National Patient Safety Alert: Risk of oxytocin overdose during labour and childbirth (24 September 2024)

Summary

This National Patient Safety Alert, issued by the NHS England National Patient Safety Team and endorsed by the Royal College of Obstetricians & Gynaecologists, Royal College of Midwives and Royal College of Anaesthetists, instructs all relevant NHS funded maternity care providers to cease pre-preparing oxytocin infusions at ward level in all clinical areas.

All actions should be completed by 31 March 2025.

Content

Midwives need to complete several tasks immediately and simultaneously following birth to ensure the safety of both the mother and baby. To support this, postpartum oxytocin infusions have been prepared in advance of being required.

If a pre-prepared oxytocin infusion is unintentionally given before the baby is born, for example if it is confused with standard fluids or the intrapartum and postpartum infusions are confused, the woman’s contractions will increase in frequency and strength. This can lower the baby’s oxygen levels and alter their heart rate, increasing the risk of placental abruption (where the placenta prematurely separates from the uterus and deprives the baby of oxygen).

A review of the National Reporting and Learning Systems over a 5 year period identified 25 incidents.

Actions required:

Review and update local clinical procedures (or equivalent documents) to ensure:

1. Oxytocin infusions for any indication are not pre-prepared at ward level in any clinical area (including delivery suites and theatres).
2. Post-partum haemorrhage (PPH) kits/ trolleys are immediately available in all clinical areas/theatres where it may be required.
3. Where a woman is identified to be at high risk of PPH: (a) the PPH kit/trolley should be brought into the labour/delivery room/theatre during the second stage of labour, (b) the postpartum oxytocin infusion should be prepared at the time of birth and not before, (c) a second midwife should be available to support the administration of the postpartum oxytocin infusion.
4. Roles and responsibilities of staff groups in the labour setting, including theatres, are clearly defined in terms of prescribing, preparation, administration and disposal of oxytocin infusions. Including: intrapartum oxytocin infusions, postpartum oxytocin infusions and unused, pre-prepared oxytocin. infusions.