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This was originally described by O’Driscoll in 1969 (1). Although components of active management are employed in labour wards throughout Britain, the 4 randomised controlled trials (RCTs) comparing active vs standard management of labour have failed to reproduce his results (2). It is therefore important to re examine the original work, the subsequent trials and current practice.

It should also be remembered that active management was designed to apply to primiparous, singleton, cephalic presentation spontaneous labours.

Aims:

• Safe delivery of women within 12 hours of admission
• Keep operative delivery to a minimum

Essential components:

• Antenatal education
• Strict definition of labour
• One to one midwifery care throughout labour
• Early amniotomy 1 hour after admission

• Early recourse to syntocinon if progress less than 1cm/hour
• In addition there was senior medical involvement on the labour ward, medical involvement in every case and daily review of all partograms.
• The current delivery statistics from the Dublin National Maternity Hospital where this is employed are:

There has been a recent increase in instrumental delivery coincident with an increase in the epidural rate.

Evidence for/explanation of the components

Antenatal Education

This is essential for all women delivering at the National Maternity Hospital and all components of active management are explained. Those women who do not wish to have their labour actively managed are offered alternative hospitals for delivery.

Strict Definition of Labour

For the purpose of active management, labour is strictly defined and those not in labour are sent home. This results in about 50% of women being readmitted within 24hours. There is no recognition of the latent phase.

One to one care in labour

A Cochrane review has shown this to be associated with decreased caesarian section and epidural rates, fewer Apgars <7 at 5 minutes and much less postnatal depression at 6 weeks (3).

The trials all involved female experienced carers. What is unclear is whether the midwife managing the labour support should be provide the support or whether doulas should be present in addition.

Routine amniotomy:

The results from a Cochrane review revealed that this does shorten labour by 60-120 minutes but does not improve outcome and leads to a higher perception of pain (although no increase in analgesia usage) (4). In addition there is a trend towards caesarian delivery and some trials resulted in more variable decelerations following amniotomy.

Repeated vaginal examination

No evidence for increased maternal or neonatal infection over the 12 hour time span.

1cm/hr progress line:

This was derived from original work by Friedman in 1955 examining 200 “ideal” labours. 1cm/hour represented the progress of the slowest 10% at the stage of labour with the maximum dilatation rate i.e. 5-8 cm. The population of labouring women was younger at that time than the current age distribution.

Philpott and Castle used a cervicogram in an African population to determine the appropriate place of delivery. The lower median maximum slope was 1.25cm/hr (5).

Studd used the same cervicogram in a Birmingham UK population with a 2 hour action line. However, it only had a 48% positive predictive value for operative delivery (6).

Thus 1cm/hour may not apply to all populations. In addition, the relative benefits of a 2 or 4 hour action line have yet to be resolved.                                                                                                                               However, the WHO partograph study did conclude that the standard use of a cervicogram with standard definitions of labour and labour progress resulted in a reduction in the incidence of prolonged labour, the need for augmentation and the caesarian section rate (7). This was not a study of the active management of labour but does support the use of a cervicogram  in standard conditions.

Syntocinon

This does shorten labours but increases contraction frequency before intensity and thus can provoke uterine hyperstimulation. Care must be taken to monitor both fetal heart and uterine activity during its usage. The following quotation is taken from the 1995 CESDI report:

 “Comments on the misuse of syntocinon were common and included its use for too long despite the lack of progress, its use despite evidence of good progress, or it’s use in the presence of clear signs of cephalopelvic disproportion or fetal compromise”

Is there an alternative?

Interestingly one trial compared syntocinon with water in a crossover fashion in a group of nulliparous women with primary dysfunctional labour (8). 39% of those randomised to water responded compared to 65% of those given syntocinon. In the former group a further 66% responded when then given syntocinon. In the group originally given syntocinon, who failed to respond, 62% were then given saline and 45% of those responded. However, none of those who initially responded to either intervention had their treatment changed and 38% of those who did not initially respond to syntocinon where continued on it.

One randomised controlled trial attempted to look at conservative management vs amniotomy alone vs amniotomy and syntocinon(9).

However, only 61 women were recruited over a five year period and therefore the sample size was too small to comment on the type of delivery. It did conclude that women preferred to have something done.

Results of the RCTs

A meta analysis of the 4 randomised controlled trials of sufficient quality (comparing active management vs standard care) has shown no reduction in the Caesarian section rate which varied from 9-19% (2). However, the trials show a strong Hawthorne effect i.e. as a result of the study the background Caesarian section rate was reduced.

There was also no difference in neonatal outcomes or instrumental delivery rates. There was a much higher rate of second stage Caesarian section rates compared to the original work (4-5% vs 0.4%).

Interestingly 3 of the 4 studies did not comment on the presence or absence of continued support in labour.

Conclusions

True active management of labour includes all of the components as listed above. Any comparisons of active and standard management should therefore aim to reproduce all features. However, care should still be taken when translating the results of trials to the labour ward where conditions may vary considerably from the trial setting.

Active management does not seek to find the cause of prolonged labour as the management is always the same.

It applies to nulliparous singleton labours with a cephalic presentation.

Continuous one to one support in labour does reduce the labour intervention rate and longterm maternal well being. What is still unanswered is by whom that support should be provided.

References

1.O’Driscoll K, Jackson JA, Gallagher JT. Prevention of prolonged labour. BMJ. 1969; 2: 447-80

2. Sadler LC, Davison T, McCowan LME. A randomised controlled trial and meta-analysis of active management of labour. Br J Obstet Gynecol. 2000; 107: 909-915

3. Hodnett ED. Caregiver support for women during childbirth (Cochrane Review). In: The Cochrane Library, Issue 1, 2002. Oxford: Update Software

4.Fraser WD, Turcot L, Krauss I, Brisson-Carrol G. Amniotomy for shortening spontaneous labour (Cochrane Review). In: The Cochrane Library, Issue 1, 2002. Oxford: Update Software.

5. Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. The alert line for detecting abnormal labour. BJOG Br Emp 1972; 79: 592-98

6. Studd JJW. Partograms and normograms of cervical dilatation in management of primigravid labour. BMJ 1973; 4: 451-5

7. World Health Organization partograph in management of labour. World Health Organization Maternal Health and Safe Motherhood Programme. Lancet. 1994 Jun 4; 343(8910): 1399-404.

8. Cardozo L, Pearce JM. Oxytocin in active-phase abnormalities of labor: a randomized study.Obstet Gynecol. 1990; 75(2): 152-7.

9. Blanch G, Lavender T, Walkinshaw S, Alfirevic Z. Dysfunctional labour: a randomised trial. Br J Obstet Gynaecol 1998; 105: 117-120.