Safety alert over 25 serious incidents linked to common drug

NHS England’s national patient safety team, backed by the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives and the Royal College of Anaesthetists, has issued an official alert instructing all providers to stop pre-preparing oxytocin infusions at ward level, in all clinical areas.

Trusts must complete this and three other actions by 31 March 2025. Oxytocin is one of the most commonly used drugs in labour and childbirth and can be administered to initiate contractions. In a much higher dose, it can treat postpartum haemorrhage, severe bleeding after birth. 

The inadvertent administration of a prenatal dose of oxytocin before a baby is born can lead to significant harm to mother and baby.

Safety reports into deaths and harm in maternity services, including the Ockenden reports into Shrewsbury and Telford Hospitals Trust and the seminal case which prompted the East Kent inquiry, that of Harry Richford, mention inappropriate use of oxytocin.

The alert states: “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 [which can lower the baby’s oxygen levels and alter their heart rate, increasing the risk of placental abruption].

“This alert seeks to balance the benefit of ensuring an oxytocin infusion can be started immediately after a woman (at high-risk of PPH) has given birth and mitigate the risk of preparing the oxytocin infusion in advance.”

Alert follows 25 incidents

The alert, issued on Tuesday, follows a review of 25 serious incidents over five years involving inappropriate use of oxytocin. They included one report of a woman receiving a pre-prepared postpartum oxytocin infusion in place of IV fluids during labour, causing the baby’s heart to slow, with the woman requiring an emergency caesarean section due to placental abruption.

The baby was born in poor condition and admitted to the neonatal intensive care unit for close monitoring. 

Others included postpartum oxytocin accidentally being given during labour or in theatre pre caesarean section, and oxytocin infusions and IV fluids being confused, leading to the former running through freely or at a significantly increased rate during labour.

The use of oxytocin in various stages of labour was reviewed by the National Institute for Health and Care Excellence last year with recommendations updated to reflect risks of administering it in the first and second stages of labour.

In the first Ockenden report, senior midwife Donna Ockenden wrote that her review team noted “many examples where oxytocin was used injudiciously; these cases occurred across the time period of the 250 cases reviewed, which suggests a failure to learn from previous cases where the outcome was poor”.

Meanwhile, the coroner’s prevention of future deaths report into Harry Richford’s death found he had been put under stress due to excessive use of a synthetic form of oxytocin called syntocinon, and the resulting hyperstimulation, when the uterus contracts too frequently or for too long.

The alert adds that all trusts must ensure PPH kits are immediately available in all clinical areas and theatres when required, and that staff roles are clearly defined in terms of prescribing, preparation, administration and disposal of oxytocin infusions, by 31 March 2025. 

Mothers considered to be at high risk of PPH should have kits brought into labour, delivery rooms or theatres during the second stage of labour, postpartum oxytocin infusions should be prepared at the time of birth and not before, and a second midwife should be available to support administration of the postpartum oxytocin infusion.