RVI abstract

Royal Victoria Infirmary abstract

Does changing the second stage of labour guidelines from time limited to progress led influence the birth outcome and birth experience for women?

Authors: L. Gilchrist, M. Blott, A. Loughney, J. Mackenzie, D. Sen, G. Smith, J. Aarvold.

Background: Traditional guidelines for the care of women in the second stage of labour are centred around the imposition of artificially constructed time limitations for progress. Beyond a fixed point in time, medical intervention is frequently advised in order to prevent maternal or fetal morbidity. The evidence behind this practice is of low level and conflicting. A review of the evidence suggests that a less restrictive approach could be equally as safe, with the additional potential benefit of reducing intervention. The aim of this study was to investigate the impact of a new guideline by assesses clinical outcome, maternal experience and satisfaction with care and carer.

Method: In excess of 5000 women give birth each year at The Royal Victoria Infirmary in Newcastle upon Tyne. An extensive education and training programme was developed. It was a mandatory requirement that all medical and midwifery staff working in delivery suite attended the programme. The staff education and training programme and the new guideline was put in place in October 2005. Data was collected from electronic maternity records, a midwife proforma (immediately after delivery) and a maternal questionnaire (within 48 hours post delivery) both pre implementation (1st March and 31st May 2005) and post implementation (1st June and 31st August 2006).

Results: All new and existing staff attended the training programme. A total of 1981 clinical outcome midwife proformas were completed (824 pre audit and 1157 post audit). Overall 734 maternal questionnaires were returned (349 pre audit and 385 post audit). There was an unexpected 16% increase in the annual birth rate from 4805 in 2004 to 5581 in 2006. There was no difference between the two groups in terms of maternal age (mean 28.5 yrs, SD 6.2 vs. 28.2 yrs, SD 6.1), however, women in the post audit were more likely to be primiparous, have a preterm delivery, to have left education before 18 years of age and to have no qualifications. Using study data there was no difference noted in mode of delivery (p = 0.51), however annual data has showed a significant reduction in the emergency caesarean section rate, which fell from 15.8% to 14.1% (p = 0.02) between 2004 and 2006. The fall in emergency caesarean sections was attributable to the proportion of women having the less urgent grade 2 and grade 3 procedures. Interestingly, the proportion of emergency caesarean sections performed in the second stage of labour fell from 16.6 % to 12.1 % of all emergency caesareans (p = 0.011). There was also a non significant reduction in the instrumental delivery rate (17.5% to 17.0%) during this time. As expected there was an increase in the length of second stage (mean 26 mins) and in maternal blood loss (mean 50 mls), neither of these were of clinical significance. There was no detrimental effect in terms of infant outcome. No difference was noted in maternal satisfaction. Women did however report feeling more fulfilled, less overwhelmed, less out of control, less detached and less powerless during the post audit. However and in contrast, women reported less favourable carer attitude including carer being less supportive, less sensitive, less warm and less considerate. Between the two data collection time points, there was a reduction in the number of women whom received one to one care during labour (90% to 79%, p < 0.0001).

Conclusion: The education programme and the new guideline has been successfully implemented into practice. Adherence to the new guideline resulted in a reduction in the emergency caesarean section rate and a more positive birthing experience. There was a reduction in positive carer attitude, however this is likely to relate to the unexpected increase in the birthing rate and a consequential reduction in the provision of one to one care. The findings from this study recommend the formal introduction of the revised guideline with the withdrawal of time restrictions around the second stage of labour.

Further details are available from:

Dr Debbie Carrick-Sen

Senior Nurse-Midwife for Research

Clinical Research Facility

4th Floor, Leazes Wing

Royal Victoria Infirmary

Newcastle upon Tyne

NE1 4LP

Telephone: 00 (44) 191 282 0087 (office) DECT 29311

Fax: 00 (44) 191 282 0064

mobile: 07843441631

Email: debbie.carrick-sen@ncl.ac.uk