Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

“Pit to Distress”: A Disturbing Reality July 8, 2009

Dear NursingBirth,


I just saw a couple of posts about “pit to distress” on Unnecessarean and Keyboard Revolutionary’s blogs. Can you comment on that as an L&D nurse?! Is the intent really to distress the baby in order to “induce” a c-section?  I’m distressed that such things may actually happen, and am holding out a little hope that it’s a misunderstanding in terms….







Dear Alev,


I wish I could put your heart and mind at ease and tell you, from experience, that this type of outrageous activity (i.e. “pit to distress”) does not happen in our country’s maternity wards but unfortunately it does.  I know that it does because:


1) I have read and heard stories from other labor and delivery nurses who have worked with birth attendants who practice “pit to distress,”


2) I have read and heard stories from women (and their doulas!) who have personally experienced the consequences of “pit to distress,”


and, most importantly…


3) I personally have worked with attending obstetricians who subscribe to this philosophy. 


Before I start my discussion on this topic I would like to quote a blog post I wrote back in April entitled “Don’t Let This Happen To You #25 PART 2 of 2: Sarah & John’s Unnecessary Induction”.  This post is actually the first post I ever wrote for my Injustice in Maternity Care Series.  It is a TRUE story (although all identifying information has been changed to adhere to HIPPA regulations) about a first time mom who was scheduled for a completely unnecessary labor induction and the following excerpt is a good example of how “pit to distress” is ordered by physicians, EVEN IF they don’t actually write it out as an order (although some actually do!)




“…At 1:30pm, right on schedule, Dr. F came into the room.  After some quick small talk he asked Sarah to get into the bed so that he could perform a vaginal exam and break her water. 


Sarah: “Umm, I was hoping we could wait a little bit longer to do that, until I am in more active labor.”


Dr. F: “Well, if I break your water it is really going to rev things up and put you into active labor.”


Sarah: “I’d really rather wait.”


Dr. F: (visibly frustrated) “Well I at least have to check you!”


(Oh lord, I love the “have to”!)  Dr. F’s exam revealed that Sarah was 4 centimeters!  Yay!


After helping Sarah to the bathroom and back to her rocking chair, I stepped out the catch Dr. F at the desk.  “Thanks for holding off on the amniotomy, it was really important to her birth plan,” I said, trying to “smooth things over” and (gently) remind him that the patient was in charge!  “Yeah well I’ll be back around 4:00pm to check her again and if she hasn’t made any progress I am going to break her water,” he said, grudgingly. 


He started to walk towards the elevator but then turned around to me and said:


Dr. F: “You have the pit at 20 right?”


(Note: The way pitocin is administered for induction in my hospital (and many others) is that you start the pitocin at 2mu/min (or 6mL/hr) and increase by 2mu/min every 15-30 min (or more) to a maximum of 20mu/min (or 60mL/hr) until you obtain an adequate contraction pattern (or, 3-5 contractions in 10 minutes).  So what does that mean?  That means that you do NOT just crank the pitocin until you get to “max pit,” rather you TITRATE it until you get 3-5 contractions in 10 minutes that are palpable and are causing cervical change.  However, this is not what many physicians I work with ask you to do.   Bottom line is everyone is different.  I personally could take a whole box of Benadryl and not so much as yawn while my husband can take one tablet and all but hallucinate!  It is no different for pitocin.  Some people are extra sensitive and only need a little bit, and others tolerate “max pit” very well.  I seem to have this same “fight” with physicians all the time at work.  They insist you “keep cranking the pit” when all you are going to do is hyperstimulate the uterus and cause the baby to go into distress.  But I digress….)


Me: “No, I have her at 10mu/min.”


Dr. F: (sarcastically)  “What!?  What are you waiting for?! 


Me: (said while biting my lip so I didn’t say something I would regret)  “She is contracting every 2-3 min and they are palpating moderate to strong.  She has to breathe through them.  And the baby is looking good on the monitor.  I want to keep it that way!”


Dr. F:  “But she’s not going anywhere!  You have to keep going up if you want her to progress.”


Me: “But she has changed to 4 centimeters…”


Dr. F:  “I was being generous!”


Me: “So you lied…”


Dr. F:  (annoyed) “Listen, keep going up on the pit, even if she is contracting every 2-3 min.  They aren’t strong enough.  Keep going up.  If we hyperstimulate her, we can just turn the pit down.”  (Note: These were his exact words.  I know this because I was so flabbergasted that he said it, I wrote it down in my notebook that very moment!  The fact is sometimes the baby is in so much distress after hyperstimulating the uterus that just turning the pitocin down isn’t enough!  And it really bothers me when doctors start sentences off with “Listen…”  Grrrrr.)


Me:  (jaw dropped, completely dumfounded) If I turn the pit up anymore, I am GUARANTEED to hyperstim her.”


Dr. F: “We’ll cross that bridge when we get to it.  I’ll be back around 4:00pm.”


By this point I was more than annoyed with Dr. F.  I explained the situation to the charge nurse and told her that I would not be cranking the pit on room 11 unless Dr. F wrote me an order that read “Regardless of hyperstimulation or contraction pattern, continue to increase pitocin until the maximum dose is reached.”  (By the way, he wouldn’t’ write me that order).  She basically told me to do what I felt was right because it was my license at stake too.”





Ladies and gentleman the account that you have just read is called “Pit to Distress” whether the pitocin order was actually written that way or not.  What Dr. F gave me was a VERBAL ORDER to increase the pitocin, regardless of contraction or fetal heart rate pattern, until I reached “max pit,” which he acknowledged would hyperstimulate her uterus.  This goes against our hospital’s policy and the physical written order that this doctor signed his name under.  However, like some other doctors I work with, none of that mattered to him.  What he wanted was for me to “crank her pit” regardless and from my experience with this doctor, at the first sign of fetal distress we would have been crashing down the hallway for a stat cesarean!


Hyperstimulation of the uterus (more appropriately called tachysystole) is harmful and dangerous for both mothers and babies: 


“If contractions are persistently more often than 5 contractions in 10 minutes, this is called “tachysystole.” Tachysystole poses a problem for the fetus because it allows very little time for re-supply of the fetus with oxygen and removal of waste products. For a normal fetus, tachysystole can usually be tolerated for a while, but if it goes on long enough, the fetus can be expected to become increasingly hypoxic and acidotic.


Tachysystole is most often caused by too much oxytocin stimulation. In these cases, the simplest solution is to reduce or stop the oxytocin to achieve a more normal and better tolerated labor pattern.”

Electronic Fetal Heart Monitoring” by Dr. M. J. Hughey


The truth, however, is that many times stopping tachysystole is not as easy as just shutting the pitocin off.  Although the plasma half-life of pitocin is about 6 minutes, it can take up to 1 hour for the effects of pitocin to completely wear off.  And for a baby in distress, one more hour in a hyperstimulated uterus is too much!  So guess what?!  The physician has two choices:


#1 Administer yet another drug (like terbutaline) to decrease contractions and wait and see (unlikely to happen), or


#2 Administer yet another drug (like terbutaline) to decrease contractions while heading to the OR for an emergency cesarean section (much more likely to happen.) 


Because in the end…who wants to “sit” on a compromised baby?!



What is also unsettling is that my encounter with Dr. F regarding the most appropriate administration of pitocin for that mother was downright pleasant as compared to some of the other encounters I have had with much more intimidating and hot-headed physicians.  Labor and delivery nurses all over this country (including myself) have been bullied, yelled at, cursed out, and down-right humiliated by birth attendants who want you to “keep cranking the pit” regardless of maternal contraction or fetal heart rate patterns or in general, refusing to be a part of or questioning other harmful obstetrical practices.


I once had an obstetrician, while in the patient’s room, call me “incompetent” in front of the patient and her entire family because I had not continuously increased the pitocin every 15 minutes until I reached “max pit” and instead, kept the pitocin at half the maximum dose because increasing it anymore caused my patient to scream and cry in pain and her uterus to contract every 1 minute without a break.  Who wants a nurse to take care of them that was just called “incompetent” by their doctor??!? 


Another time I had a physician (who via this program called “OBLink” can watch her patient’s monitor strips from her own home or office) call me on the phone from her house to chew me out about not having the pitocin higher.  When I explained that I had to shut the pitocin off an hour earlier and start back up at a slower rate because the baby started to have repetitive and deep variable decelerations despite position changes, IV fluid bolus, and 10 liters of oxygen via face mask, I was told that the decels “weren’t big enough” to warrant such a “drastic measure as shutting of the pitocin” and I was “wasting her time” because “at the rate [I] was going [her] patient wouldn’t deliver until after midnight.”


I had yet a third doctor tell me once that he wished that only the “older” nurses on the floor would take care of his patients because they aren’t “as timid” and “are not afraid to turn up the pitocin when a doctor orders them to.”  That younger nurses like me are “too idealistic” and don’t understand “how the world really works.” 


And yet another time I had a physician tell me that I needed to “crank the pit to make this baby prove himself either way” and that if I couldn’t do “what needed to be done” for his patient, then he would ask the charge nurse to “replace me with a nurse who could.”


And guess what, when I came in the next day and read the birth log, I discovered that 3 out of those 4 patients ended up with cesarean sections after I had left that night for “fetal distress.” 




Although not one of these physicians actually wrote in black and white “Pit to Distress” and they didn’t have to; their words and actions speak to their true intentions.  These physicians are smart in the fact that they know that actually writing “pit to distress” like some practitioners do can land them with a law suit if an adverse outcome happens and they find themselves in court.  So while it is true that one’s medical record might not show “pit to distress” on the order form, it doesn’t mean that it didn’t happen to you!  What these doctors do instead are bully nurses into to doing their dirty work for them.  (And I would like to note that just like Dr. F, I have yet to encounter one physician who will actually physically put their hands on the IV pump and turn up the pitocin themselves when I refuse to do it!…..They know better!)



As a registered nurse my practice must adhere to the American Nurses Association Code of Ethics for Nurses.  Here is an excerpt:


“The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.  The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”


What these practitioners don’t realize is that when they work with nurses like me (and there are many out there!!), they are working with someone who values the health and safety of women and babies (as well as their nursing license) much more than a fake cordial kiss-ass relationship with some high-and-mighty doctor!  But let me tell you, its really frigging hard to work like that!  That is, to constantly battle with practitioners who have such a different philosophy about maternity care than you do!  I mean, even the best nurses will start to doubt themselves if they are constantly being bullied and told that they “can’t cut it” or are “incompetent” if they don’t follow the status quo!  Like many other nurses, sometimes I just don’t have the energy to argue and fight.  Sometimes I have down right lied to a doctor over the phone about how high the pitocin really is (telling them it’s running at a much higher rate than it actually is).  Other times I just “forget” to turn up the pitocin for hours at a time.  One time I actually disconnected the pitocin and discretely ran it into the floor!


Women of this earth…TAKE BACK YOUR BIRTH!!!  We need YOUR voice!  We need you to choose caregivers that practice evidenced based medicine, and BOYCOTT ones that don’t!  We need you to HIT THEM WHERE IT HURTS….in their WALLET!!  We need you to DEMAND better care!!  We nurses, birth advocates, doulas, childbirth educators, midwives, etc. etc. can’t make change without YOU!!


Thank you, Thank you, THANK YOU to Jill at Keyboard Revolutionary and Jill from The Unnecessarean for their blog posts on this issue!  I second their anger, outrage, and voice for change!!!


Are you an L&D nurse who has ever been ordered to “pit to distress?”  Are you a mother who has ever experienced the consequences of a birth attendant who followed a “pit to distress” philosophy?    Please share your story with us!! 


In closing I would like to say that I am NOT anti pitocin, but like ALL labor & delivery interventions, I speak out and advocate for the appropriate, evidencedbased, and safe use of them!


Please check out my next post!  “Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions


109 Responses to ““Pit to Distress”: A Disturbing Reality”

  1. sarah Says:

    “And I would like to note that just like Dr. F, I have yet to encounter one physician who will actually physically put their hands on the IV pump and turn up the pitocin themselves when I refuse to do it!…..They know better!)”

    I think this is the scariest part. They know that it would get them a lawsuit if they did it themselves, but it doesn’t stop them from doing it, only from getting their hands dirty. It is revolting to me that they are willing to sacrifice nurses to save their own hides. I am hoping to go back to school when my children are older (I only have one 2 year old son and another on the way but hope to have 4) to get my direct to BSN (I already have a Bachelors) and then a masters in midwifery, I am already dreading clinicals having to work with people like that (of course, who knows what the future will bring, I may not end up doing it, or doctors may be better by the time I do)

  2. nursingbirth Says:

    Sarah, I agree! I am so happy to hear that you are thinking about going into nursing and then perhaps midwifery! We need more nurses for sure!!! And CONGRATS on your little bun in the oven!! I am so happy you are reading my blog and others to educate yourself on your choices in childbirth!! THANK YOU for reading!!

  3. Thanks for writing this. I don’t know if people other than nurses know how hard it can be to go against a physician order. I wrote some steps on how to do that:

    I have gotten a response from a labor nurse with a similar story as yours, with a HORRIBLE outcome. I will link to your post because it illustrates very well what nurses are up against, and the public needs to know it.

  4. Diana J. Says:

    Thanks so much for that post! I had just posted on that after reading Jill’s post, and I”m going to link to your post as “part II.” Thanks for the info!

  5. I’m so glad you (and Reality Rounds) blogged about this.

    Thank you for being amazing nurses and thank you for your voices.

  6. […] Here is an L&D nurse weighing in on this topic. She confirms that it is in fact practiced and referred to as “pit to distress” and even written on orders as such. […]

  7. Zoey Says:

    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?

  8. Nikki Lee Says:

    Back in 1989 I was working at PCOM in Philadelphia when a multip came in banging out minute-long ctx every 2-3 minutes. The resident told me to hang Pit on her. I asked him if he wanted her uterus to fall out of her body. He repeated his order. I told him that if he wanted her to have Pit, he could hang it himself.

    I didn’t report this incident to my supervisor. Looking back, I should have.

    The result was that this incident was used as a reason to justify firing me. I don’t remember what happened to that mother.

    • NursingBirth Says:

      Nikki Lee, WOW! I am so sorry that that happened to you!! That is just awful! I have had physicians call the floor to tell us they are sending in a patient and then proceed to give me the residents a verbal order to start pit on the patient when she arrives. The order for pit is then written by the residents BEFORE the patient even arrives and is assessed!! Seriously! It makes me FURIOUS!! First of all, if the patient isnt contracting enough, perhaps she shouldnt be instructed to come to the hospital quite yet! And secondly, if she IS actually in labor on her own then she DOESNT NEED PIT unless it is a LAST RESORT!!! AHHHH! THank you so much for sharing your story!

  9. jube Says:

    I’m one of those moms. I went into the hospital with water broken, 3 centimeters dilated and contracting every 4-5 minutes. The first thing the doctor did was order pitocin. The pit changed my labor pattern to one, unrelenting contraction (I got about 10 seconds between 2-3 minute contractions). The nurse later told me that she prefers to attend c-sections. The pit started a series of interventions that ultimately ended in a vacuum extraction of my 5 pound, 13 ounce baby boy (after repeated “suggestions” that I have a c-section from the doctor). Needless to say, I’m seeing the midwives at my practice for this baby (due in November).

    • NursingBirth Says:

      jube, I am so saddened by your story!! You are not alone! I am so happy you have changed birth attendants! CONGRATS on your pregnancy and KUDOS to you for doing your research!!

  10. Jill Says:

    THANK YOU!!! I have been waiting for someone who has actually experienced this firsthand to chime in on the subject! I was starting to feel like my anger was running away with me since I was getting a lot of skepticism about whether or not “pit to distress” really meant what I thought it did. You are awesome. I am so glad we have you “behind enemy lines” so to speak, because you can tell us how it REALLY goes down. You are such a very important voice in this revolution! Don’t ever stop doing what you’re doing!

  11. Stassja Says:

    Thank you so much for sharing. Makes me look, yet again, at my own induction with my son. Thinking of the hours I spent, panicked, weeping and crying from the endless pain, contractions lasting 45 seconds to 1 minute with only 10-15 seconds in between with LESS pain, but not no pain. And this when they’d already been talking about being “worried” about hyperstimulating me. My son, thankfully, handled it well, and I didn’t have an emergency c-section for distress, but I did still end up with a CS that I believe was unnecessary, and in the meantime underwent a pretty agonizing experience.

    • NursingBirth Says:

      Stassja, thank you for sharing your story. Some babies can tolerate being in a hyperstimulated uterus for much longer than others. But eventually all babies will become distressed if the hyperstimulation is allowed to continue. Lukily for your little one, he handled it very well. I am saddened that you ended up with a cesarean after and induction..this is a story I see very very often. Some people might be thinking that I am against pitocin. I am NOT. I am not against interventions but I am against the inappropriate, unsafe, overuse of interventions including pitocin. There is a RIGHT way to run pit and there is aWRONG way to run pit. And a uterus that only has 10-15 seconds of rest is WRONG! A baby needs AT LEAST 1 minute where the uterus is AT REST in between contractions. And that is the bare minimum. I have never met you, nor was I there for your baby but from what you describe I can picture how agonizing it must have been for you.

  12. WheresMyCape Says:

    Thank you for commenting on this. I’d read the post on Unnecessarean and, like the one who posed you the question, was holding out hope that it was a misunderstanding of terms. I’m glad to know the truth, but it’s all I can do to keep from crying right now. How do you, and nurses like you, wade through this kind of nonsense and still keep your sanity and perspective? It just seems like it would get very emotionally exhausting very quickly.

    • NursingBirth Says:

      WheresMYCape, thank you for your comment. For me, it is a constant internal struggle at work. I can understand why nurses leave L&D. Two nurses recently left my floor and took jobs on Endoscopy. Endoscopy!! How much farther from L&D can you get! They were just tired of the bullshit, tired of being told they couldnt make a difference! Its heartbreaking!

  13. Thank you, thank you, thank you! This information is SO vital for people to read. You inspire me! I’ve added your links (and others from the many bloggers writing about this right now) to a post of my own and hopefully we can keep the ball rolling and gathering more momentum as more and more women hear and are outraged!!

  14. amysilliman Says:

    When I was an L&D nurse I had plenty of opportunities to witness PtD first hand. Where I worked it was mostly used on women who made very slow change over a very long period (often with women whose babies had a questionable FHR tracing – “all the more likely to tank!”) – just enough progress that they couldn’t call her C/S “failure to progress.” “Fetal distress” on the other hand, from hyperstimulation is a very valid reason to section.

    Zoey: This would be hard for a woman to watch out for (geez, as if having a baby isn’t enough work, now you have to be your own advocate and worry that the people you are placing your trust in might not be trustworthy), as NB noted all women respond differently to pit, so you might need the max dose and hardly contract at all, and I might overstim on the smallest dose. Best bet is to have these conversations with your provider prior to labour and if you don’t like the answers it is time to find a new provider.

    In New Zealand we have a rather interesting induction protocol – one I think most US L&D nurses would find shocking. I will send it to you sometime. While our titration is aggressive, it is done by midwives (no L&D nurses here- our L&B (birthing) units are midwife-run) and we, in general, are not known as being fans of PtD.

    • NursingBirth Says:

      amysilliman, I would love to read more about how things work for you in NZ! Especially the pitocin protocol. Thank you for commenting. While I agree with you that babies that are truly compromised from hyperstimulation need to be helped, I think we all have to remember how they got to that point in the first place. For example. I have taken care of quite a few women who ended up with an “emergency cesarean” after a long induction for fetal distress. But when you look back….it was still an UNNECESSARY necessary cesarean. Because if they werent a victim of the cascade of interventions, then their baby wouldnt have been in distress. If they werent a victim of “pit to distress” then they wouldnt have needed the cesarean! (or at least not an emergency cesarean!)

  15. Anne Says:

    So much is appalling in this, but my jaw literally dropped when I read of the doctor who wanted to “make this baby prove himself either way”. Make this newborn baby – no, not even, yet – this FETUS “prove himself”??


    And I am struck once again by the overriding belief system that seems to be so pervasive among OBs (and frankly, among many L&D nurses, present company obviously excluded): it really seems, from the language they use as much as the interventions they wield, that they believe that Pitocin IS what makes labor happen, period. That their active management is the only way that a baby could possibly be born.

    Is anyone – ANYONE AT ALL – talking about how to improve medical education of OBs these days? Are the schools aware there is a crisis at hand? Or, like the author of the original article quips at the end, are they determined to keep believing women who advocate for improvements in maternity care are part of some crazy fringe just because Ricki Lake said so?

    Sigh. Thanks for weighing in on this. As soon as I saw the link on Facebook I thought of your blog and hoped you would.

    • NursingBirth Says:

      Anne, you write ” it really seems, from the language they use as much as the interventions they wield, that they believe that Pitocin IS what makes labor happen, period. That their active management is the only way that a baby could possibly be born.”

      I can honestly say that I have had conversations with some OBs that I work with (mainly the ones that have very high C/S and intervention/induction rates) that truly believe that active management is the ONLY way to go and that all labor, unless actively managed, is dangerous and dysfunctional. I am NOT exaggerating! It is so sad!

      Thank you so much for your comment!!

  16. atyourcervix Says:

    Yep, yep, yep. Been there, as the nurse being told to “pit to distress” and “make the baby prove itself”. Absolutely sick. I have been bullied, berated, threatened to section the patient — if I didn’t increase the pit. Or, better yet, bullied and threatened when I have cut back or shut off the pit for fetal distress!!!

    You want to “up the pit”, you’re going to have to push the buttons on the pump yourself doctor!

    We actually have a policy/protocol to follow for all oxytocin administration (initiation, increases, decreases and shutting it off). If the FHR and/or the contraction pattern meet specific guidelines, we HAVE to cut the pitocin in half, or shut it off. Likewise, if we meet specific protocol that dictates exactly what a reassuring/reactive monitor strip looks like, then we can increase the pitocin as needed.

    • NursingBirth Says:

      atyourcervix, thank you so much for replying!! Dont you hate when a doc actually THREATENS to “section her” if you dont crank the pit! As if a C/S is intended by them to be punishment! It makes me SICK!! I had one doctor tell me that a patient who ended up with a C/S after a “failed” VBAC …

      “GOT WHAT SHE DESERVED” (direct quote!!)

      Because she ended up with a cesarean. Her crime?? She had written a detailed birth plan outlining that she did NOT want Pit (and rightfully so! She was a VBAC!) and he was FURIOUS with her for refusing it! She did get to fully dilated (without pit) and pushed for 3 hours but the baby wouldnt budge. So he performed a C/S with a friggin SMIRK on his ugly face. I felt like I wanted to throw up!

  17. I wish more first time moms could read posts like these. There is such a blind trust in OBs. Women genuinely believe that OBs wouldn’t do anything that could put them in harms way.

    So, if an OB gives you Pitocin, or says VBAC is to risky, it could only be because they are looking out for OUR best interest right?

    I’ll be blogging about this and directing people to your post.

    Women need to hear it from L&D nurses because they certainly aren’t going to hear it from OBs.

    Thank you so much for the work you do.

    • NursingBirth Says:

      Jen, I will be sure to read your post!! Thanks so much for linking and reading!! I agree. Our country’s women have such a BLIND trust in their OBs (and even midwives) and not all have the patient’s interests in mind. THere are some GREAT OBs, MFMs, FPs, and Midwives out there for sure! But there are also some awful ones!

  18. […] and let her know you want it moved up slowly and to stop turning it up if you get a good pattern, you have a partner in avoiding “pitting to distress”  Your nurse can be on your side.  BUT you need to continue to be proactive in watching her and […]

  19. enjoybirth Says:

    Another great post. Thanks! I love your insiders view. I really try to stress to my Hypnobabies Students and my doula clients, if they get induced, you have the right to have the pitocin turned up SLOWLY!

  20. Audrey Says:


    I read about this at Unnecesarean, and I like your post on it as well. It’s so great to hear about this from an insider’s view. I mean, the whole idea sucks, but thank you for posting about it. I told my husband about it last night after reading it at Unnecesarean, and he said he was hoping it was a gross exaggeration. He was so shocked, he just couldn’t believe this actually happens…. and that nobody talks about it! I will be showing him this post to let him know that it’s not uncommon. Thank you for making this horrific issue known!

    Oh, and THIS is why, when I give birth to my second daughter in October, I will be laboring at home, and showing up at the hospital (for my VBAC) crowning.

  21. atyourcervix, I’m sorry I didn’t give you a heads up that I had quoted you in the original post, especially since I quoted such a big chunk of the post.

    enjoybirth, I liked your post on pit to distress in which you said [I’m paraphrasing] that regardless of whether the goal is to pit to distress or just induce labor, patients have the right to ask that the pit be turned up slowly.

  22. Elizabeth Arnold Says:

    I think this is related because the pitocin issue is intertwined with the monitoring issue. There was a new statement released by ACOG last month, updating their FHR monitoring guidelines. I am not a health professional, so I would love for you to weigh in on this. The way I am reading it, they are stating that they know continuous electronic FHR monitoring has increased negative outcomes (because of the huge false-positive rate), and has not prevented ANY CP. But they say, okay, what we’re gonna do is “define existing terminology and narrow definitions and categories so that everyone is on the same page,” Um, hello? Who was it that said that they keep narrowing the definition of “normal” until no mother fits it anymore? Shouldn’t they be saying, hey, this tool doesn’t really help in normal healthy women and actually hurts–why don’t we discontinue its use and go back to intermittent monitoring? It’s so frustrating. I haven’t seen anyone respond to or write about this new ACOG statement. Can you please address it in a future blog post? Thanks,

    • NursingBirth Says:

      Elizabeth Arnold, When the new guidelines came out at the end of 2008, my hospital’s “powers that be” set up a series of these nighttime classes that ALL L&D nurses and midwives, and docs that work at/attend deliveries at my hospital were mandated to go to. These classes were meant to teach us all the new guidelines so we (meaning the nurses and the docs/midwives) were all “on the same page.” I remember sitting in those classes FUMING when they only briefly went over the FACT that even ACOG recognizes that there is a huge false positive rate, CEFM hasnt done anything to help moms or babies and instead has only increased the C/S rate, etc etc. I kept raising my hand to REMIND everyone that technically according to our hospital’s WRITTEN policy, that intermittent auscultation was the STANDARD OF CARE for low risk moms that are not being induced or augmented (although almost every doc except a few completely ignores that and orders CEFM for EVERY patient regardless) and that we should be teaching docs and nurses how to do that! I was ignored! GRRRR! I think you have something there! I will try to write a post about it! THanks again!

  23. Saylor Says:

    Bravo to you! Love the blog. I’m trying to get pregnant and I’ve talked to my doctor about attempting a VBAC…he tried to scare me off spouting old statistics about uterine ruptures of 7%, dead babies and such. He already told me if I fall off the curve of normal labor progression (I think he used 1 cm an hour), they will section me.

    I’m taking back my birth and going to a hospital birthing center 2 hours away that has a fabulous midwife and a great OB as her back up. I plan on hitting my old doc in the wallet. If enough of us demand better care and leave their practice, they will be forced to give us the evidence-based care we deserve.

    I wish we all had a nurse like you to advocate for us! Keep up the great work and thank you for the continuing education!

  24. Zoey Says:

    Nursingbirth- thank you for responding. I can’t wait to see your post.

  25. Laura Says:

    Nice. Real nice. Thankfully, my doctor handled my (needed) augmentation really well. I was started at 1 and increaed by one every half hour and turned off about an hour and a half before delivery because I was contracting on my own so well.

    (I was augmented due to prom at 35 weeks.)

    Too bad the hospital put my hippie OB and her MW out of business…


  26. Missy Says:

    Wow. This kind of stuff leaves me speechless. It disgusts me to think that there are doctors actually getting away with this, and that they are bullying good nurses like you to do their dirty work. It makes me sick! I am definitely spreading the news on my blog.

    Thanks so much for sharing this, all women should be warned!


  27. Michelle Says:

    I had to be induced with my last birth due to pre eclampsia…I normally would have had a homebirth.

    My husband argued for me to have low pitocen slowly increased, as I TOLERATED it. And they followed that. When I asked them to not increase (on their timetable) they listened. And when I told them that a little more would help, they increased. They DID not follow a strict schedule.

    HOWEVER, the doctor came in multiple times and asked if she could break my water despite my telling her that we were going as natural as possible.

    • NursingBirth Says:

      Michelle, I am so happy you had a supportive nursing team working with you that worked within your birth plan and administerd pitocin safetly and effectively. Thank you for sharging your story! I hope you know how important YOU were in the way your birth experience turned out!

  28. Danielle Says:

    That is so horrible. UGH. Thank you for this information – I know that none of my friends have even heard about something like this, but the sad thing is, I wonder if they’d care?

  29. Amanda Says:

    Just curious, since im not a nurse but AM looking into a future of nursing or Midwivery… 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 myown decision ( not that I truely 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 thosehours having 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 wasborn 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 husbands 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 truely needed.

  30. […] labor, midwife, OBGYN, obsterician, pit to distress, pitocin 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 […]

  31. Rachel Says:

    A few random and semi-related things:
    1st, thanks for this post. Like others, I was sort of hoping nobody had ever really received such an order. Hmph.

    2nd, I heard recently that my institution (I’m a med librarian) is about to get the system for monitoring the strips remotely/electronically. Will be interested/anxious to see how that goes.

    3rd, I must be some kind of weirdo, b/c your post makes me want to be an L&D nurse as a second career just so I can go around standing up to docs. 😉

  32. Jane Says:

    This scares me. I have had all 3 of my children in European hospitals and NEVER had an IV put in my arm!! Looks to me like your call is to women of America. This is not ‘routine’ in Europe, but most people in the US seem to accept this as normal practice. Now that I live here, I dread it when my own girls have kids. I’m a firm advocate of Natural Childbirth and believe that the less interferance there is in the birthing process, the better it is for both mother and child. Labour should only be actively managed in exceptional circumstances, not as standard practice.
    I am really grateful that Natural Childbirth was my experience. As long as financial profit continues to take precedence over a woman’s right to deliver her child in the way that she chooses, then progress in the US will be limited. Unnecessary C-sections cost this country a fortune every year. I was up and walking around within hours of having my children – just as nature intended!

    • NursingBirth Says:

      Jane, thank you for sharing your different perspective! So many women don’t realize that our maternity care system is in a crisis and the way we practice in this country is UNLIKE almost every other developed country. And THEY (NOT us) have the better results!!

  33. Heather Payne Says:

    Thank you for posting this. This post makes me appreciate all the more the wonderful nurses that I had during my first child’s birth.

    My OB wanted to schedule my baby’s birth to fit around his vacation. I passed. He told me “Pitocin isn’t that bad, women only think its bad because its more painful to be in the hospital” As if pitocin could be administered at home.

    I gave birth while he was on vacation. I came in 5cm dilated and contracting every two minutes. A nurse reluctantly wanted to put an IV in. I politely declined it and she seemed to perk up. She agreed that I didn’t really need one and encouraged me to use the tub. She must have been really yelled at by the OB on the phone for this. I progressed great in the tub and was quickly at 9cm. In retrospect I realize that the OB must have told her to get me out of the tub at that point. Once I was out and the OB was there I stalled. I declined the IV twice more and after being pushed by the OB had to put it in writing. I was made to push longer than I felt comfortable and started seeing stars. Of course, my baby started having decels because I wasn’t getting enough oxygen either. So the OB got her way and a saline lock was put in my arm two pushes before she was born.

    I am so grateful to my nurses that day. I ended up with a mostly positive natural birth that could have easily ended in a cesarean if that IV had been hung. If I could guarantee that I would have supportive nurses I might give birth in a hospital again. My second child was born at home.

    • NursingBirth Says:

      Heather Payne, wow what a story!! What progress for a first baby and there is no doubt in my mind that you being mobile and laboring in the tub helped your labor progress!! Thanks so much for sharing!

  34. […] “Pit to Distress”: A Disturbing Reality Dear NursingBirth,   I just saw a couple of posts about “pit to distress” on Unnecessarean and Keyboard […] […]

  35. Alev Says:

    Thanks so much for responding to my question.

    This makes me cry. Why are they deliberately putting babies and mothers at risk?

    It also makes me so happy that I’ll be giving birth at home with a midwife unless something happens to warrant medical intervention.

    Thanks again!!!

  36. Joy Says:

    My birth plan states NO PITOCIN whatsoever. I’m one of those lightweights who doesn’t need a lot of medical intervention and breaking my water alone causes me to reach 10 within 3 hours.

    So I’m planning on making sure my wishes are honored. I don’t care if I have to be in labor for 30 hours! I do not want a drop of that junk.

  37. Jenn Says:

    Oh, if only all nurses were as reasonable as you! This is an awesome post, I’ll be posting links to it.

    Here is a link to a post I once wrote on a “Pit to distress” birth that I attended as a doula:

    I’ve had a client ask to stop upping the Pitocin, and the nurse continued to work on the pump…when challenged she said “I thought you were joking.” Ummm…no…

    Another nurse, when the mom requested to have the Pitocin turned off until the anesthesiologist could come do her epidural, insisted that she couldn’t do that without the Dr’s permission. And true to that, she called the Dr. for permission before doing it. I would have some sympathy for the nurse if I thought she said that because she feared being “chewed out” by the OB…but her whole attitude (and statements!) was one of “why are you bothering me with this, it’s only a LITTLE bit of Pitocin!” Yes, that one was at a low dose…but as it turned out, the mom was in transition, so any added intensity is just NOT appreciated at that point, especially since she had decided to get an epidural, and had to wait while the anesthesiologist finished up with a cesarean.

  38. […] 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 […]

  39. Evie Says:

    Well this sure throws the “defensive medicine” excuse off the back of the cart.

  40. […] to Pitocin …. As always, Melissa over at Nursing Birth has written two FANTASTIC posts, Pit to Distress Part I and Part II about this topic.   She gives examples, and in her “Tell it like it is […]

  41. Pampered Mom Says:

    “Although not one of these physicians actually wrote in black and white “Pit to Distress” and they didn’t have to; their words and actions speak to their true intentions. These physicians are smart in the fact that they know that actually writing “pit to distress” like some practitioners do can land them with a law suit if an adverse outcome happens and they find themselves in court. ”

    This part rang true for me in so many ways. As I’ve read medical records (my own and those of others) regarding decisions that were made for any number of things it’s never ceased to amaze me how very little can be written there. Where the medical records make things appear one way (like patient elected x, y, or z) without mentioning how the decision was reached (like doctor persuaded patient to agree to x, y, or z).

    Fantastic post!

  42. Caitlin Says:

    I just wanted to say thank you so much for knowing what’s right, and more importantly for standing up for it. Thank you for fighting the good fight and helping us all take back our birth.

  43. Thanks so much for another informative post!

  44. […] “Pit to Distress”: A Disturbing Reality […]

  45. […] or forcing a c-section for fetal distress. Start with Unnecesarean, Keyboard Revolutionary, and NursingBirth. Those starting points also include links to various other posts on the topic. Relatedly, […]

  46. Neysa Says:

    This is sad and shocking. I wonder if this is what happened to me. My daughter was born on Christmas Day, and I wonder if that also had something to do with it.

    I was told when I arrived at the hospital for a test that my water had broken. I was not having any contractions, but they gave me Pit to start the process. I supposedly never got to 4 cm, so 13 hours later I had to have a c-section because she was in distress. The pitocin made my contractions very irregular. I wanted to leave, but they insisted I had to be admitted.

    I wish I’d know this back then.
    I do hope one day to have a VBAC.

  47. […] (and possibly UK?) obstetric care of “Pit To Distress”, one from Nursing Birth titled “Pit to Distress”: A Disturbing Reality, and another from Unnecesarean titled “Pit to Distress”: Your Ticket to an […]

  48. Anji Says:

    Great post, and something I hadn’t heard of before. I was lucky enough to give birth in a birthing centre in the UK, where there are no doctors at all, but it’s terrifying to think that had my circumstances been different (and indeed if they are different if I have another child) this could have happened to me. :/

    I also wanted to let you know that this post has been featured in today’s edition of the Carnival Of Feminist Parenting along with another on this subject – there have been a few in the blogosphere recently and I thought our readers would find both posts informative and educational. 🙂

  49. Jade Says:

    This story both horrified and elated me. I have had 2 children, one in hospital with unsupportive “med-wives” and one at home (WOW).

    I am studying to be a doula and also want to become a midwife, but i was nervous about working in the confines of a hospital setting, but now i am thinking that in hospital more than anywhere, women need people like you and me to advocate for their best interests.

  50. Rachel Says:

    I wanted to thank-you for this post. As an L&D nurse, I get so frustrated with the whole pit thing. It was good to hear you take a stand and give me the courage to do so also. So many nurses just go along with this. I know I have had docs call me and inform me that I am not increasing the pit up enough or in a timely manner. Where I deliver, we almost always put pit up to 20. That’s just expected. I would love to see more moms say no, but unfortunately that just doesn’t happen. Quite honestly most moms I work with are all too happy to push their labor along.

    Anyways, long post…just wanted to say thanks. I needed to know that other nurses care about these kinds of issues also.

    • NursingBirth Says:

      Rachel, THANK YOU!!! I was just commenting to Candice that I really appreciate when L&D nurses comment! L&D nurses like us really need to stick together and encourage eachother because it can get so hard to go into work everyday setting youself up for a fight! I hate that! THank you for reading and sharing!

  51. jessica Says:

    I am an example of a “pit- to distress” that ended in an emergency c-sect. After 12 hours of active labor (contractions every 3-4 minuteslasting for 90 sec), I had failed to progress beyond 5 cm. The midwife left her shift and the OB that came on for the next shift ordered pit. I refused for 4 hours- my hubby almost kicked the dr out of the room at one point. Finally I gave in- I was too tired to refuse anymore. pit- to distress for my son was only 8 though. He started having decels at 6, but the dr ordered to continue increassing the dose. At 8, he deceled below 80 and his heartrate could not come back over 95 between contractions. Down the hall we raced.
    I know that I had stalled at 5-6 cm, but I strongly believe that had the OB been more willing to wait (not push in as many cestions in a night as possible- he did at LEAST 5 c-sections that night alone- that the nurse told me he was doing) We could have gotten thru the stall. Now, I have major scarring and deep tissue damage that is not healing 6 months later.
    Can I find anywhere in the written records that he ordered pit to distress? NO!

    • NursingBirth Says:

      jessica, I am deeply saddened to read about your story. I am so sorry! Thank you so much for sharing. Your story will surely inspire other women to learn about their options!

  52. Mimi Says:

    Thank you for getting this shameful practice exposed! I’m a Bradley Method teacher and I have to restrain myself from scaring my students. I don’t want them to mistakenly think I’m anti-doctor, just pro-parents! The baby needs an advocate and if the parents don’t get the real scoop in a childbirth class, then they’ve been conned.
    Honestly, I don’t know how these arrogant, unethical obstetricians live with themselves.What cowards some are, who know darned well they’re doing such harm, but continue anyway.

    • NursingBirth Says:

      Mimi, I hear ya! I like that you describe yourself as “pro-parents” not “anti-obstetrician”!! I try to convey that message through my writing but sometimes I don’t know if it comes off the way I intend!

  53. Cheri Says:

    Wow, this is simply a fantastic blog! If only all expectant mothers would read this. Nice work.

  54. […] disagree with; a triad of posts from L&D nurse Melissa at Nursing Birth — Pit to Distress part 1, part 2, and understanding the pitocin dosage; former L&D nurse now new CNM Rebirth Nurse; and […]

  55. Karen Joy Says:

    I commented on your Part 2 post, as well, but I just had to mention that I called a friend of mine who used to be a L&D nurse, but recently switched to couplet care because she was tired of being bullied into unethical practices by doctors, and that the hospital culture where she works does not support anything even remotely resembling natural birthing. I asked about her experiences, and she confirmed that “pit to distress” was a disturbingly common — very common — procedure. “Crank it; I have a dinner date tonight!”

  56. […] Read more about “Pit to Distress” here and here. […]

  57. Johanne Says:

    Thank you for posts like these. Sometimes we may not know our physician’s views on every single issue when we choose them, and it’s in being informed that we can stand up for ourselves when the time comes. If the patient knows about the practise, than she is likely to be able to discuss it with the doctor rather than just “go with the flow”, and then say “well, I needed the c-section”.

    Knowledge is power.

  58. SandraRh Says:

    Boy do I wish I knew then what I know now. My first birth would have been so different. I was 22. My water broke in the early AM on a Saturday. I called in to ask if I should come in or not. They told me to go ahead and come in. I wasn’t experiencing contractions that I could feel. But I was having them. They monitored me (I was 4 cm) and decided that I should be put on pitocin. So from then on I was on my back in bed hooked up to a bunch of wires and lines. Apparently I was the only one in labor that day. The nurse kept coming in every 15-20 minutes or so and upped the pit. Problem was I swear unlike you they never fluctuated it up and down. They only went UP. 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 26. I didn’t know what was too high or not but I do remember looking over at her as she hit the button up to 26 and thinking I can’t take much more of this. I wonder if she’ll notice if I cut it back down. At 8 am that morning I was 4 cm…and by almost 11 a.m. I was supposedly ONLY 6. That wasn’t good enough. for them. Funny because supposedly I was going much faster than expected but in the same breath they would say that 1/2 a centimeter an hour was just not good enough. I broke down and got an epidural. Luckily the epidural relaxed me enough that 15 minutes after he stuck the needle in my baby was coming out. I also got an unnecessary episiotomy because the doctor on call does 100% episiotomies! I also assume that he’s the one that ordered the pit to be as high as it was going. I WAS the only one in labor. I am sure he was quite put out with me for going in to labor.

  59. SandraRh Says:

    oh and since then I have had one home birth and am working on another!

  60. As a future nursing educator I found this blog to be indispensable. Over the past fifteen years of my nursing career, I have been in virtually every nursing educational setting. For this reason I have collected numerous nursing resources on the subjects of cognitive processes, learning and teaching techniques. This blog by far pulls all the information together, and it will become the most utilized of my collection. The information is laid out in a logical format that starts with the basic concepts, theories, objectives and goals of learning.

  61. […] Pit to Distress: A Disturbing Reality ~ Nursing Birth […]

  62. […] “Pit to Distress”: A Disturbing Reality « Nursing Birth Posted by Diane on Sep-1-2009 “Pit to Distress”: A Disturbing Reality « Nursing Birth. […]

  63. I am terrified that drs would do this after reading but I think that’s what happened to me with my 2nd daughter. My water broke with the 1st but I wasn’t dilated so they started pit and 6 hours later with no problems and no med our first baby was born. So it seemed normal to me with the 2nd that they started pit to speed things up but they had it turned up so high that it wasn’t doing any good there wasn’t even a good minute between contractions so I was in labor longer. Lucky for me when the dr broke my water an hour and half later my baby delivered herself and was on the table before anyone could get in there. I just thought I had to pee!!!! Again no pain med and thank the lord no csection. I am 14wks pregnant now and seriously thinking I’ll just wait this one out until there’s no need for pit. The only reason I didn’t last time was I thought I would need the strep b antibiotics and never make it back to the hospital if my water broke at home.

  64. ashley Says:

    im glad i come across this because its what they did with my daughter! i went in after my water broke and as soon as i got in there they started pumping me full of potcine. and they doc kept hollering turn it up and they were already giving me the max dose. it really worries me this time around, but know that i know about it i will be watching. im due in feb with my second and i have a new doc, hopefully things will go better this time around.

  65. […] blogosphere lit up this last week with posts about “pit to distress” (see here, and here), the practice of administering the maximum dose of Pitocin (synthetic oxytocin) to a laboring […]

  66. […] systems by induction often goes undetected for some time. This means that when the doctor orders “pit to distress” (the point when the heart rate shows the stress), you’re looking at an overly stressed out […]

  67. VW Says:

    Hi, I’m coming to this a bit late, but I’m trying to administer pitocin administration protocols to figure out what happened during my daughter’s birth last year. It wasn’t a c-section, but a forceps delivery due to non-reassuring heart beat patterns after a pitocin-aumented labor (and they would have gone to c-section if the forceps hadn’t worked). I looked at my clinical notes, and the pitocin was indeed put up all the way to 60ml/hr at the highest dose, and then, when my daughter’s heart started having late decels, first turned off and then turned down to 48ml/hr. I assume that this doesn’t count as ‘pit to distress’ since they actually did turn it down when her heart rate started taking a dive (but correct me if I’m wrong). But it did still necessitate the instrumental delivery since there was no time for her to work her way down on her own and I couldn’t push well enough b/c of the epidural and then she suffered true shoulder dystocia and a collapsed lung…you can see the train wreck!)

    Here’s my question: does pit always need to get cranked up more and more to cause cervical change, or could you keep someone at, say, 48ml/hr for the entire labor as long as they’re having regular contractions and dilating? The reason I am asking is for a future birth plan, in case I require the evil juice again (long story, but there’s some risk that the same craziness that led to the augmentation with my daughter’s birth would happen again), would it make sense to ask specifically to be given only the lowest dose of pit that is effective?

    Any info/advice would be very much appreciated! Thank you!

    • Sami Says:

      VW-I’m not a medical professional, but I’m passionate about natural birth and am well educated on the horrors of our society’s use of interventions in labor and delivery. My advice to you would be that, although your doctor may not have ordered pit to distress, that most certainly is what happened. Also, yes, I would say that no matter what condition or risk you have, if you must have Pitocin, it is always best to stick with the lowest dosage possible, especially if that low dose is proving to be effective.

  68. Erica Says:

    As a doula I see this all of the time. Docs get so pissed off when patients stand up for themselves. Thank you for sharing this.

  69. Sami Says:

    This honestly made me cry. To know there are nurses out there who care enough to let the Pit run on the floor or lie to the Dr., I can’t even explain how that makes me feel. It’s so awesome to know there are people in the health care field who will actually advocate for us, women who, even if completely well-educated on the subject, may not be able to find their voice to stand up for themselves and their rights when in the throes of labor.

    I think the most difficult thing is knowing how a doctor is actually going to act once you’re in labor. It’s scary not knowing how they will truly react. My doctor claims to be fine with my desire for a natural, unmedicated birth, but how do I know how she will really act and react to me when I’m in labor?

    FYI, if a doctor told my nurse in front of me that she is incompetent, and she was clearly only trying to stand up for me, my baby, our health and safety, I would request a new doctor! That’s absurd!

    I’m so sorry you have to deal with doctors like that, but I’m very grateful for nurses like you, who stay in the field, and continue to advocate for us!!!

    Thank you!!

  70. […] warning to consumers about the “pit to distress” syndrome,  in which healthcare providers intentionally “crank up the pit” to put the baby in […]

  71. Holly Says:

    happy to share, though i wish this wasn’t something that needed to be shared in the first place 😦 My doctor was well aware of my feelings towards natural child birth and drugs, pitocin in particular. He threated to induce and threatened c-section, broke my water with out asking and when I said “did you just break my water?” he said ” don’t know, maybe you broke it” and then I saw the wand in his hand that they use to break water. I probably wouldn’t have cared if he has asked, but man was I peeved at his comment – at least take ownership of your jackassedness. I eventually had to have iv fluids, and internal fetal monitoring (as a compromise with the dr!) and after zayden was out they gave me pitocin. Of the numerous times I asked my dr about drugs, his policies and practices he never once mentioned that it is routine to give pit after the baby is out (supposedly to prevent hemorrhaging) no matter the condition the mom is in (i was doing great!). My doula (who was AWEOSME, EVERYONE should have a doula) wasn’t aware that this was a common practice (not sure if it is or not). Moral of the story, for me at least, when you think you know your doctor, you proabably don’t, if you can and are comfertable with it get a midwife and consider homebirth

  72. […] warning to consumers about the “pit to distress” syndrome,  in which healthcare providers intentionally “crank up the pit” to put the baby in […]

  73. […] article “Pit to Distress” by NursingBirth, a Labor& Delivery Nurse’s view from the inside, is not meant to scare […]

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s