The New Pitocin Protocol - kusm

The New Pitocin
Protocol
Ben Klug, PGY-3
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Pitocin
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Oxytocin is a polypeptide hormone produced in the hypothalamus and
secreted from the posterior lobe of the pituitary gland in a pulsatile
fashion. It is identical to its synthetic analog, Pitocin.
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½ life 3-6 minutes
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HCA ½ life 10-12 minutes
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HCA= High Alert Medication= lowest possible dose that is effective
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Historically, synthetic oxytocin was diluted by placing 10 units in 1000 mL
of an isotonic solution
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Today use 60 units in 1000 mL crystalloid to allow the infusion pump
setting to match the dose administered
Oxytocin
S Contractions
S Let-down
S Social behavior
S Fear
S Trust
S Wound healing
S Autism
S Empathy
S Romantic attraction
Pitocin
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Endogenous levels= 2-4 maternal, 3 fetal= 5-7 total
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Exogenous oxytocin able to produce contractions at approximately 20
weeks of gestation, with increasing responsiveness with advancing
gestational age. There is little change in myometrial sensitivity to oxytocin
from 34 weeks to term.
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Once spontaneous labor begins, the uterine sensitivity to oxytocin
increases rapidly due to increase in myometrial oxytocin binding sites.
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Progress during spontaneous labor is not related to increasing oxytocin
concentration, uterine contractions are not associated with changes in
plasma oxytocin concentration, and hypocontractile labor does not appear
to be the result of a deficit of oxytocin.
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Inverse relationship of duration and number of available receptors (may
equal abnormal ctx patterns).
High or Low
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Protocols differ as to initial dose (0.5 to 6 mU/min), time period between
dose increments (10 to 60 minutes), and maximum dose (16 to 64
mU/minute), but success rates for varying protocols are strikingly similar.
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A literature review of randomized trials of high- versus low-dose oxytocin
regimens for augmentation or induction of labor concluded high-dose
oxytocin decreased the time from admission to vaginal delivery, but did not
decrease the incidence of cesarean delivery compared with low-dose
therapy.
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High-dose regimens are associated with a higher rate of tachysystole than
low-dose regimens and, in some studies, this has resulted in a higher rate
of cesarean delivery for nonreassuring fetal heart rate tracings, but no
significant difference in neonatal outcomes.
Timing
S Steady State- dynamic equilibrium
S 50% of steady state in 1 half life
75% in 2 half lives
87.5 % in 3 half lives
90% in 3.3
94-97% in 4-5 half lives. (clinical steady state)
Goal
S Pit increased until there is normal progression of labor, or
strong contractions occurring at two- to three-minute intervals,
or uterine activity reaches 200 to 250 Montevideo units.
S There is no benefit to increasing the dose after one of these
endpoints has been achieved.
S To continue or not continue? Conflicting evidence.
S Discontinuation prolongs labor
S No benefit of continuing once in active labor.
S No consensus reached/recommended.
Perinatal Safety Initiative
Jan. 2014
S Goal: Healthy Mom and Healthy Baby
S Understand guiding principles and standard approaches
for the safe delivery of oxytocin.
S Understand the historical perspective of the development
of the recommended guidelines and checklist for
oxytocin.
S Recognize new data supporting the standard oxytocin
practices and neonatal outcomes.
Evidence Based Medicine
S Trumps “In my experience…”
S Trumps “I feel like it today.”
S Trumps “I’m the doctor and I say so.”
S Mandates chain of command for alternative approaches
to care.
Tachysystole
Tachysystole
S By ACOG definition: greater than 5 contractions in a 10
minute period, average over 30 minute period.
S HCA definition: greater than 5 contractions in a 10 min
period, averaged over 20 minutes.
Why It Matters
S More time between contractions = more time to maximally
perfuse fetus
S SpO2 of fetus lowest at 92 sec after peak of contraction and
takes approx 90 sec to return to normal. Therefore,
contractions every 2 min or more = incomplete perfusion
S Progressive desaturation occurs with approximately 5 minutes
of tachysystole
S According to Bakker study: significantly more acidemia when
tachysystole present in labor.
Oxytocin Audit
April- September, 2013
S Each HCA facility audited designated number of consecutive
charts of women whose labors were induced with oxytocin
S Number determined to represent a statistically valid sample
size for each facility.
S Audits conducted by local, AWHONN and FHRM instructors.
S N= 14,398 charts
Compliance Parameters
S Monitoring prior to starting Pitocin
S Pelvic adequacy
S Pre-Use checklist
S In-Use checklist
S FHR tracing (95% of the time)
S Ctx tracing (95% of the time)
Outcome Parameters
S Route of delivery (SVD, OVD, or C/S)
S NICU admission
S 1 minute apgar <7
S 5 minute apgar <7
Results
Results
Importance of Results
S System compliance is suboptimal
S Non-compliance involves:
S Behavior/attitude/leadership
S Work ethic/patient load
S Knowledge deficit
S Compliance yields significantly improved outcomes
Importance of Results
S First study to document improved newborn outcomes
with the use (and proper interpretation/management) with
EFM.
S Avoids past errors of looking at diagnostic tool and
expecting it to yield therapeutic results.
S Establishes clear definition of abnormal.
S Pending peer review/publication, HCA protocol is the only
evidence-based approach to oxytocin management.
Where We Are Now
S Self Audit- 12/13
S Plan for improvement- 1/15/14
S Implement plan- Spring 2014
S Repeat 3 month audit- 4/14/14
S Goal= 95% compliance with protocol and checklists
Before We Begin…
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Pre-checklist completed
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LDR consent signed
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Signed order on chart
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Physician available
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Current H&P
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Cvx assessed & documented
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Prenatal Record
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Fetal presentation
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Indication
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Fetal assessment
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Pelvis adequate per Dr.
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Estimated fetal weight
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Gestational age
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30 min FHT, Reactive
8/8 BPP in 4 hours
No lates
No greater than 2 variables>60
sec and decreasing >60beats
In-Use Checklist
S Complete q 30 min- must be stopped if unable
S At least 1 15x15 accel in 30 min or mod var for 10 of last 30 min.
S No more than one late
S No more than 2 variables > 60sec, or decreasing 60 beats in last
30 min
S No more than 5 ctx/10min averaged over 20 min.
S No 2 ctx greater than 120 secs
S Uterus palpates soft between ctx.
S If IUPC must be less than MVU <300mm Hg, resting tone <25mm
Hg
Hard Stops
S FHR pattern does not meet criteria. If Dr. document no
variables/lates can continue. If RN not agree chain of
command. May be restarted at ½ when resolves.
S Oxygen. If resolves restart at ½.
S Continuous tracing. Interruptions >10min.
S Checklists
S Tachysystole (not irritability), decrease by at least 25%
Problems
S Same protocol, “different rules”
S New staff
S Lack of communication
S Lack of understanding of protocol
Future Data
S Rates of c/s with IOL
S Apgar outcomes
S NICU admissions
Questions?
Sources
S ACOG
S Uptodate
S HCA Perinatal Safety Initiative