Wednesday, June 29, 2011

The 43 Year Active Management of Labor Project: What have we learned?

The concept of active management of labor is familiar to most maternity care professionals.  This concept was first demonstrated  at the National Maternity Hospital in Dublin Ireland in the late 1960s.

Defined, active management of labor includes two major components.  The first component is the Organizational Component, which many have stated is the most critical of the two.  The Organizational Component includes prenatal education (which includes patient/family education about the birth process and working with labor), daily physician assessment (assessing labor progress, supportive to patient throughout labor and during the postpartum period), bedside support (emotional and educational support at the bedside by staff), and peer reviews of outcomes (evaluate the effectiveness of the approach and possible process improvement).  The other component, the Medical Component, includes a rigid inclusion criteria (ensure only term, umcomplicated nulliparas are actively managed), strict diagnosis of labor (prevent hospital admission in early labor, decrease cesarean rate), early amniotomy (to assess volume and presence of meconium), frequent cervical exams (detect early dystocia and adequate process), and high-dose oxytocin (to correct dystocia with more effective contractions).  All of this with twelve hours believed to be the maximum safe duration of spontaneous labor.

Interestingly, epidural anesthesia is not a component of the active management of labor routine.  To compound this, there is some conflicting research as to the effect of epidural anesthesia on length of labor, depending on the source.  Over all,  it is well known in the literature that women who have inductions have longer labors and higher cesarean rates.

Taking a look at the state of US maternity care today, with pregnancy outcomes (specifically maternal morbidity/mortality and infant morbidity/mortality) not improving (in fact worsening) and the cesarean rate rising significantly since 1968, it is important to assess use of active management of labor prior to its efficacy.  Many birthing facilities and care providers use some of the components of active management of labor, however several items tend to be overlooked or forgotten in the implementation of the process ~ specifically, prenatal education, bedside emotional and physical support and rigid inclusion criteria.  Therefore, with these vital components not being included, any assessment of the efficacy of active management of labor would be incongruent.   Thus, active management of labor may be misunderstood by care providers and misapplied.

One only has to look as far as the Cochrane Database to obtain a summary of RCTs and evidence-based care.  No longer do we have an excuse that evidence-based maternity care continuing education opportunities are beyond reach.  And in this case, ignorance is not bliss.  Nor is it professional.  Expectant parents look to care providers to do just that ~ give care.  Our organizations charge us with providing best practice and quality care.  Conversations, albeit heated ones, exist about the best practice vs best price conundrum.  How dare we, as a society or as a country, put currency before the health of our women and children.  How can our conscience survive knowing that we compromise care, blaming it on "that's the way we've always done it", "that's what our policy says" or more acidic comments such as "if you don't do this, your baby will die" (when in fact, the baby will not die).

Our maternity care practices in the past 43 years have not yielded better results.  The outcry of those pleading for revolutionary change in maternity care are not those who are aggressive, uneducated radicals uncomfortable with 43 years of rituals.  Many are, in fact,  physicians, midwives, nurses, childbirth educators and doulas.  They are authors, speakers, researchers, university professors.

And they all are asking the same question: What have we learned?


Listening to Mothers I & II

Boylan, P.C. Active management of labor: results in Dublin, Houston, London, New Brunswick, Singapore and Valparaiso.  Birth 1989 16: 114-9.

Declercq, E. Macdorman M., Menacker F. Recent trends and patterns in cesarean and vaginal birth after cesarean (VBAC) Deliveries in the US.  Clinical Perinatology 2011 June 38(2) 179-92.

Declercq, E. Macdorman M. Zhang J. Obstetrical intervention and the singleton preterm birth rate in the US 1991-2006. American Journal of Public Health 2010 Nov 100(11) 2241-7.

Declercq, E. Macdorman M., Menacker F. Neonatal mortality risk for repeat cesarean compared to VBAC in the US 1998-2002 birth cohorts.  Maternal and Child Health Journal 2010 Mar 14(2) 147-54.

Florence DJ, Palmer, D. "Therapeutic choices for discomforts of labor" Journal of Perinatal and Neonatal Nursing 2003 Oct-Nov 17(4) 238-49

Impey L. Boylan P. Active management of labor revisited.  British Journal of Obstetrics and Gynecology. 1999 106:183-7.

James D.C. "Routine obstetrical interventions: research agenda for the next decade." Journal of Perinatal and Neonatal Nursing.  2011 Apr-Jun 25(2): 148-52

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