Implementation Strategies to Improve the Availability and Prophylactic Use of Oxytocin by Emergency Medical Services (EMS) providers for Pre-Hospital Births

Postpartum hemorrhage (PPH) is a life-threatening condition accounting for 12% of all maternal deaths in the US. The World Health Organization and all American medical associations and colleges recommend that a uterotonic (e.g. oxytocin) be administered during the third stage of labor to prevent PPH, especially in low-resources setting with limited access to advanced care and medications. Utah EMS does not use oxytocin to prevent PPH and some agencies do not even carry oxytocin. Data from the Bureau of Emergency Medical Services and Preparedness show that oxytocin was used in less than 2% of all births attended by EMS. This project is the first step in implementing Active Management of the Third Stage of Labor (AMTSL) for pre-hospital births performed by EMS in Utah by identifying the barriers and facilitators to AMTLS.

This project has 4 objectives: 1) determine provider knowledge, attitudes, and practice around the use of oxytocin for AMTSL; 2) identify agency and medical director(s) willingness and hindrance to update the protocol; 3) conduct a landscape analysis on the scope of practice of providers and use of oxytocin across all levels; and 4) create a templated protocol for the prophylactic administration of oxytocin in Utah.

We will conduct a survey on the availability, education, safety and willingness to use oxytocin; conduct key stakeholder in-depth interviews; and conduct focus groups with stakeholders using participatory design principles to co-create a templated final AMTSL protocol. At the completion of the project, we will present the landscape analysis and templated protocol to the Utah EMS authority for consideration of adoption, and apply for NIH funds for an implementation science study that evaluates how various forms of training, including simulation, impact the adoption of AMTSL.

Current Status

2025-01-31
The objective of this project was to: 1) update the obstetric hemorrhage guideline for prehospital births statewide to include approval of prophylactic oxytocin administration; and 2) use implementation strategies to promote its adoption and increase its usage with fidelity. We engaged with statewide partners through focus groups and presented recommendations based on those groups to decision makers. In 2024 the Utah BEMS Guideline Protocol was successfully updated to include the use of prophylactic oxytocin in all pre-hospital births attended by paramedics or AEMTS. The administration of medications is a regular part of the paramedic and AEMT scope of practice and use of prophylactic oxytocin by paramedics and AEMTS is safe and effective in the prevention of postpartum hemorrhage. A survey of hospital providers demonstrated clear support for the administration of oxytocin medication by prehospital providers, further adding to the support of this protocol change. This project is on-going, including the roll-out of an educational bundle in Spring 2025 to promote adoption of this practice by rural Utah EMS agencies. Future efforts may include implementation strategies with rural clinicians that use educational bundles and simulation to increase usage rates with fidelity and clinician self-efficacy.