Time for action- oxytocin & uterotonics are lifesaving AND
dangerous: a commentary
Marx-Delaney, et al have written an excellent article documenting high
prevalence of oxytocin misuse and associated adverse outcomes during the
intrapartum period in India. They explain how use of the Safe Childbirth
Checklist and coaching led to decreased misuse of oxytocin for
augmentation and increased use of oxytocin postpartum to prevent
postpartum hemorrhage (PPH). Both effects persisted during the six month
follow-up period during which coaching ceased. Although encouraging,
changes in behavior of women, providers and health systems will be
difficult given the long-term cultural acceptance of oxytocin use during
labour. In northern India, research between 1983-1989 by Jeffrey
(Jeffrey, et al, Labour Pains and Labour Power. London:Zed Books, 1989,
111-112) found that 15% of labouring women received oxytocin from
government pharmacists. Similarly, in Van Hollen’s 2003 study (Van
Hollen C, Medical Anthropology Quarterly, 2003, 17(1), 49-77), providers
stated that women did not just ask but demanded oxytocin in southern
India. A 2011 study in four districts in India documented augmentation
rates from 53-93%, many of which were administered via intramuscular
injection or intravenous push (Stanton, et al, IJGO, 2014, 127(1),
25-30). Augmentation rates ranging from 38% in Benin (2006) to 32% in
both Honduras and Nicaragua (2006) (Lovold, et al, IJGO, 2008, 103,
276-282) imply that high rates and misuse of oxytocin for labour
augmentation, with its documented adverse outcomes, is a global issue.
Given the widespread cultural acceptance of oxytocin use by providers
and patients alike, two significant issues are raised. First, the
well-researched and appropriate recommendations proposed in numerous
studies have been largely ignored. Second, the introduction of a new
uterotonic and the increased availability of another adds to the
complexity of the augmentation landscape, potentially exacerbating the
problem, and risk to women and fetuses.
WHO produced recommendations for labour augmentation in 2014. However,
other recommendations have not been implemented, such as ensuring
awareness of the current prevalence of augmentation and intrapartum
uterotonic use in general, and documenting maternal and perinatal
outcomes associated with these practices.
Newer uterotonics, such as misoprostol and heat stable carbetocin (HSC),
are potentially lifesaving drugs to address PPH. Neither are appropriate
for augmentation, and confusion about their intrapartum safety profile
could put women and fetuses at risk. Inadequate messaging surrounding
the recent introduction of HSC has left many believing HSC to be a 1:1
substitute for oxytocin. In reality, while an excellent choice for PPHprevention , its longer half life (30-40 minutes versus 1-6
minutes for oxytocin) makes it dangerous for augmentation.
A systematic review of induction and augmentation is currently underway
to help us understand the prevalence of these practices and the extent
of adverse outcomes. It is time that the global community creates clear,
consistent, evidence-based messaging and clinical protocols to begin to
address this problem. Countries also need to contextualize and
supplement existing research and guidelines to ensure their unique needs
are being met. Urgent action is needed to decrease the misuse of
uterotonics in labour for the health and well-being of the unborn and
their mothers.
This commentary reflects the views of the author and does not
necessarily reflect the views of the U.S. Agency for International
Development or the U.S. government.
Acknowledgements: Sincere thanks to Emma Clark, Cindy Stanton and Mary
Ellen Stanton for their reviews and edits to the Commentary