Over the 28 years I’ve been a labor nurse and then a midwife, I’ve seen protocols for pitocin (oxytocin) inductions and augmentation come and go. High dose protocols were common for a while, then low-dose protocols were in vogue. Knitted in the Womb recently wrote about her experience with a midwife who clearly did not have her client’s best interests at heart when she mismanaged a pitocin induction:
Very early in my career as a doula I attended a birth with a midwife where the midwife had just attended another long-ish birth, and rather than call in another midwife in the practice when my client presented with SROM but no labor, she insisted on staying. When my client did not go into labor after repeated attempts to get things going with prostaglandins (Cervidil & Cytotec), walking, nipple stimulation, and accupressure, she proceded to order up a VERY aggressive Pitocin drip. I strongly believe that she did this because she was over tired, and just wanted to get home.
My client went from 4 cm to 10 cms in less than 1.5 hrs. I always take copious notes about medications that are given, and what the IV drip rate is set at. So later, when I researched Pitocin dosing, I would learn that my client had been started at a dose that was 2-4 times higher than the reccommended starting dose of 0.5-1 microunit per minute. Further, her dose was doubled every 15 minutes (reccommended protocol on the package insert is to “raise slowly every 30-60 minutes). By the time I went and spoke to the midwife, my client was receiving 16 microunits per minute, when the package insert says that 6 microunits per minute mimics spontaneous labor, and levels above 10 are “rarely needed.”
Of course, to be fair, I’ve only once had a client on Pitocin who did not get to 12 microunits per minute. But the “double every 15 minutes” protocol is not what I normally see used in my area. Typically the Pit is started at 2 microunits per minute, and raised by 2 every 15-30 minutes.
Unfortunately, this doula’s experience is not unusual. Physicians and midwives often press nurses to increase the pitocin rate faster than is recommended by protocols.
A recent study in the American Journal of Obstetrics and Gynecology¹ recommended that pitocin be increased no more than one milliunit every 30 minutes. The results of such a protocol estblished in one hospital included a decrease in emergency cesarean deliveries, from 10.9% to 5.7%, a decrease in use of vacuum or forceps to deliver the baby, and a decrease in neonatal intensive care unit admissions.² Yet most physicians, midwives, and nurses I have asked about this protocol are still using the old ” plan, which increases the dose 2 milliunits every 20 minutes.
When I (reluctantly) have to do an induction, here is what I like to do: if “natural” methods of induction have failed, I like to use a cervical ripening agent, such as prepidil, to soften and thin the cervix. Many times, I have applied this in the evening, monitored the woman for the required one hour following administration, then sent her home for the night. Often, this is enough to start labor on its own if we are patient. If possible, I like to try this a couple of days before our absolute deadline to have to induce, so as to give the body more time to do its thing naturally. If we must use pitocin to start contractions, I like to start it at bedtime, at 1 milliunit, and leave the dose at 1 milliunit until morning; it’s best if the woman is able to sleep during this time. This regimen often starts labor, and then the pitocin can be turned off and the woman can be free to walk, squat, sit on the ball, get in the jacuzzi, or whatever she feels like doing. If pitocin must be increased, I do it gradually, to allow the body time to respond to the medication. Once regular contractions are established, I do not continue to increase the pitocin, but gradually decrease it. The goal is not to create seismic contractions–the body doesn’t start out with transition-style contractions at 1 centimeter (at least not most of the time). Normal contractions begin very mildly and gradually increase in intensity. Contractions induced by pitocin should not be any different–the goal is consistent contractions. Once these are established, the body, given enough time, will respond on its own and gradually increase strenth of the contractions. Obviously, it’s important not to break the water at this time, because if this process takes a long time, the bag of water will protect mother and infant from infection.
So, the common sense-tip for today: Don’t rush to induction, and if you do need a pitocin drip, ask for the “slow drip”. Have your support person write down the dosage: “1 milliunit increase every 30 minutes”. Ask for a quick explanation of how to read the dosage rate on the IV pump. Keep your eye on it, and if someone is trying to turn it up faster than 1 milliunit every 30, don’t be afraid to speak up and ask why. Increasing the dosage faster will not lead to a better outcome.
1. Hayes EJ, Weinstein L. Improving patient safety and uniformity of care by a standardized regimen for the use of oxytocin. Am J Obstet Gyn 2008; 198:622
2. Bates, B. Oxytocin change cut emergency cesareans. OB-GYN News, July 2009. Retrieved 1/14/2010 from: http://findarticles.com/p/articles/mi_m0CYD/is_9_44/ai_n32429088/
Thank you for the updated resources! Those are going on my information CD I give to clients.
Following up…I had a client shortly after this post was made who ended up on Pit due to slow dilation. Before the Pit was hooked up I talked to them about the issue of Pit to distress, and gave them the article about the hospital with the 1 milliunit per half hour protocol.
The dad went out to talk to the OB, the OB wouldn’t budge on her desired protocol (raising by 2 milliunits every 15 minutes), and the dad didn’t want to argue it. Surprise, surprise, 2 hours later the OB was telling them that the baby wasn’t handling contractions very well, and before things got scary, they really ought to consider cesarean.
I very recently had another client who required induction. Her OB ordered a protocol of raising the Pit by 2 milliunits every hour. The client allowed it to be raised to 6, then held there for a couple of hours. When she felt she needed a break she gradually backed it down to 2 milliunits, and the labor get more intense! It eventually did fade away, so she slowly raised it again, this time in 1 milliunit per hour increments up to 4. Held at 4 for a few hours, then again insisted that it be dropped to 2. And again, her labor picked up steam! She rapidly proceeded to complete and pushed out her baby in less than 15 minutes. The entire labor–from start of the Pit to birth–took about 23 hours, even though the mom started at 3 cm. It was amazing how well this very low dose protocol worked.
This makes me so sad for past doula clients. One was up to 20 miliunits and even though she had really strong contractions it was kept up to that level by her midwives to the end. If only I had known then you could turn the pitocin off!
I don’t usually just turn it off. I start backing it down–I’ll cut it in half, then half again, to “wean” her off the synthetic pitocin.
Well, right. I meant eventually.
Wow…this is horrid. I read a little bit about the protocols for PIt administration on an OB forum, I believe – and was astounded that they basically overdose you on the stuff. It’s like having electric shock or something – how incredibly cruel and more painful than it needs to be.
At my very first doula birth, they gave my client pit. At one point it was so intense she begged for it to be turned down, “just a little bit…” I went out to ask the nurse if that was possible and she gave me this whole lecture about how the whole point of this was to get labor going adn the pit ws ‘necessary’ and they couldn’t turn it down or labor would stop. Her own labor had kicked in and the pit was just making things so intense. When here Dr. showed up a while later, he looked at her and said, “why don’t we turn this pitocin down a little” and it was so… she was so much more comfortable dealing with Contractions that were more like average normal contractions, and she continued to labor and did birth her baby vaginally. It still frustrates me when someone asks for something and is denied mercy. At that same birth, with a different nurse she was told, “A Pitocin contraction is just the same as a regular contraction”. HA! 8 years later, we both still remember that comment and wonder why the nurse felt the need to even say that!?!?!?
Hospital personnel often have an attitude regarding inductions that says “If you’re being induced we don’t need to fool around trying ‘natural’ things to get labor going. You’re being induced, so we’re going to make it happen as expeditiously as possible.”
I don’t agree with this attitude. There are times when it is important to get the baby out as soon as possible, but even if this is the case, pushing the pitocin hard will be more likely to cause distress in the already-at-risk baby. It is much more humane and less stressful for both mother and child to let induction mimic normal labor as much as possible.
I disagree with the nurse who told you that pitocin contractions are “just like normal labor contractions”. Anyone who has observed the shape of pitocin-induced contractions vs. normal contractions as traced on a fetal monitor can see that pitocin contractions have a much more abrupt peak and much slower decline than a normal contraction.
There are times when it is important to get the baby out as soon as possible, but even if this is the case, pushing the pitocin hard will be more likely to cause distress in the already-at-risk baby. It is much more humane and less stressful for both mother and child to let induction mimic normal labor as much as possible.
Anyone who has observed the shape of pitocin-induced contractions vs. normal contractions as traced on a fetal monitor can see that pitocin contractions have a much more abrupt peak and much slower decline than a normal contraction.
!!!
This is one of the biggest reasons why I only attend homebirths. What women go through in hospital is wrong, disgusting and dangerous to healthy mothers and babies.
Thank you… If only all midwives and OB’s were like this.
I’m surprised no one has commented so far on the midwife’s initial use of Cytotec, which I believe should no longer be used for induction.
Unfortunately, cytotec is still widely used for inductions. It is contraindicated for induction of women with a uterine scar, however.
Thank you for providing the correct protocol for Pit. My first doula client was induced for preeclampsia. They did increase by 2 microunits every 15 minutes. Then they ran her in the low 30s for the last 6 hours of her labor. Because her contractions were so irregular until the last hour or so, they never considered dialing her back. She was in serious agony all day long. Although she accepted some Nubain, she was pleased with the birth because she did it without an epidural. !!
I guess in this case, she can at least thank her OB for not just sectioning her. She can at least birth vaginally in the future… though why after that experience she would want to, I don’t know.
…I started at 15…then went up to 45 microunits per minute. I personally feel my uterus was overstimulated (think hummingbird…going so fast you can’t even see the wings anymore) and *couldn’t* do what it was supposed to do. I thought it was too high (even without being educated, 45 just seemed WAY too high). Ya live, ya learn…I think I was being pushed b/c I came in on a Thursday night and they wanted me done before the weekend. They go their wish via c-section.