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Use and Misuse of Oxytocin During Delivery
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Obstetrik)
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Obstetric malpractice claims, concerning delivery during a period of eight years, were analysed for motives behind disciplinary actions, and for the frequency of inappropriate oxytocin use.Failure to respond to signs of foetal distress, injudicious use of oxytocin and a failure to effect a timely delivery were the recurrent problems that accounted for the majority of disciplinary actions. Inappropriate use of oxytocin was more frequent than reported in earlier studies. (Paper I)

In a case-control study, differences in the obstetric management in neonates born with and without acidaemia (umbilical artery pH < 7.05), was evaluated. Out of 28,486 deliveries during 1994–2004, 305 neonates were born with acidaemia. Uterine hyperactivity and oxytocin use were independently associated to acidaemia at birth. The increased uterine activity was related to oxytocin treatment in 75 % of cases. Pathological cardiotocographic patterns occurred significantly more often in the case group. The results indicate that guidelines on oxytocin use and foetal surveillance are not followed. The duration of bearing down is less important when uterine contraction frequency has been considered. (Paper II)

In a subset of study II, cases with metabolic acidosis (umbilical artery pH < 7.05 and base deficit ≥12 mmol/L) and controls were audited for the occurrence of suboptimal intrapartum care, and the nature of such care. It was found that suboptimal care occurred in half (49%) of the cases, while it was less frequent but not uncommon among controls (13%). Suboptimal care consisted of injudicious use of oxytocin and a failure of appropriate action upon signs of foetal distress. A high rate of NICU admissions and diagnosis of encephalopathy in the case group confirms that metabolic acidosis should be avoided. We estimate that metabolic acidosis could probably have been prevented in 40-50% of the cases.(PaperIII)

Women (n=103) scheduled for elective caesarean section in regional anaesthesia were randomised to 5 or 10 units oxytocin, given as an intravenous bolus (double blinded), and electrocardiograms were analysed for ST depressions as a sign of myocardial ischaemia. ST depressions were associated with oxytocin administration significantly more often in subjects receiving 10 compared with 5 units. A dose of 10 units resulted in a more marked decrease of the mean arterial blood pressure, but no difference in increase of the heartrate. There was no difference in estimated blood loss. (paper IV)

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2009. , p. 69
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 443
National Category
Medical and Health Sciences Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
URN: urn:nbn:se:uu:diva-100357ISBN: 978-91-554-7481-2 (print)OAI: oai:DiVA.org:uu-100357DiVA, id: diva2:210374
Public defence
2009-05-15, Rosénsalen, Ingång 95/96 nb, Akademiska Sjukhuset, Uppsala, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2009-04-24 Created: 2009-03-31 Last updated: 2009-04-27Bibliographically approved
List of papers
1. Analysis of malpractice claims with a focus on oxytocin use in labour
Open this publication in new window or tab >>Analysis of malpractice claims with a focus on oxytocin use in labour
2007 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 86, no 3, p. 315-319Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The objective of this study was to analyse the motives behind disciplinary action in obstetric malpractice cases concerning delivery, and to evaluate the frequency of inappropriate oxytocin use in these cases. METHODS: An analysis of all malpractice claims resulting in disciplinary action against physicians and midwives during the period 1996-2003. Investigations and decisions made by the Board of Medical Responsibility were reviewed with special focus on the use of oxytocin. RESULTS: Of 77 cases, 60 regarded patients in labour. In the majority, there had been a normal pregnancy and spontaneous start of labour (78%). At the beginning of labour, 87% showed a normal fetal heart rate (FHR) pattern, indicating fetal well-being. In 70%, there was adverse fetal outcome with brain damage or death. The most common reason for disciplinary action was improper interpretation of fetal monitor tracings and corresponding failure to recognise fetal distress (76%). Injudicious use of oxytocin was common (68.5%), and was the primary reason for disciplinary action in 33% of the cases. CONCLUSION: In a Swedish setting, a few common clinical problems pervade; interpretation of FHR patterns and the use of oxytocin account for the majority of rulings of negligence in malpractice cases regarding delivery. Analysis of the cases suggests that the adverse fetal outcomes could possibly have been prevented.

Keywords
Labour, obstetric, malpratice, oxytocin
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-10283 (URN)10.1080/00016340601181318 (DOI)000246476100009 ()17364306 (PubMedID)
Available from: 2007-03-12 Created: 2007-03-12 Last updated: 2017-12-11Bibliographically approved
2. Acidemia at birth, related to obstetric characteristics and to oxytocin use, during the last two hours of labor
Open this publication in new window or tab >>Acidemia at birth, related to obstetric characteristics and to oxytocin use, during the last two hours of labor
2008 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 87, no 7, p. 745-750Article in journal (Refereed) Published
Abstract [en]

Objective. Evaluate obstetric characteristics during the last two hours of labor in neonates born with acidemia. Design. Case-control study. Setting. Delivery units at two university hospitals in Sweden. Study population. Out of 28,486 deliveries during 1994-2004, 305 neonates had an umbilical artery pH value <7.05 at birth. Methods. Cases: neonates with an umbilical artery pH < 7.05. Controls were neonates with pH ≥ 7.05 and an Apgar score ≥7 at 5 minutes. Obstetric characteristics, cardiotocographic patterns and oxytocin treatment during the last two hours of labor were recorded. Results. In the univariate analysis, ≥6 contractions/10 minutes (odds ratio (OR) 4.94, 95% confidence interval (CI) 3.25-7.49), oxytocin use (OR 2.20, 95% CI 1.66-2.92), bearing down ≥45 minutes (OR 1.77, 95% CI 1.31-2.38) and occipito-posterior position (OR 2.18, 95% CI 1.19-3.98) were associated with acidemia at birth. In the multivariate analysis, only ≥6 contractions/10 minutes (OR 5.36, 95% CI 3.32-8.65) and oxytocin use (OR 1.89, 95% CI 1.21-2.97) were associated with acidemia at birth. Among cases with ≥6 contractions/10 minutes, 75% had been treated with oxytocin. Pathological cardiotocographic patterns occurred in 68.8% of cases and in 26.1% of controls (p<0.001). Conclusion. A hyperactive uterine contraction pattern and oxytocin use are the most important risk factors for acidemia at birth. The increased uterine activity was related to overstimulation in the majority of cases. The duration of bearing down is less important when uterine contraction frequency has been considered.

Place, publisher, year, edition, pages
Informa Healthcare, 2008
Keywords
Acidosis/*etiology, Adult, Cardiotocography, Case-Control Studies, Female, Humans, Hydrogen-Ion Concentration, Labor Stage; Second, Multivariate Analysis, Oxytocics/administration & dosage/*adverse effects, Oxytocin/administration & dosage/*adverse effects, Pregnancy, Risk Factors, Umbilical Arteries/chemistry, Umbilical Cord, Uterine Contraction
National Category
Medical and Health Sciences Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:oru:diva-3403 (URN)10.1080/00016340802220352 (DOI)18607817 (PubMedID)
Available from: 2008-12-04 Created: 2008-12-04 Last updated: 2017-12-14Bibliographically approved
3. Metabolic acidosis at birth and suboptimal care - illustration of the gap between knowledge and clinical practice
Open this publication in new window or tab >>Metabolic acidosis at birth and suboptimal care - illustration of the gap between knowledge and clinical practice
2009 (English)In: BJOG: an international journal of obstetrics and gynaecology, ISSN 1470-0328 (Print), Vol. 116, no 11, p. 1453-1460Article in journal (Refereed) Published
Abstract [en]

Objective   To evaluate the occurrence and nature of suboptimal intrapartum care in   cases with metabolic acidosis in the newborn, and to estimate the   degree to which this may be prevented.   Design   Case-control study. Clinical audit.   Setting   Delivery units at two university hospitals in Sweden.   Population   Out of 28 486 deliveries, 161 neonates >= 34 weeks of gestational age   were born with metabolic acidosis.   Methods   Cases (n = 161): umbilical artery pH < 7.05 and base deficit >= 12   mmol/l. Controls (n = 322): pH >= 7.05 and Apgar score >= 7 at 5   minutes. Obstetric characteristics and oxytocin administration were   recorded. The last 2 hours of electronic fetal monitoring before   delivery were evaluated blinded to outcome. Intrapartum management was   analysed for suboptimal care by using predefined criteria.   Main outcome measure   Suboptimal intrapartum care.   Results   Case and control comparisons displayed an occurrence of suboptimal care   in 49.1% versus 13.0% (P < 0.001), oxytocin misuse in 46.6% versus   13.0% (P < 0.001), a failure to respond to a pathological   cardiotocographic pattern in 19.9% versus 1.2% (P < 0.001) and   suboptimal care related to vacuum deliveries in 3.1% versus 0.3% (P <   0.01) respectively.   Conclusion   Metabolic acidosis at birth is often associated with suboptimal   intrapartum care. The high rate of suboptimal care with regard to   oxytocin use and fetal surveillance illustrate a gap between guidelines   and clinical practice. Metabolic acidosis and related neonatal   morbidity could potentially be prevented in 40-50% of cases. The   adherence to guidelines must be checked.

Keywords
metabolic acidosis, suboptimal care, oxytocin, foetal surveillance, labour
National Category
Medical and Health Sciences
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:uu:diva-100461 (URN)10.1111/j.1471-0528.2009.02269.x (DOI)000269590100003 ()19656149 (PubMedID)
Available from: 2009-04-01 Created: 2009-03-31 Last updated: 2010-07-08Bibliographically approved
4. St depression at caesarean section and the relation to oxytocin dose: a randomised controlled trial
Open this publication in new window or tab >>St depression at caesarean section and the relation to oxytocin dose: a randomised controlled trial
2010 (English)In: BJOG : an international journal of obstetrics and gynaecology, ISSN 1470-0328, Vol. 117, no 1, p. 76-83Article in journal (Refereed) Published
Abstract [en]

Objective To investigate whether there is a difference in occurrence of electrocardiogram changes suggestive of myocardial ischaemia between two different doses of oxytocin. Design Double-blind randomised controlled trial Setting University hospital in Sweden. Population A total of 103 healthy women undergoing elective caesarean section under spinal anaesthesia. Methods The participants were randomised to 5 or 10 units of oxytocin, given as an intravenous bolus. A Holter monitor was used to record electrocardiograms and non invasive blood pressure and heart rate (HR) was monitored. A blood sample was obtained 12-hour postoperatively. Main outcome measures Depression of the ST segment. Secondary outcomes: symptoms, Troponon I levels, mean arterial pressure (MAP), HR and blood loss. Results There was a significant difference in occurrence of ST depressions associated with oxytocin administration, 4 (7.7%) with 5 and 11 (21.6%) with 10 units, P < 0.05. The absolute risk reduction was 13.9% (95% confidence interval, 0.5-27.3). Decrease of mean MAP from baseline to 2 minutes differed, being 9 mmHg in the 5 unit group and 17 mmHg in the 10 unit group (P < 0.01). The increase in mean HR did not differ. Troponin I levels were increased in four subjects (3.9%). There were no differences in occurrence of symptoms, Troponin I levels, or estimated blood loss. Conclusion ST depressions were associated with oxytocin administration significantly more often in subjects receiving 10 units compared with 5 units. Interventions to prevent hypotension during caesarean section may reduce the occurrence of ST depressions on electrocardiograms.

Keywords
caesarean section, regional anaesthesia, oxytocin, heart, ischemia, hypotension, electrocardiography
National Category
Medical and Health Sciences
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:uu:diva-100466 (URN)10.1111/j.1471-0528.2009.02356.x (DOI)000272566600013 ()19781043 (PubMedID)
Available from: 2010-03-09 Created: 2009-03-31 Last updated: 2011-01-03Bibliographically approved

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