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/