Correspondence
A Clinical Trial of Active Management of Labor
N Engl J Med 1996; 334:797-799March 21, 1996
- Article
To the Editor:
The purpose of active management of labor, as developed over a period of years during the 1960s at the National Maternity Hospital in Dublin, Ireland, was to enhance the quality of the experience of childbirth by preventing prolonged labor in first-time mothers; 25 years later the purpose remains the same.1 The essential features of the program include regular assessment of the early progress of labor and effective stimulation of labor whenever progress is slow. Efficient uterine action is considered the key to normal delivery.2
Active management of labor had already been standard practice in Dublin for 10 years before dystocia was identified as the explanation for the explosive growth in cesarean-birth rates, which was such a notable aspect of obstetrical practice across the United States during the 1970s. The Consensus Development Report on cesarean childbirth identified dystocia as the indication for one in every two primary operations.3 Moreover, after a search for constructive steps that could be taken to counteract the rising trend, the conclusion was that there was a compelling reason to focus attention on dystocia and factors that may affect the progress of labor.3 This is the context in which the suggestion was made that active management of labor could provide a less radical, alternative approach to the problem.4
Dr. Frigoletto and colleagues conducted a randomized trial for the specific purpose of evaluating the efficacy of active management of labor in lowering the rate of cesarean section (Sept. 21 issue).5 The study confirmed that the procedure is safe and that it is highly effective: the duration of labor was reduced significantly, whether this was measured by the median duration (reduced from 8.9 hours in the control group to 6.2 hours in the active-management group) or by the duration in excess of 12 hours (reduced from 26 percent of mothers in the control group to 9 percent of mothers in the active-management group). The critical question, therefore, must be why these impressive figures were not matched by equal improvement in the failure to progress, or dystocia.
5 ReferencesKieran O'Driscoll, M.D.
Declan Meagher, M.D.
Peter Boylan, M.D.
National Maternity Hospital, Dublin 2, Ireland1
O'Driscoll K ,Jackson RJ ,Gallagher JT . Prevention of prolonged labour. BMJ 1969;2:477-480
CrossRef | Web of Science | Medline2
O'Driscoll K ,Stronge JM ,Minogue M . Active management of labour. BMJ 1973;3:135-137
CrossRef | Web of Science | Medline3
Department of Health and Human Services, Public Health Service, National Institutes of Health. Caesarean childbirth. Consensus development report no. 82-2067. Bethesda, Md.: Department of Health and Human Services, October 1981.
4
O'Driscoll K ,Foley M ,MacDonald D . Active management of labor as an alternative to caesarean section for dystocia. Obstet Gynecol 1984;63:485-490
Web of Science | Medline5
Frigoletto FD Jr ,Lieberman E ,Lang JM , et al. A clinical trial of active management of labor. N Engl J Med 1995;333:745-750
Full Text | Web of Science | Medline
To the Editor:
On reading the article by Frigoletto et al. regarding the randomized controlled trial of active management of labor, we were pleased to note so many similarities between their findings and ours.1 With patients who fulfilled the criteria for active management at the time of admission (nulliparous women who had reached term and were in spontaneous labor with a singleton fetus in a vertex presentation), following the principles of active management led to comparable rates of cesarean section in the two studies (10.5 and 10.9 percent). In addition, both studies found that among these protocol-eligible patients, active management reduced maternal infectious morbidity by half and decreased the length of labor by approximately two hours as compared with traditional labor management in the control groups. Probably most important, additional confirmatory data are presented showing that active management of labor can be instituted without any increase in neonatal morbidity.
The difference between the two studies lies in the comparisons of rates of cesarean birth associated with active management with those associated with traditional labor management. Frigoletto and colleagues found a rate of 11.5 percent with traditional management, which was lower than that found in our control group. They provide data to suggest that although the rate appears unusually low for a hospital with a cesarean-birth rate of 23.8 percent among all nulliparous women, the rate may be appropriate for such a low-risk population meeting requirements for protocol eligibility. Our data are different, showing a rate of cesarean births of 14.1 percent among protocol-eligible control (traditionally managed) patients, during a time when the cesarean-section rate among all nulliparas was approximately 20 percent. There are no national data reflecting cesarean-birth rates among patients who meet the criteria for protocol eligibility. If, as we suspect, rates in most institutions are indeed higher for protocol-eligible patients than the 11.5 percent seen in this recent trial, it is possible that initiating active management of labor in these institutions may be found to be of benefit.
The question is not whether active management of labor is the best method of labor management, but whether it is a safe and effective method. If an institution is able to use such a program to lower its cesarean-birth rate, then the program is a success. If practitioners are already managing labor in another fashion that achieves low rates of operative intervention, then active management may not lower these rates further. The current study does not rule out the possibility that some institutions or practitioners will be able to use this program to benefit their patients.
We also lament the higher rate of second-stage interventions than that reported in Dublin. It is clear that further evaluation of practices for the management of the second stage of labor in North America is needed.
1 ReferencesAlan M. Peaceman, M.D.
Michael L. Socol, M.D.
Northwestern University, Chicago, IL 60611José A. López-Zeno, M.D.
Ponce School of Medicine, Ponce, PR 007321
Lopez-Zeno JA ,Peaceman AM ,Adashek JA ,Socol ML . A controlled trial of a program for the active management of labor. N Engl J Med 1992;326:450-454
Full Text | Web of Science | Medline
To the Editor:
It is difficult to accept the conclusions of Frigoletto et al. The study does not have the power to detect a 2 to 3 percent decrease in the cesarean-section rate.
The claim that it was a blind study is hard to accept; the protocol for the management of labor in the protocol-eligible group was strikingly different from the usual practice in the United States. It is clear that about 5 percent of pregnant women in spontaneous labor at term will not behave like the rest and will require a cesarean section in the first stage of labor. Management in the second stage appears to be the crucial issue. It is obvious that personal experience and skills and local practice play an important part.
Shorter labor (almost three hours on average), less frequent use of epidural anesthesia, less fever, and a trend toward fewer cesarean sections all sound great to me. It is unfortunate that Frigoletto and his group advocate denial of these benefits to pregnant women.
N. Manassiev, M.R.C.O.G.
2 Inglefield Rd., Stechford, Birmingham, B33 8DF, United KingdomAuthor/Editor Response
The authors reply:
To the Editor: We thank Drs. O'Driscoll et al., Peaceman et al., and Manassiev for their thoughtful comments on our work.
We concur with Dr. Manassiev that active management of labor has a number of benefits. The shortening of labor by almost three hours and the decrease in febrile morbidity experienced by mothers are real advantages that should not be ignored. However, our study focused on whether implementation of this protocol would also lead to a substantial reduction in cesarean-section rates. Since we found essentially no difference in the rates of cesarean section between the active-management and usual-care groups, our data did not support proposing this method of management as the standard of care for the purpose of lowering these rates, though it may be chosen for its other benefits.
Dr. Peaceman and his colleagues suggest that the reason our cesarean-section rate with active management was not lower than that with usual care was that the rate was already low under our existing labor-management protocol. Our usual-care rate was only slightly lower than the usual-care rate in the López-Zeno study (by 2.6 percent), however, and still twice the rate at the National Maternity Hospital. In addition, there are other possible explanations for the differences in results between the two studies. For example, our study, in contrast to that of López-Zeno et al., employed a separate staff that implemented the protocol in a physically distinct unit.
Peaceman and his colleagues also suggest that at institutions where cesarean-section rates among low-risk, nulliparous women are high, the implementation of active management of labor could result in a lower rate. Since the efficacy of any intervention is measured against the existing standard of care at a particular institution, a lower rate could result with the use of active management in a particular instance. However, because that lower rate can clearly also be achieved with the use of other, already existing practice standards, we conclude that the implementation of active management of labor as the standard of care is not likely to provide a solution to the high rate of cesarean deliveries in the United States. We believe that the more interesting comparison for understanding cesarean-section rates in this country is between the overall delivery pattern in the two studies and the pattern at the National Maternity Hospital (see Table 6 of our article). The most striking difference is the rate of second-stage cesarean section (0.2 percent at the National Maternity Hospital, 4 percent in our study, and 3 percent in the López-Zeno study). The fact that both randomized trials of active management of labor report rates of second-stage cesarean section 15 to 20 times as high as those of the Dublin hospital suggests a need to investigate the management of the second stage.
We appreciate the comments of Dr. O'Driscoll and his colleagues from the National Maternity Hospital, where the active-management protocol originated. In our trial, as at their hospital, the implementation of active management enhanced the labor experience of women by providing both shorter labors and one-to-one nursing. We believe that there is much that can be learned, especially with regard to management of the second stage of labor, by a continuing comparison of practices at the National Maternity Hospital with those in the United States.
Fredric Frigoletto, Jr., M.D.
Ellice Lieberman, M.D., Dr.P.H.
Brigham and Women's Hospital, Boston, MA 02115Janet M. Lang, Ph.D., Sc.D.
Boston University School of Public Health, Boston, MA 02118
