Caesarean section rates have increased substantially since the early 1970s; many women having their first babies are older and this may contribute to ineffective or difficult labor, most often because of inadequate uterine action (dystocia). The Active Management of Labor is a clinical protocol that includes early intervention with amniotomy and oxytocin to increase the frequency and intensity of uterine contractions (augmentation) when the progress of labor is delayed. Continued ineffective labor (‘cervical arrest’) can result in the decision to undertake a caesarian section. Early intervention also has risks that include uterine hyperstimulation and fetal heart rate abnormalities.
This review showed that a policy of early routine augmentation for mild delays in labor progress resulted in a modest reduction of the caesarean section rate compared with expectant management. The reduction in caesarian sections was most evident in the 10 trials looking at prevention of abnormal progression, rather than therapy (2 trials). The difference in caesarean risk was 1.47%. The number of women needed to treat (NNT) to prevent one caesarean section was approximately 68. This conclusion is based on 10 randomized controlled trials involving 7653 women. In these women, the time from admission to giving birth was also reduced (mean difference 1.1 hour).
The trials did not provide sufficient evidence on indicators of maternal or neonatal health, including women’s satisfaction and views on the experience. Documentation of other aspects of care, such as continuous professional support, mobility and positions during labor, was limited as was the degree of contrast between groups. Women in the control group also received oxytocin but often later than in the intervention group. The severity of delay which was sufficient to justify interventions remains to be defined.