Synthetic oxytocin which is a medicine approved by FDA (Food and Drug Administration) is commonly used in our country and the world. Usage frequency of oxytocin which is used with the aim of preventing parturition induction, therapeutic aborts, postpartum bleeding and providing postpartum lactation is increasingly raising nowadays.(1-7)
While it is declared than oxytocin was used in 708.151 parturitions (18.4% of all parturitions) in United States this rate was stated as 20% in 2000.(1,8)
Although there is no data about oxycotin usage in obstetric clinics in our country, it is known that it is commonly used for induction of parturition. In cases pregnancy is required to be ended (due to pregnancy-based hypertension, early membrane rupture, chorioamnionitis, abnormal pregnancy tests (anencephaly, chromosome anomalies etc), intrauterine growth retardation, Rh incompatibility, over termination, diabetes in mother, kidney disease, chronic obstructive lung diseases and heart disease) oxytocin usage is recommended in a pregnant in/over its termination in order to start parturition pains or to increase insufficient pains.(4,9,11,12,17)
Attentive evaluation of patient and fetus before usage and attentive monitoring of mother and fetus during usage are essential in order to prevent possible complications. Inattentive usage of oxytocin may cause damage in mother and baby.(2,4,11,12)
Start of treatment should be decided after preconditions required for the application are provided. In recent years there are 2 treatment protocols recognized by ACOG (American College of Obstetricians and Gynecologists) relating to initial and improved doses of oxytocin. ACOG explained low and high dose treatment protocols in November 1999 bulletin (Table 1).8 ACOG recommends oxytocin treatment to be prepared by adding 10 units of oxytocin in 1000cc isotonic liquid. oxytocin has some adverse effects like hyperstimulation (regardless of there is disruption in fetal heart rate), ablatio placentae, disruption in uterus blood stream, rapid parturition activity, uterus rupture, hyponatremia and postpartum bleeding which threat the health of mother and some other like fetal hypoxia, hiperbilirubinemia, fetal trauma and fetal death as a result of rapid parturition activity which affect the health of fetus. In addition, oxytocin may lead to liquid intoxication by making a weak antidiuretic hormone effect. Symptoms of liquid intoxication are lethargy, headache and defect of eyesight. A severe liquid intoxication may lead to death due to convulsions, coma and cerebral edema.(1,3,5,7,8,10,13,16)
With the aim of preventing liquid intoxication ACOG has emphasized that oxytocin should be taken in isotonic solution.1
In order to prevent complications which may affect both mother’s and fetus’ health during oxytocin administration doctors, midwives and nurses should behave attentively.
Midwives and nurses are responsible from preparation of IV (Intra Venous) solution, evaluation of patient before and during the application in terms of counter indications, and evaluation of responses of uterus and fetus to treatment.11-15
The purpose of our study is to determine the roles of doctors, midwives and nurses working in state and SSK hospitals placed in Istanbul and in which number of parturitions are so high in and the difficulties they encountered during oxytocin administration.
7 research and application hospitals dependent on Ministry of Health and monthly parturition number of which is over 100 were taken within the context of the study. The research was performed in obstetric clinics of the hospitals descriptively between 1 and 15 January 2004.
All midwives, nurses and doctors working in obstetric units of the hospitals constituted the universe of the research. 95 midwives and nurses and 55 doctors changing with shifts or rotations (who were in rotation during the research) serve in obstetric units of the hospitals. 53 midviwes-nurses and 25 doctors were taken in sampling group of the research.
Data were obtained by using question forms prepared by the researcher differently for midwives, nurses and doctors.
In question for prepared for midwives, nurses; questions including what they do before applying oxytocin treatment, their roles during the application of treatment, effects of the treatment, problems encountered during oxytocin application and solution recommendations for these problems were present.
In question form prepared for doctors their criteria to start oxytocin treatment, problems they encountered about oxytocin administration and solution recommendations, their expectations from midwives and nurses during oxytocin administration.
Question forms prepared by midwives, nurses and doctors were filled by the individuals through mutual interview techniques.
Obtained data were evaluated as percentage and qualitative.
It was determined that different oxytocin applications are performed in hospitals we have included within the context of the research and any of which does not have a oxytocin treatment protocol written and approved by the institution.
20% among 25 doctors included within the study was specialist and 80% of which was general practitioner. When we examine the working periods of doctors in obstetric clinics it was 31.9 ± 37.1 month in average.
11.3% among 53 midwives and nurses within the study was nurse and 8.1% was midwife and 7.5% was officer midwife.
64.2% of midwives and nurses graduated from two-year degree and 26.4% from health vocational high school and 9.4% has graduate degree and their working period was 6.6 ± 6.6 year in average.
All doctors have stated that they start oxytocin treatment in order to activate obstetric pains and in case parturition activity is definitely required to be started (intrauterine growth retardation, intrauterine fetal death, early membrane rupture, oligohydroamnios etc.) if condition of fetus is good and Bishop score is appropriate (Table 2).
When we ask about adverse effects of oxytocin 94.3% of midwives and nurses answered as disruption in fetal heart rate, 73.6% answered as uterus hyperstimulation, 47.2% answered as nausea-vomiting, 39.6% answered as fetal- maternal tachycardia and 1.9% answered as decrease in urine amount (Table 3).
On the other hand it was determined that 16.1% among midwives and nurses have evaluated some adverse effects not resulted from oxytocin as if they resulted from oxytocin.
When distribution among attempts of midwives and nurses before oxytocin application, it was determined that such a high percentage like 86.8% declared that patient is informed, 71.7% declared that vital findings are checked, 77.4% declared that NST application is performed (not stating a period), 67.9% declared that FHS (fetal heart sound) is checked, and such a low percentage like 26.4% declared that Leopold maneuvers are applied (Table 4).
When the follow-ups performed by midwives and nurses and their frequencies are examined in Table 5 it was determined that blood pressure of patient is followed-up regularly in a percentage of 54.7%, regular vaginal examination is performed in 43.3%, regular FHS check is performed in 47.2% (in every hour in latent phase, in every 15-30 minutes in active phase), and the color and density of amniotic fluid is evaluated regularly in 34%.
Moreover, it is determined that pulse rate of patient in 47.2%, respiration in 24.5%, food inlet and vomiting in 22.6%, control of infusion dose in 60.4%, check of obstruction in set in 66.1% are followed up not regularly.
When we examined difficulties encountered by midwives, nurses and doctors relating to oxytocin application (Table 6); 56.6% percent of midwives and nurses and 48% of doctors stated that they encounter difficulty due to incompatibility of patient with treatment (patient may try to remove prenatal applied oxytocin by reason of pain, speed up of flow for medicine application to be completed early, rejection of patient to treatment etc.), and the rate of difficulties encountered resulted from trouble in follow-ups because of insufficient number of midwives and nurses are 39.6% in midwives and nurse and 28% in doctors.
It was also determined that insufficient number of fetal monitor was indicated as a reason by such a high percentage of doctors like 56% and by 18.9% of midwives and nurses.
Doctors, and midwives and nurses encounter difficulty due to the lack of oxytocin treatment protocol in such a low rates in respectively 12% and 11.3%.
When we examined the recommendations of midwives, nurses and doctors with the aim of removing difficulties encountered about oxytocin application, it was determined that 28 midwives/nurses and 2 doctors have no recommendation. When recommendations of midwives, nurses and doctors who made a recommendation 52% of midwives and nurses and 56.5% of doctors stated that the difficulties can be removed by increasing the number of materials (monitor, doseflow, pump etc.) and through preparation of an oxytocin treatment protocol (8% of midwives and nurses and 8.6% of doctors) (Table 7 and 8).
While 52% of midwives and nurses think that the difficulties can be decreased by follow-up of pregnant women in pain clinic more regularly, 95.6% of doctors stated that the difficulties can be removed by follow up of pregnant women in pain clinic by midwives and nurses more regularly and 17.3% stated difficulties can be removed by increasing the number of midwives and nurses to work effectively in obstetric clinics.
When we examined the expectations of midwives and nurses from doctors relating to oxytocin application; 45.4% stated that doctors should be attentive and not behave impatiently while selecting patients, 27.2% stated preparation of oxytocin treatment protocol and performing dose arrangements by using this treatment protocol and 18% stated that doctors should write a formal request. It was also stated that 24 nurses among 53 do not have any expectation (Table 9).
While 39% of doctors expected from midwives and nurses to follow-up dropping speed and patients regularly, only 9% stated that midwives and nurses do not have enough information about oxytocin treatment (Table 10).
Doctors, midwives and nurses should firstly evaluate the patient while using oxytocin and should inform patient about effects and adverse effects of the treatment.(7)
Before the application Bishop scoring is required to be evaluated and obtained value should be at least (4), fetal lung maturation should be ensured, pregnancy week should be appropriate, situation of mother should be stable, size and location of fetus should be appropriate.(2,4) If Bishop score is less than (4), possibility of failure in induction is higher. (4,7)
Sometimes oxytocin treatment may be started regardless of fetal maturity in situation which threat mother’s life.(2,7)
When we examined criteria of doctors to start oxytocin treatment in our research; it was determined that all doctors use oxytocin in order to activate insufficient pains in the parturition when parturition activity is definitely required to be started and Bishop score is (5) and more in accordance with the literature.(7)
However another usage we obtained in our study and which is not appropriate with the literature is using oxytocin in order to gain time by accelerating a parturition activity in its normal progress. 16% of doctors use oxytocin with the aim of accelerating a parturition activity in its normal progress. It can be considered that this usage is resulted from excess number of patients in obstetric clinics and the aim of preventing patient accumulation however it is not a desirable method.
Oxytocin has some adverse effects both in terms of mother and baby.(7) Midwives and nurses are considerably important in terms of being informed about adverse effects of oxytocin and early notification of adverse effects.(9) It should be remembered that the person who follow-up mother and fetus closely and who notice differences to occur is midwives and nurses.
It was determined in our study that a big majority of midwives and nurses are aware of common adverse effects of oxytocin like defect in fetal heart speed and uterus hyperstimulation but not aware the adverse effect of liquid intoxication (decrease in urine amount, headache and defect I heart rate etc.) which is rarely seen. It can be considered that information which midwives and nurses are caused by their earlier experiences.(12)
Midwives and nurses should make some explanations about the purpose, reason, of oxytocin treatment, problems which may appear during the treatment and some warnings the patient should give attention during the treatment in order to ensure the patient and her family to comply with the treatment before the application.(11,12) Most of midwives and nurses have declared they give some information for patients but did not explain context of information.
Evaluation of mother and baby by midwives and nurses is so important in order to learn existing problems and discover risky situations. Vaginal and abdominal evaluation of pregnant women taken anamnesis should be fulfilled. Position and presentation of the fetus should be evaluated with Leopold maneuvers abdominally applied. Vital symptoms of pregnant woman should be recorded and fetus heart speed should be listened. If there is a counter indicated situation to start oxytocin a doctor should be notified.(4,11,12)
In the study performed by Goetzl et al it was determined that patients who experienced uterus rupture before are more possible to experience uterus hyperstimulation. For this reason oxytocin should not be applied or applied with an attentive follow-up in a patient who has a rupture history.(13)
In our study it was determined that a big majority of midwives and nurses check vital symptoms of patients before the treatment and evaluate the situation of baby with fetal monitor.(4,7,11,12,17) However, the rates of midwives and nurses who evaluate situs and habitus of the baby by applying vaginal examination, anamnesis check and Leopold maneuvers are low. We can say that these rates are such low since midwives and nurses are not given a responsibility and everything is under responsibility of doctors.
Fetal heart speed and contractions are continuously followed-up with electronic fetal monitor during the regular oxytocin application and in case of divergence from normal speed of fetal heart infusion should be urgently turned off.(4,7,11,12,17)
The rate of follow-up with fetal monitor is founded as low in our research due to the insufficient number of fetal monitor and midwives, nurses and doctors also stated fetal monitor shortfall as a problem.
In this case result from insufficient fetal monitors midwives and nurses may notice complications to appear in advance by frequently following-up FHS with manual Doppler or fetoskope and applying contraction check in every 10 minutes according to the stage of travail. However, it cannot be said in our study that FHS follow-ups are performed in phases determined in the literature (in every hour in latent phase and in every 15-30 minutes in active phase) and regularly.(4,11,12,16)
Although midwives and nurses mostly know defect in heart speed and hyperstimulation as adverse effects of oxytocin it is thought provoking that regular follow-up rates are low. Lowness of regular FHS and contraction follow-up rates may be related with the situation in some clinics where this responsibility is conferred to doctor and with insufficient number of midwives and nurses.
The earliest forerunner of liquid intoxication, uteri rupture and ablatio placentae to happen during oxytocin application is defect in woman’s vital findings and in FHS and decrease in urine outlet. For this reason, nurses are required to perform these follow-ups with regular intervals. Moreover another early symptom of liquid intoxication is defect in heart rate and heart of the patient should be followed-up regularly.(4,9,11,12,14,15)
Even though more than half of midwives and nurses in our study stated that they perform regular blood pressure check, it was determined that they do not perform pulse check regularly in a high percentage and half of midwives and nurses never perform respiration check. However, blood pressure, pulse and respiration checks should be regularly performed.
It was also determined that follow up of food inlet and vomiting is almost never performed regularly in normal pregnant women. This situation may result from that midwives and nurses do not know liquid intoxication as an adverse affect to happen as a result of oxytocin usage and there are not present easily used scaled cups in toilets.
The amount, color and density of amniotic fluid should be checked and recorded.(4,9,11,12,16)
Oxytocin oscillates in human body in a rhythmic way by its nature.6 In order to ensure IV applied oxytocin dose flows in a proper amount it should be regularly followed-up whether there is any obstruction or excess flow in the set. Excess flown oxytocin leads to uteri hyperstimulation and uterus rupture insufficient flow of oxytocin dose prevents expected effect to happen.(9,11,12,16)
It was determined in our study that midwives and nurses do not regularly check drop numbers obstructions in the set. Just like other follow-ups defects in this follow-up may be caused by insufficient number of nurses.
Patients who take oxytocin treatment should be regularly followed-up with electronic fetal monitor and infusion pumps should be used for oxytocin dose to be flown in proper amounts.(4,6,9,12,17) This justification can more easily explain why doctors encounter problems mostly caused by insufficient fetal monitor during oxytocin administration. Doctors, midwives and nurses have the common view that this difficulty can be removed by increasing the number of materials.
While doctors encounter problems mostly due to insufficient fetal monitor, midwives and nurses are in difficulty due to incompatibility of patients with the treatment (patient or her relatives may try to remove prenatal applied oxytocin by reason of pain, and speed up of flow for medicine application to be completed early). While most midwives and nurses in our study state that they inform patients before treatment, incompatibility of patients with the treatment indicates that provided information is insufficient.
While doctors recommend more regular follow-up of patients by midwives and nurses in order to remove problems encountered in oxytocin administration, midwives and nurses recommend in a similar way that doctors should follow up patients more regularly. This situation can be explained as there is a confusion relating to responsibility allocation between doctors and nurses during the follow-ups. If there were protocols in obstetric clinics which clearly indicate responsibilities of both doctors and midwives and nurses during oxytocin administration this confusion would be rarely encountered. However in our study only a small number of doctors and nurses have the view that problems can be diminished with the presence of a oxytocin treatment protocol.
Majority of the doctors expect from midwives and nurses to follow-up patients and dropping speed of oxytocin. As we determined in our study, problems resulted from irregular follow-up of oxytocin infusion speed and patients by midwives and nurses may lead doctors to state such an expectation.
On the other hand, midwives and nurses stated that they expect from the doctors to pay attention while selecting patients and not to behave impatiently.
İt was determine din our study that some problems are experienced relating to oxytocin usage, and these problems by their nature can be prevented through preparation of a oxytocin treatment and follow-up protocol, material provision and training of patients. Oxytocin treatment and follow-up protocol should be in nature which clearly state how and in which doses the medicine will be used, how much dropping application should be started with, follow-ups and frequency of follow-ups required to be performed by midwives/nurses during the medicine application, emergency cases to be encountered during the medicine application and the roles of doctors midwives/nurses during the emergency cases.Doctors, midwives and nurses should be in cooperation and the roles of each in the application should be determined in while preparing and applying a treatment and follow-up protocol. Institutions should remember that material deficiency in obstetric clinics may cause vital results and should attempt for provision of deficient materials. In addition, information should be provided for health personnel in hospitals relating to patient training methods.(5)