July 25, 2022

Dear Colleagues,

Welcome to Pharmacy Phriday, our weekly pharmacology CE article.  Continuing with the pregnancy theme from last week’s installment, we will review Oxytocin, trade name PITOCIN, a medication listed under the childbirth/obstetrical emergencies protocols.  Oxytocin is a naturally occurring hormone released during labor that causes uterine contractions. As a medication, the synthetic form is sometimes given to induce labor, but in our case, it is used by UH paramedics to prevent, control, or treat postpartum hemorrhage (PPH).

Postpartum hemorrhage (PPH) is one of the most prevalent causes of maternal morbidity and mortality worldwide, accounting for approximately 25% of maternal deaths.  After delivery of the newborn, a certain amount of vaginal bleeding is expected.  Though definitions of abnormal or excessive PPH vary, one typically is instructed to be concerned when blood loss is 300-500 ml or more.  

Excessive bleeding is most often the result of an inability of the uterus to contract and shrink in size, which squeezes the tiny uterine blood vessels. Poor post-partum contractions are the number one cause of PPH and can result following the birth of a large fetus, multiple fetuses, or prolonged labor.  PPH can also occur in cases where retained placental tissue still lines the uterine wall or blood clots are present in the uterus that prevents the uterus from shrinking even with strong contractions. 

You may recall childbirth is broken into three stages.  Delivery of the fetus occurs in the second stage of labor with the delivery of the placenta in the third stage of labor.  Following the delivery of the placenta, UH paramedics are to administer 10 units of Oxytocin IM to all OB patients regardless of the amount of bleeding. 

In conjunction with the use of Oxytocin, the provider should remember to use other treatment options known to induce the release of oxytocin naturally such as placing the newborn to the mother’s breast, as well as manual massage of the fundus to assist in stimulating adequate contractions.  

An important consideration in the administration of Oxytocin is to be alert to possible multiple births.  A thorough history and a good exam are very important.  Due to the actions of the medication, additional fetuses can suffer severe injuries such as fetal hypoxia, asphyxiation, intercranial bleeding, or death if the medication is given between multiple births.  The provider must be sure that all fetuses have been delivered prior to the administration of Oxytocin.   

The onset of the desired effects of Oxytocin will normally occur in 3-7 minutes when given IM as instructed in our UH protocol.  The medication is typically provided as a single dose vial with 10 units in a 1 ml solution making the standard dosing a simple injection.  Common side effects of the medication include nausea, vomiting, headache, drowsiness, convulsions, and arrhythmias, but usually only at higher doses than listed in our protocols.   

Childbirth in the prehospital setting is not uncommon and often is one of the most rewarding experiences of a career in EMS.  It is also an event with potentially serious complications.  Emotions during such an event can be quite intense for both the parents and the EMS providers.  As a professional health care provider, it is important to remain calm and in control.  An important part of preparing for such an event is reviewing related protocols, actions to be taken, and knowledge of treatment in cases of adverse events.  We hope this small review has been helpful for you!

Till next time, stay safe!!

Sincerely,

The UH EMS-I Team

University Hospitals

July 25, 2022

Dear colleagues:

Welcome to Pharmacy Phriday.  To introduce this week’s medication review, we open with the presentation of a case scenario chosen from our 2022 records. As you read the scenario, think of what your next steps in the care of this patient might be.

911 was called for a 20-year-old female in labor at a major intersection.  The female was being driven to the hospital after having contractions at home.  It was the first pregnancy for the patient (primigravida, or Gravida 1, Para 0).  She was 34 weeks pregnant.  While being driven to the hospital, the vehicle experienced mechanical problems.  The patient continued to have contractions lasting 1-2 minutes, 5-6 minutes apart.  After a quick assessment, the providers noticed no crowning and began transport to the ED within 6 minutes of patient contact.

After about 4-5 minutes in transit, the patient’s water broke.  The providers reevaluated the patient and noted the contractions were closer together and increasing in intensity.  Crowning was noted during contractions.  The driver was advised to pull over while the crew in the back of the squad prepared for delivery.  Approximately 5 minutes later, the patient delivered a screaming, crying baby.  After drying the neonate, the cord was clamped and cut, and the child was placed at the mother’s breast.  The one-minute APGAR score was an “8”.  Although some bleeding was present while awaiting the delivery of the placenta, the amount was minimal. The mother’s vital signs were BP 124/76, pulse of 78, respirations of 26, and a pulse ox reading of 96%.  What medication is now appropriate for the mother per protocol?

The weekly medicine review in this installment of Pharmacy Phriday is Oxytocin, one of the patient care items that should be completed.  It is a naturally occurring hormone which is released during labor that causes uterine contractions. As a medication, the synthetic form is sometimes given to induce labor, but in our case, it is used by UH paramedics to prevent or treat post-partum hemorrhage (PPH).

Post-partum hemorrhage (PPH) is one of the most prevalent causes of maternal morbidity and mortality worldwide, accounting for approximately 25% of maternal deaths.  After delivery of the newborn, a certain amount of vaginal bleeding is expected.  A blood loss of  300-500 ml or more is often cited as a point to become concerned.

Following the delivery of the fetus and after assuring there is not a chance of multiple births, protocol directs the paramedic to administer 10 units of Oxytocin IM to all OB patients regardless of the amount of bleeding.  In addition to the use of Oxytocin, the provider should remember to use other treatment options known to induce the release of Oxytocin naturally, such as placing the newborn to the mother’s breast, as well as manual massage of the fundus to assist in stimulating adequate contractions.  

In cases where excessive bleeding continues (usually greater than 500 ml of blood), the provider should refer to the “Obstetrical Emergencies” protocol for further treatment and medications.  Can you identify the two medications appropriate in these cases?

Childbirth in the prehospital setting is often one of the most rewarding experiences of a career in EMS.  Congratulations to this squad crew (you probably know who you are!) for a successful field delivery, as well as our other providers who were part of a delivery last year!  Job well done!!

Till next time, stay safe!!

Sincerely,



The UH EMS-I Team

University Hospitals