Review of The Active Management of Labour by Kieran O'Driscoll and Declan Meagher, published by W.B.Saunders Company Ltd, London, 1980.
First published in the ARM newsletter in approximately 1982, reprinted in Radical Midwifery, the collection of writings celebrating ARM's twenty first birthday.
I have an interest in O'Driscoll because I work in a hospital which routinely uses a modified form of his active management of labour. Also I was present at a joint NCT/AIMS/ARM meeting where we discussed this book. There was a lot of enthusiasm for his ideas and I was intrigued and dismayed. Previously O'Driscoll had appeared to me to be an authoritarian obstetrician who, by prescribing certain intervening actions that a midwife must take, had further and systematically curtailed the midwife's and mother's responsibility for conducting a normal labour. In order to find out how his ideas could have such an impact on a group of people I would have expected to be very sceptical, I bought and read the book.
His ideas include some which have obvious appeal to radical midwives, for example: his understanding that labour can result in a sense of achievement for the mother; his low analgesia rates; his recognition of the importance of continuity of carer in labour; and the analgesic power of the midwife. I think that this emphasis on emotional factors is most important, firstly, because there is no such thing as a purely physiological event and secondly because the emotional is often regarded as a sort of luxury. It is fine to take it into account when everything is normal or there are enough staff but as soon as there is anything amiss it is the first thing to be sacrificed. Also by codifying the pattern of intervention, he apparently achieves a lower rate of intervention than is found in some hospitals which have no coherent policy of active management.
Nevertheless I have found much worthy of criticism. Firstly his general tone is dogmatic; secondly his system has certain implications for the role of the midwife and her relationship with the medical profession; and thirdly there are certain specific criticisms of his approach.
I object to the authoritarianism of his approach because childbirth should not be an event in which a woman should look to a higher authority, especially when that authority is male and can never experience it. She may wish to seek advice, access to antenatal services such as screening and classes, book a hospital confinement, but this does not imply she should abdicate responsibility or be encouraged to do so by the professionals she meets. Also this tone appears to discourage free debate. Mothers and midwives are already at a disadvantage when confronting the medical profession because the latter assumes greater knowledge and powers.
Examples of this authoritarian tone include:
Although the principles of Active Management of Labour remain true in all circumstances, the practice should be considered only in the context of a suitable hospital environment, never in the home. (P1)
Slow progress in a primigravida should be regarded always as an expression of inefficient uterine action; the possibility of cephalopelvic disproportion should not be entertained until efficient uterine action has been assured. Slow progress in a parous woman should never be assumed to be an expression of inefficient uterine action, but an expression of obstruction... (P10).
These may be good guidelines but they are here expressed as rules.
(In classes) attention should be concentrated on primigravidae... multigravidae should be separated because as a group, their problems are quite different and too often, alas, they are prejudiced adversely by past events... A parous woman who seeks advice ... can have an unsettling effect on her primigravid sisters especially when she is in the habit of recounting events which may undermine the position of the teacher... Parous women tend to have closed minds on the subject (P67).
The extent to which husbands should be encouraged to be with their wives during... labour and delivery remains an open question. Sometimes..., it is difficult to avoid the impression that husbands are enlisted to protect their wives from the... fear of isolation. Experience in this hospital suggests that women, in general, have more to gain from the presence of a female companion who is not just sympathetic but is informed as well, and therefore is in a much better position to provide the sense of firm reassurance which is so sorely needed at this time (P81).
It can be seen from the above that this general tone of authoritarianism reflects an underlying authoritarian system of attitudes. Women are also expected to conform in their behaviour during labour:
Mothers have a duty...to those who care for them during labour. The reciprocal nature of this duty deserves much more emphasis than it has been given on the past, to the point that it should be clearly understood that nurses must not be expected to submit to the sometimes outrageous conduct of perfectly healthy women who cannot learn how to behave with dignity during the most important hours of their lives - nor should nurses be responsible in any way for the degrading scenes which sometimes result.
In practical terms his approach means that certain events, i.e. rectal exams, ARM, IVI syntocinon are routine in certain circumstances. Individuality is sacrificed to a norm of 1 cm dilatation an hour. And while midwives are expected to give individual support to each mother, it is more difficult to do so effectively when the context of the support is unvarying routine. Also there is strict division of labour. The student midwives palpate contractions, auscultate the fetal heart, support the mother and deliver the baby. The labour ward sister performs the hourly rectal examinations and puts up syntocinon. A doctor ruptures membranes. This division of labour seems to me as unsatisfying to the staff and possibly detrimental to the mother.
The word 'active' in active management of labour refers to the nature of the involvement of the consultant obstetrician, and is not intended to convey to the reader that he intervenes more often.
The consultant obstetrician determines the care which every labouring woman receives. In other words, the hospital midwife's already dubious role as a practitioner in her own right is totally subjugated to that of the obstetrician. She cannot decide when or whether to rupture membranes, when and how often to perform pelvic exams, or when to call an obstetrician. In the chapter on the role of the 'nurse' (midwife is evidently a dirty word) he puts great emphasis on the sister in charge:
She must make all the critical decisions. She must confirm or reject the diagnosis of labour in every case; she must measure the dilatation of the cervix at regular intervals; she must decide whether to accelerate slow progress, and she must carry these decisions into effect without reference to the medical staff who may be asleep...She does not consult with any doctor below the rank of senior registrar. There is always one and only one on duty day and night, to safe guard against the possible effects of a division of responsibility.
The status of the sister is clearly high and this may be another facet of O'Driscoll which appeals to radical midwives, but since the staff midwife acts in a supervisory capacity and is not ordinarily identified with an individual patient qualified midwives then do not give individual support to women in labour. Nor do they take decisions in the full range of circumstances which their training should equip them to do.
More specifically, I am concerned about his definition of labour. The diagnosis of labour according to O'Driscoll is problematic in a way no other diagnosis is, because it relies on an initial diagnosis by the 'patient', although I am not quite sure why this should pose problems. If a woman is admitted with contractions this is not sufficient to make a diagnosis of labour, There must be at least one other sign. I find his remarks on this confusing.
The external os cannot begin to open until the entire length of the cervical canal has been obliterated, i.e. until effacement is complete.
A firm diagnosis of labour is made when a woman admits herself to the hospital and the cervix is found to be completely effaced on examination.
The feature which serves to distinguish a patulous (multigravid) from a dilated cervix is complete effacement.
There is no consistent relationship in time between effacement of the cervix and onset of labour; sometimes effacement is complete before labour begins and sometimes effacement does not take place until labour is under way. He goes on to state:
a firm diagnosis of labour is made when subjective evidence of pains is supported by objective evidence of a 'show', although a cervix may not be effaced never mind dilated.
I have known women experience Braxton Hicks contractions as painful and a show to occur some days before labour. But a woman in these circumstances is judged by O'Driscoll to be in labour.
A woman who presents clearly in labour, say at 7 cm dilatation, will have the onset of labour judged from the time of admission to the hospital; no attempt will be made to judge how long she has been in labour at home. The extent of dilatation of the cervix at the time of admission is a clear indication of the efficiency of the cervix and not, as is often supposed, of the number of hours a woman has spent in labour at home.
I think that these definitions of labour are not consistent and that his guidelines can lead to as much ambiguity as he hoped to avoid equivocal terms such as false labour, latent labour, and labour which is not established, serve only as stratagems to relieve the doctor or nurse of the onus of making a decision.
It is my experience that the onset of labour in a primigravida can be a slow and ambiguous process, and I think that the terms which O'Driscoll derides serve a useful purpose. His own definitions are not logically consistent and do not serve to say anything about the process of labour as it is, but rather to serve as a basis for judging whether intervention will be successful. A woman who is deemed not to be in labour is admitted to the antenatal ward until the next day and it could be that the antenatal ward is being used as a kind of first stage ward for women in the early labour which O'Driscoll does not recognise.
I am also concerned with his distinction between primigravidae and multigravidae. Intervention is reserved for the former because primigravidae and multigravidae behave as different biological species.
It is true that primigravid labours tend to be longer (this is also true of multigravid women who have gone some years without childbearing) but the rate of 1 cm per hour seems unrealistic to expect universally for a primigravida in early labour. It is as though primigravidae are expected to conform to multigravid criteria. And primigravidae and multigravidae do not belong to different biological species. The differences between them may be physiological, psychological or socio-cultural and in the latter cases, I do not think physical intervention is the most appropriate response.
O'Driscoll has abolished the Ventouse and Kiellands forceps. If it is necessary to deliver the baby before the head has reached the pelvic floor and if syntocinon will not bring the head to the pelvic floor, a caesarean is performed, even if full dilatation has been reached.
I have no doubt that trauma may result from high cavity forceps, but I am perturbed by the apparently low value set on the integrity of the uterus. I have no experience of successfully used Ventouse, but in Sweden, the country with the lowest perinatal mortality statistics in the world, the Ventouse is widely used (by midwives) which suggests it need not be traumatic if used skilfully.
O'Driscoll does not seem to acknowledge local conditions. His hospital is very busy and pressed for labour ward beds. He describes the labour ward as a bottle neck and his approach seems to have evolved as an attempt to cope with these conditions. But these conditions do not apply universally, nor in my opinion should they apply anywhere. It is to me questionable policy to submit women routinely to hourly rectal examinations and interventionist procedures to alleviate the pressure on bed space. Also Ireland has a homogeneous population with a high proportion of grandmultiparae and potential grandmultiparae and I imagine that attitudes to childbearing must be different in these circumstances and in a country where contraception is difficult to obtain and religious doctrines are enshrined in law.
The application of O'Driscoll's method to the hospital where I work indicates some of the problems. Some women refuse the regime and, while in theory we accede to their wishes, in practice they are often seen as deviant. We are unable to offer continuity of care in labour and because we do not train student midwives the analgesic role of the labour companion often falls on the second year student nurses who spend only two weeks on the labour ward. I do not wish enthusiasm for some laudable parts of O'Driscoll's work among radical midwives to blind them to the rest.
This was written while I was still a hospital midwife, so it must have been before September 1982. Re-reading it the first thing that strikes me is the dogmatism of my tone. I was still operating within the mind-set of 1970s academia, writing a dialect of the father tongue.
The second thing is that when I re-read it now I am afraid: how dare I, effectively, have written: I, a mere staff midwife, think that this eminent obstetrician is quite simply wrong - in his authoritarianism, his dogmatism, his low threshold for intervention, his disingenuousness about labour (because I don't think for a minute that he believed that he was articulating truths about the nature of labour, I believe that he knew he was putting forward guidelines for when intervention will work, and that he knew that the need for intervention was driven by the need to unclog the labour ward). My arrogance was born of inexperience. Also I felt I was addressing a small readership of like-minded midwives. ARM was smaller then and less influential. I know now that I should have got permission for such extensive quotations. I remember the then editor raising this issue, but I don't remember getting permission. I am afraid of retrospective punishment for this, even now. There was a language and a context of opposition which no longer exists and I feel more isolated and afraid now.
This was a long piece for a review at the time. It could have been longer. I certainly endorse the substance of what I wrote then, if not the style, and I feel the need to comment further also at some length.
'Childbirth should not be an event in which a woman should look to a higher authority.' I am surprised now and proud of the simplicity and clarity of the assumptions which lie behind this. If childbirth is a normal physiological event, why shouldn't women be the experts? And use the professionals to enable her to make a series of informed choices within a range of options available? I now believe this is publicly inarticulable for reasons of politics, both gender and macroeconomic, and psychological defence, but are those reasons reason enough?
I am grateful for the naiveté or the arrogance which allowed O'Driscoll to express his authoritarianism and mysogyny so clearly. It seems not to have occurred to him that the presence of multips in a class may offer a wealth of experience, or that women's subjectivity may in itself have a value. These attitudes still exist, but they are dressed up more prettily, and can therefore not so easily be countered. Of course we offer women choice, in so far as resources allow, maintain the professionals at my local unit. But try not having a nuchal translucency scan...
It has now become a truism that a female companion in labour is beneficial, and that men's presence may be more problematic than we thought at the time when any lay support was unthinkable. But I don't think O'Driscoll was referring to doulas or any lay women at all: too unpredictable, they may not toe the party line. I believe that part of basic midwifery care should be the provision of emotional support for women in labour which is sensitive to the individual woman. I think there is a danger that emphasising lay support is a way of not addressing staff shortages or the unwillingness of certain individual midwives to expose themselves to the rawness and fear of being truly with a woman in childbirth. Doulas should be in addition to and not instead of good quality midwifery care.
His quotation about women's 'bad' behaviour in labour is at least passionate and therefore accords childbirth some weight, but my mind boggles at trying to imagine the nature of the 'degrading' scenes.
The division of labour between obstetrician, sister, staff and student midwives anticipates the concept of skill-mix, which sounds so sensible, so cost effective. Whether cost effectiveness is the best basis for judging the nature of good quality care, in labour or elsewhere, is now an unaskable question.
I wrote above that I do not believe that O'Driscoll's statements on labour were intended to throw any light on the nature of labour, but rather that they were a set of guidelines describing when interventions would work physiologically. This is an intellectually valid and useful undertaking. But because he did not make clear that this was what he was doing his statements come across as if they are statements about the nature of labour and if they are taken as such then I think there is a danger. Already there seems to be a belief that in a normal labour the cervix dilates at one centimetre an hour. This sets up a norm to which women are expected to conform and it obscures the fact that 'normal' can cover a wide range. His way of documenting the onset of labour will lead to a consistent underestimate of the length of a normal labour, and unnecessary interventions will result.
This is not trivial: all interventions carry an additional risk and I would therefore argue that unnecessary interventions are unethical. I think already that obstetric, and therefore obstetric nursing, assumptions about what is normal in labour are too restrictive and would question the whole role of clock time in a labour. If the condition of the mother and the baby is satisfactory what possible relevance is the length of time something takes? Unless of course it is necessary to unclog a bottle neck of a labour ward or to free up staff. And again I would raise an ethical question here: is it ethical to interfere with the normal physiological functioning of a person's body for these reasons? Is it ethical to perform hourly rectal examinations in any context?
There is a further question about the natural history of childbirth. What is the range of the normal? Who might be expected to know this? Obstetricians? Midwives? Women in non-industrialised societies who conduct the process without recourse to 'experts'?
I am greatly offended by the statement that multips and primips are members of different species and I am not sure why I am so offended. It is a piece of glib humour which misses the mark as far as I am concerned. It implies that the informal knowledge of women, any multip's past experience, is of no value.
The hospital where I worked which implemented a modified form of this approach seemed to me to have an unacceptably high intervention rate and I can remember the statistics for primip births for October 1983. 50% had normal deliveries in the sense that the babies were born vaginally without mechanical assistance. Normal in this context says nothing about induction, augmentation, artificial rupture of membranes, intravenous infusions, analgesia or anaesthesia, catheterisation or episiotomies. Of the remaining 50%, 30% were delivered by forceps and of the rest 9% had elective caesarean sections and 11% emergency. It was tacitly accepted, by the midwives at least, that much of this was due to the cascade of interventions. A year or so later, when I was asking about booking a woman for domino delivery who had previously had an emergency caesarean section, the senior sister looked at her case and said, Oh it was a routine primip section, she'll be fine this time. (She was.) Is this acceptable? This level of intervention was not questioned, except by me. It seemed to be considered inevitable. The women were somehow blamed, they were too well educated, too refined, modern society was too complex. Anyway it didn't matter as long as both mother and baby were physically well.
I think it matters. I think it matters to a society if women do not believe that they can give birth of their own effort.
When I first wrote these comments I thought that this work was outdated and that the review was of academic interest because it enabled me to consider the above issues. I now believe that active management of labour is more prevalent than I had believed and in the current climate is becoming unthinkingly accepted.
Now (25.6.03), in the process of reading Jo Murphy-Lawless's Reading Birth and Death I realise that I had made a number of fundamental misassumptions. I assumed that O'Driscoll had based his interventions on the need to respond to a problematic situation: that of the bottle neck in the labour ward at the National Maternity Hospital, Dublin and that these interventions were only possible because a reliable technology existed in the form of an intravenous infusion of syntocinon. This may be questionable on a number of levels but it at least has the benefit of logical consistency. However reading Jo Murphy-Lawless it is evident that the urge on the part of obstetricians to intervene and reduce the length of time of labour predates any reliable technology. Her book describes how, in the eighteenth century, completely arbitrarily, a time limit of 14 hours was decided upon and that the steps taken to accelerate labour included manual dilatation of the cervix followed by the use of forceps before the head had even entered the pelvis. The resulting lacerations at a time before the understanding of the transmission of infection were almost inevitably lethal. The thinking behind this was based on a number of ideologically driven views of women including that women were intrinsically fragile and in need of rescuing from the process of childbirth