Appraisal on Use of Oxytocin for the Management of Postpartum Hemorrhage in Pre Hospital Setting - Assignment Example

Critical Appraisal on Use of Oxytocic for the Management of Postpartum Hemorrhage in Pre Hospital Setting Table of Contents Introduction: 3 Review ofResearches on the Use of Oxytocic: 5 The Feasibility of Using Oxytocin: 8 Recommendation and Conclusion: 9 References: 11 Introduction: Postpartum hemorrhage (PPH) accounts for single most important cause of the maternal mortality worldwide. At least 150,000 maternal deaths caused by this disease every year. It has been seen that 99% of these deaths occur in the women of under developed or developing country who exceptionally receive prophylaxis because in most of the case, they give birth in the pre hospital condition. The main cause of the PPH is failure of the uterus to contract properly after the childbirth, which is also known as ‘Uterine atony’. In addition to the death PPH can lead to acute anemia, delay or even failure of breastfeeding, hemorrhagic shock, pituitary infarction, coagulopathy, renal failure/acute tubular necrosis, coma, prolonged hospital stay, emergency surgery or angiographic intervention, need for hysterectomy etc. In a population-based research, it has been seen that risk of PPH is 5.8% in first pregnancy whether 4-5% in a second or third time pregnancy. However, risk is more than 15% in the subsequent pregnancy. Risk of PPH and average blood loss both are greater in caesarean section operations. Postpartum hemorrhage (PPH) can be defined as blood loss of 500mL or even more during and at the time of childbirth. In most severe case, blood loss of 1000mL or more amount of blood loss, which can cause hemodynamic compromise. PPH can be divided in to two categories that are primary PPH and secondary PPH. Primary PPH can occur within the first 24 hours after birth where as secondary PPH can occur in between 24 hours to 6 weeks of postpartum. However, in most of the cases PPH fall under the primary PPH category (Kapungu, Koch, Miller & Geller, n.d.). Approximately 75% of the primary PPH cases are due to ‘Uterine Atony’. Secondary PPH is due to infection or retained products of conception. In developed countries, it becomes easy to manage in hospitals but in underdeveloped and developing country urgent PPH management is necessary. Risk of PPH can be reduced by almost 50% with administering oxytocic drugs. It has been seen that routine prophylaxis can help to reduce 70% of the need of oxytocics drug to heal excessive postpartum bleeding. Oxytocin is the most preferred uterotonic among the medical practitioners. It stimulates smooth muscle tissue of the upper part of the uterus (Lalonde & others, 2013). Oxytocin helps it to contract rhythmically. It facilitates constricting blood vessels and helps in decreasing blood flow in the uterus. It is an effective and safe choice for PPH treatment. Intravenous mode of infusion is preferred as it facilitates a steady flow of the drug in patient’s body. It has been seen that uterine response becomes normal within 1 hour of cessation of the intravenous infusion (Begley, Gyte, Devane, McGuire & Weeks, 2011). Before applying routine oxytocic, it must be checked according to potential disadvantages of different drugs under this group and its association with the chance of morbidity. The recommended dosages for oxytocin in the prevention of PPH include the following: Syntocinon: It is the most used drug for prevention of PPH. Advantages of syntocinon is it acts rapidly on patient and it does not have any side effects. Some other drugs usually have the side effects like titanic contractions, elevated blood pressure etc. This drug does not increase the duration of the third stage labor or risk of retained placenta. It can use after birth also. The usual dose of this drug is 5-10 units IM or in the case of intravenous access 5 units IV. Syntometrine: It is also known as mixture of oxytocin and ergometrine maleate. It has very less significance compared to other oxytocin where blood loss is less than 1000ml. However, this drug has some very acute side effects such as abdominal pain, vomiting, dizziness, cardiac arrhythmias, chest pain, and rash. The usual dose is 1mL IM after placental expulsion. In each milliliter of the drug, Syntometrine contains 0.5mg ergometrine maleate and 5 units of oxytocin. According to this study 10 units of oxytocin, which can intravenous or intramuscular is more effective in third stage of the labour in a hospital settings. Review of Researches on the Use of Oxytocic: Different researches on the present context have examined the effectiveness and efficiency of the drug oxytocin in the management of PPH in comparison with other drugs. A systematic review by the researcher André oxytocin can be used in active management of the third stage of labour (AMTSL). The components of AMTSL are oxytocin (15-30 0 centigrade), controlled cord traction, and uterine message after the delivery. The proposed use of uterotonic agents are the following: Within 1 minute after the delivery of the infant 10 IU of intramuscularly oxytocin is needed. Oxytocin is preferred over other medications because it has minimal side effects and can be used in all kind of women. Active management on third stage of labour was done on the women of two different areas. In active management of PPH, the study was done on 846 women, which includes only 50 PPH cases that is 5.9% of the cases were diagnosed as PPH in Bristol trial. In Hinchingbrooke trial, the percentage is bit high. 51 PPH cases were diagnosed per 748 women that are around 6.8 % (Devane et al., 2008). Another quasi-experimental study was done in two rural districts of northern Bangladesh. It has been seen that almost 50% of the people live below the poverty level. The women of two districts were given two type of care. According to the care given we can termed them as intervention group and control group. Intervention group received special maternity service, which includes services on delivery, antenatal, and post natal care, referral to the medical centres etc. However, the control group receives only education on health care and proper nutrition, family planning, sanitation and some basic remedial services. For the study sample size of 2017 women were taken, which was half from each area. Multinomial logistic regression analyses was done to analyze the effect of the drug in pre hospital setting and biological as well as socio economic condition related to it. Analysis of the experiment reveal that primary PPH occurred in around 84 women that is around 4.2 % according to the study. However, primary PPH was found in the intervention group. However, delivery done by skilled attendants and use of the drug oxytocin before as well as after the delivery was very common and found in higher percentage in the control area than in the intervention area. Median risk of PPH was lower in the intervention group. Outcome of the result is considered as consistent with the situation of other low-income countries as well such as India, Nepal, Srilanka, Indonesia. It can be concluded from the above experiment that delivery with unskilled birth attendants and in pre-hospital setting were higher in rate in the intervention area. Therefore, they should be educated about the proper timing of administering oxytocin or misoprostol drug to prevent PPH (Nahar, Al Mamun, Afsana, Byass & others, 2011). In another systematic study done by Blum et al (2010), researchers argued on the effectiveness of the drug oxytocin and misoprostol. The aim of this research was to establish that the administration of 800 µg sublingual misoprostol could be used as alternative to that of 40 IU intravenous oxytocin. Here sample size was 809 women suffering from PPH and 407 of them were treated with misoprostal whether 402 of them were treated with oxytocin. It has been seen that there were mostly no difference in the outcome. However, shivering and fever were very common among the women who received misoprostol (Blum et al., 2010). Buekens and Althabe (2010) did another study, which examined effect of misoprostol and oxytocin in the prevention of Post-partum Haemorrhage. Reviews of the research shown that oxytocin can reduce the risk by 50% where as misoprostolalso reduce the risk but comparatively lower than that of oxytocin. Therefore, Oxytocin becomes the drug of choice. The author has done the research in hospital setting. It has been seen that the risk of 300 ml additional blood loss is more frequent with the misoprostal than that of oxytocin. Therefore, the researcher confirmed that misoprostol could be used only if oxytocin is not available. The researcher also suggested that as a new approach use of multiple uniject IM injections should be explored (Buekens & Althabe, 2010). In yet another systematic review involving researcher Winikoff and his team aimed on to prove non-inferiority of the drug misoprostol (800 µg) compared with the drug IV oxytocin (40IU). The research was done in 4 hospitals of Ecuador, Egypt and Vietnam. Sample size was 978 women with the primary PPH, 488 women were treated with misoprostol whether 490 were treated with the drug oxytocin. However, this study was set in hospitals but administration and facilities were of very poor condition. Women with blood loss above 700 mL were treated with 800 µg or 40IU oxytocin. It has been seen that within 20 minutes active bleeding was stopped for 90% of the women treated with misoprostol and for 96% of the women treated with oxytocin. It can be concluded from the study that oxytocin performed better on several measures than Misoprostol. It was also found that in both treatments women responded faster if there uterus is not previously treated with oxytocin for prophylaxis (Winikoff et al., 2010). The Feasibility of Using Oxytocin: The Uniject system of oxytocin comprises single dose, non-reusable, pre-filled packages of oxytocin. The uniject offers many advantages over other mode of administration of the related drugs, which are the following: Single dose: To facilitate use for individual patient Non-reusable: To diminish threat of contamination Prefilled: To ensure the correct dose Compact size: For easy transport and storage Studies done to evaluate the feasibility of uniject oxytocin are administered in poor country. From the findings of another research (Prata, Gessessew, Abraha, Holston & Potts, 2009), maternal mortality rate in Ethiopia is highest among the world. With around 676 deaths happened every year on per 100000 live births. Almost 90% of the births occur at home. Around 10% of those maternal deaths is attributed to PPH. It was further estimated that the traditional birth attendant does 28 % of the delivery and 5% of the delivery are happened without any type of medical assistance. To facilitate PPH care in pre –hospital setting or without any medical assistance injectible oxytocin can be recommended. Oxytocin is more effective than other drugs in preventing PPH. Some of the advantages are following: It can be used for home births. It can be used by highly trained or even less trained health care attendants. It can be used at the time of active management of the third stage of labour or even when skilled health care attendant is not available. It can be used for any kind of management of PPH. It can be used in the areas with limited health care Infrastructure and related facilities. Conventional injection that is ampoules and needles is necessary for oxytocin administration. It requires special storage especially in tropical climate to maintain its stability in remote areas of low-income country. To promote safe medications disposable prefilled syringes are preferred. Preventing PPH in the rural area of oxytocin in uniject by using TBAs or HEWs can be two potential solutions that can be more feasible. Recommendation and Conclusion: Pregnancy and childbirth both involve significant risks. The world health organization estimated that every year around 515,000 women died from suffering pregnancy related complications (Taylor, Delorme & Miller, n.d.). Based on the findings of the studies reviewed in the abovementioned discussions, It is evident that oxytocin is an effective uterotonic agent for the management of PPH in pre-hospital as well as in the hospital. It has been seen that there are many limitations present in the feasibility of using oxytocin. It is here by recommended that, the health care providers should learn necessary mechanism to administered oxytocin. Storage condition in tropical area should be maintained otherwise drug effectiveness would be decreased. Health care providers need to make sure that there is adequate stock of uniject oxytocin and injection safety materials to facilitate the treatment for the women who gives birth at home (Stanton et al., 2009). The use of oxytocin in pre-hospital setting is become achievable due to use of uniject oxytocin which is a easy to use, simple, prefilled injection device that facilitate the administration of preventing PPH and can be attend by a less educated health care provider without compromising the quality of the service. In conclusion, it is important to note that further research is needed to develop a process, which will enable the family member of the patient to administer the drug if necessary. Review is needed to maintain quality and in the distribution of heat sensitive drugs. Further assessment is needed to evaluate the cold storage capacity especially in tropical country for heat sensitive drug like oxytocin. Factors such as affordability, competing priorities, safety needed to be thoroughly analyzed to promote oxytocin application for the treatment of postpartum hemorrhage. References: Begley, C., Gyte, G., Devane, D., McGuire, W., & Weeks, A. (2011). Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev, 11. Blum, J., Winikoff, B., Raghavan, S., Dabash, R., Ramadan, M., & Dilbaz, B. et al. (2010). Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double-blind, randomised, non-inferiority trial. The Lancet, 375(9710), 217--223. Buekens, P., & Althabe, F. (2010). Post-partum haemorrhage: beyond the confrontation between misoprostol and oxytocin., (375(9710):176-8.). Devane, D., Begley, C., Murphy, D., Gyte, G., McDonald, S., McGuire, W., & others,. (2008). 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