My rant on Pitocin

I attended a birth yesterday. Second time mom, had a Pitocin induction with her first baby for medical cause, and did NOT want to "go there" again. Unfortunately the same medical cause ended up showing up again, so after an unsuccessful attempt at starting things with 3 doses of Cytotec (don't even get me started on the lack of informed consent on that one!), she was on to Pitocin.

Pitocin seems to be almost synonomous with hospital labors anymore. I wonder how many women who labor actually manage to get through without using it at some point. One client I had switched OB practices because she had been informed that when she arrived at the hospital in active labor she would be put on Pitocin. No waiting to see how labor was progressing and if it was really needed...it was just the policy of this practice to use Pitocin on all laboring women. Medical staff will often explain away any concerns with the use of Pitocin by saying that it is just a synthetic form of the same medication that your body produces. Which is true. But that doesn't mean that putting it into an IV is the same as letting your body produce it!

One of the major problems I have with the use of Pitocin is how strongly it is generally used. It is usually used at strengths MUCH greater than what the body would naturally produce. In the case of my client today, it got to nearly 3 times the strength the body would naturally produce. Here is an excerpt from the 3rd page of the package insert on Pitocin:

The initial dose should be 0.5 – 1 mU/min (equal to 3-6 ml of the dilute oxytocin solution per hour [10 units oxytocin in 1000 ml saline was suggested a few paragraphs earlier “piggy backed” with plain saline]). At 30-60 minute intervals the dose should be gradually increased in increments of 1-2 mU/min…[. Once] the desired frequency of contractions has been reached and labor has progressed to 5-6 cm dilation, the dose may be reduced by similar increments.

Studies of the concentrations of oxytocin in the maternal plasma during oxytocin infusion have shown that infusion rates up to 6 mU/min give the same oxytocin levels that are found in spontaneous labor. At term, higher infusion rates should be given with great care, and rates exceeding 9-10 mU/min are rarely required. Before term, when the sensitivity of the uterus is lower because of lower concentration of oxytocin receptors, a higher infusion rate may be required.

My client was started at a dose of 6 mU/min. That's right...she was started at a dose that 6 to 12 times the reccommended starting point. And this after getting 3 doses of Cytotec. Then the midwife put in orders for the drip rate to be increased by 2 mU every 15 minutes. The nurse seemed to get around to upping it every 30 minutes when it was first turned on, but then later in labor she was coming around after 20 minutes to increase the dose.

When I got to the hospital my client had been on Pitocin for 2 hours, and by that point she was up to 12 mU/min. So not only was she at twice the level that would be found in a natural labor, but she was definitely above that level that is supposedly "rarely required." Of course I haven't had a client yet that I've been with as a doula who got Pitocin and didn't get to this level. Sigh.

As I indicated above, they didn't stop there. This is where the nurse started showing up every 20 minutes to increase the dosage, and in short order it was at 16 mU/min. I'm not sure why, but at this point the nurse to stop increasing the Pitocin. I don't know if the midwife told her to stop because the contractions were coming more regularly, or if the nurse just got busy, or if it was because of concerns with the baby's tolerance of the Pitocin (I know that I noted at a certain point in the labor that the baby was having late decels, but I didn't want to write that in my notes, because if someone saw that they might say that I was "practicing medicine." I know that I wanted to note it somehow though, but looking back, I don't recall when exactly that was, or what I did to note it. The only thing I can come up with is a notation I made that the baby's heart rate was 104 10-minutes after the Pitocin was raised to 16.) 40 minutes passed between changes to the Pitocin level, and this change was to drop it back down to 12 mU/min. It stayed this way for the next hour, during which time the mom labored really well, contractions were coming 2 1/2 minutes apart, about 55-70 seconds long.

However, there was trouble with keeping a good reading of the baby's heart rate on the fetal monitor unless the monitor was manually held in place, and even the contractions weren't picking up well. The midwife started talking about internal monitors. We discussed options, and I pointed out to mom that since she was 5-6 cm dialated at this point, she could consider just turning the Pitocin off, then she wouldn't need the constant fetal monitor, and could use Doppler. I also offered to manually hold the monitor.

However, the midwife managed to convince her that it was imperetive that the internal monitors be placed, and part of what I think sold her on it was the promise that this would mean less fiddling around with the monitors. Yeah...okay. I've not had a doula client have an internal monitor scalp electrode placed, so I didn't have experience with that. The dang thing kept coming off! All told, she had 5 scalp electrodes placed in 4 hours. And it really irritates me that they call them a "scalp clip." I suppose that sounds better than the reality--"a corkscrew that we put into your baby's scalp." And YES, it hurts the baby! The heart rate would temporarily jump to over 200 every time one was placed.

So anyway...she got the first one placed, and what do you know, baby is having heartrate decelarations. The Pitocin was shut off STAT. After about 20 minutes things seemed to be stable with the baby, so what do they do? Turn the Pitocin back on at 6 mU/min. Didn't bother to ask the mom if she wanted them to do that. I pointed it out to her and asked her if she wanted Pitocin at this point. I don't really think she did...but I also think she didn't want to make too many waves.

So 20 minutes later the baby starts doing some NASTY decels. Down as low as 60, when usually much below 120 is "not good." I was scared. And feeling like pounding my head against the wall and screaming "you guys had a warning that this was going to happen!!! What in the world were you thinking???" Pitocin was back off again. I was honestly shocked that we weren't on the fast track to the OR. Seemed like half the available OB staff that was on the floor was in her room. Whispered instructions were given to a nurse to start counting equipment in the OR. Fortunately I will give that the OB who is the senior Dr. in the practice with the midwife is committed to avoiding cesarean, so he really worked with the baby to get the heartrate back to an acceptable range. Medication was given to stop contractions. And after about 10-15 minutes, the drama was over--at least the medical drama.

My client and her husband did really well during all of this. But understandably, it really shook them. They both cried. She was seriously wondering if continuing to labor was wise, or should she just go straight to cesarean.

Less than 30 minutes after the baby was stabilized, and while the mom is still very emotionally charged and trying to work through the "should I just have a cesarean?" question, the nurse quietly comes in and turns the Pitocin back on to 4 mU/min. BANGING MY HEAD!!!

I again let her know that the Pitocin is back on. This time she talks to the midwife about it. She isn't happy having it on. Midwife is "sweetly" insistant on the "need" to use it to get the baby out quickly. AAARGH! Mom is breaking down. She finally just can't deal with things anymore, and asks for an epidural. She REALLY didn't want one because of a previous bad experience, and she hadn't had one with her first. I really think that the emotions of the situation just left her unable to deal with things. And I don't blame her one bit. It also dawned on her that if she winded up with an emergency cesarean she would be put under general anesthesia unless she already had an epidural in place. She INSISTED that the Pitocin be turned off, so as the anesthesiologist was prepping the epidural, it was turned off.

Of course the nurse came back in and quietly turned it back on not 10 minutes later. Didn't ask Mom about it. She just asked for it to be turned off, and she didn't ask for it to be turned off because she couldn't deal with the pain, she asked for it to be turned off because she couldn't deal with the stress of wondering if it was going to make her baby crash again. But it was "only" 2 mU/min, so I think Mom just resigned herself to it when I told her it was back on. 30 minutes later it was up to 6 mU/min, then 15 minutes after that it was up to 10 mU/min.

And surprise, surprise...15 minutes later it is turned back off because of decels, and they are having her push even though she still has a lip of cervix, no urge to push, and baby is at 0 station (and in my experience, moms aren't ready to push until +2 station). I wasn't even sure she was "really" completely dialated, as she had been 8-9 cms just 30 minutes prior, and the midwife had this "let me see if I can stretch the cervix to 10" kind of hesitation before declaring her "complete."

Pushing wasn't really going well, the lip of cervix could not be reduced, and fortunately the baby's heart rate resolved, so midwife did one of the few reasonable things of the day, and told the mom to stop pushing and just rest until she felt an urge to push. Which she did an hour later, and in less than 10 minutes she pushed out her 8 lb 8 oz baby boy, Apgars of 9 & 9. But of course there was doubt as to whether she could actually push the baby out (since they expected the baby to be large, and the midwife had earlier been very insistant on how DANGEROUS it can be to deliver a large baby--never mind that she had pushed out her first baby at 8 lbs 7 oz with no incident), so the resident OB actually did the delivery (and overly agressive pulling!) so that vaccum could be used...of course she showed her strength by pushing so fast that they got the vacuum out of the package, but couldn't get it on before the head was half out (so it just laid on the bed unused--wonder if they will bill for a vacuum birth though?).

But hey, the joys of Pitocin don't end there. Despite the fact that mom had no significant bleeding, the midwife ordered that the remainder of the bag of Pitocin in saline be run into the mom. The drip rate was set at 250 mU/min. Here is what the package insert on Pitocin has to say about fast drip rates of Pitocin:

Water intoxication with convulsions, which is caused by the inherent antidiuretic effect of oxytocin, is a serious complication that may occur if large doses (40 to 50 milliunits /minute) are infused for long periods.

She was being dosed at 5 times the level that is listed on the package insert as considered a risk of causing water intoxication! And she was already seriously retaining fluid, as demonstrated by the very concentrated urine collection that had been made about 20 minutes before the birth. Of course the concentrated urine was interpretted as "she hasn't gotten enough fluid." Of course a logical person would certainly agree with that concept. (Rolling my eyes) She had "only" gotten 4 liters via IV plus what she's been drinking over the course of the last 20 hours. That is the equivalent of drinking more than 8 oz an hour around the clock--possibly closer to 12 oz, I didn't log how much she drank. Can you imagine how much you would be peeing if you drank that?

She wasn't dehydrated folks...she was OVER HYDRATED, and unable to get rid of it. But hey, the midwife ordered another bag of saline run into her.

The poor woman. She's going to have to leave the hospital with no shoes on, her feet will be so puffy.

Note: I have a Word document explaining how to figure out what dosage of Pitocin is being administered. Ask, and I'll e-mail it to you. If you are "lucky" the Pitocin is mixed as 30 Units in 500 mls of saline, then you can just read the IV pump to directly get the mU/minute. But if a different mix is used (such as the 10 Units in 1000 mls of saline that is reccommended on the package insert), then the charts I have in the Word document will help you to quickly find what dosage is being used. I STRONGLY urge pregnant women to take a copy of it and the package insert for Pitocin with them to the hospital in labor. If Pitocin is going to be used, ask the care provider if the dosing guidelines in the package insert are going to be followed, and if not, why not. Sometimes a "quick" labor is not as safe as a slow labor. Especially if your baby is thought to be compromised already, it may not really make sense to be trying to blast the baby out.