Oxytocin Use in Labor: Legal Implications.

Oxytocin is one of the most commonly used medications in obstetrics and has been associated with claims of negligence in cases of adverse outcomes. Errors involving intravenous oxytocin administration for induction or augmentation of labor are most commonly dose related and include failure to avoid or treat tachysystole or failure to asses or treat a fetal heart rate pattern indicative of disruption in oxygenation. Clinicians should be knowledgeable regarding pharmacokinetics of oxytocin and the effect of uterine contractions on fetal oxygenation as well as safe titration of oxytocin to achieve the desired effect while minimizing harm.

The clinical and economic impact of nurse to patient staffing ratios in women receiving intrapartum oxytocin.

OBJECTIVE: To examine the relationship between nurse-to-patient staffing ratios and perinatal outcomes in women receiving oxytocin during labor. STUDY DESIGN: A retrospective analysis of perinatal outcomes in women receiving oxytocin for induction or augmentation of labor during 2010. Outcomes examined were fetal distress, birth asphyxia, primary cesarean delivery, chorioamnionitis, endomyometritis, and a composite of adverse events. Frequency of 1:1 nurse-to-patient staffing was determined for each hospital. Outcomes were compared between hospitals categorized into quartiles of staffing ratios. RESULTS: In 208,033 women delivering during 2010, there was no relation between frequency of 1:1 nurse-to-patient staffing ratio and improved perinatal outcomes. Adoption of universal 1:1 staffing in the United States would result in the need for an additional 27,000 labor nurses and a cost of $1.6 billion. CONCLUSION: Available data do not support the imposition of mandatory 1:1 nurse-to-patient staffing ratios for women receiving oxytocin in all U.S. facilities.

Time's up! Women's experience of induction of labour.

Induction of labour is a common obstetric intervention in the UK, occurring in approximately 22 per cent of labours (Birthchoice UK 2014). Much evidence exists regarding methods, efficacy, safety and outcomes, but very little is known about women's experience of induction of labour (National Institute of Health and Care Excellence (NICE) 2008). Qualitative interviews were carried out with low risk primigravid women being induced post-maturity. Women expressed fear about the induction process, described their midwife as being their primary source of information and reported that they had sufficient information prior to admission.

Oxytocin administration: the transition to a safer model of care.

The use of oxytocin, a high-alert medication, has increased dramatically in recent years as induction rates have risen. Methods for administration of oxytocin and subsequent outcomes have long been a source of debate. Furthermore, one of the leading causes of obstetrical liability claims involves the administration of oxytocin leading to tachysystole. This article describes how a collaborative of Perinatal Clinical Nurse Specialists and Obstetric Nurse Educators for a 9-hospital healthcare system throughout Colorado undertook a system-wide process-improvement project to increase safety for pregnant women receiving oxytocin. The goal of this initiative was to decrease risk exposure by successfully implementing a standardized evidence-based protocol and processes across the healthcare system. There has been implementation of standardized oxytocin mixtures, low-dose administration guidelines, and safety checklists to assure fetal and maternal well-being before initiation of oxytocin and increases in oxytocin dosages. The associated outcomes after this initiative have been shorter lengths of labor, decreased incidence of tachysystole, and decreased incidence of primary cesarean birth.

Midwives, labour induction and the Wooden Spoon award Part 2.

Rates of labour induction without clear medical indication have risen exponentially. This trend has not been without consequence of increased perinatal mortality and morbidity. Midwives must understand the importance of educating pregnant women and other obstetrical providers, about the risks associated with labour induction. Maternal-child health policy that minimises unnecessary interventions is urgently needed and prevention strategies are described in the second part of this article. Midwives are challenged to consider their role in reducing unnecessary labour inductions in a rapidly changing birth culture reflecting high intervention.

Midwives, labour induction and the Wooden Spoon award part I.

Labour induction rates have rocketed, largely due to consumer demands and provider convenience. This increase has been a significant factor in rapidly increasing caesarean birth rates and adverse perinatal outcomes. It is important that midwives understand the risks associated with labour induction. The article overviews those factors contributing to increasing induction rates and the associated risks. Midwives are challenged to consider the evidence for an intervention contributing to a cascade of birth interventions.

The amniotomy question: examining the pros and cons of rupturing membranes.

The culture of birth establishes practices and embraces rituals. Currently there is a movement toward midwifery and away from hospital births as women and professions question the values of some practices and interventions common in hospital births. Amniotomy is a well-established practice that is accepted as an intervention to help women in their birth process, with the hope that it will shorten labor. There is little research regarding the psychological implication of amniotomy on the infant. This paper explores the pros and cons of amniotomy, its role as a ritual for birth attendants and the possible psychological effects on the infant.

Management of oxytocin for labour augmentation in relation to mode of birth in Robson group 1.

OBJECTIVE: To compare mode of birth in Robson group 1 according to administration of oxytocin for labour augmentation. DESIGN AND PARTICIPANTS: A retrospective review of 724 medical records from women in Robson group 1 was performed. The outcome measurements were: mode of birth in relation to presence of labour dystocia when initiating augmentation with oxytocin, duration of augmentation with oxytocin, increase of the oxytocin infusion according to recommendations and cervical dilation when initiating augmentation with oxytocin. SETTING: The review was based on medical records from a medium-sized tertiary level obstetric unit in southern Sweden, with approximately 3700 births per year. Data was collected between January 2017 and October 2017. MEASUREMENTS AND FINDINGS: Oxytocin for labour augmentation was used in 64.1% of the births. Oxytocin administered according to the national recommendations was related to a greater likelihood of vaginal birth than when these recommendations were not followed. Only 47.8% of the women who underwent a caesarean section was treated according to recommendations. Receiving augmentation with oxytocin at a later stage of labour was related to a greater likelihood of a vaginal birth. The total time treated with oxytocin was significantly longer in women who had an assisted vaginal birth or a caesarean section than those who had a vaginal birth with augmentation. KEY CONCLUSIONS: Oxytocin for labour augmentation was over-used in Robson group 1. Oxytocin early in labour, a long duration of stimulation with oxytocin and a slower increase of the infusion than recommended had a relationship with caesarean section. IMPLICATION FOR PRACTICE: Due to risks for adverse maternal and neonatal outcomes when using oxytocin for labour augmentation, caregivers should implement strict protocols for its use. According to a high use of oxytocin there is a need to describe women's experiences of labour augmentation in labour dystocia but also when received despite normal labour progress.

Oxytocin, excessive uterine activity, and patient safety: time for a collaborative approach.

Oxytocin use for induction or augmentation of labor is a common occurrence in labor and delivery, as well as a common source of conflict between obstetric providers and nurses. Allegations regarding inappropriate oxytocin use and excessive uterine activity arise in obstetric litigation in both the United States and abroad, and oxytocin was recently added to the Institute for Safe Medical Practices list of high-alert medications, making oxytocin administration a significant risk management issue. Current efforts at standardization of terminology related to uterine activity, recent research on the relationship of excessive uterine activity to fetal oxygenation and outcome, and clinical success with adoption of standardized oxytocin administration provide clinicians with evidence to create a structured, collaborative approach to oxytocin administration in labor. This article provides a brief overview of relevant literature and suggests strategies for the implementation of such a collaborative approach.

Midwives' navigation and perceived power during decision-making related to augmentation of labour.

OBJECTIVE: to explore and understand how midwives perceive and experience decision-making about augmentation of labour. DESIGN: focus-group discussions. SETTING: Stockholm, Sweden. PARTICIPANTS: 20 midwives experienced in working in labour wards. FINDINGS: five categories were identified that illustrate the factors considered by the midwives to influence decision-making during augmentation of labour: 'regulations and guidelines'; 'shortage of delivery rooms'; 'influence of obstetricians'; 'women in labour'; and 'midwives' professional selves'. The theme identified was how midwives managed to 'navigate' these factors, which provided midwives with a decisive influence during the decision-making process. KEY CONCLUSIONS AND IMPLICATIONS: midwife job satisfaction can result from a sense of professional power over the possibility of navigating factors that influence decision-making during augmentation of labour. This sense of power can subsequently influence co-operation with both obstetricians and women during labour.

Standardizing criteria for scheduling elective labor inductions.

Induction of labor has become routine practice in perinatal units across the United States, with rates reaching a high of 21.2% of births in 2003-2004. This article describes the process our institution used to standardize the criteria for scheduling inductions. Specifically, we aimed to increase the consistency in practice for scheduling and performing elective inductions, including mandating gestational age of 39 completed weeks, ensuring cervical ripeness, and disallowing the use of cervical ripening agents. The nurses' participation, from planning to implementation, was critical in the success of this evidence-based practice change.

Nurse-physician communication during labor and birth: implications for patient safety.

OBJECTIVE: To describe communication between nurses and physicians during labor within the context of the nurse-managed labor model in community hospitals and its relationship to teamwork and patient safety. DESIGN: Multicenter qualitative study involving focus groups and in-depth interviews. SETTING: Labor and birth units in 4 Midwestern community hospitals. PARTICIPANTS: 54 labor nurses and 38 obstetricians. METHODS: Focus groups and in-depth interviews were conducted using open-ended questions. Data were analyzed using inductive coding methods to gain understanding from the perspective of those directly involved. MAIN OUTCOME MEASURES: Description of interdisciplinary interactions during labor. RESULTS: Nurses and physicians shared the common goal of a healthy mother and baby but did not always agree on methods to achieve that goal. Two clinical situations critical to patient safety (fetal assessment and oxytocin administration) were frequent areas of disagreement and sources of mutual frustration, often leading to less than optimal teamwork. Minimal communication occurred when the mother and fetus are doing well, and this seemed to be purposeful and considered normal. Physicians and nurses had distinct opinions concerning desirable traits of members of the other discipline. CONCLUSIONS: Interdisciplinary communication and teamwork could be improved to promote a safer care environment during labor and birth.