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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 441-447

The outcome of induced labor after oxytocin infusion discontinuation in the active phase


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Monofiya University, Ashmoun, Monofiya, Egypt
2 Department of Obstetrics and Gynecology at Ministry of Health, Ashmoun, Monofiya, Egypt

Date of Submission25-Sep-2017
Date of Acceptance11-Nov-2017
Date of Web Publication25-Jun-2019

Correspondence Address:
Rania A Tahoon
Shebin El-Kom, Monofiya 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_652_17

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  Abstract 


Objective
The objective was to determine whether discontinuation of oxytocin infusion after established active phase of induced labor gives good obstetric outcome without any adverse maternal and neonatal effect.
Background
Oxytocin is one of the most widely drugs used in induction of labor. Continuous infusion of oxytocin after establishment of the active phase of labor may lead to uterine atony and postpartum hemorrhage. Therefore, we should stop oxytocin infusion once the active phase has started.
Patients and methods
A total of 90 pregnant women who required labor induction and fulfilled the criteria of the study population were enlisted in this prospective controlled randomized clinical trial and then were assigned to either group A or B. In group A cases, infusion of oxytocin was started in incremental doses until 5 cm of cervical dilatation and to be maintained at that level throughout the labor, whereas in group B cases, infusion of oxytocin was started incrementally but discontinued when cervical dilatation reached 5 cm.
Results
This study showed that there was a statistically significant difference between group A and group B regarding the first stage of labor, uterine hyperstimulation, maximal and total doses of oxytocin, neonatal outcome, and incidence of postpartum hemorrhage. There was statistically insignificant difference between group A and group B regarding age, BMI, mean gestational age, parity, indications for induction of labor, detection of meconium upon rupture of membranes, and mode of delivery.
Conclusion
There is no need to continue oxytocin infusion after the establishment of active phase of labor.

Keywords: active phase, induced, labor, meconium, oxytocin, parity, uterine atony


How to cite this article:
Eissa AN, Sayyed TM, El-Halaby AE, Tahoon RA. The outcome of induced labor after oxytocin infusion discontinuation in the active phase. Menoufia Med J 2019;32:441-7

How to cite this URL:
Eissa AN, Sayyed TM, El-Halaby AE, Tahoon RA. The outcome of induced labor after oxytocin infusion discontinuation in the active phase. Menoufia Med J [serial online] 2019 [cited 2019 Sep 17];32:441-7. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/441/260907




  Introduction Top


Induction of labor is an integral part of modern obstetrics practice leading to progressive dilatation and effacement of the cervix and delivery of the baby. The safety and reliability of induction has greatly increased in recent years by applying different appropriate methods[1]. Oxytocin (Syntocinon; Novartis Pharmaceuticals Limited, Frimley, England) is the standard agent for labor induction. It is produced endogenously chiefly in the hypothalamus and released from the posterior pituitary gland[2]. It has become one of the most widely used medications in obstetrics for induction and acceleration of labor[3], which affects approximately one in four women[4],[5]. Oxytocics are the drugs of varying chemical nature that have the power to excite contraction of the uterine muscle[6]. Oxytocin stimulates uterine contraction by activation of receptor-operated calcium channels and release of calcium from sarcoplasmic reticulum[7]. The effectivity of oxytocin depends on the expression of oxytocin receptor sensitivity[8]. Once myometrial oxytocin receptor concentration reaches a certain threshold level, effective uterine contraction is triggered[9]. Oxytocin induction of labor may be associated with uterine atony, and long episode of labor induction may result in postpartum atony where bleeding cannot be stopped by intravenous oxytocin infusion[10]. However, once we start oxytocin for induction of labor, the duration, and concentration of drug administered may have an opposite effect on the course of labor by desensitizing oxytocin receptor to exogenous and endogenous oxytocin. Therefore, it is reasonable to discontinue oxytocin infusion after establishment of active phase of labor, because the process of labor is self-sustaining[8]. The aim of this study was to determine whether discontinuation of oxytocin infusion after established active phase of induced labor gives good obstetric outcome without any adverse maternal and neonatal effects.


  Patients and Methods Top


This was a prospective randomized clinical trial that was conducted on women with an indication for induction of labor after obtaining an approval from Hospital Local Medical Ethics Committee. An informed consent was obtained from all participants. The criteria of the patients who have been included in this study was as follows: patients with greater than or equal to 37 weeks to 40 weeks with singleton fetus in vertex presentation, with indication of induction of labor, postdated pregnancy (>completed 42 weeks), Bishop score of 6 or more, term premature rupture of membrane, mild pre-eclampsia/hypertension at greater than or equal to 39 weeks of pregnancy, and oligohydramnios. The following types of cases have been excluded from this study: nonvertex presentation, previous history of lower scar cesarean delivery or any scar of previous uterine surgery, multiple pregnancy/hydromnios, parity of more than three times, cervical dilatation of more than 3 cm on admission, congenital fetal anomaly, fetal distress on admission, fetal weight more than 4 km measured by ultrasound, preterm labor, and severe maternal disease/complication, for example, severe pre-eclampsia/eclampsia, antepartum hemorrhage, and heart disease. Assessment of the patients included history taking with particular aspect relevant to this study, general examination, obstetrical examination, vaginal examination, obstetrical ultrasonographic evaluation before induction of labor, and continuous monitoring of labor progress using a partograph (WHO recommended). A random number table was obtained from a statistical textbook and then the trial sequence was determined via it. Consecutive opaque sealed envelopes, which were arranged according to the original trial sequence, were prepared, where each envelope contains only one assignment to either group A or group B. A total of 90 pregnant women who required induction of labor and fulfilled the criteria of the study population were included and then assigned to either group A or B according to a hidden sequenced assignment in each envelope. They were prepared for labor, and induction was to be initiated by starting synthetic oxytocin infusion. In study group A, infusion of oxytocin was started in incremental doses until 5 cm cervical dilatation and to be maintained at that level throughout the labor. There were 42 (47%) cases in this group. In control group B, infusion of oxytocin was started incrementally but discontinued when cervical dilatation reached 5 cm. There were 48 (53%) cases in this group. The labor progress was monitored by partogram. The duration and frequency of uterine contractions was determined by palpation, and its intensity was estimated by the firmness with which the uterine muscle contracts. Fetal heart rate (FHR) was monitored during induction of labor. We did rupture of membrane when the cervical dilatation reached 5 cm. The concentration of oxytocin was 5 international unit (IU) to be added to 500ml ringer solution at a starting rate of four drops per minute (i.e., 2 mIU/min) to be increased by two drops every 20 min until 3–4 contractions are palpable per 10 min with each one lasting more than 30 s. The maximal allowed dose of oxytocin was 20 mIU/min. Owing to limited equipment resources at the hospital of study, we added 5 IU to 500 ml of Ringer's solution. As 5 IU = 5000 mIU, it means that every 1 ml of solution contains 10 mIU. A volume 1 ml of solution = around 20 drops. This means one drop of solution = 2 mIU of oxytocin. If discontinuation of oxytocin drip leads to insufficient uterine activity and in turn arrest of labor progress for 1 h, the oxytocin drip will be restarted again. Arrest of labor progress was diagnosed when no cervical dilatation for 2 h in the active phase of labor in the presence of sufficient uterine activity. Participants with such diagnosis were delivered by cesarean birth. If the cervical dilatation does not reach 5 cm after 7 h of continuous oxytocin infusion in presence of adequate sufficient uterine contractions, the patient was offered either to have repeated induction in another occasion by prostaglandins or to undergo cesarean delivery. The primary outcomes of the study included the following: duration of the stages of labor, maximal dose, total dose of oxytocin used, episode of uterine hyperstimulation (>6 contractions per 10 min), mode of delivery, maternal and neonatal outcome, and abnormality in the FHR (in case of such occurrence, oxytocin infusion we stopped temporarily, and the patient was placed on left lateral position, with intravenous fluids infusion, and ensuring good oxygenation and vasopressor in hypotensive cases). Power analysis was performed under the assumption of type I error of 5% and a power of 80%. Accordingly, a sample size of ninety patients was sufficient for detection of 1.5 h prolongation or difference of labor duration in both groups.

Data management

Data were collected, tabulated, and statistically analyzed using an IBM Corp., IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: USA) and Epi Info 2000 programs (Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA), where the following statistics were applied: descriptive analysis included mean, SD, numbers, and percentages, and analytical statistical tests included χ2-test, Student's t-test, Mann–Whitney test, Fisher's exact test, paired t-test, and Wilcoxon's test. P value of greater than 0.05 was considered not statistically significant. P value of less than or equal to 0.05 was considered statistically significant. P value of less than or equal to 0.001 was considered statistically highly significant.


  Results Top


In group A, there was only one case that led to discontinuation of the intervention with oxytocin because of occurrence of nonreassuring FHR, so the final analyzed cases of group A were 41. In group B also, there was one case that led to discontinuation of the intervention with oxytocin because of failure of progress of labor, so the final analyzed cases of group B were 47. See flow diagram in [Figure 1]. As shown in [Table 1], the mean age of the study group A was 26.31 ± 3.46 years, whereas the mean age of the control group B was 26.04 ± 3.13 years. The mean BMI of group A was 29.6 ± 3.74, whereas that of group B was 29.01 ± 3.81. The mean gestational ages (in weeks) in group A and B were 39.12 ± 0.88 and 38.83 ± 0.93, respectively. There was statistically insignificant difference between group A and group B regarding mean age, mean BMI, and mean gestational age. According to the indications of induction of labor, highest percentage of women were induced for term pregnancy with oligohydramnios. Term pregnancy with premature rupture of membranes was the second most common indication for induction of labor [Table 1]. There was statistically insignificant difference between group A and group B regarding the indications for induction of labor. The mean Bishop score on admission of group A was 6.88 ± 0.86, whereas that of group B was 7.44 ± 0.920. There was a significant difference between mean of Bishop's score on admission in both groups A and B. There was statistically insignificant difference between group A and group B regarding parity. The mean measurements of cervical dilatation (cm) before induction in groups A and B were 2.07 ± 0.77 and 2.31 ± 0.74, respectively. There was statistically insignificant difference between group A and group B regarding the cervical dilatation before induction. As shown in [Table 2], the mean periods of the first stage of labor (h) in group A and B were 6.85 ± 2.10 and 5.55 ± 1.5, respectively, whereas the mean periods of the second stage of labor (min) were 47.78 ± 20.81 and 43.08 ± 15.1, respectively. There was significant difference between the two groups in the first stage mean, and no significant difference between group A and B in second stage mean. There were seven (17.1%) cases in the study group A that were complicated by fetal distress as compared with only two (4.3%) cases in the control group B. The most common types of abnormality in FHR pattern was tachycardia (161–180 bpm) and variable deceleration. There was significant statistically difference between group A and group B regarding nonreassuring FHR. The mean of the maximal dose of oxytocin (mIU/min) in groups A and B was 12.39 ± 2.72 and 7.23 ± 2.8, respectively. There was highly statistical significance between group A and group B regarding the mean maximal dose of oxytocin. The mean of the total dose of oxytocin (IU) of groups A and B was 30.9 ± 6.8 and 18.09 ± 7.11, respectively. There was highly significant difference statistically between group A and group B regarding dose of oxytocin mean. There were nine (22%) cases in the study group A that was complicated by uterine hyperstimulation compared with only three (6.4%) cases in the control group B [Figure 2]. There was a significant difference statistically between the two groups regarding percentage of uterine hyperstimulation. There were nine (22%) cases in the study group A complicated by rupture of membranes with detection of meconium as compared with only four (8.5%) cases in the control group (group B). There was a statistically insignificant difference between group A and group B regarding the detection of meconium upon rupture of membranes. As shown in [Table 3], regarding the mode of delivery, there were 27 (65.9%) cases in group A that delivered vaginally, whereas there were 39 (83%) cases in group B that delivered vaginally. On the contrary, there were 14 (34.1%) cases in group A that required cesarean section (CS) for completion of delivery, whereas only eight (17%) cases in group B that required CS. There was a statistically insignificant difference between group A and group B regarding the mode of delivery as the percentage of CS delivery increased in group A compared with group B. The causes of CS in group A were occurrence of abnormal FHR pattern in seven cases, failure of progress of labor in three cases, occurrence of hyperstimulation syndrome in two cases, and detection of meconium upon rupture of membrane in two cases. The causes of CS in group B were occurrence of abnormal FHR pattern in three cases, failure of progress of labor in two cases, occurrence of hyperstimulation syndrome in two cases, and detection of meconium upon rupture of membrane in one case. The mean Apgar scores at the first minute of the neonate in groups A and B were 7.05 ± 0.96 and 8.08 ± 0.895, respectively, whereas the mean Apgar scores at the fifth minute of the neonate in groups A and B were 7.43 ± 1.30 and 8.67 ± 0.93, respectively. There was a highly statistically significant difference in Apgar scores in the first and fifth minute in both groups. A total of 11 (26.8%) neonates in group A needed neonatal intensive care unit (NICU) admission as compared with only two (4.3%) neonates in group B. There was significant statistically difference between group A and group B regarding NICU admission. There were four (9.7%) cases in group A that were complicated by postpartum hemorrhage, whereas there were no cases recorded in group B complicated by it [Figure 3]. There was a statistically significant difference between incidences of postpartum hemorrhage in group A compared with group B. The mean birth weight of neonates in group A was 3.10 ± 0.30, whereas that in group B was 2.98 ± 0.32. There was a statistically significant difference in birth weight in both groups.
Figure 1: Flow diagram.

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Table 1: Demographic characteristics of the studied groups

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Table 2: Intrapartum clinical features of the studied groups

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Figure 2: Uterine hyperstimulation in the studied groups.

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Table 3: Maternal mode of delivery and outcome of labor of the studied groups

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Figure 3: Percentages of postpartum hemorrhage in the studied groups.

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  Discussion Top


Approximately 15–25% of all pregnant women require oxytocin for either induction of labor[11],[12]. Despite its extensive use, there is no consensus regarding the initial dose, dosage increments, and/or the maximal dose[13],[14],[15]. There are not enough data to know whether induction of labor with oxytocin should be continued or stopped after the onset of active labor. This is an important issue considering that the main adverse effect of oxytocin is uterine hyperstimulation (six or more contractions in 10 min). This lead to unnecessary fetal compromise, dysfunctional labor, and in the most extreme cases uterine rupture[8]. In a study by Daniel-Spiegel et al.[8], oxytocin was discontinued in four women in group A because of a nonreassuring FHR tracing, and oxytocin was restarted in four women in group B because of insufficient uterine activity resulting in arrest of labor. This is similar to what has happened in the current study, but with only one case in every group. In the current study, there was a statistically nonsignificant difference between the two groups regarding parity. This may be attributed to the randomly assignment of cases in the two groups. This result corresponds to that obtained by a study by Ustunyurt et al.[11], where such difference has been detected. In contrast to the study by Ustunyurt et al.[11] that showed insignificant difference between the two groups regarding the Bishop score, the current study detected that there was a significant difference between mean of Bishop's score on admission in both groups A and B (P < 0.05). In the current study, one of the inclusion criteria for included cases was Bishop score of 6 or more, but in the study by Ustunyurt et al.[11] the included cases were with a Bishop score of less than 6 at the time of oxytocin initiation. In a study by Rashwan et al.[16], 200 pregnant women were divided into two equal groups: group A received continuous oxytocin infusion throughout labor till delivery, whereas in group B, oxytocin infusion was discontinued once the active phase of labor is established. Similar to our study, there was a highly significant difference between the two groups at the first-stage interval (5.67 ± 1.13 vs. 6.85 ± 1.011, respectively). In contrast to the current study and that by Ustunyurt et al.[11], where an insignificant difference was obtained in the second stage of labor, the study by Rashwan et al.[16] reported that there was a highly significant difference between the two groups in the second-stage interval (36.2 ± 9.86 vs. 45.16 ± 14.13, respectively). However, in the study by Ustunyurt et al.[11], the duration of the second stage of labor was longer in the oxytocin-discontinued group, but in the current study, it was shorter in the oxytocin-discontinued group. Moreover, the results of the current study correspond to what have been reported in the study by Daniel-Spiegel et al.[8], that the duration of labor was shorter and there were fewer cesarean deliveries when oxytocin induction was discontinued at the beginning of the active phase of labor. In the current study, the mean of the maximal dose of oxytocin (mIU/min) in groups A and B was 12.39 ± 2.72 and 7.23 ± 2.8, respectively. The means of the total dose of oxytocin (IU) of groups A and B were 30.9 ± 6.8 and 18.09 ± 7.11, respectively. Regarding the both mean doses, there were highly significant differences statistically between group A and group B. In the study by Ustunyurt et al.[11], the mean of the maximal dose of oxytocin (mIU/min) in groups A and B was 13.6 ± 5.4 and 13.8 ± 5.3, respectively, but in contrast to the current study, there was insignificant difference between the two groups. In the current study, there were nine (22%) cases in group A that were complicated by uterine hyperstimulation, whereas only three (6.4%) cases in group B that were complicated by it. There was a significant difference statistically between the two groups regarding percentage of uterine hyperstimulation. These results are similar to those obtained by Rashwan et al.[16] and Ustunyurt et al.[11]. In the study by Rashwan et al.[16], there was a statistically highly significant difference between group A and group B regarding uterine hyperstimulation (7 vs. 0% of patients in each group, respectively). In the study by Ustunyurt et al.[11], the rate of uterine hyperstimulation was significantly higher in oxytocin-continued group. In the current study, there were 27 (65.9%) cases in group A that delivered vaginally, whereas there were 39 (83%) cases in group B that delivered vaginally. On the contrary, there were 14 (34.1%) cases in group A that required cesarean delivery for completion of delivery, whereas only eight (17%) cases in group B required CS, i.e., the percentage of CS delivery increased in group A compared with group B. These results correspond to what the studies by Rashwan et al.[16] and Ustunyurt et al.[11] have reported. However, in the study by Rashwan et al.[16], a statistically significant difference between groups A and B regarding the mode of delivery was obtained, whereas in the current study and that by Ustunyurt et al.[11], there was no significant difference. In the current study, four (9.7%) cases in group A were complicated by postpartum hemorrhage, whereas no cases recorded in group B were complicated by it. There was statistically significant difference between incidences of postpartum hemorrhage in group A compared with group B. The type of postpartum hemorrhage in all complicated cases was the atonic one. It may be because of continuous infusion of oxytocin throughout the course of labor in group A. This may be explained by, according to prior studies, G protein-coupled receptors, as the oxytocin receptor, which undergoes desensitization after prolonged and repeated stimulation[10],[17],[18]. In the current study, there were nine (22%) cases in the study group A that were complicated by rupture of membranes with detection of meconium, whereas only four (8.5%) cases in the control group B that were complicated by it. There was statistically insignificant difference between group A and group B regarding the detection of meconium upon rupture of membranes. These results are opposite to that obtained by Rashwan et al.[16] who reported that there was a statistically highly significant difference between group A and group B regarding the detection of meconium upon rupture of membranes (29% of patients in group A vs. 10% of patients in group B). This controversy between the two studies may be because of the overall number of included cases, as it was obviously higher in the study by Rashwan et al.[16] (200 cases) than that in the current study (90 cases). In the current study, there were seven (17.1%) cases in group A that were complicated by fetal distress, whereas only two (4.3%) cases in group B were complicated by it. Similar to the study by Rashwan et al.[16] (16 vs. 6% of patients in each group, respectively), this current study reported that there was statistically significant difference between group A and group B regarding the incidence of nonreassuring FHR. In the current study, the percentage of the neonates who needed NICU admission was higher with significant statistically difference in oxytocin-continued group A than oxytocin-discontinued group B (26.8 vs. 4.3% respectively, P < 0.05). This might be attributed to the highly statistically significant difference in the mean of Apgar score in the first and fifth minute of study groups, which might be owing to prolonged uterine contractions caused by the continuous infusion of oxytocin which in turn led to fetal compromise and distress. This was also what the study by Rashwan et al.[16] assumed (10 vs. 4% of neonates of cases in continued and discontinued group, respectively). On the contrary, Ustunyurt et al.[11] reported that there was insignificant difference regarding the percentage of the neonates who needed NICU admission between oxytocin-continued group and oxytocin-discontinued group (7.15 vs. 9.8%, respectively). Ustunyurt et al.[11] study reported that there was insignificant difference regarding the 5 min Apgar score of neonates, but the current study detected the reverse that there was a highly statistically significant difference in Apgar score in the first and fifth minute in both groups.


  Conclusion Top


There is no need to continue oxytocin infusion after the establishment of active phase of labor. However, there is an increase in the duration of labor or delivery mean time after discontinuing the infusion. This new protocol significantly decreases the incidence of uterine hyperstimulation and fetal distress which may result from oxytocin infusion and may decrease cesarean delivery rate owing to oxytocin complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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