Let's Talk Pitocin

Several comments on a post by the Unnecesarean seem to indicate that more than a few mothers suspect Pitocin had been"snuck" in to their IV's during or after labor when they were unaware of it. I commented at length about it in response to these posts on the Facebook fan site for the blog, but decided to reiterate, and expand my thoughts here.

First, Pitocin is not always a bad thing. True, it is grossly overused today (I love it when a mother comes on to my unit and gives birth with nary a whiff of the stuff...and I love teasing the residents..."Look...she had a baby without Pit! Who'd a thunk it!"). But there are times when a little Pitocin can be helpful; when you've received an early epidural and things have slowed down...the longer an epidural is in place, the more likely you are to develop a fever during labor, leading to a septic work up and antibiotics for both you and baby. Of course, the way to help avoid this is either not to get an epidural at all, or to wait until labor is well established before getting one...but not all mothers want to do this...especially if they've had a long prodromal labor and desperately want some sleep. If labor has stalled, Pitocin can in all likelihood get it going again...potentially avoiding a c/section for "failure to progress". If your water has broken, and labor hasn't started after 24 hours...and you are at term, that clock, unfortunately, is ticking...loudly...and again, Pitocin can help avoid a c/section, and possibly infection from prolonged rupture of membranes. Although they are few and far between...but some mothers just don't go into labor on their own. There is rising suspicion that obesity plays a role in this, but I'm not aware of any definitive research on it yet...I imagine this could be difficult to research without placing part of the research population at some theoretical risk. For these mothers, why not try to induce before going directly to surgery? And of course, there are those mothers whose delivery, due to complications such as preeclampsia, must be expedited. Better, if there is time, to attempt to induce labor with Pitocin than to go straight to surgery.

Pitocin is the brand name for a synthetic form of the hormone oxytocin that your own body makes. That doesn't make it harmless...it's not "the same thing your body makes"...it's synthetic! Labor is a delicate balance between your hormones and the baby's, and we really don't know what truly triggers it. It may be different for each mother-baby pair, depending on the chemical balance of hormones in each. The use of Pitocin doesn't mimic the action of natural oxytocin, and I don't care how adamantly anyone insists it does. Contractions induced by Pitocin, are, by the very fact that we can control how much of it you are getting, and our goal is to get you to contract every two minutes (or at least often enough to consistently change your cervix, which will be often be "checked" as much as every two hours), usually "longer, stronger, and closer together" than what often will happen if you are laboring under the oxytocin that your body makes. Your uterus has "oxytocin receptors" on it. It is these receptors that act as the "lock" the oxytocin "key" turns to stimulate labor. Without these microscopic receptors, all the Pitocin in the world will not make your uterus contract. The number of these receptors increases during pregnancy, and during labor, when they multiply dramatically as labor progresses; thus, you become more sensitive to the action of oxytocin as your pregnancy, and then your labor, progresses; but there is a finite number of these receptors...and when they have all been used, they are saturated...and until your body makes more receptors, no amount of exogenous (outside the body) or endogenous (made inside the body) oxytocin is going to effect your uterus. There are even times when we "rest" a woman who is getting Pitocin...i.e., she has been laboring under the influence of the drug for a long time, we've steadily increased the dose, and labor has either not progressed, or is slowing down. We'll stop the Pitocin for a half hour or more, and start it up later, and at a smaller dose...and quite often, labor kicks in and takes off! Her body has had time to absorb the exogenous oxytocin, and synthesize new receptors.

Do medical personnel ever "sneak" Pitocin into a woman's IV drip? I suppose it could happen, but it would be gross malpractice. Even with Obstetrics being as egocentric as it can be, this still is something that most obstetricians would be loathe to do. In addition, on most L&D units, the drug comes pre mixed from a centralized pharmacy in a bag that is separate from any other IV fluids; that bag is clearly marked, usually with a bright red, orange, or yellow label. Kind of hard to miss, even for a preoccupied laboring woman. If you have an IV, and are in first stage labor (prior to the birth of the baby), count the number of bags that are hanging on the IV pole. If there is only one, you are not getting Pitocin. During first stage, Pitocin is always...always hung separately from a bag of "maintenance" IV fluids; and it is always run along with those fluids...it is never given alone during first stage labor; so even if the Pitocin is mixed on the unit, and not appropriately labeled (which would be a grieivous error on the part of the nurse), if there is only one bag hanging, it had better not be Pitocin!

Here's how Pitocin is commonly administered:

For first stage labor, Pitocin is always diluted in a liter (about a quart) of normal saline. The most common concentration of it is 20 milliunits to a liter of solution. The drug itself, before it is diluted, is sold in vials that contain 10 milliunits of the drug. These 10 milliunits equal a total fluid volume of 1 milliliter. To give you an idea of how tiny a volume that is, an ounce of fluid is equal to 30 milliliters so the standard concentration of Pitocin is two 1ml (milliliter) vials of 10mu (milliunits) each into a liter (1,000 milliliters) of fluid. This should also give you an idea of just how powerful a drug Pitocin is...by fluid volume, there are only 2ml active agent to 1,000 ml normal saline in the bag of fluid that will be labeled "Pitocin"...a very, very dilute concentration, but oh, so powerful.

Pitocin for labor is always run along side another bag of "maintenance" IV fluid. An IV will be started with maintenance fluid...usually Lactated Ringers or Normal Saline. The "drip rate" of that fluid will be adjusted to approximately 125 ml an hour...so, without any boluses (administration of a large amount of fluid in a short amount of time), the 1000 ml bag of maintenance fluid should take about 8 hours to fully infuse. Considering that, "normal" (not optimal, in my not-so-humble opinion) obstetric management restricts oral fluids in laboring women, this isn't an over abundance of fluid...a liter of fluid a day is the minimum amount of fluid most nutritionists recommend to promote normal healthy hydration. The caveat here is that, if you choose an epidural, you will get at least a liter of fluid in addition to this "maintenance" fluid...to help prevent or minimize the drop in blood pressure that is the most common side effect of an epidural. If the baby shows any kind of distress you will get additional boluses of fluid, to promote blood flow to, and enhance oxygenation of the placenta. Since the use of Pitocin or other induction agents can overstimulate (hyperstimulate) the uterus and contribute to, if not outright cause fetal distress, this should give you pause. Of course, if your baby is in distress, the Pitocin should immediately be shut off! Finally, a lot of hospitals hang maintenance IV fluids for healthy laboring women to "gravity", meaning that the amount of fluid being infused is not being metered through an IV pump. The thinking is that a young, healthy woman can handle a lot of fluid, so there is no need for the pump. This is not the case if any type of heart, lung, kidney or circulatory disease (including preeclampsia) is evident...in such cases, fluid will be very carefully monitored, and metered out through an IV pump; but for the average laboring woman, the rate of this "gravity" IV can change depending on her movements, and that liter of fluid can be infused much faster than intended.

Once the maintenance IV is in place, the bag of Pitocin will be placed next to the bag of maintenance fluid, and its tubing will be attached to a port on your maintenace IV tubing. This bag of fluid will be very carefully "titrated" via the use of an IV pump. A common Pitocin regimen is to run the fluid at rate of "2 milliunits per hour, increasing by 2 milliunits every 20 to 30 minutes until 'adequate labor' is achieved". Two milliunits of Pitocin per hour is equal to 6 ml...less than 1/3 of an ounce of that entire liter bag of fluid of which less than 2 hundredths of a percent is actually the drug. Now, if that amount of the infusion jump starts your labor, that's great. Most women will need more, however; and even more care providers will continue increasing that drip rate until they see contractions happening consistently every two minutes. At 20 milliunits of Pitocin you are getting the solution dripped into your vein at 60 mls, or about 2 ounces an hour, along with your maintenance fluid. This is now considered a "high dose" Pitocin regimen, and to proceed above this amount is to proceed with caution; plenty of women receive higher doses than this. At this point a wise nurse will switch her patient to a more concentrated form of Pitocin that can be run at a lower rate, to help avoid the risks of fluid overload. Personally, if there are no other contraindications, I don't mind having an intrauterine pressure catheter (IUPC) placed at this point, especially if the mother is a little "fluffy", and her contractions are challenging to palpate or see on the fetal monitor. This gives a much more clear picture of exactly how strong, long, and close together the contractions are. I know that internal monitors are invasive, and as such, they are controversial; but I can't tell you how many times I've been in a situation when a mother laboring with any dose of Pitocin, low or high, doesn't seem to be contracting much, and we place an IUPC and find that indeed she is contracting strongly, every two or three minutes. Had we continued to increase the Pit, we might have caused uterine hyperstimulation, with disasterous results; but Pitocin, in my opinion, is invasive, and a judiciously used IUPC can help to limit the adverse effects of that invasiveness. If a mother were not using Pitocin, I wouldn't suggest using an IUPC...but with high dose Pitocin in use, I think it can have some value.

High dose regimens of Pitocin increase the risk of uterine hyperstimulation, as well as the risks associated with fluid overload, including a disturbance in the electrolyte balance in your body, and "wet lungs" in both mother and baby, although, again, in healthy young women, these are rare. More often, since one of the side effects of Pitocin is vasoconstriction, a temporary "tightening" of the blood vessels (more accurately the smooth muscle lining the blood vessels), fluid leaks (is forced) out into the mother's body tissues and causes edema, or swelling. Over a few days, this swelling will leave the body, through urination and sweat, but in the mean time, it can cause some discomfort for the woman, and difficulty getting her baby to latch on to swollen breasts.

So. I've talked about Pitocin during first stage labor. A lot of women are surprised to find that even if they didn't get pitocin during first stage labor, that it is commonly run after the baby is born. Most practitioners will order the Pitocin solution to be run "wide open" (as fast as a liter or more per hour) as soon as the placenta is delivered, to help reduce the amount of bleeding after delivery. Others will order this as soon as the baby is delivered, to both expedite the delivery of the placenta and reduce the amount of bleeding. If you don't have a running IV, they will order an injection of 10mu pit into a muscle. This practice stems from the "Active Management of Labor" protocols that were developed in the United Kingdom in the 1980s. Of course, in the United States, we've adapted that protocol to our own agenda, but what else is news? Once the Pit is wide open, again, a wise nurse will turn off the maintenance fluid.

If you didn't want a lot of interventions in the first place, this is where things get tricky after the fact. Much of the time that bag or little shot of pitocin is up or in before the mother even knows what has happened..."We're going to give you a little shot to help with the bleeding", or "We're going to give you some Pitocin in your IV to keep the bleeding down"...and boom...there it is; but if you know ahead of time, and you decide you don't want it, keep your wits about you. First, if you had much in the way of intervention at all...any type of inducing agents, amniotomy (breaking the "bag of water"), frequent vaginal exams, internal monitors, a long pushing stage, "purple pushing" on your back, you might want to consider just letting them run the Pit...the more interventions you've had, the more likely you are to bleed heavily. If you had a long, exhausting labor, your uterus is tired too...and you should consider letting them run the pit...a tired uterus can't contract down effectively over the blood vessels that were opened when the placenta separated from the wall of the uterus. Second, if you are certain that you are no more at risk for postpartum hemorrhage than a mother who has given birth at home with no interventions, and you really, truly do not want the prophylactic (preventative) Pitocin after delivery, then keep your eyes open. We hang it so routinely, even with mothers who have a birth plan, and even with mothers who expressly request in their birth plan not to have it, that it's easy to forget and just hang/inject the stuff. I know it's a lot to ask if you are in the middle of recovering from labor, possibly experiencing a repair to a tear in your perineum, and bonding with your baby, but I've said it before, as it was said so wisely before me by Navelgazing Midwife, and it bears repeating "If you buy the hospital ticket, you take the hospital ride"...and part of the hospital ride is that, if you want to reduce routine medical interventions, you have to negotiate, negotiate, negotiate.

If you are adamant that you don't want Pit given to you after the fact, be aware that, for most caregivers, you are going to be asking them to step way outside of their comfort zone. If you've ever seen a postpartum hemorrhage, you'd understand...they can happen fast, with very little warning, they can get out of control even faster, and they can be devastating. Yes, I know, without many of the interventions a hemorrhage is much less likely, but consider that one of the most common reasons home births transfer to the hospital is postpartum hemorrhage. Sometimes I think we need to pick our battles. We know that induction in the absence of an absolute medical indication creates a certain amount of risk to both mother an baby. We certainly know cesarean section does; but what do we know about second stage/postpartum Pitocin? If its running full open through an IV, fluid overload is a concern; but in the absence of any other pathology, it is a small concern; it, for the most part is a temporary, reversible concern; and as soon as say, a quarter to half of the bag has run through, if your bleeding is at an acceptable level, you can request that your nurse turn the rate down to a slow drip, helping to avoid the possibility of edema. If your provider has, up to this point been truly trying to comply with your wishes (No IV, no internals, intermittent monitoring, self-selected pushing positions and techniques, immediate skin to skin with your baby), might it not be worth it, in the name of good will, to allow him or her this? There may be a few out there who are comfortable with not giving that Pit after delivery...but by few, I mean truly a few. Most are just really uncomfortable without that perceived "safety net" for their patient. In this case, it usually isn't a "control", "You patient, me Doctor" issue...and since the labor is over, it's not a "speed" issue. It truly is, even if misguided some might believe, a "standard of care" issue. If everything else has gone according to your wishes, you may want to consider...in the grand scope of things...how important is this to me?

I haven't listed the contraindications to the use of Pitocin, and I haven't listed all the potential side effects of it...just the ones most likely to be experienced. If anyone would like me to write more on the topic, I will...but there is a lot of good information out there that can give you this information...Henci Goer's "The Thinking Woman's Guide to a Better Childbirth" comes to mind. It's a good idea to keep an open mind to the use of Pitocin...but also to know your options; and you are the one who ultimately gets to decide if, and when it is going to be used. True, you may need to repeat yourself over and over, and to carefully watch the behavior of the medical staff...it's not always easy...and it's also not always advisable...because as I've said, there can be good reasons for the judicious use of Pitocin; but even if your care provider tries to convince you otherwise, the choice is yours.

For S....

You and your husband were sleeping when I left this morning...you in the bed you gave birth in a few hours ago, sweat- dampened hair askew on the pillow, your arm thrown over your face in a posture of total exhaustion...your sweet husband curled up on the hard vinyl couch of the birthing room, tightly bound in a thin white hospital blanket...as if attempting to comfort and protect himself from the pain the both of you hand just endured...and have yet to endure.

Your beautiful little boy lies wrapped in the too large gown (the closest one we had to his size), and a hand-knit cap and blanket, and placed as respectfully as we can place him in such an inadequate situation, in the clinical refrigerator on the unit, to preserve his tiny body until you ask to hold him again, perhaps for the last time, in your aching, tear-streaked arms.

I wanted so much to say goodbye to you, but I dared not wake you from your hard won sleep. I wanted so much to hug you, to tell you how strong you are, to reassure you, once again, that you will come through this...not without scars, and certainly not without seemingly unbearable sorrow for a time; but that you will survive this; that your son's life, all 26 precious minutes of it, had tremendous value; that that value will increase over time in ways that you cannot even imagine now; that this perfect, tiny, precious, all too short life will have an impact on you and those around you that will forever make you a better person, and this world a better place to be.

The night before he was born, while you still clung desperately to the "one percent" chance that a well meaning physician held out for his survival, while at the same time you grieved in anticipation of his all but inevitable death, I told you this...that your son, no matter how long or short his life, has a reason to be here; that God did not make this happen, but if it had to happen, then He would see to it that this child, this Beloved of His, would achieve his purpose on this earth, regardless of the time in which he had to accomplish it; that I believed this with all my heart. This so loved, so wanted child did live his purpose in those 26 minutes, and as time relentlessly pulls you forward, turning this painful memory into one hopefully more sweet than bitter, as your body and spirit slowly heal, you will begin to realize what that purpose was.

But I can already tell you something that together, you, your son, and your son's father accomplished...and perhaps that can be part of your son's legacy, as it is certainly yours. You helped me to believe in myself again. You reminded me that I have a purpose too...that I am where I am supposed to be; that I am strong and resilient; and that no cold administrative rule, no heartless management agenda can ever, will ever change that. In a time when my department seems to be being systematically redefined by management that gives lip-service to "customer service", but whose actions seem to placing the very lives of those we "serve" in potential jeopardy born of cost-cutting attempts and the tyrannical pressure of overzealous, under researched regulation, you all reminded me that it's worth it to stick it out; to bloom where I'm planted; to let the roots that have grown deep within this rocky soil hold me firm in the winds that are trying so hard to uproot me and my coworkers in the name of...what??? Making an example out of us? Reminding all of us nurses...the ones who really keep this place going, the ones who really protect you, advocate for you, keep you as safe as possible...that we are expendable, not important, replaceable? WRONG!

Because of you, S., and other women like you, I have a purpose in this life; part of that purpose is my work, my employment, my vocation that is also my avocation; that purpose fulfills me and brings me joy (even the painful bittersweet joy of caring for you and your sisters in such sorrow), even when the world around my workplace is in such turmoil; even when that turmoil threatens to destroy my soul, the souls of my sister (and yes, brother) nurses.

We won't succumb to the threat. We'll above this useless struggle. Those who pride themselves on being in a position to decide will soon learn that their decisions that nearly brought disaster to this place, brought about instead, their own downfall; and while I do not wish them that downfall, if it protects those I am called to serve, I will not object to it.

S., I am blessed to have served you and your sisters. I am humbled by the opportunity to be so blessed. I am without adequate words to thank you for your gift.

My prayer for you is that you will, over time, experience the same gift of perspective that I had all but lost, but that you returned to me. I will be forever grateful; and I will forever hold you and your family in my heart.