Psychosocial support or active management of labour or both to improve the outcome of labour
Scientific principles guiding the management of labour were introduced to reduce maternal and later fetal mortality and morbidity. While the decline in mortality and morbidity rates has slowed or reached a plateau, obstetric intervention rates are still on the rise. The caesarean section rate in England has risen from less than 3% in the 1950s to 11% in 1989–1990, and to about 15% in 1994–19951. The apparent lack of correlation between increasing intervention and reduction in fetal morbidity and mortality brings into question current policies for the management of labour. These are derived to agreater or lesser extent from the concept of the active management of labour based on the premise of reducing maternal and fetal morbidity, by anticipating and acting prior to the events that can adversely affect the mother or fetus. The principles of active management of the first stage of labour include a one-to-one support of the labouring woman, anticipation and early diagnosis of abnormal labour and active intervention. The intervenetions are reassurance, artificial rupture of membranes, oxytocin infusion to augment uterine contractions, appropriate pain relief, adequate nutrition and hydration, and continuous surveillance of the mother and the fetus. Although there is some evidence to support the overall concept of active management of labour, the evidence that each of these steps are of benefit is less clear2,3. On the other hand, there is some evidence to suggest that psychosocial support during labour may produce a better outcome of labour4,5. A brief review of psychosocial support and active management and their influence on the outcome of labour may help us to evaluate our own practice.
Psychosocial support in labour
Social support and its influence on the outcome of labour has been the subject of several studies in recent years6–10. A meta-analysis by Zhang et al8 considered four studies in young primiparae from low socioeconomic groups who were delivered in busy labour wards. Support by an attendant throughout labour reduced the duration of labour by 2.8 h (95% confidence interval (CI)-2.2–3.4), the oxytocin augmentation rate (relative risk (RR) 0.46,95% CI 0.3–0.7) and operative delivery rates (forceps delivery RR 0.46, 95% CI 0.3–0.7; caesarean section RR 0.54%, 95% CI 0.4–0.7). Mothers who received such support also reported greater levels of satisfaction in the postpartum period.
Chalmers and Wolman7 reviewed the benefits according to the type of individual who gave the social support during labour. Support given by fathers, family members, friends, untrained lay supporters, medical staff and trained labour coaches or doulas were considered. Untrained female supporters known or not known to the labouring woman gave the maximum benefit. Of the trained personnel, support by a doula was found to give the best results. The benefit of support by fathers was variable. Little benefit was seen with family or friends, and there was some positive effect with medical staff.
In contrast, a recent study by Langer et al.5 showed only marginal positive effects on a small number of out-comes with support in labour with doulas. There was some reduction in the duration of labour. Women's perception of control over their labour and delivery was better. More women took to exclusive breastfeeding, and there was a higher level of understanding about breastfeeding in the supported group. However, every woman had augmentation in labour with oxytocin, which appeared to be a routine policy in the study. There was no reduction in the rates of epidural analgesia, which again appeared to be a routine procedure, since more than 80% of the women had epidural analgesia in both groups. Although there were no differences in the rates of operative delivery, a sub-group analysis of women who were admitted at < 4 cm cervical dilatation (n= 161) showed a trend towards reduction in the rate of caesarean section: 18/70 (26%) in the intervention group compared with 33/91 (36%) in the control group (χ2= 2.03; P= 0.16). There was no difference in the condition of the newborn infants in the two groups. There was no improvement in mothers' anxiety, self esteem, and perception of pain or satisfaction with her labour. The authors concluded that the attitude or philosophy of the caregivers and how they manage labour rather than social support had a greater influence on the outcome of labour.
In the UK intervention rates have increased despite management policies which encourage social support in labour from the woman's partner and midwife. The reason for this may lie in the conclusion of the study by Hodnett4 which states that “the continuous presence of a trained support person reduced the likelihood for pain relief, operative vaginal delivery, caesarean delivery, and a 5 minute Apgar score < 7. This support included continuous presence, the provision of hands-on comfort, and encouragement”. The ‘continuous’ one-to-one care may be lacking and provision of such care may have economic implications. In addition to such care, there may be differences in active management policies in the UK which have to be examined.
Active management of labour
Although there are studies to support the principles of active management of labour2,11, there are differences in practice because of inadequate evidence to support the individual components. Some centres augment labour if the progress of cervical dilatation is to the right of a line drawn at 1 cm/h11; others take action using a labour stenci112 or a line drawn 3 cm parallel and to the right of a line drawn at 1 cm/h2. Different action lines may lead to different rates of augmentation. There is no evidence from randomised trials to suggest that early augmentation of labour with amniotomy with or without oxytocin titration will reduce the caesarean section There is little consensus regarding the target uterine activity that should be achieved with oxytocin titration to optimise the outcome of labour, although a target of 4 to 5 contractions in 10 minutes with each contraction lasting > 40 seconds has been suggested15. There is inadequate evidence to suggest the optimum duration of labour that may result in a vaginal delivery, in the absence of fetal hypoxia or cephalopelvic disproportion. Some studies have considered 6 to 8 hours to be optimum2,16. These issues need to be studied if women are to benefit by a policy of active management.
The high rates of obstetric intervention are unlikely to be due to inadequate or inappropriate medical training. Medico-legal considerations or the influence of one or two individuals may affect practice. That the latter may be a possibility was illustrated by the fact that every woman had an intravenous line in labour and augmentation with oxytocin and that more than 80% had epidural analgesia in the study of Langer et al.5; private practice may influence the likelihood of obstetric intervention, but this was not the case in this study. The policy of continuous one-to-one support is an important one and is a key element of Changing Childbirth in the UK, but achieving this has significant cost implications. The differences in the elements that constitute active management of labour merit further investigation, but the question posed by Langer et al.5 is more fundamental than these issues: does each centre have a policy concerning active management of labour, especially as regards oxytocin augmentation and epidural analgesia? Introduction of a policy which includes all the components of active management of labour may help to reduce the high rates of augmentation of labour, epidural analgesia, and possibly operative delivery, as was shown in the WHO study2. It is difficult to change management in another centre, especially in another country, simply by stating that a different policy is likely to give better results. In order to find out whether the introduction of a new policy is acceptable locally, a randomised trial of two different intervention policies in labour has to be conducted, with doula support in both groups. Answers obtained by such a study are more likely to be accepted by that hospital and others in that country. National societies and international organisations should support and encourage local physicians to conduct such studies.
Continuous evaluation of our own practices should also lead to better outcomes of labour. In the UK there is dissatisfaction regarding the variation in protocols for the management of labour, possibly because these are based on unsatisfactory evidence, or because practice does not follow the protocols17. Continuous review of our practice and formulation of policies and protocols based on the results of these reviews should improve the care given to women and their infants.