1 For the purposes of this paper, oxytocin’s “counter-protocol” use or “misuse” refers to administration that runs counter to established protocols, such as those cases for which the drug is clinically contraindicated and/or its administration occurs without necessary specialist supervision.

2 Nurses provided emergency labor and delivery support to LHVs, but did not ordinarily contribute to childbirth services.

3 It should be noted that my work neither seeks nor claims to empirically confirm oxytocin as the sole cause of particular health outcomes. The practices and cases detailed by my paper confirm the complex mechanics and co-morbidities contributing to iatrogenic injury and loss, as well as the impossibility of retrospectively disentangling cause from effect, especially when several drugs and interventions were used in combination, were incompletely documented by medical reporting, and preexisting risks or conditions were present.

4 The active management of the third stage of labour (AMTSL) entails oxytocin administration within a minute of birth, combined with controlled cord traction and the extraction of the placenta, and uterine massage (WHO 2006).

5 According to the FIGO Safe Motherhood and Newborn Health Committee, the three stages of labour are characterized as follows: “First stage: from the onset of regular painful contractions associated with descent of the presenting part and progressive dilatation of the cervix until the cervix is fully dilated. Second stage: from full dilatation of the cervix up to the birth of the singleton baby or the last baby in a multiple pregnancy. At the start of the second stage, the fetal presenting part may or may not be fully engaged (meaning that the widest diameter has passed through the pelvic brim), and the woman may or may not have the urge to push. Third stage: from the birth of the baby until expulsion of the placenta and membranes” (FIGO SMNHC 2012: 111).

6 For induction cases, oxytocin was routinely administered in conjunction with misoprostol, a prostaglandin intended to ripen the cervix and aid in its dilation, and start contractions.

7 In January 2011, 9.7 % (38) of 391 deliveries were stillbirths.

8 Gilgit-Baltistan’s public health sector is “managed by the District Health Officer (DHO) who is assisted by deputy district health officers [and the] district coordinator/Public Health Specialist of [vertical] national programmes” (TRF and GoP 2012b: 6), such as the Maternal Newborn and Child Health (MNCH) and National Tuberculosis (TB) Control Programmes.

9 Because of the infrequency of their attendance at the Labour Room, LMOs were not popularly understood by patients to provide obstetric care, nor were they especially trusted to do so. Even despite the proliferative risks popularly associated with Labour Room services, many patients preferred LHVs to senior medical personnel. Several women narrated how LHVs’ treatment—sometimes for dauntingly complex cases that patients had been forewarned would require specialist intervention—had saved them from what they felt were surgery’s comparatively greater dangers.

10 No matter LHVs’ stated concerns about physician supervision and the curtailing or disciplining of their practices, the majority of LMOs claimed to be unaware of the full extent of oxytocin use for childbirth cases. Their uncertainty concerning the drug’s use was made possible by the stark professional divides separating different ranks and cadres of medical personnel at the Family Wing, and physicians’ lack of engagement with Labour Room services. LMOs often expressed surprise at the practices I described having observed, such as the reuse of Ivs and even syringes for multiple patients. They claimed LHVs were the only personnel privy to all of labor and delivery patients’ case details, and argued that medical under—or mis-reporting precluded the possibility of them ever knowing the full extent of oxytocin use in those obstetric cases that had gone awry.

11 Partograms (or, partographs) were used most often for admitted Inpatient (IPD) and Intensive Care (ITC) patients, who received treatment in the Family Wing wards that flanked the Labour Room, rather than to document labour and delivery care.

12 LHVs were not the only personnel to strategize around or manipulate protocols. A number of interlocutors spoke to the precedent set by the hospital’s administration and senior medical personnel who, they argued, regularly modified public sector standards and norms of care, formally as well as informally and off the record.

13 A 2010 evaluation of maternal and neonatal service providers’ clinical competencies across Pakistan found LHVs possessed “relatively better resuscitation skills… in comparison to [Medical Officers]” and hypothesized this was a consequence of LHVs’ “greater exposure to childbirths and immediate newborn care” (Ariff, Soofi, Sadiq et al. 2010: 7).

14 Patients needing induction often came bearing small packets of misoprostol, which physicians ordered LHVs to insert intra-vaginally.

15 Following the introduction of revised protocols between my 2005 and 2010 fieldwork visits, LHVs were advised to avoid intramuscular injections whenever possible. Although I only occasionally observed LHVs inject oxytocin directly to women’s hips or thighs, after 2010, patients and other providers shared their experiences of LHVs routinely administering intramuscular injections.

16 The lack of resources and specialist coverage made for an especially fraught atmosphere in the Labour Room. The arsenal of tools LHVs had to work with was usually extremely limited. Because oxygen diffusers, vacuum extraction, sterilizers, and suction and resuscitation equipment required electricity, frequent power shortages ensured that the minor complications arising during otherwise routine deliveries could quickly progress to medical emergencies. Stethoscopes were either malfunctioning, or reserved for nurses’ use in the Intensive Care (ITC) ward situated next to the Labour Room. Even when operational, the cardiotocography (CTG) machine LHVs used to listen to fetal heart-sounds, often for a brief and medically unhelpful 10 to 15 seconds, was usually without paper.

17 In 2005, I documented how one maternity patient died from postpartum hemorrhage during the night shift because the Blood Bank was unreachable due to curfew-related restrictions, which precluded personnel from accessing different wards at the hospital, the on-call surgeon reaching the labour room, and on-duty staff shifting the patient to the Operating Theatre a short distance away.

18 Oxytocin was rarely the only pharmaceutical means by which LHVs worked to achieve good outcomes. Its administration was often preceded or followed by adjunct intramuscular injections of Buscopan, which LHVs’ said ameliorated oxytocin’s effects. They described how, by helping to “relax” the muscles, Buscopan decreased the pain felt by patients “on the outside […] though inside they’re still strong and because she’s relaxed, it helps to open the cervix faster” (LVHs 2005, August 1).

19 Diclofenac, an anti-inflammatory typically prescribed for moderate to severe menstrual or mild to moderate postpartum pain, was the primary form of pain relief offered to delivering patients.