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

RHL Summary

9 December 2013
Woman in lying position receiving oxytocin
WHO/Pallava Bagla

Findings of the review: Seven randomized controlled trials (5390 women) conducted in hospital setting in Europe, New Zealand, Nigeria, Thailand and the USA were included in the meta-analysis in this review. Active management of labour was associated with not statistically significant lower rate of caesarean sections in comparison with routine care (relative risk 0.88; 96% confidence interval 0.77–1.01). After excluding the study that had reported a high rate of post-randomization exclusions (women who were enrolled at 30 weeks, but did not receive the intervention), caesarean section rate was statistically significantly lower in the active management group compared with the routine-care group. Labour lasting less than 12 hours was more common in women in the active management group compared with the routine-care group. No difference was found in use of analgesia, rates of assisted vaginal delivery, maternal infection rates, postpartum haemorrhage, maternal satisfaction, breast-feeding rates or neonatal complications.

Implementation: The current evidence suggests that, compared with routine care, active management of labour is associated with a slight reduction in caesarean section rates. Further studies are needed to assess various aspects of the package of active management in labour.

RHL editorial note: the review data have been interpreted by the authors as favourable for implementing the package of interventions, a group of experts developing WHO guidance on augmentation of labour has cautioned that the package may be too prescriptive and interventional, undermining women’s rights, choices and autonomy as care recipients.

Cochrane review

Citation: Brown HC, Paranjothy S, Dowswell T, Thomas J. Package of care fo r active management in labour for reducing caesarean section rates in low-risk women. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD004907. DOI: 10.1002/14651858.CD004907.pub3.



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.


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 (16 April 2013).

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 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.

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.

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