Use of oxytocin during caesarean section at Princess Marina Hospital, Botswana: an audit of clinical practice

Tsima, Billy Morara (2012-03)

Thesis (MMed)--Stellenbosch University, 2012

Thesis

ENGLISH ABSTRACT : Introduction Oxytocin is widely used as a uterotonic agent for preventing post partum haemorrhage. In the setting of caesarean section (CS) the dose and mode of administration of oxytocin differs according to different guidelines. This may be a source of uncertainty among the different prescribers of the drug. Most of the guidelines available, recommend a slow intravenous bolus of 5 international units (iu). Alternatively, an infusion of 20 iu over two hours is endorsed by the World Health Organisation (WHO). However, there have been many recent studies looking at the prophylactic use of oxytocin at caesarean section to prevent haemorrhage associated with the surgery. Although these studies have unequivocally shown that doses of oxytocin needed for prophylaxis against uterine atony at caesarean section are lower than those routinely used, many clinicians still use generally higher doses. Inappropriate doses of oxytocin have been indentified as contributory to some cases of maternal deaths. Aim The main aim of this study was to clinically audit the current standard of practice with regards to the use of oxytocin during caesarean section at a referral hospital in Botswana. Methods A clinical audit of pregnant women having a caesarean section (CS) and given oxytocin at the time of the operation was conducted over a three month period. Data including indications for CS; dose regimens of oxytocin; prescribing clinician designation; type of anaesthesia used for the CS; and estimated blood loss were collected. Results A total of 139 patients were included. A wide variety of dosing regimens were observed. The most common dose was 20 iu infusion (31.7%). The potentially dangerous regimen of 10 iu intravenous bolus of oxytocin was used in 12.9% of CS. Further doses were utilized in 57(41%) patients. The top three indications for CS were fetal distress 36(24.5%), dystocia 32(21.8%) and a previous CS 25(17%). Estimated blood loss (EBL) ranged from 50-2000 ml. General anaesthesia was the most popular type of anaesthesia used during the study, accounting for 64% compared to 36% where spinal anaesthesia was used. In emergency CS general anaesthesia was used in 81/115 (70.4%) of mothers as opposed to 8/24 (33.3%) of elective CS. Conclusion The use of oxytocin during CS in the local setting does not generally follow recommended practice and current literature. This has potentially harmful consequences such as increased maternal morbidity and mortality. Education and guidance by evidence based national practice guidelines and protocols could help alleviate the problem.

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