Tag perinatalrisk

In this blog, I’ll be reviewing common allegations specific to the use of oxytocin for labor management, as well as current standards of care.  I’ll also identify some risk reduction strategies. 

Oxytocin management is a common area of professional perinatal liability claims.  Knowledge of this, and being armed with current evidence and standards of care from professional organizations can reduce a clinician’s liability risk.  

Common Allegations:

• Initiation of oxytocin in the absence of evidence of fetal well-being.  Failure to complete a non-stress test prior to initiation of oxytocin
• Failure to accurately assess maternal-fetal status during labor induction.  Continuous fetal monitoring not performed; failure to assess and document fetal heart rate and uterine activity per organizational policy and standard of care
• Excessive doses of oxytocin resulting in uterine tachysystole, with or without an indeterminate or abnormal fetal heart rate (FHR) pattern.
• Failure to discontinue or decrease oxytocin in the presence of a Category II and/or Category III fetal heart rate (FHR) tracing unresolved with intrauterine resuscitation

Standards of Care:

• Assess and document fetal well-being prior to the initiation of oxytocin
• Administer the lowest dose to achieve cervical change and labor progress (ACOG, 2017)
• Initiate oxytocin at 1-2mU/min and increase by 1-2mU/min no more frequently than every 30-40 minutes.  Approximately 90% of women at term will have labor successfully induced with 6mU/min or less (AWHONN, 2014).
• Titrate the dose of oxytocin to fetal response and uterine activity / labor progress (ACOG, 2017)
• Avoid uterine tachysystole (more than 5 contractions in 10 minutes averaged over 30 minutes) and treat (decrease or discontinue) in a timely manner if it occurs (ACOG, 2017; JOGNN, 2020)
• Avoid prolonged uterine contractions lasting greater than 2 minutes, avoid inadequate uterine resting tone (contractions occurring less than 1 minute of each other) (ACOG, 2017)
• If labor is progressing, there is no need to increase the dosage rate
• If utilizing a labor management and/or oxytocin policy, follow all policy elements
• Ensure adequate personnel are available to monitor maternal-fetal status (ACOG, 2017).  E.g. one nurse to one woman receiving oxytocin for labor induction or augmentation (AWHONN, 2014)

Risk Reduction Strategies:

• Ongoing education and periodic competence validation for health care professionals who engage in fetal heart monitoring (FHM) (JOGNN, 2015)
• Consider the requirement for electronic fetal monitoring (EFM) education for obstetrical provider re-credentialing   
• Implementation of a pre-oxytocin and in-use oxytocin checklist.  Such checklists offer a guideline for care and reinforces to the providers that if the checklists cannot be completed, Oxytocin should not be initiated and/or continued (HCA, 2009) 
• Utilize the organizational chain of command and conflict resolution policy in the event of disagreement in fetal monitor strip interpretation.  Document employment of the chain of command.
• Per JOGNN, 2020: Organizational implementation of a quality improvement initiative – Identify quality measures related to induction of labor and augmentation of labor that emphasizes
  • perinatal structure measures:
    • completed 39 weeks gestation prior to elective induction
    • criteria for prioritizing inductions based on medical necessity
    • standard policy for oxytocin administration
    • standard order set for oxytocin
    • agreed upon definitions of tachysystole base on NICHD/ACOG/AWHONN terminology
    • agreed upon and standardized treatment for tachysystole
  • perinatal process measures:
    • greater than or equal to 39 weeks gestation if elective induction
    • if <39 weeks, indication is consistent with ACOG and The Joint Commission (TJC) clinical indications
    • cervical readiness or ripening before induction
    • oxytocin protocol starting at 1-2mU/min; increase by 1-2mU/min; at least 30min. between oxytocin dosage increase
    • fetal status is normal
    • appropriate and timely interventions for tachysystole if it occurs (use of a tachysystole audit tool)
    • compliance with all aspects of care (clearly identified aspect of care)

References:

ACOG. (2017). Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles

AWHONN. (2014). Perinatal Nursing 4^th ed.

HCA. (2009). Perinatal Safety Initiative Recommended Pre-Oxytocin Checklist For Women with Term-Singleton Babies

JOGNN. (2015). Fetal Heart Monitoring

JOGNN. (2020). AWHONN Practice Monograph

P.S. Comment and Share: What has been your experience with a case involving oxytocin for labor induction or augmentation?