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Active management of labor in a low-resource setting and its impact on cesarean section rates
International Journal of Gynecology and Obstetrics (2006) 94, 54 — 55
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BRIEF COMMUNICATION
Active management of labor in a low-resource setting and its impact on cesarean section rates S. Bachani *, S. Topden Department of Obstetrics and Gynecology, Central Govt. Health Scheme Maternity And Gynae Hospital, New Delhi, India Received 3 November 2005; received in revised form 17 April 2006; accepted 19 April 2006
KEYWORDS Labor; Active management; Efficacy; Safety; Low-resource setting
Labor and delivery-related complications being the largest contributors to India’s high maternal mortality rate, optimizing labor and delivery are of utmost importance. This study analyses the safety and efficacy of active management of labor at a secondary hospital using the protocol proposed by Daftary [1]. Women in labor with a term pregnancy who consented to the protocol formed the study group. The control group was managed expectantly. The 2 groups of 700 participants each were similar regarding parity, age, and pregnancy-related complications such as pregnancy-induced hypertension, intrauterine growth retardation, and postdatism.
* Corresponding author. 294 sector 4, R. K. Puram, New Delhi 110022 India. E-mail address: [email protected] (S. Bachani).
A gel preparation containing 0.5 mg of prostaglandin E2 was instilled intracervically in women with a Bishop score of 6 or less, and oxytocin was administered for labor augmentation if necessary. The partogram was then started, and amniotomy performed [2]. At the onset of the active phase of labor, 6 mg of pentazocin (an opioid analgesic) and 2 mg of diazepam (a tranquilizer) were diluted in distilled water and administered intravenously, and 50 mg of camylofin dihydrochloride (a smoothmuscle relaxant) was administered intramuscularly. Three hours later an injection of tramadol hydrochloride (an analgesic) or drotaverine hydrochloride (an antispasmodic) was given, the latter being repeated every 2 h depending on the partogram and the patient’s pain score. An injection of 125 mg of carboprost tromethamine was given intramuscularly after delivery to promote contraction and retraction of the uterine musculature. The remainder of the pentazocine and diazepam mixture was injected while the episiotomy was being sutured. The pain score was tabulated, and the total duration of labor and labor outcomes were analyzed. P b.05 was considered significant in determining the effect of active management of labor on the rate of cesarean deliveries. An attempt was made to identify the indications that could benefit from this protocol.
0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.04.035
Active management of labor in a low-resource setting and its impact on cesarean section rates
55
Table 1 Duration of labor among women who had active management of labor (study group) and women who had expectant management (control group) Mean labor duration
Study group(n = 700)
Control group(n = 700)
Primiparas
Multiparas
Primiparas
Multiparas
1st stage, h 2nd stage, h 3rd stage, min
6.2 2.1 3.5
3.5 1 3
7.5 2.5 10
4.2 1.5 8
Table 2 Cesarean section (CS) rates among women who had active management of labor and women who had expectant management (controls) Group
Primary CS (%)
Secondary CS (%)
Emergency CS (%)
P value
Study Control
22.39 14.77
72 60.8
28.38 17.85
.23 .03
Table 3 Correlation of causative factors and cesarean sections among women who had active management of labor and women who had expectant management (controls) Causative factor
Study group
Control group
Correlation
123 21 12 06 07 04
0.99 0.64 0.90 0.94 0.90 0.63
No. of cesarean sections Fetal distress Dystocia Previous CS/postdatism Previous CS with PIH Failed induction Severe IUGR
235 37 20 14 15 10
Abbreviations: CS, cesarean section; IUGR, intrauterine growth restriction; PIH, pregnancy induced hypertension.
Compared with the control group, the duration of all stages of labor was reduced in the study group in both primiparas and multigravidas (Table 1), with a definite reduction in pain and blood loss and no adverse effects. The mean rate of emergency cesarean deliveries was 28.38% in the control group and 17.85% in the study group, which was statistically significant ( P b.05) (Table 2). The correlation with causative factors showed a lower rate of cesarean sections in women with labor dystocia and in women at high risk because of pregnancyinduced hypertension, intrauterine growth restriction, or postdatism in the study group (Table 3). There were no maternal deaths and perinatal mortality was 2.6 per 1000 live births in the study group. The stress of labor liberates catecholamines, which predispose to dysfunctional labor and compromised fetal oxygenation. This rise in catecholamine secretion can be reduced by the synergistic
use of analgesics and antispasmodics in the active phase of labor [3]. Active management is a safe and effective labor protocol to follow in a secondary setting where advanced facilities, such as an intensive care unit and a blood bank, are not available.
References [1] Daftary SN. Modern management of labour, Chapter 24. In: Saraya UB, Rao KA, Chatterjee A, editors. Principles and Practice of Obstetrics and Gynaecology for Postgraduates. New Dehli, India7 Jaypee Brothers Medical Publishers Ltd; 2003. A Federation of Obstetric and Gynaecological Societies of India (FOGSI) publication. [2] The UK Amniotomy Group. A multicentric randomized trail of amniotomy in spontaneous first labor at term. Br J Obstet Gynaecol 1994;101:307 – 9. [3] Desai SV, Deshpande V, Krishna U. Acceleration in labour. J Obstet Gynaecol India 1984;34:657 – 60.
www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Active management of labor in a low-resource setting and its impact on cesarean section rates S. Bachani *, S. Topden Department of Obstetrics and Gynecology, Central Govt. Health Scheme Maternity And Gynae Hospital, New Delhi, India Received 3 November 2005; received in revised form 17 April 2006; accepted 19 April 2006
KEYWORDS Labor; Active management; Efficacy; Safety; Low-resource setting
Labor and delivery-related complications being the largest contributors to India’s high maternal mortality rate, optimizing labor and delivery are of utmost importance. This study analyses the safety and efficacy of active management of labor at a secondary hospital using the protocol proposed by Daftary [1]. Women in labor with a term pregnancy who consented to the protocol formed the study group. The control group was managed expectantly. The 2 groups of 700 participants each were similar regarding parity, age, and pregnancy-related complications such as pregnancy-induced hypertension, intrauterine growth retardation, and postdatism.
* Corresponding author. 294 sector 4, R. K. Puram, New Delhi 110022 India. E-mail address: [email protected] (S. Bachani).
A gel preparation containing 0.5 mg of prostaglandin E2 was instilled intracervically in women with a Bishop score of 6 or less, and oxytocin was administered for labor augmentation if necessary. The partogram was then started, and amniotomy performed [2]. At the onset of the active phase of labor, 6 mg of pentazocin (an opioid analgesic) and 2 mg of diazepam (a tranquilizer) were diluted in distilled water and administered intravenously, and 50 mg of camylofin dihydrochloride (a smoothmuscle relaxant) was administered intramuscularly. Three hours later an injection of tramadol hydrochloride (an analgesic) or drotaverine hydrochloride (an antispasmodic) was given, the latter being repeated every 2 h depending on the partogram and the patient’s pain score. An injection of 125 mg of carboprost tromethamine was given intramuscularly after delivery to promote contraction and retraction of the uterine musculature. The remainder of the pentazocine and diazepam mixture was injected while the episiotomy was being sutured. The pain score was tabulated, and the total duration of labor and labor outcomes were analyzed. P b.05 was considered significant in determining the effect of active management of labor on the rate of cesarean deliveries. An attempt was made to identify the indications that could benefit from this protocol.
0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.04.035
Active management of labor in a low-resource setting and its impact on cesarean section rates
55
Table 1 Duration of labor among women who had active management of labor (study group) and women who had expectant management (control group) Mean labor duration
Study group(n = 700)
Control group(n = 700)
Primiparas
Multiparas
Primiparas
Multiparas
1st stage, h 2nd stage, h 3rd stage, min
6.2 2.1 3.5
3.5 1 3
7.5 2.5 10
4.2 1.5 8
Table 2 Cesarean section (CS) rates among women who had active management of labor and women who had expectant management (controls) Group
Primary CS (%)
Secondary CS (%)
Emergency CS (%)
P value
Study Control
22.39 14.77
72 60.8
28.38 17.85
.23 .03
Table 3 Correlation of causative factors and cesarean sections among women who had active management of labor and women who had expectant management (controls) Causative factor
Study group
Control group
Correlation
123 21 12 06 07 04
0.99 0.64 0.90 0.94 0.90 0.63
No. of cesarean sections Fetal distress Dystocia Previous CS/postdatism Previous CS with PIH Failed induction Severe IUGR
235 37 20 14 15 10
Abbreviations: CS, cesarean section; IUGR, intrauterine growth restriction; PIH, pregnancy induced hypertension.
Compared with the control group, the duration of all stages of labor was reduced in the study group in both primiparas and multigravidas (Table 1), with a definite reduction in pain and blood loss and no adverse effects. The mean rate of emergency cesarean deliveries was 28.38% in the control group and 17.85% in the study group, which was statistically significant ( P b.05) (Table 2). The correlation with causative factors showed a lower rate of cesarean sections in women with labor dystocia and in women at high risk because of pregnancyinduced hypertension, intrauterine growth restriction, or postdatism in the study group (Table 3). There were no maternal deaths and perinatal mortality was 2.6 per 1000 live births in the study group. The stress of labor liberates catecholamines, which predispose to dysfunctional labor and compromised fetal oxygenation. This rise in catecholamine secretion can be reduced by the synergistic
use of analgesics and antispasmodics in the active phase of labor [3]. Active management is a safe and effective labor protocol to follow in a secondary setting where advanced facilities, such as an intensive care unit and a blood bank, are not available.
References [1] Daftary SN. Modern management of labour, Chapter 24. In: Saraya UB, Rao KA, Chatterjee A, editors. Principles and Practice of Obstetrics and Gynaecology for Postgraduates. New Dehli, India7 Jaypee Brothers Medical Publishers Ltd; 2003. A Federation of Obstetric and Gynaecological Societies of India (FOGSI) publication. [2] The UK Amniotomy Group. A multicentric randomized trail of amniotomy in spontaneous first labor at term. Br J Obstet Gynaecol 1994;101:307 – 9. [3] Desai SV, Deshpande V, Krishna U. Acceleration in labour. J Obstet Gynaecol India 1984;34:657 – 60.