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Volume 333:745-750 September 21, 1995 Number 12 Next

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ABSTRACT

Background Active management of labor is a multifaceted program that, as implemented at the National Maternity Hospital in Dublin, is associated with a lower rate of cesarean delivery than the rate usually found in the United States. We conducted a randomized trial to evaluate the efficacy of this approach in lowering the rate of cesarean section among women delivering their first babies.

Methods We randomly assigned 1934 nulliparous women at low risk of complications of pregnancy, before 30 weeks' gestation, to active management of labor or to a usual-care group. The components of active management were customized childbirth classes; strict criteria for the diagnosis of labor; standardized management of labor, including early amniotomy and treatment with high-dose oxytocin; and one-to-one nursing. A low-risk subgroup was defined as including women with full-term, uncomplicated pregnancies who spontaneously went into labor (the protocol-eligible subgroup). Women meeting these criteria who had been randomly assigned to the active-management group were admitted to a separate unit where their labor was managed by trained, certified nurse-midwives.

Results There was no difference between groups in the rate of cesarean section either among all women (active management, 19.5 percent; usual care, 19.4 percent) or in the protocol-eligible subgroup (active management, 10.9 percent; usual care, 11.5 percent). In the protocol-eligible subgroup, the median duration of labor was shortened by 2.7 hours by active management (from 8.9 to 6.2 hours), and the rate of maternal fever was lower (7 percent vs. 11 percent, P = 0.007). The percentage of women in whom labor lasted longer than 12 hours was three times higher in the usual-care group than in the active-management group (26 percent vs. 9 percent, P<0.001).

Conclusions Active management of labor did not reduce the rate of cesarean section in nulliparous women but was associated with a somewhat shorter duration of labor and less maternal fever.

Source Information

From the Departments of Obstetrics and Gynecology (F.D.F., E.L., A.C.), Anesthesia (S.D.), and Newborn Medicine (S.R.), Brigham and Women's Hospital and Harvard Medical School; the Department of Obstetrics and Gynecology, Harvard Community Health Plan, Brigham and Women's Hospital (V.B.); and the Department of Epidemiology and Biostatistics, Boston University School of Public Health (J.M.L.) — all in Boston.

Address reprint requests to Dr. Frigoletto at the Department of Obstetrics and Gynecology, Massachusetts General Hospital, 32 Fruit St., Boston, MA 02114.

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