Pitocin WARS

Jolie, BSN · Jun 27, 2017

In a perfect world, this OB would be required to obtain informed consent from her patients reflecting her practice of administering Pitocin in a manner inconsistent with established safety guidelines, and then would be required to remain at their bedsides administering the medication herself.

I doubt that you work in a perfect world. I don't really know how to advise you, other than to refuse to accept verbal or phone orders that deviate from standard practice, go up your chain of command each and every time you receive such an order, and document both in the patient record and in an incident report the objective assessment of the patient, the physician's orders, the name and time of contact with your supervisor, and the patient's and baby's response to the intervention.

If everyone in your department follows this plan, the doctor and administration will eventually tire of this dangerous BS and come to some agreement on a safer protocol.

ETA: Do you have other OB providers who are on your side? Perhaps they can pressure their colleague to "fall in line" so to speak. In my experience, we've had some success using this tactic.

What does your risk manager say?

Good luck to you.

**LibraSunCNM, BSN, MSN, CNM** · Jun 27, 2017

She sounds like a delight. Even though I know "life isn't fair," as my mom would say, as a CNM, it will never cease to chap my butt that MDs routinely practice in an unsafe manner such as this, completely disregarding the evidence for the normal physiologic process that is childbirth, and get away with it. Meanwhile, CNMs are statistically many times more likely to follow evidence-based practice, with better outcomes for low-risk women, yet are fighting all over just to be accepted as legitimate providers, get hospital privileges, have prescriptive authority, find collaborating physicians, and get malpractice insurance.

Stepping off my soapbox.

The Consortium on Safe Labor is probably the most recent, comprehensive body of research examining what is "normal" labor progression (in terms of definitions for arrest of labor, arrest of descent, etc). A sample from the research: "The Consortium on Safe Labor data do not directly address an optimal duration for the diagnosis of active phase protraction or labor arrest, but do suggest that neither should be diagnosed before 6 cm of dilation."

Basically, a woman isn't in active labor until 6 cms, and so you can't call it "arrest of labor" before she's actually in labor. This is trickier in an induction, because the doctor could argue the patient will never get to 6 cms, but that's just throwing one idea out there for research you could look at.

As for Pitocin management, I'm between jobs right now so I don't have access to the Green Journal or UpToDate, but I know ACOG's Practice Bulletin #107 focuses solely on reasons for induction and methods for induction, which may possibly have criteria for cervical ripening and the Bishop's score (I just can't access the full text right now). I don't think there's any evidence out there looking at specific orders for Pit (like her policy to start at 4, then go up 2 every 20 until 40) but there might be something about maxing out at 20 vs. 40.

The unfortunate bottom line is that until she has a terrible outcome, she may continue to practice this way unscathed (if your institution is like many I have encountered). If your management is telling you to "just write the orders the way she says," (which in and of itself is a bit confusing to me---does she not write her own orders?), you're entirely correct that that will not help you in court. If you feel uncomfortable with her orders, I would refuse to follow them, but depending on your workplace culture, that may cause more trouble than you're willing to deal with.

I'm sorry you're dealing with that and applaud your desire to change her current practice.

**LibraSunCNM, BSN, MSN, CNM** · Jun 28, 2017

Doesn't AWHONN have an Oxytocin Safety Bundle? I let my membership lapse so I also don't have access to JOGNN, but I'm pretty sure they've created this in recent years, and the references to the evidence base should be listed.

klone, MSN, RN · Jun 28, 2017

So, I just got back from the AWHONN convention and went to a great inservice on OB nurses and litigation.

As you could imagine, mismanagement of labor and medication titration is one of the primary reasons nurses are sued. They specifically addressed your point in #3 - what she's wanting is "Pit to distress" which is a really really good way to find yourself in a lawsuit.

The point of identifying tachysystole is so that you can do something about it BEFORE the FHR responds, not after. Not responding in the face of tachysystole until the fetus starts to crump is the very definition of "pit to distress."

Always remember that it is YOUR license on the line when you manage Pit titration inappropriately. Regardless of what the OB says or wants. If she asks or demands that you titrate Pit inappropriately, you need to refuse and tell her if she wants to do it, she should come in and do it herself. Then file an incident report.

CYA.

OrganizedChaos, LVN · Jun 28, 2017

I'm not an OB nurse but geez whiz with the Pit. Her water broke? Give her Pitocin! Her water didn't break? Give her Pitocin! She's having contractions??! Give her Pitocin! She's not having contractions??? Give her Pitocin!

I never realized this until now. It's really sick. I mean, I'm all for what the *mom* wants but calm down with the Pitocin!

ashleyisawesome, BSN, RN · Jun 29, 2017

http://mail.ny.acog.org/website/OxytocinForInduction.pdf

Of note it mentions interventions for tachysytole with a reassuring FHR-- reposition, bolus with fluids, give O2, decrease the pit by half, and if it doesn't resolve in 10 mins, turn the pit off until they are not tachy anymore. It also recommends starting pit at 1 or 2 u/min and titrating to a max of 20. It does say you can go higher, but there must be a separate physician's order.

I have never gone over 30 of pit, and even that makes me nervous. I request an IUPC for anything over 20. If I am seeing decels, tachysystole, ridiculously high MVUs, etc, I turn the pit off and ask questions later.