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 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.

Implantación de las recomendaciones de la estrategia de atención al parto normal en un hospital nivel II / Implementation of the recommendations in the care strategy for normal childbirth in a level 2 hospital

Objetivo: analizar la adecuación de la atención al parto normal en el Hospital Universitario Severo Ochoa (HUSO), hospital de nivel II de la Comunidad de Madrid, a las recomendaciones de la Estrategia de Atención al Parto Normal (EAPN) y detectar los puntos fuertes y áreas de mejora. Método: estudio descriptivo transversal. Mediante muestreo consecutivo se incluyeron 346 partos de mujeres gestantes de 37 a 42 semanas. Se midieron 18 indicadores propuestos en la EAPN que evalúan la atención al parto. Se realizó un análisis bivariante aplicando la prueba Chi cuadrado de Pearson. Para establecer la prioridad de áreas a mejorar se utilizó́ el diagrama Pareto. Resultados: 'Área de mejora': amniotomías (44,8%), uso de oxitocina en partos espontáneos (42,6%), inducciones (42,2%), partograma cumplimentado (55,5%), posición de litotomía en expulsivo (54,3%), maniobra de Kristeller (15,7%), episiotomías en partos eutócicos (41,6%), manejo dirigido del alumbramiento (3,8%) y piel con piel (66,5%). 'Puntos fuertes': analgesia epidural (73,4%), desgarros grado III/IV con episiotomía y sin episiotomía (1,4%; 0%), y partos instrumentales (12,3%). Se evidenció asociación entre inducciones, uso de oxitocina y cesáreas urgentes (p< 0,004), el uso de epidural y partos instrumentales (p< 0,007) y la realización de Kristeller y desgarros grado III-VI (p< 0,000). Conclusiones: a la luz de los resultados un plan de mejora debería incluir estrategias para disminuir amniotomías y uso de oxitocina mediante la revisión de criterios para el ingreso por parto en curso y el número de partos inducidos. Trabajar en estos puntos prioritariamente disminuiría el intervencionismo en la atención al parto y podría revertir en mejores resultados obstétricos (AU)

Objectives: to analyze the adequacy of care for normal childbirth in the Hospital Universitario Severo Ochoa (HUSO), a Level 2 hospital in the Community of Madrid according to the recommendations in the Care Strategy for Normal Childbirth (CSNC), and to detect its strengths and areas to be improved. Method: a descriptive cross-sectional study. Through consecutive sampling, the study included 346 childbirths in women with 37 to 42 weeks of pregnancy. Eighteen (18) indicators stated in the CSNC were measured, assessing care during delivery. A bivariate analysis was conducted, applying Pearson's Chi Square Test. The Pareto Diagram was used to establish the priority of areas to be improved. Results: 'Area for improvement': amniotomy (44.8%), use of oxytocin in spontaneous labour (42.6%), inductions (42.2%), partogram completed (55.5%), lithotomy position during expulsion (54.3%), Kristeller maneuver (15.7%), episiotomy in normal delivery (41.6%), active management of the third stage of labour (3.8%) and skin-to-skin (66.5%). 'Strengths': epidural anesthesia (73.4%), third and fourth degree tears with and without episiotomy (1.4%; 0%), and instrumental delivery (12.3%). There was evidence of association between inductions, use of oxytocin and emergency Caesarean sections (p< 0.004), the use of epidural anesthesia and instrumental deliveries (p< 0.007), and the Kristeller maneuver and 3rd and 4th degree tears (p< 0.000). Conclusions: given these results, a plan for improvement should include strategies to reduce the number of amniotomies and the use of oxytocin, through the review of admission criteria for delivery in process and the number of induced childbirths. Working on these points as a priority would reduce the interventions during childbirth care, and could result in improved obstetric outcomes (AU)

Process Improvement to Enhance Quality in a Large Volume Labor and Birth Unit.

BACKGROUND: The goal of the perinatal team at Mercy Hospital St. Louis is to provide a quality patient experience during labor and birth. After the move to a new labor and birth unit in 2013, the team recognized many of the routines and practices needed to be modified based on different demands. METHODS: The Lean process was used to plan and implement required changes. This technique was chosen because it is based on feedback from clinicians, teamwork, strategizing, and immediate evaluation and implementation of common sense solutions. Through rapid improvement events, presence of leaders in the work environment, and daily huddles, team member engagement and communication were enhanced. The process allowed for team members to offer ideas, test these ideas, and evaluate results, all within a rapid time frame. For 9 months, frontline clinicians met monthly for a weeklong rapid improvement event to create better experiences for childbearing women and those who provide their care, using Lean concepts. At the end of each week, an implementation plan and metrics were developed to help ensure sustainment. The issues that were the focus of these process improvements included on-time initiation of scheduled cases such as induction of labor and cesarean birth, timely and efficient assessment and triage disposition, postanesthesia care and immediate newborn care completed within approximately 2 hours, transfer from the labor unit to the mother baby unit, and emergency transfers to the main operating room and intensive care unit. RESULTS: On-time case initiation for labor induction and cesarean birth improved, length of stay in obstetric triage decreased, postanesthesia recovery care was reorganized to be completed within the expected 2-hour standard time frame, and emergency transfers to the main hospital operating room and intensive care units were standardized and enhanced for efficiency and safety. Participants were pleased with the process improvements and quality outcomes. CLINICAL IMPLICATIONS: Working together as a team using the Lean process, frontline clinicians identified areas that needed improvement, developed and implemented successful strategies that addressed each gap, and enhanced the quality and safety of care for a large volume perinatal service.

Strategies to Decrease Maternal Request for Early Elective Induction.

Severe maternal discomfort in the third trimester is not a diagnostic risk justification for elective induction before 39 weeks gestation. Alternative methods of intervention and supportive resources to help sustain a woman at the end of pregnancy have been largely absent in discussions pertaining to best practices. Nurses and midwives are in an ideal position to play a leadership role in working with physician colleagues as well as other members of the health care team to broaden the conversation to include alternative and complementary interventions, and to provide guidance and assistance to help women cope with and manage the discomforts of late pregnancy.

Sense and sensibility: Swedish midwives' ambiguity to the use of synthetic oxytocin for labour augmentation.

The use of intravenous artificial oxytocin for augmentation of labour is very common in midwifery care in Sweden. Studies have shown that oxytocin is often administered to women in labour who have no signs of labour dystocia. It was the aim of this study to examine Swedish midwives' views on and experiences of labour augmentation in the context of normal labour. Individual interviews were carried out with 15 midwives from southern Sweden. The material was analysed using qualitative content analysis, which resulted in one theme: sense and sensibility and four main categories: permissible situations, motivating the decision, intervening in the birth process and iatrogenic awareness. The results showed that midwives expressed ambiguity about augmentation of labour. They were of the opinion that oxytocin was used very often and sometimes unnecessarily. There is awareness that interventions to augment labour can result in undesirable effects on the birth process. Despite this, deeper discussion of this problem was avoided in the interviews. Further research should focus on the process involved when midwives weigh pros and cons when deciding to augment labour. More knowledge is also needed about the barriers for optimal care in labour that are inherent in health-care systems.

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.

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.

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.