National Patient Safety Alert – risk of oxytocin overdose during labour and childbirth

This National Patient Safety Alert has been issued by the NHS England National Patient Safety team, endorsed by the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives and Royal College of Anaesthetists, instructing all relevant NHS funded maternity care providers to cease pre-preparing oxytocin infusions at ward level in all clinical areas.

All actions should be completed by 31 March 2025.

About this alert

Oxytocin is one of the most commonly utilised drugs in labour and childbirth. An oxytocin infusion can be administered to augment contractions during labour or in a much higher dose to treat postpartum haemorrhage. The inadvertent administration of a postnatal dose of oxytocin prior to the birth of the baby can lead to significant harm to mother and baby.

To reduce the risk of harm and inadvertent administration, NHS trusts should no longer pre-prepare oxytocin infusions at ward level, that will be administered either via infusion pumps or syringe pumps, in anticipation of its use.

To minimise any theoretical risks of delayed treatment of postpartum haemorrhage, the immediate availability of trolleys/kits is advised. Local guidelines/policies should be updated accordingly.

This National Patient Safety Alert instructs all relevant NHS funded organisations providing maternity care to cease pre-preparing oxytocin infusions at ward level in all clinical areas. All actions should be completed by 31 March 2025.

About National Patient Safety Alerts

This alert has been issued as a National Patient Safety Alert.

The NHS England National Patient Safety Team was the first national body to be accredited to issue National Patient Safety Alerts by the National Patient Safety Alerting Committee (NaPSAC). All National Patient Safety Alerts are required to meet NaPSAC’s thresholds and standards. These thresholds and standards include working with patients, frontline staff and experts to ensure alerts provide clear, effective actions for safety-critical issues.

NaPSAC requires providers to introduce new systems for planning and coordinating the actions required by any National Patient Safety Alert across their organisation, with executive oversight.

Failure to take the actions required under any National Patient Safety Alert may lead to CQC taking regulatory action. Patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).