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After several hours of mild, irregular contractions, the midwife, patient, and support person discussed options and jointly decided to begin an oxytocin infusion to help strengthen the labor pattern.Oxytocin was initiated according to policy.Shortly after oxytocin was initiated at 2 ml/hr, the iv pump alarmed for "air in line." the nurse clamped the iv tubing at the saline lock extension and used a syringe to remove the air.At 22:21, the nurse observed that the oxytocin was inadvertently infusing by gravity, resulting in an unintended bolus.The clamp had not fully occluded the line.Oxytocin was immediately disconnected.At 22:23, the patient experienced a tetanic contraction accompanied by a prolonged fetal heart rate deceleration.The nurse promptly called for additional assistance and notified the cnm [certified nurse midwife].Intrauterine resuscitation measures-including iv fluid bolus, maternal repositioning, and administration of terbutaline-were initiated immediately.The obstetrician arrived at 22:28.Cervical examination revealed 5 cm dilation.As the patient was remote from delivery, the team proceeded to the operating room for a stat cesarean section.At 22:35 in the operating room, the fetal heart rate was reassessed and found to be 160 bpm, and the uterus was soft on palpation.Given the reassuring findings, the team continued fetal monitoring in the operating room.After 20 minutes of stable monitoring, the patient and family returned to the labor room to continue laboring.The serious harm was escalation of care to the operating room and administration of terbutaline.The error was the clamp was not occluded.Rn believed she had clamped the line.On further inspection, the clamp appeared functional, but it did take extra force to "click" the clamp closed.This was a new product for the unit.Previous item did not have this clamp.The absence of the clamp would force the user to remove the line from the patient to reprime the line.
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