Implementation of an evidence-based nurse-initiated protocol for the treatment of severe hypertension in pregnancy decreases the time required to administer antihypertensive medication, time required to regain blood pressure control and nonbeneficial clinical variation. In addition, these benefits were achieved rapidly within a large hospital setting.

Objective To assess the use of an evidence-based oxytocin protocol for management of the third stage of labor to decrease non-beneficial clinical variation and improve clinical outcomes. Design This is a cohort study of pregnant patients delivering before implementation of an evidence-based oxytocin protocol compared to patients delivering after implementation of an evidence-based oxytocin protocol. Setting A level III maternal care referral hospital with an average delivery volume of approximately 3,000 deliveries Participants Pregnant patients delivering over a 60-month period from Jan 2013 to December 2017. Intervention An evidence-based oxytocin protocol: 3-units of oxytocin administered over 3 minutes, with a second 3-unit bolus if inadequate tone, then oxytocin infusion at 18 units/hr x 1 hour, then 3.6 units/hr for 3 hours. Main Outcome Measures Postpartum hemorrhage (PPH) rate (EBL ≥ 500 mL for vaginal, ≥ 1,000 mL for cesarean) Results Data from 14,603 deliveries was analyzed; 8,408 pre-protocol; 6,195 post-protocol. We demonstrated a significant decrease in PPH from 5.2% to 2.9% (p<0.001) and small but non-significant increase in transfusion rate from 1.8% to 2.3% (p=0.11). Conclusion A standardized oxytocin infusion protocol in the third stage of labor resulted in a significant decrease in PPH for both vaginal and cesarean deliveries.

INTRODUCTION: Hypertensive disorders are a leading cause of morbidity and mortality. We developed a standardized nurse driven hypertensive protocol to improve management in pregnancy. METHODS: We developed a standardized nurse initiated protocol for management of severe hypertension. The protocol used nifedipine, hydralazine or labetalol sequentially. Data on time from severe blood pressure (BP) to treatment with medication, effect of treatment, and BP monitoring was collected for 3 months prior to the protocol and compared to data after. RESULTS: We collected data on patients before (n=47) and after the protocol (n=37). The mean time to treatment of severe BPs was significantly shorter after protocol implementation (19.6 minutes), compared to before (36.9 minutes), t=3.1, p=0.002. There was also a significantly lower mean time to repeat BP (12.8 minutes) after protocol implementation compared to before (15.7 minutes), t=2.3, p=0.02, and the maximum time to repeat BP measurement decreased, from 300 minutes before to 76 minutes after. We also noted more women (89.5%) were treated within 1 hour after the protocol compared to 35% before the protocol and more women were given oral nifedipine (67%) after the protocol compared to only 4% prior to the protocol. However, there was no significant difference in mean time to blood pressure control after protocol implementation (50.3 minutes) comparted to before (67.5 minutes), t = 1.8, p = 0.08. CONCLUSION: Implementation of a standardized protocol for the treatment of hypertensive emergency decreased time to treatment, decreased variation and decreased maximum time to repeat BP measurement.