Perinatal Service Line

MATERNITY POLICY & PROCEDURE MANUAL

OXYTOCIN INDUCTION/AUGMENTATION
Policy Induction of labor is considered after evaluation of the maternal fetal status, cervical status, gestational age, and other relevant factors. Augmentation for hypocontractility is considered after evaluation of the estimated fetal weight, maternal pelvis and fetal presentation. A physician privileged to perform a cesarean birth should be readily available. Scheduling times for induction will be staggered at least one hour apart to a maximum of eight per day, seven days a week. If earlier times/bed space are available, the team leader will notify the physician of the opportunity for an earlier patient admission. If a physician order is outside the protocol, there must be a specific written order and progress note documentation as to the necessity to deviate from the protocol. Deviation from the protocol is subject to Quality Assurance Committee review. A. Indications for induction may include: Indications for induction of labor are not absolute but should take into account maternal and fetal conditions, gestational age, cervical status, and other factors. Following are examples of maternal or fetal conditions that may be indications for induction of labor: Abruptio placentae Chorioamnionitis Fetal demise (see separate procedural document) Gestational hypertension Preeclampsia, eclampsia Premature rupture of membranes Post term pregnancy Maternal medical conditions (eg, diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome) Fetal compromise (eg, severe fetal growth restriction, isoimmunization, oligohydramnios) Labor also may be induced for logistic reasons, for example, risk of rapid labor, distance from the hospital, or psychosocial indications. In such circumstances, at least one of the gestational age criteria in the box, (procedure item 3), should be met, or fetal lung maturity should be established. A mature fetal lung test prior to 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery. B. Contraindications for oxytocin induction/augmentation of labor Vasa previa or Complete placenta previa
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Transverse fetal lie Umbilical cord prolapse Previous classical cesarean delivery Active genital herpes infection Previous myomectomy entering the endometrial cavity Other maternal or fetal condition where spontaneous labor and /or vaginal birth is contraindicated.

Procedure Prior to initiation of oxytocin: 1. The woman should be counseled by her healthcare provider regarding the indications for induction or augmentation, agent(s) and method(s) to be used, potential risks and benefits; and the possibility for a repeat induction or cesarean birth. The indication for an induction should be recorded on the induction/augmentation orders. 2. In such circumstances, at least one of the gestational age criteria in the box should be met, or fetal lung maturity should be established. A mature fetal lung test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery. Ultrasound measurement at less than 20 weeks gestation supports an estimated gestational age of 39 weeks or greater. Fetal heart tones documented by Doppler for 30 weeks. 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test result

3. Initial maternal-fetal assessment should include a 30 minute reassuring fetal heart rate tracing (baseline rate, baseline variability, presence of accelerations and/or decelerations and changes of trends in the pattern over time see Fetal Monitoring policy). Confirmation of vertex presentation prior to the initiation of oxytocin. Continuous electronic fetal monitoring must be maintained with oxytocin use. 4. Oxytocin induction or augmentation should include documentation identified below: Induction: A baseline cervical evaluation within one hour prior to starting oxytocin A bishop score and estimated fetal weight performed and documented within 24hours of starting oxytocin A cervical evaluation within one hour prior to starting oxytocin Consideration by the primary care provider of estimated fetal weight

Augmentation:

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Procedure Oxytocin initiation: 1. Oxytocin concentration prepared by the pharmacy of 10 units in 500 ml of ringers lactate solution. 2. Oxytocin solution and tubing are to be labeled in the following manner. The Oxytocin solution will arrive pre-mixed from pharmacy with attached 4-part labels indicating HIGH ALERT OXYTOCIN. The labels will identify the oxytocin solution and tubing in the following manner: Large label on the solution Tubing label at the spike Tubing label at the entrance to the Alaris channel Tubing label at the port closest to the patient

3. The oxytocin solution should be intravenously piggybacked into the main intravenous line and inserted at the port nearest the venipuncture site. Other intravenous medications should not be administered via the oxytocin tubing. 4. Administration protocol: Start oxytocin infusion at 1 milliUnit/minute and increase by 1 milliUnit/minute every 30 minutes Start oxytocin infusion at 2 milliUnits/minute and increase by 2 milliUnits/minute every 30 minutes Start oxytocin infusion at 6 milliUnits/minute and increase by 3 milliUnits/minute every 30 minutes

Increase until contractions are 2-3 minutes apart and of moderate quality by palpation or 50-60 mmHg above baseline per internal uterine pressure catheter. Notify the primary health care OB provider when the infusion is at 20 milliUnits (20 milliUnits is not a maximum dose). 5. Maternal blood pressure and pulse should be monitored and recorded every 30 minutes. 6. The fetal heart rate and uterine contraction pattern should be evaluated and documented at the start of the oxytocin infusion, after any rate increase or decrease, and every 30 minutes during maintenance. 7. If uterine tachysystole ensues, the following tachysystole decision tree should be implemented:

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Administer Oxytocin drip as ordered by Primary Care Provider to achieve cervical dilation and adequate contraction pattern while maintaining a normal Fetal Heart Rate If Tachysystole develops: Contractions lasting > 2 minutes over a 10 minute period OR >5 (6 or more) Contractions in 10 minutes averaged over a 30 minute period OR Contractions occurring within 1 minute of each other over a 10 minute period Is the FHR reassuring? (Moderate variability and absence of recurrent late/variable decelerations) YES NO

Category I (Reassuring FHR Tracing) Continue to observe for approximately 30 minutes as long as FHR is reassuring Consider the following interventions: o Maternal position change o IV Fluid hydration o Increased frequency of observation o Document and report interventions

Category II / III (Indeterminate/Abnormal FHR Tracing)

Did Uterine Tachysystole resolve?

Discontinue the Oxytocin administration Notify the provider and document report and interventions used to resolve the clinical situation Interventions: o Maternal position change o IVF bolus o Oxygen at 10-12 Lpm o Increased frequency of observation o Document and report interventions

YES

NO

Continue increasing Pitocin as ordered

Consider decreasing the Pitocin by Continue to observe for an additional 30 minutes providing the FHR remains reassuring

Observe for 10-30 minutes, Pitocin may be restarted at the previous dose if FHR is reassuring and uterine activity is inadequate Consider IUPC placement

If uterine Tachysystole does not resolve after 60 minutes, notify the provider

If uterine Tachysystole reoccurs, notify provider

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Author: Perinatal Safety Team/OB/GYN Departments Approval: _________________________________________________________

OB/GYN Medical Director Date

Approval:

Department of OB/GYN January 31, 2003

References: ACOG Practice Bulletin Number 107, August 2009; ACOG Practice Bulletin No. 97, September 2008; 2008 NICHD Workshop Report Obstetrics and Gynecology Vol.112, No. 3 September 2008; MCN Oxytocin as a high-alert medication: Implications for Perinatal patient safety, volume 34(1), January/February 2009. Areas Primarily Affected: TriHealth Maternity Service Areas Implemented: Updated: January 2003; February 2003; May 2003; October 2003; December 2003; September 2006; December 2008; February 2009; September 2009; February 2010

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