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High-Dose Oxytocin Protocol Implementation and Postpartum Hemorrhage
Jourdan E Triebwasser1, Evan Keil, Joanne M Bailey
1Department of Obstetrics and Gynecology, the Department of Anesthesiology, and Von Voigtlander Women's Hospital, University of Michigan, Ann Arbor, Michigan; and the Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania.
Objective:
To evaluate the association between a high-dose oxytocin protocol (60 units of oxytocin given over 1 hour) compared with our standard-of-care oxytocin protocol (30 units over 1 hour followed by 3.6 units over 1 hour) in the third stage of labor and postpartum hemorrhage (PPH).
Methods:
We performed a single-center quality-improvement study comparing rates of PPH before and after implementation of a high-dose oxytocin protocol between January 1 and July 6, 2024. Implementation steps included updating medication orders and infusion pumps and providing staff training. Births to patients with recorded quantitative blood loss were included in the analysis, except those in patients with placenta accreta spectrum or gestational age less than 24 weeks. The primary outcome, PPH, was defined as quantitative blood loss of 1,000 mL or more. The secondary outcome was quantitative blood loss. Poisson regression with robust error variance was used to calculate adjusted relative risks (aRRs) for the primary outcome, and quantile regression was used to calculate adjusted median differences in blood loss, with an a priori plan to also assess PPH by mode of delivery.
Results:
Among 2,674 births (1,309 preimplementation, 1,365 postimplementation), high-dose oxytocin compared with standard-dose oxytocin was associated with a reduction in PPH (14.3% vs 11.2%, aRR 0.77; 95% CI, 0.64-0.93) and lower median [IQR] quantitative blood loss (444 mL [240-749 mL] vs 396 mL [200-673 mL]; adjusted median difference -43 mL, 95% CI, -72 to -14 mL). By delivery mode, high-dose oxytocin was associated with a reduction in PPH among patients with vaginal births (8.5% vs 5.2%, aRR 0.60; 95% CI, 0.42-0.86), with lower median [IQR] quantitative blood loss (317 mL [153-545 mL] vs 266 mL [147-480 mL]; adjusted median difference -33 mL, 95% CI, -65 to -1 mL), but not with a reduction in PPH among patients with cesarean births (23.4% vs 21.8%, aRR 0.89; 95% CI, 0.71-1.11).
Conclusion:
Implementation of a high-dose oxytocin protocol during the third stage of labor was associated with a significant reduction in PPH, driven by a reduction among patients with vaginal births. This protocol change may be translatable to other institutions.