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Oksitosin

Oksitosin dapat digunakan dalam induksi maupun augmentasi persalinan. Namun,


setelah pemberian oksitosin, denyut jantung janin dan kontraksi uterus harus tetap
dipantau seperti pemantauan kehamilan resiko tinggi (American College of
Obstetricians and Gynecologists).
Tujuan dari induksi maupun augmentasi persalinan adalah untuk mengefektifkan
kontraksi uterus untuk mendilatasi serviks dan turunnya fetus. Pemberian oksitosin
harus dihentikan apabila kontraksi uterus lebih dari lima dalam sepuluh menit atau
lebih dari tujuh dalam lima belas menit atau terdapat kelainan denyut jantung janin.
Dosis, Regimen, dan Interval Pemberian Oksitosin
1 mL ampul oksitosin mengandung 10 unit yang terdilusi di dalam 1000 mL larutan
kristaloid dan diadministrasi secara intravena. Setiap dosis infus oksitosin biasanya
mengandung 10-20 unit yang dilarutkan ke dalam 1000 mL cairan Ringer laktat.
Ada beberapa regimen yang direkomendasikan oleh American College of
Obstetricians and Gynecologists berdasarkan penelitian. Ada yang menyebutkan
bahwa pemberian oksitosin dimulai dari dosis 6 mU/menit, ada juga yang
menyebutkan bahwa pemberiannya dimulai dari dosis yang sangat rendah yaitu 0.51.5 mU/menit. Namun banyak studi yang mengemukakan bahwa dosis inisial
sebanyak 4.5-6 mU/menit memiliki keuntungan yang lebih.
Interval untuk meningkatkan dosis oksitosin bervariasi dari 15 hingga 40 menit.

RisksversusBenefits
Unlesstheuterusisscarred,uterineruptureassociatedwithoxytocininfusionis
rare,eveninparouswomen(Chap.41,p.790).Flannellyandassociates(1993)
reportednouterineruptures,withorwithoutoxytocin,in27,829nulliparas.
Therewereeightinstancesofovertuterineruptureduringlaborin48,718
parouswomen.Onlyoneofthesewasassociatedwithoxytocinuse.
Oxytocinhasaminoacidhomologysimilartoargininevasopressin.Becauseof
this,ithassignificantantidiureticaction,andwheninfusedatdosesof20
mU/minormore,renalfreewaterclearancedecreasesmarkedly.Ifaqueous
fluidsareinfusedinappreciableamountsalongwithoxytocin,water

intoxicationcanleadtoconvulsions,coma,andevendeath.Ingeneral,if
oxytocinistobeadministeredinhighdosesforaconsiderableperiodoftime,
itsconcentrationshouldbeincreasedratherthanincreasingtheflowrateofa
moredilutesolution.Considerationalsoshouldbegiventouseofcrystalloids
eithernormalsalineorlactatedRingersolution.

UterineContractionPressures
Contractionforcesinspontaneouslylaboringwomenrangefrom90to390
Montevideounits.AsdescribedinChapter24
(p.498),thelatterarecalculatedbysubtractingthebaselineuterinepressure
fromthepeakcontractionpressureforeachcontractionina10minutewindow.
Thepressuresgeneratedbyeachcontractionarethensummed.CaldeyroBarcia
(1950)andSeitchik(1984)withtheircoworkersfoundthatthemeanormedian
spontaneousuterinecontractionpatternresultinginaprogressiontoavaginal
deliverywasbetween140and150Montevideounits.
Inthemanagementofactivephasearrest,andwithnocontraindicationto
intravenousoxytocin,decisionsmustbemadewithknowledgeofthesafe
upperrangeofuterineactivity.Hauthandcolleagues(1986)describedan
effectiveandsafeprotocolforoxytocinaugmentationforactivephasearrest.
Withit,morethan90percentofwomenachievedanaverageofatleast200to
225Montevideounits.Hauthandassociates(1991)laterreportedthatnearlyall
womeninwhomactivephasearrestpersisteddespiteoxytocingeneratedmore
than200Montevideounits.Importantly,despitenolaborprogression,there
werenoadversematernalorperinataleffectsinthoseundergoingcesarean
delivery.Therearenodataregardingsafetyandefficacyofcontractionpatterns
inwomenwithapriorcesareandelivery,withtwins,orwithanoverdistended
uterus.

ActivePhaseArrest
FirststagearrestoflaborisdefinedbytheAmericanCollegeofObstetricians
andGynecologists(2013a)asacompletedlatentphasealongwithcontractions
exceeding200Montevideounitsformorethan2hourswithoutcervical
change.Someinvestigatorshaveattemptedtodefineamoreaccurateduration
foractivephasearrest(Spong,2012).Arulkumaranandcoworkers(1987)
extendedthe2hourlimitto4hoursandreporteda1.3percentcesarean
deliveryrateinwomenwhocontinuedtohaveadequatecontractionsand
progressivecervicaldilatationofatleast1cm/hr.Inwomenwithout
progressivecervicaldilatationwhowereallowedanother4hoursoflabor,half
requiredcesareandelivery.
Rouseandcolleagues(1999)prospectivelymanaged542womenattermwith

activephasearrestandnoothercomplications.Theirprotocolwastoachieve
asustainedpatternofatleast200Montevideounitsforaminimumof4hours.
Thistimeframewasextendedto6hoursifactivityof200Montevideounitsor
greatercouldnotbesustained.Almost92percentofthesewomenwere
deliveredvaginally.AsdiscussedinChapter23(p.459),theseandother
studiessupportthepracticeofallowinganactivephasearrestof4hours
(Rouse,2001;Solheim,2009).
Zhangandcoworkers(2002)analyzedlabordurationfrom4cmtocomplete
dilatationin1329nulliparasatterm.Theyfoundthatbeforedilatationof7cm
wasreached,lackofprogressformorethan2hourswasnotuncommonin
thosewhodeliveredvaginally.Alexanderandassociates(2002)reportedthat
epiduralanalgesiaprolongedactivelaborby1hourcomparedwithdurationof
theactivephaseasdefinedbyFriedman(1955).Considerationofthesechanges
inthemanagementoflabor,especiallyinnulliparas,maysafelyreducethe
cesareandeliveryrate.
Asdatahaveaccrued,investigatorshaveincreasinglyquestionedthe
thresholdsforlaborarrestdisordersestablishedbyFriedmanandothersinthe
1960s.Inparticular,investigatorswiththeConsortiumonSafeLaborreported
thathalfofcasesof
dystociaafterlaborinductionoccurredbefore6cmofcervicaldilation(Boyle,
2013;Zhang,2010c).Evenforwomenwithspontaneouslabor,these
researchersfoundthatactivephaselaborwasmorelikelytooccurat6cm,and
afterslowprogressbetween4and6cm(Zhang,2010a).Additionally,they
reportedthata2hourthresholdfordiagnosingarrestdisordersmaybetoobrief
whencervicaldilationis6cm(Zhang,2010b).Itwasalsoshownthatthe
durationoffirststagelaborwasmorethan2hourslongerthanhadbeen
reportedusingdatafromtheCollaborativePerinatalProject(Laughon,2012b).