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

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

The authors pose the question - What is the best treatment to reduce the need for caesarean section in nulliparous women at term with delayed first stage of labour? and state in their paper that "There is no consensus on the optimal dose regimen of oxytocin for delay in the first stage of labour in nulliparous women at term (37-42 weeks’ gestation) to reduce unplanned caesarean section and increase vaginal birth with minimal adverse events". However, they describe only low and high dose oxytocin regimens and fail to acknowledge that no oxytocin at all is associated with a spontaneous delivery just as often as when oxytocin is given (1,2) or that discontinuation of oxytocin once the active phase of labour is reached can result in higher spontaneous delivery rates than continuing oxytocin (3,4). The paper in its list of trials (box 2) only describes those addressing high and low dose oxytocin, which implies that these are the only options for addressing an improvement in the mode of delivery in slow labour. Although oxytocin shortens labour, it does so at the expense of an increase in uterine hyperstimulation and abnormal fetal heart rate patterns, and this may not be to the advantage of either the woman or her baby. Avoiding oxytocin use may be preferable because of the high proportion of litigated cases of adverse outcome associated with its use (5). We anticipate that our current on-going trial of stopping oxytocin at 6 cm of cervical dilatation following induction of labour will strengthen the evidence for limiting (not increasing) the use of oxytocin (6).

Yours sincerely,

Sidsel Boie, MD, Department of Obstetrics and Gynecology, Randers Regional Hospital, Denmark
Julie Glavind, MD, PhD, Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark
Niels Uldbjerg, Professor, DMSc, MD, Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark
Pinar Bor, Associate professor, MD, PhD, Department of Obstetrics and Gynecology, Randers Regional Hospital, Denmark
Philip Steer, Emeritus Professor, BSc, MD, FRCOG, Imperial College London

(1) Wei S, Wo BL, Qi HP, Xu H, Luo ZC, Roy C, Fraser WD. Cochrane Database Syst Rev. 2013 Aug 7;(8):CD006794. doi: 10.1002/14651858.CD006794.pub4
(2) Bugg GJ, Siddiqui F, Thornton JG. Cochrane Database Syst Rev. 2013 Jun 23;(6):CD007123. doi: 10.1002/14651858.CD007123.pub3)
(3) Vlachos DE, Pergialiotis V, Papantoniou N, Trompoukis S, Vlachos GD. J Matern Fetal Neonatal Med. 2015;28(12):1421-7.
(4) Bor P, Ledertoug S, Boie S, Knoblauch NO, Stornes I. BJOG. 2016;123(1):129-35
(5) Berglund S, Grunewald C, Pettersson H, Cnattingius S. BJOG 2008; 115(3):316-323.
(6) https://clinicaltrials.gov/ct2/show/NCT02553226

Competing interests: No competing interests

18 June 2017
Sidsel Boie
MD
Julie Glavind, MD, PhD Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark; Niels Uldbjerg, DMSc, MD Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark; Pinar Bor, Associate professor, MD, PhD, Department of Obstetrics and Gynecology, Randers Regional Hospital, Denmark; Philip Steer, Emeritus Professor, BSc, MD, FRCOG, Imperial College London
Randers Regional Hospital
Skovlyvej 1, 8930 Randers NØ, Denmark
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