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Labour - Active Management and Induction

The active management of Labour was pioneered by K O'Driscoll in 1969,1 as a means of reducing the number of prolonged labours. Its aim was to keep labour to less than 12 hours and operative delivery rates to a minimum. Even in diluted form it has been shown to be effective in reducing labouring time in randomised controlled trials.2,3 It was originally designed for primiparous women with singleton pregnancies at term, in spontaneous labour.
It has been modified significantly over time, but the core principles remain:

  • Early diagnosis, following strict criteria, by a senior midwife
  • Vaginal examination hourly for 3 hours, then every 2 hours, at least. This allows the rate of progress to be plotted on a partogram.
  • Amniotomy 1 hour after admission
  • Augmentation with syntocinon if not dilating at rate of 1cm/hour
  • Women not in labour should be sent home. 50% are readmitted within 24 hours
  • Personal, psychological support for the woman. A Cochrane Review found that the psychological support was an important factor, but only where the woman's partner was not normally present.4
  • Liberal use of epidural anaesthesia
  • Regular rounds by the obstetrician
  • Ante-natal education classes
  • Regular audit of labour ward process and outcomes

Evidence based inpatient care supports continuity of care, reduction in episiotomy rates, active management of the third stage with 10 IU syntocinon.5 More analysis of benefits and risks is required for the use of amniotomy, continuous electronic fetal monitoring, epidural and syntometrine; Cochrane Review showed that amniotomy reduced labour by 60-120 minutes, but did not improve outcome. There was also a perception of increased pain associated with the procedure and potentially more variable decelerations on cardiotocograph.6
Active Management was not designed to lower caesarean section rates, but may have decreased the number of sections performed for dystocia - failure to progress. This effect was most significant in Dublin, where it was first used, but this success has not been matched in other units.
Professor Thornton has stated his belief that routine active management of labour will disappear, but we needed a greater evidence base on which to base delivery suite guidelines.7

The Partogram

DUBLIN PARTOGRAM (OM214a.jpg)

The partogram is used to chart the progress of the woman in labour. If cervical dilatation is less than expected, or stops (progress drops below the 'action line'), augmentation may be required. Other important parameters are also recorded e.g. presence of meconium staining in the liquor and perception of strength of contractions. Many advocate its use, but there is little evidence of a positive effect on labour outcomes.8,9

Induction of Labour

Induction is the process of starting labour by uterine stimulation. It should be used when it is thought that the baby will be safer delivered than it is in utero. [Needs to be clearly distinguished from augmentation of labour, which is the enhancement of uterine contractions once labour has started.]
RCOG and NICE guidelines10,11 define its use in clinical practice:

  • It should be offered to women with healthy pregnancy after 41 weeks. Risk of stillbirth increases from 3/3000 at 42 weeks to 6/3000 at 43 weeks.
  • It should be offered to women whose pregnancy is complicated by diabetes, before term.
  • In women with pre labour ruptured membranes after 37 weeks,(6-19% of pregnancies), they should be given a choice of either immediate induction, or watchful waiting for up to maximum of 4 days.12 84% labour within 24 hours, increasing by a further 5% every 24 hours after. Beyond 4 days, risk of infection outweighs any potential benefit to mother or child.13

Commonest reasons for inducing labour are:

  • Prolonged pregnancy - 70% of such cases are induced after 41 weeks often at the mother's request. Obstetrician will usually agree if cervix is ripe.
  • Suspected fetal growth retardation
  • Hypertension and pre-eclampsia; approx. 50% women with this problem are induced
  • Planned time of delivery in best interests of baby e.g. cardiac abnormalities which may need immediate surgery after birth

Check prior to induction:

  • Need to check lie and position of fetus
  • Volume of amniotic fluid
  • Tone of uterus
  • Ripeness of cervix; this is best predictor of readiness for induction and can be scored using Bishop's system14: If score >8, probability of successful delivery with induction as same as spontaneous onset of labour.

Contraindications

These are the same as for vaginal delivery. Absolute contraindications include:

Relative contraindications include:

Induction Procedure

Procedure should be fully discussed with mother; explaining technique to be used and any possible side effects and consequences of failure (caesarean section). She needs to give her informed consent, possibly in writing or if not a signed note made in the woman's records.

  • Assess fetal maturity
  • Recheck presentation and position of fetus just before induction

Methods used include:

  • Membrane sweeping
  • Prostaglandin gel or pessary
  • Oxytocin with/ or without artificial rupture of membranes

Commonest method of induction in UK is placing prostaglandin gel or pessary high in vagina (not cervix). Drug is absorbed through vaginal and cervical epithelium and delivered to the uterus via the blood stream. Obstetrician or midwife should stay with women for 20-30 minutes with cardiotocographic monitoring of fetus in case of myometrial overreaction.

Complications of Induction

May fail and require caesarean section.
All the complications of a normal vaginal delivery, plus:

  • Uterine hyperstimulation; fetal distress and hypoxic damage to the baby15
  • Uterine rupture, especially in multiparous women
  • Intrauterine infection with prolonged membrane rupture without delivery (less likely if labour occurs within 12 hours)
  • Prolapsed cord can occur with first rush of amniotic fluid, if presenting part not well engaged
  • Amniotic fluid embolism
  • 1.5x increased risk of operative vaginal delivery and 1.8x increased risk of caesarean section


Document References
  1. O'Driscoll K, Jackson RJ, Gallagher JT; Prevention of prolonged labour. Br Med J. 1969 May 24;2(5655):477-80.
  2. Lopez-Zeno JA, Peaceman AM, Adashek JA, et al; A controlled trial of a program for the active management of labor. N Engl J Med. 1992 Feb 13;326(7):450-4. [abstract]
  3. Frigoletto FD Jr, Lieberman E, Lang JM, et al; A clinical trial of active management of labor. N Engl J Med. 1995 Sep 21;333(12):745-50. [abstract]
  4. Hodnett ED, Gates S, Hofmeyr GJ, et al; Continuous support for women during childbirth. Cochrane Database Syst Rev. 2003;(3):CD003766. [abstract]
  5. Hofmeyr GJ; Evidence-based intrapartum care. Best Pract Res Clin Obstet Gynaecol. 2005 Feb;19(1):103-15. Epub 2004 Dec 13. [abstract]
  6. Fraser WD, Turcot L, Krauss I, Brisson-Carrol G. Cochrane Review of amniotomy for shortening spontaneous labour. Cochrane Library. Issue 1. 2002. Oxford. Update software.
  7. Thornton JG; Active management of labour. BMJ. 1996 Aug 17;313(7054):378.
  8. Windrim R, Seaward PG, Hodnett E, et al; A randomized controlled trial of a bedside partogram in the active management of primiparous labour. J Obstet Gynaecol Can. 2007 Jan;29(1):27-34. [abstract]
  9. Lavender T, Alfirevic Z, Walkinshaw S; Partogram action line study: a randomised trial. Br J Obstet Gynaecol. 1998 Sep;105(9):976-80. [abstract]
  10. RCOG; Induction of Labour; Evidence based guideline 9:Induction of labour. 2005
  11. Pregnancy and childbirth - Induction of labour, NICE (2001)
  12. RCOG. Green top Guideline: PRETERM PRELABOUR RUPTURE OF MEMBRANES; November 2006
  13. Lieman JM, Brumfield CG, Carlo W, et al; Preterm premature rupture of membranes: is there an optimal gestational age for delivery? Obstet Gynecol. 2005 Jan;105(1):12-7. [abstract]
  14. Bishop EH. Pelvic scoring for elective induction. Obstet Gynaecol 1964;24:267.
  15. Bakker PC, Kurver PH, Kuik DJ, et al; Elevated uterine activity increases the risk of fetal acidosis at birth. Am J Obstet Gynecol. 2007 Apr;196(4):313.e1-6. [abstract]
Internet and Further Reading
  • Shields SG, Ratcliffe SD, Fontaine P, et al; Dystocia in nulliparous women. Am Fam Physician. 2007 Jun 1;75(11):1671-8. [abstract]
  • Chamberlain G, Zander L; ABC of labour care: induction.;BMJ 1999 Apr 10;318(7189):995-8.
Acknowledgements EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 2366
Document Version: 20
DocRef: bgp214
Last Updated: 20 Aug 2007
Review Date: 19 Aug 2009




















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