Pitocin titration

birdsnbees · Jul 30, 2006

I believe the ACOG literature states that Pitocin can be titrated as high as either 40 or 40 mU...I will have to find the exact article that addresses it. I'll pass it along when I find it.

Wow, I'd love it if you found that information!

epiphany · Jul 30, 2006

Yes that's another thing where I am. IUPC's aren't used very often. It has crossed my mind....are the doctors not using them because they don't want to know how strong/frequent these contractions really are? Also the orders say we are to increase the rate by 6 mu every 10-20 minutes until adequate contractions. The protocol says until cnx are 2-4 minutes apart, but it doesn't matter if they are 2-3 minutes apart, certain doctors insist on continuing to increase, and have been known to come over and increase it themselves, not necessarily mentioning to the nurse that they have done so. (almost everyone gets an epidural, so pain is not so much an issue, but safety IS.)
There are other problems here has well, including nurses being pressured into 'beyond scope of practice' situations.
I'm considering going back where I came from....I don't feel safe.

I feel your pain...

When I first started we used to have doctors who would come in and help themselves to the pump like it was a free buffet, until this practice was deemed unsafe, and nurses had to be in charge of titrating.

The orders say that nurses are to increase q 20 mins, but that's implied that we do this within the boundaries of safety and in a perfect world, that would be subject to nursing judgement. I think our discomfort with pitocin is due to the fact that we aren't given the proper training or the autonomy to use our judgement and make recommendations.

Evidence based practice is our best tool, although it's harder than it sounds to put into practice when you come into a floor that already has an unsuportive culture. I would love to know if there is any nurse out there who feels empowered on their floor to titrate the pitocin on their own comfort level or can work as team member with the MDs? (and where can I hand in my resume?)

BTW, here’s a recommendation from the 2006 ACOG compendium regarding use of more than 40 mU/min:

“Water intoxication can occur with high concentration of oxytocin infused with large quantities of hypotonic solutions. The antidiuretic affect is usually observed only after prolonged administration with at least 40 mU of oxytocin per minute.”

We don’t use hypotonic solutions, but still something to keep in mind since we do regularly bolus our mommies…

nurseMeghan · Jul 30, 2006

we have a low dose and high dose pitocin protocol at the hospital that i just left. the low dose was start at 1-2 mu and increase 1 mu every 15 minutes to max of 24.

The high dose was start at 4-6 mu and increase 4 mu every 30 for a max of 42.

I personally never had a patient on high dose pit thank god because that would really make me nervous. HOWEVER. I have seen patients deliver very fast with the high dose pit.

Now at the hospital it was the doctors choice between the low dose and high dose pit. I think the high dose made most the doctors nervous too. There were only a few that used it.

I have to say also we have a very up to date policy committee that completely researches the current guidelines to make our protocols so there must be some research out there to support our use of pit up to 42 mu.

RaeT,RN · Jul 30, 2006

Our Pitocin protocols are either "Standard" (begin at 1mu and increase by 2mu q 30 min for a max of 20mu/min) or "San Antonio" (begin at 2mu and increase q 40 min as follows: to 4mu, 8mu, 12mu, 16mu, 20mu.) 20mu is our max without a doc's order. My eyes are bugging out of my head at you guys who say you've seen Pitocin infusing at >30! If the doc wants my pt's Pitocin >20mu's/min, I want an IUPC. Personally, I have never pushed Pitocin past 25mu/min and would never feel comfortable doing so unless I had cold, hard MVU's in front of me. Also, there are only a few docs at my institution who will Pit VBACs. We had one doc several years ago who would titrate his own Pitocin without telling the RN. That did not last long.

Uterine hyperstim is defined by our P&P by a persistent pattern of >5 contractions in 10 min, u/c's 90-120 sec.

I am currently serving on a process improvement team at my institution looking at the safe administration of Pitocin. I will keep you updated on what we come up with and what changes come about on our unit as a result.

ldnurse7581 · Jul 31, 2006

We use 500cc d5lr w/30 units, start at 2mu (low dose) inc by 2mu q15m up to 30 or start at 6mu(high dose) inc by 6mu up to 30 for inductions. for augmentation, we usually do low dose, except a few docs still want high dose. after delivery we do 1000cc d5lr w/20units pitocin @ 125cc/hr x 4hrs

Suebee6 · Jul 31, 2006

We mix up 30 units in 500cc LR, start at 1mu and increase by 2 q15 until we gt ctx q 2 to 3 minutes. THAT is what the order reads. NO max written. Our docs dont really have a max, they all have different preferences. We usually just ask what theri limit is. Some docs say start at 4, go up 2 every 10. If I have an IUPC in, I am comfotable with however high it needs to be, as long as I have my MVUs in front of me. Of course it never has to go very high LOL...well not often anyway. Now without one...I am ok up to about 35 or so, as long as I am not hyperstimmed, FHTs reassuring of course, after that if doc wants higher I will put an IUPC in their hand first. Our docs will usually let us have our way LOL. It sounds like we are pretty aggressive compared to most..hmmmm

RaeT,RN · Jul 31, 2006

I guess I should add that our Pitocin bags are mixed BY PHARMACY (10 units in 500cc D5LR) and stored in our Pyxis. We do not mix our own Pit for induction; following delivery is different. With a doc's order we will put Pit in the IV fluids (LR or D5LR) infusing; 20 units if there is >500cc left in the bag, 10 units if there is

birdsnbees · Aug 1, 2006

Thank you to everyone who has shared their Pitocin protocols and experiences. I've written to ACOG and asked about their recommendation. They say they will send me information about inductions, but I'm still waiting for them to do that. If I hear from them, I'll share.

RNnL&D · Aug 4, 2006

I would love to know if there is any nurse out there who feels empowered on their floor to titrate the pitocin on their own comfort level or can work as team member with the MDs? (and where can I hand in my resume?)

I feel, at my facility, that the nurses have this autonomy.

We use 10 u Pit premixed by pharmacy in 500ml bags. Our low dose protocol is 1mu q 30 to a max of 20. High dose is 2 mu q 30 to a max of 24. We seem to be pretty conservative with our Pit compared to what other posters have mentioned. Rarely do these protocols not work, but I have seen an order to continue past the max dose but never past 30 mu, and generally not without an IUPC.

We titrate to moderate to palpation ctx q 2-3 minutes. In the event of hyperstim and/or fhr decels, our policy covers decreasing or turning off Pit. If a doc insists on increasing beyond what we feel is a safe zone, we have no problem insisting on an IUPC. I feel pretty empowered to titrate Pit as I see fit, because our policy is pretty clear cut and I can readily point it out to any doc that doesn't agree.

RNnL&D · Aug 4, 2006

I've been a labor nurse for a long time now and worked in a few ob units, and up until now I've seen Pitocin run up to 20 mu/min, and occasionally with a doctors order, up to 25 mu/min. I've recently started working in a unit where they routinly titrate up to 50 and 60 and even higher during a routine induction of labor. I've looked on line trying to find safe titration levels but so far I have not found info in this. Has anyone ever run Pitocin at these doses?

I'm curious what your rates of PPH are with Pitocin rates that high. It sounds very dangerous to me.

RNnL&D · Aug 4, 2006

On our floor, I've never seen it titrated much beyond 20 mu/min, and even that's rare. (And I thought our floor was bad). There is research out there - though I don't have it in front of me that says that titration above a minimal amount (around 6-10, I think) does not improve outcome.

I haven't seen the literature, but just from experience, I think you hit the magic level (around 10 seems to be what works with most of my pts) and increasing beyond that doesn't seem to make a difference.

RNnL&D · Aug 4, 2006

Another thing is though, it seems like I see more decels, and I'm wondering if it's related to the high rates of pit. I would think receptors would be saturated long before 50 mu's is reached, yet these women often do look hyperstimulated to me, and though the decels are variable in nature, there are often a lot of them, and they are deep. This is just not ok with me. There is nothing in our orders or in the protocol that gives a top number of pitocin titration. I'm feeling uncomfortable with all this.

Yes, it is related to the high rates of Pit and hyperstim. You really need a protocol with clear max dose, and protocols for decreasing Pit in the event of hyperstim and/or fetal intolerance. A baby with lots of deep variable decels is telling you he's not happy. That should be more significant to your docs than creating the perfect contraction pattern, kwim? :uhoh3: IMO, you're smart to be uncomfortable with that.

I am loving my job more and more.