This is not the most recent version of the article. View current version (7 AUG 2013)
Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care
Editorial Group: Cochrane Pregnancy and Childbirth Group
Published Online: 15 APR 2009
Assessed as up-to-date: 22 NOV 2008
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Wei S, Wo BL, Xu H, Luo ZC, Roy C, Fraser WD. Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006794. DOI: 10.1002/14651858.CD006794.pub2.
- Publication Status: Edited (no change to conclusions)
- Published Online: 15 APR 2009
This is not the most recent version of the article. View current version (07 AUG 2013)
Caesarean section rates are over 20% in many developed countries. The main diagnosis contributing to the high rate in nulliparae is dystocia or prolonged labour. The present review assesses the effects of a policy of early amniotomy with early oxytocin administration for the prevention of, or the therapy for, delay in labour progress.
To estimate the effects of early augmentation with amniotomy and oxytocin for prevention of, or therapy for, delay in labour progress on the caesarean birth rate and on indicators of maternal and neonatal morbidity.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008), MEDLINE (January 1970 to November 2008), EMBASE (1980 to November 2008), CINAHL (1982 to November 2008), MIDIRS (1985 to November 2008) and contacted authors for data from unpublished trials. We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 15 February 2012 and added the results to the awaiting classification section.
Randomized and quasi-randomized controlled trials that compared oxytocin and amniotomy to expectant management.
Data collection and analysis
Three authors extracted data independently. We stratified the analyses into 'Prevention Trials' and 'Therapy Trials' according to the status of the woman at the time of randomization. Participants in the 'Prevention Trials' were unselected women, without slow progress in labour, who were randomized to a policy of early augmentation or to routine care. In 'Treatment Trials' women were eligible if they had an established delay in labour progress.
Twelve trials, including 7792 women, were included. The unstratified analysis found early intervention with amniotomy and oxytocin to be associated with a modest reduction in the risk of caesarean section; however, the confidence interval crossed unity and was compatible with no effect (risk ratio (RR) 0.89; 95% confidence interval (CI) 0.79 to 1.01). In Prevention trials, early augmentation was associated with a modest reduction in the number of caesarean births (RR 0.88; 95% CI 0.77 to 0.99). A policy of early amniotomy and early oxytocin was associated with a shortened duration of labour (mean difference - 1.11 hour). Sensitivity analyses excluding three trials with a full package of Active Management did not substantially affect the point estimate of the effect (RR 0.87; 95% CI 0.73 to 1.04). We found no other significant effects for the other indicators of maternal or neonatal morbidity.
In prevention trials, early intervention with amniotomy and oxytocin appears to be associated with a modest reduction in the rate of caesarean section over standard care.
[Note: The five citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]
Plain language summary
Early amniotomy and early oxytocin for delay in first stage spontaneous labour compared with routine care
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.