This was originally
described by ODriscoll 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
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.
- Safe delivery of women within 12 hours of admission
- Keep operative delivery to a minimum
Vaginal examination hourly for three hours then at
least 2 hourly
- 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
- 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
|Syntocinon 1st stage
|Syntocinon 2nd stage
There has been a recent increase in instrumental delivery
coincident with an increase in the epidural rate.
Evidence for/explanation of the components
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.
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
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
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
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
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 its 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
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.
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
Active management does not seek to find the cause
of prolonged labour as the management is always the
It applies to nulliparous singleton labours with a
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.
1.ODriscoll 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;
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.