Assessment and support during early labour for improving birth outcomes

Shinobu Kobayashi; Nobutsugu Hanada; Masayo Matsuzaki; Kenji Takehara; Erika Ota; Hatoko Sasaki; Chie Nagata; Rintaro Mori

doi:10.1002/14651858.CD011516.pub2

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Analysis 1.1

Comparison 1 Assessment vs direct admission in early labour, Outcome 1 Length of labour (hours).

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Analysis 1.2

Comparison 1 Assessment vs direct admission in early labour, Outcome 2 Rate of caesarean section.

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Analysis 1.3

Comparison 1 Assessment vs direct admission in early labour, Outcome 3 Rate of instrumental vaginal birth.

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Analysis 1.4

Comparison 1 Assessment vs direct admission in early labour, Outcome 4 Baby born before arrival at hospital or unplanned home birth.

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Analysis 1.5

Comparison 1 Assessment vs direct admission in early labour, Outcome 5 Augmentation of labour.

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Analysis 1.6

Comparison 1 Assessment vs direct admission in early labour, Outcome 6 Use of epidural or any regional anaesthesia.

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Analysis 1.7

Comparison 1 Assessment vs direct admission in early labour, Outcome 7 Maternal satisfaction (score).

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Analysis 1.8

Comparison 1 Assessment vs direct admission in early labour, Outcome 8 Apgar score < 7 at 5 minutes.

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Analysis 2.1

Comparison 2 Home support vs telephone triage, Outcome 1 Length of labour (hours).

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Analysis 2.2

Comparison 2 Home support vs telephone triage, Outcome 2 Rate of caesarean section.

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Analysis 2.3

Comparison 2 Home support vs telephone triage, Outcome 3 Rate of instrumental vaginal birth.

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Analysis 2.4

Comparison 2 Home support vs telephone triage, Outcome 4 Baby born before arrival at hospital or unplanned home birth.

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Analysis 2.5

Comparison 2 Home support vs telephone triage, Outcome 5 Serious maternal morbidity.

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Analysis 2.6

Comparison 2 Home support vs telephone triage, Outcome 6 Augmentation of labour.

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Analysis 2.7

Comparison 2 Home support vs telephone triage, Outcome 7 Use of epidural or any regional anaesthesia.

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Analysis 2.8

Comparison 2 Home support vs telephone triage, Outcome 8 Duration of hospital stay (prolonged postpartum stay in hospital > 5 days).

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Analysis 2.9

Comparison 2 Home support vs telephone triage, Outcome 9 Maternal satisfaction (score).

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Analysis 2.10

Comparison 2 Home support vs telephone triage, Outcome 10 Postpartum depression (EPDS score ≥ 13).

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Analysis 2.11

Comparison 2 Home support vs telephone triage, Outcome 11 Perinatal death.

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Analysis 2.12

Comparison 2 Home support vs telephone triage, Outcome 12 Neonatal admission to special care.

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Analysis 2.13

Comparison 2 Home support vs telephone triage, Outcome 13 Apgar score < 7 at 5 minutes.

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Analysis 2.14

Comparison 2 Home support vs telephone triage, Outcome 14 Exclusive breastfeeding at discharge.

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Analysis 2.15

Comparison 2 Home support vs telephone triage, Outcome 15 Exclusive breastfeeding at six weeks.

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Analysis 3.1

Comparison 3 One‐to‐one structured care vs usual care, Outcome 1 Rate of caesarean section.

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Analysis 3.2

Comparison 3 One‐to‐one structured care vs usual care, Outcome 2 Rate of instrumental vaginal birth.

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Analysis 3.3

Comparison 3 One‐to‐one structured care vs usual care, Outcome 3 Serious maternal morbidity.

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Analysis 3.4

Comparison 3 One‐to‐one structured care vs usual care, Outcome 4 Use of epidural or any regional anaesthesia.

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Analysis 3.5

Comparison 3 One‐to‐one structured care vs usual care, Outcome 5 Perinatal death.

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Analysis 3.6

Comparison 3 One‐to‐one structured care vs usual care, Outcome 6 Neonatal admission to special care.

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Analysis 3.7

Comparison 3 One‐to‐one structured care vs usual care, Outcome 7 Apgar score < 7 at 5 minutes.

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Summary of findings for the main comparison. Assessment compared to direct admission in early labour for improving birth outcomes

Assessment compared with direct admission in early labour for improving birth outcomes
Patient or population: healthy pregnant women Setting: large hospital in Canada (high resource setting), study published 1996 Intervention: assessment Comparison: direct admission to hospital in early labour
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with direct admission in early labour	Risk with assessment
Length of labour (hours)	The mean length of labour (hours) was 8.3 hours in the intervention group and 13.5 hours in the control group	MD 5.2 lower (7.06 lower to 3.34 lower)	‐	209 (1 RCT)	⊕⊕⊝⊝ LOW ^{1, 2}	This outcome relates to the length of labour in hospital
Rate of caesarean section	Study population		RR 0.72 (0.30 to 1.72)	209 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1, 3}
	106 per 1000	76 per 1000 (32 to 182)
Rate of instrumental vaginal birth	Study population		RR 0.86 (0.58 to 1.26)	209 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1, 3}
	356 per 1000	306 per 1000 (206 to 448)
Serious maternal morbidity	Study population		‐	(0 RCTs)	‐	Serious maternal morbidity was not reported
	see comment	See comment
Use of epidural or any regional anaesthesia	Study population		RR 0.87 (0.78 to 0.98)	209 (1 RCT)	⊕⊕⊝⊝ LOW ^{1, 2}
	904 per 1000	786 per 1000 (705 to 886)
Neonatal admission to special care	Study population
	see comment	See comment
Apgar score < 7 at 5 minutes	Study population		RR 2.97 (0.12 to 72.12)	209 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1, 4}
	0 per 1000	0 per 1000 (0 to 0)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio;
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Single trial with design limitations (lack of blinding) (‐1) ² Single trial with small sample size (‐1) ³ Wide 95% CI crossing the line of no effect and small sample size (‐2) ⁴ Wide 95% CI crossing the line of no effect, small sample size and low event rate (‐2)

Summary of findings for the main comparison. Assessment compared to direct admission in early labour for improving birth outcomes

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Summary of findings 2. Home support compared to telephone triage for improving birth outcomes

Home support compared with telephone triage for improving birth outcomes
Patient or population: healthy pregnant women Setting: studies in Canada (2 multi‐centre studies) and the UK (1 study) (high resource settings); studies published 2003‐2008 Intervention: home support Comparison: telephone triage
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with telephone triage	Risk with home support
Length of labour (hours)	The mean length of labour (hours) was 9.66 in the intervention group and 9.37 in the control group	MD 0.29 higher (0.14 lower to 0.72 higher)	‐	3474 (1 RCT)	⊕⊕⊝⊝ LOW ^{1, 2}	Criteria for start of labour were not clearly described
Rate of caesarean section	Study population		RR 1.05 (0.95 to 1.17)	5170 (3 RCTs)	⊕⊕⊕⊝ MODERATE ³
	215 per 1000	226 per 1000 (204 to 252)
Rate of instrumental vaginal birth	Study population		RR 0.95 (0.79 to 1.15)	4933 (2 RCTs)	⊕⊕⊝⊝ LOW ^{3, 4}
	233 per 1000	222 per 1000 (184 to 268)
Serious maternal morbidity	Study population		RR 0.93 (0.61 to 1.42)	3474 (1 RCT)	⊕⊕⊝⊝ LOW ^{1, 2}
	25 per 1000	23 per 1000 (15 to 35)
Use of epidural or any regional anaesthesia	Study population		RR 0.95 (0.87 to 1.05)	5168 (3 RCTs)	⊕⊕⊝⊝ LOW ^{3, 5}
	505 per 1000	480 per 1000 (439 to 530)
Neonatal admission to special care	Study population		RR 0.84 (0.50 to 1.42)	5170 (3 RCTs)	⊕⊝⊝⊝ VERY LOW ^{2, 3, 6}
	58 per 1000	49 per 1000 (29 to 82)
Apgar score < 7 at 5 minutes	Study population		RR 1.19 (0.71 to 1.99)	5170 (3 RCTs)	⊕⊕⊝⊝ LOW ^{2, 3}
	10 per 1000	12 per 1000 (7 to 20)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RCT: randomized controlled trial; RR: Risk ratio; MD: mean difference
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Study with design limitations (lack of blinding) (‐1) ² Wide 95% CI crossing line of no effect (‐1) ³ All studies contributing data had design limitations (lack of blinding) (‐1) ⁴ High heterogeneity (I² 69%) (‐1) ⁵ High heterogeneity (I² 60%) (‐1) ⁶ High heterogeneity (I² 71%) (‐1)

Summary of findings 2. Home support compared to telephone triage for improving birth outcomes

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Summary of findings 3. One‐to‐one structured care compared to usual care for improving birth outcomes

One‐to‐one structured care compared to usual care for improving birth outcomes
Patient or population: healthy pregnant women Setting: multi‐centre study in North American and UK hospitals (high resource settings). Study published 2008 Intervention: one‐to‐one structured care Comparison: usual care
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with usual care	Risk with one‐to‐one structured care
Length of labour (hours)	‐	See comment	‐	(0 study)	‐	Not reported
Rate of caesarean section	Study population		RR 0.93 (0.84 to 1.02)	4996 (1 RCT)	⊕⊕⊕⊕ HIGH
	242 per 1000	225 per 1000 (203 to 247)
Rate of instrumental vaginal birth	Study population		RR 0.94 (0.82 to 1.08)	4996 (1 RCT)	⊕⊕⊕⊕ HIGH
	145 per 1000	136 per 1000 (119 to 156)
Serious maternal morbidity	Study population		RR 1.13 (0.84 to 1.52)	4996 (1 RCT)	⊕⊕⊕⊝ MODERATE ¹
	32 per 1000	36 per 1000 (27 to 48)
Use of epidural or any regional anaesthesia	Study population		RR 1.00 (0.99 to 1.01)	4996 (1 RCT)	⊕⊕⊕⊕ HIGH
	955 per 1000	955 per 1000 (946 to 965)
Neonatal admission to special care	Study population		RR 0.98 (0.80 to 1.21)	4989 (1 RCT)	⊕⊕⊕⊕ HIGH
	69 per 1000	67 per 1000 (55 to 83)
Apgar score < 7 at 5 minutes	Study population		RR 1.07 (0.64 to 1.79)	4989 (1 RCT)	⊕⊕⊕⊝ MODERATE ¹
	11 per 1000	12 per 1000 (7 to 20)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RCT: randomized controlled trial; RR: Risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Wide 95% CI crossing line of no effect (‐1)

Summary of findings 3. One‐to‐one structured care compared to usual care for improving birth outcomes

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Table 1. Labour diagnosis algorithm versus routine care (Cheyne 2008)

OUTCOME	Intervention (after ) n = 892	Control (after) n = 1279	Difference between groups adjusted for baseline differences between clusters with 95% CI	P value
Spontaneous vertex delivery	526	785	‐3.2 (‐15.1 to 8.7)	0.6
ARM	401	500	5.6 (‐2.2 to 13.4)	0.1
Electronic fetal monitoring	557	820	‐0.1 (‐14.2 to 14.1)	1.0
Assisted vaginal delivery	241	323
Caesarean section	123	168
3^rd or 4^th degree tear	7	8
Epidural	290	441	2.1 (‐8.0 to 12.2)	0.7
Additional analgesia required Opiate	532	649	1.5 (‐4.6 to 7.6)	0.6
Additional analgesia required Epidural and opiate	177	225	4.4 (‐2.8 to 11.7)	0.2
Any maternal complication	439	596	3.9 (‐9.4 to 17.2)	0.5
PP haemorrhage (specify) Intrapartum Post partum	5 10	7 20
Labour augmentation with oxytocin	343	484	0.3 (‐9.2 to 9.8)	0.9
Unplanned birth out of hospital	11	11
Fetal distress	166	242	2.4 (‐6.6 to 11.3)	0.6
Meconium stained liquor	133	211	‐0.5 (‐7.2 to 6.3)	0.9
Neonatal resuscitation	106	145	‐0.9 (‐6.4 to 4.7)	0.7
Admission to special care	29	60	‐0.4 (‐2.6 to 1.8)	0.7
Apgar score < 7 at 5 minutes	9	13
Admission to hospital at first presentation (1 admission) One presentations before admission in labour Two presentations before admission in labour Three or more presentations before admission in labour	398 305 149 35	795 366 88 20	‐19.2 (‐29.9 to ‐8.6)	0.002
Failure to progress 1^st stage Failure to progress 2^nd stage	42 142	59 119	‐3.4 (‐15.3 to 8.6) 15.2 (‐4.5 to 34.9)	0.5 0.1

Table 1. Labour diagnosis algorithm versus routine care (Cheyne 2008)

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Table 2. Labour diagnosis algorithm versus routine care (Cheyne 2008) (Continuous data)

OUTCOME

Intervention n =892

Mean

Control n=1279

Mean

Difference between groups adjusted for baseline differences between clusters

P value

Duration of labour from admission to labour ward to delivery

9.6

11.29

8.06

5.41

0.75 (‐0.55 to 2.05)

0.2

Mean number of vaginal examinations

3.67

Range 0‐11

3.46

Range 0‐11

0.2 (‐0.3 to 0.7)

0.3

Table 2. Labour diagnosis algorithm versus routine care (Cheyne 2008) (Continuous data)

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Comparison 1. Assessment vs direct admission in early labour

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Length of labour (hours) Show forest plot	1	209	Mean Difference (IV, Fixed, 95% CI)	‐5.20 [‐7.06, ‐3.34]

2 Rate of caesarean section Show forest plot	1	209	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.30, 1.72]

3 Rate of instrumental vaginal birth Show forest plot	1	209	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.58, 1.26]

4 Baby born before arrival at hospital or unplanned home birth Show forest plot	1	209	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

5 Augmentation of labour Show forest plot	1	209	Risk Ratio (M‐H, Fixed, 95% CI)	0.57 [0.37, 0.86]

6 Use of epidural or any regional anaesthesia Show forest plot	1	209	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.78, 0.98]

7 Maternal satisfaction (score) Show forest plot	1	201	Mean Difference (IV, Fixed, 95% CI)	16.0 [7.53, 24.47]

8 Apgar score < 7 at 5 minutes Show forest plot	1	209	Risk Ratio (M‐H, Fixed, 95% CI)	2.97 [0.12, 72.12]

Comparison 1. Assessment vs direct admission in early labour

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Comparison 2. Home support vs telephone triage

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Length of labour (hours) Show forest plot	1	3474	Mean Difference (IV, Fixed, 95% CI)	0.29 [‐0.14, 0.72]

2 Rate of caesarean section Show forest plot	3	5170	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.95, 1.17]

3 Rate of instrumental vaginal birth Show forest plot	2	4933	Risk Ratio (M‐H, Random, 95% CI)	0.95 [0.79, 1.15]

4 Baby born before arrival at hospital or unplanned home birth Show forest plot	1	3474	Risk Ratio (M‐H, Fixed, 95% CI)	1.33 [0.30, 5.95]

5 Serious maternal morbidity Show forest plot	1	3474	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.61, 1.42]

6 Augmentation of labour Show forest plot	2	1694	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.88, 1.04]

7 Use of epidural or any regional anaesthesia Show forest plot	3	5168	Risk Ratio (M‐H, Random, 95% CI)	0.95 [0.87, 1.05]

8 Duration of hospital stay (prolonged postpartum stay in hospital > 5 days) Show forest plot	1	3474	Risk Ratio (M‐H, Fixed, 95% CI)	1.15 [0.83, 1.60]

9 Maternal satisfaction (score) Show forest plot	1	423	Mean Difference (IV, Fixed, 95% CI)	3.47 [1.00, 5.94]

10 Postpartum depression (EPDS score ≥ 13) Show forest plot	1	2584	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [0.82, 1.42]

11 Perinatal death Show forest plot	1	3474	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.42, 2.40]

12 Neonatal admission to special care Show forest plot	3	5170	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.50, 1.42]

13 Apgar score < 7 at 5 minutes Show forest plot	3	5170	Risk Ratio (M‐H, Fixed, 95% CI)	1.19 [0.71, 1.99]

14 Exclusive breastfeeding at discharge Show forest plot	1	3474	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.96, 1.04]

15 Exclusive breastfeeding at six weeks Show forest plot	1	3474	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.97, 1.14]

Comparison 2. Home support vs telephone triage

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Comparison 3. One‐to‐one structured care vs usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Rate of caesarean section Show forest plot	1	4996	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.84, 1.02]

2 Rate of instrumental vaginal birth Show forest plot	1	4996	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.82, 1.08]

3 Serious maternal morbidity Show forest plot	1	4996	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.84, 1.52]

4 Use of epidural or any regional anaesthesia Show forest plot	1	4996	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.99, 1.01]

5 Perinatal death Show forest plot	1	4989	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

6 Neonatal admission to special care Show forest plot	1	4989	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.80, 1.21]

7 Apgar score < 7 at 5 minutes Show forest plot	1	4989	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.64, 1.79]

Comparison 3. One‐to‐one structured care vs usual care

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