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LETTERS: Dermot Ryan Caesarean delivery in the second stage of labour: Revisit the past BMJ 2006; 333: 753-b-754-b [Full text]

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Caesarean section in the second stage of labour

Chris P Spencer, Deirdre Murphy, Susan Bewley   (17 October 2006)

Evidence does not support active management of labour as routine policy

Sarah C. Vaughan   (4 December 2006)

Caesarean section in the second stage of labour 17 October 2006
Chris P Spencer, Consultant St. John's Hospital, Chelmsford, Essex, UK, Deirdre Murphy, Susan Bewley Send response to journal: Re: Caesarean section in the second stage of labour	We thank our non-obstetric colleagues for their interest in our editorial on second stage Caesarean section1. Thornton2 appears to misunderstand the real dilemma and dangers of delivery during the second stage of labour and rehearses arguments previously proposed for ‘request’ elective Caesarean, which is an entirely different topic. She suggests that we have advocated an increase in the use of high forceps delivery – this is not the case – and refers to literature about anal ultrasound findings that do not equate to long term continence. She may be influenced by her experience of a particular set of rare complications of childbirth, but is wrong to imply that obstetricians are hypocritical and prefer Caesareans for themselves. Sadly, Thornton misleads BMJ readers by referring to a frequently misquoted study of male and female obstetricians’ personal birthing choices; only 5% would want a second stage Caesarean section if operative delivery was needed at this stage of labour3. The vast majority of UK obstetricians remain completely committed to safety (which is achieved by normal labour and vaginal delivery in most cases) both for themselves and their patients. We do not agree with Ryan4 that maternity services in the UK are undermedicalised, nor that Changing Childbirth caused all our problems - although it certainly failed to stop the rise of obstetric intervention. The magic ingredients of ‘active management of labour’ used in Dublin have not proved transferable to other countries and settings or in randomised trials5-7. We believe that good midwifery, ‘hands on’ training of forceps and ventouse by senior obstetricians and an increase in the use of safe second stage delivery techniques, such as manual rotation of the head and appropriate use of effective doses of oxytocin, may help reduce the rates of second stage Caesareans, well known and recognised as the more hazardous of emergency Caesareans. Chris Spencer Deirdre Murphy Susan Bewley 1. Spencer C, Murphy D, Bewley S. Caesarean delivery in the second stage of labour. BMJ, 2006; 333: 613-614. 2. Thornton MJ. Consider the value of a functionally intact perineum. BMJ, 2006; 333: 753. 3. Al-Mufti R, McCarthy A, Fisk NM. Survey of obstetricians’ personal preference and discretionary practice. Eur J Obstet Gynecol Reprod Biol, 1997; 73: 1-4. 4. Ryan D. Revisit the past. BMJ, 2006; 333: 753-754. 5. Sadler LC, Davison T, McGowan LM. A randomised controlled trial and meta-analysis of active management of labour. Br J Obstet Gynaecol, 2000; 107: 909-915. 6. Fraser WD, Turcot L, Krauss I, Brisson-Carrol G. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev, 2000; (2): CD 000015. 7. Frigoletto FD Jr, Lieberman E, Lang JM et al. A clinical trial of active management of labour. N Engl J Med, 1995; 333: 745-750. Competing interests: None declared
Evidence does not support active management of labour as routine policy 4 December 2006
Sarah C. Vaughan, GP 18 Fouracre Rd, Downend, Bristol, BS16 6PG Send response to journal: Re: Evidence does not support active management of labour as routine policy	Dermot Ryan attributes the commendably low rates of surgical delivery in Dublin's National Maternity Hospital to their policy of active management of labour. (1) In fact, it is not possible or appropriate to draw that conclusion from either of the studies he cites, as neither includes a control group for comparison purposes. (2, 3) Randomised controlled trials that have compared active management of labour with a more judicious use of amniotomy and oxytocin have found no difference in Caesarean rates, rates of operative vaginal delivery, or neonatal outcomes. (4, 5) The only difference between routine care and the type of active management espoused by Ryan appears to be that active management shortens the first stage by between 30 and 50 minutes. This is not quite the universal bonus that might at first be thought. Anecdotally, some women find that amniotomy and/or oxytocin result in more painful, less manageable contractions; also, some women prefer their labour to be as low -tech and non-medicalised as feasible. There are therefore a number of women who would prefer to avoid the active approach even if it means some shortening in the length of the first stage. Given the lack of difference in other outcomes, it seems perfectly reasonable for this to be an area for individual patient choice rather than blanket protocols. The most important message from these studies is, of course, that it's possible to keep the rates of emergency surgical delivery much lower than they commonly are in practice. Perhaps what we should really be looking at is how both of the approaches studied in this trial differ from more everyday management of labour in UK wards generally, and how we can all best strive towards these excellent results. 1. Ryan D. Caesarean delivery in the second stage of labour: Revisit the past. BMJ 2006; 333: 753-4. 2. O'Driscoll K, Jackson RJ, Gallagher JT. Prevention of prolonged labour. BMJ 1969;2: 477-80. 3. Bohra U, Donnelly J, O'Connell MP, Geary MP, MacQuillan K, Keane DP. Active management of labour revisited: the first 1000 primiparous labours in 2000. J Obstet Gynaecol 2003;23: 118-20. 4. Cammu H., Van Eeckhout E. A randomised controlled trial of early versus delayed use of amniotomy and oxytocin infusion in nulliparous labour. Br J Obstet Gynaecol 1996; 103: 313-8. 5. Sadler L.C., Davison T., McCowan L.M.E. A randomised controlled trial and meta-analysis of active management of labour. Br J Obstet Gynaecol 2000; 107: 909-15. Competing interests: None declared