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Effect of an oxytocin protocol on secondary uterotonic use in patients undergoing Cesarean delivery

Effet d’un protocole d’ocytocine sur l’utilisation secondaire d’utérotoniques chez la patientèle bénéficiant d’une césarienne

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Abstract

Purpose

Protocol-driven oxytocin regimens can reduce oxytocin administration compared with a nonprotocol free-flow continuous infusion. Our aim was to compare secondary uterotonic use between a modified “rule of threes” oxytocin protocol and a free-flow continuous oxytocin infusion after Cesarean delivery.

Methods

We conducted a retrospective before-and-after study to compare patients who underwent Cesarean delivery between 1 January 2010 and 31 December 2013 (preprotocol) with patients who underwent Cesarean delivery between 1 January 2015 and 31 August 2017 (postprotocol). The preprotocol group received free-flow oxytocin administration and the postprotocol group received oxytocin according to a modified rule of threes algorithm. The primary outcome was secondary uterotonic use and the secondary outcomes included blood transfusion, hemoglobin value < 8 g·dL–1, and estimated blood loss.

Results

In total, 4,010 Cesarean deliveries were performed in 3,637 patients (2,262 preprotocol and 1,748 postprotocol). The odds of receiving secondary uterotonic drugs were increased in the postprotocol group (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.04 to 1.70; P = 0.02). Patients in the postprotocol group were less likely to receive a blood transfusion. Nevertheless, the two groups were similar for the composite end point of transfusion or hemoglobin < 8 g·dL–1 (OR, 0.86; 95% CI, 0.66 to 1.11; P = 0.25). The odds of an estimated blood loss greater than 1,000 mL were reduced in the postprotocol group (OR, 0.64; 95% CI, 0.50 to 0.84; P = 0.001).

Conclusions

Patients in the modified rule of threes oxytocin protocol group were more likely to receive a secondary uterotonic than those in the preprotocol group. Estimated blood loss and transfusion outcomes were similar.

Résumé

Objectif

Les schémas thérapeutiques d’ocytocine basés sur un protocole peuvent réduire l’administration d’ocytocine par rapport à une perfusion continue en débit libre hors protocole. Notre objectif était de comparer l’utilisation secondaires d’agents utérotoniques entre un protocole modifié d’ocytocine en « règle de trois » et une perfusion continue d’ocytocine à débit libre après un accouchement par césarienne.

Méthode

Nous avons mené une étude rétrospective avant-après pour comparer les personnes ayant bénéficié d’une césarienne entre le 1er janvier 2010 et le 31 décembre 2013 (pré-protocole) avec les personnes ayant subi une césarienne entre le 1er janvier 2015 et le 31 août 2017 (post-protocole). Le groupe pré-protocole a reçu une administration d’ocytocine en débit libre et le groupe post-protocole a reçu de l’ocytocine selon un algorithme de règle de trois modifié. Le critère d’évaluation principal était l’utilisation secondaire d’agents utérotoniques et les critères d’évaluation secondaires incluaient la transfusion sanguine, un indice d’hémoglobine < 8 g·dL–1 et les pertes de sang estimées.

Résultats

Au total, 4010 accouchements par césarienne ont été réalisés chez 3637 patient·es (2262 pré-protocole et 1748 post-protocole). Les chances de recevoir des médicaments utérotoniques secondaires étaient plus élevées dans le groupe post-protocole (rapport de cotes [RC], 1,33; intervalle de confiance [IC] à 95 %, 1,04 à 1,70; P = 0,02). Les patient·es du groupe post-protocole étaient moins susceptibles de recevoir une transfusion sanguine. Néanmoins, les deux groupes étaient similaires en ce qui touchait au critère d’évaluation composite de transfusion ou d’hémoglobine < 8 g·dL–1 (RC, 0,86; IC 95, 0,66 à 1,11; P = 0,25). Les risques d’une perte de sang estimée supérieure à 1000 mL ont été réduits dans le groupe post-protocole (RC, 0,64; IC 95 %, 0,50 à 0,84; P = 0,001).

Conclusion

Les patient·es du groupe du protocole d’ocytocine en règle de trois modifiée étaient plus susceptibles de recevoir un utérotonique secondaire que les personnes du groupe pré-protocole. Les pertes sanguines estimées et les résultats transfusionnels étaient similaires.

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Notes

  1. While many institutions now utilize carbetocin (which has a longer half-life, longer duration of action, and greater heat stability than oxytocin), it is practice at our centre to use oxytocin as the first-line agent to prevent/treat uterine atony.

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Author contributions

Emily E. Sharpe, Hans P. Sviggum, and Rochelle J. Pompeian conceived and designed the analysis, collected the data, contributed data or analysis tools, performed the analysis, and wrote the paper. Paul R. Davis collected the data, contributed data or analysis tools, performed the analysis, and wrote the paper. Katherine W. Arendt conceived and designed the analysis, contributed data or analysis tools, and wrote the paper. Christopher Kurian collected the data and wrote the paper. Vanessa E. Torbenson conceived and designed the analysis and wrote the paper. Phil Schulte and Andrew C. Hanson contributed data or analysis tools, performed the analysis, and wrote the paper. Kimberly D. Hamilton collected the data.

Acknowledgments

The Scientific Publications staff at Mayo Clinic provided editorial consultation and proofreading, administrative, and clerical support.

Disclosures

The authors declare no conflicts of interest.

Funding statement

This publication was supported by Center for Translational Science Activities (CTSA) Grant Number UL1 TR002377 from the National Center for Advancing Translational Science (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. The funding source had no involvement in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

Prior conference presentations

Presented at the Society for Obstetric Anesthesia and Perinatology 51st Annual Meeting (Phoenix, AZ, USA; 1–5 May 2019).

Data availability statement

The data underlying this article will be shared on reasonable request to the corresponding author.

Editorial responsibility

This submission was handled by Dr. Ronald B. George, Associate Editor, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

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Authors and Affiliations

  1. Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA

    Paul R. Davis MD, Hans P. Sviggum MD, Katherine W. Arendt MD, Rochelle J. Pompeian MD, Kimberly D. Hamilton RRT, LRT & Emily E. Sharpe MD

  2. Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA

    Christopher Kurian MD

  3. Division of Obstetrics, Mayo Clinic, Rochester, MN, USA

    Vanessa E. Torbenson MD

  4. Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA

    Andrew C. Hanson MS & Phillip J. Schulte PhD

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Correspondence to Emily E. Sharpe MD.

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Davis, P.R., Sviggum, H.P., Arendt, K.W. et al. Effect of an oxytocin protocol on secondary uterotonic use in patients undergoing Cesarean delivery. Can J Anesth/J Can Anesth 70, 1194–1201 (2023). https://doi.org/10.1007/s12630-023-02496-1

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