Caesarean section rates have increased substantially since the early 1970s; many women having their first babies are older and this may contribute to ineffective or difficult labour, most often because of inadequate uterine action (dystocia). The Active Management of Labour is a clinical protocol that includes early intervention with amniotomy and oxytocin to increase the frequency and intensity of uterine contractions (augmentation) when the progress of labour is delayed. Continued ineffective labour (‘cervical arrest’) can result in the decision to undertake a caesarean section. Early intervention also has risks that include uterine hyperstimulation and fetal heart rate abnormalities.

This review includes 14 trials, randomizing a total of 8033 women, and showed that a policy of early routine augmentation for mild delays in labour progress resulted in a modest reduction of the caesarean section rate compared with expectant management. The reduction in caesarean sections was most evident in the 11 trials looking at prevention of abnormal progression, rather than therapy (three trials). In these women, the time from admission to giving birth was also reduced (mean difference 1.3 hours).

The trials did not provide sufficient evidence on indicators of maternal or neonatal health, including women’s satisfaction and views on the experience. Documentation of other aspects of care, such as continuous professional support, mobility and positions during labour, was limited as was the degree of contrast between groups. Women in the control group also received oxytocin but often later than in the intervention group. The severity of delay which was sufficient to justify interventions remains to be defined.