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High dose versus low dose oxytocin for augmentation of delayed labour. (1).pdf

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High-dose versus low-dose oxytocin for augmentation of delayed labour (Review) Kenyon S, Tokumasu H, Dowswell T, Pledge D, Mori R This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2013, Issue 7 http://www.thecochranelibrary.com High-dose versus low-dose oxytocin for augmentation of delayed labour (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. T A B L E O F C O N T E
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  High-dose versus low-dose oxytocin for augmentation of delayed labour (Review) Kenyon S, Tokumasu H, Dowswell T, Pledge D, Mori R  Thisisareprintof aCochrane review, preparedandmaintained byThe Cochrane Collaboration andpublishedin  TheCochrane Library  2013, Issue 7http://www.thecochranelibrary.com High-dose versus low-dose oxytocin for augmentation of delayed labour (Review)Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.  T A B L E O F C O N T E N T S 1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 High versus low dose of oxytocin (all women), Outcome 1 Neonatal mortality. . . . . 20 Analysis 1.2. Comparison 1 High versus low dose of oxytocin (all women), Outcome 2 Caesarean section. . . . . 21 Analysis 1.3. Comparison 1 High versus low dose of oxytocin (all women), Outcome 3 Length of labour (hour; oxytocin todelivery). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Analysis 1.4. Comparison 1 High versus low dose of oxytocin (all women), Outcome 4 Length of labour (minute; onset of first stage to delivery). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Analysis 1.5. Comparison 1 High versus low dose of oxytocin (all women), Outcome 5 Support received by staff. . . 23 Analysis 1.6. Comparison 1 High versus low dose of oxytocin (all women), Outcome 6 Women’s internal control during labour and birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Analysis 1.7. Comparison 1 High versus low dose of oxytocin (all women), Outcome 7 Women’s external control during labour and birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Analysis 1.8. Comparison 1 High versus low dose of oxytocin (all women), Outcome 8 Spontaneous vaginal birth. . 24 Analysis 1.9. Comparison 1 High versus low dose of oxytocin (all women), Outcome 9 Diagnosis of chorioamnionitis. 25 Analysis 1.10. Comparison 1 High versus low dose of oxytocin (all women), Outcome 10 Incidence of hyperstimulation. 26 Analysis 1.11. Comparison 1 High versus low dose of oxytocin (all women), Outcome 11 Instrumental vaginal birth. 27 Analysis 1.12. Comparison 1 High versus low dose of oxytocin (all women), Outcome 12 Incidence of postpartumhaemorrhage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Analysis 1.13. Comparison 1 High versus low dose of oxytocin (all women), Outcome 13 Epidural analgesia. . . . 28 Analysis 1.14. Comparison 1 High versus low dose of oxytocin (all women), Outcome 14 Pathological cardiotocography (CTG) leading to immediate birth without fetal blood sampling. . . . . . . . . . . . . . . . . 29 Analysis 1.15. Comparison 1 High versus low dose of oxytocin (all women), Outcome 15 Neonatal admission to specialcare baby units. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Analysis 1.16. Comparison 1 High versus low dose of oxytocin (all women), Outcome 16 Apgar score less than 7 at 5minutes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Analysis 1.17. Comparison 1 High versus low dose of oxytocin (all women), Outcome 17 Umbilical cord (artery) pH. 31 Analysis 1.18. Comparison 1 High versus low dose of oxytocin (all women), Outcome 18 Subgroup analysis: Caesareansection by parity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3232 WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .34INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iHigh-dose versus low-dose oxytocin for augmentation of delayed labour (Review)Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.  [Intervention Review] High-dose versus low-dose oxytocin for augmentation of delayed labour  Sara Kenyon 1 , Hironobu Tokumasu 2 , Therese Dowswell 3 , Debbie Pledge 4 , Rintaro Mori 51 School of Health and Population Sciences, University of Birmingham, Edgbaston, UK.  2 Neonatology, Kagoshima City Hospital,Kagoshima, Japan.  3 Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK.  4 National Collaborating Centre for Women’s and Children’s Health, London, UK.  5 Department of HealthPolicy, National Center for Child Health and Development, Tokyo, JapanContact address: Rintaro Mori, Department of Health Policy, National Center for Child Health and Development, 2-10-1 Okura,Setagaya-ku, Tokyo, Tokyo, 166-0014, Japan. rintaromori@gmail.com. Editorial group:  Cochrane Pregnancy and Childbirth Group. Publication status and date:  New search for studies and content updated (no change to conclusions), published in Issue 7, 2013. Review content assessed as up-to-date:  4 July 2013. Citation:  Kenyon S, Tokumasu H, Dowswell T, Pledge D, Mori R. High-dose versus low-dose oxytocin for augmentation of delayedlabour.  Cochrane Database of Systematic Reviews   2013, Issue 7. Art. No.: CD007201. DOI: 10.1002/14651858.CD007201.pub3.Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. A B S T R A C T Background  A major cause of failure to achieve spontaneous vaginal birth is delay in labour due to presumed inefficient uterine action. Oxytocinis given to increase contractions and high-dose regimens may potentially increase the number of spontaneous vaginal births, but asoxytocin can cause hyperstimulation of the uterus, there is a possibility of increased adverse events. Objectives To compare starting dose and increment dose of oxytocin for augmentation for women delayed in labour to determine whetheraugmentation by high-dose regimens of oxytocin improves labour outcomes and to examine the effect on both maternal/neonataloutcomes and women’s birth experiences. Search methods  We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (31 May 2013) and reference lists of retrieved studies. Selection criteria   We included all randomised and quasi-randomised controlled trials for women in delayed labour requiring augmentation by oxytocincomparing high-dose regimens (defined as starting dose and increment of equal to or more than 4 mU per minute) with low-doseregimens (defined as starting dose and an increment of less than 4 mU per minute). Increase interval: between 15 and 40 minutes. Theseparation of low- and high-dose regimens is based on an arbitrary decision. Data collection and analysis Four review authors undertook assessment of trial eligibility, risk of bias, and data extraction independently. 1High-dose versus low-dose oxytocin for augmentation of delayed labour (Review)Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.  Main results  We included four studies involving 644 pregnant women. Three studies were randomised controlled trials and one trial was a quasi-randomised study. A higher dose of oxytocin was associated with a significant reduction in length of labour reported from one trial(mean difference (MD) -3.50 hours; 95% confidence interval (CI) -6.38 to -0.62; one trial, 40 women). There was a decrease in therate of caesarean section (risk ratio (RR) 0.62; 95% CI 0.44 to 0.86 four trials, 644 women) and an increase in the rate of spontaneousvaginal birth in the high-dose group (RR 1.35; 95% CI 1.13 to 1.62, three trials, 444 women), although for both of these outcomesthere were inconsistencies between studies in the size of effect. When we carried out sensitivity analysis (temporarily removing a study at high risk of bias) the differences between groups were no longer statistically significantThere were no significant differences between high- and low-dose regimens for instrumental vaginal birth, epidural analgesia, hyper-stimulation, postpartum haemorrhage, chorioamnionitis or women’s perceptions of experiences. For neonatal outcomes, there was nosignificant difference between groups for Apgar scores, umbilical cord pH, admission to special care baby unit, or neonatal mortality.The following outcomes were not evaluated in the included studies: perinatal mortality, uterine rupture, abnormal cardiotocography, women’s pyrexia, dystocia and neonatal neurological morbidity.  Authors’ conclusions Higher-dose regimens of oxytocin (4 mU per minute or more) were associated with a reduction in the length of labour and in caesareansection, and an increase in spontaneous vaginal birth. However, there is insufficient evidence to recommend that high-dose regimensare advised routinely for women with delay in the first stage of labour. Further research should evaluate the effectof high-dose regimensof oxytocin for women delayed in labour and should include maternal and neonatal outcomes as well as the effects on women. P L A I N L A N G U A G E S U M M A R Y Oxytocin in high versus low doses for augmentation of delayed labour  Women have different lengths of labour, with first labours lasting on average eight hours (and unlikely to last more than 18 hours)and second and subsequent labours lasting an average of five hours and unlikely to last more than 12 hours. Assessment of progressin labour takes into account not just cervical dilatation, but also descent and rotation of the fetal head and the strength, duration andfrequency of contractions. Some evidence suggests that up to one-third of women in their first labour experience delay. They are oftengiven a synthetic version of the hormone oxytocin to increase uterine contractions and shorten labour. Surprisingly for such a routinetreatment, the ideal dose at which it should be given is not known, although some comparisons suggest that higher-dose regimensof oxytocin could shorten labour and reduce the chance of caesarean section with an increase in the numbers of women having a spontaneous vaginal birth compared with lower-dose regimens. However, there are potentially harmful side effects as oxytocin may cause the uterustocontract tooquickly, and thebaby to become distressed. Clinicians attempttomitigate theseside effectsby adjusting the dose of oxytocin with the contractions to reduce the chances of the baby being distressed in labour.From thefour randomised controlledtrials involving 644 pregnant women thatwe included in thisreview, results indicate thatahigherdose of oxytocin (4-7 mU per minute, compared with 1-2 mU per minute) reduced the length of labour and the rate of caesareansections with increased spontaneous vaginal births, but the studies did not provide enough evidence on possible differences betweenthe high- and low-dose regimens on adverse events including hyperstimulation of the uterus, and outcomes for the newborn infant.Only one trial reported on the possible effect on women. The overall quality of the included trials was mixed, but this might reflecthow clinical trials were reported in the past. While the current evidence is promising and suggests that the high-dose regimens reduce the length of labour and the rate of caesareansections, this evidence is not strong enough to recommend that high-dose regimens are used routinely for women delayed in labour. We recommend that further research is carried out. 2High-dose versus low-dose oxytocin for augmentation of delayed labour (Review)Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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