Pitocin in late stage labor for reduction of obstetrical hemorrhage

Pitocin in late stage labor for reduction of obstetrical hemorrhage | Image Credit: ©Gorodenkoff - ©Gorodenkoff - stock.adobe.com

While the World Health Organization suggests that all women receive prophylactic oxytocin to reduce hemorrhage risk during the third stage of labor, there is a lack of consensus on the rate of oxytocin administration, according to authors of a poster highlighted at the 2023 Society of OB/GYN Hospitalists Annual Clinical Meeting in Chicago, Illinois.¹

The authors note that high rates of oxytocin are linked to maternal hypertension, tachycardia, and various adverse hemodynamic changes. They suggest that implementing a standardized oxytocin infusion protocol may increase patient safety while reducing maternal adverse effects that are associated with rapid, high rates of infusion of oxytocin, while simultaneously reducing the rate of postpartum hemorrhage.

In the study, investigators utilized a pitocin protocol consisting of the following:

• “Prior to delivery of the placenta, IV oxytocin at a rate of 300ml/hour (18 units/hour).
• If inadequate uterine tone is present after 3 minutes, increase IV oxytocin rate to 600ml/hour (36 units/hour).
• If continued inadequate uterine tone after increasing IV oxytocin rate, administer second line uterotonic (methylergonovine or carboprost) and tranexamic acid 1 gram IV over 10 minutes.”

Study investigators collected data through retrospective chart review at a single site center managed by a combined ob-gyn residency and hospitalist program. The above pitocin protocol was implemented through educating providers and use of a standardized EMR order set with “parameters for intravenous oxytocin administration. 30 units of oxytocin in 500 ml of normal saline was administered at a rate of 300 mUhr (18 units/hour) prior to placental delivery,” wrote the authors.

Data was collected and analyzed prior to pitocin protocol implementation from September 2019 to February 2020 (n = 493 patients) and post-implementation from September 2022 to February 2023 (n = 807 patients). The study’s primary endpoint was the overall rate of obstetrical hemorrhage, which the American College of Obstetricians and Gynecologists (ACOG) defines as more than 500 ml of blood loss with a vaginal delivery and more than 1000ml of blood loss with a cesarean delivery.² The authors categorized this data in the study by CMQCC stages of hemorrhage 1, 2, and 3.

Results of the study demonstrated a 28.8% decrease in obstetrical hemorrhage following the implementation of the standardized pitocin protocol. Moreover, data from before the protocol implementation revealed 3.65 out of 100 deliveries experienced obstetrical hemorrhage, while 2.6 out of 100 deliveries post-protocol implementation experienced obstetrical hemorrhage.

Further data indicated a decrease in hemorrhage rate in stage 1 hemorrhages (blood loss of 500 ml-1,000 ml) after vaginal delivery), with a decreased rate from 1.6 per 100 deliveries to 0.6 per 100 deliveries.

The authors concluded, “Using a standardized IV pitocin protocol decreased the overall rate of obstetrical hemorrhage in this patient population. Additional factors that may have contributed to the post-intervention decrease in obstetrical hemorrhage rate include earlier recognition of uterine atony and earlier utilization of tranexamic acid in the management of obstetrical hemorrhage.”

Reference:

1. Levy A, Bressman P. Utilization on of a standard Pitocin protocol for the active management of the third stage of labor to reduce the rate of obstetrical hemorrhage. 2023 Society of OB/GYN Hospitalists Annual Clinical Meeting. September 9-13. Chicago, Illinois.
2. Postpartum hemorrhage. Practice Bulletin No. 183. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e168-86.