Comparative study of oxytocin bolus and oxytocin infusion during caesarean section

Background: The incidence of postpartum haemorrhage varies from 2-11%. Postpartum haemorrhage complicates approximately 4% of deliveries in most large obstetric services. Postpartum haemorrhage is the third major cause of maternal mortality next to pregnancy induce hypertension (pre-eclampsia) and infection. Prevention, early recognition and prompt appropriate intervention are keys to minimizing its impact. Conventionally loss of more than 500 ml of blood following vaginal delivery and 1000 ml of blood following caesarean section is defined as postpartum haemorrhage. In this study we compared the efficacy of intravenous oxytocin bolus (2 IU) dose followed by infusion (160 mIU/minute) and only i.v. oxytocin infusion following delivery of fetus in elective and emergency LSCS with regard to uterine tone.Methods: This study was a prospective observational study. 200 low risk patients scheduled to undergo elective and emergency caesarean section under spinal anaesthesia in Department of obstetrics and gynecology, SSMC, Tumkur. Group A included i.v. bolus + i.v. injection, group B: i.v. infusion.Results: There was significant drop in haemoglobin and PCV in both group A and group B. But it was comparable among two groups. At 15th minute MBP was 77.2 mm of Hg and 80.04 mm of Hg in Group B. In group A better uterine tone was achieved earlier compared to group B at 2, 5, 10, 20 minutes.Conclusions: It was concluded from this study that oxytocin i.v. bolus with infusion causes earlier attainment of better uterine tone when compared with only infusion.

Women’s views and experiences of augmentation of labour with synthetic oxytocin infusion: a protocol for a qualitative evidence synthesis

Background: Augmentation of labour (AOL) is the most common intervention to treat labour dystocia. Previous research reported extensive disparities in AOL rates across countries and institutions. Despite its widespread use, women’s views on and experiences of intrapartum augmentation with infused synthetic oxytocin are limited. Methods: A qualitative evidence synthesis on women’s views and experiences of AOL with synthetic oxytocin after spontaneous onset of labour will be conducted. Qualitative studies and studies employing a mixed methods design, where qualitative data can be extracted separately, will be included, as will surveys with open-ended questions that provide qualitative data. A systematic search will be performed of the databases: MEDLINE, CINAHL, EMBASE, PsycINFO, Maternity and Infant Care and Web of Science Core Collection from the date of inception. The methodological quality of included studies will be assessed using the Evidence for Policy and Practice Information and Co-ordinating Centre’s appraisal tool. A three-stage approach, coding of data from primary studies, development of descriptive themes and generation of analytical themes, will be used to synthesise findings. Confidence in findings will be established by the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research. Discussion: This qualitative evidence synthesis may provide valuable information on women’s experiences of AOL and contribute to a review of clinical practice guidelines for maternity care providers. PROSPERO registration: CRD42021285252 (14/11/2021)

Cervical avulsion during induced labour: diagnosis, intraoperative management and postoperative course

We report the presentation, operative management and follow-up of a 31-year-old nulliparous woman who experienced a cervical avulsion injury (CAI) during labour. The woman was induced with dinoprostone gel, followed by oxytocin infusion and had a prolonged active phase. During the second stage, fetal decelerations were noted and the consultant asked to make a plan for delivery. When assessing to perform a midpelvic instrumental delivery, a cord of tissue was felt below the fetal head. A caesarean delivery was recommended based on this finding. After delivery, injuries to the broad ligament, posterior lower uterine segment vagina and cervix were repaired. The cervix was retained with the intent that some tissue be salvaged. At 6-week follow-up, transvaginal ultrasound confirmed blood flow in the cervical tissue, though cervical insufficiency was suspected on clinical examination. Our findings reinforce the seriousness of CAI and support conservative surgical management as opposed to trachelectomy or hysterectomy.

Coexistence and prevalence of obstetric interventions: an analysis based on the grade of membership

Background Obstetric interventions performed during delivery do not reflect improvements in obstetric care. Several practices routinely performed during childbirth, without any scientific evidence or basis - such as Kristeller maneuver, routine episiotomy, and movement or feeding restriction - reflect a disrespectful assistance reality that, unfortunately, remains in place in Brazil. The aims of the current study are to assess the coexistence and prevalence of obstetric interventions in maternity hospitals in Belo Horizonte City, based on the Grade of Membership (GoM) method, as well as to investigate sociodemographic and obstetric factors associated with coexistence profiles generated by it. Methods Observational study, based on a cross-sectional design, carried out with data deriving from the study “Nascer em Belo Horizonte: Inquérito sobre o Parto e Nascimento” (Born in Belo Horizonte: Survey on Childbirth and Birth). The herein investigated interventions comprised practices that are clearly useful and should be encouraged; practices that are clearly harmful or ineffective and should be eliminated; and practices that are inappropriately used, in contrast to the ones recommended by the World Health Organization. The analyzed interventions comprised: providing food to parturient women, allowing them to have freedom to move, use of partogram, adopting non-pharmacological methods for pain relief, enema, perineal shaving, lying patients down for delivery, Kristeller maneuver, amniotomy, oxytocin infusion, analgesia and episiotomy. The current study has used GoM to identify the coexistence of the adopted obstetric interventions. Variables such as age, schooling, skin color, primigravida, place-of–delivery financing, number of prenatal consultations, gestational age at delivery, presence of obstetric nurse at delivery time, paid work and presence of companion during delivery were taken into consideration at the time to build patients’ profile. Results Results have highlighted two antagonistic obstetric profiles, namely: profile 1 comprised parturient women who were offered diet, freedom to move, use of partogram, using non-pharmacological methods for pain relief, giving birth in lying position, patients who were not subjected to Kristeller maneuver, episiotomy or amniotomy, women did not receive oxytocin infusion, and analgesia using. Profile 2, in its turn, comprised parturient women who were not offered diet, who were not allowed to have freedom to move, as well as who did not use the partograph or who were subjected to non-pharmacological methods for pain relief. They were subjected to enema, perineal shaving, Kristeller maneuver, amniotomy and oxytocin infusion. In addition, they underwent analgesia and episiotomy. This outcome emphasizes the persistence of an obstetric care model that is not based on scientific evidence. Based on the analysis of factors that influenced the coexistence of obstetric interventions, the presence of obstetric nurses in the healthcare practice has reduced the likelihood of parturient women to belong to profile 2. In addition, childbirth events that took place in public institutions have reduced the likelihood of parturient women to belong to profile 2. Conclusion(s) Based on the analysis of factors that influenced the coexistence of obstetric interventions, financing the hospital for childbirth has increased the likelihood of parturient women to belong to profile 2. However, the likelihood of parturient women to belong to profile 2 has decreased when hospitals had an active obstetric nurse at the delivery room. The current study has contributed to discussions about obstetric interventions, as well as to improve childbirth assistance models. In addition, it has emphasized the need of developing strategies focused on adherence to, and implementation of, assistance models based on scientific evidence.

The First International Guideline for Oxytocin Safely Decreased Oxytocin Amount During Cesarean Section: A Single-Institution Retrospective Analysis

Purpose: It is routine to administer oxytocin following delivery of the neonate during cesarean section. However, there are many kinds of administration methods. Heesen et al. published an international consensus statement in 2019 on the use of uterotonic agents, including oxytocin during cesarean section [1]. Our institution adapted the guideline-based oxytocin infusion method. We verified the validity of the new approach after one year. Methods: A single-center retrospective study of consecutive patients who underwent cesarean section with a new protocol or the conventional manner from November 2019 to December 2020 was conducted. The primary endpoint was a significant difference in the amount of intraoperative hemorrhage and the total oxytocin amount. Secondary endpoints included differences in the incidence of intraoperative complications. Results: The study included 174 patients: 66 in the new protocol group and 108 in the conventional group. There was a statistically significant difference between the two groups for oxytocin amount (new protocol 4.2 [3.2-5.9] vs. conventional 5.0 [5.0-10] IU, p<0.01) with equivalent intraoperative hemorrhages (new protocol 558 [337-963] vs. conventional 683 [484-1012] g, p=0.08). There was no significant difference in the incidence of nausea. Conclusion: The new guideline-based oxytocin administration safely decreased the intraoperative oxytocin amount in our institution.

Labour Induction Methods: An Overview

Overall the rate of induced labours has increased and almost 25% of women undergo labour induction worldwide. Cervical ripening and cervical preparedness is necessary before labour can be induced. The status of the cervix is traditionally assessed with help of Bishop’s score. Labour induction becomes necessary when the cervix is not favourable as noted on the cervical scoring system. Mechanical or surgical methods or a combination of both can be sued for labour induction. These include Foley’s catheter induction, sweeping of membranes, amniotomy etc. Pharmacological agents like oxytocin, prostaglandins PGE1 & PGE2 and newer agents like mifepristone can be used. Mechanical methods like Foley’s catheter induction are associated with lesser FHR variability and decreased rates of caesarean section as compared with oxytocin infusion or prostaglandins used locally. Oxytocin is the most widely used pharmacological method used for induction of labour. Proper titration of oxytocin can result in contractions that mimic normal labour. Oxytocin is often combined with amniotomy. Prostaglandins PGE1 & PGE2 are safe and effective options for labour induction. Prostaglandin PGE1 or misoprostol is used in the dose of 25 microgram mcg given orally or vaginally or via the sub-lingual route. Prostaglandin PGE2 or dinoprostone is used intra-cervically or vaginally in the posterior fornix. The newer drug mifepristone is being studied as cervical ripening agents because of its anti-progesterone effect.

Epidural Analgesia With or Without Oxytocin, but Not Oxytocin Alone, Administered During Birth Disturbs Infant Pre-feeding and Sucking Behaviors and Maternal Oxytocin Levels in Connection With a Breastfeed Two Days Later

Aims This work aimed to study consequences of medical interventions in connection with birth on infant pre-feeding and feeding behaviors and on maternal oxytocin levels in connection with a breastfeed 2 days later.Materials and Methods Mothers and their full-term newborns (n = 41) were videotaped during a breastfeed 2 days after birth. Duration and quality of rooting [Infant Breastfeeding Assessment Tool (IBFAT)] were assessed. Maternal blood samples were collected, oxytocin levels were analyzed, and mean oxytocin level and variance were calculated. Data on medical interventions during birth, number of breastfeedings, and infant weight loss since birth were recorded. Data were analyzed using logistic regression models.Results The duration of infant rooting was significantly shorter when the mother had received epidural analgesia. The shorter the duration of infant rooting, the more often infants had breastfed and the greater was the infant weight loss since birth. Mothers with epidural analgesia with oxytocin had the lowest oxytocin mean levels in connection with a breastfeed. Oxytocin variance correlated positively with quality of rooting and correlated negatively with infant weight loss. In the control group alone, we found similar patterns of associations with oxytocin levels.Conclusion Epidural analgesia and epidural analgesia with oxytocin infusion in connection with birth negatively influenced infant rooting behavior and maternal mean oxytocin levels, respectively. Oxytocin infusion alone was without effect. The data also suggest that infants who suck well stimulate oxytocin release more efficiently, as expressed by a high oxytocin variance, leading to a better stimulation of milk production and consequently to a reduced infant weight loss 2 days after birth.

COMPARISON OF FREQUENCY OF ABNORMAL FETAL HEART RATE IN CONTINUOUS VERSUS DISCONTINUOUS USE OF OXYTOCIN INFUSION FOR AUGMENTATION OF LABOUR

Objective: To compare the frequency of abnormal fetal heart rate in continuous versus discontinuous use of oxytocin infusion for augmentation of labour. Study Design: Comparative cross sectional study. Place and Duration of Study: Department of Obstetrics and Gynaecology, Combined Military Hospital Lahore, from Feb to Aug 2018. Methodology: After fulfilling the inclusion criteria, 76 patients were equally divided in two groups A and B. In both groups, at 3 cm dilatation, intravenous infusion of 5 IU oxytocin in 500 cc normal saline was initiated at infusion rate 3.3mIU/minute Carditocography was initiated 10 minutes before infusion and then continued. An increment in infusion of 3.3mIU/minute was done every 20 minutes till 4 to 5 contractions in 10 minutes were achieved. After this, no more increment was done. The maximum rate was 30mIU/minute. Once cervix was 5 cm dilated, infusion was continued in group A and discontinued in group B for 2 hours. Fetal heart rate was noted on cardiotocography from 20 minutes before initiation of infusion till 2 hours after 5cm. Results: Age of the patients was 25.4 ± 3.5 years in group A and 26.1 ± 2.4 years in group B. Mean gestation age was 39.2 ± 1.1 weeks in group A and 38.6 ± 1.3 weeks in group B. Group A had significantly more abnormal fetal heart rate compared to group B (p=0.016). Conclusion: Discontinuous oxytocin infusion in labour showed significantly less abnormal fetal heart rate compared to continuous oxytocin infusion (p=0.016).