Volume 63, Number 6

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2008
by Lippincott Williams & Wilkins CME REVIEWARTICLE 16
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total
of 36 AMA/PRA Category 1 CreditsTM can be earned in . Instructions for how CME credits can be earned appear on the last
page of the Table of Contents.

Acute Tocolysis for Uterine Activity

Reduction in Term Labor
A Review
Roel de Heus, MD,* Eduard J. H. Mulder, MSc, PhD,†
Jan B. Derks, MD, PhD,‡ and Gerard H. A. Visser, MD, PhD§
*Resident Physician, †Biologist, ‡Physician, §Obstetric Department Chair, Department of Perinatology
and Gynecology, University Medical Centre Utrecht, The Netherlands

This review critically evaluates the efficacy of different tocolytics in reducing uterine pressure and
contractions in term labor. The available evidence supports the use of beta-adrenergic-receptor
agonists such as terbutaline or ritodrine; they appear to have an immediate and comparable profound
effect on uterine activity in term labor. However, the preferred type of beta-adrenergic receptor agonist
and dosage are unclear. The oxytocin receptor antagonist atosiban has a high specificity for the uterus
with limited or no systemic effects and could therefore be an attractive alternative for use in term labor.
The evidence on the tocolytic potency of a single bolus of atosiban for tocolysis in term labor is
encouraging but limited and needs further research. Moreover, atosiban lacks United States Food and
Drug Administration approval. Literature documenting efficacy and safety of nitroglycerin or magne-
sium sulfate in term labor is far from convincing. The theoretical basis for the use of tocolytics for
nonreassuring intrapartum fetal heart rate patterns is to reduce the aggravating influence of uterine
contractions. However, the clinical evidence that tocolytics in term active labor are actually beneficial
in improving neonatal outcome is very limited.
Target Audience: Obstetricians & Gynecologists, Family Physicians
Learning Objectives: After completion of this article, the reader should be able to outline the available
literature pertaining to tocolysis for term labor and appraise the effectiveness of various tocolytics in term labor.

The use of tocolytic drugs to inhibit preterm labor
is well-established, and a large number of clinical
trials have reported on the utility and side effects of
The authors have disclosed that they have no financial relation-
ships with or interests in any commercial companies pertaining to
this educational activity.
Faculty and Staff in a position to control the content of this CME
activity have disclosed that they have no financial relationships
with, or financial interests in, any commercial companies pertain-
ing to this educational activity.
Lippincott Continuing Medical Education Institute, Inc. has
identified and resolved all faculty conflicts of interest regarding
this educational activity.
Reprint requests to: Roel de Heus, MD, Department of Perina-
tology and Gynecology, University Medical Centre Utrecht,
KJ.02.507.0/P.O.Box 85090, 3508 AB Utrecht, The Netherlands.
E-mail: roeldeheus@hotmail.com.
383
the different tocolytics available (1–4). Occasionally,
tocolytics are used in term labor, for example, to facil-
itate external cephalic version or to prevent traumatic
delivery during caesarean section (CS). Another clin-
ical problem that might potentially be alleviated by
rapid uterine relaxation is a nonreassuring intrapar-
tum fetal heart rate (FHR) pattern at term. Indeed,
intra-uterine resuscitation by means of acute tocoly-
sis has become common practice in many obstetrical
units. Intrapartum fetal compromise may involve
combinations of hypoxemia and both metabolic and
respiratory acidosis and may occur when the effects
of uterine contractions exceed the compensatory
mechanism of the fetoplacental unit during labor. In
normal labor, uterine contractions affect oxygen sat-
384 Obstetrical and Gynecological Survey
uration of the uncompromised fetus but fetal oxygen-
ation is restored between contractions (5). Uterine
hyperstimulation after accidental oxytocin overdose
has been found to be associated with an incremental
decrease of fetal oxygen saturation and a drop in
FHR during each contraction (6). Cord occlusion,
either partial or complete, can cause both an increase
in fetal afterload and a decrease in fetal arterial
oxygen content, either of which will result in vagal
stimulation resulting in nonreassuring FHR patterns
(7). These findings support the rationale for using
acute tocolysis to improve the fetal condition. By
removing the aggravating influence of uterine con-
tractions, one might alleviate fetal compromise
caused by reduced oxygen supply and umbilical cord
compression. Recovery may buy time while prepa-
rations are made for emergency delivery or for labor
to be allowed to progress if the FHR pattern has
improved after tocolysis. Most of the tocolytics used
for preterm labor (beta-agonists, nitric oxide donors,
and atosiban) are also used for acute tocolysis in term
labor. However, the supporting evidence for acute
tocolysis in term labor appears to be limited. This
review critically evaluates that evidence. Because
reduction of the amount of uterine contractions in
term labor is the theoretical basis for intra-uterine
resuscitation, we will focus on the efficacy of the
different types of tocolytics in reducing uterine pres-
sure and contractions.
METHODS
Data sources used included a computerized litera-
ture search of MEDLINE (1966–2008), EMBASE
(1996–2008), the Cochrane Library, and manual
search of bibliographies of pertinent articles. The
criteria for selection of articles to be reviewed are
shown in Table 1. Only studies on acute tocolysis in
term labor that met our inclusion criteria were con-
sidered. The primary outcome parameter was effi-
ciency of the various tocolytics in reducing uterine
pressure and contractions. The selected studies pre-
sented data on uterine pressure and contractions ob-
tained by intra-uterine pressure catheters, compared
pre- and posttreatment periods, and expressed the
results as Montevideo Units, Alexandria Units, or
area under the curve (AUC) units. Secondary out-
come parameters were maternal and fetal side effects
of the tocolytics. For each subgroup of tocolytics
discussed in this review, we also briefly summarize
the mechanisms of action and evidence for efficacy
and maternal and fetal side effects in preterm labor.
TABLE 1
Inclusion/exclusion criteria for studies on acute tocolysis in term
labour
Category Criteria
Study population Hospitalized pregnant women gestational
age 37 weeks or more
Condition Term active labour with or without a
non-reassuring fetal heart rate pattern or
uterine tachysystole
Study settings Continuous measurement of intra-uterine
pressure with catheter
Outcomes Data on uterine pressure/contractions
before and after treatment with
tocolytic agent
Time period 1966 to 2008
Publication language English
Study designs Prospective studies
RESULTS
Beta-Adrenergic Receptor Agonists
Beta-adrenergic receptor agonists inhibit myome-
trial contractions by interacting with uterine smooth
muscle cell membrane beta-receptors and have been
used as tocolytics since 1961. These agents are
known to be successful in postponing preterm deliv-
ery for 24 to 48 hours (1,8). Beta-adrenergic agonists
may cause a variety of side effects. They rapidly
cross the placenta and common effects on the fetus
include fetal tachycardia, increased cardiac output
and redistribution of fetal blood flow. Because they
cause maternal hyperglycemia, rebound hypoglyce-
mia and hyperinsulinemia may occur in the neonate
after prenatal treatment (8–10). Four studies investi-
gating the effects of beta-adrenergic receptor ago-
nists on uterine contractions in term labor qualified
for inclusion (Table 2). Gerris et al (11) published
one of the first randomized trials of 2 beta-mimetic
drugs for acute intrapartum tocolysis. Twenty-four
women in active labor were randomly allocated to a
30-minute infusion of either fenoterol (1, 2, or 4
␮g/min) or ritodrine (100, 200, or 400 ␮g/min). Both
agents led to a dose-related inhibition of uterine
activity (to an average of approximately 25% of the
preinfusion activity). Sheybany et al (12) showed
similar results after a 3-minute infusion of ritodrine
(6-mg bolus) in 47 women with a nonreassuring FHR
pattern. At the time of the decision to perform a CS,
the women were given either ritodrine (n ⫽ 24) or no
treatment (n ⫽ 23). Uterine activity was reduced to
an average of 22% after ritodrine infusion and was
unchanged in the control subjects. Although treat-
ment was not randomized, baseline characteristics
were not significantly different between the treat-
 Acute Tocolysis for Uterine Activity Reduction in Term Labor Y CME Review Article 385

ment and control groups. The effects of another type

No responders
Responding

26 out of 29
both groups
of beta-adrenergic agonist, a single injection of ter-
Patients

All patients

All patients

All patients

All patients
butaline 250 ␮g, were studied by Ingemarsson et al
(13) In a group of 15 women with spontaneous labor,
terbutaline administration reduced uterine activity to
16.3% during the first 15 minutes compared with
Terbutaline (no oxytocin) 84%
Fenoterol 75% ritodrine 75%

Ritodrine 55% atosiban 54%

Terbutaline 55% magnesium
Uterine Activity Reduction

preinjection uterine activity. In a second group of 10

terbutaline (oxytocin) 75%

Nitroglycerin no reduction
patients with augmented labor and oxytocin infusion,
control (oxytocin) 22%
Ritodrine 78% control

uterine activity was reduced to 25% of the preinjec-

control no reduction
tion value. The terbutaline injection had an immedi-
ate profound effect on uterine contractions within
no reduction

no reduction
several minutes in both treatment groups. Magann et
al (14) performed a prospective randomized study
comparing terbutaline 250 ␮g subcutaneously with a
magnesium sulfate 4-g intravenous bolus. Forty-six
women in active labor who were to undergo a cesar-
4, 4, 4 vs. 4, 4, 4
Group Size

ean delivery for a nonreassuring FHR pattern were

15, 10 vs. 10

randomly allocated to receive one of the 2 agents. In

24 vs. 23

23 vs. 23

29 vs. 29

the first 10 minutes after terbutaline administration,

6 vs. 6

there was a significant reduction to 45% of the pre-

treatment uterine activity. In contrast, uterine activity
Prospective randomized

Prospective randomized

Prospective randomized

was not significantly altered following magnesium

2 prospective treatment
groups 1 control group
Prospective treatment

sulfate administration.
placebo controlled
group and control

In summary, we found 4 studies that met our in-

Method

clusion criteria in which the beta-adrenergic receptor

Double blind

randomized

agonists ritodrine, fenoterol, and terbutaline were

studied. Although the number of patients investi-
gated in the reports was low, the postinjection inter-
vals studied short, and most of the data presented not
supported by statistical analyses, there was consistent
Subcutaneous vs.
Administration

evidence that beta-adrenergic receptor agonists exert

Intravenous

Intravenous

Intravenous

Intravenous
intravenous

a tocolytic effect in term labor. In a recent random-

Studies on acute tocolysis in term labour that met the inclusion criteria

Sublingual

ized trial comparing terbutaline with nitroglycerin

(n ⫽ 110), a reduction of uterine contractions from 5
in 10 minutes before drug administration to 2.9 in 10
minutes after terbutaline was described in a second-
1, 2, 4 ␮g/min
vs. 100, 200,

ary analysis (15). In this study it was unclear whether

0.25 mg vs.
400 ␮g/min
Dosage

10 mg vs.

intra-uterine pressure catheters were used in all pa-

0.25 mg

0.80 mg

6.75 mg

tients. Concerning maternal side effects, all studies

6 mg

4 gm

reported maternal tachycardia after beta-adrenergic

receptor agonist administration, but no changes in
Terbutaline vs.

systolic and diastolic blood pressure. Fetal tachycar-

Fenoterol vs.

Nitroglycerin

Ritodrine vs.
Tocolytic

magnesium
Terbutaline

dia developed after ritodrine and fenoterol adminis-

Ritodrine

atosiban
sulphate
ritodrine

tration. The terbutaline studies presented no data on

FHR. However, development of fetal tachycardia
after terbutaline administration has been reported
First Author (reference)

Ingemarsson 1985 (13)

elsewhere (16,17).
Buhimschi 2002 (25)
Sheybany 1982 (12)

de Heus 2008 (30)

Magann 1993 (14)
Gerris 1980 (11)

Nitric Oxide Donors

TABLE 2

Nitric oxide donors are thought to act as a tocolytic

agent by inducing a powerful inhibitory effect on
smooth muscle contraction. Their mechanism of ac-
386 Obstetrical and Gynecological Survey
tion is not entirely understood but is thought to
involve the metabolite of nitroglycerin, nitric oxide
(NO), which acts either as a secondary messenger or
activates other secondary messengers in the myome-
trial cells leading to a reduction in intracellular cal-
cium. The potential effectiveness and relatively
few side effects of glyceryl trinitrate (GTN, a NO
donor) when administered by transdermal patch,
lead to the investigation of this agent for the pre-
vention of preterm delivery (18,19). Since that
time, several studies have reported varying degrees
of success with GTN in preterm labor (20,21).
Bisits et al (22) found GTN to be less efficacious
compared with beta-sympathicomimetics, and a
Cochrane review (23) concluded that there is in-
sufficient evidence to support the routine admin-
istration of nitric oxide donors in the treatment of
preterm labor. However, in a recent, relatively
small study by Smith et al (24), transdermal nitro-
glycerin was compared with placebo. The authors
demonstrated a reduction in neonatal morbidity
and mortality as a result of decreased risk of birth
before 28 weeks with the use of GTN patches.
We found only one study examining the effects
of NO donors in term labor. Buhimschi et al (25)
performed a double blind randomized placebo-
controlled study of the effects of sublingual nitro-
glycerin on uterine contractility. They randomly
assigned twelve patients in the active phase of
labor at term to 3 doses of sublingual nitroglycerin
(800 ␮g) or placebo given at 10-minute intervals.
The 3 doses of nitroglycerin failed to reduce in-
trauterine pressure and contraction frequency. The
mean maternal arterial pressure decreased signifi-
cantly by 20% after the first dose of nitroglycerin.
The authors suggested that higher doses of sublin-
gual nitroglycerin might be effective, but, if so, at
the cost of increasing maternal and fetal risks.
With their study, Buhimschi et al corroborate ear-
lier findings by Mercier et al (26). The latter
authors treated 24 term women with intrapartum
fetal distress with 60 or 90 ␮g nitroglycerin intra-
venously and studied the maternal cardiovascular
side effects. Six women developed profound hy-
potension after a 90-␮g bolus, with a systolic
blood pressure less than 100 mm Hg. Despite
changing the route of administration from intrave-
nous to sublingual, maternal side effects after ni-
troglycerin administration would likely remain a
limiting factor for the use of this type of tocolytic
in term labor, even if they could be shown to have
efficacy.
Oxytocin Antagonists
The oxytocin antagonist atosiban acts by blocking
the myometrial cell membrane oxytocin receptors by
competitive inhibition (27). Randomized trials have
shown atosiban to be at least as effective as three beta
agonists, ritodrine, salbutamol, and terbutaline, but
with significantly fewer maternal cardiovascular side
effects (2,4,28,29). Atosiban has a high specificity
for the uterus with limited or no systemic effects and
could therefore be an attractive alternative for use as
a tocolytic in term labor. It is not available in the
United States, however, as it lacks Food and Drug
Administration approval.
We recently studied in a prospective randomized
design the effects of atosiban compared with rito-
drine in term active labor. Primary endpoints were
the effects on maternal blood pressure and heart rate,
and a secondary end point was the effect on uterine
pressure (30). Women in term labor were random-
ized to either atosiban 6.75 mg (Tractocile, Ferring
Pharmaceuticals A/S, Copenhagen, Denmark) di-
luted in 4.9 mL saline administered as an intravenous
bolus (n ⫽ 70) or ritodrine 10 mg (Prepar, Solvay-
Pharmaceuticals S. A., Brussels, Belgium) diluted in
9 mL saline intravenous bolus (n ⫽ 70). In 58 pa-
tients (ritodrine n ⫽ 29, atosiban n ⫽ 29) intrauterine
pressure was recorded for at least 20 minutes both
before and after tocolytic administration using a
sensor-tip pressure catheter. Compared with baseline,
uterine pressure was significantly reduced by a maxi-
mum of 55% after ritodrine administration, compared
with a maximal reduction of 54% after atosiban admin-
istration. In both groups, 26 out of the 29 women with
adequate uterine activity data responded to tocolytic
administration. The most profound reduction was found
in the women undergoing oxytocin augmentation,
whereas the effect of atosiban on uterine pressure in
women in spontaneous labor was mild and not signifi-
cant. In a small observational pilot study fifteen women
with uterine hyperactivity were treated with atosiban
6.75 mg intravenously (31). Alleviation of uterine ac-
tivity was achieved in 14 out of 15 cases. Unfortunately,
no data were presented on reduction of uterine contrac-
tions by comparing pre- and postinjection intervals. The
lack of serious maternal and fetal effects found in the
preterm labor trials was mirrored in the studies of term
women described above.
DISCUSSION
We found only 6 studies meeting our inclusion cri-
teria that presented data on the effects of different
 Acute Tocolysis for Uterine Activity Reduction in Term Labor Y CME Review Article
tocolytics on uterine pressure and contractions during
term labor. The available evidence best supports the use
of beta-adrenergic-receptor agonists. Beta-adrenergic
receptor agonists such as terbutaline or ritodrine appear
to have an immediate and comparable profound effect
on uterine activity. However, the preferred choice of
type of beta-adrenergic receptor agonist and dosage
remains unclear and has to be further investigated. Our
review has focused on reduction in uterine activity in
term labor and not on the effects of tocolytics on FHR
or fetal pH. Several, mainly observational studies, have
been published on this topic (32–34). However, these
studies are hard to interpret because of many method-
ological limitations, such as absence of randomization
or control groups, and of large imbalances in group
sizes.
A Cochrane Review by Kulier and Hofmeyr as-
sessed the effects of tocolytic therapy for suspected
fetal distress on fetal, maternal, and perinatal out-
comes (35). After selection, only three studies could
be included (14,36,37) The reviewers concluded that
the limited evidence suggests that beta-adrenergic
receptor agonist therapy appears to be able to reduce
the incidence of FHR abnormalities. Recently, Pullen
et al (15) published a large randomized trial that
compared the effects of intravenous terbutaline or
nitroglycerin on nonreassuring FHR patterns. The
authors claimed similar successful acute resuscitation
rates on FHR recovery (terbutaline 71.9% and nitro-
glycerin 64.2%; P ⫽ 0.38). Surprisingly, the median
number of contractions per 10 minutes before and
after nitroglycerin administration was not signifi-
cantly lower suggesting a rather poor tocolytic effect.
Despite this trial, the literature documenting efficacy
and safety of nitroglycerin in term labor is very
limited and far from convincing.
In another recent trial in which neonatal outcome
was the primary end point, Briozzo et al (38) ran-
domized fetuses with nonreassuring heart rate for
emergency delivery or intrauterine resuscitation
with fenoterol infusion. The risk of admission to a
neonatal care unit and a large umbilical artery base
deficit was higher in the emergency delivery than in
the resuscitation group. As reviewed earlier in this
journal, this trial alone is not sufficient to recom-
mend routine tocolysis for intrauterine resuscitation,
even although it had few methodologic limitations (39).
Recent literature questions the role of magnesium
sulfate in preterm labor (40). The only article on term
labor has reported no reduction of uterine activity
after magnesium sulfate (14). Magnesium sulfate
has, therefore, no role as a tocolytic in term intrapar-
tum tocolysis. The theoretical basis for the use of
387
tocolytics for a nonreassuring intrapartum FHR pat-
tern is to reduce the aggravating influence of uterine
contractions. However, the evidence to support this
theoretical benefit is very limited. Furthermore, the
beta-adrenergic receptor agonist effects on the ma-
ternal and fetal cardiovascular systems remain con-
cerning and should not be underestimated, especially
in women undergoing cesarean delivery. In general,
it seems wise not to treat women with a history of
cardiovascular disease, hypertension, or diabetes
with a beta-adrenergic receptor agonist. Because of
its more favorable side-effect profile, the oxytocin
antagonist atosiban should be further investigated for
acute tocolysis in term active labor.
REFERENCES
1. Treatment of preterm labor with the beta-adrenergic agonist
ritodrine. The Canadian Preterm Labor Investigators Group.
N Engl J Med1992;327:308–312.
2. Effectiveness and safety of the oxytocin antagonist atosiban
versus beta-adrenergic agonists in the treatment of preterm
labour. The Worldwide Atosiban versus Beta-agonists Study
Group. Br J Obstet Gynaecol 2001;108:133–142.
3. Papatsonis DN, Van Geijn HP, Ader HJ, et al. Nifedipine and
ritodrine in the management of preterm labor: a randomized
multicenter trial. Obstet Gynecol 1997;90:230–234.
4. Treatment of preterm labor with the oxytocin antagonist atosi-
ban: a double-blind, randomized, controlled comparison with
salbutamol. Eur J Obstet Gynecol Reprod Biol 2001;98:177–
185.
5. McNamara H, Johnson N. The effect of uterine contractions
on fetal oxygen saturation. Br J Obstet Gynaecol 1995;102:
644–647.
6. Johnson N, van Oudgaarden E, Montague I, et al. The effect of
oxytocin- induced hyperstimulation on fetal oxygen. Br J Ob-
stet Gynaecol 1994;101:805–807.
7. Ball RH, Parer JT. The physiologic mechanisms of variable
decelerations. Am J Obstet Gynecol 1992;166:1683–1688;
discussion 1688–1689.
8. Higby K, Xenakis EM, Pauerstein CJ. Do tocolytic agents stop
preterm labor? A critical and comprehensive review of efficacy
and safety. Am J Obstet Gynecol 1993;168:1247–1256; dis-
cussion 1256–1259.
9. Leake RD, Hobel CJ, Okada DM, et al. Neonatal metabolic
effects of oral ritodrine hydrochloride administration. Pediatr
Pharmacol (New York) 1983;3:101–106.
10. Musci MN Jr, Abbasi S, Otis C, et al. Prolonged fetal ritodrine
exposure and immediate neonatal outcome. J Perinatol 1988;
8:27–32.
11. Gerris J, Thiery M, Bogaert M, et al. Randomized trial of two
beta-mimetic drugs (ritodrine and fenoterol) in acute intra-
partum tocolysis. Eur J Clin Pharmacol 1980;18:443–448.
12. Sheybany S, Murphy JF, Evans D, et al. Ritodrine in the
management of fetal distress. Br J Obstet Gynaecol 1982;89:
723–726.
13. Ingemarsson I, Arulkumaran S, Ratnam SS. Single injection of
terbutaline in term labor. II. Effect on uterine activity. Am J
Obstet Gynecol 1985;153:865–869.
14. Magann EF, Cleveland RS, Dockery JR, et al. Acute tocolysis
for fetal distress: terbutaline versus magnesium sulphate.
Aust N Z J Obstet Gynaecol 1993;33:362–364.
15. Pullen KM, Riley ET, Waller SA, et al. Randomized comparison
of intravenous terbutaline vs nitroglycerin for acute intrapar-
388 Obstetrical and Gynecological Survey
tum fetal resuscitation. Am J Obstet Gynecol 2007;197:414
e1–e6.
16. Shekarloo A, Mendez-Bauer C, Cook V, et al. Terbutaline
(intravenous bolus) for the treatment of acute intrapartum fetal
distress. Am J Obstet Gynecol 1989;160:615–618.
17. Kurup A, Arulkumaran S, Tay D, et al. Can terbutaline be used
as a nebuliser instead of intravenous injection for inhibition of
uterine activity? Gynecol Obstet Invest 1991;32:84–87.
18. Rowlands S, Trudinger B, Visva-Lingam S. Treatment of pre-
term cervical dilatation with glyceryl trinitrate, a nitric oxide
donor. Aust N Z J Obstet Gynaecol 1996;36:377–381.
19. Black RS, Lees C, Thompson C, et al. Maternal and fetal
cardiovascular effects of transdermal glyceryl trinitrate and
intravenous ritodrine. Obstet Gynecol 1999;94:572–576.
20. Lees CC, Lojacono A, Thompson C, et al. Glyceryl trinitrate
and ritodrine in tocolysis: an international multicenter random-
ized study. GTN Preterm Labour Investigation Group. Obstet
Gynecol 1999;94:403–408.
21. El-Sayed YY, Riley ET, Holbrook RH Jr, et al. Randomized
comparison of intravenous nitroglycerin and magnesium sul-
fate for treatment of preterm labor. Obstet Gynecol 1999;93:
79–83.
22. Bisits A, Madsen G, Knox M, et al. The Randomized Nitric
Oxide Tocolysis Trial (RNOTT) for the treatment of preterm
labor. Am J Obstet Gynecol 2004;191:683–690.
23. Duckitt K, Thornton S. Nitric oxide donors for the treatment of
preterm labour. Cochrane Database Syst Rev 2002;
CD002860.
24. Smith GN, Walker MC, Ohlsson A, et al. Randomized double-
blind placebo-controlled trial of transdermal nitroglycerin for
preterm labor. Am J Obstet Gynecol 2007;196:37 e1–e8.
25. Buhimschi CS, Buhimschi IA, Malinow AM, et al. Effects of
sublingual nitroglycerin on human uterine contractility during
the active phase of labor. Am J Obstet Gynecol 2002;187:
235–238.
26. Mercier FJ, Dounas M, Bouaziz H, et al. Intravenous nitroglyc-
erin to relieve intrapartum fetal distress related to uterine
hyperactivity: a prospective observational study. Anesth
Analg 1997;84:1117–1120.
27. Andersen LF, Lyndrup J, Akerlund M, et al. Oxytocin receptor
blockade: a new principle in the treatment of preterm labor?
Am J Perinatol 1989;6:196–199.
28. Tsatsaris V, Papatsonis D, Goffinet F, et al. Tocolysis with
nifedipine or beta- adrenergic agonists: a meta-analysis. Ob-
stet Gynecol 2001;97:840–847.
29. Moutquin JM, Sherman D, Cohen H, et al. Double-blind, ran-
domized, controlled trial of atosiban and ritodrine in the treat-
ment of preterm labor: a multicenter effectiveness and safety
study. Am J Obstet Gynecol 2000;182:1191–1199.
30. Heus de R, Mulder EJ, Derks JB, et al. A prospective random-
ized trial of acute tocolysis in term labour with atosiban or
ritodrine. Eur J Obstet Gynecol Reprod Biol. 2008; EPUB.
31. Lurie S, Sadan O, Ben Aroya Z, et al. Atosiban treatment for
uterine hyperactivity during active labor: a pilot study. J Peri-
nat Med 2004;32:137–139.
32. Palomaki O, Jansson M, Huhtala H, et al. Severe cardiotoco-
graphic pathology at labor: effect of acute intravenous toco-
lysis. Am J Perinatol 2004;21:347–353.
33. Cabero L, Vaz-Romero M, Cerqueira MJ, et al. Conservative
treatment of intrapartum fetal acidosis with a betamimetic
agent. Eur J Obstet Gynecol Reprod Biol 1988;28:185–190.
34. Burke MS, Porreco RP, Day D, et al. Intrauterine resuscitation
with tocolysis. An alternate month clinical trial. J Perinatol
1989;9:296–300.
35. Kulier R, Hofmeyr GJ. Tocolytics for suspected intrapartum
fetal distress. Cochrane Database Syst Rev 2000;CD000035.
36. Patriarco MS, Viechnicki BM, Hutchinson TA, et al. A study on
intrauterine fetal resuscitation with terbutaline. Am J Obstet
Gynecol 1987;157:384–387.
37. Kulier R, Gulmezoglu AM, Hofmeyr GJ, et al. Betamimetics in
fetal distress: randomised controlled trial. J Perinat Med 1997;
25:97–100.
38. Briozzo L, Martinez A, Nozar M, et al. Tocolysis and delayed
delivery versus emergency delivery in cases of non-reassuring
fetal status during labor. J Obstet Gynaecol Res 2007;33:266–
273.
39. Briozzo L, Martinez A, Nozar M, et al. Tocolysis and delayed
delivery versus emergency delivery in cases of non-reassuring
fetal status during labor. Obstet Gynecol Surv 2007;62:762–
764.
40. Crowther CA, Hiller JE, Doyle LW. Magnesium sulphate for
preventing preterm birth in threatened preterm labour. Co-
chrane Database Syst Rev 2002;CD001060.