Normal Labour and Interventions - Case Study Example

Are low risk women in normal labor receiving too many interventions Background Pregnancy is a physiological process but this physiological process may change to a pathological one at any time during the course of antenatal period. Although this sudden change to a pathological process is rare and is unpredictable. World Health Organization (WHO) recommends at least four antenatal visits over the course of whole pregnancy. (1) To be on the safe side, most of the obstetricians or other medical staff takes every effort to detect any minor chance of complication. In this effort these health professionals may go beyond normal or recommended frequency of some of the procedures or interventions at the time of delivery. In normal labor the package of routine care becomes very flexible one. These interventions depend upon the place of delivery; at home most of the time moral support and attachment are the major interventions while at a well-equipped health facility the staff utilizes more interventions in the management of any pregnant women. (2) In the UK, the routine practice at the time of delivery is carrying out various activities related to any task of maternal and fetal care. Usually, the intensity and frequency of these activities crosses any line or level recommended. Most of the time these activities are carried out without any supportive evidence and at times these may become dangerous instead of beneficial. Findings from the study carried out by Hofmeyr stressed on the inconclusive evidence of routine use of oxytocin, routine amniotomy, continuous electronic fetal heart rate, etc (2). Use of analgesia has got its own untoward effects. Epidural analgesia may convert the normal labor to a prolonged labor at one end; further, it may also increases the probability of performing other interventions, as they are needed due to the long duration of labor. So after getting epidural analgesia which results in prolonged labor eventually results in exhaustion on the side of the woman with weaker and infrequent labor pains fro which drugs for augmentation are required supported by episiotomy. (3) The frequency and types of interventions used during intrapartum period in the UK especially in low risk women has not been looked for and estimated. (4) There are strong recommendations not to overuse interventions when they are not indicated. (5) There is a common agreement of obstetricians and midwives that most of the obstetric interventions cannot be explained. (6) Therefore, as is well known that these interventions are at times dangerous especially when used in excess and at the same time the frequency of use of these interventions is not available. To get reliable information on the utilization of these interventions appropriately a study is proposed with a research question of are low risk women in normal labor receiving too many interventions Objectives To look for level of intrapartum interventions used in normal labor in the UK. Methodology Study design A cross sectional survey will be carried out to reach the objective of this study. Sampling frame A sampling frame of all the consultant maternity units in Great Britain was obtained from the annual returns to the Royal College of Obstetricians and Gynecologist (RCOG). This list contains the data, which is believed to be almost complete. Aim was to complete data collection in one year. The sampling frame captured 237 hospitals but the final number of hospital to be included in the study was 226. The hospitals with less than 1000 births per annum were excluded from the list. Sample size determination To get an appropriate number of women to capture all major interventions, a sample size of 4040 women was finalized. It was decided to collect information from 40 women from each hospital to complete the data collection in an appropriate time without putting extra burden on the hospitals. For this purpose, 101 hospitals were randomly selected from the sampling frame and from each hospital at least 40 consecutive cases of delivery were proposed to be selected for further work on data collection. (7) So there were total of 4040 (101*40=4040) pregnant women. Entry criteria All the pregnant women entered into the study at the onset of the labor if they were delivering in hospital after an uneventful antenatal periods, at 37>= weeks of pregnancy and with the fetal head presenting. Study Setting This study was carried out in maternity units in Great Britain. Study Period This study was conducted during February 1993 through January 1994 Data Collection and management To maintain the quality of data collection, the principal investigator checked completed questionnaires daily. Any missing and inconsistent information in the questionnaires or any other problem during the process of data collection was discussed with the data collectors and remediable solutions sought. Final editing was done after the completion of whole process of data collection. Statistical Analyses EPI INFO version 6.04 (8) was used for the double entry of the data from questionnaires and analysis was performed in SPSS software version 14.0 (9). Plan of analysis We took the variable of type of delivery with three categories as the main point of focus. We planned to look for the associated factors especially interventions with the normal delivery. For this purpose first we recoded the variable of type of delivery into dichotomous variable and ran the analysis. Univariat Analysis To answer the primary question of whether low risk pregnant women are receiving much interventions even if the delivery is uneventful we performed univariate analysis. Through this analysis we could identified the association between independent and dependant variables at the individual level. Table 1 provides information on various factors associated individually at univariate analysis level with the outcome variable i.e.; type of delivery. We can see that almost all the interventions are significantly associated at the univariate level. This analysis gives some idea about the interventions being offered to the normal low risk pregnant women. Table 1: Univariat analysis Variable Odds Ratio (OR) 95 % CI Episiotomy No Yes 1 22.79 13.54-38.36 Pain relief measures at stage II No Any type 1 15.54 10.24-23.58 Pain relief measures at stage I No Any type 1 6.60 3.16-13.80 Vaginal examination 1-5 6-10 1 6.56 4.74-9.08 Drugs used for augmenting the labor No During stage 1 During stage 2 Both stages 1 4.27 4.30 6.51 3.03-6.02 2.70-6.88 3.62-11.72 Fetal Monitoring at day 2 No Any type 1 2.38 1.83-3.10 Multivariat analysis All those variables which show association with the dependant variable with as high p-value as 0.25low and all those, which have got biological plausibility, were selected for multivariate analysis. In this analysis, the variables with the strongest association with the dependant variable will be taken first in the model and then followed by another variable in the model. Our aim is to prepare parsimonious model. At the multivariate analysis level three factors kept their strong association. Three variables were: episiotomy, pain relief at the time of deliveries and vaginal examinations during delivery. Table 2: Multivariate analysis Variable Odds Ratio (OR) 95 % CI Episiotomy No Yes 1 24.93 11.81-52.65 Vaginal examination 1-5 1-10 1 3.85 2.03-7.33 Pain relief measures at stage II No Any type 1 10.50 6.34-17.38 We could see that in normal labor more of the women were being examined during labor. Similarly the association of those women who asked for the drugs during labor to get pain relief was significant with normal delivery. This way three out of six interventions being utilized during labor have shown significant association when they were put together simultaneously in a multivariate model. These models also control the confounding effect of the variables. We also did check any interaction term to be associated significantly but it was not. These findings strongly support the answer that low risk pregnant women in normal labor receive more interventions. References 1. Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Belizan MJ, Farnot U, et al. WHO antenatal care randomized trial for the evaluation of a new model of routine antenatal care. Lancet 2001; 357:1551-64. 2. Hofmer GJ. Evidence-based intrapartum care. Best Prec Res Clin Obstet Gynaecol. 2005; 19:103-15 3. Alder BB, Bonder K, Kimberger O, Wagenbichler P, Kaider A, Husslein P, et al. The effect of epidural analgesia on the occurrence of obstetric lacerations and on the neonatal outcome during spontaneous vaginal delivery. Arch Gynecol Obstet 2002; 267:81-4 4. Williams FL, Florey Cdu, Ogston SA, Patel NB, Howie PW and Tindall VR. UK Study of intrapartum care for low risk primigravidas: a survey of interventions. J Epidemiol Community Health 1998;52:494-500. 5. Health Committee. Maternity services. London: HMSO. 6. Tindall VR (Chair). Women in normal labour: a report of a CSAG Committee on women in normal labour. London: HMSO, 1995. 7. Scheaffer RL, Mendenhall III W, Ott L. Elementary survey sampling. 5th ed. New York: Duxbury press; 1996. 8. Epi Info version (6.04): A word processing, database and statistics program for Public Health [computer program]. Atlanta, GA: Centers for Disease Control and Prevention, 1995. 9. SPSS (14.0) for windows. Chicago, IL: SPSS Inc, 2006. Read More