Bedside Availability of Prepared Oxytocin and Rapid Administration After Delivery to Prevent Postpartum Hemorrhage: An Observational Study in Karnataka, India

INTRODUCTION

Worldwide, greater than a quarter million maternal deaths occur each year,¹ and postpartum hemorrhage (PPH) is the leading direct cause.² Incidence and severity of PPH can be reduced by active management of the third stage of labor (AMTSL), which includes early provision of uterotonics such as oxytocin.^3–5

As a prophylactic intervention, it is essential that oxytocin be administered as quickly as possible after childbirth; current guidelines recommend administration of a uterotonic as part of AMTSL,³ and the International Confederation of Midwives (ICM) and International Federation of Gynaecology and Obstetrics (FIGO) recommend oxytocin administration within 1 minute of delivery.⁴ Unfortunately, many women globally do not receive this recommended preventive intervention.⁶ In addition, a multicountry study found that, even when oxytocin is given, there are errors in its administration, most commonly that administration is delayed beyond the recommended 1-minute postpartum time frame.⁷

Multiple studies have quantified poor rates of adherence to recommended AMTSL guidelines.^6–11 In addition, qualitative research has explored possible causes of variation in use of AMTSL (including oxytocin administration), such as availability of supplies, lack of and low confidence in skills, and challenges in preparing and administering oxytocin rapidly after labor.^12–15 However, little is known about factors associated with the timing of oxytocin use after delivery. In this investigation, we analyzed baseline observational data from a quality improvement study, of the Safe Childbirth Checklist (SCC) program of the World Health Organization (WHO), to explore whether preparing oxytocin injection prior to delivery and making it available at bedside was associated with increased likelihood of its rapid postpartum use in a hospital in India.

RESULTS

Our analyses were based on 330 deliveries. Oxytocin was prepared and available at bedside for 38.8% of deliveries (Table 1). Use of oxytocin within the recommended 1-minute time frame was higher when prepared oxytocin was available at bedside than when it was not prepared and available (15.6% of observed deliveries vs. 3.0%, respectively; P< .001). We found similar results when extending the time frame of administration: oxytocin was given within 2 minutes of delivery 43.8% of the time when it was prepared and available at bedside, compared with only 16.3% of the time when it was not (P< .001). The average time to oxytocin administration when oxytocin was prepared and available at bedside was 4.2 minutes—significantly shorter than the average time of 7.5 minutes when oxytocin was not prepared and at bedside (P< .001).

Regression models assessing the association between bedside availability and rapid oxytocin use suggest that deliveries in which oxytocin was prepared and available at bedside were nearly 5 times more likely than deliveries in which oxytocin was not available at bedside to have the medication administered within 1 minute postpartum, after adjusting for time of day and maternal risk factors for hemorrhage (adjusted risk ratio [RR] = 4.89, 95% confidence interval [CI] = 2.61, 9.16) (Table 2). When extending the time frame of administration to 2 minutes after childbirth, deliveries in which oxytocin had been prepared and available at bedside were 2.61 times more likely to have oxytocin administered than when it was not ready at the bedside (in the adjusted model, with covariates for time of day and maternal risk factors for hemorrhage) (95% CI = 1.26, 5.41). When time was examined as a continuous variable, deliveries in which oxytocin was prepared and available at bedside had oxytocin administered, on average, about 3 minutes sooner than deliveries in which oxytocin was not ready for administration at bedside, after adjusting for time of delivery and maternal hemorrhage risk factors (–2.9 minutes, 95% CI = –5.0, –0.9).

DISCUSSION

Advance preparation and bedside availability of oxytocin was associated with a significantly increased likelihood of its rapid use postpartum, when considering the ICM/FIGO-recommended 1-minute time frame as well as an expanded time frame of 2 minutes and time-to-use overall. Covariates representing time of day of the delivery and maternal risk factors for hemorrhage did not attenuate this effect.

Those seeking to implement global guidelines for the prevention of postpartum hemorrhage may therefore want to consider adding operational recommendations to make oxytocin ready for administration and available at bedside—such as ensuring adequate supplies of the medication in the delivery room, preparing oxytocin syringes in advance, and assigning responsibility to guarantee these steps are routinely followed. The advent of prefilled oxytocin syringes (e.g., Oxytocin-in-Uniject devices) may facilitate rapid use after delivery.^15,19 An important constraint is that oxytocin is not heat stable, although recent evidence from Ghana suggests that it may be shelf-stable around the point of care.²⁰ So until additional evidence confirms the parameters of oxytocin’s stability, hospitals should seek to extend the cold chain into the labor ward (using an ice box, for example), so oxytocin can be stored close to the point of use rather than in general hospital drug storage. Behavioral prompts for providers may also be useful, such as keeping an empty needle and syringe near, or prepackaged in, the delivery kit. Finally, use of the SCC may help drive change, as results from the pilot study found that the intervention increased both pre-labor preparation of oxytocin and its prompt administration to women postpartum.¹⁶ Such changes could help increase the likelihood that health workers will deliver this potentially lifesaving intervention to all women in a timely manner.

The findings from this study suggest that health system constraints and opportunities should be considered when developing global protocols. Medical practitioners may be responsible for implementing a number of different clinical guidelines—and policy makers should seek to understand how such guidelines are used in practice, and whether any operational challenges might be overcome with simple procedural solutions. We encourage future research on the barriers and enablers faced by health workers and health systems in implementing clinical guidelines to continue to drive improvement in obstetrics and beyond.

CONCLUSION

Adherence to global recommendations on preventing PPH through rapid administration of oxytocin was much higher when oxytocin was prepared and at bedside prior to delivery than when it was not. During the busy immediate postpartum period, under-resourced health systems with overtaxed health workers may have the additional need for such advance planning to enable rapid postpartum oxytocin administration—which also may have spillover effects to newborns, particularly those with urgent postpartum care needs. In resource-limited settings where a single health care worker must care for both mother and infant, advance preparation of oxytocin can facilitate rapid administration and thus avoid interfering with a health worker’s ability to promptly address the needs of the infant. Simple interventions, such as advance preparation of oxytocin and other essential birth supplies before delivery, are a core component of the SCC, and a study is underway to determine the impact of these and other critical components of care on maternal and neonatal morbidity and mortality.