The development and testing of an algorithm for diagnosis of active labour in primiparous women
Introduction
Within the UK and across much of the developed world, home birth is now uncommon (US Department of Health and Human Services, 1999; Kitzinger, 2000; Scottish Executive, 2002). Despite continuing debate about the relative safety and efficacy of hospital or home birth (Olsen, 1997; Vedam, 2003; Macfarlane, 2004), and world-wide concern among health-care professionals over steadily increasing rates of intervention in normal labour (WHO, 1996), most women experience labour and birth in hospital. This predominantly institutionalised model of care requires a clear cut, if somewhat artificial, distinction to be made between the latent phase of labour (a poorly defined period from onset of regular contractions, during which the woman might be expected to remain at home) and the active phase, the phase in which there is increasing cervical dilatation (Austin and Calderon, 1999), when most women would be admitted to hospital.
The judgement about whether a woman is in labour or not is an important issue for midwives, who are the principal care providers for women through normal pregnancy and childbirth. Although, on paper, it would seem to be a straightforward judgement, there is evidence that, in practice, it is often problematic and that there can be serious clinical and resource implications if misjudgements are made. The extent of the problem is illustrated by the findings of an audit of a workforce planning tool for midwifery services (Ball and Washbrook, 1996), which reported that up to 30% of women admitted to labour wards in the UK were subsequently found not to be in labour. Challenges include identifying the way in which midwives make a judgement about whether or not a woman is in labour and, if appropriate, developing ways of supporting them with this process.
Following the framework suggested by the Medical Research Council for evaluating complex interventions in health care (MRC, 2002), we conducted a series of studies in which we deconstructed the process of judgement and decision-making by women and midwives about onset of labour in order to explore these in more depth (Cheyne et al., 2004a, Cheyne et al., 2004b, Cheyne et al., 2006). Reported in this paper are the findings of one of these studies, the development and testing of an algorithm to assist with the diagnosis of active labour in primiparous women.
Section snippets
Background
Where a woman is admitted to the labour ward while not yet in labour, or in the latent phase, there are implications that extend beyond the unnecessary use of resources. Several studies have identified that these women are more likely to receive some form of intervention (including caesarean section) than those admitted in active labour (Hemminki and Simukka, 1986; Thornton and Lilford, 1994; Holmes et al., 2001; Klein et al., 2003).
Once identified as being in active labour, the clock starts
Clinical judgement in midwifery
The process of judgement has been characterised as the assessment of alternatives (Dowie and Elstein, 1994); thus identifying whether or not a woman is in active labour could be considered to be a form of diagnostic judgement, where a diagnosis is defined as a judgement between competing alternatives (Swets, 2000). This is in contrast to other types of judgement that a midwife may make during pregnancy or labour, such as whether or not a woman's condition has altered (evaluative judgement) or
Methods
Data for this study were collected between August 2002 and December 2003. Before the start of the study, in order to assess the need for a decision-support tool, an informal telephone survey of maternity units throughout Scotland was conducted. All senior midwifery managers who took part in the survey expressed support for the development of such a tool and confirmed that no algorithm or guideline for the diagnosis of labour was in use. The stages in developing and testing the algorithm are
Findings
The characteristics of the participants are presented in Table 2.
Discussion
The premise of this study was that the diagnosis of active labour is of central importance to midwives, is often difficult in practice, and may be improved by the introduction of decision support. This premise raises a number of interesting and perhaps controversial questions. In particular, whether use of the term ‘diagnosis’ is appropriate in this context and whether the use of decision-support tools, such as the algorithm, undermine the clinical expertise of the midwife and mediate against
Conclusions
Diagnosis of labour is straightforward on paper but frequently problematic in practice. Within the predominantly institutionalised setting for intrapartum care in developed countries, the diagnosis of labour is made in a high pressured environment where conflicting pressures of workload, limited resources and emotional pressures add to the complexity of the judgement. We offer a valid and reliable tool as an aid in this process.
Acknowledgements
This study was supported by a research grant from The Scottish Executive Health Department Chief Scientist Office. Thanks are also due to the midwives and midwifery managers who participated in, or facilitated this study.
References (68)
- et al.
Triaging patients in the latent phase of labour
Journal of Nurse Midwifery
(1999) - et al.
Obstetric decision making: the effect of varying the presentation of partogramme information
Lancet
(1992) - et al.
The timing of hospital admission and progress of labour
European Journal of Obstetrics, Gynecology, and Reproductive Biology
(1986) Management of the third stage of labour: another cascade of intervention?
Midwifery
(1985)- et al.
Early labour assessment and support at home: a randomised controlled trial
Journal of Obstetrics and Gynaecology Canada
(2003) Whose evidence counts? An exploration of health professionals’ perceptions of evidence-based practice, focusing on the maternity services
Midwifery
(2001)Practical Statistics for Medical Research
(1991)- et al.
Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review
British Medical Journal
(2003) - et al.
Birthrate Plus: A Framework for Workforce Planning and Decision Making for Midwifery Services
(1996) Measuring Disease
(1995)
Effect of active management of labour on the incidence of cesarean section for dystocia in nulliparas
American Journal of Perinatology
Midwifery diagnosis of labour onset
British Journal of Midwifery
Integrated care pathways
British Medical Journal
Midwives’ diagnostic judgement and management decisions in making the diagnosis of labour
Journal of Advanced Nursing
Clinical decision-making by midwives: managing case complexity
Journal of Advanced Nursing
Clinical versus actuarial judgement
Clinical problem solving and diagnostic decision making: selective review of the cognitive literature
British Medical Journal
Medical problem solving: a ten-year retrospective
Evaluation and the Health Professions
Personality and Individual Differences: A Natural Science Approach
Use of vignettes to elicit responses to broad concepts
Nursing Research
Normal and dysfunctional labour
A clinical trial of active management of labour
New England Journal of Medicine
Effects of computerized clinical decision support systems on practitioner performance and patient outcomes. A systematic review
Journal of the American Medical Association
Using vignettes to collect data for nursing research studies: how valid are the findings?
Journal of Clinical Nursing
Predictive strategies in diagnostic tasks
Nursing Research
Nursing Diagnosis: Process and Application
Clinical versus mechanical prediction: a meta-analysis
Psychological Assessment
All-wales clinical pathway for normal labour launched
Practicing Midwife
Judgement and decision making in dynamic tasks
Information and Decision Technologies
Rational Choice in an Uncertain World
The relationship between cervical dilatation at initial presentation in labour and subsequent intervention
British Journal of Obstetrics and Gynaecology
Cited by (13)
Primiparous women's preferences for care during a prolonged latent phase of labour
2015, Sexual and Reproductive HealthcareWomen's perspectives of the stages and phases of labour
2013, MidwiferyCitation Excerpt :For clinicians there have been attempts to standardise the diagnosis of active labour by means of an algorithm for midwives to use when assessing women admitted to hospital in labour. However, the use of this algorithm did not result in a better understanding for clinicians or reduced intervention during labour (Cheyne et al., 2008). The need to differentiate the boundaries between each stage and phase of labour is driven by professional and organisational requirements.
An exploration of clinical decision-making among students and newly qualified midwives
2012, MidwiferyCitation Excerpt :Although decision-making has been studied less extensively in midwifery (Jefford et al., 2010; Masterson, 2010), this situation is beginning to change with the publication of midwifery research studies by Cheyne et al. (2006), Cheyne et al. (2007), Harris et al. (2011) and Styles et al. (2011). Two studies carried out in Australia concentrated on midwifery students and certified midwives (Cioffi and Markham, 1997; Cioffi et al., 2005), however, most studies make reference to experienced midwives (Sookhoo and Biott, 2002; Cheyne et al., 2006, 2007; Harris et al., 2011; Styles et al., 2011). Less attention has been paid to the acquisition of decision-making skills in midwifery students or newly qualified midwives.
Complex interventions in midwifery care: Reflections on the design and evaluation of an algorithm for the diagnosis of labour
2011, MidwiferyCitation Excerpt :We used focus groups with midwives to assess the content validity of the algorithm, to gain further understanding of the way in which midwives diagnose labour, and to explore additional contextual factors for labour diagnosis and management (Cheyne et al., 2006). The algorithm was then tested for face and content validity and inter-rater reliability using questionnaires and vignettes (Cheyne et al., 2008a, b). Although this implies a linear process, in practice, the process was more interactive in nature, with the data from the focus groups, vignettes and questionnaires all informing each other.