In Dublin more than 30 years ago, O'Driscoll and associates (1984) pioneered the concept that a disciplined, standardized labor management protocol reduced the number of cesarean deliveries for dystocia. Their overall cesarean delivery rate was 5 percent in the 1970s and 1980s with such management. The approach is now referred to as active management of labor. Two of its components-amniotomy and oxytocinhave been widely used, especially in English-speaking countries outside the United States. With this protocol, labor is diagnosed when painful contractions are accompanied by complete cervical efacement, bloody "show," or ruptured membranes. Women with such indings are committed to delivery within 12 hours. Pelvic examination is performed each hour for the next 3 hours, and thereafter at 2-hour intervals. When dilation has not increased by at least 1 cm/hr, amniotomy is performed. Progress is again assessed at 2 hours, and high-dose oxytocin infusion, described in Chapter 26 (p. 509), is started unless dilation of at least 1 cm/hr is attained. Women are constantly attended by midwives. If membranes rupture before admission, oxytocin is begun for no progress at the I-hour mark.
such active management with their "traditional" approach to cago. hey randomly assigned 705 nulliparas with uncompli cated pregnancies in spontaneous labor at term. he cesarean delivery rate was significantly lower with active versus tradi tional management-10.5 versus 14.1 percent, respectively.
Subsequent studies did not show this. Wei and associates tion in cesarean delivery rates when active management of labor was compared with standard care. Frigoletto and coworkers (1995) reported another randomized trial with 1934 nullipa rous women at Brigham and Women's Hospital in Boston.
ened labor, it did not afect the cesarean delivery rate. hese observations have since been reported by others (Brown, 2013).
A partograph was designed by the World Health Organization (WHO) for use in developing countries (Dujardin, 1992). According to Orji (2008), the partograph is similar for nulliparas and multiparas. Labor is divided into a latent phase, which should last no longer than 8 hours, and an active phase. The active phase starts at 3 cm dilation, and progress should be no slower than 1 cm/hr. A 4-hour wait is recommended before intervention when the active phase is slow. Labor is graphed, and analysis includes use of alert and action lines. Lavender and colleagues (2006) randomized 3000 nulliparous women to labor interventions at 2 hours versus 4 hours as recommended by WH O. Their cesarean delivery rate was unafected, and they concluded that interventions such as amniotomy and oxytocin were needlessly increased using the 2-hour time interval. From their Cochrane Database review, Lavender and associates (2013) do not recommend use of the partograph for standard labor management.