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Pattern of Uterotonic usage in Canada: A National Survey of the Academic Hospitals
Abstract Number: SAT-15
Abstract Type: Original Research
The pattern of uterotonic usage for the management of postpartum hemorrhage (PPH) in Canada is unknown. A recent retrospective study in the USA suggests that the pattern of 2nd line uterotonic usage is highly variable . Oxytocin is the primary uterotonic agent used in the prevention of PPH [1,2]; however, Canadian uterotonic usage (as compared to the USA) is more complex due to the availability of carbetocin as an alternative to oxytocin. Canada is the only country to recommend carbetocin in the management of third stage of labor as part of obstetric practice guidelines . The objective of this study was to determine the pattern of uterotonic usage in academic hospitals in Canada.
This study was conducted as a survey targeting chiefs or directors of Obstetrics and Gynecology, and Obstetric Anesthesia at university-affiliated hospitals across Canada. The survey was sent out electronically by the program ‘SurveyMonkey’ during the period November 2016 to January 2017. Two reminder emails were sent. We collected the following data: number of deliveries per year; epidural/cesarean delivery (CD) rate; institutional PPH rate; 1st and 2nd line uterotonic agents in vaginal and CDs; rationale behind choices of 1st and 2nd line uterotonic agents.
The survey was sent to 109 clinicians of which 34 (31.2%) responded (21 Anesthesiologists, 13 Obstetricians). About 50% responders reported a delivery rate of 2500-5000/year and an epidural rate of 51-75% in their institutions. 77% responders reported their institutional CD rate of 21-30%. About 65% responders were unaware of the rate of PPH in their institution. The first line agent for vaginal deliveries was reported as oxytocin by 91% and carbetocin by 9% responders. For women at low risk for PPH undergoing CDs, 66% reported oxytocin while 34% reported carbetocin as the first line uterotonic. For CDs at high-risk for PPH, 60% reported oxytocin and 40% reported carbetocin as the first line agents. The use of 2nd line uterotonics was also variable amongst institutions with the use of additional oxytocin, carboprost, misoprostol and ergometrine reported by 48%, 28%, 17% and 7% responders, respectively. The majority of responders stated that choice of 1st and 2nd line uterotonic usage was based on efficacy.
Our study reinforces the lack of a unified approach to the use of oxytocin, carbetocin and 2nd line uterotonics for prevention of PPH, and echoes the findings of a previous study from the USA . The choice of 1st and 2nd line uterotonic agent was mainly based on presumed efficacies of the selected drugs, although the evidence in the literature is lacking. An evidence-based approach to uterotonic usage, as well as consensus of obstetricians and anesthesiologists is warranted in order to improve the prevention and management of PPH due to uterine atony.
1. Anesth Analg 2014;119:1344-9.
2. Obstet Gynecol 2006;108:1039-47.
3. JOGC 2009;235:980-993.