Nurses Introduce Oxytocin Checklist to Push “the Pit” Safely and Effectively

How you administer oxytocin to push “the pit” matters, according to Jill H. Mahony, MSN, APN, WHNP-BC, RNC-OB, a perinatal clinical nurse specialist, and Deborah Moorhouse, BSN, RN-BC, a staff registered nurse (RN), Capital Health System, Trenton, NJ. They presented at the Association of Women’s Health, Obstetric and Neonatal Nurses annual meeting a new checklist they use at their tertiary perinatal center to ensure the safe administration of this high-risk drug.

They followed a protocol developed by Clark and colleagues (Am J Obstet Gynecol. 2007;197:480.e1-480.e5) to determine if it would help improve maternal and fetal outcomes.

“We wanted to use a checklist to make induction and labor safer,” Ms Mahony said. “Oxytocin is a high-risk medication and not a numbers game. Without a standardized approach, you are throwing the dice. The risk is fetal deoxygenation and possible compromise.”

The leading cause of obstetric liability is oxytocin administration leading to hyperstimulation and fetal injury. “This is completely preventable,” she said. “And it is part of the inspiration for our research.”

Ms Mahony explained that the therapeutic index of oxytocin is complex. In the presence of higher doses, the drug’s half-life shortens. When it comes to oxytocin, “less is more,” she emphasized. “Most women at term have a successful induction with 6 mU/min or less.”

You want to achieve a steady state in which the rate of administration equals the rate of elimination. The necessary time interval to achieve a steady state with the recommended physiologic regimen is at least 30 to 40 minutes. If the dose is increased before a steady state is achieved, uterine tachysystole and fetal decompensation can occur.

“You have to balance the amount [of oxytocin] needed to cause contractions with the amount that will cause toxicity,” she said. “Few drugs are so unpredictable. Before you increase the dose, you need evidence that your current rate is ineffective.”

Oxytocin Management Checklist “The oxytocin checklist is not intended to hinder progress in labor, but to enhance the safe use of oxytocin,” Ms Moorhouse added. It also helps the labor nurse maintain established criteria for safe titration, promotes critical thinking, and improves collaborative communication among the obstetrical team.

Before administering oxytocin, the nurse first assures that several factors have been documented in the chart— order, history and physical, and prenatal record; gestational age; indication for induction; adequacy of pelvis; cervical examination; vertex presentation; estimated fetal weight by clinical examination or ultrasound; signed consent; and awareness of physician, who is readily available.

The nurse makes sure that in the previous 30 minutes the fetal heart rate pattern has shown at least 1 of the following:

• ≥2 Accelerations (15 bpm x 15 sec) OR
• A biophysical profile of 8/10 within the past 4 hours OR
• Moderate variability.

There must also be no late decelerations and ≤2 variable decelerations >60 seconds and decreasing >60 bpm from baseline. If these cannot be verified, then the preoxytocin checklist cannot be completed and the drug cannot be initiated.

Once oxytocin is started, the ongoing management checklist is used to ensure safe administration (Box). If any of the assessment criteria cannot be satisfied for the previous 30-minute time-frame, then the oxytocin rate cannot be increased. “There are no exceptions,” Ms Moorhouse stressed.

The nurse completes this checklist every 30 minutes, assesses maternal– fetal status every 15 minutes, and documents every change in dosage. If there is no change, this is noted every 30 minutes as well. If the oxytocin is stopped, another preoxytocin checklist must be completed before it is restarted.

Since instituting the protocol, the nurses have used a lower initial oxytocin dose, starting at 1 mU/min and increasing by 2 mU/min every 30 minutes. The checklist is now mandatory for all physicians, nurse midwives, and labor-skilled RNs at their center.

Outcomes have improved with the institution of this checklist, Ms Mahony reported. The length of labor and cesarean rates have not increased, and mean peak doses of oxytocin have decreased significantly. In addition, mean episodes of nonintervened uterine tachysystole have declined sig nificantly, from 1.4 mU/min to 0.5 mU/min, she said.

“We use less oxytocin for an effective delivery,” Ms Mahony said. “We believe the protocol-driven safety checklist for oxytocin administration should be used for every labor induction and augmentation