European guidelines on management of arrested or protracted labor in nulliparous women

Arrested or protracted labor in nulliparous women caused by insufficient uterine contractility is a common problem in obstetrics, for which few management guidelines exist. The European Association of Perinatal Medicine nominated an expert panel, consisting of specialists in obstetrics and gynecology and midwives representing their respective professional national societies in nine European countries and patient representatives. The panel developed an evidence-based guideline for clinical practice supported by the Knowledge Institute of the Dutch Association of Medical Specialists. Five priority clinical questions (PICOs) were identified on nulliparous women, at term, with a singleton fetus, in cephalic presentation, and the diagnosis of arrested or protracted labor. For each question relevant outcome measures were defined as well as a minimal clinically important difference for each of them. Five literature searches were performed by an information specialist and articles were selected independently by two panel members. The GRADE methodology was used to write evidence summaries, considerations, and recommendations. The draft guideline was sent out for review to scientific societies involved in perinatal care in 20 European countries. Comments were answered, and the guideline was revised accordingly. The following procedures should be offered to women: 1) Amniotomy alone may be considered. 2) Women should be informed that there is no scientific evidence regarding the beneficial effects of immediate (<1 h) or delayed administration of oxytocin, although the first option may reduce the duration of labor. A joint decision is recommended, based on clinical judgment, and women's values and preferences. 3) A low-dose oxytocin regimen for labor augmentation should be considered. 4) Amniotomy should be considered before the administration of oxytocin infusion during the first stage of spontaneous labor. 5) Oxytocin augmentation for at least four hours with adequate uterine contractions should be considered, before an operative delivery is proposed, provided that fetal and maternal conditions are adequate.