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Effective Health Care Program

Labor Dystocia

Systematic Review Draft

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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.

Key Messages

  • Modern labor curves constructed from the Consortium on Safe Labor demonstrate that "normal" labor is significantly longer in nulliparous women compared to parous women.
  • Older maternal age is associated with a longer first stage of labor among nulliparous women, and longer second stage of labor in both nulliparous and parous women.
  • These modern labor curves suggest a longer “normal” duration of the first stage of labor, although the high prevalence of augmentation in these data prevent drawing inferences about the duration of normal labor in the absence of interventions.
  • Use of partograms did not impact important maternal or neonatal outcomes.
  • Amniotomy is likely to decrease the total duration of labor in nulliparous women with no differences in adverse outcomes.
  • Amniotomy plus oxytocin decreases duration of labor without increasing cesarean delivery rates in both nulliparous and parous women.
  • Emotional support interventions may reduce cesarean deliveries and instrumental deliveries.
  • For women choosing analgesia, type (epidural vs. combined spinal epidural, or epidural versus patient-controlled intravenous analgesia) or timing during labor is likely to not affect cesarean delivery rates.
  • Higher doses of oxytocin augmentation are likely to result in lower cesarean delivery rates compared to low-dose protocols, but cesarean rates may not be affected by timing in labor or by pulsatile versus continuous administration.

Structured Abstract

Objectives: This review evaluates the comparative effectiveness of different strategies for treating labor dystocia (difficult or obstructed labor) 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 January 2016.

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 identified 111 articles (105 unique studies). This included 12 studies relevant to defining abnormal labor, eight studies about amniotomy, 50 studies on supportive care measures, 22 studies regarding epidural analgesia, one study regarding cervical examination, 1 study relevant to intrauterine pressure catheters, 12 studies relevant to high-dose versus low-dose oxytocin protocols, no studies on fetal monitoring strategies, and 2 studies of timing of pushing in the second stage. Evidence suggests that the duration and pattern of "normal" labor progress based on modern management is quite different than historical data, and that labor progress is longer in nulliparous compared to parous women. Use of partograms (graphs of cervical dilation versus time) did not impact important maternal or neonatal outcomes, although the applicability of this evidence to modern U.S. settings is limited. Routine amniotomy decreases the total duration of labor in nulliparous women without affecting other outcomes (moderate SOE), while routine amniotomy with oxytocin augmentation as needed decreased duration of labor without increasing cesarean delivery (high SOE). Although supportive care therapies are often seen as benefiting parental satisfaction with the birthing process, these outcomes were rarely assessed in clinical trials. However, an existing systematic review of 11 studies did find that women receiving continuous emotional support were less likely to rate their birth experience negatively (moderate SOE). 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, type (epidural vs. combined spinal epidural, or epidural vs. patient-controlled intravenous analgesia) or timing during labor did not affect cesarean delivery rates (moderate SOE).

Conclusions: Dystocia is a common indication for cesarean delivery. Recent data demonstrate that the normal progress of labor with current practice is quite different from curves originally described, although there is still uncertainty about the duration of “normal” labor in the absence of augmentation. Amniotomy and oxytocin decrease duration of labor without increasing cesarean delivery. Emotional support reduces operative delivery rates and patient satisfaction. Further work is needed to identify strategies for management of labor that optimize maternal and neonatal outcomes and patient preferences while minimizing cesarean delivery rates.