Pitocin Induction and Postpartum Hemorrhage
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Is Pitocin Induction a Factor in Postpartum Hemorrhage?
The induction of oxytocin injection has been a bane of contention in the medical community not only because it has been listed as a high-alert medication, which incurs serious risks to the patient, the fetus and the institution. It is also used frequently to manage postpartum hemorrhage. This quantitative correlational study analyzes and presents the findings of five updated and authoritative sources on the subject and answers the questions surrounding the induction of oxytocin in postpartum hemorrhage and its appropriateness, efficacy and safety.
Postpartum hemorrhage occurs when there is blood loss greater than 500 ml during spontaneous vaginal delivery or 1,000 ml during a cesarean section delivery (Yiadom, 2010). Fortunately, in most cases, healthy females can tolerate much blood loss of more than 500 ml without incurring adverse conditions. The two types are early hemorrhage and late hemorrhage. Early hemorrhage occurs within 24 hours of delivery. And lat hemorrhage occurs 24 hours to a week after delivery. Most cases fall under the early type. Signs and symptoms include hypovolemia, which consists of lightheadedness, tachycardia, syncope, fatigue, and oliguria. Any bleeding, which is left adequately untreated, can develop into postpartum hemorrhage. Women who develop this condition fall under any of three categories. The first consists of women who are too close to delivery and moved to another facility. The second consists of women who deliver at home or another non-hospital setting or on the way to the hospital but who are hemodynamically unstable for the transfer to another facility or another floor within the hospital. And th third consists of women who have been discharged in stable condition but suffer from bleeding, which requires emergency attention (Yiadom).
Pitocin is a sterile, clear, and colorless aqueous solution of synthetic oxytocin intended for intravenous infusion or intramuscular injection (JHP, 2009). It is administered to induce uterine contractions during the third stage of labor as well as to control postpartum hemorrhage. This product is manufactured by JHP Pharmaceuticals LLC (JHP).
The purpose of this study is to determine the overall value of pitocin in postpartum hemrrohage. It will seek to answer questions on its efficacy in preventing the condition, the proper dose in caesarean sections, the risks incurred by its being a high-alert medication, its comparison with intravaginal msoprofol application and the nurse’s role in its application.
II. Literature Review
Postpartum hemorrhage has been linked to about a fourth of all maternal deaths and severe maternal illnesses in the world (Souza, 2013). Uterine atony has been identified as the most common underlying condition leading to it. It is the failure of the uterus to naturally contract after delivery. It has also been found that the use or induction of uterotonics during the third stage of labor is efficacious in minimizing postpartum bleeding. One such uterotonic of choice I oxytocin, as recommended by the World Health Organization at 10 IU. Misoprostol and other injectable uterotonica are also recommended as alternatives to oxytocin (Souza).
A team conducted a cluster-randomized trial of the injection among 689 women volunteers in 54 community health centers in the rural areas of Ghana to establish its feasibility and safety as a prophylactic (Souza, .2013) It was administered through a Uniject device, which was previously filled with 10 IU of oxytocin. This was found to be most suitable form for this under-resourced location. Results of the study showed that its use reduced the risk of postpartum hemorrhage as a safe and feasible preventive measure against postpartum hemorrhage in women who deliver at home. This finding is significant in that it serves as additional evidence of the efficacy and feasibility of uterotonics in preventing postpartum hemorrhage, especially in rural and scantily-resourced areas. It indicates that oxytocin can be suitably used by community health officers for all pregnant women during their the third stage of labor. Moreover, it is a useful component of a timely and comprehensive emergency care, referral systems, and quality care for all women at risk for complications during pregnancy, childbirth and at postpartum (Souza).
The authors (Stephens & Brussels, 2012) reviewed recent literature in determining the ideal dose of oxytocin for use in pregnant women for delivery via caesarean section. They derived 1,379 articles from Medline, Embase and the Cochrane databases. Of this number, 7 met their criteria of elective caesarean section and laboring caesarean sections. These were 7 clinical trials of randomized, double-blind design involving only 626 women. Findings suggest that low-risk pregnant women may benefit from a skiw 0.3 to 1 IU, followed by an infusion of 20-40 IU in one liter of isotonic solution over four hours. This may be repeated once of twice before resorting to an alerntive uterotonic drug. Laboring women may be given a slow 3 IU, followed by an infusion. If this is not insufficient, the 3 IU may be repeated once. Further use will not be effective because of receptor down-regulation and reduced responsiveness. Hence, the choice of an alternative uterotonic drug should be made early enough (Stephens & Brussels).
The author and his team (Balci et al., 2011) sought to compare the effectiveness and the complications of intravaginal misoprostol application with oxytocin infusion alone for use in labor. Their study involved the participation of 101 primigravidae women with singleon pregnancies. The volunteers were separated into two groups. Group 1 had 50 patients and Group 2 had 51. Group 1 was given a 50 ug dose of intravaginal misoprostol with an oxytocin infusion, which was given 3 hours later. Group 2 was given only an oxytocin infusion 3 hours later. The time difference from induction to delivery, the rute of delivery and complications were noted and analyzed (Balci et al.).
Results showed that the mean time between induction and delivery was 10.4 in Group 1 and 13.7 in Group 2 (Balci et al., 2011) . The two groups had comparable rates of vaginal delivery, placnntal abruption and postpartum hemorrhage. The study concluded that the intravaginal application of 50 ug of misoprostol before oxytocin infusion was more efficacious than oxytocin infusion alone among primigravidae (Balci et al.).
Patient injury from drug therapy is a most significant and sensitive consideration in-patient settings (Simpson & Knox, 2009). This incurs huge costs in patients, healthcare providers, and the hospital itself. Medications, which pose substantial risk of error, called “high-risk medications.” In 2007. The Institute added oxytocin administration for use in labor or for its augmentation to its list of such medications. Oxytocin is frequently used and errors in its dose are among the most common. Such errors can result in excessive uterine activity, mistaken administration of IV fluids with oxytocin for IV fluid resuscitation during non-reassuring fetal heart rate, maternal low blood pressure, and inappropriate induction of oxytocin to women with less than 39 gestation weeks. Luckily, oxytocin medication errors and harm on patients are generally preventable. Perinatal professionals can evolve strategies to reduce risks for both mother and child in connection with oxytocin induction for safety (Simpson & Knox).
The nurse has a pivotal role in the management of oxytocin during the induction or augmentation of labor (Clayworth, 2000). She is at the bedside of the woman in labor. It is the nurse who makes decisions concerning oxytocin titration, based on her assessment of the woman’s condition. The nurse’s decision must, therefore, be appropriate. It must be based on and drawn from, sound and reliable knowledge of the properties and effects of oxytocin on uterine contractions, and the response to it by the woman and her fetus to contractions. Furthermore, the nurse should be knowledgeable about the standards and guidelines of care guiding her actions concerning and curing induction and/or augmentation (Clayworth).
This study uses the quantitative correlational type of study in gathering, recording, describing, analyzing and comparing updated and precise data from authoritative sources.
It covers a two-month period and will determine if pregnant women voluneers with severe postpartum hemorrhage, secondary to uterine atone, should receive more oxytocin injections as compared with those free of the condition.
This will be a case-control study to be approved by a selected hospital’s review board. The hypothesis will be that women with severe postpartum hemorrhage secondary to uterine atony, should recive more oxytocin as compared to controls.
Volunteers with severe postpartum hemorrhage will receive blood transfusion and will be compared with matched controls. Total exposure will be calculated and the variables compared.
An expected limitation will be that this study will rely on data derived from medical records. All these truly severe cases must be identified and described as having postpartum hemorrhage secondary to uterine atony. These medical records shall have been reviewed by at least three physicians and the study variables collected according to patients’ age, height, weight, gravidity, parity, number of fetuses, gestational age at delivery, history of postpartum hemorrhage, with a previous delivery and other criteria. Patient data confidentiality will be observed with utmost care by securing permission from the responsible committee protection such rights. #
Balci, O. et al. (2011). Comparison of induction of labor with vaginal misoprostol plus
Oxytocin vs. oxytocin alone in term primigravidae. Vol. 2 # 9, Journal of Maternal
and Neonatal Medicine: Informa Healthcare Publishing Technology. Retrieved on January 12, 2014 from http://www.ingenta.connect.com/content/apl/mfn/2011/00000024/00000009/art00002
Clayworth, S. (2000). The nurse’s role during Oxytocin administration. Vol. 25 # 2, The
American Journal of Maternal and Child Nursing: Lippincott Williams & Wilkins, Inc.
Retrieved on January 12, 2014 from http://journals/ww.com./mcnjournals/Abstract/2000/03000/The_Nurse_s_Role_During_Oxytocin_Adminisstration7.aspx
JHP (2009). Pitocin. Daily Med: JHP Pharmaceuticls, LLC. Retrieved on January 14,
2014 from http://www.dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=10055
Simpson, K.R. And Knox, E. (2009). Oxytocin as a high-alert medication: implications for perinatal patient safety. Vol. 34 # 1, Research Gate: Research Gate.net. Retrieved on January 12, 2014 from http://www.researchgate.net/publication/23685884_Oxytocin_as_a_high_alert_medication_for_perinatal_patient_safety
Souza, J.P. (2013). The prevention of postpartum hemorrhage in the community. Vol. 10
# 10, Public Library of Medicine: PubMed. Retrieved on January 11, 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC37948553794855
Stephens, L.C. And Brussel, T. (2012). Systematic review of Oxytocin dosing at Caesarean section. Anaesthesia and Intensive Care: Australian Society of Anaesthesia.
Retrieved on January 11, 2014 from http://www.thefreelibrary.com/Systematic+review+of+oxytocin_dosing_at_caesarean_section.a0286719392
Yiadom, M.Y.A.B. (2010). Postpartum hemorrhage in emergency medicine. Medscape:
WebMD LLC. Retrieved on January 15, 2014 from http://emedicine.medscape.com/article/796785-overview#showall
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