Oxytocin Use During Labour: An Analysis of Canadian Medico-legal Obstetrical Case Files (2020–2024)
Oxytocin Use During Labour: An Analysis of Canadian Medico-legal Obstetrical Case Files (2020–2024)
Abstract
Objectives: We used Canadian medico-legal case data to examine patterns of oxytocin use in labour induction and augmentation and explore factors associated with adverse maternal and neonatal outcomes.
Methods: We conducted a qualitative descriptive study with thematic analysis of Canadian medico-legal cases closed between 2020 and 2024. We identified 43 obstetric cases involving an oxytocic agent and peer expert criticism specifically related to oxytocin management. Two reviewers independently analysed de-identified case summaries and expert reports; the findings were refined through multidisciplinary discussion.
Results: Peer criticism clustered around 4 recurring patterns of oxytocin misuse: failure to reduce or discontinue oxytocin in the presence of atypical or abnormal fetal heart rate or uterine tachysystole, initiation despite clear contraindications, unsafe restart after fetal heart rate decelerations, and unjustified dose escalation. Peer experts criticized insufficient maternal and fetal monitoring across all cases. Three intersecting themes (health care provider issues, communication breakdowns, and system limitations) often co-occurred. Overall, 70% of cases involved low-risk pregnancies, and maternal morbidity occurred in 16% of cases. Severe adverse neonatal outcomes occurred in 93% of cases and were commonly attributed by causation experts to prolonged intrapartum hypoxia exacerbated by oxytocin misuse.
Conclusions: Medico-legal events involving oxytocin in Canada reveal recurring patterns of potentially preventable oxytocin misuse embedded in cumulative breakdowns across the labour care environment rather than isolated errors. These findings support interventions such as robust oxytocin protocols, enhanced situational awareness, improved fetal surveillance skills, and reliable communication and escalation pathways to promote safe oxytocin use during labour.
Reference
El Sherif R, Barbosa K, Bentz JA, Darling R, Ji J, Garber G, Dy J. Oxytocin Use During Labour: An Analysis of Canadian Medico-legal Obstetrical Case Files (2020–2024). Journal of Obstetrics and Gynaecology Canada, 2026; 48. https://www.jogc.com/article/S1701-2163(26)00301-4/fulltext
