National Guideline On The Use Of Oxytocin To Accelerate Or Induce Labour

In April 2016, the Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland, together with the Clinical Strategy and Programme Division of the HSE published a Clinical Practice Guideline in relation to the use of oxytocin (Syntocinon) to accelerate or induce labour.  Prior to the publication of this guideline, there had been no national guideline in relation to the administration of oxytocin in Ireland.  Following research published by the State Claims Agency in 2015, it became apparent that significant variation and variability in practice existed across Ireland’s 19 Maternity Units in relation to the use of oxytocin. Oxytocin is listed as a high risk medication and was identified by The State Claims Agency as a causative and/or contributory factor in a substantial number of obstetric medical negligence claims in Ireland.

National Guideline

The guideline was published in April 2016, the stated purpose of which was “to improve the use of oxytocin to accelerate or induce labour in delivery units in Ireland.”  The document states that “the guideline is not intended to replace clinical judgment.  In individual cases a senior obstetrician or midwife may, after careful consideration, decide to deviate from the guideline if it is deemed to be in the best interests of the baby or the mother.”

Key Recommendations:

1. Every Maternity unit should have a single clinical guideline for the use of oxytocin to accelerate or induce labour which is based on the national guideline.
2. If the membranes are intact, an amniotomy (artificial rupture of membranes) should be performed before oxytocin in commenced.
3. In a woman who has never given birth previously, and where the pregnancy is at or greater than 37 weeks gestation (with a singleton pregnancy, cephalic presentation), a senior midwife may commence oxytocin in the first or second stage of labour.
4. Continuous electronic foetal monitoring should be performed for a minimum of 20 minutes before starting oxytocin, and should be continued until the baby is delivered.
5. Oxytocin should not be commenced if there is non-reassuring foetal testing.
6. In a woman who has given birth previously, a clinical assessment must be undertaken by a senior obstetrician before commencing oxytocin in the first or second stage of labour.
7. Where a woman has given birth previously by caesarean section (with a low transverse uterine scar), a clinical assessment should be performed by a senior obstetrician prior to commencing oxytocin and the decision to commence oxytocin should be made by a consultant obstetrician.
8. Oxytocin should not be started in the second stage of labour where a woman has a previous uterine scar.
9. Where a woman has given birth previously and does not have a uterine scar, the decision to start oxytocin in the second stage of labour should be made by a consultant obstetrician.
10. Oxytocin in labour should be constituted by adding 10 IU oxytocin to 1 litre of 0.9% normal saline starting at an infusion rate of 6-30 ml per hour, which may be increased every 15 minutes up to a maximum of 180 ml per hour.

The guideline states that all Maternity Units should audit their use of oxytocin to accelerate or induce labour and in individual cases of adverse clinical outcomes, any review at departmental multidisciplinary meetings should consider whether the hospital guidelines were followed or not.

Conclusion

This first national clinical guideline on the use of oxytocin is a welcome development in the standardisation of obstetric care across all Maternity Units in Ireland and could result in a reduction of adverse clinical outcomes associated with the use of oxytocin.  It should be noted, however, that the guideline is silent as to the procedure around obtaining a woman’s informed consent prior to commencing oxytocin and this was specifically highlighted by the State Claims Agency, prior to the publication of the guideline, as an area that must be addressed.  The guideline is due for revision in April 2019.