Reducing Hemodynamic Variations from Oxytocin Administration during Cesarean Sections: Clinical Practice Guideline

Abstract

Problem & Purpose: Oxytocin is administered during cesarean sections to prevent uterine atony; however, oxytocin’s adverse side effects include decreased systemic vascular resistance, reflex tachycardia, arrhythmias, bradycardia, transient asystole, myocardial ischemia, and ST segment changes. In the 1990s and early 2000s, intravenous bolus doses of 10 units were commonly administered, which have led to significant hemodynamic effects and, in some cases, patient demise. Similar cardiovascular effects have been observed in the five-unit bolus dosing range. Currently, oxytocin is administered as an unregulated infusion with the potential for 20-30 units in a minimum of ten minutes. Methods used in clinical practice vary profoundly and no widely accepted oxytocin uterotonic management guideline exists. The purpose of this Quality Improvement (QI) project is to develop a Clinical Practice Guideline (CPG) that examines administration methods to reduce variable hemodynamics. Methods: This project consisted of four phases, which included: formation of a stakeholder team and CPG development using AGREE II tool feedback, dissemination of a formalized presentation, revision of the CPG using the responses elicited via the Practitioner Feedback Questionnaire (PFQ), and a confidential data analysis. Although improvements in hemodynamics were observed in clinical practice, this data was not collected or analyzed. Results: The AGREE II had high quality scoring for the overall guideline (93%). Key stakeholders recommended use of the CPG in practice. PFQ indicated an 80.7% (n=12) agreement among the questionnaires for quality, recommendation acceptance, recommendations applicability, comparative value, and outcome variables. Providers and students subjectively reported reductions in hemodynamic variability and the lack of definitive data precluded a formal analysis. Conclusion: Circumventing practice variation will mitigate hemodynamic instability and communication failures. Practitioners deemed the CPG as high quality and easily translatable to practice; however, resistance persists for widespread clinical implementation. Future recommendations include reducing these institutional barriers, performing data analyses of hemodynamic changes pre and post utilization of the CPG, and evaluating the extent of improved patient outcomes.