Abstract

Background: Oxytocin is one of the most common drugs administered in obstetrics. Since its designation as
a high-alert medication by the Institute for Safe Medication Practices in 2007, there has been much attention to
oxytocin administration during labor. Oxytocin is generally safe when administered correctly, but adverse perinatal
outcomes can occur during uterine tachysystole.
Purpose: The purpose of this project was to evaluate and compare results of maternal and fetal outcomes of
induction of labor for women at term prior to and after implementation of a newly developed oxytocin checklist.
Project Design and Methods: To evaluate the practice change associated with the implementation of the
new oxytocin checklist, 200 cases based on retrospective medical record reviews were compared with 200 cases
after implementation.
Results: Use of the checklist was associated with several significant clinical outcomes, including decreases in
tachysystole, decreases in cesarean births for concern about fetal status based on electronic fetal monitoring data,
Downloaded from https://journals.lww.com/mcnjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD38k+bDukTnmYBRphaf6yoiyNY068aJMc9u+YOYCHDe14= on 05/05/2018

decreases in length of first stage labor, and decreases in maximum dose of oxytocin.
Clinical Implications: Results are similar to previous research. Early physician buy-in, clinical team educa-
tion, and ongoing evaluation enhanced facilitation of the oxytocin checklist. Clinical outcomes were favorable.
Key words: Fetal heart rate; Labor induction; Oxytocic effect; Oxytocin.

Implementation of an
OXYTOCIN
CHECKLIST
to Improve Clinical Outcomes
Courtney Sundin, MSN, RNC-OB, C-EFM, Lauren Mazac, BSN, RNC-OB,
Kathleen Ellis, PhD, RN, and Candon Garbo, MSN, RN

Shutterstock

May/June 2018 MCN 133

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

 xytocin, the naturally occurring hormone
ated with negative effects on both mother and fetus.

O and Pitocin, the synthetic version stimu-

Risks include uterine tachysystole, uterine rupture, fetal
late and strengthen uterine contractions
acidemia, and fetal hypoxemia (Bakker, Kurver, Kuik, &
and manage excessive bleeding after birth
Van Geijn, 2007; Gilstrop & Sciscione, 2015; Simpson,
(Sakala, Romano, & Buckley, 2016). Al-
2011; Simpson & James, 2008). Intravenous oxytocin is
though oxytocin and Pitocin have a similar mechanism,
listed as a high-alert medication due to its risk of causing
the difference in endogenous and exogenous delivery of
significant harm to patients when used inappropriately
the hormone can create difficulty in labor management.
(Institute for Safe Medication Practices, 2014; Simpson
Endogenous oxytocin is produced naturally by the hypo-
& Knox, 2009).
thalamus and is secreted by the posterior pituitary gland.
Uterine tachysystole (an average of more than five
Oxytocin receptor cells provide continual feedback to the
contractions in 10 minutes during a 30-minute period) is
pituitary gland (Simpson, 2011). The woman’s body is
associated with rapid increases in IV oxytocin adminis-
able to monitor its own needs through this feedback sys-
tration (more frequent than every 30–40 minutes) and
tem in order to release additional oxytocin when needed
higher levels of oxytocin (Simpson, 2011). Adequate fetal
(Arrowsmith & Wray, 2014). Exogenous oxytocin (Pito-
oxygenation relies on multiple factors, including ade-
cin) is helpful in inducing and augmenting labor. When
quate maternal–fetal oxygen exchange at the intervillous
working together, endogenous and exogenous oxytocin
space in the placenta. During a contraction, blood flow to
increase uterine contractions (Simpson, 2011). The body’s
the fetus is temporarily restricted. This is not completely
feedback loop, however, is only effective on endogenous
restored until approximately 2 minutes postcontraction
sources of oxytocin, allowing for the possibility of over-
(Simpson & Miller, 2011). Most fetuses have adequate
administration. reserves to withstand these periods, but prolonged and/or
The most recent data indicate labor was induced in
too frequent contractions increase the risk of fetal hypox-
23.8% of all births in the United States in 2015 (Martin,
emia and acidemia (Simpson, 2011). Complications from
Hamilton, Osterman, Driscoll, & Mathews, 2017).
tachysystole and subsequent effects on the fetus may also
This rate has shown a steady increase since 1990, in
lead to litigation (Smith, Zacharias, Lucas, Warrick, &
which induction of labor accounted for 9.6% of all births
Hamilton, 2014).
(Osterman & Martin, 2014). With increasing use, it is
One helpful approach is use of a systematic method for
vital to weigh advantages of using oxytocin with the
assessment, intervention, and continuous monitoring
disadvantages. of women undergoing labor induction or augmentation.
Use of intravenous (IV) oxytocin has been associated
Use of checklists, adapted from processes in the aviation
with decreased cesarean birth rate (Kenyon, Tokumasu,
industry, has been gaining popularity within healthcare.
Dowswell, Pledge, & Mori, 2013; Wei et al., 2013) and
Checklists provide a method to standardize care, improve
decreased labor duration at higher doses (Kenyon et al.).
communication, and incorporate evidence-based practice
However, administration of excessive oxytocin is associ-
(Arora et al., 2016). However, it is important to note
that checklists must be incorporated
with education and culture changes
Minimizing risks of oxytocin starts with a thorough to be successful (Clay-Williams &
understanding of safe administration and Colligan, 2015).
Current evidence suggests there
management of the drug. may be effects of use of an oxytocin
administration checklist (Clark et al.,
2007). One retrospective study dem-
onstrated a general improvement in
outcomes for both mothers and
infants. Specific findings included
significant decreases in length of stay,
meconium presence, episiotomies,
maternal fever, low Apgar scores
(<7 at 5 minutes), and operative
vaginal birth (Wojnar, Cowgill,
Hoffman, & Carlson, 2014). Rohn,
Bastek, Sammel, Wang, and Srinivas
(2015) used a retrospective cohort
design to evaluate use of a low-dose
oxytocin checklist. Although the
lower dose approach was sought to
avoid the risks of higher doses of
oxytocin, the researchers discovered
that women on the low-dose protocol

134 volume 43 | number 3 May/June 2018

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FIGURE 1: In-Use Checklist
Oxytocin “In Use” Checklist
Recommended Oxytocin “In Use” Checklist for women
with Term Singleton Babies
Checklist to be evaluated every 30 min during Pitocin
use. Pitocin should be maintained, decreased or
stopped if the following criteria are not met:
Fetal Assessment
At least one acceleration of 15x15 bpm in 30 min, or
moderate variability for 10 of the previous 30 min
No more than one late deceleration occured
No more than two variable decelerations exceeding
60 sec in duration and decreasing greater than 60
bpm from baseline within the previous 30 min
Uterine contractions
No more than 5 contractions in 10 min for any 20
min interval
No two contractions greater than 120 sec duration
Uterus palpates soft in between contractions.
If IUPC in place, MVUs must calculate less than 300
mmHg and baseline resting tone less than 25 mmHg
Adapted in part from Clark et al. (2007).
had significant increases in time to birth from admission
and higher rates of chorioamnionitis. Effect on cesarean
birth rate was mixed, as women were more likely to have
surgical birth for labor dystocia, but less likely to have
one for fetal heart rate (FHR) abnormities requiring in-
trauterine resuscitation (Rohn et al., 2015).
The purpose of this study was to evaluate and com-
pare the results of maternal and fetal outcomes of women
who had inductions of labor at term prior to and after
implementation of the oxytocin checklist.
Methods
This quality improvement project was implemented in an
urban, nonprofit, private hospital with an average of
6,000 births per year, including 150 to 200 inductions per
month. In-use safety checklists for oxytocin administra-
tion were not standard at this hospital. A literature review
of current evidence-based practice was conducted and a
quality group (QG) was formed consisting of three labor
and delivery (L&D) staff nurses to draft an in-use oxyto-
cin checklist. The oxytocin checklist that was developed
was based on the work of Clark et al. (2007). Following
unit manager approval, the draft and supporting literature
were presented to the Chief Obstetrician (COB). Ethical
concerns were discussed with the COB and it was deter-
mined that no harm, violation of privacy, or conflicts
would occur during implementation of checklist. After ap-
proval from the COB, the checklist was presented to the
May/June 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Medical Executive and the Quality Improvement Com-
mittees, which were formed of obstetricians representing
different physician groups. Once both committees ap-
proved the checklist, it was then presented to all physi-
cians during quarterly Grand Rounds by the COB and
Women’s Services Director. A timeline was adapted to in-
clude education of all L&D nurses along with the imple-
mentation start date. Nurse education included oxytocin
facts and mechanism of action, common errors when in-
fusing oxytocin, and other oxytocin-related study out-
comes from the literature review. Explanation of the in-
use checklist for induction and augmentation of labor was
discussed as well as appropriate documentation during
checklist use.
It was recommended that L&D nurse would use the
oxytocin checklist during labor inductions of women
with singleton, vertex, and term pregnancies. Fetal heart
rate and uterine assessments would occur every 15 min-
utes while evaluating the need to increase oxytocin every
30 minutes, according to Association of Women’s Health,
Obstetric and Neonatal Nurses (2015) guidelines. After
ascertaining that all required parameters were met, docu-
mentation was to include “criteria met,” when initiating
or increasing oxytocin. If the checklist criteria could not
be met due to FHR abnormalities and/or contraction pat-
tern, the oxytocin should be decreased or stopped. The
checklist specifically stated that it was only a guideline;
the physician was to direct individualized medical care.
For accessibility as a reference, the oxytocin checklist
was placed in all L&D rooms, at each nurses’ station,
and in each of the patients’ medical record (Figure 1).
A study examining 100 patient’s outcomes prior to im-
plementation and after use of an oxytocin checklist was ref-
erenced during the literature review phase of this QI project
(Clark et al., 2007). It was determined that medical record
reviews of 200 inductions would be sufficient to illustrate
differences between the two methods. Prior to implementa-
tion of the checklist, 200 retrospective chart reviews were
conducted of inductions meeting criterion. Data collected
included the following demographics: maternal age, parity,
gestational age, and Bishop score. Birth type, Apgar scores
and cord gas values, if applicable were recorded. Maximum
dosage of oxytocin, total oxytocin infusion time, and
whether or not the oxytocin was discontinued and/or re-
duced at any point of the labor process were also document-
ed. Complications during labor and/or birth: tachysystole,
postpartum hemorrhage, shoulder dystocia, chorioamnion-
itis, and FHR abnormalities requiring intrauterine resuscita-
tion were assessed. Length of first, second, and third stages
of labor was calculated from labor curves. Following initia-
tion of the oxytocin checklist, 200 additional cases were
compared with collected retrospective medical record data.
For continuity, only the three QG nurses conducted the
medical record audits. Medical record auditors were aware
of checklist use by reviewing documentation of “criteria
met” when oxytocin was started or increased by the nurse.
After 2 weeks, qualitative data, including physician feed-
back, as well as polling of staff nurses on ease of checklist
use and recommendations to adjust implementation were
MCN 135
TABLE 1. Results obtained. Quantitative data collec-
Pre Post tion included medical record re-
Checklist Checklist T-test, df Significance views from inductions to determine
nurses’ adherence to documenta-
Demographics
tion of “criteria met.”
Maternal age 27.9 27.37 t = .88, df = 398 p = 0.38 To ensure accuracy of the medi-
Parity 2.255 1.325 t = 6.75, df = 398 p < 0.001 cal record reviews, a worksheet
was created to guide the auditor.
Gestational age 39.5 39.4 t = 1.05, df = 397 p = 0.29
For inclusion purposes, if docu-
Weight in grams 3402.42 3401.55 t = .02, df = 398 p = 0.98 mentation of “criteria met” was
Bishop score 5.21 5.59 t = -1.82, df = 397 p = 0.07 not present or if gestational age
was less than 37 weeks, data from
Cervical ripening 57 (28.5%) 49 (24.5%) t = .96, df = 398 p = 0.37
these cases were not included in
Oxytocin Outcomes the sample. All appropriate data
Total oxytocin time (hr) 10:43:23 10:22:38 t = 5.84, df = 280 p < 0.001 collected were entered into a
spreadsheet for comparison of pre-
Maximum dose of 14.28 10.92 t = 4.99, df = 387 p < 0.001 and post-data. If extraneous com-
oxytocin (mU/min)
plications were present, these com-
Oxytocin stopped 54 (27%) 14 (7%) t = 5.32, df = 398 p < 0.001 plications were noted to determine
Oxytocin reduced 72 (36%) 40 (2%) t = 8.67, df = 398 p < 0.001

Monitoring Assessment
Oxytocin
O
Variable decelerations 56 (28%) 48 (24%) t = .912, df = 398 p = 0.36
Late decelerations 25 (12.5%) 14 (7%) t = 1.85, df = 398 p = 0.64
cch
checklists
Decreased variability 4 (2%) 1 (0.5%) t = 1.35, df = 398 p = 0.18
m
may provide
Extended tachycardia 1 (0.5%) 2 (1%) t = .58, df = 398 p = 0.56 iincreased patient
Tachysystole 19 (9.5%) 7 (3.5%) t = 2.43, df = 398 p = 0.02 safety and lead to
Labor Outcomes improvement of
1st stage labor (hr) 5:11:17 4:15:51 t = 2.73, df = 277 p = 0.007 maternal and fetal
2nd stage labor (hr) 3:26:43 3:04:02 t = 1.5, df = 318 p = 0.13 well-being.
3rd stage labor (min) 1:58:57 1:55:48 t = .36, df = 318 p = 0.72
if there was any other significant
Birth Outcomes
correlation. For statistical analysis,
Cesarean for labor 13 (6.5%) 17 (8.5%) t = .76, df = 398 p = 0.45 a multivariate approach was used.
arrest Prior to checklist implementa-
Cesarean for fetal 40 (20%) 11 (5.5%) t = 4.35, df = 398 p < 0.001 tion, mandatory nurse education
status was conducted on the L&D unit
Cesarean birth total 53 (26.5%) 28 (14%) t = 3, df = 398 p = 0.003 in small groups of nurses using a
slide presentation. Pre- and post-
Vacuum assisted 4 (2%) 2 (1%) t = .823, df = 398 p = 0.41 testing was completed to ensure
Forceps assisted 1 (0.5%) 2 (1%) t = .58, df = 398 p = 0.56 nurses’ understanding of material
presented. An email was sent to all
Infant Outcomes
nurses on the first day of imple-
NICU admission 9 (4.5%) 2 (1%) t = 2.14, df = 398 p = 0.33 mentation reminding nurses to
NICU assessment 2 (1%) 0 (0%) t = 1.42, df = 398 p = 0.16 follow project guidelines. Fre-
quent and ongoing medical record
Apgar 1 min 8.475 8.325 t = 1.52, df = 397 p = 0.13
reviews were conducted by the
Apgar 5 min 8.93 8.98 t = -1.2, df = 294 p = 0.23 project nurses during implementa-
Ph <7.10 3/26 (11.5%) 2/34 (5.8%) t = .79, df = 58 p = 0.43 tion for adherence to documenta-
tion of “criteria met.” Additional
Complications email reminders were sent to nurs-
Postpartum 6 (3%) 3 (1.5%) t = 1.01, df = 398 p = 0.31 es following a meeting with the
hemorrhage COB 2 weeks after project initia-
Shoulder dystocia 2 (1%) 2 (1%) t = 0, df = 398 p=1 tion that consisted of accurately
documenting cervical exams to
Chorioamnionitis 8 (4%) 7 (3.5%) t = .26, df = 398 p = 0.79
calculate starting Bishop scores,

136 volume 43 | number 3 May/June 2018

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Shutterstock
documenting “criteria met” when oxytocin was increased,
and reminding them that the attending obstetrician directs
individual care. Flyers and pocket-sized cards were posted
and handed out to nurses as a resource.
Results
There was a significant decrease in the cesarean birth rate
(p = 0.003). See Table 1. Cesarean births for FHR abnor-
malities requiring intrauterine resuscitation declined from
40 (20%) to 11 (5.5%) (p < 0.001). Tachysystole was
significantly reduced by 63% in the postchecklist group
(p = 0.02). Significant decreases in other oxytocin out-
come metrics included: decreased total oxytocin time in
hours (p < 0.001); decreased maximum oxytocin dose in
milliunits per minute (mU/min) (p < 0.001), reduction in
the number of times oxytocin was discontinued
(p < 0.001), and in the number of times oxytocin was
decreased (p < 0.001).
Although the total length of labor was not signifi-
cantly decreased, average first stage of labor was de-
creased by approximately 56 minutes (p = 0.007). Fol-
lowing the checklist implementation, it was determined
that the maximum dose of oxytocin was reduced by
24% with the average of all maximum doses reaching
10.9 mU/min. There were no differences between groups
for chorioamnionitis.
A survey of nurses was conducted 1 month postim-
plementation to determine the “ease of use” and “help-
fulness” of the checklists. The survey revealed positive
results with 98% of nurses agreeing the checklists were
helpful and 92% indicating satisfaction with the ease of
use. Comments such as this has been a very helpful
guideline and I’m so glad we have this now were in-
cluded with the survey.
May/June 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Suggested Clinical Implications
• Integrating an oxytocin checklist can improve outcomes
and decrease complications of labor.
• Early physician buy-in and communication between the
multidisciplinary team can assist in facilitation of quality
improvement projects.
• Education, ongoing evaluation, and diverse reminders
can assist nurses with the transition into new procedures.
• Education on the pharmacological background of
oxytocin ensures optimal understanding on titration of
the medication.
There were approximately 22 cases that could not be
included in post implementation data due to lack of docu-
mentation of “criteria met” when oxytocin was increased.
Lack of consistency in documentation was associated
with the number of nurses who cared for the women dur-
ing the induction period.
Elements of Success
Several elements were found to be key to implementa-
tion success: early COB buy-in, previous successes docu-
mented in literature, and adequate time for L&D nurse
education and discussion. Results of this project are
consistent with previous research (Clark et al., 2007;
Rohn et al., 2015; Wojnar et al., 2014), showing im-
proved outcomes when a standardized in-use oxytocin
checklist was used for women at term having an induc-
tion of labor. With this knowledge, the nurses were able
to successfully implement the checklist, using it as a
guide throughout the induction process. Nurses felt the
MCN 137
 The
Th improved outcomes
of this project affirm the
o reserved.
g
growing body of literature
ti use of standardized in-
supporting
use oxytocin checklists to safely and
effectively administer oxytocin for
term, pregnant women undergoing
labor induction.
checklist brought a much-needed uniform approach to
the induction process, alleviating any guesswork en-
countered by the L&D nurse even with varying degrees
of nursing experience.
Limitations: Several limitations were noted during the
implementation of the project. Lack of adherence to doc-
umentation requirements was due to nurses misunder-
standing need to note “criteria met” with each initiation
and increase in oxytocin. Following reminder emails
about documenting correctly, nurses who continued to
lack adequate documentation were given one-on-one ed-
ucation of expectations of charting. In one specific case,
there was frustration over use of the checklist between
the physician and the nurse. The physician expressed the
need to increase the oxytocin due to the clinical situation,
whereas the nurse did not feel that an increase met the
checklist criteria. The charge nurse reviewed the FHR
tracing and collaboratively decided that an increase was
appropriate. Education was reiterated to physician and
nurses that the physician still dictates the care of the
women; however, if the safety of the fetus is in question,
chain of command should be initiated.
Our findings affirm the growing body of literature sup-
porting use of standardized in-use oxytocin checklists to
safely and effectively administer oxytocin for term, preg-
nant women undergoing inductions. Because of the signifi-
cant clinical impact of maternal infection/chorioamnionitis,
future work should investigate the impact of oxytocin
checklists in preventing this complication. We recommend
that oxytocin checklists be implemented universally during
induction and augmentation of labor with oxytocin for
maternal–fetal safety. ✜
Courtney Sundin is a Clinical Nursing Supervisor, Baylor
Scott & White All Saints Medical Center, Fort Worth,
TX. The author can be reached via e-mail at Courtney.
Sundin@bswhealth.org
Lauren Mazac is a Clinical Nursing Supervisor, Baylor
Scott & White All Saints Medical Center, Fort Worth, TX.
Kathleen Ellis is a Nurse Scientist, Baylor Scott &
White All Saints Medical Center, Fort Worth, TX.
Candon Garbo is an Instructor of Nursing, Univer-
sity of Mississippi Medical Center, School of Nursing,
Jackson, MS.
The authors declare no conflicts of interest.
138 volume 43 | number 3
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights
DOI:10.1097/NMC.0000000000000428
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