Oxytocin

Oxytocin is the hormone that causes contractions.

Oxytocin (trade names Pitocin and Syntocinon) has long been used as the standard agent for labor
induction but doesn’t work well when the cervix is not yet ripe.

In addition to being used alone to induce labor, the misoprostol may be used in conjunction with
oxytocin.

A synthetic version of oxytocin is given to women when contractions do not start naturally, Oxytocin
is given through a drip and enters a vein in the arm.

Labour is induced or augmented using intravenous oxytocin (syntocinon) infusion.

The use of oxytocins is expected to expedite birth with clinically indicated.

Oxytocin 2.5 units are usually mixed with 500 ml of normal saline or ringer's lactate given as an
intravenous infusion.

Gradually increasing the rate of infusion until good labor is established.

The dose is regulated with the adjustment of the IV drip running time i.e. in drop per minute.

Mode of action
Myometrial oxytocin receptor concentration increases maximum (100-200 fold) during labor.

Oxytocin acts through receptor and voltage-mediated calcium channels to initiate myometrial
contractions.

It stimulates amniotic and decidual prostaglandin production.

Bound intracellular calcium is eventually nobilized from the sarcoplasmic reticulum to activate the
contractile protein.

The uterine contractions are physiological, i.e. causing fundal contraction with the relaxation of the
cervix.

Preparation
Synthetic oxytocin (syntocinon or Pitocin) is available in ampoules containing 5 IU/ml ampoule

Syntometrine: A combination of syntocinon 5 units and ergometrine 0.5 mg

Oxytocin nasal solution contains 40 units/ ml.

Route of administration
Controlled IV infusion for induction and augmentation of labor and management of PPH (20-40 units
in 1000ml).

Intramuscular 10 units as a routine for active management of the third stage of labor.

Indication
Oxytocin may be used in pregnancy, labor, or puerperium. The indications are:

 Therapeutic
 Diagnostic

Therapeutic
 In early pregnancy:
o To accelerate abortion
o To stop bleeding following the evacuation of the uterus
o Used as an adjunct to induction of abortion along with another abortifacient
agent (PGE1 or PGE2)
 In late pregnancy:
o To induce labor
 In labor:
o Augmentation of labor
o Uterine inertia
o Inactive management of the third stage
o Following the expulsion of the placenta
 In puerperium:
o To minimize blood loss and to control postpartum hemorrhage
o Management of atomic postpartum hemorrhage

Diagnostic
 Contraction stress test (CST)
 Oxytocin sensitivity test (OST)

Contraindication
 In later months of pregnancy:
o Grand Multipara
o Contracted pelvis
o History of cesarean section or hysterotomy
o Malpresentation
 During Labour
o All the contraindications of pregnancy
o Obstructed labor/ cephalopelvic disproportion
o Hypertonic uterus
 o Uncoordinated uterine contraction
o Fetal distress
 Any time:
o Hypovolaemic state
o Cardiac disease
o Hypersensitivity reaction

Risk and side effect of intravenous oxytocin

 Foetal hyposis and asphysia (Fetal distress)
 Uterine hyperstimulation (overactivity) or tonic uterine contraction
 Increased risk for uterine rupture: uterine rupture causes are if wrong selection (multigravida
or previous cesarean section), overdose, improper supervision, hypersensitivity of the uterus.
 Water intoxication/ Fluid retention due to the mild antidiuretic effect of oxytocin.
 Postpartum hemorrhage.
 Amniotic fluid embolism.
 Failed induction with the need for repeat induction or possibly cesarean.
 Injury of the fetus due to precipitate labor.

Equipment of IV Oxytocin infusion

 IV set with IV cannula size 18.
 IV fluid 500 ml of Ringer's lactate or normal saline.
 Injection oxytocin (syntocinon) 2.5 units' ampoules.
 Syringe 2 or 5 ml with needle.
 Spirit or betadine and cotton swabs.
 Tourniquet
 Scissors
 Leucoplast

Procedure of oxytocin infusion

 Monitor the woman's pulse, blood pressure. If the maternal pulse is rapid (110 or more) and
weak, perform a rapid evaluation of the general condition of the woman.
 Check and record the contractions and the fetal heart rate.
 Explain to the woman and her family what you are going to do.
 Obtain oral informed consent from the woman before proceeding.
 Review for indications.
 Perform abdominal palpation to conform to fetal lie and presentation.
 Encourage the woman to empty her bladder and bowel.
 Vaginal examination before starting the syntocinon infusion and record the finding.
 Ensure that the woman is lying on her left side.
 Remove the sleeve of the woman's arm on which you want to place the IV drip.
 Look for a good vein, choose a vein on the lateral aspect of the forearm or the dorsum at the
hand.
 Apply a rubber tourniquet over the arm above the site you intend to insert the needle.
 Clean the puncture site with a betadine swab. Do not touch the site with unclean fingers after
swabbing.
 Hold the cannula with the bevel facing up. Insert the cannula obliquely at a shallow angle the
skin, and enter the vein.
 Push it in 1 to 2 cm. Once the blood is observed to flow into the cannula, gently push in the
needle a few more millimeters before proceeding further.
 Push the outer cannula into the vein without inserting the needle further.
 Remove the needle.
 Attach the giving set, to the cannula. Tape the cannula and tube with leucoplast.
 Connect the IV set to the bottle.
 Set up the bottle on the stand and let the fluid flow into the tube of the IV set.
 Start 10 drops per minute.
 Add 2.5 units of oxytocin into a bottle in 500 ml of Ringer lactate or normal saline and label
on the bottle. Add the loaded syntocinon to the intravenous bottle after adjusting the drops per
minute. A sudden increase or decrease in syntocinon concentration may lead to an abnormal
uterine contraction.
 Return the articles to the proper place.
 Monitor and record the following every 30 minutes:
o Rate of infusion of oxytocin.
o Duration and frequency of contractions.
o Fetal heart rate:
Listen every 30 minutes, always immediately after a contraction. If the fetal heart
rate is abnormal (less than 100 or more than 180 beats per minute), stop the infusion
and manage for fetal distress.
o Maternal pulse:
If the maternal pulse is rapid (110 or more) and weak, perform a rapid evaluation of
the general condition of the woman including vital signs (pulse, blood pressure,
respiration, temperature).
 Increase the infusion rate by 10 drops per minute every 30 minutes until a good contraction
(three contractions in 10 minutes, each lasting more than 40 seconds) pattern is established
but not more than 60 drops.
 If there is a good contraction pattern established (three contractions in 10 minutes, each
lasting more than 40 seconds), maintain the same rate until delivery.
 If the fetal heart rate is abnormal (less than 100 or more than 180 beats per minute), stop the
infusion and manage fetal distress.
 If there are more than four contractions in 10 minutes, or if any contraction lasts longer than
60 seconds, stop the infusion, and manage as hyperstimulation.
o Discontinue oxytocin infusion immediately.
o Relax the uterus using tocolytics. Terbutaline 250 microgram (mcg) IV slowly over
five minutes or Salbutamol 10 mg in 1L in fluid (normal saline or Ringer's lactate) at
10 drops per minute.
o Place the mother in the left lateral position.
o Monitor closely the fetal heart rate and its pattern and record.
o Give oxygen to women.
o Inform the doctor on duty.
  If a good contraction pattern has not been established with the infusion rate at 60 drops per
minute.
o Increase the oxytocin concentration to 5 units in 500ml of Ringer lactate or normal
saline and adjust the infusion rate to 30 drops per minute.
o Increase the infusion rate by 10 drops per minute every 30 minutes until a good
contraction pattern is established or the maximum rate of 60 drops per minutes
reached.
o If labor still has not been established at a maximum of 60 drops of oxytocin after
four hours and her labor is not progressing according to the partograph. Plan to
transfer to CEOC site.
 In primigravida:
If a good contraction pattern still has not been established using the higher concentration of
oxytocin (10 units in 500ml).
 If good contractions are not established at the maximum dose, deliver by cesarean section.
 In multigravida and women with previous cesarean scars, induction has failed delivery by
cesarean section.
 Syntocinon drop should be continued for at least 1 hour after the placenta is expelled.

Advantages
 Wider availability.
 It has rapid action and does not cause side effects in most cases.
 Less systemic side effects.
 Cheaper