Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Pitocin Protocol for Labor Induction/Augmentation Decoded July 9, 2009

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

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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:

  • Anaphylactic reaction
  • Postpartum hemorrhage
  • Cardiac arrhythmia
  • Fatal afibrinogenemia
  • Hypertensive episodes
  • Nausea
  • Vomiting
  • Premature ventricular contractions
  • Pelvic hematoma
  • Subarachnoid hemorrhage
  • Hypertensive episodes
  • Rupture of the uterus
  • Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.
  • Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been reported.

 

2) Potential adverse reactions in the fetus or neonate related to hyperstimulation of uterus:

  • Bradycardia
  • Premature ventricular contractions and other arrhythmias
  • Permanent CNS or brain damage
  • Fetal death
  • Neonatal seizures have been reported with the use of Pitocin.

 

3) Potential adverse reactions in the fetus related to use of oxytocin in the mother:

  • Low Apgar scores at five minutes
  • Neonatal jaundice
  • Neonatal retinal hemorrhage

 

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

Advertisements
 

46 Responses to “Pitocin Protocol for Labor Induction/Augmentation Decoded”

  1. Jennifer Says:

    Here’s something interesting for you- on my unit, we have a physician who started the trend of “actively managing labor.”
    This means that the only women who do not get pit augmentation are the ones who deliver precipitously before we can get pit set up. It also means that we start pit at 6 and go up by 6 every 15 minutes to a max dose of 42. Crazy, no? And we get yelled at if our pit isn’t at lease at 30 after 2 hours regardless of ctx pattern. We do about 300 deliveries a month, 40% c/s (we are high risk, so that partially accounts for the very high rate). Our epidural rate is about 90% of all vaginal deliveries. I wonder why?

    • NursingBirth Says:

      Jennifer….WOW! I am so glad you commented. You write “And we get yelled at if our pit isn’t at lease at 30 after 2 hours regardless of ctx pattern. ” See, now if the OB (or whomever) was using pitocin appropriately then you wouldnt be yelled at for that. Because not everyone needs to be at “max pit” to deliver! ARRRRRG!!! SOOOO FRUSTRATING!!! I hope everyone who reads this post reads your comment. All over the web I have read reviews of my and others blog posts on this topic. Most are corroborating my story. Others reject it as exhaggeratino like “oh that cant POSSIBLY be true!” Well WAKE UP AMERICA! It is!!!

  2. atyourcervix Says:

    We can titrate pitocin up to 30 mu/min. Anything above that, we need further written orders. Absolute max is 40 mu/min. Once I hit 30 mu/min, I ask the MD to write up concentrated pitocin (40 units in 1000cc), so I don’t have to worry so much about fluid overload and water intoxication – though I am still VERY worried about it. We tend to run LR at 125cc/hr while the pt is on pitocin. That’s a heck of a lot of fluid!!! (30 mu/min is 90cc/hr with our 20 units in 1000cc standard bags.)

    Add in the LR bolus for the epidural (500-1000cc) plus any boluses for fetal distress, plus the mainline LR, plus the pitocin…..no wonder these ladies are so full of fluid still at the 2 week check up!!!

    • NursingBirth Says:

      at your cervix….oh man you are so right! I try to heplock a mom whenever possible. I think everyone forgets while most of our mothers are young healthy women and can handle IV fluid….we still can’t use it carelessly!! 40mu/min! Wow! We can’t go above 30 at our hospital. That is a lot!!

  3. Michelle Says:

    I’ve been reading your blog and really enjoying it. I even sent one post to some friends….who promptly posted it on facebook. LOL. Your famous now.

    I wondered if you had heard of a lady named Carri who recently lost her baby and almost her life from an embulism. Sorry I can’t remember the exact name of the condition. It’s all over the internet circles. Unfortunately instead of a community pulling together and being there for this family they are defaming her.

    I ran across a blog which I despise and a particular post I dislike. What do you think?

    http://skepticalob.blogspot.com/2009/06/homebirth-midwives-are-quacks.html

    • NursingBirth Says:

      Michelle, I have not heard about this story at all. I also have been out of town for the last 5 days with limited access to TV and internet. That post by that doctor infuriates me beyond belief. I can’t really comment further because I don’t know the entire story. I think Skeptical OB is making many BIG mistakes in her post that many anti-homebirth docs make all the time.

      These BOGUS and FALSE claims include 1) all home birth midwives are “lay” midwives. 2) direct entry midwives have no training or education. 3) good quality research has proven that homebirth is dangerous. 4) mothers and babies do not die in the hospital, 5) there are no current maternity care practices that hosptial based birth attendants practice that are harmful to mothers and babies and cause harmful outcomes. 6) unassisted homebirth is the same thing as homebirth attended by a home birth midwife. (again these are all claims that Skeptical OB makes that are FALSE)

      I def need to learn more about this story! Perhaps this particular homebirth midwife did make harmful misjudgements. But guess what, there are many many homebirth midwives out there that are qualified, trainied, educated, safe, and supportive Not all homebirth midwives are great. Not all nurses are great. Not all police officers are great. Not all teachers are great. and guess what….not all OBs are great too! In fact, many do more harm to childbirth than good! So to say that “All homebirth midwives are quacks” is OUTRAGEOUS, JUDGEMENTAL, IGNORANT, HARMFUL, AND BLIND!

      Thanks for alerting me to this story!

  4. Erin Says:

    I know you were directing your question to nursingbirth, Michelle, but I have to say that post is revolting. Are you saying that the community is defaming the woman who lost her child because she was having a homebirth when she had an embolism? At any rate, the thing that is most ridiculous and outrageous about that post is the idea that a) most or all deaths of children or mothers happen during homebirths, which I think any statistical survey would plainly say isn’t true; and b) because this is so, deaths that occur in hospitals aren’t “unnecessary” but only happen when “everything was done that could be done.” Whereas the truth is, if that poster really cared about women and babies s/he would be outraged about the state of obstetrical care in the US and the unnecessary procedures that put the lives of women and babies at risk every day, as we saw in the videos about the memorial quilt and the ridiculously high infant and maternal death rates we have in this country. But the poster isn’t really interested in any of those things. Or, you know, FACTS – meaning the results of multiple evidence based medical research studies from different sources. (In addition to the fact that CPMs in many states are in fact licensed, not just random women pretending to be midwives, and those in other states are actively TRYING to be licensed.) It’s pretty funny to think that the same doctor who wouldn’t do a homebirth “because of the danger” would also jack up a woman’s pit to stress for convenience/ ignorance, even though this can be extremely dangerous (did you notice in the video on the quilt how many women who died did so from adverse reactions to pit and other induction drugs?).

  5. pinky Says:

    Each hospital is different. You cannot look at the numbers on the pump and tell what amount of pitocin is being infused. At Saint Elizabeth’s hospital in Boston, the Pitocin mixture was so strange that we had a cheat sheet to figure it out. Reason being, it was in a 250 ml bag so that a woman would not get a lot of fluid after delivery with her pitocin.

    I personally never get to max pitocin. If a woman is having max pit, she probably isn’t in effective labor. Like the saying goes, sometimes less is more.

  6. Michelle Says:

    The bad thing about this woman’s blog and what she is saying about Carri is that it’s not accurate. Carri was planning a UC but as soon as she thought she might be having twins she hired a midwife. She also got an ultrasound. The midwife said, over and over, that they could hear 2 heartbeats…Carri at home could too. Mistake, but nothing to beat Carri up over.

    She makes Carri seem like this terrible person. Really a terrible thing happened to a nice person. I don’t know why this has caused so much turmoil. No one creates this level of stress when a doctor loses a baby. I just don’t get it.

    Also she has this terrible post: http://skepticalob.blogspot.com/2009/07/homebirth-kills-babies.html

    • NursingBirth Says:

      Michelle you write: “No one creates this level of stress when a doctor loses a baby. I just don’t get it.”

      Interesting isn’t it! I can’t even read these horrible posts without crying!! WOW this OB is so outrageous!

  7. Erin Says:

    @ Michelle – what makes me sad about the post (the second one you linked) is that the statistics she cites are interesting, maybe even important, and should be discussed – especially considering the plain fact that MD-attended births have a higher death rate than CNMs. (Does she demonize her own profession the way she demonizes direct entry midwives?) But the whole tone and intent of the post makes it difficult to have a conversation rather than a fight (though the first response to the poster was thoughtful). . . The post also made me realize something – is the argument in favor of prophylactic C-sections a theoretical decline in stillbirths? How would such a decline compare to the other dangers C-sections pose to mothers and babies? (I find a supposed gain by C-sections difficult to imagine since the maternal and infant mortality rates in this country are staying stable.) I think everybody should be talking about these issues seriously, rather than dressing them up in hyperbolic and demonizing language (eg, CPMs are quacks, homebirth kills, etc etc.). Honestly, I respect and support a woman’s right to birth in her own home, with any kind of attendant she chooses; at the same time, I considered home birth and this was ultimately not a choice I felt comfortable with. But hospitals drive some women out of their care with the kinds of practices nursing birth talks about. . .

    • NursingBirth Says:

      Erin, YES YES YES YES YES!!!!

      Ditto to everything you wrote including: “I think everybody should be talking about these issues seriously, rather than dressing them up in hyperbolic and demonizing language (eg, CPMs are quacks, homebirth kills, etc etc.).” AND “But the whole tone and intent of the post makes it difficult to have a conversation rather than a fight”

  8. Aisha Says:

    That doctor that wrote those blogs does have a point, unnassisted home births are extremely dangerous, that is why soo many women throughout the world die from childbirth because of the lack of prenatal care which is partly the reason why such OB interventions do exist.
    The midwives that the OB is talking about are direct entry midwives whom are not trained as nurses like a Certified Nurse midwife would be and whom may or may not be able to identify emergency scenarios.
    Not all women in antiquity survived childbirth, we cannot forget that.
    You cannot deny that in a way this OB is defending CNM’s in the US and in Europe because they are highly trained and treat specifically low risk births which is why they have even lower mortality rates than OB’s whom treat high risk and low risk births. With a DEM (direct entry midwife) States may not regulate whether they can treat high risk births and put the mother at risk and the baby, which is what I think this OB’s argument is.

    • NursingBirth Says:

      Aisha, I see where you are going but I respectfully disagree. If “Skeptical OB” was arguing against Unassisted Homebirth (which I have been honest that I too am uneasy about but I also ackknowledge that I know little to nothing about the movement) then she wouldnt have made the HORRIBLE, IGNORANT, MISINFORMED, HARMFUL claim that homebirth= unassisted home birth. THEY ARE NOT THE SAME! Planned homebirth with an educated, licensed, experienced birth attendant with an established plan/option for a safe and swift transfer to the hospital if necessary for low risk, healthy women experiencing uncomplicated pregnancies has been shown through quality research to be AS SAFE IF NOT SAFER than planned hospital births. Women who are planning homebirths do obtain prenatal care from their birth attendant, whether that be a direct entry midwife (which includes among others CPM, CM, LM, etc) or acertified nurse midwife. I disagree with the claim that any midwife that went through midwifery school but did not become a nurse first cannot identify emergency scenarios. Direct entry midwives are not just women who have had no education or formal training. This is a harmful and untrue myth. Also states that “do not regulate” direct entry/home birth midwives do so by choice,….that is, thier choice is to OUTLAW direct entry/homebirth midwives all together. THerefore these midwives are forced to practice underground or not practice at all.

      There is a huge can of worms that “Skeptical OB” is opening here and she does not have the knowledge about this topic that she thinks she does. She is misinformed, ignorant, stubborn, and harmful. If she really wanted to present a “con” side to homebirth in a professional way, then she wouldnt be using flamboyant, sensationalized, defamatory, demonizing language. I cannot take her seriously because of this very fact.

      In Holland 30%, that’s right….THIRTY PERCENT OF BIRTHS occur at home. Holland also has the lowest maternal and infant mortality rates in the world, including both developed and undeveloped nations.

      • Aisha Says:

        I didn’t mean to deffend the OB, I do think she’s being a little close minded, but I do try to see her point, even as extremely biased as she was on her rant, I try to give her a fair chance. As a woman giving birth in 3 weeks, I feel more trusting going with a Certified Nurse Midwife rather than a Direct Entry Midwife because I feel that her education, training and certification is more verifyable than that of a DEM.

        I am, as mentioned previously having all my prenatal care and labor and delivery with a CNM. I chose her contiously because I do not believe that I need an OB to handle a low risk birth. I personally wouldn’t deliver at home, I don’t feel spiritually or a sentimental attachment to my home during birth and I feel more comfortable being in a center or hospital where I know that if any complications arise, it would be handled immediately rather than an ambulance call away. But that’s my general prefference.

        I love reading your blog because it is very imformative and I can understand the unfair and unnecessary practices done in hospital settings and I would like to learn to avoid them in my own delivery. Eventhough I favor normal birth, I am very aware and grateful for the medical advances that have been done by modern medicine, however I’d preffer if it were used only for absolutely necessary situations rather than any regular, low risk situation.
        To be fair, balanced and objective, I’d ask if you could give us more information on when those medical interventions are necessary.

        • NursingBirth Says:

          Aisha, First and foremost thank you, thank you, THANK YOU for your support, your comments, your opinion, and your suggestions. I truly do take them to heart.

          That being said, I do believe that I am fair, balanced, and objective in my writing as well as honest about when medical interventions are necessary. I believe this because I personally make a conscious effort to be fair, balanced, and objective in my writing because I place VALUE on those qualities. In fact, if “the flip side” isn’t explicitly presented in a certain post, it is often addressed by myself or another reader in the comments section. However, I would like to take this opportunity to remind all of my readers that this blog is my PERSONAL blog. I am not paid for this, I do not blog for a certain organization, and blogging is my hobby, not my career. So if during a post I decide to be unfair, lopsided, and opinionated then it is indeed my prerogative Also I am not a midwife or a doctor, nor have I ever claimed to be and therefore this blog is meant only to be thought provoking and NOT a substitute for midwifery or medical advice.

          Furthermore I would like to say that I completely agree with you when you write” ” I am very aware and grateful for the medical advances that have been done by modern medicine, however I’d prefer if it were used only for absolutely necessary situations rather than any regular, low risk situation” as well as your personal feelings about where you feel you would be most comfortable giving birth.

          Please check out my prior blog post: My Philosophy: Birth, Breastfeeding, and Advocacy at https://nursingbirth.wordpress.com/2009/04/25/my-philosophy-birth-breastfeeding-and-advocacy/

          If I could quote myself……” I believe that every woman should have the opportunity to give birth as she wishes in an environment in which she feels nurtured and secure and her emotional well-being, privacy, and personal preferences are respected, whether that be in a hospital, birthing center, or at home.” So KUDOS to you for seeking out a birth attendant and birth place that makes you feel safe and comfortable.

          And as far as Skeptical OB is concerned, it is my personal philosophy in life to NOT give anyone a “fair chance” that doesn’t fight fair. And Skeptical OB does NOT fight fair. Perhaps you and I differ in that way, which I to indeed respect.

          Thanks again for your thought provoking comment.

          • Aisha Says:

            I promise this is the last reply 😉
            I’m not saying that you are not being fair, balanced and objective, but I do feel like I get more and more scared of setting foot at the hospital from reading about pitosin and epidurals and c-sections when sometimes they are used in a safe and necessary way. So, I would love to know when those interventions can be used in a safe way. Or why they started being used in the first place.
            You say that you are not a midwife but you are a medical professional and so your eyes, experience, opinion and educational knowledge on this subject is relevant and although it is meant to be thought provoking, it comes from a reliable source because of your education and first hand experience. I try to do my own research, but for some reason real life experience counts.
            Thanks again!

  9. B Says:

    Hiya,
    I just wanted to send you some positive vibes! I’m a midwife in the UK and all your stories are 99% of the time (although sadly not always…) a million miles away from what I experience. You should come over here and get some birth experience British-style!
    I’m not saying it is perfect, far from it, but I think in light of really focusing on Women-centred care, and ensuring midwives are the leading carers in normal birth (as opposed to obsetetrics) we are beginning to really empower women to have the birth experience they deserve.
    If only we could teach obstetricians about normal physiology the world would be a better place, eh?

    Thanks
    B
    xx

    • NursingBirth Says:

      B, I am so glad to hear that!!! I love hearing stories from midwives or women who practice/live in other countries like the UK, Australia, NZ, Holland, etc etc. Thank you for reading. Do you have a blog that talks about your experiences being a midwife? IF so I’d love to check it out!!

  10. Candice Says:

    We are another 6 up 6 q 15 to 30 max unit here. 😦 And they want AROM asap with it… ASAP, people! Our protocol is 2 up 2 q 15, but with our overly aggressive docs, the 6 Pit protocol is used more. So wrong. 😦

  11. Aron Says:

    just de-lurking to point out (as a future nurse-midwife) that direct-entry midwives are in fact highly trained and go through several years of education, and are licensed in many states (meaning the states regulate them plenty). Europe has about an equal number of DEMs and CNMs working in their various health care settings. The greatest factor in third world maternal/infant deaths (as well as those in antiquity) is not the local witchwife chanting and waving herbs over a gray floppy baby, it is the lack of proper nutrition and sanitation. Good prenatal care – which DEMs do in fact provide – includes education to women in these settings to help them with those things as well as pointing them towards any community resources available. DEMs are trained specifically to care for women in out of hospital settings – meaning they need to be able to identify and act on potential problems quickly without relying on code teams to run to their aid. They have outstanding statistics in terms of maternal/infant safety (see the 2006 Brittish Journal of Medicine study that compared births of over 50,000 low-risk women in the care of doctors and homebirth DEMs which concluded resoundingly that homebirth under the care of a skilled direct entry midwife was as safe for babies and safer for mothers in terms of outcomes).

    Anyway, stepping off of soap box now and ending mini-rant. I’m choosing the nurse midwifery route because it’s the most expedient for my circumstances and I believe that nurse midwives are equally competent and compassionate birth attendants, but both routes offer real value in terms of education and opportunities and women should be supported in chosing the care providers that best suit their own situational needs.

    • NursingBirth Says:

      Aron, I appreciate your “mini-rant”. SO TRUE and SO well written!! DITTO TO IT ALL!! THANK YOU!

      You write, ” I believe that nurse midwives are equally competent and compassionate birth attendants, but both routes offer real value in terms of education and opportunities and women should be supported in chosing the care providers that best suit their own situational needs.”

      I couldnt agree more!! Thank you again!

  12. Kim Says:

    OT-Breech protocol.

    Hey. This doesn’t apply to this particular topic, but I was hoping to find out what the best route to take for a breech near term? Ever since I heard about Canada’s policy reversal, I’ve been thinking about it more and more. I would be so sad to have a CSec just because it’s policy. I wouldn’t want to be foolish about it either though. Are there circumstances where a ‘trial of labor’ (for lack of a better term) for breech mama’s might be acceptable? What could be done to find a provider who would be on-board with that?

  13. Kim Says:

    About the SkepticalOB blog….I find it hard to respect anything that someone who uses so much hate and emotion to make their point says. Amy Tuteur has never impressed me with any of the data she presents. I’m much more inclined to take something more impartial and that presents more evidence and multiple sides of the argument. To make such a blanket black and white statement like “Homebirths Kill Babies” is really unprofessional and closed minded in my point of view. On the other hand I don’t really appreciate the other end of the spectrum that says “Doctors are evil and CSecs are never worth it.” We don’t live in a black and white world, and we should recognize that and take the risks we feel are personally appropriate without demonizing each other over it. I may feel fine about taking the risk of birthing at home…but for someone else that may just be unacceptable. That’s fine. Neither of us are “wrong.”

  14. Stephanie Says:

    I would be interested in knowing when pitocin is actually medically necessary since that is what the OB is implying just by ordering it, though it is obviously not always true. What are some actual situations where it is viably needed. Sorry if I missed it in your post I’d just like to be aware so I know what circumstances to listen/look for in my own experiences. Thank you for all your helpful. I can’t tell you enough how much I enjoy reading your blog – hope my next nurse is just like you!
    p.s. Can’t help but reiterate the point that there are exceptional as well as horrible people in every profession – DEM, OB, convienence store clerk. I’ve had one delivery with a doctor (in a hospital) one with a midwife (at home) and am expecting another little one in September who will probably be born in a small hospital. Both experiences where great because I was working with good individuals who respected me, my choices and goals. Because we’ve had to move around a bit we can’t stick with the same provider for each pregnancy. My experiences have been great because I found the best provider for me and each situation and we worked together as a team. If when finding a provider you don’t feel you have any good options where you are looking expand your search – you may find exactly what you need. (Has worked both ways in switching to a midwife when I couldn’t find the right OB and going with an OB when I couldn’t find a good midwife.)

  15. […] 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 finally, Nicole at It’s Your Birth Right […]

  16. Erin Marshall Says:

    Thank you so much for posting this. I have been struggling with the decision to induce at 39 weeks (I have gestational hypertension) because of the horror stories I have heard about pitocin. I really wanted to attempt a natural child birth, and induction puts quite a damper on that hope. However, after reading your post and others, I realize that induction does not HAVE to be a nightmare, if there is proper administration of pit. I will be printing out your blog and bringing it with me to the hospital next week. I agree that this baby is better off coming sooner rather than later, but I refuse to be a victim of poor OB practices.

    • NursingBirth Says:

      Erin, I am glad that this post has helped you. Just curious…Have you ever heard of the BRAN method? It is something that Sarah J. Buckely, a family practice doc from Australia writes about in her book “Gentle Birth, Gentle Mothering.” BRAN stands for “Benefits, Risks, Alternative, (Do) Nothing”. Have you talked to your doctor about the not just the benefits but the RISKS and the ALTERNATIVES of induction at 39 weeks for gestational hypertension as well as what happens if you do nothing (that is, go into labor spontaneously?) What I am getting as is without signs or symptoms of a more serious condition called Preeclampsia, and as long as the baby is not showing signs of distress, say, on a non-stress test or a Biophysical profile, what is your doctor saying is the reason she wants to induce you at 39 weeks r/t gestational hypertension?

  17. Erin Says:

    @ Erin M: going back to the issue of pitocin, that made me think of another issue with its use, which is not life-threatening (I don’t think) but something I had never heard before. And please, correct me if I’m wrong and don’t understand what happened to me, nursingbirth. I was given pitocin in what I believe was a responsible and medically-necessary way 24 hrs into a labor that stalled at 7 cm for 8 hours or so; baby was born about 5 hrs later. I know they were turning the pit up and down, because I remember dimly hearing the midwife say that every time they turned it down my contractions would stop. Anyway, because pitocin is administered through saline (or some other liquid), this means that one’s body is being kind of overloaded with liquid, leading for some women to fluid retention postpartum. Basically, when I went to leave the birthing center, I realized that I couldn’t get my feet into my shoes, and eventually my legs were so swollen from hip to toe that my feet were almost unrecognizable as feet. Because my blood pressure was normal, the doctor was not concerned, but it was a postpartum side effect that a) I did not expect and frightened me and b) inhibited my mobility until the fluid eventually expelled itself (but this took 4-5 days). I’m only writing this in case this happens to you too. If you’re concerned at all, get your blood pressure checked. If that’s normal, you’re ok; if it’s high call the dr. immediately.

    • NursingBirth Says:

      Erin, the fluid overload you experienced was probably related to the fact that pitocin cannot be hung as a main line. That is, something else, like normal saline or lactated ringers hangs as the PRIMARY line at a much faster rate, say, 125mL/hr or more if the nurse gives you a “bolus” of fluid for fetal distress, while the pitocin hangs as a secondary line and is titrated at a much slower rate. Therefore the fluid overload you experienced (which is a quite common post partum experience for many women in your position) is more related to the fact that you were receiving large amounts of IV fluid throughout your induction/augmentation, not necessarily because pitocin happens to be mixed in a bag of LR or normal saline. Thanks for sharing!!

    • Erin Marshall Says:

      Just a follow up post…. I am grateful for this site because although I did go through with my induction on July 21st, I educated myself beforehand on proper pitocin protocall and informed the doctors/nurses they were to do NOTHING without speaking to me first, unless my life was in danger. I gave my husband the print out of “safe” pitocin levels, and when my contractions became so close together and painful and I was unable to communicate my wishes, my husband informed the nurse he wanted the pitocin decreased. They did as he asked, and I was able to have a very pleasant rest of my labor/delivery. I did get an epidural, but it was a low-dose and allowed me to experience my entire delivery pain-free but still aware and able to feel contractions. My birth was attended by a CNM, who worked with me to prevent any unneccesary tearing or augmentations. We chitchatted in between pushes!!! It was wonderful. I did have the inevitable fluid build-up afterwards, and couldn’t see my ankles for about a week after. Anyhow, I had a great birth and my baby was very healthy. 5 months later we are both healthy and happy. Thanks everyone!

      • Erin Marshall Says:

        Oh, also, I wasn’t favorable for induction when I went it, but my blood pressure had spiked up to dangerous levels by the time I agreed to be induced. The used Cytotec to soften my cervix, then a Foley catheter (uncomfortable but very effective) to dilate me, then broke my water when I was more favorable. I had zero complications and minimal tearing, so I am happy with my decision to induce. But it was MY decision, and I think that’s very important to point out. Ladies, don’t ever let a doctor make you do anything you don’t want to do. Educate yourselves, because unfortunately not all doctors have your VERY best interests in mind. I was polite but assertive to all 3 shifts I encountered during my labor, and they were wonderful in accomodating my wishes as best as they could. I was hooked to an IV, but allowed to get up and move around the room whenever I wanted. Etc etc etc you get the point!

  18. contortingmom Says:

    I have a question that maybe you can address in another post. I am about to give birth – and during my one false alarm at 30 weeks – I was introduced to the hospital consent form. They have you signing consent to everything in the book – including pitocin, IV, episiotomy, csection, and all that entails. I read in Wagner’s book that you can legally alter the consent form, but I’ve heard elsewhere that this set off major alarm bells with the hospital staff. Like you suddenly have “trouble” tattoed on your forehead. Anyway, I thought I would *asterisk anything like that and add “pending additional verbal informed consent” at the bottom.

    What do you think?

    • NursingBirth Says:

      contortingmom, I have had a few patients alter thier consent forms. I personally feel that it is your right as a patient to do so. Now I can’t say that that didnt really piss off those patient’s doctors, because it did. And youre right, sometimes in those situations it’s like you have “trouble” tatooed across your forehead. But that reaction from staff or birth attendants stems from their insecurity and their desire to be the one in control which isnt right. But it does happen.

      As far as putting “pending additional verbal informed consent” at the bottom, I personally feel that it is just too vague and really wouldnt help you out. Who’s to say you didn’t give that additional verbal consent? If the doc writes in his note that you did provide the verbal consent, then its like you did, even if you didnt. But he can’t forge your name. So just be aware of what you sign. It is your RIGHT to informed refusal as well as informed consent.

      But that is just my humble opinion. In the end you have to do what you feel is best for you and your baby/family.

      Good luck!!!

      • contortingmom Says:

        So, what should I do? Just not initial the parts I don’t consent to? What would be a good way to alter the form? I just don’t get why you have to sign all your consent away when you walk in the door.

        • NursingBirth Says:

          contortingmom, I know, it is extrememly frustrating!!!!! And I feel so badly because I don’t have a lot of experience with this topic as most of the “hard” consents are done by the residents or attendings at my (and other) hospitals. What about drawing a line through anything you don’t consent to, writing “NO” next to the line, and then next to the “NO” writing your initials with a circle around them. If you change your mind, you can always sign a new consent form.

        • Erinn Streeter Says:

          FWIW, the tip our local Bradley instructor hands out about consent forms is based on the experience of one of her former students.

          The hospital asked her to sign a consent form regarding epidural anesthesia. Included in the verbiage of the form was something along the lines of , “I aver that I am not pregnant at the time this form of pain relief is being administered.”

          In an attempt to automate the consent process, the form used at this hospital had become a ‘blanket’ one.

          That instructor recommends what this mom did: her solution was to put a line through that sentence and initial it. And it did tick off her attending OB, who viewed her action as wayward. Things turned out alright in the end and everyone had a happy birth, but for a little while, there was cause for tension and concern – and all because of a form.

          In true emergency situations, a consent form is highly unlikely to be offered because a true emergency is one where you’re incapable of consenting and action is being taken to save lives. Also, consent forms are a legal gray area; if it can be proven that true informed consent wasn’t achieved by way of the form, then in those unfortunate situations where legal action is taken, a signed form may become a moot point.

  19. Erin Says:

    Why would a hospital ask a patient to sign a blanket consent form in the first place? Is this just so they don’t have to go through the formality of asking for consent in the moment (ie in case of emergency)? Why would anybody consent to a procedure before it was medically necessary?

  20. a newbie doula Says:

    From a birth story, told from a dad’s perspective:

    [The nurse] came in shortly after with…. a box. It was a plastic, electronic box that attached to the IV pole and plugged into the wall, and had a red LED display. On that display, all I remember was a small numeral; later, as it did its job, it read 20 at first, then 20 minutes later 40, then twenty minutes after that 60… As [the nurse] attached it to the IV pole and plugged it in, [mom] asked her how much she could move around, and [the nurse] shrugged and said, “You really can’t go farther than the cords can reach.” The cords only went about five feet from the bed. “But don’t worry, you’ll be alright with this much space.” By the tone of her voice when she said it, I took that to mean, ‘Don’t worry, you won’t be walking around much.’

    By the time the pitocin box was dripping at 60, her contractions were so intense, that she stood up, bent over and leaned on the bed, palms down and elbows locked. As this continued, with every contraction coming about two to three minutes apart, she began to whimper in pain. At one point, I held her through the contractions, her arms around my neck, as she cried into my shoulder.

    Before [the nurse] could come back to turn the pitocin from 60 to 80 mL/hr, [mom] broke down and begged for something for the pain.

    It doesn’t say in this excerpt, but having read the whole story, it sounds to me like the entire birth from start of pitocin to baby’s arrival was less than four hours. Does that sound…reasonable? Every 20 minutes, the pit was upped until mom was eventually at 80 mL/hr. Or is ‘reasonable’ subjective to the physical nature of the mom and baby involved in an induction situation?

  21. Gigi Says:

    I’ve been an inpatient L&D nurse for 20 years in addition to being married to an OB/Gyn. All the stuff about maxing out the pit is basically true, although some doctors choose to be more aggressive with it than others. And yes, they typically like to round shortly after the 7am shift begins and break everybody’s water. Rupturing the membranes cause some biochemical things to start happening, which work in concert with the pit and really enhance the process.

    What I really haven’t seen on this blog though is a discussion of the patient being FAVORABLE for induction. That’s basically how dialated, and effaced the patient is when the pitocin is started. (Google “Bishops Score”).

    Anyway, the more “favorable” the cervix the more successful the induction/augmentation. The process goes smoother and quicker, with less potential for complications. And it stands to reason the better impression the patient will have of their experience.

    Also patients… think long and hard about home birth. Just two weeks ago, we had undiagnosed twins present 9cm, with bulging membranes. While frantically racing around getting her admitted, she ruptured her membranes and delivered twin A normally (vertex presentation). Twin B’s presenting part was it’s shoulder (acromium process presentation). Of course baby could not be delivered that way and twin B was sectioned
    (stat c/section).

    So while MOST of the time, delivery is within what is considered normal, you never know when things can go bad. My OB/Gyn husband told me many years ago (when I was a young nurse and had a crush on him) “Be prepared for anything when you pull the sheets off an OB patient.” He was right.

    So patients educate yourselves, remember you’re goal oriented (healthy mom and babe), and not method oriented (rigid in my birth experience expectation). Good luck and Godspeed to you.

    Now something precious after my quasi-rant. “There is only one beautiful baby in the world, and every mother has it.” ~ Anonymous

    • marissa Says:

      I think sometimes the definition of healthy mother is a mother who is alive post-partum. my OB would have called me healthy even though I couldn’t get in and out of bed without help for 24 hours, couldn’t walk or sit without pain for a week. had a migrain for a week, not from an epidural. had a misaligned pelvis. still had pain from an episiotomy for 6 months, and had post-partum depression, mainly because I was in so much pain. but the OB on-call didn’t care if I was in pain post-partum, she cared about doing things how she wanted.

  22. […] of the interventions and medications that may be used during labor and delivery.  Cervidil.  Pitocin.  Epidurals.  Narcotic pain relief.  Amniotomy.  Cesarean section. Episiotomy.  And many […]


Leave a Reply

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

WordPress.com Logo

You are commenting using your WordPress.com 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 )

Google+ photo

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

Connecting to %s