Advice and information needed

I've received several requests for information and resources about VBAC, VBAMC, twins, Bandl's Ring, and shoulder dystocia. I can't personally respond to all of these requests but I didn't want to just let them go unanswered. So I'm asking for your help! Several of the questions are fairly brief and it's hard to answer them without more specifics and background information. Nevertheless, let's see what we can do when we all put our heads together.

Request #1:
I have a friend that I'm trying to help. She is due in December with her third child. She's had 2 prior c-sections and is coming to find out that she does not want a third. I have some questions about what resources I should help her with and what she should look for in hospital policy.

Request #2: 
My best friend is having twins. She is currently 33 1/2 wks. Both babies are breech. Dr's of course want to section her bc of it. She is wanting true info on the safety of section versus breech birth. (I don't think there are any good studies on CS vs vaginal birth for breech twins. I mean, the Hannah Term Breech Trial was the biggest of its kind and that was only applicable for term, singleton breech babies.)

Request #3:
I have been curious about VBAMC for obvious reasons...Also, Rixa. Do you know where I might find info about Bandl's Ring? (if she is who I think she is, she's had 2 c-sections, and during the last one they discovered a Bandl's ring)

Request #4:
I have a question for you regarding shoulder dystocia. I have had 2 natural births, and both of them my daughters shoulders got stuck, it seemed they never rotated properly. The second time it happened I was in a hands and knees position though slightly upright leaning into an inclined bed. I was wondering if you could give me any information as to the best way to deal with this if it happens again (I'm pregnant with my 4th baby and a little worried about it happening again). Could it be that I am pushing to urgently and not giving the baby enough time to rotate before the shoulders pass? Thank you so much for your time!

Request #5:
I am interested in what the recent research shows about Pitocin administration and risk of uterine rupture in patients attempting a VBAC. For some reason, I thought that Pitocin was contraindicated for VBAC moms, but my OB tells me that she is comfortable administering Pitocin to augment (but not induce) labor. I'm not sure how I feel about this. I've done some of my own research, but find mostly mixed reviews. So, I thought I'd ask you since you are very familiar and up to date with obstetric research.

In case you were wondering about my background, I am expecting my 2nd child, in about 3 weeks. And I'm preparing and hoping for a VBAC. I had a c-section with my first for "failure to progress". It's a long story, so I'll try be concise: my water broke spontaneously 8 days before my due date; I waited for 12 hours for labor to start and had no contractions; was started on Pitocin-- labored on Pitocin for 12 hours and dilated to 1/2 centimeter; turned down the offer to do a c-section (since it had been 24 hours and they worry about infection risk), but I wanted to give labor a real chance; had Cervidil placed on my cervix and waited for 12 more hours-- no contractions; after 12 hours of Cervidil, I was dilated to 2.5 centimeters and "soft"; labored on Pitocin for 12 more hours and got to 5 centimeters when I stopped dilating. I never got an epidural and was up and moving during all the laboring; and by the time I got to that point, I was exhausted and it had been over 48 hours since my water broke, so I opted for a c-section. It was a tremendous disappointment and I felt like I never really got to do what I was preparing for. I still have no idea why my water broke, why my body didn't labor on its own, or why it didn't respond favorably to Pitocin. But, my doctor is very supportive of a VBAC. And I feel very lucky to be delivering at a hospital that does support VBACs.

Anyway, I guess the reason why I'm so worried about Pitocin is because I can't help but wonder what I'll do this time around if that situation happens again-- it's the only frame of reference that I have, you know? I've heard other doctors and other CNMs say that Pitocin can help VBAC moms, but I'm not necessarily interested in an opinion, I'd like to know what the research says. I am still just hoping and praying that I will go into labor on my own and that my water won't break until I'm far along, but I want to be prepared in case labor does slow down and/or stall. In fact, I just checked out some books on Acupressure because I've been told that it can help during labor. Do you have any other suggestions, I'd like to have more cards to play than just the Pitocin card.

I spoke with this last woman on the phone and gave several things to look into if this same situation arises, including nipple stimulation/breast pump, waiting a bit longer for labor to start on its own, asking her doctor about the possibility of low-dose pitocin, etc. We also talked about things that are theorized to make the amniotic sac stronger or prevent PROM. I wasn't able to find my files on UR rates and Pitocin administration during a VBAC, although I know that information is out there.

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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.

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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.

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Crank it up

A few days ago, Jill of Keyboard Revolutionary wrote about the practice of "pit to distress"--a term for aggressive administration of IV Pitocin during labor. Jill of Unnecesarean wrote more about it two days ago. Today L&D nurse blogger Nursing Birth wrote about her personal experience negotiating Pitocin protocols with her OB colleagues. It's a fascinating glimpse into the behind-the-scenes power struggles over patient care.

I'd love to hear from other L&D nurses about Pitocin protocols where they work. Do the physicians you work with tend to be aggressive with their recommendations for Pitocin? Is it fairly common to negotiate, ignore, or disagree with the attending physician about your patient's Pitocin regimen? Please share your stories!

Question 243 from a practice NCLEX exam shows this image and asks:

The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?

1. Instruct the client to push

2. Perform a vaginal exam

3. Turn off the Pitocin infusion

4. Place the client in a semi-Fowler's position.

I'd guess #3?

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What does giving birth feel like?

I remember reading a book by Sheila Kitzinger back in my early graduate school years called Giving Birth: How It Really Feels. I can't remember too many specifics from the book at this point, but it reminded me to write a post about what labor & birth feels like. This event is hard to describe, because there's really no other physical experience quite like it. Most of us resort to metaphor or analogy, usually in reference to some bodily function: menstruation, elimination, & sex are the most common.

The closest I can come to describing what a contraction feels like is: a sharp, knifelike menstrual cramp that I feel right above my pubic bone, from hipbone to hipbone. It's funny that I use menstrual cramps as my analogy, because for me cramps are a dull, constant ache, whereas contractions are strong, sharp, and intermittent. But that's the closest sensation I can compare it to. Many women describe their contractions as coming in waves or peaks. I would do the same. The prevalence of electronic fetal monitoring has probably cemented that imagery, since the contractions are traced on paper as oscillating peaks. If I think of peaks (as in mountain peaks or steep hills), I think of something that requires effort, that becomes harder and harder, and then goes downward and becomes easier.

When my body began pushing, I experienced three distinct sensations. During Zari's labor, I had about an hour of "throwing down": abdominal pushiness/heaving that felt just like throwing up, only it was in a downward direction. No rectal pressure, very mild. I skipped this stage with Dio's labor. Next, I felt intense rectal pressure as the baby moved down, like my butt was going to split in two. I really didn't like this sensation. And finally, the rectal pressure subsided as the baby began crowning. In its place I felt intense stretching and stinging as the baby's head emerged more and more.

I was thinking about something one of my sisters-in-law told me about her experiences of labor. Her first three births (with obstetricians) were either augmented or induced with Pitocin and, not too surprisingly, followed by epidurals. She had told me that labor felt like your skin was being turned inside out--basically that it was pretty awful. Then with her fourth and fifth babies, she had unmedicated hospital births (with CNMs) and no Pitocin during labor. She realized that the awfulness that she had assumed was inherent in labor itself was due to the Pitocin.

We know that a majority of women in the U.S. receive Pitocin during labor. It's not entirely clear how big of a majority it is, but the Listening to Mothers II survey found that 50% of the mothers surveyed received Pitocin to either induce or augment labor. Others have estimated that the number is much higher. Of the women Robbie Davis-Floyd interviewed for her 1992 book Birth as an American Rite of Passage, 81% received Pitocin during labor. In any case, at least half and quite likely three-quarters or more of women experience a Pitocin-enhanced labor.

I wonder if this is responsible for a large part of our culture's fear of labor pain. It's no wonder that so many women talk about labor as being excruciating if more than half of them have had Pitocin! Almost all women who have labored both with and without Pitocin report that Pitocin makes labor much more painful. Pitocin contractions are usually longer, stronger, and closer together than those of a spontaneous labor. I haven't ever had Pitocin during labor, so I can't comment personally on this.

So I would love to hear from you:

• What did labor and birth feel like for you?
  
• What made labor more or less painful for you?
  
• If you have experienced labors with and without Pitocin, how would you describe the difference between the two?

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Cesarean section and uterine rupture

Two recent studies--one still in press--that I find quite fascinating relating to uterine rupture. I have the full text of the first one, and hope to access the second one* as soon as it is officially published. As always, email me if you'd like to take a look at the full text.

A few comments/questions/observations:

• I hope that the evidence from the first study won't be used to risk out women who never went into labor before their cesarean section. Instead, I hope it will simply be used to give extra confidence and reassurance to women who did experience labor before they had a cesarean.
• In the second study, note the correlation between oxytocics (i.e., Pitocin) and uterine rupture in both scarred and unscarred uteri. 21 of the 41 uterine true ruptures occurred in connection with oxytocics--9 among women with previous cesarean sections and 12 among women with unscarred uteri. This, of course, doesn't mean that using Pitocin = uterine rupture, but certainly it suggests the need for prudence and caution when administering Pitocin during labor--not just among women having a VBAC, but also among women with no previous cesarean section.
  

1) Laboring before a primary C/S reduces the risk of uterine rupture in a subsequent intended VBAC
C.S. Algert et al. "Labor before a primary cesarean delivery: reduced risk of uterine rupture in a subsequent trial of labor for vaginal birth after cesarean." Obstet Gynecol. 2008 Nov;112(5):1061-6.

OBJECTIVE: To estimate the effect of the onset of labor before a primary cesarean delivery on the risk of uterine rupture if vaginal birth after cesarean (VBAC) is attempted in the next pregnancy.
METHODS: Longitudinally linked birth records were used to follow women from a primary cesarean delivery to a trial of labor at term for their next birth. The effects of characteristics of both the trial of labor and primary cesarean deliveries on the risk of uterine rupture were examined.
RESULTS: Of 10,160 women who had a trial of labor, 39 (0.38%) had a uterine rupture. Women who were induced or augmented for their trial of labor had a greater relative risk (RR) of uterine rupture (crude RR 4.24, 95% confidence interval [CI] 2.23-8.07). Women whose primary cesarean delivery was planned or followed induction of labor also had an increased risk of uterine rupture (crude RR 2.61, 95% CI 1.24-5.49), and this risk remained after adjustment for other factors. Women with a history of either spontaneous labor or vaginal birth had one uterine rupture for every 460 deliveries; women without this history who required induction or augmentation to proceed with a VBAC attempt had one uterine rupture for every 95 deliveries.
CONCLUSION: Labor before the primary cesarean delivery can decrease the risk of uterine rupture in a subsequent trial of labor. A history of primary cesarean delivery preceded by spontaneous labor is favorable for VBAC.
LEVEL OF EVIDENCE: II.

2) Half of all true uterine ruptures are not associated with prior cesarean section
Porreco RP, Clark SL, Belfort MA, Dildy GA, Meyers JA. The changing specter of uterine rupture. Am J Obstet Gynecol. 2009 Jan 9. [Epub ahead of print] Presbyterian/St. Luke's Medical Center, Denver, CO.

OBJECTIVE: The objective of the study was to review all patient records discharged with codes for uterine rupture in 2006 in Hospital Corporation of America hospitals. STUDY DESIGN: All patient charts were distributed to a committee of perinatologists and general obstetricians. Case report forms were analyzed for variables of interest to determine validity of coding and quality of care.
RESULTS: Of 69 cases identified, only 41 were true ruptures. Twenty patients had previous cesareans, and in 9 of these patients, concurrent use of oxytocics was documented. Among the 21 patients without previous cesareans, 7 had previous uterine surgery, and oxytocics were documented in 12 of the remaining 14 patients. Standard of care violations were identified in 10 of 41 true rupture cases.
CONCLUSION: Epidemiological data on uterine rupture based on hospital discharge codes without concurrent chart review may be invalid. Patients with previous cesareans represent only half of true uterine ruptures in contemporary practice.

* thanks to Jill for this one!

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