8 Chapter 1 Madeline* – a case study Madeline is a client in our practice. A few weeks ago, she phoned to tell that she hadn’t been able to sleep that night, because of irregular contractions. Madeline was 40 weeks pregnant with her third child and had given birth twice at home in a birthing pool. She asked if it was possible to get a check-up because she would like to know if she already had some cervical dilatation or not. If possible, she would like to have her membranes swept in the hope that labour would start. On checking, she was two centimetres dilated, the baby was in good condition, and her membranes were swept as she had requested. An hour or three later, Madeline called that her contractions came every 5 minutes. I visited Madeline at home and she was six centimetres dilatated. However, I was not really impressed with the contractions. They were irregular, and above all, they appeared not very strong. Madeline was very relaxed and chatted with everyone in the room. Of one thing she was determined, she wanted to give birth tonight and she was ready to jump into the birthing pool. But what was I going to do? Was I facing ineffective uterine contractions? Should I rupture the membranes or go to the hospital? Should I prepare for an increased risk of severe blood loss? What do our regional protocols say about this situation, and who is the obstetrician on call tonight? Or was this situation still physiological and should I just be present and wait for stronger contractions? *Madeline is a fictitious name and this case study has been edited to hide her identity. Practice variation in maternity care Clinical variation in interventions, such as diagnoses, treatments, and drug prescriptions, appears in a wide range of acute and chronic care specialities, both in primary care and in hospital settings. A systematic review of variation in medical practice variation in OECD countries, including 836 published studies, described variation between regions and hospitals, with differences in physician practices for same conditions (1). Practice variation in maternity care has also been described, with variation in rates of caesarean section and induction of labour as being the most commonly reported (2). Remarkably is the variation of the same interventions between different countries. In 2017, for example, 21.4% of all births in the Netherlands were induced, while America had a rate of induction of labour of 25.7% and Australia 33.0% (3–5).
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