Oxytocin Protocols

Essential Elements You Need to Include

Objectives

• Value of a Protocol• Potential Problems• ACOG Guidelines• Pharmacologic considerations• Power, Passenger, Passage• Physiology of Labor• Pulling it together

Value of Protocols

• In virtually every field of human endeavor studied, uniform processes lead to improved outcomes

• When several equally appropriate approaches exist in a given situation, a health care team that simply picks one good approach and implements it in the same way, time after time, will have better outcomes than a group of providers that approaches a given problem in a different way every time.

Value of Protocols

• Ambiguous guidelines leave much to interpretation; while potential justification for many types of practice may be inferred from such ambiguity, this lack of clarity also opens the door to endless debate as well as honest differences of opinion and testimony about how the guidelines should have been interpreted or applied in a specific situation.

Value of Protocols

• In addition to our primary goal of improving patient outcomes, such protocols, provided they are followed, offer a good deal of protection from litigation.

Potential Problems

• Oxytocin remains the drug most commonly associated with preventable adverse events during childbirth.

• Oxytocin is also frequently implicated in professional liability claims and thus poses a dual concern for individual clinicians and the organizations in which they practice.

Potential Problems

• Recently, oxytocin was added to the list of high-alert medications designated by the Institute for Safe Medication Practices (ISMP), a distinction reserved to only 11 other specific drugs. Such drugs are defined as those “bearing a heightened risk of harm when they are used in error” and that may “require special safeguards to reduce the risk of error.”

Institute for Safe Medical Practices. High alert medications. (www. Ismp.org)

What Does ACOG Say?

Not Much

ACOG

• Basic considerations for Induction– Maternal and fetal conditions– Gestational age– Cervical status

Maternal and Fetal Considerations• Abruptio placenta• Chorioamnionitis• Fetal demise• Gestational hypertension• Preeclampsia, eclampsia• PROM• Post term pregnancy• Maternal medical conditions• Fetal compromise

Contraindications

• Vasa previa• Transverse fetal lie• Umbilical cord prolapse• Previous classical delivery• Active genital herpes• Previous myomectomy entering the

endometrial cavity

Logistic Indications

• Risk of rapid labor• Distance from hospital• Psychosocial indications• In the above circumstances, at least one

gestational age criteria must be met

Gestational Age

Cervical Status

• In the absence of a favorable cervix, the patient should be thoroughly counseled regarding – the indications for induction – the agents/methods of labor stimulation– Possible need for repeat induction and/or

cesarean section– In the nulliparous patient, an unfavorable cervix

should give pause if elective induction is being considered.

ACOG

• Any of the low or high dose regimens outlined are appropriate for labor induction.

• Each hospital’s obstetrics and gynecology department should develop guidelines for the preparation and administration of oxytocin.

ACOG

• A numeric value for the maximum dose of oxytocin has not been established.

• The FHR and uterine contractions should be monitored closely.

• Oxytocin should be administered by trained personnel

ACOG

• If something bad happens, try something different

Pharmacologic Considerations

• Onset of action of a given dose of oxytocin is relatively slow with a half life of 3-10 minutes and steady state levels at 40 minutes

• The therapeutic index is highly unpredictable. For any given dose of oxytocin, the effects may range from no effect to hypertonic contractions

• With rare exception, detrimental effects are exclusively generated by dose related effects on uterine activity.

Some thoughts…….

• Increasing the dosing of oxytocin at an interval significantly faster than steady state (40 minutes) is essentially a blind procedure in which additional drug is given before the full effects of the previous dose can be know.

• Because of the wide therapeutic index– The drug should be started at a relatively low dose– Dosing that involves locked-in increases without

regard to uterine response are inappropriate

Some thoughts….

Physiology

Physiology

Adequacy of Labor

• All management schemes based on contraction patterns draw conclusions drawn from inexact data.

• Two definitions of acceptable uterine contractions:– Achievement of 200-220 MVU’s– 1 contraction every 2-3 minutes, lasting 80-90

seconds and palpating strong by an experienced labor nurse

Adequacy of Labor

Unfortunate Realities

• No other area of medicine so readily administers a potentially dangerous drug to accomplish a physiologic process that left alone would complete itself without the risk of drug administration.

• From a patient safety perspective, convenience as a driver of labor augmentation is counterintuitive.

Administration Variations

Administration Variations

Administration Variations

Protocols

Reduction of elective inductions.pdfImplementation of a conservative checklist.pdf

Conclusions

• There will be initial resistance!• A protocol is only as good as its

implementation.• Hard stops must be in place so that variation

from the protocol requires documentation as to the reason prior to proceeding.

• Should include evaluation of the passage, passenger and powers.

• Less is more in the administration of oxytocin.