title: The effect of early oxytocin augmentation in labor: a meta-analysis.
abstract: OBJECTIVE
  To estimate the effects of early augmentation with oxytocin for slow progress of labor on the delivery method and on indicators of maternal and neonatal morbidity.
  
  
  METHODS
  We conducted electronic database searches of PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published through February 2009 using the keywords "oxytocin," "augmentation," "active management of labor," "cesarean section," and "labor." Primary authors were contacted directly if the data sought were unavailable.
  
  
  METHODS
  We included randomized controlled trials comparing early oxytocin augmentation with a more conservative approach to care in labor. We included only those studies in which membrane management was similar in the two groups. Early oxytocin augmentation was defined as immediate oxytocin administration when dystocia was identified. Data were extracted by two authors independently and evaluated for potential sources of bias. Relative risk (RR) and 95% confidence interval (CI) were calculated using fixed and random effects models.
  
  
  RESULTS
  Nine trials with 1,983 women met the inclusion criteria. Early oxytocin was associated with an increase in the probability of spontaneous vaginal delivery (RR 1.09, 95% CI 1.03-1.17). For every 20 patients treated with early oxytocin augmentation, one additional spontaneous vaginal delivery is expected. Although the point estimate for the effect on cesarean delivery (RR 0.87, 95% CI 0.71-1.06) and on operative vaginal delivery (RR 0.84, 95% CI 0.70-1.00) showed modest protective effects, the CIs for both estimates included the null effect. A decrease in antibiotic use (RR 0.45, 95% CI 0.21-0.99) was observed with early intervention. Early oxytocin was associated with an increased risk of hyperstimulation (RR 2.90, 95% CI 1.21-6.94) without evidence of adverse neonatal effects. Women in the early oxytocin group reported higher levels of pain and discomfort in labor.
  
  
  CONCLUSIONS
  Early oxytocin for augmentation in labor is associated with an increase in spontaneous vaginal delivery.
authors.affiliation: From the Department of Obstetrics and Gynecology, University of Montreal, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, the First Affiliated Hospital, Harbin Medical University, Heilongjiang, People's Republic of China.
authors.forename: Shu-Qin
authors.initials: SQ
authors.lastname: Wei
authors.forename: Zhong-Cheng
authors.initials: ZC
authors.lastname: Luo
authors.forename: Hairong
authors.initials: H
authors.lastname: Xu
authors.forename: William D
authors.initials: WD
authors.lastname: Fraser
mesh_terms: D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D007751:Labor, Induced; D007744:Obstetric Labor Complications / Q000628:therapy*; D010120:Oxytocics / Q000008:administration & dosage*; D010121:Oxytocin / Q000008:administration & dosage*; D011247:Pregnancy; D016896:Treatment Outcome
chemical_list: D010120:Oxytocics; D010121:Oxytocin
references.citation: MacDorman MF, Menacker F, Declercq E. Cesarean birth in the United States: epidemiology, trends, and outcomes. Clin Perinatol 2008;35:293–307.
references.citation: Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Breart G. Postpartum maternal mortality and cesarean delivery. Obstet Gynecol 2006;108:541–8.
references.citation: Leitch CR, Walker JJ. The rise in cesarean section rate: the same indications but a lower threshold. Br J Obstet Gynaecol 1998;105:621–6.
references.citation: Peaceman AM, Gersnoviez R, Landon MB, Spong CY, Leveno KJ, Varner MW, et al. The MFMU Cesarean Registry: impact of fetal size on trial of labor success for patients with previous cesarean for dystocia. Am J Obstet Gynecol 2006;195:1127–31.
references.citation: O’Driscoll K, Foley M, MacDonald D. Active management of labor as an alternative to cesarean section for dystocia. Obstet Gynecol 1984;63:485–90.
references.citation: Philpott RH. Obstructed labor. Clin in Obstet and Gynaecol 1982;9:625–40.
references.citation: Peisner DB, Rosen MG. Transition from latent to active labor. Obstet Gynecol 1986;68:448–51.
references.citation: Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol 2009;200:35.e1–6.
references.citation: Clark S, Belfort M, Saade G, Hankins G, Miller D, Frye D, et al. Implementation of a conservative checklist-based protocol for oxytocin administration: maternal and newborn outcomes. Am J Obstet Gynecol 2007;197:480.e1–5.
references.citation: Bréart G, Mlika-Cabane N, Kaminski M, Alexander S, Herruzo-Nalda A, Mandruzzato P, et al. Evaluation of different policies for the management of labour. Early Hum Dev 1992;29:309–12.
references.citation: Cammu H, Van Eeckhout E. A randomized controlled trial of early vs. delayed use of amniotomy and oxytocin infusion in nulliparous labor. Br J Obstet Gynaecol 1996;103:313–8.
references.citation: Cluett ER, Pickering RM, Getliffe K, St George Saunders NJ. Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labor. BMJ 2004;328:314–8.
references.citation: Cohen GR, O’Brien WF, Lewis L, Knuppel RA. A prospective randomized study of the aggressive management of early labor. Am J Obstet Gynecol 1987;157:1174–7.
references.citation: Frigoletto FD, Lieberman E, Lang JM, Cohen A, Barss V, Ringer S, et al. A clinical trial of active management of labor. N Engl J Med 1995;333:745–50.
references.citation: Hogston P, Noble W. Active management of labor—the Portsmouth experience. J Obstet Gynaecol 1993;13:340–2.
references.citation: Lopez-Zeno JA, Peaceman AM, Adashek JA, Socol ML. A controlled trial of a program for the active management of labor. N Engl J Med 1992;326:450–4.
references.citation: Rogers R, Gilson GJ, Miller AC, Izquierdo LE, Curet LB, Qualls CR. Active management of labor: does it make a difference? Am J Obstet Gynecol 1997;177:599–605.
references.citation: Sadler LC, Davison T, McCowan LM. A randomized controlled trial and meta-analysis of active management of labour. Br J Obstet Gynaecol 2000;107:909–15.
references.citation: Serman F, Benavides C, Sandoval J, Pazols R, Bermedo J, Fuenzalida R, et al. Active labour management in primiparas. Prospective study. Rev Chil Obstet Ginecol 1995;60:6–10.
references.citation: Somprasit C, Tanprasertkul C, Kamudhamas A. Reducing cesarean delivery rates: an active management labor program in a setting with limited resources. J Med Assoc Thai 2005;88:20–5.
references.citation: Tabowei TO, Oboro VO. Active management of labour in district hospital setting. J Obstet Gynaecol 2003;23:9–12.
references.citation: Rouse DJ, McCullough C, Wren AL, Owen J, Hauth JC. Active-phase labor arrest: a randomized trial of chorioamnion management. Obstet Gynecol 1994;83:937–40.
references.citation: Cummiskey KC, Gall SA, Dawood MY. Pulsatile administration of oxytocin for augmentation of labor. Obstet Gynecol 1989;74:869–72.
references.citation: Satin AJ, Leveno KJ, Sherman ML, Brewster DS, Cunningham FG. High- versus low-dose oxytocin for labor stimulation. Obstet Gynecol 1992;80:111–6.
references.citation: Lazor LZ, Philipson EH, Ingardia CJ, Kobetitsch ES, Curry SL. A randomized comparison of 15- and 40-minute dosing protocols for labor augmentation and induction. Obstet Gynecol 1993;82:1009–12.
references.citation: Xenakis EM, Langer O, Piper JM, Conway D, Berkus MD. Low-dose versus high-dose oxytocin augmentation of labor - a randomized trial. Am J Obstet Gynecol 1995;173:1874–8.
references.citation: Merrill DC, Zlatnik FJ. Randomized, double-masked comparison of oxytocin dosage in induction and augmentation of labor. Obstet Gynecol 1999;94:455–63.
references.citation: Majoko F. Effectiveness and safety of high dose oxytocin for augmentation of labour in nulliparous women. Cent Afr J Med 2001;47:247–50.
references.citation: Jamal A, Kalantari R. High and low dose oxytocin in augmentation of labor. Int J Gynaecol Obstet 2004;87:6–8.
references.citation: Cardozo L, Pearce JM. Oxytocin in active-phase abnormalities of labor: a randomized study. Obstet Gynecol 1990;75:152–7.
references.citation: Blanch G, Walkinshaw S, Alfirevic Z. Dysfunctional labour: a randomized trial. Br J Obstet Gynaecol 1998;105:117–20.
references.citation: Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:557–60.
references.citation: Moher D, Cook D, Eastwood S, Olkin I, Rennie D, Stroup D. Improving the quality of meta-analyses of randomized controlled trials: the QUOROM statement: Quality of Reporting of Meta-analyses. Lancet 1999;354:1896–900.
references.citation: Bidgood KA, Steer PJ. A randomized control study of oxytocin augmentation of labour. 1. Obstetric outcome. Br J Obstet Gynaecol 1987;94:512–7.
references.citation: Hemminki E, Lenck M, Saarikoski S, Henriksson L. Ambulation versus oxytocin in protracted labour: a pilot study. Eur J of Obstet Gynecol and Reprod Biol 1985;20:199–208.
references.citation: Hinshaw K, Simpson S, Cummings S, Hildreth A, Thornton J. A randomized controlled trial of early versus delayed oxytocin augmentation to treat primary dysfunctional labour in nulliparous women. Br J Obstet Gynaecol 2008;115:1289–95.
references.citation: Hunter DJS. Dystocia: where do we stand with the diagnosis and treatment? Contemp Rev Obstet Gynaecol 1993;5:5–8.
references.citation: Pattinson RC, Howarth GR, Mdluli W, Macdonald AP, Makin JD, Funk M. Aggressive or expectant management of labour: a randomized clinical trial. Br J Obstet Gynaecol 2003;110:457–61.
references.citation: Read JA, Miller FC, Paul RH. Randomized trial of ambulation vs. oxytocin for labor management: a preliminary report. Am J Obstet Gynecol 1981;139:669–72.
references.citation: 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;4:78–81.
references.citation: Murphy DJ, Liebling RE, Verity L, Swingler R, Patel R. Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study. Lancet 2001;358:1203–7.
references.citation: Simpson KR, James DC. Effects of oxytocin-induced uterine hyperstimulation during labor on fetal oxygen status and fetal heart rate patterns. Am J Obstet Gynecol 2008;199:34.e1–5.
references.citation: Fraser W, Venditelli F, Krauss I, Bréart G. Effects of early augmentation of labour with amniotomy and oxytocin in nulliparous women: a meta-analysis. Br J Obstet Gynecol 1998;105:189–94.
references.citation: Patka JH, Lodolce AE, Johnston AK. High- versus low-dose oxytocin for augmentation or induction of labor. Ann Pharmacother 2005;39:95–101.