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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      Linked Article

      • Oxytocin: less opinion, more studies
        American Journal of Obstetrics & GynecologyVol. 201Issue 3
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          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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        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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