WHO recommendation on the use of a package of care for active management of labour for prevention of delay in labour

Woman in labour, Kenya.

WHO recommendation on the use of a package of care for active management of labour for prevention of delay in labour


A package of care for active management of labour for prevention of delay in labour is not recommended.

(Weak recommendation, low-quality evidence)


Publication history

First published: May 2014

Updated: prioritized for updating in 2018

Assessed as up-to-date:  May 2014



  • The GDG agreed that this package of interventions has potential benefits in terms of reducing the duration of labour and possibly caesarean section rate. However, the group did not support its recommendation as it considered the approach to be highly prescriptive and interventional and one that could undermine women’s rights, choices and autonomy as recipients of care. In addition, the intervention is considered to be a complex package that exerts considerable demands on health resources, which may not be feasible in many settings. The GDG chose not to recommend the package because the reported clinical benefits do not clearly outweigh these other considerations.
  • The GDG also noted that continuous one-to-one care is the only component of the package that has been shown to be beneficial, and is probably the component responsible for the benefits attributed to the package. Continuous support during labour as a separate intervention is recommended in the guideline on continuous companionship during labour.



Difficult labour (or dystocia) is characterized by abnormally slow labour progress arising from inefficient uterine contractions, abnormal fetal presentation or position, inadequate bony pelvis or abnormalities of the pelvic soft tissues of the mother. (1, 2) Evidence suggests that up to one third of first-time mothers experience delay in the first stage of labour.  (3)

Augmentation of labour is the process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the onset of spontaneous labour. It has commonly been used to treat delayed labour when uterine contractions are assessed to be insufficiently strong or inappropriately coordinated to dilate the cervix. Labour augmentation has traditionally been performed with the use of intravenous oxytocin infusion and/or artificial rupture of amniotic membranes (amniotomy). The procedure aims to shorten labour in order to prevent complications relating to undue prolongation, and to avert caesarean section. There is evidence that a significant proportion of women with uncomplicated pregnancies are subjected to routine augmentation of labour with oxytocin. (4)

While augmentation of labour may be beneficial in preventing prolonged labour, its inappropriate use may cause harm. Augmentation with synthetic oxytocin may result in uterine hyperstimulation, with adverse effects such as fetal asphyxia and uterine rupture, and thus increase the risk of a cascade of interventions during labour and delivery. (5)



The recommendation was developed using standardized operating procedures in accordance with the process described in the “WHO handbook for guideline development”, guided by the GRADE approach.(6) Outcomes used for this recommendation were aligned with the prioritized outcomes from the WHO recommendations on augmentation of labour (2014).(7)

A Cochrane systematic review was conducted on  packages of care for the active management of labour compared with routine care.(8) In the review, randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks.

WHO convened a Guideline Development Group (GDG) meeting on recommendations on augmentation of labour in September 2013, where this recommendation was developed. The GDG comprised of a group of independent experts, who used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here


Recommendation question

For this recommendation, we aimed to answer the following question:

  • in pregnant women in labour (P), does the use of a package of active management of labour (I), compared to no intervention, (C) prevent delay in labour (O)?


Evidence Summary

Evidence on packages of care for the ative management of labour compared with routine care was extracted from a Cochrane systematic review of seven trials (> 5000 women).(8) The trials were conducted in high-, middle- and low-income countries: three in the United States of America (USA) and one each in Belgium, New Zealand, Thailand and Nigeria.

All but one of the trials recruited women in early spontaneous labour. To be included in the review, the predefined package of care in labour had to be clearly described in trial reports and care had to include more than two, or all of the key elements described traditionally as “active management of labour”: early routine amniotomy and augmentation with oxytocin; strict criteria for the diagnosis of labour, abnormal progress in labour and fetal compromise; continual presence of a midwife/nurse during labour; peer review of assisted deliveries and progress of labour plotted using a graph. The comparative care in the included trials was also clearly described. Most of the included trials used higher starting and increment oxytocin doses for women receiving the package of care for active management of labour compared to those receiving usual care.

Package of care for active management in labour versus routine care: maternal outcomes

  • None of the trials reported maternal mortality.
  • There was a statistically significant reduction in the duration of labour for women in the active management of labour group (MD –1.27 hrs, 95% CI –2.19 to –0.36; four trials, 2431 women). The direction of the effect was consistent in all trials, with women in the intervention group having shorter labour; however, the size of the mean reduction varied considerably in different trials from between a few minutes to up to two hours.
  • There was a significant reduction in the length of the first stage of labour (MD –1.56, 95% CI –2.17 to –0.96; four trials, 2431 women). The length of the second stage of labour was very similar in the two groups (MD –0.02, 95% CI –0.06 to 0.02; five trials, 2737 women).
  • There was no significant difference in the frequencies of PPH (blood loss > 500 ml) between the comparison groups (RR 0.93, 95% CI 0.67 to 1.31; three trials, 1504 women).
  • For caesarean section, the observed difference between groups was not statistically significant, although there was a trend towards a modest reduction in caesarean section in the active management group (RR 0.88, 95% CI 0.77 to 1.01; seven trials, 5390 women). More than 40% of the weight in this analysis was due to a trial that recruited women early in the third trimester and by labour more than a third of them were no longer eligible. If data for women who were still eligible at the time of labour are included, the pooled effect size is increased, and the difference between the groups is statistically significant, favouring active management (RR 0.82, 95% CI 0.69 to 0.97; seven trials, 4738 women). If data from this trial are excluded altogether the difference between groups remains significant (RR 0.77, 95% CI 0.63 to 0.94; six trials, 3475 women).
  • The frequency of prolonged labour (defined as > 12 hrs) was considerably reduced in the active management group (RR 0.47, 95% CI 0.32 to 0.69; six trials, 3242 women).
  • There were no clear differences between the groups for rates of assisted vaginal birth (RR 0.99, 95% CI 0.87 to 1.14) or epidural analgesia (RR 1.06, 95% CI 0.98 to 1.14).
  • There was no significant difference between the groups for maternal infection (various definitions) (RR 1.14, 95% CI 0.65 to 1.98).
  • Maternal satisfaction with experience during labour was very similar in both groups (RR 1.04, 95% CI 0.94 to1.15).

Package of care for active management in labour versus routine care: infant outcomes

  • Few infant outcomes were reported in this review. There were no statistically significant differences in admission to NICU (RR 0.92, 95% CI 0.59 to 1.43), Apgar score < 7 at five minutes (RR 1.12, 95% CI 0.76 to 1.64) or meconium staining (RR 0.93, 95% CI 0.7 to 1.24).

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at: http://apps.who.int/iris/bitstream/handle/10665/112826/WHO_RHR_14.15_eng...


Implementation considerations

  • The successful introduction of this recommendation into national programmes and health-care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. The adaptation and implementation processes may include the development or revision of existing national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into a locally appropriate document that can meet the specific needs of each country and health service. Any changes should be made in an explicit and transparent manner.
  • A set of interventions should be established to ensure that an enabling environment is created for the use of the recommendations (including, for example, the availability of augmentation agents and monitoring capacity), and that the behaviour of the healthcare practitioner changes towards the use of this evidence-based practice.
  • In this process, the role of local professional societies is important and an all-inclusive and participatory process should be encouraged.


Research implications

The GDG did not identify further research priorities on this topic.


Related Links

WHO recommendations for augmentation of labour (2014) –full document and evidence tables


Supporting systematic review:

Brown HC, Paranjothy S, Dowswell T, Thomas J. Package of care for active management in labour for reducing caesarean section rates in low-risk women. The Cochrane database of systematic reviews. 2013(9):Cd004907.



  1. Ronel D, Wiznitzer A, Sergienko R, Zlotnik A, Sheiner E. Trends, risk factors and pregnancy outcome in women with uterine rupture. Archives of gynecology and obstetrics. 2012;285(2):317-21.
  2. McClure EM, Saleem S, Pasha O, Goldenberg RL. Stillbirth in developing countries: a review of causes, risk factors and prevention strategies. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstet. 2009;22(3):183-90.
  3. Kjaergaard H, Olsen J, Ottesen B, Dykes AK. Incidence and outcomes of dystocia in the active phase of labor in term nulliparous women with spontaneous labor onset. Acta obstetricia et gynecologica Scandinavica. 2009;88(4):402-7.
  4. Bernitz S, Oian P, Rolland R, Sandvik L, Blix E. Oxytocin and dystocia as risk factors for adverse birth outcomes: a cohort of low-risk nulliparous women. Midwifery. 2014;30(3):364-70.
  5. Jonsson M, Norden-Lindeberg S, Ostlund I, Hanson U. Acidemia at birth, related to obstetric characteristics and to oxytocin use, during the last two hours of labor. Acta obstetricia et gynecologica Scandinavica. 2008;87(7):745-50.
  6. WHO Handbook for Guideline Development. Geneva: World Health Organization; 2014. World Health Organization. 2011.
  7. WHO recommendations for augmentation of labour. World Health Organization: Geneva. 2014.
  8. Brown HC, Paranjothy S, Dowswell T, Thomas J. Package of care for active management in labour for reducing caesarean section rates in low-risk women. The Cochrane database of systematic reviews. 2013(9):Cd004907.



WHO Reproductive Health Library. WHO recommendation on the use of a package of care for active management of labour for prevention of delay in labour (May 2014). The WHO Reproductive Health Library; Geneva: World Health Organization.