Implementation of guidelines on oxytocin use at caesarean section: A survey of practice in Great Britain and Ireland

Abstract 

Objective

Caesarean section is one of the most commonly performed major operations on women worldwide. Operative morbidity includes haemorrhage, anaemia, blood transfusion and in severe cases, maternal death. Various clinical guidelines address oxytocin use at the time of caesarean section. We previously reported wide variation in practice amongst clinicians in the United Kingdom in the use of oxytocin at caesarean section. The aim of this current study was to determine whether the variation in approach is universal across the individual countries of Great Britain and Ireland and whether this reflects differences in interpretation and implementation of clinical practice guidelines.

Study design

We conducted a survey of practice in the five individual countries of Great Britain and Ireland. A postal questionnaire was sent to all lead consultant obstetricians and anaesthetists with responsibility for the labour ward. We explored the use of oxytocin bolus and infusion, the measurement of blood loss at caesarean section and the rates of major haemorrhage. Existing clinical guidelines from the National Institute for Clinical Excellence (NICE), the Royal College of Obstetricians and Gynaecologists (RCOG) and ALSO (Advanced Life Support in Obstetrics) were used to benchmark reported practice against recommended practice for the management of blood loss at caesarean section.

Results

The response rate was 82% (391 respondents). Use of a 5IU oxytocin bolus was reported by 346 respondents (85–95% for individual countries). In some countries, up to 14% used a 10IU oxytocin bolus despite recommendations against this. Routine use of an oxytocin infusion varied greatly between countries (11% lowest–55% highest). Marked variations in choice of oxytocin regimens were noted with inconsistencies in the country-specific recommendations, e.g. NICE (which covers England and Wales) recommends a 30IU oxytocin infusion over 4h, but only 122 clinicians (40%) used this.

Conclusions

Clinicians’ approach to the use of oxytocin at the time of caesarean delivery varies between countries. Even in countries with on-site visits to ensure guideline implementation (e.g. Clinical Negligence Scheme for Trusts in England), deviations from guideline recommendations exist. These variations may reflect a lack of robust evidence and the need for future research in this area.

Keywords: Oxytocin: caesarean section, Blood loss, Guideline implementation, Survey