Purpose of Review
To review the evidence on the definition of "normal" labor progression and the comparative effectiveness of different strategies for treating labor dystocia in women with otherwise uncomplicated pregnancies. Strategies assessed include amniotomy, supportive care measures, epidural analgesia, frequency of cervical examination, intrauterine pressure catheters, high- versus low-dose oxytocin protocols, electronic fetal monitoring or intermittent auscultation during augmentation with oxytocin, and delayed or Valsalva pushing.
- Use of partograms did not impact important maternal or neonatal outcomes.
- Amniotomy plus oxytocin decreases duration of labor without increasing cesarean delivery rates.
- Emotional support interventions may reduce cesarean deliveries and instrumental deliveries.
- Much of the evidence on different interventions came from studies performed outside the United States. Differences in patient, provider, health system, and other characteristics may affect the applicability of these results to a U.S. setting.
Objectives. This review evaluates the comparative effectiveness of different strategies for treating labor dystocia in women with otherwise uncomplicated pregnancies.
Data sources. We searched PubMed®, Embase®, CINAHL®, and the Cochrane Database of Systematic Reviews (CDSR), limiting the searches to studies in the English language and comparative studies published from January 1, 2005, to February 15, 2019.
Review methods. Two investigators screened each abstract and full-text article for inclusion, abstracted data, rated quality and applicability, and graded evidence. When possible, random-effects models were used to compute summary estimates of effects.
Results. Our review included 167 articles (158 unique studies). Studies included 25 relevant to defining abnormal labor, 12 relevant to amniotomy, 75 relevant to supportive care measures, 25 relevant to epidural analgesia, 1 relevant to cervical examination, 1 relevant to intrauterine pressure catheters, 17 relevant to high-dose versus low-dose oxytocin protocols, 1 relevant to fetal monitoring strategies, and 7 relevant to timing of pushing in the second stage. Evidence suggests that the duration and pattern of “normal” labor progress based on modern management are quite different from historical data, and that labor progress differs between nulliparous and parous women. Use of partograms did not change important maternal or neonatal outcomes, although the applicability of this evidence to modern U.S. settings is limited. Routine amniotomy decreased the total duration of labor in nulliparous women without affecting other outcomes (moderate strength of evidence [SOE]); routine amniotomy with oxytocin augmentation decreased labor duration without increasing cesarean delivery (high SOE). Although supportive care is considered to improve parental satisfaction with the birthing process, satisfaction outcomes were rarely assessed in the included clinical trials. An existing systematic review of 11 studies found that women receiving continuous emotional support were less likely to rate their birth experience negatively. Of the different types of supportive therapies, only emotional support interventions showed reductions in cesarean (low SOE for doula support, moderate SOE for continuous emotional support) and instrumental deliveries (moderate SOE). For women choosing analgesia (epidural vs. combined spinal epidural, or epidural vs. patient-controlled intravenous analgesia), neither type nor timing affected cesarean delivery rates (moderate SOE).
Conclusion. The normal progress of labor given current practice is quite different from that originally described, although there is still uncertainty about the duration of “normal” labor in the absence of augmentation. Further work is needed to identify (1) the cesarean delivery rate that optimally balances maternal and neonatal outcomes and patient preferences, and (2) the best strategies to achieve this rate.
Suggested citation: Myers ER, Sanders GD, Coeytaux RR, McElligott KA, Moorman PG, Hicklin K, Grotegut C, Villers M, Goode A, Campbell H, Befus D, McBroom AJ, Davis JK, Lallinger K, Fortman R, Kosinski A. Labor Dystocia. Comparative Effectiveness Review No. 226. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2015-00004-I.) AHRQ Publication No. 29-EHC007. Rockville, MD: Agency for Healthcare Research and Quality; May 2020. DOI: 10.23970/AHRQEPCCER226. Posted final reports are located on the Effective Health Care Program search page.