Thursday, July 09, 2009

Crank it up, part 2

I've already linked to posts about "Pit to distress" from Nursing Birth (make sure you read it!) and Jill at Unnecesarean. As (Keyboard Revolutionary) Jill pointed out in It's Gone Viral, several more bloggers, all of them nurses or midwives, have commented on the practice.

One problem with all the uproar about "Pit to distress" is that the term means a few different things. Some nurse bloggers have seen physicians Pit to distress deliberately, others carelessly. Others claim that no physician would ever intentionally push Pit aggressively enough to force or even accidentally trigger a cesarean section. The optimist in me would hope that no nurse or physician would ever use Pitocin so aggressively that it would provoke a cesarean, intentionally or not. But I've been listening to women's stories long enough to be more of a realist than an optimist.

N is for Nurse's post was the initial trigger for the whole conversation. She refused to keep upping the Pit on a woman who was already in trouble:
...possibly abrupting, had a strip with recurrent lates and minimal variability and I was supposedly "pitting to distress." BTW, I don't pit to distress when our anesthesia team is not on the floor and is instead down on their third gunshot wound in the trauma bay of our ED. So there. I don't care how much the docs bully me--they wanted to force a crash c-section. Nope. Not on my watch, with a woman I believe was abrupting. Scary. They had originally called the section, then backed out--then we lost anesthesia to the ED, so they wrote pit orders on a woman who was already hyperstimming by herself, bleeding and baby looked like crap. I was really hating my job that night--fighting three residents is loads of fun.So, I hung the pit at 2 units and didn't touch it for 2 hours. I also watched mom like a hawk and made my general displeasure known (and charted it all of course) to my charge who agreed with me and the attending who didn't want to "cut" this woman in the 1st place. Dude, she needed a c-section, just NOT a crash section.
Rebirth's Take on "Pit to Distress" is that it doesn't happen, at least "never in a way to purposely gain a reason for performing a c-section. It was done more because the thinking was 'more equals better and gets the job done quicker' and then all of a sudden trouble began."

In No Doctor, Reality Rounds discusses how nurses juggle their own professional obligations against their physicians' orders:
A nurse is ethically, morally and professionally obligated to advocate for her patients. We are not subordinate to physicians. We are our own profession, governed by other nurses. We are to assist physicians and carry out their orders in regards to the overall plan of care for the patient. We need to work as a team for the health and safety of the patient. A nurse CAN refuse to carry out a physician order. A prudent nurse should refuse any order she feels would cause harm to the patient (like "pit to distress"), or was a procedure not legally consented for ("No I won’t assist with the circumcision until the paper is signed. Don’t care that you just talked to the parents"), or one that she is just plain uncomfortable with ("No I will not hand you any surgical instruments until we do a “Time Out” to make sure we are amputating the correct leg").
Morag of Mama Mid(wife) Madness, on the other hand, is a pessimist in regards to "Pit to distress":

I've spent a little time researching this "Pit to Distress" and have found, justly, that L&D nurses don't like it a helluva lot. I wouldn't either if I was the one being told to administer the doses when the only desired consequence (that I can see) is to stress a baby and clear the bed, probably due to a thoroughly iatrogenic "emergency" cesarean for fetal distress. This also handily would allow OB residents to rack up another surgery before the end of a shift. I fervently hoped that this protocol is NEVER used on VBAC women. Sadly, many of the tales on nursing message boards discussing "pit to distress" were of VBAC mamas whose labors were augmented this way simply to ensure that their TOLAC (trials of labor after cesarean) failed, and quickly. What's the bet the women had NO idea that their labors were being forced to a frightening conclusion.


  1. When nurses REALLY begin to advocate for the patient, things will change fast. We won't see any more Cytotec or other prostaglandins used for one thing. We won't see any more 41 week inductions for low amniotic fluid for another. Nurses know darn well that these things are harmful and go along with them because "I'll lose my job", "I want to pick my battles", "It's our protocol" or other rationalizations. Every time they go along with a harmful procedure that a doctor orders, they are part of the problem. Don't even get me started on the nurses role in infant circumcision.

  2. Pessimist? Maybe. I do see that Pit to distress is probably the (logical?) extension of a more acceptable (?) practice to start pit and gradually increase it to the point that babe starts to look iffy and then back it down (and hope that backing it down will work to resolve the distress). Either way, you're messing with the labor so significantly that your odds of winding up with a surgical outcome are dramatically and to my mind unacceptably increased, to say nothing of the attendant risks of postpartum hemorrhage (those receptors are so saturated with pitocin that the uterus won't involute properly and stem bleeding). Tachysytole is a bad scene. Too much pit is going to get you tachysytole.

  3. I hope that this blogging will help moms see how important it is to make good choices in their care providers and to PAY ATTENTION if they are getting induced. Let your care provider know you want the pitocin turned up SLOWLY!

    Women do have power to change these things. Obviously it would be so much better if care providers didn't do this. But now that we know they may, we can be more proactive in preventing it.

    I know as a doula when I attend an induction, I talk to the mom about this topic. And I watch the nurse like a hawk!

  4. Hi, I'm a student midwife in Australia and have heard from an Obs mouth "push the synt a bit more to give me some decels so we can get her into section". I was horrified and thought maybe I didn't know what she was really talking about as it was my first intrapartum placement. Now know that yes, I did hear correctly, and it did mean exactly what I'd initially thought!

  5. Can I link to your post? You have layed out the problem so clearly, it seems silly for me to reduplicate it. LMK! Thanks, Shanon

  6. Gloria,
    I am intrigued by your comment. It inspired me to write a post about nursing advocacy. I would love for you to comment to this on my site.


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