The active management of labour was pioneered by K O'Driscoll in 1969, as a means of reducing the number of prolonged labours. Its aim was to keep labour to fewer than 12 hours and operative delivery rates to a minimum.
Even in diluted form, in randomised controlled trials it has been shown to be effective in reducing labouring time.It was originally designed for primiparous women with singleton pregnancies at term, in spontaneous labour.
- Early diagnosis following strict criteria, by a senior midwife.
- Vaginal examination hourly for three hours, then every two hours, at least. This allows the rate of progress to be plotted on a partogram.
- Amniotomy one hour after admission.
- Augmentation with Syntocinon® if not dilating at rate of 1 cm/hour.
- Women not in labour should be sent home. 50% are re-admitted within 24 hours.
- Personal, psychological support for the woman.
- Liberal use of epidural anaesthesia.
- Regular rounds by the obstetrician.
- Antenatal education classes.
- Regular audit of labour ward process and outcomes.
Evidence-based inpatient care supports continuity of care, reduction in episiotomy rates, active management of the third stage with 10 IU Syntocinon®.
More analysis of benefits and risks is required for the use of amniotomy, continuous electronic fetal monitoring, epidural and Syntometrine®.
A Cochrane review showed that early intervention with amniotomy and oxytocin appears to be associated with a modest reduction in the rate of caesarean section over standard care.'Active management' was not designed to lower caesarean section rates, but may have decreased the number of sections performed for dystocia - failure to progress. This effect was most significant in Dublin, where it was first used, but this success has not been matched in other units.
The partogram is used to chart the progress of the woman in labour. If cervical dilatation is less than expected or stops (progress drops below the 'action line'), augmentation may be required. Other important parameters are also recorded - eg, presence of meconium staining in the liquor and perception of strength of contractions. Many advocate its use, but, in the absence of any active management of labour, there is little evidence of a positive effect on labour outcomes.
Induction of labour
Induction is the process of starting labour by uterine stimulation. It should be used when it is thought that the baby will be safer delivered than it is in utero. (Needs to be clearly distinguished from augmentation of labour, which is the enhancement of uterine contractions once labour has started.)
The national mean induction of labour rate in England in 2011/2012 was 26.9% for primiparous women and 21.4% for multiparous women.
It has been shown in some studies that elective induction of labour at term gestation can reduce perinatal mortality and the rate of caesarean section in developed countries without increasing the risk of operative delivery.[8, 9]One study found that induction of labour in women with previous caesarean delivery may reduce repeat caesarean delivery, but increases the risks of neonatal complications.
A Cochrane review found that a policy of labour induction compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections. Some infant morbidities such as meconium aspiration syndrome were also reduced with a policy of post-term labour induction.
However, the statistics for England in 2011/2012 show an increased rate of emergency caesarean section for those women having an induction of labour compared with those women having a spontaneous labour:
- Primiparous women: national mean rate of 30.2% for induction of labour compared with 11.6% for spontaneous labour.
- Multiparous women: national mean rate of 13.2% for induction of labour compared with 6.2% for spontaneous labour.
The Royal College of Obstetricians and Gynaecologists and the National Institute for Health and Care Excellence guidelines define its use in clinical practice:
- It should be offered to women with healthy pregnancy after 41 weeks. Risk of stillbirth increases from 3/3,000 at 42 weeks to 6/3,000 at 43 weeks. Randomised controlled trials suggest that elective induction of labour at 41 weeks of gestation and beyond may be associated with a decrease in both the risk of caesarean section and of meconium-stained amniotic fluid.
- It should be offered to women whose pregnancy is complicated by diabetes, before term.
- In women with pre-labour ruptured membranes after 37 weeks (6-19% of pregnancies), they should be given a choice of either immediate induction, or watchful waiting for up to maximum of four days. 84% labour within 24 hours, increasing by a further 5% every 24 hours after. Beyond four days, risk of infection outweighs any potential benefit to mother or child.
The most common reasons for inducing labour are:
- Prolonged pregnancy - 70% of such cases are induced after 41 weeks, often at the mother's request. The obstetrician will usually agree if the cervix is ripe.
- Suspected intrauterine growth restriction.
- Hypertension and pre-eclampsia - approximately 50% of women with this problem are induced.
- Planned time of delivery in the best interests of the baby - eg, cardiac abnormalities which may need immediate surgery after birth.
Check prior to induction:
- Need to check lie and position of fetus.
- Volume of amniotic fluid.
- Tone of uterus.
- Ripeness of cervix; this is the best predictor of readiness for induction and can be scored using Bishop's system:If the score is >8, the probability of successful delivery with induction is the same as spontaneous onset of labour
These are the same as for vaginal delivery. Absolute contra-indications include:
- Severe degree of placenta praevia.
- Transverse fetal lie.
- Severe cephalopelvic disproportion.
- Cervix <4 on Bishop's score - can be overcome by ripening with prostaglandins.
Relative contra-indications include:
The procedure should be fully discussed with the mother; explaining the technique to be used and any possible side-effects and consequences of failure (caesarean section). She needs to give her informed consent, possibly in writing or, if not, a signed note made in the woman's records.
- Assess fetal maturity.
- Re-check presentation and position of fetus just before induction.
Methods used include:
- Membrane sweeping.
- Prostaglandin gel or pessary.
- Oxytocin with/or without artificial rupture of membranes.
The most common method of induction in the UK is placing prostaglandin gel or pessary high in the vagina (not cervix). The drug is absorbed through vaginal and cervical epithelium and delivered to the uterus via the blood stream. The obstetrician or midwife should stay with the woman for 20-30 minutes with cardiotocographic monitoring of the fetus in case of myometrial overreaction.
Complications of induction
It may fail and require caesarean section. All the complications of a normal vaginal delivery, plus:
- Uterine hyperstimulation; fetal distress and hypoxic damage to the baby.
- Uterine rupture, especially in multiparous women.
- Intrauterine infection with prolonged membrane rupture without delivery (less likely if labour occurs within 12 hours).
- Prolapsed cord can occur with first rush of amniotic fluid, if the presenting part is not well engaged.
- Amniotic fluid embolism.
Further reading and references
Shields SG, Ratcliffe SD, Fontaine P, et al; Dystocia in nulliparous women. Am Fam Physician. 2007 Jun 175(11):1671-8.
O'Driscoll K, Jackson RJ, Gallagher JT; Prevention of prolonged labour. Br Med J. 1969 May 242(5655):477-80.
Zhang J, Branch DW, Ramirez MM, et al; Oxytocin regimen for labor augmentation, labor progression, and perinatal outcomes. Obstet Gynecol. 2011 Aug118(2 Pt 1):249-56. doi: 10.1097/AOG.0b013e3182220192.
Hofmeyr GJ; Evidence-based intrapartum care. Best Pract Res Clin Obstet Gynaecol. 2005 Feb19(1):103-15. Epub 2004 Dec 13.
Wei S, Wo BL, Qi HP, 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 Syst Rev. 2013 Aug 78:CD006794. doi: 10.1002/14651858.CD006794.pub4.
Brown HC, Paranjothy S, Dowswell T, et al; Package of care for active management in labour for reducing caesarean section rates in low-risk women. Cochrane Database Syst Rev. 2008 Oct 8(4):CD004907.
Windrim R, Seaward PG, Hodnett E, et al; A randomized controlled trial of a bedside partogram in the active management of primiparous labour. J Obstet Gynaecol Can. 2007 Jan29(1):27-34.
Patterns of Maternity Care in English NHS Hospitals 2011/12; Royal College of Obstetricians and Gynaecologists
Stock SJ, Ferguson E, Duffy A, et al; Outcomes of elective induction of labour compared with expectant management: population based study. BMJ. 2012 May 10344:e2838. doi: 10.1136/bmj.e2838.
Darney BG, Snowden JM, Cheng YW, et al; Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes. Obstet Gynecol. 2013 Oct122(4):761-9. doi: 10.1097/AOG.0b013e3182a6a4d0.
Stock SJ, Ferguson E, Duffy A, et al; Outcomes of induction of labour in women with previous caesarean delivery: a retrospective cohort study using a population database. PLoS One. 20138(4):e60404. doi: 10.1371/journal.pone.0060404. Epub 2013 Apr 2.
Gulmezoglu AM, Crowther CA, Middleton P, et al; Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev. 2012 Jun 136:CD004945.
Induction of labour; NICE Clinical Guideline (July 2008)
Caughey AB, Sundaram V, Kaimal AJ, et al; Maternal and neonatal outcomes of elective induction of labor. Evid Rep Technol Assess (Full Rep). 2009 Mar(176):1-257.
Preterm Prelabour Rupture of Membranes (November 2006 - minor amendment October 2010); Royal College of Obstetricians and Gynaecologists
Lieman JM, Brumfield CG, Carlo W, et al; Preterm premature rupture of membranes: is there an optimal gestational age for delivery? Obstet Gynecol. 2005 Jan105(1):12-7.
Crane JM; Factors predicting labor induction success: a critical analysis. Clin Obstet Gynecol. 2006 Sep49(3):573-84.
Bakker PC, Kurver PH, Kuik DJ, et al; Elevated uterine activity increases the risk of fetal acidosis at birth. Am J Obstet Gynecol. 2007 Apr196(4):313.e1-6.
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