Question: Does active labour management reduce the caesarean section rate in primiparous women?
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Answer: A Cochrane review to determine whether active management of labour reduces CS rates in low-risk women (Brown) identified 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.
Another Cochrane review to estimate the effects of early augmentation with amniotomy and oxytocin for prevention of, or therapy for, delay in labour progress on the caesarean birth rate (Wei) included twelve trials, including 7792 women. The unstratified analysis found early intervention with amniotomy and oxytocin to be associated with a modest reduction in the risk of caesarean section; however, the confidence interval crossed unity and was compatible with no effect (risk ratio (RR) 0.89; 95% confidence interval (CI) 0.79 to 1.01). In Prevention trials, early augmentation was associated with a modest reduction in the number of caesarean births (RR 0.88; 95% CI 0.77 to 0.99).
A Cochrane review of amniotomy for shortening spontaneous labour (Smyth) included 14 studies, involving 4893 women. There was no clear statistically significant difference between the amniotomy and control groups in caesarean section (RR 1.26, 95% CI 0.98 to 1.62)
All three of these Cochrane reviews were last assessed as up-to-date in 2007-08. No more receent evidence was identified.
The 2007 NICE guideline on Intrapartum care found that "The package known as active management of labour (one-to-one continuous support, diagnosis of labour, early amniotomy, 2 hourly vaginal examinations and oxytocin if labour becomes slow) appears to reduce the duration of the first stage of labour but has no effect on the incidence of CS." and recommends that active management is not routinely offered.
(Level of evidence Ia)
References:
- Brown Heather C, Paranjothy Shantini, Dowswell Therese, Thomas Jane. Package of care for active management in labour for reducing caesarean section rates in low-risk women. Cochrane Database of Systematic Reviews: Reviews 2008 Issue 4 John Wiley & Sons, Ltd Chichester, UK DOI: 10.1002/14651858.CD004907.pub2. Abstract and full text (restricted in some countries). Full text available to Fellows, Members and Trainees here
- National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Health and Clinical Excellence. Intrapartum care: care of healthy women and their babies during childbirth. London: RCOG Press, 2007
- Smyth RMD, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006167. DOI: 10.1002/14651858.CD006167.pub2 Abstract and full text (restricted in some countries) Full text available to Fellows, Members and Trainees here
- Wei Shuqin, Wo Bi Lan, Xu Hairong, Luo Zhong-Cheng, Roy Chantal, Fraser William D. 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: Reviews 2009 Issue 2 John Wiley & Sons, Ltd Chichester, UK DOI: 10.1002/14651858.CD006794.pub2 Abstract and full text (restricted in some countries) Full text available to Fellows, Members and Trainees here
Search date: May 2011
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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