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Discussion

Pitocin induction

I have a scenario that I need feedback on. I've just finished my first year of L and D nursing and need a more experienced perspective on how I managed my Pitocin induction last night.

So, the Pt was a G1 P0 at 38.6 weeks who was being induced for having a non reactive NST at a prenatal appointment and with Gestational Hypertension. When I came on her Pitocin was at 9mu/min and she was 1/70/-2. The FHR had had minimal variability for hours, as I got in report, with no acccels but no decels either.

An hour into the shift she had a three minute decel that went down to 75-100 for 3 minutes from a baseline of 135. I couldn't tell if it was with a UC or not because the Toco had fallen off. During this decel, I turned the pitocin off. I told the resident MD's, who are in house, that the Pitocin was turned off and they said to let the baby recover and restart it in one hour.

FHR continues with the same pattern of minimal variablity, but no decels, so I turn the Pitocin back on starting at 2mu/min. She has 20 minute period with repetitive lates that resolve spontaneously. I gradually get it up to 10 mu/min and then baby has another decel down to the 80-90's for 120 seconds. Meanwhile, she was rechecked and still was 1/70/-2. During this decel I turned the Pitocin off again and the residents said to wait a half hour and start it back up again.

By the time the day MD's have come on, her Pitocin is back on at 6mu/min but her uc's are spaced out 4-5 minutes apart. FHR still minimal variabiliy, no accels. I am reassured by my charge nurse that she is most likely going to be a C/S based on the non reassurring stip, but I still feel like I failed to get this induction going.

But my rationalization was that with such a flat strip with no accels and the decels and lates, I felt very uncomfortable increasing the pitocion and admittedly was quick to turn it off during the decels. The resident MD's were aware of having the pitocin off, but the attending didn't seem thrilled that after the whole night of inducing the patient, her Pit was only at 6mu/min and she hadn't changed her cervix. Any thoughts???

Featured Replies

Not only would I (and I'm sure, the rest of the nurses I work with) have done the same thing, but we probably would have gone for C/S sooner. Our docs tend to panic a little early.

With little progress and what the fetus was showing you, I think she would have been a C/S after the second decel, in light of no variability and no accels. Sounds like you acted to protect the pt/baby and used good judgement. Don't be hard on yourself. Pt. safety outranks pleasing the docs in the eyes of God and the jury!

  • Experts

The attending didn't seem thrilled that after the whole night of inducing the patient, her Pit was only at 6mu/min and she hadn't changed her cervix.

Too freakin' bad. That mom and baby are your priority, and you did what you had to do protect them. Tough noogies if the attendings don't like it. And as a primip, her cervix may not have been READY to change if she was at 38-39 weeks! Nobody at my facility would've pumped up the Pit to be sure, if the strip was that flat.

I hate to be the negative voice in the group.....but after you turned it off the first time. I would have NEVER turned it back on until I had a "reactive" strip. 2 15X15s. I know that how things are done in the real would vs. policy and procedure are different. But you will never be able to defend running pit on a non-reactive strip. I would tell the doctor. "I am not turning the pit back on until she has accels....if you would like to walk into the room and turn it on, I would be happy to monitor the patient"

I also would not have turned the pit back on without a reactive strip. Our protocol is a reactive strip must be obtained prior to starting pit, placing cervidil etc... If the doc wanted to start it himself as stated above, I'd tell him to feel free. But in light of the fact that the induction was started for a non reasuring strip, I'd be willing to guess that our docs would probably have sectioned her when there was no cervical change and she was having decels.

  • Guides

I agree with the last two posts.

To the op - don't let docs intimidate you or make you feel bad.

We'd be quick to OR and a cesarean too.

steph

You ran the Pit appropriatly. Since you were inducing for a non reactive strip, there's no reason to wait for an acceleration to restart the Pit. If this baby had been having accelerations, you wouldn't have been inducing in the first place. This baby was telling you that it needed to be delivered soon, one way or another. You gave it the best chance you could to deliver lady partslly.

In my small hospital, with no 24hr in house anesthesia or OR staff, we would have not been as agressive and would have sectioned sooner. When I worked in a large well staffed teaching hospital with the ability to do a section immediatly, we did many inductions as you described. Some were able to deliver lady partslly, some weren't. You did well.

  • Author

thanks for the reassurance. Working with Pitocin can be a tricky thing, and this was a scenario I had never been in. Too bad I'd been stressing about it all day yesterday. thanks for the feedback.

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