Up the Pit or stop it?

[APL&D]

So, just started working with a new doc who is really aggressive with his Pit. I had a patient the other day: prime, post-dates induction. Had a round of cervidil and was started on Pit when I got her. The Pit was at 8, she was 3-4 cm, 50%, high. Contraction pattern inadequate. She would couple or triple, and then her uterus would do nothing for 7-8 minutes. Baby looked good. She did not have any pain meds. Then variability was minimal. I thought baby was sleeping. But then after her coupling or tripling contractions she would have a late decel. I turned her to side and gave her a bolus of fluid. I did not want to shut the Pit off just yet. Well, then she had 3 or 4 late decels. I talked to the doc about stopping the Pit, but he said to just up the Pit to get her in a regular contraction pattern. He saw her lates, but was not concerned about them, because they occurred after coupling and tripling. Not sure what happened with the patient, because I went home. I can't wait to ask the nurse who took over for me. But what are your thoughts about increasing Pit in this situation? I understand the doc wanted her to deliver faster and she would not dilate with that contraction pattern, but clearly the baby was not tolerating Pit at that contraction pattern. Would the baby tolerate it when she was contracting every 2 to 3 minutes? And why is it that we are taught one thing, and the docs tell us something else? Where do they get their reasoning? I can't justify increasing Pit in a situation like that in my documentation. Please, help.

[cayenne06, MSN, CNM]

It's hard to comment without knowing more and seeing the actual strip- you mentioned minimal variability, but I wasn't clear whether that was just a normal sleep period or a larger trend. Min variability with lates is much much more concerning than if moderate variability is maintained. If lates are only occurring after double or triple contractions, the baby might very well do fine with increasing the pit, with the idea that it will help promote a regular contraction pattern with adequate rest between each squeeze.

In the situation you are describing, i would definitely either increase or decrease the pit (depending on the whole picture); doesn't make sense to keep on at the same level. Intrauterine resusc is definitely a good idea too.

Just like any area of nursing, there is a lot of nuance in obstetrics that cannot really be taught in nursing school. Interpreting and managing FHR patterns is tricky, subjective, and subject to change as we learn more and more about the usefulness and limitations of CEFM.

[APL&D]

Thanks so much. To clarify, I think min. variability was just due to sleep cycle. Def. agree with you on limited EFM for low-risk patients.

[ElizabethAnatom]

And why is it that we are taught one thing, and the docs tell us something else? Where do they get their reasoning? I can't justify increasing Pit in a situation like that in my documentation. Please, help.

They get it from experiece. Because real life is different then the books. You sometimes have to change and adapt.

[melmarie23, MSN, RN]

We have a great algorithm/policy for managing category II tracings. With the limited picture you painted, it would have instructed me to first decrease the pit (by half) and do my intrauterine rescuitation measures. If the fetal tracing does no improve and/or mom is not making progress, then I would have to stop the pit. If the provider is telling me to do something that disagrees with this, then I am encouraged to use my chain of command. It's about patient safety. Pitting through a category II tracing, especially if mom is not making progress (no cervical change, no fetal descent during second stage), the fetus becomes increasingly compromised and will eventually lose its reserves. No one wants to see that baby once delivered.

[cayenne06, MSN, CNM]

I do not subscribe to the "pit to distress" school of practice, but if I am concerned about a baby's tracing, then that generally means I am thinking about how to most safely get that kid born, and often that means cautiously continuing on with an IOL. In the scenario as described (assuming min variability was self limiting and overall variability was moderate), as a (student) provider I would do intrauterine resusc, watch the kid like a hawk, and probably up the pit in the hopes that baby will be happier with a better contraction pattern. As an RN, I would do intrauterine resusc and stop the pit unless a provider told me differently (and I agreed with their rationale. not pitting anyone unless I think it is safe, regardless of what a provider says).

[Katie71275]

Depending on how it looked, yes I would have upped the Pit. When in a poor contraction pattern, coupling/tripling, even if it's closer together, I will up it and try to knock them out of that poor pattern. It often works for me and then the baby will usually tolerate it much better because they aren't being squeezed back to back 2-3x in a row.

[APL&D]

An update: So I spoke to the staff who took care of the patient after me. They kept stopping and starting the Pit on her because she kept having recurrent lates. Finally it was decided that the Pit would be stopped for two hours and restarted at the lowest rate. It took her forever, but the pt delivered lady partslly. However, her placenta looked like crap and the cord was very skinny. I really think that the baby would have crashed if we kept going up on Pit. I am so happy that the outcome was great and the pt got to have a lady partsl delivery. Thanks for all your input.

[Mesmerize]

We have a pit protocol, there is a checklist we have to follow. If it doesn't meet the checklist we turn it off, and reassess! Doctors have to follow the protocol as well! Makes it so much easier! We used to have problems before, the nurses would see a late decel or minimal variability and the doctors called it a variable and moderate variability, just to keep the pit going!

Instead of saying " have a nice day" I'll start saying " have the day you deserve" ya know, let karma sort that sh..t out 😂

[MotherToPeanut]

The previous hospital I worked at had a pit protocol that all nurses and providers had to follow. In the event of an ineffective pattern of uterine activity that the provider felt would resolve with an increase in pitocin, the provider would have to fill out a variance form and have it approved by the department manager before proceeding. With a category II tracing, pitocin was decreased by half and resusc measures implemented. If not resolved within 30 minutes, pit off. I'm working at a different hospital now. I'll just say that I really miss that protocol.