Aggressive or expectant management of labor: A randomized clinical trial

This randomized multicenter trial compared an aggressive approach to managing labor in 344 women with expectant management in 350. Those enrolled were nulliparous women in active labor with regular and painful contractions who had no serious disease such as preeclampsia and whose fetus was not distressed. Aggressive management utilized a partogram with a single alert line on which cervical dilation was plotted. Vaginal examination was repeated every 2 hours. Oxytocin was infused if cervical dilation moved to the right of the alert line as long as fetal distress and gross cephalopelvic disproportion were ruled out. Later in the study, membranes were not intentionally ruptured for fear of transmitting HIV. Cesarean delivery was carried out after 2 hours if labor was obstructed or fetal distress was diagnosed. Expectant management relied on a two-line partogram with the alert line and a parallel active line 4 hours to the right. Vaginal examination was done every 4 hours, and oxytocin begun if the action line was reached. Women subsequently were reassessed every 2 hours. Analgesia was allowed if requested. The 2 study groups were very similar at the outset. Nearly half of the women in each group had progressing labor with cervical dilation crossing the alert line. Significantly fewer women who were managed aggressively had a cesarean section (relative risk, 0.68). Operative delivery in the expectant management group was most often done for poor progress and cephalopelvic disproportion. Including forceps deliveries and vacuum deliveries, there were 70 operative deliveries in the aggressively managed group and 97 with expectant management. Significantly more women who were managed aggressively received oxytocin. Approximately two thirds of women in each management group had an episiotomy after vaginal delivery. Apgar scores at 1 and 10 minutes did not differ significantly. Compliance was not good with either protocol. The major problem with aggressive management was not giving oxytocin when indicated, and with expectant management, performing the next vaginal examination too soon. Aggressive management of labor lowers the rate of cesarean section in nulliparous women, but more intensive nursing care is required. In developing countries especially, a balance will have to be found between staffing the labor wards and an excessive number of cesarean deliveries.