Sunday, July 12, 2009

Pitocin protocol and emergency cesareans

Speaking of Pitocin and emergency cesareans, a recent study found that adopting a less aggressive Pitocin protocol halved the rate of emergency cesarean deliveries. By administering a lower dose of Pitocin in smaller increments and in longer intervals, emergency cesareans fell from 10.9% to 5.7%. It's one of those "well, duh!" studies. Of course you're going to have more emergency cesareans with a more aggressive use of Pitocin. (To better understand the technicalities of Pitocin administration, please read Nursing Birth's recent post Pitocin Protocol For Labor Induction/Augmentation Decoded.)

I had to blink a few times when I read that the hospital's rate of Pitocin usage began at 93.3% and declined to only 78.9%. Seriously? Less than 7% of all laboring women did NOT have Pitocin? I cannot imagine any reasonable justification for Pitting 78% of all laboring women, let alone 93%. At times I wonder if I am mistaken in my belief that our birth culture is overly medicalized and, basically, really screwed up. But when I hear that a hospital administered IV Pitocin to more than 93% of its laboring patients, I don't think that I am overreacting at all.

Anyway, ranting aside, here is the report:

Hospital’s Oxytocin Protocol Change Sharply Reduces Emergency C-Section Deliveries

CHICAGO (EGMN) – The modification of the oxytocin infusion protocol at a large university-affiliated community hospital nearly halved the number of emergency cesarean deliveries over a 3-year period, reported Dr. Gary Ventolini.

As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%, Dr. Ventolini said at the annual meeting of the American College of Obstetricians and Gynecologists.

Other birth outcomes improved as well at an 848-bed community hospital that serves as the primary teaching hospital of the Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

These included significant declines in emergency vacuum and forceps deliveries and a sharp reduction in neonatal ICU team mobilization for signs of fetal distress (P = .0001 in year 3 compared with year 1).

“More and more data are showing us that we are using too much oxytocin too often,” Dr. Ventolini, professor and chair of obstetrics and gynecology at the university, said in an interview.

“Our pivotal change was to modify the oxytocin infusion from 2 by 2 units every 20 minutes to 1 by 1 unit every 30 minutes. And we see the results,” he said.

Outcomes of 14,184 births from 2005, 2006, and 2007 were retrospectively analyzed to determine any impact of the change in an oxytocin protocol implemented in 2005. Patient characteristics were similar in all three calendar years.

The most profound changes were in emergency deliveries, including caesarean deliveries, vacuum deliveries (which dropped from 9.1% to 8.5%), and forceps deliveries (which fell from 4% to 2.3%).

The overall cesarean section rate remained unchanged, as did the rates of cord prolapse, preeclampsia, and abruption.

Dr. Ventolini cited a recent article in the American Journal of Obstetrics and Gynecology that suggests guidelines for oxytocin use, including avoidance of dose increases at intervals shorter than 30 minutes in most situations (Am. J. Obstet. Gynecol. 2009;200:35.e1-.e6).

Dr. Ventolini and his associates reported no financial conflicts of interest relevant to the study.


  1. They did see a drop in emergency cesarens, forceps & vacuum by using Pitocin less agressively, but the over-all cesarean rate did not drop--which tells me that they just substituted "failure to wait" cesareans for the emergency ones.

  2. I have long considered myself lucky if I get to attend a birth withOUT Pit. The number of inductions alone were a big chunk of that, but it seemed like almost everyone ended up getting it at some point. Contractions not strong, contractions not regular, progress too slow, pushing taking too long, labor stalling, etc.

    What has always stuck in my mind was working with a woman who came in, SROM, light contractions, minimal dilation. She wanted to go unmedicated. She had been ruptured for at most a few hours when she arrived at the hospital; I got there not long after she showed up and the midwife had already ordered Pitocin and the IV was being placed. As they started running it she looked at me and said "Is this really necessary?" I just didn't know what to say. This was during my AmeriCorps service and I'd never met the woman before, and she'd already agreed to the Pit and it was running. I think I said something along the lines of, not necessarily, but let's see how things go and you can ask for it to be turned down/off. She went on to have an extremely fast and intense labor - she delivered within a few hours. I don't think they turned the Pitocin off till close to the end.

    Did the Pitocin kickstart her labor? Did it make things more intense than they needed to be? Did it make no difference? We'll never know, but the fact is this woman had a three hour labor and STILL managed to get Pit (in a midwife's care no less). There was zero "watchful waiting". If she can get it, everyone can get it.

  3. This totally makes sense. I have had a few friends induced here in Germany, and it sounded like it was a completely different protocol than what they do in the U.S. (all friends who were induced here had natural births except one whose baby was in a very dangerous position).

    It sounds like the procedure here was to try to stimulate the body by the least aggressive means possible. If the first attempts did not work, they would try again and then eventually move to pit only in the extreme cases or only at the very end of labor.

    One friend who had her second baby in Germany after having her first in the UK (with induction both times) was terrified of being induced again because of her experience with the pit induction. She was so happy that she was able to have a epidural-free birthing experience the second time. She had tears in her eyes telling me about it.

  4. the above story of a 3 hour labor sounds like my friend.

    she went in to be induced for "post dates" of 40 weeks. Her decision since she was tired of being pregnant.

    started pit at 8:30am had a baby by 11:45am. it was insane. the nurse kept coming in and turning up the pit every 10 minutes. i told her she wanted to talk to her midwife and turn down the pit, and she was told she "could get an epidural if she wanted but the midwife was busy. if we stop the pit your contractions will go away!"

    my mom had labors of 3 hours, 2 hours and 45 minutes with my siblings.
    amazingly she was induced with the last 2, and not for health reasons. they wanted her to be in the hospital and not have a baby in the car. i was a much needed c-section for placenta previa.

  5. Not surprised. If you add an epidural to the mix you often need to add a little pitocin. However, you don't need to add a lot of pitocin. It should be used for the body to be stimulated into making its own. I usually end up turning the pit way down by the time a woman is fully because she is having too many contractions.

    Interesting study. Also Pitocin is a hot topic for legal cases in OB. So being heavy handed with pitocin is not doing anyone any good.

  6. 93%?!? Yuck! I knew it was way up there, but geez, that's nearly ALL WOMEN. Just more proof that the obstetrical field has absolutely ZERO understanding of how birth works. I bet the doctors at that hospital go stir crazy when they get one of the 7% who don't want Pitocin (or don't have time to get it).

    And it's doing no one any favors in regards to demystifying birth as a whole, either. Our mothers and grandmothers were tied down, told not to push till the doctor got there, recieved huge episiotomies, had their babies yanked out with forceps. So they tell us that birth is terrifying and painful. We go on to give birth with artificial contractions squeezing the life out of us, similarly tethered to the bed by monitors, and think our mothers were right. Of COURSE birth is going to be terrifying and painful with that nasty crap surging through your veins! I would rather have ten more homebirths without so much as a Tylenol for the pain than have another birth on Pitocin!

  7. I am one of the 7% of women who refused Pitocin for my first pregnancy. Not pleasant being in labor and arguing with a resident over Pitocin (I was already in labor, so I did not see the need for it). It took me about 10 hours to go from 4cm to complete naturally. Maybe that was to slow for them. Unfortunately I ended up with a C-section even though I was never on Pit (Nurse Curse).

  8. Yet another reason I will NEVER give birth in a hospital unless I have serious reason to do so. It's such a shame. Even if it is POSSIBLE to birth 'naturally' in a hospital setting, it takes a hell of a lot of resistance. I don't want to have to spend my labor fighting with strangers, as Reality Rounds did!

    What has to change, I feel, is the entire active management philosophy - the mindset that hospital maternity care providers maintain (as a whole - there are notable exceptions, of course).

    A perfect example of this occurs in "The Business of Being Born", when touring a L&D department; a nurse gestures to an IV bag and says "And this is Pitocin, which is the medication given through the IV that causes contractions." That struck me from the very first time I saw it - the way she phrases it, it really seems as though she BELIEVES that Contractions Are Caused by Pitocin. Not that it's a facsimile of the real thing, not that it's a synthetic substitute, not that it's an artificial means we occasionally have to use in certain circumstances when extra help is needed. No, IT causes contractions.

    Very revealing. And this study confirms, to me, that she is far from alone.

  9. Many yrs ago, I took a friend to a homebirth. She was a labour/dly nurse who had given birth very quickly to her only child. She couldn't believe how stop and start and "non-progressive" the homebirth was. Of course, it resulted in a baby after about 12 hours of up and down, meandering contractions. I realized that, if the birth had happened in the hosp., the mother would have had pit because you're not allowed to stop, start, meander or "fail to progress" in there. At home, it's just another way to do it.

  10. The interesting thing is that if you have a homebirth with a midwife in Ontario, start/stop/stall labours are probably just as risky to have at home as in the hospital. Because of the legislation around what midwives can/cannot do, they still might transfer to the hospital for 'failure to progress' if your labour takes longer than 1 cm per hour.

    93% is almost unbelievable! I mean, I'm not really surprised, except that 93% of women are either that grossly misinformed or unable to advocate for themselves :(

  11. This is great information. It really shows how prevelant pitocin is and how it can lead to interventions. Thanks for sharing!

    When I do my birth statistics from my Hypnobabies Class and my Doula clients, I have overall statistics and then out of curiosity I did statistics of moms who had no pitocin. It was interesting to see the difference. You can see at my blog if you are interested. Just search for statistics.

  12. Kim, it's the same drill if you have a B.C. registered midwife--so called failure to progress is the biggest reason for transport to hospital. That's part of the medicalization of what used to be authentic midwifery.

  13. I got pitocin with my first child, without my knowledge or consent. I had just arrived at the hospital at 9.5 cm. What the heck?
    For my second child, my sister was under orders to throw herself between me and anyone who wanted to give me pitocin. Also, I had a midwife.


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