A Cochrane review [Abstract] 1 included 14 studies with a total of 8 033 women. 10 trials enrolled nulliparous women who were in normal spontaneous labour at randomisation, allocating them either to early amniotomy and oxytocin if slow progress in labour ensued or to expectant management (“prevention trials”). 2 trials including only women with an established abnormality in the progress of labour were grouped as “therapy” trials. Amniotomy is virtually impossible to mask, and oxytocin was not blinded. There was a trend towards reduced risk of caesarean section with early intervention with amniotomy and oxytocin in all trials (RR 0.89; 95% CI 0.79 to 1.01; 14 trials, n=8 033 ), and especially in “prevention trials” (RR 0.87; 95% CI 0.77 to 0.99; 11 trials, n=7 753). A policy of early amniotomy and early oxytocin was associated with a shortened duration of labour (mean difference- 1.28 hours; 95% CI -1.97 to -0.59; 8 trials, n=4 816). Sensitivity analyses excluding 4 trials with a full package of Active Management (consisting of early amniotomy, frequent vaginal examinations, high dose oxytocin augmentation for cervical dilatation less than 1 cm/hour, and continuous social support) did not substantially affect the point estimate of the effect for caesarean section (0.87; 95% CI 0.73 to 1.05; 10 trials; n=5 165). No other significant effects for the other indicators of maternal or neonatal morbidity were found.
Comment: The quality of evidence is downgraded by inconsistency (difficulty in obtaining a contrast between treatment groups in the interventions provided in several studies) and by imprecise results.
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