Where has evidence come from, what do we have now and what will we have in the future?

Examining the evidence for The International Confederation of Midwives’ essential competencies for midwifery practice

OBJECTIVE

to present the evidence for inclusion of selected midwifery tasks (skills) as essential practice competencies for midwives throughout the world. The tasks addressed are those presented to the International Confederation of Midwives (ICM) Council of Delegates in 2002 for discussion and adoption, based on the fact that during field-testing, notable variance was encountered.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

evidence-based practice should be characterised by the use of best practices derived from rigorous research, combined with and balanced by client perspectives and the expert judgement based on the critical thinking of the clinician. Much of midwifery practice is considered an art based on common sense, tradition, and woman-centred approaches to caring, as most of the women who seek midwifery care are healthy and require a health-promotion model of care that may not easily lend itself to examination by scientists or clinicians. However, when intervention is indicated to save the lives of mother, baby, or both, those interventions must be based on the best available evidence from a variety of sources leading to the most effective choices for action. The ICM Essential Competencies for Midwifery Practice (2002) are based on evidence derived from a variety of quantitative and qualitative methodologies. Expert clinical consensus may serve as to the best form of evidence at certain points in the evolution of knowledge. Every midwife needs to understand where the gaps exist in supporting traditional practices that have yet to be fully examined in a scientific manner. In summary, a multi-matrix or triangulated approach may be most appropriate to the delineation of evidence underpinning best midwifery practice.

Prevention of urinary and anal incontinence: role of elective cesarean delivery

PURPOSE OF REVIEW

Currently, prophylactic elective cesarean to prevent incontinence is being promoted without robust evidence supporting it, this has created confusion among health personnel [corrected]. Past research centered on defining the damaging effect of vaginal birth on continence whilst the limited research on elective cesarean considered it protective. Cesarean delivery has economic, obstetric, gynecological and psychosocial consequences, but incontinence is not uncommon with a persistent morbidity. There is confusion among health personnel about advocating elective cesarean delivery to prevent incontinence. Reviewing current research would facilitate obstetric thinking.

RECENT FINDINGS

Multiplanar endosonography and three-dimensional magnetic resonance imaging scanning are reportedly better in delineating structural alterations in the continence mechanism following vaginal birth and could be applied to postcesarean incontinence. Incontinence can follow vaginal or elective cesarean delivery and the severity following either mode is comparable. Urinary incontinence can resolve, persist or start de novo and the primiparous prevalence is similar following cesarean or vaginal birth. Transient anal incontinence can manifest during pregnancy. Paradoxically, pelvic floor strengthening exercises are beneficial for pregnancy-related incontinence, yet urinary incontinence occurs in nulliparas notwithstanding a strong pelvic floor.

SUMMARY

Improved imaging techniques should promote a better understanding of postcesarean incontinence. Since severe incontinence can occur after elective cesarean, its reportedly preventative role deserves more scrutiny. When incontinence occurs without labor, it is transient or shows exercise-related improvement; the role of elective cesarean delivery seems tenuous and needs careful evaluation. Current evidence does not support the routine use of elective cesarean to prevent incontinence so the delivery mode should continue to be dictated by obstetric considerations.