AW H O N N P R A C T I C E B R I E F

Guidelines for Oxytocin Administration

after Birth: AWHONN Practice Brief
Number 2

An official practice brief

from the Association of
Recommendation
Women’s Health, Obstetric AWHONN recommends oxytocin administration for management of third stage of labor for all births.
and Neonatal Nurses

AWHONN 2000 L Street, oxytocin pre-mixed bags should be prominently

NW, Suite 740, Magnitude of the Problem
Washington, DC 20036, r Each year, approximately 125,000 women in
and clearly labeled and stored separately to pre-
(800) 673–8499 vent a 1000 milliliter bag with oxytocin being mis-
the United States (or 2.9% of all births) expe-
taken for a plain 1000 milliliter bag used for IV fluid
rience postpartum hemorrhage (Callaghan,
AWHONN periodically resuscitation bolus.
Kuklina, & Berg, 2010).
updates practice briefs. For r Every year there are 14 million cases of
the latest version go to As a high alert medication, IV oxytocin pre-mixed
http://www.AWHONN.org. postpartum hemorrhage worldwide (United
bags should be
The information herein is States Agency for International Development
designed to aid nurses in [USAID], 2010). r
providing evidenced–based r Postpartum hemorrhage occurs in more than
Infused via an IV infusion pump to control
care to women and oxytocin administration
newborns. These 10% of all births and accounts for 25% of r Prominently and clearly labeled with bright
recommendations should maternal deaths (World Health Organization colored labeling
not be construed as [WHO], 2006). r
dictating an exclusive r Oxytocin is routinely administered to prevent
Stored separately to prevent a 1000 milliliter
course of treatment or IV bag with oxytocin being mistaken for a
procedure. Variations in and treat postpartum hemorrhage (Butwick, plain 1000 milliliter bag used for IV fluid re-
practice may be warranted Coleman, Cohen, Riley, & Carvalho, 2010; suscitation bolus
based on the needs of the
Dyer, Butwick, & Carvalho, 2011; King,
individual patient,
resources, and limitations Douglas, Unger, Wong, & King, 2010). Administration Options. Administer IV oxytocin by
unique to the institution or providing a bolus dose followed by a total mini-
type of practice. mum infusion time of 4 hours after birth. For women
Oxytocin Doses and Administration who are at high risk for a postpartum hemorrhage
r Oxytocin should be administered only by the or who have had cesarean births, continuation be-
intramuscular (IM) or intravenous (IV) route, yond 4 hours is recommended. Rate and duration
not by IV push (Butwick et al., 2010; De- should be titrated according to uterine tone and
vikarani & Harsoor, 2013; George, McKeen, bleeding.
Chaplin, & McLeod, 2010; King et al., 2010).
r Ideal dose and infusion rates have yet to be Option 1
established in the literature (Dyer, Butwick, r Oxytocin 20 units in 1 liter normal saline (NS)
& Carvalho, 2011; Westoff, Cotter, & Tolosa,
or lactated Ringer’s (LR) solution
2013). r Initial bolus rate 1000 ml/hour bolus for 30
minutes (equals 10 units) followed by a main-
Oxytocin Administration tenance rate 125 ml/hour over 3.5 hours
(equals remaining 10 units)
Guidelines
IV Oxytocin Warning. The accidental administra- Option 2
tion of IV fluid oxytocin instead of plain IV fluid
has been documented and is preventable (Simp- r Some facilities supply only one standard pre-
son & Knox, 2009). As a high alert medication, IV mixed concentration of IV fluid with oxytocin

JOGNN, 44, 161–163; 2015. DOI: 10.1111/1552-6909.12528

http://jognn.awhonn.org 
C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 161
 AWHONN Practice Brief

Table 1: Various Guidelines and Studies Using Oxytocin

Oxytocin
Research Studies Concentration Fluid Volume Rate

George et al., 2010 15u 1000 ml 1000 ml/hr

Devikarani et al., 2010 20u 1000 ml 600 ml/hr for a few minutes

20u 1000 ml 60–120 ml/hr

King et al., 2010 40u 500 ml Bolus

20u 1000 ml 125 ml/hr

Books

Cunningham et al., 2014 20u 1000 ml 600–1200 ml/hr for a few minutes

20u 1000 ml 60–120 ml/hr

Ricci et al., 2013 20–40u 1000 ml

Simpson & Creehan, 2013 10–40u 500–1000 ml 50 mu/min

20u 1000 ml 150 ml/hr

Trioano et al., 2012 10–40u 1000 ml 20–50 mu/min

20u 1000 ml 60–150 ml/hr

Guidelines

California Maternal Quality Care 10–40u 1000 ml 500 ml/hr if bleeding, titrate to uterine tone
Collaborative, 2010

J.P.H. Pharmaceuticals, 2007 10–40u 1000 ml Adjust rate to sustain contractions

used for both intrapartum labor induction supported (National Institute for Health and
and postpartum third stage management. For Care Experience, 2014).
those facilities that have only, for example, 30 r AMTSL consists of administration of utero-
units in 500 ml of NS or LR solution, set the tonic agents, controlled cord traction, and
infusion pump rate to 334 ml/hour for 30 min- uterine massage after the delivery of the
utes (10 units in 167 ml), then reduce the rate placenta (International Confederation of
to 95 ml/hour (remaining 20 units) over 3.5 Midwives & International Federation of
hours. Gynaecologists and Obstetricians, 2003).
r AMTSL reduces the risk of postpartum hem-
orrhage (Soltani, Hutchon, & Poulose, 2010).
Option 3
r Researchers found no difference in amount
r Give oxytocin 10 units IM in women without
of blood loss or incidence of retained pla-
centa when oxytocin was given at the time
IV access.
of the delivery of the anterior shoulder com-
pared to administration after the delivery of
the placenta (Soltani et al., 2010).
Active Management of the Third r In a study on the effectiveness of the indi-
Stage of Labor (AMTSL) vidual components of AMTSL, IV oxytocin
r Women who are at low risk for postpartum reduced the risk of postpartum hemor-
hemorrhage and wish to avoid routine ad- rhage by 70% compared to IM adminis-
ministration of postpartum oxytocin should tration, although the route of administration
be advised that active management of the had no greater effect when combined with
third stage of labor has been shown to reduce cord traction and uterine massage (Sheldon,
the risk of PPH; if a woman still chooses not Durocher, Winikoff, Blum, & Trussell, 2013).
to have oxytocin administered, her informed r Of all the AMTSL interventions, uterotonics
decision to follow physiological or expectant are the most effective element in preventing
management of the third stage should be PPH (WHO, 2012). Women should be offered

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AWHONN Practice Brief

uterotonics after birth (Gizzo et al., 2013). J.P.H. Pharmaceuticals. (2007). Pitocin. Prescribing information.
Oxytocin is recommended as the first utero- Retrieved from http://www.parsterileproducts.com/products/
brands/pitocin.php
tonic of choice (WHO, 2012).
King, K. J., Douglas, M. J., Unger, W., Wong, A., & King, R. A. (2010).
Five unit bolus oxytocin at cesarean delivery in women at risk

Suggested Equipment of atony: A randomized double blind controlled trial. Anesthesia

r IV infusion pump
and Analgesia, 111(6), 1460–1466.

r Liters of NS or LR solution
National Institute for Health and Care Experience. (2014). Intra-

r Vials of oxytocin and syringes (for IM admin-

partum care overview. London, UK: Author. Retrieved from
http://pathways.nice.org.uk/pathways/intrapartum-care?fno=1#
istration) path=view%3A/pathways/intrapartum-care/normal-labour-and-
r Have other uterotonics on hand such as birth.xml&content=view-index

methylergonovine (Methergine), misoprostol Ricci, S. S., Kyle, T., & Carmen, S. (2013). Essentials of maternity, new-
born, and women’s health nursing. Philadelphia, PA: Lippincott.
(Cytotec), and carboprost (Hemabate).
Williams, and Wilkins.
Sheldon, W. R., Durocher, J., Winikoff, B., Blum, J. & Trussell, J. (2013).
REFERENCES How effective are the components of active management of the
Butwick, A. J., Coleman, L., Cohen, S. E., Riley, E. T., & Carvalho, B. third stage of labor? BMC Pregnancy and Childbirth, 13(46),
(2010). Minimum effective bolus dose of oxytocin during elective 1–8.
caesarean delivery. British Journal of Anaesthesia, 104(3), 338– Simpson, K. R., & Creehan, P. A. (2013). AWHONN perinatal nurs-
343. ing. (4th ed.). Philadelphia, PA: Lippincott. Williams, and
Callaghan, W. M., Kuklina, E. V, & Berg, C. J. (2010). Trends in Wilkins.
postpartum hemorrhage: United States, 1994–2006. American Simpson, K. R., & Knox, G. E. (2009). Oxytocin as a high-alert medica-
Journal of Obstetrics and Gynecology, 202(4), 353.e1–353.e6. tion: Implications for perinatal patient safety. American Journal
doi:10.1016/j.ajog.2010.01.011 of Maternal Child Nursing, 34(1), 8–15.
California Maternal Quality Care Collaborative. (2010). OB hem- Sultani, H., Hutchon, D. R., & Poulose, T. A. (2010). Timing of pro-
orrhage toolkit. Stanford, CA: Author. Retrieved from: phylactic uterotonics for the third stage of labour after vaginal
https://www.cmqcc.org/ob_hemorrhage birth. Cochrane Database of Systematic Reviews, 8, CD006173.
Cunningham, F., Leveno, K., Bloom, S., Spong, C. Y., & Dashe, J., Hoff- doi:10.1002/14651858.CD006173.pub2
man, B.L., . . . Sheffield, J. S. (Eds.). (2014). Williams obstetrics. Trioano, N. H., Chez, B. F., & Harvey, C. J. (2012). AWHONN high
(24th Ed.). New York: McGraw-Hill Professional Publishing. risk and critical care obstetrics. Philadelphia, PA: Lippincott,
Devikarani, D., & Harsoor, S. S. (2010). Are we using right dose of Williams, and Wilkins.
oxytocin? Indian Journal of Anaesthesia, 54(5), 371–373. United States Agency for International Development. (2010). Active
Dyer, R. A., Butwick, A. J., & Carvalho, B. (2011). Oxytocin for management of the third stage of labor for prevention of post-
labour and caesarean delivery: Implications for the anaesthe- partum hemorrhage: A fact sheet for policy makers and program
siologist. Current Opinions in Anaesthesiology, 24(3), 255–261. managers. Retrieved from http://www.k4health.org/toolkits/pc-
doi:10.1097/ACO.0b013e328345331c mnh/active-management-third-stage-labor-amtsl-prevention-
George, R. B., McKeen, D., Chaplin, A. C., & McLeod, L. (2010). Up- post-partum-hemorrhage-fact
down determination of the ED90 of oxytocin infusions for the Westoff, G., Cotter, A. M., & Tolosa, J. E. (2013). Prophylactic oxytocin
prevention of postpartum uterine atony in parturients undergoing for the third stage of labour to prevent postpartum haemorrhage.
cesarean delivery. Canadian Journal of Anesthesia, 57, 578– Cochrane Database of Systematic Reviews, 10, CD001808.
582. doi:10.1002/14651858.CD001808.pub2
Gizzo, S., Patrelli, T.S., Gangi, S.D., Carrozzini, M., Saccardi, C., & World Health Organization. (2006). Prevention of postpartum haem-
Zambon, A. (2013). Which uterotonic is better to prevent post- orrhage by active management of third stage of labour.
partum hemorrhage. Latest news in terms of clinical efficacy, MPS technical update. Geneva, Switzerland: Author. Retrieved
side effects, and contradictions: A systemic review. Reproduc- from http://www.who.int/maternal_child_adolescent/documents/
tive Sciences, 20, 1011–1019. postpartum/en/
International Confederation of Midwives & International Federation of World Health Organization. (2012). WHO recommendations for the
Gynaecologists and Obstetricians. (2003). Joint statement: Man- prevention and treatment of postpartum haemorrhage. Geneva,
agement of the third stage of labour to prevent post-partum Switzerland: World Health Organization. Retrieved from http://
haemorrhage. Retrieved from http://www.figo.org/files/figo-corp/ apps.who.int/iris/bitstream/10665/75411/1/9789241548502_
docs/PPH%20Joint%20Statement.pdf eng.pdf

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