Guidelines for Oxytocin
Shared Quality Initiatives in Obstetrical Care
The Obstetrical Society of Philadelphia
Deborah A. Driscoll, MD
November 17, 2012
Background
 In 2008 UPHS Ob service established an interdisciplinary work
group to develop a standardized protocol for oxytocin use
• Rationale:
– Protocols for oxytocin use were inconsistent across the health
system.
– Paid claims often allege oxytocin misuse.
– Recent studies suggest that implementation of a uniform specific
checklist-based protocol improves newborn outcome and
decreases overall adverse outcomes, and can reduce claims
(Clark et al. 2007; 2008).
– Meta-analysis demonstrated that low dose protocols result in
fewer episodes of hyperstimulation, higher rate of vaginal birth,
less post-partum hemorrhage and maternal infection (Crane
1998).
2
UPHS Oxytocin Protocol
 Checklist based protocol for administration of
oxytocin for induction or augmentation of
labor was introduced in summer 2009 at HUP.
•
•
•
•
Ob providers evaluate indication for oxytocin use,
maternal and fetal status, and complete PreOxytocin checklist
Nursing assessment recorded every 30 minutes
using Oxytocin checklist
Specific recommendations for:
– Recurrent decelerations
– Oxytocin-induced tachysystole with reassuring
FHR tracing
Triggers to notify Ob provider to reevaluate plan of
care
 Deviation from the protocol requires Ob
provider documentation in the chart including
justification.
 Protocol was modified after 4 month pilot and
then introduced at PAH.
3
HUP Experience
 Collected data for 14 months pre- and post-implementation
• Pre: 1/08-3/09 and Post: 1/10-3/11
 5077 of 8717 women received oxytocin
 Results:
• Time of admission to delivery among those who received
oxytocin
– median admission to delivery increased in the postimplementation group (534 vs 466 min, p<0.001)
• Cesarean delivery rates
– 18.1% vs 19.3%, p=0.28
 Challenges and Controversies
Fall 2012 - Work Group convened to review experience and
consider modifications to protocol.
4
Guiding Principles for Administration of Oxytocin











Attending physician must be present in the hospital
FHR and uterine activity will be monitored electronically
Oxytocin solution should be given in pre-mixed piggy back infusion
Pre-Oxytocin checklist should be completed prior to initiation
If criteria are not met then discuss management plan, document deviation
from protocol
High or low dose oxytocin regimens are appropriate (ACOG Practice
Bulletin 107, 2009)
If prostaglandin used for cervical ripening then oxytocin should not be
initiated sooner than 4 hrs after last misoprostol or 1 hr after removal of
dinoprostone
Follow NICHD FHR interpretation guidelines and adjust oxytocin infusion
according to the Oxytocin Maintenance Checklist
Dosages > 20mU/min require patient reevaluation and notification of
provider
Maximum infusion rate 40mU/min, notify provider after 2 hrs
If at any time team is not in agreement then initiate chain of command
5
Perspectives on Ob Guidelines
 Engage your providers in guideline development and
implementation – build consensus early in the process
 Take an interdisciplinary approach
 Involve residents in the process
 Collect and share data
 Assess the impact
 Review guidelines on a regular basis and modify as needed
 Be open to learning from others – value your colleague’s
perspective and experience
These guidelines should not be construed as dictating an exclusive course of treatment. Deviation should
be appropriately based on needs of the individual patient and documented in the medical record.
6