The active management of labor JOHN M. BEAZLEY, M.D., F.R.C.O.G. Liverpool, England
T H E P u R P o s E of my paper is to present for your consideration three concepts which, I believe, underlie the major developments in modern obstetric practice.
cept of the minimal-risk labor should be invariable. Of the many different features which may affect the minimal-risk situation, none is more universally important than time. Through the ages Time has not proved a reliable ally to the obstetrician. Though the adverse effects of prolonged labor have long been recognized, it is only in recent years that significant progress has been made to harness Time to the obstetricians' use. In this endeavor no man has made a greater impact than Friedman, and it is on the basis of his original graphical analysis of the four phases of labor that most modern partograms have been founded. One typical e)5ample of a partogram in common use at the Liverpool Maternity Hospital is shown in Fig. 1. Eighty per cent of normal labors may be expected to follow a course, the graph of which lies on or to the left of the lines shown. From 2 em. of cervical dilatation to delivery, it will be noted, is only 11 hours in primigravid patients and 6 hours in multipara. How distant now seem the days when "tincture of time" was prescribed for protracted labor, or when parturition was managed according to the addage that the sun should not set twice on a mother in labor. The modern partogram enables the obstetrician not only to recognize at an early stage the onset of delayed labor, but also to assess the efficiency of any remedial treatment he may prescribe. It is important to have some objective measure of the result of therapy because the human nature of physicians is such that the subjective impression of the treatment we offer is nearly always favorable. Fig. 2 illustrates how readily the modern partogram facilitates early recognition of both delay in labor and the result of the corrective measure applied in this instance. One of the most valuable criticisms of the type of partogram shown here has been offered by O'Driscoll, who rightly points out that the time at which a patient is admitted to the labor room is a very precise moment in the sequence of events which
The concept of minimal-risk labor
The diagnosis of normal labor can be made with confidence only after the event. It is, however, no part of the obstetrician's role to be a historian. His duty is more that of a prophet who must see into the future~at least so far as it concerns the wellbeing of his patient. Regrettably few obstetricians are qualified to undertake the prophet's role. Sensible anticipation is the most we can achieve. We are fortunate, however, that both national and international statistics, which draw attention to real and potential hazards in obstetric management, are now more readily available than at any time in the history of our discipline. Excellent British examples may be found in the series of Reports on confidential enquiries into maternal deaths in England and Wales, and in those publications of the National Birthday Trust entitled Perinatal mortality and Perinatal problems. These and similar reports facilitate some calculation of the risks involved in the many circumstances which influence pregnancy and parturition. To interpret this type of information, both in the light of personal experience and in relation to the particular environment of our work, enables each consultant to deduce in a meaningful way the obstetric situation which offers the least hazard to his patients. This minimal-risk situation will, of course, not be identical in the different obstetric centers of the world. Nevertheless, the conFrom the Department of Obstetrics and Gynecology, University of Liverpool. The Annual Guest Lecture, presented at the Forty-second Annual Meeting of the Central Association of Obstetricians and Gynecologists, New Orleans, Louisiana, October 3-5, 1974. Reprint requests: Dr. John M. Beazley, Department of Obstetrics and Gynecology, Liverpool University, Liverpool, England.
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VAGINAL EXAMINATION
Fig. i. Partogram in use at Liverpooi Maternity HospitaL
lead eventually to delivery. If, however, the partegram of the future is to start at "admission time," it becomes imperative to ascertain that the patient is in early labor when the graph is commenced. The self-diagnosis of labor is, not surprisingly, often incorrect. Confirmatory objective evidence of labor must therefore always be elicited before the partogram is established, and the following regimen has shown itself to be eminently practical in modern labor suites. Pelvic examination is performed on admission to the delivery suite. In the presence of symptoms suggesting uterine contractions detection of cervical dilatation is accepted as confirmatory evidence that labor has begun. Should the cervix be closed, however, evidence of spontaneous rupture of the membranes or of a definite "show" is considered sufficient to commence a partogram. In the absence of such confirmatory evidence the patient is transferred to an antenatal ward for observation, where she may rest comfortably until parturition is established. In summary, normal labor is a diagnosis of little value to the accoucheur. By contrast, minimal-risk labor is a concept against which the hazards of parturition may be more accurately assessed in any particular situation. One universal enemy is time, but this, through the development of the modern partogram, has now been visibly exposed and its components utilized in the service of obstetrics.
The concept of labor as an intensive-care situation
Parturition is now recognized as a time in which a woman requires the undivided attention of her attendants. No matter how careful the management of labor 1night be, and despite the rnost diligent antenatal preparation, partuntwn always takes place under the shadow of such potential hazards as maternal or fetal distress, antepartum or postpartum hemorrhage, shoulder dystocia, or prolapse of the cord. No patient, therefore, who does not immediately require specialized skills, should compete for the attention of the labor-room staff. As O'Driscoll points out, only parturient women should occupy the intensive-care beds reserved for them, and those not in labor should be elsewhere. Experience dictates that the policies which promote safe delivery and best serve the intensive-care situation concern matters of maternal comfort, the quick detection of maternal and fetal problems, and the rapid correction of problems as they arise. I shall consider these briefly in turn. Maternal comfort
Pain is a very personal symptom and one which the doctor can never deny his patient, though, on occasion, he may choose to ignore it. In the patient's mind, fear and pain are often intimately entwined. The constant availability of one who can
Volume 122 Number 2
Active management of iabor
Del.
163
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Fig. 2. The effect of oxytocin ["Syntocinon"J administered after the detection of delay in labor due to inefficient uterine action.
comfort and dispel a patient's anx1eties will do much to relieve her pain also. In some centers the presence of the husband to support his wife during labor is advocated. Of greater importance in my view is the ready availability of a competent, compassionate, and personal nurse. As the Irish school has shown, this personal service is most likely to be achieved in labor rooms where there is no competition for attention from patients who are not in labor. It has always been the prerogative of the parturient woman to accept or decline the obstetrician's offer of analgesics to relieve the pain of labor. So it is today; but whereas in the past there may have been less reason to suppose that the decision mattered overmuch, there is now, I believe, a duty to recommend that labor be free of pain. The intensive-care situation, for example, necessitates conditions which facilitate strict control of the duration of labor and the quick detection of problems that can arise in both the mother and her baby. Such conditions are best achieved only when the mother, undistracted by pain, can remain calm. Despite the common use of Pethidine injections
for labor, experience continues to demonstrate that the sensible utilization of diamorphine (heroin), where this is possible, provides much better parenteral analgesia and is safe. Elective epidural analgesia, though requiring more specialized facilities, remains the most valuable form of pain relief. Insertion of an epidural catheter prior to induction of labor has proved to be a most useful sequence of events in Liverpool, facilitating analgesia when required without further discomfort to the patient. Obviously it is far more inconvenient for a mother, and more difficult for the anesthetist too, for an epidural catheter to be inserted part way through labor. When early recourse to epidural analgesia seems desirable in labor, as it does in a steadily increasing number of patients, the immediate availability of such a service should be the aim of all intensivecare units. It is equally true that in a unit where epidural analgesia is used regularly, constant and informed nursing and medical care is essential if maternal supine hypotension or caval compression problems (including discrimination between genuine and apparent fetal distress) are to be avoided-
· -. .,·,- -, Am . j. ()h:-; · . f \tH;
T H E P u R P o s E of my paper is to present for your consideration three concepts which, I believe, underlie the major developments in modern obstetric practice.
cept of the minimal-risk labor should be invariable. Of the many different features which may affect the minimal-risk situation, none is more universally important than time. Through the ages Time has not proved a reliable ally to the obstetrician. Though the adverse effects of prolonged labor have long been recognized, it is only in recent years that significant progress has been made to harness Time to the obstetricians' use. In this endeavor no man has made a greater impact than Friedman, and it is on the basis of his original graphical analysis of the four phases of labor that most modern partograms have been founded. One typical e)5ample of a partogram in common use at the Liverpool Maternity Hospital is shown in Fig. 1. Eighty per cent of normal labors may be expected to follow a course, the graph of which lies on or to the left of the lines shown. From 2 em. of cervical dilatation to delivery, it will be noted, is only 11 hours in primigravid patients and 6 hours in multipara. How distant now seem the days when "tincture of time" was prescribed for protracted labor, or when parturition was managed according to the addage that the sun should not set twice on a mother in labor. The modern partogram enables the obstetrician not only to recognize at an early stage the onset of delayed labor, but also to assess the efficiency of any remedial treatment he may prescribe. It is important to have some objective measure of the result of therapy because the human nature of physicians is such that the subjective impression of the treatment we offer is nearly always favorable. Fig. 2 illustrates how readily the modern partogram facilitates early recognition of both delay in labor and the result of the corrective measure applied in this instance. One of the most valuable criticisms of the type of partogram shown here has been offered by O'Driscoll, who rightly points out that the time at which a patient is admitted to the labor room is a very precise moment in the sequence of events which
The concept of minimal-risk labor
The diagnosis of normal labor can be made with confidence only after the event. It is, however, no part of the obstetrician's role to be a historian. His duty is more that of a prophet who must see into the future~at least so far as it concerns the wellbeing of his patient. Regrettably few obstetricians are qualified to undertake the prophet's role. Sensible anticipation is the most we can achieve. We are fortunate, however, that both national and international statistics, which draw attention to real and potential hazards in obstetric management, are now more readily available than at any time in the history of our discipline. Excellent British examples may be found in the series of Reports on confidential enquiries into maternal deaths in England and Wales, and in those publications of the National Birthday Trust entitled Perinatal mortality and Perinatal problems. These and similar reports facilitate some calculation of the risks involved in the many circumstances which influence pregnancy and parturition. To interpret this type of information, both in the light of personal experience and in relation to the particular environment of our work, enables each consultant to deduce in a meaningful way the obstetric situation which offers the least hazard to his patients. This minimal-risk situation will, of course, not be identical in the different obstetric centers of the world. Nevertheless, the conFrom the Department of Obstetrics and Gynecology, University of Liverpool. The Annual Guest Lecture, presented at the Forty-second Annual Meeting of the Central Association of Obstetricians and Gynecologists, New Orleans, Louisiana, October 3-5, 1974. Reprint requests: Dr. John M. Beazley, Department of Obstetrics and Gynecology, Liverpool University, Liverpool, England.
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VAGINAL EXAMINATION
Fig. i. Partogram in use at Liverpooi Maternity HospitaL
lead eventually to delivery. If, however, the partegram of the future is to start at "admission time," it becomes imperative to ascertain that the patient is in early labor when the graph is commenced. The self-diagnosis of labor is, not surprisingly, often incorrect. Confirmatory objective evidence of labor must therefore always be elicited before the partogram is established, and the following regimen has shown itself to be eminently practical in modern labor suites. Pelvic examination is performed on admission to the delivery suite. In the presence of symptoms suggesting uterine contractions detection of cervical dilatation is accepted as confirmatory evidence that labor has begun. Should the cervix be closed, however, evidence of spontaneous rupture of the membranes or of a definite "show" is considered sufficient to commence a partogram. In the absence of such confirmatory evidence the patient is transferred to an antenatal ward for observation, where she may rest comfortably until parturition is established. In summary, normal labor is a diagnosis of little value to the accoucheur. By contrast, minimal-risk labor is a concept against which the hazards of parturition may be more accurately assessed in any particular situation. One universal enemy is time, but this, through the development of the modern partogram, has now been visibly exposed and its components utilized in the service of obstetrics.
The concept of labor as an intensive-care situation
Parturition is now recognized as a time in which a woman requires the undivided attention of her attendants. No matter how careful the management of labor 1night be, and despite the rnost diligent antenatal preparation, partuntwn always takes place under the shadow of such potential hazards as maternal or fetal distress, antepartum or postpartum hemorrhage, shoulder dystocia, or prolapse of the cord. No patient, therefore, who does not immediately require specialized skills, should compete for the attention of the labor-room staff. As O'Driscoll points out, only parturient women should occupy the intensive-care beds reserved for them, and those not in labor should be elsewhere. Experience dictates that the policies which promote safe delivery and best serve the intensive-care situation concern matters of maternal comfort, the quick detection of maternal and fetal problems, and the rapid correction of problems as they arise. I shall consider these briefly in turn. Maternal comfort
Pain is a very personal symptom and one which the doctor can never deny his patient, though, on occasion, he may choose to ignore it. In the patient's mind, fear and pain are often intimately entwined. The constant availability of one who can
Volume 122 Number 2
Active management of iabor
Del.
163
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Fig. 2. The effect of oxytocin ["Syntocinon"J administered after the detection of delay in labor due to inefficient uterine action.
comfort and dispel a patient's anx1eties will do much to relieve her pain also. In some centers the presence of the husband to support his wife during labor is advocated. Of greater importance in my view is the ready availability of a competent, compassionate, and personal nurse. As the Irish school has shown, this personal service is most likely to be achieved in labor rooms where there is no competition for attention from patients who are not in labor. It has always been the prerogative of the parturient woman to accept or decline the obstetrician's offer of analgesics to relieve the pain of labor. So it is today; but whereas in the past there may have been less reason to suppose that the decision mattered overmuch, there is now, I believe, a duty to recommend that labor be free of pain. The intensive-care situation, for example, necessitates conditions which facilitate strict control of the duration of labor and the quick detection of problems that can arise in both the mother and her baby. Such conditions are best achieved only when the mother, undistracted by pain, can remain calm. Despite the common use of Pethidine injections
for labor, experience continues to demonstrate that the sensible utilization of diamorphine (heroin), where this is possible, provides much better parenteral analgesia and is safe. Elective epidural analgesia, though requiring more specialized facilities, remains the most valuable form of pain relief. Insertion of an epidural catheter prior to induction of labor has proved to be a most useful sequence of events in Liverpool, facilitating analgesia when required without further discomfort to the patient. Obviously it is far more inconvenient for a mother, and more difficult for the anesthetist too, for an epidural catheter to be inserted part way through labor. When early recourse to epidural analgesia seems desirable in labor, as it does in a steadily increasing number of patients, the immediate availability of such a service should be the aim of all intensivecare units. It is equally true that in a unit where epidural analgesia is used regularly, constant and informed nursing and medical care is essential if maternal supine hypotension or caval compression problems (including discrimination between genuine and apparent fetal distress) are to be avoided-
· -. .,·,- -, Am . j. ()h:-; · . f \tH;
