Active management of labor using oxytocin administration and artificial rupture of membranes, which is effective in reducing labor duration, has been widely used since the 1980s.1–3 Although it has been proposed to reduce cesarean delivery rates, it is not clear whether it actually does.3–5 Furthermore, augmentation of labor has been associated with adverse maternal and neonatal outcomes such as postpartum hemorrhage, uterine tachysystole, abnormal fetal heart rate patterns, and asphyxia.6–8
Since 2003, several health authorities have published guidelines regarding the use of oxytocin administration and artificial rupture of membranes.9–12 These guidelines intend to reduce the use of oxytocin administration and artificial rupture of membranes in women with spontaneous labor by restricting their use to their evidence-based indication, that is, abnormally progressive labor.
The report from the French National Perinatal Survey of 2016 shows a reduction in the crude rates of oxytocin administration and artificial rupture of membranes since 2010.13 Indeed, the two prior French Perinatal Surveys performed in 2010 and 2016, and reporting medical practices indicators, showed that the rate of oxytocin administration fell from 57.6% to 44.3% and the rate of artificial rupture of membranes from 51.1% to 41.4% in women in spontaneous labor. These data published in 2017 include all spontaneous labors but do not take the changes in the characteristics of the population and maternity units into account. Furthermore, these data do not report intrapartum cesarean delivery rates and cesarean delivery indications among spontaneous laboring women. Thus, we aim at confirming the crude reduction in the rate of oxytocin administration and artificial rupture of membranes in France and determine whether it was accompanied by an increase in the intrapartum cesarean delivery rate or a change in cesarean delivery indications.
The French national perinatal surveys are population-based studies conducted routinely every 6 or 7 years to monitor the main indicators of perinatal health, medical practices, and risk factors. Every survey follows the same protocol, which has been described elsewhere.14 Briefly, the sample includes all live births and stillbirths at a gestational age of at least 22 weeks or a birth weight of at least 500 g during a full week in March in all French maternity units.
The design includes almost all births in France—only 0.4% of births do not occur in hospitals.15 Data on delivery and neonatal characteristics are collected from the medical records, and mothers are interviewed before their discharge to obtain maternal social and demographic characteristics and additional information about the pregnancy and their care. Each maternity unit also completes a questionnaire to provide information about its characteristics and organization.
The surveys are approved by the National Council on Statistical Information (Comité du Label), the French Data Protection Authority (CNIL), and the INSERM (Institut National de la Santé et de la Recherche Médicale) ethics committee. This approval covers use of the data from the surveys by its coordinating team and our research team at the National Institute of Health and Medical Research. The commission did not require written informed consent. The 2016 approval numbers were 2016X703SA (Comité du Label), 915197 (CNIL) and IRB00003888 no. 14–191 (INSERM ethics committee).
For this cross-sectional analysis, we included women with singleton pregnancies who gave birth to a liveborn neonate in cephalic presentation at or after 37 weeks of gestation after spontaneous labor. We excluded women who went into labor spontaneously despite a planned cesarean delivery. Because the oral interviews allow access to the sociodemographic information recorded in the medical files, only those women who consented to these oral interviews were included in this analysis.
For the analyses we created three subgroups:
- Nulliparous low obstetric risk women: women who had never given birth after 22 weeks of gestation before the current pregnancy being studied and were at low obstetric risk (see below)
- Multiparous low obstetric risk women
- Women with a previous cesarean delivery; more precisely, those women with a previous cesarean delivery and a trial of labor for this pregnancy.
The group of Low obstetric risk women excluded women with either a chronic disease (chronic hypertension, preexisting diabetes, organ failure, inflammatory and immune diseases, thrombophilia, epilepsy, chronic infection with viral hepatitis, or human immunodeficiency virus [HIV]), a previous obstetric complication (cesarean delivery, preeclampsia or hypertension during a previous pregnancy, fetal death), or a complication during the current pregnancy (preeclampsia, gestational diabetes requiring insulin, small for gestational age fetus, or fetal growth restriction).
We first compared the following women and maternity units' characteristics in 2010 and 2016: age at delivery, body mass index (BMI), place of birth, parity, gestational age at delivery, use of epidural analgesia, previous cesarean deliveries, and maternity unit status (public teaching hospital, public hospital or private hospital) and volume. The maternity unit's volume reflects the number of in-house staff as regulations concerning the type and number of in-house staff depends on the latter.
We then studied the frequency of use between 2010 and 2016 of three augmentation of labor-indicators: the use of oxytocin infusion before the third stage of labor, the use of artificial rupture of membranes, and the combination of both during labor. At the same time, we studied the rate of cesarean delivery during labor. These trends were analyzed in the overall study population, as well as in the three subgroups.
To evaluate whether the year of delivery, which reflects the medical practices at that time, was associated with changes in the rates of the augmentation of labor indicators and the potential change in intrapartum cesarean delivery rates between 2010 and 2016, we performed multivariable analyses. We constructed four multivariable models, one for each augmentation labor indicator and one for cesarean delivery, which all included the women and maternity units' characteristics that had significantly changed from 2010 to 2016.
Finally, we compared indications for cesarean deliveries in 2010 and 2016 in our overall population and in each subgroup, by distinguishing four types of indications: labor arrest, abnormal fetal heart rate, both labor arrest and abnormal fetal heart rate, and other indications. The “other indications” included cord prolapse, abnormal presentation, suspected uterine rupture, and failed instrumental extraction.
The bivariate analyses were performed with χ2 tests and the multivariable analyses with logistic regression models. Results are expressed as adjusted odds ratios (aORs) and their 95% CIs. Because less than 3% of data were missing for any variable in the study population, we chose to perform complete case analysis. All statistical analyses were performed with Stata 15.
Among the 27,828 women included in the national perinatal surveys of 2010 (n=14,681) and 2016 (n=13,147), 16,527 women met the inclusion criteria for our analysis: 9,012 from 2010 to 7,515 from 2016 (Fig. 1). The nulliparous, low obstetric risk group included 5,994 women, the multiparous low obstetric risk group 6,829 women, and the previous cesarean delivery group 1,099 women. A total of 2,605 women did not meet the criteria of any subgroups and were analyzed only in the overall population.
All maternal and maternity unit characteristics differed significantly in the 2 years, except for mother's place of birth and gestational age at delivery (Table 1). Compared with 2010, women in 2016 were older and had higher BMIs, higher rates of epidural analgesia during labor, and higher rates of previous cesarean delivery. Similarly, women in 2016 delivered more frequently in public hospitals and in large maternity units.
In the overall study population, each augmentation of labor indicator decreased significantly from 2010 to 2016: 58.3% vs 45.2% (P<.01) for oxytocin administration; 52.4% vs 42.6% (P<.01) for artificial rupture of membranes, and 34.1% vs 22.4% (P<.01) for the combination of both interventions (Appendixes 1 and 2, available online at http://links.lww.com/AOG/B666). The cesarean delivery rate remained stable: 6.9% in 2010 and 6.6% in 2016 (P=.56). The same patterns were observed in each subgroup (Appendixes 1 and 2, http://links.lww.com/AOG/B666).
In the overall study population, the multivariable analysis showed that deliveries in 2016 were associated with lower rates of oxytocin administration (aOR 0.51; 95% CI 0.47–0.55), artificial rupture of membranes (aOR 0.66; 95% CI 0.62–0.71), and the two interventions combined (aOR 0.53; 95% CI 0.50–0.58), but not with cesarean deliveries (aOR 0.93; 95% CI 0.82–1.06) (Table 2).
In each subgroup, compared with women giving birth in 2010, those delivering in 2016 had a significantly lower probability of oxytocin or artificial rupture of membranes or both interventions but the same probability of cesarean delivery (Appendix 3, available online at http://links.lww.com/AOG/B666). The distribution of cesarean delivery indications did not differ in 2010 and 2016 in the overall study population or in any subgroup (Fig. 2). In particular, the proportions of cesarean delivery for labor arrest were similar in both years in the overall study population (40.7% vs 42.4%) and in each subgroup.
In France, the rates of oxytocin administration and artificial rupture of membranes fell significantly from 2010 to 2016, without any significant increase in the cesarean delivery rate. These reductions in labor augmentation from 2010 to 2016 took place in all studied subgroups; the intrapartum cesarean delivery rate remained stable, as did the rate of the cesarean deliveries indicated for arrest of labor.
Our study has a number of strengths. Because the surveys include all maternity units in France, our results cover the diversity of medical practices in this country. The overall sample of each perinatal survey (all births occurring during the study week in March) is representative of all annual births in France14; however, the women who were not interviewed (6% of the total French Perinatal Survey population) were not included in our study, which may slightly bias our sample; for example, the proportion of foreign women among those interviewed in 2016 was 14.3% compared with 17.1% in the French vital statistics.16 The design of the survey was identical in both years,14 and the data were collected by technician research midwives, which ensures its quality and completeness.
In this study, the maternal and organizational factors associated with oxytocin administration, artificial rupture of membranes, and cesarean births are those previously reported in the literature.17 The changes in the women and maternity units’ organizational characteristics between 2010 and 2016 do not explain the observed reduction in augmentation of labor indicators. Even though our multivariable models attempt to adjust for potential confounding factors, we cannot exclude a residual bias. One could argue that the reduction of augmentation of labor could be the result of other changes in medical practices, such as the mode of onset of labor or the rate of assisted delivery. But, the rate of cesarean deliveries before labor and of induction of labor slightly but significantly declined and the rate of assisted delivery was stable between 2010 and 2016 in France.13 Moreover, except for the 2012 guidelines on “Delivery in Women With Previous Cesarean Section or Other Uterine Surgery,” which state that the use of oxytocin was possible for induction and during labor of women with a history of cesarean delivery, there were no other French national guidelines regarding labor augmentation or other clinical practices during labor between 2010 and 2016.18
A limitation of this analysis is the absence of detailed information on oxytocin administration (indication, cervical dilation at onset, dose, and duration). The purpose of the French national perinatal surveys is to follow key perinatal health indicators and French medical practices. It is therefore not designed to collect detailed data on specific topics. This lack of information prevents us from analyzing whether the change in oxytocin administration concerns only the rate or also the dose and duration of administration. The consequences of the reduction in oxytocin and artificial rupture of membranes on maternal and fetal health in terms of postpartum hemorrhage or abnormal fetal heart rate could not be analyzed here. Moreover, data from the survey does not allow evaluating whether augmentation of labor was initiated because of a misdiagnosis of spontaneous onset of labor. Nevertheless, there is no reason to believe that the number of such misdiagnoses would differ between the two studied surveys.
In the present study, the 10.5% and 1.8% cesarean delivery rates, respectively for nulliparous and multiparous women in spontaneous labor at term with fetuses in vertex presentation (Appendix 1, http://links.lww.com/AOG/B666), are comparable with those reported in a retrospective population-based study in 2009–2011 in Nordic countries,19 and slightly lower than the 12.3% and 4.4% rate for nulliparous and multiparous women reported in an American population-based study in 2014.20
Owing to the lack of existing national population-based studies reporting rates of oxytocin administration and artificial rupture of membranes, it is difficult to compare French data with those of other countries. But, it seems that even with the observed recent reduction, the rates remain relatively high.16,21–23 In a Dutch nationwide, population-based study, Zwart et al report a 19% rate of oxytocin administration in 2004–200622; Oscarsson et al in Sweden report a 33% rate in women with term singletons in vertex presentation in 2001–2002.16 Data from different data sources in the United States tend to show a similar reduction in the use of oxytocin administration and artificial rupture of membranes across recent years. The Consortium on Safe Labor in 2002–2007 indeed shows a 45.9% rate of oxytocin administration, a 53.1% rate of artificial rupture of membranes for nulliparous women in spontaneous labor.24 The report of the Third National U.S. Survey of Women's Childbearing Experiences showed a 36% rate of oxytocin administration and a 30% rate of artificial rupture of membranes in 2011–2012.25
In France, the significant reduction in the use of oxytocin and artificial rupture of membranes, which took place from 2010 to 2016, was not accompanied by an increase in the rate of intrapartum cesarean deliveries. These results support the need for evidence-based use of medical interventions, in line with the international guidelines.
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