ACTIVE MANAGEMENT
OF LABOUR
What is the active management
of labour?
Active Management of Labour (AML), a term given by the
British Medical Journal in 1973,
describes an approach to labour which was first initiated in 1963 in The National Maternity Hospital (NMH), Dublin, Ireland.
Since then AML has continued to evolve, but has remained based on the principles
summarised in Active Management of Labour.
The philosophy behind AML has always been the prevention
of prolonged labour,
in particular the prevention of the physical and
psychological morbidity that usually follows it. Prolonged labour was first defined as 36
hours in 1963, reduced to 24 hours in 1968 and finally to 12 hours in 1972. Ensuring
efficient uterine action and fetal and maternal well-being are the key requirements
needed to achieve this and the principles of AML described below, set out the framework
within which those targets are achieved.
These principles include the importance of antenatal
education, the difference between nulliparous and multiparous women, spontaneous
and induced labour, single cephalic pregnancies and malpresentations and multiple
pregnancies. Furthermore the specific attention and importance given to the diagnosis
of labour, as well as fetal and maternal well-being, in particular the personal
attention given to each woman during labour. Of most interest, but probably least known, is
the organisation of the labour ward which is totally midwifery based, but benefits from
a very close working relationship to senior obstetric colleagues resulting in
a very satisfying working environment. Lastly all these principles are held
together by continuous, rigorous peer review audit leading to constant changes in the
management of labour. The main focus of AML however, has undoubtedly always been on the
care in labour of the single cephalic, term pregnancy, in nulliparous women.
In the 1970s caesarean section rates started to increase
particularly in the United States, and although there was a simultaneous decrease
in the perinatal mortality rate O?Driscoll showed that a decrease in the perinatal
mortality rate did not necessarily require an increase in the caesarean rate4.
Furthermore O?Driscoll maintained that the difference between the caesarean section rates in the
United States and the NMH could be accounted for almost entirely by a different
approach to the management of labour in nulliparous women and suggested AML as an
alternative to caesarean section for dystocia5.
Since then AML has always unfortunately been associated with being the answer to rising caesarean section rates and
although some have successfully reduced their caesarean section rates by
using its principles6,
it must be emphasised that it was never the purpose of AML to
reduce caesarean section rates.
AML will continue to evolve as informed maternal choice
becomes more influential in intrapartum care, but the prevention of prolonged
labour and its associated complications will be as important to women in the
future as it has been to women in the past.
The impact of AML on outcome of labour is best
demonstrated on examining the detailed outcome of spontaneously labouring nulliparous
women with a single cephalic pregnancy at term7.
As far as advantages and disadvantages of Aml are concerned, all women should have access to the relevant
information on labour outcome. If they prefer a shorter (rather than longer)8
labour with a high chance of
a normal delivery then they will be opting for AML.
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. 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 Caesarean delivery. Indeed there is a trend toward
an increase in Caesarean section.
Amniotomy has been associated with a
reduction in labour duration of between 60 and 120 minutes.0001
The likelihood of a 5 minute Apgar score less than 7 was reduced in
association with early amniotomy. There was a statistically
significant association of amniotomy with a decrease in the use of
oxytocin.
Lopez-Zeno et al9201
found a reduction the incidence of dystocia and an increase
in the rate of vaginal delivery without increasing
maternal or neonatal morbidity. There is evidence of economic benefits from
adoption of active management of labour as there is a reduction in the
rate of caesarean sections.0002
Frigoletto et al9501
found that active management of labour did not reduce the rate of caesarean
section in nulliparous women but was associated with a somewhat shorter
duration of labour and less maternal fever.
Pattinson et al0301
observed thataggressive
management of labour reduces the caesarean section rate in nulliparous
women but requires more intensive nursing.
Lavender et al,
whilst assessing different partograms, found that women prefer the
active management of labour.9801
The principles of
active management of labour have not been accepted universally. Wagner,
Thornton and Lilford9401,
in a review of observational data, supplemented by evidence
from four separate overviews of relevant randomised trials concluded that
the routine use of amniotomy and early
oxytocin should not recommended.
What is the active management of labour?
Active Management of Labour (AML), a term given by the British Medical Journal in 1973, describes an approach to labour which was first initiated in 1963 in The National Maternity Hospital (NMH), Dublin, Ireland. Since then AML has continued to evolve, but has remained based on the principles summarised in Active Management of Labour.
The philosophy behind AML has always been the prevention of prolonged labour, in particular the prevention of the physical and psychological morbidity that usually follows it. Prolonged labour was first defined as 36 hours in 1963, reduced to 24 hours in 1968 and finally to 12 hours in 1972. Ensuring efficient uterine action and fetal and maternal well-being are the key requirements needed to achieve this and the principles of AML described below, set out the framework within which those targets are achieved.
These principles include the importance of antenatal education, the difference between nulliparous and multiparous women, spontaneous and induced labour, single cephalic pregnancies and malpresentations and multiple pregnancies. Furthermore the specific attention and importance given to the diagnosis of labour, as well as fetal and maternal well-being, in particular the personal attention given to each woman during labour. Of most interest, but probably least known, is the organisation of the labour ward which is totally midwifery based, but benefits from a very close working relationship to senior obstetric colleagues resulting in a very satisfying working environment. Lastly all these principles are held together by continuous, rigorous peer review audit leading to constant changes in the management of labour. The main focus of AML however, has undoubtedly always been on the care in labour of the single cephalic, term pregnancy, in nulliparous women.
In the 1970s caesarean section rates started to increase particularly in the United States, and although there was a simultaneous decrease in the perinatal mortality rate O?Driscoll showed that a decrease in the perinatal mortality rate did not necessarily require an increase in the caesarean rate4. Furthermore O?Driscoll maintained that the difference between the caesarean section rates in the United States and the NMH could be accounted for almost entirely by a different approach to the management of labour in nulliparous women and suggested AML as an alternative to caesarean section for dystocia5. Since then AML has always unfortunately been associated with being the answer to rising caesarean section rates and although some have successfully reduced their caesarean section rates by using its principles6, it must be emphasised that it was never the purpose of AML to reduce caesarean section rates.
AML will continue to evolve as informed maternal choice becomes more influential in intrapartum care, but the prevention of prolonged labour and its associated complications will be as important to women in the future as it has been to women in the past.
The impact of AML on outcome of labour is best demonstrated on examining the detailed outcome of spontaneously labouring nulliparous women with a single cephalic pregnancy at term7. As far as advantages and disadvantages of Aml are concerned, all women should have access to the relevant information on labour outcome. If they prefer a shorter (rather than longer)8 labour with a high chance of a normal delivery then they will be opting for AML.
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. 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 Caesarean delivery. Indeed there is a trend toward an increase in Caesarean section. Amniotomy has been associated with a reduction in labour duration of between 60 and 120 minutes.0001 The likelihood of a 5 minute Apgar score less than 7 was reduced in association with early amniotomy. There was a statistically significant association of amniotomy with a decrease in the use of oxytocin.
Lopez-Zeno et al9201 found a reduction the incidence of dystocia and an increase in the rate of vaginal delivery without increasing maternal or neonatal morbidity. There is evidence of economic benefits from adoption of active management of labour as there is a reduction in the rate of caesarean sections.0002 Frigoletto et al9501 found that active management of labour did not reduce the rate of caesarean section in nulliparous women but was associated with a somewhat shorter duration of labour and less maternal fever. Pattinson et al0301 observed thataggressive management of labour reduces the caesarean section rate in nulliparous women but requires more intensive nursing. Lavender et al, whilst assessing different partograms, found that women prefer the active management of labour.9801
The principles of active management of labour have not been accepted universally. Wagner, Thornton and Lilford9401, in a review of observational data, supplemented by evidence from four separate overviews of relevant randomised trials concluded that the routine use of amniotomy and early oxytocin should not recommended.
