Active Management of Labor

Midwifery Today E-News 3:16, 18 Apr 2001

[Version française]

The principles of active management of labor were developed in the 1970s at the National maternity Hospital in Dublin, Ireland. The basic [abbreviated] principles are: diagnosis of labor based either on painful contractions and complete cervical effacement or rupture of membranes; one hour after admission, progress is assessed and amniotomy performed; cervical dilation must advance by at least 1 cm per hour or oxytocin is started and increased until mother has 5-7 contractions every 15 mins; maximum labor length is 12 hours; a midwife stays with each woman throughout labor; the midwives manage labor, senior staff consults; induction is rare; pain medication is available but discouraged.

Any woman who did not progress at the statistical mean of 1 cm per hour dilation should be given oxytocin to correct her problem. At one stroke, her deviation from average became pathological, and a philosophical basis was created for devising a protocol to force all primiparous labors to conform to the average. Achieving this goal meant giving 40% of women oxytocin. If 40% of women need oxytocin to progress normally, then something is wrong with the definition of normal, but this point escaped the Dublin doctors.

A study of women's opinions of oxytocin augmentation [Crowther et al] found 80% of mothers said labor hurt more and over half would not want it again. Penny Simkin (1986) surveyed 159 new mothers and found that 76% of them said oxytocin drips were stressful and 46% said the same of amniotomy. Vaginal exams were rated "stressful" by 56%. Rectal exams, the norm in Dublin, would presumably be worse. For 55% and 61% respectively, external and internal electronic fetal monitoring was stressful. Restriction to bed stressed 64% of women, and restricting movement in bed, stressed 77%.

Even diehard cesarean apologists do not try to defend a 24% cesarean rate [American rate by 1986], so when active management appeared, American doctors jumped at it... Unfortunately, the only pieces of the program that survived the Atlantic crossing were routine amniotomy, the liberal use of oxytocin, and the time limit on labor. Other parts -- the continuous support of an experienced woman, that residents did not make decisions, the minimal use of epidurals (5%), the minimal use of induction (<10%), not using painful contractions as the sole diagnosis of labor -- did not make it... Moreover, the Dublin doctors expected women to give birth vaginally...

Active management may be better than what it replaces, but that proves nothing but how injurious typical obstetric management is... Even among proponents of active management, waiting one more hour before starting an oxytocin drip led to an equally low cesarean rate and half the number of augmentations. Based on their study of amniotomy and oxytocin, Seitchik, Holden, and Castillo argue that 1 cm pr hour progress is too rigid a standard and that oxytocin should not be used until two hours with no progress. But the real point is active management is not needed at all. Midwives also maintain 4% cesarean rates simply by leaving most women alone.

Sheila Kitzinger, commenting on active management, offered insight into its hidden agenda. The medicalization of birth, she said, denies and suppresses female sexuality, which obstetricians perceive to be dangerous, threatening, and disruptive. By viewing women as defective machines to be managed on the fetus's behalf, by draining the warmth and sensuality out of the experience, by converting it to a timetable-driven mechanical process, by becoming the central figure in the drama and controlling every aspect of the mother's behaviour and activities down to the sounds she may make, birth comes to feel safe to the doctor.

In an article on delivery after previous caesarean section, Dublin obstetrician Michael Turner comments that in 10 years the Coombe hospital had 15 cases of uterine rupture in 65,488 deliveries. Thirteen of the 15 were in women with a previous caesrean and 13 had had oxytocic drugs to induce or speed up labour. He also gives the caesarean rates for the three Dublin maternity hospitals for 1994: 12.6% at the Coombe, 16.4% at the Rotunda, and 8.8% at the National.

Association for Improvements in Maternity Services (AIMS) comment:

Without the use of oxytocin and protaglandins the risk of rupture of the uterus even after a caesarean operation seems very small-about one in 33,000 deliveries in this series, and it confirms the findings in other areas. Dublin still has women who have had large families, and therefore have a uterus more vulnerable to rupture. This study confirms our experience, that using prostaglandins and oxytocin is a major risk factor for rupture in women who had a previous caesarean.

Active management illustrates the confusion in the medical approach to what is normal and what is pathological in birth. Active management is an extreme form of medicalization in which the clock has been speeded up. If a woman's labor is not progressing at a rate doctors arbitrarily define as satisfactory, the woman is said to be suffering from "dystocia" and in need of intervention to augment labor.

A critical element of active management is the need for doctors to control the birth. Since labor is involuntary, unpredictable and out of control, the only things doctors have had any success with controlling is pain and length of labor. Active management is primarily for the benefit of doctors and hospitals, not for the birthing woman. The inventors of active management extol its "military efficiency" and ability to relieve staff from the frustration of waiting out "tedious hours." Promoters also state it allows much better planning for staffing needs.

Proponents also claim active management reduces the need for cesareans. But active management is an aggressive, invasive protocol that carries all kinds of associated risks. Other much less dangerous ways of lowering cesarean rates are readily available: use of labor companions; using midwives rather than doctors as the birth attendant; out-of-hospital birth. In fact, an entire country, The Netherlands, has a cesarean section rate as low as the hospital in Dublin, Ireland -- where active management started -- without resorting to active management.

Active management lacks a scientific base. It has been used for 25 years, yet not a single randomized controlled trial has been undertaken to compare active management with other methods of reducing cesarean section rates.

Ironically, the only component of active management that has been shown scientifically to reduce excessive cesareans is the continuous presence of the midwife. Yet this essential component is often ignored and many people in the United States and elsewhere attempting to replicate active management in their own hospitals fail to include this component.

And in the Dublin hospital, 40% of all women having their first baby are found to have a "dysfunctional myometrium" incapable of expelling baby without the help of doctors and drugs. But the inventors of active management have never attempted to measure myometrial activity.

Scientific literature on active management of labor (AFAR bibliographical database)

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