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 hemorrhage².  A 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 hours^3-7.   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.

Jennifer 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.

2. AWHONN. Practice Brief: Clinical Management for Women’s Health and Perinatal Nurses: Oxytocin administration for management of third stage of labor. May, 2014. (2).
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.