February 16, 2024 • 38 mins
Discover the hormone oxytocin and its role in the birthing process in the latest ObsPod episode. We unravel the dual nature of this potent hormone, once an unquestioned staple in Active Management of Labour. Listen as we share an engaging conversation about its physiological impacts, the delicate balancing act required for its use in inducing labor, and the critical examination of its application in natural labor progression.
We discuss use of oxytocin over time, We tackle the tough questions about its contribution to caesarean birth rates and dissect the role that confirmation bias has played in obstetric intervention. With a focus on the value of one-to-one midwifery care and the potential consequences of oxytocin use, such as hyperstimulation and fetal distress, our discussion paints a comprehensive picture of the complexities involved in labor management. We take a look at the risks associated with administering oxytocin during labor. Highlighting scenarios where its use is beneficial against those where caution is paramount, we stress the importance of respecting natural labor progression, discussing alternatives. I extend an invitation to our listeners to contribute to the conversation and support the ObsPod, remember that this episode isn't just about the clinical—it's about informed consent and empowering women to make the right choices for their births.
Want to know more?
https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1996.tb09734.x
https://www.cochrane.org/CD007123/PREG_the-effectuse-of-the-drug-oxytocin-as-a-treatment-for-slow-progress-in-labour
https://www.nice.org.uk/guidance/ng235
https://www.nice.org.uk/guidance/ng235/evidence/f-use-of-oxytocin-in-the-first-or-second-stage-of-labour-pdf-13186672963
Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
Keeping my podcast running without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to support theobspod please head over to my buy me a coffee page https://bmc.link/theobspodV any donation very gratefully received however small.
Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
(00:49):
Episode 165, oxytocin Use.
Today's episode covers a topicthat, it suddenly occurred to me
, might be useful to peopleworking in the maternity space
and those using maternityservices, and that is the use of
(01:13):
oxytocin.
And I almost called thisepisode use or abuse, because
it's a tricky one.
The use of oxytocin can be verybeneficial in some
circumstances, but far less thanwe probably use it, and
(01:38):
therefore I thought I wouldunpick that a little bit today.
The reason I thought aboutdoing this episode is I had a
slight epiphany in my lastepisode when I was talking to Dr
Kirsten Small aboutintermittent oscultation.
Kirsten discussed the fact thatwe're very good as human beings
(02:01):
at telling stories, making upstories that explain the world
around us that we don'tunderstand, and then believing
those stories and not realizingthat those are just that they
are stories.
So I had a moment ofrealization when I was a very
junior obstetrician and had juststarted out in my training.
(02:24):
I believed in just that.
I believed in a story calledActive Management of Labour.
And I wasn't the only one thatbelieved in this story.
Many, many units believed inthis story.
And I guess one of the thingsabout having been in a career
for 20 or 30 years means thatover time it's inevitable that
(02:48):
some of the things you did whenyou were more junior or earlier
on in your career become lesswell accepted practice, because
the science, the medicineevolves and you learn and
understand.
And it may be that I'm justtelling myself a series of new
stories and that they're nobetter than the old story, but I
(03:10):
thought I would discuss alittle bit my thoughts and
reflections on my own experienceof oxytocin usage.
Oxytocin, what is it?
I'm going to go right back tothe physiology.
Oxytocin we're all familiarwith.
(03:32):
People often call it the lovehormone, which has always seemed
to me incredibly strange givenits use in obstetrics.
But oxytocin is a hormonereleased from the posterior
pituitary gland, so that's anendocrine gland in the brain.
(03:53):
The release of oxytocin,naturally, is controlled by
nerve impulses that come downfrom the hypothalamus, down
through the nerves to theposterior pituitary.
And alongside oxytocin, thereis another drug, vasopressin,
(04:15):
that is produced from theposterior pituitary, and it's
very similar in structure, andI'll come on to why that's
important shortly.
So oxytocin is released from theposterior pituitary gland as
the result of nerve stimulation,and that might be from the womb
(04:38):
, the uterus or from the breast,and that's often why people
talk about a bit of breastmassage or stimulation or
expressing milk to help improveoxytocin levels in labor.
What the oxytocin does in thewomb is has an effect on the
(05:01):
receptors in the womb muscle andcauses stimulation and
contraction.
What is the missing bit of thejigsaw is, though, that at some
points the womb is completelyunresponsive or has very little
(05:24):
response to oxytocin, and atsome points has lots of
receptors.
So what happens is that thewomb's sensitivity to oxytocin
increases towards the end ofpregnancy and in labor, so that
in early pregnancy, oxytocin hasvery little effect the womb is
(05:46):
very insensitive, whereas inlabor, and particularly in
established labor, the womb isvery sensitive, so that very
small doses of oxytocin cancause a significant increase in
the number, duration andstrength of contractions.
So, in labor, a woman's bodywill release oxytocin, and as
(06:14):
the labor gets going thecontractions will increase,
partly due to an increase in thesensitivity of the womb to
respond to the oxytocin beingreleased.
But the oxytocin does have somedownsides too.
(06:35):
Remember I said that structureis very similar to vasopressin,
also produced by the posteriorpituitary, and because of this
the oxytocin has an effect onthe kidneys, which is called
anti-diuretic, which can lead towater retention in labor, and
(06:58):
if you want to know more aboutthat, you can go back to my
episode 147 on fluid balance andabout water intoxication in
pregnancy.
So that is oxytocin naturallyproduced by the body, by the
woman triggering labor, that'snot a problem and then, once
(07:21):
she's had her baby, she'llcontinue to release oxytocin as
the baby starts to feed andstimulate the breast, and it's a
key hormone in the productionof breast milk and breast
feeding.
What I'm going to talk abouttoday, though, is the use of
(07:48):
oxytocin, or centosin, onsynthetic oxytocin and in some
areas of the world it's calledpitocin by midwives and
obstetricians, and this kind ofbreaks into two parts If one is
(08:12):
having an induction of labor,and I've talked about this also
previously on the podcast.
We are trying to initiate labor.
We will use a combination,usually of prostagandins and
oxytocin, so once we haveripened the cervix and hopefully
(08:39):
initiated some contractions,we'll then often need oxytocin.
The woman is not contractingand we need to give her
something to make the wombcontract.
And whilst we need to becautious doing that, I don't
disagree with that as anapproach.
(09:00):
What I want to focus on insteadis the use of oxytocin or
centosin on in established labor.
That is, the woman has come inin labor, the labor has started
spontaneously, her body'sinitiated it and then for some
(09:20):
reason usually the fact thatlabor is slow we decide to give
her oxytocin.
Maybe the contractions havespaced out, or maybe the
progress, the dilatation anddescent of the head, is slow and
we want to give her oxytocin.
And this is where activemanagement of labor comes in.
(09:46):
And this is a story that I verymuch subscribed to for a
significant part of my careerthe idea that if a woman was
progressing slowly, that if wegave her oxytocin judiciously,
(10:08):
carefully, at the right moment,we might change the outcome of
that labor.
So we might have a woman whowas in our minds heading for
potential caesarean birthbecause of very slow progress in
labor or stalled labor, and wewould give oxytocin and we would
(10:33):
congratulate ourselves that wepotentially corrected her labor
and managed to avoid her havinga caesarean birth.
And it's tricky for me to makethis podcast and admit that this
(10:54):
is something I'm very muchsubscribed to.
I used to get irritated when Icame onto the labor ward and
took over and discovered a womanthat had been languishing in
labor for a very long period oftime and people hadn't acted,
they hadn't performed anamniotomy that is breaking the
waters, they hadn't given herstintocin on and therefore I
(11:17):
felt that I was being left witha situation which was beyond
rescue.
She was now in a situationwhere she was inevitably going
to need a caesarean birth.
And that very much comes backto the way we're taught about
(11:41):
the mechanics of labor, thepower, the passage, the
passenger, and therefore one ofthe things I could adjust was
the power, the power ofcontractions, by prescribing
centosinom, and it seemed to mebad obstetrics, bad medicine, if
(12:02):
I didn't give the woman thedrug that I felt could make a
difference.
Let's take a step back andthink where did this story come
from Well, it came from Ireland.
In the 1960s and 1970s in Dublinan obstetrician, o'driscoll,
(12:28):
introduced active management oflabor, and that was once a woman
was diagnosed as being inestablished labor.
They had their waters brokenand if they were dilating at
less than one centimetre perhour they were given synthetic
(12:51):
oxytocin to correct their laborand I'm not kidding, that was
the language used correct theirlabor.
These are women in spontaneouslabor and in the early work that
was published, around 55% offirst time mothers were given
(13:15):
oxytocin during their labor.
That's a phenomenally highnumber.
Remember, these are not womenthat are being induced.
These are women who've come inin labor so effectively.
We're saying more than 50% ofwomen.
Their body doesn't know how tolabor and when you look back at
(13:37):
that evidence, this led to aquicker turnover of women
through their labor ward.
The labor was faster.
They were aiming for a woman'slabor to be less than 12 hours.
That means you can maximize theefficiency of your labor ward
because the quicker women givebirth, the quicker the midwife
(14:00):
can look after the next womanand the quicker a room becomes
available to do so and thereforewomen potentially might like it
because the labor is shorterand staff like it because
(14:20):
there's more efficiency and flowthrough the unit and if you
look back at that work it doessay that but somehow, a bit like
Chinese whispers, that storygets changed into oh, they
actually improved the outcome ofthose women because they tied
(14:46):
it into the rate of cesareanbirth.
Now I started my career in 1994,that's when I started in
obstetrics and to some degreeit's not my fault that these
were the stories I believedbecause at that time this was
(15:10):
very much in vogue.
We drew lines on the pategramaction lines and to think about
this topic today I've gone backthrough my training portfolio
where I've got audits that I'vedone to look at whether midwives
were following the guidance andfollowing those action lines
(15:32):
and appropriately requesting thedoctor's review and start
centosinone if a woman'sprogress was slow.
People were dealing with risingcaesarean rates across the
western world and people werelooking for a way to reduce that
, seeing that as a bad thing andI know that's a controversial
(15:56):
statement in itself these days,but unless a woman wants a
caesarean, we should be keepinga caesarean to a minimum, to his
major surgery.
It's not how the body wasdesigned to give birth.
So people were looking aroundto try and reduce the rising
(16:19):
caesarean rate.
But looking at and thinkingabout this topic for today's
episode, I quickly discoveredsome papers published in 1996.
So only a couple of years afterI got started in obstetrics
(16:41):
that clearly demonstrated thatthe early use of amniotomy and
oxytocin versus using it laterin labor didn't make any
difference to outcomes, so didnot have an effect on the
caesarean section rate, and thatmore important were things that
(17:03):
we take for granted now, suchas one to one mid-riff free care
and support in labor, ratherthan the oxytocin itself.
I am interested that this studycompared early use of oxytocin
with selective use rather thanwith no use of oxytocin at all,
(17:28):
and that in itself to me showspart of the mindset of the time
in which we were practicing.
So when I reflect, I'm thinkingwhy has it taken me a really,
really long time to lose thatfirm belief that using centosin
(17:56):
would reduce the chance ofcaesarean birth?
And you might think that on thelabor ward you would see that
that you'd see it didn't makeany difference and therefore you
would quickly change yourbeliefs.
But actually the opposite istrue.
(18:17):
You would see women that you'dgiven centosin on to have a
vaginal birth and rather thanrealizing that actually, given
time, they probably would havehad a vaginal birth.
Anyway, you would think, aha,that's because I corrected her
labor, I gave her oxytocin andnow she's had a vaginal birth.
Fantastic result.
(18:39):
I did the right thing.
And I guess some of that isconfirmation bias, isn't it?
And it's not realizing thatactually left her own devices,
that woman would have had avaginal birth.
Anyway, the other thing that Ibelieved was that if there was a
(19:00):
male position so the baby wasback to back, that using
oxytocin might help the rotationof that baby.
It might help with moreeffective, more powerful
contractions.
That would help the baby withits rotation and therefore help
(19:24):
correct that.
And maybe that was going to behow I was going to avoid a
caesarean birth.
And alongside this, we had thestory that oxytocin is a bad
thing, so giving centosin oncould cause fetal distress, and
(19:47):
that was very real.
We didn't know that.
But equally, I remember oncearguing with a professor about
this, because he was saying ifthere was fetal distress, one
needed to turn off the oxytocinand give the baby a break,
(20:14):
whereas I was thinking if Iturned off the oxytocin and gave
the baby a break, great, butthat baby would never be born
unless I did a cesarean.
So I wanted to use the oxytocin, but use it carefully.
Let's think about what's thedownside of oxytocin.
(20:34):
Well, it can causehypostimulation, so too many
contractions, one on top of theother because you're
overstimulating the wound, andthat can cause fetal distress.
So it can cause decelerationsin the baby's heartbeat and in
(20:54):
that situation we need to stopthe oxytocin.
It can mean the woman has whatwe call no resting time, so the
wound doesn't properly relaxbetween contractions, or she can
be having contractions, maybemore than five in 10 minutes, so
that she and the baby don't getany rest by any breathing space
(21:16):
in between.
Therefore, we have to useoxytocin, since it's not,
extremely carefully and we haveto consider is this baby fit and
able to cope with the use ofoxytocin?
And these days in my unit wetalk a lot about is this baby
(21:38):
fit for labour when we'rethinking about birth, and
sometimes we do a cesareanbecause this baby isn't going to
be able to cope with oxytocinin an induction process.
And of course, the downsidesaren't all for the baby, they're
a downsides for the woman.
(21:59):
Not only could she experienceconsiderable pain if she's hyper
stimulated, although oftenwomen with oxytocin will choose
an epidural, partly for thereason that they feel the
contractions are more intensebecause we're forcing her body
(22:21):
to do something that it's notnaturally generating and pacing.
But also, if we have a woman onoxytocin for a long period of
time, then those oxytocinreceptors potentially get
saturated, and when we want thewoman to contract after she's
(22:43):
had her baby, so we've ended updoing the inevitable cesarean,
or she has given birth vaginally.
The womb has then been floggedand she's more likely to have a
postpartum hemorrhage.
There's plenty of evidence ofthis when I've done reviews of
(23:07):
cases where women's hemorrhaged,and also plenty of evidence
about poor use of centosin oncausing fetal distress a worst
case, long-term harm to the baby.
If you look at medical legalstatistics and all the
(23:33):
initiatives looking at improvingoutcomes for babies and
reducing hypoxic, ischemic andkephalopathy HIE, centosin on is
ever present as a considerablerisk factor and that's why I was
(23:53):
thinking about calling thisepisode use and abuse.
So is there ever a situation inwhich we should be using
centosin on spontaneous labour?
And there probably is, but Inow use it far less than I ever
(24:16):
did.
If you look at the niceguidance, it clearly says that
if a woman is beyond fivecentimetres dilated.
So she's in herwell-established spontaneous
labour, that there is no benefitto using centosin on in terms
of the outcome of cesarean orvaginal birth, but that it may
(24:41):
speed up her labour, shorten itby up to two hours.
And these days in my unitpartly thanks to Susanna Pereira
, who has now left us but did anenormous amount of work on
(25:03):
people monitoring in labour wereally stopped using centosin on
in spontaneous labour, so thatwe use it hardly at all,
particularly if a woman is inthe latter stages of labour
maybe seven centimetres orbeyond and we think instead
(25:26):
about the position of the baby,what we can do naturally, such
as breast stimulation orbiomechanics, because if her
body isn't progressing to avaginal birth, then all we're
doing by adding centosin on isincreasing the risks for both
(25:49):
her risk of bleeding and herbaby's risk of distress and
injury, and we're potentiallyusing those very strong,
powerful contractions to wedgethe baby into the pelvis in a
(26:09):
way that it isn't progressivelydescending and rotating and
doing all the things we need itto do.
It's just impacting it and thisis a very real negative
consequence of the action we'retaking, and you can see this in
the fact that we now havealgorithms and guidance on how
(26:33):
to manage an impacted fetal headat cesarean and that this
incidence is increasing, and oneof the associations with this
situation is augmentation anduse of centosin.
On the other very realcomplication associated with
(27:00):
Centosanon in this obstructivesituation is that of uterine
rupture, and we often think ofthe womb rupturing in women that
have had a previous cesareanbirth, a rupture along the
cesarean scar, and it's truethat that increases with the use
(27:23):
of Centosanon.
But equally, if one has a womanwho's had babies before
multi-paras women and we useCentosanonon in a situation
where her labor is obstructed,she can rupture her uterus,
which is extremely dangerous forboth her and her baby.
(27:44):
Rupture is not something we seein women having their first
baby, but is a very real factorthat we need to consider
extremely carefully when we'reconsidering the use of
(28:05):
Centosanon in these specificsituations, and we really do
need to proceed with caution,but also having fully explained
to the woman the praise and consso that she can make her own
individual, well-informeddecision about whether to
proceed.
(28:26):
So we need to be even morereluctant to use Centosanon in
multi-paras women.
Let's go back to think aboutthose first-time mums who've
come in in spontaneous labor whoI may or may not be thinking
(28:49):
should have Centosanon.
What am I considering before Itake the decision or make a
recommendation to them?
So if I'm going to useCentosanon in this situation, we
need to do a very carefulvaginal examination to see are
(29:09):
there any signs of anyobstruction, any soft tissue
swelling cappert on the baby'shead, any moulding, any
malposition, any suggestion thatthis labor is obstructed?
What's her urine like?
Is it bloodstained?
How is she coping and howfrequent are the contractions?
And maybe maybe, if all thosethings are okay and maybe her
(29:38):
contractions are quite spacedout, maybe once in every 10
minutes and once we've had areally good conversation with
her about actually this mighthelp.
It probably won't change theoutcome in terms of whether you
have a caesarean or a vaginalbirth, but it may make things a
bit quicker, may make your labora bit shorter, reaching that
(30:01):
inevitable outcome.
So would you like to try it?
So we need to have a goodconversation with women in labor
if we're going to use it, andthat in itself is difficult
unless she's already chosen anepidural, because having a
conversation with a woman aboutthis when she's contracting
(30:22):
strongly and considering that tobe informed consent can be
really tough.
So, essentially, women are insome ways not more sensible than
us.
So a lot of women have done so.
Anti-natal classes a lot ofwomen are frightened or scared
(30:42):
of our sintation.
On drip a lot of women arereluctant to have the drip I see
this quite a lot, even ininduction of labor and they
don't want it.
They will decline it and that'sokay.
That's informed consent.
It is much harder when you'rehaving an induction.
(31:03):
With an induction, it's highlylikely, having a first baby,
that you will require somesintation on to get your labor
started.
Not all the time, sometimesprostaglandins will be
sufficient, but it's much morelikely that we will need it.
But then again, what will oftenhappen is we'll start it, your
(31:26):
body will start responding andthen your body will take over.
We will often then be able toturn the sintation on down,
reduce the dose and turn it off.
The final thing I want to talkabout is when we do have that
hypostimulation with Centosin on.
(31:47):
What do we do?
Well, we turn it off and wewait.
We wait and see how the babyrecovers and how the contraction
space out.
But what do we then do?
Do we turn it back on?
And I'd like you to have alittle look at a new interpartum
(32:10):
care evidence review that wasjust published at the end of
last year and that is around theuse of restarting oxytocin once
hypostimulation has happenedand what dose it should be
restarted and after what timeperiod.
And the answer is that, havingexamined all the evidence that
(32:35):
there's no consensus In thisreview, they have decided that
the recommendation should becontracting every three to four
times in ten minutes and ifthere are more than four
contractions in ten minutes,oxytocin should be reduced or
stopped.
(32:56):
And that's a new thing becausethe nice guidance used to say
four to five in ten minutes.
So that's a significant change.
They acknowledge the fact thatoxytocin is a very powerful drug
and has an increased risk ofadverse outcomes, but they
(33:16):
didn't find any kind ofagreement as to what dose it
should be restarted and timing.
So they did agree that thegeneral consensus of restarting
after 30 minutes is likely to beokay, but again, no firm
(33:40):
evidence.
And they emphasized a lot theneed for an obstetrician and
midwife to look at the wholeclinical picture and also take
into account the woman's wishes,because to have people rushing,
turn off your drip and thenhalf an hour later tell you they
want to turn it on despitewhatever adverse event has just
(34:03):
happened to your baby isextremely anxiety-provoking and
worrying.
So my zesty bit is rememberthis is an extraordinarily
powerful drug that we sometimesgive out almost like smarties on
the label board and really, fora drug that is in use in every
(34:28):
label board in the country, itis quite shocking that we have
so little evidence.
Remember that it won't changethe outcome in terms of mode of
birth, so whether you're goingto have a vaginal birth or
caesarean, it won't make adifference, but it may make a
difference to the speed of yourlabor, but also it can have a
(34:50):
significant negative impact.
So try and think about usingoxytocin, manius and induction
medication rather than for usein spontaneous labor.
And when and if you do use itin spontaneous labor, you've got
to be extremely cautious andreally careful.
(35:11):
And if you're a pregnant womanlistening to this, then don't be
afraid of centosinone, becauseit isn't the drug itself, it's
the way we're using it.
So when people talk to youabout the use of centosinone,
the key thing to keep in yourmind is did you go into labor
(35:32):
naturally or not?
If you went into labornaturally, it's unlikely that
you should need centosinone andit's not going to make a
difference to which way yourbaby is born, whereas if you're
having an induction it's muchmore likely that it will be of
some benefit.
(35:52):
So I hope that's not been toomuch rambling.
I hope that's been useful, mythoughts on the use of
centosinone and I'd love to knowother people's thoughts and
opinions, because I still thinkwe're wedded to that story that
it makes a difference.
(36:13):
Thanks for listening.
I very much hope you found thisepisode of the OBS pod
interesting.
If you have, it be fantastic ifyou could subscribe, rate and
review on whatever platform youfind your podcasts, as well as
recommending the OBS pod toanyone you think might find it
(36:37):
interesting.
There's also tons of episodesto explore in my back catalog
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
very seriously and take greatcare not to use any patient
(37:01):
identifiable information unlessI have expressly asked the
permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
(37:25):
the programme notes where I'veattached some links.
If you want to get in touch tosuggest topics for future
episodes, you can find me at theOBS pod on Twitter and
Instagram and you can email methe obspod at gmailcom.
(37:46):
Finally, it's very important tome to keep the OBS pod free and
accessible to as many people aspossible, but it does cost me a
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and by chance, you do
(38:08):
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it freevia my link to buy me a coffee.
Don't feel under any obligation, but if you'd like to
contribute, you now can.
Thank you for listening.
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
(00:49):
Episode 165, oxytocin Use.
Today's episode covers a topicthat, it suddenly occurred to me
, might be useful to peopleworking in the maternity space
and those using maternityservices, and that is the use of
(01:13):
oxytocin.
And I almost called thisepisode use or abuse, because
it's a tricky one.
The use of oxytocin can be verybeneficial in some
circumstances, but far less thanwe probably use it, and
(01:38):
therefore I thought I wouldunpick that a little bit today.
The reason I thought aboutdoing this episode is I had a
slight epiphany in my lastepisode when I was talking to Dr
Kirsten Small aboutintermittent oscultation.
Kirsten discussed the fact thatwe're very good as human beings
(02:01):
at telling stories, making upstories that explain the world
around us that we don'tunderstand, and then believing
those stories and not realizingthat those are just that they
are stories.
So I had a moment ofrealization when I was a very
junior obstetrician and had juststarted out in my training.
(02:24):
I believed in just that.
I believed in a story calledActive Management of Labour.
And I wasn't the only one thatbelieved in this story.
Many, many units believed inthis story.
And I guess one of the thingsabout having been in a career
for 20 or 30 years means thatover time it's inevitable that
(02:48):
some of the things you did whenyou were more junior or earlier
on in your career become lesswell accepted practice, because
the science, the medicineevolves and you learn and
understand.
And it may be that I'm justtelling myself a series of new
stories and that they're nobetter than the old story, but I
(03:10):
thought I would discuss alittle bit my thoughts and
reflections on my own experienceof oxytocin usage.
Oxytocin, what is it?
I'm going to go right back tothe physiology.
Oxytocin we're all familiarwith.
(03:32):
People often call it the lovehormone, which has always seemed
to me incredibly strange givenits use in obstetrics.
But oxytocin is a hormonereleased from the posterior
pituitary gland, so that's anendocrine gland in the brain.
(03:53):
The release of oxytocin,naturally, is controlled by
nerve impulses that come downfrom the hypothalamus, down
through the nerves to theposterior pituitary.
And alongside oxytocin, thereis another drug, vasopressin,
(04:15):
that is produced from theposterior pituitary, and it's
very similar in structure, andI'll come on to why that's
important shortly.
So oxytocin is released from theposterior pituitary gland as
the result of nerve stimulation,and that might be from the womb
(04:38):
, the uterus or from the breast,and that's often why people
talk about a bit of breastmassage or stimulation or
expressing milk to help improveoxytocin levels in labor.
What the oxytocin does in thewomb is has an effect on the
(05:01):
receptors in the womb muscle andcauses stimulation and
contraction.
What is the missing bit of thejigsaw is, though, that at some
points the womb is completelyunresponsive or has very little
(05:24):
response to oxytocin, and atsome points has lots of
receptors.
So what happens is that thewomb's sensitivity to oxytocin
increases towards the end ofpregnancy and in labor, so that
in early pregnancy, oxytocin hasvery little effect the womb is
(05:46):
very insensitive, whereas inlabor, and particularly in
established labor, the womb isvery sensitive, so that very
small doses of oxytocin cancause a significant increase in
the number, duration andstrength of contractions.
So, in labor, a woman's bodywill release oxytocin, and as
(06:14):
the labor gets going thecontractions will increase,
partly due to an increase in thesensitivity of the womb to
respond to the oxytocin beingreleased.
But the oxytocin does have somedownsides too.
(06:35):
Remember I said that structureis very similar to vasopressin,
also produced by the posteriorpituitary, and because of this
the oxytocin has an effect onthe kidneys, which is called
anti-diuretic, which can lead towater retention in labor, and
(06:58):
if you want to know more aboutthat, you can go back to my
episode 147 on fluid balance andabout water intoxication in
pregnancy.
So that is oxytocin naturallyproduced by the body, by the
woman triggering labor, that'snot a problem and then, once
(07:21):
she's had her baby, she'llcontinue to release oxytocin as
the baby starts to feed andstimulate the breast, and it's a
key hormone in the productionof breast milk and breast
feeding.
What I'm going to talk abouttoday, though, is the use of
(07:48):
oxytocin, or centosin, onsynthetic oxytocin and in some
areas of the world it's calledpitocin by midwives and
obstetricians, and this kind ofbreaks into two parts If one is
(08:12):
having an induction of labor,and I've talked about this also
previously on the podcast.
We are trying to initiate labor.
We will use a combination,usually of prostagandins and
oxytocin, so once we haveripened the cervix and hopefully
(08:39):
initiated some contractions,we'll then often need oxytocin.
The woman is not contractingand we need to give her
something to make the wombcontract.
And whilst we need to becautious doing that, I don't
disagree with that as anapproach.
(09:00):
What I want to focus on insteadis the use of oxytocin or
centosin on in established labor.
That is, the woman has come inin labor, the labor has started
spontaneously, her body'sinitiated it and then for some
(09:20):
reason usually the fact thatlabor is slow we decide to give
her oxytocin.
Maybe the contractions havespaced out, or maybe the
progress, the dilatation anddescent of the head, is slow and
we want to give her oxytocin.
And this is where activemanagement of labor comes in.
(09:46):
And this is a story that I verymuch subscribed to for a
significant part of my careerthe idea that if a woman was
progressing slowly, that if wegave her oxytocin judiciously,
(10:08):
carefully, at the right moment,we might change the outcome of
that labor.
So we might have a woman whowas in our minds heading for
potential caesarean birthbecause of very slow progress in
labor or stalled labor, and wewould give oxytocin and we would
(10:33):
congratulate ourselves that wepotentially corrected her labor
and managed to avoid her havinga caesarean birth.
And it's tricky for me to makethis podcast and admit that this
(10:54):
is something I'm very muchsubscribed to.
I used to get irritated when Icame onto the labor ward and
took over and discovered a womanthat had been languishing in
labor for a very long period oftime and people hadn't acted,
they hadn't performed anamniotomy that is breaking the
waters, they hadn't given herstintocin on and therefore I
(11:17):
felt that I was being left witha situation which was beyond
rescue.
She was now in a situationwhere she was inevitably going
to need a caesarean birth.
And that very much comes backto the way we're taught about
(11:41):
the mechanics of labor, thepower, the passage, the
passenger, and therefore one ofthe things I could adjust was
the power, the power ofcontractions, by prescribing
centosinom, and it seemed to mebad obstetrics, bad medicine, if
(12:02):
I didn't give the woman thedrug that I felt could make a
difference.
Let's take a step back andthink where did this story come
from Well, it came from Ireland.
In the 1960s and 1970s in Dublinan obstetrician, o'driscoll,
(12:28):
introduced active management oflabor, and that was once a woman
was diagnosed as being inestablished labor.
They had their waters brokenand if they were dilating at
less than one centimetre perhour they were given synthetic
(12:51):
oxytocin to correct their laborand I'm not kidding, that was
the language used correct theirlabor.
These are women in spontaneouslabor and in the early work that
was published, around 55% offirst time mothers were given
(13:15):
oxytocin during their labor.
That's a phenomenally highnumber.
Remember, these are not womenthat are being induced.
These are women who've come inin labor so effectively.
We're saying more than 50% ofwomen.
Their body doesn't know how tolabor and when you look back at
(13:37):
that evidence, this led to aquicker turnover of women
through their labor ward.
The labor was faster.
They were aiming for a woman'slabor to be less than 12 hours.
That means you can maximize theefficiency of your labor ward
because the quicker women givebirth, the quicker the midwife
(14:00):
can look after the next womanand the quicker a room becomes
available to do so and thereforewomen potentially might like it
because the labor is shorterand staff like it because
(14:20):
there's more efficiency and flowthrough the unit and if you
look back at that work it doessay that but somehow, a bit like
Chinese whispers, that storygets changed into oh, they
actually improved the outcome ofthose women because they tied
(14:46):
it into the rate of cesareanbirth.
Now I started my career in 1994,that's when I started in
obstetrics and to some degreeit's not my fault that these
were the stories I believedbecause at that time this was
(15:10):
very much in vogue.
We drew lines on the pategramaction lines and to think about
this topic today I've gone backthrough my training portfolio
where I've got audits that I'vedone to look at whether midwives
were following the guidance andfollowing those action lines
(15:32):
and appropriately requesting thedoctor's review and start
centosinone if a woman'sprogress was slow.
People were dealing with risingcaesarean rates across the
western world and people werelooking for a way to reduce that
, seeing that as a bad thing andI know that's a controversial
(15:56):
statement in itself these days,but unless a woman wants a
caesarean, we should be keepinga caesarean to a minimum, to his
major surgery.
It's not how the body wasdesigned to give birth.
So people were looking aroundto try and reduce the rising
(16:19):
caesarean rate.
But looking at and thinkingabout this topic for today's
episode, I quickly discoveredsome papers published in 1996.
So only a couple of years afterI got started in obstetrics
(16:41):
that clearly demonstrated thatthe early use of amniotomy and
oxytocin versus using it laterin labor didn't make any
difference to outcomes, so didnot have an effect on the
caesarean section rate, and thatmore important were things that
(17:03):
we take for granted now, suchas one to one mid-riff free care
and support in labor, ratherthan the oxytocin itself.
I am interested that this studycompared early use of oxytocin
with selective use rather thanwith no use of oxytocin at all,
(17:28):
and that in itself to me showspart of the mindset of the time
in which we were practicing.
So when I reflect, I'm thinkingwhy has it taken me a really,
really long time to lose thatfirm belief that using centosin
(17:56):
would reduce the chance ofcaesarean birth?
And you might think that on thelabor ward you would see that
that you'd see it didn't makeany difference and therefore you
would quickly change yourbeliefs.
But actually the opposite istrue.
(18:17):
You would see women that you'dgiven centosin on to have a
vaginal birth and rather thanrealizing that actually, given
time, they probably would havehad a vaginal birth.
Anyway, you would think, aha,that's because I corrected her
labor, I gave her oxytocin andnow she's had a vaginal birth.
Fantastic result.
(18:39):
I did the right thing.
And I guess some of that isconfirmation bias, isn't it?
And it's not realizing thatactually left her own devices,
that woman would have had avaginal birth.
Anyway, the other thing that Ibelieved was that if there was a
(19:00):
male position so the baby wasback to back, that using
oxytocin might help the rotationof that baby.
It might help with moreeffective, more powerful
contractions.
That would help the baby withits rotation and therefore help
(19:24):
correct that.
And maybe that was going to behow I was going to avoid a
caesarean birth.
And alongside this, we had thestory that oxytocin is a bad
thing, so giving centosin oncould cause fetal distress, and
(19:47):
that was very real.
We didn't know that.
But equally, I remember oncearguing with a professor about
this, because he was saying ifthere was fetal distress, one
needed to turn off the oxytocinand give the baby a break,
(20:14):
whereas I was thinking if Iturned off the oxytocin and gave
the baby a break, great, butthat baby would never be born
unless I did a cesarean.
So I wanted to use the oxytocin, but use it carefully.
Let's think about what's thedownside of oxytocin.
(20:34):
Well, it can causehypostimulation, so too many
contractions, one on top of theother because you're
overstimulating the wound, andthat can cause fetal distress.
So it can cause decelerationsin the baby's heartbeat and in
(20:54):
that situation we need to stopthe oxytocin.
It can mean the woman has whatwe call no resting time, so the
wound doesn't properly relaxbetween contractions, or she can
be having contractions, maybemore than five in 10 minutes, so
that she and the baby don't getany rest by any breathing space
(21:16):
in between.
Therefore, we have to useoxytocin, since it's not,
extremely carefully and we haveto consider is this baby fit and
able to cope with the use ofoxytocin?
And these days in my unit wetalk a lot about is this baby
(21:38):
fit for labour when we'rethinking about birth, and
sometimes we do a cesareanbecause this baby isn't going to
be able to cope with oxytocinin an induction process.
And of course, the downsidesaren't all for the baby, they're
a downsides for the woman.
(21:59):
Not only could she experienceconsiderable pain if she's hyper
stimulated, although oftenwomen with oxytocin will choose
an epidural, partly for thereason that they feel the
contractions are more intensebecause we're forcing her body
(22:21):
to do something that it's notnaturally generating and pacing.
But also, if we have a woman onoxytocin for a long period of
time, then those oxytocinreceptors potentially get
saturated, and when we want thewoman to contract after she's
(22:43):
had her baby, so we've ended updoing the inevitable cesarean,
or she has given birth vaginally.
The womb has then been floggedand she's more likely to have a
postpartum hemorrhage.
There's plenty of evidence ofthis when I've done reviews of
(23:07):
cases where women's hemorrhaged,and also plenty of evidence
about poor use of centosin oncausing fetal distress a worst
case, long-term harm to the baby.
If you look at medical legalstatistics and all the
(23:33):
initiatives looking at improvingoutcomes for babies and
reducing hypoxic, ischemic andkephalopathy HIE, centosin on is
ever present as a considerablerisk factor and that's why I was
(23:53):
thinking about calling thisepisode use and abuse.
So is there ever a situation inwhich we should be using
centosin on spontaneous labour?
And there probably is, but Inow use it far less than I ever
(24:16):
did.
If you look at the niceguidance, it clearly says that
if a woman is beyond fivecentimetres dilated.
So she's in herwell-established spontaneous
labour, that there is no benefitto using centosin on in terms
of the outcome of cesarean orvaginal birth, but that it may
(24:41):
speed up her labour, shorten itby up to two hours.
And these days in my unitpartly thanks to Susanna Pereira
, who has now left us but did anenormous amount of work on
(25:03):
people monitoring in labour wereally stopped using centosin on
in spontaneous labour, so thatwe use it hardly at all,
particularly if a woman is inthe latter stages of labour
maybe seven centimetres orbeyond and we think instead
(25:26):
about the position of the baby,what we can do naturally, such
as breast stimulation orbiomechanics, because if her
body isn't progressing to avaginal birth, then all we're
doing by adding centosin on isincreasing the risks for both
(25:49):
her risk of bleeding and herbaby's risk of distress and
injury, and we're potentiallyusing those very strong,
powerful contractions to wedgethe baby into the pelvis in a
(26:09):
way that it isn't progressivelydescending and rotating and
doing all the things we need itto do.
It's just impacting it and thisis a very real negative
consequence of the action we'retaking, and you can see this in
the fact that we now havealgorithms and guidance on how
(26:33):
to manage an impacted fetal headat cesarean and that this
incidence is increasing, and oneof the associations with this
situation is augmentation anduse of centosin.
On the other very realcomplication associated with
(27:00):
Centosanon in this obstructivesituation is that of uterine
rupture, and we often think ofthe womb rupturing in women that
have had a previous cesareanbirth, a rupture along the
cesarean scar, and it's truethat that increases with the use
(27:23):
of Centosanon.
But equally, if one has a womanwho's had babies before
multi-paras women and we useCentosanonon in a situation
where her labor is obstructed,she can rupture her uterus,
which is extremely dangerous forboth her and her baby.
(27:44):
Rupture is not something we seein women having their first
baby, but is a very real factorthat we need to consider
extremely carefully when we'reconsidering the use of
(28:05):
Centosanon in these specificsituations, and we really do
need to proceed with caution,but also having fully explained
to the woman the praise and consso that she can make her own
individual, well-informeddecision about whether to
proceed.
(28:26):
So we need to be even morereluctant to use Centosanon in
multi-paras women.
Let's go back to think aboutthose first-time mums who've
come in in spontaneous labor whoI may or may not be thinking
(28:49):
should have Centosanon.
What am I considering before Itake the decision or make a
recommendation to them?
So if I'm going to useCentosanon in this situation, we
need to do a very carefulvaginal examination to see are
(29:09):
there any signs of anyobstruction, any soft tissue
swelling cappert on the baby'shead, any moulding, any
malposition, any suggestion thatthis labor is obstructed?
What's her urine like?
Is it bloodstained?
How is she coping and howfrequent are the contractions?
And maybe maybe, if all thosethings are okay and maybe her
(29:38):
contractions are quite spacedout, maybe once in every 10
minutes and once we've had areally good conversation with
her about actually this mighthelp.
It probably won't change theoutcome in terms of whether you
have a caesarean or a vaginalbirth, but it may make things a
bit quicker, may make your labora bit shorter, reaching that
(30:01):
inevitable outcome.
So would you like to try it?
So we need to have a goodconversation with women in labor
if we're going to use it, andthat in itself is difficult
unless she's already chosen anepidural, because having a
conversation with a woman aboutthis when she's contracting
(30:22):
strongly and considering that tobe informed consent can be
really tough.
So, essentially, women are insome ways not more sensible than
us.
So a lot of women have done so.
Anti-natal classes a lot ofwomen are frightened or scared
(30:42):
of our sintation.
On drip a lot of women arereluctant to have the drip I see
this quite a lot, even ininduction of labor and they
don't want it.
They will decline it and that'sokay.
That's informed consent.
It is much harder when you'rehaving an induction.
(31:03):
With an induction, it's highlylikely, having a first baby,
that you will require somesintation on to get your labor
started.
Not all the time, sometimesprostaglandins will be
sufficient, but it's much morelikely that we will need it.
But then again, what will oftenhappen is we'll start it, your
(31:26):
body will start responding andthen your body will take over.
We will often then be able toturn the sintation on down,
reduce the dose and turn it off.
The final thing I want to talkabout is when we do have that
hypostimulation with Centosin on.
(31:47):
What do we do?
Well, we turn it off and wewait.
We wait and see how the babyrecovers and how the contraction
space out.
But what do we then do?
Do we turn it back on?
And I'd like you to have alittle look at a new interpartum
(32:10):
care evidence review that wasjust published at the end of
last year and that is around theuse of restarting oxytocin once
hypostimulation has happenedand what dose it should be
restarted and after what timeperiod.
And the answer is that, havingexamined all the evidence that
(32:35):
there's no consensus In thisreview, they have decided that
the recommendation should becontracting every three to four
times in ten minutes and ifthere are more than four
contractions in ten minutes,oxytocin should be reduced or
stopped.
(32:56):
And that's a new thing becausethe nice guidance used to say
four to five in ten minutes.
So that's a significant change.
They acknowledge the fact thatoxytocin is a very powerful drug
and has an increased risk ofadverse outcomes, but they
(33:16):
didn't find any kind ofagreement as to what dose it
should be restarted and timing.
So they did agree that thegeneral consensus of restarting
after 30 minutes is likely to beokay, but again, no firm
(33:40):
evidence.
And they emphasized a lot theneed for an obstetrician and
midwife to look at the wholeclinical picture and also take
into account the woman's wishes,because to have people rushing,
turn off your drip and thenhalf an hour later tell you they
want to turn it on despitewhatever adverse event has just
(34:03):
happened to your baby isextremely anxiety-provoking and
worrying.
So my zesty bit is rememberthis is an extraordinarily
powerful drug that we sometimesgive out almost like smarties on
the label board and really, fora drug that is in use in every
(34:28):
label board in the country, itis quite shocking that we have
so little evidence.
Remember that it won't changethe outcome in terms of mode of
birth, so whether you're goingto have a vaginal birth or
caesarean, it won't make adifference, but it may make a
difference to the speed of yourlabor, but also it can have a
(34:50):
significant negative impact.
So try and think about usingoxytocin, manius and induction
medication rather than for usein spontaneous labor.
And when and if you do use itin spontaneous labor, you've got
to be extremely cautious andreally careful.
(35:11):
And if you're a pregnant womanlistening to this, then don't be
afraid of centosinone, becauseit isn't the drug itself, it's
the way we're using it.
So when people talk to youabout the use of centosinone,
the key thing to keep in yourmind is did you go into labor
(35:32):
naturally or not?
If you went into labornaturally, it's unlikely that
you should need centosinone andit's not going to make a
difference to which way yourbaby is born, whereas if you're
having an induction it's muchmore likely that it will be of
some benefit.
(35:52):
So I hope that's not been toomuch rambling.
I hope that's been useful, mythoughts on the use of
centosinone and I'd love to knowother people's thoughts and
opinions, because I still thinkwe're wedded to that story that
it makes a difference.
(36:13):
Thanks for listening.
I very much hope you found thisepisode of the OBS pod
interesting.
If you have, it be fantastic ifyou could subscribe, rate and
review on whatever platform youfind your podcasts, as well as
recommending the OBS pod toanyone you think might find it
(36:37):
interesting.
There's also tons of episodesto explore in my back catalog
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
very seriously and take greatcare not to use any patient
(37:01):
identifiable information unlessI have expressly asked the
permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
(37:25):
the programme notes where I'veattached some links.
If you want to get in touch tosuggest topics for future
episodes, you can find me at theOBS pod on Twitter and
Instagram and you can email methe obspod at gmailcom.
(37:46):
Finally, it's very important tome to keep the OBS pod free and
accessible to as many people aspossible, but it does cost me a
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and by chance, you do
(38:08):
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it freevia my link to buy me a coffee.
Don't feel under any obligation, but if you'd like to
contribute, you now can.
Thank you for listening.
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