How to deal with "coupling" or "doubling" contractions?

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Hello,

I have questions regarding to "coupling" or "doubling" contractions. One of my patients whom I took care of two weeks ago had "doubling" contractions every 3 minutes and she was already on pitocin 2 mu/min. I was hesitate to add pitocin to her when I found that she had "doubling" contractions . I consulted with one of my experienced co-workers, she said it was ok to add more units pitocin. I then added one more unit. The pt delivered two hours later with good outcome. However, when I read books when I got home, I noticed one of books said that most "doubling" contractions caused by persistent OP or OT position, and pitocin need to be discontinued; Whereas in another book, it says "coupling can be normal or may suggest a hypotonic pattern", and then the book suggests to initiate agmentation. I am wondering which statement is correct, and what you will do if your patients have "doubling" contraction? Thanks.

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Specializes in Ante-Intra-Postpartum, Post Gyne.

I was taught that "coupling" is ineffective/dysfunction contractions and the pit needs to be turned up. It is interesting that two sources say different things. I would try to find any research done on this. When in doubt I turn to EBP

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I agree with HeartsOpenWide. In early labor when they have pit already going and start coupling I turn it up as coupling is a dysfunctional pattern.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Recent literature actually recommends turning DOWN pitocin in the face of doubling and tripling contractions. Saturating oxytocin receptors too soon in labor can cause MORE dysfunction not less. And you may create a hypoxic state in the fetus whereby he/she will tolerate later labor and pushing very poorly.

See Perinatal Nursing by Kathleen Rice Simpson and Patrician Creehan from AWHONN. Very good chapter on pitocin augmentation and induction in there with the complete rationale and physiology of why it's best to turn down, not up, pitocin in the face of this type of dysfunctional labor.

Here is the book I am talking about:

http://www.amazon.com/AWHONNs-Perinatal-Nursing-Co-Published-Simpson/dp/0781767598/ref=sr_1_1?ie=UTF8&s=books&qid=1266789661&sr=8-1

I , also, was originally taught to turn up pitocin, but that is becoming "old school" thinking. 13 years ago when I started, we were actually to induce people starting at 6mu/in and going up by 6mu/min every 30 minutes! WOW have things changed. Read up on more current literature for a more complete explanation as to why this is so. Less is more, it turns out, with pitocin. Most of the time you can get the job done with 8-10 mu/min in labor. A laboring mom has about 6-10 mu/min oxytocin circulating without augmentation. When you are seeing doubling and tripling, try position changes, ----get her out of bed and on a birth ball or toilet if possible---you can monitor moms this way too------also, try additional hydration as needed and patience. It works!

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Not evidence based, but on the natural side of things I have always been taught that coupling is normal, especially in transition. Also that coupling may be a symptom of OP position.

Medically I have been taught to up the pit to break away from the coupling which does seem to work.

I will have to look it up also- let us know what you find out.

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Specializes in OB.

Interesting about the pitocin. I have been told you can "pit them out of it", but I guess it depends. I always assume that it means the baby is OP, and I get my pt. moving whether it be position changes in an unmedicated mom, or flipping a mom with an epidural, side to side.

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Specializes in Cardiac.
Recent literature actually recommends turning DOWN pitocin in the face of doubling and tripling contractions. Saturating oxytocin receptors too soon in labor can cause MORE dysfunction not less. And you may create a hypoxic state in the fetus whereby he/she will tolerate later labor and pushing very poorly.

See Perinatal Nursing by Kathleen Rice Simpson and Patrician Creehan from AWHONN. Very good chapter on pitocin augmentation and induction in there with the complete rationale and physiology of why it's best to turn down, not up, pitocin in the face of this type of dysfunctional labor.

Here is the book I am talking about:

http://www.amazon.com/AWHONNs-Perinatal-Nursing-Co-Published-Simpson/dp/0781767598/ref=sr_1_1?ie=UTF8&s=books&qid=1266789661&sr=8-1

I , also, was originally taught to turn up pitocin, but that is becoming "old school" thinking. 13 years ago when I started, we were actually to induce people starting at 6mu/in and going up by 6mu/min every 30 minutes! WOW have things changed. Read up on more current literature for a more complete explanation as to why this is so. Less is more, it turns out, with pitocin. Most of the time you can get the job done with 8-10 mu/min in labor. A laboring mom has about 6-10 mu/min oxytocin circulating without augmentation. When you are seeing doubling and tripling, try position changes, ----get her out of bed and on a birth ball or toilet if possible---you can monitor moms this way too------also, try additional hydration as needed and patience. It works!

ok this is what I was thinking! I do remember something from school!

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Read the literature, Shortstuff. It discusses much more articulately what I am saying. You are RIGHT: coupling/tripling are associated with dysfunctional labor and positioning. Which is why "pitting them out of it" is really antiquated thinking. You are better off helping with position changes and hydrating the mom than "Cranking up the pit". The doctors are the ones so hard to convince!

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Thank you all for your comments. I really appreciate that.

I found the original statements about "doubling" contractions in my books. In Michelle Murray's " Antepartal and Intrapartal fetal monitoring," it says," Action in response to doubling include discontinuing the oxytocin infusion and evaluating the pelvis and fetal position and size for fit (Pg 45)". It says, " If the fetus is not in malposition, and the pelvis is found to be adequate for the fetus to descend and deliver lady partslly, and oxytocin was infusing, and the FHR pattern demonstrated fetal well being, the oxytocin infusing could be continued in order to establish a normal UA pattern. If the fetus has decelerations and oxytocin ordered to continue, the physician should be readily available to handle complications." In my "EFM Case Book" from CCPR, in a case with a coupling contraction , the rationale says, "...coupling ...may suggest a hypotonic pattern or occur after administration of medication. In this case, plotting a labor curve could help the nurse assess the progress of labor. If this woman's cervix is dilating less than 1.2 cm per hour during this active phase, a protraction disorder may be diagnosed and augmentation initiated."

My understanding is when we find "coupling" or "doubling" contractions, we need to assess pelvis status first. If the pelvis is adequate for NSVD, FHR is reassuring, and contraction is not adequate for cervix to dilate, we add more pitocin (if there is order for pitocin). What do you think? Thanks.

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