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Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour

  1. George J Bugg1,*,
  2. Farah Siddiqui2,
  3. Jim G Thornton3

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 23 JUN 2013

Assessed as up-to-date: 17 JUN 2013

DOI: 10.1002/14651858.CD007123.pub3


How to Cite

Bugg GJ, Siddiqui F, Thornton JG. Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD007123. DOI: 10.1002/14651858.CD007123.pub3.

Author Information

  1. 1

    Nottingham University Hospitals NHS Trust, Department of Obstetrics and Gynaecology, Nottingham, UK

  2. 2

    Queens Medical Center, Fetomaternal Medicine, Nottingham, UK

  3. 3

    University of Nottingham, Department of Obstetrics and Gynaecology, Nottingham, Nottinghamshire, UK

*George J Bugg, Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus, Derby Road, Nottingham, NG12 4AA, UK. george.bugg@nuh.nhs.uk.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 23 JUN 2013

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Characteristics of included studies [ordered by study ID]
Bidgood 1987

MethodsRCT.


Participants60 nulliparous women were recruited to the study. All the women were spontaneous labour, with vertex presenting and within 3 weeks of term. The diagnosis of labour was established by full effacement of the cervix and a dilatation of at least 3 cm, regular contractions with a frequency of at least 1 every 5 min and partographic evidence of cervical progress. All women had ruptured membranes prior to randomisation. Slow progress in labour was diagnosed if the rate of cervical dilatation was less than 0.5 cm/hour.


InterventionsThere were 3 management groups: 1) the expectant management group (n = 20) where oxytocin was deferred for 8 hours and given at the discretion of the supervising clinician; 2) a low-dose oxytocin group (n = 20) where the oxytocin was infused at an initial rate of 2 mU/min and increased by 2 mU/min every 15 minutes until stable contractions; and 3) a high-dose oxytocin intervention group (n = 20) where the oxytocin infusion was started at 7 mU/min and increased by 7 mU/min every 15 min, limited by a frequency of 7 contractions in 15 minutes.


Outcomes
  • Mode of delivery
  • Hyperstimulation
  • Rate of cervical dilation
  • Admission to delivery time
  • Randomisation to delivery interval
  • Duration of second stage
  • Cord pH artery at delivery
  • Apgar score < 7 at 5 mins


NotesFor the purposes of this review the 2 oxytocin groups were combined to form the experimental group (n = 40) and were compared with the expectant management group acting as the control group (n = 20).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk150 envelopes were "shuffled at the beginning of the study".

Allocation concealment (selection bias)Low riskSealed envelopes kept in a location apart from the delivery suite.

Blinding (performance bias and detection bias)
Rate of cervical dilatation prior to randomisation
High risk

Blinding (performance bias and detection bias)
Rate of cervical dilation post randomisation
High risk

Blinding (performance bias and detection bias)
Operative vaginal delivery rates
High risk

Blinding (performance bias and detection bias)
Caesarean section rate
High risk

Blinding (performance bias and detection bias)
Hyperstimation rates
High risk

Blinding (performance bias and detection bias)
Delay delivery interval
High risk

Blinding (performance bias and detection bias)
Length of second stage
High risk

Blinding (performance bias and detection bias)
Analgesia requirements
High risk

Blinding (performance bias and detection bias)
Arterial cord gas
High risk

Blinding (performance bias and detection bias)
Apgar scores
High risk

Blinding (performance bias and detection bias)
Admission to NNU
High risk

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThere was no trial flow diagram. There was no mention of missing envelopes.

Selective reporting (reporting bias)Unclear riskThe trial had been approved by an ethics committee but the protocol had not been otherwise registered.

Other biasHigh riskThe original plan was to recruit 50 participants per group giving a total of 150. In fact only 60 were recruited due to 'limitations of time'.

Blanch 1998

MethodsRCT.


Participants61 women (both primiparous and multiparous women) making slow progress in the active phase of spontaneous labour with intact membranes were randomised. Inclusion criteria were singleton fetus; cephalic presentation; gestation greater than 37 weeks; full cervical effacement; cervical dilatation greater than 3 cm dilation, with at least 1 contraction in every 5 mins. Slow progress in labour was diagnosed by using a partogram with an alert line representing cervical dilatation of 1 cm per hour and an action line drawn 3 hours to the right of the action line.


InterventionsIn the amniotomy and oxytocin group (n = 21) the infusion was started immediately after amniotomy. In the amniotomy alone group (n = 20) and the expectant management group (n = 20), if progress was still slow after 4 hours management of labour was shifted to the standard labour ward protocol which included the use of oxytocin. The oxytocin infusion started with 2 mU/min and doubled every 30 minutes.


Outcomes
  • Cervical dilatation rate
  • Before randomisation
  • After randomisation during first 4 hours
  • After randomisation until delivery
  • Randomisation - delivery interval (mins)
  • Epidural analgesia
  • Caesarean section
  • Failure to progress
  • Fetal distress
  • Instrumental delivery
  • Cord pH
  • Apgar < 7 at 5 mins
  • Admission to NNU


NotesIn order to only study the effects of intravenous oxytocin on labour, we compared the amniotomy and oxytocin group with the amniotomy alone group. Women in the expectant management group were not included in the review. Nulliparous women represented 76% of the experimental group and 70% of the control group. Although nulliparous and multiparous women were randomised separately they have been analysed together. For this review 30 primiparous women and 11 multiparous women were included.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskThe allocation sequence was determined using a table of random numbers.

Allocation concealment (selection bias)Low riskConsecutively numbered sealed opaque envelopes were used.

Blinding (performance bias and detection bias)
Rate of cervical dilatation prior to randomisation
High risk

Blinding (performance bias and detection bias)
Rate of cervical dilation post randomisation
High risk

Blinding (performance bias and detection bias)
Operative vaginal delivery rates
High risk

Blinding (performance bias and detection bias)
Caesarean section rate
High risk

Blinding (performance bias and detection bias)
Hyperstimation rates
High risk

Blinding (performance bias and detection bias)
Delay delivery interval
High risk

Blinding (performance bias and detection bias)
Length of second stage
High risk

Blinding (performance bias and detection bias)
Analgesia requirements
High risk

Blinding (performance bias and detection bias)
Arterial cord gas
High risk

Blinding (performance bias and detection bias)
Apgar scores
High risk

Blinding (performance bias and detection bias)
Admission to NNU
High risk

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThere was no trial flow diagram. Missing data was recorded for cord pH (7 cases) and base excess (12 cases) but not for the pre-specified outcomes in the review.

Selective reporting (reporting bias)Unclear riskThe trial was not registered.

Other biasUnclear riskThe intended sample size was 'at least' 120 in 3 groups. However, the achieved sample size was 60 in 3 groups. 1 participant was randomised in error because of a breech presentation and excluded from analysis.

Cheewawattana 1991

MethodsDouble blinded RCT.


ParticipantsThe trial included 87 nulliparous women in the active phase of labour diagnosed as cervical dilatation equal to 4 cm. Slow progress in labour was diagnosed when uterine contractions were less than 3 times in 10 minutes.


InterventionsThe women either received an Intravenous infusion of 5% dextrose saline including oxytocin 10 units/litre (n = 45) or a placebo infusion of 5% dextrose saline (n = 42).The initial infusion rate was started at 5 drops per minute and increased by 2 drops per minute until contractions were sufficient or up to a maximal dose of 40 drops per minute.


Outcomes
  • The successful rate of delivery after augmentation (%)
  • Mode of delivery (normal delivery, caesarean section, instrumental vaginal delivery)
  • Obstetrics complications
  • Indication of obstetrics operation
  • Analgesic drug used
  • Deterioration in the fetal heart rate
  • Apgar score at 1 and 5 mins


NotesThe paper needed to be translated from Thai to English


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo details were given. The method described was 'drawing lots'.

Allocation concealment (selection bias)Unclear riskNo details were given. The method described was 'drawing lots'.

Blinding (performance bias and detection bias)
Rate of cervical dilatation prior to randomisation
Unclear riskNo details were given. The method was 'drawing lots'.

Blinding (performance bias and detection bias)
Rate of cervical dilation post randomisation
Low risk

Blinding (performance bias and detection bias)
Operative vaginal delivery rates
Low risk

Blinding (performance bias and detection bias)
Caesarean section rate
Low risk

Blinding (performance bias and detection bias)
Hyperstimation rates
Low risk

Blinding (performance bias and detection bias)
Delay delivery interval
Low risk

Blinding (performance bias and detection bias)
Length of second stage
Low risk

Blinding (performance bias and detection bias)
Analgesia requirements
Low risk

Blinding (performance bias and detection bias)
Arterial cord gas
Low risk

Blinding (performance bias and detection bias)
Apgar scores
Low risk

Blinding (performance bias and detection bias)
Admission to NNU
Low risk

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAll the outcomes were reported for caesarean section and instrumental vaginal delivery. Missing data were not clearly reported for other outcomes.

Selective reporting (reporting bias)Unclear riskThe trial protocol was not registered.

Other biasUnclear riskData was extracted from a partial translation from Thai to English.

Dencker 2009

MethodsRCT.


Participants630 nulliparous women with primary dysfunctional spontaneous labour were included in the study. All women had low-risk pregnancies and were at greater than 37 weeks but less than 42 weeks of gestation. Active labour was defined when the cervical dilatation was greater than 4 cm. Slow progress in labour was defined when the rate of cervical dilatation was less than 1 cm over 3 hours or there was no cervical dilatation over 2 hours.


InterventionsWomen were either randomised into the intervention group (n = 314) where an oxytocin infusion was started within 20 mins of randomisation or the control group (n = 316) where oxytocin was withheld for a period of 3 hours. Oxytocin was infused at a rate of 3.3 mU/min and raised by 3.3 mU/mins every 30 minutes until efficient contractions were achieved.


Outcomes
  • Mode of delivery
  • Instrumental deliveries (for either failure to progress or non-reassuring CTG)
  • LSCS (failure to progress, failed instrumental, non reassuring CTG, non reassuring CTG abnormal scalp pH)
  • Spontaenous vaginal delivery
  • Duration of labour
  • Randomisation to delivery interval
  • Haemorrhage
  • Haemorrhage > 1000 ml
  • Sphincter laceration
  • Epidural analgesia
  • Birthweight
  • Head circumference
  • Apgar score < 7 at 5 mins
  • Arterial pH in umbilical artery
  • Arterial pH < 7 and BE <-12
  • Transferred to NICU
  • Days in NICU
  • Phototherapy treatment
  • Visual analogue scale assessment of pain
  • Women's experiences (Childbirth Experience Questionnaire)


Notes36 cases did not meet the randomisation criteria; however, these were subsequently added to the 593 giving a total no of 630. Within the experimental group there were 16 such cases; 11 were randomised at a cervical dilatation of 10 cm, 1 at 3 cm of cervical dilatation, 1 at 42 weeks of gestation and 3 before amniotomy. Within the control group 21 women were randomised in error, 9 were randomised at a cervical dilatation of 10 cm, 5 at 3 cm of cervical dilatation, 3 at 42 weeks of gestation and 4 before amniotomy.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomisation was performed in blocks of 10 using a computer randomisation sequence generation program.

Allocation concealment (selection bias)Low riskOpaque sealed serially numbered [envelopes] were placed in another department.

Blinding (performance bias and detection bias)
Rate of cervical dilatation prior to randomisation
Low risk

Blinding (performance bias and detection bias)
Rate of cervical dilation post randomisation
High risk

Blinding (performance bias and detection bias)
Operative vaginal delivery rates
High risk

Blinding (performance bias and detection bias)
Caesarean section rate
High risk

Blinding (performance bias and detection bias)
Hyperstimation rates
High risk

Blinding (performance bias and detection bias)
Delay delivery interval
High risk

Blinding (performance bias and detection bias)
Length of second stage
High risk

Blinding (performance bias and detection bias)
Analgesia requirements
High risk

Blinding (performance bias and detection bias)
Arterial cord gas
High risk

Blinding (performance bias and detection bias)
Apgar scores
High risk

Blinding (performance bias and detection bias)
Admission to NNU
High risk

Incomplete outcome data (attrition bias)
All outcomes
Low risk

Selective reporting (reporting bias)Unclear riskThe trial was not registered. Although the data collection was completed in 2003 the trial was not reported until 2008.

Other biasLow riskA sample of 247 per group was estimated to have 80% power (alpha 0.05) to show an increase in spontaneous vaginal delivery from 81.2% to 90%. The intended sample size was increased by 20% to 296 per group to allow for protocol violations. The achieved sample size was 314 and 316 per group respectively.

Hemminki 1985

MethodsRCT.


Participants57 women with singleton pregnancies in active but protracted labour were randomised in this study. 24 multiparous women were included in this study. Active labour defined as regular contractions (more than 2 contractions in 10 mins) with dilatation of the cervix. Slow progress in labour was determined by the doctors in charge. The study protocol gave an advisory definition: no progress in the cervical dilatation or with no descent of the fetus as shown by 2 examinations 2 hours apart. If the membranes were still intact at the time protracted labour was diagnosed, amniotomy was performed. At least 2 hours were then allowed to elapse to see whether labour began to progress.


InterventionsWomen randomised to oxytocin group (n = 27) received the standard treatment of the hospital; oxytocin was given by intravenous drip and controlled by hand according to the clinical response. The control group (n = 30) consisted of ambulant women; ambulation was considered to have failed if: 1) 4 hours had elapsed since randomisation without any progress; 2) 8 hours had elapsed from randomisation and the child’s birth was not expected within a short period of time (about 1 hour). When the treatment was judged to have failed, the women were given oxytocin or other appropriate treatment.


Outcomes
  • Randomisation-delivery interval (mins)
  • Epidural analgesia
  • Caesarean section
  • Failure to progress
  • Fetal distress
  • Instrumental delivery
  • Blood loss
  • Apgar < 7 at 5 mins
  • Admission to NNU
  • Women's experiences of labour


NotesFor the purposes of this review ambulation was not considered to be an active intervention. Women in the ambulant group were given delayed oxytocin if they failed to progress after a prescribed time interval. Nulliparous women represented 56% of the experimental group and 60% of the control group. Although nulliparous and multiparous women were randomised separately, they have been analysed together.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe method of sequence generation was not properly reported, women were just described as being 'randomly allocated'.

Allocation concealment (selection bias)Low riskSealed envelopes were reportedly used.

Blinding (performance bias and detection bias)
Rate of cervical dilatation prior to randomisation
High risk

Blinding (performance bias and detection bias)
Rate of cervical dilation post randomisation
High risk

Blinding (performance bias and detection bias)
Operative vaginal delivery rates
High risk

Blinding (performance bias and detection bias)
Caesarean section rate
High risk

Blinding (performance bias and detection bias)
Hyperstimation rates
High risk

Blinding (performance bias and detection bias)
Delay delivery interval
High risk

Blinding (performance bias and detection bias)
Length of second stage
High risk

Blinding (performance bias and detection bias)
Analgesia requirements
High risk

Blinding (performance bias and detection bias)
Arterial cord gas
High risk

Blinding (performance bias and detection bias)
Apgar scores
High risk

Blinding (performance bias and detection bias)
Admission to NNU
High risk

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThe number of participants with valid outcomes was not reported. Outcome data were reported as percentages or as means with standard deviations.

Selective reporting (reporting bias)Unclear riskThe trial protocol was not registered.

Other biasUnclear riskNo pre-determined sample size estimate or power calculation was reported.

Hinshaw 2008

MethodsRCT.


Participants412 low-risk nulliparous women at term (37 to 42 weeks) were randomised to this study. All the women had a low-risk pregnancy with a singleton fetus presenting by the vertex. Slow progress in labour was defined as when the cervical dilatation had progressed by 2 cm or less over 4 hours from an initial dilatation of between 3 cm and 6 cm. As a result women with secondary arrest of labour were excluded from the study.


InterventionsAll participating women underwent amniotomy if the membranes were intact prior to randomisation. Women randomised to active management (n = 208) commenced an oxytocin infusion within an intended 20 mins of randomisation. If the participant was randomised to conservative management (n = 204), oxytocin was withheld for a period of 8 hours unless intervention became clinically indicated. The oxytocin was infused at a rate of 2 mU/min, increasing every 30 minutes until 4 contractions were achieved in 5 minutes or a maximum infusion rate of 32 mU/min.


Outcomes
  • Rate of cervical dilatation after randomisation
  • Incidence of hyperstimulation
  • Randomisation to delivery interval
  • Length of second stage
  • Analgesic requirements
  • Instrumental deliveries (for either failure to progress or non reassuring CTG)
  • LSCS (failure to progress, failed instrumental, non reassuring CTG, non reassuring CTG abnormal scalp pH)
  • Maternal psychological well being at 48 hrs and 2 weeks (Edingburgh Post Natal Scale; Labour agency Scale, McGill Pain Questionaire, Attitudes towards Pregnancy and the Baby Scales)
  • Postnatal maternal infection
  • Arterial cord pH
  • Apgar scores
  • Intubation
  • Admission to NNU
  • Serious perineal sequelae


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskA computer generated randomisation sequence was stratified by the unit.

Allocation concealment (selection bias)Low riskNumbered, sealed, opaque envelopes were kept on a gynaecology ward.

Blinding (performance bias and detection bias)
Rate of cervical dilatation prior to randomisation
Low risk

Blinding (performance bias and detection bias)
Rate of cervical dilation post randomisation
High risk

Blinding (performance bias and detection bias)
Operative vaginal delivery rates
High risk

Blinding (performance bias and detection bias)
Caesarean section rate
High risk

Blinding (performance bias and detection bias)
Hyperstimation rates
High risk

Blinding (performance bias and detection bias)
Delay delivery interval
High risk

Blinding (performance bias and detection bias)
Length of second stage
High risk

Blinding (performance bias and detection bias)
Analgesia requirements
High risk

Blinding (performance bias and detection bias)
Arterial cord gas
High risk

Blinding (performance bias and detection bias)
Apgar scores
High risk

Blinding (performance bias and detection bias)
Admission to NNU
High risk

Incomplete outcome data (attrition bias)
All outcomes
Low risk

Selective reporting (reporting bias)Unclear riskThe trial protocol was not registered. Recruitment ended in 2001; however, the trial was not published until 2008.

Other biasLow risk

Illia 1996

MethodsDouble blind RCT.


Participants37 nulliparous women were randomised. All pregnancies were low risk with a gestational age greater than or equal to 38 weeks. All women were in active labour, defined as a cervical dilatation greater than 4 centimetres, 50% of cervical effacement and with at least 2 uterine contraction in 10 minutes. Slow progress in labour was defined as cervical dilatation less than 2 centimetres over 4 hours.


InterventionsThis was a double blinded study; both the experimental (n = 14) and control group (n = 23) received an identical infusion of saline, only the experimental group's infusion contained oxytocin (10 units/litre).


Outcomes
  • Rate of cervical dilatation before randomisation
  • Rate of cervical dilatation after randomisation
  • Delay - delivery interval
  • Length of second stage
  • Instrumental deliveries
  • Caesarean section
  • Arterial cord pH
  • Apgar scores


NotesThe authors state that the difference in the size of the groups was due to the randomisation. The original paper was in Spanish and was translated to English.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer generated.

Allocation concealment (selection bias)Low riskMethod not reported.

Blinding (performance bias and detection bias)
Rate of cervical dilatation prior to randomisation
Low riskDouble blind.

Blinding (performance bias and detection bias)
Rate of cervical dilation post randomisation
Low risk

Blinding (performance bias and detection bias)
Operative vaginal delivery rates
Low risk

Blinding (performance bias and detection bias)
Caesarean section rate
Low risk

Blinding (performance bias and detection bias)
Hyperstimation rates
Low risk

Blinding (performance bias and detection bias)
Delay delivery interval
Low risk

Blinding (performance bias and detection bias)
Length of second stage
Low risk

Blinding (performance bias and detection bias)
Analgesia requirements
Low risk

Blinding (performance bias and detection bias)
Arterial cord gas
Low risk

Blinding (performance bias and detection bias)
Apgar scores
Low risk

Blinding (performance bias and detection bias)
Admission to NNU
Low risk

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo reason given for disparity in group sizes; the authors state that the difference in the size of the groups was due to the randomisation but this is very unlikely.

Selective reporting (reporting bias)Unclear riskThe trial protocol was not published.

Other biasUnclear riskThere was no predetermined sample size.

Read 1981

MethodsRCT.


Participants14 women were randomised to his study, 10 of these women were nulliparous, 4 were multiparous. All women had ruptured membranes, were thought to have failure to progress in labour over 1 to 2 hours, had inadequate contractions and were deemed by the attending clinician to need augmentation. The average gestation of the women was 40 weeks.


InterventionsWomen randomised to the experimental group received oxytocin infusions (n = 6) and those in the ambulatory group (n = 8) remained out of bed, walking, standing and sitting. Oxytocin was infused at a rate of 0.2 mU/min and increased every 15 minutes until a contraction occurred every 2-3 minutes.


Outcomes
  • Normal spontaneous vaginal delivery
  • Forceps
  • Caesarean section
  • Apgar score at 1 min
  • Apgar score at 5 mins


NotesThis was a pilot study. For the purposes of this review ambulation was not considered to be an active intervention.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThis was not reported.

Allocation concealment (selection bias)Unclear riskThis was not reported.

Blinding (performance bias and detection bias)
Rate of cervical dilatation prior to randomisation
Unclear riskThis was not reported.

Blinding (performance bias and detection bias)
Rate of cervical dilation post randomisation
High risk

Blinding (performance bias and detection bias)
Operative vaginal delivery rates
High risk

Blinding (performance bias and detection bias)
Caesarean section rate
High risk

Blinding (performance bias and detection bias)
Hyperstimation rates
High risk

Blinding (performance bias and detection bias)
Delay delivery interval
High risk

Blinding (performance bias and detection bias)
Length of second stage
High risk

Blinding (performance bias and detection bias)
Analgesia requirements
High risk

Blinding (performance bias and detection bias)
Arterial cord gas
High risk

Blinding (performance bias and detection bias)
Apgar scores
High risk

Blinding (performance bias and detection bias)
Admission to NNU
High risk

Incomplete outcome data (attrition bias)
All outcomes
Low risk

Selective reporting (reporting bias)High riskThe trial protocol was not registered.

Other biasHigh riskThere was no predetermined sample size. The study was reported as a 'pilot' but no definitive trial has subsequently appeared.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Arraztoa 1994This is a study of augmentation after caesarean section and previous caesarean section is one of the exclusion criteria for this review.

Arulkumaran 1989aThis is a trial of monitoring the strength of the uterine contractions and did not report on any of the primary and secondary outcomes listed in the methods.

Breart 1992This study was a randomised controlled study of amniotomy and oxytocin with existing protocols. Only a proportion of women in the experimental group received oxytocin and it was not clear whether any effect was due to amniotomy or oxytocin or both.

Cammu 1996This study was a randomised controlled study comparing a package of active management with existing protocols. Only 53% of women in the active arm received oxytocin, and all received other co-interventions.

Cardozo 1990This was a randomised controlled study of oxytocin versus saline, the subjects were crossed over from active treatment to saline after 6 hours in primigravida and 3 hours in multigravidas. The patients who were not responding the oxytocin were also crossed over to the saline treatment at the same time. There was also loss to follow-up of a large proportion of randomised women. It was not possible to extract outcome data by initial allocation group.

Chalk 1969This study investigated the effects of buccal oxytocin in women whose labour had been failed to be induced by artificial membrane rupture alone.

Cluett 2001This pilot study compared labouring in water versus augmentation with oxytocin. Only 4 women were recruited to each arm. The group felt that labouring in water was an active intervention.

Cluett 2004The studied compared labouring in water with augmentation with oxytocin. The group felt that labouring in water was an active intervention.

Compitak 2002The randomised controlled study compared 2 different regimes of oxytocin administration for the induction of labour at term.

Curtis 1999This study compared the effect of nipple stimulation with oxytocin in prolonged active labour. The group felt that nipple stimulation was an active intervention

Daniel-Spiegel 2001This randomised controlled study studied the effects of continuing oxytocin into the 2nd stage of labour. The study was excluded as it was not designed to study the effects on a prolonged active first stage.

Fraser 1988This was a meta-analysis of 12 studies comparing a policy of early labour with amniotomy and oxytocin.

Grubb 1996This was a study of the effects of the active management of latent labour with an unknown uterine scar. As the study was primarily on patients who had had a previous caesarean section the study was excluded.

Hunter 1991Healthy nulliparous women were randomised to either aggressive or expectant management protocols based on 2 different definitions of slow progress, a 'tight' definition and a 'less tight' definition. All women were in normal spontaneous active labour at randomisation. Only women who ultimately had slow progress in labour after randomisation would receive oxytocin. Only 51.6% and 40.5% actually received oxytocin in either group respectively and this is the reason for this study's exclusion.

Kececi 1994Abstract of a randomised controlled trial investigating the effects of oxytocin on the rate of operative delivery and maternal morbidity. Unfortuantely the method of randomisation was not described and no analytical data were presented in the abstract.

Labrecque 1994This was a study of the effects of oxytocin on the latent phase of labour.

Majoko 2001This study compared high-dose oxytocin protocols to low dose and was therefore excluded from the review.

Pattinson 2003Healthy nulliparous women were randomised to either aggressive or expectant management protocols based on the use of different alert lines on partograms and which included the use of oxytocin. All women were in normal spontaneous active labour at randomisation. Only women who ultimately had slow progress in labour after randomisation received oxytocin and this is the reason for this studies exclusion.

Pickrell 1989This study was excluded as it was designed to study the effects of augmentation in the second stage in women who had an epidural.

Qui 1999This study examined the use of a Chinese herbal medicine (Chanlibao) in 2nd stage of labour.

Rogers 1997This study compared active management with usual care protocols. Only 56% of women in the active management group were commenced on oxytocin and they also received many other co-interventions.

Rouse 1994  This studied compared oxytocin augmentation with intact membranes against oxytocin augmentation with the membranes absent.

Sadler 2000This study compared active management with routine care. Only 53% of the women in the active management group were commenced on oxytocin and they also received many other co-interventions.

Setchik 1982This study determine the effectiveness of a specific oxytocin dose on uterine contractility.

Shennan 1995Women having an epidural, not necessarily in primary dysfunctional labour, were randomised into having a oxytocin infusion or placebo.

Stein 1990This was a randomised controlled study comparing nipple stimulation with augmentation with oxytocin. Nipple stimulation was considered to be an active intervention.

Van Lier 1987This was a randomised controlled study comparing nipple stimulation with augmentation with oxytocin. Nipple stimulation was considered to be an active intervention.

Zhang 1994The women in this study were randomised to receive either oxytocin or chanliboa, a herbal Chinese medicine which strengthens uterine contractions.

 
Comparison 1. Intravenous oxytocin versus no treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Caesarean section3138Risk Ratio (M-H, Fixed, 95% CI)0.84 [0.36, 1.96]

 2 Instrumental vaginal delivery3138Risk Ratio (M-H, Fixed, 95% CI)1.04 [0.45, 2.41]

 3 Apgar score less than seven at five minutes187Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Normal vaginal delivery3138Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.84, 1.25]

 
Comparison 2. Early use of intravenous oxytocin versus delayed use

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Uterine hyperstimulation with fetal heart rate changes necessitating intervention2472Risk Ratio (M-H, Fixed, 95% CI)2.51 [1.04, 6.05]

 2 Caesarean section51200Risk Ratio (M-H, Fixed, 95% CI)0.88 [0.66, 1.19]

 3 Serious neonatal morbidity or perinatal death2469Risk Ratio (M-H, Fixed, 95% CI)0.98 [0.06, 15.57]

 4 Uterine hyperstimulation without fetal heart rate changes160Risk Ratio (M-H, Fixed, 95% CI)6.66 [0.39, 112.60]

 5 Epidural analgesia31083Risk Ratio (M-H, Random, 95% CI)0.90 [0.76, 1.06]

 6 Instrumental vaginal delivery51200Risk Ratio (M-H, Random, 95% CI)1.17 [0.72, 1.88]

 7 Apgar score less than seven at five minutes51200Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.46, 2.28]

 8 Neonatal intensive care unit admission41140Risk Ratio (M-H, Fixed, 95% CI)0.95 [0.60, 1.50]

 9 Postpartum haemorrhage31099Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.59, 1.15]

 10 Woman not satisfied1281Mean Difference (IV, Fixed, 95% CI)3.00 [-3.33, 9.33]

 11 Woman not satisfied (number of women with negative memories of childbirth)1442Risk Ratio (M-H, Fixed, 95% CI)1.04 [0.84, 1.30]

 12 Woman not satisfied (number of women saying depressed by childbirth experience)1442Risk Ratio (M-H, Fixed, 95% CI)0.94 [0.71, 1.23]

 13 Normal vaginal delivery41143Risk Ratio (M-H, Random, 95% CI)1.02 [0.88, 1.19]

 14 Emergency caesarean section for fetal distress3909Risk Ratio (M-H, Fixed, 95% CI)1.08 [0.59, 2.00]

 15 Time from randomisation to delivery31083Mean Difference (IV, Random, 95% CI)-2.20 [-3.29, -1.10]

 16 Women undelivered after 12 hours from randomisation21042Risk Ratio (M-H, Random, 95% CI)0.32 [0.07, 1.43]