Ostentatious Oxytocin: A High Alert Medication

Purpose for the program: The primary goal of implementing a low dose pitocin regimen is stimulation of contractions that are normal in intensity, duration, and frequency while avoiding tachysystole and its’ potentially harmful sequelae.  Additional goals are less overall Pitocin administration, concerning FHR (fetal heart rate) patterns, risk of CS (cesarean section) for concerning FHR patterns and liability exposure and risk without clinically significant longer labor or increased risk of CS for labor dystocia

Proposed change: Standardized policy (across a 9 hospital system) for a 1:1 concentration of Pitocin preparation, IV titration, definition of tachysystole, and treatment of Pitocin-induced tachysystole guided by fetal status.  Key points of the new policy are to administer the lowest dose possible to achieve cervical change and labor progress, starting at 0.5 – 1 mU/min and increase by 1-2 mu/min q 30-40 minutes (~90% women at term will have a successful induction with < 6 mU/min), titrating dosage to fetal response and uterine activity/labor progress, no need to increase dosage if labor is progressing at 1 centimeter/hour, utilizing checklists addressing specific safety criteria prior to the initiation of pitocin and every thirty minutes during administration of the medication, avoiding uterine tachysystole, treating it in a timely manner if it occurs, clear definition of tachysystole (> 5 contractions in 10 minutes) and interventions when it is encountered: interventions aren’t delayed until the FHR is concerning, treatment regimens are outlined for Pitocin-induced tachysystole with  normal and concerning FHR patterns, and resumption of Pitocin after tachysystole resolution.

Implementation, outcomes and evaluation: Policies were revised, pitocin checklists were added to the obstetrical electronic documentation system, and providers and nurses were educated by nurse and physician perinatal safety champions at all nine facilities.  After implementation of the low dose regimen, the average length of labor for a primigravida was 9.19 hours, compared to 10 hours prior to implementation.  Multipara’s average length of labor was  6.40 hours, compared to 7.8 hours before the low dose protocol.  The incidence of tachysystole went from an average of 45% for all women on Pitocin across the facilities, to a mean of 23% following implementation of the low dose Pitocin regimen.

Implications for nursing practice: Use of conservative, specific protocols and checklists for monitoring effects of pitocin on mother and fetus improves outcomes without significantly lenthening labor.  Implementation of these guidelines is appropriate in a culture increasingly focused on patient safety.

Keywords: Pitocin, oxytocin, low-dose, tachysystole