204 BIRTH 15:4 December 1988

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3. ’hrner M, Brassil M, Gordon H. Active management of labor associated with a decrease in the cesarean section rate in nulliparas. Obstet Gynecol 1988;71: 150-154.

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ican Gynecological and Obstetrical Society. Hot Springs, VA, 1986.

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Commentary: Yes, Virginia, you can combine active management of labor with high cesarean rates.. . .

Judith furnley, M.A., M.B., B.S., Ph.D.

The contrasting beliefs and practices that come to light in the paper by Curtis and Safransky and the comment by Boylan and MacDonald center on the appropriate pattern of oxytocin administration. The former make the claim, based mainly on a literature review of physiologic and pharmacologic research, that current orthodox regimens in the United States lead to “uncoordinated, unproductive uterine ac- tivity and hyperstimulation, with fetal distress and/ or lack of progress in labor.” The latter, who use even higher doses, counter with their results, too well-known to require emphasis.

My confusion on this topic comes from local practice. In this state, one-third of all women in labor receive oxytocin, either to induce or to aug- ment labor. At one major teaching hospital the pro- tocols for induction and augmentation are identical and closer to the Dublin protocol than to the or- thodox United States one cited above. Most hos-

Judith Lumley is with the Department of Paediatrics, Monash University, Clayton, Victoria, 3168, Australia.

pitals give between 20 and 45 percent of their clients oxytocin; the highest user gives it to 54 per- cent. Yet our cesarean delivery rates are more than three times those of Dublin; 16.4 percent in 1986.

Nulliparas in Victoria made up 39 percent of all women giving birth in 1986. Six percent of them had an elective cesarean delivery. Of the rest, one- fourth had labor induced, most commonly with membrane rupture plus oxytocin, and a further 26 percent received oxytocin for augmentation. De- spite this active management of labor, 18.6 percent of nulliparas were delivered by cesarean section.

The Dublin group would be critical of the high induction rate; Curtis and Safransky would deplore the pharmacologic doses of oxytocin. To confound the arguments further, it should be noted that in Victoria we have few teenage births (4.6% of births in 1986), and we have care by midwives and much husband support in labor. We have an ethnically more diverse population than Dublin, but with little evidence of major differences according to eth- nicity in the management of labor. Any explana- tions of or suggestions for changing these outcomes would be most welcome.