title: 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.
  
  
  OBJECTIVE
  To determine whether active management of labour reduces CS rates in low-risk women and improves satisfaction.
  
  
  METHODS
  We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (16 April 2013).
  
  
  METHODS
  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.
  
  
  METHODS
  At least two review authors extracted data. We assessed included studies for risk of bias.
  
  
  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 with 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 12 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.
  
  
  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.
authors.affiliation: Department of Obstetrics and Gynaecology, Royal Sussex County Hospital, Eastern Road, Brighton, UK, BN2 5BE.
authors.forename: Heather C
authors.initials: HC
authors.lastname: Brown
authors.forename: Shantini
authors.initials: S
authors.lastname: Paranjothy
authors.forename: Therese
authors.initials: T
authors.lastname: Dowswell
authors.forename: Jane
authors.initials: J
authors.lastname: Thomas
mesh_terms: D002585:Cesarean Section / Q000706:statistics & numerical data* / Q000639:trends; D005260:Female; D006801:Humans; D007751:Labor, Induced / Q000379:methods*; D007743:Labor, Obstetric; D010120:Oxytocics; D010121:Oxytocin; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic
chemical_list: D010120:Oxytocics; D010121:Oxytocin
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