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Volume 93 March 1999
Active-Phase Labor Arrest: Oxytocin
Augmentation for at Least 4 Hours
DWIGHT J. ROUSE, MD, JOHN OWEN, MD, AND JOHN C. HAUTH, MD
Objective: To assess a labor-management protocol that man-
dated at least 4 hours of oxytocin augmentation before
cesarean delivery for active-phase labor arrest.
Methods: We prospectively evaluated term gravidas in
spontaneous labor with active-phase labor arrest (cervix at
least 4 cm dilated and 1 cm or less of cervical progress in 2
hours). Exclusion criteria included nonvertex presentation,
previous cesarean, multiple gestation, and a nonreassuring
fetal heart rate tracing or chorioamnionitis at the time of
labor arrest. After the diagnosis of active-phase arrest, oxy-
tocin was initiated with an intent to achieve a sustained
uterine contraction pattern of greater than 200 Montevideo
units. Cesarean delivery was not performed for labor arrest
until at least 4 hours of a sustained uterine contraction
pattern of greater than 200 Montevideo units, or a minimum
of 6 hours of oxytocin augmentation if this contraction
pattern could not be achieved.
Results: Five hundred forty-two women were managed by
the protocol, and 92% delivered vaginally. The subsequent
vaginal delivery rate for parous women who had not pro-
gressed (1 cm of cervical dilation or less) despite 2 hours of
oxytocin augmentation was 91%, and it was 74% for nullip-
aras. With no labor progress after 4 hours of oxytocin
augmentation, the subsequent vaginal delivery rates were
88% for parous women and 56% for nulliparas. There were
From the Division of Maternal-Fetal Medicine, Department of Ob-
stetrics and Gynecology, University of Alabama at Birmingham, Bir-
mingham, Alabama.
VOL. 93, NO. 3, MARCH 1999
Number 3
no severe maternal complications. One neonate had persis-
tent fetal circulation and one had a positive blood culture,
but both did well.
Conclusion: Extending the minimum period of oxytocin
augmentation for active-phase labor arrest from 2 to at least
4 hours was effective and safe. (Obstet Gynecol 1999;93:
323– 8. © 1999 by The American College of Obstetricians
and Gynecologists.)
In 1970, the cesarean delivery rate in the United States
was 5.5%. By 1978 it had nearly tripled, to 15.2%.1 The
National Institutes of Health Cesarean Birth Task Force
determined that dystocia was the single leading factor
contributing to the increase. Accordingly, the Task
Force recommended that dystocia and its management
should be the focus of further research.1 Subsequent
research on uterine contraction pressures contributed to
the following 1989 ACOG recommendation: “before the
diagnosis of arrest in the first stage of labor is made,
both of the following two criteria should be met:
1. The latent phase of labor has been completed with
the cervix dilated 4 cm or more.
2. A uterine contraction pattern of $200 Montevideo
units in a 10-minute period has been present for 2
hours without cervical change.”2
0029-7844/99/$20.00 323
PII S0029-7844(98)00448-7
 Despite this recommendation, in 1994 the United
States cesarean delivery rate reached 22%.3
In the United States, dystocia continues to contribute
substantially to the high cesarean delivery rate, but data
to support an optimum duration of oxytocin augmen-
tation for active-phase labor arrest are lacking. There-
fore, we developed and implemented a clinical protocol
that mandated a minimum of 4 hours of oxytocin
augmentation, with a sustained uterine contraction pat-
tern of greater than 200 Montevideo units, before per-
forming a cesarean delivery for active-phase labor ar-
rest. The efficacy and safety of that protocol form the
basis of this report.
Material and Methods
The protocol was instituted on February 1, 1996 at the
Maternal-Fetal Medicine service of the University of
Alabama at Birmingham Hospital, which has approxi-
mately 3000 deliveries annually. Deliveries on this
service are performed by resident physicians under the
direct 24-hour supervision of one of 11 members (fac-
ulty and fellows) of the Maternal-Fetal Medicine Divi-
sion.
All members of the Maternal-Fetal Medicine Division
agreed to manage eligible women according to proto-
col. Before institution of the protocol, the resident staff
received in-service education. Women were eligible for
the protocol if they were at or beyond 36 weeks’
gestation and met two criteria: 1) spontaneous active-
phase labor, defined as a cervical dilatation of at least
4 cm and spontaneous, regular uterine contractions (at
least two in 10 minutes); and 2) labor arrest, defined as
1 cm or less of cervical progress in 2 hours. We allowed
1 cm of cervical progress over 2 hours to qualify as
arrest because during the period of this study, a diag-
nosis of labor arrest was required for the administration
of oxytocin. Because several physicians shared respon-
sibilities for the same woman, we wanted to minimize
the possibility that interexaminer variation would result
in prolonged periods of no actual labor progress before
the administration of oxytocin. Exclusion criteria in-
cluded a nonvertex presentation, previous cesarean
delivery, multiple gestation, and, at the time of labor
arrest, a nonreassuring fetal heart rate tracing, chorio-
amnionitis, or spontaneous uterine contractions equal
to or exceeding 250 Montevideo units.
Upon the diagnosis of active-phase labor arrest, an
internal uterine pressure catheter was placed (after
amniotomy if necessary). Dilute intravenous oxytocin
was initiated at one mm/minute and increased every 15
minutes over 2 hours to 30 mm/minute, or until either
a uterine contraction pattern of greater than 200 Mon-
tevideo units was achieved or labor progressed. Before
324 Rouse et al 4-Hour Oxytocin Minimum
a cesarean delivery for labor arrest was performed, the
protocol mandated at least 4 hours of oxytocin augmen-
tation with a sustained uterine contraction pattern of
greater than 200 Montevideo units. However, because it
is not always possible to achieve a sustained uterine
contraction pattern of greater than 200 Montevideo
units, cesarean delivery for labor arrest was permitted
after 6 hours of oxytocin augmentation regardless of the
uterine contraction pattern. For those patients who, on
initial assessment, had greater than 200 but less than
250 Montevideo units, oxytocin was also begun and
titrated with an intent to achieve at least 250 Monte-
video units.
To ensure complete ascertainment of protocol-eligible
patients, oxytocin orders were available only in sequen-
tially numbered envelopes on the labor and delivery
suite. On a daily basis, a research nurse determined for
which patients oxytocin had been ordered and identi-
fied protocol-eligible patients. The charts of eligible
patients and their infants were then abstracted for
selected demographic and clinical variables. Specific
maternal complications assessed included clinically di-
agnosed chorioamnionitis, postpartum hemorrhage,
postpartum endometritis, need for blood transfusion,
and abdominal wound infection. Intrapartum chorio-
amnionitis was diagnosed with a temperature of at least
37.8C and at least one of the following supporting
symptoms or signs: uterine tenderness, maternal or
fetal tachycardia (greater than 100 and greater than 160
beats per minute, respectively), or purulent amniotic
fluid or cervical discharge. The diagnosis of intrapar-
tum chorioamnionitis precluded the diagnosis of post-
partum endometritis, which was defined as a tempera-
ture of at least 38.0C in the postpartum period and at
least one of the following symptoms or signs: uterine
tenderness, maternal tachycardia (greater than 100
beats per minute), or purulent cervical discharge.
Throughout the study, intrapartum antibiotics were
administered to patients with risk factors for early-
onset neonatal group B streptococcal disease.4
Neonatal outcomes and complications assessed in-
cluded 1- and 5-minute Apgar scores, umbilical cord
blood gas indices including fetal acidemia (pH less than
7.0), confirmed sepsis (by blood or cerebrospinal fluid
culture), need for antibiotics, supplemental oxygen re-
quirement outside of the delivery room, use of mechan-
ical ventilation, phototherapy for hyperbilirubinemia,
and a diagnosis of pneumonia, necrotizing enterocolitis,
intraventricular hemorrhage, seizures, or death.
The primary outcomes for this investigation were the
overall vaginal delivery rate and protocol safety (rates
of maternal and fetal or neonatal complications). Vagi-
nal delivery rates and safety were analyzed both by
parity and by whether labor had progressed (defined as
Obstetrics & Gynecology
Table 1. Vaginal Delivery and Complication Rates of Parous Women With Active-Phase Labor Arrest Categorized by Labor
Progress After the Initiation of Oxytocin Augmentation
Eventual vaginal
Time delivery rate (%) Chorioamnionitis (%) Endometritis (%) Transfusion (%)

After 2 hours of oxytocin

Labor progress (n 5 187) 99 1* 2 1
No labor progress (n 5 46) 91 7* 7 2
No cervical examination (n 5 21) 86 0* 5 5
After 4 hours of oxytocin
Labor progress (n 5 229) 98 1 2† 1
No labor progress (n 5 16) 88 6 13† 0
No cervical examination (n 5 9) 78 0 11† 11
* P 5 .03.
†
P 5 .02.

more than 1 cm of cervical dilatation) or delivery had
occurred by both 2 and 4 hours after the initiation of
oxytocin augmentation. Vaginal delivery rates were
analyzed further for the subset of patients with no labor
progress despite 2 hours of uterine activity greater than
200 Montevideo units. For the purposes of analysis, a
patient was considered to have had a “2-hour cervical
examination” if a cervical examination was docu-
mented in the chart from 91 to 179 minutes after the
initiation of oxytocin, and a “4-hour cervical examina-
tion” if the examination was performed between 211
and 299 minutes after the initiation of oxytocin. Patients
who did not have a cervical examination in the 2- or
4-hour examination window were also analyzed, and
their outcomes were reported for comparison.
Using Fisher exact test, we compared complication
rates among three groups: the group that progressed,
the group that did not progress, and the group that was
not examined 2 or 4 hours after the initiation of oxytocin
augmentation. Data were analyzed using the SAS sys-
tem 6.12 for personal computers (SAS Institute, Cary,
NC). P , .05 was considered significant. We established
a target sample size of at least 500 women. A cohort of
this size yields high precision (narrow confidence inter-
vals) around observed event rates. For example, the
upper limit of the 99% confidence interval for an event
with an observed rate of 1% is less than 2%.
Results
From February 1, 1996 through April 6, 1998, 554
protocol-eligible women experienced active-phase labor
arrest. Twelve (2%) of these women did not receive
oxytocin because of spontaneous progress of labor
before initiation of the drug. These women all delivered
vaginally, and because they did not receive oxytocin,
they were not considered further in the analysis of this
protocol. Thus, 542 women were eligible for the proto-
col and received oxytocin.
Of the women managed by the protocol, 288 (53%)
were nulliparous and 254 (47%) were parous. Parous
and nulliparous women were similar demographically:
The mean age was 23 and 20 years, respectively; mean
weight was 81 and 79 kg; 68% and 74% were black; and
27% and 24% were white. The mean gestational age at
delivery was 40 weeks for both groups; the mean birth
weight was 3427 and 3301 g, respectively; and 89% and
96% received lumbar epidural analgesia for labor.
The vaginal delivery rate for the cohort of protocol-
managed women was 92%: 97% for parous women and

Table 2. Vaginal Delivery and Complication Rates of Nulliparas With Active-Phase Labor Arrest Categorized by Labor
Progress After the Initiation of Oxytocin Augmentation
Eventual vaginal
Time delivery rate (%) Chorioamnionitis (%) Endometritis (%) Transfusion (%)

After 2 hours of oxytocin

Labor progress (n 5 159) 97 7 4 1
No labor progress (n 5 80) 74 14 7 1
No cervical examination (n 5 49) 82 16 7 0
After 4 hours of oxytocin
Labor progress (n 5 238) 94 6* 5 0
No labor progress (n 5 27) 56 22* 14 0
No cervical examination (n 5 22) 68 41* 0 5
* P , .001.

VOL. 93, NO. 3, MARCH 1999 Rouse et al 4-Hour Oxytocin Minimum 325
88% for nulliparas. The median time from the diagnosis
of active-phase labor arrest to the initiation of oxytocin
was 15 minutes. Analysis by whether labor had pro-
gressed (including delivery) by 2 and 4 hours after the
initiation of oxytocin demonstrated that the majority of
women with no progress despite 2 or even 4 hours of
oxytocin augmentation eventually underwent a vaginal
delivery (Tables 1 and 2). Parous women with no
progress despite 2 hours of oxytocin augmentation had
a vaginal delivery rate of 91%, whereas nulliparas had
a vaginal delivery rate of 74%. Even with no labor
progress 4 hours after the initiation of oxytocin, 88% of
parous women and 56% of nulliparas eventually deliv-
ered vaginally.
No patients experienced uterine rupture or under-
went hysterectomy. Rates of chorioamnionitis and en-
dometritis for nulliparas were 10% and 5%, respec-
tively, and both were 2% for parous women. Labor
progress (and lack thereof) correlated with the risk of
maternal infectious complications: Rates of chorioam-
nionitis and endometritis were increased among pa-
tients who had not progressed (or were not examined)
by 2 and 4 hours after the initiation of oxytocin (Tables
1 and 2). Four percent of the patients experienced
postpartum hemorrhage and 1% received a red blood
cell transfusion. The risk of red blood cell transfusion
was less consistently (and not significantly) related to
labor progress than was the risk of maternal infection
(Tables 1 and 2). One patient experienced a postcesar-
ean abdominal wound infection.
In general, fetal and neonatal outcomes were excel-
lent. There were no stillbirths or neonatal deaths. Two
infants, one with congenital diaphragmatic hernia and
the other with multiple severe congenital malforma-
tions, died after protracted courses of disease. With the
exception of the latter infant, the lowest 5-minute Apgar
score was 6. Two infants had an umbilical artery pH of
less than 7.0. This acidemia was respiratory in nature,
and both infants were vigorous at birth. One infant,
born to a parous woman who had progressed after 2
hours of oxytocin, had a positive blood culture, re-
ceived antibiotics, and was discharged without appar-
ent sequelae on day 14 of life. Four infants were placed
on mechanical ventilation: the two who died, one with
Noonan syndrome and an associated cardiac malforma-
tion, and one with persistent fetal circulation. This last
infant, born to a parous woman who did not have a
2-hour cervical examination, was on the ventilator for
48 hours and was discharged on day 10 of life without
apparent sequelae. Six percent of the newborns received
antibiotics, and none suffered necrotizing enterocolitis,
intraventricular hemorrhage, or seizures. One percent
had hyperbilirubinemia requiring phototherapy and 2%
required supplemental oxygen (exclusive of mechanical
326 Rouse et al 4-Hour Oxytocin Minimum
ventilation) outside of the delivery room. In the infants
of both parous and nulliparous patients, these compli-
cations did not differ significantly among the three
groups (progress, no progress, and no examination
groups) at either 2 or 4 hours after the initiation of
oxytocin.
Because most women progressed after 2 hours of
oxytocin, we identified only 52 women with no
progress 2 hours after achieving a uterine contraction
pattern of greater than 200 Montevideo units. The
eventual vaginal delivery rate was 63% for the 40
nulliparas in this group and 58% for the 12 parous
women. Although this group had a high rate of mater-
nal infection (chorioamnionitis 27%, endometritis 12%),
their other outcomes were essentially equivalent to
those of the overall cohort of protocol-managed
women, with no severe adverse neonatal outcomes,
including sepsis.
Indications for the 42 cesarean deliveries performed
included labor arrest (n 5 24), nonreassuring fetal
status (n 5 10), and both labor arrest and nonreassuring
fetal status (n 5 8). Women who ultimately underwent
cesarean for labor arrest either had no cervical progress
after the diagnosis of labor arrest or made progress
initially but had arrest again later. These women re-
ceived oxytocin for a median duration of 7.1 hours
(range 4.3–13.0). Before cesarean for labor arrest, 88% of
the women achieved a uterine contraction pattern of
greater than 200 Montevideo units.
Discussion
We conducted the present investigation to evaluate a
protocol that focused on three principal elements: 1) an
intent to achieve a sustained uterine contraction pattern
of greater than 200 Montevideo units; 2) a more liberal
minimum of 4 hours (as opposed to the currently
sanctioned 2 hours5) of oxytocin-augmented labor ar-
rest with a sustained uterine contraction pattern of
greater than 200 Montevideo units before proceeding to
cesarean delivery for active-phase labor arrest; and 3)
for patients who could not achieve a sustained uterine
contraction pattern of greater than 200 Montevideo
units, a minimum of 6 hours of oxytocin augmentation
before proceeding to cesarean delivery for active-phase
labor arrest. Thus, we were able to address what we
perceived as two practical limitations of the current
recommendations5 for active-phase labor arrest: 1) that
a 2-hour minimum might deny some women the op-
portunity for a safe vaginal delivery, and 2) that some
women are never able to achieve an augmented uterine
contraction pattern of greater than 200 Montevideo
units.
This protocol was effective, resulting in a high rate of
Obstetrics & Gynecology
vaginal delivery (92%), and safe, with no severe adverse
maternal and fetal or neonatal outcomes. Although the
risk of maternal infection was increased for those
women who had not progressed in labor by 2 and 4
hours after the initiation of oxytocin, the majority (80%)
of these women delivered vaginally. They therefore
avoided the attendant surgical and increased infectious
risks of cesarean delivery. Other adverse outcomes,
both maternal and neonatal, were unrelated to labor
progress 2 and 4 hours after the initiation of oxytocin.
For example, the only neonate with a positive blood
culture was born to a woman who had progressed 2
hours after the initiation of oxytocin. Thus, in terms of
decreasing the cesarean delivery rate for those women
who had not made progress in labor, the clinical benefit
of extending the duration of oxytocin for active-phase
labor arrest from 2 to at least 4 hours seemed to more
than offset the observed rates of maternal and neonatal
morbidity associated with (but potentially unrelated to)
continued oxytocin augmentation.
Few studies have focused on the optimal duration of
oxytocin administration for active-phase labor arrest.
Although a strict definition of labor arrest, in terms of
uterine activity and duration of arrest, has been a
component of recent institutional programs to lower the
cesarean birth rate, in general these programs have
used the 2-hour definition of labor arrest.6,7 Thus,
although these programs are successful, they provide
no insight into the efficacy and safety of policies that
require longer oxytocin administration in the face of
continued labor arrest. Perhaps the most relevant inves-
tigation of this issue was performed by Arulkumaran et
al.8 In a study of 319 women of mixed parity, they
evaluated the effect of an additional 4-hour period of
oxytocin augmentation in women with “unsatisfactory”
progress in the active phase of labor 4 hours after the
commencement of oxytocin (less than 1 cm/hour of
cervical progress over the 4-hour period). Like us, they
demonstrated that an additional 4 hours of oxytocin
administration was beneficial by allowing 48 of the 92
women (42%) with unsatisfactory labor progress to
achieve safe vaginal delivery.
The majority of women (93%) in this cohort received
continuous lumbar epidural analgesia, and this proba-
bly had an impact on their labor course. Three random-
ized clinical trials have shown that epidural analgesia
prolongs the duration of labor.9 –11 In response to this
observed effect, it was suggested recently12 that when
epidural analgesia is used for pain relief during labor,
physicians should consider modifying the guidelines
for management of the first stage of labor, as has been
done for the second stage.13 The results of our study
support that suggestion.
We believe our findings may have important impli-
VOL. 93, NO. 3, MARCH 1999
Table 3. 1990 International Comparison by Indication of
Cesarean Births per 100 Vaginal and Cesarean
Deliveries15
Indication Sweden Scotland United States
Dystocia 1.7 4.0 7.1
Previous cesarean 3.1 3.1 8.5
Breech 1.8 2.0 2.6
Fetal distress 1.6 2.4 2.3
Other 2.4 2.7 3.2
Total 10.7 14.2 23.6
cations for reducing the high cesarean delivery rate in
the United States. Although repeat cesarean is the
leading indication for all cesareans performed in the
United States, more than 50% of all primary cesareans
are performed for dystocia. Because dystocia was the
original indication for most repeat cesareans, it follows
that the majority of cesareans in the United States are
ultimately related to the diagnosis of dystocia.14 More-
over, the principal reason that the cesarean delivery rate
in the United States is so much higher than in other
developed countries is that cesarean for dystocia occurs
at a much higher rate in this country. In 1990, 7.1 births
per 100 in the United States were cesareans performed
for dystocia. In turn, the United States had a high rate of
repeat cesarean delivery— 8.5 births per 100. Thus, as a
result of primary cesareans for dystocia (and the down-
stream consequence of repeat cesareans), the United
States has a much higher cesarean rate than other
western countries such as Sweden and Scotland (Table
3).15 Clearly, reducing the number of cesareans per-
formed for dystocia would dramatically lower our high
national cesarean delivery rate.
The potential for reducing the number of cesarean
deliveries by adopting a more stringent definition of
dystocia (specifically, of active-phase labor arrest) is
evident by considering the benefits of continued oxyto-
cin augmentation in the face of continued labor arrest.
For example, 126 women in this cohort had no labor
progress despite 2 hours of oxytocin augmentation. Of
these women, 101 achieved vaginal delivery. Had we
delivered all of them by cesarean after 2 hours of
oxytocin, the cesarean delivery rate for this cohort
would have been 26%, as opposed to the 8% rate that
was achieved. In the smaller subset of women with no
progress 2 hours after achieving a uterine contraction
pattern of greater than 200 Montevideo units, continued
oxytocin augmentation allowed 32 of 52 women (62%)
to achieve vaginal delivery. Even women with no labor
progress despite 4 hours of oxytocin augmentation
benefited from the protocol: 29 of 43 such women (67%)
achieved vaginal delivery and were thereby spared an
unnecessary cesarean.
Rouse et al 4-Hour Oxytocin Minimum 327
 Certain limitations of our data warrant comment. We
studied only women in spontaneous labor who had
experienced active-phase labor arrest. Therefore, our
findings are not directly applicable to women undergo-
ing induction of labor. The data also may not be
applicable to women who experience active-phase labor
arrest while receiving oxytocin (eg, women who receive
oxytocin for protraction disorders or according to the
principles of active management of labor). Because we
excluded women with previous cesareans and those
with chorioamnionitis at the time of active-phase labor
arrest, the safety of this protocol for such women and
their fetuses requires further investigation. Finally, al-
though we studied more than 500 women, our ability to
perform in-depth subanalyses (eg, by cervical dilatation
at labor arrest) was limited by the relatively small
numbers of women in specific subgroups.
The above limitations notwithstanding, this labor-
management protocol was safe and effective. We en-
courage others to investigate this protocol. If, with
larger samples, the efficacy and safety of this protocol
are confirmed, the minimum recommended duration of
oxytocin augmentation for active-phase labor arrest
should be increased.
References
1. National Institutes of Health. Cesarean Birth Task Force Develop-
ment Report. Obstet Gynecol 1981;57:537– 45.
2. American College of Obstetricians and Gynecologists. Dystocia.
ACOG technical bulletin no. 137. Washington DC: American
College of Obstetricians and Gynecologists, 1989.
3. Clarke SC, Taffel SM. Rates of cesarean and VBAC delivery, United
States, 1994. Birth 1996;23:166 – 8.
4. American College of Obstetricians and Gynecologists. ACOG
committee opinion no. 173. Prevention of early-onset group B
streptococcal disease in newborns. Washington DC: American
College of Obstetricians and Gynecologists, 1996.
5. American College of Obstetricians and Gynecologists. Dystocia
328 Rouse et al 4-Hour Oxytocin Minimum
and the augmentation of labor. ACOG technical bulletin no. 218.
Washington DC: American College of Obstetricians and Gynecol-
ogists, 1995.
6. Sanchez-Ramos L, Kaunitz AM, Peterson HB, Martinez-Schnell B,
Thompson RJ. Reducing cesarean sections at a teaching hospital.
Am J Obstet Gynecol 1990;163:1081– 8.
7. Myers SA, Gleicher N. A successful program to lower cesarean-
section rates. N Engl J Med 1988;319:1511– 6.
8. Arulkumaran S, Koh CH, Ingemarsson I, Ratnam SS. Augmenta-
tion of labour—mode of delivery related to cervimetric progress.
Aust N Z J Obstet Gynaecol 1987;27:304 – 8.
9. Sharma SK, Sidawi JE, Ramin SM, Lucas MJ, Leveno KJ, Cunning-
ham FG. Cesarean delivery. A randomized trial of epidural versus
patient-controlled meperidine analgesia during labor. Anesthesi-
ology 1997;87:472– 6.
10. Thorp JA, Parisi VM, Boylan PC, Johnston DA. The effect of
continuous epidural analgesia on cesarean section for dystocia in
nulliparous women. Am J Obstet Gynecol 1989;161:670 –5.
11. Ramin SM, Gambling DR, Lucas MJ, Sharma SK, Sidawi JE,
Leveno KJ. Randomized trial of epidural versus intravenous
analgesia during labor. Obstet Gynecol 1995;86:783–9.
12. Alexander JM, Lucas MJ, Ramin SM, McIntire DD, Leveno KJ. The
course of labor with and without epidural analgesia. Am J Obstet
Gynecol 1998;178:516 –20.
13. American College of Obstetricians and Gynecologists. Operative
vaginal delivery. ACOG technical bulletin no. 196. Washington
DC: American College of Obstetricians and Gynecologists, 1994.
14. Centers for Disease Control and Prevention. Rates of cesarean
delivery. MMWR Morb Mortal Wkly Rep 1993;42:287–9.
15. Notzon FC, Cnattingius S, Bergsjø P, Cole S, Taffel S, Irgens L, et al.
Cesarean section delivery in the 1980s: International comparison
by indication. Am J Obstet Gynecol 1994;170:495–504.
Reprints are not available.
Received June 22, 1998.
Received in revised form August 25, 1998.
Accepted September 3, 1998.
Copyright © 1999 by The American College of Obstetricians and
Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology