Standardizing Postpartum Oxytocin Administration

by, Jennifer Doyle, MSN, WHNP-BC
Director, AWHONN Executive Board
APN, Women’s Service Line
Summa Health
Akron City Hospital
Akron, OH

Photo: Jennifer Doyle assessing and caring for fellow colleague Amy Burkett, MD, FACOG.

Somewhere in a Labor and Delivery unit, a woman gives birth.  A family is born. A nurse remains at the bedside.  A sentinel, who assesses, plans, and intervenes.  The nurse is equipped with knowledge and skills to holistically care for mom and baby.  The nurse’s primary focus is to promote bonding and breastfeeding. However, despite a safe birth, risk remains.  Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality.  It is often preventable.

As a labor and delivery staff nurse, there were countless occasions when I held vigil at the side of my patients after they gave birth.  I was prepared with an array of resources to treat PPH. In part, this included uterine massage, oxytocin, methylergometrine, carboprost, and misoprostol.   As a nurse caring for a woman in the immediate postpartum period, my goal was to assess maternal bleeding and avoid PPH, or treat early if it occurred.  I would often stand at the bedside, pondering how much oxytocin I should administer to this new mother, and for how long.

For years, I have wondered about postpartum oxytocin administration.  How much is too much?  Are we as nurses administering enough?  What is the optimal dosage to prevent PPH without causing negative side effects?

I know that I am not alone in my contemplations.

There continues to be a dichotomy between postpartum oxytocin administration and healthcare’s current climate of standardization of practice, checklists, and evidence-based practice.  Typically, diluted oxytocin is administered intravenously during the postpartum period based on what is left ‘in the bag’ after birth.  Example, if there is 200 ml ‘in the bag’, the woman receives 200 ml.  If there is 900 ml ‘in the bag’, the woman may receive 400, 700, or 900 ml.  Additional oxytocin administration may occur if increased vaginal bleeding is noted after delivery, but amount and duration of administration is almost always variable.

Currently, no standardization exists with respect to dosage or duration of oxytocin postpartum1.  Further, very little evidence exists to validate optimal dosage and duration for the prevention of postpartum hemorrhage2A team at my institution has embarked on a project to address this clinical quandary. 

In 2011, our multidisciplinary team developed a standardized postpartum oxytocin administration protocol to prevent postpartum hemorrhage (PPH).  Our protocol was based on the limited evidence available at that time.  A multidisciplinary team reviewed several trials’ data in which 10 units to 80 or more units of oxytocin were given postpartum for a duration of <1 to 12 hours3-7.   Our protocol is a “middle of the road’’ approach in which a total of oxytocin 60 U is administered intravenously post-delivery via infusion pump.  Our protocol is as follows:  a bolus of oxytocin 15 U in 250 mL of lactated Ringers solution (LR) at delivery followed by an additional oxytocin 15 U in 250 mL LR over the next hour, then oxytocin 30 U in 500 mL LR at a rate of 125 mL/hr for the following 4 hours. Thus, the total time for oxytocin administration post-delivery is 5 hours.

We have since performed a retrospective quality improvement assessment comparing PPH rates at 6-months pre-protocol (n = 1267) with rates at 6-months post-protocol (n = 1440) implementation. PPH was defined as PPH treatment by pharmaceutical, mechanical, or surgical methods. Inclusion criteria included all births at greater than 23 weeks’ gestation from April 2012 to March 2013. Patient characteristics for both cohorts were similar for race, age, parity, gestational age, delivery type, and neonatal weight.

The PPH rate decreased 37% after protocol implementation (adjusted relative risk [ARR], 0.63; 95% confidence interval [CI], 0.46–0.91). Administration of misoprostol, carboprost, methylergonovine maleate, and blood products decreased post-protocol implementation by 36%, 38%, 32%, and 22%, respectively. The PPH rate for women with a vaginal delivery decreased significantly after protocol implementation (5.9% pre-protocol vs 3.8% post-protocol; P = .03). The PPH rate for women undergoing cesarean delivery increased, but not significantly, after protocol implementation (6.9% pre-protocol vs 8.6% post-protocol; P = .34).  We did not control for some PPH risk factors, including abnormal insertion of placenta, preeclampsia, and multiple gestation. Despite this limitation, our PPH rate for women undergoing cesarean delivery is lower than other published rates.8,9

These findings were a preliminary step.  Based on our 6 month pre/post outcomes, our team was very enthusiastic about performing a larger analysis to see if we would confirm these initial findings.   However, a lack of funding prevented data retrieval and analysis.  Our health system’s management supported the expansion of the project, if we could obtain funding. AWHONN seemed the perfect fit for our project’s aims.  AWHONN’s  PPH Project is a national model for PPH quality improvement. Our team responded to AWHONN’s  call for grant applications and  were extremely honored when we were notified that our  project:  Evaluation of a Standardized Protocol for Oxytocin Administration to Prevent Postpartum Hemorrhage, was selected as the 2015 Hill-Rom, Celeste Phillips Family-Centered Maternity Care Award Recipient!

This $10,000 award provides the funding necessary to complete a full 2 year pre/post review, which is now underway!

We believe that the results of our full 4 year review will be of great  interest and value to nurses practicing at the bedside.  We believe our project and subsequent results will have widespread implications for any multidisciplinary team caring for women in the postpartum period.  Personally, I hope that the protocol study and results will help my fellow nurses who find themselves at the bedside, just as I have, wondering about the dose and duration of oxytocin to prevent PPH.  Preventing maternal morbidity and mortality through reduction of PPH is a timely topic of extreme importance.

We are thankful to AWHONN, AWHONN’s Research Advisory Panel, and Hill Rom for the award.  We hope that our findings lead to better outcomes and increased safety for the women and families that we serve.

Doyle_JenniJennifer Doyle, MSN, WHNP-BC
Jennifer Doyle, a member of AWHONN’s Board of Directors and is also the perinatal outreach educator/APN for the Women’s Service line at Summa Health System’s Akron City Hospital in Ohio. Jennifer leads multiple research and quality improvement projects within her facility and across the state of Ohio. Many of her projects focus on intrapartum safety.

 

References

1.Harvey, C. and Dildy, G. Obstetric Hemorrhage.  Practice Monograph.  Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).  2012.

  1. AWHONN. Practice Brief: Clinical Management for Women’s Health and Perinatal Nurses: Oxytocin administration for management of third stage of labor. May, 2014. (2).
  2. Tita AT, Szychowski JM, Rouse DJ, et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012;119(2 pt 1):293–300.
  3. Munn MB, Owen J, Vincent R, Wakefield M, Chestnut DH, Hauth JC. Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2001;98(3):386–390.
  4. Murphy DJ, MacGregor H, Munishankar B, McLeod G. A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section: pilot study. ISRCTN 40302163. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):30–33.
  5. King KJ, Douglas MJ, Waldmar U, Wong A, King RAR. Five-unit bolus oxytocin at cesarean delivery in women at risk of atony: a randomized, double-blind, controlled trial. Anesth Analg. 2010;111(6):1460–1466.
  6. Gungorduk K, Asicioglu O, Celikkol O, Olgac Y, Ark C. Use of additional oxytocin to reduce blood loss at elective caesarean section: a randomized control trial. Aust N Z J Obstet Gynaecol. 2010;50(1):36–39.
  7. Dagraca J, Malladi V, Nunes K, Scavone B. Outcomes after institution of a new oxytocin infusion protocol during the third stage of labor and immediate postpartum period. Int J Obstet Anesth. 2013;22(3):194–199.
  8. Sheehan SR, Montgomery AA, Carey M, et al. Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial. BMJ. 2011;343:d4661. doi:10.1136/bmj.d4661.

13 thoughts on “Standardizing Postpartum Oxytocin Administration

  1. Phyllis says:

    I am wondering if this study will include how much pitocin women received during induction. Most importantly how long was the induction….ie, one hour or 3 days. I am very interested in this research.

  2. Lisa A. Miller, CNM, JD says:

    Great work and perhaps more importantly, great reporting of objective findings and plans for ongoing analysis. These are the projects that make a difference in all of our lives, and this type of scientific, multidisciplinary collaboration is what makes AWHONN so important to the health of women and children in the US and abroad. Kudos to you and your team, Jennifer, and I look forward to learning more once your 4-year review is completed!
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  3. Beamishgirl says:

    As a labor nurse, I agree that minimizing PPH risk is important and I like the idea of standardization based on evidence. But the question that keeps coming up for me is: how does this affect bonding? We know that artificial oxytocin does not cross the blood-brain barrier , causing moms to feel warm and fuzzy, as does their natural oxytocin. We also know that it inhibits the mother’s oxytocin production.
    I’m curious is more research comes out around cord pulsation, and leaving the dyad uninterrupted and connected for longer, if there will be any research around PPH in low risk situations. We know the baby emits pheramones from the top of their head that help mother’s placenta release and the uterus clamp down. I wonder if our management has affected the rates of PPH over the years.
    Conversely, I’m all for having the standardized protocols in place for treating at risk mothers.

  4. MOM says:

    Very interesting and exceptional project. Definitely makes sense since there is such variation in Pitocin use post delivery. THanks for this valuable information, keep up the good work!

  5. Alex Andreitchouk, MD, FACOG says:

    Decrease on PPH is directly related to dose/longevity of oxytocin infusion. There is no “magic”dose or hours. Many experts reccommeded longer infusion of oxytocin and results are better. Your protocol is just another variation in prophylactic administration of oxytocin. Personally I prefer lower dose and longer up to 12 hours infusion in higher risk patient. Combination of meds also could be very interesting and cost effective. Agree, studies are important in this area.

  6. Patti van Dalen says:

    Would be very interested in your study & results! I work ion OB and shred your information w/some co-workers. Be very interested in protocol & amounts pit used. Thank you!!

  7. Tina Hobbs says:

    I am in the process of PPH simulation and have recently written a clinical pathway for PPH, as well as an updated policy for management of PPH. I am extremely interested in this topic and am excited that someone is digging deeper into standardization of Pitocin in the 4th stage of labor. I have spoken to a few nurses on our unit about their clinical practice for Pitocin administration after delivery, and have had variable results, also. I think it is noteworthy that you have seen a decrease in PPH during the time of implementation of this change in your department. Thank you!

  8. li2211 says:

    PPH is one of those “worse case scenarios” for a nurse. Working directly with postpartum patients and unfortunately having experienced more postpartum hemorrhages than I’d like to count, I would like to see a thorough and specific universal protocol for these patients. I’d like to learn more about correlations between lengths of induction, length of labor and postpartum hemorrhaging. Also,for a patient who receives Pitocin after delivery, how is bonding with the newborn affected and is there anything we can do differently as nurses? (Now that we know that their own oxytocin- the one that helps with bonding, is trumped by the synthetic stuff). For the patients who hemorrhage after delivery, how does that extra bag of Pitocin affect bonding with their newborn, and in turn, does this decrease the likelihood of breastfeeding not only successfully, but exclusively? A standard protocol for Pitocin administration is very important to have and know. The more research about standard pitocin infusion there is, the better the service we can provide to our patients will be in order to enhance their postpartum experience and allow mom and newborn to be the protagonists, not a postpartum hemorrhage.

  9. Steven Roth says:

    I am an OBGYN and had a private practice in the US for nearly 20 years. In the past 10 years I have worked in exclusively in New Zealand and Australia. When I first started in New Zealand I immediately noted that the PPH rate was astronomical compared to my US experience. I pointed this out to a midwife that asked if the 3rd stage was managed actively or physiologically. I didn’t know there was more than one way. Clearly physiologic management is associated with significantly more blood loss and yet the midwives here fight tooth and nail to continue this practice. Not only this issue, but it is routine that anesthesia gives undiluted boluses of oxytocin IV after delivery during c-section. Thank you for showing this significant reduction in PPH at your institution. It helps me battle to get rid of physiologic management and IV boluses. Maternal hemorrhage continues to be the number one cause of maternal death worldwide.

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