One thing that I suggest to my doula clients facing induction is to ask their care providers if they can turn up the pitocin SLOWLY. Even turn it down once pressure waves have started.
I know that this is possible. Here is a great post from Birth Sense about a hospital based midwife who does just this. I have seen it done for some of my doula clients. It is a nice way to make an induction more gentle and enjoyable for mom and baby!
Not all care providers are open to this idea. Why not? If mom and baby are doing well, why not go slowly?
Anyone care to comment? I really want to understand.
A Labor and Delivery nurse posted about a recent experience when a mom requested this. The midwife told the nurse to not tell the parents when she was turning it up. I am so happy that this nurse didn’t do that, but how many do? Her post made me so sad and mad at the same time.
Why won’t they do it slowly?
It lets me know how important it is to talk to care providers EARLY about their induction routines. If they are not open to upping it slowly, then that probably says a lot about their induction attitudes, and their reluctance to move outside of their routines.
Who are “they” and what is “slowly?” In general there are “high dose” pitocin protocols which involve turning pitocin up by “so many” milliunits every “so many” minutes, but, in general, these are not first choice for pitocin use. As a physician, pitocin is a “means to an end,” which is to say, if labor is adequate (progress is being made) then an increase in pitocin is not needed.
However, if labor is delayed or stalled (especially in an induction, after epidural analgesia, or in the case of PROM where the membranes are ruptured, but labor has not yet started), then pitocin is increased until the labor pattern is adequate for cervical change. Once adequate labor is established, most do not push the pitocin dose up further. Usually the dose increase happens every 15-60 minutes until contractions are adequately spaced (every 2-3 minutes) if measuring by external tocometer, or by adequte MVUs (Montevideo units) via IUPC.
The only valid way to truly measure the strength of the contractions is via an intrauterine pressure catheter…something that many would wish to avoid should they not be immobilized. A less accurate way would be regular interval cervical examinations. Other than observing the frequency and palpable intensity of the contractions by palpation, these are the only ways to gage weather or not pitocin is producing an adequate labor or if it is not.
That is the frustrating thing, every doctor does things differently and some are not willing to do it slowly, even though it can still work that way. I can see if there is an urgent reason to get the baby out, to do it more quickly, but if it is not urgent and mom wants to take it slowly, that should be a valid option.
“The only valid way to truly measure the strength of the contractions is via an intrauterine pressure catheter”
I feel like assessing cervical change is a very valid way. If the women is changing (which different providers use different amounts…some will go by the 1cm/hour, others by 1/2 cm per hour, others just assess any change), then the pitocin is working. I have seen women change quite well with MVU’s much less than the recommended amount. In fact, I had one patient dilate to 7 cm with MVU’s less than 100. Plus, with a labor that is being induced it can take quite a while to get up to 4 or 5 cm (just like a normal labor). I have had women labor all day at a three and then change within an hour to complete. All of this on lower doses of pitocin. This doesn’t mean we need to keep upping the pit, it just means they aren’t in active labor. There is also some research showing that once labor is established, then the pitocin can be decreased without any problems.
By just going with MVU’s you may be giving the woman much more pitocin than she actually needs. I personally don’t use IUC’s much unless the toco is not picking up the contractions. I find assessing cervical change as well asis a much more reliable indicator, and poses less risk of increasing the pitocin too high.
Here’s some research to back up my point that IUC are not more accurate than using a toco.
Outcomes after internal versus external tocodynamometry for monitoring labor.Citation Only Available
(eng; includes abstract) By Bakker JJ, Verhoeven CJ, Janssen PF, van Lith JM, van Oudgaarden ED, Bloemenkamp KW, Papatsonis DN, Mol BW, van der Post JA, The New England Journal Of Medicine [N Engl J Med], ISSN: 1533-4406, 2010 Jan 28; Vol. 362 (4), pp. 306-13; PMID: 20107216
With inductions the Fetal Health Surveillance Working Group published a paper here
Journal Of Obstetrics And Gynaecology Canada: JOGC = Journal D’obstétrique Et Gynécologie Du Canada: JOGC [J Obstet Gynaecol Can] 2002 Apr; Vol. 24 (4), pp. 342-55.
that recommends using IUC, palpatation or toco as all valid ways to monitor contractions.
There is a great post here http://www.themidwifenextdoor.com/?p=587
on this topic.
Enjoybirth~ Well, all labors and all women are also different, as are physicians. I think that most of us practice within the standard of care, although the elective induction rate is by far more patient-driven than it is physician-driven, IMO. If I am doing an induction, then I *do* feel that the baby needs to come out as quickly as safely possible. If I am inducing a PROM, I feel the same way, as infection rates can climb with prolonged rupture, therefore placing both mother and baby at risk for chorioamnionitis.
Rachel~ Sorry if the language I used was unclear, but what I meant to itierate was that an IUPC is the only valid way to monitor the *strength* (power or force) of the contractions, not necessarily the *efficacy* of the contraction. I think we are saying the same thing here.
Of course cervical change is the best way to gage labor progress (or, adequate labor). Changing = adequate labor. Not changing = not adequate. High tech is not needed in the event of a naturally progressing labor. In the aforementioned scenarios, the cervix is not going to change without assistance with pitocin. I don’t think that most OBs would rely only on MVUs if labor was effecting cervical change, it is only when it is not that pitocin is warranted or indicated. Not every woman on pitocin needs an IUPC, but if cervical change is not occuring, then IUPCs provide valuable information about how to better acheive cervical change/progress in labor. You can’t really go by Friedman curves when labor is being induced, but it is always expected that “latent labor” will not progress as quickly as “active labor.”
Thankfully the hospital I birthed my second daughter at knew I wanted another low intervention birth, so when I had to be induced to extremely high blood pressure at 39 weeks they did start the pit slowly and then turned it off once my contractions were strong and steady. I know I was lucky to have staff that was open to as all natural as my complication warranted…and they even offered up nipple stimulation to get things going before the pit was ever turned on.
drwhoo- “IUPC is the only valid way to monitor the *strength* (power or force) of the contractions” That makes more sense. I would be curious to look at patients perceptions of induction…i.e. do they feel pressured or not or who is really driving the induction rate. I agree that many women choose to be electively induced, but I wonder how many feel like they were encouraged or persuaded to be.
In any case, pitocin has it’s uses, obviously. But it is also one one of the number one reasons Dr’s are sued. So, something is going on. And including women in their care by using informed consent more and talking to them more about pitocin and allowing them to make the decisions may be a way to help with this.
What ever happened to allowing a woman’s endogenous oxytocin do its job? I think it’s a shame the way the birth process is controlled and manipulated. I think many doctors would argue that interventions improve safety and outcome. Why then are U.S. maternal and infant mortality and morbidity rates so high? We are pathetic when compared with other countries of comparable wealth. I believe some doctors (and to be fair some certified nurse midwives) don’t go out of their way to explain why they should carefully consider the potential problems of inducing. Pitocin induction often leads to epidural. Epidural leads to ineffective laboring (walking epidural my foot!) which leads to more Pitocin, a worn out woman and maybe a C-section. If a woman is low risk, don’t add things that could cause a system meltdown. Oh, and doctors, lithotomy position gives you a better view, but makes me work against gravity, makes pelvis smaller and pulls my perineum tight making it more likely to tear, have shoulder dystocia, etc. Mother Nature is wise. Women know how to birth babies and can if supported to do it. Birth is a normal body function, there’s no pathology – stop looking for it.