Speeding up labor, or labor augmentation, is a process of stimulating the uterus to increase the frequency, intensity, and duration of contractions after spontaneous labor has started. Usually, speeding up of labor is done as a treatment for delayed labor. The objective of the intervention is to avert prolonged labor and at the same time deal with the increasing global problem—cesarean delivery.
Traditional methods include infusion of intravenous oxytocin and amniotomy (artificially rupturing the membranes). Considering the context of speeding up of labor, interventions could be beneficial. However, if they are used inappropriately, it can cause harm such as hyperstimulation of the uterus and adverse effects including rupture of the uterus and fetal asphyxia.
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World Health Organization (WHO) Recommendations
WHO has formulated 20 recommendations for speeding up labor The ultimate aim of the recommendations is to improve the health outcome and the quality of care associated with labor augmentation.
In Recommendation 1, the use of partographs is emphasized. A partograph is a composite graphical record of maternal and fetal data during labor. It confirms the inclusion of partographs with 4 hour action lines in health management information system, in-service and pre-service materials, and national guidelines for monitoring progress of labor.
In Recommendation 2, conducting digital vaginal examinations in a 4 hour interval is suggested for regular assessment and for identifying slowdown in active labor. WHO says that while carrying out vaginal examinations more frequently, women’s preferences and wishes should be given priority. If women find rectal exams to be uncomfortable, they should not be used for assessing routine labor.
As the package of interventions is highly prescriptive and can challenge the autonomy and choice of women, Recommendation 3 advises avoiding the use of active management of labor so that a possible delay in labor can be prevented.
Early administration of oxytocin and routine amniotomy (breaking the water bag) is not recommended for speeding up a slow labor (Recommendation 4). Recommendation 5 states that the use of oxytocin in women who get epidural analgesia be avoided.
Recommendation 6 says that using only amniotomy for preventing labor delay is not advisable. For HIV-infected women, WHO advises against early amniotomy because it could increase the risk of perinatal HIV transmission.
The use of antispasmodic agents is not advised per Recommendation 7. In spite of the fact that pain relief can have significant benefits in the labor and that it is an indispensable constituent of good-quality intrapartum care, Recommendation 8 does not suggest pain relief for labor delay prevention and for decreasing augmentation use in labor. The use of intravenous fluids with an objective to cut down labor duration is not advised per Recommendation 9.
For low-risk women, intake of food and oral fluids (Recommendation 10) and upright position and mobility during labor (Recommendation 11) are recommended. For improved labor outcomes, Recommendation 12 suggests constant companionship throughout labor.
Recommendation 13 does not recommend administering enemas for decreasing the use of labor augmentation.
While the use of only oxytocin for treating labor delay is advised (Recommendation 14), Recommendation 15 does not suggest speeding up of labor with intravenous oxytocin before confirming slow labor. If oxytocin is used as an intervention without confirming delay in labor, there is a higher risk of hyperstimulation in the uterus and heart rate changes in the fetus, and the neonatal and maternal results could be poor.
As there are few reports on neonatal results when commencing and increasing oxytocin at higher dosages while speeding up labor, per Recommendation 16, WHO suggests not to use a higher starting oxytocin dose schedule for labor augmentation. WHO recommends exercising caution while using oxytocin considering the risk associated with it.
Recommendation 17 does not suggest oral misoprostol for speeding up labor. Misoprostol is not considered to be a safe substitute for oxytocin for speeding up labor. Its use can lead to hyperstimulation of the uterus, changes in heart rate of the fetus, and neonatal and maternal outcomes that can be adverse.
The data available on regular amniotomy for treating slow labor are limited (only a small trial study has been conducted so far) and not sufficient to draw any conclusions about the harms or benefits. Therefore, WHO does not recommend the use of amniotomy only for treating slow labor (Recommendation 18).
Recommendation 19 suggests using oxytocin and amniotomy for stimulating uterine contractions as a practical clinical choice provided the slow labor is confirmed and if the delay in labor is connected with lack of normal contractions of the uterus.
Compared with external tocodynamometry (contracton monitoring), internal tocodynamometry is a resource-intensive procedure and not generally followed in many instances. Its potential harms outweigh the benefits. Consequently, WHO has suggested avoiding internal tocodynamometry (Recommendation 20).
Reviewed by Catherine Shaffer, M.Sc.
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