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Later admission in labor and collaborative care increase spontaneous vaginal delivery in low-risk women

Women who are admitted into the hospital too early in labor (cervical dilation of 3 cm or less) tend to have long labors, more obstetric complications, and more technical interventions, including cesarean births (often done for lack of labor progress). Delaying hospital admission until active labor is established (cervical dilation of at least 4 cm) and collaborative care by a certified nurse midwife (CNM) and obstetrician increase the chance that a low-risk woman will have a spontaneous vaginal delivery, that is, unassisted by forceps, cesarean, or other intervention, according to a study supported in part by the Agency for Healthcare Research and Quality (HS07161).

Perinatal nurses should encourage low-risk women to wait until active labor before seeking admission to the birth facility, suggests AHRQ principal investigator William H. Swartz, M.D., of the University of California San Diego School of Medicine. The researchers studied 2,196 low-income, low-risk pregnant women admitted for delivery during spontaneous labor. Using data from medical records and two self-administered patient questionnaires, they compared the independent and joint effects of perinatal care provider (collaborative team care by a CNM and obstetrician or traditional obstetrician care) and cervical dilation at admission on delivery method.

Almost half of the women in the traditional obstetrician care group were admitted when dilated less than 4 cm compared with a quarter of the women in collaborative CNM care. Also, fewer (23.4 percent) of the collaboratively managed women were admitted directly upon presentation compared with those in the obstetrician care group. Women in obstetrician care had 9 percent to 30 percent fewer spontaneous vaginal deliveries than women in collaborative care. Women admitted early in labor, regardless of care provider, also had 6 to 34 percent fewer spontaneous deliveries than women admitted later in labor. There were no differences between the groups in neonatal complications and other outcomes such as Apgar score.

See "Impact of collaborative management and early admission in labor on method of delivery," by Debra J. Jackson, R.N.C., M.P.H., D.Sc., Janet M. Lang, Ph.D., Sc.D., Jeffrey Ecker, M.D., and others, in the March 2003 Journal of Obstetric, Gynecologic & Neonatal Nursing 32(2), pp. 147-157.

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