BELLY UP - Time ticking away

The term "active management" refers to a particular philosophy of birth, an overall approach to how labour 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 antenatal teacher 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 standardised, 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 labour 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 personalised dining experience.  

In essence, active management of labour is much like the "fixed price" menu. Caregivers adopt a standardised approach to caring for women in labour. Routine practices and procedures are adopted - for example, all women being admitted to hospital in labour will be expected to have an IV set up. Labour 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 labour does not correspond with this model - for example, when the onset of labour 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. Labour 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 labour. 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 labour. Doctors guaranteed that women would not labour 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 labour and birth should be managed. On admittance to hospital, women were first assessed to determine whether labour 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 labour was managed according to the following standards:

• Labour not to last more than 12 hours. The doctors expected women to be able to manage without pain medication so long as labour 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 labour 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 caesarean.

   

• Women in labour 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 caesarean 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 foetal monitoring in labour, episiotomies, and active management of the third stage of labour.  Some elements of the original approach appear to have been "lost" over time - most notably the strict definition of when labour is said to begin, and the use of continuous one on one support for labouring women. Concurrently, the rate of epidural use has increased significantly.

What are the benefits of active management?

For women in labour, one of the primary benefits (as was intended by the Dublin doctors) is a reduction in the overall length of labour. 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 caesarean rates - at the time the Dublin trials were published, caesarean 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 caesarean 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 standardised approach makes managing women in labour much simpler, and staffing and scheduling are easier, particular in busy hospitals. More labours 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 labour that fall outside that definition.

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 labour 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, recognise 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 antenatal teacher?

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 foetal 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 foetal 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 labour?)

L - how Long? (what sort of time limits do you have for first stage or pushing?)

I - Induction (under what circumstances would you induce labour?)

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 labour?)

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. Antenatal teacher 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.