Active Management of Labor vs Expectant Management of Labor

All of the literature available to pregnant women today encourages them to “talk to your doctor or midwife.” This is sound advice. A good relationship with a well-matched, compatible care provider is of utmost importance in your pregnancy and birth. Yet the fluidity of those terms being used together can give the impression that the two are one and the same. It seems to suggest that your care will be only slightly different with a midwife than it would be with a doctor.

The reality is much different. Doctors and midwives approach pregnancy, labor, and birth from two profoundly different foundations of training. When it comes to the actual labor and birth, their training drives their decision making, and the approaches they take could not be more different.

Doctors tend to practice what is known as “active management” of labor and midwives mostly practice “expectant management” of labor. Of course there are exceptions, but by and large, this is what you will find in your doctor or midwife. Your choice of care provider matters more than you may think – and it’s worth it to understand the difference between the two approaches before hiring a doctor or midwife.

“Active Management of Labor” was invented in Dublin during the 70’s. It was the first method used to define labor, determine what is “normal” for clinical purposes, and establish protocols to keep women’s labors within its defined set of “normal.” Active management of labor protocols was not based on evidence, yet they were fully embraced as such without question. Active management of labor made its way to the United States soon after it was invented in Dublin.

According to Midwifery Today: The basic [abbreviated] principles are: diagnosis of labor based either on painful contractions and complete cervical effacement or broken water; one hour after admission, progress is assessed and amniotomy (water broken) performed; cervical dilation must advance by at least 1 cm per hour or oxytocin is started and increased until mother has 5-7 contractions every 15 mins; maximum labor length is 12 hours; a midwife stays with each woman throughout labor; the midwives manage labor, senior staff consults; induction is rare; pain medication is available but discouraged.

Unfortunately, the only pieces of the program that survived the Atlantic crossing (from Dublin) were routine amniotomy (breaking the water), the liberal use of oxytocin, and the time limit on labor. Other parts–the continuous support of an experienced woman, that residents did not make decisions, the minimal use of epidurals (5%), the minimal use of induction (<10%), not using painful contractions as the sole diagnosis of labor–did not make it…. Moreover, the Dublin doctors expected women to give birth vaginally….

In short, active management of labor is committed to the defined process, and to keep a woman’s labor on track with the arbitrary definition of “normal”. It does not allow for the many variations of normal in labor, and the goal is for a woman to have her baby within a certain time frame, whatever the cost.

Expectant management of labor, by contrast, is the approach that midwives tend to take. In this approach, the attendant sees birth as a normal and uncomplicated process that only requires intervention in a small number of cases. In contrast to the active management approach, a midwife sees normal birth with a wide range of variation. Birth does not need to be confined to a set standard, especially so long as the mom and baby are both doing ok.

An expectant management approach can also be called the “wait and see” approach. Rather than jumping on the use of interventions right away, a care provider who practices expectant management may take a step back and allow the birth process to unfold the way it needs to, provided that safety is of utmost importance.

To demonstrate the difference between active management and expectant management, imagine a woman is in labor and the labor slows down. By definition of the active management approach, the woman’s labor is now “stalled” and requires synthetic oxytocin in order to stay on track per the definition of labor. She is given intravenous Pitocin, her cervix is checked every hour to ensure “proper” progress, and she has now become a high-risk case due to the use of medication. Furthermore, she has now started what can quickly become the snowball of interventions.

An expectant management provider, however, would see a slowed labor through a different lens. She may see it as the laboring body giving mom a rest. She may see that the labor has, up until this point, been working on positioning the baby properly, and she may just leave well alone. She approaches it from a respect for the birthing process rather than seeing or feeling the need to make the labor conform to a pre-set idea.

Not all care providers are the same, and certainly, there are going to be doctors with a more expectant approach and midwives with a more active approach. Active management of labor has been the standard used and taught to doctors and hospitals for so long that creating change toward a more expectant approach is slow, but change is fortunately happening.
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Until then, make sure you know you are hiring the right provider for you. Interview them thoroughly. Understand the differences between the two approaches, and carefully decide which is right for you. Your choice of care provider is a crucial one, and as a doula, I’m always willing to help match you up with a provider whose values align with yours, whether that be expectant or active.

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