The blog-o-sphere is buzzing right now about a practice called “Pit to Distress.” Apparently Keyboard Revolutionary started it all with her post, which was quickly followed by Unnecesarean the same day. Now both of these blogs are written by “lay women”–that is, “JUST” moms, not medical professionals. So I was quite happy to see one of my favorite L&D nurse blogs jump into the fray–Nursing Birth. The Nursing Birth piece should be required reading for ANY woman who is planning a hospital birth, so that she doesn’t let this happen to her.
Pitocin seems to be almost synonomous with hospital labors anymore. I wonder how many women who labor actually manage to get through without using it at some point. One client I had switched OB practices because she had been informed that when she arrived at the hospital in active labor she would be put on Pitocin. No waiting to see how labor was progressing and if it was really needed…it was just the policy of this practice to use Pitocin on all laboring women. Medical staff will often explain away any concerns with the use of Pitocin by saying that it is just a synthetic form of the same hormone that your body produces. Which is true. But that doesn’t mean that putting it into an IV is the same as letting your body produce it!
I’ve seen some “interesting” things happen with Pitocin in my doula experience.
- One mom was induced with Pitocin, and just when she seemed to be making progress, the Pitocin was turned off, and she was eventually taken for a cesarean for “failure to progress.” At that point she was only 12 hours into her induction, which started at 0 cm, and she was 9 cm dialated. I never did figure out how that was failure to progress.
- One mom asked for her Pitocin to be turned off until after her epidural was in place (anesthesiologist was with another woman, and my client just didn’t know how much longer she could handle the Pit), and the nurse said that she couldn’t do that without the Dr’s consent. Funny, but I thought in America mentally competent adults could refuse any medication.
- One mom told her nurse that she didn’t want the Pitocin drip turned up any further, the nurse said something to the effect of “yeah, it’s rough stuff,” and then went over to the IV pump and began upping the dose. The father stepped up and said “she said she didn’t want it raised anymore,” and the nurse got a shocked look on her face and said “oh, I thought you were just joking.”
- One mom had not responded to multiple attempts to induce labor with prostaglandins, so was put on an IV drip of Pitocin. Her drip rate was doubled every 15 minutes, until I went out to the nurse’s station and commented to the care provider about the intensity of her contractions. The care provider said “this is what labor is” without even observing the woman’s contractions. She did come into the labor room a few minutes labor, observed a contraction, and then quietly turned the drip down. The woman went from 4 cms to 10 cms in less than 2 hours. This inspired me to research reccommended Pitocin dosing, and I learned that this woman had been started on 2-4 times the reccommended starting dosage, and the dose she was at when I commented to the care provider was actually 160% higher than the level of oxytocin that would “mimic natural labor.” Even the dose that it was turned back to was 20% above the level that was described as “rarely needed.” This woman also had a post-partum hemmorhage.
- I’ve only had two clients have cesareans for fetal distress. Both were on Pitocin at the time.
The worst example I’ve seen by far though, has to be a client that I’m sure was on a “Pit to Distress” protocol. Here is what happened (shared with her consent):
This was a second time mom who’d had a Pitocin induction with her first baby for medical cause, and did NOT want to “go there” again. Unfortunately the same medical cause ended up showing up again, so after an unsuccessful attempt at starting things with 3 doses of Cytotec (don’t even get me started on the lack of informed consent on that one!), she was on to Pitocin.
One of the major problems I have with the use of Pitocin is how strongly it is generally used. It is usually used at strengths MUCH greater than what the body would naturally produce. In the case of my client, it got to nearly 3 times the strength the body would naturally produce. Here is an excerpt from the 3rd page of the package insert on Pitocin:
The initial dose should be 0.5 – 1 mU/min (equal to 3-6 ml of the dilute oxytocin solution per hour [10 units oxytocin in 1000 ml saline was suggested a few paragraphs earlier “piggy backed” with plain saline]). At 30-60 minute intervals the dose should be gradually increased in increments of 1-2 mU/min…[. Once] the desired frequency of contractions has been reached and labor has progressed to 5-6 cm dilation, the dose may be reduced by similar increments.
Studies of the concentrations of oxytocin in the maternal plasma during oxytocin infusion have shown that infusion rates up to 6 mU/min give the same oxytocin levels that are found in spontaneous labor. At term, higher infusion rates should be given with great care, and rates exceeding 9-10 mU/min are rarely required. Before term, when the sensitivity of the uterus is lower because of lower concentration of oxytocin receptors, a higher infusion rate may be required.
My client was started at a dose of 6 mU/min. That’s right…she was started at a dose 6 to 12 times the reccommended starting point. And this after getting 3 doses of Cytotec. Then the midwife put in orders for the drip rate to be increased by 2 mU every 15 minutes. The nurse seemed to get around to upping it every 30 minutes when it was first turned on, but then later in labor she was coming around after 20 minutes to increase the dose.
When I got to the hospital my client had been on Pitocin for 2 hours, and by that point she was up to 12 mU/min. So not only was she at twice the level that would be found in a natural labor, but she was definitely above that level that is supposedly “rarely required.” Of course I haven’t had a client yet that I’ve been with as a doula who got Pitocin and didn’t get to this level–even when they were told they were only getting a “little bit of Pitocin.” Sigh.
As I indicated above, they didn’t stop there. This is where the nurse started showing up every 20 minutes to increase the dosage, and in short order it was at 16 mU/min. I’m not sure why, but at this point the nurse stopped increasing the Pitocin. I don’t know if the midwife told her to stop because the contractions were coming more regularly, or if the nurse just got busy, or if it was because of concerns with the baby’s tolerance of the Pitocin (I noted that the baby was having late decels, but I didn’t want to write that in my notes, because if someone saw that they might say that I was “practicing medicine.” So I made a notation that the baby’s heart rate was 104 10-minutes after the Pitocin was raised to 16.)
40 minutes passed between changes to the Pitocin level, and this next change was to drop it back down to 12 mU/min. It stayed this way for the next hour, during which time the mom labored really well, contractions were coming 2 1/2 minutes apart, about 55-70 seconds long.
However, there was trouble with keeping a good reading of the baby’s heart rate on the fetal monitor unless the monitor was manually held in place, and even the contractions weren’t picking up well. The midwife started talking about internal monitors. We discussed options, and I pointed out to mom that since she was 5-6 cm dialated at this point, according to the Pitocin package insert she could consider just turning the Pitocin off, then she wouldn’t need the constant fetal monitor, and could use Doppler. I also offered to manually hold the monitor.
However, the midwife managed to convince her that it was imperetive that the internal monitors be placed, and part of what I think sold her on it was the promise that this would mean less fiddling around with the monitors. Yeah…okay. I’d not had a doula client have an internal scalp electrode placed, so I didn’t have experience with that. The dang thing kept coming off! All told, she had 5 scalp electrodes placed in 4 hours. And it really irritates me that they call them a “scalp clip.” I suppose that sounds better than the reality–”a corkscrew that we put into your baby’s scalp.” And YES, it hurts the baby! The heart rate would temporarily jump to over 200 every time one was placed.
So anyway…she got the first one placed, and what do you know, baby is having heartrate decelarations. The Pitocin was shut off STAT. After about 20 minutes things seemed to be stable with the baby, so what do they do? Turn the Pitocin back on at 6 mU/min. Didn’t bother to ask the mom if she wanted them to do that. I pointed it out to her and asked her if she wanted Pitocin at this point. I don’t really think she did…but I also think she didn’t want to make too many waves.
So 20 minutes later the baby starts doing some NASTY decels. Down as low as 60, when usually much below 120 is “not good.” I was scared. And feeling like pounding my head against the wall and screaming “you guys had a warning that this was going to happen!!! What in the world were you thinking???” Pitocin was back off again. I was honestly shocked that we weren’t on the fast track to the OR. Seemed like half the available OB staff that was on the floor was in her room. Whispered instructions were given to a nurse to start counting equipment in the OR. I would later learn that the OR was not ready to go, thus why my client was not taken down for a cesarean.
Fortunately I will give that the OB who is the senior Dr. in the practice with the midwife is committed to avoiding cesarean, so he really worked with the baby to get the heartrate back to an acceptable range. Medication was given to stop contractions. And after about 10-15 minutes, the drama was over–at least the medical drama.
My client and her husband did really well during all of this. But understandably, it really shook them. They both cried. She was seriously wondering if continuing to labor was wise, or should she just go straight to cesarean?
Less than 30 minutes after the baby was stabilized, and while my client is still very emotionally charged and trying to work through the “should I just have a cesarean?” question, the nurse quietly comes in and turns the Pitocin back on to 4 mU/min. BANGING MY HEAD!!!
I again let her know that the Pitocin is back on. This time she talks to the midwife about it. She isn’t happy having it on. Midwife is “sweetly” insistant on the “need” to use it to get the baby out quickly. AAARGH! My client is breaking down. She finally just can’t deal with things anymore, and asks for an epidural. She REALLY didn’t want one because of a previous bad experience, and she hadn’t had one with her first baby. I really think that the emotions of the situation just left her unable to deal with things. And I don’t blame her one bit. It also dawned on her that if she wound up with an emergency cesarean she would be put under general anesthesia unless she already had an epidural in place.
She INSISTED that the Pitocin be turned off, so as the anesthesiologist was prepping the epidural, it was turned off.
Of course the nurse came back in and quietly turned it back on not 10 minutes later. Didn’t ask my client about it. She just asked for it to be turned off, and she didn’t ask for it to be turned off because she couldn’t deal with the pain, she asked for it to be turned off because she couldn’t deal with the stress of wondering if it was going to make her baby crash again. But it was “only” 2 mU/min, so I think my client just resigned herself to it when I told her it was back on. 30 minutes later it was up to 6 mU/min, then 15 minutes after that it was up to 10 mU/min.
And surprise, surprise…15 minutes later it is turned back off because of decels, and they are having her push even though she still has a lip of cervix, no urge to push, and baby is at 0 station (and in my experience, moms aren’t ready to push until +2 station). I wasn’t even sure she was “really” completely dialated, as she had been 8-9 cms just 30 minutes prior, and the midwife had this “let me see if I can stretch the cervix to 10″ kind of hesitation before declaring her “complete.”
Pushing wasn’t really going well, the lip of cervix could not be reduced. But fortunately the baby’s heart rate resolved, so the midwife did one of the few reasonable things of the day, and called a stop to the pushing.
An hour later my client felt an urge to push, and craziness ensued again. The midwife doubted whether my client could actually push the baby out (since they expected the baby to be large, and the midwife had earlier been very insistant on how DANGEROUS it can be to deliver a large baby–never mind that my client had pushed out her first baby at 8 lbs 7 oz with no incident) She decided that vacuum extraction would be required, so called in a resident OB. I don’t think she informed my client of the planned use of vacuum. The resident was rushed in, the nurse opened up the vacuum, handed it to the resident, and the resident promptly dropped it on the bed because the baby was crowning. The resident did manage to do some over agressive pulling, resulting in a birth in less than 10 minutes of pushing. I wonder if the vacuum was billed to my client’s insurance? The baby was 8 lb 8 oz, Apgars of 9 & 9.
But hey, the joys of Pitocin don’t end there. Despite the fact that mom had no significant bleeding, the midwife ordered that the remainder of the bag of Pitocin in saline be run into the mom. The drip rate was set at 250 mU/min. Here is what the package insert on Pitocin has to say about fast drip rates of Pitocin:
Water intoxication with convulsions, which is caused by the inherent antidiuretic effect of oxytocin, is a serious complication that may occur if large doses (40 to 50 milliunits /minute) are infused for long periods.
She was being dosed at 5 times the level that is listed on the package insert as considered a risk of causing water intoxication! Granted, the concern is with “long periods [of time],” but she was already seriously retaining fluid, as demonstrated by the very concentrated urine collection that had been made about 20 minutes before the birth.
The concentrated urine was interpretted as “she hasn’t gotten enough fluid.” A logical person would certainly agree with that concept. (Rolling my eyes) She had “only” gotten 4 liters via IV plus what she’s been drinking over the course of the previous 20 hours. That is the equivalent of drinking more than 8 oz an hour around the clock–possibly closer to 12 oz, I didn’t log how much she drank. Can you imagine how much you would be peeing if you drank that?
She wasn’t dehydrated folks…she was OVER HYDRATED, and unable to get rid of it. But hey, the midwife ordered another bag of saline run into her.
The poor woman. She must have left the hospital with no shoes on, her feet would have been so puffy.
Note: I have a Word document explaining how to figure out what dosage of Pitocin is being administered. Ask, and I’ll e-mail it to you. If you are “lucky” the Pitocin is mixed as 30 Units in 500 mls of saline, then you can just read the IV pump to directly get the mU/minute. But if a different mix is used (such as the 10 Units in 1000 mls of saline that is reccommended on the package insert), then the charts I have in the Word document will help you to quickly find what dosage is being used. I STRONGLY urge pregnant women to take a copy of it and the package insert for Pitocin with them to the hospital in labor. If Pitocin is going to be used, ask the care provider if the dosing guidelines in the package insert are going to be followed, and if not, why not. Sometimes a “quick” labor is not as safe as a slow labor. Especially if your baby is thought to be compromised already, it may not really make sense to be trying to blast the baby out.
Update: There is a great follow up post to the whole “Pit to Distress” flurry at Woman to Woman Childbirth. I definitely encourage my readers to check it out!