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INTRAPARTUM OXYTOCIN AND CESAREAN BIRTH RATE

The Role of Oxytocin in Primary Cesarean Birth Among Low-Risk Women: A Review

Rachel Neale

IPC 511

Dr. Cynthia Castaldi

January 30, 2022

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A current healthcare problem in obstetrics is protracted labor/arrest of descent in NTSV

patients-NTSV standing for nulliparous, term pregnancy (typically >37weeks gestation),

singleton pregnancy, and vertex presentation. Women and Babies Hospital is using this

percentage as a quality improvement marker month-to-month, because a successful vaginal

delivery improves maternal outcomes as opposed to cesarean delivery (Clark et al., 2021).

The study by Clark et al. (2021) had a purpose to see if there is a correlation between

oxytocin levels administered in labor and NTSV cesarean birth rate. The study was great at

addressing current research and possible associations regarding primary cesarean delivery in

NTSV patients, but the literature review was almost exclusively in the discussion section of the

study. It compared the results of the study to that of current research being utilized in the field.

One of the most popular studies mentioned was the ARRIVE trial, which suggested that

inductions in low-risk patients actually lowers the cesarean rate (Grobman et al., 2018). This is

particularly interesting as there are providers at Women and Babies Hospital that point to this

study as proof of offering elective inductions at 39 weeks despite other research suggesting

inductions increase risk for cesarean deliveries (Grobman et al., 2018). The Clark et al. study

mentioned the differences in study participants from the ARRIVE trial, including a change in the

definition of “low-risk”(Clark et al., 2021). This in-depth description of the ARRIVE trial and

comparing it to the present study was a good example of the depth of knowledge of the

healthcare problem by the researchers.

There was no specific hypothesis stated in the study, though it did reference in the discussion

section that the hypothesis may have been that higher levels of oxytocin correlate positively with

cesarean delivery (Clark et al., 2021). The discussion section specifically states that the

researchers did not predict in any way a level at which oxytocin administration may correlate
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with cesarean delivery (Clark et al., 2021). No theoretical framework was mentioned in this

study. The study was quantitative in nature, and utilized analysis of secondary data with a

retrospective cohort design (Clark et al., 2021). The data was from the Consortium on Safe Labor

as well as electronic health records and surveys sent to hospitals to determine knowledge about

the hospitals and their providers (Clark et al., 2021).

The study included NTSV patients, those with and without a variety of conditions including

pre-eclampsia, gestational hypertension, gestational diabetes, etc. (Clark et al., 2021). Clark et

al., says this regarding criteria: “Inclusion criteria were (1) gestational age greater than or equal

to 37 weeks and less than 42 weeks, (2) parity of 0, (3) singleton fetus, (4) vertex presentation,

and (5) exposure to oxytocin during labor” (Clark et al., 2021). Those excluded were multiparous

patients, no exposure to oxytocin during labor, incomplete information regarding oxytocin

administration, and those with cesarean delivery prior to labor. A total of 17,331 patients were

included in the study (Clark et al., 2021). This was a low ethical risk study, and therefore was

deemed exempt by the Johns Hopkins institutional review board (Clark et al., 2021).

The study collected a large quantity of information from the database and medical records:

race, BMI, medical conditions, total dose of oxytocin administered prior to delivery, induction

vs. spontaneous labor, mode of delivery, age of patient, gestational age, and hospital type

(university hospital vs. community) (Clark et al., 2021). Then the researchers ran the data

through the STATA software to compare independent variables with the main dependent

variable of cesarean birth rate (Clark et al., 2021). The software was able to make adjustments of

data to accommodate changes in independent variables, such as race or maternal age. The main

model was a “logistic regression model with primary cesarean birth as the outcome”, with

adjustments to other independent variables (Clark et al., 2021). The researchers had to limit the
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groups of total dose of oxytocin as initially there was a wide range of doses given to patients

intrapartum: The range of oxytocin dose given was large, and they initially grouped total dose of

oxytocin into categories every 300 milliunits of oxytocin delivered. This still gave over 300

groups, at which point they gathered the data into five statistically significant groups (Clark et

al., 2021). And then finally researchers were able to separate data into two groups based on

statistically significant change in rate of cesarean birth, oxytocin dose less than 11,400 milliunits

and oxytocin dose greater than 11,400 milliunits (Clark et al., 2021).

The most significant result was that the cesarean birth rate did not increase until a total dose

of 11,400 milliunits, a rather significant amount according to researchers (Clark et al., 2021).

Another interesting finding was that patients who were induced did not see a change in the rate

of cesarean delivery based on total dose of oxytocin, but the patients that received oxytocin and

were not induced were 2.7 times more likely to have a cesarean birth (Clark et al., 2021).. This

could be due to other factors, including malpositioning of fetus or cephalopelvic disproportion,

which the researchers did mention (Clark et al., 2021). More studies would need to be performed

to strengthen this association.

Another significant, though not new, finding was that patients with high BMI were more

likely to have a cesarean birth irrespective of their total dose of oxytocin (Clark et al., 2021). The

study says, “When the interaction between BMI and oxytocin was examined, however, exposure

to greater than 11,400 mU of oxytocin (compared with <11,400mU) within each BMI category

did not have a statistically significant effect on the odds of a cesarean.”(Clark et al., 2021, page

59). This seems to indicate that elevated BMI is a risk factor for cesarean birth unrelated to total

oxytocin dose.
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Overall this study confirmed that there is a positive correlation between oxytocin

administration in labor and cesarean birth but in this study it is more related to patients receiving

oxytocin for augmentation, not induction purposes (Clark et al., 2021). The patients in the

induction category actually did not have significantly different cesarean birth rates based on

oxytocin administration. This could mean that elevated cesarean birth rates have less to do with

the level of oxytocin administration and more so to do with other factors impeding the labor

process. It may be beneficial to providers to withhold oxytocin administration to augment labor,

or to limit its use.

Evidence based practice (EBP) is critical in Labor and Delivery, where emergent situations

can appear at any time, and can be life-threatening to mother and baby. Healthcare providers

need to continually adapt to the latest research in order to provide the best care for patients and

maintain patient outcomes. Polit and Beck say that “EBP is a ‘three-legged stool’, each ‘leg’ of

which is essential to the process: best evidence, clinical expertise, and patient preferences and

values (Polit & Beck, 2021, page 21). This captures well the impact the study may have with

regards to EBP in obstetrics. This study is well presented evidence, though not the sturdiest of

research such as systematic review (see page 25), but it must be taken in consideration with what

clinicians deduce to be the best care for the patient, as well as what the patient themselves may

desire (Polit & Beck, 2021).Healthcare provider must consider the wishes of the patient in order

to maintain patient rights and hopefully empower the pregnant patient to be charge of his/her

care, and that may mean minimizing pitocin, having an elective induction, staying on pitocin,

etc. Ultimately this study should push for more research to inform EBP in the future regarding

oxytocin doses in labor, but at the least can educate patients on the benefits and possible risks of

oxytocin administration so that they may be able to make an informed decision on their care.
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References

Clark, R.R.S., Warren, N., Shermock, K.M., et al. (2021). The role of oxytocin in primary
cesarean birth among low-risk women. Journal of Midwifery and Women’s Health, 66(1),
54-61. Doi: 10.1111/jmwh .13157

Grobman, W.A., Rice, M.M, Reddy, U.M, et al. (2018). Labor induction versus expectant
management in low-risk nulliparous women. New England Journal of Medicine, 379(6),
513-523. Doi: 10.1056/NEJMoa1800566

Polit, D. F., & Beck, C. T. (2021). Nursing research: Generating and assessing evidence for
nursing practice. Wolters Kluwer.