How high is too high for pitocin

SmilingBluEyes · May 11, 2005

50-60mu/min? OMG wow. Never heard of using so much pitocin.

Our protocol calls for no greater than 20mu/min to be overriden ONLY by a separate doctor's order. And then, never, ever greater than 30mu/min will be use in any case. On VBAC's, we may not exceed 20mu/min at all.

That is scary. Too much pitocin not only can hyperstimulate someone, (and yes, lead to potential for uterine rupture)---- but oxytocin abuse can cause some serious fluid balance overload (it acts like ADH) and subsequent hemodilution, which----, paradoxically,--- can lead to excessive bleeding immediately postpartum. (less clotting factors available in blood to keep bleeding in check postpartum).

I know AWHONN has addressed the use of oxytocins time and again and I would say that is the place to start. I am sure if you search, you can find some articles discussing the abuse of oxytocin and hyperstimulation and fluid volume overload.

http://www.awhonn.org for your reference. I also know Michelle Murray has discussed pitocin use ad nauseum. Perhaps you can find some of her works or attend a conference? She will scare the poop out of you.

Also, take this situation to your PERINATAL COMMITTEE and Chief of OB, risk management team, as well as hospital CEO, if need be, ASAP---esp if this is just ONE doctor doing this. The guy or gal is very, very dangerous.

Minou · May 11, 2005

Wow, that is a lot of pitocin. my L&D is level 1 so our unit protocol says 20 m.u./hour and only a few docs give us orders to increase up to 30 m.u..

But you know what ( of course mention that to a doc and they don't believe you ) if your pt is on 20 m.u. and doing zilch then chances are she's not going to get going with 30 m.u. either. what often works is cutting it back and re-cranking it... But what do I know !

Minou

SheaTab · May 11, 2005

We don't go over 40 milliunits/min without an order. However, I rarely get that high. We have a couple of MDs that will come in and adjust your pit with and without your knowledge. When they say..."Increase the pit" I just smile and say OK. Then I use my nursing judgment as to how much they need. I would never feel comfortable going above 20 milliunits without a IUPC. That's just me. I would NEVER EVER pit a VBAC patient without an IUPC and would want to keep her mvu's relatively low. I don't know girl.... This sounds like some scary stuff going on in your facility. If an MD wants to be too aggressive with the pit on my watch, I will gladly tell him/her to adjust it and sit at the bedside himself! AND... YOU MUST... DOCUMENT, DOCUMENT, DOCUMENT! I'm really tired of this cattle herding of women... this rushing... the stupid labor curve. I had a labor/delivery last weekend that lasted a total of about 4 hours. A PRIMIP! The MD was like "6 milliunits every 15 minutes." "jet-pit" I smiled and said "sure"... and would you know that I never increased it to more than 8 milliunits! hehe BUT... he kept coming into my room to check the patient... (this was mother's day). AND... funny how she began to bleed after his exams. He is notorious for "stretching/ripping" a cervix! Sad Sad... he just didn't want to be there. I'm sorry for the rant. You should first and foremost advocate for your patient's safety. T.

BENNETTRN · May 12, 2005

I am trying to find references for guidelines on what the upper limit of pitocin is for both scarred and unscarred uterus's. It is not unusual to run pitocin at more than 50-60 milliunits even on VBACs and without IUPCs. This scares the hell out of many of us, but God forbid we don't increase it at the ordered intervals, turn it down or even off!! Despite what is going on with the strip, we can be (and have been) chewed out by a doctor for not turning the pitocin up on schedule. Notice it is "a" doctor.
I am trying to gather amunition to go to the nurse manager with so we can get administration's backing on putting a limit on how high we can run pitocin. I would really love it if I could get access to those references online, but any guidance would be greatly appreciated.
Heather

Heather, your license is on the line here, and that as well as a positive outcome for your pt and baby are the bottom line! I think you are going to be hard pressed to find any RN to back this practice up. On my unit, we go to a max of 24, anything over that we call the doc, then the highest we go at our hospital is 40 (that high is rare), which is not generally done, the pt must have NO risk factors, and godforbid can not be a VBAC. Also we maybe have one or two docs that will Pit a VBAC, and if it is done its of course 1:1 and done with the greatest caution! We do have a couple of doc's who always say "be aggressive with the Pit, even if the strip is bad, and just like another person said, I smile say okay and then do what I know is right, using my judgement. I cant understand why some docs will risk so much, just so they can be at the dinner table by 1800? Gather all your facts ASAP and start up the chain of command because this is crazy!!!!! Best of luck to you!!!!!!!

Mahogany · May 12, 2005

I am trying to find references for guidelines on what the upper limit of pitocin is for both scarred and unscarred uterus's. It is not unusual to run pitocin at more than 50-60 milliunits even on VBACs and without IUPCs. This scares the hell out of many of us, but God forbid we don't increase it at the ordered intervals, turn it down or even off!! Despite what is going on with the strip, we can be (and have been) chewed out by a doctor for not turning the pitocin up on schedule. Notice it is "a" doctor.
I am trying to gather amunition to go to the nurse manager with so we can get administration's backing on putting a limit on how high we can run pitocin. I would really love it if I could get access to those references online, but any guidance would be greatly appreciated.
Heather

This sounds like a very serious matter. You must have a Policy on Pitocin administration, which should be accessible on your Unit. Standards of Practice should be enough ammunition for you to approach an uneven table. There may be a slight difference in hospital policies. However, fetal well-being, contraction pattern and maternal response must be considered when administering Pitocin.

Was it a typo when you mentioned 50-60mU (per min)? As a group, you should approach your manager with your concerns, because in the end, you will be liable for not following policy and the doctor will wiggle his way out. At my institution, the maximum dose is 32mU/min, but I have never seen it higher than 24mU for induction. Where is your manager in this? The doctor needs to review the Policy and you need to leave a paper-trail--that you spoke to the powers that be, and that you made a copy of the Policy available to the doctor. And you better have good documentation as per your Policy.

You also need to pay close attention as to the indication for Pitocin-induction or augmentation. We do low-dose pitocin on VBACs but never without an IUPC.

Good luck.

Mahogany

SmilingBluEyes · May 12, 2005

any news, OP? Did you discuss taking this to perinatal committee with your manager?>

And yes, good point, what IS your policy on the unit regarding pitocin augmentation/induction????

fourbirds4me · May 12, 2005

A couple of things... First of all... how is your pitocin mixed? You may be confusing cc with mu/min. That being said... I have heard of this before. There have been studies that say that a high dose pit regimin is as safe and more effective especially in the nulliparous pt. (Dublin Protocol) I have worked with nurses who came from places where they would use this protocol... start at 6 MU and go up by 6mu q 15-20min. They reported no higher incidence of hyperstim or c/s. Just wondering but could this be because this dosage routine doesn't allow for a "oxytocin feed back loop".

Currently, our protocol is for induction .... start at 2mu increase to 4mu then go up by 4 q 30min. Cannot go above 20 without an order or an IUPC.

Courious about what everyone else does?

htrn · May 13, 2005

Sorry to scare you all, but it was 50-60+ milliunits - 20 units of pitocin in one liter of fluid running at over 180 ml/hr. Our facility does not have a facility limit on pitocin and our manager just wants to keep everyone happy. I am trying to gather all my sources and approach her with a letter and documentation from both a liability stand point and medical stand point. I appreciate the input.

Dawn27 · May 13, 2005

Just thought I would let you know the reccomendations in UK The Royal Collegege Of Obstericians and Gynaecologists have published guidlenes and they state :

In the summary of product characteristics the licensed maximum dose is 20 milliunits per minute.

If higher doses are used the maximum dose used should not exceed 32 milliunits per minute.

Useful references:

American College of Obstetricians and Gynecologists. Induction of labour. Washington DC: ACOG;1999. Practice Bulletin no. 10.

Society of Obstetricians and Gynaecologists of Canada.Induction of Labour. Ottawa: SOGC; 1996.SOGC Policy Statement no. 5

The full guidelines can be found at http://http://www.rcog.org.uk/resources/public/pdf/rcog_induction_of_labour.pdf

Mahogany · May 13, 2005

Is your facility accredited? How could you not have a Policy on the drug most commonly used in labor? Not only have you to be concerned about the mom, where is the baby in all this? What other Policies have you not got? Do you document that despite hyperstimulation x 1 hour, Pitocin infusion was increased to 50 mU/min by RN. and Doc.Doe informed? What is the baby doing during hyper stim-hypoxic may be? I really do not think that you appreciate how serious this violation is.

Your manager-how knowledgable is he/she? Maybe he/she has nothing to lose. What will he/she do when there are law suits and he/she can no longer keep you all happy?

There seems to be the need to review the systems that are in place--Policies, people, etc. and do some major revamping. What does your Mission Statement say? I would not be caught dead working in such a danger zone.

babyktchr, BSN, RN · May 13, 2005

Scary to think that your manager is more interested in keeping people happy more than keeping patients safe. The use of pitocin that high is insane. As someone said earlier, if it isn't working at 20mu..then it certainly isn't gonna work at 50mu. The receptors are sooo saturated by that time, that all you are going to get is a hemmorhage afterwards.

There must be something on the ACOG site that has some sort of guidelines for pitocin practice. I haven't had the chance to go there and research it.

Gosh...I can't even begin to imagine pit running at 180cc/hr. Its a wonder your patients aren't insane from water intoxication. Its so frustrating, isn't it?

I wish you luck. I think one of the policies that every hospital should have is that MD's are NOT allowed to touch IV infusion pumps...not no how...no no where. (just my two cents)