Active Management of Labor

The active management of labor refers to active control over the course of labor. There are three essential elements to active management are careful diagnosis of labor by strict criteria, constant monitoring of labor, and prompt intervention (eg, amniotomy, high dose oxytocin) if progress is unsatisfactory.

I. Criteria for active management of labor:

A. Nulliparous

B. Term pregnancy

C. Singleton infant in cephalic presentation

D. No pregnancy complications

E. Experiencing spontaneous onset of labor.

II. Diagnosis of labor

A. The diagnosis of labor is made only when contractions are accompanied by any one of the following:

1. Bloody show

2. Rupture of the membranes

3. Full cervical effacement

B. Women who meet these criteria are admitted to the labor unit.

III. Management of labor

A. Rupture of membranes. Intact fetal membranes are artificially ruptured one hour after the diagnosis of labor is made to permit assessment of the quantity of fluid and the presence of meconium. Rupture of the membranes may accelerate labor.

B. Progress during the first stage of labor

1. Satisfactory progress in the first stage of labor is confirmed by cervical dilatation of at least 1 cm per hour after the membranes have been ruptured.

2. In the absence of medical contraindications, labor that fails to progress at the foregoing rate is treated with oxytocin.

3. Progress during the second stage of labor is measured by fetal descent and rotation.

a. The second stage of labor is divided into two phases: the first phase is the time from full dilatation until the fetal head reaches the pelvic floor; the second phase extends from the time the head reaches the pelvic floor to delivery of the infant.

b. The first phase of the second stage is characterized by descent of the fetal head. If the fetal head is high in the pelvis at full dilatation, the woman often has no urge to push and should not be encouraged to do so. Oxytocin treatment may be useful if the fetal head fails to descend after a period of observation.

C. Administration of oxytocin. Oxytocin is administered for treatment of failure of labor to progress, unless its use is contraindicated. Oxytocin may only be administered if the following conditions are met:

1. Fetal membranes are ruptured

2. Absence of meconium in amniotic fluid

3. Singleton fetus in a vertex position

4. No evidence of fetal distress

High Dose Oxytocin (Pitocin) Regimen

Begin oxytocin 6 mU per minute IV

Increase dose by 6 mU per minute every 15 minutes

Maximum dose: 40 mU per minute

D. Failure to progress (dystocia) is diagnosed when the cervix fails to dilate at least 1 cm per hour during the first stage of labor or when the fetal head fails to descend during the second stage of labor. Three possible causes for failure to progress are possible (excluding malpresentations and hydro-cephalus):

1. Inefficient uterine action

2. Occiput-posterior position

3. Cephalopelvic disproportion.

E. Inefficient uterine action is the most common cause of dystocia in the nulliparous gravida, especially early in labor. Secondary arrest of labor after previously satisfactory progress may be due to an occiput-posterior position or cephalopelvic disproportion. It is often difficult for the clinician to differentiate among these entities, thus oxytocin is administered in all cases of failure to progress (unless a contraindication exists).

F. In the first stage, progressive cervical dilatation of at least 1 cm per hour should occur within one hour of establishing efficient uterine contractions (five to seven contractions within 15 minutes) with oxytocin. The second stage is considered prolonged if it extends longer than two hours in women without epidural anesthesia and longer than three hours in women with epidural anesthesia despite adequate contractions and oxytocin augmentation.

References: See page 184.

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