The Agency for Healthcare Research and Quality commissioned a systematic review of the evidence on labor dystocia published from January 1, 2005 to February 15, 2019 with a goal of identifying effective treatment measures for healthy women in spontaneous labor without pregnancy complications (Myers et al., 2020). Because labor dystocia is a common reason for cesarean birth, conducting this systematic review was a significant endeavor to promote perinatal patient safety. As an initial step, various definitions of "normal" labor progress and their evidence were considered, including use of labor partograms. What constitutes the length of normal labor has changed over the years; applying partograms did not affect labor outcomes. Approaches to treating labor dystocia that were assessed in the review included amniotomy, supportive care measures, epidural analgesia, frequency of cervical examination, intrauterine pressure catheters, high- versus low-dose oxytocin protocols, electronic fetal monitoring or intermittent auscultation during augmentation with oxytocin, and immediate, coached, or Valsalva pushing compared with delayed or spontaneous pushing during second-stage labor (Myers et al.). Systematic reviews, meta-analyses, and randomized controlled trials were included in the review. By including systematic reviews and meta-analyses, data from studies conducted outside of the publication dates for the review were included in the analyses. Review authors noted many of the studies assessed were not conducted in the United States. Study heterogeneity, for example, differences in variables, interventions, methodology, care providers, participants, and settings, limited the ability to draw conclusions that could be immediately translated into clinical practice in the United States (Myers et al.).

Major findings (Myers et al., 2020):

* Amniotomy with use of oxytocin shortens the length of labor but does not affect the rate of cesarean birth (9 RCTs).

* Supportive care techniques including continuous emotional support, perineal massage, water birth, acupuncture, ambulation, and various maternal positions (61 RCTs) were studied; most, but not all, were ranked low in strength of evidence, making conclusions challenging. Some interventions such as emotional support show promise; more evidence is needed.

* Epidural analgesia does not significantly affect length of labor or increase risk of cesarean birth (22 RCTs).

* Frequency of cervical exams did not have enough evidence for any type of conclusion.

* Intrauterine pressure catheters compared with external monitoring did not offer any advantage for shortening labor or decreasing risk of cesarean birth (1 systematic review).

* Low-dose oxytocin versus high-dose oxytocin comparisons based on the outcomes of labor duration and cesarean birth produced inconsistent results. There were no differences in cesarean rates among women receiving oxytocin compared with women expectantly managed based on 1 RCT. Four RCTs did not find any differences in cesarean rates based on oxytocin protocol. Two RCTs found no differences in cesarean rates when oxytocin was started early. Systematic reviews that included studies conducted earlier than 2005 had various results.

* Intermittent auscultation versus continuous electronic fetal monitoring did not have enough evidence for any type of conclusion.

* Valsalva, coached, or immediate pushing versus delayed or spontaneous pushing during second-stage labor did not decrease risk of cesarean birth or shorten labor (5 RCTs).

Patient safety implications of the evidence review highlight challenges of the current state of clinical science on how to effectively treat labor dystocia that promotes vaginal birth, a healthy mother and baby, and respect for the woman's choices. It is hard to advise women in the context of so many gaps in the evidence. This is an opportunity for nurse researchers to carefully read the entire evidence review, identify gaps they can fill based on clinical nursing research, prepare study proposals, secure funding, conduct studies, and move forward in making a difference in the childbirth process for healthy mothers and babies in the United States. Based on this report, the gaps in this body of evidence are many and wide.

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