Safety alert issued over common drug administered to women giving birth

NHS officials have issued a national safety alert after reported overdoses of a common drug used in labour and after childbirth.

Oxytocin is a hormone that is used to alter contractions during labour or in significantly higher doses to control bleeding after childbirth.

But accidental administration of a postnatal dose of oxytocin before to the birth of the baby can lead to “significant harm” to mother and baby, NHS officials said.

NHS officials have issued a patient safety alert over the “risk of oxytocin overdose during labour and childbirth”, after 25 oxytocin overdose incidents have been reported in the last five years.

A woman (received) a pre-prepared postpartum oxytocin infusion in place of IV fluids while in labour. The baby’s heart rate slowed, and the woman required an emergency caesarean section due to a placental abruption

The alert describes how a baby was sent to intensive care after a mishap.

“A woman (received) a pre-prepared postpartum oxytocin infusion in place of IV fluids while in labour,” the alert states.

“The baby’s heart rate slowed, and the woman required an emergency caesarean section due to a placental abruption.

“The baby was born in poor condition and admitted to the neonatal intensive care unit (NICU) for close monitoring.”

Other reports described include postpartum oxytocin accidentally given during labour or in theatre before a caesarean section.

And others included oxytocin infusions and IV fluids being “confused”, leading to oxytocin “running through freely or at a significantly increased rate during labour”.

The alert has been issued by NHS England’s national patient safety team and endorsed by the Royal College of Obstetricians and Gynaecologists , Royal College of Midwives and the Royal College of Anaesthetists.

It calls for maternity providers to stop pre-preparing oxytocin infusions at ward level, in all clinical areas, including delivery suites and theatres.

To minimise any potential risks of delayed treatment of excessive bleeding after birth, post-partum haemorrhage kits or trolleys should be made available in all clinical areas, the alert adds.