Active Management of Labor

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Chapter 195 Active Management of Labor

THE CHALLENGE

Active management of labor is a system of labor management designed to promote effective labor and reduce the need for cesarean delivery.

Scope of the Problem: Cesarean birth rate for nulliparous patients approximates 30% in many areas. Active management has been associated with cesarean delivery rates of less than 5% for its developers (Ireland).

Objectives of Management: To reduce cesarean delivery rates through a system of management that includes education, strict criteria for labor and abnormal progress, one-on-one care, and the use of high-dose oxytocin (when needed).

TACTICS

Relevant Pathophysiology: As developed in Ireland, active management of labor is based on the following:

• Patient education

• Strict criteria for the diagnosis of labor, the determination of abnormal progress, and the diagnosis of fetal compromise

• One-on-one nursing care during labor

• Use of high-dose oxytocin infusion (when needed)

• Peer review of all operative deliveries

Strategies: In Ireland, where this technique was developed, active management of labor is restricted to nulliparous patients with singleton pregnancies in vertex presentation with no evidence of fetal compromise. Women are carefully instructed to come to the hospital early in labor. Labor is confirmed by the presence of complete effacement, the passage of the mucous plug, or rupture of the membranes. If these criteria are met, the patient is admitted to the hospital and the membranes are ruptured within 1 hour (if not already ruptured). Vaginal examination is performed hourly, and administration of high-dose oxytocin is begun if dilation falls below 1 cm/hour. Oxytocin is begun at 6 mU/min, and the dose is increased every 15 minutes until a maximum of 40 mU/min is reached, active labor is established, or hyperstimulation occurs. As a part of this process, one-on-one nursing care is provided, and fetal status is assessed by auscultation every 5 minutes. Fetal compromise is diagnosed by fetal scalp pH. Cesarean delivery is performed if delivery is not imminent 12 hours after admission or if fetal compromise is diagnosed.

Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP004 (How to Tell When Labor Begins).

IMPLEMENTATION

Special Considerations: The Irish experience with active management of labor has resulted in a reduced rate of births by cesarean delivery without untoward events. Which elements of the management (education, early amniotomy, intensive nursing, aggressive use of oxytocin, or methods of establishing distress) are directly responsible for this success is unknown. Attempts to apply only some elements of the program have generally not yielded the same reductions in cesarean section rates. It should be noted that conduction (epidural) anesthesia is also less common in Ireland.

Bolnick JM, Velazquez MD, Gonzalez JL, et al. Randomized trial between two active labor management protocols in the presence of an unfavorable cervix. Am J Obstet Gynecol. 2004;190:124.

Cohen GR, O’Brien WF, Lewis L, Knuppel RA. A prospective randomized study of the aggressive management of early labor. Am J Obstet Gynecol. 1987;157:1174.

Frigoletto FDJr, Lieberman E, Lang JM, et al. A clinical trial of active management of labor. N Engl J Med. 1995;333:745.

Lavender T, Alfirevic Z, Walkinshaw S. Partogram action line study: a randomised trial. Br J Obstet Gynaecol. 1998;105:976.

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.

Pattinson RC, Howarth GR, Mdluli W, et al. Aggressive or expect-ant management of labour: a randomised clinical trial. BJOG. 2003;110:457.

Rogers J, Wood J, McCandlish R, et al. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. Lancet. 1998;351:693.

Rogers RG, Gardner MO, Tool KJ, et al. Active management of labor: a cost analysis of a randomized controlled trial. West J Med. 2000;172:240.

Sadler LC, Davison T, McCowan LM. A randomised controlled trial and meta-analysis of active management of labour. BJOG. 2000;107:909.

Shetty A, Stewart K, Stewart G, et al. Active management of term prelabour rupture of membranes with oral misoprostol. BJOG. 2002;109:1354.

Alexander JM, Lucas MJ, Ramin SM, et al. The course of labor with and without epidural analgesia. Am J Obstet Gynecol. 1998;178:516.

Fraser W, Vendittelli F, Krauss I, Breart G. Effects of early augmentation of labour with amniotomy and oxytocin in nulliparous women: a meta-analysis. Br J Obstet Gynaecol. 1998;105:189.

Frigoletto FDJr, Lieberman E, Lang JM, et al. A clinical trial of active management of labor. N Engl J Med. 1995;333:745.

Rouse DJ, Owen J, Hauth JC. Active-phase labor arrest: oxytocin augmentation for at least 4 hours. Obstet Gynecol. 1999;93:323.

American College of Obstetricians and Gynecologists. Induction of labor. ACOG Practice Bulletin 10. Washington, DC: ACOG, 1999.

American College of Obstetricians and Gynecologists. Dystocia and augmentation of labor. ACOG Practice Bulletin 49. Obstet Gynecol. 2003;102:1445.

Leighton BL, Halpern SH, Wilson DB. Lumbar sympathetic blocks speed early and second stage induced labor in nulliparous women. Anesthesiology. 1999;90:1039.

Peaceman AM, Socol ML. Active management of labor. Am J Obstet Gynecol. 1996;175:363.

Rogers R, Gilson G, Kammerer-Doak D. Epidural analgesia and active management of labor: effects on length of labor and mode of delivery. Obstet Gynecol. 1999;93:995.

Rogers R, Gilson GJ, Miller AC, et al. Active management of labor: does it make a difference? Am J Obstet Gynecol. 1997;177:599.

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