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

Results The response rate was 82% (391 respondents). Use of a 5 IU oxytocin bolus was reported by 346 respondents (85–95% for individual countries). In some countries, up to 14% used a 10 IU 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 30 IU oxytocin infusion over 4 h, 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 1 Introduction Caesarean section is one of the most commonly performed major operations on women throughout the world. Over the past three decades, rates of caesarean section have risen dramatically [1–4] . Operative morbidity includes haemorrhage, anaemia, blood transfusion and in severe cases, maternal death. The value of routine oxytocics in the third stage of vaginal delivery has been well established [5] and it has been assumed that these benefits apply to caesarean delivery as well [6,7] . Despite the changing patterns in mode of delivery there has been limited work to date on the prevention of haemorrhage at caesarean section. We previously conducted a survey of the use of oxytocin at caesarean section in the United Kingdom, demonstrating wide variation in reported practice amongst obstetricians and anaesthetists [8] . Various clinical guidelines, readily accessible to clinicians, address the use of oxytocin at the time of caesarean section [9,10] . In the current study, we wished to explore whether the variation in approach is universal across the individual countries of the United Kingdom and Ireland and whether this reflects differences in the interpretation and implementation of clinical practice guidelines. This study has been performed within the context of a randomised controlled trial that we are currently conducting to evaluate the role of an oxytocin infusion in the control of blood loss at elective caesarean section. The pilot randomised controlled trial was completed in Scotland [11] and the ongoing multi-centre randomised controlled trial is being conducted in the Republic of Ireland. We extended the survey to include the Republic of Ireland for the current study and have benchmarked reported practice against recommended practice within the published clinical guidance [9,10] . The aim of our study was to determine the extent to which clinicians across the countries of Great Britain and Ireland have implemented the recommendations of published clinical guidelines and if and where variations in practice exist. 2 Materials and methods Existing clinical guidelines available at the time of the survey were used to benchmark reported practice against recommended practice for the management of blood loss at caesarean section. The National Collaborating Centre for Women's and Children's Health issued a clinical guideline on “Caesarean section” in 2004 recommending a slow intravenous bolus of 5 IU oxytocin following delivery of the infant at caesarean section [9] . This guideline is supported by the National Institute for Health and Clinical Excellence (NICE) and the Royal College of Obstetricians and Gynaecologists (RCOG). NICE Guidelines specifically target practice within England, Wales and Northern Ireland but are readily accessible to practitioners within Scotland and the Republic of Ireland via the RCOG web-based link. The Advanced Life Support in Obstetrics (ALSO) manual (2000) also recommends a 5 IU bolus dose and clinicians from all five countries attend ALSO training courses [10] . There is no specific guidance provided on the use of an oxytocin infusion for the prevention of haemorrhage. In the event of a postpartum haemorrhage at caesarean section, NICE recommends using a 30 IU oxytocin infusion whereas ALSO recommends a 40 IU infusion. Specific guidelines for the management of caesarean section have not been issued to date in Scotland, Northern Ireland and the Republic of Ireland. A questionnaire was developed addressing the management of blood loss at caesarean section. It comprised a series of closed answer questions. Free-text options were also included to explore additional issues raised by individual clinicians. Use of oxytocin at caesarean section, perceived frequency of side effects, methods of estimating blood loss and the incidence of postpartum haemorrhage (>500 ml) were investigated. Clinicians were asked to describe the dosage used for both oxytocin boluses and infusions. The indications for use of a prophylactic oxytocin infusion were also explored. Side effects, including hypotension, nausea, vomiting, headache, flushing and other serious adverse reactions, were described in terms of frequency of occurrence. Clinicians were asked to estimate the average blood loss at both an elective and an emergency caesarean section. Categorical responses ranging from 0% to 5% up to greater than 20% were included to gather information on the reported incidence of postpartum haemorrhage (defined as >500 ml) at both elective and emergency caesarean section. The questionnaire was piloted on all obstetricians and anaesthetists within a single Scottish maternity hospital and was finalised and distributed following final editing of errors and inconsistencies. From the websites, www.birthchoiceuk.com and www.cuidiu-ict.ie , 237 maternity units were identified across Great Britain and Ireland. Each unit was then telephoned to ascertain or confirm contact details for each lead labour ward consultant obstetrician and anaesthetist. The questionnaire was distributed to all lead labour ward consultant obstetricians and anaesthetists in England, Scotland, Wales, Northern Ireland and the Republic of Ireland. Stamped addressed envelopes were enclosed to assist response. Six weeks after initial contact, a reminder letter and questionnaire were sent to non-responders. Four countries, England, Scotland, Wales and Northern Ireland were surveyed in February 2006. The principal investigator then relocated to Ireland. As Ireland was now to become the site for the multi-centre randomised controlled trial, it was deemed prudent to survey clinicians in this country, and this was done in August 2008. The clinical guidelines had not changed during that time period. 3 Results Of the 474 questionnaires sent, 391 clinicians replied with a response rate of 82%. No clinician indicated that the questionnaire was inapplicable to their practice. Of the 391 responders, 194 (49.6%) were obstetricians and 197 (50.4%) anaesthetists. Results are presented as the proportion of those responding to each question. There were occasional instances where respondents did not answer all of the questions or gave more than one answer, thus accounting for minor variation in denominators between questions. Annual birth rates overall ranged from 200 to 8700 with a median of 3000 (interquartile range (IQR) 1800). Caesarean section rates ranged from 12% to 34% with a median of 23% (IQR 4). Use of a slow bolus of 5 IU intravenous oxytocin after delivery of the infant in keeping with recommended practice was reported by 346 responders overall (85–95% for individual countries), with a slow bolus of 10 IU oxytocin reported by 14% of responders in England and none in Wales ( Table 1 ). The routine use of an oxytocin infusion varied greatly between countries (11–55%), with highest use in Ireland ( Table 1 ). Marked variations in choice of oxytocin regimens were noted. There were 38 different regimens used to administer an oxytocin infusion. Doses of 30 IU or 40 IU over 4 h were reported most frequently, in keeping with the NICE and ALSO recommendations, with additional regimens of 10 IU, 15 IU, 20 IU, 25 IU, 50 IU or 80 IU infusions. Volumes of infusion from 20 ml up to 1 l were reported, with use of a syringe driver for smaller volume infusions. Normal saline was the preferred solution for oxytocin administration. The timescale over which the infusion was given ranged from 1 h to 8 h according to the volume of infusion. The rate at which oxytocin infused varied from 3.33 IU/h to 20 IU/h with 10 IU/h being the mode. Overall, an infusion of 40 IU oxytocin over 4 h was the most popular regimen. The ALSO guidance on infusion protocol was preferred in the Republic of Ireland and the NICE guidance in Northern Ireland with a more divided approach in England, Wales and Scotland. More than half of the clinicians (52.4%) make a global estimate of blood loss (visual estimate) without objective measurement ( Table 2 ). Average estimated blood loss reported for elective caesarean section ranged from 150 ml to 1000 ml (median 500 ml, IQR 100), while for emergency caesarean section the estimated loss ranged from 200 ml to 1500 ml (median 600 ml, IQR 250). There were small differences between the reported approach of obstetricians and anaesthetists within individual countries with the only notable consistency in Wales where neither obstetricians nor anaesthetists ever use a 10 IU bolus oxytocin, in keeping with recommended practice ( Table 3 ). 4 Discussion We achieved a high response rate representing a wide spectrum of obstetricians and anaesthetists throughout Great Britain and Ireland. There did not appear to be any difficulty in completing the questionnaire and there were very few inconsistencies in the responses within questionnaires. The free text responses enhanced the quality of information provided and suggested that this was a subject of particular interest and relevance to the respondents. Although the clinicians in the Republic of Ireland were surveyed more recently we would not expect this to introduce bias as the published guidelines had not been updated during the study time period. Clearly with any survey of this type there is a possibility that the non-responders may hold views that are at strong variance with the study findings. There appears to be general consistency in the use of a bolus dose of oxytocin at caesarean section, with the majority of clinicians preferring to use a slow 5 IU intravenous bolus dose of oxytocin for the prevention of haemorrhage in keeping with existing clinical guidelines. Use of a 10 IU bolus dose is far less popular, most likely reflecting published concerns of a link with such doses and maternal hypotension, arrhythmias and death [12] . In England, however, up to 14% of clinicians use a 10 IU bolus of oxytocin despite recommendations against this, compared to Wales where no clinicians use a 10 IU bolus, and both countries should be implementing NICE guidance. Recent dose-finding studies suggest that very low doses of oxytocin (1–2 IU) may be sufficient to prevent haemorrhage at caesarean section and this further questions the need to use a 10 IU bolus [13,14] . The dose of oxytocin used for infusions varies greatly, with the majority using either 30 IU or 40 IU over 4 h in keeping with the two recommended approaches. Numerous other doses were described, however, using a variety of alternative solutions and alternative time regimens. When benchmarked against the country-specific recommendation, marked variations in choice of oxytocin regimens were noted. An example of this is that only 122 clinicians (40%) in England and Wales use a 30 IU oxytocin infusion over 4 h despite its recommended use by NICE, which covers these two countries. The variation in practice exposes trainees in particular to the potential for drug errors when rotating from centre to centre and responding to major haemorrhage in the emergency setting [15,16] . The majority of clinicians (79% overall) report use of an oxytocin infusion selectively, however. Ireland had the highest rate of routine infusion use (36% Republic of Ireland, 55% Northern Ireland). This may be related to a heightened awareness of the risk of (potentially avoidable) hysterectomy at the time of caesarean delivery due to a high profile hospital enquiry in Ireland [17] . Overall, global estimation is the most widely used method of documenting blood loss (54%). There was marked variation in the individual clinician's perception of average blood loss at caesarean section and rates of postpartum haemorrhage at elective or emergency caesarean section. It is widely accepted that clinicians underestimate blood loss and hence this practice of estimation remains of great concern [18] . Given the importance of recognising and responding to excess blood loss, a defined approach to measuring blood loss (weighing swabs and measuring suction volume, with or without adjustment for liquor volume) should be addressed by future guidelines. 5 Conclusion The evidence that active management of the third stage of labour reduces postpartum haemorrhage has led to clinicians prescribing prophylactic oxytocin routinely at caesarean section. Our survey found that clinicians’ approach to use of oxytocin at the time of caesarean delivery varies between countries and while there is good consensus about the 5 IU bolus dose, both the use and dose of infusion vary greatly, reflecting the limited guidance available at present. Even in countries with on-site visits to ensure guideline implementation (e.g. Clinical Negligence Scheme for Trusts in England), marked deviations from guideline recommendations exist. Some of the variation seen reflects a lack of robust evidence and the need for future research in this area. ECSSIT (Elective Caesarean Section Syntocinon Infusion Trial) is a multi-centre randomised controlled trial which we are currently conducting in the Republic of Ireland. This trial will evaluate the role of an oxytocin infusion on the control of blood loss at caesarean section. It compares a 5 IU oxytocin bolus and placebo infusion with a 5 IU oxytocin bolus and 40 IU oxytocin infusion [19] . We hope to address some of the uncertainty that surrounds the prevention of postpartum haemorrhage at caesarean section described within the current study and to see this implemented within future clinical guidelines. Acknowledgements This survey was part-funded by a grant from Tenovus Scotland . We are grateful to the clinicians who participated in this survey. References [1] J.A. Martin B.E. Hamilton S.J. Ventura F. Mnacker M.M. Park P.D. 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