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Developing a reliable process for the administration of synthetic oxytocin when used for the induction or augmentation of labourAngela Cunningham, Associate Nurse Director for Women and Children’s Services [email protected] Muir, Labour Suite Co-ordinator & SPSP Fellow [email protected]

BackgroundSynthetic Oxytocin is a high risk medication that is used on a daily basis within labour wards to induce and augment labour.

It is associated with adverse outcomeswithin the intrapartumperiod such as tachysystole, uterine rupture and Hypoxic Ischaemic Encephalopathy.

Following a significant adverse event review a local audit of use identified inconsistency in the initiation and escalation of oxytocin

Oxytocin Driver Diagram

To introduce a standardised guideline for the initiation of oxytocin for the induction and augmentation of labour in Ayrshire Maternity Unit by June 2015

Appropriate Risk Assessment

Motivated and competent workforce

Aim Primary Drivers

Reliable Care Processes

• Develop guidance for initiation of oxytocin for

induction of labour

• Develop guidance for management of labour once oxytocin has been commenced

• Continuous risk assessment of women using the bundles.

Secondary Drivers

• Uniformity of information given to women about

Induction of labour both verbal and written given to women in the antenatal period

• Single standardised oxytocin regime used for

induction of labour for all groups of women

• Review and update CTG interpretation guidance

• Staff have annual CTG training (K2)

• Multidisciplinary CTG sessions

• Education sessions to increase confidence

of midwives and medical staff in the usage of oxytocin infusions.

•

Change Concepts

Initiation of oxytocin guidance for induction/augmentation of labour

Update plan of care for induction of labour with oxytocin

Single low dose oxytocin regime escalating every 45 minutes

Develop a checklist of information to be discussed regarding the use of oxytocin for induction of labour for VBAC women

CTG interpretation sticker and guidance

PDSA (Plan, Do, Study, Act) tests of change were formulated commencing initially with the group of Primigravid Low Risk postdates induction.

Outcome/Results

PDS

A

PD S

A

P DSA

PDS A

PDSA Oxy

tocin

Regime

Cycle 1: Regime and Guidance developed

Cycle 2: Regime tested with 1 postdates, primigravid woman and 1 midwife in April 2015

Cycle 3: Test extended to all primigravid women

Cycle 4: Regime implemented August 2015

ConclusionThis project has demonstrated that we have been able to reduce the exposure of primigravid women to a high risk medication whilst maintaining the caesarean section rate

A standardised low dose oxytocin regime has been implemented for all groups of women with tailored guidance for individual risk groups.

When using Oxytocin for the induction and augmentation of labour, our learning and experience is that ‘Less is More’

Key References MaterialsNICE clinical guideline 190 Intrapartum care: care of healthy women and their babies during childbirth (Issued: December 2014)

Krening CF, Rehling-Anthony K, Garko C. Oxytocin Administration: the transition to a safer model of care. J Perinatal Neonatal Nursing 2012 Jan-Mar 26 (1): 15-24

Heuser C, Knight S et al. Tachysystole in term labor: incidence, risk factors, outcomes and effects on fetal heart tracings Am J Obstet Gynecol 2013; 209 (1): 32 e 1-6

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Oxy

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Rate of oxytocin infusion needed to establish labour

Primigravid woman number

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% CS All Primigravida (Prim) - inclusion =37wks, singleton, cephalic , excluding category 4 CS

PDSA all primigravidastartedMay 2015

PDSA 1 woman, 1 midwifeApril 2015

Guideline finalisedAugust 2015

% caesarean section

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% Spontaneous onset labour + augmentation with oxytocin -inclusion ≥37wks, singleton, cephalic

PDSA all primigravidastartedMay 2015

% sp

onta

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s lab

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Guideline finalisedAugust 2015

PDSA1 woman, 1 midwifeApril 2015

Effective uterine contractions can be established at lower rates of oxytocin administration for primigravid women.

A lower dosage of oxytocin infusion is effective whilst maintaining the caesarean section rate

A reduction in the use of synthetic oxytocin for augmentation of spontaneous labour

Is it making a difference?Reduced incidence of tachysystole (5 contractions or more over 20 minute period) as evidenced by the feedback from midwives and snapshot Deep Dive.

Midwives reported 100% confidence with using the new regime

Comments• The regime is easy to follow

• It is good to know the physiological action of oxytocin – did not know this

• I notice that women’s’ contractions are established on lower rates of infusion than I expected

• The escalation of oxytocin is much steadier, less overstimulation

• Reads well. Like the option to use midwife discretion to make changes of 3 ml/hr (1 milliunit/min)

What did we want to do?This project aimed to standardise the administration of oxytocin when clinically appropriate using a low dose regime

How did we do it?A Driver Diagram defining our improvement plans was formulated and shared with obstetricians and midwives

Oxytocin driver diagram

Danger!

Oxytocin Regime Vaginal Birth After Caesarean Section (VBAC)

Final Version L Muir

March 2016

Oxytocin (Syntocinon®) Infusion Regime

Add 10 units of oxytocin (1ml) to 500ml bag of Sodium Chloride 0.9%

► 3ml/hour = 1 milliunit/minute

The decision to commence oxytocin must be made by a Consultant Obstetrician

Commence infusion at 6ml/hour = 2 milliunits/min

Increase infusion rate by 6ml/hr (2 milliunits/min) at 45 minute intervals

Aim for maximum of 4 regular contractions in 10 minutes lasting 60-90 seconds

Once labour is established (cervix fully effaced and cervical os 4cm), expected

dilatation should be 0.5cm per hour as a minimum (2cm in 4 hours)

Ensure membranes are absent prior to initiating oxytocin infusion. If forewaters are

identified at a subsequent vaginal assessment, reduce oxytocin rate by 2 increments

following artificial rupture of membranes (ARM)

Vaginal assessment should be performed 4 hours after the onset of established regular

contractions or 6 hours after starting the infusion. Subsequent vaginal examinations

should be 4 hourly unless otherwise clinically indicated

Contraction strength and frequency must be documented in the partogram/birth record

throughout first and second stage over 10 minute intervals. Be alert to scar/shoulder tip

pain or increasing maternal pulse which may be an indicator of impending uterine rupture

For High parity ≥ 3, if oxytocin not tolerated at 6ml/hr, reduce to 3 ml/hr. Consider

discontinuing Oxytocin when contractions are well established, 3- 4:10mins

Midwives can use their discretion to make incremental changes of 3ml/hr (1milliunits/hr)

when titrating infusion to uterine activity

Reduce oxytocin by 2 increments if tachysystole (contractions of 5:10 mins or more for 20

minutes) occurs. If tachysystole is not resolved in 15 minutes, discontinue infusion. Seek

medical review

If oxytocin is stopped for 30 minutes or less and requires to recommence, start at 2

increments less than rate stopped

If oxytocin is stopped for more than 30 minutes, restart at rate when initially commenced

If this regime needs to be tailored to individual woman’s plan then this is to be documented

in the labour and birth record by the Consultant Obstetrician on call for that shift

N.B. Oxytocin Pharmacological Information

The biological half-life of oxytocin is 10-12 minutes. Steady state plasma levels are reached after 40

minutes. Waiting 45 minutes prior to escalation will avoid flooding of oxytocin receptor sites in the

myometrium which can inhibit contractions

See over for infusion regime

Oxytocin Regime High Parity ≥ 3


September 2015




Commence infusion at 6ml/hour = 2 milliunits/min


Aim for maximum of 3-4 regular contractions in 10 minutes lasting 60-90 seconds


dilatation should be 0.5cm per hour as a minimum (2cm in 4 hours). High parity

women may progress more rapidly. Review progress in previous labours to guide

clinical decision making



following ARM


contractions or 6 hours after starting the infusion. Subsequent vaginal examinations should

be 4 hourly unless otherwise clinically indicated

Commence infusion at 6ml/hr. If not tolerated reduce to 3ml/hr


throughout first and second stage over 10 minute intervals

Consider discontinuing Oxytocin when contractions are well established, 3- 4:10mins



Stop oxytocin if tachysystole (contractions of 5:10 mins or more for 20 minutes) occurs.

Seek medical review



If oxytocin is stopped for 30 minutes or more, restart at rate when initially commenced








Oxytocin Regime for Primigravid Women and Parity ≤ 2


August 2015




Commence infusion at 6ml/hour = 2 milliunits/minute


Aim for maximum of 4 regular contractions in 10 minutes lasting 60-90 seconds


dilatation should be 0.5cm per hour as a minimum (2cm in 4 hours)



following ARM


contractions or 6 hours after starting the infusion. Subsequent vaginal examinations should

be 4 hourly unless otherwise clinically indicated

A vaginal assessment should be performed immediately prior to a plan being made to

commence oxytocin (when used for augmentation in primigravid women)


throughout first and second stage over 10 minute intervals

Oxytocin may require to be de-escalated or discontinued when labour well established



Reduce oxytocin by 2 increments if tachysystole (contractions of 5:10 mins or more for 20

minutes) occurs. If tachysystole is not resolved in 15 minutes, discontinue infusion. Seek

medical review



If oxytocin is stopped for more than 30 minutes, restart at rate when initially commenced








Regime guidance

Scotland

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