A randomised controlled trial and meta-analysis of active management of labour

Objective To test whether a policy of active management of nulliparous labour would reduce the rate of caesarean section and prolonged labour without influencing maternal satisfaction. Design Randomised controlled trial. Setting Tertiary referral obstetric unit, Auckland, New Zealand. Population Nulliparous women in spontaneous labour at term with singleton pregnancy and cephalic presentation and without fetal distress. Methods After the onset of active labour, previously consented women were randomly assigned to active management (n = 320) or to routine care (n = 331). Active labour was defined as regular painful contractions, occurring at least once in five minutes, lasting at least 40 seconds, accompanied by either spontaneous rupture of the membranes, or full cervical effacement and dilatation of at least two centimetres. Active management included early amniotomy, two-hourly vaginal assessments, and early use of high dose oxytocin for slow progress in labour. Routine care was not prespecified. Prolonged labour was > 12 hours duration. Maternal satisfaction with labour care was assessed by postal questionnaire at six weeks postpartum. Main outcome measures Mode of delivery, duration of labour, and maternal satisfaction. Results Active management of labour did not reduce the rate of caesarean section 30/320 (9.4%), compared with 32/331 (9.7%) for routine care, but did shorten the length of first stage of labour (median 240 min vs 290 min; P = 0.02), and reduce the relative risk of prolonged labour (RR 0.39; 95% CI 0.22, 0.71). There were no differences between groups in the rates of newborn nursery admission, neonatal acidosis, low Apgar scores, or postpartum haemorrhage. Satisfaction with labour care was high (77%) and did not differ between groups. Conclusions Active management of labour reduced the duration of the first stage of labour without affecting the rate of caesarean section, maternal satisfaction, or other maternal or newborn morbidity.