Research www. AJOG.

org

OBSTETRICS
Effects of oxytocin-induced uterine hyperstimulation during
labor on fetal oxygen status and fetal heart rate patterns
Kathleen Rice Simpson, PhD, RNC; Dotti C. James, PhD, RNC

OBJECTIVE: The objective of the study was to evaluate effects of oxy-
tocin-induced hyperstimulation on fetal oxygen saturation and fetal
heart rate patterns.
STUDY DESIGN: Uterine activity of 56 women was evaluated retro-
spectively for hyperstimulation lasting 30 minutes using 2 defini-
tions: group 1: 5 or more but less than 6 contractions in 10 min-
utes (n ⫽ 102, 30-minute periods); group 2: 6 or more contractions in
10 minutes (n ⫽ 56, 30-minute periods). Fetal oxygen saturation
and heart rate patterns during each period and the preceding
30 minutes of less than 5 contractions in 10 minutes were
compared.
RESULTS: Hyperstimulation was associated with significant oxygen
desaturation: (group 1 ⫽ 10.68 [20%] decrease from 52.14 to 41.46;
P ⬍ .001); group 2 ⫽ 15.34 [29%] decrease from 52.02 to 36.68: P
⬍ .001) and significantly more nonreassuring fetal heart rate charac-
teristics, compared with normal uterine activity.
CONCLUSION: Hyperstimulation is associated with negative effects on
fetal status. The more contractions in 30 minutes, the more pro-
nounced the effect.
Key words: electronic fetal monitoring, fetal oxygen saturation/fetal
pulse oximetry, fetal safety, labor induction, oxytocin-induced uterine
hyperstimulation

Cite this article as: Simpson KR, James DC. Effects of oxytocin-induced uterine hyperstimulation during labor on fetal oxygen status and fetal heart rate patterns.
Am J Obstet Gynecol 2008;199:34.e1-34.e5.

A lthough fetal heart rate monitoring

has been the subject of numerous
studies over the last 5 decades, assess-
compared with contractions that were
less frequent.1
Earlier research concerning the effects
became hypoxemic, recovering only
after oxytocin was discontinued.3
Comparable effects of too frequent
ment of uterine activity as it relates to of uterine contractions on fetal oxygen contractions on fetal cerebral oxygen
fetal status has received much less atten- saturation (FSpO2) found that FSpO2 saturation were noted by other research-
tion. Recently, in a study of uterine ac- decreased during contractions, reaching ers. Contraction intervals of less than 2-3
tivity involving 1433 labors and births, the lowest level 92 seconds after the peak minutes were associated with a decrease
uterine activity that included 5 or more of the contraction, with approximately in fetal cerebral oxygen saturation when
contractions in 10 minutes during the 90 seconds required for FSpO2 to re- compared with longer contraction inter-
last hour of the first stage of labor or 5.5 turn to previous levels.2 When con- vals, leading to the conclusion that con-
or more contractions in 10 minutes over tractions were occurring every 2 min- tractions occurring repeatedly at inter-
the course of the second stage of labor utes or more, recovery of FSpO2 to vals less than 2-3 minutes were likely to
was significantly associated with a higher previous baseline levels was incom- result in progressive fetal cerebral oxy-
incidence of neonatal acidemia (umbili- plete.3 FSpO2 decreased incrementally gen desaturation.4
cal arterial pH 7.11 or less) at birth when after each contraction, and the fetus Frequency of contractions used in the
definitions of hyperstimulation dis-
cussed in the American College of Obste-
From Labor and Delivery, St John’s Mercy Medical Center (Dr Simpson), and Doisy College
tricians and Gynecologists (ACOG)
of Health Sciences School of Nursing, Saint Louis University, St Louis, MO (Dr James).
practice bulletins has varied from 5 or
Presented at the National Congress on the State of the Science in Nursing Research, Council for
the Advancement of Nursing Science, American Academy of Nursing, Washington, DC, Oct. 12- more contractions in 10 minutes (induc-
14, 2006, and the Association of Women’s Health, Obstetric and Neonatal Nurses National tion of labor),5 more than 5 contractions
Convention, Orlando, FL, June 23-27, 2007. in 10 minutes (dystocia and augmenta-
Received July 22, 2007; revised Oct. 12, 2007; accepted Dec. 19, 2007. tion of labor),6 and 6 or more contrac-
Reprints: Dr Kathleen Rice Simpson, 7140 Pershing Ave, St Louis, MO 63130. tions in 10 minutes (intrapartum fetal
krsimpson@prodigy.net. heart rate monitoring )7; however, there
This study was supported by the Association of Women’s Health, Obstetric and Neonatal Nurses is minimal evidence concerning the ef-
through a technology grant from Philips Medical Systems, Andover, MA; St John’s Mercy Medical
fects of excessive uterine activity on the
Center Perinatal Nursing Research Fund; and a Saint Louis University Beaumont Faculty
Development Grant. fetus to guide clinical practice. There are
0002-9378/$34.00 • © 2008 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2007.12.015 limited data on when and how to treat
oxytocin-induced uterine hyperstimula-

34.e1 American Journal of Obstetrics & Gynecology JULY 2008

www.AJOG.org
tion. Some clinicians believe interven-
tions are not warranted until there are
resultant nonreassuring changes in the
fetal heart rate (FHR) pattern. We there-
fore conducted this retrospective study
to evaluate the effects of hyperstimula-
tion on fetal oxygen status as measured
by FSpO2 and characteristics of FHR pat-
terns. Interventions used to treat hyper-
stimulation also were evaluated based on
their efficacy in terms of time of hyper-
stimulation resolution.
We previously reported a prospective
study of the effects of common intra-
uterine resuscitation techniques during
the first stage of labor on fetal oxygen
status with nulliparous women who
were having elective labor induction
with oxytocin.8 This is a secondary anal-
ysis of uterine activity, FSpO2 and FHR
patterns using that dataset.
M ATERIALS AND M ETHODS
The effects of uterine activity on FSpO2
and FHR patterns were retrospectively
evaluated in 56 healthy nulliparous
women who were admitted for elective
labor induction with oxytocin and had
consented to participate in the study. In-
stitutional review board approval was
obtained from St John’s Mercy Medical
Center and Saint Louis University in St
Louis, MO. Additional inclusion criteria
were a singleton fetus in a vertex presen-
tation and a reassuring FHR pattern at
the time of enrollment. Women with
medical or obstetrical complications or a
maternal condition that could poten-
tially influence maternal SpO2 (eg, his-
tory of smoking, asthma, chronic or
acute pulmonary or cardiac disease) and
those who did not meet criteria for
FSpO2 sensor insertion were excluded.
The first patients who met eligibility
criteria on days selected for research
study enrollment were invited to partic-
ipate. If the first eligible patient declined
participation, the next eligible candidate
was approached until 1 woman agreed or
there were no further eligible candidates
that day. Women were not in labor when
they were approached about possible
study participation or consented. Sixty
women were approached for study par-
ticipation and 56 women agreed to
participate.
Continuous electronic fetal monitor-
ing (EFM) was used for all patients, and
an FSpO2 sensor was inserted as soon as
clinically feasible (upon rupture of
membranes, cervical dilation of at least 2
cm, and fetal station of at least -2) along
with an Intran intrauterine pressure
catheter (Utah Medical Products, Inc,
Midvale, UT) and fetal spiral electrode
(Kendall-LTP, Chicopee, MA). The
EFM model M1350C (Philips Medical
Systems, Andover, MA) was used with
the OxiFirst FSpO2 sensor (Nellcor, Inc,
Pleasanton, CA). Electronic fetal moni-
tor and FSpO2 data were continuously
collected via the OB TraceVue electronic
information system (Philips Medical
Systems).
We used 2 definitions of hyperstimu-
lation (group 1: 5 or more but less than 6
contractions in 10 minutes; group 2: 6 or
more contractions in 10 minutes) to
identify periods of excessive uterine ac-
tivity. We considered 30 minutes to be
clinically relevant, so inclusion criteria
required that the excessive uterine activ-
ity continued for at least 30 minutes. The
preceding 30 minutes of normal uterine
activity (less than 5 contractions in 10
minutes) was used as a comparison
group. We excluded periods of labor
when women were in the supine position
and when an intravenous (IV) fluid bo-
lus and maternal oxygen administration
were being tested as intrauterine resusci-
tation techniques in the previous study,
as well as the second stage of labor, leav-
ing 522.5 hours (1045 30-minute peri-
ods) of labor available for evaluation.
For each of the groups (group 1, group
2, and normal uterine activity), the mean
FSpO2 of the 5 minutes prior to the 30
minutes being evaluated and the mean
FSpO2 during the last 5 minutes of the
same 30-minute period were compared
using the paired Student t test. Repeated
measures analysis of variance (ANOVA)
was used to compare the differences in
the 5 minutes prior and last 5 minutes
means among all 3 groups.
ANOVA was used to compare the per-
centage of change in the means among
the 3 groups as well as the mean FHR and
mean dose of oxytocin among groups.
JULY 2008 American Journal of Obstetrics & Gynecology
Obstetrics Research
The Pearson ␹2 statistic was used to com-
pare differences in characteristics of FHR
patterns (absent or minimal variability;
accelerations; and late, variable, pro-
longed, or recurrent decelerations)
among groups. The mean FHR and vari-
ability were evaluated in the last 10 min-
utes of the 30-minute period. If absent or
minimal variability was noted any time
during the last 10 minutes, it was consid-
ered present as long as it continued for at
least 10 minutes. The 10-minute period
of absent or minimal variability required
to meet the criteria for a baseline vari-
ability change could extend beyond the
30 minute period of uterine activity un-
der evaluation.
Accelerations and decelerations were
evaluated over the entire 30-minute pe-
riod and were considered present if 1 or
more were noted, except for recurrent
decelerations that were considered
present if they were occurring with 50%
or more of contractions in a 20-minute
period. In some cases, more than 1 type
of deceleration was noted.
The mean number of minutes until
resolution of hyperstimulation based
on 1 or more interventions was com-
pared using ANOVA. We considered
hyperstimulation to be resolved when
there were less than 5 contractions in
10 minutes for at least 20 minutes. To
measure resolution, we calculated the
number of minutes from the time the
intervention/s was/were noted in the
medical record to the end of the last
contraction in the series of contrac-
tions that represented hyperstimula-
tion. These criteria were chosen based
on the change in uterine activity that
could potentially minimize physio-
logic stress to the fetus.
The Statistical Program for Social Sci-
ences (SPSS 13.0 for Windows; SPSS,
Chicago, IL) was used for data analysis.
The criteria used to evaluate FHR pat-
terns in this study were based on the def-
initions from the National Institute of
Child Health and Human Development
(NICHD) Research Planning Workshop.9
The investigators independently re-
viewed the FHR patterns, compared in-
terpretation, and reached consensus
based on strict adherence to the NICHD9
definitions.
34.e2
Research Obstetrics www.AJOG.org

R ESULTS FIGURE
There were 102 30-minute periods of la-
Effects of uterine hyperstimulation on FSpO2
bor with 5 or more but less than 6 con-
tractions in 10 minutes (group 1) and 56 Effects of Uterine Hyperstimulation of FSpO2 Over 30 Min
30-minute periods with 6 or more con-
tractions in 10 minutes (group 2), repre- 60
senting 15.1% of the total time the labor-
ing women were exposed to intravenous 55
51.29
52.14 50.82 51.4 51.49 50.88 51.31 51.12
oxytocin. These periods were compared
with the preceding 30-minute periods of 50
52.02
46.76

uterine activity with less than 5 contrac-
tions in 10 minutes of groups 1 and 2
(n ⫽ 158).
Hyperstimulation was identified and
analyzed in 41 of the 56 patients, with 15
patients having no 30-minute periods of
hyperstimulation. In group 1, the mean
FSpO2 5 minutes prior to the 30 minutes
of hyperstimulation was 52.14% and
41.46% in the last 5 minutes of hyper-
stimulation, representing an absolute
decrease of 10.68 and a negative 20%
change (P ⬍ .001). In group 2, the mean
FSpO2 5 minutes prior to the 30 minutes
of hyperstimulation was 52.02% and
36.68% in the last 5 minutes of hyper-
stimulation, representing an absolute
decrease of 15.34 and a negative 29%
change (P ⬍ .001). There was no signif-
icant difference (P ⫽ .65) in the mean
FSpO2 5 minutes prior to the 30 minutes
of normal uterine activity (51.29%) and
in the last 5 minutes of normal uterine
activity (51.12%). The decreases in
FSpO2 were significantly different
among all groups (P ⬍ .001) and be-
tween groups 1 and 2 (P ⬍ .001); thus, as
contraction frequency increased, the ef-
fect on FSpO2 was more pronounced.
The Figure is a graphic representation of
the progressive oxygen desaturation
during 30 minutes of hyperstimulation
using FSpO2 values plotted every 5
minutes.
Although the dose of oxytocin in all 3
groups was relatively low, there were sig-
nificant differences (P ⬍ .001) among
groups based on the mean dose of oxy-
tocin being infused: 6.08 (SD 4.46) mU/
min; 9.64 (SD 5.46) mU/min and 12.03
(SD 5.31) mU/min in the normal uterine
activity group and groups 1 and 2,
respectively.
The characteristics of FHR patterns
were compared among the 3 groups, in-
FSpO2
45
46.09
40
35
30
Prior 5 Min
Blue squares indicate less than 5 contractions in 10 minutes; green circles indicate 5 or more but
less than 6 contractions in 10 minutes; red diamonds indicate 6 or more contractions in 10 minutes.
Fetal oxygen saturation mean values are plotted every 5 minutes over the course of 30 minutes.
Simpson. Oxytocin-induced uterine hyperstimulation during labor on fetal oxygen status and fetal heart rate. Am J Obstet
Gynecol 2008.
cluding mean FHR; absent or minimal
variability; accelerations; and late, vari-
able, prolonged, or recurrent decelera-
tions (Table). When compared with nor-
mal uterine activity, there were no
differences in the baseline FHR; how-
ever, there were more periods of absent
and minimal variability, less accelera-
tions, and more late and recurrent decel-
erations in the 2 hyperstimulation
groups (Table).
Differences in several FHR character-
istics also were noted between groups 1
and 2. When compared with group 1, in
group 2, there were less accelerations (P
⫽ .014) and more recurrent (P ⫽ .031)
decelerations. There were no significant
differences between groups 1 and 2 for
absent or minimal variability (P ⫽ .063),
variable decelerations (P ⫽ .554), late
decelerations (P ⫽ .093), or prolonged
decelerations (P ⫽ .912). The mean time
before changes in variability appeared
was 24 minutes in group 1 and 22 min-
utes in group 2 (P ⫽ .081); however, fetal
oxygen desaturation was noted in both
groups within the first 5 minutes of ex-
cessive uterine activity, progressively de-
45.35
43.94
43 42.62 41.46
43
41
39
37.5
36.68
10 Min 15 Min 20 Min 25 Min 30 Min
Mean FSpO2 Every 5 Min
creasing over the course of 30 minutes
(Figure).
Four types of interventions were used
to treat hyperstimulation, including de-
creasing the rate of oxytocin by half, dis-
continuing the oxytocin infusion (D/C
oxytocin), lateral repositioning, and an
IV fluid bolus of approximately 500 mL
of lactated Ringer’s solution. In most
cases, more than 1 intervention was
used. Interventions were able to be iden-
tified from the medical record in 148
of the 158 periods of hyperstimulation.
Efficacy of interventions to resolve hy-
perstimulation was compared based on
type of intervention/s: D/C oxytocin
(n ⫽ 35); D/C oxytocin and an IV fluid
bolus (n ⫽ 69); and D/C oxytocin, an IV
fluid bolus, and lateral repositioning
(n ⫽ 38).
There were only 6 cases of decreasing
oxytocin by half (all in group 1), so these
cases were not included in the ANOVA
used for comparison because of the small
number. The mean time for resolution
on the basis of decreasing the oxytocin
rate by half was 23 minutes in these 6
cases.

34.e3 American Journal of Obstetrics & Gynecology JULY 2008

www.AJOG.org Obstetrics Research

TABLE
Changes in fetal oxygen saturation and fetal heart rate patterns based on frequency of uterine activity
Group 1, 5 or
Normal, less than more but less than Group 2, 6 or more
FSpO2 and FHR 5 contractions in 6 contractions in contractions in 10 Level of
characteristics 10 min, n ⴝ 158 10 min, n ⴝ 102 min, n ⴝ 56 significance
FSpO 2 No change 2 10.68 (-20%) 2 15.34 (-29%) ⬍.001 a
................................................................................................................................................................................................................................................................................................................................................................................
b
Mean FHR (beats/min) 135 (⫾ 11.5) 139 (⫾ 10.9) 138 (⫾ 12) .46
................................................................................................................................................................................................................................................................................................................................................................................
c
Absent variability 0 (0) 2 (1.9) 2 (3.58) .011
................................................................................................................................................................................................................................................................................................................................................................................
c
Minimal variability 12 (7.6) 11 (10.8) 9 (16.1) .011
................................................................................................................................................................................................................................................................................................................................................................................
Accelerations 136 (86) 79 (77.5) 35 (62.5) ⬍.001 c
................................................................................................................................................................................................................................................................................................................................................................................
c
Variable decelerations 28 (17.7) 30 (29.4) 14 (25) .451
................................................................................................................................................................................................................................................................................................................................................................................
c
Late decelerations 14 (8.9) 16 (15.7) 15 (26.8) .032
................................................................................................................................................................................................................................................................................................................................................................................
c
Prolonged decelerations 0 (0) 4 (3.9) 2 (3.6) .085
................................................................................................................................................................................................................................................................................................................................................................................
c
Recurrent decelerations 15 (9.5) 22 (21.6) 21 (37.5) .002
................................................................................................................................................................................................................................................................................................................................................................................
Data are presented as mean (percent change), mean (⫾ SD) and n (percent).
a
Repeated-measures ANOVA.
b
ANOVA.
c
Pearson ␹2.
Simpson. Oxytocin-induced uterine hyperstimulation during labor on fetal oxygen status and fetal heart rate. Am J Obstet Gynecol 2008.

The majority of women were laboring crease in FSpO2 of 18% as well as decel- nonreassuring. In this study, progressive
in an upright or semi-Fowler position. erations after each contraction. Crane et fetal oxygen desaturation began within
There were significant differences in res- al10 also found that late decelerations the first 5 minutes of excessive uterine
olution of the hyperstimulation pattern and other worrisome FHR changes may activity (Figure), well before nonreassur-
based on the interventions used. Use of occur during excessive uterine activity. ing changes in FHR variability appeared
all 3 interventions resolved the hyper- Uterine contractions cause an inter- (22-24 minutes). The absolute decrease
stimulation pattern more quickly (6.1 mittent decrease or interruption in and the percentage of negative change in
minutes, SD 1.9, SEM 0.31) than 2 inter- blood flow to the intervillous space in FSpO2 after only 30 minutes of hyper-
ventions (9.8 minutes, SD 3.1, SEM 0.38) which oxygen exchange between the stimulation are of potential concern for
or 1 intervention (14.2, SD 2.6, SEM mother and fetus occurs.11 In most fetal well-being. Although we were un-
0.44; P ⬍ .001). Resolution time was healthy fetuses, the physiologic effects of able to measure the effects on the fetus of
based on the number of minutes from contractions occurring with normal fre- hyperstimulation lasting longer than 30
the time the intervention/s was/were quency are well tolerated.12 Crane et al10 minutes, it seems logical to conclude, on
noted in the medical record to the end of found that hyperstimulation (using the the basis of these data, that progressive
the last contraction in the series of con- criteria of more than 5 contractions in 10 fetal oxygen desaturation could poten-
tractions that represented hyperstimula- minutes for 2 consecutive 10 minute pe- tially continue if hyperstimulation was
tion. If calculated instead using the end- riods) occurred in more than 30% of la- left untreated.
point as the beginning of the first bors induced with oxytocin. If excessive Treatment of oxytocin-induced uter-
contraction in the series of contractions uterine activity causes the intermittent ine hyperstimulation has not been well
representing normal uterine activity, the interruption of blood flow to the inter- studied; however, some interventions
resolution time would have been found villous space to exceed a critical level, are often used routinely in clinical prac-
to be approximately 2-3 minutes longer. there is risk of fetus hypoxemia.11 The tice. Recommended interventions from
more time between contractions, the ACOG5 for hyperstimulation with a
C OMMENT more time there is to maximally perfuse nonreassuring FHR pattern include de-
In this study, hyperstimulation was asso- the placenta and deliver oxygen to the creasing or discontinuing the oxytocin
ciated with a negative effect on FSpO2 fetus.13 infusion, with additional interventions
and characteristics of FHR patterns. Potentially adverse effects on the fetus such as lateral repositioning; more intra-
These results are consistent with John- may be avoided by minimizing periods venous fluids; and, if hyperstimulation
son et al,3 who found that 20 minutes of of hyperstimulation and treating it in a persists, terbutaline. When the FHR is
hyperstimulation resulted in a rapid fetal timely manner when occurring rather persistently nonreassuring, discontinu-
oxygen desaturation with an average de- than waiting until the FHR pattern is ing the oxytocin infusion is recom-

JULY 2008 American Journal of Obstetrics & Gynecology 34.e4

Research Obstetrics
mended.7 ACOG5-7 does not provide
suggestions for treatment of hyper-
stimulation without nonreassuring FHR
changes.
Based on the results of this study, col-
lective use of discontinuation of the oxy-
tocin infusion, an IV fluid bolus of ap-
proximately 500 mL of lactated Ringer’s
solution, and lateral repositioning may
be more effective in resolving oxytocin-
induced hyperstimulation than discon-
tinuing oxytocin along with an IV fluid
bolus or solely discontinuing oxytocin.
These 3 interventions concurrently may
be considered to treat hyperstimulation
both with and without nonreassuring
FHR changes, based on the individual
clinical situation.
The more nonreassuring FHR changes
noted in groups 1 and 2 when compared
with the normal uterine activity group
may be related to the differences in
FSpO2 values in the last 5 minutes of the
30-minute periods of labor studied
(5.12%, 41.46%, and 36.68% during
normal uterine activity; 5 or more but
less than 6 contractions in 10 minutes;
and 6 or more contractions in 10 min-
utes, respectively), although the mean
FSpO2 remained above 30% in all
groups. After 20 minutes of hyperstimu-
lation in group 2, mean FSpO2 was below
40%, whereas in group 1, mean FSpO2
remained above 40% for the entire 30-
minute period (Figure). FSpO2 below
40% may represent low-normal values.
Two previous studies demonstrated dif-
ferent effects of maternal oxygen admin-
istration on FSpO2 between fetuses with
FSpO2 of 40% or greater and fetuses with
FSpO2 less than 40%.8,14 Fetuses in the
latter group responded with significantly
greater increases in FSpO2 than in the
former group when their mothers were
given oxygen.8,14
There are several shortcomings associ-
ated with this study. We were limited to a
retrospective review because of the obvi-
34.e5 American Journal of Obstetrics & Gynecology JULY 2008
ous inappropriateness of inducing hy-
perstimulation to prospectively study its
effects on the human fetus. The patient
sample was relatively small, although it
allowed an evaluation of 1045 30-minute
potential time periods for hyperstimula-
tion. Even so, only 102 and 56 30-minute
periods were identified in groups 1 and 2,
respectively.
We were unable to evaluate the effects
on the fetus of more than 30 minutes of
hyperstimulation because it was usually
identified and treated before it pro-
gressed beyond this time frame. The data
set was originally part of another study
for a different objective; however, we felt
these data were appropriate for use for
this study because healthy women hav-
ing elective labor induced with oxytocin
represent clinical characteristics of con-
temporary obstetrical practice in which
at least some periods of hyperstimula-
tion may often occur, even with excellent
care.1,10
We conclude that fetal well-being may
be in jeopardy when oxytocin-induced hy-
perstimulation occurs during labor. Based
on our findings and the findings of oth-
ers,1,3,4 the frequency component of the
definition of hyperstimulation as 5 or
more contractions in 10 minutes may be
more conducive to safe care for the fetus
during labor than other commonly used
definitions that include more than 5 con-
tractions in 10 minutes or 6 or more con-
tractions in 10 minutes. Retrospective
studies with much larger samples are re-
quired to evaluate the effects of uterine hy-
perstimulation on neonatal outcomes. f
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