a comparison of low-risk pregnant women booked for delivery in two systems of care: shared-care...

British Journal of Obstetrics and Gynaecology February 1983, Vol. 90, pp. 123-128

A comparison of low-risk pregnant women booked for delivery in two systems of care: shared-care (consultant) and integrated general practice unit. 11. Labour and delivery management and neonatal outcome MICHAEL KLEIN*, IVOR LLOYD?, CHRISTOPHER REDMANS, MICHAEL BULL$ & A. C. TURNBULLS, SNu.eld Department of Obstetrics and Gynaecology, Oxford, and *McGill University .~ Department of Family Medicine, Montreal, Quebec, Canada

Summary. A random sample of low-risk pregnant women were equally divided into four groups of 63 nulliparae and multiparae each booked for care in a integrated general practice unit (GPU) and a shared-care (consultant) system. Selection criteria included only women who were admitted because they were in spontaneous labour or thought they were. Nulliparous women booked for shared-care came into hospital at a less advanced state of cervical dilatation than those booked for the GPU and spent longer (11 compared with 8 h) in hospital before delivery; the comparable durations in multiparae were 6 and 4 h. Both the first and second stages of labour were longer in the GPU-booked women but they received less pethidine and fewer had epidural analgesia; they received less electronic fetal monitoring, augmentation and forceps delivery, and fetal distress was diagnosed less often. The 1-min Apgar score was <6 in 17.5% of infants of nulliparae booked for the shared-care system compared with 1.6% of those booked for the GPU. The intubation rate of infants of nulliparae was 11% in the shared-care system compared with no intubations in the GPU. These comparisons demonstrate the simplicity and safety of delivery of low-risk women in the GPU as compared with deliveries of similar women in a shared-care (consultant) unit.

In our previous study (Klein et al. 1983) of apparently comparable low-risk women who were delivered in two systems of maternity care we found that obstetrical procedures were less often applied in the women booked for delivery in the Oxford General Practice Unit (GPU) than in the women booked and delivered in a consultant unit (shared-care system). The newborn short-term outcomes were as good in the GPU-booked

?Present address: Department of Experimental

$East Oxford Health Centre, Oxford, UK. Psychology, University of Oxford, Oxford.

0306-5456/83/0200-0 123$02.00 0 1983 British Journal of Obstetrics and Gynaecology

women as in the women in the shared-care system.

In the present paper we analyse in more detail the management of labour and delivery in the two systems of care.

Method

The method described in the previous study (Klein et al. 1983) relied on information con- tained on an existing computer tape of all births in 1978 at the John Radcliffe Hospital. In the present study, we used the computer only for introducing certain further restrictions and to obtain a random sample of medical records so

123

124 M. Klein et a1

that events and procedures during labour and delivery could be analysed more closely by direct review.

Since induction of labour was a more frequent occurrence in the consultant-booked or shared- care system we were reluctant to compare women in whom labour was induced with women who were delivered after spontaneous labour. Further- more, we determined that any consultant-booked woman who received procedures or treatments that would have led to transfer had she been booked in the GPU would be excluded. For example, women who were admitted with presumed fetal growth retardation, antepartum

haemorrhage or who had a caesarean section were excluded.

In this study therefore we looked at women in the two systems of care who arrived in hospital either because they were in spontaneous labour or because they thought they were in labour.

Results (Tables 1-6)

Numbers

When these restrictions were applied to the existing 1978 tape, 63 of the 91 GPU-booked nulliparae (69%) were identified on the computer generated list. All of these medical records were

Table 1. Cervical dilation and time to delivery in women booked for delivery in a general practice unit (GPU) and a consultant unit (shared-care)

Nulliparous Multiparous

Shared-care GPU Shared-care GPU (n=63) (n=63) (n=63) (n=63)

Mean cervical dilatation on arrival (cm) 3.43 4.95**** 4.35 5.47*** Mean time from arrival to delivery (h) 11.00 8.35; 6-21 4.10**

Significance of difference between GPU and shared-care: *P<0.05; **P<0.02; ***P<0,01; ****P<O.OOl (one- tailed t-test).

Table 2. Management of early labour in women booked for delivery in a general practice unit (GPU) and a consultant unit (shared-care)



One or more home visits (%) One or more surgery visits (%) Admitted not in labour (%)

Unknown 61.9 Unknown 33.3 Unknown 3 .2 Unknown 22.2

22.2 6.4* 12.7 3.2*

Significance of difference between GPU and shared-care: *P<0.02 (Z-test).

Table 3. Length of labour in women booked for delivery in a general practice unit (GPU) and a consultant unit (shared-care)

Length of labour

Nulliparous Mu 1 tip a r o u s

Shared-care GPU Shared-care G PU (n=63) (n=63) (n=63) (n=63)

Mean length of first stage (h) 8.28 10.6* 5.43 5 .95

Second stage >60 min (%) 30.20 36.5 0 0

Mean length of second stage (min) 44.30 50.8 16.00 15.80 First stage >12 h (%) 14.30 41.3;; 3.20 7.90

Significance of difference between GPU and shared-care: *P<O.Ol (one-tailed t-test); **P<O.OOI (Z-test).

A comparison of two systems of care 125

Table 4. Management of labour pain in women booked for delivery in a general practice unit (GPU) and a consultant unit (shared-care)

Anaesthesia/analgesia

~~


Shared-care GPU Sharedcare GPU (n=63) (n=63) (n=63) (n=63)

n (%) n (5%) n (96) n (W

Epidural Pethidine (+ Phenergan) Nitrous oxide + oxygen None

18 (28.6) 9 (14.3)* 3 (4.8) 2 (3.2) 39 (61.9) 24 (38. I)** 22 (34.9) 8(12.7)** 21 (33.3) 19 (30.2) 25 (39.7) 10 (15.9)**

7(11.1) 23(36,5)*** 21 (33.3) 49(77.8)***

Significance of difference between GPU and sharedcare: 'P(0.02; **P<O-01; ***P<0,001 (Z-test).

Table 5. Labour procedures in women booked for delivery in a general practice unit (GPU) and a consultant unit (shared-care)

Procedure



n (%) n (%) n (%) n (%I

Electronic fetal monitor Augmentation Forceps

~ ~~

22 (34.9) 1 I (17.5)** 12(19.1) 2 (3'2)***

13 (20.6) 13 (20.6) 4 (6.4) 6) 21 (33.3) 12 (19.1). 8 (12.7) 4 (6.4)

Significance of difference between GPU and shared-care: *P<0.05; **P<0.02; ***P<O.Ol (Z-test).

Table 6. Fetal condition in women booked for delivery in a general practice unit (GPU) and a consultant unit (shared-care)



n (%) n (%) n (%) n ('16)

Meconium Fetal distress Apgar score < 6 Intubation

8 (12.7) 4 (6.4) 3 (4.8) 8 (12.7) 11 (17.5) 6 (9.5) 5 (7.9) 2 (3.2) 1 1 (17.5) l(1.6). 5 (7.9) 4 (6.4) 7 (11.1) 0 (O)* 2 (3.2) 1 (1.6)

Significance of difference between GPU and shared-care: *P<O.O1 (Z-test).

reviewed. For GPU-booked multiparae every Of the 63 nulliparae booked for the GPU, 18 third chart was reviewed until 63 patients had (29%) were transferred and of the 63 multiparae, been collected. For nulliparae and multiparae three were transferred (5%). The lower rates of booked for shared-care, the same procedure was transfer compared with those in the previous used, every sixth and tenth chart respectively was study (Klein et al. 1983) are due to the further reviewed until 63 patients had been identified in restrictions on patient selection in the present each group. study.

126 M . Klein et al.

Characteristics of the women in the study

Looking at the same characteristics detailed in Table 1 of our previous study (Klein et al. 1983) we have compared the four sets of 63 women in the two systems of maternity care. GPU-booked nulliparae included significantly more smokers (P(O.01) but there were no other differences.

Presentation and length of labour (Tables 1-3)

Both multiparous and nulliparous women having shared-care were admitted to hospital at a less advanced cervical dilatation (Table 1). As a con- sequence, a nullipara booked for shared-care spent almost 3 h longer in hospital before delivery than her GPU-booked ‘sister’ did. Multiparous women in shared-care also spent more time in hospital before delivery (Table 1).

Home visiting was a major part of the management of early labour in the GPU-booked women, 62% of the nulliparous women were visited at least once by the community midwife (Table 2). Since the GPU-booked patient carries her own hospital notes, this is easy to verify. The shared- care patient has a co-operation card and not her own hospital or common notes so we cannot say absolutely that no home visits in labour occurred, but verification with the community midwife service confirms that virtually no home visits occurred. One-third of the multiparous women in the GPU-booked group were seen in early labour in the home and 22.2% of them in the G P surgery (Table 2).

Both nulliparous and multiparous women were admitted in unestablished (false) labour more frequently in the shared-care system (Table 2).

Acknowledging the subjectivity of the measurement, and the differences of record keeping because of home and surgery visits, it appears that GPU-booked classically defined labours were longer in both the first and second stage in nulliparae. First stage labours lasting 12 h were found in 14% of the women having shared-care compared with 41% of the GPU-booked women. Second stages were also slightly longer (Table 3).

Management of labour pain (Table 4 )

Epidural analgesia was used twice as often in nulliparae in shared-care and multiparae had a low rate in both systems.

Pethidine was used in 62% of nulliparae booked for shared-care compared with 38% of

those who were booked for the GPU. Likewise it was used almost three times as often in multiparae in the shared-care stystem (Table 4).

Pethidine was used almost always with promethazine hydrochloride (Phenergan). The mean pethidine dose in the shared-care system was 147 mg in nulliparae and 116 mg in multiparae, whereas in the GPU-booked women nulliparae received a mean dose of 114 mg and multiparae 71 mg. The promethazine hydrochloride dose was almost always 25 mg in both systems.

Nitrous oxide and oxygen was used in approx. a third of nulliparae in both systems, however, in multiparae it was used in 40% of those having shared-care and in 16% of those booked for the GPU.

No anaesthesia or analgesia was used in 11% of nulliparae having shared-care compared with 36% of. those booked for the GPU. In multiparous women the corresponding rates were 33 and 78% respectively.

Labour procedures and fetal outcomes (Tables 5,6)

In nulliparae electronic fetal monitoring was carried out twice as often in the women booked for shared-care. In multiparae the rates were 19% in shared-care compared with 3% in those booked for the GPU.

Augmentation of labour with oxytocin was carried out more frequently in women in shared- care than in the GPU (33 and 19% for nulliparae, 13 and 6% for multiparae).

Fetal distress was diagnosed twice as often in the women having shared-care (Table 6), but electronic monitoring was rarely used in the GPU. Overall the occurrence of meconium- stained amniotic fluid was similar in both systems of care.

Forceps were rarely used in multiparae in either system and were used equally in nulliparae in both systems (Table 5).

One minute Apgar scores of <6 were examined (Table 6). This cut-off was chosen because we felt that subjectivity in assigning the score was less likely at this level. Low scores were recorded in 17% of infants of nulliparae having shared-care compared with 2% of those booked for the GPU. This difference was not seen in the infants of multiparous women. Intubation was carried out in 11% of infants born to nulliparae in shared- care whereas none of the infants of the GPU-

A comparison of two systems of care 127

natural tendency for high-risk care to spill over into their management. We believe there is a need to identify women at low risk and to tailor their management so that it is based primarily on supportive care by midwives in their traditional role.

From the data it is impossible to select which procedures used in the consultant unit could explain the differences in infant outcome that we have observed, but the extensive use of analgesia and perhaps anaesthesia merits further attention.

We have shown the role of home assessment in early labour by experienced midwives in the GPU. This approach can only be extended to low-risk women in the larger shared-care system by expanding the community midwifery service. We speculate that the present strict demarcation between the hospital and community midwives could be modified by establishing a larger community role for hospital-based midwives. This would mean an expansion of the midwifery service so that more community midwives could look after the needs of patients booked for shared-care.

Access to the GPU could also be extended to limited numbers of women in G P practices which do not use the GPU, by sharing care with G P practices that do. This is already beginning to occur in Oxford.

While the measurement of overall perinatal mortality rates and the assessment of outcome in high-risk obstetrics remains as important as ever, the regular auditing of obstetric practice and outcome for women at low risk is an important area for development. This requires a unified system of record keeping and information retrieval for the shared-care and GPU systems. Obstetric units with and without an associated GPU should begin to look on a regular basis at the care received by the majority of women for whom pregnancy, labour and delivery should be an uncomplicated and satisfying experience.

booked nulliparae required intubation (Table 5). Infants of multiparae were rarely intubated in either system.

Discussion

Because of active early assessment at home by community midwives, the GPU system kept women out of hospital during early labour or when in unestablished labour. The shared-care system used more hospital time and admitted more women to hospital in unconfirmed (false) labour. These differences in early labour management may be in part due to the fact that more women in the shared-care system live at a greater distance from the hospital. This means that early contact between these women and hospital-based midwives is limited to telephone conversations which inevitably reduces the range of management options. In addition it should be remembered that the shared-care system must respond to a mixture of high- and low-risk women which makes it appropriate to recommend early admission in labour in some cases. Therefore our data cannot be used to justify an admission policy for all women.

The shared-care system used epidural analgesia more often (only in nulliparae) and more pethidine analgesia (in both parity groups). There was also more electronic fetal monitoring, augmentation and a tendency to diagnose more fetal distress. In an apparently comparable group of GPU-booked nulliparae, who were receiving fewer of these interventions and treatments, there were fewer low Apgar scores a t 1-min and intubation was less often practised. We cannot say with certainty whether these differences indicate real discrepancies in the neonatal condition. The assignment of a low Apgar score could include a subjective component which may have been different in the two systems of care. Subjective bias is less likely for the act of intubation which was always done by members of a single team of on-call paediatricians.

A picture emerges of two systems operating side by side, with excellent inter-relationships, but markedly different styles of care for low-risk women. The midwives working in the shared-care system have an intrinsically more difficult task because they need to manage women with a wide range of problems at the same time as those at low risk. The difficulty of the shared-care system for those women at low risk may be that they are grouped with high-risk women, and there is the

Acknowledgments

With many thanks to the GPs of the G P unit, Chloe Fisher and the community midwives and the obstetricians of Oxford for their encourage- ment, and to Dr Iain Chalmers for editorial critique, Sister Paula Malloy and Misha Klein for medical record review. Dr J. Aidan Macfarlane deserves my special thanks for hosting me during my sabbatical year and introducing me to the many others who helped with the project (M.K.).

128 M. Klein et al.

The study was partially funded by: The Medical Research Fund of the Oxford Clinical Medical School; The Nuffield Department of Obstetrics and Gynaecology; The College of Family Physicians of Canada; The Nuffield Foundation of London; The Canadian Paediatric Society; The McGill University Department of Family Medicine; The Department of Family Medicine of the Sir Mortimer B. Davis, Jewish General Hospital, Montreal.

References Klein, M., Lloyd, I., Redman, C., Bull, M. & Turnbull,

A. C. (1983) A comparison of low-risk pregnant women booked for delivery in two systems of care: shared-care (consultant) and integrated general practice unit. I. Obstetrical procedures and neonatal outcomes. Br J Obstet GynaecoZ90, 1 18- 122.

Received 21 April 1982 Accepted 5 August 1982

a comparison of low-risk pregnant women booked for delivery in two systems of care: shared-care...

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