Practice Uncertainties

What is the best treatment to reduce the need for caesarean section in nulliparous women at term with delayed first stage of labour?

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2469 (Published 06 June 2017) Cite this as: BMJ 2017;357:j2469
  1. Sara Kenyon, professor of evidence based maternity care1,
  2. Julia Sanders, reader, consultant midwife2,
  3. Lee Middleton, senior statistician3,
  4. Tracey Johnston, consultant in maternal and fetal medicine4
  1. 1Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
  2. 2Healthcare Sciences, Cardiff University, Cardiff CF24 0AB, UK
  3. 3Birmingham Clinical Trials Unit, School of Cancer Sciences, Robert Aitken Institute, University of Birmingham, Birmingham
  4. 4Birmingham Women's and Children’s NHS Foundation Trust, Birmingham
  1. Correspondence to: S Kenyon s.kenyon{at}bham.ac.uk

What you need to know

  • Prolonged labour is associated with adverse outcomes for mother and fetus, and intravenous oxytocin is the mainstay of treatment

  • There is uncertainty as to the optimal regimen of oxytocin to decrease the chances of caesarean section with minimal adverse effects, and there is some evidence that high dose regimens may be effective

  • Administer oxytocin in hospital where the mother and baby can be closely monitored

Labour is commonly divided into three stages. The duration of the first and second stages of labour vary, dependent on parity. Figure 1 depicts the stages of labour and expected duration as defined by the National Institute for Health and Care Excellence (NICE).1 Nulliparous women tend to have a longer labour than multiparous women. Delay can result from poor uterine contractions or the relationship between size, presentation, and position of the fetus and the maternal pelvis that obstructs vaginal delivery. Uterine contractile dysfunction affects between 11% and 30% of nulliparous women234 and is the focus of this paper.

Fig 1 The three stages of labour and their expected duration1

Delayed labour—There is some variation worldwide in the definition of delayed labour (table 1). The World Health Organization considers delay as a rate of cervical dilation of less than 0.5-1 cm in four hours once labour is established, whereas NICE recommends waiting a further two hours with cervical dilation of less than 1 cm before delay is confirmed. Prolonged labour is associated with higher rates of chorioamnionitis9 with risk of neonatal sepsis and of unplanned caesarean section with associated risks of infection and bleeding.101112

View this table:
Table 1

Summary of professional guidelines for normal duration of labour, definition of delay in the first stage of labour, and recommended treatment with oxytocin in nulliparous women

Oxytocin—Treatment for a confirmed delay …

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