From the Editor
21st Century norms for assessing the progress of labor
We are in a new era. Our patients, and their labors, have changed on a global scale. To optimally manage labor you need to use these new norms in...
4- TO 8-HOUR OXYTOCIN RULE
A key gap in our cesarean delivery protocols is a standardized recommendation concerning the duration of the oxytocin infusion following cesarean delivery. To my knowledge, no national organization has made a firm recommendation concerning the duration of oxytocin infusion following cesarean delivery.
One recent clinical trial studied PPH following cesarean delivery utilizing two oxytocin regimens: a bolus of oxytocin following delivery of the baby versus a bolus of oxytocin followed by a 4-hour IV infusion of oxytocin.12 In this trial, 2,058 women undergoing a scheduled cesarean delivery with a singleton pregnancy were randomly assigned to an oxytocin bolus alone, oxytocin 5 U administered intravenously over 1 minute, or an oxytocin bolus plus a 4-hour oxytocin infusion at a rate of 10 U/hr. The 4-hour postoperative oxytocin infusion was formulated by adding 40 U of oxytocin to 500 mL saline and infusing the solution at 125 mL/hr, equivalent to 0.167 U of oxytocin per minute. In this trial, 65% of the women were undergoing a repeat cesarean delivery and 35% were undergoing a primary cesarean delivery.
The authors reported that women who received the oxytocin bolus alone were significantly more likely to be diagnosed with uterine atony requiring additional uterotonic treatment than women who received both the bolus and the 4-hour postoperative infusion (18.4% versus 12.2%, respectively; P <.001). There was no difference in the rate of PPH between the two groups.
The rate of PPH was 16% in women receiving an oxytocin bolus alone and 15.7% in women receiving both an oxytocin bolus and the continuous oxytocin infusion. However, among less experienced surgeons, the rate of PPH was significantly greater in the group that received the oxytocin bolus alone compared with the women receiving the bolus and continuous infusion (22.2% versus 17.3%, respectively). The authors concluded that obstetricians should consider using a 4-hour infusion of oxytocin following cesarean delivery to reduce the risk of uterine atony.
In a recent evidence-based review of optimal interventions in cesarean delivery, the authors recommended an IV infusion of 10 to 40 U of oxytocin administered over 4 to 8 hours after cesarean delivery.7 Following cesarean, an IV infusion of crystalloid solution is typically maintained for at least 4 to 8 hours. Consequently, adding oxytocin (which costs approximately $1 for 10 units) to the crystalloid infusion does not add substantially to the cost of the patient’s postoperative care and may reduce the risk of uterine atony and PPH.
Related article: Act fast when confronted by a coagulopathy postpartum Robert L. Barbieri, MD (Editorial, March 2012)
My bottom-line recommendation. In the United States, we should adopt a policy of maintaining a continuous infusion of oxytocin for 4 to 8 hours following a cesarean delivery. Following a 4- to 8-hour rule will decrease the rate of uterine atony and excessive bleeding, thereby improving the safety of our cesarean delivery surgery.
INSTANT POLL
How many hours following cesarean delivery do you think that an oxytocin infusion should be maintained to reduce the risk of uterine atony and postpartum hemorrhage?
If the patient is a Jehovah’s Witness and refuses the transfusion of all blood products, how many hours following cesarean delivery do you think that an oxytocin infusion should be maintained to reduce the risk of uterine atony and postpartum hemorrhage?
Tell us—at rbarbieri@frontlinemedcom.com Please include your name and city and state.