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Meta-Analysis
. 2013 Sep 16;2013(9):CD004907.
doi: 10.1002/14651858.CD004907.pub3.

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

Heather C Brown  1 , Shantini Paranjothy, Therese Dowswell, Jane Thomas
Affiliations
Meta-Analysis

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

Heather C Brown et al. Cochrane Database Syst Rev. .

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 (16 April 2013).

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 with 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 12 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.

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Conflict of interest statement

None known.

Figures

1.1
1.1. Analysis
Comparison 1 Active management versus routine care: caesarean section rate, Outcome 1 Caesarean section rate ‐ all women.
1.2
1.2. Analysis
Comparison 1 Active management versus routine care: caesarean section rate, Outcome 2 Caesarean section rate (Sensitivity analysis: Frigoletto (1995) study excluded).
2.1
2.1. Analysis
Comparison 2 Active management versus routine care: maternal satisfaction with care, Outcome 1 Overall satisfaction with care.
2.2
2.2. Analysis
Comparison 2 Active management versus routine care: maternal satisfaction with care, Outcome 2 Maternal views ‐ would choose this style of care again.
2.3
2.3. Analysis
Comparison 2 Active management versus routine care: maternal satisfaction with care, Outcome 3 Maternal views ‐ mother feels strong sense of achievement.
2.4
2.4. Analysis
Comparison 2 Active management versus routine care: maternal satisfaction with care, Outcome 4 Maternal views ‐ staff always explained enough.
2.5
2.5. Analysis
Comparison 2 Active management versus routine care: maternal satisfaction with care, Outcome 5 Maternal views ‐ pain relief was adequate.
3.1
3.1. Analysis
Comparison 3 Active mangement versus routine care: duration of labour, Outcome 1 Prolonged labour (> 12 hours).
3.2
3.2. Analysis
Comparison 3 Active mangement versus routine care: duration of labour, Outcome 2 Length of labour (admission to delivery).
3.3
3.3. Analysis
Comparison 3 Active mangement versus routine care: duration of labour, Outcome 3 Duration of first stage of labour (hours).
3.4
3.4. Analysis
Comparison 3 Active mangement versus routine care: duration of labour, Outcome 4 Duration of second stage (hours).
4.1
4.1. Analysis
Comparison 4 Active management versus routine care: epidural analgesia, Outcome 1 Number of women having epidural analgesia.
5.1
5.1. Analysis
Comparison 5 Active management versus routine care: use of analgesia (other than epidural), Outcome 1 Use of analgesia (other than epidural).
6.1
6.1. Analysis
Comparison 6 Active management versus routine care: assisted vaginal deliveries, Outcome 1 Assisted vaginal delivery rates.
7.1
7.1. Analysis
Comparison 7 Active management versus routine care: neonatal outcome, Outcome 1 Low APGAR score at 5 minutes.
7.2
7.2. Analysis
Comparison 7 Active management versus routine care: neonatal outcome, Outcome 2 Meconium staining.
7.3
7.3. Analysis
Comparison 7 Active management versus routine care: neonatal outcome, Outcome 3 Admission to special care (various definitions).
8.1
8.1. Analysis
Comparison 8 Active management versus routine care: maternal complications, Outcome 1 Maternal infection (various definitions).
8.2
8.2. Analysis
Comparison 8 Active management versus routine care: maternal complications, Outcome 2 Postpartum haemorrhage (blood loss > 500 ml).
9.1
9.1. Analysis
Comparison 9 Active management versus routine care: breastfeeding, Outcome 1 Breastfeeding (various measurement points).
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References

References to studies included in this review

Cammu 1996 {published data only}
    1. Cammu H, Eeckhout E. A randomised controlled trial of early vs delayed use of amniotomy and oxytocin infusion in nulliparous labor. British Journal of Obstetrics and Gynaecology 1996;103:313‐8. - PubMed
Frigoletto 1995 {published data only}
    1. Frigoletto FD, Lieberman E, Lang JM, Cohen A, Barss V, Ringer S, et al. A clinical trial of active management of labor. New England Journal of Medicine 1995;333:745‐50. - PubMed
Lopez‐Zeno 1992 {published data only}
    1. Lopez‐Zeno JA, Peaceman AM, Adashek JA, Socol ML. A controlled trial of a program for the active management of labor. New England Journal of Medicine 1992;326:450‐4. - PubMed
    1. Lopez‐Zeno JA, Peaceman AM, Socol ML. Active management of labor (AMOL) ‐ an evaluation of its efficacy. American Journal of Obstetrics and Gynecology 1991;164:306.
Rogers 1997 {published data only}
    1. Rogers R, Gilson G, Kammerer‐Doak D. Epidural analgesia and active management of labor: effects on length of labor and mode of delivery. Obstetrics & Gynecology 1999;93(6):995‐8. - PubMed
    1. Rogers R, Gilson GJ, Miller AC, Izquierdo LE, Curet LB, Qualls CR. Active management of labor: does it make a difference?. American Journal of Obstetrics and Gynecology 1997;177(3):599‐605. - PubMed
    1. Rogers RG, Gardner MO, Tool KJ, Ainsley J, Gilson G. Active management of labor: a cost analysis of a randomized controlled trial. Western Journal of Medicine 2000;172:240‐3. - PMC - PubMed
Sadler 2000 {published data only}
    1. Sadler LC, Davison T, McCowan LM. A randomised controlled trial and meta‐analysis of active management of labour. BJOG: an international journal of obstetrics and gynaecology 2000;107(7):909‐15. - PubMed
    1. Sadler LC, Davison T, McCowan LME. Maternal satisfaction with active management of labor: a randomized controlled trial. Birth 2001;28(4):225‐35. - PubMed
Somprasit 2005 {published data only}
    1. Somprasit C, Tanprasertkul C, Kamudhamas A. Reducing cesarean delivery rates: an active management labor program in a setting with limited resources. Journal of the Medical Association of Thailand 2005;88(1):20‐5. - PubMed
Tabowei 2003 {published data only}
    1. Tabowei TO, Oboro VO. Active management of labour in a district hospital setting. Journal of Obstetrics and Gynaecology 2003;23(1):9‐12. - PubMed

References to studies excluded from this review

Cohen 1987 {published data only}
    1. Cohen GR, O'Brien WF, Lewis L, Knuppel RA. A prospective randomized study of the aggressive management of early labor. American Journal of Obstetrics and Gynecology 1987;157:1174‐7. - PubMed
Hinshaw 1995 {published data only}
    1. Hinshaw K. Oxytocin augmentation in the management of primary dysfunctional labour in nulliparous women ‐ effect on caesarean section rate: a randomised controlled trial. The Research Findings Register. Summary number 1244. Retrieved 11 January 2005, from http://www.ReFeR.nhs.uk/ViewRecord.asp?ID=1244 (accessed 2005).
    1. Hinshaw K, Moustafa A, Wilson K, Boyd P, Fawzi H, Kumarendran K. Oxytocin augmentation versus conservative management for primary dysfunctional labour in nulliparous women: a randomised controlled trial. 27th British Congress of Obstetrics and Gynaecology; 1995 July 4‐7; Dublin, Ireland. 1995:207.
Hogston 1993 {published data only}
    1. Hogston P, Noble W. Active management of labour ‐ the Portsmouth experience. Journal of Obstetrics and Gynaecology 1993;13:340‐2.
Jyoti 2006 {published data only}
    1. Jyoti M, Singhal P, Choudhary D. Programed labor. Journal of Obstetrics and Gynaecology of India 2006;56(1):53‐5.
Lieberman 2000 {published data only}
    1. Lieberman E, Lang J, Richardson DK, Frigoletto FD, Heffner LJ, Cohen A. Intrapartum maternal fever and neonatal outcome. Pediatrics 2000;105(1 Pt 1):8‐13. - PubMed
Pattinson 2003 {published data only}
    1. Howarth GR, Pattinson RC, Mdluli WPP, Macdonald AP, Funk M, Makin J. Aggressive or expectant management of labour; a randomised controlled trial. 20th Conference on Priorities in Perinatal Care in Southern Africa; 2001 March 6‐9; KwaZulu‐Natal, South Africa. 2001.
    1. Pattinson RC, Howarth GR, Mdluli W, Macdonald AP, Makin JD, Funk M. Aggressive or expectant management of labour: a randomised clinical trial. BJOG: an international journal of obstetrics and gynaecology 2003;110(5):457‐61. - PubMed
Peaceman 1993a {published data only}
    1. Peaceman AM, Lopez‐Zeno J, Minogue JP, Socol ML. Factors that influence route of delivery ‐ active vs traditional labor management. American Journal of Obstetrics and Gynecology 1993;169:940‐4. - PubMed
Serman 1995 {published data only}
    1. Serman VF, Benavides AC, Sandoval ZJ, Pazols JR, Bermedo SJ, Fuenzalida FR, et al. Active management of labour in primiparas Prospective study [Manejo activo del parto en primiparas, estudio prospectivo]. Revista Chilena de Obstetricia y Ginecologia 1995;60:6‐11. - PubMed
Treisser 1981 {published data only}
    1. Treisser A, Breart G, Blum F, Jouhet P, Pigne A, Barrat J. Dystocia at the onset of labour. An evaluation of the different treatments available. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 1981;10:91‐8. - PubMed
Wood 1974 {published data only}
    1. Wood C, Ng KH, Hounslow D, Benning H. A control trial demonstrates that speeding birth favourably affects cord blood Ph. [abstract]. Journal of Reproduction and Fertility 1974;36(2):472‐3. - PubMed
    1. Wood C, Ng KH, Hounslow D, Benning H. Time ‐ an important variable in normal delivery. Journal of Obstetrics and Gynaecology of the British Commonwealth 1973;80:295‐300. - PubMed

References to studies awaiting assessment

Abo 2001 {published data only}
    1. Abo Omar A. Active versus more selective management of labor. Journal of the Bahrain Medical Society 2001;13(3):139‐42.
Manpreet 2011 {published data only}
    1. Manpreet K, Mohi KM, Shalika B, Sarbhjit K. Programmed labour versus normal labour. 54th All India Congress of Obstetrics and Gynaecology; 2011 January 5‐9; Hyderabad, Andhra Pradesh, India. 2011:143.
Snehlata, 2011 {published data only}
    1. Snehlata, Sawant V. Comparison of active management of labour versus 'traditional' approach. 54th All India Congress of Obstetrics and Gynaecology; 2011 January 5‐9; Hyderabad, Andhra Pradesh, India. 2011:246‐7.

Additional references

Betran 2007
    1. Betran AP, Merialdi M, Lauer JA, Bing‐Shun W, Thomas J, Look P, Wagner M. Rates of caesarean section: analysis of global, regional and national estimates. Paediatric and Perinatal Epidemiology 2007;21(2):98‐113. - PubMed
Bidgood 1984
    1. Bidgood KA, Steer PJ. A randomised control study of oxytocin augmentation of labour. 1. Obstetric outcome. British Journal of Obstetrics and Gynaecology 1987;94(6):512‐7. - PubMed
Bragg 2010
    1. Bragg F, Cromwell DA, Edozien LC, Gural‐Urganci I, Mahmood TA, Templeton A, et al. Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study. BMJ 2010;341:c5065. - PMC - PubMed
Bugg 2013
    1. Bugg GJ, Siddiqui F, Thornton JG. Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour. Cochrane Database of Systematic Reviews 2013, Issue 6. [DOI: 10.1002/14651858.CD007123.pub3] - DOI - PMC - PubMed
Higgins 2008
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions 5.0.0 [updated February 2008] In: The Cochrane Library. Chichester, UK: John Wiley and Sons, Ltd, 2008.
Hodnett 2012
    1. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2012, Issue 10. [DOI: 10.1002/14651858.CD003766.pub4] - DOI - PMC - PubMed
Lavender 2012
    1. Lavender T, Hart A, Smyth RMD. Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database of Systematic Reviews 2012, Issue 8. [DOI: 10.1002/14651858.CD005461.pub3] - DOI - PMC - PubMed
Najmi 2000
    1. Najmi RS, Rehan N. Prevalence and determinants of caesarean section in a teaching hospital in Pakistan. Journal of Obstetrics and Gynaecology 2000;20(5):479‐83. - PubMed
NICE 2004
    1. National Collaborating Centre for Women's and Children's Health. Caesarean Section, Clinical Guidelines. Commissioned by the National Institute for Clinical Excellence. London: RCOG Press, April 2004. - PubMed
NICE 2007
    1. National Institute for Health and Clinical Excellence. Intrapartum care: care of healthy women and their babies during childbirth. NICE clinical guideline 55. www.nice.org.uk (accessed 2007).
NVSR 2007
    1. Centre for Disease Control. Births: preliminary data for 2006. National Vital Statistics Report, National Centre for Health Statistics December 2007; Vol. 56, issue 7:18.
O'Driscoll 1970
    1. O'Driscoll K, Jackson RJ, Galagher JT. Active management of labour and cephalopelvic disproportion. Journal of Obstetrics and Gynaecology of the British Commonwealth 1970;77(5):385‐9. - PubMed
O'Driscoll 1973
    1. O'Driscoll K, Stronge JM, Minogue M. Active management of labour. BMJ 1973;3:135‐7. - PMC - PubMed
O'Driscoll 1984
    1. O'Driscoll K, Foley M, MacDonald D. Active management of labour as an alternative to cesarean section for dystocia. Obstetrics & Gynecology 1984;63(4):485‐90. - PubMed
Paranjothy 2005
    1. Paranjothy S, Frost C, Thomas J. How much variation in CS rates can be explained by case mix differences?. BJOG: an International Journal of Obstetrics and Gynaecology 2005;112:658‐66. - PubMed
Peaceman 1993
    1. Peaceman AM, Lopez‐ Zeno JA, Minogue JP, Socol ML. Factors that influence route of delivery ‐ active versus traditional labor management. American Journal of Obstetrics and Gynecology 1993;169(4):940‐4. - PubMed
RevMan 2008 [Computer program]
    1. The Cochrane Collaboration. Review Manager (RevMan). Version 5.0 for Windows. Copenhagen: The Nordic Cochrane Centre: The Cochrane Collaboration, 2008.
Smyth 2013
    1. Smyth RMD, Markham C, Dowswell T. Amniotomy for shortening spontaneous labour. Cochrane Database of Systematic Reviews 2013, Issue 6. [DOI: 10.1002/14651858.CD006167.pub4] - DOI - PMC - PubMed
Thomas 2001
    1. Thomas J, Paranjothy S. The National Sentinel Ceasarean Section Audit Report. London: RCOG, 2001.
Thornton 1994
    1. Thornton JG, Lilford RJ. Active management of labour: current knowledge and research issues. BMJ 1994;309(6951):366‐9. - PMC - PubMed
Villar 2007
    1. Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ 2007;335(7628):1025. - PMC - PubMed
Walker 2002
    1. Walker R, Turnbull D, Wilkinson C. Strategies to address global caesarean section rates: a review of the evidence. Birth 2002;29(1):28‐39. - PubMed
Wei 2012
    1. Wei S, Wo BL, Qi HP, Xu H, Luo ZC, Roy C, et al. Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care. Cochrane Database of Systematic Reviews 2012, Issue 9. [DOI: 10.1002/14651858.CD006794.pub3] - DOI - PMC - PubMed

References to other published versions of this review

Brown 2008
    1. Brown HC, Paranjothy S, Dowswell T, Thomas J. Package of care for active management in labour for reducing caesarean section rates in low‐risk women. Cochrane Database of Systematic Reviews 2008, Issue 4. [DOI: 10.1002/14651858.CD004907.pub2] - DOI - PMC - PubMed

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