MATERIAL

ON
DRUGS USED
IN
OBSTETRICS

OXYTOCIN

SUBMITTED TO: SUBMITTED BY:

MADAM ( MRS. )ANUGRAH MILTON MS. MALLIKA JOON

TUTOR M.N.(P)
RAKCON RAKCON

PHARMACOLOGY:
Oxytocin is a nonapeptide. It is synthesized in the supraoptic and paraventricular nuclei of
the hypothalamus. By nerve axons it is transported from the hypothalamus to the posterior
pituitary where it is stored and eventually released.
Oxytocin has a half-life of 3–4 minutes and a duration of action of approximately 20
minutes. It is rapidly metabolized and degraded by oxytocinase.
Trade names: Pitocin, Syntocin.
Available dose: 5 units/ 1 ampule.
Action: Initiates myometrial contractions

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 mobilized from the sarcoplasmic reticulum to activate the contractile protein. The
uterine contractions are physiological, i.e. causing fundal contraction with relaxation of the
cervix.

PREPARATIONS USED:
(i) Synthetic oxytocin (Syntocinon-Sandoz or Pitocin-Parke-Davis) is widely used. It has only
got oxytocic effect without any vasopressor action.
The Syntocinon is available in ampoules containing 5 IU/mL: Pitocin 5 IU/mL.
(ii) Syntometrine (Sandoz)—A combination of syntocinon 5 units and ergometrine 0.5 mg.
(iii) Desamino-oxytocin—It is not inactivated by oxytocinase and is 50–100 more effective
than oxytocin. It is used as buccal tablets containing 50 IU.
(iv) Oxytocin nasal solution contains 40 units/mL.

EFFECTIVENESS:
In the first trimester, the uterus is almost refractory to oxytocin. In the second
trimester, relative refractoriness persists, and, as such, oxytocin can only supplement other
abortifacient agents in induction of abortion. In later months of pregnancy and during labor in
particular, it is highly sensitive to oxytocin even in small doses.
Oxytocin loses its effectiveness unless preserved at the correct temperature (between 2°C
and 8°C).

INDICATIONS:
Oxytocin may be conveniently used in pregnancy, labor or puerperium.
The indications are grouped as follows:
 Therapeutic : Diagnostic:
i. Pregnancy
ii. Labor
iii. Puerperium

 THERAPEUTIC:
Pregnancy
Early:
— To accelerate abortion—inevitable or missed and to expedite expulsion of hydatidiform
mole
— To stop bleeding following evacuation of the uterus
— Used as an adjunct to induction of abortion along with other abortifacient agents (PGE1 or
PGE2).
Late:
— To induce labor
— To ripen the cervix before induction.
— Augmentation of labor
— Uterine inertia
Labor:
— Inactive management of third stage of labor
— Following expulsion of placenta as an alternative to ergometrine.

Puerperium:
To minimize blood loss and to control postpartum hemorrhage.

 DIAGNOSTIC:
Contraction stress test: To assess the foetal wellbeing during pregnancy l mU/ min
which is stepped up at interval of 20 minutes until effective uterine contractions
established.
Oxytocin sensitivity test: To assess the irritability of uterus following administration
of oxytocin. 0.01 units of oxytocin is injected intravenously at the end of spontaneous
uterine contractions, at one minute intervals until an induced contraction starts.

SIDE EFFECTS:
Maternal
• Uterine hyperstimulation • Uterine rupture
• Water intoxication • Hypotension
• Antidiuresis • Transient hypotension
• Reflex tachycardia • Nasal irritation
• Rhinorrhoea • Lachrymation (following nasal admin)
• Uterine bleeding • Hypertonicity
• Spasm • Nausea • Vomiting.

Foetal
• Foetal distress • Foetal hypoxia • Foetal death • Jaundice • Arrhythmias • Bradycardia
• Seizure • Retinal haemorrhage • Low Apgar score

CONTRAINDICATIONS:
• Grand multipara • Contracted pelvis
• History of caesarean section • Malpresentation
• Obstructed labour • Inco-ordinate uterine contractions
• Foetal distress • Hypovolaemic state
• Contraindicated vaginal delivery (Cardiac diseases, Invasive cervical cancer, Active genital
herpes, Prolapse of the cord, Cord presentation, Total placenta previa or Vasa previa)
• Severe pre-eclamptic toxaemia

DANGERS OF OXYTOCIN:
The dangers are particularly noticed when the drug is administered late in pregnancy or
during labor.
 Maternal
 i. Uterine hyperstimulation (overactivity)—is a frequently observed side effect. There
may be excessive duration of uterine contraction (hypertonia) or increased frequency
(> 6 in 10 min time) of contractions (polysystole). It is often associated with
abnormal FHR pattern
ii. Uterine rupture—may be seen with violent uterine contractions common. High-risk
cases are: grand multipara, malpresentation, contracted pelvis, prior uterine scar
(hysterotomy) and excessive oxytocin use.
iii. Water intoxication is due to its antidiuretic function when used in high dose (30–40
mIU/min). Water intoxication is manifested by hyponatremia, confusion, coma,
convulsions, congestive cardiac failure and death. It is prevented by strict fluid
intake and output record, use of salt solution and by avoiding high dose oxytocin for a
long time.
iv. Hypotension: Bolus IV injections of oxytocin cause hypotension especially when
patient is hypovolemic or with a heart disease. Occasionally oxytocin may produce
anginal pain.
v. Antidiuresis: Antidiuretic effect is observed when oxytocin infusion rate is high (40–
50 mIU/min) and continued for a long time.

FETAL:
Fetal distress, fetal hypoxia or even fetal death may occur due to uterine hyperstimulation.
Uterine hypertonia or polysystole causes reduced placental blood flow.

ROUTES OF ADMINISTRATION
 Controlled intravenous infusion is the widely used method
 Bolus IV or IM—5–10 units after the birth of the baby as an alternative to ergometrine
 Intramuscular—the preparation used is syntometrine
 Buccal tablets or nasal spray—Limited use on trial basis.

METHODS OF ADMINISTRATION OF OXYTOCIN:

 Controlled intravenous infusion  Intramuscular
Controlled Intravenous Infusion:
Oxytocin infusion should be ideally by infusion pump. Fluid load should be minimum. It is
started at low dose rates (1–2 mIU/min) and increased gradually.

 For induction of labor

Principles:
(1) Because of safety, the oxytocin should be started with a low dose and is escalated at an
interval of 20–30 minutes where there is no response. When the optimal response is
achieved (uterine contraction sustained for about 45 seconds and numbering 3 contractions in
10 minutes), the administration of the particular concentration in mIU/minute is to be
continued. This is called oxytocin titration technique.
(2) The objective of oxytocin administration is not only to initiate effective uterine
contractions but also to maintain the normal pattern of uterine activity till delivery and at
least 30–60 minutes beyond that.

Calculation of the infused dose:

Nowadays the infusion is expressed in terms of milliunits per minute. This can give an
accurate idea about the exact amount administered per minute irrespective of the
concentration of the solution.
Regulation of the drip:
The drip is regulated by—
(1) Manually, counting the drops per minute commonly practiced.
(2) Oxytocin infusion pump which automatically controls the amount of fluid to be infused.

Convenient regime:
Because of wide variation in response, it is a sound practice to start with a low dose (1–2
mIU/min) and to escalate by 1–2 mIU/min at every 20 min intervals up to 8 mIU/min.
The patient should preferably lie on one side or in semi-Fowler’s position to minimize
venacaval compression.

High-dose oxytocin begins with 4 mIU/min and increased 4 mIU/min at every 20–30 min
interval. It is mainly used for augmentation of labor and in active management of labor. Risks
of uterine hyperstimulation and fetal heart irregularities are more with high-dose regime.

In majority of cases, a dose of less than 16 mIU/min (2 units in 500 mL Ringer solution
with drop rate of 60/minute) is enough to achieve the objective. Conditions where fluid
overload is to be avoided, infusion with high concentration and reduced drop rate is
preferred

 For augmentation of labor

Oxytocin infusion is used during labor in uterine inertia or for augmentation of labor or in the
active management of labor .The procedure consists of low rupture of the membranes
followed by oxytocin infusion when the liquor is clear. Fetopelvic disproportion must be
ruled out beforehand.
Indications of stopping the infusion
(1) Nature of uterine contractions—
(a) Abnormal uterine contractions occurring frequently (every 2 minutes or less) or
lasting more than 60 sec (hyperstimulation) or polysystole.
(b) Increased tonus in between contractions.
(2) Evidences of fetal distress
(3) Appearance of untoward maternal symptoms

NURSE’S RESPONSIBILITIES:
• Maintain the rate of flow of infusion according to the uterine response, to avoid hyper-
stimulation.
• Uterine contractions—number of contractions per 10 min duration of contraction and
period of relaxation are noted. ‘Fingertip’ palpation for the tonus of the uterus in between
contractions may be done where gadgets are not available.
• Peak intrauterine pressure should be monitored by using intrauterine pressure monitor.
Peak intrauterine pressure of 50–60 mm Hg with a resting tone 10–15 mm Hg is optimum
when intrauterine pressure monitoring is used .
• FHR monitoring should be done by auscultation at every 15 minutes interval or by
continuous electronic foetal monitoring.
• Assessment of progress of labour should be done (descent of the head and rate of cervical
dilatation)
• Help the client to use breathing exercises to manage her contractions (pain).
• After achieving the adequate number of contractions, Oxytocin infusion should be
maintained in a slow rate (<10 drops).
 Rate of flow of infusion by counting the drops per minute or monitoring the pump.