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NHS England has requested pharmacy teams to consider producing ready-to-administer oxytocin infusions in a clearly labelled bag, following reports of women receiving pre-prepared postpartum oxytocin infusions instead of intravenous (IV) fluids during labour.
The NHS England Patient Safety team issued a national patient safety alert on 24 September 2024, which advised that oxytocin infusions should not be pre-prepared for any indication at ward level in any clinical area.
Instead, maternity services should discuss production of oxytocin infusions with their pharmacy department or consider buying ready-to-administer infusions from a commercial manufacturer.
Oxytocin is a cyclic nonapeptide, synthesised identical to the natural hormone, released in response to suckling and labour.
It stimulates the smooth muscle of the uterus and is licensed for induction of labour for medical reasons, during caesarean section following delivery, and prevention or treatment of postpartum uterine atony and haemorrhage.
The safety alert was published following a review of the National Reporting and Learning Systems over a five-year period, which identified 25 incidents related to oxytocin infusions, including one case where a female patient received the infusion in place of IV fluids while in labour.
The incident resulted in the woman undergoing an emergency caesarean section owing to a placental abruption. The baby was born in poor condition, requiring admission to the neonatal intensive care unit for close monitoring.
Other reports revealed during the review included postpartum oxytocin regimens accidentally given during labour or in an operating theatre before a caesarean section, as well as oxytocin infusion and IV fluids being confused, leading to oxytocin infusion running at a significantly increased rate during labour.
Under the safety alert recommendations, by 31 March 2025, maternity service providers will be required to review and update their clinical procedures to ensure that no oxytocin infusions are pre-prepared in wards and ensure that post-partum haemorrhage (PPH) kits are immediately available.
They should also ensure that roles and responsibilities of staff groups in labour settings are clearly defined around prescribing, preparation, administration and disposal of oxytocin infusions.
Commenting on the safety alert, Zoë van Zuylen, lead women and neonatal pharmacist at Imperial College Healthcare NHS Trust, said: “Oxytocin has long been recognised as a high-risk drug and it is important that it is managed carefully on obstetric wards as errors can have serious and severe outcomes. Fortunately, these errors are rare.
“PPH kits have been introduced in many trusts and can help to support midwives caring for women at high risk of haemorrhage.
“While the alert recommends that ready-to-administer products could be a good alternative option, there are currently no licensed products available and access to local central intravenous additive services (CIVAs) varies widely amongst trusts.
“Access to pre-prepared products will be extremely variable so a national manufacturer could be a valuable addition,” said Zuylen.
On 26 September 2024, NHS England informed The Pharmaceutical Journal that the number of reported incidents of an incorrect dosage of oxytocin administration was low. However, following detailed consultation with clinical experts and to minimise future risk, it said all maternity units should no longer pre-pare oxytocin infusions at ward level.
NHS England also said that, upon engagement with NHS Pharmaceutical Aseptic Services Group, it does not believe that pharmacy aseptic services currently prepare oxytocin infusions on a routine basis.
Commenting on the latest alert, Sally Ashton-May, director for midwifery policy and practice at Royal College of Midwives, said: “NHS trusts should ensure that robust processes are put in place to prevent future incidents. Learning from these incidents, and from those services demonstrating good practice, is vital if we are to drive up safety.
“Ensuring the safe supply, preparation, checking and administration of all drugs requires adequate time, appropriate resources, knowledge and training.
“However, under this new guidance, oxytocin infusions that are required will now need to be prepared at the time of the event. This puts further pressure on services to ensure that there are adequate levels of staff,” said Ashton-May.
- This story was amended on 27 September 2024 to clarify some comments from NHS England
