Comparison of the Effectiveness of 5 Iu Oxytocin Bolus and 20 Iu Infusion on Uterine Contraction and Hemodynamic Response in Caesarean Section

Uterine atonic can result in postpartum hemorrhage, gravid hysterectomy and maternal mortality. Oxytocin is the most commonly used agent for the prevention and treatment of atonic uterine during cesarean section. However, the provision of rapid and increasing the dose may result in hemodynamic instability, cardiovascular collapse, and death. This study aimed to compare the effectiveness of oxytocin bolus 5 IU and oxytocin infusion 20 IU to contractions of the uterus and the hemodynamic response in cesarean section with spinal anesthesia. An experimental study, Randomized Controlled Trial (RCT) was conducted in the operating room Mohammad Hoesin Hospital Palembang from July to August 2016. It was obtained a 44 pregnant at term women who will do a cesarean section that meet the inclusion and exclusion criteria. The frequency and distribution of data are described in tables and comparisons between the two groups were analyzed using SPSS. Of the 44 pregnant women at term, 22 women in the group of oxytocin bolus 5 IU and 22 women in the group of oxytocin infusion 20 IU. By statistical analysis, there was no significant hemodynamic changes after bolus administration of oxytocin 5 IU or oxytocin infusion 20 IU (p> 0.05) and there were no significant hemodynamic differences between oxytocin bolus 5 IU and infusion of 20 IU oxytocin (p> 0.05). In addition, there are significant changes in uterine contractions after bolus administration of oxytocin 5 IU or oxytocin infusion 20 IU (p< 0.05) and there were significant differences in uterine contraction in the 3rd minute (p = 0.006), 6th minute ( p = 0.010) and 9th minute (p = 0.008) between oxytocin bolus 5 IU and infusion of oxytocin 20 IU. It can be concluded that there is no significant hemodynamic changes after administration of oxytocin 5 IU bolus and oxytocin infusion 20 IU and there are differences in uterine contractions significantly in the 3rd minute, 6th minute and 9th minute between oxytocin bolus 5 IU and oxytocin infusion 20 IU.


Introduction
Uterine atony can result in postpartum hemorrhage, gravid hysterectomy, and maternal death.
Oxytocin is the agent most frequently used for the prevention and treatment of uterine atony during cesarean section; However, rapid administration and increasing doses can result in hemodynamic instability, cardiovascular collapse, and death.
Although there is a demonstration of adequate uterine tone after cesarean section with low-dose oxytocin (<3 These side effects, particularly those associated with oxytocin, may be related to dose and speed of administration. 1,3 There are several guidelines and studies that support slow intravenous bolus of oxytocin 5 IU.
Among them, the Royal College of Obstetricians and Gynecologists (RCOG) Guideline on Caesarean section recommends giving a slow intravenous 5 IU bolus dose of oxytocin after the birth of the baby. This dose is a lower dose than previously used, which is 10-20 IU and is based on concerns about the side effects of oxytocin, such as maternal hypotension. 12 The British National Formulary also recommends that oxytocin should be given in a dose of 5 IU by slow intravenous injection after delivery in cesarean section.

Research methods
This research is an experimental study with a randomized controlled trial (RCT), double blind, add on. (p> 0.005) was obtained, which means that there was no significant difference in gestational age between the two groups.
The highest parity of both the 5 IU slow bolus oxytocin group and the 20 IU infusion of oxytocin was> 2, where each parity> 2 was 17 people (77.3%) and 11 people (50%). With the Chi Square test, the p value was obtained = 0.147 (p> 0.005), which means that there was no significant difference in parity between the two groups.
The mean ± SD height of the 5 IU slow bolus oxytocin group was 153.9 ± 4.05, while the 20 IU infusion oxytocin group was 153.9 ± 3.78. Because the data distribution was not normal (p = 0.017), the Mann Whitney test was used to compare the two groups. With the Mann Whitney test, the p value was obtained = 0.689 (p> 0.005), which means that there was no significant difference in height between the two groups.
The mean ± SD body mass index of the 5 IU slow bolus oxytocin group was 25.21 ± 3.59, while the 20 IU infusion oxytocin group was 25.54 ± 4.33. Because the data distribution was normal (p = 0.071), unpaired T test was used to compare the two groups. With the unpaired T test, the value of p = 0.785 (p> 0.005) was obtained, which means that there was no significant difference in body mass index between the two groups.
The mean ± SD systolic blood pressure of the 5 IU slow bolus oxytocin group was 122.1 ± 17.98, while the 20 IU infusion oxytocin group was 126.5 ± 10.80.
Because the data distribution was normal (p = 0.127), unpaired T test was used to compare the two groups.
With the unpaired T test, the value of p = 0.325 (p> 0.005) was obtained, which means that there was no significant difference in systolic blood pressure between the two groups.
The mean ± SD diastolic blood pressure of the 5 IU slow bolus oxytocin group was 75.23 ± 9.63, while the 20 IU infusion oxytocin group was 77.18 ± 6.77. Because the data distribution was not normal (p = 0.027), the Mann Whitney test was used to compare the two groups.
With the Mann Whitney test, the p value was found to be 0.114 (p> 0.005), which means that there was no significant difference in diastolic blood pressure between the two groups.
The mean ± SD mean arterial pressure of the 5 IU slow bolus oxytocin group was 89.53 ± 12.59, while the 20 IU infusion oxytocin group was 93.62 ± 7.19. Because the data distribution was normal (p = 0.106), unpaired T test was used to compare the two groups. With the unpaired T test, the p value was 0.195 (p> 0.005), which means that there was no significant difference in mean arterial pressure between the two groups.
The mean ± SD pulse rate of the 5 IU slow bolus oxytocin group was 85.14 ± 14.29, while the 20 IU infusion oxytocin group was 88.18 ± 14.42. Because the data distribution was normal (p = 0.153), unpaired T test was used to compare the two groups. With the unpaired T test, the p value was 0.486 (p> 0.005), which means that there was no significant difference in pulse rates between the two groups.

Hemodynamics and uterine contractions of bolus and infusion oxytocin groups before and after treatment
Hemodynamic variables (systolic blood pressure, diastolic blood pressure, mean arterial pressure, pulse rate, respiratory rate, oxygen saturation) and uterine 0.000 (p <0.05); 0.000 (p <0.05) and 0.000 (p <0.05), which means that the data for systolic blood pressure, diastolic blood pressure, mean arterial pressure and pulse rate for both groups were normally distributed (p> 0.05), because the data distribution was normal. so that to see the difference in systolic blood pressure, diastolic blood pressure, mean arterial pressure and pulse rate before and after treatment, a paired T test was used, while the data on breath rate, oxygen saturation and uterine contraction of the two groups were not normally distributed (p <0.05). To see the difference in breath rate, oxygen saturation and uterine contraction before and after treatment, the Wilcoxon test was used.

Breath Rate
The breath rates of the two groups were checked at 0, 3, 6, 9, 12 and 15 minutes then a statistical test was performed to see the difference between the two groups.
With the Kolmogorov-Smirnov normality test, the probability of all minutes was obtained <0.05, which means that the data were not normally distributed, so the Mann-Whitney statistical test was used. From the statistical test, it was found that there was no difference in the respiratory rate at 0, 3, 6, 9, 12 and 15 minutes between groups of 5 IU bolus oxytocin and 20 IU infusion of oxytocin (p> 0, 05).

Oxygen Saturation
Oxygen saturation of both groups was checked at 0, 3, 6, 9, 12 and 15 minutes then statistical tests were performed to see the difference between the two groups.
With the Kolmogorov-Smirnov normality test, the probability of all minutes is obtained <0.05, which means that the data is not normally distributed, so the statistical test used is the Mann-Whitney test. From the statistical test, it was found that there was no difference in oxygen saturation at 0, 3, 6, 9, 12 and 15 minutes between groups of 5 IU bolus oxytocin and 20 IU infusion of oxytocin (p> 0.05).

Uterine contractions
The uterine contractions of the two groups were examined at 0, 3, 6, 9, 12 and 15 minutes then a statistical test was performed to see the difference between the two groups. With the Kolmogorov-Smirnov normality test, the probability of all minutes is obtained <0.05, which means that the data is not normally distributed, so the statistical test used is the Mann-Whitney test. From the statistical test, it was found that there was no difference in uterine contractions at 0, 12 and 15 minutes between the 5 IU bolus of oxytocin and 20 IU of oxytocin infusion (p> 0.05) and there was a significant difference after oxytocin administration. bolus 5 IU and oxytocin infusion of 20 IU in the 3rd, 6th and 9th minutes, where uterine contractions after 5 IU bolus oxytocin administration were greater than the 20 IU infusion of oxytocin.

Side effects
The incidence of hypotension (systolic blood pressure <90 mmHg or a decrease in blood pressure> 30% from baseline in the 5 IU slow bolus oxytocin group was 4 people (18%) and in the 20 IU infusion oxytocin group was 1 person (4.5%).
The average use of ephedrine in the 5 IU slow bolus oxytocin group was 12.5 ± 14.29, while the 20 IU infusion oxytocin group was 7.73 ± 19.50. Because the data distribution was not normal (p = 0.000), the Mann Whitney test was used to compare the two groups. With the Mann Whitney test, the p value was 0.053 (p> 0.005), which means that there was no significant difference in the use of ephedrine between the two groups. Post partum, patients were followed up for 6 hours and after 24 hours after cesarean section for any signs of uterine atony or bleeding. None of the samples in each of the study groups experienced uterine atony or post partum hemorrhage.

Discussion
The demographic characteristics of research subjects were examined statistically, in this study the results showed that there were no differences in age group (p = 1,000), gestational age (p = 1,000), parity (p = 0.147), height (p = 0.689), body weight ( p = 1,000) and body mass index (p = 0.785) between the two groups significantly. This confirms that the hemodynamic differences and uterine contractions between the two groups after the intervention were not influenced by demographic characteristics.
From the results of the statistical test for hemodynamic characteristics, there was also no difference in systolic blood pressure (p = 0. The results of this study are also in line with a study The incidence of hypotension (systolic blood pressure <90 mmHg or a decrease in blood pressure> 30% from baseline in the 5 IU slow bolus oxytocin group was 4 people (18%) and in the 20 IU infusion oxytocin group was 1 person (4.5%).
The average use of ephedrine in the 5 IU slow bolus oxytocin group was 12.5 ± 14.29, while the 20 IU infusion oxytocin group was 7.73 ± 19.50. With the Mann Whitney test, the p value was 0.053 (p> 0.005), which means that there was no statistically significant difference in the use of ephedrine between the two groups significantly. In

Conclusions
There were no significant hemodynamic changes after 5 IU slow bolus oxytocin administration, and there were changes in diastolic blood pressure, and mean arterial pressure at 3, 9 minutes, and changes in diastolic pressure at 6 minutes in the 20 IU infusion of oxytocin group. . There was a significant change in uterine contractions after 5 IU slow bolus oxytocin and 20 IU infusion of oxytocin. There was no significant