The term "active management" refers to a particular
philosophy of birth, an overall approach to how labor
and birth should be "managed". Caregivers who have this
philosophy will operate in a fundamentally different way
than caregivers who have a philosophy of expectant
management. This has significant implications for women
choosing these caregivers to support them during birth.
Helping
clients to understanding where their particular caregiver is coming from, and
exploring how that "fits" with what the client is looking for can therefore be a
critical part of the role of a doula and/or childbirth educator in the run up to
birth, as well as having a major impact on what their role will be at that
birth.
To
understand the difference between active and expectant management, it can be
helpful to think of it as the "fixed menu" approach versus the "a la carte".
In the
"fixed menu" approach the restaurant offers the consumer a given set of choices
- starter, main course, dessert, coffee. The approach is standardized, the range
of choices being the same for everyone. For the consumer the process of
decision-making is greatly simplified, service is usually faster, and the price
is kept low. For the restaurant, planning is easier, costs are kept down because
the range of options and ingredients is smaller and it is less labor intensive
to produce, which also means that a much greater number of customers can be
served.
|
... planning
is easier, costs are kept down because the range
of options and ingredients is smaller and it is
less labor intensive to produce, which also
means that a much greater number of customers
can be served. |
In the "a la
carte" version, the consumer is offered a greater range of choices. They may
select two starters, or skip the starter altogether, depending on their appetite
and mood. The consumer is much more involved in the decision-making process.
Service may be slower since each dish must be cooked to order, but the consumer
knows they will receive a much more personalized dining experience.
In essence,
active management of labor is much like the "fixed price" menu. Caregivers
adopt a standardized approach to caring for women in labor. Routine practices
and procedures are adopted - for example, all women being admitted to hospital
in labor will be expected to have an IV set up. Labor and birth are expected to
proceed in line with a model of what is "normal" and time limits are applied to
enable progress to be tracked against a set of standard protocols. Medical
intervention is used proactively whenever labor does not correspond with this
model - for example, when the onset of labor exceeds the estimated due date then
induction is routinely recommended. In this model, the responsibility for
decision-making rests clearly with the caregiver.
In contrast,
expectant management caregivers take a "wait and see" approach. Labor is closely
monitored and medical intervention is used when the circumstances require it,
but are not routinely offered to everyone. Time limits are not routinely applied
to labor. Caregivers adopting this philosophy generally expect that their
clients will take on a much greater involvement in the decision-making process.
How did the
active management philosophy originate?
Active
management was first described by doctors working at the National Maternity
Hospital in Dublin in the 1970's. In its original form, it was intended to help
first-time mothers primarily by preventing prolonged labor. Doctors guaranteed
that women would not labor for more than 12 hours, that is, 10 hours to dilate
and 2 to push out the baby.
In what
have since become widely known as the "Dublin trials" a set of protocols were
developed for how labor and birth should be managed. On admittance to hospital,
women were first assessed to determine whether labor had begun according to a
strict definition based on cervical dilatation and pattern of contractions. If
not, women were sent home. If it had, then labor was managed according to the
following standards:
-
Labor not to
last more than 12 hours. The doctors expected women to be able to manage without
pain medication so long as labor was kept within these limits although
epidurals were not denied if women requested them.
-
Vaginal
exams used at regular intervals to determine progress. Progress defined as
cervical dilation at 1cm per hour after 3cm dilated.
-
Oxytocic
drugs and amniotomy (rupture of membranes) used to speed labor if it did not
proceed according to this pattern. Ventouse extraction and/or forceps used to
expedite delivery once the "12 hour" limit has been exceeded, or proceed to
cesarean.
-
Women in
labor to receive continuous support from either a midwifery or medical student.
The
results of the Dublin trial generated a great deal of interest and excitement.
One of the primary benefits of the Dublin trials was seen to be a reduction in
the cesarean rate. Partly because of this, the principles of active management
rapidly spread around the world and have been widely adopted as the norm.
Other
interventions have now become a standard part of the active management approach
that were not initially part of the Dublin trials, such as the routine use of
ultrasound during pregnancy, routine induction at term, the use of continuous
fetal monitoring in labor, episiotomies, and active management of the third
stage of labor. Some elements of the original approach appear to have been
"lost" over time - most notably the strict definition of when labor is said to
begin, and the use of continuous one on one support for laboring women.
Concurrently, the rate of epidural use has increased significantly.
What are the
benefits of active management?
For women in
labor, one of the primary benefits (as was intended by the Dublin doctors) is a
reduction in the overall length of labor. This does indeed seem to be the case
since time limits are still a key feature of the approach. There is some debate
about the impact on cesarean rates - at the time the Dublin trials were
published, cesarean rates in that hospital were very low, but the rate of
assisted deliveries (forceps, ventouse) increased. Various studies have been
done since the Dublin trials to confirm or deny whether the cesarean rate is
reduced by a policy of active management and results vary. However it is
complicated by the fact that the definition of what active management is tends
to vary from the Dublin protocols.
For doctors,
the standardized approach makes managing women in labor much simpler, and
staffing and scheduling are easier, particular in busy hospitals. More labors
and births occur during normal working hours. Decision-making is simplified by
adherence to a set of protocols that do not vary.
So what is
the problem with active management?
Active
management has a number of drawbacks. Since such a precise definition of
"normal" is used, it is inevitable that many women will experience patterns of
labor that fall outside that definition.
|
Cascade of Intervention
Picture the following scenario.
A first time mother is admitted to hospital in early
labor. She is given a vaginal examination, an enema, and has an IV put
up. She is attached to a CTG for continuous fetal monitoring. More than
likely she will not be allowed to eat or drink. After a number of hours
she is given a vaginal exam and it is found that she has not progressed
significantly.
According to active management she is then given a
continuous infusion of oxytocin and her membranes are ruptured. Some
hours later, she is given another IV. Little or no progress.
Because of the pain of the artificially induced
contractions she requests an epidural. Because this renders her immobile
and relaxes the muscles of the pelvic floor she is unable to use
positioning and gravity to help the baby move down into a good position
for birth.
If she is fortunate, labor will progress normally
and the baby will be born vaginally, although often with the assistance
of forceps or ventouse (vacuum). An episiotomy will most likely be cut.
A common scenario however is that labor will not
progress "normally" in accordance with the time limits. Fetal distress,
as a result of the stronger oxytocin contractions, if often a concern by
this stage. Cesarean is an all too common outcome. |
|
The
primary risk of active management is that it results in the so-called cascade of
interventions whereby a seemingly innocuous and routine intervention has
repercussions down the track which lead to more and further interventions thus
changing the whole outcome of the birth (see insert on right).
The other
key disadvantage of active management is that it sees birth as a process that
occurs in linear fashion according to strict timescales and milestones. In
reality, of course, birth is not a linear process, and each woman will labor
differently. Active management takes control of the situation away from the
mother and places it firmly in the hands of the caregivers whose role it is to
monitor and manage the whole process. In contrast, expectant management
caregivers with their "wait and see" approach, recognize the individuality of
birth. They are therefore less likely to intervene routinely but will instead
play a watchful role.
What does this mean for me as a doula and/or childbirth educator?
If your
client is with a strongly active management doctor, her range of options and
choices for her birth is likely to be limited. If you are supporting her through
that birth experience, you have an important role to play in helping her
understand the routine procedures to which she is likely to be required to
consent, and what the implications of those procedures may be.
At an active
management birth, the role of a doula focuses much more on the provision of
physical comfort and to some extent emotional support than it does on
information giving and decision making support. For example, if you know that a
particular caregiver has a firm policy on the use of continuous fetal
monitoring, you know that your client's options as far as positioning may be
limited - this will therefore have implications for the range of pain relief
options available to her (she may not, for example, be permitted to use the
tub). However, if you have a client whose caregiver is open to the use of
intermittent monitoring, or no monitoring at all, you are able to play a much
more proactive role in helping her explore her options, try different
strategies, and so on.
If you have
a client who is completely comfortable with her caregiver, and happy to have her
birth managed in this way, then there may not be any issues or problems to
resolve. However there are circumstances in which it may be a problem:
-
If your
client has expectations which you know cannot be met with her current caregiver
- e.g. she wants to avoid episiotomy but you know her caregiver routinely
performs them
-
If your
personal values and philosophies on birth differ to the extent that it becomes
personally stressful to you to be in a situation where your clients' options,
and therefore your ability to support her, are limited.
The first
step in working your way through these dilemmas is to have a clear understanding
of how an individual doctor works.
How do I tell what philosophy of birth a caregiver follows?
Of course,
it is entirely possible for a client, or indeed a doula, to determine this just
by asking the caregiver which philosophy they adhere to. However it is always
possible that the Dr. may not themselves have a clear understanding of the
different philosophies, or it may be that they espouse a policy of expectant
management while in reality practicing active management. For example, they may
say they only do episiotomies "when they are necessary", but in reality they
find them to be necessary 99% of the time.
During
pregnancy there is often little to distinguish one doctor from another, and it
is only during the process of birth itself that their modus operandii becomes
clear. Of course by that stage it is too late!
Some clear
signals during pregnancy that indicate a doctor follows an active management
philosophy include:
-
Antenatal
appointments are typically kept short (5-10 minutes) with little time for
questions or concerns to be aired.
-
Ultrasound
is used at every antenatal appointment to assess fetal growth, there is little
or no abdominal palpation; fundal height is not measured.
-
Vaginal
examinations are routinely performed from 38 weeks.
-
The
caregiver is reluctant to answer many questions or is dismissive of the concept
of a birth plan. The caregiver may tell the woman that there is no need to
discuss these things in advance and they will be taken care of well.
Whilst you
may find it relatively straightforward to discover whether a doctor has an
active or expectant management approach, your client may find it more difficult.
An excellent tool for determining what a caregiver's beliefs are, is the simple
phrase B'LIEFS. The mother has to ask only 5 questions to develop a thorough
understanding of her caregiver's beliefs and philosophy. It is important that
the mother ask open rather than closed questions. A closed question simply
requires a yes or no answer, while an open questions elicits considerably more
information. The benefit of using a tool such as B'LIEFS is that the mother can
ask questions in an assertive yet non-confrontational way. She does not have to
go into her caregivers office with an agenda or concern herself at this stage
with whether or not she agrees with the doctor's beliefs. It is simply a tool to
discover more information.
B - Bed
(how do you feel about me being in positions off the bed for labor?)
L - how
Long?
(what sort of time limits do you have for first stage or pushing?)
I -
Induction
(under what circumstances would you induce labor?)
E -
Episiotomy
(how often do you find it is necessary to do an episiotomy?)
F - Food
(how do you feel about me eating and drinking during labor?)
S -
Supporters
(what are your thoughts on me having a doula or additional supporter)
Teaching
your clients how to use B'LIEFS and providing plenty of opportunities for them
to practice it will assist them in identifying whether or not they have the same
beliefs and philosophy as their caregiver. Once they have determined that they
can then identify their options if they discover the philosophies are mismatched
- either readjust their own expectations and desires, or change caregivers. We
have provided an article written for parents that helps them to understand the
differences between active and expectant management. You are welcome to add it
to your own website, provided it is displayed in its entirety. You can read the
article here.
Childbirth International courses focus on teaching
clients skills so they can determine the care that is
right for them. Childbirth educator students look at
integrating skills based learning into their classes and
use an active teaching approach so clients are involved
in their learning and classes are relaxed and enjoyable.
Doulas spend time in their training learning techniques
for clients to become more assertive when asking
questions of their caregivers and examining their
choices, enabling them to make informed decisions.
How does Childbirth International
address these issues?
The
concepts of active and expectant management are
a core part of the physiology covered in
Childbirth International courses. As a student
with CBI you will examine the impact of active
management and learn about the research that has
been carried out on this subject. All Childbirth
International courses focus on evidence-based
care and explore the evidence for common medical
interventions.
All courses are provided
through flexible learning, meaning you can study
at home, in your own time. No need for
workshops, travel or child care.
When choosing a training program, consider whether you
want to get through your training as quickly as possible
in order to be certified, or if you want the most
comprehensive training that will help you develop both
professionally and personally.
For more information on
training with Childbirth International, take a
look at our
website at
www.childbirthinternational.com,
or
contact us.
Childbirth International
offers training programs for Birth Doulas,
Postpartum Doulas and
Childbirth Educators. From September 2008 we will
also be launching a Breastfeeding Counseling
course.
Author: Nikki
Macfarlane
Last Updated: November 5 2007
