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Oxytocin: new perspectives on an old drug

      Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes and was recently added by the Institute for Safe Medication Practices to a small list of medications “bearing a heightened risk of harm,” which may “require special safeguards to reduce the risk of error.” Current recommendations for the administration of this drug are vague with respect to indications, timing, dosage, and monitoring of maternal and fetal effects. A review of available clinical and pharmacologic data suggests that specific, evidence-based guidelines for the intrapartum administration of oxytocin may be derived from available data. If implemented, such practices may reduce the likelihood of patient harm. These suggested guidelines focus on limited elective administration of oxytocin, consideration of strategies that have been shown to decrease the need for indicated oxytocin use, reliance on low-dose oxytocin regimens, adherence to specific semiquantitative definitions of adequate and inadequate labor, and an acceptance that once adequate uterine activity has been achieved, more time rather than more oxytocin is generally preferable. The use of conservative, specific protocols for monitoring the effects of oxytocin on mother and fetus is likely not only to improve outcomes but also reduce conflict between members of the obstetric team. Implementation of these guidelines would seem appropriate in a culture increasingly focused on patient safety.

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      References

        • Freeman R.A.
        • Nageotte M.
        A protocol for the use of oxytocin.
        Am J Obstet Gynecol. 2007; 197: 445-446
        • Pritchard J.A.
        • MacDonald P.C.
        Williams obstetrics.
        in: 16th ed. Appleton-Century-Crofts, New York1980: 661
        • Clark S.L.
        • Belfort M.A.
        • Dildy G.A.
        Reducing obstetric litigation through alterations in practice patterns—experience with 189 closed claims.
        Am J Obstet Gynecol. 2006; 195: 118(S)
        • Strunk A.L.
        • Esser L.
        Overview of the 2003 survey of professional liability.
        (Vol 9, November-December) American College of Obstetricians and Gynecologists, Washington, DC2004
        • Institute for Safe Medical Practices
        High alert medications.
        (Accessed March 8, 2008)
        • Ventura S.J.
        • Martin J.A.
        • Curtin S.C.
        • Mathews T.J.
        Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention: report of final mortality statistics.
        Mon Vital Stat Rep 1197. 1995; 45: 1
        • Seitchek J.
        • Amico J.
        • Robinson A.G.
        • Castillo M.
        Oxytocin augmentation of dysfunctional labor, 4.
        Am J Obstet Gynecol. 1984; 150: 225
        • Caldeyro-Barcia R.
        • Poseiro J.J.
        Physiology of uterine contraction.
        Clin Obstet Gynecol. 1960; 3: 386-392
        • Satin A.J.
        • Leveno K.J.
        • Sherman M.L.
        • McIntire D.D.
        Factors affecting the dose response to oxytocin for labor stimulation.
        Am J Obstet Gynecol. 1992; 166: 1260-1264
        • Clark S.L.
        • Belfort M.A.
        • Saade G.A.
        • et al.
        Implementation of a conservative, checklist driven protocol for oxytocin administration: Maternal and newborn outcomes.
        Am J Obstet Gynecol. 2007; 197: e480.e1-e480.e5
        • Bakker P.C.
        • Kurver P.H.
        • Kuik D.J.
        • Van Geijn H.P.
        Elevated uterine activity increases the risk of fetal acidosis at birth.
        Am J Obstet Gynecol. 2007; 196: 313.e1-313.e6
        • Johnson V.
        • Van Oudgaarden E.
        • Montague I.
        • McNamara H.
        The effect of oxytocin-induced hyperstimulation on fetal oxygen.
        Br J Obstet Gynaecol. 1994; 101: 805-807
        • Simpson K.R.
        • James D.C.
        Effects of oxytocin-induced uterine hyperstimulation during labor on fetal oxygen status and fetal heart rate patterns.
        Am J Obstet Gynecol. 2008; 199: 34.e1-34.e5
        • Peebles D.M.
        • Spencer J.A.D.
        • Edwards A.D.
        • et al.
        Relation between frequency of uterine contractions and human fetal cerebral oxygen saturation studied during labour by near infrared spectroscopy.
        Br J Obstet Gynaecol. 1994; 101: 44-48
      1. American College of Obstetricians and Gynecologists practice bulletin #49. Dystocia and the augmentation of labor, December.
        American College of Obstetricians and Gynecologists, Washington, DC2003
        • Caldeyro-Barcia R.
        • Alvarez H.
        • Reynolds S.R.M.
        A better understanding of uterine contractility through simultaneous recording with an internal and seven-channel external method.
        Surg Obstet Gynecol. 1950; 91;: 641-646
        • Hauth J.C.
        • Hankins G.D.V.
        • Gilstrap L.C.
        • et al.
        Uterine contraction pressures with oxytocin induction/augmentation.
        Obstet Gynecol. 1986; 68: 305-309
        • Hauth J.C.
        • Hankins G.D.V.
        • Gilstrap L.C.
        • et al.
        Uterine contraction pressures achieved in parturients with active phase arrest.
        Obstet Gynecol. 1991; 78: 344-348
        • Daniel-Spiegel E.
        • Weiner Z.
        • Ben-Shlomo I.
        • Shalev E.
        For how long should oxytocin be continued during induction of labour?.
        BJOG. 2004; 111: 331-334
        • Rouse D.J.
        • Owen J.
        • Hauth J.C.
        Active phase labor arrest: Oxytocin augmentation for at least 4 hours.
        Obstet Gynecol. 1999; 93: 323-327
        • Zhang J.
        • Troendle J.F.
        • Yancey M.K.
        Reassessing the labor curve in nulliparous women.
        Am J Obstet Gynecol. 2002; 187: 824-828
        • Clark S.L.
        • Belfort M.A.
        • Dildy G.A.
        • et al.
        Maternal death in the 21 century: causes, prevention and relationship to cesarean delivery.
        Am J Obstet Gynecol. 2008; 199: 36.e1-36.e5
        • Ben-Harousch A.
        • Yogev Y.
        • Bar J.
        • et al.
        Indicated labor induction with vaginal prostaglandin E2 increase the risk of cesarean section even in multiparous women with no previous cesarean section.
        J Perinat Med. 2004; 32: 31-36
        • Kolderup L.
        • McLean L.
        • Grullon K.
        • et al.
        Misoprostol is more efficacious for labor induction than prostaglandin E2, but is it associated with more risk?.
        Am J Obstet Gynecol. 1999; 180: 1543-1550
        • Barger L.K.
        • Cade B.E.
        • Avas N.T.
        • et al.
        Extended work shifts and the risk of motor vehicle crashes among interns.
        N Engl J Med. 2005; 352: 125-134
        • Landrigan C.P.
        • Rothschild J.M.
        • Cronin J.W.
        • et al.
        Effect of reducing interns' work hours on serious medical errors in intensive care units.
        N Engl J Med. 2004; 351: 1838-1848
        • Block K.P.
        • Williams S.A.
        Normalize deviance at your peril: do not let longtime incident free operation justify a design or procedure that is not justifiable.
        Chemical Engineering. 2004 (May 1)
        • Schwartz J.
        For NASA, misjudgements led to latest shuttle woes.
        New York Times. 2005 (July 31)
        • Satin A.J.
        • Leveno K.J.
        • Sherman M.L.
        • et al.
        High- vs. low-dose oxytocin for labor stimulation.
        Obstet Gynecol. 1992; 80: 111
        • Simpson K.R.
        • Creehan P.A.
        AWHONN perinatal nursing.
        Lippincott Williams and Wilkins, Philadelphia2007
        • Simpson K.R.
        • James P.C.
        • Knox G.E.
        Nurse-physician communication during labor and birth: Implications for patient safety.
        J Obstet Gynecol Neonatal Nurs. 2006; 35: 547-550
        • Sadler L.C.
        • Davidson T.
        • McCowan L.M.
        A randomized controlled trial and meta-analysis of active management of labour.
        BJOG. 2000; 107: 909-915
        • Crane J.M.G.
        • Young D.C.
        Metanalysis of low dose versus high dose oxytocin for labour induction.
        J Obstet Gynaecol Can. 1998; 20: 1215-1223
        • Wennberg J.E.
        Unwarranted variations in healthcare delivery: implications for academic medical centers.
        BMJ. 2002; 325: 961-965
        • Clark S.L.
        • Belfort M.A.
        • Hankins G.D.V.
        • et al.
        Variation in the rate of operative delivery in the United States.
        Am J Obstet Gynecol. 2008; 196 (e1-5): 526
        • Kenton K.
        • Brincat C.
        • Mutone M.
        • Brubaker L.
        Repeat cesarean section and primary elective cesarean section: recently trained obstetrician-gynecologist practice patterns and opinions.
        Am J Obstet Gynecol. 2005; 192: 1872-1875
        • Meikle S.F.
        • Steiner C.A.
        • Zhang J.
        • Lawrence W.L.
        A national estimate of the elective primary cesarean delivery rate.
        Obstet Gynecol. 2005; 105: 751-756
        • Fraser W.D.
        • Turcot L.
        • Krauss I.
        • Grisson-Carrol G.
        Amniotomy for shortening spontaneous labour (Cochrane Review).
        Cochrane Database of Systemic Reviews. 2006 (Issue 3)
        • Smythe R.M.D.
        • Alldred S.K.
        • Markham C.
        Amniotomy for shortening spontaneous labour.
        Cochrane Database of Systemic Reviews. 2007 (Issue 4)
        • Garite T.J.
        • Weeks J.
        • Peters-Phair K.
        • Pattillo C.
        • Brewster W.R.
        A randomized controlled trial of the effect of increased intravenous hydration on the course of labor in nulliparous women.
        Am J Obstet Gynecol. 2000; 183: 1544-1548
        • Eslamian L.
        • Marsoosi V.
        • Pakneeyat Y.
        Increased intravenous fluid intake and the course of labor in nulliparous women.
        Int J Obstet Gynecol. 2006; 93: 102-105
        • Shrivasta V.
        • Garite T.
        • Jenkins S.
        • et al.
        A randomized controlled trial comparing normal saline with and without glucose on the course of labor in nulliparas.
        Am J Obstet Gynecol. 2008; 197: S18
        • Gagnon A.J.
        • Waghorn K.
        • Covell C.
        A randomized trial of one to one nurse support of women in labor.
        Birth. 1997; 24: 71-77
        • Hodnett E.D.
        • Gates S.
        • Hofmeyr G.J.
        • Sakala C.
        Continuous support for women during childbirth.
        Cochrane Database of Systemic Reviews. 2003 (Issue 3)
        • Friedman E.A.
        • Sachtleben M.R.
        Dysfunctional labor.
        Obstet Gynecol. 1965; 25: 844-847

      Linked Article

      • Oxytocin: less opinion, more studies
        American Journal of Obstetrics & GynecologyVol. 201Issue 3
        • Preview
          It is reasonable to predict that nothing will replace oxytocin. Liability concerns will prohibit any pharmaceutical company to market a new uterine inotrope. Therefore, oxytocin must be understood as well as possible. Opinions and bias continue to have an undue influence guiding our use of oxytocin. The opinion article by Clark et al1 unfortunately gives us more of the same. They cite Seitchik et al2 as evidence that steady states of oxytocin are reached after only 40 minutes. This 1984 study had only 11 subjects and a wide range of plasma clearance (11.2-32.5 mL/kg per minute).
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      • Reply
        American Journal of Obstetrics & GynecologyVol. 201Issue 3
        • Preview
          The tendency to ignore an overwhelming amount of good evidence while awaiting the mythical perfect study has contributed greatly to the clinical anarchy and poor outcomes sometimes seen in contemporary obstetric practice. The data of Seitchik et al,1 although not perfect, remain the best data available regarding pharmacokinetics of oxytocin. Hence, the practice of evidence-based medicine requires that it be incorporated into practice until and unless better data become available. Furthermore, a single trial showing that one can usually get away with using a high-dose oxytocin regimen does not compare with 2 metanalyses of such trials, referenced in our article, demonstrating not only a lack of clinical benefit but also an increased risk of harm with high-dose regimens.
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