CHAPTER I

TITLE OF THE RESEARCH

Knowledge regarding oxytocin administration among nurses.

1.1 Background of the study

Induction of labour is the initiation of uterine contraction before their spontaneous
onset for the purpose of bringing about delivery. Induction may be indicated for a
variety of medical and obstetric reason. It would take place as a natural event in the
condition where the continuation of pregnancy may be hazardous to mother or fetus.
An ideal method of induction of labour should combine safety for the mother and and
fetus. Both a short induction to delivery interval, absence of side effect and
convenience for both patient and medical staff. Oxytocin has been used since a long
time without satisfying all the criteria (Bobak, 1991).
In current obstetric practices, induction of labour is often carried out for various
maternal or fetal indication. Induction of labour has been defined as the initiation of
uterine activity by an independent stimulus to achieve vaginal delivery after 28 weeks
of gestation and before the onset of spontaous labour clinically, two types of drug,
oxytocin and prostaglandin can be considered for pharmacologic induction of labour
(Anderson, 1983).
Injection oxytocin is a hormone which is used to stimulate contraction of the uterus
and smooth muscle tissue. The drug will be either injected into a large muscle muscle
or added to an intravenous fluid that will drip through a needle or catheter into the
vein. Oxytocin exerts a selective stimulatous effect on the smooth muscle of the
uterus and blood vessels. Oxytocin affects the myometrial cells of the uterus by
increasing the excitability of the muscle cell and increasing the strength of muscle
contraction. Oxytocin is use to include labour at term and to augment uterine
contraction in the first and second stage of labour. Oxytocin may be used immediately
after delivery to stimulate uterine contraction and thereby control uterine atony.

Since the early 1950s when oxytocin was synthesized induction of labour has become
increasing popular and accepted as an option in management of selected case of high
risk pregnancies in which the continuation of pregnancy is likely to adversely affect
the maternal health or the perinatal outcomes (Daftory S.N 2001).
Approximately 20 % to 30 % of all pregnancies are induced making labour induction
a frequent medical intervention. Oxytocin is a safe and effective initiater of uterine
contraction to induce labour (Christensen, 2002).
IV administration of oxytocin for the induction or augmentation of labour is one of
the essential obstetric cares, which is carried out by nurses working in the labour
room when oxytocin is administration to pregnant women, it is potentially dangerous
to both mother and fetus. The potential dangerous may be fetal distress, hypertonic
uterine contraction and water intoxication. So nurses knowledge and appropriate
practices on oxytocin administration can prevent these dangerous outcomes. Thus the
nurse working at labour room should have current medical knowledge on
administration drug including its affect, side effect, indication, contraindication and
complication. They should also be competent enough to put their knowledge into
practice so that they could be able to provide complete obstetric nursing care to the
pregnant women to meet the role of reducing maternal mortality and mortality.
1.2 Statement of the problem:
Complications of pregnancy and childbirth are the leading causes of morbidity and
mortality among women of reproductive age in developing countries. There are
approximately 529,000 pregnancy-related deaths worldwide each year (Harriet and
Heilbrunn R., Department of Population and Family Health, Columbia). Over recent
decades, more and more pregnant women around the world have undergone induction
of labour to deliver their babies. In developed countries, up to 25% of all deliveries at
term now involve induction of labour and in developing countries, the rates are
generally lower, but in some settings they can be as high as those observed in
developed countries (WHO, 2011). Globally 8 % maternal death is due to prolong
labour (WHO, 2006a). In India, 5 % maternal death is due to obstructed and
prolonged labour (Vib Ban, 10 Jun 2009). Current MMR (eight districts) of Nepal was
found to be 229 per 100,000 live births, which included prolong labour is 6%, down
2

from 13% in 1998 (Nepal maternal mortality and morbidity study 2008/09). However,
maternal death can prevent if the causes of maternal death are managed in timely.
Among these causes the prolong labour also the one of the causes of maternal death
so it should be managed by using injection Oxytocin. So, this study is to identify the
knowledge regarding oxytocin administration among nurses in the Phect Nepal.

1.3 Rational of the study:

Exogenous oxytocin is a powerful uterine stimulant; therefore, dosage should
simulate the amount normally released endogenously during labor to achieve a
physiologic steady state.
Recent studies suggest that smaller dose regimens are as effective as previous larger
dose regimens and that adverse effects of oxytocin are dose related. Physiologic
principles provide an understanding of why oxytocin dosage during labor induction or
augmentation should be kept as low as possible to prevent adverse maternal and fetal
effects.So nurses must know the relationship between the physiology of normal labor
and the pharmacokinetics and safe administration of oxytocin during labor.
Niswander (1985) stated that oxytocin induction is not without some risk. Rapid
progression of infusion rates or continuous of a particular rate without adequate
assessment of uterine contraction may lead to hyperstimulation of the uterus, fetal
distress due to decrease placental perfusion. A rapid labour and birth with the danger
of cervical or perineal laceration or uterine rupture and water intoxication may occur
if a large dose is given in electrolyte to free solution over a prolonged period of time.
So, the nurse must have knowledge about oxytocin administration, nursing must
include constant observation, fetal heart monitoring as well as uterine contraction
monitoring. If the nurses dont have an adequate knowledge about oxytocin
administration, then many complication related to oxytocin may arise. Nurses must be
aware of the changes in practice regarding oxytocin administration and must revise
and implement protocols for labor induction and augmentation accordingly. So it is
important to have knowledge about oxytocin.

1.4 Significant of the study:

This study will help to find out level of knowledge of nurse regarding oxytocin
administration including their practice of administrating it, such as their practice of
frequency of measuring the fetal heart sound and their technique in monitoring uterine
contraction during first stage of labour.
This study will help the in service education co-ordinator and concerned authority for
arranging refreshing training to the nurse.
This study will be helpful to the nurse of labour room for keeping up to date
knowledge about oxytocin administration.
During the researchers work experience the researcher found inadequate knowledge
and inappropriate practice about oxytocin administration among nurses working at
labour room like not maintaining drop rate accurately not assessing the patient
frequently and not listening the fetal heart sound regularly. Inadequate knowledge and
inappropriate practice may lead to many complication for the mother and the fetus. So
researcher wanted to assess the knowledge and observe the practice of staff nurses
regarding oxytocin administration.
1.5 Objectives of the study:
General objectives:
To assess knowledge of nurses regarding oxytocin administration at lobur room and
birthing centre of Phect Nepal.

1.6.

Research questions

What are the knowledge of nurses regarding oxytocin administratin for

induction/augmentation of labour.

1.7.

Variables

Independent variables:-

work experience
Educational background
4

Training
Dependent variables:-

Knowledge

1.8.

Conceptual framework

The conceptual framework is a diagram or model that shows the possible linkages of
one variables with another in resulting the specified outcome. It helps the readers to
understand the study systematically and methodology. The framework describes the
interrelatilonship between independent and dependent variables.

Independent variables:

Dependent
variable:

Educational background
Work experience
Training

Knowledge on
oxytocin
administration.

1.9.

Operational definition

2. Knowledge:
Knowledge refers to theoretical concepts and idea about oxytocin administration.
3. Practice:
Practice refers to the performance of nurses during oxytocin administration.
4. Oxytocin:
Oxytocin is a drug that stimulate contractibility of myometrium of the pregnant
uterus.

5. First stage of labour:

From onset of true labour to the full dilatation of cervix.
5

6. Induction:
Starting labour by the use of IV oxytocin.
7. Nurse:
Who passed PCL nursing from authorized institute and working in the labour room
and who takes part in oxytocin administration.
8. Nursing care:
Care provided by the nurse to the mother during oxytocin administration.
9. Five rights:
Five rights include right patient, right medicine, right time, right route and right dose.

CHAPTER II
1. LITERATURE REVIEW
High-dose oxytocin was associated with a moderate decrease in the risk of C/S
(relative risk RR, 0.85; 95% confidence interval CI, 0.75-0.97), a small increase in
spontaneous vaginal delivery (RR, 1.07; 95% CI, 1.02-1.12), and a decrease in labor
duration (mean difference: -1.54 hours, 95% CI, -2.44 to -0.64). While
hyperstimulation was increased with high-dose oxytocin (RR, 1.91; 95% CI, 1.496

2.45), there was no evidence of an increase in maternal or neonatal morbidity. The

conclusion was that high-dose oxytocin for labor augmentation is associated with a
decrease in cesarean section and shortened labor, (A J OG, 2010).
In 2004, the Perinatal Safety Division assisted with the establishment of a system
wide uniform, checklist-based protocol for oxytocin administration by work groups
composed of representative practicing physicians, nurses, and pharmacists from the
entire organization, as well as consultants from other institutions in areas served by
the hospitals. During the first year of system wide implementation of this protocol
(2006), the primary cesarean delivery rate in approximately 220,000 deliveries fell
from 23.6% (2005) to 21.0% (2006) in contrast to an annual increase in rate of
primary cesarean of 1-4% in previous years. A comparison of newborn outcomes
demonstrated a statistically significant difference in 1 minute Apgar scores, with
improved 1 minute Apgar scores in the checklist managed group (Clark et al, (2007).
Oxytocin as a drug associated with a heightened risk of harm and one that may
require special safeguards to reduce the risk of error was recently included in the list
of high-alert medications [Clark, Simpson, Knox, and Garite, 2009: 35.e1].
Clark et al. point out that recommendations on oxytocin administration currently used
in practice are vague and that in many instances, the apparent efficacy and safety of
the various anecdotally derived means of administration (the way we have always
done it) owe their success primarily to the resiliency of maternal-fetal biology rather
than carefully considered scientific evidence [Clark et al., 2009: 35.e1].
There is a cumulative body of evidence to suggest that using oxytocin at high rates,
increasing the dosage at intervals inconsistent with basic pharmacology (less than
every 30 to 40 minutes), and causing uterine hyperstimulation will not result in a
clinically significant decrease in the length of labor ( Crane & Young, 1998 ) .
Fetal O2 desaturation begins within the first 5 minutes of excessive uterine activity
and has already progressed before any non reassuring changes in FHR occur. The
authors propose redefining uterine hyperstimulation as five or more contractions
during a 10-minute period and suggest that the three concurrent interventions are best
for rectifying hyperstimulation. Clearly, oxytocin use in the labor setting requires

closer surveillance and more attention from obstetricians, midwives, and nurses,
(Diane J. Angelini June 19, 2008) .
A review of studies on the use of oxytocin and misoprostol in seven low-income
countries showed that up to 50 percent of deliveries in public hospitals were induced
or augmented (up to 20 per cent in Ethiopia and Tanzania, and 40-50 percent in the
other five countries). These high percentages of induced and augmented labours are
worrying in the context of developing countries where current evidence-based
guidelines are rare, care is less regulated, and staffing and monitoring capabilities are
limited. Oxytocin is often administered without the aid of a precise dose/time
regulatory infusion pump, external fetal monitor or one-on-one care [Lovold et al.,
2008: 277].
To manage safely and effectively oxytocin administration, nurses must be
knowledgeable in theory and skilled in technique. Current theory is explored
regarding initiation of labor and cervical ripening. The pharmacology of oxytocin,
uterine response to endogenous and exogenous stimulation of oxytocin, and current
methods being used to induce/augment labor are discussed. A protocol to provide safe,
effective guidelines for managing induction/augmentation of labor is provided. The
goal in oxytocin administration is to use the minimum dose necessary to facilitate and
maintain an effective uterine response and avoid hyperstimulation and fetal distress
(Marshall C., 1985).
The exogenous oxytocin is a synthetic hormone used to artificially stimulate labour.
The half life of oxytocin is 10 to 12 minutes and 3 to 4 half lives are needed to reach a
steady-states plasma concentration. During initial phase of exposure to oxytocin
during induction or augmentation of labour, uterine contraction will increase
progressively in frequency and intensity. However after several hour exposure to
increasing doses no longer cause normal increases in uterine forces and may produce
adverse side effects such as hyper stimulation (greater than 5 contraction in 10
minutes, contraction lasting longer than 90 seconds or increase in baseline uterine
tone). During oxytocin infusion, nurses often focus on rate increases section of the
protocol while ignoring the clinical criteria for increases. For example, if cervical
effacement is occurring or if the women is progressing in labour at approximately
1cm per hour, there is no need to increase oxytocin rate, even if contraction appear to
8

be mild and infrequent. Labour progress and maternal-fetal response to drug should
be the primary consideration (Simpson, 2003).
Multiple clinical studies and current data based on physiologic and pharmacologic
principles have shown that 90% of pregnant women at term will have labour
successfully induced with 6mU/min or less of oxytocin (Simpson, 2002 ) .
WHO (2003 a) recommendations, that suggest a starting dose of 2.5 units in 500ml of
dextrose (or normal saline). The dose should be increased until 3 contractions lasting
40 seconds in 10 minutes are attained with maximum infusion rate of 60 drops per
minute. If satisfactory contractions are not established, the concentration of oxytocin
should be increased to 5 units in 500ml dextrose (or normal saline) with the same rate
of infusion and increments as above. Women should be carefully observed
throughout, and their pulse, blood pressure and contractions monitored; the foetal
heart should be monitored every 30 minutes and the IV infusion should be stopped in
the event of abnormal foetal heart rate or of uterine hyperstimulation. The guidelines
provided by NICE and by WHO are alike in requiring oxytocin to be administered by
IV infusion and the continuous monitoring of contractions and foetal heart rate.
Injected oxytocin analogues are used for labor induction and to support labor in case
of non-progression of parturition.Oxytocin is relatively safe when used at
recommended doses, and side effects are uncommon. Some maternal events have
been reported if not used properly i.e. Subarachnoid hemorrhage, Increased heart
rate, Decreased blood pressure,Cardiac arrhythmia and premature ventricular
contraction, Impaired uterine blood flow, Pelvic hematoma, Afibrinogenonemia
which can lead to hemorrhage and death. Excessive dosage or long term
administration (over a period of 24 hours or longer) have been known to result in
tetanic uterine contractions, uterine rupture, PPH, and water intoxication, sometimes
fatal. Increased uterine motility has led to some complications in the fetus/neonate i.e.
Decreased heart rate or heart rate decelerations, Cardiac arrhythmia, Brain damage,
Seizures, Death. So the nurses responsibility is to closely monitoring while using
oxytocin to indue labour. ( Wikipedia, the free encyclopedia)

Summary of the literature reviewed

9

Above literature show that the oxytocin is a synthetic hormone which is used for
induction of labour if the labour is not onset naturally and ineffective progress of
labour. The oxytocin is safe when used at recommended doses. While using
exogenous oxytocin the obstetrician or midwives or the nurses who are working in
labour room should follow the standard protocol not use haphazardly and they should
take great precuation. The low dose use of oxytocin is effective and harmless then
high doses and the low dose use of oxytocin reduces the risk of caesarean section
delivery. During oxytocin administration it is most important to monitor oxytocin
drop per minute to evaluate the high dose oxytocin. The oxytocin drip should be used
according to protocol and the drop should be maintain correctly. The nurses must
monitor the uterine contraction and fetal heart sound frequently. Because the high
doses of oxytocin causes hyperstimulation of uterus resulting uterine rupture and fetal
O2 desaturation and water intoxication. Increase uterine motility has led to some
complication to fetus such as heart rate decelerations, cardiac arrhythmia, brain
damage and death. So the nurses must be knowledgeable in theory and skilled in
technique to manage safely and effectively oxytocin administration. Nurses must be
knowledgeable

about

oxytocin

contraindication, complication

drugs

its

action,

side

effects,

indication,

and its uses, about the oxytocin administration

protocol. The nurses must have enough knowledge and practical skill to save the life
of mother and fetus

CHAPTER - III
METHODOLOGY
This chapter deals with the research design and procedure that will be used in this
study. It contains the research design, study area, population and sample, sampling
technique, instrument, ethical consideration and statistical tools that will be used for
data analysis.

3.1. Study design

10

A small scale descriptive study of explorative nature will be used at labour room
and

birthing centre of Phect Nepal. This chapter is concerned with the methodology

which adopted for assessing the knowledge of nurses regarding oxytocin

administration.

3.2. Study area / setting

This study will be conducted at labour and birthing centre of Phect Nepal .

3.3. Study population

Nurses working at labour room and birthing centre of Phect Nepal.

3.4. Sample size

At least 30 nurses will total sample of the study.

3.5. Inclusion criteria

All staff working at labour room and birthing centre of Phect Nepal.

3.6.

Exclusion criteria
Nursing personnel who will not willing to participate in this study.

3.7. Sampling technique

Non probability purposive sampling technique will be used. Sample will be taken
those nurses who are on duty and and those nurses cannot participate who are not
interested to participate

3.8. Data collection procedure

A structured questionnaire will distributed then collect the information.

3.9.

Data collection tools/instrument

A structured closed-ended questionnaires based on research objectives.

The questionnaire contained two parts:
Demographic information
Question related to knowledge.

1.6.

Validity and reliability of tool (Pretesting)

11

 The validity of instrument was maintained by consulting advisor, research,

teacher, experts and colleagues.
By reviewing the related literature.
The questionnaire will be tested on 10% of respondents working in
labour room of NMC.

1.7.

Ethical consideration
Verbal and written permission will be taken from the hospital authority by

submitting the official letter from the KAMHSON.

Official letter will be submitted to the related advisor.
The researcher will take verbal permission from the ward in-charge and
respondents and

explain the purpose of study to each respondent before

giving the questionnaire.

The desire of the participants will be highly appreciated i.e. they will be forced.
Every precaution will be taken to safeguard the right and welfare of the
respondents.
Privacy, confidentiality and anonymity will be maintained.

1.8.

Data processing and analysis

Simple descriptive statistics will be used for data analysis e.g. percentage, frequency
and mean score after the analysis of data the findings were presented through
tabulation and graphic presentation

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C. Steven, B. Michael, S. George, H. Gary, D. Miller, F. Donna and M. Janet
(November 2007), Implementation of a conservative checklist-based protocol for
oxytocin administration American Journal of Obstetrics & Gynecology, doi:
10.1016/j.ajog.2007.08.026
(2068/02/26)
Clark S. L., Simpson, K. R., Knox, G. E. (2009): Oxytocin: new perspectives on an
old drug, American Journal of Obstetrics and Gynecology, 200, 35.e31-35.e36.
Crane, J. M., & Young, D. C. (1998), Meta-analysis of low-dose versus high-dose
oxytocin for labour induction. Journal of the Society of Obstetricians and
Gynaecologists of Canada, 20, 1215-1223. (2068/02/28)
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Christensen (2002), J Obstet Gynaecol induction of labour; 22

http:// www.virtualmedicalcentre.com/treatments.asp?sid=164&page=2 (2068/02/25)
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Lovold et al., (2008: 277), Intrapartum Oxytocin (Mis) use in South Asia / Brhlikova,
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(1):22-8 http://www.ncbi.nlm.nih.gov/pubmed/3844458 (2068/02/25)

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