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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.

This case represents the first EXIT procedure completed at Naval Medical Center San Diego. Although this case is unique, the clinical skills and coordination of care required to perform this procedure are exemplified in our daily practice of stabilizing, transporting, and definitively treating our wounded warriors. The ability to work in coordination across multiple armed services to provide the EXIT procedure to our military families, for potentially life-saving procedures, is a true testament to the current state of Military Medicine.

Despite the widespread use of inhalational anesthesia with spontaneous ventilation in many studies of otariid pinnipeds, the effects and risks of anesthetic‐induced respiratory depression on blood gas and pH regulation are unknown in these animals. During such anesthesia in California sea lions (Zalophus californianus), blood gas and pH analyses of opportunistic blood samples revealed routine hypercarbia (highest PCO2 = 128 mm Hg [17.1 kPa]), but adequate arterial oxygenation (PO2 > 100 mm Hg [13.3 kPa] on 100% inspiratory oxygen). Respiratory acidosis (lowest pH = 7.05) was limited by the increased buffering capacity of sea lion blood. A markedly widened alveolar‐to‐arterial PO2 difference was indicative of atelectasis and ventilation‐perfusion mismatch in the lung secondary to hypoventilation during anesthesia. Despite the generally safe track record of this anesthetic regimen in the past, these findings demonstrate the value of high inspiratory O2 concentrations and the necessity of constant vigilance and caution. In order to avoid hypoxemia, we emphasize the importance of late extubation or at least maintenance of mask ventilation on O2 until anesthetic‐induced respiratory depression is resolved. In this regard, whether for planned or emergency application, we also describe a simple, easily employed intubation technique with the Casper “zalophoscope” for sea lions.