ObjectiveTo determine whether intravenous oxytocin is more effective than intramuscular oxytocin at preventing postpartum haemorrhage at vaginal delivery.DesignDouble blind placebo controlled randomised trial.SettingUniversity affiliated maternity unit in the Republic of Ireland.Participants1075 women aged 18 years or older, at term with a singleton pregnancy who were aiming for a vaginal delivery with an actively managed third stage of labour.InterventionsWomen were allocated to an intravenous bolus of oxytocin (10 IU in 1 mL given slowly over one minute) and placebo intramuscular injection (1 mL 0.9% saline) or an intramuscular bolus of oxytocin (10 IU in 1 mL) and placebo intravenous injection (1 mL 0.9% saline given slowly over one minute) at vaginal delivery. Allocation was by a secure web based randomisation service with masking of participants and clinicians to the trial intervention.Main outcome measuresThe primary outcome was postpartum haemorrhage (PPH, measured blood loss ≥500 mL). Secondary outcomes were severe PPH (measured blood loss ≥1000 mL), need for blood transfusion, admission to a high dependency unit, and side effects to oxytocin.ResultsBetween 4 January 2016 and 13 December 2017, 1075 women were randomised and 1035 (96.3%) included in the primary and secondary analyses (517 in the intravenous oxytocin group and 518 in the intramuscular oxytocin group). The incidence of PPH was not significantly lower in the intravenous group (18.8%, 97/517) compared with intramuscular group (23.2%, 120/518): adjusted odds ratio 0.75 (95% confidence interval 0.55 to 1.03). The incidence of severe PPH, however, was significantly lower in the intravenous group (4.6%, 24/517) compared with intramuscular group (8.1%, 42/518): 0.54 (0.32 to 0.91) as was the need for blood transfusion (1.5% v 4.4%, 0.31, 0.13 to 0.70) and admission to a high dependency unit (1.7% v 3.7%, 0.44, 0.20 to 0.98). The number needed to treat to prevent one case of severe PPH was 29 (95% confidence interval 16 to 201) and to prevent one case of blood transfusion was 35 (20 to 121). The incidence of side effects to oxytocin was not increased in the intravenous group compared with intramuscular group (4.1% v 5.2%, 0.75, 0.42 to 1.35).ConclusionIntravenous oxytocin for the third stage of labour results in less frequent severe PPH, blood transfusion, and admission to a high dependency unit than intramuscular oxytocin, and without excess side effects.Trial registrationCurrent Controlled Trials ISRCTN14718882.

Involuntary psychiatric admission or ‘sectioning’ is a serious event with clear implications for the right to liberty, among other rights. Rates of involuntary admission vary considerably across jurisdictions. The rate of involuntary admission in England is approximately double that in the Republic of Ireland. Why? This paper examines potential explanations for this difference, including the prevalence of mental disorder in the two jurisdictions, factors relating to mental health legislation, differing levels of police involvement in care-pathways, funding and resources, and attitudes to risk among the public and professionals. Overall, it appears that the relatively high rate of involuntary admission in England might be attributable to the role of perceived risk in shaping mental health law in England but not Ireland, the broader definition of ‘mental disorder’ in the Mental Health Act, 1983 in England, broader legal criteria for involuntary admission in the 1983 Act, differences in the operational definitions of ‘voluntary patient’ between the two jurisdictions and, possibly, increased involvement of police in pathways to care in England and differences in relation to different ethnic groups. The relatively higher number of inpatient beds in England could be a cause or a consequence of higher rates of involuntary admission. Future research could usefully focus on other factors that are also likely relevant: issues relating to social care, substance misuse, availability of alternative treatment options in the community and various other factors that are, as yet, unknown. The potential impact of risk aversion among mental health professionals and others merits particular attention.

(BMJ. 2018;362:k3546) Postpartum hemorrhage (PPH) is a leading cause of maternal mortality and has been increasing over the last 15 years in many developed countries. While uterotonic drugs such as oxytocin have been established as useful tools in preventing PPH, the best administration method remains unclear. When given intramuscularly, a uterotonic effect will be obtained in 3 to 7 minutes, with the effect lasting 30 to 60 minutes. Intravenous oxytocin has an effect almost immediately and the plateau concentration is reached at 30 minutes. However, intravenous administration has been associated with hypotension and tachycardia. At these investigators’ medical center, the practice of administering oxytocin 10 international units (IU) intravenously after delivery was changed in 2010 to intramuscular oxytocin, following Royal College of Obstetricians and Gynaecologists guidelines. This randomized, controlled trial, the Labour Oxytocin Route (LabOR) was prompted by concerns from midwives and obstetricians at the study center regarding a perceived rise in PPH after this change in practice was adopted. The LabOR trial aimed to determine whether intravenous oxytocin 10 IU was more effective than intramuscular oxytocin 10 IU at preventing PPH after vaginal delivery.

AimsThe Mental Heath Commission (MHC) is an independent body in Ireland, set up in 2002, to promote, encourage and foster high standards and good practices in the delivery of mental health services and to protect the interests of patients who are involuntarily admitted. Guidelines on the rules governing the use of seclusion are published by the MHC. These guidelines must be followed and recorded in the patient's clinical file during each seclusion episode. A Seclusion Integrated Care Pathway (ICP) was devised in 2012 for use in the Approved Centre in Tallaght University Hospital. This ICP was developed in conjunction with the MHC guidelines to assist in the recording and monitoring of each seclusion episode. Since its introduction in 2012, this ICP has become an established tool used in the Approved Centre in Tallaght University Hospital.The aim of this audit was to assess adherence to MHC guidelines on the use of seclusion in the Approved Centre in Tallaght University Hospital 8 years after the introduction of an ICP and compare it to adherence prior to its introduction and immediately after its introduction.MethodThirteen rules governing the use of seclusion have been published by the MHC. These include the responsibility of registered medical practitioners (RMP), nursing staff and the levels of observations and frequency of reviews that must take place during each seclusion episode. Using the seclusion register we identified a total of 50 seclusion episodes between August 2019 and July 2020. A retrospective chart review was conducted to assess documentation of each seclusion episode.ResultThere was an overall improvement in adherence with MHC guidelines compared to adherence prior to the introduction of the ICP and immediately after its introduction. Areas of improvement included medical reviews, nursing reviews, informing patient of reasons for, likely duration of and circumstances that could end seclusion, and informing next of kin. The range of compliance levels across the thirteen MHC guidelines improved from 3–100% to 69–100%. Post intervention there was 100% compliance with five of the thirteen guidelines.ConclusionThe introduction of an ICP led to an overall improvement in compliance with MHC guidelines. The ICP has ensured that many of the rules governing seclusion are explicitly stated; however adjustments and revisions to the document and ongoing staff training are needed to ensure full adherence to MHC guidelines.