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Active Management of Labour | |||||
ACTIVE MANAGEMENTOF LABOURWhat is the active management of labour?
2000 Department of Obstetrics and Gynaecology, Laval
University, CHUQ, St Francois d'Assise Pavilion, 10, rue de l'Espinay,
Quebec, Province of Quebec, Canada, G1L 3L5. william.fraser@ogy.ulaval.ca
Early amniotomy has been
advocated as a component of the active management of labour. Several
randomised trials comparing routine amniotomy to an attempt to conserve
the membranes have been published. Their limited sample sizes limit
their ability to address the effects of amniotomy on indicators of
maternal and neonatal morbidity. The register of clinical
trials maintained and updated by the Cochrane Pregnancy and Childbirth
Group. All acceptably
controlled trials of amniotomy during first stage of labour were
eligible. Data were
extracted by two trained reviewers from published reports. Trials were
assigned methodological quality scores based on a standardized rating
system. Typical odds ratios (ORs) were calculated using Peto's method. Amniotomy was associated
with a reduction in labour duration of between 60 and 120 minutes. There
was a marked trend toward an increase in the risk of Cesarean delivery:
OR = 1.26; 95% Confidence Interval (CI)=0.96-1. 66. The likelihood of a
5 minute Apgar score less than 7 was reduced in association with early
amniotomy (OR = 0.54; 95% CI = 0.30-0.96). Groups were similar with
respect to other indicators of neonatal status (arterial cord pH, NICU
admissions). There was a statistically significant association of
amniotomy with a decrease in the use of oxytocin: OR = 0.79; 95% CI =
0.67-0.92. REVIEWER'S Routine early
amniotomy is associated with both benefits and risks. Benefits include a
reduction in labour duration and a possible reduction in abnormal
5-minute Apgar scores. The meta-analysis provides no support for the
hypothesis that routine early amniotomy reduces the risk of Cesarean
delivery. Indeed there is a trend toward an increase in Cesarean
section. An association between early amniotomy and Cesarean delivery
for fetal distress is noted in one large trial. This suggests that
amniotomy should be reserved for women with abnormal labour progress.
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