Active Management of Labor Versus Expectant Management of Primiparous Women With a Prolonged Latent Phase: A Randomized Trial

Abstract

Introduction: 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 centimeters 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 prolonged latent phase. Thus, two attitudes are possible: Expectant management with spontaneous labour and active management with amniotomy and oxytocin infusion. The aim of our study was to compare the outcomes of expectant management to those of active management strategy in case of 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 July 1st 2021 and December 31 2021. We included in our study primiparous women with spontaneous labor beginning and with prolonged latent phase. Only single evolutive pregnancy with cephalic presentation were included. Patients were randomized into two groups. For Active Management Group (AMG), the intervention was amniotomy followed by an oxytocin influsion. For the expectant management group (EMG), amniotomy and oxytocin infusion were not performed unless indicated. The primary outcome was the rate of cesarean sections. Results: Our study population consisted of 340 primiparous parturients with spontaneous labor 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 hemorrhage (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 operation and vaginal delivery was longer for the EMG (15 hours and 47min versus 8 hours, p = 0.001). The mean duration of the latency phase in our study was 20 hours 38min for the EMG versus 13h and 19min for the AMG (p < 0.001). The average duration of the active phase was 5 hours 14min for the EMG versus 3 hours and 58min for the AMG (p < 0.001). Concerning the satisfaction of the parturients, 68.2% for the AMG were satisfied with the delivery process versus 82.4% for the EMG; p = 0.003. For immediate postpartum satisfaction, the majority of patients were very satisfied with no significant difference. Conclusion: The active attitude compared to the expectant attitude has shown several disadvantages: it gives more caesarean section rate, more maternal complications, less safety for the newborn, a longer hospital stay with less satisfied parturients. At the end of this study, and in the light of the results found in the literature, expectant management to manage the prolonged latency phase seems to be an effective alternative and we suggest its generalization.