Active management of labour.

Wendy Savage, retired obstetrician.

Active management of labour (AMoL) is over 30 years old having been described in 1969 by KieranO'Driscoll and colleagues (1). They showed how the judicious use of synthetic oxytocin to accelerate slow labour reduced the need for caesarean section in primigravidae with no detriment to the baby. Although this was not a randomised controlled study, this new technique was taken up rapidly by obstetricians throughout the world. In 1970 the caesarean section rate (CSR) in England and Wales was about 4.6%, in the USA 5%, yet despite the fact that within 10 years up to 40% of women were having their labours accelerated, the CSR began to climb.

The ingredients of active management of labour (1) were: definite diagnosis of labour, early artificial rupture of the membranes, regular rectal/vaginal examinations to ensure dilatation was occurring at 1 cm. per hour, advising women that their labours would not last longer than 12 hours, using Syntocinon to achieve this, and providing one to one midwifery care. What struck me when I visited the National Maternity Hospital in Dublin was the small, peaceful, uncluttered labour ward. What was missing in the other units which followed this management plan were peace and quiet, and continuous care by one midwife.

In the last few years reviews of the literature suggest that psychosocial support is as effective as AMoL (2,3) and yet globally the CSR continues to increase and one of the major reasons for this is dystocia (1) or difficult labour, or failure to progress (4-6). My own view of O'Driscoll's original work was that dealing with the inefficient uterine action associated with the occipito-posterior position (OPP) explained his successful results. Is OPP becoming more common, as Jean Sutton suggests, due to our sedentary life style? (7) Are women less prepared for labour now and are their expectations of instant success interfering with the process of labour? Are babies getting bigger as obesity becomes more prevalent in our society? Is the way we have set up birth in hospitals actually interfering with the woman's ability to get in touch with her own body and yield to the powerful natural forces of labour? Are women who are used to being in control of their lives unable to relinquish this control, and so interfering with their ability to give birth? How much do we as professionals interfere with the woman's confidence to give birth by our inappropriate language and by the reinforcement of natural anxiety by screening programmes and the use of ultrasound? Little research has been done in many of these areas, which are hard to investigate. Diagnosis of OPP prior to labour is not easy, and attempting a trial of different management strategies problematic, but this needs to be done. One Chinese study found a reduction in persistent OPP if the lateral rather than the supine position was used (8). I will present some data in relation to the incidence of OPP and the use of AMoL.

References
1. O'Driscoll K Jackson RJ Gallagher JT. Prevention of prolonged labour. BMJ 1969 vol 2.pp 477-80
2. Arulkumaran S Symonds IM. Psychosocial support or active management of labour or both to improve the outcome of labour. BJOG 1999 vol 106 pp617-9
3. Thornton JG. Active management of labour. Current Opinion in Obstetrics and Gynaecology 1997 vol 9 pp366-9
4. Task Force (1981) Cesarean Childbirth US Institute of Health and Human services. National Institutes of Health. Washington.
5. Panel and Planning Committee of the National Consensus Conference on Aspects of Cesarean Birth (1986). Indications for Cesarean section: final statement of the panel of the National Consensus Conference on Aspects of Cesarean Birth. Can Med Assoc J 134:1348-6
6. Wilkinson C, McIlwaine G, Boulton-Jones and Cole S. (1998) Is a rising caesarean section rate inevitable? BJOG vol 105 pp45-52
7. Pleased to meet you. Jean Sutton [interview by Tricia Anderson]. Practising Midwife. 2(7):62, 1999 Jul-Aug.
8. Ou X. Chen X. Su J. Correction of occipito-posterior positionby maternal posture during the process of labod. Chinese Chung-Hua Fu Chan Ko Tsa Chih; Chinese Journal of Obstetrics & Gynecologyl. 32(6):329-32, 1997 Jun. Abstract from Medline

The three surveys of births in England and Wales, Douglas (1946) Maternity in Great Britain, Butler and Bonham (1958), and Chamberlain G and Chamberlain R (Eds) (1970) British Births Vol 1. Heinemann Medical Books, London, are important sources of data about length of labour etc..