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Association between duration of intrapartum oxytocin exposure and obstetric hemorrhage

  • Maternal-fetal Medicine
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Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Purpose

Prolonged duration of intrapartum oxytocin exposure is included as a risk factor within widely adopted obstetric hemorrhage risk stratification tools. However, the duration of exposure that confers increased risk is poorly understood. This study aimed to assess the association between duration of intrapartum oxytocin exposure and obstetric blood loss, as measured by quantitative blood loss, and hemorrhage-related maternal morbidity.

Methods

This was a retrospective cohort study of all deliveries from 2018 to 2019 at a single medical center. We included patients who had received any intrapartum oxytocin, and we categorized them into 1 of 5 groups: > 0–2, ≥ 2–4, ≥ 4–6, ≥ 6–12, and ≥ 12 h of intrapartum oxytocin exposure. The primary outcomes were mean quantitative blood loss, proportion with obstetric hemorrhage (defined as quantitative blood loss ≥ 1000 mL), and proportion with obstetric hemorrhage-related morbidity, a composite of hemorrhage-related morbidity outcomes. Secondary outcomes were hemorrhage-related pharmacologic and procedural interventions. A stratified analysis was also conducted to examine primary and secondary outcomes by delivery mode.

Results

Of 5332 deliveries between January 1, 2018 and December 31, 2019 at our institution, 2232 (41.9%) utilized oxytocin for induction or augmentation. 326 (14.6%) had exposure of > 0–2 h, 295 (13.2%) ≥ 2–4 h, 298 (13.4%) ≥ 4–6 h, 562 (25.2%) ≥ 6–12 h, and 751 (33.6%) ≥ 12 h. Across all deliveries, there was higher mean quantitative blood loss (p < 0.01) as well as increased odds of obstetric hemorrhage (adjusted odds ratio [aOR] 1.52, 95% confidence interval [CI] 1.21–1.91) for those with ≥ 12 h of oxytocin compared to all groups between > 0-12 h of exposure. In our stratified analysis, ≥ 12 h of oxytocin exposure was associated with higher mean quantitative blood loss (p = 0.04) and odds of obstetric hemorrhage in vaginal deliveries (aOR 1.47, 95% CI: 1.03–2.11), though not in cesarean deliveries (aOR 1.16, 95% CI 0.82–1.62). There were no differences in proportion with obstetric hemorrhage-related morbidity across all deliveries (p = 0.40) or in the stratified analysis.

Conclusion

Intrapartum oxytocin exposure of ≥ 12 h was associated with increased quantitative blood loss and odds of obstetric hemorrhage in vaginal, but not cesarean, deliveries.

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Data availability

Data available on request from the authors.

References

  1. Geller SE, Adams MG, Kelly PJ, Kodkany BS, Derman RJ (2006) Postpartum hemorrhage in resource-poor settings. Int J Gynecol Obstet 92(3):202–211. https://doi.org/10.1016/j.ijgo.2005.12.009

    Article  CAS  Google Scholar 

  2. Petersen EE, Davis NL, Goodman D et al (2021) Vital signs: pregnancy-related deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017. https://www.cdc.gov/mmwr. Accessed 17 Apr 2021

  3. Creanga AA, Syverson C, Seed K, Callaghan WM, Author OG (2017) Pregnancy-related mortality in the United States, 2011–2013 HHS public access author manuscript. Obstet Gynecol 130(2):366–373. https://doi.org/10.1097/AOG.0000000000002114

    Article  PubMed  PubMed Central  Google Scholar 

  4. Bateman BT, Berman MF, Riley LE, Leffert LR (2010) The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Soc Obstet Anesth Perinatol 110(5):1368–1373. https://doi.org/10.1213/ANE.0b013e3181d74898

    Article  Google Scholar 

  5. Mehrabadi A, Hutcheon JA, Lee L, Kramer MS, Liston RM, Joseph KS (2013) Epidemiological investigation of a temporal increase in atonic postpartum haemorrhage: a population-based retrospective cohort study. BJOG. https://doi.org/10.1111/1471-0528.12149

    Article  PubMed  PubMed Central  Google Scholar 

  6. Balki M, Erik-Soussi M, Kingdom J, Carvalho JCA (2013) Oxytocin pretreatment attenuates oxytocin-induced contractions in human myometrium in vitro. Anesthesiology 119(3):552–561. https://doi.org/10.1097/ALN.0B013E318297D347

    Article  CAS  PubMed  Google Scholar 

  7. Robinson C, Schumann R, Zhang P, Young RC, Charleston P (2003) Oxytocin-induced desensitization of the oxytocin receptor. Am J Obstet Gynecol. https://doi.org/10.1067/mob.2003.22

    Article  PubMed  Google Scholar 

  8. Gabel K, Lyndon A, Main E (2015) CMQCC obstetric hemorrhage toolkit: risk factor assessment. https://www.cmqcc.org/content/risk-factor-assessment. Accessed 20 Apr 2021

  9. Committee on Practice Bulletins-Obstetrics (2017) Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol 130(4):e168–e186. https://doi.org/10.1097/AOG.0000000000002351

    Article  Google Scholar 

  10. Khireddine I, le Ray C, Dupont C, Rudigoz RC, Lè Ne Bouvier-Colle MH, Deneux-Tharaux C (2013) Induction of labor and risk of postpartum hemorrhage in low risk parturients. PLoS ONE 8(1):E54858. https://doi.org/10.1371/journal.pone.0054858

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Ekin A, Gezer C, Solmaz U, Taner CE, Dogan A, Ozeren M (2015) Predictors of severity in primary postpartum hemorrhage. Arch Gynecol Obstet 292:1247–1254. https://doi.org/10.1007/s00404-015-3771-5

    Article  PubMed  Google Scholar 

  12. Tran G, Kanczuk M, Balki M (2017) The association between the time from oxytocin cessation during labour to Cesarean delivery and postpartum blood loss: a retrospective cohort study. Can J Anesth 64(8):820–827. https://doi.org/10.1007/s12630-017-0874-4

    Article  PubMed  Google Scholar 

  13. Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M (2005) Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Mater-Fetal Neonatal Med 18(3):149–154. https://doi.org/10.1080/14767050500170088

    Article  Google Scholar 

  14. Grotegut CA, Paglia MJ, Johnson LN, Thames B, James AH (2011) Oxytocin exposure in women with postpartum hemorrhage secondary to uterine atony. Am J Obstet Gynecol 204(1):56.e1-56.e6. https://doi.org/10.1016/j.ajog.2010.08.023

    Article  CAS  PubMed  Google Scholar 

  15. Belghiti J, Kayem G, Dupont C, Rudigoz RC, Bouvier-Colle MH, Deneux-Tharaux C (2011) Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case control study. BMJ Open. https://doi.org/10.1136/bmjopen-2011-000514

    Article  PubMed  PubMed Central  Google Scholar 

  16. Wetta LA, Szychowski JM, Seals S, Mancuso MS, Biggio JR, Tita AT (2013) Risk factors for uterine atony/postpartum hemorrhage requiring treatment after vaginal delivery. Am J Obstet Gynecol 209(1):51.e1-51.e6. https://doi.org/10.1016/j.ajog.2013.03.011

    Article  PubMed  Google Scholar 

  17. Sosa CG, Althabe F, Belizán JM, Buekens P (2009) Risk factors for postpartum hemorrhage in vaginal deliveries in a Latin-American population. Obstet Gynecol 113(6):1313–1319. https://doi.org/10.1097/AOG.0b013e3181a66b05

    Article  PubMed  PubMed Central  Google Scholar 

  18. Foley A, Gunter A, Nunes KJ, Shahul S, Scavone BM (2018) Patients undergoing cesarean delivery after exposure to oxytocin during labor require higher postpartum oxytocin doses. Anesth Analg 126(3):920–924. https://doi.org/10.1213/ANE.0000000000002401

    Article  CAS  PubMed  Google Scholar 

  19. Driessen M, Bouvier-Colle MH, Dupont C, Khoshnood B, Rudigoz RC, Deneux-Tharaux C (2011) Postpartum hemorrhage resulting from uterine atony after vaginal delivery: factors associated with severity. Obstet Gynecol 117(1):21–31. https://doi.org/10.1097/AOG.0b013e318202c845

    Article  PubMed  PubMed Central  Google Scholar 

  20. Ende HB, Lozada MJ, Chestnut DH et al (2021) Risk factors for atonic postpartum hemorrhage. Obstet Gynecol 137(2):305–323. https://doi.org/10.1097/AOG.0000000000004228

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Birth Sisters (2021) Boston Medical Center. https://www.bmc.org/obstetrics/birth-sisters. Accessed 07 Dec 2021

  22. Lyndon A, McNulty J, VAnderWal B, Gabel K, Huwe V, Main E (2015) Cumulative quantitative assessment of blood loss. CMQCC obstetric hemorrhage toolkit version 2.0. Calif Mater Qual Care Collab

  23. IBM Corp (2020) Released 2020. IBM SPSS statistics for windows, version 27.0. IBM Corp

    Google Scholar 

  24. Erickson EN, Carlson NS (2020) Predicting postpartum hemorrhage after low-risk vaginal birth by labor characteristics and oxytocin administration. J Obstet Gynecol Neonatal Nurs 49(6):549–563. https://doi.org/10.1016/j.jogn.2020.08.005

    Article  PubMed  PubMed Central  Google Scholar 

  25. Committee on Practice Bulletins-Obstetrics (2009) Practice Bulletin No. 107: Induction of Labor. Obstet Gynecol 114(2 Pt 1):386–397. https://doi.org/10.1097/AOG.0b013e3181b48ef5

    Article  Google Scholar 

  26. Lertbunnaphong T, Lapthanapat N, Leetheeragul J, Hakularb P, Ownon A (2016) Postpartum blood loss: visual estimation versus objective quantification with a novel birthing drape. Singap Med J 57(6):325–328. https://doi.org/10.11622/smedj.2016107

    Article  Google Scholar 

  27. Razvi K, Chua S, Arulkumaran S, Ratnam SS (1996) A comparison between visual estimation and laboratory detennination of blood loss during the third stage of labour. Aust N Z J Obstet Gynaecol 36(2):152–154. https://doi.org/10.1111/J.1479-828X.1996.TB03273.X

    Article  CAS  PubMed  Google Scholar 

  28. (2019) Quantitative blood loss in obstetric hemorrhage: ACOG committee opinion summary, number 794. Obstet Gynecol 134(6):1368-1369. https://doi.org/10.1097/AOG.0000000000003565

  29. Hancock A, Weeks AD, Lavender DT (2015) Is accurate and reliable blood loss estimation the “crucial step” in early detection of postpartum haemorrhage: an integrative review of the literature. BMC Pregnancy Childbirth. https://doi.org/10.1186/S12884-015-0653-6

    Article  PubMed  PubMed Central  Google Scholar 

  30. Prasertcharoensuk W, Swadpanich U, Lumbiganon P (2000) Accuracy of the blood loss estimation in the third stage of labor. Int J Gynecol Obstet 71(1):69–70. https://doi.org/10.1016/S0020-7292(00)00294-0

    Article  CAS  Google Scholar 

  31. Toledo P, McCarthy RJ, Hewlett BJ, Fitzgerald PC, Wong CA (2007) The accuracy of blood loss estimation after simulated vaginal delivery. Anesth Analg 105(6):1736–1740. https://doi.org/10.1213/01.ANE.0000286233.48111.D8

    Article  PubMed  Google Scholar 

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Funding

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Author information

Authors and Affiliations

  1. Boston University School of Medicine, Boston, MA, USA

    Megan V. Alexander, Akanksha Srivastava, Swetha Tummala, Diana Abbas, Sara Young, Lindsey Claus, Christina Yarrington & Ashley Comfort

  2. Department of Obstetrics and Gynecology, Boston Medical Center, 770 Albany Street, Dowling 4, Boston, MA, 02118, USA

    Megan V. Alexander, Michelle J. Wang, Christina Yarrington & Ashley Comfort

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  1. Megan V. Alexander
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Contributions

MA: conceptualization, methodology, validation, formal analysis, investigation, writing—original draft, and visualization. MW: conceptualization, methodology, validation, investigation, data curation, writing—review and editing, and project administration. AS: investigation, and writing—review and editing. ST: investigation, and writing—review and editing. DA: investigation, and writing—review and editing. SY: investigation, and writing—review and editing. LC: investigation, and writing—review and editing. CY: conceptualization, methodology, and writing—review and editing. AC: conceptualization, methodology, writing—review and editing, and supervision.

Corresponding author

Correspondence to Megan V. Alexander.

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Conflict of interest

The authors declare that no funds, grants, or other supports were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Approval was granted by the Boston Medical Center/Boston University Medical Campus Institutional Review Board (IRB H-39914).

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Appendices

Appendix 1

Boston Medical Center Obstetric Hemorrhage Bundle Components

Readiness

 System level readiness

  Hemorrhage carts are available on labor and delivery floor and operating rooms, triage and postpartum floors, with massive transfusion supplies, hemorrhage response checklist, intrauterine balloons, and compressions stitches

  Hemorrhage medications are available in labor and delivery floor and operating rooms, triage and postpartum floors medication dispenser (Pyxis)

  Emergency response team: back-up obstetric MD attending and 24/7 on-call back-up advanced gynecologic surgical specialist who can be called in for complex cases, 24/7 on-call interventional radiology

  Transfusion: massive transfusion protocol and emergency release transfusion protocols

  Unit education on protocols for all team members (RN, OB MD, FM MD, Anesthesia MD, CNM, residents)

  Anesthesia: all patients receive an anesthesia consult on admission to labor and delivery and are thereby screened for hemorrhage risk factors as a part of that admission work-up

Recognition and prevention

 Definition, early recognition and triggers

  Definition of hemorrhage as quantitative blood loss > 1000 mL

  Early recognition: regular interval assessment during delivery and postpartum of QBL

  Intraoperative antibiotics redosing after > 1500 mL QBL

  Tranexamic acid: consider giving after > 1000-1500 mL QBL

 Risk assessment (see Appendix 2)

  Assessment of hemorrhage risk: a specific form is used on admission, every 12 h of delivery care, and on transfer to postpartum to assess an individual patient’s risk of obstetric hemorrhage

  Universal screening: all patients admitted get a blood type and screen drawn. If the patient is considered high risk via the risk assessment tool, a crossmatch is ordered as well

 Cumulative quantitative blood loss

  Vaginal deliveries: Under-buttocks drape with clear conical pouch with QBL measurements in 50 mL increments printed on the outside of the drape for easy visual quantification. Quantification initiated following delivery (prior to placental delivery). Blood soaked items weighed and blood volume calculated by subtracting weight of wet from dry (with 1 g additional weight equivalent to 1 mL blood loss). Add calculated blood volume from weighted soaked item and drape volume

  Cesarean deliveries: Suction device, graduated cylinders and drapes utilized, all blood-soaked materials weighed and irrigation/amniotic sac rupture accounted for. Quantification starts after amniotic sac rupture or after delivery. Frequent intake and output measurements verbally shared with all team members throughout the case. Cumulative volume calculated from weighted soaked items and blood in suction cannister

 Active management of third stage of labor

  Prophylactic oxytocin administration immediately after delivery of infant

  Uterine massage immediately after delivery of infant

  Umbilical cord traction for placental delivery

Response

 Emergency management plan

  Staged response to blood loss: checklist and poster posted in every L&D room, on labor and delivery, inside of the operating room, and on the hemorrhage carts that includes medications to give at specific QBL cutoffs, pagers, or numbers to contact for emergency

Reporting/systems

 Perinatal quality improvement/safety

  Perinatal safety specialist instills and promotes culture of team huddles for high-risk patients and systematically debriefing after all clinically significant events to identify successes and opportunities

Hemorrhage data are collected and analyzed on a regular basis. Safety specialist investigates all hemorrhages (all deliveries with QBL > 1000 cc)

  Quality improvement team helps to find barriers to implementation and make system-level adjustments to improve the implementation of this new protocol

  1. Outline of Boston Medical Center Institutional Bundle structure modeled from the following resources:
  2. California Maternal Quality Care Collaborative Hemorrhage Toolkit in National Partnership for Maternal Safety Hemorrhage Bundle Sections (https://www.cmqcc.org/resource/ob-hem-executive-summary)
  3. Council on Patient Safety in Women’s Health Care’s Obstetric Hemorrhage Patient Safety Bundle (https://safehealthcareforeverywoman.org/wp-content/uploads/safe-health-care-for-every-woman-Obstetric-Hemorrhage-Bundle.pdf)

Appendix 2

figure a

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Alexander, M.V., Wang, M.J., Srivastava, A. et al. Association between duration of intrapartum oxytocin exposure and obstetric hemorrhage. Arch Gynecol Obstet 309, 491–501 (2024). https://doi.org/10.1007/s00404-022-06901-w

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