Oxytocin, the naturally occurring hormone and Pitocin, the synthetic version stimulate and strengthen uterine contractions and manage excessive bleeding after birth (Sakala, Romano, & Buckley, 2016). Although oxytocin and Pitocin have a similar mechanism, the difference in endogenous and exogenous delivery of the hormone can create difficulty in labor management. Endogenous oxytocin is produced naturally by the hypothalamus and is secreted by the posterior pituitary gland. Oxytocin receptor cells provide continual feedback to the pituitary gland (Simpson, 2011). The woman's body is able to monitor its own needs through this feedback system in order to release additional oxytocin when needed (Arrowsmith & Wray, 2014). Exogenous oxytocin (Pitocin) is helpful in inducing and augmenting labor. When working together, endogenous and exogenous oxytocin increase uterine contractions (Simpson, 2011). The body's feedback loop, however, is only effective on endogenous sources of oxytocin, allowing for the possibility of overadministration.
The most recent data indicate labor was induced in 23.8% of all births in the United States in 2015 (Martin, Hamilton, Osterman, Driscoll, & Mathews, 2017). This rate has shown a steady increase since 1990, in which induction of labor accounted for 9.6% of all births (Osterman & Martin, 2014). With increasing use, it is vital to weigh advantages of using oxytocin with the disadvantages.
Use of intravenous (IV) oxytocin has been associated with decreased cesarean birth rate (Kenyon, Tokumasu, Dowswell, Pledge, & Mori, 2013 ; Wei et al., 2013) and decreased labor duration at higher doses (Kenyon et al.). However, administration of excessive oxytocin is associated with negative effects on both mother and fetus. Risks include uterine tachysystole, uterine rupture, fetal acidemia, and fetal hypoxemia (Bakker, Kurver, Kuik, & Van Geijn, 2007 ; Gilstrop & Sciscione, 2015 ; Simpson, 2011 ; Simpson & James, 2008). Intravenous oxytocin is listed as a high-alert medication due to its risk of causing significant harm to patients when used inappropriately (Institute for Safe Medication Practices, 2014 ; Simpson & Knox, 2009).
Uterine tachysystole (an average of more than five contractions in 10 minutes during a 30-minute period) is associated with rapid increases in IV oxytocin administration (more frequent than every 30–40 minutes) and higher levels of oxytocin (Simpson, 2011). Adequate fetal oxygenation relies on multiple factors, including adequate maternal–fetal oxygen exchange at the intervillous space in the placenta. During a contraction, blood flow to the fetus is temporarily restricted. This is not completely restored until approximately 2 minutes postcontraction (Simpson & Miller, 2011). Most fetuses have adequate reserves to withstand these periods, but prolonged and/or too frequent contractions increase the risk of fetal hypoxemia and acidemia (Simpson, 2011). Complications from tachysystole and subsequent effects on the fetus may also lead to litigation (Smith, Zacharias, Lucas, Warrick, & Hamilton, 2014).
One helpful approach is use of a systematic method for assessment, intervention, and continuous monitoring of women undergoing labor induction or augmentation. Use of checklists, adapted from processes in the aviation industry, has been gaining popularity within healthcare. Checklists provide a method to standardize care, improve communication, and incorporate evidence-based practice (Arora et al., 2016). However, it is important to note that checklists must be incorporated with education and culture changes to be successful (Clay-Williams & Colligan, 2015).
Current evidence suggests there may be effects of use of an oxytocin administration checklist (Clark et al., 2007). One retrospective study demonstrated a general improvement in outcomes for both mothers and infants. Specific findings included significant decreases in length of stay, meconium presence, episiotomies, maternal fever, low Apgar scores (<7 at 5 minutes), and operative vaginal birth (Wojnar, Cowgill, Hoffman, & Carlson, 2014). Rohn, Bastek, Sammel, Wang, and Srinivas (2015) used a retrospective cohort design to evaluate use of a low-dose oxytocin checklist. Although the lower dose approach was sought to avoid the risks of higher doses of oxytocin, the researchers discovered that women on the low-dose protocol had significant increases in time to birth from admission and higher rates of chorioamnionitis. Effect on cesarean birth rate was mixed, as women were more likely to have surgical birth for labor dystocia, but less likely to have one for fetal heart rate (FHR) abnormities requiring intrauterine resuscitation (Rohn et al., 2015).
The purpose of this study was to evaluate and compare the results of maternal and fetal outcomes of women who had inductions of labor at term prior to and after implementation of the oxytocin checklist.
This quality improvement project was implemented in an urban, nonprofit, private hospital with an average of 6,000 births per year, including 150 to 200 inductions per month. In-use safety checklists for oxytocin administration were not standard at this hospital. A literature review of current evidence-based practice was conducted and a quality group (QG) was formed consisting of three labor and delivery (L&D) staff nurses to draft an in-use oxytocin checklist. The oxytocin checklist that was developed was based on the work of Clark et al. (2007). Following unit manager approval, the draft and supporting literature were presented to the Chief Obstetrician (COB). Ethical concerns were discussed with the COB and it was determined that no harm, violation of privacy, or conflicts would occur during implementation of checklist. After approval from the COB, the checklist was presented to the Medical Executive and the Quality Improvement Committees, which were formed of obstetricians representing different physician groups. Once both committees approved the checklist, it was then presented to all physicians during quarterly Grand Rounds by the COB and Women's Services Director. A timeline was adapted to include education of all L&D nurses along with the implementation start date. Nurse education included oxytocin facts and mechanism of action, common errors when infusing oxytocin, and other oxytocin-related study outcomes from the literature review. Explanation of the in-use checklist for induction and augmentation of labor was discussed as well as appropriate documentation during checklist use.
It was recommended that L&D nurse would use the oxytocin checklist during labor inductions of women with singleton, vertex, and term pregnancies. Fetal heart rate and uterine assessments would occur every 15 minutes while evaluating the need to increase oxytocin every 30 minutes, according to Association of Women's Health, Obstetric and Neonatal Nurses (2015) guidelines. After ascertaining that all required parameters were met, documentation was to include “criteria met,” when initiating or increasing oxytocin. If the checklist criteria could not be met due to FHR abnormalities and/or contraction pattern, the oxytocin should be decreased or stopped. The checklist specifically stated that it was only a guideline; the physician was to direct individualized medical care. For accessibility as a reference, the oxytocin checklist was placed in all L&D rooms, at each nurses' station, and in each of the patients' medical record (Figure 1).
A study examining 100 patient's outcomes prior to implementation and after use of an oxytocin checklist was referenced during the literature review phase of this QI project (Clark et al., 2007). It was determined that medical record reviews of 200 inductions would be sufficient to illustrate differences between the two methods. Prior to implementation of the checklist, 200 retrospective chart reviews were conducted of inductions meeting criterion. Data collected included the following demographics: maternal age, parity, gestational age, and Bishop score. Birth type, Apgar scores and cord gas values, if applicable were recorded. Maximum dosage of oxytocin, total oxytocin infusion time, and whether or not the oxytocin was discontinued and/or reduced at any point of the labor process were also documented. Complications during labor and/or birth: tachysystole, postpartum hemorrhage, shoulder dystocia, chorioamnionitis, and FHR abnormalities requiring intrauterine resuscitation were assessed. Length of first, second, and third stages of labor was calculated from labor curves. Following initiation of the oxytocin checklist, 200 additional cases were compared with collected retrospective medical record data. For continuity, only the three QG nurses conducted the medical record audits. Medical record auditors were aware of checklist use by reviewing documentation of “criteria met” when oxytocin was started or increased by the nurse. After 2 weeks, qualitative data, including physician feedback, as well as polling of staff nurses on ease of checklist use and recommendations to adjust implementation were obtained. Quantitative data collection included medical record reviews from inductions to determine nurses' adherence to documentation of “criteria met.”
To ensure accuracy of the medical record reviews, a worksheet was created to guide the auditor. For inclusion purposes, if documentation of “criteria met” was not present or if gestational age was less than 37 weeks, data from these cases were not included in the sample. All appropriate data collected were entered into a spreadsheet for comparison of pre- and post-data. If extraneous complications were present, these complications were noted to determine if there was any other significant correlation. For statistical analysis, a multivariate approach was used.
Prior to checklist implementation, mandatory nurse education was conducted on the L&D unit in small groups of nurses using a slide presentation. Pre- and posttesting was completed to ensure nurses' understanding of material presented. An email was sent to all nurses on the first day of implementation reminding nurses to follow project guidelines. Frequent and ongoing medical record reviews were conducted by the project nurses during implementation for adherence to documentation of “criteria met.” Additional email reminders were sent to nurses following a meeting with the COB 2 weeks after project initiation that consisted of accurately documenting cervical exams to calculate starting Bishop scores, documenting “criteria met” when oxytocin was increased, and reminding them that the attending obstetrician directs individual care. Flyers and pocket-sized cards were posted and handed out to nurses as a resource.
There was a significant decrease in the cesarean birth rate (p = 0.003). See Table 1. Cesarean births for FHR abnormalities requiring intrauterine resuscitation declined from 40 (20%) to 11 (5.5%) (p < 0.001). Tachysystole was significantly reduced by 63% in the postchecklist group (p = 0.02). Significant decreases in other oxytocin outcome metrics included: decreased total oxytocin time in hours (p < 0.001); decreased maximum oxytocin dose in milliunits per minute (mU/min) (p < 0.001), reduction in the number of times oxytocin was discontinued (p < 0.001), and in the number of times oxytocin was decreased (p < 0.001).
Although the total length of labor was not significantly decreased, average first stage of labor was decreased by approximately 56 minutes (p = 0.007). Following the checklist implementation, it was determined that the maximum dose of oxytocin was reduced by 24% with the average of all maximum doses reaching 10.9 mU/min. There were no differences between groups for chorioamnionitis.
A survey of nurses was conducted 1 month postimplementation to determine the “ease of use” and “helpfulness” of the checklists. The survey revealed positive results with 98% of nurses agreeing the checklists were helpful and 92% indicating satisfaction with the ease of use. Comments such as this has been a very helpful guideline and I'm so glad we have this now were included with the survey.
There were approximately 22 cases that could not be included in post implementation data due to lack of documentation of “criteria met” when oxytocin was increased. Lack of consistency in documentation was associated with the number of nurses who cared for the women during the induction period.
Elements of Success
Several elements were found to be key to implementation success: early COB buy-in, previous successes documented in literature, and adequate time for L&D nurse education and discussion. Results of this project are consistent with previous research (Clark et al., 2007 ; Rohn et al., 2015 ; Wojnar et al., 2014), showing improved outcomes when a standardized in-use oxytocin checklist was used for women at term having an induction of labor. With this knowledge, the nurses were able to successfully implement the checklist, using it as a guide throughout the induction process. Nurses felt the checklist brought a much-needed uniform approach to the induction process, alleviating any guesswork encountered by the L&D nurse even with varying degrees of nursing experience.
Limitations: Several limitations were noted during the implementation of the project. Lack of adherence to documentation requirements was due to nurses misunderstanding need to note “criteria met” with each initiation and increase in oxytocin. Following reminder emails about documenting correctly, nurses who continued to lack adequate documentation were given one-on-one education of expectations of charting. In one specific case, there was frustration over use of the checklist between the physician and the nurse. The physician expressed the need to increase the oxytocin due to the clinical situation, whereas the nurse did not feel that an increase met the checklist criteria. The charge nurse reviewed the FHR tracing and collaboratively decided that an increase was appropriate. Education was reiterated to physician and nurses that the physician still dictates the care of the women; however, if the safety of the fetus is in question, chain of command should be initiated.
Our findings affirm the growing body of literature supporting use of standardized in-use oxytocin checklists to safely and effectively administer oxytocin for term, pregnant women undergoing inductions. Because of the significant clinical impact of maternal infection/chorioamnionitis, future work should investigate the impact of oxytocin checklists in preventing this complication. We recommend that oxytocin checklists be implemented universally during induction and augmentation of labor with oxytocin for maternal–fetal safety.
Suggested Clinical Implications
- Integrating an oxytocin checklist can improve outcomes and decrease complications of labor.
- Early physician buy-in and communication between the multidisciplinary team can assist in facilitation of quality improvement projects.
- Education, ongoing evaluation, and diverse reminders can assist nurses with the transition into new procedures.
- Education on the pharmacological background of oxytocin ensures optimal understanding on titration of the medication.
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