Package of care for active management in labour for reducing caesarean section rates in low-risk women

Abstract

Background Approximately 15% of women have caesarean sections (CS) and while the rate varies, the number is increasing in many countries. This is of concern because higher CS rates do not confer additional health gain but may adversely affect maternal health and have implications for future pregnancies. Active management of labour has been proposed as a means of reducing CS rates. This refers to a package of care including strict diagnosis of labour, routine amniotomy, oxytocin for slow progress and one to one support in labour. Objectives To determine whether active management of labour reduces CS rates in low-risk women and improves satisfaction. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (February 2008), MEDLINE (1966 to December 2007), EMBASE (1980 to 2007), MIDIRS (1985 to 2007) and CINAHL (1982 to 2007). Selection criteria Randomised controlled trials comparing low-risk women receiving a predefined package of care (active management) with women receiving routine (variable) care. Trials where slow progress had been diagnosed before entry into the trial were excluded. Data collection and analysis At least two review authors extracted data. We assessed included studies for risk of bias. Main results We included seven trials, with a total of 5390 women. The quality of studies was mixed. The CS rate was slightly lower in the active management group compared to the group that received routine care, but this difference did not reach statistical significance (RR 0.88, 95% CI 0.77 to 1.01). However, in one study there was a large number of post-randomisation exclusions. On excluding this study, CS rates in the active management group were statistically significantly lower than in the routine care group (RR 0.77 95% CI 0.63 to 0.94). More women in the active management group had labours lasting less than twelve hours, but there was wide variation in length of labour within and between trials. There were no differences between groups in use of analgesia, rates of assisted vaginal deliveries or maternal or neonatal complications. Only one trial examined maternal satisfaction; the majority of women (over 75%) in both groups were very satisfied with care. Authors’ conclusions Active management is associated with small reductions in the CS rate, but it is highly prescriptive and interventional. It is possible that some components of the active management package are more effective than others. Further work is required to determine the acceptability of active management to women in labour.

Comparison of midwife-led and consultant-led care of healthy women at low risk of childbirth complications in the Republic of Ireland: a randomised trial

“…As in MidU, four studies included in the Cochrane Review [7] found significant reduced rates of augmentation of labour in MLUs, but the remaining six showed no difference. Overall, meta-analyses do not show a significant difference in this outcome, with or without the addition of MidU data [6]. In the MidU study, induction of labour, PPH and low Apgar scores were not different between the two groups, in accord with the Cochrane Review findings.…”

“…Certainly, early routine ARM, one facet of AML, has been criticised as "not scientifically justified" [4] and a Cochrane Review found "no shortening of the length of first stage of labour and a possible increase in caesarean section", concluding "routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged" [5]. Another Cochrane Review found that AML was associated with a small decrease in caesarean section (CS), but that it was "highly prescriptive and interventional" [6] and the authors advised further research to determine the acceptability of AML to women [6]. …”

Does Labor Augmentation with Oxytocin Increase the Risk of Postpartum Hemorrhage? A Randomized Controlled Trial

“…Augmentation of labour is the process of uterine stimulation using intravenous oxytocin infusion to increase frequency, duration and intensity of contractions after the onset of spontaneous labour. It is used to treat delayed labour when uterine contractions are not strong or coordinated enough to cause cervical dilatation [4]. Labour augmentation aims to shorten labour so prevent complications related to prolonged labour.…”

The social process of escalation: a promising focus for crisis management research

“…A simple example of how the process of situating constructs the obstetric situation could make use of the concept of active management of labour [59]. Here, midwifes are instructed not to accept patients to the delivery unit unless they are in active labour.…”