Methergine with Oxytocin at Cesarean Section
Methergine (methylergonovine) should NOT be routinely administered with oxytocin during cesarean section in patients without hypertension or preeclampsia, as it is contraindicated due to significant risk (>10%) of vasoconstriction and hypertension. 1, 2
Primary Recommendation
The European Society of Cardiology explicitly states that methylergonovine is contraindicated in the postpartum period because of the risk (>10%) of vasoconstriction and hypertension. 1, 2
Oxytocin remains the first-line uterotonic agent for prevention and treatment of postpartum hemorrhage during cesarean delivery. 3, 4
Appropriate Oxytocin Administration Protocol
Administer oxytocin as a slow intravenous infusion (<2 U/min or approximately 33 mU/min) after placental delivery to avoid systemic hypotension. 1, 2
Avoid rapid IV bolus administration of oxytocin, as this can cause severe hypotension, tachycardia, and uterine hyperstimulation. 2
For elective cesarean sections in nonlaboring women, the effective dose (ED90) is approximately 0.35-0.5 IU as initial bolus, followed by continuous infusion of 40 mU/min. 5
Continuous infusion of low doses is preferred over bolus administration to minimize cardiovascular side effects. 3, 4
When Additional Uterotonics Are Needed
If oxytocin alone fails to achieve adequate uterine contraction:
Prostaglandin F analogues (such as carboprost) are useful alternatives for treating postpartum hemorrhage, unless an increase in pulmonary artery pressure is undesirable. 1
Tranexamic acid (1g IV over 10 minutes) should be administered early (within 3 hours of birth) for clinically diagnosed postpartum hemorrhage, regardless of whether bleeding is due to uterine atony or trauma. 1
A second dose of tranexamic acid (1g IV) may be given if bleeding continues after 30 minutes or restarts within 24 hours. 1
Critical Monitoring Requirements
Pulse oximetry and continuous ECG monitoring should be utilized as clinically indicated for patients receiving oxytocin. 2
Hemodynamic monitoring must be continued for at least 24 hours after delivery due to significant fluid shifts that may precipitate complications. 1, 2
Systemic arterial pressure and maternal heart rate require continuous monitoring during oxytocin administration. 1
Common Pitfall to Avoid
The most critical error is administering methylergonovine routinely with oxytocin "for better uterine contraction." This practice exposes patients to unnecessary risk of severe hypertension and vasoconstriction without evidence of benefit when oxytocin is properly dosed. 1, 2 Methylergonovine should be reserved only for refractory cases of uterine atony where oxytocin and prostaglandins have failed, and only after careful consideration of contraindications.