Olufemi Oladapo, from the WHO Department of Reproductive Health and Research, coordinated the development of the guideline and drafted this document. Therese Dowswell and Helen West, from the Cochrane Pregnancy and Childbirth Group, University of Liverpool, UK, reviewed the scientific evidence related to augmentation of childbirth, prepared the GRADE tables and prepared the narrative summaries of the evidence presented in this context. was used. The WHO extends its sincere thanks to Zahida Qureshi, from the University of Nairobi, Kenya, for chairing the technical consultation.
Special thanks go to the authors of the systematic reviews used in this guide for their help and cooperation in updating the reviews. Traditional methods of labor augmentation have been with the use of intravenous infusion of oxytocin and artificial rupture of membranes (amniotomy). These include: (i) identification of priority questions and critical outcomes, (ii) retrieval of up-to-date evidence, (iii) evaluation and synthesis of evidence, (iv) formulation of recommendations using input from a wide range of stakeholders. and (v) planning for the dissemination, implementation, impact assessment and updating of the guide.
Background
Target audience
It provides the general principles and specific recommendations for labor augmentation and is intended as information for the development of protocols and health policies related to labor augmentation.
Methods
Declaration of interests by participants at the WHO technical consultation
Decision-making during the technical consultation
All GDG members and other participants therefore had to fill in the declaration of interest form before the technical one. By default, the strength of each recommendation was initially aligned with the quality of the evidence, so that at the start of the discussion, strong recommendations were based on evidence that was considered to be of moderate and high quality, while weak recommendations were based on evidence that was rated as low and very low quality. In addition to evaluating the scientific evidence and its quality, the following factors were considered in determining the strength and direction of the final recommendation: values and preferences, magnitude of effect, ratio of benefits to harms, use of resources, and feasibility (14).
The values and preferences, resource use, and feasibility of each recommendation were based on the experiences and opinions of GDG members. Balance sheet worksheets were used to record and synthesize these considerations and to record reasons for changes to the default strength of recommendations (see Appendix 3). In general, a high-quality, strong recommendation means that further research on the particular question is not a priority.
Document preparation and peer review
Results
Guiding principles
Application of the recommendations should be based on consideration of the general condition of the woman and her baby, her wishes and preferences, and respect for her dignity and autonomy. Augmentation of labor should only be performed when there is a clear medical indication and the expected benefits outweigh the potential harms. Augmentation of labor with oxytocin is appropriate and should only be performed after performing clinical assessment to rule out cephalopelvic disproportion.
Augmentation of labor should be performed with caution as the procedure carries the risk of uterine hyperstimulation, with the potential consequences of fetal distress and uterine rupture. Wherever labor augmentation is performed, facilities should be available to monitor fetal heart rate and uterine contraction pattern closely and regularly. Augmentation of labor should be performed in facilities where there is capacity to manage its potential outcomes, including adverse effects and failure to achieve spontaneous vaginal birth.
Definition of delay in the first stage of labour
These principles, in addition to the implementation, monitoring and evaluation strategies presented later in the document, are expected to guide end users in the process of adapting and implementing the guideline in a range of contexts and settings. Since the evidence for these recommendations was largely based on studies conducted among women with pregnancies in cephalic presentation and.
Evidence and recommendations
Overall, there was no significant difference in caesarean section frequency (RR 0.64, 95% CI 0.24 to 1.70), although the findings were not consistent between the two studies. Evidence summary: early amniotomy and early oxytocin to prevent delay in first stage labor (EB Tables 4a-4c). Four of the studies included in the review include the use of early amniotomy and early oxytocin as part of a care package for the active management of labor (which includes strict diagnosis of labor, regular vaginal exams to assess progress, and one-on-one care).
Summary of evidence: Use of routine amniotomy (only) to prevent delay in first stage of labor (EB Tables 6a–6b). Evidence for the use of amniotomy as a single intervention to prevent first stage delay was obtained from a Cochrane systematic review of 14 RCTs (> 5000 women) comparing routine amniotomy with preservation of the amniotic membranes (19). There was a significant difference between the groups in the frequency of labor augmentation, with fewer women in the hypnosis group requiring this intervention (RR 0.29, 95% CI 0.19 to 0.45).
Trials were conducted in the US (four), Iran (three), Ireland (one) and India (one). Trials were conducted in the UK (three), the Netherlands (one) and Canada (one). There were no significant differences between the groups in the use of other birth interventions.
There were no significant differences between the groups regarding the need for synthetic oxytocin during labor. Summary of evidence: Oxytocin (alone) for the treatment of slow progress in the first stage of labor (EB Tables 14a–14b). Summary of evidence: early and delayed oxytocin for the treatment of slow progress in the first stage of labor (EB Tables 15a–15b).
Two of the trials were conducted in the United Kingdom and one trial each was conducted in the United States and Iran. Evidence summary: The use of routine amniotomy alone in the treatment of delay in the first stage of labor (EB Tables 18a-18b). Evidence summary: Amniotomy and oxytocin for the treatment of delay in the first stage of labor (EB table 19a-19b).
Two of the studies were conducted in the United Kingdom and one in Israel. Women with established delay in first stage labor were assigned to amniotomy and oxytocin versus usual care.
Dissemination and
Guideline dissemination and evaluation
What are the effects of herbal remedies when used to prevent or treat labor delay? What are the effects of interventions to reduce the use of herbal medicines during childbirth? What are the effects of the different methods of labor augmentation when used to treat delayed labor in multiparous compared to nulliparous women.
What is the safest and most effective incremental rate of oxytocin infusion for labor augmentation.
Research implications
Key research priorities
Other research questions
Guideline implementation
Applicability issues
Anticipated impact on the organization of care and resources
Monitoring and evaluating the guideline implementation
Updating the guideline
Incidence and outcomes of dystocia in the active phase of labor in nulliparous women at term with spontaneous onset of labor. Active labor management care package for reducing caesarean section rates in low-risk women. Acidemia at birth, related to obstetric characteristics and the use of oxytocin during the last two hours of labor.
Routine vaginal examinations to assess the progress of labor to improve outcomes for women and infants at term. Early amniotomy and early oxytocin for prevention or treatment of delayed spontaneous labor in the first stage compared with routine care. Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour.
Bakker JJH, Janssen PF, van Halem K, van der Goes BY, Papatsonis DNM, van der Post JAM, et al.
External experts and WHO staff involved in the preparation of the guideline
Participants at the WHO technical consultation on augmentation of labour
Guideline Steering Group
External Review Group
Critical and important outcomes for decision-making
Summary of considerations related to strength of recommendations (balance sheets) These and all EB tables are presented in the Evidence base document available at: www.who.int/reproductivehealth/topics/maternal_perinatal/augmentation -birth framework 1. Summary of considerations regarding the strength of the recommendations (Recommendations No. 1-5) Recommendation No. 12345 Intervention Partograph to monitor labor progress Routine vaginal examination to assess labor progress Care package for active labor management Early amniotomy and early oxytocin to prevent delay Oxytocin increase in women under epidural analgesia Quality of evidence High Moderate Low Very low. Summary of considerations related to the strength of the recommendations (Recommendations Nos. 6-10) Recommendation no. 678910 Intervention Amniotomy alone to prevent delayed labor Antispasmodics to prevent delayed labor Effect of pain relief on duration of labor and increase in oxytocin Intravenous fluids to shorten duration of labor Oral fluid and food intake during labor. Quality of evidence High Moderate Low Very low.
Summary of considerations for strength of recommendations (Recommendations #11–15) Recommendation 1112131415 Intervention Maternal position and mobility during labor Continuous monitoring during labor Routine enema to improve labor outcomes Oxytocin alone for treatment of delayed labor Early amniotomy and early oxytocin for delayed treatment Quality of evidence High Moderate Low Very low. Summary of Recommendation Strength Considerations (Recommendations #16-20) Recommendation 1617181920 Intervention High initial and increased oxytocin dosing regimen for augmentation. Oral misoprostol to induce labor. Only amniotomy to treat delay. Amniotomy and oxytocin for the treatment of delay. Internal versus external tocodynamometry in accelerated labor. Quality of evidence High Moderate Low Very low.
Template for summary of considerations related to the strength of the recommendations with explanations for completing the template RecommendationWhich recommendation. If the quality of the evidence is low or very low, consider more carefully the other criteria below to determine the strength of the recommendation. This refers to values that health workers, policy makers, patients and other stakeholders have placed on the intended outcomes of the intervention.
The greater the potential effects and the longer the period of the potential effects, the more likely the intervention is to receive a strong recommendation. Ideally, the costs of the benefits of an intervention should be reasonable, affordable and sustainable. The ‘technical’ feasibility of interventions also depends on sufficient functional organizational and institutional structures to manage, follow up and monitor the implementation of the recommendation.
Direction of recommendation In favor of the intervention Against the intervention Overall ranking Strong recommendation Weak recommendation.
