Oxytocin Protocol Research Articles

Oxytocin protocols during Cesarean delivery: optimizing the tone zone

Oxytocin protocols during Cesarean delivery: optimizing the tone zone

Effect of an Oxytocin Protocol on Secondary Uterotonic Use in Patients Undergoing Cesarean Delivery

(Can J Anaesth. 2023;70(7):1194–1201) Following childbirth, it is customary to administer oxytocin to prevent postpartum hemorrhage (PPH). Oxytocin, the first line uterotonic, is typically given intravenously immediately after vaginal and cesarean delivery. Different oxytocin protocols exist and the optimal dosing regimen is yet to be determined. A rule of three’s oxytocin protocol was previously described and found to reduce the overall amount of oxytocin administered during scheduled cesarean deliveries (CD) while maintaining adequate uterine tone. The aim of the study was to compare a modified rule of three’s oxytocin protocol to a free-flow oxytocin infusion after CD.

Protocolized oxytocin infusion for elective cesarean delivery: a retrospective before-and-after study

PurposeTo elucidate the clinical impact of the novel oxytocin protocol using a syringe pump with a stratified dose compared with the conventional practice of putting oxytocin into the bag.MethodsThis is a retrospective cohort study. We collected the data of the patients who underwent elective cesarean delivery under neuraxial anesthesia between June 2019 and May 2020. The patients were allocated to two groups according to oxytocin administration methods; the control group (the attending anesthesiologist put oxytocin 5–10 units in the infusion bag and adjusted manually after childbirth) and the protocol group (the oxytocin protocol gave oxytocin bolus 1 or 3 units depending on the PPH risk, followed by 5 or 10 unit h−1 via a syringe pump). We compared the total amount of oxytocin within 24 h postpartum, estimated blood loss, and adverse clinical events within 24 h postpartum between the two groups.ResultsDuring the study period, 262 parturients were included. Oxytocin doses of intraoperative and postoperative were significantly lower in the protocol group (9.7 vs. 11.7 units, intraoperative, 15.9 vs. 18 units, postoperative). The subgroup analyses showed that the impact was more remarkable in the low PPH risk than in the high PPH risk. The multivariate linear regression analyses also confirmed the difference. The groups had no significant difference in blood loss, requirement of additional uterotonics, and other adverse events.ConclusionsOur oxytocin infusion protocol significantly reduced oxytocin requirements in elective cesarean delivery under neuraxial anesthesia without increasing blood loss. However, we could not find other clinical benefits of the novel protocol.

Effect of an oxytocin protocol on secondary uterotonic use in patients undergoing Cesarean delivery.

Protocol-driven oxytocin regimens can reduce oxytocin administration compared with a nonprotocol free-flow continuous infusion. Our aim was to compare secondary uterotonic use between a modified "rule of threes" oxytocin protocol and a free-flow continuous oxytocin infusion after Cesarean delivery. We conducted a retrospective before-and-after study to compare patients who underwent Cesarean delivery between 1 January 2010 and 31 December 2013 (preprotocol) with patients who underwent Cesarean delivery between 1 January 2015 and 31 August 2017 (postprotocol). The preprotocol group received free-flow oxytocin administration and the postprotocol group received oxytocin according to a modified rule of threes algorithm. The primary outcome was secondary uterotonic use and the secondary outcomes included blood transfusion, hemoglobin value < 8 g·dL-1, and estimated blood loss. In total, 4,010 Cesarean deliveries were performed in 3,637 patients (2,262 preprotocol and 1,748 postprotocol). The odds of receiving secondary uterotonic drugs were increased in the postprotocol group (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.04 to 1.70; P = 0.02). Patients in the postprotocol group were less likely to receive a blood transfusion. Nevertheless, the two groups were similar for the composite end point of transfusion or hemoglobin < 8 g·dL-1 (OR, 0.86; 95% CI, 0.66 to 1.11; P = 0.25). The odds of an estimated blood loss greater than 1,000 mL were reduced in the postprotocol group (OR, 0.64; 95% CI, 0.50 to 0.84; P = 0.001). Patients in the modified rule of threes oxytocin protocol group were more likely to receive a secondary uterotonic than those in the preprotocol group. Estimated blood loss and transfusion outcomes were similar.

Impact of Adherence to a Standardized Oxytocin Induction Protocol on Obstetric and Neonatal Outcomes

Oxytocin protocols are employed to induce uterine contractions and progressive cervical changes, but they are associated with adverse maternal and neonatal outcomes. The aim of this study was to determine whether compliance with a checklist-based protocol for oxytocin administration was associated with changes in neonatal and maternal outcomes. A retrospective cohort study of 86,786 pregnant women undergoing term (> 37 weeks) induction of labor between January 2015 and December 2017 was performed. Systemwide training in the use of an oxytocin administration protocol was provided to obstetricians and nurses. Pre-use and in-use oxytocin checklists were incorporated into each unit's policies and procedures. Subsequently, charts were reviewed and individually audited by an obstetric nurse who scored each record based on the documentation of variables in an oxytocin administration protocol and ranked adherence as complete or absent. Primary outcomes were postpartum hemorrhage, neonatal ICU (NICU) admission, and delivery by cesarean section. Bivariate analyses (t-tests) were performed on adherent and nonadherent groups for comparison of selected demographic variables and the primary outcome variables. Logistic regression was completed on the primary outcome variable with eight covariates. Among patients with complete adherence to the oxytocin administration protocol, the rate of cesarean section in the unadjusted analysis was 16.20%, compared to 18.54% for those with incomplete adherence; the rates of postpartum hemorrhage were 2.64% vs. 3.14%, respectively, and the rates of NICU admission were 3.03% vs. 3.86%, respectively. In the multivariable logistic regression, complete protocol adherence was associated with significantly lower odds of postpartum hemorrhage (adjusted odds ratio [OR] 0.85, 95% confidence interval [CI] 0.76-0.94) but higher odds of Cesarean section (adjusted OR 1.07, 95% CI 1.01-1.13); the adjusted OR for NICU admission was 0.90, which did not reach statistical significance (95% CI 0.81-1.00). Among the covariates, nulliparity and elective induction were the strongest predictors of the primary outcomes of cesarean section, postpartum hemorrhage, and NICU admission. Adherence to the oxytocin administration protocol was associated with a decrease in postpartum hemorrhage but an increased risk of delivery by cesarean section.

Comparison of delivery outcomes in low-dose and high-dose oxytocin regimens for induction of labor following cervical ripening with a balloon catheter: A retrospective observational cohort study.

A variety of oxytocin regimens are used for labor induction and augmentation. Considering the increasing rates of labor induction, it is important to assess the most optimal oxytocin regimen without compromising maternal and fetal safety. The aim of this study was to compare delivery outcomes of low-dose and high-dose oxytocin induction protocols. This retrospective cohort study of 487 women comparing low-dose oxytocin protocol (n = 280) and high-dose oxytocin protocol (n = 207) in labor induction following cervical ripening by balloon catheter was performed in Helsinki University Hospital after implementation of a new oxytocin induction protocol. The study included two six-month cohorts from 2016 and 2019. Women with vital singleton pregnancies ≥37 gestational weeks, cephalic presentation, and intact amniotic membranes were included. The primary outcome was the rate of vaginal delivery. The secondary outcomes were the rates of maternal and neonatal infections, postpartum hemorrhage, umbilical artery blood pH-value, admission to neonatal intensive care, and induction-to-delivery interval. Statistical analyses were performed by using IBM SPSS Statistics for Windows (Armonk, NY, USA). The rate of vaginal delivery was higher [69.9% (n = 144) vs. 47.9% (n = 134); p<0.004] and the rates of maternal and neonatal infection were lower during the new high-dose oxytocin protocol [maternal infections 13.6% (n = 28) vs. 22.1% (n = 62); p = 0.02 and neonatal infection 2.9% (n = 6) vs. 14.6% (n = 41); p<0.001, respectively]. The rates of post-partum hemorrhage, umbilical artery blood pH-value <7.05 or neonatal intensive care admissions did not differ between the cohorts. The median induction-to-delivery interval was shorter in the new protocol [32.0 h (IQR 18.5-42.7) vs. 37.9 h (IQR 27.8-52.8); p<0.001]. In conclusion, implementation of the new continuous high-dose oxytocin protocol resulted in higher rate of vaginal delivery and lower rate of maternal and neonatal infections. Our experience supports the use of high-dose continuous oxytocin induction regimen with a practice of stopping oxytocin once active labor is achieved, and a 15-18-hour maximum duration for oxytocin induction in the latent phase of labor following cervical ripening with a balloon catheter.

High- vs low-dose oxytocin in lean and obese women: a double-blinded randomized controlled trial

Women with obesity are likely to experience longer lengths of labor and are at an increased risk of cesarean delivery. We hypothesized that high-dose oxytocin would decrease the time to delivery in a cohort of women with obesity undergoing induction of labor. This study aimed to assess whether women with obesity benefited from higher doses of oxytocin for induction of labor. A double-blinded randomized controlled trial was conducted to evaluate the effect of low-dose and high-dose oxytocin on length of labor. We recruited women who were undergoing induction of labor at ≥37 weeks of gestation. Patients were randomly assigned in a 1:1 ratio to receive low-dose or high-dose oxytocin stratified by obesity level (obese and lean). The primary outcome was length of time (minutes) to vaginal delivery. The secondary outcomes included overall cesarean delivery rate, cesarean delivery for labor arrest, maximum oxytocin infusion rate, oxytocin infusion discontinuation, oxytocin infusion decrease, blood loss, neonatal intensive care unit admission, and neonatal Apgar scores. A total of 140 patients were randomized into receiving low-dose and high-dose oxytocin stratified into obese and lean stratum (35 for all strata). The primary outcome, time to vaginal delivery, was similar between the low-dose and high-dose oxytocin groups in the lean stratum (796 [±411] vs 694 [±466] minutes; P=.363) and the stratum with obesity (715 [±497] vs 762 [±594] minutes; P=.733). Kaplan-Meier curves between the low-dose and high-dose oxytocin groups were not significantly different in the lean stratum (P=.391) and the stratum with obesity (P=.692). There were 5 cesarean deliveries (14.29%) in the low-dose oxytocin lean stratum vs 2 cesarean deliveries (5.71%) in the high-dose oxytocin lean stratum (P=.232). There were 4 cesarean deliveries (11.43%) in the low-dose oxytocin stratum with obesity vs 1 cesarean delivery (2.86%) in the high-dose oxytocin stratum with obesity (P=.164). There was no difference in the incidence of postpartum hemorrhage between the lean stratum (P=0.526) and the stratum with obesity (P=0.212). There was no difference in mean estimated blood loss between the lean stratum (P=.472) and the stratum with obesity (P=.215). There was no difference in time to delivery between the low-dose and high-dose oxytocin protocols in either the lean cohorts or cohorts with obesity undergoing induction of labor. We did observe a trend toward a lower rate of cesarean delivery in both lean women and women with obesity when high-dose oxytocin was used.

Maternal outcomes before and after new oxytocin protocol at cesarean delivery.

The primary objective was to describe the incidence of post-partum hemorrhage at cesarean delivery before and after implementation of a new high dose oxytocin protocol at Chris Hani Baragwanath Academic Hospital. This was a cross sectional retrospective record review 3months before and 3months after the implementation of a high dose oxytocin protocol. The study included all women that underwent cesarean delivery between 1 November 2016 and 30 April 2017 with a gestation of >24weeks. A total of 4604 Cesarean deliveries were performed during the study period, 2162 before the implementation of the new protocol and 2442 after. The incidence of post-partum hemorrhage was 4.8% (n=91) in the Before group and 3.9% (n=89) in the After group (P=0.17). There was a 17.9% change in incidence of postpartum hemorrhage between the groups (P=0.17). There was no significant difference in uterine atony between the Before and After groups (21.8% and 30.1%, P=0.30). There was no difference in the incidence of postpartum hemorrhage at cesarean delivery after the implementation of a high dose oxytocin protocol.

Prophylactic Phenylephrine Increases the Dose Requirement of Oxytocin to Treat Uterine Atony During Cesarean Delivery: A Double-Blinded, Single-Center, Randomized and Placebo-Controlled Trial.

Purpose: Studies involving mouse models and human uterine smooth muscle cells have shown that phenylephrine inhibits uterine contractions in non-pregnant mice and human in vitro cell via cyclic adenosine monophosphate (cAMP) signaling. However, there has been no limited exploration to date of the effect of phenylephrine on uterine contractions in clinical practice. This study aimed to compare the dose requirement of oxytocin with or without the infusion of prophylactic phenylephrine to prevent post spinal hypotension during cesarean delivery under combined spinal and epidural anesthesia. Methods: This was a double-blinded, single-center, randomized, control study. One hundred and sixty pregnant patients provided informed consent and were randomly allocated to the phenylephrine (phenylephrine infusion) and control (saline infusion) groups. Patients randomized to the phenylephrine group received an intravenous prophylactic phenylephrine infusion at a fixed rate of 0.5 μg/kg/min. The control group received a saline placebo at the same rate and used the same apparatus for delivery. After neonatal delivery and clamping of the umbilical cord, patients received a standard institutional oxytocin protocol. The primary outcome measure was the total dose of oxytocin administered during CD. Secondary outcomes including the proportion (%) of patients requiring a secondary uterotonic agent and estimated blood loss (EBL) in the first 24 h after surgery. Results: The median oxytocin dose administered was significantly higher in the phenylephrine group than in the control group [6.9 ± 2.5 international standardized units (IU) vs. 5.4 ± 2.4 IU, p = 0.0004]. The number of patients that required a secondary uterotonic agent was significantly higher in the phenylephrine group than in the control group (24.2% vs. 9.1%; p = 0.034). The EBL in the first 24-h postoperatively was similar between the two groups (467 ± 47 ml vs. 392 ± 38 ml; p = 0.22). Conclusions: Prophylactic infusion of phenylephrine used to prevent post-spinal hypotension during CD was associated with a higher dose of oxytocin. This has important clinical implications, as the suboptimal use of oxytocin is associated with an increased risk of postpartum hemorrhage and increased maternal morbidity and mortality. Further studies are now needed to confirm these findings.

Oral Misoprostol alone versus oral misoprostol followed by oxytocin for labour induction in women with hypertension in pregnancy (MOLI): protocol for a randomised controlled trial

BackgroundEvery year approximately 30,000 women die from hypertensive disease in pregnancy. Magnesium sulphate and anti-hypertensives reduce morbidity, but delivery is the only cure. Low dose oral misoprostol, a prostaglandin E1 analogue, is a highly effective method for labour induction. Usually, once active labour has commenced, the misoprostol is replaced with an intravenous oxytocin infusion if ongoing stimulation is required. However, some studies have shown that oral misoprostol can be continued into active labour, a simpler and potentially more acceptable protocol for women. To date, these two protocols have never been directly compared.MethodsThis pragmatic, open-label, randomised trial will compare a misoprostol alone labour induction protocol with the standard misoprostol plus oxytocin protocol in three Indian hospitals. The study will recruit 520 pregnant women being induced for hypertensive disease in pregnancy and requiring augmentation after membrane rupture. Participants will be randomised to receive either further oral misoprostol 25mcg every 2 h, or titrated intravenous oxytocin. The primary outcome will be caesarean birth. Secondary outcomes will assess the efficacy of the induction process, maternal and fetal/neonatal complications and patient acceptability. This protocol (version 1.04) adheres to the SPIRIT checklist. A cost-effectiveness analysis, situational analysis and formal qualitative assessment of women’s experience are also planned.DiscussionAvoiding oxytocin and continuing low dose misoprostol into active labour may have a number of benefits for both women and the health care system. Misoprostol is heat stable, oral medication and thus easy to store, transport and administer; qualities particularly desirable in low resource settings. An oral medication protocol requires less equipment (e.g. electronic infusion pumps) and may free up health care providers to assist with other aspects of the woman’s care. The simplicity of the protocol may also help to reduce human errors associated with the delivery of intravenous infusions. Finally, women may prefer to be mobile during labour and not restricted by an intravenous infusion. There is a need, therefore, to assess whether augmentation using oral misoprostol is superior clinically and economically to the standard protocol of intravenous oxytocin.Trial registrationClinical Trials.gov, NCT03749902, registered on 21st Nov 2018.

An evidence-based oxytocin protocol for the third stage of labor to improve hemorrhage outcomes.

To assess the use of an evidence-based oxytocin protocol for management of the third stage of labor to decrease non-beneficial clinical variation and improve clinical outcomes. This is a cohort study of pregnant patients delivering before implementation of an evidence-based oxytocin protocol compared to patients delivering after implementation of an evidence-based oxytocin protocol. A level III maternal care referral hospital with an average delivery volume of approximately 3000 deliveries. Pregnant patients delivering over a 60-month period from January 2013 to December 2017. An evidence-based oxytocin protocol: 3 units of oxytocin administered over 3 minutes, with a second 3-unit bolus if inadequate tone, then oxytocin infusion at 18 units/hour × 1 hour and then 3.6 units/hour for 3 hours. Postpartum hemorrhage (PPH) rate (EBL ≥500 ml for vaginal and ≥1000 ml for cesarean). Data from 14 603 deliveries were analyzed, 8408 pre-protocol and 6195 post-protocol. We demonstrated a significant decrease in PPH from 5.2% to 2.9% (P < 0.001) and a small but non-significant increase in the transfusion rate from 1.8% to 2.3% (P = 0.11). A standardized oxytocin infusion protocol in the third stage of labor resulted in a significant decrease in PPH for both vaginal and cesarean deliveries.

Safety of medical second trimester abortions for women with prior cesarean sections.

Medical second-trimester abortion in women with prior cesarean section (CS) is becoming an increasingly common phenomenon. However, data about the safety of the procedure are limited. This study addresses this issue. Retrospective cohort single-center study, done in Hadassah Medical Center in Jerusalem, a tertiary-care university hospital. This study included 779 women who needed pregnancy termination between 13 and 26 gestational weeks. 128 women had at least one previous CS (study group), whereas 651 had no CS (reference group). Protocols used were: (1) misoprostol tablets, 800 mcg vaginally followed by 400 mcg orally every 3h up to four oral doses, (2) Oxytocin drip. Nearly one-fourth of the women received mifepristone as a preliminary treatment for cervical ripening. The outcomes assessed included the following complications: retained placenta, bleeding with or without requiring blood transfusion, infection, cervical lacerations, uterine adhesions and uterine ruptures. Previous CS does not appear to increase the incidence of complications, excluding clinical bleeding without requiring blood transfusions (p value 0.05), which has a minimal clinical significance. Oxytocin protocol had 3.44 OR for complications, compared to misoprostol (p value 0.03, CI; 1.12- 10.52). No significant correlation was found between Misoprostol dosage and complications (Mann-Whitney U test, p value 0.057). Medical second-trimester abortions for women with prior CS should be considered a safe and effective procedure, with a low complication rate. The most serious complication is uterine rupture, which is uncommon; we recorded one case only. Misoprostol protocol should be preferred. IRB 0177-17-HMO, 5/2014.

641: High versus low dose oxytocin in lean and obese women: a double-blinded randomized controlled trial

Obese women have longer labors and are more likely to require a cesarean delivery. We hypothesized that high dose oxytocin would decrease time to delivery in an obese cohort undergoing an induction of labor. We randomized lean and obese women into four groups: lean women receiving low dose oxytocin, lean women receiving high dose oxytocin, obese women receiving low dose oxytocin and obese women receiving high dose oxytocin. This was a double blinded randomized controlled trial with an intention to treat analysis. We recruited lean and obese women at ≥37weeks gestational age who were undergoing induction of labor. 35 patients in each of the 4 groups were recruited with a total sample size of 140. The lean and obese cohorts were randomized to receive either low or high dose oxytocin infusions. The primary outcome was length of time to delivery defined by number of minutes from induction of labor to delivery. Randomization and provision of study medication was performed by the research pharmacy. Study medication provided by the pharmacy appeared identical per arm. The primary outcome, time to vaginal delivery, was similar between the low and high groups in the lean group (796 (± 411) versus 694 (± 466) minutes, P=0.363) and the obese group (715 (± 497) versus 762 (± 594) minutes, P=0.733). Kaplan-Meier curves between the low and high groups were not significantly different in the lean (P=0.391) and obese (P=0.692) groups. There were 5 (14.29%) cesarean deliveries in the low dose lean group, compared to 2 (5.71%) in the high dose lean group. There were 4 (11.43%) cesarean deliveries in the low dose obese group, compared to 1 (2.86%) in the high dose obese group. There was no difference between the incidence of postpartum hemorrhage for the lean (p = 0.706) and the obese (p = 0.324) groups. There was no difference in mean estimated blood loss for the lean (p = 0.472) and the obese (p = 0.215) groups. There was no difference in time to delivery between the low and high dose oxytocin protocol in either the lean or obese cohort undergoing an induction of labor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

514: The effect of a postpartum physiologic oxytocin protocol on blood loss

Oxytocin is widely used to prevent excessive blood loss postpartum. Previous studies have found that oxytocin bolus can cause hypotension and that physiologic doses of oxytocin are much lower than previously thought. The objective of this study was to determine the effect of a physiologic postpartum oxytocin protocol on postpartum blood loss as compared to oxytocin bolus. A retrospective cohort study of women delivered at Stony Brook University Hospital between March 2014 and March 2016 was conducted. In March 2015 the postpartum oxytocin protocol changed from a bolus of 40U in 1L (4U/min) to oxytocin delivered via a pump. Both protocols started after delivery of the placenta and were administered after both vaginal and cesarean births. In the study group the oxytocin was started at 0.3U/min and could be increased to 0.6U/min if uterine atony occurred. We excluded women with multiple gestations, preterm delivery, unknown gestational age, or without post-partum hematocrit value. Demographics and delivery data was collected. The primary outcome was average change in hematocrit between admission and post-partum. Secondary outcomes were number of blood transfusions and use of uterotonics. A total of 2005 records were included. Demographic and obstetric characteristics were similar between groups.There was a significant decrease in average change in hematocrit (5.2±4.8 vs. 4.6±5.1, p=0.009)with the new protocol. However, there was no significant difference in the percent of women requiring additional uterotonics (8.9% vs. 8.4%, p=0.695) or transfusion (2.4% vs. 1.5%, p=0.178) between groups. A significant decrease in blood loss and no change in uterotonics and transfusion was seen after implementation of the new protocol. Our data suggests that a physiologic dose of oxytocin may be superior to a bolus.

A Standardized Postpartum Oxytocin Protocol to Reduce Hemorrhage Treatment: Outcomes by Delivery Mode

Postpartum hemorrhage prophylaxis guidelines lack consensus and do not address the major factor of delivery mode. This creates quality and safety concerns. The objective of this study was to evaluate the effect of implementing a standardized prophylaxis protocol on postpartum hemorrhage treatment by delivery mode. A secondary analysis was conducted of all women ≥ 24 weeks' gestational age who delivered from January 2010 to June 2015 at one perinatal center. Women were grouped according to delivery pre-protocol (nonstandardized postpartum oxytocin) or post-protocol (standardized postpartum oxytocin). This retrospective cohort study compared outcomes by delivery mode. The primary outcome was treatment for postpartum hemorrhage or uterine atony. A total of 16,811 women were studied, stratified by three delivery modes: spontaneous vaginal (n = 10,542), operative vaginal (n = 963), and cesarean (n = 5,306). Delivery post-protocol introduction was associated with a lower treatment rate of postpartum hemorrhage for spontaneous vaginal (5.7% vs. 3.1%; p < 0.001) and cesarean (9.4% vs. 7.8%; p = 0.036) modes. Delivery post-protocol introduction was associated with a decreased risk of the primary composite outcome across all modes: spontaneous vaginal (adjusted odds ratio [AOR] = 0.537; 95% confidence interval [CI]: 0.442-0.653), operative vaginal (AOR = 0.490; 95% CI: 0.285-0.842), and cesarean (AOR = 0.812; 95% CI: 0.666-0.988). A standardized oxytocin protocol was associated with a lower postpartum hemorrhage treatment rate for cesarean and vaginal deliveries, but not for operative vaginal deliveries. The prophylactic effect of our higher dose protocol had the strongest benefit with women delivering vaginally.

A Standardized Oxytocin Administration Protocol After Delivery to Reduce the Treatment of Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a leading cause of maternal death, and its rate and severity have been increasing. Oxytocin is widely recommended for PPH prophylaxis, but consensus is lacking on the dose or duration, leading to disparate and subjective practices. In this study, clinical outcomes were compared before and after introduction of a quality measure: a standardized oxytocin protocol for PPH prophylaxis. A retrospective cohort study was conducted of postpartum women ≥24 weeks' gestation delivered from 2010 to 2015. Women were grouped according to delivery pre-protocol (PREP) or post-protocol (POSTP) then subgrouped by specified criteria indicating low risk for PPH. The protocol was standardized for all POSTP women: 60 units of oxytocin over 5.25 hours postdelivery. The primary outcome was a composite: defined treatment for hemorrhage or uterine atony. Of 16,811 women included, 46.3% were PREP (n = 7,791), and 53.7% were POSTP (n = 9,020). A total of 2,315 subjects (13.8%) met low risk for PPH criteria. The primary outcome rate was lower after protocol introduction for all subjects (7.0% vs. 4.6%; p <0.001) and low-risk subset women (3.8% vs. 1.4%; p <0.001). Delivery after protocol introduction was associated with a decreased risk of the primary outcome among all subjects women (adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI] = 0.55-0.72) and low-risk subset women (AOR, 0.33; 95% CI = 0.19-0.57). Standardized, higher-dose postpartum oxytocin may be associated with less PPH treatment in this cohort. These findings support standardization and set the stage for a randomized controlled trial.

Improvement of Outcomes With a Standardized Postdelivery Oxytocin Protocol

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in the United States and the world. The administration of oxytocin for control of postpartum bleeding in women is recommended and generally used with most births. However, there is no standard dosing or delivery rate. In Arizona, common postpartum order sets prescribe oxytocin and titration for control of bleeding. Concentration of oxytocin varies by institution.

134: Are higher doses of oxytocin needed for obese women to achieve vaginal delivery?

Obesity is a risk factor for cesarean delivery, failed induction of labor and labor dystocia, and prolonged labor curves, especially among women with class III obesity. The objective of our study was to compare oxytocin doses among women achieving vaginal delivery based on BMI class. This is a retrospective cohort study of patients delivering at MedStar Washington Hospital Center and MedStar Georgetown University Hospital between August 1, 2010 and July 1, 2016. The cohort was stratified by delivery BMI class with the normal weight group as the reference. The primary outcome was the mean highest oxytocin rate (mU/min). Secondary outcomes included women receiving a maximum oxytocin rate >20 mU/min, highest oxytocin dose (mU), and mean duration of oxytocin exposure. Comparisons were made by route of delivery subgroups. Differences between the groups were compared using ANOVA, Chi-square and Fisher exact test as appropriate. There were a total of 10, 372 births included in the analysis. Our cohort was comprised of 33% of women who were classified as overweight (BMI 25-29.9) and 53% who were classified as obese (BMI >30.0), 12% of whom had a BMI >40. Among women undergoing an induction of labor, the mean duration of oxytocin augmentation to achieve vaginal delivery in the class III obesity group was 12.76 hours with a cumulative oxytocin dose of 12453.8 mU compared to the reference group that had 9.44 hours of oxytocin use and a cumulative oxytocin dose of 7625.9 (p <.0001). Women in the class III obesity group were significantly more likely to require a maximum oxytocin dose >20 mU/min to achieve a vaginal delivery (24.6% vs 10.4%, p<0.001). Obese women require higher doses of oxytocin to achieve a vaginal delivery. We propose that further research is needed to determine whether higher oxytocin protocols should be considered for obese women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Multipar gebelerde yüksek ve düşük doz oksitosin protokollerinin doğum eylem süreleri ve fetal-maternal komplikasyonlar açısından karşılaştırılması

Multipar gebelerde yüksek ve düşük doz oksitosin protokollerinin doğum eylem süreleri ve fetal-maternal komplikasyonlar açısından karşılaştırılması

Induction of labour practices in New South Wales hospitals: Before and after a statewide policy.

Midwifery Unit Managers completed surveys in 2008 and 2014 to determine methods of induction of labour. There was an increase in balloon catheter use for cervical ripening (rate difference 37%, P=0.007). Currently, all respondent hospitals have an oxytocin protocol; district hospitals had a significant increase in use of post-maturity protocols (rate difference=40%, P=0.01) but there was no change in use of prostaglandin protocols.