Original Research
Association of Oxytocin Rest During Labor
Induction of Nulliparous Women With Mode
of Delivery
Molly McAdow, MD, PhD, Xiao Xu, PhD, Heather Lipkind,
and Jessica L. Illuzzi, MD, MS
OBJECTIVE: To evaluate the association between tem-
porary cessation in oxytocin infusion (oxytocin rest) and
mode of delivery in women undergoing induction of
labor with a protracted latent phase.
METHODS: We conducted a retrospective cohort analysis
of nulliparous women with term, vertex, singleton gestations
who were undergoing induction of labor with continuous
oxytocin infusion at a large academic medical center.
Episodes of oxytocin rest were identified among patients
who were exposed to 8 hours of continuous oxytocin yet
remained in latent labor (ie, protracted latent labor).
Multivariable logistic regression analysis was performed to
estimate the association between duration of oxytocin rest
and mode of delivery while adjusting for duration of latent
phase, maternal age, gestational age, body mass index, and
indications for induction and oxytocin cessation. Maternal
and neonatal morbidities were also compared among
patients with different durations of oxytocin rest.
RESULTS: From January 2012 to December 2016, 1,193
patients met eligibility criteria. Among these patients, 267
patients (22.4%) underwent an oxytocin rest that lasted
at least 1 hour. After adjusting for potential confounders,
the odds ratios of cesarean delivery for patients with
From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale
School of Medicine, New Haven, Connecticut.
Presented at the 66th Annual Meeting of the Society for Reproductive Investiga-
tion, March 12–16, 2019, Paris, France.
The authors thank Erica Moreira at the Yale Joint Data Analytics Team for her
assistance in data acquisition from the electronic medical record.
Each author has confirmed compliance with the journal’s requirements for
authorship.
Corresponding author: Molly McAdow, MD, PhD, Yale School of Medicine,
Department OB/GYN & Reproductive Sciences, New Haven, Connecticut;
email: molly.mcadow@yale.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2020 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/20
VOL. 00, NO. 00, MONTH 2020
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
MD, MS, Uma M. Reddy, MD, MPH,
oxytocin rest compared with those with no oxytocin rest
were as follows: 1.12 (95% CI 0.79–1.58) for less than 1
hour, 0.78 (95% CI 0.48–1.27) for 1–2 hours, 0.60 (95% CI
0.35–1.04) for 2–8 hours, and 0.43 (95% CI 0.24–0.79) for
8 hours or more. We did not detect an association
between oxytocin rest of more than 8 hours and a com-
posite of maternal or neonatal morbidities.
CONCLUSION: An oxytocin rest of at least 8 hours is
a clinical tool that may reduce the risk of cesarean
delivery among women with protracted latent labor
without significantly increasing maternal or neonatal
morbidity.
(Obstet Gynecol 2020;00:1–7)
DOI: 10.1097/AOG.0000000000003709
I
nduction of labor is performed for 24.5% of all
births in the United States.1 Indications for induc-
tion include maternal comorbidities (eg, diabetes mel-
litus, hypertensive diseases) and conditions that affect
fetal wellbeing (eg, prelabor rupture of membranes,
fetal growth restriction).2 Typically, an induction of
labor starts with cervical ripening followed by contin-
uous infusion of synthetic oxytocin to promote regu-
lar, repetitive contractions. Occasionally, despite
prolonged exposure to oxytocin, a regular contraction
pattern is not attained, or cervical change does not
occur. In these circumstances, some clinicians tempo-
rarily discontinue the oxytocin infusion (“oxytocin
rest”) with the theory that it will re-sensitize the my-
ocyte’s response to oxytocin.
The practice of oxytocin rest has biological
plausibility. As with other G protein-coupled recep-
tors, oxytocin receptors on myocytes become satu-
rated after prolonged oxytocin exposure and are
internalized and degraded.3,4 Oxytocin receptor
mRNA becomes down-regulated.5,6 Consequently,
the uterine response to additional oxytocin treatment
diminishes.4,7–10
OBSTETRICS & GYNECOLOGY 1
 Despite this evidence, the clinical efficacy of
oxytocin rest during induction of labor remains
unclear. Evidence examining its use in latent labor is
limited. Complete cessation of oxytocin during the
active phase of labor has no effect on mode of
delivery.11 Our objective was to assess whether oxy-
tocin rest in a protracted latent phase during induction
of labor, here defined as 8 hours of oxytocin without
entering active phase, is associated with the mode of
delivery among parturients and, if so, to identify the
duration of oxytocin rest associated with the lowest
risk of cesarean delivery.
METHODS
This is a retrospective cohort study of patients who
underwent induction of labor with intravenous oxy-
tocin infusion at one large tertiary medical center
(Yale New Haven Hospital) with two campuses from
January 1, 2012, through November 30, 2016. This
study was approved by the Yale University Human
Investigation Committee.
Nulliparous women with singleton, vertex preg-
nancies who underwent induction of labor at term
were identified from the electronic medical record
(EMR). Patient characteristics including age, race or
ethnicity, body mass index (BMI, calculated as weight
in kilograms divided by height in meters squared) at
time of admission, gestational age at the time of
delivery, and neonatal birth weight were extracted
from the EMR. Maternal comorbidities and obstetric
risk factors were identified using International Classi-
fication of Diseases (ICD) codes (Appendix 1, avail-
able online at http://links.lww.com/AOG/B730). The
labor flowsheet that is maintained by the patient’s
nurse during the course of her induction was used to
assess the timing of the patient’s oxytocin initiation
and dosing, cervical dilation throughout her labor
course, and the Eunice Kennedy Shriver National Insti-
tute of Child Health and Human Development
(NICHD) fetal heart rate category at the time of oxy-
tocin rest. Indications for induction of labor were
incompletely coded in the EMR, so for this analysis,
medical or obstetric complications associated with the
admission were used as the indication. For patients
who did not have a medical or obstetric complication
but who were at 41 weeks of gestation or greater, the
indication for induction was listed as “late term or
postterm.” Remaining patients were listed as being
induced for “other or elective.”
At our institution, patients who present with an
unripe cervix first undergo cervical ripening before
initiation of oxytocin. Intrauterine balloons are most
frequently used; pharmacologic agents (vaginal miso-
2 McAdow et al Oxytocin Rest and Mode of Delivery
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
prostol) are also used when an intrauterine balloon
cannot be placed. During the years comprising this
analysis, nulliparous patients rarely underwent con-
current mechanical ripening and oxytocin infusion.
At our institution, the administration of oxytocin
for induction of labor is protocol driven. Oxytocin is
started at a rate of 1–2 milliunits/min and increased
by 2 milliunits/min every 15 minutes to achieve a reg-
ular contraction pattern to a maximum infusion rate
of 20 milliunits/min. Oxytocin is stopped for signs of
fetal compromise, as defined by NICHD criteria or
tachysystole. Before a revision to the protocol in 2015,
providers could override the protocol to administer
infusion rates up to 30 milliunits/min, though this
was not standard. If oxytocin infusion is stopped, it
cannot be restarted for 15 minutes. If it is restarted
after less than 40 minutes and fetal status is reassuring,
it can be administered at a rate one half of the rate that
necessitated its discontinuation. If the infusion was
discontinued for more than 40 minutes, the oxytocin
is restarted at a dose of 1 or 2 milliunits/min and
titrated as above.
Among nulliparous women who underwent
induction of labor at term, patients who had at least
8 hours of continuous intravenous oxytocin infusion
before entering the active phase of labor (defined here
as protracted latent labor) were included in the
analysis. Among those women, oxytocin rests that
occurred before documentation of a dilation of 6
centimeters (cm) or greater were identified and
calculated as the time from the discontinuation of
oxytocin (rate of 0 milliunits/min) until the time when
the infusion was restarted, as documented by the
patient’s nurse in the labor flowsheet. The longest
oxytocin rest for each patient was used for the analy-
sis. To confirm that these calculations correctly iden-
tified episodes and duration of oxytocin rest, 11
patients were identified at random and their medical
record reviewed in detail, which validated the statisti-
cal and mathematical coding using the raw data from
the EMR.
For the purposes of this analysis, the duration of
each patient’s latent phase was calculated as the time
between initiation of oxytocin infusion and when
a cervical dilation of 6 cm or greater was first docu-
mented in the labor flowsheet. For patients who
underwent a cesarean delivery before achieving cer-
vical dilation of 6 cm, the duration of the latent phase
was calculated as the time when oxytocin infusion was
first initiated until the delivery time of the neonate
through cesarean. Among patients who underwent
an oxytocin rest, the duration of the latent phase
was adjusted by subtracting the duration of the
OBSTETRICS & GYNECOLOGY
oxytocin rest. Duration of the latent phase was found
to have a nonnormal distribution. Therefore, for the
purposes of the multivariable regression analysis, the
latent phase was converted to a logarithmic scale.
As the duration of oxytocin rest increased, the
number of patients exposed to each duration
decreased. Among patients who had an oxytocin rest
for more than 1 hour, a univariate analysis was
performed to divide patients roughly equally into
tertiles of 1 hour to less than 2 hours, 2 hours to less
than 8 hours, and 8 hours or more.
The primary outcome of interest was mode of
delivery (ie, cesarean vs vaginal delivery), which was
extracted from the EMR. Secondary outcomes
included maternal and neonatal morbidities. For
maternal outcomes, we measured postpartum hemor-
rhage, chorioamnionitis, endometritis, venous throm-
boembolism, cerebrovascular accident, eclampsia,
disseminated intravascular coagulation, and intensive
care unit (ICU) admission, which were extracted from
the EMR using ICD diagnosis codes and information
from the EMR (Appendix 1, http://links.lww.com/
AOG/B730).12,13 Internal hospital procedure codes
were used to identify transfusion of red blood cells.
A maternal composite outcome was counted as posi-
tive if the patient experienced any of the aforemen-
tioned diagnoses. Neonatal outcomes of interest,
including meconium aspiration syndrome, moderate
or severe infection, birth trauma, seizure, and hypoxic
ischemic encephalopathy, were identified using rele-
vant ICD diagnosis codes and information from the
EMR.14 The need for respiratory support was identi-
fied by internal hospital procedure codes for respira-
tory therapy. A neonatal composite outcome was
counted as positive if the neonate experienced any
of the aforementioned diagnoses. Maternal and neo-
natal ICU admissions were also reported.
To determine whether additional cervical ripen-
ing methods were used during oxytocin rest, the
charts of all patients who had an oxytocin rest of 4
hours or longer were individually reviewed to identify
whether mechanical or pharmacologic cervical ripen-
ing was performed during the patient’s longest oxyto-
cin rest. At our institution, the protocol for induction
of labor precludes administration of oxytocin for 4
hours after the most recent dose of prostaglandin,
and, therefore, oxytocin rest of less than 4 hours was
not considered long enough for additional cervical
ripening to have occurred.
Chi-square test or Fisher exact test (for variables
with expected cell counts less than 5) were employed
to compare baseline characteristics among patients
with continuous oxytocin, with brief (less than 1 hour)
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cessation of oxytocin, oxytocin rest lasting 1 to less
than 2 hours, 2 hours to less than 8 hours, or 8 hours
or longer. Analysis of variance and Kruskal-Wallis
tests were used to compare normally and nonnor-
mally distributed data. Characteristics that differed
among the exposure groups were included in a mul-
tivariable logistic regression analysis to examine the
association between oxytocin rest and mode of
delivery. Based on the number of potential parame-
ters, the initial model yielded a global shrinkage factor
of 0.91, and a difference in apparent and adjusted
Nagelkerke R2 of 0.01 (Appendix 2, available online
at http://links.lww.com/AOG/B730).15 Using the
partial F-statistic to evaluate the full and reduced mod-
els, we sequentially eliminated parameters that did not
contribute meaningfully to the model to arrive at
a model with optimized parsimony. Additionally, we
used chi-square test or Fisher exact test (for variables
with expected cell counts less than 5) to compare sec-
ondary outcomes (maternal and neonatal morbidities)
among patients based on oxytocin rest duration. A
multivariable regression analysis was performed to
evaluate the association between neonatal intensive
care unit (NICU) admissions with oxytocin rest while
adjusting for maternal diabetes. All data analysis was
performed using SAS 9.4. Statistical significance was
determined based on two-sided tests with P value
,.05.
RESULTS
A cohort of 3,136 nulliparous, term, vertex-
presenting, singleton patients underwent induction
of labor during the study period (Fig. 1). Of those,
1,193 patients remained in the latent phase after 8
hours of continuous oxytocin, and 267 patients
(22.4%) underwent an oxytocin rest that lasted at least
1 hour. Our sample was 58.6% white, 18.4% black,
12.7% Hispanic, 6.0% Asian, and 4.4% listed as
“other.”
Six hundred forty-two patients (53.8%) experi-
enced no interruption of oxytocin infusion, 284
(23.8%) had oxytocin discontinuation for less than 1
hour, 106 (8.9%) had oxytocin rest 1 hour to less than
2 hours, 89 (7.4%) had oxytocin rest lasting 2 hours to
less than 8 hours, and 72 (6.0%) had oxytocin rest
lasting 8 hours or longer. Certain baseline character-
istics differed significantly across the exposure groups
(Table 1). Longer durations of oxytocin rest were
associated with higher BMI, longer latent phase,
hypertension, and diabetes (P,.05).
The overall rate of cesarean delivery in our
cohort of nulliparous inductions of labor with at least
8 hours of oxytocin before entering active phase was
McAdow et al Oxytocin Rest and Mode of Delivery 3
 Fig. 1. Cohort assembly.
McAdow. Oxytocin Rest and Mode of
Delivery. Obstet Gynecol 2020.

47.0% (n5561). A multivariable regression analysis
was used to assess the association between duration
of oxytocin rest and mode of delivery (Table 2). Sig-
nificant confounding factors that contributed to our
model included maternal age in years (adjusted odds
ratio [aOR] 1.05 [95% CI 1.03–1.07]); gestational age
in weeks (aOR 1.31 [95% CI 1.19–1.44], BMI (aOR
1.04 [95% CI 1.02–1.06]); the duration of latent phase
in log (hours) (aOR 3.33 [95% CI 2.40–4.62]); diabe-
tes (aOR 1.47 [95% CI 0.97–2.23]); and NICHD fetal
heart rate category at the time of oxytocin rest (aOR
1.43 [95% CI 1.00–2.04]). Compared with parturients
who received continuous oxytocin without rest, the
risk of cesarean delivery decreased over the time in-
tervals (P value for trend ,.02); at less than 1 hour
aOR 1.12 (95% CI 0.79–1.58), 1 hour to less than 2
hours aOR 0.78 (95% CI 0.48–1.27), 2 hours to less
than 8 hours aOR 0.60 (95% CI 0.35–1.04); 8 hours or
longer aOR 0.43 (95% CI 0.24–0.79). Patients in the
cohort who had an oxytocin rest 8 hours or longer
had a reduced risk of cesarean delivery compared
with parturients who had no oxytocin rest.

Table 1. Demographic and Baseline Characteristics of Patients in the Cohort

Oxytocin Rest (h)

Continuous
Oxytocin Less Than 1 1 to Less Than 2 2 to Less Than 8 8 or Longer
Characteristic (n5642) (n5284) (n5106) (n589) (n572) P*

Age (y) 29.466.0 30.065.8 28.765.8 28.565.8 28.566.7 .078

Gestational age (wk) 40.061.3 40.061.3 39.961.4 39.761.5 39.861.5 .080
BMI (kg/m2) 33.366.6 34.267.0 36.068.5 36.668.5 35.368.6 ,.001
Duration of latent phase (h) 12.2 (6.8) 14.2 (8.5) 20.9 (10.0) 24.2 (14.1) 28.8 (19.9) ,.001
[median (IQR)]
Indication for induction†
Hypertension 134 (20.9) 67 (23.6) 28 (26.4) 29 (32.6) 34 (47.2) ,.001
Diabetes 53 (8.3) 33 (10.4) 8 (7.6) 12 (13.5) 13 (18.1) .038
PROM 114 (17.8) 53 (18.7) 11 (10.4) 12 (13.5) 6 (8.3) .070
Oligohydramnios 63 (9.8) 27 (9.5) 18 (17.0) 14 (15.7) 8 (11.1) .115
Fetal growth restriction 7 (1.1) 3 (1.1) 1 (0.9) 1 (1.1) 1 (1.4) .99
Late term or postterm 147 (22.9) 61 (21.5) 24 (22.6) 16 (18.0) 15 (20.8) .87
Other or elective 153 (23.8) 58 (20.4) 26 (24.5) 16 (18.0) 10 (13.9) .23
BMI, body mass index; IQR, interquartile range; PROM, prelabor rupture of membranes.
Data are mean6SD or n (%) unless otherwise specified.
* Chi-square test or Fisher exact test for variables with expected cell count is less than 5. Kruskal-Wallis test was used for duration of latent
phase, which had a nonnormal distribution.
†
Column totals may sum to greater than total n owing to multiple indications for induction in some patients.

4 McAdow et al Oxytocin Rest and Mode of Delivery OBSTETRICS & GYNECOLOGY

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Table 2. Multivariable Logistic Regression Analysis of Mode of Delivery

Cesarean Delivery Adjusted Cesarean

Oxytocin Rest (h) Rate (%) Adjusted OR* 95% CI Delivery Rate (%)* 95% CI

No oxytocin rest 42.5 Ref 48.7 0.45–0.52

0 to less than 1 53.2 1.12 0.79–1.58 47.9 0.45–0.51
1 to less than 2 53.8 0.78 0.48–1.27 46.8 0.44–0.50
2 to less than 8 50.6 0.60 0.35–1.04 43.5 0.40–0.47
8 or longer 48.6 0.43 0.24–0.79 30.3 0.21–0.41
OR, odds ratio; Ref, reference.
* Initial model adjusted for age, gestational age, body mass index (BMI), latent phase (logarithmic scale), hypertension, diabetes, prelabor
rupture of membranes, cervical ripening during oxytocin rest, and oxytocin discontinued for Eunice Kennedy Shriver National Institute
of Child Health and Human Development fetal heart rate abnormality. The final regression model includes age, gestational age, BMI,
latent phase (logarithmic scale), diabetes, and oxytocin discontinued for fetal heart rate abnormality.

To evaluate whether the association between
oxytocin rest and mode of delivery was a result of
additional cervical ripening that occurred during that
interval, a multivariable regression analysis was per-
formed to adjust for this factor. Sixty-five patients had
additional cervical ripening, either misoprostol
(35.9%), intrauterine balloon (54.7%) or both (9.4%)
during oxytocin rest. In our multivariable regression
analysis, additional cervical ripening during oxytocin
rest was not associated with the odds of cesarean
delivery, aOR 1.22 (95% CI 0.47–3.16) and did not
affect the association between oxytocin rest and mode
of delivery and was therefore not included in the final
model.
To investigate whether the lower odds of cesarean
delivery associated with oxytocin rest came at the
expense of higher risk for maternal and neonatal
morbidities, secondary outcomes were compared
among patients with different oxytocin rest durations
(Table 3). We did not detect a higher odds ratio (OR)
of a composite of maternal or neonatal morbidity
among women with an oxytocin rest in hours: OR
1.02 (95% CI 0.98–1.06) and OR 1.03 (95% CI
0.97–1.08), respectively. A potentially higher odds
of NICU admission was noted with increasing dura-
tion of oxytocin rest, OR 1.04 (95% CI 1.00–1.08).
However, after adjusting for the effect of maternal
diabetes on NICU admission (aOR 3.73 [95% CI
2.48–5.62]), the odds of NICU admission fell, aOR
1.03 [95% CI 0.99–1.07], suggesting that NICU ad-
missions may be more strongly influenced by other
factors such as the institutional hypoglycemia
protocol.
DISCUSSION
Oxytocin rest is a clinical practice sometimes used
during inductions of labor when women remain in the
latent phase, despite prolonged oxytocin exposure.
There is biological plausibility borne out in the basic
science literature that uterine myometrial cell
response to oxytocin will diminish with prolonged
continuous oxytocin exposure.4,7–10,16 In our cohort
of nulliparous women undergoing induction of labor
with a protracted latent phase, an oxytocin rest of at
least 8 hours was associated with lower odds of cesar-
ean delivery. Patients in this category had a higher
BMI and were more likely to have hypertension and
diabetes, yet this reduction in risk of cesarean delivery
was not accompanied by significantly higher odds of
maternal or neonatal morbidity. Importantly, our
study was not powered to evaluate these uncommon
secondary outcomes.
There are several mechanisms by which oxytocin
rest might be protective against cesarean delivery.
Allowing time for the oxytocin receptor to be upregu-
lated and replenished on the myocyte cell surface is
one possible mechanism. Oxytocin is also thought to
act as a transcription factor to increase the expression
of gap junction proteins, which synchronize contrac-
tions, and to increase the expression of prostaglandin
F2a.17 Myometrial cells lose optimal functionality in
a state of starvation ketosis; oxytocin rest may therefore
represent an opportunity for patients to eat after a pro-
longed fasting period. It may also give patients an
opportunity to ambulate, shower, and feel increased
control over their induction course, which may have
circulatory and psychological benefits.
Other factors may contribute to the apparent
effect of an oxytocin rest. Because fetal heart rate
abnormalities may be a reason for discontinuing
oxytocin and may also be an indication for cesarean
delivery, it is important to include the contribution of
NICHD fetal heart rate category at the time of
oxytocin rest in estimating the association between
oxytocin rest and cesarean delivery. After adjusting
for NICHD fetal heart rate category at the time of
oxytocin rest, there was no association between
oxytocin of rest less than 1 hour and cesarean delivery

VOL. 00, NO. 00, MONTH 2020 McAdow et al Oxytocin Rest and Mode of Delivery 5

© 2020 by the American College of Obstetricians

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Unauthorized reproduction of this article is prohibited.
Table 3. Secondary Outcomes by Duration of Oxytocin Discontinuation

Oxytocin Rest (h)

Continuous
Oxytocin Less Than 1 1 to Less Than 2 2 to Less Than 8 8 or Longer
Outcome (n5642) (n5284) (n5106) (n589) (n572) P*

Maternal outcomes
Maternal composite† 90 (14.0) 40 (14.1) 23 (21.7) 16 (18.0) 11 (15.3) .29
VTE during hospital 2 (0.3) 0 (0) 0 (0) 0 (0) 0 (0) ..99
admission
Chorioamnionitis 31 (4.8) 19 (6.7) 11 (10.4) 8 (9.0) 7 (9.7) .10
Endometritis 6 (0.9) 3 (1.1) 4 (3.8) 2 (2.3) 1 (1.4) .13
Postpartum 42 (6.5) 16 (5.6) 8 (7.6) 8 (9.0) 4 (5.6) .82
hemorrhage
Blood transfusion 3 (0.5) 4 (1.4) 2 (1.9) 0 (0.0) 2 (2.8) .08
CVA 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) NA
Eclampsia 0 (0) 1 (0.4) 2 (1.9) 0 (0) 0 (0) .02
DIC 13 (2.0) 4 (1.4) 1 (0.9) 0 (0) 0 (0) .67
ICU Admission 2 (0.3) 0 (0) 1 (1.0) 0 (0) 0 (0) .55
Neonatal outcomes
Neonatal composite‡ 37 (5.8) 24 (8.5) 7 (6.6) 3 (3.4) 5 (6.9) .43
Meconium 4 (0.6) 1 (0.4) 1 (0.9) 1 (1.1) 1 (1.4) .47
aspiration syndrome
Need for 7 (1.1) 3 (1.1) 1 (0.9) 0 (0) 1 (1.4) .95
respiratory support
Moderate or 1 (0.2) 1 (0.4) 0 (0) 1 (1.1) 0 (0) .34
severe infection
Birth trauma 25 (3.9) 20 (7.0) 4 (3.8) 1 (1.1) 4 (5.6) .12
Seizure 2 (0.3) 3 (1.1) 1 (0.9) 0 (0) 0 (0) .47
HIE 0 (0) 2 (0.7) 0 (0) 0 (0) 0 (0) .21
NICU admission 88 (13.8) 46 (16.3) 28 (26.7) 21 (23.6) 14 (19.4) .005
VTE, venous thromboembolism; CVA, cerebrovascular accident; NA, not applicable; DIC, disseminated intravascular coagulation; ICU,
intensive care unit; HIE, hypoxic ischemic encephalopathy; NICU, neonatal intensive care unit.
Data are n (column %) unless otherwise specified.
* Chi-square test or Fisher exact test for variables with expected cell count is less than 5.
†
Maternal composite defined as having any of the subsequent diagnoses.
‡
Neonatal composite defined as having any of the subsequent diagnoses.

(Table 2). During oxytocin rest, providers may per-
form additional cervical ripening, but we did not find
an association between cervical ripening and mode of
delivery in our cohort.
One limitation of our study is that information
about certain aspects of patient care were not available
for analysis. First, whether oxytocin cessation was
intended as an “oxytocin rest” by the provider is not
available. Second, the timing of artificial rupture of
membranes was not accounted for in our analysis
for lack of consistent documentation in the EMR.
However, it is not our practice to perform an inten-
tional oxytocin rest in the setting of ruptured mem-
branes. The interplay between these potential
confounders and the effect of an oxytocin rest is less
clear and is an important area of future investigation.
Lastly, it should be noted that, although we included
patients who had been on oxytocin without entering
the active phase for 8 hours, this is not the definition
of a protracted latent phase.
A potential source of bias in the study is that
providers who employ oxytocin rest may also be
more cautious about proceeding toward cesarean
delivery and may be more likely to adhere to
recommendations that prevent cesarean delivery.18
These unmeasured provider characteristics may con-
found our findings and warrant further investigation.
Although this study demonstrates an association
between oxytocin rest and mode of delivery, prospec-
tive, randomized studies should be undertaken to
identify whether a causal relationship exists.
The rate of induction of labor is increasing and is
performed for a quarter of U.S. births,1 a number that
may increase further given growing evidence for
reduced risk of cesarean delivery and gestational
hypertension with induction of labor at 39 weeks of
gestation in studies such as the ARRIVE trial.1,19–21
However, a failed induction of labor results in cesar-
ean delivery,18 the prevention of which is an impor-
tant goal in the field of obstetrics.18,22 Sometimes,

6 McAdow et al Oxytocin Rest and Mode of Delivery OBSTETRICS & GYNECOLOGY

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
despite cervical ripening and oxytocin infusion, pa-
tients remain in latent labor. When it is medically safe
to do so, our results suggest that oxytocin rest for
more than 8 hours may optimize a woman’s chance
of vaginal delivery.
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PEER REVIEW HISTORY
Received August 28, 2019. Received in revised form December 4,
2019. Accepted December 12, 2019. Peer reviews and author cor-
respondence are available at http://links.lww.com/AOG/B731.
McAdow et al Oxytocin Rest and Mode of Delivery 7