Optimization of Oxytocin Dosing During the Intraoperative Period: Rule of Three’s

Abstract

Problem and Purpose: Due to the lack of national guidelines for intraoperative oxytocin administration, anesthesia providers utilize various oxytocin dosing regimens during cesarean deliveries to attain uterine tonicity and prevent postpartum hemorrhage (PPH). Large, unregulated oxytocin infusions result in high serological levels of oxytocin that cause significant hemodynamic instability. The literature has demonstrated similar efficacy with less adverse side effects when using smaller and regulated oxytocin regimens, like the “Rule of Three’s. The “Rule of Three’s” provides a systematic approach to obtain uterine tonicity through small intravenous oxytocin boluses and an infusion. The purpose of this Quality Improvement (QI) project is to develop a Clinical Practice Guideline (CPG) for intraoperative oxytocin administration among the cesarean population at a tertiary Baltimore hospital. Methods: The first project phase began with the formation of a stakeholder team to design and formulate a CPG based upon an extensive literature review. The proposed CPG underwent quality review utilizing the AGREE II tool. After preliminary approval from the chief anesthesiologist (MDA), a formal presentation was conducted discussing the CPG and current evidence based oxytocin management. CPG feedback was anonymously collected through the Practitioner Feedback Questionnaire (PFQ) and revisions were made based upon the data collected. Final approval was then received from the chief MDA for institutional use. All data was analyzed using inferential and correlational statistics. Results: The CPG achieved a 93% rating for overall quality based upon the AGREE II tool, which translates to a high quality CPG that would be recommended for clinical use. The PFQ (n=12) results indicated an overall 80.7% agreement among the questionnaires for CPG’s quality, acceptance of recommendations, applicability of recommendations, comparative value, and outcome variables. Conclusion: Based upon the AGREE II tool and PFQ results, practitioners regarded the CPG as high quality with a high acceptance of recommendations into clinical practice. Limitations of the QI project includes the resistance from anesthesia providers to change current practice and lack of generalizability. Thus, the next phase of this project includes reducing these institutional barriers to sustain a practice change in order to reduce the incidence of PPH, quantitative blood loss and use of secondary uterotonic agents.