Introduction
This is a protocol for safe preparation and administration for induction of labor with oxytocin. It lists the “standard criteria” for use of the medication, as well as the safe dosage that should be administered for all patients to reduce potential risks that such medications can cause when administered over the prescribed dose (Cherouny & Morgan, 2011). It provides a list of maternal and fetal contraindications, tools used for the administration such as IV drip, and assessments and interventions that are necessary to perform before and during the administration of such medication to increase patient, safety and decrease provider’s liability (Cherouny & Morgan, 2011).
A maternal and fetal baseline assessment must be performed such as electronic fetal monitoring (EFM) to verify a “reactive fetal heart rate tracing over 30 minutes” and continuous electronic fetal monitoring is essential while on oxytocin with an intrauterine pressure catheter (IUPC). Following the maternal and fetal assessment, peripheral intravenous (IV) must be placed with an 18- or 20-gauge needle as a primary line for the administration of fluids. Lactated ringers (LR) are to be infused to secure IV access in case oxytocin needs to be discontinued. Pre-mixed IV solutions of 30 units of oxytocin (Pitocin) in 500mL LR is to be obtained, verified, and placed as a piggyback into the primary line that is closest to the IV line (Cherouny & Morgan, 2011).
The induction/augmentation of labor using oxytocin starts with the infusion at 1 or 2 milliunit/minute, the physician must be available within 10 minutes of the Labor and Delivery (L&D) unit before administration. The dose is to be increased by 1 to 2 milliunits/minute (mU/min) every 30 to 60 minutes to achieve uterine contractions of 2 to 3 minutes apart and an IUPC value of 50 to 60 mmHg. During induction of labor, cervical dilation must be progressed by 0.5 to 1 centimeter per hour (cm/hr), especially with nulliparous (not given birth previously) women. The rate increase should not surpass 20mU/min unless ordered by the physician. Acceptable labor induction uterine activity is reached when 3 to 5 contractions occur every 10 minutes with 5 contractions maximum, lasting 40 to 90 seconds and/or “moderate-to-strong” intensity (Cherouny & Morgan, 2011).
Maternal and fetal assessment, fetal heart rate (FHR), uterine activity, how the mother is responding to labor, maternal vital signs, and intake and output – must be performed every 15 minutes while oxytocin is being administered, whether the dose is being increased or decreased. A decrease or discontinuation of oxytocin may have to be done in certain scenarios. If the patient experiences tachysystole, meaning, “more than five contractions in 10 minutes, contractions lasting 2 minutes or more, or contractions occurring within 1 minute of each other,” oxytocin should be decreased or discontinued based on the provider’s order. This should also be done if there is the insufficient resting tone or IUPC pressure above 25mmHg between contractions. In the event of a non-reassuring FRH pattern, maternal hypotension, and signs and symptoms of uterine rupture, oxytocin must be immediately discontinued, the provider notified, and emergency delivery anticipated (Cherouny & Morgan, 2011).
Clinical Practice Protocol from a Historical Perspective
The use of Oxytocin for the induction of labor first started in the 1950s. Before this, in the 18th and 19th centuries, the induction of labor was only for pelvic deformities and before the fetus grew too large to deliver (Drife, 2021). It was not until the 20th century that synthetic oxytocin and prostaglandin were available for induction (Drife, 2021). The administration of oxytocin was infused intravenously and originally in a constant low-dose infusion and then replaced by titrated doses (MacKenzie, 2006). Titration was determined by the intensity and frequency of uterine contractions assessed by the staff, and they did this by using mechanical pumps or electronic drip counters (MacKenzie, 2006). Induction of labor with oxytocin comes with its risk such as “uterine hyperstimulation, fetal distress, and a greater likelihood of postpartum hemorrhage” (Harman & Kim, 1999). Due to these risks, it has developed a new protocol as discussed previously to prevent worsening symptoms. One of the protocols is administering a continuous infusion of oxytocin in a low dose which is the most effective method for cervical ripening and with the least adverse effects.
Review of Evidence
The issue of the use of oxytocin during induced labor and its relationship with postpartum hemorrhage has been extensively studied by researchers. Doyle et al. (2018) explored the topic of the effects of oxytocin on postpartum hemorrhage, which is the main cause of maternal death. The results of the study demonstrated a higher dose of oxytocin could potentially reduce the risk of the development of postpartum hemorrhage in pregnant women. The article provides comprehensive knowledge on the utilization of oxytocin. The fact that the study was published in Joint Commission Journal on Quality and Patient Safety indicates its high quality.
The topic in question was also analyzed from the perspective of studying the link between the induction of labor and postpartum hemorrhage in different settings. The study conducted by Khireddine et al. (2013) showed that induction of labor, including through oxytocin, was associated with a higher risk of postpartum hemorrhage than in the case of spontaneous labor. At the same time, no considerable risk of the condition was discovered in women who experienced non-standard labor indications. Thus, based on the evidence, it is possible to conclude that a higher risk of postpartum hemorrhage due to labor induction can be attributed to unfavorable childbirth situations.
There is also research that gives insight into the effects of different doses and durations of oxytocin on the risk of postpartum hemorrhage. Specifically, Erickson & Carlson (2020) found that the risk of postpartum hemorrhage grew when oxytocin was administered for more than seven hours. The risk of the condition further significantly increased after an induction lasting longer than 12 hours. Based on the details presented in the article, it is important to note that the duration of the period of oxytocin administration must be controlled to reduce the risk of postpartum hemorrhage.
Clinical Practice Guidelines in the Practice Setting
To increase compliance with new protocols and clinical practice guidelines in the practice setting involving the usage of oxytocin to induce labor and a potential outcome of postpartum hemorrhage, it is important to continuously monitor the health and well-being of the mother during labor and postpartum, as well as provide updated research and education to healthcare staff members regarding therapeutic usage of the drug and potential risk factors (Simpson, 2011). Researchers need to identify a proper therapeutic dosage of oxytocin to induce labor, as well as properly identify any potential risk factors that a woman may have with the usage of this drug to induce labor (Doyle et al., 2018). To implement a clinical practice guideline regarding proper education on the usage of oxytocin to induce labor in women, informational staff meetings can be implemented for the nurses in a laboring and delivery unit or postpartum couplet care unit to receive education about the pros and cons of oxytocin used to induce labor.
According to the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), it is a woman’s individual choice to decide to induce labor with the use of oxytocin after 39 weeks gestation based on the recommendations of the woman’s provider (AWHONN, 2019). It is known that nurses and healthcare physicians and providers play an important role in educating laboring women about the risks and benefits of utilization of oxytocin to induce labor after 39 weeks of gestation, as well as other nonpharmacological interventions to induce labor or wait for spontaneous labor (AWHONN, 2019). Nursing staff members can increase compliance with these protocols by ensuring that they are providing education throughout the laboring process for the woman, as well as include the patient and the provider in active communication regarding the risks and benefits of utilizing an oxytocin agent to induce labor.
Conclusion
According to the American Sentinel College of Nursing “Nursing-sensitive quality indicators are an important part of the equation when it comes to establishing evidence-based practice guidelines,” (2011). Evidence-based practice on the management of induction of labor educates medical health professionals on contraindications, discontinuation of oxytocin, interventions, and administration of oxytocin. When induction of labor is initiated, nurses need to monitor the patient and fetus closely for any possible adverse effects of the medication. The patient and fetus can be monitored for any changes in heart rate, changes in the frequency of contractions, oxygen levels, dysrhythmias, decreased or absent fetal movement, maternal hypertension, meconium discharge, etc. Furthermore, any changes should be reported immediately, and interventions should be implemented promptly to prevent further complications. The implementation of these interventions will optimize nursing-sensitive outcomes.
References
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