Pitocin induction-pit rates

strn96 · Feb 4, 2007

Our P/P is typically start at 1-2 and up by 1-2 q 30min. One of our docs will occasionally write for start at 6 and up by 6 q 30 for primips.

I have a new question for you though. One of our FP docs (doesn't deliver any more) had us start pit in am per protocol (2x2) but then at 10pm if no ROM and mom not over 5cm he would have us turn pit off for an hour, let mom shower and walk and then restart Pit and run at 2mu through the night, then start increasing again p 6am. Have any of you heard of this "low dose overnight" procedure before? Personally, I think he just wanted to get a good night's sleep, but wondered if any of you know anything about pros/cons of this. It seemed to me that these patients usually ended up not only with extremely long labors, but also ultimately needing higher doses of pit in order to deliver. Any input?

htrn · Feb 4, 2007

Depends on the doc:

Doc #1: Start at 2 and up by 2 q 20 minutes until adequate labor. He'll AROM if he can possibly get a hook through the cervix (fingertip and thick), then commit her to delivery - and likely a C-section. Also schedules many inductions so that HE can deliver his patients.

Doc #2: Start at 6 and up by 2 q 30 minutes until adequate labor. Less likely to AROM unless there is progress.

Doc #3: Start at 1 and increase by 1 q 15 minutes (sometimes to 35+ milliunits) and DO NOT TURN PIT DOWN OR OFF unless she tells you too - even with decels - unless you would like a new oraface. We do it anyway. Oh, and absolutely no, No, NO IUPC - EVER!! and don't even ask.

Pitocin has it's place, but I really think it is so highly abused by many of our docs - Ohhh, my favorite - let's induce a VBAC, without an IUPC if you're a certain doctor!!!!

Another very good reason to work the night shift.

SmilingBluEyes · Feb 4, 2007

All of our docs are in concurrence. We start at 1-2 mu/min and move up by 1-2 mu/min every 15-30 minutes, up to no higher than 20 mu/min at any time. Low and slow is definately the way to go, particularly in moms whose amnions are ruptured. I have also found in such moms, 8-10 mu/min is plenty to achieve and maintain adequate labor, even in the presence of epidural anesthesia. More and more HCPs are seeing it's not a good idea to "pit to distress" as would happen often with the 6 by 6 standard. It's been years since I saw a doctor who ordered that formula, thank goodness.

I have had a doc or two get in my face for not going fast enough or turning off pit in the presence of repetitive lates or deep variables, but stood my ground, refusing to turn it on. I even told one who was very angry with me, she would have continue the induction by herself. She growled at me and went to the sleep lounge and said if no change in 2 hours, we were doing a c/section. I let her sleep, (well more than 2 hours), kept the pit off, and fortunately, the baby looked much better after that. The patient made progress on her own, w/o pit on at all, and was pushing a few hours later. The sleepy doc walked in just in time to see the baby crowning. When she asked how much pit we had to use, I was glad to say , ZERO. Solid nursing judgement is not something we can give up or walk away from just cause a physician is a bully. The liability in pit drip labor is HUGE---and doctors and nurses have been hung to dry over inappropriate use of pitocin drips.

Also keep in mind, pitocin acts like anti-diuretic hormone. It tends to cause fluid retention---so that is another reason to use it carefully. Keep scrupulous I/O counts when using pit---I have seen one case of pulmonary edema in a healthy woman due to inappropriate use of pitocin and large infusions of fluids. She wound up in the ICU and was sick for quyite a while after that. Don't take pitocin lightly just cause we use it so often. It's a dangerous drug in the wrong hands.

SmilingBluEyes · Feb 4, 2007

I have heard of low-dose overnight inductions, yes. We rarely do this anymore. If a woman is not ripe, her cervix won't generally respond to pit, no matter what rate. If the woman needs ripening, she gets cytotec, followed by pitocin in the AM. And if a person is ripe, the induction begins at 6 and more often than not, delivers within 8-12 hours just doing this.

The body is a funny thing. Oxytocin levels vary all the time and we must always be mindful that the pituitary is already excreting oxytocin in labor anyhow. Also, particularly in actively-laboring women or ones who are ROM'd, there are prostaglandins freely circulating, as well, that cause contractions on their own. I have learned after a few years doing this, what is just barely enough pitocin in one hour of labor to cause adequate contractions, may be drastically too much in the next hour, even without changing the rate/drip. I have seen hyperstim happen fast even on very low doses of pitocin. This is partly why I would have problems with turning off pit at 5 cm and letting a woman shower. We have no way of really knowing how much circulating prostaglandins and oxytocin are present at that point as each person can vary. Things can happen in that time frame while she is off the monitor, and we may not be aware. I am not sure I could be comfortable with that concept myself. We started something (an induction) and I am not comfortable with discontinuing monitoring in this case. But that may just be me.

SmilingBluEyes · Feb 4, 2007

One alternative to having low dose overnight drips, having a woman stimulate her own nipples. Just a thought....

NPinWCH · Feb 9, 2007

We've been using the slow pit (start at 1 up by 1-2 q 30) for 3 years now. When we first changed the policy our docs were not happy campers.

We gathered the stats and the slow pit worked better and faster with fewer bad outcomes (hyperstim, fetal distress and c-sections). Our policy was always to notify the doc at 20mu, then we could continue to 30mu. Since the policy change I rarely, in fact I can't remember the last time, get past 10mu.

I can't tell you how many times I used to "max out the pit" and still not have adequate ucs. Of course these pts ended up as FTP and were sectioned.

The literature shows that during spontaneous labor the oxytocin gradually increases to give the oxytocin receptors time to respond...pouring in the pit sometimes works, but it can also cause hyperstim in pts with "receptive" receptors or it may do nothing. If the receptors aren't availabe, the pit can't do it's job. By taking it slow you allow the reptors time to sync, so you get good quality ucs.

LDRNMOMMY, BSN, RN · Feb 10, 2007

We have two protocols low dose and high dose.

Low dose: Start at 1-2 milliunits increase by 1-2 every 30 min until adequate pattern. Max of 20 milliunits. Notify MD when 20 milliunits is reached.

High dose: Start at 6 millunits and increase by 6 millunits every 30 minutes. Max of 42. Notify MD at 42 milliunits. (I HATE high dose pit!) Thankfully it isn't used that much. The few times I have had it ordered on a patient, I have had to back down on it, or shut it off dut to hyperstimulation or repetitive decels.

crissrn27, RN · Mar 11, 2007

I know this thread is kinda old but I just had to tell you guys what we do at our hospital. Now, I'm not an L andD nurse, I work in the nursery but we do go to all deliverys, but I don't know much about pit rates, etc. I do know that, I'll say 80% of ALL our mom's end up on 60-70 mu of pit. not just inductions, but "augmentation" basically, if you don't come in at 8cm or up you get pit. I have seen it as high as 80mu (just last night)....BTW I end up doing alot of resusitation

HappyNurse2005, RN · Mar 11, 2007

I know this thread is kinda old but I just had to tell you guys what we do at our hospital. Now, I'm not an L andD nurse, I work in the nursery but we do go to all deliverys, but I don't know much about pit rates, etc. I do know that, I'll say 80% of ALL our mom's end up on 60-70 mu of pit. not just inductions, but "augmentation" basically, if you don't come in at 8cm or up you get pit. I have seen it as high as 80mu (just last night)....BTW I end up doing alot of resusitation

i really, really hope that is supposed tomean 60-70ml (which would be 20-23 mu's of pit, at our concentration of 20units in 1000ml), b/c 60mu's just blows my mind (and her uterus)

mitchsmom · Mar 11, 2007

We always do 1-2mu's to start, up by 1-2 q30min and I rarely need to go over 10-15mu/m.

Our docs rupture anyone and everyone that's available when they round each morning.

SmilingBluEyes · Mar 11, 2007

Again, this much pitocin (60, 70 or more Mu/min) is unnecessary and dangerous. Usually, if a person's truly ready for induction/augmentation, it does not take much more than 10 mu/min to get the job done. The receptors are either ready or not; and saturated, won't perform well, either. Plus the very real risk of fluid volume overload is something I don't really want to risk in any patient. One case of pulmonary edema was all it took to scare me and really respect this med. I would have to wonder about policies allowing more than 30mu/min in any case. I would be more than uncomfortable working in such places.

I have to worry that with so many inductions for convenience/social reasons will keep upping the ante. And if lots of infant resuscitation is required/done, well, you see the damage we are doing to babies, too.

crissrn27, RN · Mar 12, 2007

No it is really 60-70mu and up to 80mu/m. Like I said I don't work directly in L and D but go to all the deliverys-I'm an Rn in the nursery. I didn't know this wasn't the "norm". Our docs would laugh at 8-10mu pit.:angryfire They(at least one of the docs) also still turn the kids upside down and smack them a little after their born. We do things really old school and as much as I've pushed nothing has changed. The older nurses want to get a release form for the moms to sign to keep their babies in their rooms. I would go to another hospital where things are more upto date but this is the only hospital within 60 miles......and I really love working with the new moms and babies. what can I do to get them to change this when I don't work in L and D? I can't just ignore it now that I know its harmful.