Chilliwack Journal Club - April 4th, 1996 (fwd) TEXT
From: Michael Klein (mklein@unixg.ubc.ca)
Tue Apr 30 22:26:09 1996
Here is the text as promised
Michael
---------- Forwarded message ----------
Date: Tue, 30 Apr 1996 11:48:10 -0700 (PDT)
From: Mark Longhurst <longm@unixg.ubc.ca>
To: ubc-family@unixg.ubc.ca
Subject: Chilliwack Journal Club - April 4th, 1996
>
> Journal Club - April 4, 1996
> Presented by John Hamilton, 2nd Year Resident
>
>Clinical Question:
>
>Does "active management of labour" decrease the rate of cesarean sections?
>
>Question Background
>
>John had heard Dr. Michael Klein (a UBC-FAMILY member) talk about O'Driscoll's
>study with active management of labour and his reported 4.8% cesarean rate.
>Repeated studies have supported O'Driscoll's study (which was done in 1984)
>and the
>ACOG guidelines mention active management of labour in their standards.
>
>Article Reviewed:
>
>Authors
> Frigoletto FD Jr. Lieberman E. Lang JM. Cohen A. Barss V. Ringer S.
> Datta S.
>Institution
> Department of Obstetrics and Gynecology, Brigham and Women's Hospital,
> Boston, MA, USA.
>Title
> A clinical trial of active management of labor.
>Source
> New England Journal of Medicine. 333(12):745-50, 1995 Sep 21.
>Abstract
> BACKGROUND. Active management of labor is a multifaceted program that, as
> implemented at the National Maternity Hospital in Dublin, is associated
> with a lower rate of cesarean delivery than the rate usually found in the
> United States. We conducted a randomized trial to evaluate the efficacy of
> this approach in lowering the rate of cesarean section among women
> delivering their first babies. METHODS. We randomly assigned 1934
> nulliparous women at low risk of complications of pregnancy, before 30
> weeks' gestation, to active management of labor or to a usual-care group.
> The components of active management were customized childbirth classes;
> strict criteria for the diagnosis of labor; standardized management of
> labor, including early amniotomy and treatment with high-dose oxytocin;
> and one-to-one nursing. A low-risk subgroup was defined as including women
> with full-term, uncomplicated pregnancies who spontaneously went into
> labor (the protocol-eligible subgroup). Women meeting these criteria who
> had been randomly assigned to the active-management group were admitted to
> a separate unit where their labor was managed by trained, certified
> nurse-midwives. RESULTS. There was no difference between groups in the
> rate of cesarean section either among all women (active management, 19.5
> percent; usual care, 19.4 percent) or in the protocol-eligible subgroup
> (active management, 10.9 percent; usual care, 11.5 percent). In the
> protocol-eligible subgroup, the median duration of labor was shortened by
> 2.7 hours by active management (from 8.9 to 6.2 hours), and the rate of
> maternal fever was lower (7 percent vs. 11 percent, P = 0.007). The
> percentage of women in whom labor lasted longer than 12 hours was three
> times higher in the usual-care group than in the active-management group
> (26 percent vs. 9 percent, P < 0.001). CONCLUSIONS. Active management of
> labor did not reduce the rate of cesarean section in nulliparous women but
> was associated with a somewhat shorter duration of labor and less maternal
> fever.
>
>Discussion:
>
>Statement of Purpose:
>
>Good statement of purpose. The paper clearly stated that "we conducted a
>randomized trial to evaluate this strategy [active management of labour]
>for lowering the rate of cesarean section in nulliparous women" (pg. 745).
>
>Study Design:
>
>This is a randomized trial - through telephone contact.
>They could not double or single blind the patients or the health
>care workers for this study.
>
>Population studied
>
>1. Subjects were recruited from 17 prenatal care sites, they were nulliparous,
>at least 18years old, english speaking and planning to delivery their
>babies at Brigham and Women's Hospital in Boston. Women at risk
>for preterm or cesarean deliveries were ineligible. We are not told any
>information about the women's ethnicity - a factor that may have impact
>on the length of time of labour and cesarean rate.
>
>2. All subjects were accounted for in the analysis however, 19 people
>dropped out from the study - and were not included in the analysis (we
>discussed whether drop outs should automatically be grouped with the
>ones who didn't have successful outcomes with the treatment).
>
>Methodology:
>
>1. While the methodology for the treatment group (the "active management
>of labour" group) was well described in this paper, we have very little
>information
>on the control group.
>
>2. We are not told WHO is providing the "active management of labour" .
>Very little information is provided as to the physicians or the nurses who
>are providing care for either the control group or the treatment group.
>
>Outcome of Study:
>
>The study found that there was no difference in the rate of cesarean
>section, between the treatment and control group. Nor was there any
>difference between the two groups in the frequency of jaundice, seizures,
>treatment for sepsis, resuscitation at birth or admission to the neonatal
>intensive care unit. The only difference was a lower incidence of fever
>in the "active management of labour group" (the treatment group).
>
>The authors discuss the possibility of the Hawthorne effect influencing
>the outcome - in other words, because they were watching the rate of
>cesarean sections, the rates were lower in the usual-care group (control
>group) were lower and therefore, did not differ significantly from the
>treatment
>group.
>
>Discussion surrounding issues prompted by paper:
>
>1. One of the key elements of this and the O'Driscoll study is the definition
>of "labour". Apparently O'Driscoll's study defined labour as 3-4 cm cervical
>dilation - the criteria in this study were painful contractions accompanied by
>effacement of at least 80 per cent, bloody show (not precipitated by vaginal
>examination), or spontaneous rupture of the membranes. If we are going to
>compare outcomes, (i.e. this study versus O'Driscoll's) , then the definitions
>of labour should be the same.
>
>2. The motivation for doing this and other studies like this was discussed
> - the feeling that Insurance Companies (especially in the United States)
>will be motivated to conduct studies like this one to see if there is a way to
>reduce surgery, length of stay and therefore costs for the company.
>
>How Will This Paper Influence Your Practice?
>
>While this particular paper won't change his practice, John stated that
>he is very interested in learning more about active management of labour
>and wanted to keep investigating it's usefulness for his patients.
>
