Second Edition
This edition first published 2017 © 2010, 2017 by John Wiley & Sons, Ltd.
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Library of Congress Cataloging‐in‐Publication Data
Names: Norwitz, Errol R., author. | Saade, George R., 1960– author. | Miller, Hugh S. (Hugh Stephen), author. | Davidson, Christina (Christina Marie) author.
Title: Obstetric clinical algorithms / Errol R. Norwitz, George R. Saade, Hugh Miller, Christina M. Davidson.
Description: 2nd edition. | Chichester, West Sussex, UK ; Hoboken, NJ : John Wiley & Sons, Inc., 2017. | Preceded by: Obstetric clinical algorithms : management and evidence / Errol R. Norwitz ... [et al.]. 2010. | Includes bibliographical references and index.
Identifiers: LCCN 2016024815 (print) | LCCN 2016026085 (ebook) | ISBN 9781118849903 (pbk.) | ISBN 9781118849873 (pdf) | ISBN 9781118849880 (epub)
Subjects: | MESH: Pregnancy Complications–diagnosis | Pregnancy Complications–therapy | Algorithms | Decision Support Techniques
Classification: LCC RG571 (print) | LCC RG571 (ebook) | NLM WQ 240 | DDC 618.3–dc23
LC record available at https://lccn.loc.gov/2016024815
A catalogue record for this book is available from the British Library.
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Cover image: Jasmina/Gettyimages
Recent advances in obstetrical practice and research have resulted in significant improvements in maternal and perinatal outcome. Such improvements carry with them added responsibility for the obstetric care provider. The decision to embark on a particular course of management simply because “that’s the way we did it when I was in training” or because “it worked the last time I tried it” is no longer acceptable. Clinical decisions should, wherever possible, be evidence‐based. Evidence‐based medicine can be defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” [1]. In practice, evidence‐based medicine requires expertise in retrieving, interpreting, and applying the results of scientific studies and in effectively communicating the risks and benefits of different courses of action to patients. This daunting task is compounded by the fact that the volume of medical literature is doubling every 10–15 years. Even within the relatively narrow field of Obstetrics & Gynecology, there are more than five major publications each month containing an excess of 100 original articles and 35 editorials. How then does a busy practitioner maintain a solid foundation of up‐to‐date knowledge and synthesize these data into individual management plans? New information can be gleaned from a variety of sources: the advice of colleagues and consultants, textbooks, lectures and continuing medical education courses, original research and review articles, and from published clinical guidelines and consensus statements. The internet has created an additional virtual dimension by allowing instant access to the medical literature to both providers and patients. It is with this background in mind that we have written Obstetric Clinical Algorithms: Management and Evidence, 2nd edition.
Standardization of management reduces medical errors and improves patient safety and obstetrical outcomes [2,3]. In this text, we have developed a series of obstetric algorithms based on best practice to mimic the decision‐making processes that go on in our brains when faced with a vexing clinical problem. To further facilitate decision‐making, we have superimposed “levels of evidence” as defined by the report of the US Preventive Services Task Force (USPSTF) of the Agency for Healthcare Research Quality, an independent panel of experts appointed and funded by the US government to systematically review evidence of effectiveness and develop recommendations for clinical preventive services [4]. The table below summarizes the ‘levels of evidence’ used in this text.
‘Levels of Evidence’ used in Obstetric Clinical Algorithms: Management and Evidence, 2nd edition:
Color key | Levels of evidence available on which to base recommendations* | Recommendation/suggestions for practice |
Red bold | Level I/II‐1 | Definitely offer or provide this service |
Red regular | Level II‐1/II‐2 | Consider offering or providing this service |
Red italics | Level II‐2/II‐3/III | Discuss this service, but insufficient evidence to strongly recommend it |
Black regular | Level II‐3/III | Insufficient evidence to recommend this service, but may be a reasonable option |
* Levels of evidence are based on the ‘hierarchy of research design’ used in the report of the 2nd US Preventive Services Task Force:
Level I: Evidence obtained from at least one properly powered and conducted randomized controlled trial (RCT); also includes well‐conducted systematic review or meta‐analysis of homogeneous RCTs.
Level II‐1: Evidence obtained from well‐designed controlled trials without randomization.
Level II‐2: Evidence obtained from well‐designed cohort or case‐control analytic studies, preferably from more than one center or research group.
Level II‐3: Evidence obtained from multiple time series with or without the intervention; dramatic results from uncontrolled trials might also be regarded as this type of evidence.
Level III: Opinions of respected authorities, based on clinical experience; descriptive studies or case reports; or reports of expert committees.
Obstetric care providers can be broadly divided into two philosophical camps: those who believe that everything possible should be offered in a given clinical setting in the hope that something may help (also called the “we don’t have all the information we need” or “might as well give it, it won’t do any harm” group) and those who hold out until there is consistent and compelling scientific evidence that an individual course of action is beneficial and has a favorable risk‐to‐benefit ratio (sometimes referred to as “therapeutic nihilists”). As protagonists of the latter camp, we argue that substantial harm can be done—both to individual patients and to society as a whole—by implementing management plans that have not been the subject of rigorous scientific investigation followed by thoughtful introduction into clinical practice. In Obstetric Clinical Algorithms: Management and Evidence, 2nd edition, we provide evidence‐based management recommendations for common obstetrical conditions. It is the sincere hope of the authors that the reader will find this book both practical and informative. However, individual clinical decisions should not be based on medical algorithms alone, but should be guided also by provider experience and judgment.
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