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No labor progress (n 16) 88 6 13
0
No cervical examination (n 9) 78 0 11
11
* P .03.
P .02.
VOL. 93, NO. 3, MARCH 1999 Rouse et al 4-Hour Oxytocin Minimum 325
88% for nulliparas. The median time from the diagnosis
of active-phase labor arrest to the initiation of oxytocin
was 15 minutes. Analysis by whether labor had pro-
gressed (including delivery) by 2 and 4 hours after the
initiation of oxytocin demonstrated that the majority of
women with no progress despite 2 or even 4 hours of
oxytocin augmentation eventually underwent a vaginal
delivery (Tables 1 and 2). Parous women with no
progress despite 2 hours of oxytocin augmentation had
a vaginal delivery rate of 91%, whereas nulliparas had
a vaginal delivery rate of 74%. Even with no labor
progress 4 hours after the initiation of oxytocin, 88% of
parous women and 56% of nulliparas eventually deliv-
ered vaginally.
No patients experienced uterine rupture or under-
went hysterectomy. Rates of chorioamnionitis and en-
dometritis for nulliparas were 10% and 5%, respec-
tively, and both were 2% for parous women. Labor
progress (and lack thereof) correlated with the risk of
maternal infectious complications: Rates of chorioam-
nionitis and endometritis were increased among pa-
tients who had not progressed (or were not examined)
by 2 and 4 hours after the initiation of oxytocin (Tables
1 and 2). Four percent of the patients experienced
postpartum hemorrhage and 1% received a red blood
cell transfusion. The risk of red blood cell transfusion
was less consistently (and not signicantly) related to
labor progress than was the risk of maternal infection
(Tables 1 and 2). One patient experienced a postcesar-
ean abdominal wound infection.
In general, fetal and neonatal outcomes were excel-
lent. There were no stillbirths or neonatal deaths. Two
infants, one with congenital diaphragmatic hernia and
the other with multiple severe congenital malforma-
tions, died after protracted courses of disease. With the
exception of the latter infant, the lowest 5-minute Apgar
score was 6. Two infants had an umbilical artery pH of
less than 7.0. This acidemia was respiratory in nature,
and both infants were vigorous at birth. One infant,
born to a parous woman who had progressed after 2
hours of oxytocin, had a positive blood culture, re-
ceived antibiotics, and was discharged without appar-
ent sequelae on day 14 of life. Four infants were placed
on mechanical ventilation: the two who died, one with
Noonan syndrome and an associated cardiac malforma-
tion, and one with persistent fetal circulation. This last
infant, born to a parous woman who did not have a
2-hour cervical examination, was on the ventilator for
48 hours and was discharged on day 10 of life without
apparent sequelae. Six percent of the newborns received
antibiotics, and none suffered necrotizing enterocolitis,
intraventricular hemorrhage, or seizures. One percent
had hyperbilirubinemia requiring phototherapy and 2%
required supplemental oxygen (exclusive of mechanical
ventilation) outside of the delivery room. In the infants
of both parous and nulliparous patients, these compli-
cations did not differ signicantly among the three
groups (progress, no progress, and no examination
groups) at either 2 or 4 hours after the initiation of
oxytocin.
Because most women progressed after 2 hours of
oxytocin, we identied only 52 women with no
progress 2 hours after achieving a uterine contraction
pattern of greater than 200 Montevideo units. The
eventual vaginal delivery rate was 63% for the 40
nulliparas in this group and 58% for the 12 parous
women. Although this group had a high rate of mater-
nal infection (chorioamnionitis 27%, endometritis 12%),
their other outcomes were essentially equivalent to
those of the overall cohort of protocol-managed
women, with no severe adverse neonatal outcomes,
including sepsis.
Indications for the 42 cesarean deliveries performed
included labor arrest (n 24), nonreassuring fetal
status (n 10), and both labor arrest and nonreassuring
fetal status (n 8). Women who ultimately underwent
cesarean for labor arrest either had no cervical progress
after the diagnosis of labor arrest or made progress
initially but had arrest again later. These women re-
ceived oxytocin for a median duration of 7.1 hours
(range 4.313.0). Before cesarean for labor arrest, 88% of
the women achieved a uterine contraction pattern of
greater than 200 Montevideo units.
Discussion
We conducted the present investigation to evaluate a
protocol that focused on three principal elements: 1) an
intent to achieve a sustained uterine contraction pattern
of greater than 200 Montevideo units; 2) a more liberal
minimum of 4 hours (as opposed to the currently
sanctioned 2 hours
5
) of oxytocin-augmented labor ar-
rest with a sustained uterine contraction pattern of
greater than 200 Montevideo units before proceeding to
cesarean delivery for active-phase labor arrest; and 3)
for patients who could not achieve a sustained uterine
contraction pattern of greater than 200 Montevideo
units, a minimum of 6 hours of oxytocin augmentation
before proceeding to cesarean delivery for active-phase
labor arrest. Thus, we were able to address what we
perceived as two practical limitations of the current
recommendations
5
for active-phase labor arrest: 1) that
a 2-hour minimum might deny some women the op-
portunity for a safe vaginal delivery, and 2) that some
women are never able to achieve an augmented uterine
contraction pattern of greater than 200 Montevideo
units.
This protocol was effective, resulting in a high rate of
326 Rouse et al 4-Hour Oxytocin Minimum Obstetrics & Gynecology
vaginal delivery (92%), and safe, with no severe adverse
maternal and fetal or neonatal outcomes. Although the
risk of maternal infection was increased for those
women who had not progressed in labor by 2 and 4
hours after the initiation of oxytocin, the majority (80%)
of these women delivered vaginally. They therefore
avoided the attendant surgical and increased infectious
risks of cesarean delivery. Other adverse outcomes,
both maternal and neonatal, were unrelated to labor
progress 2 and 4 hours after the initiation of oxytocin.
For example, the only neonate with a positive blood
culture was born to a woman who had progressed 2
hours after the initiation of oxytocin. Thus, in terms of
decreasing the cesarean delivery rate for those women
who had not made progress in labor, the clinical benet
of extending the duration of oxytocin for active-phase
labor arrest from 2 to at least 4 hours seemed to more
than offset the observed rates of maternal and neonatal
morbidity associated with (but potentially unrelated to)
continued oxytocin augmentation.
Few studies have focused on the optimal duration of
oxytocin administration for active-phase labor arrest.
Although a strict denition of labor arrest, in terms of
uterine activity and duration of arrest, has been a
component of recent institutional programs to lower the
cesarean birth rate, in general these programs have
used the 2-hour denition of labor arrest.
6,7
Thus,
although these programs are successful, they provide
no insight into the efcacy and safety of policies that
require longer oxytocin administration in the face of
continued labor arrest. Perhaps the most relevant inves-
tigation of this issue was performed by Arulkumaran et
al.
8
In a study of 319 women of mixed parity, they
evaluated the effect of an additional 4-hour period of
oxytocin augmentation in women with unsatisfactory
progress in the active phase of labor 4 hours after the
commencement of oxytocin (less than 1 cm/hour of
cervical progress over the 4-hour period). Like us, they
demonstrated that an additional 4 hours of oxytocin
administration was benecial by allowing 48 of the 92
women (42%) with unsatisfactory labor progress to
achieve safe vaginal delivery.
The majority of women (93%) in this cohort received
continuous lumbar epidural analgesia, and this proba-
bly had an impact on their labor course. Three random-
ized clinical trials have shown that epidural analgesia
prolongs the duration of labor.
911
In response to this
observed effect, it was suggested recently
12
that when
epidural analgesia is used for pain relief during labor,
physicians should consider modifying the guidelines
for management of the rst stage of labor, as has been
done for the second stage.
13
The results of our study
support that suggestion.
We believe our ndings may have important impli-
cations for reducing the high cesarean delivery rate in
the United States. Although repeat cesarean is the
leading indication for all cesareans performed in the
United States, more than 50% of all primary cesareans
are performed for dystocia. Because dystocia was the
original indication for most repeat cesareans, it follows
that the majority of cesareans in the United States are
ultimately related to the diagnosis of dystocia.
14
More-
over, the principal reason that the cesarean delivery rate
in the United States is so much higher than in other
developed countries is that cesarean for dystocia occurs
at a much higher rate in this country. In 1990, 7.1 births
per 100 in the United States were cesareans performed
for dystocia. In turn, the United States had a high rate of
repeat cesarean delivery8.5 births per 100. Thus, as a
result of primary cesareans for dystocia (and the down-
stream consequence of repeat cesareans), the United
States has a much higher cesarean rate than other
western countries such as Sweden and Scotland (Table
3).
15
Clearly, reducing the number of cesareans per-
formed for dystocia would dramatically lower our high
national cesarean delivery rate.
The potential for reducing the number of cesarean
deliveries by adopting a more stringent denition of
dystocia (specically, of active-phase labor arrest) is
evident by considering the benets of continued oxyto-
cin augmentation in the face of continued labor arrest.
For example, 126 women in this cohort had no labor
progress despite 2 hours of oxytocin augmentation. Of
these women, 101 achieved vaginal delivery. Had we
delivered all of them by cesarean after 2 hours of
oxytocin, the cesarean delivery rate for this cohort
would have been 26%, as opposed to the 8% rate that
was achieved. In the smaller subset of women with no
progress 2 hours after achieving a uterine contraction
pattern of greater than 200 Montevideo units, continued
oxytocin augmentation allowed 32 of 52 women (62%)
to achieve vaginal delivery. Even women with no labor
progress despite 4 hours of oxytocin augmentation
beneted from the protocol: 29 of 43 such women (67%)
achieved vaginal delivery and were thereby spared an
unnecessary cesarean.
Table 3. 1990 International Comparison by Indication of
Cesarean Births per 100 Vaginal and Cesarean
Deliveries
15
Indication Sweden Scotland United States
Dystocia 1.7 4.0 7.1
Previous cesarean 3.1 3.1 8.5
Breech 1.8 2.0 2.6
Fetal distress 1.6 2.4 2.3
Other 2.4 2.7 3.2
Total 10.7 14.2 23.6
VOL. 93, NO. 3, MARCH 1999 Rouse et al 4-Hour Oxytocin Minimum 327
Certain limitations of our data warrant comment. We
studied only women in spontaneous labor who had
experienced active-phase labor arrest. Therefore, our
ndings are not directly applicable to women undergo-
ing induction of labor. The data also may not be
applicable to women who experience active-phase labor
arrest while receiving oxytocin (eg, women who receive
oxytocin for protraction disorders or according to the
principles of active management of labor). Because we
excluded women with previous cesareans and those
with chorioamnionitis at the time of active-phase labor
arrest, the safety of this protocol for such women and
their fetuses requires further investigation. Finally, al-
though we studied more than 500 women, our ability to
perform in-depth subanalyses (eg, by cervical dilatation
at labor arrest) was limited by the relatively small
numbers of women in specic subgroups.
The above limitations notwithstanding, this labor-
management protocol was safe and effective. We en-
courage others to investigate this protocol. If, with
larger samples, the efcacy and safety of this protocol
are conrmed, the minimum recommended duration of
oxytocin augmentation for active-phase labor arrest
should be increased.
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Reprints are not available.
Received June 22, 1998.
Received in revised form August 25, 1998.
Accepted September 3, 1998.
Copyright 1999 by The American College of Obstetricians and
Gynecologists. Published by Elsevier Science Inc.
328 Rouse et al 4-Hour Oxytocin Minimum Obstetrics & Gynecology