Active management of labour versus expectant management of primiparous women with a prolonged latent phase: a randomized trial

ABSTRACT
Background. The duration of the latent phase of labour is variable and can reach 20 hours. According to the World Health Organization (WHO), a prolonged latent phase is the absence of cervical dilation beyond four or six centimetres after eight hours of regular uterine contractions. In this situation, women are at higher risk of medical interventions with a higher rate of emergency caesarean sections. There is no consensus regarding the management of the prolonged latent phase. Thus, two attitudes are possible: Expectant management with spontaneous labour and active management with amniotomy and oxytocin infusion.
Our study aimed to compare the outcomes of expectant management to those of active management strategy in the case of a prolonged latent phase.
Patients and Methods. We undertook a prospective experimental randomized clinical trial, in the gynecology and obstetrics department of the university hospital Hédi Chaker, Sfax, Tunisia, between 1 July 2021, and 31 December 2021. We included in our study primiparous women with spontaneous labour beginning and with prolonged latent phase. Only single evolutive pregnancies with cephalic presentation were included. Patients were randomized into two groups. For Active Management Group (AMG), the intervention was an amniotomy followed by an oxytocin infusion. For the expectant management group (EMG), amniotomy and oxytocin infusion were not performed unless indicated. The primary outcome was the rate of caesarean sections.
Results. Our study population consisted of 340 primiparous parturients with spontaneous labour beginning and with a prolonged latent phase. The caesarean section rate was 27.6% for the EMG versus 43.5% for the AMG (p < 0.001). Immediate complications were found in 18.2% of patients for the AMG versus 2.9% for the EMG (p < 0.001). The most common complication was postpartum haemorrhage (PPH) and was more frequent for AMG (12.4%). At birth, 93.5% of newborns for the EMG had an Apgar score between 8 and 10 versus 84.7% for the AMG (p = 0.01). Medical reanimation was required for 25 newborns after AMG and for 10 cases with EMG (p = 0.01). Five newborns for EMG (2.9%) and 15 newborns for GPA (8.8%) were admitted to the neonatal intensive care unit (p=0.03). The average time between randomization and vaginal delivery, for patients who had vaginal birth, was longer for the EMG (15 hours and 47 minutes versus 8 hours, p=0.001). The mean duration of the latent phase, for patients who had vaginal birth, in our study was 20 hours and 38 minutes for the EMG versus 13 hours and 19 minutes for the AMG (p < 0.001). The average duration of the active phase, for patients who had vaginal birth, was 5 hours and 14 minutes for the EMG versus 3 hours and 58 minutes for the AMG (p < 0.001). Concerning the satisfaction of the parturient, 68.2% of the AMG were satisfied for the labour progression versus 82.4% for the EMG; p = 0.003. For immediate postpartum satisfaction, the majority of patients were delighted with no significant difference.
Conclusions. The active attitude compared to the expectant attitude has shown several disadvantages: it gives a higher caesarean section rate, more maternal complications, less safety for the newborn, and a longer hospital stay with less satisfied parturient. At the end of this study, and in the wake of the results found in the literature, expectant management to manage the prolonged latent phase seems to be an effective alternative and we suggest its widespread use.