Friday, June 13, 2008

High Dose Pitocin Inductions

Apparently high dose pitocin inductions are becoming all the rage. Hospital in the big city number 2 at which I work is doing a study on them.

Color me unimpressed.

"The Literature" says women deliver more rapidly with HDPIs and that HDPIs decrease the number of C-sections. I'm skeptical, I can't wait to read the studies.

This was my first, and only I should add, experience with an HDPI.

Mom was a first timer, barely "past dates" (she was due on a Friday, we started the induction on Wednesday after her due date), she was given cervidil, a cervical ripening agent, overnight, which caused mild cramping but not much else. I placed the cervidil and BOY was her cervix posterior! I could barely reach the posterior fornix, the little pocket just behind the cervix, and I had a very difficult time trying to get to the opening of her cervix, the os, to check her dilation. In otherwords, her body had very few indicators of being ready for labor. In fact, her Bishops score, which we use to measure a woman's "inductability" was 2, not impressive.

So she recieved her cervidil overnight and pit was started, at FOUR MILLIUNITS AN HOUR, the next morning. Apparently in some places they're starting it at six milliunits an hour!

If we use the analogy of labor being like running a marathon, think of an induction as being tied to a car with which you must keep up in order to reach the finish line. Most times, the car would start slow, walking pace, like two miles an hour, and over the course of the day, the car (pitocin) would go a little faster, and a little faster, 'til you're finally running along at a good clip, and hopefully not being dragged behind the car! With HDPIs you sort of get pushed out of the car when it's already going 25 miles and hour and you just go faster from there.

When I took her the next afternoon, her pitocin was already up to 30 milliunits, which is pretty much the maximum recommended dose for any laboring woman, she couldn't feel it though because of course she had an epidural, not that I blame her a bit, I doubt I could take a pit induction that high myself without some pharmaceutical help.

Unfortunately, such a high dose caused, surprise surprise, hyperstimulus of the uterus so baby was having deep decels, and her uterus wasn't relaxing between contractions and she was contracting every minute.

We cut her pit in half and she started having a nicer labor pattern, but every so often baby would have a very deep variable deceleration. We suspected the cord might be wrapped around something at that point.

We started easing the pit back up again, this time using a low dose protocol, and soon her water broke with clear fluids. Whew! Despite the stress, baby hadn't pooped inside of her. Good.

Her uterus seemed to be pooping out (not suprising that she wasn't maintaining contractions with all the pit pumped into her from before, this is pretty common) so we kept increasing the pit.

About an hour after her water broke, we started seeing meconium, the baby's first bowl movement. Thick, thick, pea soup mec.

Finally, she was complete, we had her start pushing. The baby was having fewer variables, but his baseline had risen, which can indicate fever, or stress in a fetus, I was afraid he was on the verge of pooping out completely and he'd be plummeting down, and we'd be headed for a section.

After an hour an forty minutes of pushing, a pretty average time for a first time mom, the baby was born, covered head to toe in thick mec, floppy, dusky as all get out, with that glazed unfocused very not-present look. Yeesh. He had his cord wrapped around his neck AND his left had, which because of the cord was tucked up along side his head when he was born. I am so so thankful the Neotal Nurse Practitioner was there, I would not have wanted to try and resucitate that baby myself. She intubated him twice, and he didn't give his first small cries until four minutes after he was born. His apgars were five(!) and eight. Yikes. Yikes. Yikes.

So, what do I think about HDPIs so far. It seems like an impossible induction to do without drugs, I think it's a good set up to stress out babies, as well as leading to hyperstimulation of the uterus, which in turn could cause the uterus to rupture. The dreaded abruption.

Ladies, do your research, advocate for yourself, and if you can't, get a doula who will advocate for you.

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