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Cochrane Database of Systematic Reviews

Labour assessment programs to delay admission to labour


wards (Review)

Lauzon L, Hodnett ED

Lauzon L, Hodnett ED.


Labour assessment programs to delay admission to labour wards.
Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD000936.
DOI: 10.1002/14651858.CD000936.

www.cochranelibrary.com

Labour assessment programs to delay admission to labour wards (Review)


Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Analysis 1.1. Comparison 1 Early labour assessment versus direct admission, Outcome 1 discharged undelivered. . . 7
Analysis 1.2. Comparison 1 Early labour assessment versus direct admission, Outcome 2 length of time from hospital
admission to delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Analysis 1.3. Comparison 1 Early labour assessment versus direct admission, Outcome 3 artificial rupture of membranes. 8
Analysis 1.4. Comparison 1 Early labour assessment versus direct admission, Outcome 4 intrapartum oxytocics. . . 9
Analysis 1.5. Comparison 1 Early labour assessment versus direct admission, Outcome 5 any intrapartum analgesia. . 9
Analysis 1.6. Comparison 1 Early labour assessment versus direct admission, Outcome 6 epidural analgesia. . . . 10
Analysis 1.7. Comparison 1 Early labour assessment versus direct admission, Outcome 7 intrapartum narcotic/inhalation
analgesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Analysis 1.8. Comparison 1 Early labour assessment versus direct admission, Outcome 8 forceps/vacuum extraction. 11
Analysis 1.9. Comparison 1 Early labour assessment versus direct admission, Outcome 9 Caesarean section. . . . 11
Analysis 1.10. Comparison 1 Early labour assessment versus direct admission, Outcome 10 perceived control. . . . 12
Analysis 1.11. Comparison 1 Early labour assessment versus direct admission, Outcome 11 1-minute Apgar < 7. . . 12
Analysis 1.12. Comparison 1 Early labour assessment versus direct admission, Outcome 12 5-minute Apgar < 7. . . 13
Analysis 1.13. Comparison 1 Early labour assessment versus direct admission, Outcome 13 neonatal resuscitation. . 13
FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Labour assessment programs to delay admission to labour wards (Review) i


Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Labour assessment programs to delay admission to labour


wards

Leeanne Lauzon1 , Ellen D Hodnett2

1 Family and Newborn Unit, IWK Health Centre, Halifax, Canada. 2 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto,

Toronto, Canada

Contact address: Leeanne Lauzon, Family and Newborn Unit, IWK Health Centre, 5850/5980 University Avenue, P.O. Box 9700,
Halifax, Nova Scotia, B3K 6R8, Canada. leeanne.lauzon@iwk.nshealth.ca.

Editorial group: Cochrane Pregnancy and Childbirth Group.


Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 30 January 2004.

Citation: Lauzon L, Hodnett ED. Labour assessment programs to delay admission to labour wards. Cochrane Database of Systematic
Reviews 2001, Issue 3. Art. No.: CD000936. DOI: 10.1002/14651858.CD000936.

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

Background

The aim of labour assessment programs is to delay hospital admission until labour is in the active phase, and thereby to prevent
unnecessary interventions in women who are not in established labour.

Objectives

The objective of this review was to assess the effects of labour assessment programs that aim to delay hospital admission until labour is
in the active phase.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group trials register (January 2004).

Selection criteria

Randomised trials which compare labour assessment programs with direct admission to labour wards.

Data collection and analysis

Trial quality was assessed.

Main results

One study of 209 women was included. The trial was of excellent quality. Women who were randomised to the labour assessment unit
spent less time in the labour ward (weighted mean difference -5.20 hours, 95% confidence interval -7.06, -3.34), were less likely to
receive intrapartum oxytocics (odds ratio 0.45, 95% confidence interval 0.25 to 0.80) and analgesia (odds ratio 0.36, 95% confidence
interval 0.16 to 0.78), than women who were admitted directly to the labour ward. Women in the labour assessment group reported
higher levels of control during labour (weighted mean difference 16.00, 95% confidence interval 7.52 to 24.48). There is insufficient
evidence to assess effects on rate of caesarean section and other important measures of maternal and neonatal outcome.
Labour assessment programs to delay admission to labour wards (Review) 1
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Authors’ conclusions

Labour assessment programs, which aim to delay hospital admission until active labour, may benefit women with term pregnancies.

PLAIN LANGUAGE SUMMARY

Labour assessment programs to delay admission to labour wards

Pregnant women coming into hospital with signs of labour, may benefit from formal assessment by a specialised program.

Hospital labour assessment programs are specialised programs that confirm whether women coming into hospital with signs of labour,
are in active labour (with the neck of the womb opening), before going to labour ward. Women with full term pregnancies in these
programs spend time in the assessment unit, walk in the grounds, go home or are admitted to labour ward. The review found they have
shorter labour ward stays, feel more control and use fewer drugs to progress labour or for pain relief. There is not enough evidence on
other effects on the mother or baby or on unplanned out-of-hospital birth.

BACKGROUND views [’Caregiver support for women during childbirth’ (Hodnett


2001), ’Amniotomy for shortening spontaneous labour’ (Fraser
Timely diagnosis of progressive labour is problematic for caregivers 2001a), and ’Early amniotomy and early oxytocin for delay in nul-
and expectant women. Methods of distinguishing active or pro- liparae compared with routine care’ (Fraser 2001b)]. The fourth
gressive labour from latent phase or Braxton-Hicks contractions component, an approach to labour assessment that uses pre-de-
vary greatly, are not universally applied, and have not been sub- fined criteria to restrict admission to labour wards until such time
jected to scientific scrutiny (Thornton 1994). While the diagnosis as labour is active, is the subject of this Review. While formal
of active labour is self-evident in retrospect, retrospective diagnosis approaches to labour assessment may be beneficial, as indicated
is of little value in the clinical setting when decisions regarding above, they may also have negative effects. These include: psycho-
admission for care and/or intrapartum care interventions are oc- logical distress, in women who are very anxious or experiencing
curring in a relatively brief period of time (Crowther 1989). painful contractions, but who are sent home because they do not
While Braxton-Hicks contractions and even prolonged latent meet labour ward admission criteria; and unplanned out-of-hos-
labour may pose no problem for a woman and her fetus, the mis- pital birth.
taken diagnosis of active labour is not without consequence. Fail- A related Review focuses on the effectiveness of teaching pregnant
ure of the cervix to dilate within a prescribed period of time, as women a set of criteria for self-diagnosis of active labour (Lauzon
would be expected in the active phase of labour, results in the 1998). A related Protocol addresses the question of the utility of
diagnosis of dystocia (Baskett 1991; Friedman 1989; O’Driscoll a partogram in assessing labour progress (Lavender 2005).
1984). One Canadian study found that over 40% of caesarean sec-
tions performed for dystocia were performed before the establish-
ment of true labour (Stewart 1990). Labour that is non-progres-
sive may be augmented with oxytocics in an attempt to correct the OBJECTIVES
presumed inefficiency of the uterus (O’Driscoll 1984; Thornton To assess the effectiveness of labour assessment programs aimed at
1994), which may increase the incidence of analgesia use and uter- delaying admission to the labour ward until labour is in the active
ine hyperstimulation (Thornton 1994). Mothers’ confidence in phase. The main outcomes of interest are:
their caregivers may be undermined, their self-confidence eroded,
and the perception of their birth experience negatively affected
• rates of caesarean delivery;
when an incorrect labour diagnosis is amended (O’Driscoll 1984;
Simkin 1996). • rates of other intrapartum complications;

Three of the components of the Active Management of Labour • use of oxytocics, analgesics, and other intrapartum
protocol (O’Driscoll 1984) have been the subjects of Cochrane Re- interventions;
Labour assessment programs to delay admission to labour wards (Review) 2
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
• mothers’ evaluations of their birth experiences and care 1. quarterly searches of the Cochrane Central Register of
provided; Controlled Trials (CENTRAL);
2. monthly searches of MEDLINE;
• rates of hospital discharge diagnoses of ’not in labour’ or
3. handsearches of 30 journals and the proceedings of major
’false labour’;
conferences;
• rates of out-of-hospital emergencies (eg unplanned out-of- 4. weekly current awareness search of a further 37 journals.
hospital births); Details of the search strategies for CENTRAL and MEDLINE,
the list of handsearched journals and conference proceedings, and
• admission rates to neonatal intensive care units.
the list of journals reviewed via the current awareness service can be
found in the ’Search strategies for identification of studies’ section
within the editorial information about the Cochrane Pregnancy
METHODS and Childbirth Group.
Trials identified through the searching activities described above
are given a code (or codes) depending on the topic. The codes are
Criteria for considering studies for this review linked to review topics. The Trials Search Co-ordinator searches
the register for each review using these codes rather than keywords.

Types of studies
Randomised controlled trials comparing labour assessment pro- Data collection and analysis
grams with direct admission to labour wards; violations of allo- The reviewers independently selected and assessed the single trial
cated management not sufficient to materially affect outcomes; resulting from the search. Names of authors, related institutions,
missing data insufficient to materially affect the comparison. journals of publication, and study results were known by the re-
viewers when inclusion criteria were applied. Trials under consid-
Types of participants eration were evaluated for methodological quality and appropri-
ateness for inclusion, regardless of results, using standard Cochrane
All pregnant women at term gestation.
criteria. No identified trials were excluded from this review. In-
cluded trial data were processed as described in Clarke 2000.
Types of interventions
Any hospital or community-based programs that aim to delay
hospital or labour ward admission until active labour, through
application of specific criteria for diagnosing active labour. RESULTS

Types of outcome measures Description of studies


The main outcomes of interest are: caesarean delivery; other in- See: Characteristics of included studies.
trapartum interventions; intrapartum complications; labour aug- See table of ’Characteristics of included studies’.
mentation; patient satisfaction; hospital discharge diagnoses such The single trial included in this review compared a Labour Assess-
as ’not in labour’ and ’false labour’; out-of-hospital emergencies; ment program, in a separate homelike unit within the hospital,
and neonatal outcomes, including admission rates to neonatal in- with direct admission to the labour ward.
tensive care.

Risk of bias in included studies


Search methods for identification of studies
The single included trial (McNiven 1998) is of excellent qual-
ity. Randomisation methods were clear and adequately controlled.
Electronic searches Only one randomised woman was lost to follow-up.

We searched the Cochrane Pregnancy and Childbirth Group trials


register (January 2004).
The Cochrane Pregnancy and Childbirth Group’s trials register is
Effects of interventions
maintained by the Trials Search Co-ordinator and contains trials In the Labour Assessment group, 20% were admitted to the labour
identified from: ward within five minutes to one hour, 18% were sent home because

Labour assessment programs to delay admission to labour wards (Review) 3


Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
labour was not established, and the remaining 62% spent one to delivery, unplanned out-of-hospital birth, or other important ma-
four hours either in the labour assessment unit or out walking, ternal and neonatal outcomes. A larger multi-centre trial would
prior to admission to the labour ward. Sixteen per cent of the help to determine the benefits and risks of this intervention.
Direct Admission group were sent home because they were not
in established labour. The length of stay in the labour ward was
significantly shorter for women in the Labour Assessment group AUTHORS’ CONCLUSIONS
(weighted mean difference = -5.20 hours, 95% confidence interval
-7.06, -3.34). Women in the Labour Assessment group were less Implications for practice
likely to receive intrapartum oxytocics (odds ratio = 0.45; 95%
confidence interval 0.25, 0.80) and analgesia (odds ratio = 0.36; Because only 209 women in a single Canadian centre have been
95% confidence interval 0.16, 0.78), and reported higher levels studied, there are no implications for changes to existing practices.
of control during labour and birth (weighted mean difference =
16.00, 95% confidence interval 7.52, 24.48). Implications for research
Although some benefits were associated with the Labour Assess-
ment program, a multi-centre randomised controlled trial is nec-
essary to determine the risks and benefits of the same or a similar
DISCUSSION intervention. Participants should be of sufficient number to allow
for the determination of clinically important outcomes, such as
The one trial in this review demonstrated some positive effects of the effect on caesarean section rates, neonatal well-being, rates of
the labour assessment program. The use of strict criteria for the intrapartum interventions, women’s evaluations of their care, and
diagnosis of active labour may prevent the misdiagnosis of dysto- costs. Potential risks should also be evaluated. These include un-
cia. It is also possible that other aspects of the Labour Assessment planned out-of-hospital births and the potentially harmful effects
program were different from routine care (including the homelike of withholding caregiver support and attention to women in early
environment, additional advice or encouragement from caregivers, or latent phase labour.
or the opportunities to eat, walk around, etc) and that these differ-
ences accounted for the benefits. Limitations of this study include
the small sample size and the unavoidable fact that participants and
their caregivers were unblinded to their study group assignment
ACKNOWLEDGEMENTS
(they either received initial care in an early labour assessment area
or were sent directly to the labour ward). The trial had insufficient The authors would like to thank Patricia McNiven for graciously
power to test the effects of the intervention on rates of caesarean making available her doctoral dissertation.

REFERENCES

References to studies included in this review (RevMan) [Computer program]. Version 4.1. Oxford,
England: The Cochrane Collaboration, 2000.
McNiven 1998 {published and unpublished data}
McNiven P. Feasibility study for a multi-centre randomized Crowther 1989
trial of the effect of an early labour assessment program on the Crowther C, Enkin MW, Keirse MJNC, Brown I.
rate of cesarean delivery [doctoral dissertation]. University of Monitoring the progress of labour. In: Chalmers I, Enkin
Toronto, 1996. MW, Keirse MJNC editor(s). Effective Care in Pregnancy

McNiven PS, Williams, JI, Hodnett E, Kaufman K, and Childbirth. Vol. 2, 1989:833–45.
Hannah ME. An early labour assessment program: A
Fraser 2001a
randomised, controlled trial. Birth 1998;25(1):5–10.
Fraser WD, Turcot L, Krauss I, Brisson-Carrol G.
Additional references Amniotomy for shortening spontaneous labour (Cochrane
Review). The Cochrane Library 2001, Issue 2.[Art. No.:
CD000015. DOI: 10.1002/14651858.CD000015.pub2]
Baskett 1991
Baskett TF. Essential Management of Obstetrical Emergencies.
Fraser 2001b
2nd Edition. Bristol, UK: Clinical Press Ltd, 1991.
Fraser WD, Roy C, Turcot L. Early amniotomy and early
Clarke 2000 oxytocin for delay in nulliparae compared with routine care
Clarke M, Oxman AD, editors. Cochrane Reviewers’ (Protocol for a Cochrane Review). The Cochrane Library
Handbook 4.1 [updated June 2000]. In: Review Manager 2001, Issue 2.
Labour assessment programs to delay admission to labour wards (Review) 4
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Friedman 1989 of labor as an alternative to cesarean section for dystocia.
Friedman E. Normal and dysfunctional labour. In: Cohen Obstetrics and Gynecology 1984;63(4):485–90.
WR, Acker DB, Friedman EA editor(s). Management of Simkin 1996
Labour. 2nd Edition. Rockville, MD: Aspen Publishers, Simkin P. The experience of maternity in a woman’s life.
1989. Journal of Obstetric Gynecologic and Neonatal Nursing 1996;
Hodnett 2001 25(3):247–52.
Hodnett ED. Caregiver support for women during Stewart 1990
childbirth (Cochrane Review). The Cochrane Library Stewart P, Dulberg C, Arnill A, Elmslie T, Hall P. Diagnosis
2001, Issue 2.[Art. No.: CD000199. DOI: 10.1002/ of dystocia and management with cesarean section among
14651858.CD000199] primiparous women in Ottawa-Carleton. Canadian Medical
Lauzon 1998 Association Journal 1990;142(5):459–63.
Lauzon L, Hodnett ED. Antenatal education for self- Thornton 1994
diagnosis of the onset of active labour at term. Cochrane Thornton JG, Lilford RJ. Active management of labour:
Database of Systematic Reviews 1998, Issue 4. [Art. No.: Current knowledge and research issues. British Medical
CD000935. DOI: 10.1002/14651858.CD000935] Journal 1994;309:366–9.
Lavender 2005
Lavender T, O’Brien P, Hart A. Effect of partogram use on
References to other published versions of this review
outcomes for women in spontaneous labour at term. The
CDSR 2001
Cochrane Database of Systematic Reviews 2005.[Art. No.:
Lauzon L, Hodnett E. Caregivers’ use of strict criteria for
CD005461. DOI: 10.1002/14651858.CD005461.pub2]
diagnosing active labour in term pregnancy (Cochrane
O’Driscoll 1984 Review). The Cochrane Library 2001, Issue 2.
O’Driscoll K, Foley M, MacDonald D. Active management ∗
Indicates the major publication for the study

Labour assessment programs to delay admission to labour wards (Review) 5


Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

McNiven 1998

Methods Randomised controlled trial, random allocation by sealed, opaque envelopes. Participants were recruited
upon presentation to hospital for labour assessment, by labour and delivery nurses trained in the study
method

Participants 209 low-risk nulliparous women at a teaching hospital in Ontario, Canada, were randomly allocated
to experimental (n = 105) or control (n = 104) groups. All were 37+ weeks singleton gestation, with a
spontaneous onset of labour. No significant differences in groups with regard to time of recruitment, age,
marital status, type of hospital coverage, location of residence, physician, or newborn characteristics. One
subject was excluded after randomisation because she was < 37 weeks gestation

Interventions Women in the experimental group received Labour Assessment, which included the determination of
fetal heart rate, maternal blood pressure and urine tests, frequency and duration of contractions, status of
amniotic membranes and presence of bloody show. A vaginal examination was performed by a medical
intern or an assessment area nurse, and a participant was determined to be in active labour with a cervical
dilatation of 3+ cms in the presence of regular, painful, contractions. Participants not found to be in
active labour were given advice, support, and encouragement, and were instructed to walk outside or
return home. Instruction was given regarding when to return to hospital. Control group participants were
admitted directly to the labour ward and received routine care, which included discharge if they were not
in labour

Outcomes Caesarean delivery, amniotomy, anaesthesia/analgesia, episiotomy, forceps delivery, vacuum delivery,
length of labour, length of stay in labour and delivery and in postpartum unit, oxytocin augmentation,
one- and five-minute Apgar scores, patient satisfaction

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Doctoral dissertation as basis for McNiven 1998 publication.


RCT = randomised controlled trial

Labour assessment programs to delay admission to labour wards (Review) 6


Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES

Comparison 1. Early labour assessment versus direct admission

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 discharged undelivered 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 1.13 [0.55, 2.31]
2 length of time from hospital 1 209 Mean Difference (IV, Fixed, 95% CI) -5.20 [-7.06, -3.34]
admission to delivery
3 artificial rupture of membranes 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.75 [0.44, 1.29]
4 intrapartum oxytocics 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.45 [0.25, 0.80]
5 any intrapartum analgesia 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.36 [0.16, 0.78]
6 epidural analgesia 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.42 [0.20, 0.89]
7 intrapartum narcotic/inhalation 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.51 [0.05, 4.91]
analgesia
8 forceps/vacuum extraction 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.79 [0.45, 1.41]
9 Caesarean section 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.70 [0.27, 1.79]
10 perceived control 1 201 Mean Difference (IV, Fixed, 95% CI) 16.0 [7.53, 24.47]
11 1-minute Apgar < 7 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 1.76 [0.69, 4.51]
12 5-minute Apgar < 7 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 7.32 [0.15, 368.87]
13 neonatal resuscitation 1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.79 [0.21, 2.98]

Analysis 1.1. Comparison 1 Early labour assessment versus direct admission, Outcome 1 discharged
undelivered.
Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 1 discharged undelivered

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 19/105 17/104 100.0 % 1.13 [ 0.55, 2.31 ]

Total (95% CI) 105 104 100.0 % 1.13 [ 0.55, 2.31 ]


Total events: 19 (Treatment), 17 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.33 (P = 0.74)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Labour assessment programs to delay admission to labour wards (Review) 7


Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.2. Comparison 1 Early labour assessment versus direct admission, Outcome 2 length of time
from hospital admission to delivery.

Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 2 length of time from hospital admission to delivery

Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

McNiven 1998 105 8.3 (5.6) 104 13.5 (7.9) 100.0 % -5.20 [ -7.06, -3.34 ]

Total (95% CI) 105 104 100.0 % -5.20 [ -7.06, -3.34 ]


Heterogeneity: not applicable
Test for overall effect: Z = 5.49 (P < 0.00001)
Test for subgroup differences: Not applicable

-10 -5 0 5 10
Favours treatment Favours control

Analysis 1.3. Comparison 1 Early labour assessment versus direct admission, Outcome 3 artificial rupture
of membranes.
Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 3 artificial rupture of membranes

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 49/105 56/104 100.0 % 0.75 [ 0.44, 1.29 ]

Total (95% CI) 105 104 100.0 % 0.75 [ 0.44, 1.29 ]


Total events: 49 (Treatment), 56 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.04 (P = 0.30)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Labour assessment programs to delay admission to labour wards (Review) 8


Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.4. Comparison 1 Early labour assessment versus direct admission, Outcome 4 intrapartum
oxytocics.

Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 4 intrapartum oxytocics

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 24/105 42/104 100.0 % 0.45 [ 0.25, 0.80 ]

Total (95% CI) 105 104 100.0 % 0.45 [ 0.25, 0.80 ]


Total events: 24 (Treatment), 42 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 2.72 (P = 0.0065)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Analysis 1.5. Comparison 1 Early labour assessment versus direct admission, Outcome 5 any intrapartum
analgesia.

Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 5 any intrapartum analgesia

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 84/105 96/104 100.0 % 0.36 [ 0.16, 0.78 ]

Total (95% CI) 105 104 100.0 % 0.36 [ 0.16, 0.78 ]


Total events: 84 (Treatment), 96 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 2.57 (P = 0.010)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Labour assessment programs to delay admission to labour wards (Review) 9


Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.6. Comparison 1 Early labour assessment versus direct admission, Outcome 6 epidural analgesia.

Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 6 epidural analgesia

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 83/105 94/104 100.0 % 0.42 [ 0.20, 0.89 ]

Total (95% CI) 105 104 100.0 % 0.42 [ 0.20, 0.89 ]


Total events: 83 (Treatment), 94 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 2.27 (P = 0.023)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Analysis 1.7. Comparison 1 Early labour assessment versus direct admission, Outcome 7 intrapartum
narcotic/inhalation analgesia.

Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 7 intrapartum narcotic/inhalation analgesia

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 1/105 2/104 100.0 % 0.51 [ 0.05, 4.91 ]

Total (95% CI) 105 104 100.0 % 0.51 [ 0.05, 4.91 ]


Total events: 1 (Treatment), 2 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.59 (P = 0.56)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.8. Comparison 1 Early labour assessment versus direct admission, Outcome 8 forceps/vacuum
extraction.
Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 8 forceps/vacuum extraction

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 32/105 37/104 100.0 % 0.79 [ 0.45, 1.41 ]

Total (95% CI) 105 104 100.0 % 0.79 [ 0.45, 1.41 ]


Total events: 32 (Treatment), 37 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.78 (P = 0.43)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Analysis 1.9. Comparison 1 Early labour assessment versus direct admission, Outcome 9 Caesarean section.

Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 9 Caesarean section

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 8/105 11/104 100.0 % 0.70 [ 0.27, 1.79 ]

Total (95% CI) 105 104 100.0 % 0.70 [ 0.27, 1.79 ]


Total events: 8 (Treatment), 11 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.74 (P = 0.46)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.10. Comparison 1 Early labour assessment versus direct admission, Outcome 10 perceived
control.
Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 10 perceived control

Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

McNiven 1998 99 158 (27) 102 142 (34) 100.0 % 16.00 [ 7.53, 24.47 ]

Total (95% CI) 99 102 100.0 % 16.00 [ 7.53, 24.47 ]


Heterogeneity: not applicable
Test for overall effect: Z = 3.70 (P = 0.00022)
Test for subgroup differences: Not applicable

-10 -5 0 5 10

Analysis 1.11. Comparison 1 Early labour assessment versus direct admission, Outcome 11 1-minute Apgar
< 7.
Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 11 1-minute Apgar < 7

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 12/105 7/104 100.0 % 1.76 [ 0.69, 4.51 ]

Total (95% CI) 105 104 100.0 % 1.76 [ 0.69, 4.51 ]


Total events: 12 (Treatment), 7 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.18 (P = 0.24)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.12. Comparison 1 Early labour assessment versus direct admission, Outcome 12 5-minute Apgar
< 7.
Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 12 5-minute Apgar < 7

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 1/105 0/104 100.0 % 7.32 [ 0.15, 368.87 ]

Total (95% CI) 105 104 100.0 % 7.32 [ 0.15, 368.87 ]


Total events: 1 (Treatment), 0 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.00 (P = 0.32)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Analysis 1.13. Comparison 1 Early labour assessment versus direct admission, Outcome 13 neonatal
resuscitation.
Review: Labour assessment programs to delay admission to labour wards

Comparison: 1 Early labour assessment versus direct admission

Outcome: 13 neonatal resuscitation

Peto Peto
Study or subgroup Treatment Control Odds Ratio Weight Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
McNiven 1998 4/105 5/104 100.0 % 0.79 [ 0.21, 2.98 ]

Total (95% CI) 105 104 100.0 % 0.79 [ 0.21, 2.98 ]


Total events: 4 (Treatment), 5 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.35 (P = 0.72)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
FEEDBACK

Gotzsche and Middleton, July 1999

Summary
Objectives:
The stated objective is to assess effectiveness of specific criteria for diagnosis of active labour, but the intervention includes advice and
support, and is a comparison with direct admission to labour ward, rather than routine practice which would include sending some
women home.
Criteria for considering studies for the review:
The criteria for type of study are restrictive and subjective. It would be better to include all randomised trials and then discuss problems
with compliance and missing data within the review.
The list of outcomes is duplicated, as it is also under ’objectives’.
Methodological quality:
The statement about performance bias should be explained and justified. Only in the characteristics of trials table is it stated that all
the control group should have been kept in hospital.
Results:
This should state there was one trial, and the number of participants.
Conclusions:
This review is not testing diagnostic criteria alone, as other support is included in the intervention. The review should be re-oriented
to reflect this, or should state no eligible studies were found.

Reply
October 1999:
The objective was to assess the effects of caregivers applying specific criteria to diagnose labour. The advice and support would have
been available to women in both groups.
No other trials were found, even when a broader search strategy was used. Performance bias was mentioned as some women in the
control group received labour assessment and were discharged home, when the intention was to keep them in hospital until they gave
birth. However, this could be considered part of the routine care to which they were randomised. This will be clarified in the next
review update.
The effects of caregiver support are assessed in other Cochrane reviews. For this review, the defining comparison is based on whether
or not specific criteria for the diagnosis of labour were applied.
[Summary of reply from Leeanne Lauzon, October 1999]
March 2001:
In a substantive update to the review, we reconsidered the comments/criticisms. We fully agree with them, and as a consequence have
made significant changes throughout the review. The title now more accurately reflects the objective of the review, and the text has
been revised to make the purpose clearer, and to clarify the methods and results. The discussion has been expanded. The review now
states that one trial was found and gives the number of participants. No other trials were found, even with a broader search strategy .
[Summary of reply from Ellen Hodnett and Leeanne Lauzon, March 2001]

Contributors
Summary of comments from Peter Gotzsche and Philippa Middleton, July 1999.

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
WHAT’S NEW
Last assessed as up-to-date: 30 January 2004.

Date Event Description

12 November 2008 Amended Added published note about the next update of this review - see Published notes.

11 September 2008 Amended Converted to new review format.

HISTORY
Protocol first published: Issue 1, 1998
Review first published: Issue 4, 1998

Date Event Description

31 January 2004 New search has been performed Search rerun but no new trials identified.

CONTRIBUTIONS OF AUTHORS
Both authors independently selected and extracted data. L Lauzon wrote the original Review as part of the requirements for a MSc
degree, under E Hodnett’s supervision. Both authors wrote subsequent updates of the Review.

DECLARATIONS OF INTEREST
Ellen Hodnett was a co-investigator for the McNiven 1998 trial.

SOURCES OF SUPPORT

Internal sources
• University of Toronto, Canada.

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
External sources
• No sources of support supplied

NOTES
This review will be updated following a new protocol (in preparation) which will combine the currently published review by Lauzon
1998 with this review, to include all interventions for labour assessment and care to delay hospital admission. When the review following
the new protocol is published, this review will be withdrawn from publication.

INDEX TERMS

Medical Subject Headings (MeSH)


∗ Hospitalization; ∗ Labor Onset; Prenatal Care; Program Evaluation; Randomized Controlled Trials as Topic

MeSH check words


Female; Humans; Pregnancy

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.