MEDIA REVIEWS

Family Practice ObstetricsStephen D. Ratcliffe, Elizabeth G. Baxley,Janis E. Byrd, and Ellen L. Sakornbut

2nd Edition, 2001Hanley and Belfus, Inc.,

Philadelphia, PAwww.hanleyandbelfus.com

688 pp, $55 (US) $60 (outside US), pb

Following closely on the heels of the third edition ofA Guide to Effective Care in Pregnancy and Childbirth,comes the second edition of another indispensablereference text for those who are learning and provi-ding primary care obstetrics—Family Practice Ob-stetrics.

Although one might expect a textbook of pri-mary care obstetrics to focus predominantly onlow-risk birth, this is not the case here. The editorsstate ‘‘in some settings family physicians are morelikely to be providing care to high risk and indigentpopulations than are their obstetrical colleagues,’’and ‘‘family physicians continue to provide birthcare in settings where there are no obstetric consultsavailable.’’ Since the book is written by familyphysicians, it models the philosophy of patient-centered, prevention-oriented, and educational care.‘‘Family-centered birthing defines the birth processas a normal physiologic process that should bemanaged expectantly, positively, and conservativelywith the expectation of a good outcome untilproved otherwise.’’

Family Practice Obstetrics is extraordinarily com-prehensive, with 20 chapters, which are furtherdivided into succinct subsections. Unlike the firstedition, these subsections are delineated in thecontents page for easier reference. Many sectionsare supplemented with tables, where the reader canobtain more detailed information. There are 32contributing authors (more than double the firstedition), bringing an overall wealth of expertise andperspective to this publication.

The book moves chronologically through preg-nancy, beginning with obstetric risk management, thecontent of prenatal care, and patient and familyeducation. It then discusses problems encountered inpregnancy: pregnancy-related complications, under-lying medical disorders, common discomforts inpregnancy, and psychiatric issues. The seven subse-quent chapters review antenatal assessment, laborissues (preterm, normal, and abnormal), intrapartumcomplications, malpresentations, and intrapartumprocedures. The final chapters deal with newbornissues in the first month of life as well as postpartummedical and psychiatric concerns.

Almost all chapters in this edition have beenexpanded, and additional subsections now addressalternative medicine and prenatal care, exercise inpregnancy, return-to-work issues, persistent occiputposterior, and infection in the newborn. An entirelynew chapter on mental health issues in pregnancy wasadded. Like its predecessor, the authors rely heavilyon The Cochrane Library and the Cochrane summarytables. The editors have introduced the concept ofnumber needed to treat in several subsections, with arelated appendix on measuring clinical effectiveness.

Newly added to the section on screening inpregnancy are recommendations from the UnitedStates Preventive Task Force. The discussion onmanagement of labor uses the World Health Organ-ization classification of practices in normal birth.This resource appropriately divides obstetric routinesand procedures into those that are useful, ineffective,or harmful; often used inappropriately; or wherethere is insufficient evidence for or against. The‘‘Fetal Tolerance of Labor’’ subsection (previouslycalled ‘‘Fetal Distress’’) uses the National Institutesof Health guidelines for interpretation of electronicfetal monitoring. As a reader from north of the 49thparallel, I was also pleased to see the inclusion ofevidence in some areas from the Society of Obstetri-cians of Gynecologists of Canada, and the CanadianTask Force on the Periodic Health Examination.

Discussions in other areas of controversy andchanging practice have been expanded, such asgestational diabetes, group B streptococcus screen-ing, triple screening for fetal anomalies, the use ofregional anesthesia, prelabor rupture of membranesat term, and prostaglandins for labor induction.

Clearly not all obstetric interventions and practiceshave been subjected to extensive randomized con-trolled trials, and thus the authors have had to rely onother levels of evidence. In these situations, which areoften controversial, it would have been good to seemore detailed discussions of the actual source andquality of evidence for statements and recommenda-tions in some areas, such as the association ofperiodontal disease with preterm labor, interventionsto prevent preterm birth, much of the section onalternative medicine, antenatal testing (particularlythe contraction stress test), weight gain in pregnancy,and management strategies for women with anelevated alpha-fetoprotein level and no obviousabnormalities.

Textbook authors must also struggle with thepublication of new, relevant meta-analyses and otherevidence-based reports that appear simultaneouslywith their work. Family Practice Obstetrics is notimmune from this, since they have not included therecent Agency for Health Care Research and Quality

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and Cochrane database reviews on the treatment ofhypertension in pregnancy. In addition, the termbreech trial and a subsequent updated Cochranereview on this subject have recently been published.

With these minor limitations, Family PracticeObstetrics does an admirable job of providing acomprehensive and evidence-based overview of theentire subject area of relevance to those of us whoprovide primary obstetrics care to women in a varietyof settings, including those involving higher riskpatients. A monumental effort, this edition had addedsignificantly more evidence and discussion in all areas,with the inclusion of some entirely new subjects.Those of us involved in teaching will also find this anexcellent reference manual for medical students andresidents–it will be one of those books that I will needto chain to my desk. Family Practice Obstetrics sitsright next to An Effective Guide to Pregnancy andChildbirth on my obstetrics resource shelf.

Elizabeth Shaw, MDAssistant Professor of Family

Medicine McMaster UniversityDepartment of Family Medicine1200 Main Street W. Hamilton,

Ontario L8N 3Z5, Canada

Humane Perinatal CareBeverley Chalmers and Adik Levin

2001 TEA Publishers, Ltd. 28 Liivalaia Str., 10118,Tallinn, Estonia Fax: 372 6 459 208;

e-mail export@tea.ee 111 pp, $17.00, pbNote: If readers experience difficulties ordering the

book from Estonia, please contactDr. Beverley Chalmers, e-mail: bevc@cgocable.net.

This is a clearly and passionately written book, givingevidence for and advocating an increasingly higherstandard of humane perinatal care worldwide. It isthe product of an unusual collaboration and ongoingwork between the psychologist Beverley Chalmers, ofToronto, Canada, and the neonatologist Adik Levinof Tallinn, Estonia, in the former Soviet Union.

Professor Chalmers and Dr. Levin met in 1992 inRussia at the launch of the Baby Friendly HospitalInitiative there, sponsored by UNICEF and theWorld Health Organization. They found that theyshared a common belief and history of work showingthat mothers and their preterm or ill babies shouldnot be separated and should be breastfed. Dr. Levin,especially, had been courageous in starting, morethan 20 years ago, a rooming-in unit for preterm andsick babies and their mothers, thereby flying in theface of strong current regulations and custom in theformer Soviet Union.

The book is divided into three sections. The firstsection, titled ‘‘Humane Neonatal Care Initiative,’’describes Dr. Levin’s neonatal unit. Here, pretermor ill babies and their mothers (and fathers) areencouraged to be together 24 hours a day, withcomfortable rooming-in and innovative bedding-infacilities. Continuous skin-to-skin contact is expec-ted, and breastfeeding is totally supported. More-over, and going beyond what we generally do inthe West, care is given predominantly by mothers,assisted by professionals. The approach is asdemedicalized as is appropriate for an individualbaby. Medical procedures are grouped to provideas little pain and disturbance to the baby aspossible, and only what is essential is done. Themother-baby unit, not the professionals, is thecentral focus.

Early results using these advanced methods show agreater weight gain in babies largely cared for bymothers rather than nurses, less infection, less use oftherapies, earlier discharge, and less cost. Thesecertainly are win/win results, in line with the workof John Kennell and Marshall and Phyllis Klaus, andthe studies on kangaroo care. More extensive studies,and over a longer period in the life of the family,would be helpful, and also might very well substan-tiate psychological benefits.

The second section of the book broadens the scopefrom the preterm or ill baby and his or her parents tolook at humane perinatal care worldwide (theauthors’ unique perspective), which is defined as‘‘the practice of family-centered, psycho-socially sen-sitive, multiculturally adapted, multidisciplinary, evi-dence-based care...’’ This means for all parents,everywhere, throughout the childbearing cycle, stress-ing that it is the parents who must have the power,with professionals providing information and appro-priate assistance. Obviously, various areas of theglobe exhibit wide variation. For example, in theWestern world we are at least used to the idea thatwomen should have a voice, which they may not havein Eastern European or other countries. On the otherhand, postpartum care may be much more supportivein the former Soviet Union.

Humane Perinatal Care contains a number ofexcellent sections—an especially strong one is onsensitivity to previous violence and (sexual) abuse,and the implications of this for obstetrical andlifelong gynecological procedures. Another excellentsection, and a bright spot, is on demedicalizingperinatal care and the appropriate use of technologythrough evidence-based care as shown in the Coch-rane Collaboration.

The third and final section of this book addressesissues for the future. Many questions are raisedabout the status quo and the need by healthprofessionals to challenge it through evidence-basedresearch. Possible topics are listed. The UnitedNations and its agencies and declarations are dis-

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cussed as a positive force for implementing changeglobally. Finally, a website is listed for references andcontact: www.hnci.ee.

This little book has a great deal to say, and it is astrong, thoughtful, and cogent voice for humaneperinatal care worldwide. It is a worthy continuationand update to the classic Implementing Family-

Centered Maternity Care with a Central Nursery,by Doris and John Haire (1971), and as such, Istrongly recommend it.

Ruth T. Wilf, CNM, PhD712 Arlington Road

Narbeth, Pennsylvania 19072-1503

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