Cochrane for Clinicians
Putting Evidence into Practice
Oxytocin Augmentation During Labor with Epidural Analgesia
Am Fam Physician. 2013 Jun 1;87(11):760-761.
Does oxytocin (Pitocin) augmentation of labor in women with epidural analgesia decrease the rate of operative deliveries, or neonatal and maternal morbidity?
Oxytocin augmentation does not reduce the frequency of cesarean delivery, instrumental vaginal delivery, or the combined outcome of both. Oxytocin also has no effect on low five-minute Apgar scores, postpartum hemorrhage, uterine hyperstimulation, or neonatal intensive care unit admission. (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)
Many commonly practiced labor interventions aim to propel labor forward,1,2 based on the assumption that longer labor is associated with more maternal or neonatal complications. Evidence indicates that epidural analgesia prolongs the second stage of labor and increases the frequency of instrumental deliveries.3 Oxytocin augmentation of labor with epidural analgesia might then improve outcomes. But, does evidence support this assumption?
The authors searched the Cochrane Pregnancy and Childbirth Group's Trials Register and found two high-quality randomized controlled trials that addressed the topic. Both trials studied the effect of oxytocin augmentation on nulliparous women at different stages of labor. The first study randomized 226 fully dilated patients to oxytocin infusion (2 to 16 mU per minute) or saline.4 Oxytocin shortened the duration of the second stage of labor (134 vs. 151 minutes; P = .04) and increased the rate of rotational forceps deliveries (18% vs. 9%; P = .03), but did not affect the rate of nonrotational deliveries, overall forceps deliveries, cesarean deliveries, or fetal outcomes. The second study randomized 93 patients who were dilated to 6 cm or less to artificial rupture of membranes and oxytocin (2 to 32 mU per minute) or to saline infusion, and evaluated the same newborn outcomes as above.5 Oxytocin hastened completion of the first stage of labor (578 vs. 696 minutes; P < .05), but changed no other outcomes.
These data may have limited applicability to current U.S. practice because of the low rates of cesarean deliveries (3% and 16%) and the high rates of forceps deliveries (53% and 58%) in both trials.4,5 In 2010, the primary cesarean delivery rate in the United States was 23.6%.6 Currently, the rate of vacuum-assisted deliveries in the United States is about 3%, whereas the rate of forceps deliveries is 0.6%.1 On the other hand, doses of oxytocin in the two trials were the same as those used today.4,5
Although oxytocin augmentation of labor with epidural analgesia appears to modestly reduce labor duration, evidence does not show other clinical benefits. In addition, recent cohort studies have shown that our assumptions about the proper speed of labor should be tempered. Spontaneous yet healthy successful labor is slower and more variable than the Friedman curve taught in medical school.7 Augmentation of labor should thus be employed judiciously, keeping in mind the need to balance speed and diligence.
SOURCE: Costley PL, East CE. Oxytocin augmentation of labour in women with epidural analgesia for reducing operative deliveries. Cochrane Database Syst Rev. 2012;5:CD009241.
The practice recommendations in this activity are available at http://summaries.cochrane.org/CD009241.
REFERENCESshow all references
1. Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Wilson EC, Mathews TJ. Births: final data for 2010. Natl Vital Stat Rep. 2012;61(1):1–72....
2. Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences. New York, NY: Childbirth Connection; October 2006.
3. Anim-Somuah M, Smyth RM, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. 2011;(12):CD000331.
4. Saunders NJ, Spiby H, Gilbert L, et al. Oxytocin infusion during second stage of labour in primiparous women using epidural analgesia: a randomised double blind placebo controlled trial. BMJ. 1989;299(6713):1423–1426.
5. Shennan AH, Smith R, Browne D, Edmonds DK, Morgan B. The elective use of oxytocin infusion during labour in nulliparous women using epidural analgesia: a randomised double-blind placebo-controlled trial. Int J Obstet Anesth. 1995;4(2):78–81.
6. Centers for Disease Control and Prevention. User Guide to the 2010 Natality Public Use File. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdf. Accessed September 20, 2012.
7. Zhang J, Landy HJ, Branch DW, et al.; Consortium on Safe Labor. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol. 2010;116(6):1281–1287.
These are summaries of reviews from the Cochrane Library.
The series coordinator for AFP is Corey D. Fogleman, MD, Lancaster General Hospital Family Medicine Residency, Lancaster, Pa.
A collection of Cochrane for Clinicians published in AFP is available at http://www.aafp.org/afp/cochrane.
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