Use of uterotonic agents during caesarean section: International consensus statement
An international consensus statement on the use of uterotonic agents during caesarean section has been developed and released.
It is routine to give a uterotonic drug following delivery of the neonate during caesarean section. However, there is much heterogeneity in the relevant research, which has largely been performed in low‐risk elective cases or women with uncomplicated labour. International guidelines on uterotonic use during caesarean section are variable. Most guidelines make a single recommendation for uterotonic use and do not discuss the use of additional agents in the presence of persistent uterine atony. Management of uterine tone after delivery involves giving a prophylactic uterotonic, and the use of controlled cord traction to facilitate the delivery of the placenta and minimize blood loss. This is usually accomplished with a single drug – however, supplementary drugs are sometimes required.
Recommendations for clinical practice
- Oxytocin or carbetocin are recommended for routine administration immediately after delivery of the fetus during caesarean section to prevent postpartum hemorrhage.
- Oxytocin and carbetocin dose requirements for intrapartum caesarean section are several times greater than that for low‐risk elective caesarean section, and therefore a universal dose for all cases is not appropriate.
- Oxytocin has significant adverse effects when given as a rapid high‐dose bolus. It should, therefore, be given slowly to reduce these effects. A small initial dose followed by a controlled infusion is the optimum approach. Suggested doses are given in Box.
- Research is lacking on oxytocin dose requirements for women having elective caesarean section who are at high risk of uterine atony and hemorrhage. In this situation, it may be appropriate to follow the dose regimen for intrapartum caesarean section.
- Infusion regimens for oxytocin are highly variable, but large total oxytocin doses should be avoided to minimize the antidiuretic effect. Administration of a concentrated solution using a syringe pump may be required for women who require fluid restriction.
- Carbetocin is a longer‐acting analog of oxytocin, with a similar mechanism of action and adverse effects profile. The increased duration of action of carbetocin compared with oxytocin eliminates the requirement for an infusion after the initial dose. It may, therefore, become the preferred first‐line drug, rather than oxytocin.
- If oxytocin/carbetocin do not provide adequate uterine tone, a second‐line drug (ergot alkaloids or a prostaglandin) should be considered early. Administration of a second‐line agent should be guided by the clinical context and presence of contraindications, and follow local hospital policies and availability.
- In resource‐constrained settings, where controlled intravenous (i.v.) infusions are not readily available, the intramuscular (i.m.) route can be considered for a sustained duration of drug action.
- Women with significant cardiac disease may be very sensitive to the adverse effects of oxytocin and other uterotonics, and their management needs to be individualized.
- As accidental administration of uterotonic drugs before delivery of the fetus may result in a catastrophic outcome, extreme care must be taken to ensure that pre‐prepared syringes or solutions are not confused with other drugs that may be given during this period.