Recommendations for research
The guideline committee has made the following recommendations for research.
As part of the 2017 update, the committee removed a research recommendation on intermittent auscultation compared with cardiotocography. Details can be found in addendum 190.1.
As part of the 2016 update, the standing committee made an additional research recommendation on different models of midwifery-led continuity of care, which was adapted from research recommendation 8 in the 2007 full guideline. Details can be found in addendum 190.2.
What are the clinical and cost effectiveness of midwifery-led continuity of care compared with standard care in the UK for healthy pregnant women, their babies and healthcare professionals throughout the antenatal, intrapartum and postnatal periods?
Midwifery-led continuity of care encompasses both continuity of care and relational continuity. Relational continuity involves the woman being cared for by a known midwife (or midwives) during pregnancy and birth. Standard care for healthy pregnant women in the UK is midwifery-led care in which the woman is cared for by a midwife or midwives during pregnancy and birth, from the booking appointment to sign-off. This includes varying degrees of continuity of care and relational continuity. A study comparing midwifery-led continuity of care with standard UK practice will determine the clinical and cost effectiveness of midwifery-led continuity of care. This will allow recommendations on this topic to be included in future updates of this guideline.
How does the provision of accurate, evidence‑based information affect women's decision‑making processes and choice of place of birth?
A report by Coxon et al. (2013) identifies in detail why women make choices about where to give birth and how these choices can be influenced. Influences may include written and verbal information (both online and from midwives and doctors), previous experience, and word‑of‑mouth advice from friends and family. The Birthplace study concluded that giving birth outside an obstetric unit is the optimal choice for low‑risk women. This finding should be used to restructure the way in which information is provided, so that it is presented in a more accurate, less risk‑based way in order to support women's choices. This change should be evaluated in a quantitative observational study and/or qualitative study that records any changes in women's choice‑making about place of birth. Outcomes include understanding why and how women make choices about where to give birth and how this can influence the provision of appropriate and accessible information, a measure of informed decision‑making, and fearfulness and absence of fearfulness when choosing place of birth.
What are the long‑term consequences for women and babies of planning birth in different settings?
The long‑term consequences of birth experiences and birth outcomes are poorly understood, particularly in relation to place of birth. A large population‑based observational study would compare women's experiences and outcomes in different birth settings (with subgroup analysis by mode of birth) in relation to the wellbeing of the women and their children over different periods of time (for example, 2, 5, 10, 15, 20 and 30 years). A secondary analysis could compare different providers where birth philosophies are different. Outcomes would be compared by accessing medical records and through qualitative interviews. Primary outcomes are long‑term physical morbidity, pain after birth, readmission to hospital, infection, psychological morbidity (for example, postnatal depression, bonding, relationship breakdown with partner, fear of giving birth in future) and breastfeeding rates. Secondary outcomes are impact on attachment between mother and child, obesity in children, autoimmune disease, chronic illness, educational achievement and family functioning.
Does enhanced education specifically about the latent first stage of labour increase the number of nulliparous women who wait until they are in established labour before attending the obstetric or midwifery unit (or calling the midwife to a home birth), compared with women who do not receive this education?
Studies show that antenatal education about labour and birth in general makes a difference to some birth outcomes, but there is limited evidence focusing on education about the latent first stage of labour specifically. The aim of this study (randomised controlled trial or prospective observational study) would be to compare 2 groups of women experiencing their first labour and birth: a group who receive an education session in late pregnancy covering what to expect in the latent first stage of labour and how to recognise the onset of established labour, and a group who have not received this focused education. Primary outcomes would be mode of birth, satisfaction with the birth experience and the woman's physical and emotional wellbeing after birth. Secondary outcomes would be use of pharmacological pain relief, use of oxytocin to augment labour, and time from first contact in confirmed established labour to birth.
What is the most effective treatment for primary postpartum haemorrhage?
There is uncertainty about the most effective drug treatments and dosage regimes, and about which other treatments should be used, for women who develop a postpartum haemorrhage. The most effective sequencing of interventions is also uncertain. The psychological impact of postpartum haemorrhage for women can be significant, and identifying the approach that minimises this impact is important. Randomised controlled trials comparing different dosage regimes for oxytocin and misoprostol, as well as comparisons with ergometrine and carboprost, are needed. Trials of mechanical measures such as intrauterine balloons or interventional radiology as early second‑line treatment (rather than an alternative drug treatment) are also needed. Alternatively, a trial comparing the effectiveness of a complex intervention (for example, an educational component, sequence of interventions, immediate feedback and quality improvements) compared with standard care could be undertaken. Important outcomes include blood and blood product transfusion, need for further intervention, need for hysterectomy and psychological outcomes for the woman.