Which is the nurses responsibility when a clients labor is being stimulated with an oxytocin?

KindProteinOrganismHumansPharmacological action

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General FunctionVasopressin receptor activitySpecific FunctionReceptor for oxytocin. The activity of this receptor is mediated by G proteins which activate a phosphatidylinositol-calcium second messenger system.Gene NameOXTRUniprot IDP30559Uniprot NameOxytocin receptorMolecular Weight42770.99 Da

  1. Spyranti Z, Fragiadaki M, Magafa V, Borovickova L, Spyroulias GA, Cordopatis P, Slaninova J: In position 7 L- and D-Tic-substituted oxytocin and deamino oxytocin: NMR study and conformational insights. Amino Acids. 2010 Jul;39(2):539-48. doi: 10.1007/s00726-009-0470-1. Epub 2010 Jan 27. [Article]
  2. Frantz MC, Rodrigo J, Boudier L, Durroux T, Mouillac B, Hibert M: Subtlety of the structure-affinity and structure-efficacy relationships around a nonpeptide oxytocin receptor agonist. J Med Chem. 2010 Feb 25;53(4):1546-62. doi: 10.1021/jm901084f. [Article]
  3. Gimpl G, Reitz J, Brauer S, Trossen C: Oxytocin receptors: ligand binding, signalling and cholesterol dependence. Prog Brain Res. 2008;170:193-204. doi: 10.1016/S0079-6123(08)00417-2. [Article]
  4. Ahn TG, Han SJ, Cho YS, An TH, Pak SC, Flouret G: In vivo activity of the potent oxytocin antagonist on uterine activity in the rat. In Vivo. 2004 Nov-Dec;18(6):763-6. [Article]
  5. Furman DJ, Chen MC, Gotlib IH: Variant in oxytocin receptor gene is associated with amygdala volume. Psychoneuroendocrinology. 2011 Jul;36(6):891-7. doi: 10.1016/j.psyneuen.2010.12.004. Epub 2011 Jan 3. [Article]
  6. Ding C, Leow MK, Magkos F: Oxytocin in metabolic homeostasis: implications for obesity and diabetes management. Obes Rev. 2019 Jan;20(1):22-40. doi: 10.1111/obr.12757. Epub 2018 Sep 25. [Article]

Alpha-hypophamine; manufactured versions – syntocinon and pitocin (both synthetic oxytocin); carbetocin (an analogue of oxytocin with similar structure)

What is oxytocin?

Oxytocin is produced in the hypothalamus and is secreted into the bloodstream by the posterior pituitary gland. Secretion depends on electrical activity of neurons in the hypothalamus – it is released into the blood when these cells are excited.

The two main actions of oxytocin in the body are contraction of the womb (uterus) during childbirth and lactation. Oxytocin stimulates the uterine muscles to contract and also increases production of prostaglandins, which increase the contractions further. Manufactured oxytocin is sometimes given to induce labour if it has not started naturally or it can be used to strengthen contractions to aid childbirth. In addition, manufactured oxytocin is often given to speed up delivery of the placenta and reduce the risk of heavy bleeding by contracting the uterus. During breastfeeding, oxytocin promotes the movement of milk through the ducts in the breast, allowing it to be excreted by the nipple. Oxytocin is also present in men, playing a role in sperm transport and production of testosterone by the testes.

In the brain, oxytocin acts as a chemical messenger and has an important role in many human behaviours

Oxytocin is a hormone that acts on organs in the body (including the breast and uterus) and as a chemical messenger in the brain, controlling key aspects of the reproductive system, including childbirth and lactation, and aspects of human behaviour.

Alternative names for oxytocin

Alpha-hypophamine; manufactured versions – syntocinon and pitocin (both synthetic oxytocin); carbetocin (an analogue of oxytocin with similar structure)

What is oxytocin?

Oxytocin is produced in the hypothalamus and is secreted into the bloodstream by the posterior pituitary gland. Secretion depends on electrical activity of neurons in the hypothalamus – it is released into the blood when these cells are excited.

The two main actions of oxytocin in the body are contraction of the womb (uterus) during childbirth and lactation. Oxytocin stimulates the uterine muscles to contract and also increases production of prostaglandins, which increase the contractions further. Manufactured oxytocin is sometimes given to induce labour if it has not started naturally or it can be used to strengthen contractions to aid childbirth. In addition, manufactured oxytocin is often given to speed up delivery of the placenta and reduce the risk of heavy bleeding by contracting the uterus. During breastfeeding, oxytocin promotes the movement of milk through the ducts in the breast, allowing it to be excreted by the nipple. Oxytocin is also present in men, playing a role in sperm transport and production of testosterone by the testes.

In the brain, oxytocin acts as a chemical messenger and has an important role in many human behaviours including sexual arousal, recognition, trust, romantic attachment and mother–infant bonding. As a result, oxytocin has been called the 'love hormone' or 'cuddle chemical'.

The effect of oxytocin on the brain is complex. Current research is focused on examining the role of oxytocin in various disorders including addiction, depression, post-traumatic stress, anxiety and anorexia.

How is oxytocin controlled?

Oxytocin production and secretion is controlled by a positive feedback mechanism where release of the hormone causes an action that stimulates more of its own release. For example, when contraction of the uterus starts during childbirth, oxytocin is released. This stimulates more contractions and more oxytocin to be released. In this way, contractions increase in intensity and frequency.

There is also a positive feedback involved in the milk-ejection reflex. Stimulation of the nipple during breastfeeding leads to increased oxytocin production and secretion into the blood, which then causes milk to be let down into the breast. The positive feedback cycle is maintained until the baby stops suckling. The production of oxytocin during childbirth is also self-limiting; release of the hormone is stopped once the baby is delivered. 

What happens if I have too much oxytocin?

At present, the implications of having too much oxytocin are not clear. High levels have been linked to benign prostatic hyperplasia, a condition which affects the prostate in more than half of men over the age of 60. This may cause difficulty in passing urine.

It may be possible to treat this condition by manipulating oxytocin levels; however, more research is needed before any possible treatments are available.

What happens if I have too little oxytocin?

Similarly, it is not fully understood at present if there are any implications of having too little oxytocin in the body. A lack of oxytocin in a nursing mother would prevent the milk-ejection reflex and prevent breastfeeding.

Low oxytocin levels have been linked to autism and autistic spectrum disorders (e.g. Asperger syndrome) – a key element of these disorders being poor social functioning. Some scientists believe oxytocin could be used to treat these disorders. In addition, low oxytocin has been linked to depressive symptoms and it has been proposed as a treatment for depressive disorders. However, there is not enough evidence at present to support its use for any of these conditions.

Last reviewed: Dec 2020

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Oxytocin is indicated and approved by the FDA for two specific time frames in the obstetric world: antepartum and postpartum. In the antepartum period, exogenous oxytocin is FDA-approved for strengthening uterine contractions with the aim of successful vaginal delivery of the fetus. There are three situations during the antepartum period, which indicate the use of oxytocin. These include mothers with preeclampsia, maternal diabetes, premature rupture of the membranes, mothers with inactive uteri that require stimulation into labor, and mothers with inevitable or incomplete abortions in their second trimester. Postpartum, oxytocin is FDA-approved when it is time to deliver the placenta during the third stage of labor and control postpartum hemorrhage. This activity outlines the indications, mechanism of action, methods of administration, significant adverse effects, contraindications, monitoring, and toxicity of oxytocin so providers can direct patient therapy to optimal outcomes where oxytocin has therapeutic benefit.

Objectives:

  • Identify the indications for the therapeutic use of oxytocin.

  • Describe the mechanism of action of oxytocin that gives it its therapeutic effects.

  • Review the potential adverse events and contraindications to using oxytocin.

  • Outline the importance of collaboration and communication among interprofessional team members to improve outcomes and treatment efficacy for patients who might benefit from therapy with oxytocin.

Access free multiple choice questions on this topic.

Oxytocin is indicated and approved by the FDA for two specific time frames in the obstetric world: antepartum and postpartum. In the antepartum period, exogenous oxytocin is FDA-approved for strengthening uterine contractions with the aim of successful vaginal delivery of the fetus. There are three situations during the antepartum period in which oxytocin is indicated:

  • For mothers who have preeclampsia, maternal diabetes, premature rupture of the membranes

  • For mothers with inactive uteri that require stimulation to start labor

  • For mothers with inevitable or incomplete abortions in their second trimester

In regards to the postpartum period, oxytocin is FDA-approved when it is time to deliver the placenta during the third stage of labor and control postpartum hemorrhage. A former version of oxytocin in the United States included an intranasal formula to encourage postpartum milk ejection. Other non-FDA-approved indications for exogenous oxytocin include treatment of delayed orgasm, inducing sexual arousal, and treatment of autism. Oxytocin has long been known as a hormone that plays a role in social behaviors and bonding. Because women release oxytocin during sexual intercourse, it is thought to play a role in bonding. Autism is not known to be caused by lower levels of oxytocin when compared to non-autistic people; however, previous studies have shown that giving oxytocin to children with autism seems to spark social skills. Further studies and larger sample sizes are needed.[1][2][3]

Oxytocin is an oligopeptide hormone that contains nine amino acyl residues, or in other words, a nonapeptide hormone. It is one of the two hormones stored and released from the posterior pituitary gland but created in the hypothalamus. It is specifically released from the paraventricular nucleus of the hypothalamus into the posterior pituitary gland for later use. This specific part of the posterior pituitary gland that stores oxytocin is called the pars nervosa, also known as the neural or posterior lobe. Most hormones create negative feedback loops after they are released, but oxytocin is one of the few that exhibit positive feedback loops, i.e., that the release of oxytocin leads to actions that stimulate even more of a release of oxytocin. This feedback contrasts with antidiuretic hormone (ADH), also known as vasopressin (the second and only other hormone stored and released from the posterior pituitary), which exhibits a negative feedback loop after release. Less of this hormone will be released after it exhibits its effect on the body.[4]

Exogenous oxytocin causes the same response in the female reproductive system as that of endogenous oxytocin. Both types of oxytocin stimulate uterine contractions in the myometrium by causing G-protein coupled receptors to stimulate a rise in intracellular calcium in uterine myofibrils. Oxytocin receptor activation causes many signals that stimulate uterine contraction by increasing intracellular calcium levels, which is where positive feedback comes into play. When oxytocin is released, it stimulates uterine contractions, and these uterine contractions, in turn, cause more oxytocin to be released; this is what causes the increase in both the intensity and frequency of contractions and enables a mother to carry out vaginal delivery completely. The head of the fetus pushes against the cervix, the nerve impulses from this action travel to the mother’s brain, which activates the posterior pituitary to secrete oxytocin. This oxytocin is then carried through the blood to the uterus to increase uterine contractions further, and the cycle continues until parturition.[5][4][5]

Not only does oxytocin stimulate uterine contractions, but it also causes contractions of the myoepithelial cells in the female breasts. This activity occurs in the alveolar ducts. Such contractions are what force milk from these ducts into even larger sinuses, which enable milk expulsion. Positive feedback is also relevant to this milk-ejection reflex. A baby attempting to latch on to his mother’s breast signals oxytocin secretion into the blood in the same manner as vaginal delivery, except, instead of uterine contractions, milk is ejected from the breast. The oxytocin makes its way to the brain at the same time to increase more oxytocin secretion.[6]

Lastly, oxytocin also has both antidiuretic and vasodilatory effects, increasing cerebral, coronary, and even renal blood flow.[7][8]

An injected form of oxytocin is administered intravenously using the drip method in the setting of delayed and potentially complicated labor. The same route of administration is indicated for both incomplete and inevitable abortions as well. Lastly, in the case of persistent uterine bleeding after giving birth, oxytocin may be given either intramuscularly or intravenously.[9][10]

Dosing for labor induction/augmentation:

  • 0.5 to 2 milliunits/minute IV, with increases of 1 to 2 milliunits every 15 to 40 minutes until there is an established contraction pattern.

Dosing for postpartum hemorrhage:

  • Prophylactic dosing: 10 units IM once following placental delivery. 

  • Therapeutic dosing: 60 to 200 milliunits/minute IV.

Common side effects of oxytocin administration include the following: erythema at the site of injection, intensified contractions, more frequent contractions, nausea, vomiting, stomach pain, and loss of appetite. Serious adverse effects that require monitoring after oxytocin administration include cardiac arrhythmias, seizures, anaphylaxis, confusion, hallucinations, extreme increase in blood pressure, and blurred vision.[11]

Specific contraindications to oxytocin include hypersensitivity to the hormone itself or any part of its synthetic version and vaginal deliveries that are in themselves contraindicated. These include the patient having an active genital herpes infection, vasa previa, complete placenta previa, invasive cervical cancer, and prolapse or presentation of the umbilical cord). Other contraindications to administering oxytocin include the fetus in an abnormal position (most notably including a transverse lie) and the fetus exhibiting distress when delivery is not about to happen. Antepartum usage of oxytocin is also contraindicated for women with pelvises not large enough to handle an infant passing through her birth canal and for when the woman's uterus is either hyperactive or hypertonic.[12]

It is essential to monitor patient fluids (both intake and outtake) while administering oxytocin and the frequency of uterine contractions, patient blood pressure, and heart rate of the unborn fetus.

An inappropriate dosage of oxytocin can lead to dangerous tachycardia, arrhythmias, and myocardial ischemia. High dosages of oxytocin can cause uterine rupture, hypertonicity, and spasms. When oxytocin is given to women in the first or second stages of labor or to women to cause induction of labor, uterine rupture, maternal subarachnoid hemorrhages, maternal death, and even fetal death can result. If oxytocin is given in dosages too large or even slowly during 24 hours, the medication can exhibit an antidiuretic effect resulting in extreme water intoxication; this can result in coma, seizures, and even death of the mother. Note that patients who receive fluids orally are at higher risk for water intoxication and antidiuretic effects when given exogenous oxytocin.[13][14]

Oxytocin is primarily used by the obstetrician and labor and delivery nurses. Its use and monitoring require the efforts of an interprofessional healthcare team that includes clinicians, specialists, obstetric nurses, and pharmacists. Clinicians who do prescribe this hormone should be familiar with its side effects. An inappropriate dosage of oxytocin can lead to dangerous tachycardia, arrhythmias, and myocardial ischemia. High dosages of oxytocin can cause uterine rupture, hypertonicity, and spasms. When oxytocin is given to women in the first or second stages of labor or to women to cause induction of labor, uterine rupture, maternal subarachnoid hemorrhages, maternal death, and even fetal death can result. If oxytocin is given in dosages too large or even slowly during 24 hours, the medication can exhibit an antidiuretic effect resulting in extreme water intoxication. This excessive dosing can result in coma, seizures, and even death in the mother.; hence, the pharmacist needs to check the dosage ordered carefully. Note that patients who receive fluids orally are at higher risk for water intoxication and antidiuretic effects when given exogenous oxytocin. When used at therapeutic doses, the drug is safe and effective.[15][16] [Level 5]

Review Questions

1.

Sentilhes L, Madar H, Ducarme G, Hamel JF, Mattuizzi A, Hanf M. Outcomes of operative vaginal delivery managed by residents under supervision and attending obstetricians: a prospective cross-sectional study. Am J Obstet Gynecol. 2019 Jul;221(1):59.e1-59.e15. [PubMed: 30807764]

2.

Saccone G, Della Corte L, Maruotti GM, Quist-Nelson J, Raffone A, De Vivo V, Esposito G, Zullo F, Berghella V. Induction of labor at full-term in pregnant women with uncomplicated singleton pregnancy: A systematic review and meta-analysis of randomized trials. Acta Obstet Gynecol Scand. 2019 Aug;98(8):958-966. [PubMed: 30723915]

3.

Saccone G, Della Corte L, D'Alessandro P, Ardino B, Carbone L, Raffone A, Guida M, Locci M, Zullo F, Berghella V. Prophylactic use of tranexamic acid after vaginal delivery reduces the risk of primary postpartum hemorrhage. J Matern Fetal Neonatal Med. 2020 Oct;33(19):3368-3376. [PubMed: 30704334]

4.

Li XH, Matsuura T, Xue M, Chen QY, Liu RH, Lu JS, Shi W, Fan K, Zhou Z, Miao Z, Yang J, Wei S, Wei F, Chen T, Zhuo M. Oxytocin in the anterior cingulate cortex attenuates neuropathic pain and emotional anxiety by inhibiting presynaptic long-term potentiation. Cell Rep. 2021 Jul 20;36(3):109411. [PubMed: 34289348]

5.

Ellis JA, Brown CM, Barger B, Carlson NS. Influence of Maternal Obesity on Labor Induction: A Systematic Review and Meta-Analysis. J Midwifery Womens Health. 2019 Jan;64(1):55-67. [PMC free article: PMC6758543] [PubMed: 30648804]

6.

Perkinson MR, Kim JS, Iremonger KJ, Brown CH. Visualising oxytocin neurone activity in vivo: The key to unlocking central regulation of parturition and lactation. J Neuroendocrinol. 2021 Nov;33(11):e13012. [PubMed: 34289195]

7.

Sapolsky RM. Doubled-Edged Swords in the Biology of Conflict. Front Psychol. 2018;9:2625. [PMC free article: PMC6306482] [PubMed: 30619017]

8.

Viteri OA, Sibai BM. Challenges and Limitations of Clinical Trials on Labor Induction: A Review of the Literature. AJP Rep. 2018 Oct;8(4):e365-e378. [PMC free article: PMC6306280] [PubMed: 30591843]

9.

Gallos ID, Papadopoulou A, Man R, Athanasopoulos N, Tobias A, Price MJ, Williams MJ, Diaz V, Pasquale J, Chamillard M, Widmer M, Tunçalp Ö, Hofmeyr GJ, Althabe F, Gülmezoglu AM, Vogel JP, Oladapo OT, Coomarasamy A. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev. 2018 Dec 19;12:CD011689. [PMC free article: PMC6388086] [PubMed: 30569545]

10.

Bhargava R, Daughters KL, Rees A. Oxytocin therapy in hypopituitarism: Challenges and opportunities. Clin Endocrinol (Oxf). 2019 Feb;90(2):257-264. [PubMed: 30506703]

11.

Simpson KR. Considerations for Active Labor Management with Oxytocin: More May Not be Better. MCN Am J Matern Child Nurs. 2020 Jul/Aug;45(4):248. [PubMed: 32604188]

12.

Ghorbani Z, Mirghafourvand M. The efficacy and safety of intravaginal oxytocin on vaginal atrophy: A systematic review. Post Reprod Health. 2021 Mar;27(1):30-41. [PubMed: 32814499]

13.

Zhang H, Liu H, Luo S, Gu W. Oxytocin use in trial of labor after cesarean and its relationship with risk of uterine rupture in women with one previous cesarean section: a meta-analysis of observational studies. BMC Pregnancy Childbirth. 2021 Jan 06;21(1):11. [PMC free article: PMC7786988] [PubMed: 33407241]

14.

Pursche T, Diedrich K, Banz-Jansen C. Blood loss after caesarean section: depending on the management of oxytocin application? Arch Gynecol Obstet. 2012 Sep;286(3):633-6. [PubMed: 22569708]

15.

Smorti M, Ponti L, Tani F. The effect of maternal depression and anxiety on labour and the well-being of the newborn. J Obstet Gynaecol. 2019 May;39(4):492-497. [PubMed: 30773960]

16.

Charles D, Anger H, Dabash R, Darwish E, Ramadan MC, Mansy A, Salem Y, Dzuba IG, Byrne ME, Breebaart M, Winikoff B. Intramuscular injection, intravenous infusion, and intravenous bolus of oxytocin in the third stage of labor for prevention of postpartum hemorrhage: a three-arm randomized control trial. BMC Pregnancy Childbirth. 2019 Jan 18;19(1):38. [PMC free article: PMC6339323] [PubMed: 30658605]