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

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Amanda,

This is a GREAT question.  Okay here it goes…

The way it works at the big city hospital that I used to work for (and many others for that matter) is that the bag of pitocin that is used is premixed by the drug company in the concentration of 20 Units of Pitocin per 1 Liter of Lactated Ringers or Normal Saline.  (Some do 10 Units of Pitocin per 1 Liter of fluid but I have never worked with this concentration so I’ll stick to what I have the most experience with).  This is in large part so that nurses do not have to mix their own, hence making less chance for medication errors. 

Most “low dose” pitocin protocols (as was the policy of the big city hospital I used to work for) is that pitocin is started at 2 milliunits per minute (mu/min) and increased by 1-2mu/min every 15-30 min to a maximum of 20mu/min.  The goal:  To obtain an effective and adequate contraction pattern of 3-5 contractions in 10 minutes (and no more) that cause cervical change.  However, IV pumps infuse in milliliters per hour NOT milliunits per minute and therefore there are conversion charts that nurses follow.  In this concentration, 2mu/min converts to 6 milliliters per hour (mL/hr) and therefore if you do the math 20mu/min converts to 60mL/hr.  So no, you are not going crazy!  The pump most likely did read 60!

[Addendum 3/30/2010:  In order to get a 1:1 ratio of milliunits/min to milliliters/hour the concentration of pitocin must be 30 units of Pitocin in 500mL of LR (or D5LR).  Hence when you do the math, 2 milliunits/min equals 2mL/hr and so on and so forth.  At a community hospital I worked at in the beginning of 2010 (which I not so affectionately refer to as “Bait & Switch Community Hospital”), the pitocin was hung in this particular concentration and the orders typically read: “Start pitocin at 2 milliunits per minute (mu/min) and increased by 2mu/min every 15-20 min to a maximum of 34mu/min.”  This was by far the scariest order for pitocin I was ever faced with and is one of the reasons that I am leaving this hospital!]

Okay, so if a doctor wants to go above “max pit” which, according to the “low dose pitocin protocol” that a big city hospital I used to work for follows, is anything above 20mu/min (60mL/hr), then they have to write out an entirely separate order.  At that hospital the “absolute max pit” is 30mu/min (90mL/hr).  Now, the higher the dose and the longer the infusion runs for the greater the risk for side effects and adverse reactions.

These potential adverse reactions include (source: RxList Drug Guide)

1) Potential adverse reactions in the mother:

  • 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

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