Acta Obstetricia et Gynecologica.

2009; 88: 1352–1357

ORIGINAL ARTICLE

Use and abuse of oxytocin for augmentation of labor

LOTTA SELIN1,2, ELISABETH ALMSTRÖM1, GUNNAR WALLIN3 & MARIE BERG2
1

Department of Obstetrics and Gynecology, NU Hospital Group, Trollhättan, Sweden, 2The Institute of Health and Care
Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden, and 3The Institute of Clinical Sciences, Department of
Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden

Abstract
Objective. To investigate the use of oxytocin for augmentation of labor and its relation to labor progress and delivery outcome.
Design and setting. A retrospective observational study undertaken in a Swedish hospital during 2000–2001. Sample. Singleton
pregnancies at ‡ 37 weeks of gestation with cephalic presentation and spontaneous onset of labor. Methods. Data were collected
from 1,263 clinical records. The partogram was used to diagnose labor dystocia (LD). Main outcome measures. Prevalence of
oxytocin administration, LD and operative delivery. Results. Oxytocin was administered to 55% of the women (75% of
primiparas and 38.1% of multiparas); a majority did not meet LD criteria. LD frequency was 19.8% (32.7% in primiparas and
7.4% in multiparas). Oxytocin was started both ‘too early’ and ‘too late’ in relation to the diagnosis of LD. Cesarean section
(CS) was performed on 17.1% of primiparous and 2.4% of multiparous oxytocin recipients with LD, compared to 2.3 and
1.5%, respectively, of oxytocin recipients without diagnosed LD. Conclusions. Oxytocin augmentation was undertaken in an
unstructured manner; some women were inadequately treated and others were treated unnecessarily. Oxytocin recipients with
LD underwent operative delivery to a higher extent than oxytocin recipients without LD, suggesting that the main reason for
CS was the underlying problem of LD rather than the oxytocin augmentation itself.

Key words: Labor dystocia, prolonged labor, oxytocin augmentation, cesarean section

Introduction
Labor dystocia (LD) is a commonly identified problem in modern delivery care with three described
possible causes: inefficient uterine action, occiputposterior position and cephalopelvic disproportion.
Inefficient uterine action is the most common complication of labor in primiparous women (1). LD is
related to increased maternal morbidity and operative
deliveries (2) and is one of the main reasons for
cesarean section (CS) (3–5).
However, despite extensive research, there is no
universal definition of LD and thus consensus concerning management, including timing for active
intervention in the process, is lacking (5). This makes
it more difficult to evaluate and compare outcomes in
different settings.

The partogram is a useful tool for following
labor progress and determining when to intervene.
In Sweden, the partogram is used in most hospitals,
albeit mostly without applying an action line, and
the diagnosis of LD is probably often based on
individual assessment, taking several factors into
consideration (6).
Parenteral oxytocin is a medication frequently used
to remedy ineffective uterine contractions. Oxytocin
use varies greatly between hospitals (7). A study comparing 11 hospitals in Sweden showed a variation of
use between 18.6% and 40.5% of all deliveries and an
increased use over time (8). Considerable variation
exists in the dosage of oxytocin, both initial doses and
in the interval and frequency of dose increase (9).
LD is one of the most important causes of increasing CS rates (3–5). In Sweden, the CS rate increased
from 12% in 1996 to 17.5% in 2007 (10), despite the

Correspondence: Lotta Selin, Department of Obstetrics and Gynecology, NU Hospital Group, 46186 Trollhättan, Sweden. E-mail: lotta.selin@vgregion.se.
(Received 10 June 2009; accepted 21 September 2009)
ISSN 0001-6349 print/ISSN 1600-0412 online  2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.3109/00016340903358812

2% (n = 14) of multiparas.2 hours (SD ± 1. and oxytocin infusion. time of LD diagnosis (hours from established labor to LD diagnosis).8%. during the second stage. all women undergoing elective CS and acute CS during the latent phase were excluded. increased use of oxytocin for augmentation of labor.8% of primiparas and 38. The SPSS statistical package version 16. Identified variables were: maternal age. oxytocin use. . 57% (n = 256) of the primiparas and 82. Among the 1. According to the augmentation protocol. USA) was used for the analysis. Oxytocin augmentation Oxytocin for augmentation of labor was used in 55% (n = 695). postpartum hemorrhage > 1. administered dose > prescribed dose). gestational age ‡ 42 weeks. 7. with a maximum of 5/10 minutes. This was in accordance with the recommended practice at the delivery ward.263 deliveries. There were 5. The frequency of prolonged labor was higher in the group given lower doses. The prescribed oxytocin dose for treatment of LD was 5 units in 500 ml of 5% glucose solution.3% (n = 72). The objective of this study was to investigate the use of oxytocin for augmentation of labor and its relation to labor progress and delivery outcome. i. Oxytocin augmentation was started both ‘too early’ and ‘too late’ in relation to the diagnosis of LD (Figure 1).000 g. IL. the doses can be increased faster and to higher levels.4% in multiparas. 24. During data analysis. administration of oxytocin (administered dose < prescribed dose.e. Prolonged labor was identified in 18% (n = 111) of primiparas and 2. time of oxytocin augmentation (hours from established labor to oxytocin augmentation). epidural analgesia. The NU Hospital Group is situated in western Sweden and has one delivery unit at the Trollhättan hospital. Of 695 women treated with oxytocin. i. Recommended clinical practice for treatment of LD at the delivery ward was amniotomy if intact membranes. the maximum infusion rate should not exceed 30 mU/minute during the first stage of labor. 32. labor progress from established labor until delivery was retrospectively assessed by a partogram. prolonged labor (more than 8 hours from established labor). The average duration of established labor was 6. P < 0. A majority of oxytocin recipients. and LD identified and diagnosed based on the partogram’s alert and action lines. starting with 2. Statistical associations between categorical variables were tested using the c2-test and the two-tailed Fisher exact test was used if the expected cell frequencies were too small. The questions of how effective oxytocin is for treating an abnormal labor process and whether it is used appropriately are thus pertinent. Multiparas without a previous vaginal delivery were also excluded.5 mU/ minute and increasing by 5 mU/minute every 20–30 minutes until contractions were established. the LD frequency was 19. did not meet the criteria for LD.0 (SPSS Chicago. LD was diagnosed if the cervical dilation rate crossed the action line. Established labor was defined as cervix effaced and dilated ‡ 4 cm and regular painful uterine contractions. vacuum extraction and CS). As LD only occurs during the active phase of labor.1354 L. Inclusion criteria were singleton gestation at ‡ 37 weeks gestation. Results Descriptive statistics for the study population are presented in Table I.263 electronic antenatal and delivery records were randomly chosen from sequences in the NU Hospital Group register (2000–2001). birthweight > 4.3% were given higher doses and 42. parity (primipara. mode of delivery (spontaneous vaginal delivery. cephalic presentation and spontaneous onset of labor.05. which also corresponded to the policy described in the current Swedish state of the art document for management of normal delivery (6). LD (cervical dilation rate crossing the action line 2 hours to the right of the alert line). The alert line represented a progress rate of 1 cm per hour.6% were given lower doses than those stipulated by general policy at the department.7% in primiparas and 7. The two-sample t-test was used to analyze normally distributed continuous variables.9) in multiparas. and umbilical cord arterial pH < 7.000 ml. perineal trauma (thirdand fourth-degree lacerations). multipara). Exclusion criteria were lack of partogram and cervical dilation ‡ 7 cm on admission to the delivery ward. in which 1.e. 2 hours to the right of the alert line or if the second stage lasted more than 2 hours.1% of multiparas. Apgar score < 7 at 5 minutes.9) in primiparas and 3.9% (n = 204) of the multiparas.05 was considered to denote statistical significance. 72. prescribed dose administered.702 deliveries during the period of this study. The decision to use oxytocin to augment labor was made by the attending physician or midwife.0 hours (SD ± 2. either together or individually. Material and methods This is a retrospective observational study approved by the regional Ethics Committee (Dnr: 520-02). Selin et al.

c Third. Oxytocin was often given in lower doses than those Line: time (h) of LD diagnosis and time (h) of oxytocin augmentation “too late” “too early” 2 3 4 9 10 5 6 7 8 Time (h) of LD diagnosis 11 12 Figure 1. a b compared to 12.6% and 0.001).1%.1% were given lower oxytocin doses than prescribed by general policy. respectively. when LD occurs.05) compared to none in the non-oxytocin group (p = 0.001).8% vacuum extraction and 17% CS). compared to 44. often implemented in an unstructured manner and without a correct diagnosis of LD.5% (n = 50) in those given prescribed or higher doses (p < 0.4) Prolonged labor 111 (18.3% CS) in primiparous oxytocin recipients without LD (p < 0.4% (n = 3) in the oxytocin vs. respectively. Indications for CS were: LD in 74.8) 246 (38.2) 498 (80. Dots below the line indicate use of oxytocin before LD diagnosis (‘too early’) and those above indicate use of oxytocin after LD diagnosis (‘too late’).7) 622 (96. labor dystocia. i.7% and 1. 16 14 12 10 8 6 4 2 0 -2 -4 -6 -8 -10 This study shows a high use of oxytocin for augmentation of labor.3) Mode of delivery Spontaneous vaginal delivery Vacuum extraction 78 (12. there were 1. compared to 13. The frequency of operative delivery in primiparous oxytocin recipients with LD was 40. compared to those not given oxytocin. 1355 There was a higher frequency of CS among women treated with oxytocin. Of the study population.001). mean ± SD 27. Discussion Delivery outcome in relation to parity. Primipara n = 617a Multipara n = 646a Maternal age (years). according to the protocol.1) LDb 202 (32.7 Gestational age ‡ 42 w 23 (3. asphyxia in 23. oxytocin use and LD Time (h) of oxytocin augmentation The frequency of CS in the composite study population was 3.9% of the oxytocin recipients delivered by vacuum extraction and 40% of oxytocin recipients who underwent spontaneous vaginal delivery (p < 0. The line in the diagram indicates the optimal time to start oxytocin augmentation.Use and abuse of oxytocin in labor Table I.9) Postpartum hemorrhage > 1.035).70 ± 4.6) Birthweight > 4.3) Values are given as n (%) and means ± standard deviation (SD). labor dystocia.6% in primiparas and 0. 0.6% (11. Descriptive statistics for the study population.09 ± 4. in multiparas (Figure 2). LD.7) 15 (2. Among the oxytocin recipients undergoing CS.000 g 126 (20.6) 10 (1. Note: LD.0) 14 (2.000 ml 38 (6.9% (23. Consequently. .7%. The frequency of Apgar score < 7 did not differ between the two groups: 0.5) 202 (31.9% in multiparas.2% (p < 0. in primiparas and 1.6) 18 (2.3% vacuum extraction and 2.5%.3) Perineal traumac 32 (5.7) 48 (7.01).3) Epidural analgesia 349 (56.6) 6 (0.6) 153 (23. A plot of the relationship between time (h) of LD diagnosis and time (h) of oxytocin augmentation. some women were inadequately treated while others were treated before LD was confirmed.8) Cesarean section 41 (6.4% and others in 2.632).7 30. 72.101 deliveries for which umbilical arterial pH was available.e.7) Oxytocin augmentation 449 (72. 8.2% (n = 1) in the non-oxytocin group (p = 0. 6.5% (p = 0.21).2) 28 (4.and fourth-degree lacerations. and 1% (n = 6) of the neonates in the oxytocin group had acidemia (pH < 7.

normal labor progress was often accelerated with oxytocin. Shortening the duration of labor might be an important advantage for parturients.2%) VE n = 3 (1. oxytocin was withheld for as long as eight hours in cases of delayed augmentation (15). prolonged labor and CS were more common when oxytocin was given in a lower than prescribed dose. The effectiveness of oxytocin for remedying ineffective uterine contractions and preventing adverse outcome has been examined. stipulated by general policy at the delivery ward and an association between lower doses and prolonged labor.3%) LD n = 193 (43. Likewise. research results diverge regarding low vs. in CS was also found. Perhaps high-dose oxytocin might lower the CS frequency if safety can be .18) and that prolonged labor is connected to perceived loss of control and inadequate trust in the body’s competence (19). Note: LD. vacuum extraction. Concerning dosage of oxytocin perfusion. labor dystocia.1356 L. pressure from other midwives or obstetricians.0%) VE n = 29 (11.3%) CS n = 6 (2. compared to oxytocin recipients without LD. Nonetheless.5%) Figure 2. VE.e. 57% of the primiparous and 83% of the multiparous oxytocin recipients did not have a diagnosis of LD. Studies on women’s experiences indicate that they are more satisfied with intervention leading to shorter labor.6%) LD n = 42 (17. It has even been suggested that partogram use can lead to unnecessary interference and limit flexibility in treating each woman as an individual. compared to the frequency of LD (11.7%) CS n = 4 (1.11.8%) CS n = 2 (1.9%) VE n = 8 (3.1%) VE n = 14 (5. other indications for treatment than LD or the decision to withhold treatment when necessary. high doses and their respective effects on labor outcome (20). In our study a partogram was usually used. That oxytocin augmentation significantly reduces the overall length of labor has been documented previously (15. but without a marked action line and seldom with an alert line.16). In one of the studies. Some report a decrease of CS with a high-dose oxytocin protocol (6-mU/minute dosage increment).7%) Primiparas n = 617 (48. and shortage of delivery rooms (13). According to birth outcome comparisons of early and delayed administration of oxytocin in women with prolonged labor have not shown any differences in the frequency of CS (15.12). other studies show a disproportionately frequent use of oxytocin.9%) Oxytocin n = 246 (38.6%) CS n = 47 (3. some of the factors that influenced midwives’ decision-making related to augmentation of labor were their own experiences of the option being considered.12). cesarean section.1%) VE n = 6 (14.6%) Non Oxytocin n = 168 (27. respectively. oxytocin use and LD related to parity.8%) VE n = 75 (16. indicating that administration can correspond to the lack of good routines for augmentation rather than to a real need (9.22) and to administration of oxytocin as a single agent (23).4%) Non Oxytocin n = 400 (61. at the expense of more interference.9%) VE n = 78 (12.9%) VE n = 4 (1. Flow diagram of delivery outcome. CS.6%) CS n = 41 (6. Previous studies show major variation in administration and dose. It is alarming that many women in our study were given oxytocin without having LD. According to another Swedish study. than with expectant management (17.1%) VE n = 18 (2. lack of clear routines.0%) CS n = 2 (0.1%) Multiparas n = 646 (51.7%) CS n = 39 (8.7%) Non LD n = 256 (57.5%) Non LD n = 204 (82. Study population n = 1263 VE n = 96 (7. Oxytocin recipients with LD had a significantly higher frequency of operative deliveries.0%) VE n = 46 (23.8%) CS n = 33 (17. Selin et al.9%) CS n = 3 (1. while other researchers consider the partogram a very useful tool in following labor progress (14).2%) Oxytocin n = 449 (72. The reason for this unstructured management may be lack of diagnosis. both related to active management of labor (21.3%) CS n = 1 (2. i.16). This corresponds to our results.8%) CS n = 6 (0.

2006. we believe that the unstructured use revealed in this study may create a productive debate and evoke reflections. Ottesen B. Olsen J. 2. Further analyses of the oxytocin recipients showed higher frequencies of both CS and operative vaginal delivery in women with LD than in those with no LD. Robson M. however. Active Management of Labour. Furthermore. Meagher D. suggesting that the main reason for CS was not the oxytocin augmentation. compared to women who were not. It was surprising to find that a third of primiparas in our study had LD. Acknowledgements The authors wish to express their gratitude to the Fyrbodal R&D Council and to the Department of Obstetrics and Gynecology. Cesarean section in Sweden 1990-2001. se/Publicerat/2005/8750/2005-112-3. We did not find a higher frequency of Apgar score < 7 at 5 minutes. Int J Gynaecol Obstet. but the underlying problem of LD. Available at: http://www. both concerning timing of initiation and determination of dose. The fact that there was a higher frequency of CS among women treated with oxytocin. Indications associated with increased cesarean section rates in a Swedish hospital.e. Publication no. The negative effects of oxytocin. our study highlights the abuse of oxytocin. Dykes AK. Centre of Epidemiology. Only just over half (59%) of the primiparas with LD succeeded with spontaneous vaginal delivery. but the underlying problem of LD. In conclusion. There is also a need to explore more non-pharmacological interventions in labor progress. Obstetric risk indicators for labour dystocia in nulliparous . Clinical management entailing the use of oxytocin must be questioned. this finding is in accordance with a prospective study performed in Denmark (28).Use and abuse of oxytocin in labor maintained. The fact that LD diagnosis was based on cervical dilation. NU Hospital Group for support and to Anne Wennberg for participating in the study. have been highlighted previously (8. is an important risk factor for fetal acidemia at birth (24). Florica M. such as descent of the head. despite oxytocin treatment. Curr Obstet Gynaecol.27). suggesting that the main reason for CS was not oxytocin augmentation by itself. Furthermore. National Board of Health and Welfare. The high incidence of prolonged labor in the group of women given lower doses indicates that 1357 other reasons than adequate uterine contractions kept the doses low. however. it is not just a question of hyperstimulation but also of incorrect use. particularly if uterine hyperstimulation and fetal hypoxia can be avoided. but a higher frequency of acidemia in the neonates of oxytocin recipients. Nordstrom L. 4. USA: Elsevier Limited. It is. Kjaergaard H. Further research is needed to examine the use of oxytocin for treatment of LD.socialstyrelsen. no information on women’s perceptions regarding the use of oxytocin for augmentation of labor was available.24).25) and a high frequency of obstetric malpractice claims has also been associated with its use. without taking other signs of progress. O’Driscoll K. Jonsson et al. both inadequate and excessive doses as well as administration too early or too late in relation to LD diagnosis. El-Hamamy E. no differences in neonatal outcome were shown (26. The high incidence of oxytocin administration to both primiparas and multiparas indicates a low likelihood that it corresponds to a real need. Different standardized protocol models for improved patient safety have been proposed (9. Arulkamaran S. i.24. into account might have led to an overestimation of LD in this study. which might contribute to the creation of good evidence-based routines promoting normal birth. Poor progress of labour. 3. not possible to conclude that augmentation with oxytocin increases the CS frequency. Stephansson O. One of these includes a simple checklist-based protocol mainly assessing uterine response and fetal response to uterine contraction (25). have shown that a hyperactive uterine contraction pattern. References 1. Kejsarsnitt i Sverige 1990-2001. As oxytocin use is very common in modern obstetric care. Nyberg P. Oxytocin recipients with LD had higher frequencies of both CS and operative vaginal delivery than oxytocin recipients without LD. Declaration of interest: The authors report no conflicts of interest. especially the risk of uterine hyperstimulation and adverse maternal and neonatal outcomes.92:181–5. of this medication.25). The authors alone are responsible for the content and writing of the paper. The liberal use of epidural analgesia and the steady increase in birthweight might be underlying reasons (29). when low-dose and high-dose regimens (6 mU/minute dose increments) were compared.15:1–8. The reason for administration of lower oxytocin doses to the high number of women is unclear. in the majority of cases related to overstimulation. 2003. The weakness of this study is its retrospective design and that information regarding uterine contractions was unfortunately not available.2005-112-3.htm.12). 5. Accessed 2005 (in Swedish). as was found in earlier studies together with an increased need for neonatal intensive care (8. 2005. echoes other findings (8.

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