Changing Attitudes in Obstetrics and Gynecology - How Evidence Based Medicine is Changing Our Practice?

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Changing Attitudes
in Obstetrics and Gynecology
– How Evidence Based Medicine
is Changing Our Practice?
Hesham Al-Inany and Amr Wahba
Cairo University Hospital,
Egypt
1. Introduction
Evidence-based medicine (EBM) is the process of systematically reviewing, appraising and
using clinical research findings to aid the delivery of optimum clinical care to patients
(Rosenberg and Donald, 1995). It is considered a new trend in both teaching medicine and
supporting the clinical decisive process, answering the clinical questions. The basis of the
evidence-based medicine comprises of analysing and interpreting current and reliable
medical publications concerning certain subject (Laudański and Pierzyński., 2000).
Evidence-based practice is “a process of care that takes the patient and his or her preferences
and actions, the clinical setting including the resources available, and current and applicable
scientific evidence, and knits the three together using the clinical expertise and training of
the health-care providers.” (Haynes et al., 2002).
Thus, EBP as illustrated in Figure (1) is the integration of clinical expertise, patient values, and
the best research evidence into the decision making process for patient care. Clinical expertise
refers to the clinician's cumulated experience, education and clinical skills. The patient
brings to the encounter his or her own personal and unique concerns, expectations, and
values. The best evidence is usually found in clinically relevant research that has been
conducted using sound methodology (Sackett et al., 2000).
Despite its ancient origins, evidence based medicine remains a relatively young discipline
whose positive impacts are just beginning to be validated, and it will continue to evolve
(Bennett et al., 1987; Shin et al., 1993).
The aim of this chapter is to explore different aspects of evidence based medicine including
background on its development, motives towards changing our attitudes in practice and
how can evidence be extracted. The chapter will also highlight the major role of evidence
based medicine in changing attitudes towards evidence based practice which ensures safety
and efficiency of the health service provided, in the field of obstetrics and gynecology; a
domain that has greatly participated in the establishment of evidence based medicine and
evidence based practice. Many examples on how evidence based medicine has changed
attitudes in practice will be displayed to demonstrate and emphasize this role.

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Fig. 1. Evidence Based Practice (EBP)
2. Why changing attitudes in practice
Although clinical research is consistently producing new findings that may contribute to
effective and efficient patient care, the findings of such research will not change population
outcomes unless health services and health care professionals adopt them in practice
(Grimshaw et al., 2001).
However, the enormous volume of information that is published in an ever-increasing
number of available medical journals constitute a major obstacle and a real challenge to
obtaining reliable evidence for clinical practice from research. Over half a million papers on
gynecology, infertility, pregnancy and obstetrics are published each year. To sift through
these MEDLINE records, let alone the full papers that may be relevant, to identify those
which should form the basis of clinical practice is an overwhelming and nearly impossible
task. How, then, can busy clinicians have easy access to, and identify, the most appropriate
information on which to base their clinical decisions? (Dodd and Crowther, 2006).
The contribution of evidence-based medicine to improved patient outcomes in general
practice is incontestable. Evidence based practice promotes practices that have better
outcomes and are scientifically proven to be effective. It aims to eliminate unsound or risky
practices, thus improving quality of care, providing best service to the patient and
promoting patient safety.
Actually, evidence based practice is one step toward making sure that each patient gets the
best service possible. Furthermore, it helps physicians to keep knowledge up to date and
supplements clinical judgment; very vital benefit especially in the light of the rapidly
growing literature and medical advances.

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3. Evidence based and experience oriented practice
Clinical medicine is currently in transition from experience-oriented practice to an evidence-
based one which requires the best available evidence that answers our clinical questions for
better safety and efficacy. However, there is a balance, and even tension, between evidence
and clinical expertise:
"Without clinical expertise, practice risks becoming tyrannized by external evidence, for
even excellent external evidence may be inapplicable to or inappropriate for an individual
patient. Without current best external evidence, practice risks becoming rapidly out of date,
to the detriment of patients." Good doctors use both individual clinical expertise and the
best available external evidence, and neither alone is enough (Sackett et al., 1996).
Evidence based medicine helps clinicians to integrate the best external clinical evidence
from systematic research with individual clinical expertise to make effective decisions about
patient treatment and care.
Best available external clinical evidence means clinically relevant research, often from the basic
sciences of medicine, but especially from patient centred clinical research into the accuracy and
precision of diagnostic tests, the power of prognostic markers, and the efficacy and safety of
therapeutic, rehabilitative, and preventive regimens.
External clinical evidence can inform, but can never replace, individual clinical expertise, and
it is this expertise that decides whether the external evidence applies to the individual patient
at all and, if so, how it should be integrated into a clinical decision (Sackett et al., 1996).
4. How can evidence be extracted?
The best evidence is usually found in clinically relevant research that has been conducted
using sound methodology (Sackett et al., 2000). EBM is not restricted to randomized trials
and meta-analyses. Actually, it involves tracking down the best external evidence with
which to answer our clinical questions.
Thus, to find out about the accuracy of a diagnostic test, we need to find proper cross-
sectional studies of patients clinically suspected of harboring the relevant disorder, not a
randomized trial while for a question about prognosis, we need proper follow-up studies (i.e.
prospective cohort studies) of patients assembled at a uniform, early point in the clinical
course of their disease. And, sometimes, the evidence we need will come from the basic
sciences, such as genetics or immunology.
It is when asking questions about therapy that we should try to avoid the non-experimental
approaches, because these routinely lead to false-positive conclusions about efficacy.
Because the randomized trial, and especially the systematic review of several randomized
trials, is so much more likely to inform us and so much less likely to mislead us, it has
become the "gold standard" for judging whether a treatment does more good than harm
(Sackett et al., 1996).
5. Development of evidence based practice in obstetrics
Although the term ‘evidence-based medicine’ was first used by Gordon Guyatt of McMaster
University, Canada, in 1990, (Guyatt and Rennie, 2002) the development of evidence-based

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practice in obstetrics began in the early 1970s. Archie Cochrane, in his now well-known
writings (Cochrane, 1972), awarded the ‘wooden spoon’ to obstetricians for having made the
poorest use of randomized controlled trials, and having widely incorporated changes into
clinical practice without appropriate evaluation(Cochrane, 1972).
Such observation inspired Iain Chalmers in 1974 to start the enormous task of collecting all
randomized controlled trials related to the field of perinatal medicine. More than 3000 trials
conducted between 1940 and 1984 were identified. This collection was first published in
1985 as the Oxford Database of Perinatal Trials (ODPT) (Chlamers et al., 1986). In 1989, the
first comprehensive synthesis of evidence for pregnancy care, entitled "Effective Care in
Pregnancy and Childbirth" (ECPC), was published; it included systematic reviews of the
identified randomized trials (Enkin et al., 1989).
This two-volume book was condensed into the paperback "A Guide to Effective Care in
Pregnancy and Childbirth (GECPC)" summarizing the available evidence on the effects of
pregnancy care, and categorizing care practices into those with evidence of known benefit,
those of uncertain benefit, and those of known harm (Enkin et al., 1989). All of these early
pregnancy and childbirth initiatives were important forerunners to the Cochrane
Collaboration (The Cochrane Library, 2005).
6. Examples for how evidence based medicine changed practices in
obstetrics and gynecology
We will be displaying in the coming section many practical examples elaborating the great
noticeable role of evidence based medicine in shifting the practices in obstetrics and
gynecology towards better safety and higher efficacy and in eliminating risky unsafe
practices. Evidence based medicine has changed attitudes towards interventions,
therapeutics and diagnostics.
6.1 Changing attitudes towards interventions (evidence based interventions)
What matters in health care is identifying and using interventions that have been shown by
strong research evidence to achieve the best outcomes within available resources for
everyone (Fletcher and Lancet, 1999). Examples for such interventions will be discussed.
6.1.1 The term breech trial
Among most issues in the field of obstetrics that have been very controversial is the breech
delivery. Approximately 4% of all infants are in breech presentation. Delivery in this
position is more difficult, with increased risk of complications to the fetus such as umbilical
cord prolapse, hypoxia, and fetal injury.
Despite increased risks, breech deliveries are usually accomplished without complications
and without the need for ‘expert assistance’ from an experienced, trained clinician or
midwife. However, in the event that expert assistance is needed but not obtained,
permanent damage can occur during breech births because of the lack of appropriate and
well-timed actions by the birth attendant.
Historically, vaginal breech deliveries were considered the norm until 1959, when routine
cesarean delivery was shown to reduce perinatal mortality and morbidity (Wright, 1959).

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While there was a general belief that planned cesarean delivery was better than planned
vaginal delivery for breech deliveries, evidence was inconclusive because most studies were
observational, two small RCTs showed no difference, and evidence suggested that
improved neonatal outcomes might occur at the expense of poorer maternal outcomes.
The Term Breech trial, a multi-center trial across 121 centers in 26 countries randomizing
2088 women to ‘planned cesarean delivery’ or ‘planned vaginal’ deliveries (1997 – 2000). The
trial found during interim analyses that cesarean delivery was associated with a reduced
risk of perinatal morbidity and mortality. The term breech trial had an immediate dramatic
impact on the management of term breech deliveries with policies changed in accordance
with the trials findings. Rapid change in clinical practice occurred in many locations,
although not universally, as some desired more evidence and others were reticent to accept
the trials results as conclusive (Hannah et al., 2000).
Several comparison studies showed alteration of clinical practice via examining rates of
vaginal breech delivery versus cesarean delivery in various countries (e.g., New Zealand,
Australia) (Kaushik and Gudgeon, 2003).
6.1.2 Examples of other obstetrical interventions
There was widespread variation in clinical practice in areas such as the role of external
cephalic version (ECV) for breech presentation (effective in reducing the need for caesarean
delivery), the use of prophylactic antibiotics at caesarean delivery (effective in reducing
maternal puerperal sepsis), the use of antenatal corticosteroids for fetal lung maturation
(effective in reducing the risk of neonatal respiratory disease and mortality in infants born
preterm), the use of vacuum-assisted vaginal births (effective in reducing maternal vaginal
and perineal trauma), and selective versus routine use of episiotomy (effective in reducing
maternal perineal trauma).
The systematic reviews first published in Effective Care in Pregnancy and Childbirth
(ECPC) and The Oxford Database of Perinatal Trials (ODPT), and by the Cochrane
Collaboration Pregnancy and Childbirth review group, summarized the best available
evidence at the time, indicating benefit for all of these interventions. For some of these
interventions, clinical practice has indeed changed.
Prenatal corticosteroids are now widely prescribed for women at risk of preterm birth, with
82% of mothers of infants born at less than 34 weeks’ gestation admitted to the neonatal
intensive care unit in Australia, having been administered corticosteroids prior to birth
(Donoghue et al., 2002). The uptake of ECV for breech presentation at term has been less
successful, with only 67% of obstetricians surveyed in Australia and New Zealand offering
ECV (Phipps et al., 2003).
6.1.3 The obstetrical outcomes after conservative treatment of intraepithelial
neoplasia or early invasive lesions
With the establishment of effective screening programmes for cancer cervix, women are
more commonly diagnosed early with preinvasive lesions and microinvasive cervical
cancers which make younger women with such lesions candidate for conservative treatment
for the sake of preservation of the potential for childbearing.