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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