Despite a growing awareness among providers of the notion of evidence-based practice, many clinicians and policymakers are reluctant to make changes to practice, even in the face of overwhelming evidence of the need to do so. Several new challenges to current practice have arrived on the scene.
Current practice: withholding food during labor.
Tranmer and colleagues examined whether allowing women the option of eating what they wanted during early labor would decrease the incidence of dystocia (difficult or nonprogressing labor). They randomized more than 300 nulliparous women before labor began to receive either usual care, consisting of ice chips, popsicles, or sips of fluid while in the hospital, or an intervention, consisting of a "booklet containing easy-to-read guidelines on suggested nutrient and fluid intake during labor based on nutritional guidelines for individuals who participate in prolonged, moderate, aerobic exercise." (Oral intake was restricted, though, if the woman received epidural analgesia or developed intrapartum complications.)
The study data and patient questionnaires did not in fact support the authors' hypothesis that women encouraged to eat early in labor would fare better. But neither did the results reveal a sound basis for preventing them from doing so. There was no difference between the two groups in the rate of dystocia, nor were there differences in the rates of nausea or vomiting, both oft-cited reasons for restricting oral intake. In addition, there were no instances of gastric aspiration or death in either group.
Although the authors don't call for a change in current practice, they do recommend more research and telling patients about the study so that they can decide whether to bring food to the hospital.
Current practice: routine use of episiotomy during labor.
Despite a growing body of evidence indicating that the routine use of episiotomy isn't in women's best interests, the procedure is still common, occurring, according to many estimates, in nearly a third of all U.S. births. (In some settings, the rate may be as high as 80%.) The Agency for Healthcare Research and Quality recently performed a review of the English-language literature on the subject. Of nearly 1,000 articles identified, 26 met the inclusion criteria; five primary areas of investigation were determined.
The results showed that routine use of episiotomy confers no benefit. Women in groups in which the use of episiotomy was restricted (episiotomy rates ranged from 7.6% to 10.2%; in the routine-use groups, the range was 44% to 53%) had less-severe posterior perineal trauma and less need for suturing. They also were more likely to resume intercourse sooner and less likely to experience pain during intercourse. The authors write, "In the absence of benefit and with a potential for harm, a procedure should be abandoned. . . . [C]linicians have the opportunity to forestall approximately 1 million episiotomies each year that are not improving outcomes for mothers."
Current practice: withholding food from children before surgery.
The practice of having children fast before surgery, often for 12 hours or more, is still common, despite insufficient supporting evidence and several guidelines recommending the opposite. Brady and colleagues reviewed randomized, controlled trials for the Cochrane Collaboration to "systematically identify, appraise and synthesise the evidence of the effects of different preoperative fasting regimens" in children.
Different durations of fasting were examined, as well as types of food or fluid allowed. The primary outcomes included the rates of adverse events such as aspiration or regurgitation (or both) or complications arising from aspiration such as pneumonia or death. Gastric contents were measured. Secondary outcomes included thirst and hunger, pain, comfort, and nausea and vomiting.
Again, the available data revealed there is no benefit to the current practice. According to the review authors, "there is no evidence to indicate that children permitted fluids up to 120 minutes preoperatively experience higher gastric volumes or lower gastric pH values than those children who fasted." They added that children who are not thirsty and hungry are "better behaved and more comfortable."
Whether these three studies will have an effect on current practice is unknown. In the latter two cases at least, the data were already there and recommendations have been made. For real change to be effected, clinicians and policymakers will need to start paying attention to them. -Doug Brandt
Tranmer JE, et al. J Obstet Gynecol Neonatal Nurs 2005;34(3):319-28;Hartmann K, et al. JAMA 2005;293(17): 2141-8;Brady M, et al. Preoperative fasting for preventing perioperative complications in children (Cochrane review). In:The Cochrane library, Issue 2, 2005. Chichester, UK: John Wiley and Sons; 2005.