By Summers Williams
Feb 23, 2022
Active Management of Labor is a set of procedures that varies, from location to location, and is meant to speed up the process of labor, prevent or treat an arrest of labor and avoid cesareans and instrumental deliveries. This type of augmentation of labor was first written about in a prospective study of 1,000 women titled “Prevention of Prolonged Labour” by Kieran O'Driscoll, Reginald J. A. Jackson, and John T. Gallagher. They were interested in reducing the duration of labor as a benefit for mothers. Today, active management in labor is performed in hospitals around the world.
“Prolonged labour presents a picture of mental anguish and physical morbidity which often leads to surgical intervention and may produce a permanent revulsion to childbirth, expressed by the mother as voluntary infertility; it constitutes a danger to the survival and subsequent neurological development of the infant (Jeffcoate et al., 1952,; Lancet, 1963). The harrowing experience is shared by relatives, and by doctors and nurses to the extent that few complications so tarnish the image of obstetrics.” (O’Driscoll)
The idea for active management and the thought that labor should be easier and more comfortable came on the heels of the twilight era of childbirth. Although naturally derived pain relief has probably always been used and varied from culture to culture, Women had gained more rights by the early 1900s in the US. They were beginning to demand more access to pain relief in childbirth now that it was medically available, diethyl ether, chloroform, and nitrous oxide took hold then and lead to the now commonly used epidural. The feminist movements have ebbed and flowed in their perspective of how women should birth and to what degree of pain they should experience. Today we theoretically have a society where the prevalence of technological choices makes it possible to have less pain in childbirth, and for women to choose from a spectrum of options ranging from elective cesareans to having a fully physiological birth. (6)
Why Use Active Management
Today, many women are having their first babies at an older age which could contribute to ineffective or difficult labor, because of inadequate uterine action. Early intervention consists of augmentation including amniotomy and synthetic oxytocin to increase the frequency and intensity of uterine contractions. Continued ineffective labor can result in the decision for a cesarean section. (3)
The increase of labor dystocia may in fact be more a symptom of a failure to wait through natural labor plateaus and a lack of patience of providers and birthing people. After the O’Driscoll study, and between 1970 and 1990 the rate of cesarean sections in the United States rose from 5 percent to 25 percent of deliveries, mostly because of the increase in the frequency of dystocia also known as an arrest of labor. The most recent CDC data (2019) on cesarean rates in the US ranges from 21% to 38.5% depending on the state. (1) (4)
Main Components of Active Management
The O'Driscoll trial was the first trial of its kind and is the basis for active management procedures. The thought was that prolonged labor can be prevented by effective stimulation. After a spontaneous start of labor, the main components of actively managing labor are an amniotomy (rupture of membranes) followed by a synthetic oxytocin infusion if needed to simulate the progress of normal labor. Synthetic oxytocin would not immediately be administered unless normal labor of dilation 1cm or more per hour was evident from an early stage. Women were also accompanied by a dedicated professional labor support nurse for the full duration of their labor. (5)
The previous duration of labor could be 48 hours or more and was shown to decrease with active management to as little as 12 hours before a cesarean would be performed. Since there is no precise definition of the moment when labor begins, it is estimated and is therefore subject to personal interpretation. The O'Driscoll trial focused on only admitting women in active labor and sending home those who were not. This proved wrong in a few cases in their study because women returned very soon to the labor ward. This also leaves out the time period when women labored at home and that time is not accounted for in their 12-hour goal from admittance to birth. (5)
Today, dedicated support has now been replaced with technological observation techniques. It is further complicated by the Covid-19 restrictions in place in hospitals. There has been a reduction of face-to-face time for all practitioners and patients and in many places restriction of in-person support.
Outcomes of Active Management
In 2013 a review that included 14 randomized trials of 8033 women, the active management procedures resulted in only a modest reduction of the cesarean section with early routine augmentation for the mild delay in labor progress compared with expectant management and less intervention. It is important to note that the severity of a delay which is sufficient to justify interventions is not universally defined. Time from admission to giving birth was reduced by a mean difference of 1.3 hours. (3)
The prevalence of high doses of synthetic oxytocin and its effectiveness have been called into question. In France, a 2020 study comparing data from 2016 to 2010 found that even with a decrease in the levels of synthetic oxytocin administration and artificial rupture of membranes, the 2016 data did not show an increase in cesarean delivery for women who entered labor spontaneously. This leads one to wonder why women with a spontaneous start to labor would need active management and labor augmentation at all if reducing the levels of intervention does not result in a higher rate of operative delivery. (2)
To further support the French study, in a 2019 study of 1295 women, approximately 650 women were assigned to either a high dose or low dose group in an intention-to-treat-analysis. Cesarean rates were similar, 12.4% and 12.3% percent respectively. High doses resulted in a 24-minute reduction in labor duration however that came at the cost of more uterine tachysystole (excess uterine activity) 43.2% versus 33.5%. Instrumental deliveries were similar between groups, however, higher doses correlated with more fetal distress and less with failure to progress. The study found no advantages for routine high doses. (7)
Risks of Interventions
The risks of labor augmentation are not often mentioned in studies citing their benefits. Early intervention has risks that include uterine hyperstimulation and fetal heart rate abnormalities. Often these nonreassuring fetal heart tones caused by synthetic oxytocin contractions are what send women to the operating table. Synthetic oxytocin contractions are well known to be more painful, stronger, and of greater frequency than a naturally occurring contraction and therefore harder on the fetus. (3)
Another risk related to hastened labor is operative deliveries which are associated with significant fetal and maternal morbidity. These effects can be both short and long-term and have a lasting impact on subsequent pregnancies. All operative deliveries are associated with increased rates of maternal mortality, as well as increased rates of blood transfusions, hysterectomy, and intensive care unit admissions when compared with spontaneous vaginal delivery (9).
The hormonal effects of synthetic oxytocin are not well studied in humans. The use of synthetic oxytocin has been shown to down-regulate receptors in the uterus during augmented labor. Women exposed to Pitocin® (synthetic oxytocin) in labor combined with an epidural demonstrated significantly lower oxytocin levels during breastfeeding. Oxytocin binding in other areas of the body such as the maternal brain, breast, heart, intestine, or immune system also needs to be studied to better understand the effects of down-regulation of receptors in those areas. Given the prevalence of this practice, it deserves much more consideration than it currently receives. (10)
Currently, there are only 4 studies on the effects of synthetic oxytocin and its relationship to postpartum depression. A systematic review done in 2020 stated that out of twelve studies focused on endogenous oxytocin which is naturally occurring, eight studies suggested an inverse relationship, which is when lower levels of natural oxytocin correlate with higher levels of depressive symptoms. This study called for more research on the effects of synthetic oxytocin as well as more work to define the relationship postpartum depression has with oxytocin. (8)
Today's common use of oxytocin both during active management and immediate postpartum should indicate the need for a greater understanding of their effects than is currently documented. The effects of natural oxytocin have been shown to have protective effects during labor, for instance in preventing incidents of neonatal hypoxia. Oxytocin also has biological benefits that promote the bonding of the mother-baby dyad immediately after birth. Synthetic oxytocin decreases the body's ability to sense a need to produce its own, therefore inhibiting the natural effects of physiological birth. To what degrees this matters is unknown and therefore unquantifiable by the current research. The vulnerability of postpartum people and neonates is well known and therefore any medical intervention that could potentially interfere with the most beneficial processes should be thoroughly researched and thoughtfully considered past the immediate effects of labor. (10)
Conclusion
There are many decisions for a person going into labor. Thoughtful consideration of active management procedures should be well understood before consent is given, not just the potential benefits, but also including the effects of, or risks related, to any augmentation and explanation of further augmentation that may be deemed necessary. This paper has not discussed the concepts of pain being potentially purposeful in labor as the body's way of transforming or the potential reframing of pain as a positive intensity with purpose. Nor has it discussed the seemingly obvious and well-documented benefits to birthing people that a dedicated professional support person including but not limited to a birth doula has on the mental and physical outcomes of both the birthing person and neonate.
Works Cited
López-Zeno, J A et al. “A controlled trial of a program for the active management of labor.” The New England journal of medicine vol. 326,7 (1992): 450-4. doi:10.1056/NEJM199202133260705
Girault, Aude et al. “Association of Oxytocin Use and Artificial Rupture of Membranes With Cesarean Delivery in France.” Obstetrics and gynecology vol. 135,2 (2020): 436-443. doi:10.1097/AOG.0000000000003618
Wei S, Wo BL, Qi HP, Xu H, Luo ZC, Roy C, Fraser WD. “Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care.” Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD006794.[PubMed]
“Cesarean Delivery Rate by State” CDC.GOV
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Selin, Lotta et al. “High-dose versus low-dose of oxytocin for labour augmentation: a randomised controlled trial.” Women and birth : journal of the Australian College of Midwives vol. 32,4 (2019): 356-363. doi:10.1016/j.wombi.2018.09.002
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Souza, J., Gülmezoglu, A., Lumbiganon, P. et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med 8, 71 (2010). https://doi.org/10.1186/1741-7015-8-71
Bell, Aleeca F et al. “Beyond labor: the role of natural and synthetic oxytocin in the transition to motherhood.” Journal of midwifery & women's health vol. 59,1 (2014): 35-42: quiz 108. doi:10.1111/jmwh.12101 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3947469/#R21