Active Management of Labour
Michael Robson, Consultant obstetrician and gynaecologist, Wycombe Hospital.

Active Management of Labour (AML), a term coined 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. Regular international courses are held in the hospital for both midwives and obstetricians explaining these principles, and they have resulted in many of them being adopted elsewhere.

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, malpresentations and multiple pregnancies. Furthermore they include the specific attention and importance given to the diagnosis of labour, as well as to fetal and maternal well-being, in particular by 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 with 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 Kieran O'Driscoll showed that a decrease in the perinatal mortality rate did not necessarily require an increase in the caesarean rate. 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 dystocias. 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 principles, it must be emphasised that this was never the purpose of AML.

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 in the past.

References
1. O'Driscoll K, Stronge JM, Minogue M. Active Management of Labour. BMJ 1973; 3: 135- 137.
2. O'Driscoll K, Meagher D, Boylan P. Active Management of Labour, Third edition. London: Mosby 1993.
3. O'Driscoll K, Jackson R, Gallagher J. Prevention of prolonged labour. BMJ 1969; 2: 477-480.
4. O'Driscoll K, Foley M. Correlation of decrease in perinatal mortality and increase in caesarean section rates. Obstet Gynecol 1983; 61: 1-5.
5. O'Driscoll K, Foley M, MacDonald D. Active management of labour as an alternative to caesarean section for dystocia. Obstet Gynecol 1984; 63: 485-490.
6. Robson MS, Scudamore I, Walsh S. Using the medical audit cycle to reduce the caesarean section rate. Am J Obstet Gynecol 1996; 174: 199-205.