Early Labor Assessment and Support at Home Versus Telephone Triage: A Randomized Controlled Trial

Abstract

Obstetrical triage is thought by some to lessen the need for cesarean delivery. Trials have confirmed lower rates of operative delivery, epidural analgesia, and oxytocin augmentation following triage at hospital. The present study compared cesarean delivery rates in healthy nulliparous women in labor at term who were randomly assigned to either telephone triage (n = 731) or to "hands on" triage during a home visit by a nurse (n = 728). Women triaged via telephone were advised to come in if amniotic fluid was colored, vaginal bleeding was present, fetal movements decreased, they could no longer cope with contractions, or contractions lasted longer than 1 minute or occurred more often than every 5 minutes. A nurse carried out home triage when women sought advice about when to come to the hospital. In addition to the same questions, the nurse took vital signs, palpated the abdomen, auscultated the fetal heart rate, assessed contractions, and examined the cervix. The relative risk (RR) of cesarean delivery for home-triaged women, compared with those given only telephone support, was 1.12, with a 95% confidence interval (CI) of 0.94-1.32; this was not a significant difference. Indications for cesarean delivery were similar in the two groups. Significantly fewer home-triaged women were admitted with cervical dilatation of 3 cm or less (RR, 0.85; 95% CI, 0.76-0.94). Significantly more women having a nurse visit their home did not need to go to the hospital for assessment (RR, 1.54; 95% CI, 1.23-1.92). No significant group differences were found in the use of either narcotic analgesia or epidural analgesia, or in augmentation of labor. Women assigned to home support were significantly less likely to be judged as not coping with their labor when reaching the hospital (RR, 0.74; 95% CI, 0.62-0.90). Among women who entered labor spontaneously, those given home support spent an average of 50 minutes less in hospital. Infants in the two groups had comparable 1- and 5-minute Apgar scores and similar rates of neonatal resuscitation. These healthy nulliparous women in early labor did not require cesarean delivery substantially less often when visited at home by a nurse as opposed to telephone triage. A home visit does, however, help women to cope with labor and reduces the number of hospital visits during latent-phase labor.