Intramuscular injection, intravenous infusion, and intravenous bolus of oxytocin in the third stage of labor for prevention of postpartum hemorrhage: a three-arm randomized control trial

Abstract

BackgroundOxytocin for postpartum hemorrhage (PPH) prophylaxis is commonly administered by either intramuscular (IM) injection or intravenous (IV) infusion with both routes recommended equally and little discussion of potential differences between the two. This trial assesses the effectiveness and safety of 10 IU oxytocin administered as IM injection versus IV infusion and IV bolus during the third stage of labor for PPH prophylaxis.MethodsIn two tertiary level Egyptian maternity hospitals, women delivering vaginally without exposure to pre-delivery uterotonics were randomized to one of three prophylactic oxytocin administration groups after delivery of the baby. Blood loss was measured 1 h after delivery, and side effects were recorded. Primary outcomes were mean postpartum blood loss and proportion of women with postpartum blood loss ≥500 ml in this open-label, three-arm, parallel, randomized controlled trial.ResultsFour thousand nine hundred thirteen eligible, consenting women were randomized. Compared to IM injection, mean blood loss was 5.9% less in the IV infusion arm (95% CI: -8.5, − 3.3) and 11.1% less in the IV bolus arm (95% CI: -14.7, − 7.8). Risk of postpartum blood loss ≥500 ml in the IV infusion arm was significantly less compared to IM injection (0.8% vs. 1.5%, RR = 0.50, 95% CI: 0.27, 0.91). No side effects were reported in any arm.ConclusionsIntravenous oxytocin is more effective than intramuscular injection for the prevention of PPH in the third stage of labor. Oxytocin delivered by IV bolus presents no safety concerns after vaginal delivery and should be considered a safe option for PPH prophylaxis.Trial registrationclinicaltrials.gov #NCT01914419, posted August 2, 2013.

<p>A Randomized Control Trial of 3 IU IV Oxytocin Bolus with 7 IU Oxytocin Infusion versus 10 IU Oxytocin Infusion During Cesarean Section for Prevention of Postpartum Hemorrhage</p>

“…A large-scale study conducted in Egypt showed that IV Oxytocin bolus was more effective than IV infusion or IM injections without any significant adverse effects. 4 Other studies have shown that there is less blood loss when Oxytocin bolus is used. However, the adverse effects seen with IV bolus Oxytocin are more with doses of 10 IU or 5 IU.…”

“…20 However, doses of 3 IU have not shown to cause statistically significant hemodynamic changes. 4 Various studies have used higher doses of Oxytocin infusion of 40 IU. 21 This would lead to excessive use of Oxytocin which may be unnecessary and would lead to extra cost.…”

“…In a largescale study conducted in Egypt, it was observed that in comparison to10 IU Oxytocin IM injection, the mean blood loss was 5.9% less with 10 IU IV infusion and 11.1% less with 10 IU IV bolus Oxytocin when used as prophylaxis during vaginal delivery. 4 Other studies have shown that 5 IU of Oxytocin IV bolus was as effective as 10 IU, with lesser variation in the heart rate and blood pressure when used during cesarean section. 5 Doses of 3 IU bolus have been studied and have shown to be as effective as the 10 IU intravenous bolus doses of Oxytocin with fewer adverse effects.…”

Epidemiology, prevention and management of early postpartum hemorrhage — a systematic review

“…Economic issues should also be considered because of a higher carbetocin cost. Moreover, an intravenous administration of oxytocin was shown as more effective (due to severe EPH, blood transfusion and admission to a high dependency unit) than intramuscular administration in the 3 rd stage of labor [33]. Another trial showed acceptable outcomes of misoprostol in comparison with oxytocin, but a high price of misoprostol was emphasized [34].…”

Intravenous oxytocin bolus and infusion versus infusion alone on the blood loss during caesarean section

“…2 The recommendations are more widely accepted for vaginal delivery; and both IV infusion and IV bolus have been shown to have no safety concerns after vaginal delivery. 3 However, there are concerns about the hemodynamic changes associated with bolus dose of oxytocin during caesarean section. 4 The practice in United States is to use oxytocin infusion alone, whereas the standard practice among the obstetricians and anaesthetists in UK is the use of IV bolus 5-10 U and the Royal college of Obstetricians also recommends 5U I/V oxytocin bolus alone after cord clamping, even though oxytocin has a short half-life of 4-10 minutes.…”