Augmentation of labour

Torbjrn Moe Eggeb. Stavanger University Hospital [email protected]

Janne Rossen. Srlandet sykehus Kristiansand. [email protected]
Liv Ellingsen, Oslo University Hospital. [email protected]
Helene Christine Heide, Breum Hospital
[email protected]
Saba Muneer. Akershus University Hospital. [email protected]
Stian Westad. Lillehammer Hospital. [email protected]

Recommendations
Definition of start of labour (strong recommendation)
Definition of start of active labour, WHO definition (4 cm cervical dilation and regular
contractions (recommendation)
Use of a partogram (strong recommendation)
Definition of slow progress (strong recommendation)
Use of alert line and action line (recommendation)
Use of WHO's definition with action line delayed by 4 hours (suggestion)

Other measures to stimulate contractions such as encouraging the adoption of mobility and
upright position, empty the urine bladder and offer oral fluid and food intake before the
action line is crossed (proposal)
One to one support (strong recommendation)
Amniotomy before oxytocin augmentation (strong recommendation)
Augmentation with oxytocin is recommended in women with slow progress due to
insufficient contractions (strong recommendation)
Oxytocin augmentation may be relevant in nulliparous women with ineffective contractions in
latency phase and effaced cervix dilated <3-4 cm (proposal)
Fetal surveillance with CTG should be used in all women accelerated with oxytocin. (strong
recommendation)
Consider operative delivery after one hour with active pushing (recommendation)

Litterateur search
Up to date, pub-med, National Institute for Health and Clinical Excellence guidelines,
Cochrane Database, guidelines from the Royal College of Obstetricians & Gynaecologists,
Danish and Swedish guidelines.

Definition
The process of stimulating the uterus to increase the frequency, duration and intensity
of contractions after onset of the active phase of labour
Hyperstimulation is defined as > 5 contractions / 10 min or duration of the contraction > 2
minutes1. Stimulation of contractions should be regarded as the continuation of a
physiological process the body itself has already started (as opposed to induction of labor)2.

Stages of labour
The birth contains three stages. First stage lasts from the start of contractions until the cervix
is completely dilated. This stage is divided into a latency phase and an active phase. The
active phase starts, in accordance to the WHO's definition, when cervix is dilated to 4 cm in a
woman with regular contractions3-6. Some will define the start of active phase earlier if cervix
is effaced. The second stage lasts from cervix is fully dilated until the child is delivered and
this stage is also divided into a latency phase (until leading part has reached the pelvic floor)
and an active phase (time of bearing down)5 .The third stage is the time from the child is born
until the placenta is expelled.

The partograph
Partographs have not documented differences in perinatal or maternal morbidity or mortality7
and a Cochrane review concludes that the benefits of using a partograph are not documented8.
Nevertheless, the partograph is the most important tool in surveillance of labour progress, and
use of a partograph is strongly recommended9 [IV]. Cervical dilation and station is recorded
graphically in the partograph. WHO recommends a partograph with an alert line and an action
line delayed 4 hours. The alert line follows 1cm dilatation / hour.

WHO partograph with alert line and action line

Slow progress
No evidence for an upper limit of normal duration exists10 or the definition of how slow
progress should be defined11. However, all labour wards should have their own guideline
defining slow progress to avoid incautious use of oxytocin augmentation12. Structured care
during birth improves outcomes13 [Ib].

First stage
The latency phase can last up to 20 hours in nulliparous and 14 hours in multiparous women3,
14
. Generally it is recommended that women stay at home in the latency phase, because
hospitalisation is associated with increased use of obstetrical interventions15 [Ib]. However,
some women need hospitalization and analgesia. The follow-up should be individualised5.
Epidural analgesia can be started in the latency phase without prolonging the labour16.

Several definitions of slow progress in the active phase of labor exist.

When cervical dilatation crosses the alert line
WHO partograph with four hours delay between alert line and action line6, 17
3 hours between the lines18
2 hours between the lines7
 No change in dilatation or station within two hours3
<2cm change in dilatation during four hours5
Slow progress in the first stage active phase3
<1.2 cm / hour in nulliparous women
<1.5cm / hour in multiparous women
In a prospective study women using action line two hours delayed were most satisfied19, but
the use of action line earlier than four hours increases the need of augmentation without better
birth outcomes5, 8 [Ib]. NICE guidelines suggest using the WHO recommendations5, and we
agree.

Second stage
Active pushing should not start until the fetal head has reached the pelvic floor unless an
immediate birth is needed due to fetal distress or suspected infection. Several labour wards
practice one hour as limit for the duration of the latency phase, but other wards accept two
hours. Evidence of best practice is limited.
Some countries allow two hours of bearing down in nulliparous women5, but it is shown that
active pushing exceeding 30 minutes is associated with increased risk of asphyxia. The
probability of spontaneous delivery decreases with duration of bearing down20 [Ib]. We
suggest considering an operative delivery after 60 minutes of active pushing both in
nulliparous and multiparous women. This recommendation should also be applied in women
with epidural analgesia.

Causes of slow progress

Slow progress in labour may be due to ineffective contractions, malpresentations, fetal-
maternal disproportions (pelvis and passenger) or a combination of these factors. Problems
are more common in nulliparous women. Oxytocin augmentation is only indicated in cases
with insufficient contractions.
A clinical examination is indicated when slow progress is diagnosed. Recent studies have
shown that fetal position and level can be assessed by ultrasound21 , but routinely use cannot
be recommended due to limited evidence22.
Malpresentations as brow, mento posterior or transverse face presentations or posterior
asynclitism are incompatible with vaginal birth, but the malpresenataions often change
spontaneously. Most fetuses in occiput posterior position will rotate spontaneously (also in
the second stage)22 [IIb].

Actions when slow progress is suspected

All women in the latent phase should be offered a meal. Eating and drinking is also important
in the active phase and might effect the duration of labour23, 24 [III].
Empty the urinary bladder
Change maternal position and recommend activity
One to one supervision increases the likelihood of an uncomplicated vaginal delivery25 [Ia].
Some studies have shown that acupuncture can shorten duration of labour26, 27 [Ib].
Amniotomy shortens duration of labour, but routinely amniotomy is not recommended11, 28.
The combination of amniotomy and augmentation with oxytocin is more effective than the
use of the factors alone29 [Ib].
Amniotomy should be performed before oxytocin augmentation is started

Oxytocin augmentation
Oxytocin augmentation is recommended in women with ineffective contractions. Oxytocin
augmentation shortens birth outcomes [Ia], but an eventual reduction in instrumental delivery
is not documented, although the drug has been used for this indication in over 40 years1, 30, 31.
Clinical assessment of the strength of contractions is subjective. A huge variation in the use of
oxytocin augmentation is published, 32-60% among nulliparous women and 14-27% in
parous women32, 33.
One Swedish study has documented that the use of oxytocin is unstructured12.
Oxytocin augmentation does not affect the frequency of instrumental vaginal deliveries in
women with epidural analgesia34.
In a randomised controlled trial early augmentation with oxytocin was not associated with
better birth experience35.

Risks associated to prolonged labour

Prolonged latency phase and prolonged active birth has been associated with operative
vaginal birth, cesarean sections, chorioamnionitt, postpartum haemorrhage, low Apgar scores,
and poor birth experience causing request for cesarean section in the next birth19, 36-42. The
partograph is an important tool in recording labour progress, indications of oxytocin
augmentation and indications for operative interventions9. One to one supervision is important
when the progress in slow25.

Risks associated to oxytocin augmentation

Oxytocin is a drug with side effects and misuse may cause serious damage to the mother and
fetus43. The sensitivity of the drug is individual, and the augmentation should be
individualised1. Hyperstimulation might affect the placental circulation causing fetal distress1,
44, 45
. Hyperstimulation is one of the main causes of birth asphyxia43, 46, 47. Oxytocin
augmentation is also associated with uterine rupture, especially in women with a previous scar
in uterus48, 49.

Two special managements

Active management of labour2
This concept from the National Maternity Hospital in Dublin includes:
One to one follow-up
Duration of the active stage <12 hours
Definition of active phase
Routinely amniotomy
Vaginal examination every second hour
Oxytocin acceleration in women with cervical dilatation <1cm/hour after two hours in
active phase in nulliparous women and after four hours in multiparous women.
Active management of labour might reduce the need of cesarean sections11, but intensive
surveillance is required50, 51. New evaluations of the concept are recommended4, 51, 52.

Proactive labour
Prolonged latency phase is associated with complications for both mother and child53, 54.
Some women (<10%) have dysfunctional contractions during the latency phase and early
amniotomy and oxytocin augmentation can bring them into the active phase55. Short and
careful use of oxytocin in this phase is probably associated with less risk compared to
augmentation later in labour. One-to one support is important throughout the birth in these
women.
Administration of oxytocin
Intravenous infusion of five international units (0.01mg) oxytocin in 500 ml saline should be
administered. The infusion rate starts at 6 milliunits/minute (30 milliliter per hour), and a dose
increment by 3 milliunits/minute (15ml/h) every 15 minutes to a maximum of 40
milliunits/minute (180 ml/h) is recommended until progress in labor or regular contractions at
a rate of 3-5/10 min are achieved.
The use of 0.1ml (1IE) oxytocin im (or iv) during the final stage of labour should be avoided
because of increased risk of hyperstimulation and subsequent fetal distress. In exceptional
cases it might be indicated when the fetal head is supposed to be delivered during the next
contraction. Oxytocin augmentation should not be used in situations with shoulder dystocia.

Monitoring
The fetus should be monitored continuously with CTG (or STAN) when the labours are
accelerated with oxytocin5 [IV]. Duration, strengths and frequency of contractions should be
continuously recorded56. Continuous surveillance is mandatory and eventual hyperstimulation
should be observed. Whenever hyperstimulation is suspected the infusion rate should be
reduced or discontinued.


1. 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 Syst Rev. 2011.
2. O'Driscoll K, Meagher D, Robson M. Active management of labour : the Dublin
experience. 4th ed. ed. Edinburgh: Mosby; 2004.
3. Joy S. Abnormal labor. 2011
4. Royal Collage of Obstetricians and Gynaecologists. Active labour management -
query bank. 2011 Vurdert 20. september 2012
5. National Institute for Health and Clinical Excellence
http://www.nice.org.uk/nicemedia/live/11837/36275/36275.pdf. 2007
Retrieved March 11 2015
6. WHO.
http://www.who.int/reproductivehealth/publications/maternal_perinatal_healt
h/augmentation-labour/en/. 2014 Retrieved March 11 2015
7. Lavender T, Alfirevic Z, Walkinshaw S. Effect of different partogram action lines
on birth outcomes: a randomized controlled trial. Obstetrics and gynecology.
2006;108:295-302.
8. Lavender T, Hart A, Smyth RM. Effect of partogram use on outcomes for women
in spontaneous labour at term. Cochrane Database Syst Rev. 2008.
9. Best Practices. The partograph: an essential tool for decision-making during
labor.
10. Blix E, Kumle M, ian P. Hvor lenge kan en normal fdsel vare? Tidsskr Nor
Legeforen. 2008; 128:686-9.
11. Wei S, Wo BL, Xu H, Luo ZC, Roy C, Fraser WD. Early amniotomy and early
oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour
compared with routine care. Cochrane Database Syst Rev. 2009:CD006794.
12. Selin L, Almstrom E, Wallin G, Berg M. Use and abuse of oxytocin for
augmentation of labor. Acta Obstet Gynecol Scand. 2009;88:1352-7.
13. Hodnett ED, Stremler R, Willan AR, Weston JA, Lowe NK, Simpson KR, et al. Effect
on birth outcomes of a formalised approach to care in hospital labour assessment
units: international, randomised controlled trial. BMJ. 2008;337:a1021.
14. Friedman. The graphic analysis of labor. Am J Obstet Gynecol. 1954;68:1568-75.
15. McNiven PS, Williams JI, Hodnett E, Kaufman K, Hannah ME. An early labor
assessment program: a randomized, controlled trial. Birth. 1998;25:5-10.
16. Wang F, Shen X, Guo X, Peng Y, Gu X. Epidural analgesia in the latent phase of
labor and the risk of cesarean delivery: a five-year randomized controlled trial.
Anesthesiology. 2009;111:871-80.
17. Philpott RH. Graphic records in labour. British medical journal. 1972;4:163-5.
18. Nationella Medicinske Indikationer. Indikation fr vrkstimulering med oxytocin
under aktiv frlossning. 2011 Vurdert 20. september 2012
19. Lavender T, Wallymahmed AH, Walkinshaw SA. Managing labor using
partograms with different action lines: a prospective study of women's views.
Birth. 1999;26:89-96.
20. Yli BM KG, Rasmussen S, Khoury J, Norn H, Amer-Whlin I, Saugstad OD, Stray-
Pedersen B. How does the duration of active pushing in labor affect neonatal
outcomes? J Perinat Med. 2011;;40(2):171-8. doi:.
21. Torkildsen EA, Salvesen KA, Eggebo TM. Prediction of delivery mode with
transperineal ultrasound in women with prolonged first stage of labor.
Ultrasound in obstetrics & gynecology : the official journal of the International
Society of Ultrasound in Obstetrics and Gynecology. 2011;37:702-8.
22. Verhoeven CJ, Ruckert ME, Opmeer BC, Pajkrt E, Mol BW. Ultrasonographic fetal
head position to predict mode of delivery: a systematic review and bivariate
meta-analysis. Ultrasound in obstetrics & gynecology : the official journal of the
International Society of Ultrasound in Obstetrics and Gynecology. 2012;40:9-13.
23. O'Sullivan G, Liu B, Hart D, Seed P, Shennan A. Effect of food intake during labour
on obstetric outcome: randomised controlled trial. BMJ. 2009;338:b784.
24. Dencker A, Berg M, Bergqvist L, Lilja H. Identification of latent phase factors
associated with active labor duration in low-risk nulliparous women with
spontaneous contractions. Acta Obstet Gynecol Scand. 2010;89:1034-9.
25. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during
childbirth. Cochrane Database Syst Rev. 2012;10:CD003766.
26. Gaudernack LC, Forbord S, Hole E. Acupuncture administered after spontaneous
rupture of membranes at term significantly reduces the length of birth and use of
oxytocin. A randomized controlled trial. Acta Obstet Gynecol Scand.
2006;85:1348-53.
27. Ramnero A, Hanson U, Kihlgren M. Acupuncture treatment during labour--a
randomised controlled trial. BJOG : an international journal of obstetrics and
gynaecology. 2002;109:637-44.
28. Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous
labour. Cochrane Database Syst Rev. 2007.
29. Nachum Z, Garmi G, Kadan Y, Zafran N, Shalev E, Salim R. Comparison between
amniotomy, oxytocin or both for augmentation of labor in prolonged latent
phase: a randomized controlled trial. Reproductive biology and endocrinology :
RB&E. 2010;8:136.
30. Hinshaw K, Simpson S, Cummings S, Hildreth A, Thornton J. A randomised
controlled trial of early versus delayed oxytocin augmentation to treat primary
 dysfunctional labour in nulliparous women. BJOG : an international journal of
obstetrics and gynaecology. 2008;115:1289-95.
31. Dencker A, Berg M, Bergqvist L, Ladfors L, Thorsen LS, Lilja H. Early versus
delayed oxytocin augmentation in nulliparous women with prolonged labour--a
randomised controlled trial. BJOG : an international journal of obstetrics and
gynaecology. 2009;116:530-6.
32. Oscarsson ME, Amer-Wahlin I, Rydhstroem H, Kallen K. Outcome in obstetric care
related to oxytocin use. A population-based study. Acta Obstet Gynecol Scand.
2006;85:1094-8.
33. Blix E, Pettersen SH, Eriksen H, Royset B, Pedersen EH, Oian P. Bruk av oksytocin
som ristimulerende medikament etter spontan fdselsstart. Tidsskrift for den
Norske laegeforening : tidsskrift for praktisk medicin, ny raekke. 2002;122:1359-
62.
34. Costley PL, East CE. Oxytocin augmentation of labour in women with epidural
analgesia for reducing operative deliveries. Cochrane Database Syst Rev. 2013;7.
35. Bergqvist L, Dencker A, Taft C, Lilja H, Ladfors L, Skaring-Thorsen L, et al.
Women's experiences after early versus postponed oxytocin treatment of slow
progress in first childbirth - a randomized controlled trial. Sexual & reproductive
healthcare : official journal of the Swedish Association of Midwives. 2012;3:61-5.
36. Rossen J, Okland I, Nilsen OB, Eggebo TM. Is there an increase of postpartum
hemorrhage, and is severe hemorrhage associated with more frequent use of
obstetric interventions? Acta Obstet Gynecol Scand. 2010;89:1248-55.
37. Le Ray C, Fraser W, Rozenberg P, Langer B, Subtil D, Goffinet F. Duration of
passive and active phases of the second stage of labour and risk of severe
postpartum haemorrhage in low-risk nulliparous women. European journal of
obstetrics, gynecology, and reproductive biology. 2011;158:167-72.
38. Cheng YW, Shaffer BL, Bryant AS, Caughey AB. Length of the first stage of labor
and associated perinatal outcomes in nulliparous women. Obstet Gynecol.
2010;116:1127-35.
39. Waldenstrom U, Borg IM, Olsson B, Skold M, Wall S. The childbirth experience: a
study of 295 new mothers. Birth. 1996;23:144-53.
40. Seguin L, Therrien R, Champagne F, Larouche D. The components of women's
satisfaction with maternity care. Birth. 1989;16:109-13.
41. Kringeland T, Daltveit AK, Moller A. What characterizes women in Norway who
wish to have a caesarean section? Scandinavian journal of public health.
2009;37:364-71.
42. Tschudin S, Alder J, Hendriksen S, Bitzer J, Popp KA, Zanetti R, et al. Previous
birth experience and birth anxiety: predictors of caesarean section on demand?
Journal of psychosomatic obstetrics and gynaecology. 2009;30:175-80.
43. Berglund S, Grunewald C, Pettersson H, Cnattingius S. Severe asphyxia due to
delivery-related malpractice in Sweden 1990-2005. BJOG : an international
journal of obstetrics and gynaecology. 2008;115:316-23.
44. 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. American journal of obstetrics and gynecology.
2007;197:480
45. Wray S. Insights into the uterus. Experimental physiology. 2007;92:621-31.
46. Jonsson M, Norden-Lindeberg S, Ostlund I, Hanson U. Acidemia at birth, related to
obstetric characteristics and to oxytocin use, during the last two hours of labor.
Acta Obstet Gynecol Scand. 2008;87:745-50.
47. Andreasen S, Backe B, Jorstad RG, Oian P. A nationwide descriptive study of
obstetric claims for compensation in Norway. Acta Obstet Gynecol Scand.
2012;91:1191-5.
48. Dekker GA, Chan A, Luke CG, Priest K, Riley M, Halliday J, et al. Risk of uterine
rupture in Australian women attempting vaginal birth after one prior caesarean
section: a retrospective population-based cohort study. BJOG : an international
journal of obstetrics and gynaecology. 2010;117:1358-65.
49. SOGC. Clinical practice guidelines. Guidelines for vaginal birth after previous
caesarean birth. Int J Gynaecol Obstet 2005 2005.; 89:319-31.
50. Pattinson RC, Howarth GR, Mdluli W, Macdonald AP, Makin JD, Funk M.
Aggressive or expectant management of labour: a randomised clinical trial. BJOG :
an international journal of obstetrics and gynaecology. 2003;110:457-61.
51. Brown HC, Paranjothy S, Dowswell T, Thomas J. Package of care for active
management in labour for reducing caesarean section rates in low-risk women.
Cochrane Database Syst Rev. 2013;9.
52. Neilson JP. Amniotomy for shortening spontaneous labour. Obstet Gynecol.
2008;111:204-5.
53. Chelmow D, Kilpatrick SJ, Laros RK, Jr. Maternal and neonatal outcomes after
prolonged latent phase. Obstet Gynecol. 1993;81:486-91.
54. Maghoma J, Buchmann EJ. Maternal and fetal risks associated with prolonged
latent phase of labour. Journal of obstetrics and gynaecology : the journal of the
Institute of Obstetrics and Gynaecology. 2002;22:16-9.
55. Reuwer P, Bruinse H, Franx A. Proactive support of labor : the challenge of
normal childbirth. Cambridge: Cambridge University Press; 2009.
56. Bakker PC, van Geijn HP. Uterine activity: implications for the condition of the
fetus. Journal of perinatal medicine. 2008;36:30-7.