Aggressive or expectant management of labour: a randomised clinical trial.
OBJECTIVE
To compare labour outcomes using aggressive or expectant management protocols.


METHODS
Randomised trial.


METHODS
Pretoria Academic Complex, South Africa. It serves an indigent urban population.


METHODS
Healthy nulliparous women in active labour, at term, with a health singleton pregnancy and cephalic presentation.


METHODS
The women were randomised to either aggressive (n = 344) or expectant (n = 350) management protocols. Aggressive management entailed using a single line partogram, a vaginal examination every two hours and use of an oxytocin infusion if the line was crossed. Expectant management entailed using a two line partogram, with the alert line and a parallel action line four hours to the right, with a vaginal examination every four hours. If the action line was reached, oxytocin was started. The women were reassessed every two hours thereafter. Analgesia was prescribed on request.


METHODS
Mode of birth, use of oxytocin and analgesia and neonatal outcome.


RESULTS
The groups were similar with respect to maternal age, cervical dilation at trial entry, number crossing the alert line and birthweight of the infants. Significantly fewer women managed aggressively had caesarean sections (16.0%) than those managed expectantly (23.4%) (relative risk [RR] 0.68, 95% confidence intervals [CI] 0.50, 0.93). Significantly more oxytocin was used in the aggressive management group, but there was no difference with respect to the use of analgesia or episiotomy or in neonatal outcome with respect to the Apgar score at 1 or 10 minutes. There were three perinatal deaths. One woman was found to have an intrauterine death before trial entry and the other two were in the aggressive management group but did not receive oxytocin. Compliance by staff was poor in the aggressive management group.


CONCLUSIONS
Aggressive management of labour reduces the caesarean section rate in nulliparous women but requires more intensive nursing.
MRC Maternal and Infant Health Strategies Research Unit, Department of Obstetrics and Gynaecology, Kalafong Hospital and University of Pretoria, South Africa.
R C
RC
Pattinson
G R
GR
Howarth
W
W
Mdluli
A P
AP
Macdonald
J D
JD
Makin
M
M
Funk
D000328:Adult; D001034:Apgar Score; D002585:Cesarean Section / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007751:Labor, Induced; D007743:Labor, Obstetric; D010121:Oxytocin / Q000627:therapeutic use; D011247:Pregnancy; D011256:Pregnancy Outcome; D011295:Prenatal Care / Q000379:methods*; D012307:Risk Factors
D010121:Oxytocin