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.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
REALLY: If you are in doubt, why on earth take chances? Turn off the pit! You can always turn it back on if things prove to be ok. I don't get when we put O2 on, fluid bolus people and the like and don't do that one thing as well. It's a proper intrauterine resuscitation routine. I have had a dr or two give me grief and when they did, I told them they could turn it on if they chose to. I won't til I know its safe. Believe me, they won't back you up in court if you fail to take such measures and a bad outcome is a result.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Do you have your certification in OB nursing? If not, you should go for it. It forces you to keep on all the latest literature and evidence-based practices out there. And the latest literature suggests we slow down our pitocin inductions.....in other words, instead of upping pit every 15 or 20 min, now the best standard is really 40 minutes. It takes that long for the body to adjust to new levels and oxytocin receptors change all the time. Honestly, you can't go wrong erring on the side of caution. It's your patient's safety and your license on the line.
Again, knowing what type of decels you are seeing helps. And yes, it could be related to the epidural. But again, in a fetus in which you suspect compromise, you should turn off the pitocin until things improve.
I wouldn't have turned off pit as a first step. Decelerations are pretty common close to delivery; however, when you can't figure out what the baby's heart rate is, and your attending isn't right there, and you're unsure of what's going on, it couldn't hurt to turn it off to give the kid a break.
from smilingblueyes: 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.
so, why do we do this?
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.
aren't we supposed to advocate for our patient (patients in this case, mom & baby!)?
there is so much evidenced based practice proving the dangers of "pit to distress" pitocin, the dangers of continuous fetal monitoring, the dangers of immobile laboring....it all seems to just be ignored in l&d. why is that? honestly?
i've just started my ob rotation in school and i am appalled. it's like a factory, an assembly line - the same story over and over, and over, the same protocols (that have been proven at best ineffective and at worst dangerous and leading to a cascade of further dangerous interventions) applied to all the laboring women...it's bizarre.
anyway- don't mean to hijack this informative thread! just really mystified by what i'm seeing in my nyc hospital...
Specializes in Nurse Leader specializing in Labor & Delivery.
Not all hospitals are "pit to distress". The place I work now is very much in favor of low-dose pit. I just recently had a pt for which I had the pit up to 30 (the max for this care provider - she had an IUPC so we know that it was appropriate, and even then her MVUs were about 100 - I suspect her receptors were simply saturated) and the other RNs, who had never worked elsewhere, were flipping out. Of course, I came from a facility at which it wasn't unheard of to bring the pit up to 36 before resting the pt, so bringing it up to 30 was no big deal to me. Anyway, my point is, again - not all places are like what you describe. A lot of current research indicates that low-dose pit is just as effective.
What was the variability like. UCSF comes to teach us advanced fetal monitoring and they can not stress enough how important the variability is, even more than decels. They do not recommend turning the Pitocin off but turning it down. Yes sure, if you are going to the O.R. because it is so bad, turn it off; but they said in most situations you should turn it down, not off.
I agree with SmilingBlueEyes 100%, if you've got decels to the 100s and you're not sure what they're all about, just turn the pitocin off while you're doing your other interventions, it may not help, but it certainly isn't going to hurt to turn it off. Just thinking about this situation, you say her UCs were q 3 minutes so you "know" she is not hyperstimulating, but how do you really "know" that? She could have been popping off ridiculously strong/long contractions with inadequate relaxation that were too much for that baby. Since you found her to be complete, in this instance, most likely the decels were due to rapid descent, but I think what the midwife was wanting you to think about is what your actions should have been to prevent a bad outcome in a situation where the patient wasn't now complete and ready to push. If she is complete and the baby is right there, she doesn't need the pitocin anymore anyway. The worst thing that can happen (really) if you do turn off the pitocin and the baby totally recovers and looks fantastic in a few minutes is that you get scolded by the doc/midwife for being too jumpy and turning off the pitocin, and believe me, I will gladly take 100 scoldings for being to quick to turn down/off the pitocin over a single scolding for not turning it off fast enough!
Temper-MENTAL readheads posts sound like exactly how we practice in our unit. We do intrauterine resustative measures (o2 on, position change, fluid bolus, pit off) boom, boom, boom just like that. The pit is the last intervention of the 4. Of course we also perform a SVE, maybe a scalp lead and terb if needed. As stated in a previous post, the oxytocin receptors can get oversaturated=PP hemorrhage. Also, if IUPC wasn't picking up, did you palpate the abdomen? It is so hard not to always watch the monitors but rely on your basic skills. Also another really important thing that was previoiusly stated...were there accels? good varibililty? (I know that difficult to assess when you are trying to intervene to keep that babe healthy) BUT it is good to learn to try and assess that too. Everyday is a learning opportunity! Im sure you are doing great.
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SmilingBluEyes
20,964 Posts
REALLY: If you are in doubt, why on earth take chances? Turn off the pit! You can always turn it back on if things prove to be ok. I don't get when we put O2 on, fluid bolus people and the like and don't do that one thing as well. It's a proper intrauterine resuscitation routine. I have had a dr or two give me grief and when they did, I told them they could turn it on if they chose to. I won't til I know its safe. Believe me, they won't back you up in court if you fail to take such measures and a bad outcome is a result.