Objective: The primary objective was to evaluate the effectiveness of nurses as providers of labor support, within the context of North American hospitals. A Cochrane Review of 14 randomized controlled trials of continuous labor support concluded that it reduced the likelihood of cesarean delivery and a number of other adverse childbirth outcomes, but the applicability of the results to typical North American birth settings was uncertain. Furthermore the feasibility of ensuring 1:1 support for all women had not been addressed.
Design: Multi-center randomized controlled trial, with prognostic stratification for hospital and parity. Prior to the trial, core groups of volunteer nurses at each site received training in labor support, and a staffing consultant offered advice to the hospitals regarding how to introduce sufficient flexibility to their staffing models, to allow for 1:1 care without adding to the staffing complement.
Population, Sample, Setting, Years: Eligibility criteria included: live singleton fetus or twins, >=34 weeks gestation, no contraindications to labor, in established labor but second stage not imminent, not expecting continuous professional support. We randomized 6915 women at 13 USA and Canadian hospitals, between May, 1999 and June, 2001.
Intervention and Outcome Variables: The intervention, continuous support by a specially trained nurse during labor, was compared to usual nursing care. The primary outcome was cesarean delivery. Other outcomes included intrapartum events and indicators of maternal and neonatal physical and psychosocial morbidity, both immediate and in the first 6-8 weeks post delivery.
Methods: Eligible women who consented to participate were randomized to either usual nursing care or care by a nurse with special training in labor support. Randomization was centrally controlled at the data coordinating center. The nurses were part of the regular staffing complement on that shift. Only the amount and nature of nursing support varied between groups. In all other respects, the nursing and medical care was in accordance with usual hospital practices and policies. Data were collected from the medical records of participants and their infants, by a questionnaire completed by participants during the postpartum hospital stay, and by a questionnaire at 6-8 weeks postpartum. Data analysis was by intention to treat.
Findings: Protocol compliance was excellent; >94% received the care to which they were assigned. Data were received for all 6915 women and their infants (n=6949). The rates of cesarean delivery were almost identical in the two groups (12.5% in the Continuous Labor Support Group and 12.6% in the Usual Care Group). There were no significant differences in other maternal or neonatal events during labor, delivery, or the hospital stay. There were no significant differences in women’s perceived control during childbirth or depression, measured at 6-8 weeks postpartum. All comparisons of women’s likes and dislikes about the experience, and their future preference for amount of nursing support, favored the Continuous Labor Support Group. In the total sample (of primarily low-risk healthy pregnant women), 62% of labors were induced or augmented with oxytocics, 77% had continuous electronic fetal monitoring, and 75% had regional analgesia.
Conclusions: Women appreciate and prefer continuous labor support by nurses, but it does not affect cesarean delivery rates or other medical or psychosocial outcomes of labor and birth. Our results are contrary to those of the Cochrane Review, but similar to the two other trials of support by nurses in high-intervention settings. We conclude that the benefits of labor support are overpowered by environments characterized by high rates of routine medical interventions.
Implications: Important research questions concern a) the impact of the hospital birth environment on both the providers and recipients of nursing care, and b) the evaluation of evidence-based, hospital-wide strategies to alter the hospital birth environment, such that effective nursing care is possible. At present, labor support is the only known intrapartum intervention that reduces the likelihood of cesarean delivery. If it is not possible for nurses to provide effective labor support, inevitably questions will arise about how -and with whom - to staff hospital labor and delivery units.
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