Variations in oxytocin regimes in Scottish labour wards in 1998

How much synthetic oxytocin is infused during labour? A review and analysis of regimens used in 12 countries

Objective

To compare synthetic oxytocin infusion regimens used during labour, calculate the International Units (IU) escalation rate and total amount of IU infused over eight hours.

Design

Observational study

Setting

Twelve countries, eleven European and South Africa.

Sample

National, regional or institutional-level regimens on oxytocin for induction and augmentation labour

Methods

Data on oxytocin IU dose, infusion fluid amount, start dose, escalation rate and maximum dose were collected. Values for each regimen were converted to IU in 1000ml diluent. One IU corresponded to 1.67μg for doses provided in grams/micrograms. IU hourly dose increase rates were based on escalation frequency. Cumulative doses and total IU amount infused were calculated by adding the dose administered for each previous hour. Main Outcome Measures Oxytocin IU dose infused

Results

Data were obtained on 21 regimens used in 12 countries. Details on the start dose, escalation interval, escalation rate and maximum dose infused were available from 16 regimens. Starting rates varied from 0.06 IU/hour to 0.90 IU/hour, and the maximum dose rate varied from 0.90 IU/hour to 3.60 IU/hour. The total amount of IU oxytocin infused, estimated over eight hours, ranged from 2.38 IU to 27.00 IU, a variation of 24.62 IU and an 11-fold difference.

Conclusion

Current variations in oxytocin regimens for induction and augmentation of labour are inexplicable. It is crucial that the appropriate minimum infusion regimen is administered because synthetic oxytocin is a potentially harmful medication with serious consequences for women and babies when inappropriately used. Estimating the total amount of oxytocin IU received by labouring women, alongside the institution’s mode of birth and neonatal outcomes, may deepen our understanding and be the way forward to identifying the optimal infusion regimen.

An exploratory mixed-methods study of Scottish midwives' understandings and perceptions of clinical near misses in maternity care

OBJECTIVE

adverse outcomes and near misses are believed to share many characteristics in terms of clinical situations and care management problems. Little is documented concerning what prevents adverse outcomes from happening once the 'accident trajectory' begins. This two-stage pilot study set out to investigate midwives' understandings and recollections of clinical near misses.

DESIGN

anonymous self-completion questionnaire and follow-up group interviews.

SETTING/PARTICIPANTS

clinically based midwives working in four maternity units in Scotland (questionnaire [n = 34]; interviews [n = 26]).

FINDINGS

despite a low response rate to the questionnaire, the cited examples seem to confirm that near misses and adverse outcomes follow essentially similar routes until the former are halted by a saving intervention. Dangerous situations are created by heavy workloads, and are aggravated by sub-optimal skill-mix, poor communication and individuals making mistakes or not following accepted procedures. Overwhelmingly, what prevents this situation from resulting in an adverse outcome is an intervention by another practitioner--often reported to be by chance and not design. In the interviews, these situations were discussed with reference to unit culture, the causes of errors and near misses, helping to prevent mistakes, the consequences of near misses and staff confiding in one another.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

this limited study reaffirms the view that clinical near misses have the same origins as actual poor outcomes. Practitioners need to be able to discuss clinical and operational matters openly with colleagues. Although the 'blame culture' was reported to be less prevalent when things go wrong, not all midwives feel comfortable about discussing incidents or near misses. This exploratory study makes no claim to encapsulate this complex and sensitive subject. Further detailed research into the nature and extent of near misses is required. Identifying what prevents a poor outcome from happening may be a valuable clinical resource.