Oxytocin protocol

TITLE:

Oxytocin protocol

PURPOSE

To provide a standardized procedure for the use of Oxytocin in Induction or augmentation of labor when indicated.

CONDITION/APPLICABILITY:

This policy is applied for all patient required induction and augmentation by oxytocin

DEFINITIONS:

Oxytocin: is a hormone, neuropeptide and medication used to cause contraction of the uterus in order to start labor or increase speed of labor, and to stop bleeding following delivery.

POLICY:

This policy is used to initiate induction and augmentation by oxytocin for all the patient indicated taking in consideration the dos and frequency of titration of oxytocin according to the patient situation

PROCEDURE:
1. Induction or augmentation will be undertaken when indicated. Physician order must be documented (Refer to Transcription Physician’s Order Policy).
2. Full medical consideration will be given to maternal and fetal health.
3. The decision to use oxytocin in grand multigravida patients must be made by consultant and registrar obstetrician.
4. Oxytocin should be started if the membranes have been ruptured unless otherwise ordered by senior obstetrician.
5. Abdominal palpation and pelvic examination should be performed, as well as cardiotocograph fetal monitoring prior commencing oxytocin.
6. Baseline fetal heart rate and uterine activity level will be recorded for 30 minutes prior initiation of the oxytocin infusion.
7. Oxytocin should be administered for augmentation only in the labor room under continuous bedside attendance.
8. Insert a large bore IV cannula, if not already in situ. Commence mainline intravenous fluids, as ordered (D5NS or RL) oxytocin should be delivered through a secondary IV connected as close to the primary venipuncture site as possible via 3-way stopcock.
9. Add IV tube sticker to oxytocin line, total IV fluid from both lines should not exceed 125cc/hr.
10. Oxytocin regimen
  1. Regimen A: Oxytocin for primigravida

Add 10 units oxytocin to 500ml (LR/saline). Start by 2 M International unit/min “6ml/hrs. “increase by 2 M International unit/min 6ml/hrs.” every 20 minutes till 3 to 4 regular contraction in 10 min “follow the table for doses for primigravida” the maximum dose should not exceed 40mU/min for Primigravida.

Regime B: Multigravida/previous caesarian section scar.

Add 10 units oxytocin to 500ml (LR/saline). Start by 1 M International unit/min “3ml/hrs” increase by 1 M International unit/min “3ml/hrs “every 30 minutes till 3 to 4 regular contraction in 10 min “follow the table for doses for multigravida patients. The maximum dose should not exceed 32mU/min for multigravida and patient with previous scar 32mU/min.

The concentration can be adjusted in the cases need restricted amount of IV fluid administration under the condition of keeping the dose Start by 2 M International unit/min and increase by 2 M International unit/min every 20 minutes till 3 to 4 regular contraction in 10 min in primigravida and Start by 1 M International unit/min increase by 1 M International unit/min every 30 minutes till 3 to 4 regular contraction in 10 min in multigravida and previous caesarean section
Continuous electronic monitoring of fetal heart rate and uterine activity is required while the patient is receiving oxytocin infusion.
Commence portogram and record baselines vital signs, urinalysis, vaginal examination findings and contraction pattern (Use of Partogram in Labor Policy).
In case of augmentation following Prostin induction, six hours must elapse from the last dose, prior commencing a oxytocin infusion (Refer LAD-030 (Rev-2)Policy).
Oxytocin may be initiated, if necessary, anytime beyond 30 minutes after removal of the insert PROPESS refer to LAD-030 (Rev-2) policy

The maximum dose of syntocinon can be exceeded only by a consultant order.
Strength of contraction is. (Mild 0-20 seconds, moderate 20-40 seconds, Strong 40-60 seconds).
Midwife “or nurse” caring for the patient on oxytocin infusion must contact the Registrar to review the patient if:
1. Patient has > 5 contractions in 10 minutes.

5.16.2. The duration of the contraction felt on palpation ≥ 60 seconds.

5.16.3. No resting phase between contractions.

5.16.4. If abnormal Cardiotocograph tracing seen.

Uterine Activity Assessment
1. Palpation and external electronic methods can be used to monitor uterine activity. Palpation yields information about frequency (number in10 minutes), duration (in seconds) and relative intensity.
2. External monitoring provides a recording of frequency and relative intensity. The sensitivity adjustment of the CTG is adjusted to a resting pressure of 10-20 mmHg.
3. The recording gives a relative reading and cannot be used to define actual strength of the contractions. Maternal weight, maternal position during recording of the pattern, maternal and fetal movement, and tightness of the belt may all alter the reading.
Absolute Contraindications;
1. Transverse lie
2. Absolute Cephalopelvic Disproportion
3. Active Genital Herpes
4. Previous Classical Caesarian Section or Metroplasty.
5. More than one previous Low Segment Cesarean Section
6. Invasive cancer of the cervix.
7. Placenta Previa.
Caution should be exercise in the following situations.

5.19.1 Presence of Low Segment Cesarean Section scar.

5.19.2 Grand Mutiparity (more than 5).

5.19.3 Unfavorable Cervix (Bishop’s score less than 5).

5.19.4 Multiple Pregnancy.

5.19.5 Breech Presentation

5.19.6 Polyhydramnios

5.19.7 prostaglandin induction within the preceding six hours.

5.19.8 Suspected Macrosomia.

5.20 Complications;

5.20.1 Water Intoxication

5.20.2 Pulmonary Edema

5.20.3 Hyper stimulation

5.20.4 Uterine Rupture

5.20.5 Fetal Distress.

5.21 Management of the Complications

5.21.1. When there is noted fetal distress, the nurse/midwife must:

5.21.1.1. Discontinue oxytocin infusion immediately and increase rate of main line.

5.21.1.2. Administer oxygen via face mask at 8-12 L/min.

5.21.1.3. Notify resident on duty.

5.21.1.4. Reposition patient; lateral position avoid supine.

5.21.1.5. Prepare for vaginal examination and application of fetal scalp electrode, if the tracing is not clear women obese or moving too much).

5.21.1.6. Re-start oxytocin infusion, as per registrar order.

5.21.2 Tachysystole

5.21.2.1 Decrease or discontinue oxytocin.

5.21.2.2 Position the woman in left side.

5.21.2.3 Increase intravenous fluids.

5.21.2.4 Review by resident.

5.21.2.5 Oxygen at 6 liters for duration of fetal compromise.

5.21.2.6 Palpate the uterus to determine uterine response to management (Serum half-life of Oxytocin is2-3 minutes, thus

5.21.2.7 Stopping the infusion will diminish uterine activity, rapidly.)

If hyperstimulation (>5 contractions in 10mins with CTG abnormality) – give Injection Terbutaline 0.25mg subcutaneously.

5.21.2.8 In patients with previous uterine scar, observe for scar tenderness and fresh per vagina loss, every30 minutes. Notify registrar stat if occurred (May be indicative of uterine rupture). Record input and output on Fluid Balance Chart.

REFERENCE:
1. NICE Intrapartum Care, Care of Healthy Women and their babies during Childbirth September 2007.
2. Up to date 2023

7.0. RESPONSIBILITY:

All the physician and nurses in labor and delivery room

FORMS/ EQUIPMENTS:

Oxytocin dose and titration table

10 unit oxytocin in 500 ml 1 mile international Unit =3 ml micro drop/min (3 ml/hrs

If you don’t have micro infusion pump you can use macro infusion

5 unit oxytocin in 1000 ml 1 m IU international unit 1 miu /3 macro drop for primigravida start by 6 macro drop and increase by 6 macro drop for multigravida start by 3 macro drop and increase by 3 macro drop till 3 regular contraction in 10 min

APPROVALS:

REVISION: