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A PROTOCOL-GUIDED “RULE OF THREES” ALGORITHM FOR LOW DOSE OXYTOCIN AND UTEROTONIC AGENTS DURING ELECTIVE CESAREAN DELIVERY
Abstract Number: T-8
Abstract Type: Original Research
INTRODUCTION: The current practice for establishing uterine tone following cesarean delivery utilizes excessive doses of oxytocin and an empiric approach to additional uterotonic agents (1). This non-evidence based approach leads to adverse events and complications. We hypothesized that an algorithm employing lower oxytocin doses, timed evaluations, and a protocol driven approach to uterotonic agent use could effectively control uterine tone and minimize side effects (1).
METHODS: Sixty non-laboring patients with no risk factors for uterine atony and scheduled for cesarean delivery were enrolled. In this randomized, double-blind trial, patients were allocated into a standard care versus protocol group. The “uterotonic” infusion contained either oxytocin 30 U in 500 mL (standard group) or 0.9% Saline in 500 mL (protocol group). The ‘uterotonic’ syringe contained either 0.9% saline in 3 mL (standard group) or oxytocin 3U in 3 mL (protocol group). Uterine tone scale (0-10 VAS) and adequacy (yes/no) were assessed every 3 min for total of 12 min by the blinded obstetrician. An “adequate” uterine tone for either group at any time point resulted in administration of oxytocin at 3 U/hr for total of 6 hours.
At delivery and if “inadequate” uterine tone at 3 and 6 min, the “uterotonic” infusion and “uterotonic” syringe were given. If “inadequate” uterine tone at 9 min and 12 min, IM methylergonovine, 0.2 mg and IM carboprost, 0.25 mg were given, respectively; requests prior to 9 and 12 min for these agents resulted in IM 0.9% saline 1 mL being given.
The primary outcome variable was oxytocin dose for the first 12 min; secondary outcomes included use of methylergonovine and carboprost, uterine tone, change in hematocrit, and side effects (e.g. nausea, headache, flushing, ECG changes and chest pain).
RESULTS: The standard care group received higher doses of oxytocin (8.3U vs. 4.0U, P=0.00001). Most patients achieved adequate uterine tone by 3 min with 16% in both groups requiring additional oxytocin at 6 min. No rescue uterotonic agents were needed at 9 min. There were no significant differences in the uterine tone, the incidence of side effects (P=0.7) or change in hematocrit (P=0.6).
SUMMARY: The current study presents a memorable, stepwise algorithm for uterotonic agent administration for elective, non-laboring cesarean delivery patients. Further studies are needed to elucidate this protocol’s benefits in laboring women undergoing cesarean delivery and patients with risk factors for uterine atony.
REFERENCES: 1.Tsen L et al. IJOA 2010;19:243-5.