Management of Labor

Conclusion Grading Worksheet B – Annotation #66 Management of Labor
(Management of Protracted Labor) Third Edition/May 2009
Authors' Conclusions/
Work Group's Comments (italicized)
Population Studied/Sample Size Primary Outcome Measure(s)/Results (e.g., p-value,
confidence interval, relative risk, odds ratio, likelihood
ratio, number needed to treat)
-5 trials were nulliparous women only; 4 were mix
comparing routine amniotomy of nulliparous and multiparous
to an attempt to conserve the -Use of oxytocin varied in studies (heterogeneity)
membranes; categorical data -Early use of amniotomy leads to an average reduc-
available on major indicators of tion of labor duration of 60-120 minutes; length of
maternal & neonatal morbidity; labor (from randomization to delivery) was signifi-
acceptable methodological qualcantly reduced by 54 minutes in early amniotomy
ity, no evidence of systematic group (NOTE: data from 3 studies)
error in randomization or fol- -Incidence of dystocia was reduced in the amniotlow-up
processes; women in omy group (OR=0.63) (NOTE: data from 1 study)
spontaneous labor
-Trend toward increased risk of Caesarean with
early amniotomy
Class Quality
+,–,ø
Author/Year Design
Type
-Amniotomy is an effective method to
shorten labor duration and reduce the frequency
of oxytocin administration. There
was no evidence of adverse neonatal consequences.
It would seem reasonable to reserve
amniotomy for labors that are progressing
slowly.
M N/A -Included: 9 randomized trials
Systematic
Review
Fraser, Turcot,
Krauss, Brisson-Carrol
(2000)
NOTES: studies were done in centers where
a large proportion of mothers received
epidural anesthesia; compliance with the
conservative approach was low
-The management protocol used in this study
resulted in a high rate of vaginal delivery
(92%) with no severe adverse maternal, fetal
or neonatal outcomes. Extending the minimum
period of oxytocin augmentation for
active-phase labor from 2 to at least 4 hours
was effective and safe.
Case
Series
Rouse, Owen,
& Hauth (1999)
Institute for Clinical Systems Improvement
NOTES: oxytocin dose was one m#/min increased
every 15 min over 2 hrs to
30m#/min; 93% received continuous lumbar
epidural analgesia
-542 eligible: 288 (53%) nulliparous, 254 (47%)
parous; groups were similar demographically
-Vaginal delivery rate 92% overall (97% for parous
group, 88% for nulliparous)
-Vaginal delivery rates among those with no progress
after 2 hrs of oxytocin: 91% for parous group,
74% for nulliparous group
-Vaginal delivery rates among those with no progress
after 4 hrs of oxytocin: 88% for parous group,
56% for nulliparous group
-No uterine rupture or hysterectomy; rates of
chorioamnionitis (10%) and endometritis (5%) were
higher for nulliparas than parous women (both 2%);
labor progress (or lack thereof) correlated with risk
of maternal infectious complications
-No stillbirths or neonatal deaths; complications did
not differ based on whether there was labor progress,
no progress, or no examination
-42 Caesarean deliveries (24 labor arrest, 10
non-reassuring fetal status, 8 both labor arrest and
non-reassuring status)
D ø -Women !36 wks gestation with
1) spontaneous active phase labor
(dilatation !4 cm, at least 2
contractions in 10 minutes) & 2)
labor arrest ("1 cm cervical
progress in 2 hrs)
-Excluded: nonvertex presentation;
previous Caesarean delivery;
multiple gestation; nonreassuring
FHR tracing,
chorioamnionitis, or spontaneous
contractions !250 Montevideo
units at time of labor arrest
-Oxytocin administered at diagnosis
of active-phase labor arrest;
Caesarean delivery for labor
arrest done after 4 hrs of
oxytocin with sustained contraction
pattern >200 Montevideo
units or 6 hrs oxytocin regardless
of contraction pattern
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