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RESEARCH: Helen Cheyne, Vanora Hundley, Dawn Dowding, J Martin Bland, Paul McNamee, Ian Greer, Maggie Styles, Carol A Barnett, Graham Scotland, and Catherine Niven Effects of algorithm for diagnosis of active labour: cluster randomised trial BMJ 2008; 337: a2396 [Abstract] [Full text]

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Research into effective care in early labour: Where do we go from here?

Mechthild M Gross   (12 December 2008)

labour -diagnosis

koneru gangadhara rao, Helen Cheyne, Vanora Hundley, Dawn Dowding, J Martin Bland, Paul McNamee, Ian Greer, Maggie Styles, Carol A Barnett, Graham Scotland, and Catherine Niven   (30 December 2008)

Research into effective care in early labour: Where do we go from here? 12 December 2008
Mechthild M Gross, PhD, Senior Research Fellow Hannover Medical School, Midwifery Research Unit, Dept. Obs, Gyn & Reproductive Medicine Send response to journal: Re: Research into effective care in early labour: Where do we go from here?	Dear Editor, The trial conducted by Helen Cheyne and colleagues (1) did not succeed in proving the effectiveness of an algorithm in assisting midwives with the diagnosis of active labour in primiparous women. The use of the algorithm did not reduce the number of women who received oxytocin or other medical interventions as compared with standard care. Despite its unanticipated result, the fact that it was possible for this adequately powered study to be conducted is a great step forward, even though this may be measured more in terms of the questions it raises than of satisfactory answers given. While the results of the comparison between using an algorithm for diagnosing labour and standard diagnosis (1) are disappointing at first glance, what is really interesting is that this randomised controlled study turns out to be one more in a series where a care-related intervention during early labour did not achieve the anticipated success regarding outcomes (2-4). These studies make comparisons between telephone advice and a home visit during early labour (2), between a structured early labour assessment programme and standard care (3), or between a home visit and standard care (4). All these studies aimed to optimise care during early labour before admission or the timing of admission itself with a view to influencing the need for intrapartum interventions after admission and/or the mode of birth, but all without success with regard to their respective primary outcomes. Women differ in their reasons for seeking admission to a labour suite during early labour. Their symptoms may vary from sleeping disorders and emotional upheaval to bloody show or watery fluid loss. All these self- diagnosed symptoms show characteristic variations in the median interval between their occurrence and the professional diagnosis of the onset of labour (5). But most of these differences do not amount to an overall (adjusted) difference when multivariate analysis has been performed (5). The position is probably similar with regard to those secondary outcomes in the Telsis trial (1) related to duration of active labour, time from the first admission assessment to delivery, and time from final admission to labour suite until delivery: None of these intervals mentioned as secondary outcomes in the Telsis trial (1) differ significantly between the experimental and the control group. The most likely reason for the variations in the distributions of interval lengths and further outcomes being less than significant is the fact that the really important factors leading to oxytocin administration or other medical interventions were distributed equally between the two groups. It must be frustrating for researchers, caregivers, funders, editors and ultimately also for the women undergoing childbirth not to know what is beneficial during early labour. It is even more disappointing to come to the conclusion that the testing of better forms of care by means of randomised controlled trials leaves us with more open than answered questions. Where should we go from here? Women come to hospital not always knowing whether it is time to present themselves or not. Anecdotally, I observed that a woman who experienced forceps delivery had a good birth experience overall because of the “spoiling” care she received during early labour. She reported to me that the “more than needed care” during early labour compensated for her difficult experience later on in the birth process. This report raises some questions. Are we choosing the right outcomes? How do we define onset of labour? When do we apply appropriate interventions? Effective care in early labour is essential for an optimal childbirth. The gold standard in investigating effective care during labour used to be randomised controlled trials. Even if various randomised controlled trials have had negative results (1,2-4), this does not mean that the rationale for conducting them was poor. With hindsight, the conclusion may be drawn that these trials were not designed as well as they might have been in respect of achieving an improved outcome compared to the standard form of care. This knowledge was not available to the researchers when they planned their studies. Currently it seems that gaining new knowledge regarding effective early labour care will require some consideration of what makes sense and what doesn’t in terms of the normal process of birth. Researchers should not ignore this insight. Otherwise randomised controlled trials might become a red herring in future research into effective care in early labour. References 1. Cheyne H, Hundley V, Dowding D, Bland JM, McNamee P, Greer I, Barnett CA. Scotland G Niven C. The effects of an algorithm for diagnosis of active labour: a cluster randomised trial. BMJ 2008; 2. Hodnett E, Stremler R, Willan AR, Weston JA, Lowe NK, Simpson KR, Fraser WD, Gafni A, the SELAN Trial Group. Effect on birth outcomes of a formalised approach to care in hospital labour assessment units: international, randomised controlled trial. BMJ 2008;337:a1021 3. Janssen PA, Still D, Klein MC, Singer J, Carty EA, Liston RM et al. Early labor assessment and support at home versus telephone triage. Obstet Gynecol 2006;108:1463-9. 4. Spiby H, Green JMG, Renfrew MJ, Crawshaw S, Stewart P, Lishman J et al. Improving care at the primary/secondary interface: a trial of community-based support in early labour. The ELSA trial. Final report submitted to the National Co-ordinating Centre for NIHR Service Delivery and Organisation (NCCSDO), under peer review. 2008 5. Gross MM, Hecker H, Matterne A, Guenter HH, Keirse MJNC. Does the way that women experience the onset of labour influence the duration of labour? BJOG 2006;113:289-94. Competing interests: None declared
labour -diagnosis 30 December 2008
koneru gangadhara rao, professor nri medical college,vijayawada-10,ap,india, Helen Cheyne, Vanora Hundley, Dawn Dowding, J Martin Bland, Paul McNamee, Ian Greer, Maggie Styles, Carol A Barnett, Graham Scotland, and Catherine Niven Send response to journal: Re: labour -diagnosis	It is difficult to diagnose early labour and often many use induction drugs,analgesics un neccessarily.In doubtful cases we can take electronic foetal monitoring tracings of uterinetocogram and foetal heart tracings.By seeing tocogram pressures,clincal palpation,vaginal examination we can screen the cases easily whether they are in labour or not and rationalise the use of drugs accordingly. Competing interests: labour diagnosis,use of drugs