Package of care for active management in labour for reducing caesarean section rates in low-risk women

 

Abstract

Background

Approximately 15% of women have caesarean sections (CS) and while the rate varies, the number is increasing in many countries. This is of concern because higher CS rates do not confer additional health gain but may adversely affect maternal health and have implications for future pregnancies. Active management of labour has been proposed as a means of reducing CS rates. This refers to a package of care including strict diagnosis of labour, routine amniotomy, oxytocin for slow progress and one to one support in labour.

Objectives

To determine whether active management of labour reduces CS rates in low-risk women and improves satisfaction.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2008), MEDLINE (1966 to December 2007), EMBASE (1980 to 2007), MIDIRS (1985 to 2007) and CINAHL (1982 to 2007).

Selection criteria

Randomised controlled trials comparing low-risk women receiving a predefined package of care (active management) with women receiving routine (variable) care. Trials where slow progress had been diagnosed before entry into the trial were excluded.

Data collection and analysis

At least two review authors extracted data. We assessed included studies for risk of bias.

Main results

We included seven trials, with a total of 5390 women. The quality of studies was mixed. The CS rate was slightly lower in the active management group compared to the group that received routine care, but this difference did not reach statistical significance (RR 0.88, 95% CI 0.77 to 1.01). However, in one study there was a large number of post-randomisation exclusions. On excluding this study, CS rates in the active management group were statistically significantly lower than in the routine care group (RR 0.77 95% CI 0.63 to 0.94). More women in the active management group had labours lasting less than twelve hours, but there was wide variation in length of labour within and between trials. There were no differences between groups in use of analgesia, rates of assisted vaginal deliveries or maternal or neonatal complications. Only one trial examined maternal satisfaction; the majority of women (over 75%) in both groups were very satisfied with care.

Authors' conclusions

Active management is associated with small reductions in the CS rate, but it is highly prescriptive and interventional. It is possible that some components of the active management package are more effective than others. Further work is required to determine the acceptability of active management to women in labour.

 

Plain language summary

A package of care to actively manage labour in women who are at low risk of complications to reduce caesarean section rates

Many countries have an increasing rate of caesarean section. Higher rates do not always give additional health gains, they can increase maternal risks and affect subsequent pregnancies. Active management of labour has been proposed to reduce the number of caesarean births. Active management includes routine amniotomy (artificial rupture of the membranes), strict rules for diagnosing slow progress, use of the intravenous drug oxytocin to increase contractions of the uterus and one-to-one care. The disadvantages of active management are that it can possibly lead to more invasive monitoring, more interventions and a more medicalised birth in which women have less control and less satisfaction. The review included seven trials involving 5390 women. These studies show that women who received active management were slightly less likely to have a caesarean section and were more likely to have shorter labours (less than 12 hours). There was no difference in the number of assisted deliveries, nor was there any difference in complications for mothers or their babies when comparing women in the active management group with those receiving routine care.

 

摘要

背景

前胎進行剖腹產，之後選擇繼續剖腹產或選擇引產的比較

當婦女曾經剖腹產，後來懷孕而需要引產時，有2種選擇：選擇再用剖腹產、或者計畫引產。選擇再用剖腹產或計畫引產兩者都有風險和利益，目前的資訊僅限非隨機之世代研究的資料。這類研究顯然會有偏見，根據這些結果的後續結論的可信度有限，詮釋上須謹慎。

目標

使用現有的最佳證據，評估曾經剖腹產之婦女，選擇再用剖腹產或計畫引產的利弊。

搜尋策略

我們搜尋Cochrane Pregnancy和Childbirth Group's Trials Register (2006年1月)、Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1) 以及PubMed (1966年2006年1月)。

選擇標準

曾經剖腹產之婦女，比較選擇再用剖腹產與計畫引產對於母嬰預後影響的隨機控制試驗。

資料收集與分析

未進行資料摘錄。

主要結論

沒有適用的隨機控制試驗。

作者結論

曾經剖腹產之婦女，選擇再用剖腹產或計畫引產兩種都各有利弊。這些照護實務的證據來自非隨機研究，可能有偏見。因此，任何結果和結論都需謹慎詮釋。需要隨機控制試驗來提供有關曾經剖腹產之婦女，選擇再用剖腹產或計畫引產之最可信賴的證據。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

前胎進行剖腹產，之後選擇繼續剖腹產或選擇引產的比較。 當婦女曾經剖腹產，後來懷孕要生產時，有2種選擇：選擇再用剖腹產、或者計畫引產。兩者都有風險和利益，沒有可以幫助婦女、其伴侶與照護者進行選擇的試驗。