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

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Abstract

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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.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Plain language summary

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A package of care to actively manage labour in women who are at low risk of complications to reduce caesarean section rates

Many countries have an increasing rate of caesarean section. Higher rates do not always give additional health gains, they can increase maternal risks and affect subsequent pregnancies. Active management of labour has been proposed to reduce the number of caesarean births. Active management includes routine amniotomy (artificial rupture of the membranes), strict rules for diagnosing slow progress, use of the intravenous drug oxytocin to increase contractions of the uterus and one‐to‐one care. The disadvantages of active management are that it can possibly lead to more invasive monitoring, more interventions and a more medicalised birth in which women have less control and less satisfaction. The review included seven trials involving 5390 women. These studies show that women who received active management were slightly less likely to have a caesarean section and were more likely to have shorter labours (less than 12 hours). There was no difference in the number of assisted deliveries, nor was there any difference in complications for mothers or their babies when comparing women in the active management group with those receiving routine care.