REVIEW The management of normal labour Sue Taylor MRCOG lthough many people hold strong opinions about the management of normal labour. these are often A based upon weak evidence. Many former standard practices, such as the universal administration of enemas or the routine use of episiotomy, have been modified or abandoned. Changes of this kind may be in response to evidence from randomised trials, from re-evaluation of observational data, or simply as a result of a move to a less paternalistic style of practice. Patient pressure or campaigns by groups such as the National Childblrth Trust also have a role - a notable example being the increased tendency in Table 1. Management decisions and type of evidence available Decision Home versus hospital delivery Continuous fetal monitoring versus intermittent auscultation Active management of labour versus non-intervention Eating and drinking in labour Position during labour Benefitsand disadvantages of routine analgesia Pharmacological contraction of the uterus versus physiologicalmanagement of the third stage Evidence Prospective observational studies Randomised controlled trials and observational studies Randomised controlled trial Small randomisedcontrolled trial, too small to assess clinical outcome Randomised controlled trial Randomised controlled trials for opiate and epidural anaesthesia Randomised controlled trial Jim Thornton FRCOG recent years towards a 'physiological' third stage. In this review, we address the questions listed in Table I, using, where possible. evidence from randomised contrrol- led trials. The conclusions apply to low-risk labours only. W.IIEKII SIIOI '1.1) K~OllI;h I.:\HOI K! At present, fewer than 2% of births in the IJK take place at h0me.l It is frequently assumed that labour in hospital must be safer than in the home. However, careful analysis of the perinatal mortality figures for the various sites of delivery do not support the view that hospital is safer for low-risk pregnancies. Recent prospective studies in the Netherlands, where 31% of women give birth at home,2 and in the UK,3 conclude that there is no increased risk. The IJK study looked at 3466 home deliveries over a period of 14 years, from 1981 to 1994. It found that, although the overall perinatal mortality was higher for home deliveries (38.7 per 1000 against 9.7 per loPo>, this was due almost entirely to deliveries that had originally been booked for hospital (45 per 1000 for unplanned home deliveries against 1.6 per 1000 for planned home deliveries). The perinatal mortality rate for planned home deliveries was less than half that of the hackground population. The total number of perinatal deaths in the planned home delivery group was 14 and, of these, 11 actually delivered in hospital. One hundred and thirty-four deaths had actually occurred following home delivery but? of these, 131 were to women who had either planned hospital delivery or who had received no antenatal care. 69 ?he Obstetriciun G Gynuecolqyist April 2001 Vol. 3 No. 2