Diven, Liany C, MD

Eid, Sherrine, MPH3

Gogle, Julia, RN

Quiñones, Joanne N, MD, MSCE

Rochon, Meredith, MD

Smulian, John C, MD,MPH

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of Obstetrics & GynecologyInduction of Labor with Oxytocin: When ShouldOxytocin Be Held?Liany C. Diven MDLehigh Valley Health Network, Liany.Diven@lvhn.orgJulia Gogle RNLehigh Valley Health Network, Julia.Gogle@lvhn.orgMeredith Rochon MDLehigh Valley Health Network, Meredith_L.Rochon@lvhn.orgSherrine Eid MPH3Lehigh Valley Health Network, Sherrine.Eid@lvhn.orgJohn C. Smulian MD,MPHLehigh Valley Health Network, john.smulian@lvhn.orgSee next page for additional authorsFollow this and additional works at: http://scholarlyworks.lvhn.org/obstetrics-gynecologyPart of the Amino Acids, Peptides, and Proteins Commons, Hormones, Hormone Substitutes,and Hormone Antagonists Commons, Maternal, Child Health and Neonatal Nursing Commons,and the Obstetrics and Gynecology CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtDiven, L., Gogle, J., Rochon, M., Eid, S., Smulian, J., & Quinones, J. (2011). Induction of Labor with Oxytocin: When Should Oxytocin BeHeld?AuthorsLiany C. Diven MD; Julia Gogle RN; Meredith Rochon MD; Sherrine Eid MPH3; John C. SmulianMD,MPH; and Joanne N. Quiñones MD, MSCEThis poster is available at LVHN Scholarly Works: http://scholarlyworks.lvhn.org/obstetrics-gynecology/131Department of Obstetrics and Gynecology, 2Division of Maternal Fetal Medicine, 3Department of Community Health and Health Studies, Lehigh Valley Health Network, Allentown, PennsylvaniaInduction of Labor with Oxytocin: When Should Oxytocin Be Held?Liany C. Diven, MD1; Julia Gogle, RN1; Meredith L. Rochon, MD2; Sherrine Eid, MPH3, John C. Smulian, MD, MPH2; Joanne N. Quiñones, MD, MSCE2Abstract: Objective:  To determine whether there is an increase in the cesarean delivery rate and labor length in women undergoing induction when oxytocin is discontinued in the active phase of labor. STUDY DESIGN:  Prospective randomized controlled trial of women undergoing induction of labor with a term singleton gestation during February 2009-August 2011. Women were randomized to either oxytocin as routinely used (ROUTINE) or oxytocin discontinuation (DC or DISCONTINUATION) once in active labor. Induction method and labor management were otherwise left at the discretion of the obstetrician. Analysis was by intention to treat.RESULTS:  252 patients were eligible for study analysis: 128 patients randomized to ROUTINE and 124 patients randomized to DC once active labor was reached. Cesarean delivery (CD) rate was similar between the groups (ROUTINE 25.0% [n=32] vs. DC 19.4% [n=24], p=0.28). There was a higher chorioamnionitis rate (ROUTINE 5.5% [n=7] vs. DC 12.9% [n=16], p=0.04) and slightly longer active phase in those randomized to DC. In adjusted analysis, the rate of chorioamnionitis was not different by randomization arm but was explained by a longer active phase of labor [AOR 1.27 (95% CI 1.10, 1.47), p=0.001].CONCLUSION:  Discontinuation of oxytocin once active labor is reached may decrease receptor desensitization without significantly increasing the CD rate, but longer labor duration is associated with an increased risk of chorioamnionitis.Methods: Prospective randomized controlled trial of women undergoing induction with a singleton gestation ≥ 37 weeks at Lehigh Valley Health Network from February 2009 – August 2011. Women were randomized to either the ROUTINE group (oxytocin administered as an induction agent was continued once active labor was achieved) or the DISCONTINUATION group (oxytocin was discontinued once the patient was determined to be in active labor). Primary outcome was cesarean delivery rate between groups. Secondary outcomes included length of latent phase of labor, length of active phase of labor and maternal/neonatal outcomes. Institutional review board approval was obtained. Induction method and labor management was otherwise at the discretion of the provider. Active labor was defined both by cervical exam (4-5 cm with regular contractions) and clinical assessment. The provider could restart oxytocin at any time in patients assigned to the DISCONTINUATION group if felt to be clinically indicated. Inclusion criteria:  •  Singleton gestation ≥ 37 weeks undergoing induction of labor with either misoprostol, oxytocin and cervical Foley balloon placement.  Results: •  128 randomized to ROUTINE group, 124 to DISCONTINUATION group.  • The most common method of induction in both groups was oxytocin.  •  Oxytocin was restarted in the DISCONTINUATION group in 57 (47%) patients at the discretion of the provider. •  Cesarean delivery rate was similar between groups (ROUTINE 19.4% vs. DISCONTINUATION 25%, p=0.28). •  The median length of the active phase of labor (3.0 hrs vs. 3.9 hrs, p=0.02) and rates of chorioamnionitis (5.5% vs. 12.9%, p=0.04) were higher in the DISCONTINUATION group.  Conclusion: In women undergoing induction, discontinuation of oxytocin once in active labor is not associated with an increased rate of cesarean delivery, but it is associated with longer labor duration and increased risk of chorioamnionitis. Exclusion criteria:  •  Multiple gestations  •  Previous cesarean delivery  •  Documented fetal anomalies•  After controlling for potential confounders, oxytocin discontinuation did not increase the rate of cesarean delivery (AOR 0.52 [95% CI 0.14 – 1.89], p=0.32). •  The risk of chorioamnionitis was not increased due to discontinuation of oxytocin (AOR 1.42 [95% CI 0.44, 4.57], p=0.56) but was related to nulliparity (AOR 4.94 [95% CI 1.20, 20.4], p=0.03), length of the active phase of labor (AOR 1.27 [95% CI 1.10, 1.47], p=0.001), and the Bishop score (AOR 0.31 [95% CI 0.10, 0.96], p=0.04). •  Only length of the active phase of labor was significantly associated with an increased risk of chorioamnionitis (AOR 1.26 [1.07, 1.47], p=0.004) when controlling for the length of the active phase and number of cervical exams. Figure 1: Study enrollment algorithmPatients Approachedn=493Declinedn=190Acceptedn=303Ineligiblen=51Enrolledn=252ROUTINEn=128DCn=124Table 4. Unadjusted analysis of potential predictors of cesarean delivery and chorioamnionitis           Variable Cesarean delivery ChorioamnionitisNulliparity RR 5.91 (2.91, 12.0), p<0.001 RR 6.56 (2.0, 21.5) p<0.001Chorioamnionitis RR 1.91 (1.08, 3.37), p=0.04 ----Bishop score >4 RR 0.46 (0.29, 0.72), p<0.001 RR 0.36 (0.16, 0.81), p<0.001Resident vs. Private RR 1.12 (0.70, 1.79), p=0.64 RR 0.45 (0.20, 1.02), p=0.05Any co-morbidity RR 1.46 (0.84, 2.50), p=0.17 RR 0.63 (0.29, 1.38), p=0.25Length of latent phase OR 1.09 (1.03, 1.16), p=0.004 OR 1.07 (1.01, 1.14), p=0.03Length of active phase OR 1.22 (1.06, 1.40), p=0.005 OR 1.36 (1.19, 1.55), p<0.001Number cervical exams OR 1.11 (0.99, 1.25), p=0.08 OR 1.45 (1.22, 1.73), p<0.001Table 1. Demographic characteristics of the patient population by randomization group           Characteristics Routine (n=128) DC (n=124) p-valueMaternal age (+SD) 27.0 + 5.6 27.7 + 5.7 0.33Nulliparity (%) 63 (49.2) 54 (51.6) 0.70Marital status (%)     Married     Divorced/widow     Never married56 (43.8)1 (0.7)71 (55.5)66 (53.2)1 (0.8)57 (46.0) 0.32Race/ethnicity (%)     Caucasian     African American     Latina     Other 87 (68.0)8 (6.3)27 (21.0)6 (4.7)81 (65.3)7 (5.7)30 (24.2)6 (4.8) 0.95Insurance (%)     Government     Private     Self-Pay53 (41.4)60 (46.9)15 (11.7)44 (35.5)61 (49.2)6 (4.8) 0.54 Resident service [vs. private] (%) 57 (44.5) 58 (46.8) 0.72Tobacco use (%) 17 (13.3) 18 (14.5) 0.78Alcohol use (%) 0 (0) 1 (0.8) 0.31Drug use (%) 0 (0) 2 (1.6) 0.15Body mass index - kg/m2 (+SD) 31.6 + 7.3 31.0 + 7.4 0.51Any co-morbidity (%) 88 (69.3) 81 (65.3) 0.50Pregestational diabetes (%) 1 (0.8) 1 (0.8) 0.99Gestational diabetes (%) 14 (10.9) 17 (13.7) 0.50Essential hypertension (%) 5 (3.9) 6 (4.8) 0.71Gestational hypertension or preeclampsia (%) 46 (35.9) 41 (33.1) 0.63Obesity (%) [BMI > 30] 40 (31.3) 30 (24.2) 0.21History of preterm birth (%) 3 (2.4) 7 (5.7) 0.19Table 2. Intrapartum characteristics of the patient population by randomization group           Characteristics Routine (n=128) DC (n=124) p-valueGestational age at admission (weeks) 39.8 + 1.3 40.0 + 1.0 0.19Primary indication for labor induction (%)     Prolonged pregnancy     Premature rupture of membranes     Non reassuring testing     Oligohydramnios     Gestational hypertension or preeclampsia     Intrauterine growth restriction     Any diabetes     Elective     Other33 (25.8)6 (4.7)14 (10.9)14 (10.9)21 (16.4)1 (0.8)10 (7.8)19 (14.8)19 (7.8)35 (28.2)9 (7.3)5 (4.0)12 (9.7)19 (15.3)1 (0.8)13 (10.5)15 (12.1)15 (12.1) 0.54First method of induction (%)     Misoprostol     Oxytocin     Foley bulb and oxytocin22 (17.2)99 (77.3)7 (5.5)21 (17.0)89 (71.8)14 (11.3) 0.24Insurance (%)     Government     Private     Self-Pay53 (41.4)60 (46.9)15 (11.7)44 (35.5)61 (49.2)6 (4.8) 0.54 Bishop score (median) 5 (0-10) 5 (0-10) 0.82Bishop score >4 (%) 82 (64.1) 79 (63.7) 0.95Membrane status (%)     Amniotomy     Spontaneous rupture of membranes     Premature rupture of membranes104 (81.3)15 (11.7)9 (7.0)100 (80.6)13 (10.5)11 (8.9) 0.84Anesthesia (%)     Epidural     Spinal     Local     Intravenous sedation     None123 (96.1)1 (0.8)1 (0.8)0 (0)3 (2.3)117 (94.4)0 (0)2 (1.6)1 (0.8)4 (3.2) 0.63Table 3. Labor and delivery characteristics by randomization group           Cesarean delivery (%) Routine (n=128) DC (n=124) p-valueCesarean delivery (%) 32 (25.0) 24 (19.4) 0.28Indications for cesarean delivery (%)     Nonreassuring fetal heart tracing     Arrest of the active phase     Arrest of descent     Failed induction of labor     Malpresentation     Other8 (25.0)12 (37.5)7 (21.9)2 (6.3)2 (6.3)1 (3.0)7 (29.0)11 (45.8)6 (25.0)0 (0)0(0)0(0) 0.53Oxytocin dose in active labor (mu/min) 9.8 + 5.4 10.8 + 6.3 0.25Maximum oxytocin dose (mu/min) 13.0 + 6.8 13.1 + 6.7 0.85Intrapartum complications     Preeclampsia     Chorioamnionitis     Abruptio placentae     Other*5 (3.9)7 (5.5)1 (0.8)12 (9.4)2 (1.6)16 (12.9)1 (0.8)8 (6.5) 0.29Postpartum complications     Postpartum hemorrhage     Preeclampsia diagnosed postpartum     Endometritis     Acute blood loss anemia7 (5.5)1 (0.8)0 (0)13 (10.2)8 (6.5)0 (0)1 (0.8)21 (17.0) 0.32Latent phase of labor (hours)     Mean     Median9.6 + 6.87.7 (1.3, 54.6)10.2 + 5.010.6 (0.3, 23.7)0.430.06Active phase of labor (hours)     Mean     Median 3.8 + 2.93.0 (0.1, 15.3)4.8 + 3.53.9 (0.1, 15.5)0.020.02Second stage of labaor (hours)     Mean     Median1.0 + 1.20.50 (0.0, 6.7)1.1 + 1.30.50 (0.0, 6.5)0.530.77*Other – includes conditions such as elevated blood pressures without a diagnosis of hypertension or elevated temperature without diagnosis of chorioamnionitis

Induction of Labor with Oxytocin: When Should Oxytocin Be Held?

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Induction of Labor with Oxytocin: When Should Oxytocin Be Held?

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