Sunday, June 11, 2006

WHO and active management

Homebirth advocates often cite the World Health Organization's strong support for midwifery as evidence that midwifery is safe and effective at managing pregnancy complications. Therefore, I was very surprised to find that the WHO strongly supports active management of labor.

Active management of labor is just what it sounds like, the liberal use of obstetric interventions to speed labor and make it conform to a pre-determined idea of what labor should look like. Active management of labor is based in large part on the Friedman curve. There are different programs of active management, but most involve a strict definition of labor, rupture of membranes as soon as feasible, frequent vaginal exams, and automatic use of pitocin if labor does not progress at 1 cm/hr. Proponents of active management claims that it decreases the C-section rate while simultaneously shortening labor.

The WHO strongly supports active management of labor and strongly supports the graphing of all labor curves to compare it with a "normal" curve. The WHO promotes this in their literature and in the training of birth assistants and midwives in developing countries.

I'm sure you can guess what my question is. If I am supposed to accept that homebirth is safe based on the WHO endorsement, doesn't that mean that homebirth advocates must accept the WHO's recommendations that all labors should be actively managed with multiple obstetric interventions?

18 Old Comments:

The WHO advocates active management of the third stage of labor . That is meant to facilitate a rapid delivery of the placenta and to reduce hemorrhage in women with a limited or lack of access to advanced medical care.

Though partograms are used, indications for augmentation are quite different than how pitocin is used in the US based on Friedman's curve. Can you imagine the WHO traning traditional birth attendants in rural Gambia or Nepal to administer pitocin in labor to what, 30+ percent of women in labor?

The partogram is meant to identify obstructed labor and the need for referral to a higher level of care to prevent morbidity and mortality. At that time, pitocin may be begun. Of course, this is not different than midwifery management in the United States, either in philosophy or practice. Some women will need augmentation. If all cargivers in the US used the WHO process, I bet the c/section rate would be less than 10%. I'm all for that.

The WHO also strongly advises for symphesiotomy and craniotomy, when needed. These can be life saving interventions.

Here is the WHO document upon which training is based

http://www.who.int/reproductive-health/impac/Clinical_
Principles/Normal_labour_C5
7_C76.html

By Anonymous maribeth, CNM, at 11:43 AM  

doesn't that mean that homebirth advocates must accept the WHO's recommendations that all labors should be actively managed with multiple obstetric interventions?

So, to more specifically address your question...

Multiple obstetric interventions? I think that's an exaggeration of the WHO guidelines. They say, for example "Vaginal examinations should be carried out at least once every 4 hours during the first stage of labour". I know homebirth midwives follow that more than OB providers. I think the WHO guidelines more properly identify true labor from pre-labor (a big problem in modern OB care these days).

I think professional homebirth midwives pretty much do follow the guidelines, as of course "active management of labor" is needed sometimes. If it wasn't, of course there would be no transfers.

By Anonymous maribeth, CNM, at 12:15 PM  

WHO also states that "Midwives are the most appropriate primary care provider to be assigned to the care of normal pregnancy and normal birth."

And, that "Respecting women's informed choice of PLACE of birth" SHOULD BE ENCOURAGED.

If only US hospitals and OBs would would read and heed Practices which are Clearly Harmful or Ineffective AND Should be Eliminated and Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue.

Seriously,
another formerly mainstream woman turned twice to empowering home births and midwife care after the first hospital birth experience

By Anonymous seriously, at 12:29 PM  

Thanks for clarifying Maribeth.

The WHO advocates active management of the THIRD STAGE OF LABOR.

By Anonymous Anonymous, at 1:01 PM  

Here's another great read in reference to the Dublin method of active managment of labor, including early amniotomy and pitocin augmentation (not promoted by the WHO Guidelines). From physician and epidemiologist, and former director of WHO, Marsden Wagner:

http://www.acegraphics.com.
au/articles/wagner01.html

By Anonymous maribeth, CNM, at 1:03 PM  

I am partway through reading the link you posted above, Maribeth, and I have a request.

Amy, will you please write your next blog on this article specifically so that it can be discussed in greater detail? Or at least respond to it here in the comments section?

I am most interested in what you and others have to say about it. It seems extremely relevant to your discussions so far, and to this section. I'll C&P the short quote from WHO.
Cherrie

"By medicalizing birth, i.e. separating a woman from her own environment and surrounding her with strange people using strange machines to do strange things to her in an effort to assist her (and some of this may occasionally be necessary), the woman's state of mind and body is so altered that her ways of carrying through this intimate act must also be altered and the state of the baby born must equally be altered. The result is that it is no longer possible to know what births would have been like before these manipulations. Most health care providers no longer know what "non-medicalized" birth is. This is an overwhelmingly important issue.

Almost all women in most developed countries give birth in hospitals, leaving the providers of the birth services with no genuine yardstick against which to measure their care. What is the range of length of safe labor? What is the true (i.e. absolute minimum) incidence of respiratory distress syndrome of newborn babies? What is the incidence of tears of the tissues surrounding the vaginal opening if the tissues are not first cut? What is the incidence of depression in women after "non-medicalized" birth? The answer to these, and many more questions is the same: no one knows. The entire modern obstetric and neonatology literature is essentially based on observations of medicalized birth. (WHO 1985a)."

By Anonymous Cherrie, at 1:32 PM  

"Of course, this is not different than midwifery management in the United States, either in philosophy or practice."

It seems to me that this is very different. First of all, all labors are supposed to be graphed and compared to the Friedman curve. The graph is called a partogram.

When a patient in labor is at least 4 cm dilated, the attendant is supposed to draw a line connecting the dilatation (e.g. 4 cm) to 10 cm. This line defines normal labor. The attendant is supposed to draw another line (the action line) to the right of the original line. If the labor falls off the original line and reaches the second line, the labor is not longer considered normal. This will happen if the patient fails to dilate at least 1 cm an hour over a four hour period. You can view the modified WHO partogram here.

If the labor crosses the action line, the labor is no longer considered normal and interventions must be started. These interventions include immediate rupture of membranes and pitocin augmentation.

Obviously, if the attendant is not trained to use pitocin, she must seek help or transfer the patient.

So the WHO's definition of active management includes diagnosis of labor at 4 cm, strict criteria for assessing progress (which will require frequent vaginal exams if the patient has not made adequate progress from initial exam), rupture of membranes and pitocin augmentation.

Active management of the third stage of labor is a separate practice, but it is also recommended by the WHO and involves intervetions.

By Blogger Amy Tuteur, MD, at 1:52 PM  

"Many Western doctors hold the belief that we can improve everything, even natural childbirth in a healthy woman. This philosophy is the philosophy of people who think it deplorable that they were not consulted at the creation of Eve, because they would have done a better job" (Kloosterman 1994).

By Anonymous Anonymous, at 1:53 PM  

I forgot to include the link to the WHO recommendations. Sorry.

By Blogger Amy Tuteur, MD, at 1:53 PM  

Amy, as you described yourself, 'active management of labor' (AML) is a specific protocol developed in Dublin. It includes:

- amniotomy at the diagnosis of labor
- cervical assessment every 2 hours
- oxytocin augmentation if <2 cm change in that interval
- high-dose oxytocin protocol, with a starting dose of 6 mU per minute and increased by 6 mU every 15 minutes to a maximum dose of 36 mU per minute

The WHO's partogram, and definition of prolonged labor, is not the same as AML.

By Anonymous maribeth, CNM, at 2:27 PM  

my said: 'If the labor crosses the action line, the labor is no longer considered normal and interventions must be started. These interventions include immediate rupture of membranes and pitocin augmentation.'

Nobody knew where I was with labour was last time because I said no VE. I feel it to be an unnecessary intrusion into labour. Not all labours follow the normal line because not all women are the same. What might be abnormal for you is in fact normal for the woman.

By Anonymous Anonymous, at 2:32 PM  

Maribeth:

"The WHO's partogram, and definition of prolonged labor, is not the same as AML."

It is not the same as the Dublin model, but it is a form of active management. Most importantly, it implies that there is such as thing as a "normal" labor and it is based on the Friedman curve.

Furthermore, it also tells us that the WHO thinks that such a large number of labors are going to be abnormal that all birth attendants everywhere should be trained to diagnose it.

To tell you the truth, I didn't know about this until I read it this morning. I was very surprised.

By Blogger Amy Tuteur, MD, at 5:52 PM  

It's not a "form" of active management, it's an assessment tool for differentiation of normal and abnormal labor.

"WHO thinks that a large number of labors are going to be abnormal"

A large number, Amy? What is that statement based on?

Feigning surprise that (worldwide) some labors are abnormal and require intervention rings a little hollow. Of course there are appropriate criteria for normal labor. Of course obstructed labor needs intervention. I don't see what the implication is on US midwifery though. If you think the WHO protocol translates to a 40 plus perfect pitocin rate (as the US has) you misunderstand it completely.

By Anonymous maribeth, CNM, at 6:51 PM  

ACK, percent, I meant percent. Hardly perfect!

By Anonymous maribeth, CNM, at 7:19 PM  

So, Maribeth, are you saying that you agree with the WHO partogram and labor management protocol?

By Blogger Amy Tuteur, MD, at 8:12 PM  

Yes, Amy, in rural places without skilled birth attendants, where medical care may be a half day away, I do agree with the WHO partogram and protocol. I taught it in SE Asia, FWIW.

By Anonymous maribeth, CNM, at 8:28 PM  

Maribeth:

"in rural places without skilled birth attendants, where medical care may be a half day away, I do agree with the WHO partogram and protocol."

It is my understanding that it is supposed to apply to everyone in developed countries as well as third world countries.

By Blogger Amy Tuteur, MD, at 9:31 AM  

I think it's important to distinguish betw. WHO's recommendations for poorer countries (inherent problems like distance to hospital, malnutrition of mums, etc.) and what they recommend for the industrialized nations.

I don't *know* there is a difference, but believe there might be. Anyone know?

By Anonymous Anonymous, at 12:11 PM