Background: Protocols for the use of oxytocin (Pitocin) and individual physician use of the drug to induce labor varies widely in the United States, and there are limited outcomes data to guide optimal dosing. Using the fundamental principle of quality improvement (greater practice variation generally leads to poorer outcomes), Clark and colleagues devised and implemented a conservative checklist protocol based on uterine contraction pattern and fetal heart rate response rather than on dosing to tailor oxytocin administration.
The Study: A multidisciplinary working group made up of physicians, nurses, and pharmacists from Hospital Corporation of America hospitals designed the checklist-based oxytocin protocol. The protocol was the default model for oxytocin use in singleton, vertex, term pregnancies, unless the individual physician documented the rationale for using different dosing. The retrospective study was conducted in a tertiary, nonteaching hospital and included 100 consecutive labor and deliveries in the month preceding implementation of the protocol and the first 100 labor and deliveries after the implementation. A single nurse reviewer extracted data on the clinical course of labor and maternal and fetal outcomes. The study had adequate power to detect a 50 percent reduction in composite adverse outcomes.
Results: The protocol and nonprotocol groups were demographically similar, except for a statistically higher birth weight in the protocol group. There were no variations from the protocol in the postimplementation group. Although the maximum dose of oxytocin was significantly lower in the protocol group (13.8 versus 11.4 mU per minute), there were no differences in maternal outcomes, including length of labor at any stage, total infusion time of oxytocin, and rate of instrumented vaginal delivery or cesarean delivery. There were no differences in newborn outcomes in any individual category, but the composite data of newborns with one or more complications were barely statistically lower in the protocol group.
Conclusion: The authors conclude that the use of a conservative, checklist-based oxytocin protocol decreases the total dose of oxytocin used without increasing labor length or delivery complications and may improve newborn outcomes. The authors suggest that the medical field look to other industries that have greatly improved safety outcomes by using standardized protocols and checklists.