A comparison of breast stimulation and intravenous oxytocin for the augmentation of labor

Intrapartum nipple stimulation therapy for labor induction: a randomized controlled external pilot study of acceptability and feasibility

OBJECTIVE

Nipple stimulation is purported as a natural and inexpensive method for inducing labor, but its use is understudied. We aimed to assess whether conducting a large randomized controlled trial comparing intrapartum nipple stimulation therapy versus oxytocin infusion is feasible and acceptable to patients and obstetric care providers.

STUDY DESIGN

This single-center parallel-group randomized controlled external pilot study (NCT04756089) included women with gestations ≥36 weeks who were planned to receive exogenous oxytocin for their labor induction. Those <18 years old, non-English-speaking, or with fetuses at increased risk for neonatal intensive care were excluded. Stratified by parity, women were randomized 3:1 to intrapartum nipple stimulation therapy or immediate receipt of oxytocin. Women assigned to nipple stimulation therapy were asked to stimulate with an electric breast pump or by hand for periods of at least 30 minutes, with breaks as needed for up to 15 minutes at a time, for at least a cumulative two hours prior to considering initiation of oxytocin, and to complete intrapartum diaries. Labor characteristics and outcomes were examined. Validated questionnaires were used to assess the participants' pain level during the intervention, their sense of control during childbirth, and their breastfeeding success. Primary outcome measures were recruitment, adherence to study protocol and follow-up, and cross-over rates.

RESULTS

620 women underwent labor induction from 3/13/21-6/23/21. Of 557 potentially eligible women, 53 were approached by available research staff. 24 (45%) consented and enrolled: 18 randomized to nipple stimulation and 6 randomized to oxytocin. One woman assigned to nipple stimulation withdrew due to delay of clinical care and received oxytocin (cross-over rate of 1/24 (4%)), and one woman assigned to oxytocin did not receive it due to spontaneous labor progress. All other participants followed their assigned intervention. The 17 women who performed nipple stimulation stimulated for a median duration of 198 (IQR 125-291) minutes and required a median of 69 (IQR 21-80) minutes of stimulation prior to achieving at least three contractions in a 10-minute window, averaged over 30 minutes (a.k.a. "adequate" contractions) Among those assigned to nipple stimulation therapy, 15/17 (88%) later received oxytocin infusion prior to delivery. The median time from intervention start to delivery was 16.4 (IQR 0.6-28.2) and 20.6 (IQR 14.2-23.4) hours for women assigned to nipple stimulation therapy versus oxytocin infusion, respectively. 12 (50%) women completed their postpartum study questionnaires.

CONCLUSION

Random assignment to intrapartum nipple stimulation therapy versus oxytocin infusion for labor induction is feasible and acceptable to patients and obstetric care providers.

Effects of breast stimulation for spontaneous onset of labor on salivary oxytocin levels in low-risk pregnant women: A feasibility study

Objectives

This preliminary study aimed to 1) determine changes in the salivary oxytocin (OT) level during breast stimulation for promoting the spontaneous onset of labor in low-risk term pregnancies, and 2) clarify the feasibility of the breast stimulation intervention protocol in terms of practicality and acceptability.

Methods

We used a single arm trial design. Sixteen low-risk pregnant women between 38 and 40 weeks of gestation with cephalic presentation participated. They performed breast stimulation for 3 days with an attendant midwife in a single maternity hospital. Each breast was stimulated for 15 minutes for a total of 1 hour per day. Saliva was collected 10 minutes before the intervention and 15, 30, 60, 75, and 90 minutes after the intervention, yielding 18 samples per woman.

Results

Among a total of 282 saliva samples from the 16 participants, OT level was measured in 142 samples (missing rate: 49.6%). The median OT level showed the highest values on day 3 of the breast stimulation, with a marked increase 30 min after the intervention. In the mixed models after multiple imputation for missing data, the OT level on the first day of intervention was significantly lower than that on the third day of intervention. Fatigue from breast stimulation decreased on subsequent days, and most of the women (75%) felt no discomfort with the protocol. Uterine hyperstimulation was not observed.

Conclusion

Following a 3-day breast stimulation protocol for spontaneous onset of labor, the mean OT level showed the highest values on day 3. The breast stimulation intervention protocol showed good feasibility in terms of practicality and acceptability among the pregnant women. Additional large-scale studies are warranted to confirm the protocol’s effectiveness.

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour

BACKGROUND

Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed.

OBJECTIVES

To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2013) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors.

MAIN RESULTS

We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review.

AUTHORS' CONCLUSIONS

For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.

Uterine hyperstimulation by intravenous access in a mammary vein: a case report and literature review

Breast stimulation can produce contractions in a contraction stress test and has been considered for the augmentation of labor and prevention of postpartum hemorrhage. We present a case of intravenous access of a mammary vein in an obstetric patient that led to uterine hyperstimulation. Potential dangers of mammary vein intravenous access are discussed.

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour

BACKGROUND

Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed.

OBJECTIVES

To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2011) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors.

MAIN RESULTS

We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review.

AUTHORS' CONCLUSIONS

For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.

Breast stimulation to augment labor: history, mystery, and culture

This paper describes the development of a researchable project, arising from the clinical observation of a physiologic phenomenon during labor. Augmentation of labor by breast stimulation has been used in a variety of cultures for centuries. The process of developing a clinical study of augmentation in the modern obstetric environment is discussed, with reference to cultural attitudes of patients and health care workers.