Recognizing the onset of labor. Active management of labour in a district hospital setting. A randomized controlled trial of a bedside partogram in the active management of primiparous labour. Dysfunctional labour: a randomised trial. An early labor assessment program: a randomized, controlled trial. A clinical trial of active management of labor. An evaluation of transcutaneous electrical nerve stimulation for pain relief in labour. A randomised controlled trial and meta-analysis of active management of labour. Fetal health surveillance: a community-wide approach versus a tailored intervention for the implementation of clinical practice guidelines.
An experimental study compared the use of an educational technique based on patient participation with routine instructions to prepare patients to recognize the onset of active labor. The number of visits to the labor suite that resulted in the patient being discharged undelivered was significantly lower in patients who received the educational intervention. The study revealed that, without any increase in time, nurses can prepare patients to make judgments about the need for hospitalization. The aim of this randomised trial was to determine the effect of the policy of active management of labour in all its components on the rate of caesarean section in a Nigerian district hospital setting. Two hundred and twenty-one nulliparous women fulfilling selected inclusion criteria were randomised to receive active management of labour, and 227 control women received routine labour management. Labour was significantly shortened by over 2 hours with active management of labour, and caesarean section reduced (9% vs. 16%, RR 0.57, 95% CI 0.34-0.95). There were no significant differences in maternal infectious morbidity, uterine hyperstimulation syndromes, ruptured uterus or neonatal Apgar scores between the two groups. We conclude that active management of labour shortens primigravid labour and reduces caesarean risk. The partogram is a pictorial representation of the progress of labour, used in an effort to enhance early recognition of dystocia and help avoid Caesarean section (CS). The objective of this study was to evaluate the effect of partogram use on the CS and obstetric intervention rates.
                We conducted a randomized controlled trial of use of the partogram in 1932 primiparous women with uncomplicated pregnancies at term. Patients were randomly assigned to one of two groups: the standard group, who had the progress of labour charted in written notes, or the partogram group, whose progress in labour was recorded using a bedside graphical partogram as well as in written notes. Outcomes were stratified according to whether labour was spontaneous or induced and whether membranes were initially intact or ruptured. The primary outcome was the rate of CS; secondary outcome measures were rates of obstetric intervention for dystocia.
                There was no significant difference between the groups in rates of CS (partogram 24%, standard notes 25%), rates of other interventions, amniotomy, oxytocin use, or the mean cervical dilatation in labour.
                In this study, the use of a partogram without a mandatory management of labour protocol had no effect on rates of CS or other intrapartum interventions in healthy primiparous women at term. Sixty-one women making slow progress in the active phase of spontaneous labour with intact membranes were randomised to oxytocin and amniotomy, amniotomy only or expectant management. The data show that oxytocin significantly increases the rate of cervical dilatation and shortens prolonged labour, when compared with amniotomy alone and expectant management (P = 0.0144 and 0.0006, respectively). The impact on the operative delivery rate and neonatal outcome is difficult to assess due to the small number of relevant adverse outcomes. Women reported higher satisfaction score in the two groups where intervention followed the diagnosis of dysfunctional labour. Approximately 31 percent of cesarean deliveries in the United States and Canada are performed for dystocia. The aim of this study was to determine the effectiveness of early labor assessment to reduce cesarean birth rates for low-risk nulliparous women.
                Two hundred and nine low-risk nulliparous women were randomly allocated to either the early labor assessment group or the direct admission to hospital group. Women in the early labor assessment group were evaluated and, if found to be in false or latent labor, were encouraged to go home or walk before admission to the labor unit. Those in the direct admission group were admitted to the labor unit without an assessment. Data were collected and analyzed about method of delivery, duration of labor, intrapartum interventions, and neonatal well-being. Women completed an evaluation of their experience in the early postpartum period.
                Significant decreases occurred in duration of labor, use of epidural analgesia for pain, and use of oxytocin to augment labor in the early labor assessment group. These women evaluated their labor and birth experience more positively than women in the direct admission group. No significant differences were found in the frequency of cesarean section or instrumental vaginal delivery for the two groups.
                Early labor assessment has the potential to reduce the number of women receiving oxytocin for augmentation, the rate of epidural analgesia for pain relief, and the duration of the active and second stages of labor, and to improve women's evaluations of their labor and birth experiences. Active management of labor is a multifaceted program that, as implemented at the National Maternity Hospital in Dublin, is associated with a lower rate of cesarean delivery than the rate usually found in the United States. We conducted a randomized trial to evaluate the efficacy of this approach in lowering the rate of cesarean section among women delivering their first babies.
                We randomly assigned 1934 nulliparous women at low risk of complications of pregnancy, before 30 weeks' gestation, to active management of labor or to a usual-care group. The components of active management were customized childbirth classes; strict criteria for the diagnosis of labor; standardized management of labor, including early amniotomy and treatment with high-dose oxytocin; and one-to-one nursing. A low-risk subgroup was defined as including women with full-term, uncomplicated pregnancies who spontaneously went into labor (the protocol-eligible subgroup). Women meeting these criteria who had been randomly assigned to the active-management group were admitted to a separate unit where their labor was managed by trained, certified nurse-midwives.
                There was no difference between groups in the rate of cesarean section either among all women (active management, 19.5 percent; usual care, 19.4 percent) or in the protocol-eligible subgroup (active management, 10.9 percent; usual care, 11.5 percent). In the protocol-eligible subgroup, the median duration of labor was shortened by 2.7 hours by active management (from 8.9 to 6.2 hours), and the rate of maternal fever was lower (7 percent vs. 11 percent, P = 0.007). The percentage of women in whom labor lasted longer than 12 hours was three times higher in the usual-care group than in the active-management group (26 percent vs. 9 percent, P < 0.001).
                Active management of labor did not reduce the rate of cesarean section in nulliparous women but was associated with a somewhat shorter duration of labor and less maternal fever. The effectiveness of transcutaneous nerve stimulation (TENS) for pain relief in labour was evaluated by randomizing 280 patients in early labour into 2 groups. Inoperative sham machines were applied to patients in the control group and active units to those in the test group. Neither patients nor attending labour ward staff were aware of which group the patient was in. The intensity of low back pain and abdominal pain was assessed by the patient each hour on a visual analogue pain scale. Each patient served as her own control by switching off the machine for 2 contractions every hour and then recording the intensity of pain. The amount of conventional analgesia each patient received was recorded by labour ward staff. There was no difference in the intensity of pain recorded by each group. Nor was there any difference between the 2 groups in the change of pain experienced when the machine was switched off. Moreover there was no difference in the amount of other analgesia required. Some differences were found when those with little low back pain were excluded from the study. We conclude that TENS is ineffective as a routine method of pain relief in labour. It is likely to benefit only those with severe back pain and then only to a modest degree. To test whether a policy of active management of nulliparous labour would reduce the rate of caesarean section and prolonged labour without influencing maternal satisfaction.
                Randomised controlled trial.
                Tertiary referral obstetric unit, Auckland, New Zealand.
                Nulliparous women in spontaneous labour at term with singleton pregnancy and cephalic presentation and without fetal distress.
                After the onset of active labour, previously consented women were randomly assigned to active management (n = 320) or to routine care (n = 331). Active labour was defined as regular painful contractions, occurring at least once in five minutes, lasting at least 40 seconds, accompanied by either spontaneous rupture of the membranes, or full cervical effacement and dilatation of at least two centimetres. Active management included early amniotomy, two-hourly vaginal assessments, and early use of high dose oxytocin for slow progress in labour. Routine care was not prespecified. Prolonged labour was > 12 hours duration. Maternal satisfaction with labour care was assessed by postal questionnaire at six weeks postpartum.
                Mode of delivery, duration of labour, and maternal satisfaction.
                Active management of labour did not reduce the rate of caesarean section 30/320 (9.4%), compared with 32/331 (9.7%) for routine care, but did shorten the length of first stage of labour (median 240 min vs 290 min; P = 0.02), and reduce the relative risk of prolonged labour (RR 0.39; 95% CI 0.22, 0.71). There were no differences between groups in the rates of newborn nursery admission, neonatal acidosis, low Apgar scores, or postpartum haemorrhage. Satisfaction with labour care was high (77%) and did not differ between groups.
                Active management of labour reduced the duration of the first stage of labour without affecting the rate of caesarean section, maternal satisfaction, or other maternal or newborn morbidity. The decreased use of electronic fetal monitoring (EFM) for healthy women in labour and the increased provision of professional support to all women in labour is recommended by experts. We evaluated the effectiveness of a community-wide approach to transferring research results to practice using a regional committee, newsletter articles and annual conference presentations compared with an additional tailored hospital intervention involving workshops to enhance self-efficacy for nurses, policy review, multidisciplinary meetings, rounds and unit discussions.
                We compared the proportion of women at low risk who received EFM and the proportion of nurses' time spent providing labour support before and after the intervention within each of 4 hospitals (2 tertiary and 2 secondary). One hospital of either type was randomly selected to receive the tailored intervention. Randomly selected charts (n = 200) were reviewed for the use of EFM at each hospital before (1995) and after (1996) the intervention. Trained observers at randomly selected times recorded the nurses' activities, including time spent providing labour support before and after the intervention.
                At the intervention secondary hospital, there was a large decrease in the use of EFM, from 90.1% before to 41.0% after the intervention (p < 0.001), but no change in nurses' time spent providing labour support. At the intervention tertiary hospital there was no change in EFM rates, but there was a small, statistically significant increase in time spent providing labour support (23.5% to 29.8%, p < 0.001). A negative effect on time spent providing labour support was found at the control secondary hospital (decrease from 19.6% to 12.8%, p < 0.001), with no change in the EFM rate. At the control tertiary hospital there was a small decrease in the use of EFM, from 99.5% to 91.4% (p < 0.001), but no change in time spent providing labour support.
                The results are mixed, and the tailored intervention thus appeared to have limited effects. No association was found between the reduction in the use of EFM and an increase in nurses' time spent providing labour support.
There is not enough evidence to evaluate the use of a specific set of criteria for self-diagnosis of active labour.