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Institution of Low-dose Oxytocin Protocol for Cesarean Delivery Without Antecedent Labor.
Abstract Number: F3H-438
Abstract Type: Original Research
Introduction: Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide. Prophylactic post-delivery oxytocin administration is the most common practice used to prevent PPH. Untoward side effects of oxytocin are dose-dependent. The standard oxytocin regimen for cesarean delivery formerly used in our hospital was to administer a total 40 IU of oxytocin (20 IU per 1L crystalloid) following delivery of the placenta. After publication of the “Rule of Threes” , we decided to incorporate a lower dose oxytocin protocol into our practice. The change was made in November 2017, and was standard practice by January 1, 2018. Upon delivery of the placenta, we administer 3 IU of oxytocin i.v. and after 3 min the obstetrician assesses uterine tone. If the tone is not adequate, the cycle is repeated two more times, if necessary, up to a total of 9 IU. If uterine tone remains inadequate, we administer second-line uterotonics. Postoperatively, an infusion 2.5 IU/hour of oxytocin is started in the PACU, and continued for a total of 8 hours. The aim of this study was to evaluate the impact of this new low-dose oxytocin protocol on quantified blood loss (QBL) for planned cesarean delivery.
Methods: We retrospectively reviewed the electronic health records of 3,260 patients who underwent cesarean delivery from November 2015 to December 2018 at our institution. The months of November and December 2017 were excluded, as this was the interval when the new low-dose oxytocin protocol was being introduced. Our standard oxytocin regimen was in effect through October 2017, and the new protocol was in effect from January 2018 through December 2018. For each encounter we extracted demographic data, obstetrical information, and QBL. All patients with multiple gestations or those in labor prior to cesarean were excluded. Stepwise multiple linear regression was used to assess the association between the change in oxytocin protocol and QBL, adjusted for potential confounder variables (p value of <0.25 in the univariable analysis).
Results: There was a statistically significant association between the implementation of the new low-dose oxytocin protocol and QBL, adjusted for gestational age and birth weight (b coefficient [b] = -84 mL, 95% confidence interval [CI], -130 to -37, p value<0.001).
Discussion: Implementation of a new low-dose oxytocin protocol of at our institution was associated with a lower QBL, a proxy for uterine tone. While we recognize that other factors are involved with blood loss during cesarean delivery in addition to inadequate uterine tone, the introduction of this new oxytocin regimen at our hospital has resulted in a decrease in the dose of oxytocin administered and a concomitant reduction in QBL for planned cesarean deliveries.
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2. Kovacheva VP, et al. Anesthesiology. 2015 Jul;123(1):92-100