CORRESPONDENCE

267

The UK Amniotomy Group 1994).The caesarean section rates in both the United Kingdom and the United States have risen despite different approaches to our management of labour. The adoption of more aggressive regimes of oxytocin administration in the United States may not be the answer to their problems, and it is likely that we may have to look elsewhere for the solution on both sides of the Atlantic.

performed after 6 c m dilation has been achieved. Until such a study has been carried out, the debate will continue.

E. Hiadzi & R. A. OConnor

Lister Hospital, Stevenage

Reference
UK Amniotomy Group (1994) A multicentre randomised trial of amniotomy in spontaneous first labour at tern. BP J Obstet Gynaecol 101. 307-309.
AUTHORS REPLY

K. S. Olah & J. P. Neilson

Department of Obstetrics and Gynaecology, University of Liverpool

References
Breart G., Garel M. & Mlika-Cabanne V. (1992) Evaluation of different policies of the management of labour for primiparous women. Trial A. Results of the early amniotomytrial. In Evaluation in Pre, Peri and Postnatal Care Delivery Systems. EEC, Brussels : pp. 43-56. Chamberlain G . (1993) What is the correct caesarean section rate? Br J Obstet Gynaecol 100, 403-404. Cohen G. R., OBrien W. F., Lewis L. & Knuppel R. D. (1987) A prospective randomised study of the aggressive management of early labour. Am J Obstet Gynecoll57, 1174- 1177. Lopez-Zen0 J. A., Peaceman A. M., Adashek J. A. & Socol M. A. (1992) A controlled trial of a programme for the active management of labour. N Engl J Med 326, 450-454. Olah K. S. & Neilson J. P. (1994) Failure to progress in the management of labour. Br J Obstei Gynuecol101, 1-3. The UK Amniotomy Group (1994) A multicentre randomised trial of amniotomy in spontaneous first labour at term. Br J Obstet Gynaecol101, 307-309.
Sir, Our final sentence and Dr Weeks suggested alternative are not mutually exclusive. It is possible to offer an intervention without recommending it. However, patients have often reported difficulty in refusing routine amniotomy, especially if their attendants claimed that it was safer for the baby and reduced operative intervention. Now that our trial and others have failed to confirm either of these benefits, women can decide on the basis of the effect on labour duration. With respect to Drs Hiadzi and OConnors comments, we did not exclude mothers in the delay group who underwent amniotomy before 4cm, or those in the early group who underwent it after 6cm, since the former probably include a disproportionate number with primary arrest of labour, fetal distress and so on, and the latter many women making very rapid progress. Excluding them would have introduced bias in favour of delaying amniotomy. However, Drs Hiadzi and OConnor are correct to suggest that poor compliance with treatment allocation may have caused the lack of observed effect in our trial. The effect of always performing amniotomy early in labour, or never performing it artificially till after 6 cm can only be measured by a higher compliance trial. This is difficult to organise and expensive; our group have a protocol but have not yet achieved funding. We agree that our trial alone does not settle the question of active management of labour. That requires an overview of all the well designed trials of the various components of active management. These suggest that active management does reduce caesarean and operative vaginal delivery rates but that the effective component is not the routine amniotomy or the early high dose oxytocin, but the presence of a companion in labour (Thornton t Lilford 1994).

A multicentre randomised trial of amniotomy in spontaneous first labour at term

Sir,

The U K Amniotomy Group (Vol 101, April 1994) conclude that beyond a modest shortening of labour, a policy of routine episiotomy has little effect on important outcomes and should not be recommended. Would not a more patient-centred conclusion be that routine amniotomy safely reduces the length of labour by 11YOwithout changing analgesia requirement or affecting other important outcomes. It should be offered to all labouring women for this purpose.?

Andrew D. Weeks
Jessop Hospital for Women, Shefield

J. Thornton

Reference
The UK Amniotomy Group (1994) A multicentre randomised trial of amniotomy in spontaneous first labour at term. Br J Obstet Gynaecol 101, 307-309.
Sir, The recent publication from the UK Amniotomy Group addresses an important issue. Working, however, in a unit that manages labours actively, we question the validity of their results. The ethos of the active management of labour is the accurate diagnosis of labour and early amniotomy, usually performed at or before 3 c m dilation. This is followed by syntocinon augmentation if progress is slow. Despite a small statistical significance, the comparison of amniotomy at a cervical dilation of 5.1 cm with that of 6.7 cm is really comparing like with like. Table 1 is somewhat difficult to interpret, but it would appear that 24 YOof mothers allocated to early amniotomy had it performed after 6cm. While 18% allocated to the late amniotomy group had their waters artificially ruptured before 4 cm dilation. Surely, these mothers should have been excluded from the trial? It is not surprising the odds ratio for both the maternal and fetal outcome measures cross unity. The trial that is really needed is a comparison of amniotomy at 3 c m with late amniotomy

The General Infirmary at Leeds

Reference
Thornton J. G. & Lilford R. J. (1994) Active management of labour; current knowledge and research issues. Br Med J 309, 366-369.

Ampicillin and metronidazole treatment in preterm labour : a multicentre, randomised trial

Sir, We applaud the efforts of Norman et a / . (101, May 1994) in conducting research in the very difficult and yet important area of preterm labour. However, we believe that their report has fundamental flaws. Whether at term or preterm, labour in primigravid women is different from that in multigravida. Our opinion is that the study should have been confined to primigravida, or failing that, the study groups should have been stratified so as to clearly allow for the possible influence of parity, and also so that the study and control groups could be shown to be comparable. Most studies on preterm labour are bedevilled by poor definition of labour. In this report, no data are provided on