Yesterday in my post entitled “Pit to Distress: A Disturbing Reality” I wrote about a troubling way of administering the drug pitocin to augment or induce labor that some birth attendants are practicing in our country’s maternity wards. Called “pit to distress”, the intention is to order a nurse (either verbal or written) to continue to turn up (or “crank” as is the current L&D slang) the pitocin in order to induce hyperstimulation/tachysystole of the uterus so that a women is experiencing more than 5 contractions in a 10 minute period. This action, sooner or later, will cause fetal distress as research has shown that a baby needs AT LEAST a 1 minute break in between contractions where the uterus is AT REST in order for the baby to continue to receive adequate oxygenated blood flow from the placenta and not have to dip into his reserve.
Inspiration for my post came from two posts on the subject written by Keyboard Revolutionary and The Unnecesarean. Since yesterday I have received many comments regarding this upsetting trend and one comment in particular has inspired me to address the topic again:
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July 8, 2009
Dear NursingBirth,
I really enjoy your blog and I learn a lot from all your posts. I am wondering if there is a way (as the patient) to know if something like this is happening and refuse it? Is the patient always told how much pitocin she is getting and can she say at a certain point that she doesn’t want it any higher if she is making progress?
Sincerely,
Zoey
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Dear Zoey,
This is a GREAT question. I love hearing from women who desire to learn more about their choices in childbirth and become more proactive in the care they are receiving. KUDOS to you for doing both!! I have thought a lot about this and I have come up with a list that I hope you find helpful. Please pass it along to all of your friends, both expecting and not, so that we can both work to inspire more women to do as you do….that is, DO their research and DEMAND better care!!!
TOP 7 WAYS TO PROTECT YOURSELF FROM UNNECESSARY AND HARMFUL OBSTETRICAL INTERVENTIONS (including “Pit to Distress”!)
#1 Interview different birth attendants/practices before or during early pregnancy and CHOOSE a birth attendant that practices in a way that aligns with your personal childbirth/postpartum philosophy, is appropriate for your health status, and (optimally) who practices a midwifery model of care!
I wish I could scream this from the roof tops! Sometimes I feel like a broken record I say this so often but I say it so often because it is SO important!! The bottom line here ladies is that if you think you can pick any care provider you want and then just write a birth plan that clearly states your philosophy and preferences and just get what you want…..THINK AGAIN! Birth attendants are creatures of HABIT more than anything else. If they cut an episiotomy on the majority of their patients then what makes you think that if you ask, they won’t cut one on you? In fact, not only will they cut one on you but they will come up with some bogus reason why it was necessary. Likewise, if your birth attendant induces most of their patients, what makes you think that he won’t start pressuring you to set up an induction date once you hit 37 weeks!
Think of it this way, if the birth attendant has a high elective induction rate, they probably feel more comfortable managing pitocin induced or augmented labors as opposed to spontaneous labors and hence, they will probably try to do everything in their power [including persuasion (e.g. the “convenience” card and the “aren’t you sick of being pregnant” card) as well as scare tactics (e.g. the “big baby” card, the “I might not be there to deliver you if you don’t” card, or my favorite the “if you don’t your baby might be stillborn/dead baby” card)] to convince you that your labor needs to be induced or augmented with pitocin. Why? It probably is a mix between how they were taught (i.e. medical model of maternity care), what they are used to (a self fulfilling prophecy), and a desire to be the one in “control.”
Writer Lela Davidson quotes professional childbirth educator and doula, Kim Palena James in her article Create a Better Birth Plan: How to Write One and What It Can and Cannot Do For You:
“Too many parents create birth plans with the expectation that it will be the actual script of their baby’s birth. There is no way! Nature scripts how your child is born into this world: short, long, hard, easy, early, late, etc… The health care providers you choose, and the facility they practice in, will script how you and your labor are treated. The variations are vast. I wish every expectant parent spent less time writing birth plans and more time selectively choosing health care providers that align with their philosophy on health care, match their health status and their needs for bedside manner.” (Emphasis mine)
So PLEASE for the LOVE of all mothers and babies, PLEASE do your homework!
Of course there is always the chance that you do interview a particular birth attendant and they act one way in the office with you and then, WHAM!, are a completely different person when you step foot on L&D. I see it happen ALL THE TIME where I work. Just because a doctor gives you his home phone number and is sweeter than sugar in the office, doesn’t mean he won’t section you just to get to the company Christmas party! (This actually happened to a patient I took care of! NO lie!) So what can you do about that!
Jill from Keyboard Revolutionary recently blogged about this:
“Ya know, sometimes I feel bad for the good physicians out there. I know they exist. We all do. We’ve all shaken our fists in righteous indignation at the rants of Marsden Wagner. We’ve listened intently to the poetic, thickly accented declarations of Michel Odent. We’ve swooned over the tender ministrations of “Dr. Wonderful,” a.k.a Dr. Robert M. Biter. God bless those diamonds in the rough, particularly in the obstetrical field. It must be twice as hard to shine when the lumps of coal around you are so horrifically ugly.
I was pondering just now in the shower how so many of us think we’ve got a real gem of an OB (or any other doctor, really) until show time, and suddenly we’re hit with the ol’ bait-and-switch. Sometimes there are warning flags along the way, sometimes not. Sometimes the flags don’t pop up until it’s too late. It sucks that for many women, we don’t realize what a crock we’ve been fed until we’ve already digested it. How do you know whether you’ve got a bad egg or your own Dr. Wonderful?”
This leads me to my second point…
#2 Ask the RIGHT QUESTIONS and the RIGHT PEOPLE when researching potential birth attendants.
Two of my favorite posts from Nicole at It’s Your Birth Right! are her posts about choosing the right birth attendant entitled Choose Wisely I and Choose Wisely II. She writes:
“The decision about WHO is going to be your birth attendant should NOT be left to chance. Where you deliver, how you choose to labor, what you chose to do while pregnant and in labor, while these things are definitely important, without the proper WHO, the plan will have difficulty coming together.
I get questions, all the time from friends, friends of friends and even strangers. They want my thoughts about pregnancy, labor and childbirth. I have spent HOURS talking with women providing answers and information they should be able to get from their prenatal provider/birth attendant. I think to myself at the end of those conversations, “Why isn’t she able to get this information from her? If he doesn’t make her feel special, does not answer her questions, and doesn’t agree with her philosophy on childbirth and labor, why on earth is she allowing him to be her birth attendant?!”
When I pose this question to the women themselves, the answers unfortunately never include “Because I did my research and I found him to be the best match for me and my desired childbirth experience.” Most of the answers I receive fall into [one of] four categories, none of which are good enough reasons alone to choose a prenatal care provider/birth attendant. They are: “She delivered my sister/girlfriend”, “She is my gynecologist,” “He is the best/most popular person in area,” and “Her office is so close and convenient to my office/house.””
Now I am not trying to say that you shouldn’t trust your sister, sister-in-law, or best friend’s opinion about her personal birth attendant but if you are going to ask such a person for advice please remember that she probably has only had limited experience with that birth attendant as compared to, say, an L&D nurse or doula, and it is important to ask her exactly why she loves her birth attendant so much. Does she love him because he trusts in birth and strived to facilitate a positive and empowering birth experience for her or does she love him because he was the only OB in the area that would agree to induce her at 38 weeks because she was sick of being pregnant? There is a difference!!
If you have done some research and found a birth attendant that you think you really like, I would recommend tapping into some community resources to get the “inside scoop” about your birth attendant. Here are some ideas:
1) Contact your local grassroots birth advocacy group like International Cesarean Awareness Network (ICAN) or BirthNetwork National and try to attend a meeting. The women that attend these meetings are often in tune with the birth culture in their community and can be GREAT resources for which birth attendants are true and which are really wolves in sheep’s clothing! Also, don’t count out ICAN as a resource even if you have never had a cesarean. We have a quite a few moms currently in my local ICAN group that are first timers and decided to start attending because they said they were learning so much about birth in general from our meetings!
2) Sign up for a childbirth preparation class that is NOT funded/run by a hospital and ask the instructor for her opinion on different birth attendants. It is the only way to guarantee that your instructor is not held back from speaking her true feelings since hospital based childbirth instructors are working for the interest and promotion of their hospital by the very nature of their job. Independent childbirth instructors like Lamaze, Hypnobabies, Birthing From Within, Bradley etc. etc. can be GREAT resources as to which birth attendants follow which philosophies because often times their clients come back and tell them about their experiences.
2) Consider consulting or hiring a doula. A doula is a great resource as to the true nature of a birth attendant because she is someone who is actually in the labor and delivery room with her clients and has as close to an “insider’s view” as you can get without actually working for the hospital. If you hire a doula to be with you during your labor, they will also advocate for you, your needs, and your birth plan as well as provide essential labor support that (unfortunately) even the most well intentioned nurse might not have the time to do.
#3 Do NOT agree to an induction of labor unless there is a legitimate obstetrical, maternal, or fetal reason for delivering the baby before natural spontaneous labor begins!! PLEASE Do NOT agree to an unnecessary elective induction of labor.
This might seem like a no brainier ladies but so many get sucked in! They don’t call it “the seduction of induction” for nothing!
Bottom line is if you want to protect yourself from such an asinine, unnecessary, and dangerous intervention as “Pit to Distress” then DON’T agree to be induced unless there is a very important medical reason!
BABIES AND MOTHERS HAVE THE BEST OUTCOMES WHEN THEY ARE ALLOWED TO BEGIN LABOR SPONTANEOUSLY AS WELL AS LABOR AND DELIVER WITH MINIMAL INTERVENTIONS!
In the Lamaze Institute for Normal Birth’s MUST READ patient education bulletin entitled Care Practice #1: Labor Begins on Its Own, author Debby Amis, RN, BSN,CD(DONA), LCCE, FACCE, and editor Amy M. Romano, MSN, CNM write:
“There is growing evidence that induction of labor is not risk-free. In 2007, Goer, Leslie, and Romano reviewed the entire body of literature on the risks of induction in healthy women with normal pregnancies and found that when labor was induced, the following problems may be more common:
- vacuum or forceps-assisted vaginal birth;
- cesarean surgery;
- problems during labor such as fever, fetal heart rate changes, and shoulder dystocia;
- babies born with low birth weight;
- admission to the NICU;
- jaundice;
- increased length of hospital stay.”
Okay, enough said!
#4 If you have to be induced or augmented with pitocin for a true medical or obstetrical reason, be honest with your nurse about how you are feeling and have one of your labor companions keep track of how often your contractions are coming.
And this does NOT mean for your labor companion to “monitor watch”!! It’s not a TV for goodness’ sake!
Research has shown that due to the risks of pitocin, continuous electronic fetal monitoring (CEFM) is a safety requirement for anyone being induced or augmented with it. However, remember CEFM is a machine and machines have limitations. The tocodynamometer or “toco” is “pressure transducer that is applied to the fundus of the uterus by means of a belt, which is connected to a machine that records the duration of the contractions and the interval between them on graph paper.” However, depending on your body type, how “fluffy” your abdomen is, your position, and your gestational age, the toco might not be recording your contractions appropriately. You might be having contractions every minute but the machine is not registering them. This is why I always remind women that they have to tell me how they are feeling.
If you are being augmented or induced with pitocin your nurse SHOULD:
1) Be palpating (feeling) your fundus (top of your uterus above the belly button) before, during, and after contractions periodically throughout your labor to judge how strong they are (mild, moderate, or strong). Palpation before and after contractions also assures the nurse that your uterus is actually coming to rest (is soft) between contractions, which assures that the baby (and mom!) are getting a break! Remember, unless you have an IUPC (intrauterine pressure catheter) in, the toco can only tell the nurse how far apart and how long the contractions are NOT how strong they are! That’s right! Unless you have an IUPC in, the height of the contractions on the monitors is ABSOLUTELY MEANINGLESS! So therefore the only way for the nurse to know how strong the contractions are is to TOUCH your belly and ASK you!
2) Ask you about your pain level (for example to “rate” your pain on a scale of 0 to 5 or 0 to 10) regularly during your labor unless you have specifically asked her not to ask you about your pain.
3) Give you periodic updates on your progress and the progress of the pitocin.
[Note: I can only speak for myself here but what I do when I have a patient on pitocin is first and foremost to explain the process of titrating the pitocin and what the desired outcome is (and according to our hospital’s policy the desired outcome is moderate to strong contractions that are coming every 2-3 minutes, or 3-5 in a 10 minute period), as well as keep her informed throughout the process when I am increasing or decreasing the pitocin and for what reason. For example, I might say “It looks to me like you are contracting every 4 minutes. What is your pain level? Do you feel like you are getting an adequate break? Would you like to change position? I would like to increase to pitocin to achieve a more regular pattern. What do you think?” or “It looks like the baby continues to have variable decelerations in his heart rate despite all of the position changes we have tried. I am going to give you a small IV fluid bolus and turn the pitocin down some to see if it helps to resolve the decels. The baby’s variability is still very reassuring and she is still having accelerations so she is doing well. I just would like to keep her that way!” Your nurse should be keeping you “in the loop” so to speak and if she is not, it is your right to ask questions!]
It is also important to remember that that running pitocin is much more of an art than a science. Therefore you might think she is being “mean” if she is increasing your pitocin since you are only contracting every 6 minutes but remember, running the pitocin lower than is needed to cause cervical change isn’t going to help you either. No nurse wants her patient to end up in the OR for “failure to progress” because she didn’t turn the pitocin up enough. There is a happy medium somewhere that most nurses are trying to find. So please, know that sometimes, even if you really feel like those “every 6 minute” contractions are strong enough already, it is important for the nurse to titrate the medication to achieve an effective labor pattern that promotes a vaginal delivery with a healthy baby.
If your nurse is NOT doing these things then it is your right to ask questions!!! However, please remember for your own sake that when asking questions, one attracts more flies with honey than vinegar. Don’t start yelling at her or demanding a new nurse. Give her a chance and ask questions first! She might just be so busy that day that she is in the zone. Most nurses are happy to teach when asked!
#5 Learn about and practice non-pharmacological methods of pain relief as part of your childbirth preparation and consider not getting or postponing an epidural until all other methods of non-pharmacological pain relief have been exhausted.
Okay, I know that this one is a bit controversial but please here me out first.
It is the truth that pitocin contractions, especially when the pitocin is being abused, are typically stronger and longer than spontaneous labor contractions. Also, being that you have to be on continuous monitoring can also limit your movement and hence, one of your most effective and instinctual coping methods for the pain. For this reason, many people feel that it is crazy for a woman to go though a pitocin labor without an epidural. And when “Pit to Distress” is in play, it is truly unbearable to both experience and to witness. However, if pitocin is administered compassionately and appropriately it is important to know that an epidural is NOT an absolute necessity. I have seen many women do it without an epidural and many who have done it with an epidural. So if you have to be induced with pitocin and you desire an “unmedicated” birth, your hands aren’t completely tied. You CAN do it. However, I have said time and time again, I would rather a woman have a vaginal delivery with an epidural than a cesarean section without. That being said, the pitocin and epidural partnership has a dark side too.
While an epidural can help the woman relax and allow the pitocin to work more effectively, most birth attendants that practice “Pit to Distress” persuade and even bully their patients into getting an epidural specifically so the nurse can “crank the pit” without the woman objecting. But I would like to remind you that even if you can’t feel those contractions, your baby IS feeling them. Also, epidurals themselves CAN and DO cause fetal distress and anyone who tells you that epidurals pose no risk to the baby is being dishonest! At my work, we nickname this the “ten by ten”. That is, almost without fail, many women who get an epidural are is likely to experience a whopping fetal heart rate deceleration lasting approximatly ten minutes about ten minutes after she is put back to bed, which of course throws everyone into a tizzy.
All of a sudden mom finds herself with her face planted into the bed, her ass in the air, a mask of oxygen on her face, an anesthesiologist pushing adrenaline into her IV to increase her blood pressure and a doctor with his hands up her vagina screwing a monitor onto the baby’s head. Most babies do recover from said decel and go on to deliver vaginally. But it is NOT rare for the baby to NOT recover which lands mom…you know where….in the OR. And guess what! Since she already has that epidural in place, why they can just cut her open even faster!
Please know that I am not condemning any woman who requests an epidural in labor, especially if she is on pitocin. I just want all you women out there to know that sometimes that epidural that they keep waving in your face is just a way for them to shut you up so they can CRANK the pit.
#6 If you feel like you are contracting strongly at least every 2-3 minutes (3-5 in a 10 minute period) and the nurse or birth attendant desires to increase your pitocin, you might want to consider requesting a vaginal exam.
Now, I know limiting vaginal exams is very important to many women as they are invasive and uncomfortable/painful. I completely understand! However, if your care provider wants to increase the pitocin and you feel it is unnecessary, asking for a vaginal exam is a way to reveal if you are making any cervical change. If you ARE making cervical change then there is no real need to continue to go up on the pitocin! Remember the TRUE goal of pitocin administration is to stimulate an effective labor pattern that causes cervical change. It is NOT (despite how many birth attendants practice) just about getting a patient to “max pit.” Every woman is different!
Lastly,
#7 You could always try writing something about pitocin administration in your birth plan.
For example: “If deemed necessary, I would like to try non-pharmacological methods of labor augmentation and induction including (blank) first before resorting to pharmacological methods. However, if my birth attendant and I agree that pitocin will be administered to me, I request that the pitocin be administered following the “low dose” protocol and is increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each dose increase.”
I will be very honest with you. If your birth attendant or hospital does not practice in this way, it is doubtful that this request will be granted. However, I suppose it can’t hurt and is worth a shot! At least it can provide a sympathetic nurse with another platform on which to argue with the birth attendant if necessary (like, “But Doctor X, your patient has specifically requested a low dose pit protocol!”)
This should be a last resort! Remember, writing something in your birth plan does not guarantee you it is going to happen if your birth attendant doesn’t practice that way! Please refer back to point #1 about choosing the RIGHT birth attendant for you!!!
All My Best,
NursingBirth
Pitocin Protocol for Labor Induction/Augmentation Decoded July 9, 2009
Tags: cesaren section, hospital birth, hyperstimulation, L&D, labor and delivery, OBGYN, pitocin, pitocin to distress
Dear NursingBirth,
Just curious, since I’m not a nurse but AM looking into a future of nursing or midwifery… on the Pit pump, is the max number that is shown 20? Or is it 60? The reason I ask is because I had an unnecessary induction via my own decision (not that I truly wanted to, my husband was going to be out of town and first baby.. I was scared to possibly not have him around). I was labored with pit for 12hours with 11of those hours having a broken amniotic sac. My doc said I would have my baby between 5-6pm and I believe they went above the max to make that happen (she was born at 5:47 pm). Months after I had my daughter (which was quite painful not having an epidural) I found pictures of me laboring in my husband’s phone. And the machine said 69… I was wondering if that is still a norm or what. I refuse to have pit administered ever again casually if there is not a dire need… Hell I might not ever deliver at the hospital ever again unless truly needed!
Sincerely,
Amanda
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Amanda,
This is a GREAT question. Okay here it goes…
The way it works at the big city hospital that I used to work for (and many others for that matter) is that the bag of pitocin that is used is premixed by the drug company in the concentration of 20 Units of Pitocin per 1 Liter of Lactated Ringers or Normal Saline. (Some do 10 Units of Pitocin per 1 Liter of fluid but I have never worked with this concentration so I’ll stick to what I have the most experience with). This is in large part so that nurses do not have to mix their own, hence making less chance for medication errors.
Most “low dose” pitocin protocols (as was the policy of the big city hospital I used to work for) is that pitocin is started at 2 milliunits per minute (mu/min) and increased by 1-2mu/min every 15-30 min to a maximum of 20mu/min. The goal: To obtain an effective and adequate contraction pattern of 3-5 contractions in 10 minutes (and no more) that cause cervical change. However, IV pumps infuse in milliliters per hour NOT milliunits per minute and therefore there are conversion charts that nurses follow. In this concentration, 2mu/min converts to 6 milliliters per hour (mL/hr) and therefore if you do the math 20mu/min converts to 60mL/hr. So no, you are not going crazy! The pump most likely did read 60!
[Addendum 3/30/2010: In order to get a 1:1 ratio of milliunits/min to milliliters/hour the concentration of pitocin must be 30 units of Pitocin in 500mL of LR (or D5LR). Hence when you do the math, 2 milliunits/min equals 2mL/hr and so on and so forth. At a community hospital I worked at in the beginning of 2010 (which I not so affectionately refer to as "Bait & Switch Community Hospital"), the pitocin was hung in this particular concentration and the orders typically read: "Start pitocin at 2 milliunits per minute (mu/min) and increased by 2mu/min every 15-20 min to a maximum of 34mu/min." This was by far the scariest order for pitocin I was ever faced with and is one of the reasons that I am leaving this hospital!]
Okay, so if a doctor wants to go above “max pit” which, according to the “low dose pitocin protocol” that a big city hospital I used to work for follows, is anything above 20mu/min (60mL/hr), then they have to write out an entirely separate order. At that hospital the “absolute max pit” is 30mu/min (90mL/hr). Now, the higher the dose and the longer the infusion runs for the greater the risk for side effects and adverse reactions.
These potential adverse reactions include (source: RxList Drug Guide)
1) Potential adverse reactions in the mother:
2) Potential adverse reactions in the fetus or neonate related to hyperstimulation of uterus:
3) Potential adverse reactions in the fetus related to use of oxytocin in the mother:
Remember the most serious of these adverse reactions occurs when pitocin is run at concentrations higher than 20mu/min for hours or even days of induction. But unfortunately this abuse of pitocin does happen.
There is also something called a “high dose” pitocin protocol. The way the big city hospital that I used to work for described it (right after it said that we were NOT allowed to order/follow it at our hospital) is the following: Pitocin is started at 6 mu/min (18 mL/hr) and is increased by 1 to 6 mu/min (3 to 18 mL/hr) every 20 minutes until a maximum of 42 mu/min (126 mL/hr). Now, I am sure that there a subtle variations on this, for example, some birth attendants/hospitals that follow this protocol will only do “high dose pit” on nulliparous women (first time moms). However, again, the higher the dose and the longer it is infusing for, the greater chance of complications and adverse reactions.
Now the other option could have been that the hospital that you went to uses bags of pitocin with a concentration of 10 units per liter instead of 20 units per liter. If this is the case then everything would be doubled. With a 10 unit/liter concentration, 2mu/min would actually be 12 mL/hr. So that could be the case as well, although that is more unlikely.
Now again, other nurses might report slight variations in this but I am confident that many hospital’s pitocin policy looks a lot like the ones I’ve worked at both in nursing school and as a nurse.
Last but not least please check out a great post from Jenn, a doula who blogs at Knitted in the Womb Notes. She wrote a post a while back entitled My Rant On Pitocin and she actually copied the package insert from the pitocin bag that the nurse hung. What saddens me most about that story is that at one point her client was considering just “going ahead” with a cesarean because the higher they put the pitocin the more the baby deceled. However LABOR was not causing the baby distress…the ABUSE of PITOCIN was causing the baby distress! That’s why when I hear things like “The pitocin was causing my baby’s heart rate to decel so they did an emergency c/s and Thank GOD because that OB saved my baby” I want to vomit. Okay so if I STAB you and then bandage your wound so you don’t bleed to death….did I save your life???
Thanks again for your great question Amanda!
All My Best,
NursingBirth