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Intravenous oxytocin better than intramuscular to prevent postpartum hemorrhage
Clinical Question
Is intravenous oxytocin more effective than intramuscular oxytocin to prevent postpartum hemorrhage at vaginal delivery?
Bottom line
Although some guidelines recommend intramuscular (IM) delivery of oxytocin during the third stage of labor, this study found the risk of severe postpartum hemorrhage (PPH) to be lower with intravenous (IV) bolus injection. The number needed to treat to prevent one case of severe PPH was 29 (95% CI 16 - 201) and the number needed to treat to prevent one case of blood transfusion was 35 (20 - 121). Rates of side effects were similar. 1b
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Foundation
Setting: Inpatient (ward only)
Synopsis
The authors enrolled 1075 women at term with a singleton pregnancy who were aiming for vaginal delivery. The women received (allocation concealed) 10 IU oxytocin either via IM or IV bolus injection, with matching placebo injection during active management of their third stage of labor. All women were hospitalized and 48% were nulliparous. PPH of at least 500 mL (measured via direct collection of blood and by weighing soiled materials) occurred in 19% of IM-treated women and 23% of IV-treated women (difference P =.07). However, severe hemorrhage (at least 1000 mL) was higher with IM oxytocin (8% vs 5%; P = .02). The need for blood transfusion was twice as likely with IM oxytocin (4% vs 2%; P = .005). Hospitalization longer than 3 days was not different between the 2 groups. Side effects, including tachycardia and hypotension, occurred in 4% to 5% of women and were not significantly different.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
I don't do obstetrics anymore but this is useful information. We always used to use iv oxytocin so we were apparently doing the right thing years ago.
What has not been mentioned in this review are the EKG changes commonly seen in patients given an oxytocin bolus greater than 5u. These are not routinely seen b/c most laboring patients are not hooked up to EKG leads. However, in the OR, the anaesthesiologist will never give a 10unit bolus. They will run an infusion, and/or bolus in 2-3u increments as the need arises. This is because they are watching the EKG pulse and they see these changes not infrequently with larger doses. Granted they are reversible, but a large bolus of oxytocin can cause cardiac effects that are NOT being monitored. The hypotension and tachycardia caused by a large bolus of oxytocin may also be misinterpreted as being caused by blood loss and encourage blood transfusion prematurely. IM oxytocin does not cause these same effects. It does take 10 minutes to reach full efficacy so it should be given earlier than later, but IV oxytocin boluses really should be limited to 5units
This is the fact I always know about. It is common thing that intravenous oxytocin better than intramuscular to prevent postpartum hemorrhage.
good poem
I do not practice obstetrics