Five Unit Bolus Oxytocin at Cesarean Delivery in

Women at Risk of Atony: A Randomized,

Double-Blind, Controlled Trial
Kylie J. King, MBBS, FANZCA,* M. Joanne Douglas, MD, FRCPC,† Waldemar Unger, MD, FRCSC,‡
Areta Wong, BSc,† and Robert A. R. King, PhD§

BACKGROUND: IV bolus oxytocin is used routinely during cesarean delivery to prevent postpar-
tum hemorrhage. Its adverse hemodynamic effects are well known, resulting in a recent change
in dose from 10 IU to 5. Whether a 5 IU bolus has any advantages over infusion alone is unclear.
We tested the hypothesis that a 5 IU IV bolus of oxytocin before the initiation of a continuous
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infusion decreases the need for additional uterotonic drugs in the first 24 hours after delivery in
women with risk factors for uterine atony undergoing cesarean delivery, compared with infusion
alone.
METHODS: A prospective, randomized, double-blind, controlled trial was conducted in 143
subjects undergoing cesarean delivery with at least 1 risk factor for uterine atony. Subjects
received 5 IU bolus of oxytocin or normal saline IV over 30 seconds after umbilical cord clamping.
All subjects received an infusion of 40 IU oxytocin in 500 mL normal saline over 30 minutes,
followed by 20 IU in 1 L over 8 hours. The primary outcome was the need for additional
uterotonics in the first 24 hours after delivery. Secondary outcomes included uterine tone as
assessed by the surgeon (5-point Likert scale: 0 ⫽ “floppy,” 4 ⫽ “rock hard”), estimated blood
loss, side effects of bolus administration, and the oxytocin bolus–placental delivery interval.
RESULTS: There was no difference in the need for additional uterotonic drugs in the first 24
hours between groups. There was a significant difference in uterine tone immediately after
placental delivery (P ⬍ 0.01) (2.8 in the oxytocin group [95% confidence interval 2.6 –3.0] vs 2.2
in the saline group [95% confidence interval 1.8 –2.5]), which disappeared after 5 minutes. There
were no differences in observed or reported side effects between groups.
CONCLUSIONS: We found that a 5 IU IV bolus of oxytocin added to an infusion did not alter the
need for additional uterotonic drugs to prevent or treat postpartum hemorrhage in the first 24
hours in women undergoing cesarean delivery with risk factors for uterine atony, despite causing
an initial stronger uterine contraction. Our study was not powered to find a difference in side
effects between groups. These results suggest that an oxytocin infusion may be adequate
without the need for a bolus, even in high-risk patients. (Anesth Analg 2010;111:1460 –6)

O xytocin is routinely administered by anesthesiolo-

gists to prevent and treat postpartum hemorrhage
due to atony during cesarean delivery. The best
way to give oxytocin at cesarean delivery is uncertain. A
maternal death in the United Kingdom drew attention to
the potential hazard of administering a rapid IV injection or
bolus of 10 IU oxytocin.1 This dose is no longer recom-
mended. Current guidelines in the United Kingdom,2 Can-
ada,3 and Australiaa recommend a 5 IU bolus, given slowly.
a
New South Wales Health Policy Directive: Postpartum Haemorrhage
(PPH)—Framework for Prevention, Early Recognition & Management.
Available at: http://www.health.nsw.gov.au/policies/PD/2005/pdf/
PD2005_264.pdf. Accessed October 1, 2009.
From the *Department of Anaesthesia, John Hunter Hospital, New South
Wales, Australia; Departments of †Anesthesia, and ‡Obstetrics, British
Columbia Women’s Hospital, Vancouver, Canada; and §School of Math-
ematical and Physical Sciences, University of Newcastle, New South Wales,
Australia.
Accepted for publication August 11, 2010.
Study funding information is provided at the end of the article.
Disclosure: The authors report no conflicts of interest.
Address correspondence and reprint requests to Kylie J. King, MBBS,
FANZCA, Department of Anaesthesia, John Hunter Hospital, Locked Bag 1,
Hunter Region Mail Centre, New South Wales 2310, Australia. Address
e-mail to kylie.king@hnehealth.nsw.gov.au.
Copyright © 2010 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181f8930a
A recent survey4 of lead consultant anesthesiologists and
obstetricians in the United Kingdom found that 92% of
anesthesiologists and 86% of obstetricians routinely used
oxytocin this way. However, a 5 IU bolus is also associated
with significant side effects, such as hypotension.5–9 The
benefit of oxytocin use at vaginal delivery is widely under-
stood and supported by a systematic review.10 In compari-
son, there are relatively few published studies investigating
the benefits of a 5 IU bolus at cesarean delivery.6,8,11,12
A controlled, double-blind, randomized trial was per-
formed. We tested the hypothesis that a 5 IU IV bolus of
oxytocin, in addition to an oxytocin infusion, decreases the
need to give additional uterotonic drugs to prevent post-
partum hemorrhage in women with risk factors for uterine
atony at cesarean delivery compared with an oxytocin
infusion without a bolus.
METHODS
This trial was approved by the Clinical Research Ethics
Board of the University of British Columbia and the Hos-
pital Review Board of the British Columbia Women’s
Hospital. Written informed consent was obtained from all
subjects. Pregnant women who were to undergo cesarean
delivery at BC Women’s Hospital, and who had ⱖ1 of the
following risk factors for postpartum hemorrhage due to
uterine atony were approached about the study:

1460 www.anesthesia-analgesia.org December 2010 • Volume 111 • Number 6

 1. An overdistended uterus, due to
a. Macrosomia13–17: reported on prenatal
ultrasound
b. Multiple gestation14–17
c. Polyhydramnios15,16: reported on prenatal
ultrasound
2. Eight or more hours of oxytocin augmentation
before cesarean delivery15–17
3. Chorioamnionitis16–18: temperature ⬎38.5°C and
antibiotic treatment
4. History of uterine atony/postpartum hemorrhage15,17
5. Placenta previa14 (other than anterior)
6. High parity17 (⬎5 previous deliveries)
Patients scheduled for elective and or emergency cesarean
delivery at a time when an investigator was available were
approached, provided the treating team agreed there was
sufficient time to obtain informed consent. Patients with
cardiac disease, hemodynamic instability before com-
mencement of surgery, bleeding disorders, or who were
younger than 19 years, or could not understand or read
English were excluded.
Patients were randomized to receive either bolus oxyto-
cin or saline. The group allocation was randomly generated
by computer and was placed in a sealed, opaque envelope.
The envelope was opened after consent was obtained, and
before commencement of surgery by an anesthesiologist
not involved in the study or the subject’s care. The study
drug syringes were prepared by this person and labeled
only with the subject’s study number. The subject, all care
providers, and all investigators remained blinded to group
allocation until data collection was complete.
The primary outcome of the study was defined as the
need for additional uterotonic drugs in the first 24 hours as
determined by the surgeon’s usual clinical judgment and
practice. Secondary outcomes included uterine tone, esti-
mated blood loss, side effects including hypotension, need
for blood transfusion, and time from bolus to delivery of
the placenta.
The subjects were anesthetized according to the attend-
ing anesthesiologist’s clinical judgment and usual practice.
As soon as the umbilical cord was clamped immediately
after delivery the study drug was given. The oxytocin
group received IV oxytocin, 5 IU diluted to 3 mL with
normal saline, slowly over 30 seconds. The placebo group
received IV placebo of 3 mL normal saline slowly over 30
seconds. The anesthesiologist delivered the study drug
manually, using a stopwatch to ensure it was given over
the 30 seconds. All patients immediately received an infu-
sion of 40 IU oxytocin in 500 mL normal saline over 30
minutes via an infusion pump, then a second infusion of 20
IU oxytocin in 1 L normal saline at 125 mL/h. The surgeon
used assisted spontaneous placental delivery.19 The surgeon
was asked to palpate the uterus, which was not exterior-
ized, and rate the uterine tone according to a 5-point Likert
scale (0 ⫽ “floppy,” 4 ⫽ “rock hard”) immediately after
delivery of the placenta and then every 5 minutes until
abdominal closure began. Standard monitoring was used,
including noninvasive arterial blood pressure measure-
ment, electrocardiography, and pulse oximetry. Hypoten-
sion was defined as a decrease in systolic blood pressure
ⱖ20% from baseline within 5 minutes of the oxytocin bolus
December 2010 • Volume 111 • Number 6
administration. Blood pressure measurements were taken
every minute starting from the commencement of surgery.
The 3 readings immediately before the oxytocin bolus were
averaged to calculate the baseline. After the bolus, the
blood pressure was measured every minute for 5 minutes,
and then as per standard practice.
The subjects were observed and questioned immedi-
ately after the bolus about the presence of any side effects
that could have been attributed to the bolus. They were
asked how they were feeling immediately after the bolus,
and specifically questioned about nausea and headache.
The subjects were observed for facial flushing and vomit-
ing, and the monitor was observed for changes in heart rate
(at least 10 bpm) or rhythm. Other spontaneously voiced or
observed side effects were recorded by the anesthesiologist.
Side effects were treated according to the anesthesiologist’s
usual practice.
The surgeon was able to request the administration of
additional uterotonic drugs at any time during the next 24
hours, according to his or her usual clinical judgment and
practice. The available options were additional oxytocin,
either an additional 5 IU bolus, or increasing the concentration
of the infusion, ergonovine, 15-methyl prostaglandin F2␣, and
misoprostol. The type and amount of additional uterotonic
drugs were recorded from the time of delivery to 24 hours
after the bolus study drug. Hemoglobin levels (if mea-
sured), blood transfusion (if given), or need to return to the
operating room because of bleeding were recorded. Blood
loss was visually estimated at completion of surgery by the
attending anesthesiologist. The time from study drug bolus
administration to delivery of the placenta was recorded.
Sample size analysis indicated 62 subjects per group,
assuming 40% of the saline group required additional
uterotonics compared with 20% in the oxytocin group (␤
error 0.2, ␣ 0.05, for a 1-tailed Fisher exact test [p1 ⬎ p2]).20
We based this on previous studies21,22 and our assessment
that a reduction from 40% to 20% would be clinically
significant. The primary outcome was analyzed using a
1-sided ␹2 test. Uterine tone over time was analyzed using
repeated-measures analysis of variance. All other bivariate
comparisons were made using t tests, ␹2 tests, or the Fisher
exact test as appropriate. Uterine tone was compared
between groups using a randomization test that made no
distributional assumptions.23 Logistic regression was used
to investigate the effect of the treatment while accounting
for the inclusion criteria, using the following model: addi-
tional uterotonics in 24 hours (binary) ⬃ drug ⫹ macroso-
mia ⫹ multiple gestation ⫹ ⬎8 hours oxytocin ⫹ placenta
previa ⫹ combined other inclusion criteria. P ⬍ 0.05 was
considered significant. Analyses were performed using
SPSS software (SPSS Inc., Chicago, IL) and R (R Develop-
ment Core Team, Austria, http://www.r-project.org).
RESULTS
Data were collected between November 2005 and October
2006. Figure 1 shows the study flow diagram. Those who
met the inclusion criteria but were excluded before ran-
domization either declined to participate or had difficulty
with the English language. Seven patients were random-
ized but did not commence the study protocol or receive a
study drug. There were no differences between groups in
www.anesthesia-analgesia.org 1461
Bolus Oxytocin at Cesarean Delivery

Figure 1. Study flow diagram. OR ⫽ operating room.

Table 1. Demographics, Obstetric, and Table 2. Inclusion Criteria

Anesthetic Data Oxytocin Saline
Oxytocin Saline (n ⴝ 70) (n ⴝ 73) P value
(n ⴝ 70) (n ⴝ 73) Multiple gestation 24 (34) 16 (22) 0.10a
Age (y) 34 (5) 34 (6) Macrosomia 16 (23) 21 (29) 0.41a
Height (cm) 162 (8) 162 (7) ⬎8 h intrapartum oxytocin 15 (21) 22 (30) 0.25a
Weight (kg) 81 (18) 83 (19) Posterior placenta previa 9 (13) 10 (14) 0.82a
BMI (kg/m2) 31 (6) 32 (6) History of PPH 8 (11) 5 (7) 0.41a
Gravida 2 (1–12) 2 (1–9) Polyhydramnios 3 (4) 4 (6) 1b
Parity 0 (0–6) 0 (0–4) Chorioamnionitis 3 (4) 3 (4) 1b
Gestational age (wk) 37 (3) 38 (2) Parity ⬎5 1 (1) 0 (0) 0.49b
Neonatal weight (g) 4002 (1143) 3953 (986) Values are expressed as n (%).
Duration of surgery (min) 48 (17) 50 (15) PPH ⫽ postpartum hemorrhage.
Elective/nonelective 37/33 39/34 ␹ test.
a 2
delivery (n) b
Fisher exact test (2-sided alternative).
Anesthetic type: epidural/ 20/38/9/1/2 21/42/7/2/1
spinal/CSE/GA/neuraxial ⫹ GA
Values are expressed as mean (SD), median (range), or number. groups (odds ratio 2.29, 95% CI 1.06 – 4.94, P ⫽ 0.04, 2-sided
BMI ⫽ body mass index; CSE ⫽ combined spinal epidural; GA ⫽ general Fisher exact test).
anesthesia.
There was a significant difference in uterine tone imme-
diately after placental delivery (time 0) (P ⬍ 0.01, random-
the subjects’ baseline demographic, obstetric, and anes- ization t test23). The mean tone was 2.8 in the oxytocin
thetic data (Table 1). Table 2 shows the risk factors for group (95% CI 2.6 –3.0) compared with 2.2 in the control
hemorrhage by treatment group. There were no significant group (95% CI 1.8 –2.5) (Fig. 2). The difference in tone was
differences between groups. Some patients had ⬎1 risk transient and disappeared after 5 minutes. There was no
factor. Thirty-four staff obstetricians participated in the difference between groups in the time taken to deliver the
study and performed the cesarean deliveries. No obstetri- placenta (oxytocin mean: 1.5 minutes [95% CI 1.2–1.7];
cian contributed ⬎6 subjects. None of the cesarean deliver- control: 1.5 minutes [95% CI 1.3–1.6]) or other secondary
ies was performed by residents. outcomes, estimated blood loss, or number needing blood
The primary outcome, the number of subjects requiring transfusion (Table 3). There were no differences in side
additional uterotonics, was similar in patients who re- effects between groups (Table 4). No subject had a change
ceived the oxytocin bolus (29%) compared with patients in heart rate ⬎10 bpm. A logistic regression to investigate
receiving the saline bolus (40%) (P ⫽ 0.11; odds ratio 1.65, the effect of the treatment while accounting for the inclu-
95% confidence interval [CI] 0.82–3.31) (Table 3). Twenty- sion criteria gave consistent results. Both forward and
six percent of patients had macrosomia as a risk factor for backward model selection procedures selected only macro-
hemorrhage. These patients were more likely to need somia as an independent variable (P ⫽ 0.03), with oxytocin
additional uterotonics compared with all other high-risk bolus the next candidate (P ⫽ 0.20).

1462 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA

 et al.,21 using the same primary outcome, demonstrated a
Table 3. Outcome Measures difference between high- and low-dose oxytocin infusions.
Oxytocin Saline Although somewhat subjective, the implication of the ab-
Outcome measure (n ⴝ 70) (n ⴝ 73) P value
sence of a request for additional uterotonics is that the
Additional uterotonics
1st h, n (%) 12 (17) 15 (21) 0.38a
uterus is contracted and bleeding is not excessive. Further-
24 h, n (%) 20 (29) 29 (40) 0.11a more, the need for additional uterotonics is clinically sig-
Additional oxytocin, mean nificant because all uterotonic drugs have significant side
doseb effects. Our surgeons were skilled consultants who were
1st h (IU) 16.5 (12.5) 20.6 (21.2) 0.28c
blinded to the treatment group. Because of the number
24 h (IU) 44.0 (42.0) 45.1 (37.5) 0.47c
Uterotonics other than involved, we believe that bias caused by individual differ-
oxytocin ences in practice was minimized.
15-Methyl PG F2␣ 2 2 0.67d We chose to study patients with risk factors for postpar-
Ergonovine 1 1 0.74d tum hemorrhage. This has not been done before. Carvalho
Misoprostol 1 3 0.93d
et al.25 estimated the 90% effective dose (ED90) of oxytocin
Estimated blood loss 812 (761–862) 902 (825–980) 0.92c
(mL) in healthy women at cesarean delivery as 0.35 IU. They
No. needing blood 1 (1.4) 3 (4.1) 0.33d excluded all patients with conditions that predispose to
transfusion uterine atony and postpartum hemorrhage such as “pla-
Values are n (%), mean (SD), or mean (95% confidence interval). centa previa, multiple gestation, preeclampsia, macroso-
PG ⫽ prostaglandin. mia, hydramnios, uterine fibroids, history of uterine atony
a
One-sided ␹2 test. and postpartum bleeding” from their study. Thus, this
b
Of those who received additional oxytocin.
c ED90 applies to a low-risk population for postpartum
t test, 1-sided alternative.
d
Fisher exact test, 1-sided alternative. hemorrhage. This same research group26 investigated 30
women requiring cesarean delivery for labor arrest and ⬎2
hours of intrapartum oxytocin augmentation, and found an
DISCUSSION ED90 of 3 IU. Again, those with the same risk factors for
In this study, we examined the effect of a 5 IU IV oxytocin hemorrhage were excluded. We did not specifically test for
bolus in addition to a continuous infusion on the need for the ED90 but believe that our study population would need
additional uterotonic drugs in women undergoing cesarean an ED90 ⬎3 IU because our study included many of the
delivery at risk of uterine atony. Despite showing increased groups excluded by Carvalho et al.25 and Balki et al.,26 as
uterine tone immediately after placental delivery compared well as patients who had received oxytocin for ⬎8 hours.
with the control group, the addition of a 5 IU oxytocin There are several limitations to this study. The study
bolus to an oxytocin infusion did not reduce the need for included a heterogeneous sample of patients, with various
additional uterotonics over 24 hours. There was also no risk factors for postpartum hemorrhage. We chose these
difference in estimated blood loss or need for blood trans- risk factors after examining the available literature and
fusion. Hypotension was not significantly increased com- input from our obstetric colleagues. Because the need for
pared with saline, but the study was underpowered to additional uterotonics in our study was 30% to 40%, we
show a difference in side effects between groups. believe we were successful in selecting a group that was
We chose the need for additional uterotonic drugs, truly high risk. The effectiveness of an oxytocin bolus in
determined by the surgeon according to their usual clinical preventing postpartum hemorrhage may vary according to
practice, as our primary outcome. Previous studies inves- the underlying pathophysiology. For example, labor aug-
tigating the ability of uterotonic drugs to contract the mentation probably causes oxytocin receptor desensitiza-
uterus and prevent postpartum hemorrhage have used the tion resulting in decreased responsiveness to oxytocin.26
following outcomes: need for additional uterotonics,21,22,24 Future studies concentrating on 1 risk factor may be
uterine tone assessed by a surgeon on a Likert scale11 or as worthwhile.
satisfactory/unsatisfactory,7,25,26 visually estimated blood Interestingly, in our study, those with macrosomia
loss,27 calculated blood loss using the preoperative hemat- seemed to be at highest risk for requiring additional
ocrit value and at 48 hours,25,26 change in hematocrit,27 uterotonics, even though our definition relied on the ultra-
decrease in hemoglobin by the second postoperative sound report, rather than a specific measure such as
day,28 incidence of blood transfusion,29 and incidence of estimated fetal weight. Our subjects’ ultrasounds were
postpartum hemorrhage. Many of these outcomes rely on done by many different practitioners and no single mea-
subjective assessment. Visually estimated blood loss is sure of macrosomia was used consistently. Because esti-
inaccurate.29 Changes in hemoglobin or hematocrit are mated measures of the fetal weight and amniotic fluid
difficult to interpret because of the large fluid shifts that index were not available on all ultrasound reports, the
occur around the time of delivery.30 Blood transfusions are sonographer’s assessment of polyhydramnios or fetal mac-
rare, requiring very large sample sizes to show a difference rosomia was accepted as sufficient criteria for inclusion. It
between treatment groups. Hemodynamic effects of utero- is possible the macrosomia effect was attributable to
tonic drugs are easier to measure objectively, but these are chance, given the P value of the ␹2 analysis and the number
side effects. There is no evidence that a change in arterial of hypotheses tested. However, the logistic regression
blood pressure, heart rate, or cardiac output indicates that analysis, which included the study drug and other inde-
the administered drug is effectively contracting the uterus pendent variables, selected macrosomia as the sole factor
and preventing postpartum hemorrhage. A study by Munn predicting the requirement for additional uterotonics.

December 2010 • Volume 111 • Number 6 www.anesthesia-analgesia.org 1463

Bolus Oxytocin at Cesarean Delivery

4
3

Figure 2. Uterine tone versus time after placental

Uterine Tone

delivery. Mean uterine tone on a scale of 0 to 4

where 0 ⫽ floppy and 4 ⫽ rock hard, as assessed
2

by obstetrician in minutes after placental delivery

(which occurred approximately 1 minute after bo-
lus). Vertical lines represent 95% confidence inter-
vals (there is a significant difference at 0 minute
and none elsewhere).
1

Oxytocin
Placebo
0

0 5 10 15 20

Minutes since placenta delivery

results must be read in the context of a study designed to

Table 4. Side Effects test superiority. Post hoc power was calculated to be 33% to
Side effect Oxytocin (n ⴝ 70) Saline (n ⴝ 73) P valuea detect a change from 0.40 to 0.29 in the proportion needing
Hypotension 18 (6) 10 (14) 0.07 additional uterotonics.
Facial flushing 6 (9) 8 (11) 0.63
Nausea 0 (0) 1 (1) 0.33
General anesthesia is a risk factor for uterine atony.17,18
Tachycardia 1 (1) 1 (1) 0.98 Studies investigating healthy elective subjects are often
Headache 1 (1) 0 (0) 0.30 standardized to a single anesthetic technique. We were
Light-headed 1 (1) 0 (0) 0.30 unable to do this in our high-risk group. The risk of, or
Vomiting 0 (0) 0 (0) NA
presence of actual bleeding affects the choice of anesthetic
Values are expressed as n (%). technique on a case-by-case basis. No single technique
NA ⫽ not applicable.
could have met the needs of our whole group. Women with
␹ test.
a 2
multiple gestation usually had spinal anesthesia for an
elective cesarean delivery. Those with ⬎8 hours intrapar-
An additional limitation was that neither the anesthetic tum oxytocin usually had epidural anesthesia. Bleeding can
nor the obstetric surgical techniques were standardized to also result in the conversion from 1 technique to another
enhance acceptability and perceived safety of the study in a (i.e., neuraxial to general, which occurred in 3 of our
population of patients considered to be at high risk for subjects). We intended to analyze general anesthesia as a
hemorrhage. As a result, our results are generalizable to subgroup, but the number in this subset was not large
other centers where obstetric and anesthetic practice will enough. Future studies that limit the inclusion criteria to 1
vary depending on the practitioner. risk factor may be able to better standardize the anesthetic
We used a 1-sided alternative in the hypothesis test for technique.
our primary outcome, following the argument of Bland and IV bolus oxytocin has serious side effects, including
Bland,31 “In general a one-sided test is appropriate when a hypotension, dysrhythmias, and myocardial ischemia.32
large difference in one direction would lead to the same These side effects seem to be related to both the dose and
action as no difference at all.” In this study, a large increase the speed of injection.5 Unfortunately, many previous
in the need for additional uterotonics with use of an studies did not specify the speed of bolus injection, and
oxytocin bolus would lead to discontinuing use of the published recommendations often say “give it slowly”
bolus, as would a finding of no difference, thus a 1-sided without defining how slowly is slow enough.2,3 We arbi-
alternative is appropriate. Readers who do not agree with trarily chose to give our bolus over 30 seconds to standard-
this postulate would require a 2-sided alternative and ize our study. More research is needed to determine the
conclude our study is underpowered. Similarly, this study optimal speed of administration. Interestingly, most ad-
was not designed as an equivalence study and the negative verse effects of oxytocin boluses described in the literature

1464 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA

have occurred in anesthetized patients (neuraxial or gen-
eral anesthesia). Whether this is because coadministration
of anesthetics enhances the adverse effects of the bolus
(because most anesthetic drugs are vasodilators) or because
anesthetized patients have been better studied is unclear.
The little information available suggests that nonanesthe-
tized women receiving a bolus after vaginal delivery may
tolerate it better.33
Using a placebo in a high-risk group for whom the
treatment, although not previously well studied, is believed
to be effective by many Canadian practitioners created
challenges. We gave a high-dose infusion to every subject
immediately after the bolus, so as not to disadvantage any
of our subjects, all of whom were at high risk of postpartum
hemorrhage. Our infusion was higher than that normally
used in our institution (20 or 40 IU over 8 hours), and was
chosen after consultation with our obstetric colleagues. Our
results suggest that an appropriately dosed oxytocin infu-
sion may be adequate without the need for a bolus, even for
high-risk patients. Munn et al.21 reported favorable results
with an even higher infusion rate (80 IU over 30 minutes)
with no bolus. More research is needed to determine the
most effective infusion regime.
In summary, we found that a 5 IU IV bolus of oxytocin
added to an infusion did not alter the need for additional
uterotonic drugs to prevent or treat postpartum hemor-
rhage in the first 24 hours in women with risk factors for
uterine atony undergoing cesarean delivery, despite caus-
ing an initial stronger uterine contraction. This study was
not powered to show a difference in side effects between
groups; however, bolus side effects have been well docu-
mented in other studies. More research is needed to iden-
tify the ideal dose and rate of oxytocin administration.
We believe an adequate infusion dose will protect even
high-risk patients against the threat of postpartum hem-
orrhage, while minimizing the side effects associated
with bolus use.
STUDY FUNDING
Supported by the Grace Barraclough Research Award from the
Women’s Health Research Institute, British Columbia, Canada,
and the Department of Anesthesia, British Columbia Women’s
Hospital, Vancouver, Canada.
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