{"id":{"repo_id":"utswmed","oai_identifier":"oai:utswmed-ir.tdl.org:2152.5/10611"},"canonical_url":"https://search.dev.ndltd.org/etd/utswmed/oai:utswmed-ir.tdl.org:2152.5/10611","repository":{"repo_id":"utswmed","name":"University of Texas Southwestern Medical Center","base_url":"https://utswmed-ir.tdl.org/server/oai/request"},"display":{"title":"The Right Uterotonic at the Right Time","abstract":"The file named "MOLLINGS PUENTES-PRIMARY-2023.pdf" is the primary dissertation file. Four (4) supplemental files are also available and may be viewed individually.","abstract_html":"The file named "MOLLINGS PUENTES-PRIMARY-2023.pdf" is the primary dissertation file. Four (4) supplemental files are also available and may be viewed individually.","abstract_has_math":false,"creators":["Mollings Puentes, Cira Yoena"],"institution":null,"degree_name":null,"degree_level":null,"degree_discipline":null,"degree_department":null,"school":null,"contributors":["Reed, W. Gary","Horsager-Boehrer, Robyn","Morgan, Jamie"],"advisors":[],"committee_chairs":[],"committee_members":[],"year":2025,"date_issued":"2025-06-03T19:52:49Z","date_published":"2025-06-03T19:52:49Z","updated_at":"2026-07-24T05:52:38Z","subjects":["Oxytocics","Postpartum Hemorrhage","Practice Guidelines as Topic","Quality Improvement","Delivery, Obstetric"],"languages":["en"],"rights":[],"rights_urls":[],"identifier_entries":[{"key":"dc:identifier","label":"Identifier","values":["1522122298"],"render_values":[{"text":"1522122298","href":null,"code":true}]}]},"links":{"outbound_url":"https://hdl.handle.net/2152.5/10611","outbound_label":"Handle","outbound_source":"dc:identifier"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:contributor","label":"Contributor","values":["Reed, W. Gary","Horsager-Boehrer, Robyn","Morgan, Jamie"]},{"key":"dc:creator","label":"Author","values":["Mollings Puentes, Cira Yoena"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"dc:date","label":"Dc Date","values":["2025-06-03T19:52:49Z","2023-05","May 2023","2025-06-03T19:52:50Z"]},{"key":"dc:type","label":"Dc Type","values":["Thesis","text"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["Oxytocics","Postpartum Hemorrhage","Practice Guidelines as Topic","Quality Improvement","Delivery, Obstetric"]}]},{"id":"language_rights","label":"Language and Rights","entries":[{"key":"dc:language","label":"Dc Language","values":["en"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier","label":"Identifier","values":["https://hdl.handle.net/2152.5/10611","1522122298"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description","label":"Description","values":["The file named "MOLLINGS PUENTES-PRIMARY-2023.pdf" is the primary dissertation file. Four (4) supplemental files are also available and may be viewed individually.","BACKGROUND: Postpartum hemorrhage (PPH) causes significant obstetric morbidity and is a leading cause of preventable maternal mortality . While there are numerous potential causes of PPH, uterine atony is by far the most common etiology, accounting for 70-80% of hemorrhage cases.. In the United States, prophylactic administration of Pitocin, a synthetic version of oxytocin that promotes smooth muscle contraction, is universally administered after delivery as a first-line strategy to prevent bleeding and reduce the risk of PPH. However, hemorrhage still occurs in 3-5% of all deliveries despite Pitocin prophylaxis and requires additional interventions. In direct contrast to the virtually ubiquitous approach to PPH prevention with Pitocin administration, treatment of PPH is highly variable from hospital to hospital and provider to provider. While one of three available second-line uterotonic agents (Methergine, carboprost or misoprostol) is usually administered alone or in combination when hemorrhage occurs, the timing, dosing frequency and order of use diverges significantly based on local protocols, level of provider comfort and prior training experience. Methergine and carboprost are both administered intra-muscularly and have similar rapid therapeutic efficacy. Conversely, misoprosol, which is administered either buccally, sublingually or rectally, lags these parenteral agents in reaching therapeutic levels, especially when given via the rectal route as is often the case. The delayed pharmacokinetics of misoprostol may, therefore, hinder efficacious treatment of uterine atony, potentially leading to unnecessary blood loss and excess morbidity. Timely administration and appropriate selection of faster-acting parenteral treatment agents over misoprostol can reduce postpartum hemorrhage caused by uterine atony. Inconsistent use of uterotonic agents and the absence of monitoring practices could result in preventable cases of PPH requiring significant surgical interventions. Best practices indicate that maintaining uterotonic agents readily available prior to delivery, and during the two-hour postpartum observational period improves the response and outcomes of postpartum hemorrhage. The goal of this quality improvement project was to increase the selection of a parenterally administered uterotonic as second-line therapy and reduce the time to treatment onset in the setting of uterine atony. LOCAL PROBLEM: In contemporary obstetric practice uterotonic agents utilized are prostaglandins (PG) or ergot alkaloids [6]. Among the prostaglandins, Hemabate (15-methyl PG F2a) also known as carboprost and misoprostol (PGE1 analog, Cytotec) are the most commonly used. Although these three uterotonic agents are used widely to treat uterine atony, the available data suggests that they are not equally effective[7]. William Clements University Hospital (CUH) is a teaching hospital within the UT Southwestern Medical Center. The hospital is part of an academic training center located in Dallas where the obstetric hemorrhage rates for the county range between 118.8 and 202.4 cases for every 10,000 deliveries. In accordance with the maternal safety bundle published by the Alliance for Innovation on Maternal Health (AIM), postpartum hemorrhage kits containing Methergine and Hemabate have been integrated into the labor and delivery unit. The ability of readily available parenteral uterotonic kits to improve readiness to postpartum hemorrhage and function as a sustainable practice had not been evaluated in previous studies or guidelines. METHODS: CUH implemented a process that placed "PPH kits" containing methergine and carboprost at the bedside of laboring patients. Staff used PDSA cycles to improve adherence to the protocol. We compared data on presence of kit at delivery, medication selection, time to administration, and other delivery outcomes pre- and post-implementation. The utility of the postpartum hemorrhage kit was established by comparing the baseline values for rates of postpartum hemorrhage, uterotonic agent utilization, compliance, and administration time for deliveries in 2018 with deliveries in 2019-2022. A process map was developed to identify elements which hindered the retrieval of PPH kits prior to delivery. The list of possible interventions was determined via a multi-voting exercise among labor and delivery unit nurses and FMEA analysis was completed to identify the most effective intervention. Four PDSA cycles followed to determine the efficacy of optimizing the PPH kit protocol. INTERVENTIONS: The current protocol requires several overrides in the medical cabinet system (Pyxis) to retrieve refrigerated UTAs for postpartum hemorrhage kits. Therefore, pyxis overrides were removed and orders for Methergine and Hemabate were integrated in the admission order set for deliveries. This intervention had the capacity to increase access to PPH kits, compliance and improve PPH kit management. To maintain awareness of the PPH kits, education reminder in Quick-kit meetings were given in each nursing shift. Handover charge sheets and 2-step verifications were implemented to record PPH use and encourage storage of unused kits. RESULTS : In the 4-year period following implementation, kits were present for 94% of vaginal deliveries and 89% of cesarean sections for an overall utilization of 92.2%. Use of Methergine or Hemabate as the second-line therapy for atony increased significantly from 71% to 93.2% (p<0.0001). For vaginal deliveries, the rate of parenteral UTAs as second-line agents increased from 51% to 90.1% (p<0.0001). The median and mean time to administration of any UTA was reduced by 6 minutes (p=0.0007-0.00). Accessibility was most important for vaginal deliveries in which time to administration of parenteral uterotonics was decreased by 23-24 minutes when PPH kits were at bedside (p=0.0005). CONCLUSION: Placement of a PPH kit containing parenteral uterotonics in the patient's room before delivery and throughout a 120-minute recovery period results in increased utilization of parenteral uterotonics and timely administration. Without interfering with physician autonomy or decision making PPH kits were a sustainable intervention for standardizing parenteral uterotonic usage."]},{"key":"dc:format","label":"Dc Format","values":["application/pdf"]},{"key":"dc:title","label":"Title","values":["The Right Uterotonic at the Right Time"]}]}],"canonical_facts":{"dc:contributor":["Reed, W. Gary","Horsager-Boehrer, Robyn","Morgan, Jamie"],"dc:creator":["Mollings Puentes, Cira Yoena"],"dc:date":["2025-06-03T19:52:49Z","2023-05","May 2023","2025-06-03T19:52:50Z"],"dc:description":["The file named "MOLLINGS PUENTES-PRIMARY-2023.pdf" is the primary dissertation file. Four (4) supplemental files are also available and may be viewed individually.","BACKGROUND: Postpartum hemorrhage (PPH) causes significant obstetric morbidity and is a leading cause of preventable maternal mortality . While there are numerous potential causes of PPH, uterine atony is by far the most common etiology, accounting for 70-80% of hemorrhage cases.. In the United States, prophylactic administration of Pitocin, a synthetic version of oxytocin that promotes smooth muscle contraction, is universally administered after delivery as a first-line strategy to prevent bleeding and reduce the risk of PPH. However, hemorrhage still occurs in 3-5% of all deliveries despite Pitocin prophylaxis and requires additional interventions. In direct contrast to the virtually ubiquitous approach to PPH prevention with Pitocin administration, treatment of PPH is highly variable from hospital to hospital and provider to provider. While one of three available second-line uterotonic agents (Methergine, carboprost or misoprostol) is usually administered alone or in combination when hemorrhage occurs, the timing, dosing frequency and order of use diverges significantly based on local protocols, level of provider comfort and prior training experience. Methergine and carboprost are both administered intra-muscularly and have similar rapid therapeutic efficacy. Conversely, misoprosol, which is administered either buccally, sublingually or rectally, lags these parenteral agents in reaching therapeutic levels, especially when given via the rectal route as is often the case. The delayed pharmacokinetics of misoprostol may, therefore, hinder efficacious treatment of uterine atony, potentially leading to unnecessary blood loss and excess morbidity. Timely administration and appropriate selection of faster-acting parenteral treatment agents over misoprostol can reduce postpartum hemorrhage caused by uterine atony. Inconsistent use of uterotonic agents and the absence of monitoring practices could result in preventable cases of PPH requiring significant surgical interventions. Best practices indicate that maintaining uterotonic agents readily available prior to delivery, and during the two-hour postpartum observational period improves the response and outcomes of postpartum hemorrhage. The goal of this quality improvement project was to increase the selection of a parenterally administered uterotonic as second-line therapy and reduce the time to treatment onset in the setting of uterine atony. LOCAL PROBLEM: In contemporary obstetric practice uterotonic agents utilized are prostaglandins (PG) or ergot alkaloids [6]. Among the prostaglandins, Hemabate (15-methyl PG F2a) also known as carboprost and misoprostol (PGE1 analog, Cytotec) are the most commonly used. Although these three uterotonic agents are used widely to treat uterine atony, the available data suggests that they are not equally effective[7]. William Clements University Hospital (CUH) is a teaching hospital within the UT Southwestern Medical Center. The hospital is part of an academic training center located in Dallas where the obstetric hemorrhage rates for the county range between 118.8 and 202.4 cases for every 10,000 deliveries. In accordance with the maternal safety bundle published by the Alliance for Innovation on Maternal Health (AIM), postpartum hemorrhage kits containing Methergine and Hemabate have been integrated into the labor and delivery unit. The ability of readily available parenteral uterotonic kits to improve readiness to postpartum hemorrhage and function as a sustainable practice had not been evaluated in previous studies or guidelines. METHODS: CUH implemented a process that placed "PPH kits" containing methergine and carboprost at the bedside of laboring patients. Staff used PDSA cycles to improve adherence to the protocol. We compared data on presence of kit at delivery, medication selection, time to administration, and other delivery outcomes pre- and post-implementation. The utility of the postpartum hemorrhage kit was established by comparing the baseline values for rates of postpartum hemorrhage, uterotonic agent utilization, compliance, and administration time for deliveries in 2018 with deliveries in 2019-2022. A process map was developed to identify elements which hindered the retrieval of PPH kits prior to delivery. The list of possible interventions was determined via a multi-voting exercise among labor and delivery unit nurses and FMEA analysis was completed to identify the most effective intervention. Four PDSA cycles followed to determine the efficacy of optimizing the PPH kit protocol. INTERVENTIONS: The current protocol requires several overrides in the medical cabinet system (Pyxis) to retrieve refrigerated UTAs for postpartum hemorrhage kits. Therefore, pyxis overrides were removed and orders for Methergine and Hemabate were integrated in the admission order set for deliveries. This intervention had the capacity to increase access to PPH kits, compliance and improve PPH kit management. To maintain awareness of the PPH kits, education reminder in Quick-kit meetings were given in each nursing shift. Handover charge sheets and 2-step verifications were implemented to record PPH use and encourage storage of unused kits. RESULTS : In the 4-year period following implementation, kits were present for 94% of vaginal deliveries and 89% of cesarean sections for an overall utilization of 92.2%. Use of Methergine or Hemabate as the second-line therapy for atony increased significantly from 71% to 93.2% (p<0.0001). For vaginal deliveries, the rate of parenteral UTAs as second-line agents increased from 51% to 90.1% (p<0.0001). The median and mean time to administration of any UTA was reduced by 6 minutes (p=0.0007-0.00). Accessibility was most important for vaginal deliveries in which time to administration of parenteral uterotonics was decreased by 23-24 minutes when PPH kits were at bedside (p=0.0005). CONCLUSION: Placement of a PPH kit containing parenteral uterotonics in the patient's room before delivery and throughout a 120-minute recovery period results in increased utilization of parenteral uterotonics and timely administration. Without interfering with physician autonomy or decision making PPH kits were a sustainable intervention for standardizing parenteral uterotonic usage."],"dc:format":["application/pdf"],"dc:identifier":["https://hdl.handle.net/2152.5/10611","1522122298"],"dc:language":["en"],"dc:subject":["Oxytocics","Postpartum Hemorrhage","Practice Guidelines as Topic","Quality Improvement","Delivery, Obstetric"],"dc:title":["The Right Uterotonic at the Right Time"],"dc:type":["Thesis","text"]},"updated_at":"2026-07-24T05:52:38Z"}