Pitocin and Decels

Specialties Ob/Gyn

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I am in need of an opinion. I'm sure some people have differnet reasonings/philosophies on this, so I would love to hear it. Pt was on low dose pit, ctx every 3 minutes. After epidural placement (blood pressures fine) baby starts deceling down to 100. Unable to tell what kind really because our monitors werent picking up well, only could go by what we could hear, but they would occassionally pick up hr good. So we flipped her to see if that worked, which it didnt, caused baby to dip down to 90. So we checked her to see if maybe she was ready to push, which she was, baby was literally right there..so we flipped her on her other side again and baby started to drop down to 70's..we were trying to see if it was picking up moms hr becuase our monitors still werent picking up well. We werent sure if it was moms or not because she was runnign around the same pulse. Decided to throw some o2 on her just to be safe and call the midwife to come asap and evaluate. She was there within a minute and put a scalp electrode in and meanwhile said if pit wasnt off (which it wasnt at this time) to get it off. Baby ended up being in the 70's, but eventualy picked up to the 120-130's occasionally. In the end, baby turned out fine, but me and another nurse were to explain the events to the midwife that led up to what happened. So we did and she told us the first thing we should have done was turn off the pit, that we missed that first huge step and could have made things worse than what they were. We didnt think that was really the first thing necessarily to do, we always thought position changes to see if you can get her in a better position, and then if that didnt work to throw on some oxygen and d/c the pit. I understand you need to d/c the pit, but it wasnt like baby was deceling d/t being hyperstimulated. I would love to hear opinions on how you would have handled the situation because I am a new nurse and need some advice, as I have not ran into situations liek this before.

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In my experience I probably would have called out for the doc and extra hands. Turned off PIT, One person trying to pick up heart rate, other doing position changes all while putting on the O2. We L+D ladies need to grow extra arms. There are always so many things going on its just best to have a few extra people in the room if possible. ;)

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Yeah, we ended up getting a lot of extra hands, but when it was just me and her, it took both of us to turn her because of her epidural, so in between all of that both of us kinda forgot that she was even on pitocin, prob not the smartest thing, but thankfully she was only at like 4 mu's and ctx were about 3 minutes apart, but still. And honestly, we didnt think it was all that bad because we figured positioning first to see if just a change of position would help baby out. So this all happened prob within not even a couple minutes from the time she deceled to cnm at bedside and pit off.

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

I disagree with the midwife. I agree with you that the decels were not caused by hyperstim or uterine tetany, but from rapid descent and possibly post-epidural perfusion issues. I would not turn off the pit as a first course of action, but rather do what you did first - position changes, checking cervix, applying an FSE, applying O2, maybe giving a fluid bolus. In all likelihood, as long as the baby looked good prior to that, it was simply caused by head/cord compression due to its station, and mom just needed to get baby out.

Were these *decels* into the 90s-100s, or did baby's baseline shift and was now bradycardic? If they were decels, and not late decels, and recovery was good after the UC, then that wouldn't even faze me in the slightest. I would simply call the midwife in for delivery, and maybe have a Kiwi or Mightyvac handy.

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

I agree with the above:

Get extra help in the room asap, then:

Intrauterine rescuscitative measures: turn OFF pit, Move to left side, O2 by nonrebreather mask, scalp lead on, IV open for a fluid bolus, (this actually dilute the amount of oxytocin circulating in mom and can slow the contractions down).....

Also: try an O2 sat on mom to try and differentiate the heart rates of mom and baby....

ANd possibily some Terbutaline if hypertonus is present. And in cases like this, if baby were not right there, ready to be born, I would place an IUPC so I would KNOW where the decels are really occuring; are they early or late? You can only really know by knowing what your contraction pattern is doing.

Know the whole picture. THere may be decels, but are there also ACCELS? A seriously compromised fetus rarely has accels; the poorly oxygenated/perfused baby won't have great variability.

The others said it better than I did. WE all learn by doing. Hang in there and just keep learning.

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Yeah, she did have fluids wide open and a pulse ox on (we always have them on with epi's) and at times it was hard to tell if it was mom or babies. Before all this had happened it was me and another nurse already in the room, so as soon as the other nurses seen what was going on on the monitors in pp, they were back helping pretty rapid. Baby was too close to delivery for an iupc. Fetal scalp electrode wasnt picking up a good reading until towards the end where it started to have longer periods of time where heart rate was in the 60's/70's and only a few seconds of 130's. So what your saying is no matter what, pit should be turned off first instead of trying position changes to see if it improves heart rate?

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.
So what your saying is no matter what, pit should be turned off first instead of trying position changes to see if it improves heart rate?

I think you were talking to SmilingBluEyes, but my answer is no, I do not turn pit off first. I try the other parts of intrauterine resuscitation first (position change, O2, fluid bolus in that order) and then turn the Pit off if it doesn't resolve. If they're serious, scary decels, then I don't wait for the fluid bolus to take effect, but would turn the Pit off if the position change and O2 didn't immediately improve things.

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Well thats what we thought too, to try position changes first. The docs will get upset if you turn pit off with every decel you see, and we werent even sure if we had a true decel to begin or we were picking up mom until we got the scalp electrode. But my lesson learned with that midwife (she just started working there too), I will just turn the pit off when I see any kind of decel, even earlies, LOL.

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Specializes in High Risk OB.

If she had just received an epidural, was this caused from the epidural(did she get a CSE?)? What was her BP? If it was low, this could have been decreased perfusion to the placenta which in turn could have caused the decel! In this case she really just needed fluid, position change (supine with legs elevated, works great!) and possibly a little ephedrine if she really became hypotensive and TIME!!. I agree that the pitocin probably had nothing to do with it but if everything else you did did not improve the FHR then pitocin should have gone off(she was fully anyways). Usually, depending on your policy, you can turn the pitocin back on to the same setting if its within 20min.

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

If you are talking to me, here is what I believe:

In the face of repetitive late decelerations,: There exists a school of thought that states if you need supplemental oxygen, fluid boluses and other intrauterine measures (besides changing maternal position), you should turn off the pit. I subscribe to it. I believe it is better to turn it off for a bit, even if things do slow down considerably for a while, than to continue to stress an already compromised fetus. It would be quite hard to defend yourself continuing with interventions that compromise the baby in the face of distress. You can turn the drip off, let the oxytocin receptors in mom's body become less saturated, and then turn it back on when things look better. Chances are good, her labor will be even MORE efficient if you back off the pitocin for a bit. I can say, with experience, this often is the case.

The recent literature about pitocin use/induction backs up what I am saying here. We use way too much pitocin at dangerously high rates for hours and hours. We set up mom for post partum hemorrhage and compromise way too many fetuses with inappropriately high doses of pitocin.

Most times 8-10 mu/min does the job and beautifully. Physiologically, in labor, most women have the equivalent of approximately 8 mu/min of oxytocin already circulating without adding it artificially.

Part of the problem is, we have too many 9-5 obstetricians who want to "pit to distress" so they can have their patients delivered by 5 or 6 at night. This is dangerous. I use pitocin with great respect and caution.

The book, Perinatal Nursing by Simpkin, et al. has a good chapter on induction/augmentation of labor. I learned a lot about what I was doing wrong when I studied it for my certification for inpatient OB nursing. Sorry I was not more clear in my other post.

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So even in doubt when you arent sure what kind of decels are going on, or arent sure if you're picking up moms heart rate, its better to turn pit off the same time you are trying position changes? I mean, we were gonna turn the pit off, it wasnt a matter of us not turning it off at all, we just figured we would try a few position changes to see if we could pick it up better to get a true picture. It just happened so fast when we were changing positions that the midwife came in, it was within minutes, and then turned pit off.

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Specializes in High Risk OB.

Absolutely agree with Smilingblueyes!! The theory of only needing 8-10mu/min of pitocin has proven sooo true in my practice! I tend to slow down in my advancement of pitocin around these units. There is an attending on my floor that has eluded to this and since then I have been noticing that if I just hang out around 9mu/min for a while my patients seem to follow a very nice labor curve without ever going any further! In regards to your decel, don't kill yourself over this, you made appropriate interventions and from the sounds of it I am sure turning off the pitocin a few minutes earlier wouldn't have made a difference! Maybe she was hypotensive AND she was fully, perfect combination for fetal bradycardia. Did you ever get a cord pH???

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