PubL Hlth., Lond. (1975) 89, 191-197
Current Trends in Obstetric Services Mark McCarthy M.R.C.P,, M.F.C.M.
Senior Registrar in Communit}/ Medicine, Kent Area Hea/th Author/t}/, Maidstone, Kent Terence G. McCarthy F.R.C.S., M.R.C.O.G.
Senior Registrar, Department of Obstetrics and Gynaeco/ogy, St Thomas Hospita/, London S.E. 1. The planning of health services necessitates the identification and evaluation of innovations. Recent developments in obstetric care include the measurement of foetal growth and maturity in the antenatal period, increasing use of monitoring, induction and "acceleration" of labour, epidural anaesthesia and very short stay in hospital during the postnatal period. Some implications of these changes for the planning of future services are considered and matters for further research, particularly the acceptability of these developments to the mother and her family, are suggested. Introduction Health service planning is to be one of the major activities of the new Health Authorities in the reorganized National Health Service. The annual cycle of planning presented in the management arrangements (Department of Health and Social Security, 1972a) involves a process of identification of needs, formulation of objectives and allocation of resources, with subsequent monitoring of the outcome of the plan. However, a large part of the resources of the Health Service is allocated to activities for which direct measures of outcome are difficult to define. The objectives of the planning team will often therefore be merely to improve the standards of existing services and to extend their scope where unmet needs have been identified. Planning is dependent on the recognition of technical and therapeutic changes that are occurring within the services and may have an influence on the way resources are used in the future. Two examples of such changes in the 1960s were the introduction of the cervical cytology and the renal dialysis programrnes. In the present decade it may be that, for example, surgery for coronary artery occlusion will have an effect of similar magnitude (Editorial B.M.J., 1973). The planner must therefore consider not only current practice and needs but keep a weather eye open for innovations in the field. Forward thinking in obstetric services is the purpose of this article--to identify new patterns of care, determine their efficiency and encourage service evaluation. This helps the planner anticipate demands that may arise rapidly if an innovative regimen becomes acceptable and widely desired by patients. It is also in line with the aims for applied research of the Rothschild report (1971) and of the chief scientist at the Department of Health (Black, 1974). Antenatal Care Antenatal care is undertaken to follow progress of all mothers-to-be, to ensure so far as possible that the pre-conditions for normal full-term delivery are present and to identify high risk patients and institute prophylactic care or treatment as required.
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Patients with a poor obstetric history, pre-eclampsia, essential hypertension antepartum haemorrhage and certain medical conditions, particularly diabetes, will continue to occupy a great proportion of antenatal beds. Recently however, the concept of the small-for-dates baby has emerged and it has been shown that such babies are at increased risk not only during pregnancy and labour (Alberman, 1974) but also in their subsequent development of verbal and mental ability (Fitzhardinge & Steven 1971 ; Rhodes, 1973). Rest in bed, often in hospital where close monitoring is easier, is recommended for intrauterine growth retardation (McClure Browne, 1973). Campbell (1974) has shown that only 30 ~ of such retarded babies are diagnosed by clinical examination alone and with increasing recognition these patients may add significantly to the need for antenatal beds. The recent development of tests that will predict the probability of neonatal respiratory distress (Gluck, Kulovich, Borer, Brenner, Anderson & Spellacy, 1971; Clements, Platzker, Tierney, Hobel, Creasey, Margolis, Thibeult, Tooley, Oh., 1972) means that patients with placental insufficiency will_ often now remain in hospital until the balance of factors has reached the optimum time for induction of labour. Another innovation in antenatal treatment is the use of intravenous infusions of alcohol (Zlatnik & Fuchs, 1972) or ~-adrenergic agents (Bieniarz & Scommegna, 1972; Liggins & Vaughan, 1973) to delay or postpone the onset of premature labour. Even 48 hours respite will allow time for the mother to be given a corticosteroid such as betamethasone, which will induce surfactant in the feotal lung (Liggins & Howie, 1973) and thus lower the incidence of neonatal respiratory distress. Ambulatory antenatal care will probably continue to be shared between hospital, general practitioner and midwife. The optimum arrangement would be to refer the patient to hospital early in pregnancy for booking and estimation of the date of delivery and then, unless in a high risk group, the patient would be seen at a centre where she could be cared for by her local practitioner, perhaps with an experienced obstetrician from the hospital in attendance to offer specialist advice. A study of mothers receiving antenatal care only after the thirty-second week showed that they were mainly unmarried or multigravida, groups which include a large number of high risk cases (Butler & Bonham, 1963, pp. 16 and 20). It has been suggested that an incentive for booking earlier might be to make it a part condition of the maternity benefit, as in France (Robertson & Carr, 1970). Several important new methods have evolved for antenatal assessment of foetal health and growth. Serial placental hormone assays and ultrasound cephalometry are firmly established, while the monitoring of foetal breathing in utero (Boddy & Mantell, 1972), changes in the foetal heart rate before labour (Wheeler & Guerard, 1974) and the frequency of intrauterine foetal movements (Matthews, 1972) are currently under assessment. Placental hormones in the maternal urine, particularly oestriol (Beischer & Brown, 1972), have been shown to be a useful guide to placental function. Although there is considerable variation over time, and between individuals, serial estimations using 24-hr urine samples give either reassurance of probable satisfactory foetal welfare or an indication of placental insufficiency. However, blood samples are much more reliably collected and the development of immunoassay methods for plasma oestriol (Masson, 1973) and another placental hormone, human placental lactogen (Letchworth & Chard, 1972), have been useful advances. Ultrasound has an important place in many problems in antenatal care (Donald, 1968). Campbell has refined the technique of cephalometry to make accurate and reproducable measurements of the biparietal diameter from the fourteenth week onwards and has shown that growth of the foetal head is rapid and linear during the second trimester with relatively
Current trends in obstetric services
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little variation in size between foetuses at the same stage of gestation (Campbell & Newman, 1971). Not only has it proved possible to diagnose intrauterine growth retardation (Campbell & Dewhurst, 1971) but also to estimate the date of delivery at least as accurately as could be calculated with a known menstrual period and a normal regular cycle (Campbell, 1974). Robinson (1973), using ultrasound measurement of the crown-rump length of the embryo before the fourteenth week, has also been able to estimate the maturity of the pregnancy with great accuracy. The technique of ultrasonography requires considerable skill and application, although it has been taught with success to people without medical training. The constraint therefore to widespread application of ultrasound is one of training technicians to a high degree of reproducibility of results (Donald & Campbell, 1971). These are as yet not strictly comparable even between experienced workers (Davison, Lind, Farr & Whittingham, 1973; Campbell, 1973), and it has been suggested that ultrasound should be introduced only where clinicians are motivated to obtain accurate measurements. All the experimental and clinical evidence so far available shows that ultrasound, as it is used at present, has a wide margin of safety (Taylor & Dyson, 1972; Hellman, Duffus, Donald & Sunden, 1970), especially where it replaces ionizing radiation with its known hazards to the foetus, but the long-term effects are still unknown. Integration of Service The role of primary care maternity services may need review. The 1958 Perinatal Mortality Survey showed that general practitioners delivered only 4.4 ~ of the babies, and were present at another 7.3 ~ of births (Butler & Bonham, 1963, Table 49). If active management of labour becomes the preferred method it will need to be undertaken in a hospital maternity unit. Despite the benefit of proximity for visitors that a local general practitioner unit provides, it is likely that a short-stay district hospital admission will be acceptable to the majority of patients (Russell & Miller, 1970). It is hoped that, with reorganization of the National Health Service, community and hospital midwifery services will be completely integrated, with antenatal care in general practice, labour in hospital and domiciliary attendance in the puerperium. This may lessen professional desire for independent maternity units. Management of Labour The major change in the conduct of labour has been the introduction of an active approach, and this has been brought about by the recognition of the benefits and safety to the mother and baby of a monitored oxytocin infusion either at induction or if progress in labour is slow (Tacchi, 1971 ; Walker, Martin & Higginbottom, 1972; Turnbull & Anderson, 1968). Recent work on oral prostaglandins has suggested that these advantages may possibly be available without the necessity of an intravenous drug (Ratnam, Khew, C h e n & Lira, 1974). The confusion which surrounded the use of oxytoxic drugs with abnormal uterine contraction, particularly inco-ordinate uterine action, has been resolved and clinical practice has shown that adequate analgesia, together with oxytocin if necessary, results in sustained progress in labour provided no gross cephalo-pelvic disproportion is present (Meehan, 1969). Amniotomy in the active phase also reduces the length of the first stage of labour (Philpot & Stewart, 1974), allows meconium staining of the liquor amnii to be easily detected and opens the possibility for foetal blood sampling and scalp electrodes to monitor the foetal heart rate. Minor degrees of cephalo-pelvic disproportion are not contra-indications to oxytocin (O'Driscoll, Jackson & Gallagher, 1970), nor is a previous caesarian section scar provided close supervision is maintained (Meehan, Moolgacker & Stallworthy, 1972). O'Driscoll
194
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et al. (1969) suggested that amniotomy, followed by oxytocin if there was delay in progress,
did not precipitate a "hypertonic uterus" but speeded dilatation of the cervix and increased spontaneous rotation of occipito-posterior positions so that there was a "sharp decline in forceps delivery". Whether the cervical vibrator (Bran t & Lachelin, 1971) will find any permanent place in delay in the first stage of labour is at present unproved. Using an active approach O'Driscoll et al. (1969) delivered 1000 consecutive primigravid patients in under 25 hours and Francis, Turnbull & Thomas (1970) showed that when oxytocin was started at the same time as induction of labour, using an automatic infusion pump, an average induction-delivery interval of less than 8 hours was achieved. The danger of planned induction of labour has always been that failure to establish good uterine contractions will result in a prolonged first stage of labour and the increased possibility of intrauterine infection or the need for caesarian section. Now that it is possible to stimulate the uterus safely, the number of surgical inductions for only minor obstetric indications is~ increasing and one Manchester hospital, for instance, reported a rise in inductions over the four years 1968-71 of 20 to 65 ~ (Walker et al., 1972). The obstetricians involved stated that "our experience of the advantages encourages us to try to increase the induction rate still more". Epidural anaesthesia, usually by the lumbar route (Crawford, 1972) is also rapidly increasing in the hospitals where an on demand service is available (Steel, 1972). This is partly a response to patients' preferences, since such good analgesia is obtained, but there are also major advantages to the obstetrician and to the baby. Not only is uterine action often helped by the relief of pain and anxiety, but many obstetric complications, particularly rotation forceps, twin delivery, breech delivery and removal of a retained placenta are more safely performed without the need of an emergency general anaesthetic with its relatively high maternal mortality (Department of Health and Social Security, 1972b). The use of bupivacaine rather than other local anaesthetics for epidural anaesthesia has advantages from its prolonged analgesic effect, the absence of tachyphylaxis and a low ratio of neonatal to maternal concentration (Reynolds & Taylor, 1971). Most practising obstetricians believe that there is a higher incidence of forceps delivery with epidural anaesthesia but, with encouragement by the midwife, spontaneous vaginal delivery is often achieved and the patient is wide awake and able to participate in the moment of delivery rather than experience the clouding of perception which often accompanies opiate analgesics and inhaled anaesthetics. Assessment of progress in the first stage of labour has been simplified by the use of partograms (Beazley & Kurjak, 1972; Studd, 1973). If oxytocin is used, careful monitoring of the foetus and the uterine contractions is necessary and a nurse should be present at all times with the patient. Her presence is also important to guard against the postural hypotension which is a common but easily reversible complication of epidural anaesthesia. Foetal heart rate monitoring, using either a sensitive microphone (e.g. Hewlett-Packard Cardiotocograph) or an ultra-sound monitor (e.g. Sonic aid FM-2), can be set up by the nursing staff, but the interpretation of these traces and the procedure for obtaining a foetal blood sample require a doctor permanently available for the labour ward. Clayton (1971) has stressed the importance of using both types ofintra-partum monitoring together. A major effect of active~management is an increased number of deliveries in each labour ward. Using these methods at the National Maternity Hospital, Dublin, three times as many babies were born, in proportion to the number of nurses, as at comparable hospitals in the United Kingdom, yet each mother received personal attention from a student midwife throughout labour (O'Driscoll, 1972). Indeed, since the majority of deliveries are within less than eight hours of admission to the labour ward, there can be much more complete individual care by the nursing staff. Accele-
Current trends in obstetric services
195
rated delivery is less tiring to the mother than longer labour and a majority of mothers could probably be discharged home within 48 hours. More intensive use of labour wards and earlier discharge in the postnatal ward would mean that, for many districts, the rise to 100 % hospital confinement could be effected without increasing beds, though this would depend on the current proportions of care in hospital and GP units respectively. Postnatal beds could nevertheless be reduced substantially since at present (nationally) over 50 % of mothers remain in hospital for six days or more (Department of Health and Social Security, 1973). Active management of all patients will require an experienced obstetrician to be present on the labour ward throughout the 24 hours since expert technical monitoring and decisions on progress will be more frequent. At present labour-ward duties are often shared with other demands on time, such as the out-patient department, to the detriment of both. Probably the optimal organization for an epidural anaesthetic service will be to have a consultant anaesthetist in charge, with designated sessions and assistance from junior anaesthetic or obstetric staff or clinical assistants. The extent to which epidural anaesthetics should be given routinely is very unclear and is a question to be answered by future research. The benefits of accurate knowledge of the mother's dates and of foetal maturity can be reviewed. Planned induction and accelerated delivery is convenient for both patients and obstetric services, and is being increasingly implemented. The Perinatal Mortality Survey (Butler & Bonham, 1963, Table 36) showed delivery to be associated with the lowest mortality scores between the thirty-ninth and forty-first weeks. It would thus seem reasonable to offer the opportunity to mothers of planned induction of labour in the thirty-ninth week which would include about two-thirds of all deliveries. In fact a comparative trial has been made on these principles in Glasgow (Macnaughton, 1974) and it was found that, though a small number of the induction group went into premature labour before 39 weeks, over 33 % of the non-induction group required induction for post maturity or obstetric complications subsequently.
Implications for Research There seem to be three applied research aspects of the recent developments in obstetric care which need to be considered. (1) Efficacy. While the initial reports of active management, epidural anaesthesia and ultrasound cephalometry suggest that they are techniques with low morbidity and discernable benefits, it is important that each of these innovative techniques should undergo evaluation in such a way that the benefits and side effects are determined as precisely as possible, not only in the innovating centres but also in the district general hospitals. In particular the long-term outcomes on the child need to be monitored. It may be that certain of the techniques should be applied in the first instance to selected groups--for example, foetal monitoring for high-risk deliveries--and that a two-tier system should be considered whereby mothers for intensive observation during labour would be looked after at regional centres. The benefit gained to the patient, however, would need to be demonstrated and balanced against travelling difficulties and the implication of "second-best care" that this might have for district general hospitals. (2) Acceptability. There is a need for further studies on the social and psychological aspects of the innovations, since so far the accounts published have been impressionistic and unsystematic (Russell & Miller, 1970; Carr & Viggers, 1972; Bardon, 1973; Robinson, 1974). We need to determine the value placed by the mother and her family on planned induction, painless labour and early discharge. We need to know whether it conflicts with cultural ideas about natural child birth, maternal need to experience birth pains, or
196
(3)
M. McCarthy and T. G. McCarthy the desire of mothers to stay in hospital after delivery so as to be free from worries of domestic management. Equally, we need to determine whether suitable antenatal counselling can allay these fears, and indeed to consider whether fuller discussions of the problems between the obstetric service staff themselves would be helpful. Organization. Some points of organizational research have already been mentioned, particularly the need to develop a pilot scheme for training technicians in ultrasound. Probably the biggest change will be in re-thinking the midwife's role, in the balance between hospital and the community, and this problem needs urgent attention. The changes in staffing can be identified at progressive centres, and then extrapolated to provide indications of the likely national effects. Operational research models have been developed for obstetric units and could be used to give new optimization of resources (Fetter & Thompson, 1965; Barr & Oddie, 1966). With these measures it should be possible to project the cost implications and direct resources accordingly. References
Alberman, E. (1974) Clinics in Obstetrics and Gynaecology. Vol. 1. London: W. B. Saunders. Bardon, D. (1973). Lancet, 2, 555. Barr, A. & Oddie, J. (1966). Medical Care, 4, 180. Beazley, J. M. & Kurjak, A. (1972). Lancet, 2, 348. Beischer, N. A. & Brown, J. M. (1972). Obstetrical and Gynaecological Survey, 27, 303. Bieniarz, J. M. & Scommegna, A. (1972). Obstetrics and Gynaecology, 40, 65. Black, D. (1974). British Medical Bulletin, 30, 199. Boddy, K. & Mantell, C. D. (1972). Lancet, 2, 1219. Brant, H. A. & Lachelin, G. C. L. (1971). Lancet, 2, 686. Butler, N. R. & Bonham, D. C. (1963). Perinatal Mortafity. Edinburgh and London: E. S. Livingstone. Campbell, S. (1974). Clinics in Perinatology. Ed. Milunsky, A. Vol. 2. Philadelphia: W. B. Saunders (in press). Campbell, S. (1973). Lancet, 2, 1145. Campbell, S. & Newman, G. B. (1971). Journal of Obstetrics and Gynaecology of the British Commonwealth, 78, 513. Campbell, S. & Dewhurst, C. J. (1971). Lancet, 2, 1002. Campbell, S. & Kurjak, A. (1972). British Medical Journal, 4, 336. Cart, D. & Viggers, J. (1972). Proceedings of the Royal Society of Medicine, 65, 758. Clayton, S. (1971). Methods for monitoring the foetus in pregnancy and labour. P. 236, Royal College of Obstetricians and Gynaecologists, London. (Mimeographed). Clements, J. A., Platzker, A. C. G., Tierney, D. F., Hobel, C. J., Creasy, R. K., Margolis, A. J., Thibeault, D. W., Tooley, W. H. & Oh. W. (1972). New England Journal of Medicine, 286, 1077. Crawford, J. S. (1972). British Journal of Anaesthetics, 44, 1277. Davison, J. M., Lind, T., Farr, V & Whittingham, T. A. (1972). Journal of Obstetrics and Gynaecology of the British Commonwealth, 80, 769. Department of Health and Social Security (1972a). Management Arrangements for the Re-organised National Health Service. London : Her Majesty's Stationery Office. Department of Health and Social Security (1972b). Report on Confidential Enquiries into Maternal Deaths in Englandand Wales. P. 67, 1967-1969. London: Her Majesty's Stationery Office. Department of Health and Social Security (1973). Annual Report of the Chief Medical Officer. London: Her Majesty's Stationery Office. Donald, I. (1968). British Medical Bulletin, 24, 71. Donald, I. & Campbell, S. (1971). Methods of monitoring the foetus in pregnancy and labour. P. 103. Royal College of Obstetricians and Gynaecologists, London (mimeographed). Editorial (1973). British Medical Journal, 3,420. Fetter, R. B. & Thomson, J. D. (1965). Operations Research, 13, 698.
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Fitzhardinge, P. M. & Steven, E. M. (1972).Paediatrics, 50, 50. Francis, J. G., TurnbuJ1, A. C. & Thomas, F. F. (1970). Journal of Obstetrics and Gynaecology of the British Commonwealth, 77, 594. Gluck, L., Kulovich, M. V., Borer, R. C., Brenner, P. H., Anderson, G. G. & Spellacy, W. N. (1971). American Journal of Obstetrics and Gynaeeology, 109, 440. Hellman, L. M., Duffus, G. M., Donald, I. & Sunden, B. (1970). Lancet, 1, 1133. Letchworth, A. T. & Chard, T. (1972). Lancet, 1,704. Liggins, G. C. & Howie, R. N. (1973). Foetal and Neonatal Physiology. Proceedings of the Sir Barcroft Centenary Symposium. Cambridge University Press. Liggins, G. C. & Vaughan, G. S. (1973). Journal of Obstetrics and Gynaeeology of the British Commonwealth, 80, 29. McClure Browne, J. C. (1973). Postgraduate Obstetrics and Gynaecology. 4th ed. P. 635. London: Butterworths. MacNaughton, M. C. (1974). Planned Delivery. P. 37. 20th British Congress of Obstetrics a~nd Gynaecology. Masson, G. M. (1973). Journal of Obstetrics and Gynaeeology of the British Commonwealth, 80, 423. Matthews, D. D. (1972). British Medical Journal, 1, 439. Meehan, F. P. (1969). Proceedings of the Royal Society of Medicine, 62, 185. Meehan, F. P., Moolgacker, A. S. & Stallworthy, J. T. (1972). British Medical Journal, 2, 740. O'Driscoll, K., Jackson, R. J. A. & Gallagher, J. T. (1"969). British Medical Journal, 2, 477. O'Driscoll, K., Jackson, R. J. A. & Gallagher, J. T. (1970). Journal of Obstetrics and Gynaecology of the British Commonwealth, 77, 385. O'Driscoll, K. (1972). Proceedings of the Royal Society of Medicine, 65, 697. Philpot, R. H., Stewart, K. S. (1974). Clinics in Obstetrics andGynaecology, 1,241. Ratnam, S. S., Khew, K. S., Chen, C. & Lira, T. C. (1974). Australian and New Zealand Journal of Obstetrics and Gynaecology, 14, 26. Reynolds, F. & Taylor, G. (1971). British Journal of Anaesthesia, 43, 436. Rhodes, P. (1973). British Medical Journal, 1,399. Robertson, J. S. & Carr, G. (1970). In the Beginning. Eds McLachlan, G. & Shegog, R. London: Oxford University Press for Nuffield Provincial Hospitals Trust. Robinson, H. P. (1973). British Medical Journal, 4, 28. Robinson, J. (1974). The Times, August 12, p. 6. Rothschild, Lord (1971). The Organization and Management of Government Research and Development in a Framework for Government Research and Development. London: Her Majesty's Stationery Office. Russell, J. R. & Miller, M. R. (1970). In the Beginning. Eds McLachlan, G. and Shegog, R. London: Oxford University Press for Nuffield Provincial Hospitals Trust. Steel, G. C. (1972). British Journal of Hospital Medieine, 8, 595. Studd, J. (1973). British Medical Journal, 4, 451. Tacchi, D. (1971). Lancet, 2, 1134. Taylor, J. K. W. & Dyson, M. (1972). Britt~h Journal of Hospital Medicine, 8, 571. Turnbull, A. C. & Anderson, A. B. M. (1968). Journal of Obstetrics and Gynaecology of the British Commonwealth, 75, 32. Walker, P. A., Martin, R. H. & Higginbottom, J. (1972). Lancet, 2, 374. Wheeler, T. & Guerard, P. (1974). Journal of Obstetrics and Gynaeeology of the British Commonwealth, 81,348. Zlatnik, F. J. & Fuchs, F. (19~r2). American Journal of Obstetrics and Gynaecology, 112, 610.
Current Trends in Obstetric Services Mark McCarthy M.R.C.P,, M.F.C.M.
Senior Registrar in Communit}/ Medicine, Kent Area Hea/th Author/t}/, Maidstone, Kent Terence G. McCarthy F.R.C.S., M.R.C.O.G.
Senior Registrar, Department of Obstetrics and Gynaeco/ogy, St Thomas Hospita/, London S.E. 1. The planning of health services necessitates the identification and evaluation of innovations. Recent developments in obstetric care include the measurement of foetal growth and maturity in the antenatal period, increasing use of monitoring, induction and "acceleration" of labour, epidural anaesthesia and very short stay in hospital during the postnatal period. Some implications of these changes for the planning of future services are considered and matters for further research, particularly the acceptability of these developments to the mother and her family, are suggested. Introduction Health service planning is to be one of the major activities of the new Health Authorities in the reorganized National Health Service. The annual cycle of planning presented in the management arrangements (Department of Health and Social Security, 1972a) involves a process of identification of needs, formulation of objectives and allocation of resources, with subsequent monitoring of the outcome of the plan. However, a large part of the resources of the Health Service is allocated to activities for which direct measures of outcome are difficult to define. The objectives of the planning team will often therefore be merely to improve the standards of existing services and to extend their scope where unmet needs have been identified. Planning is dependent on the recognition of technical and therapeutic changes that are occurring within the services and may have an influence on the way resources are used in the future. Two examples of such changes in the 1960s were the introduction of the cervical cytology and the renal dialysis programrnes. In the present decade it may be that, for example, surgery for coronary artery occlusion will have an effect of similar magnitude (Editorial B.M.J., 1973). The planner must therefore consider not only current practice and needs but keep a weather eye open for innovations in the field. Forward thinking in obstetric services is the purpose of this article--to identify new patterns of care, determine their efficiency and encourage service evaluation. This helps the planner anticipate demands that may arise rapidly if an innovative regimen becomes acceptable and widely desired by patients. It is also in line with the aims for applied research of the Rothschild report (1971) and of the chief scientist at the Department of Health (Black, 1974). Antenatal Care Antenatal care is undertaken to follow progress of all mothers-to-be, to ensure so far as possible that the pre-conditions for normal full-term delivery are present and to identify high risk patients and institute prophylactic care or treatment as required.
192
M. McCarthy and T. G. McCarthy
Patients with a poor obstetric history, pre-eclampsia, essential hypertension antepartum haemorrhage and certain medical conditions, particularly diabetes, will continue to occupy a great proportion of antenatal beds. Recently however, the concept of the small-for-dates baby has emerged and it has been shown that such babies are at increased risk not only during pregnancy and labour (Alberman, 1974) but also in their subsequent development of verbal and mental ability (Fitzhardinge & Steven 1971 ; Rhodes, 1973). Rest in bed, often in hospital where close monitoring is easier, is recommended for intrauterine growth retardation (McClure Browne, 1973). Campbell (1974) has shown that only 30 ~ of such retarded babies are diagnosed by clinical examination alone and with increasing recognition these patients may add significantly to the need for antenatal beds. The recent development of tests that will predict the probability of neonatal respiratory distress (Gluck, Kulovich, Borer, Brenner, Anderson & Spellacy, 1971; Clements, Platzker, Tierney, Hobel, Creasey, Margolis, Thibeult, Tooley, Oh., 1972) means that patients with placental insufficiency will_ often now remain in hospital until the balance of factors has reached the optimum time for induction of labour. Another innovation in antenatal treatment is the use of intravenous infusions of alcohol (Zlatnik & Fuchs, 1972) or ~-adrenergic agents (Bieniarz & Scommegna, 1972; Liggins & Vaughan, 1973) to delay or postpone the onset of premature labour. Even 48 hours respite will allow time for the mother to be given a corticosteroid such as betamethasone, which will induce surfactant in the feotal lung (Liggins & Howie, 1973) and thus lower the incidence of neonatal respiratory distress. Ambulatory antenatal care will probably continue to be shared between hospital, general practitioner and midwife. The optimum arrangement would be to refer the patient to hospital early in pregnancy for booking and estimation of the date of delivery and then, unless in a high risk group, the patient would be seen at a centre where she could be cared for by her local practitioner, perhaps with an experienced obstetrician from the hospital in attendance to offer specialist advice. A study of mothers receiving antenatal care only after the thirty-second week showed that they were mainly unmarried or multigravida, groups which include a large number of high risk cases (Butler & Bonham, 1963, pp. 16 and 20). It has been suggested that an incentive for booking earlier might be to make it a part condition of the maternity benefit, as in France (Robertson & Carr, 1970). Several important new methods have evolved for antenatal assessment of foetal health and growth. Serial placental hormone assays and ultrasound cephalometry are firmly established, while the monitoring of foetal breathing in utero (Boddy & Mantell, 1972), changes in the foetal heart rate before labour (Wheeler & Guerard, 1974) and the frequency of intrauterine foetal movements (Matthews, 1972) are currently under assessment. Placental hormones in the maternal urine, particularly oestriol (Beischer & Brown, 1972), have been shown to be a useful guide to placental function. Although there is considerable variation over time, and between individuals, serial estimations using 24-hr urine samples give either reassurance of probable satisfactory foetal welfare or an indication of placental insufficiency. However, blood samples are much more reliably collected and the development of immunoassay methods for plasma oestriol (Masson, 1973) and another placental hormone, human placental lactogen (Letchworth & Chard, 1972), have been useful advances. Ultrasound has an important place in many problems in antenatal care (Donald, 1968). Campbell has refined the technique of cephalometry to make accurate and reproducable measurements of the biparietal diameter from the fourteenth week onwards and has shown that growth of the foetal head is rapid and linear during the second trimester with relatively
Current trends in obstetric services
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little variation in size between foetuses at the same stage of gestation (Campbell & Newman, 1971). Not only has it proved possible to diagnose intrauterine growth retardation (Campbell & Dewhurst, 1971) but also to estimate the date of delivery at least as accurately as could be calculated with a known menstrual period and a normal regular cycle (Campbell, 1974). Robinson (1973), using ultrasound measurement of the crown-rump length of the embryo before the fourteenth week, has also been able to estimate the maturity of the pregnancy with great accuracy. The technique of ultrasonography requires considerable skill and application, although it has been taught with success to people without medical training. The constraint therefore to widespread application of ultrasound is one of training technicians to a high degree of reproducibility of results (Donald & Campbell, 1971). These are as yet not strictly comparable even between experienced workers (Davison, Lind, Farr & Whittingham, 1973; Campbell, 1973), and it has been suggested that ultrasound should be introduced only where clinicians are motivated to obtain accurate measurements. All the experimental and clinical evidence so far available shows that ultrasound, as it is used at present, has a wide margin of safety (Taylor & Dyson, 1972; Hellman, Duffus, Donald & Sunden, 1970), especially where it replaces ionizing radiation with its known hazards to the foetus, but the long-term effects are still unknown. Integration of Service The role of primary care maternity services may need review. The 1958 Perinatal Mortality Survey showed that general practitioners delivered only 4.4 ~ of the babies, and were present at another 7.3 ~ of births (Butler & Bonham, 1963, Table 49). If active management of labour becomes the preferred method it will need to be undertaken in a hospital maternity unit. Despite the benefit of proximity for visitors that a local general practitioner unit provides, it is likely that a short-stay district hospital admission will be acceptable to the majority of patients (Russell & Miller, 1970). It is hoped that, with reorganization of the National Health Service, community and hospital midwifery services will be completely integrated, with antenatal care in general practice, labour in hospital and domiciliary attendance in the puerperium. This may lessen professional desire for independent maternity units. Management of Labour The major change in the conduct of labour has been the introduction of an active approach, and this has been brought about by the recognition of the benefits and safety to the mother and baby of a monitored oxytocin infusion either at induction or if progress in labour is slow (Tacchi, 1971 ; Walker, Martin & Higginbottom, 1972; Turnbull & Anderson, 1968). Recent work on oral prostaglandins has suggested that these advantages may possibly be available without the necessity of an intravenous drug (Ratnam, Khew, C h e n & Lira, 1974). The confusion which surrounded the use of oxytoxic drugs with abnormal uterine contraction, particularly inco-ordinate uterine action, has been resolved and clinical practice has shown that adequate analgesia, together with oxytocin if necessary, results in sustained progress in labour provided no gross cephalo-pelvic disproportion is present (Meehan, 1969). Amniotomy in the active phase also reduces the length of the first stage of labour (Philpot & Stewart, 1974), allows meconium staining of the liquor amnii to be easily detected and opens the possibility for foetal blood sampling and scalp electrodes to monitor the foetal heart rate. Minor degrees of cephalo-pelvic disproportion are not contra-indications to oxytocin (O'Driscoll, Jackson & Gallagher, 1970), nor is a previous caesarian section scar provided close supervision is maintained (Meehan, Moolgacker & Stallworthy, 1972). O'Driscoll
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et al. (1969) suggested that amniotomy, followed by oxytocin if there was delay in progress,
did not precipitate a "hypertonic uterus" but speeded dilatation of the cervix and increased spontaneous rotation of occipito-posterior positions so that there was a "sharp decline in forceps delivery". Whether the cervical vibrator (Bran t & Lachelin, 1971) will find any permanent place in delay in the first stage of labour is at present unproved. Using an active approach O'Driscoll et al. (1969) delivered 1000 consecutive primigravid patients in under 25 hours and Francis, Turnbull & Thomas (1970) showed that when oxytocin was started at the same time as induction of labour, using an automatic infusion pump, an average induction-delivery interval of less than 8 hours was achieved. The danger of planned induction of labour has always been that failure to establish good uterine contractions will result in a prolonged first stage of labour and the increased possibility of intrauterine infection or the need for caesarian section. Now that it is possible to stimulate the uterus safely, the number of surgical inductions for only minor obstetric indications is~ increasing and one Manchester hospital, for instance, reported a rise in inductions over the four years 1968-71 of 20 to 65 ~ (Walker et al., 1972). The obstetricians involved stated that "our experience of the advantages encourages us to try to increase the induction rate still more". Epidural anaesthesia, usually by the lumbar route (Crawford, 1972) is also rapidly increasing in the hospitals where an on demand service is available (Steel, 1972). This is partly a response to patients' preferences, since such good analgesia is obtained, but there are also major advantages to the obstetrician and to the baby. Not only is uterine action often helped by the relief of pain and anxiety, but many obstetric complications, particularly rotation forceps, twin delivery, breech delivery and removal of a retained placenta are more safely performed without the need of an emergency general anaesthetic with its relatively high maternal mortality (Department of Health and Social Security, 1972b). The use of bupivacaine rather than other local anaesthetics for epidural anaesthesia has advantages from its prolonged analgesic effect, the absence of tachyphylaxis and a low ratio of neonatal to maternal concentration (Reynolds & Taylor, 1971). Most practising obstetricians believe that there is a higher incidence of forceps delivery with epidural anaesthesia but, with encouragement by the midwife, spontaneous vaginal delivery is often achieved and the patient is wide awake and able to participate in the moment of delivery rather than experience the clouding of perception which often accompanies opiate analgesics and inhaled anaesthetics. Assessment of progress in the first stage of labour has been simplified by the use of partograms (Beazley & Kurjak, 1972; Studd, 1973). If oxytocin is used, careful monitoring of the foetus and the uterine contractions is necessary and a nurse should be present at all times with the patient. Her presence is also important to guard against the postural hypotension which is a common but easily reversible complication of epidural anaesthesia. Foetal heart rate monitoring, using either a sensitive microphone (e.g. Hewlett-Packard Cardiotocograph) or an ultra-sound monitor (e.g. Sonic aid FM-2), can be set up by the nursing staff, but the interpretation of these traces and the procedure for obtaining a foetal blood sample require a doctor permanently available for the labour ward. Clayton (1971) has stressed the importance of using both types ofintra-partum monitoring together. A major effect of active~management is an increased number of deliveries in each labour ward. Using these methods at the National Maternity Hospital, Dublin, three times as many babies were born, in proportion to the number of nurses, as at comparable hospitals in the United Kingdom, yet each mother received personal attention from a student midwife throughout labour (O'Driscoll, 1972). Indeed, since the majority of deliveries are within less than eight hours of admission to the labour ward, there can be much more complete individual care by the nursing staff. Accele-
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rated delivery is less tiring to the mother than longer labour and a majority of mothers could probably be discharged home within 48 hours. More intensive use of labour wards and earlier discharge in the postnatal ward would mean that, for many districts, the rise to 100 % hospital confinement could be effected without increasing beds, though this would depend on the current proportions of care in hospital and GP units respectively. Postnatal beds could nevertheless be reduced substantially since at present (nationally) over 50 % of mothers remain in hospital for six days or more (Department of Health and Social Security, 1973). Active management of all patients will require an experienced obstetrician to be present on the labour ward throughout the 24 hours since expert technical monitoring and decisions on progress will be more frequent. At present labour-ward duties are often shared with other demands on time, such as the out-patient department, to the detriment of both. Probably the optimal organization for an epidural anaesthetic service will be to have a consultant anaesthetist in charge, with designated sessions and assistance from junior anaesthetic or obstetric staff or clinical assistants. The extent to which epidural anaesthetics should be given routinely is very unclear and is a question to be answered by future research. The benefits of accurate knowledge of the mother's dates and of foetal maturity can be reviewed. Planned induction and accelerated delivery is convenient for both patients and obstetric services, and is being increasingly implemented. The Perinatal Mortality Survey (Butler & Bonham, 1963, Table 36) showed delivery to be associated with the lowest mortality scores between the thirty-ninth and forty-first weeks. It would thus seem reasonable to offer the opportunity to mothers of planned induction of labour in the thirty-ninth week which would include about two-thirds of all deliveries. In fact a comparative trial has been made on these principles in Glasgow (Macnaughton, 1974) and it was found that, though a small number of the induction group went into premature labour before 39 weeks, over 33 % of the non-induction group required induction for post maturity or obstetric complications subsequently.
Implications for Research There seem to be three applied research aspects of the recent developments in obstetric care which need to be considered. (1) Efficacy. While the initial reports of active management, epidural anaesthesia and ultrasound cephalometry suggest that they are techniques with low morbidity and discernable benefits, it is important that each of these innovative techniques should undergo evaluation in such a way that the benefits and side effects are determined as precisely as possible, not only in the innovating centres but also in the district general hospitals. In particular the long-term outcomes on the child need to be monitored. It may be that certain of the techniques should be applied in the first instance to selected groups--for example, foetal monitoring for high-risk deliveries--and that a two-tier system should be considered whereby mothers for intensive observation during labour would be looked after at regional centres. The benefit gained to the patient, however, would need to be demonstrated and balanced against travelling difficulties and the implication of "second-best care" that this might have for district general hospitals. (2) Acceptability. There is a need for further studies on the social and psychological aspects of the innovations, since so far the accounts published have been impressionistic and unsystematic (Russell & Miller, 1970; Carr & Viggers, 1972; Bardon, 1973; Robinson, 1974). We need to determine the value placed by the mother and her family on planned induction, painless labour and early discharge. We need to know whether it conflicts with cultural ideas about natural child birth, maternal need to experience birth pains, or
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(3)
M. McCarthy and T. G. McCarthy the desire of mothers to stay in hospital after delivery so as to be free from worries of domestic management. Equally, we need to determine whether suitable antenatal counselling can allay these fears, and indeed to consider whether fuller discussions of the problems between the obstetric service staff themselves would be helpful. Organization. Some points of organizational research have already been mentioned, particularly the need to develop a pilot scheme for training technicians in ultrasound. Probably the biggest change will be in re-thinking the midwife's role, in the balance between hospital and the community, and this problem needs urgent attention. The changes in staffing can be identified at progressive centres, and then extrapolated to provide indications of the likely national effects. Operational research models have been developed for obstetric units and could be used to give new optimization of resources (Fetter & Thompson, 1965; Barr & Oddie, 1966). With these measures it should be possible to project the cost implications and direct resources accordingly. References
Alberman, E. (1974) Clinics in Obstetrics and Gynaecology. Vol. 1. London: W. B. Saunders. Bardon, D. (1973). Lancet, 2, 555. Barr, A. & Oddie, J. (1966). Medical Care, 4, 180. Beazley, J. M. & Kurjak, A. (1972). Lancet, 2, 348. Beischer, N. A. & Brown, J. M. (1972). Obstetrical and Gynaecological Survey, 27, 303. Bieniarz, J. M. & Scommegna, A. (1972). Obstetrics and Gynaecology, 40, 65. Black, D. (1974). British Medical Bulletin, 30, 199. Boddy, K. & Mantell, C. D. (1972). Lancet, 2, 1219. Brant, H. A. & Lachelin, G. C. L. (1971). Lancet, 2, 686. Butler, N. R. & Bonham, D. C. (1963). Perinatal Mortafity. Edinburgh and London: E. S. Livingstone. Campbell, S. (1974). Clinics in Perinatology. Ed. Milunsky, A. Vol. 2. Philadelphia: W. B. Saunders (in press). Campbell, S. (1973). Lancet, 2, 1145. Campbell, S. & Newman, G. B. (1971). Journal of Obstetrics and Gynaecology of the British Commonwealth, 78, 513. Campbell, S. & Dewhurst, C. J. (1971). Lancet, 2, 1002. Campbell, S. & Kurjak, A. (1972). British Medical Journal, 4, 336. Cart, D. & Viggers, J. (1972). Proceedings of the Royal Society of Medicine, 65, 758. Clayton, S. (1971). Methods for monitoring the foetus in pregnancy and labour. P. 236, Royal College of Obstetricians and Gynaecologists, London. (Mimeographed). Clements, J. A., Platzker, A. C. G., Tierney, D. F., Hobel, C. J., Creasy, R. K., Margolis, A. J., Thibeault, D. W., Tooley, W. H. & Oh. W. (1972). New England Journal of Medicine, 286, 1077. Crawford, J. S. (1972). British Journal of Anaesthetics, 44, 1277. Davison, J. M., Lind, T., Farr, V & Whittingham, T. A. (1972). Journal of Obstetrics and Gynaecology of the British Commonwealth, 80, 769. Department of Health and Social Security (1972a). Management Arrangements for the Re-organised National Health Service. London : Her Majesty's Stationery Office. Department of Health and Social Security (1972b). Report on Confidential Enquiries into Maternal Deaths in Englandand Wales. P. 67, 1967-1969. London: Her Majesty's Stationery Office. Department of Health and Social Security (1973). Annual Report of the Chief Medical Officer. London: Her Majesty's Stationery Office. Donald, I. (1968). British Medical Bulletin, 24, 71. Donald, I. & Campbell, S. (1971). Methods of monitoring the foetus in pregnancy and labour. P. 103. Royal College of Obstetricians and Gynaecologists, London (mimeographed). Editorial (1973). British Medical Journal, 3,420. Fetter, R. B. & Thomson, J. D. (1965). Operations Research, 13, 698.
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Fitzhardinge, P. M. & Steven, E. M. (1972).Paediatrics, 50, 50. Francis, J. G., TurnbuJ1, A. C. & Thomas, F. F. (1970). Journal of Obstetrics and Gynaecology of the British Commonwealth, 77, 594. Gluck, L., Kulovich, M. V., Borer, R. C., Brenner, P. H., Anderson, G. G. & Spellacy, W. N. (1971). American Journal of Obstetrics and Gynaeeology, 109, 440. Hellman, L. M., Duffus, G. M., Donald, I. & Sunden, B. (1970). Lancet, 1, 1133. Letchworth, A. T. & Chard, T. (1972). Lancet, 1,704. Liggins, G. C. & Howie, R. N. (1973). Foetal and Neonatal Physiology. Proceedings of the Sir Barcroft Centenary Symposium. Cambridge University Press. Liggins, G. C. & Vaughan, G. S. (1973). Journal of Obstetrics and Gynaeeology of the British Commonwealth, 80, 29. McClure Browne, J. C. (1973). Postgraduate Obstetrics and Gynaecology. 4th ed. P. 635. London: Butterworths. MacNaughton, M. C. (1974). Planned Delivery. P. 37. 20th British Congress of Obstetrics a~nd Gynaecology. Masson, G. M. (1973). Journal of Obstetrics and Gynaeeology of the British Commonwealth, 80, 423. Matthews, D. D. (1972). British Medical Journal, 1, 439. Meehan, F. P. (1969). Proceedings of the Royal Society of Medicine, 62, 185. Meehan, F. P., Moolgacker, A. S. & Stallworthy, J. T. (1972). British Medical Journal, 2, 740. O'Driscoll, K., Jackson, R. J. A. & Gallagher, J. T. (1"969). British Medical Journal, 2, 477. O'Driscoll, K., Jackson, R. J. A. & Gallagher, J. T. (1970). Journal of Obstetrics and Gynaecology of the British Commonwealth, 77, 385. O'Driscoll, K. (1972). Proceedings of the Royal Society of Medicine, 65, 697. Philpot, R. H., Stewart, K. S. (1974). Clinics in Obstetrics andGynaecology, 1,241. Ratnam, S. S., Khew, K. S., Chen, C. & Lira, T. C. (1974). Australian and New Zealand Journal of Obstetrics and Gynaecology, 14, 26. Reynolds, F. & Taylor, G. (1971). British Journal of Anaesthesia, 43, 436. Rhodes, P. (1973). British Medical Journal, 1,399. Robertson, J. S. & Carr, G. (1970). In the Beginning. Eds McLachlan, G. & Shegog, R. London: Oxford University Press for Nuffield Provincial Hospitals Trust. Robinson, H. P. (1973). British Medical Journal, 4, 28. Robinson, J. (1974). The Times, August 12, p. 6. Rothschild, Lord (1971). The Organization and Management of Government Research and Development in a Framework for Government Research and Development. London: Her Majesty's Stationery Office. Russell, J. R. & Miller, M. R. (1970). In the Beginning. Eds McLachlan, G. and Shegog, R. London: Oxford University Press for Nuffield Provincial Hospitals Trust. Steel, G. C. (1972). British Journal of Hospital Medieine, 8, 595. Studd, J. (1973). British Medical Journal, 4, 451. Tacchi, D. (1971). Lancet, 2, 1134. Taylor, J. K. W. & Dyson, M. (1972). Britt~h Journal of Hospital Medicine, 8, 571. Turnbull, A. C. & Anderson, A. B. M. (1968). Journal of Obstetrics and Gynaecology of the British Commonwealth, 75, 32. Walker, P. A., Martin, R. H. & Higginbottom, J. (1972). Lancet, 2, 374. Wheeler, T. & Guerard, P. (1974). Journal of Obstetrics and Gynaeeology of the British Commonwealth, 81,348. Zlatnik, F. J. & Fuchs, F. (19~r2). American Journal of Obstetrics and Gynaecology, 112, 610.
