Postpartum Care

Enhanced Recovery After Cesarean Delivery

The Enhanced Recovery After Surgery (ERAS) Society cesarean delivery pathway represents the most comprehensive, evidence-based approach to surgical birth, demonstrating reductions in length of stay, complications, and readmissions while improving maternal outcomes. 1

Preoperative Optimization (30-60 minutes before incision)

• Administer prophylactic antibiotics within 60 minutes before skin incision using weight-based cefazolin, with azithromycin 500mg IV added for patients in labor or with ruptured membranes to reduce infectious morbidity 1, 2, 3
• Document the specific indication for cesarean delivery (repeat cesarean, breech presentation, failed induction, fetal distress) as this drives all subsequent clinical decisions 2
• Assess prior cesarean history including number of prior sections, inter-delivery interval, type of uterine incision, and complications for risk stratification 2
• Confirm gestational age with a target of 38 weeks for scheduled cesarean sections 2

Intraoperative Management

• Use regional anesthesia (spinal or epidural) as the preferred method as part of enhanced recovery protocol 1, 2, 3
• Administer intrathecal morphine 50-100μg for superior postoperative analgesia, combined with multimodal non-opioid analgesics (paracetamol and NSAIDs) administered after delivery 2, 3
• Maintain normothermia through forced-air warming, warming of intravenous fluids, and increasing operating room temperature 3
• Use blunt expansion of the transverse uterine hysterotomy and perform two-layer hysterotomy closure to reduce future uterine rupture risk 1, 2
• Close skin with subcuticular sutures 1
• Delay cord clamping for at least 1 minute for term births 1, 3
• Administer slow IV oxytocin infusion (<2 U/min) after placental delivery to prevent hemorrhage 2, 4

Postoperative Care

• Remove urinary catheter immediately after surgery rather than waiting for traditional timepoints 1, 2
• Resume regular diet within 2 hours after cesarean delivery instead of traditional feeding trials 1, 3
• Consider gum chewing if delayed oral intake is planned, as it reduces time to flatus by 7 hours and decreases postoperative ileus (odds ratio 0.39,95% CI 0.19-0.80), though it may be redundant with early feeding protocols 1
• Implement scheduled multimodal analgesia to minimize opioid use, including paracetamol, NSAIDs, and intrathecal morphine 2, 3
• Encourage early mobilization after cesarean delivery 3
• Continue hemodynamic monitoring for at least 24 hours postoperatively due to significant fluid shifts 2

Nausea and Vomiting Prevention

• Use a multimodal approach to prevent nausea and vomiting, which occurs in 21-79% of patients during regional anesthesia 1
• Administer fluid preloading (colloid or crystalloid), intravenous ephedrine or phenylephrine, and lower limb compression to reduce anesthesia-related hypotension 1
• Combine 5-HT3 antagonists (ondansetron, granisetron) with either droperidol or dexamethasone, as combination regimens are significantly more effective than single agents 1
• Use dopamine antagonists (metoclopramide 20 mg, droperidol) and sedatives (midazolam, propofol) for intraoperative nausea and vomiting 1
• Administer anticholinergic agents (scopolamine) for postoperative nausea and vomiting 1
• Consider tropisetron 2 mg combined with metoclopramide 20 mg as highly effective prevention 1

Intrapartum Care for Low-Risk Women

Low-risk mothers and babies do not benefit from birth in hospital obstetric units or from many previously "routine" but unindicated labor interventions. 1

Model of Care

• Provide one-to-one care in labor as the standard model of care 1
• Ensure good communication, support, and compassion from staff, with respect for women's wishes to help create a positive birth experience 1
• Explain to both multiparous and nulliparous women their options for planned place of birth 1

Extended Postpartum Care and Long-Term Consequences

The traditional 6-week postpartum period is inadequate, as heightened risks from childbirth persist up to and beyond 1 year after birth, with mortality risk remaining 20% higher at 42 days to 4 months postpartum compared to baseline. 1

Comprehensive Postpartum Assessment

• Assess genitourinary function systematically, including screening for faecal or urinary incontinence, pelvic floor dysfunction, and perineal healing 1
• Evaluate for uterine tenderness, lochia, or symptoms of inflammation 1
• Examine perineal or vaginal tears and assess healing of any perineal wound 1
• Ask about resumption of sexual intercourse and whether dyspareunia is present 1
• Screen for vaginal discharge or bleeding beyond expected parameters 1

Psychosocial Assessment

• Evaluate mental health status, including screening for postpartum depression, anxiety, and post-traumatic stress 1
• Assess social support systems, including partner support, family support, and community resources 1
• Identify housing stability, financial concerns, and immigration status issues 1
• Determine carer responsibilities for other children, young people, or adults 1

Critical Pitfalls to Avoid

• Never assume absence of menstruation guarantees lack of fertility after 6 weeks postpartum 5
• Avoid using misoprostol for cervical ripening in patients with prior cesarean section due to increased uterine rupture risk 2
• Do not delay antibiotic administration beyond 60 minutes before incision 2
• Never omit azithromycin in patients in labor or with ruptured membranes 2
• Avoid single-layer uterine closure as it increases future uterine rupture risk 2
• Do not perform blind digital examination before excluding low-lying placenta or vascular abnormalities in postpartum bleeding 5
• Avoid aggressive sharp curettage that could perforate the thinned cesarean scar if retained products of conception removal is needed 5
• Never use methylergonovine in patients with hypertension or vascular disease due to vasoconstriction risk 2, 6

Postpartum Bleeding Management

• Obtain transvaginal ultrasound as the primary diagnostic tool for retained products of conception, looking for vascular echogenic mass or endometrial thickness >8-13 mm 5
• Use color Doppler to identify vascular retained products requiring additional intervention 5
• Consider that cesarean scar defects occur in 24-88% of women and may cause abnormal bleeding patterns 5
• If hemodynamically unstable, initiate resuscitation, obtain stat labs, and activate massive transfusion protocol if indicated 5

Discharge Planning

• Provide standardized written discharge instructions including wound care, pain management expectations, warning signs, and individualized opioid prescribing to minimize unnecessary consumption 2
• Maintain close hemodynamic monitoring for 24-48 hours after retained products treatment, with serial hemoglobin checks and surveillance for delayed complications 5

Research Priorities and Knowledge Gaps

Representative prevalence data for medium-term and long-term postpartum conditions in low- and middle-income countries are urgently needed, as current evidence relies heavily on facility-based studies with non-representative sampling. 1

• Standardized measurement tools and study designs are necessary to ensure prevalence data are reliable, comparable, and representative 1
• High-quality, evidence-based guidelines developed specifically for low- and middle-income country contexts are lacking 1
• The burden of conditions including obstetric fistula, faecal incontinence, urinary incontinence, peripartum cardiomyopathy, and postpartum infections requires comprehensive research prioritization 1