Background. Active management of labor is a multifaceted program that,
as implemented at the National Maternity Hospital in Dublin, is assoc
iated with a lower rate of cesarean delivery than the rate usually fou
nd in the United States. We conducted a randomized trial to evaluate t
he efficacy of this approach in lowering the rate of cesarean section
among women delivering their first babies. Methods. We randomly assign
ed 1934 nulliparous women at low risk of complications of pregnancy, b
efore 30 weeks' gestation, to active management of labor or to a usual
-care group. The components of active management were customized child
birth classes; strict criteria for the diagnosis of labor; standardize
d management of labor, including early amniotomy and treatment with hi
gh-dose oxytocin; and one-to-one nursing. A low-risk subgroup was defi
ned as including women with full-term, uncomplicated pregnancies who s
pontaneously went into labor (the protocol-eligible subgroup). Women m
eeting these criteria who had been randomly assigned to the active-man
agement group were admitted to a separate unit where their labor was m
anaged by trained, certified nurse-midwives. Results. There was no dif
ference between groups in the rate of cesarean section either among al
l women (active management, 19.5 percent; usual care, 19.4 percent) or
in the protocol-eligible subgroup (active management, 10.9 percent; u
sual care, 11.5 percent). In the protocol-eligible subgroup, the media
n duration of labor was shortened by 2.7 hours by active management (f
rom 8.9 to 6.2 hours), and the rate of maternal fever was lower (7 per
cent vs. 11 percent, P = 0.007). The percentage of women in whom labor
lasted longer than 12 hours was three times higher in the usual-care
group than in the active-management group (26 percent vs, 9 percent, P
<0.001). Conclusions. Active management of labor did not reduce the ra
te of cesarean section in nulliparous women but was associated with a
somewhat shorter duration of labor and less maternal fever.