Background: Exogenous oxytocin was approved by the FDA in 1962 and has been administered to help induce labor, advance a prolonged labor, assist with placental delivery, and manage postpartum bleeding. However, the use of this synthetic oxytocin is commonly both inconsistent and incautious in timing and dosing, with outcomes of uterine tachysystole (hyperstimulation), subsequent fetal oxygen desaturation and alterations in fetal heart rate patterns, all potentially leading to emergency cesarean sections (CS). Since such associations have been established, would the implementation of a guideline-based approach on the precautious use of synthetic oxytocin in labor augmentation reduce emergency CS rates?
Methods: An exhaustive literature search was performed using MEDLINE-PubMed, CINAHL, Proquest, and Web of Science databases. Key terms searched include oxytocin, intervention, fetal distress, reduc*, obstetric labor complications, education, guidelines as topic, protocol, and checklist. Articles that included a guideline approach to using oxytocin in labor augmentation and reported on emergency CS rates were included. Exclusion criteria included guidelines based on the third stage of labor. The remaining articles and their references were screened for eligibility, were critically appraised, and the quality of their evidence was assessed with the GRADE working group approach.
Results: Four studies met the inclusion and exclusion criteria and were eligible to be included in this systematic review. All were observational studies, 2 prospective and 2 retrospective. One study reported a significant reduction in the frequency of oxytocin use and a significant increase in overall emergency CS, but also a significant increase in oxytocin used in labors without dystocia. A second study found a significant reduction in the frequency of oxytocin use, emergency CS overall, and emergency CS indicated for fetal distress with a non-significant decrease in CS due labor dystocia. A third study reported a statistically significant reduction in the maximum oxytocin dose, with a non-significant decrease in CS rate post-checklist. The fourth study found a statistically significant reduction in the frequency of oxytocin use, a non-significant decrease in CS rate, a statistically significant increase in CS due to labor dystocia with a statistically significant reduction in those due to fetal distress. All studies were assessed as very low quality of evidence based on GRADE.
Conclusion: The studies collectively demonstrate that a guideline-based approach on the precautious use of synthetic oxytocin during labor management leads to a reduced frequency of its use and/or a decrease in the maximum dose. However, the impact on emergency CS rates became a moving target as each study used different guidelines. This reveals the necessity of a standardized approach that includes a universal definition of labor dystocia and a protocol that guides when to start, continue, or stop oxytocin. This could be accomplished by a future study that assessed a dose response curve to evaluate if a low or high dose oxytocin regimen, in combination with a universal guideline with provided markers for when to initiate and stop synthetic oxytocin, would correlate to a decline in emergent CS rates.
Keywords: oxytocin, intervention, fetal distress, reduc*, obstetric labor complications, education, guidelines as topic, protocol, and checklist.
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