SEMINAR

ON
OXYTOCIN
AND
TOCOLYTIC
AGENT

SUBMITTED TO : SUBMITTED BY
MRS.BHUVANESWARI,MSC (N) MRS.DHIVYA BHARATHI.B
ASSISTANT PROFESSOR MSC (N) I ST YEAR
PGP COLLEGE OF NURSING PGP COLLEGE OF NURSING
NAMAKKAL. NAMAKKAL.

SUBMITTED ON :
Oxytocin and Tocolytic
agent

Oxytocin (Pitocin)

INTRODUCTION:

Oxytocin is a natural hormone that manages key aspects of the

female and male reproductive systems, including labour and
delivery and lactation, as well as aspects of human behaviour.
Your hypothalamus makes oxytocin, but your posterior
pituitary gland stores and releases it into your bloodstream.
Hormones are chemicals that coordinate different functions in
your body by carrying messages through your blood to your
organs, muscles and other tissues. These signals tell your body
what to do and when to do it.
Your hypothalamus is the part of your brain that controls
functions like blood pressure, heart rate, body temperature and
digestion.
Your pituitary gland is a small, pea-sized endocrine gland
located at the base of your brain below your hypothalamus.
Definition:
Oxytocin is a hormone secreted from the posterior
pituitary gland used to help start or continue labour and to
control bleeding after delivery. It is also sometimes used to
help milk secretion in breast-feeding. Oxytocin has a half life
of 3-4 minutes and a duration of action of approximately 20
minutes.It is rapidly metabolised and degraded by
oxytocinase.

Types of oxytocics:

A) Syntocinon :
Syntocinon is a synthetic form of the natural oxytocin
produced by the woman's anterior pituitary gland in the brain.
It is the same drug given to induce labour or augment a slow
labour, but it is given in one injection into the woman's thigh
and in a much higher dose for managing the 3rd stage (rather
than in gradual, small doses through a drip in the vein when
inducing or augmenting the labour). Syntocinon makes the
uterus contract within 2 to 3 minutes after being given as an
intramuscular injection into the woman's thigh and will last up
to 5 to 10 minutes.

B) Ergometrine:
Ergometrine , known as 'Ergot' is an ergot alkaloid
medication. It became routine to use it to treat postpartum
haemorrhage (PPH). It is an uterotonic drug that increases the
tone of the uterine muscles, causing stronger, more frequent
and sometimes sustained contractions of the uterus.
Ergometrine takes about 5 to 7 minutes to start working after
being given as an intramuscular injection into the thigh,
stimulating the uterus to contract almost continuously for up
to 2 to 4 hours.

C) Syntometrine :
Syntometrine is a mix of Syntocinon and ergometrine, and
became popular for routine use during the 3rd stage of labour.
It contains 5 units (5IU) of Syntocinon and 500 micrograms
(500 mg) of Ergometrine. If given intramuscularly the
Syntocinon will act within 2 to 3 minutes (lasting 5 to 10
minutes) and the ergometrine within 6 to 7 minutes (lasting 2
to 4 hours). When combined, their action makes the uterus
contract sooner and sustains more intense contractions for a
longer period of time after the birth.

Dosage and Routes of administration

A) Dose for Induction:
➔ Initial dose: 0.5 to 1 milliunits IV infusion per hour.
B) Dose for Postpartum Bleeding:
➔ 10 to 40 units IV infusion in 1000 mL at a rate
sufficient to control bleeding.
➔ 10 units IM after delivery of placenta.
C) Dose for Abortion:
➔ After suction or sharp curettage for an incomplete,
inevitable or elective abortion: 10 units in 500 mL IV
infusion.
➔ Adjust rate to assist uterus in contraction.

METHODS OF ADMINISTRATION:
➢ Controlled intravenous infusion:
 Oxytocin infusion should be ideally by infusion
pump.fluid load should be minimum. It is started at low
dose rates(1-2mIu/min)and increases gradually.
*For induction of labour
*For augmentation of labour

For induction of labour :

Principles:
1. Because of safety ,the oxytocin should be started with
a low dose and is escalated at an interval of 20-30
minutes where there is no response .
2. The objective of oxytocin is not only to initiate
effective uterine contraction but also to maintain the
normal pattern of uterine activity till delivery and at
least 30-60 minutes beyond that.

Calculation of the infused dose:

Infusion is expressed in terms of milliunits per
minute. This can give accurate idea

Regulation of the drips:

1. Manually counting the drops per minutes
2. Oxytocin infusion pump

Convenient regime:
It is a sound practice to start with a low dose (1-2mU/min)and
to escalate by 1-2 mIU/min at every 20 min.interval up to 8
mU/min.
For augmentation of labour:
Oxytocin infusion is used during labour in uterine inertia or for
augmentation of labour or in the active management of labour
.
● Observation during oxytocin infusion
★ Rate of flow of infusion by counting the drops per
minutes or monitoring the pump.
★ Uterine contraction- number of contraction per 10
min duration of contraction and period of relaxation
are noted ‘finger tip ‘ palpation for the tonus of the
uterus in between contraction may be done where
gadgets are not available .
★ Peak intrauterine pressure of 50 - 60 mm hg with a
resting tone 10-15 mm hg is optimum when
intrauterine pressure monitoring is used.
★ FHR monitoring is done by auscultation at every 15
min interval or by continuous EFM.
★ Assessment of progress of labour.

➢ Intramuscular

Physiologic and pharmacologic effect:

1- Uterine stimulation
2- Milk ejection
3- Water retention

DIAGNOSTIC:
● Contraction stress test(CST)
● Oxytocin sensitivity test(OST)
Indication of oxytocics:
Pregnancy:
1. To induce abortion (inevitable, missed).
2. To expedite expulsion of hydatidiform moles.
3. For the oxytocin challenge test.
4. To stop bleeding following evacuation
5. To induce labour.
Labour:
1. To augment labour
2. In uterine inertia.
Postpartum:
1. To prevent and treat postpartum haemorrhage
2. To initiate milk let-down in breast engorgement.

Contraindications:
Oxytocin is contraindicated in any of the following
conditions:
● Significant cephalopelvic disproportion
● Unfavourable foetal positions or presentations i.e.,
transverse lies.
● In obstetrical emergencies where the benefit for either
the foetus or the mother favours surgical intervention.
● In cases of foetal distress.
● Hypertonic uterine patterns.
● Patients with hypersensitivity to the drug.
● Induction or augmentation of labour in those cases
where vaginal delivery is contraindicated, such as cord
 presentation or prolapse, total placenta previa, and vasa
previa.

Side effects and toxic effects :

MATERNAL
● Water intoxication may occur when large doses of
oxytocin have been infused for long periods.
● Allergic reactions may occur.
● Oxytocin can cause maternal death due to uterine
rupture.
● Hypotension Hypertensive crisis and cerebral
haemorrhage.
● Pelvic hematomas, bradycardia, and arrhythmias also
occur.
FOETAL
● Arrhythmias may also occur in the foetus, and foetal
death.
● Foetal distress

Nursing intervention for women taken oxytocin :

1- Monitor FHR and uterine contraction for (frequency,
duration, intensity of contraction and resting tone).
2- Check blood pressure and pulse.
3- Once the desired frequency of contractions has been
reached labour has progressed to 6 cm dilatation,
oxytocin may be reduced by similar increment.
4- If hyper stimulation of the uterus occurs or non-
reassuring FHR pattern occur, following action are taken:
 ➢ Turn off oxytocin.
➢ Change position (left lateral position).
➢ Give an oxygen mask.
➢ Monitoring of foetal heart rate.

Tocolytic agents
Definition :
Tocolytics (also called anti-contraction medications or labour
suppressants) are medications used to suppress premature
labour

Types
Several different classes of drugs are used for tocolysis,
including:

1. Betamimetics (such as terbutaline)

2. Magnesium sulphate
3. Prostaglandin inhibitors (like indomethacin, ketorolac)
4. Calcium channel blockers (such as nifedipine)
5. Nitrates (like nitroglycerine)
6. Oxytocin receptor blockers (such as atosiban)

Action and uses:

 Relax the uterus and arrest threatened abortion or delay
premature labour.

1. Betamimetics :
i)Terbutaline
ii)Ritodrine
iii) Isoxsuprine

Mechanism of action:
Activation of the intracellular enzymes reduces intracellular
free calcium and inhibits activation of MLCK
Reduced interaction of actin and myosin leads to smooth
muscle relaxation receptor stimulation causes smooth muscle
relaxation.

Dose :
Ritodrine is given by infusion ,50 ug/min and is increased by
50 ug every 10 min until contraction ceases.
Terbutaline has longer half life and has fewer side effects
subcutaneous injection of 0.25 mg every 3 to 4 hours is given

Side effects and precaution:

Maternal : headache ,palpation ,tachycardia , pulmonary
oedema, hypotension,cardiac failures, hyperglycemia,ARDS,
hyper-insulinaemia, lactic acidaemia, hypokalaemia and even
death
Fetal : tachycardia ,heart failure , IUFD.
Neonatal : hypoglycaemia and intraventricular haemorrhage .
2. Magnesium sulphate :
 Mechanism of action
It acts by competitive inhibition to calcium ion either at
the motor end plate at the cell membrane reducing
calcium influx.decreases acetylcholine releases and its
sensitivity at the motor end plate.Direct depressant action
on the uterine muscle.
Doses
Loading dose 4-6 g IV over 20-30 min followed by an
infusion of 1-2 g/hr leads to continue tocolysis for 12 hrs
after the contraction have stopped .Tocolytic effect is
poor.
Contraindication
Myasthenia gravis
Impaired renal function.
Side effects
Maternal side effects
Flushing ,perspiration headache and muscle
weakness,rarely pulmonary oedema.
Neonatal side effects
Lethargy ,hypotonia, rarely respiratory depression.
3. Prostoglandin inhibitor
i)Indomethacin
ii)Sulindac another NSAID is also used as it has less
placental.
Mechanism of action : Reduces synthesis of
prostoglandins there by reduces intracellular free calcium
,activation of MLCK and uterine contraction .
Doses
 Loading dose 50 mg or PR followed by 25 mg every 6
hrs for 48 hours.
Contraindication
Hepatic disease, active peptic ulcer, coagulation disorder.
Side effects
Maternal side effects
Heart burn, asthma , GI bleeding , thrombocytopenia ,
renal injury.
Fetal and neonatal side effects
Contriction of the ductus arteriosus
,oligohydraminos,neonatal pulmonary
hypertension,IUGR.

4.Calcium channel blockers (Nifedipine)

Causes relaxation of myometrium
Markedly inhibits the amplitude of spontaneous and oxytocin-
induced contractions.
Mechanism of action
Nifedipine blocks the entry of calcium inside the cell.it is
equally effective to mgso4
Doses
Oral (not sublingual)
10-20 mg every 3-6 hours
Side effects
Hypotension, flushing, headache and nausea

Side effects
1. Hypotension
2. Flushing
 3. Constipation
4. Ankle edema Coughing, Wheezing be careful with
asthmatic pts.
5. Tachycardia
6. Dizziness, Headache

5.Nitrates (like nitroglycerine)

Mechanism of action
Smooth muscle relaxant
Doses
Patches
Side effects
Cervical ripening ,headache

6.Oxytocin receptor blocker :

● New tocolytic agent, expensive, not used widely.
● Compete with oxytocin at its receptors on the uterus.
● Given by IV infusion for 48 hrs (long)
● May be less effective as tocolytic than β2 agonists.
● It is better tolerated than β2 agonists, especially with
regards to cardiovascular side effects and may be a useful
alternative.

Contraindications to tocolysis
1. Foetus is older than 34 weeks gestation
2. Foetus weighs less than 2500 grams or has intrauterine
growth restriction (IUGR) or placental insufficiency
3. Lethal congenital or chromosomal abnormalities
4. Cervical dilation is greater than 4 centimetres
5. Chorioamnionitis or intrauterine infection is present
6. Mother has severe pregnancy-induced hypertension,
eclampsia/preeclampsia, active vaginal bleeding, placental
abruption, a cardiac disease, or another condition which
indicates that the pregnancy should not continue.
7. Other causes of foetal distress or foetal death.

Side effects :
Maternal side effects :
● Metabolic hyperglycemia
● hyperinsulinemia
● hypokalemia
● antidiuresis
● altered thyroid function
● physiologic tremor
● palpitations
● nervousness
● nausea or vomiting, fever, hallucinations

Foetal and neonatal side effects:

● Neonatal tachycardia
● hypoglycemia
● hypocalcemia
● hyperbilirubinemia
● hypotension
● intraventricular haemorrhage

Nursing considerations:
 ➔ Assess Maternal and foetal heart tones during infusion.
Intensity and length of uterine contractions
➔ Fluid intake to prevent fluid overload, discontinue if this
occurs.
➔ Positioning of patient in left lateral recumbent position
to decrease hypotension and increase renal blood flow.
➔ Evaluate therapeutic response: length of contraction,
absence of preterm labour, decreased BP.

Conclusion
The most commonly administered drugs to the parturient and
other obstetric patients The varied pharmacological actions of
these drugs and their possible interactions with anaesthetic
agents, make them of significant importance from
anaesthesiologist's point of view!
bibliography
❖ Goodman & Gillman's- The pharmacological basis of
Therapeutics,13 Edition, By Laurence L. Brunton, Page
no. 783-785
❖ Essentials of Medical Pharmacology, Sixth Edition By
KD TRIPATHI, Page no.319-324
❖ Basic & Clinical Pharmacology, 14ª Edition By Bertram
G. Katzung, Page no.680-681
❖ Principles of Pharmacology, Edition By HL. Sharma and
K K Sharma, Pagenо. 590-594
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