One of the birth interventions most commonly performed in US hospitals today is active management of the third stage of labor. With active management, pitocin is given to the woman through an IV, starting immediately after the birth of the baby. This is supposed to facilitate delivery of the placenta and minimize bleeding after birth.
Other recent research has indicated that physiologic management of the third stage of labor may produce better results, with less blood loss after birth. Physiologic management of the third stage involves waiting for the placenta to detach spontaneously, rather than pulling on the umbilical cord (termed controlled cord traction in OB lingo) to hasten delivery of the placenta.
One problem with studies supporting active management of labor is that they do not compare active management with physiologic management; instead they compare immediate pitocin administration and facilitation of the delivery of the placenta by controlled cord traction with controlled cord traction alone. This raises the obvious concern that controlled cord traction may be contributing to postpartum bleeding, by causing partial separation of the placenta before it is ready, leading to excessive bleeding, or by causing small fragments of the placenta to be retained, leading to postpartum hemorrhage even days after birth.
Now a new study in the January 2011 edition of AJOG has raised another question: is severe postpartum hemorrhage related to the amount of pitocin that a woman receives during labor?
We know that the brain has receptors which receive signals from oxytocin (the body’s natural form of pitocin), stimulating uterine contractions. However, with prolonged or high-dose pitocin administration, these receptors become saturated and desensitized, and no longer produce effective uterine contractions. What generally happens then, is that the pitocin dose is increased, because the labor nurse can see that the contractions are spacing out or becoming milder. The increase in pitocin results in further desensitization and increased lack of response.
In the AJOG study, researchers looked at 109 women who had experienced “severe” postpartum hemorrhage. This was defined by women who hemorrhaged enough to require blood transfusions postpartum. In my clinical practice site, this could vary depending on the woman’s hematocrit levels prior to birth, and whether she was experiencing symptoms of dizziness or fainting when she tried to get up, but most typically this would be a woman who lost 2,000 milliliters of blood or more.
The researchers then matched the 109 women with severe postpartum hemorrhage with other women who received pitocin during labor, but at lower doses or for shorter duration of time. They attempted to match characteristics of the women, such as body mass index, age, how many babies they’d had, whether there were underlying conditions that could contribute to excessive bleeding, race, etc.
They concluded there is significant evidence that risk of severe postpartum hemorrhage increases with increasing dosage and/or duration of pitocin administration. While the authors suggest that further study and investigation is needed, their findings warrant our attention.
What does this mean to pregnant women? Simply that you have the ability to reduce your risk of postpartum hemorrhage. The most common use of pitocin is for induction of labor, or augmentation of labor—strengthening or increasing frequency of contractions that started on their own.
How can a pregnant woman avoid the use of pitocin during labor? It’s easy to tell her “just say no” to pitocin, but when your doctor is pressing you and giving you multiple reasons why it’s best for you and your baby to accept pitocin, it can be hard to say no. But there are simple things you can do to avoid being offered pitocin, and alternatives you can consider if you are being told you need it:
- Stay home in labor until contractions are at least every 3 minutes, and lasting for sixty seconds or more. Labor may stop and start; it may get stronger and then diminish in intensity for a while. This is often NORMAL, but a common reason why providers decide to use pitocin. Nobody wants to have a labor bed occupied by a woman who is not making active progress toward delivery.
- Consider a midwife-attended home birth or birth center birth. Alternatively, consider hiring a midwife to check you during early labor and help you decide when to go to the hospital. Many midwives will provide this service for women who want hospital births with an OB, but want to minimize risk of interventions. Midwives at home or birth centers tend to be more patient with the time that a normal labor can take.
- Ask your doctor, early in your pregnancy, when s/he considers pitocin augmentation of labor to be recommended. Ask what alternative methods of labor stimulation your provider would consider. If s/he cannot think of any, you may want to consider finding a different provider.
- Avoid induction. Induction of labor should be a last resort, used for a medical situation where to continue pregnancy is clearly more dangerous to mother and/or baby than to wait for spontaneous labor.
- Be patient with the variations of normal labor. So what if labor stalls or slows for a while? This may be your body’s way of giving you a needed rest. Take advantage of it and sleep. As long as baby is doing well, there is no harm in waiting. Understand that normal labor may stop and start for some time before kicking into high gear. Use the stop and start time to catch little naps and refresh yourself, rather than becoming frustrated and trying to hurry the process.
- Avoid artificially breaking the bag of waters. Not only has this not been shown to speed labor, it puts you on a time clock. Your provider will be less willing to work with the natural lulls of labor if s/he is concerned about potential infection because the water has broken.
- Become familiar with alternate ways to enhance labor. Walking, nipple stimulation, position changes, water immersion, herbs, and accupressure have all been used with varying degrees of success to stimulate a sluggish labor.
- If you must use pitocin, start with a very low dose (0.5 milliunits – 1 milliunit per minute IV) and give your body time to respond. If we could measure the levels of natural oxytocin in the bloodstream during labor, do you think they would spike to a high level immediately? Of course not. That is why labor usually starts out with mild, short contractions, which progressively get stronger, longer, and closer together. When labor is augmented with pitocin, it should be started at a very low dose and only turned up gradually, to simulate normal labor. Once frequent, regular contractions are established, even if they are mild, the body will often continue on its own and the pitocin can be turned off–if the provider is willing to allow for the time that a normal labor takes. The purpose of pitocin in most cases should be simply to “jump start” the body’s own process if other measures have failed, and if it is determined to be truly necessary to expedite delivery.
While more study is needed to determine exactly how pitocin affects the risks of postpartum hemorrhage, the wise woman, in the meantime, will educate herself with knowledge of alternatives to pitocin in labor.