Early amniotomy and early oxytocin for prevention of, or therapy for, delay in the first stage of labour compared with routine care (Review)

Département d'Obstétrique-Gynécologie, Université de Montréal, Hôpital, Canada.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 11/2012; 9(2):CD006794. DOI: 10.1002/14651858.CD006794.pub3
Source: PubMed


Caesarean section rates have increased substantially since the early 1970s; many women having their first babies are older and this may contribute to ineffective or difficult labor, most often because of inadequate uterine action (dystocia). The Active Management of Labor is a clinical protocol that includes early intervention with amniotomy and oxytocin to increase the frequency and intensity of uterine contractions (augmentation) when the progress of labor is delayed. Continued ineffective labor (‘cervical arrest’) can result in the decision to undertake a caesarian section. Early intervention also has risks that include uterine hyperstimulation and fetal heart rate abnormalities. This review showed that a policy of early routine augmentation for mild delays in labor progress resulted in a modest reduction of the caesarean section rate compared with expectant management. The reduction in caesarian sections was most evident in the 10 trials looking at prevention of abnormal progression, rather than therapy (2 trials). The difference in caesarean risk was 1.47%. The number of women needed to treat (NNT) to prevent one caesarean section was approximately 68. This conclusion is based on 10 randomized controlled trials involving 7653 women. In these women, the time from admission to giving birth was also reduced (mean difference 1.1 hour). The trials did not provide sufficient evidence on indicators of maternal or neonatal health, including women’s satisfaction and views on the experience. Documentation of other aspects of care, such as continuous professional support, mobility and positions during labor, was limited as was the degree of contrast between groups. Women in the control group also received oxytocin but often later than in the intervention group. The severity of delay which was sufficient to justify interventions remains to be defined.

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    • "Oxytocin is widely recognised as playing a major role in parturition by promoting myometrial contractility. Currently, oxytocin is the most potent uterotonin available and is extensively used in the clinical management of dysfunctional labour (Wei et al., 2013). However, myometrial contractions represent a late event in the cascade leading to labour and are preceded by cervical ripening and fetal membrane activation and remodelling. "
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    • "An example of this is the current research into dystocia, a complication of labour that is the principal contributor to caesarean section in nulliparous women (Gregory, 2000). Most of the research has explored interventions to speed up labour – there are currently at least three relevant Cochrane reviews on the prevention (Wei et al., 2009) and treatment of dystocia (Bugg et al., 2011; Kenyon et al., 2013) – or on women's experience of dystocia (Nystedt et al., 2008). The methods utilised in these studies have been randomised controlled trials and phenomenology in the main. "
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    • "Midwifery (BMI), infertility, epidurals and stress during labour (Nerum et al., 2010; National Medical Indications, 2011). The consequences of augmentation of labour with oxytocin, both positive and negative, are subject to investigation and attention worldwide (Oscarsson et al., 2006; Berglund et al., 2008; Reuwer et al., 2009; Clark et al., 2009; Bugg et al., 2011; Wei et al., 2012). Even though the results should be interpreted with caution, observational studies have found associations between the use of oxytocin and adverse outcomes for newborns (Oscarsson et al., 2006; Kjaergaard et al., 2009), and increased operative birth rates (Bugg et al., 2006; Oscarsson et al., 2006; Kjaergaard et al., 2009). "
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    ABSTRACT: OBJECTIVES: augmented and not augmented women without dystocia were compared to investigate associations between oxytocin and adverse birth outcomes. Augmented women with and without dystocia were compared, to investigate associations between dystocia and adverse birth outcomes. DESIGN: a cohort of low-risk nulliparous women originally included in a randomised controlled trial. SETTING: the Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway. PARTICIPANTS: the study population consists of 747 well defined low-risk women. MEASUREMENTS: incidence of oxytocin augmentation, and associations between dystocia and augmentation, and mode of delivery, transfer of newborns to the intensive care unit, episiotomy and postpartum haemorrhage. FINDINGS: of all participants 327 (43.8%) were augmented with oxytocin of which 139 (42.5%) did not fulfil the criteria for dystocia. Analyses adjusted for possible confounders found that women without dystocia had an increased risk of instrumental vaginal birth (OR 3.73, CI 1.93-7.21) and episiotomy (OR 2.47, CI 1.38-4.39) if augmented with oxytocin. Augmented women had longer active phase if vaginally delivered and longer labours if delivered by caesarean section if having dystocia. Among women without dystocia, those augmented had higher body mass index, gave birth to heavier babies, had longer labours if vaginally delivered and had epidural analgesia more often compared to women not augmented. KEY CONCLUSION: in low-risk nulliparous without dystocia, we found an association between the use of oxytocin and an increased risk of instrumental vaginal birth and episiotomy. IMPLICATIONS FOR PRACTICE: careful attention should be paid to criteria for labour progression and guidelines for oxytocin augmentation to avoid unnecessary use.
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