#212 | A Conversation on Pitocin with an L&D Nurse and Expert Witness

Pitocin is the narcotic of obstetrics where you can use narcotics appropriately when need be, but they have to be used very judiciously. When you're working in a medical setting and you have certain technology available to you, then sometimes it's hard not to let that medical technology overtake all the other tools and skills and resources that we have that are underutilized in the hospital setting.

That's exactly why Cynthia and I jokingly but seriously say often, that we're so amazed and impressed by the women who actually have physiologic birth in the hospital, because it is the hardest place to have a physiologic birth.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Hi, I'm Connie. I am an board certified labor and delivery nurse. I've been working for over eight years working for different hospitals. I also consult as a nurse expert witness for medical malpractice attorneys where obstetric nursing cases come into question. I actually became a labor and delivery nurse precisely because I was mistreated at my own birth. So a lot of times people come to nursing because they were inspired by their nursing care. Unfortunately for me, I felt the opposite that I was mistreated at my own births. I actually also have a podcast that have the birth Lee podcast. So I tell my stories there if anyone wants to hear that. And that is been my passion of my my line of work. And I love listening to the Down to Earth podcasts because there's always something new to learn in every single episode. I love hearing perspectives of both you too. And also of your guests. I love hearing the perspectives of people, women who are giving birth.

Yes, so Honey, we're really excited to speak with you today. Because Pitocin in particular is a topic that we feel very passionate about it is an extremely commonly used medication and birth. And most women are not aware of the risks, it's really treated as sort of as a benign intervention or just a way to kind of kickstart or jumpstart your labor. And this is an area that you have a lot of experience with as an expert witness. And so this will be wonderful for our community to hear the inside scoop on what you see.

So here's the quick spiel that I give my patients before I start Pitocin in labor on any single patient Pitocin is an artificial form of the hormone that we make oxytocin and you guys have spoken about that on your podcast many times. But the way Pitocin works as it creates the body to make contractions, every single person, every woman is going to respond in a different way to that Pitocin based on how sensitive their uterine receptors are. And so because of that, we have to start the Pitocin really slow, because we don't know how much someone is going to respond to some people can be flooded with Pitocin. If that receptors are not there, they're not going to have those contractions. And then other people that one or two tiny little whiffs millions of Pitocin. And they're going to respond very quickly. Now, also, we have to do it slow, because everything we're generating the contractions for a baby. And when we generate contractions, you know, as medical staff, then every contraction is a stressor on the baby in general Labor's distress around the baby. But most of the time, women have that extra, you know, reserve in their placenta in order for the baby to be able to handle it. But the Pitocin contractions are a little bit different. They're not the natural physiological contractions. And if there was the baby that is compromised already even to begin with, before we start the labor, we have to be really careful to make sure that we're not causing that baby stress when we're giving that Pitocin and there's no way for a doctor or a nurse or any medical professional to know what each woman's individual physiology is going to tolerate with Pitocin without trial and error, basically. So, you know, we it's just sort of like a crapshoot when you start Pitocin as to whether or not it will be sufficient for her or harmful to her or her baby.

Right. And so that's why somebody needs to be on continuous monitor During you know, we can't, if someone is having a Pitocin infusion, you can't have intermittent monitoring, you have to have the continuous monitoring, although there are many limitations to it, that's the best that we have if we are starting a medication like this, and we can discontinue the Pitocin. If we see, if we see any signs of potential compromise, we can just continuing and that being said, compromise is a very subjective thing when it comes to electronic fetal monitoring and interpreting the strip. You know, most babies have dips here or there in labor, it's a normal thing. And the whole entire system of EFM is difficult to really pinpoint an exact time where this means the baby's compromised. So sometimes we can see signs of compromised and the baby's really actually not compromised. And sometimes we can let those signs go on for too long. And the baby indeed has become compromised. And so most of the time when I review cases, I would say that, most of the time, the cases that I've reviewed were because a baby was a mother was receiving a Pitocin infusion either it was started before the we were able to determine that the baby was actually you know, great a okay, we call it a category one twisting where it's really, really good at predicting that category one twisting that a baby is not compromised doing well, either the Pitocin was started before we were actually able to see that tracing to make sure that the baby was Okay, before we were adding more stress, or we let it go on for too long and the baby was too compromised.

Why would anyone start Pitocin without understanding how the baby was doing without having a tracing.

They can have a tracing, but it may not be a category one tracing. So when we categorize trace things, the category one tracing is excellent at predicting that a baby's doing well. And the category retracing is excellent at predicting that a baby is really not doing well. 80% of tracings are category two 80%. And so sometimes Pitocin was started on someone with a category two tracing where we don't know for sure, maybe the characteristics in the category two tracing didn't seem so bad, etcetera, etcetera. And sometimes you also have where multiple providers are misinterpreting the strip, like there are a lot of nuances involved in that. And they continue to Pitocin effusion, while misinterpreting the strip repeatedly. But I will tell you, the majority of the time, what I've seen is is that there was a lack of communication between the providers and the patient explaining what exactly was going on to the patient and why they needed the Pitocin infusion, etc.

Are you talking about Pitocin during labor? Or are you talking about? So let's just acknowledge that Pitocin is being overused during labor, because just the conversation I'm afraid is normalizing it. It just what do you what is your opinion about how often it's being used in the first place?

You're definitely right. I think it also varies from hospital to hospital provider to provider, I happen to be grateful to work in places where there's a little bit more mindfulness regarding starting Pitocin. Even though the joke is is when a patient comes in with a normal physiological labor spontaneously, no interventions, no epidural and gives birth. It's kind of I like to turn to my colleagues and like say, well, but we would or not people can sometimes give birth without a Pitocin infusion. Now that's a joke. But it's not as overused, as I've heard from people and other giving birth in other hospitals like I've heard women tell me Well, after they gave me the epidural, I saw them hanging an infusion and they said, Hey, what is that? Oh, it's Pitocin. It's standard to start together with the epidural. We don't I don't come from a place that we do it that way. But, you know, what I've come to see is that if you're working in a setting where you don't have a Pitocin infusion, say at home or in a birth center, you have other tools at your disposal, and you're being resourceful with using those tools to help LIBOR get going. Like there are the three P's of labor power, which is the power of the contractions, which sometimes Pitocin is helpful for but then there's also the pathogen the passenger, right. And so, the pathogen the passenger a lot of times the you know midwifery model of care concentrates on that on proper positioning on staying upright on helping the baby's head rotate the baby's the passenger. But when you're working in a medical setting and you have certain technology available to you, then sometimes it's hard not to let that medical technology overtake all the other tools and skills and resources that we have that are underutilized in the hospital setting versus in you know home birth or in a birth center.

That's exactly why Cynthia and I jokingly but seriously say often, that we're so amazed and impressed by the women who actually have physiologic birth in the hospital. Because it is the hardest place to have a physiologic birth. Everything about the hospital environment is kind of working against that. So just from the bright lights to the strangers to the noise to the interruptions to the immediate access to Pitocin epidurals, other pain relieving measures to somebody constantly asking you if you're ready for that epidural yet? Or can you just give you a whiff of Pitocin? It'll just kind of help you along the way you look tired? All that stuff? What is the percentage of women in your nursing world that get Pitocin in labor?

I actually recently looked up a report, it was just we were we were playing around trying to get some statistics. And I think in the last month, maybe I think it was over 50% of patients that had had some form of Pitocin, either induction or augmentation where they're already in labor. You can't quote me on it. Exactly. But it was quite high. And then we're also looking at is that also part of the C section group? I don't know if it was the entirety of the births. Were Some patients have a scheduled C section. In that case, it would make the percentage higher among those who have had a vaginal delivery.

Yeah, I would actually, I would say that 50% actually sounds a little bit low to me in a hospital setting.

But in your hospital, you said it is lower? Right. Yeah.

So I don't know, it may be lower. It's just that I've worked in different places. And I have colleagues and I have, you know, just, again, people reach out to me. And I think that is a by region varies from hospital to hospital, what their culture, the philosophy about the use of something like Pitocin is, and policies in place. I know we a lot of times policies that are used as an evil term, but sometimes that are also good, because I will refer to the policy and say, I'm sorry, cannot start Pitocin on a patient like this, or I'm sorry, I have to discontinue Pitocin on a patient that's having XYZ, because this is what the policy says it's not safe. So I can actually use that to protect me and the patient. In order to say no, I'm sorry, I have to just continue the Pitocin in general policies at hospitals are put in place to protect the patient and somewhat to protect the institution and the provider. But the problem with policies is that it when they are actually doing the job of protecting the patient, they're great, but they are doing the job of interfering with the patient's individual needs to get in the way.

Well, the other thing to pay attention to is the fact that it was sort of what Connie was saying about how it changes regionally. Our hospitals in the United States have C section rates varying between 7% and 70%, of full order of magnitude in this one in this country. So it just goes to show that if some hospitals are producing C section rates of 70%, but others are seven, eight, 10%. That you know that isn't a function of the population of women who's going there. It's a function of the culture within that hospital and how they practice and how they pick up from each other how to continue practicing the rhetoric, they pick up the things they say to to their patients.

Yeah, sure. And extend the what you said about the immense divide between percentages of C sections and different hospitals, and how that can be related to policy. It has been linked to that as well as the oversight. But you know, with the arrive trial, and all the controversy that it's gotten, and people asking me, my doctor said I should have been induced at 39 weeks because it lower my chances of success. And I always say to them, first check your hospitals, C section rates and if they reach if they are the same or lower than the C section rates in the arrive trial, which were much better C section rates compared to many other hospitals, 18 and 22%. First, first find that out if they're higher than that, then well, the arrived trial wasn't a blind study. And that's why they were low. That's a red flag right there. Like they were suspiciously low. It was like 18.6% versus 22%. It's like, this is a little low. This was done in the United States. And we have so the answer to that is the fact that it was not a blind study and look at how well they got their C section rates down. Just by being watched and knowing those C sections were being counted. They all got them down low. Trisha and I it's worth mentioning did a deep dive on all of the research and all of the faults in the analysis of the arrive trial in a live stream webinar on our Patreon platform that anyone can go access. It's an hour long and I would really say it's one of the most important things for any pregnant woman to to go watch and listen to because the rhetoric around the arrived trial has been causing so much additional harm. They created conclusions around it, that were never the things they were studying. And they're ignoring all the limitations of that study. And there's just a lot to it. And we believe women should be prepared to go say to the doctor, do you actually know what happened in that trial, because it's not what you're telling me. So tell us, so take it from there, tell us tell us more about your experience there about being an expert witness. And so I was practicing as a nurse for a little over four years, and I beat my philosophy is, is really understanding why we're doing what we are doing. And when I went to nursing school, that was really the overarching, you know, way that they taught us. And I'm very grateful about that, because they said skills are great. Learning how to put in a catheter is great, and all that, but you'll learn that on the job. But understanding the rationale, understanding evidence based practice what it means to be leader, what it means to try to implement change. That was really a lot of what I got in nursing school. And so I practice that way as a labor and delivery nurse. And that's why I love learning and listening to podcasts and hearing the different perspectives of patients and learning new things. Again, what's one of the most overarching things that I've learned from this is the overuse of Pitocin, and how many times it's caused harm to the fetus and not being shut off at the right time, or decreased, like it needs to really be watched. When when a patient is getting this Pitocin. And I had a lawyer refer to it in a brilliant, brilliant way. He told me, he said Pitocin is the narcotic of obstetrics where you can use narcotics appropriately when need be. But they have to be used very judiciously. And they shouldn't be just thrown out to any patient that can just use Motrin or Tylenol. And how Pitocin in labor can have can be a very valuable tool when needed. But it needs to be used carefully. And appropriately.

When you when you said that. The another thought came into my head that it's also a little bit the cocaine obstetrics, because it's like an addictive medication for providers. It's, it's like just another round of Pitocin, another round of Pitocin, we get so used to it.

I hate to share things like this, but I just feel the need. One nurse involved in a magazine publication I used to work with a little bit and publishing a little bit. One nurse came forward and read left her work. And she said they had a they had a phrase they used in the hospital in which the doctor would commend the nurse with the following words he would say pit to distress. And she said it was our job to administer Pitocin and crank it to the point that we can call fetal distress and give a C section and I see you nodding to tell...

Well, it's definitely something I've heard of. In my case, I haven't experienced I've heard of pit to distress. In my case, what I've experienced, what I've seen referred to is that the baby will prove itself. Meaning to say, if we start Pitocin, the baby will be in distress. And so if a patient is just two centimeters dilated and needs to go to delivery, you know, you try the Pitocin the Pitocin doesn't work. And then what doesn't Well, same thing.

It's not because what you're saying Cynthia is is like a intentionally we're going to intentionally harm this baby. What she's saying is it's totally manipulative, because it's like, oh, let's test this baby's reserves. Let's give an artificial external stimulation to see how tolerant this baby is when this baby was never designed in this mother was never designed to have that.

It does sound like the exact same thing, the same intention. It's just cushions differently, like, Oh, let's see if the baby can handle this. Why it's manipulative, stressful condition, we're putting it under. And if it does, they probably think it. It's evil. That's pure evil. It's still like I can't believe so it's horrible because that to other people. It's hard. What's hard is is that sometimes there really is medical indication to proceed to birth, say a baby that has true and intrauterine growth restriction. I know that there can be subjectivity and I know that providers can throw that out more casually. But when there is let's say, I'm just throwing out an example when there's true, true true intrauterine growth restriction. The baby has been measured and measurements have been followed for weeks, etc. And the placenta is clearly deteriorating, which means that the baby's gonna have a harder time. I'm tolerating labor to begin with, right? Because the placenta is not growing as well. And so it's kind of the patient needs to proceed to birth because the baby's not growing. And then well, you could also argue that the baby in that situation is going to have a much lower threshold for Pitocin. So yes, we need to get this baby born at some point, and we're trying to weigh the risks of the IUGR versus the induction of labor. But to push the baby and the body to the point of distress in that situation still seems unreasonable and unfair.

Unethical. Yeah, and, and so for me, here's the thing, here's what I've noticed over the years of my practice, I'll tell you a funny story. I'm the peanut bowl queen. And for those of your listeners who don't know what a peanut bowl is, it's basically what looks like a giant like yoga ball, except it's shaped in a piano. And we can use it to make to put the patient in different positions, both during labor with an epidural without an epidural, etc. It can be a very useful tool, and I'm the peanut ball queen. And I actually research and teach myself we're depending on where the baby is in the pelvis, what the best positions are, I'm very aggressive with it with an epidural, etc. And so I've come to be known among some of the doctors as Oh, you know, just ask funny, she'll still make it work for you. And once that may came into the hospital, and a doc, I was assigned to a patient that was having they were having a hard time helping the patient progress in labor, I don't remember the exact situation whether there was or was not Pitocin. And the doctor said to me, oh, I need you to work your magic on this patient. And I looked at the doctor and I said, it's not magic. It's basic, basic birth physiology. And she was like, oh, yeah, yeah. And so she said, Oh, yeah, I've heard about that. It's magic to her because she doesn't understand, right, she has no idea what that is.

Exactly. And so that was kind of like a lightbulb moment for me. Where doctors, I have a lot of respect for the doctors, I work with the they have in need to know an immense amount of things. They're not just doing labor and delivery, they're doing all kinds of obstetrics and gynecology and everything like that. And so I think practically speaking, realistically, it's impossible for them to concentrate on the nuances and little details of birth physiology, when they when they have so much else going on. Like you know, I see the doctor sitting next to me, they're getting calls for birth control refills, for testing for miscarriages, etc. But I think that midwives, especially those who are just in the birth arena, like this is literally their specialty, like they know all these details of the birth physiology. And as nurses, we should be the same because we're literally, with patients during their labor, I think we should, we don't have enough training on the birth physiology at all. And I have nurses, one, my nurse colleagues always asking me, like, can you help me out? Can you like, show me how to do this, this move, and this, this, and I'm trying to get education into our hospital for the nurses, but I think any nurse, that's a labor and delivery nurse, this is like should be, you know, one to one for them, even though unfortunately, that doesn't happen. And I have medical students and residents, but most of the medical students because they're really just, you know, they they come in, they're watching everything that's going on, that have told me the medical students are like, wow, like this is so interesting, all the things you told the patient about the three P's of labor, and the birth physiology and Republic inlet and the outlet. And they're like you should give a talk. I've had med students tell me, I should give a talk to them about all this stuff, because they don't learn this.

That's what Barbara Harper spends her life doing training doctors all around the world, and water birthing, they all need to be trained.

Because somewhere in those young minds of medical students and residents and new hobbies, they have that, you know, they came in to that line of work because they must value birth to some extent. And so within them, there is that place where they, they know that the physiology of birth matters. It's just not taught. It's not even taught in nursing school very much. It's the foundation of understanding birth. So when they hear you talk about it, they're like, oh, wait, that's right. There's something really important in that.

And the irony of how busy they are, is that their lives and their work would become so much simpler. And they would be so much less involved, if they did learn to be hands off and only intervene when they actually were when that when that risk to benefit ratio tips in the other direction.

I cannot even tell you I had the funnest time a few months ago when I had a normal physiological birth. That was uninterrupted and those patients are so few and far between and every time it happens, I'm just like, my heart is just you know, exploding with joy and the peace student was pushing on all fours. And the President was standing there and kind of saying like, this is weird, like, I don't know where to put my hands. So I looked at him like, if only we can have every birth where you don't even know how to put your hands like it's in your pocket. Right? Right. Like, it's great. She's doing it. And then the patient's mom was there. And she's like, Oh, is it safe, that she's pushing on all fours? Like, is that safe? And I'm sitting there, like, just enjoy because I'm explaining it to the mom. But really, I'm explaining it to the, to the resident and the medical students that are there. And I'm like, No, actually, it's really great because her coccyx bone has more room to open up. And like I'm explaining all the physiology. And I was just enjoying it so much, because I don't know if they've ever heard of that again, I have to tell you, I once was talking to a third year resident third year, who didn't know what the training of a certified nurse midwife was. She said, Oh, they have to be a nurse first. Oh, I thought it was like the kind of thing where like, you just became a nurse or you became a midwife? I said, No. And when I went into the depth about the length of time that the training happens over oh, oh, they have? I couldn't believe it. How? How can you not know this when you are expected to actually work closely with this profession, and she never learned it? Not in medical school, not in residency.

They should have learned it because the statistics globally show that midwifery care is the safest form of care. And it would benefit them to study a little bit and say, Well, what are midwives doing differently? And even if they value obstetrics, more greatly? Can we learn anything from this group of people or resulting in better outcomes for women around the world? So given all your insights, what if you could make any change to the American hospital system? What change would you make?

From a nursing perspective from a labor and delivery nurses perspective, really appropriate staffing, because I see so much how it burns out nurses and nurses are the primary ones caring for patients and labor, we have the most face time with nurses and labor. And sometimes I will feel like I'm working with my hands tied behind my back because I know I can give a patient more support, but then I have a second and third patient that I also have to take care of. And it the nursing staffing and treating nurses appropriately, I feel like really will transfer back into good patient care, I will say most nurses really truly want to give good patient care, but there are deficits in their training, there are problems with hospital culture, and also they they really it's easier for them to just get the patient an epidural than to sit there and help the patient, you know, to different positions. And with comfort measures. One of the best things to say to a nurse or any of the health care providers is is I know that this is something that's routine for you. But it's not something that's routine for me and this is a very special and important event for me. And I ask that you take that into consideration with how you treat me. So the more you know, the better you'll be able to do that and be that active participant in decisions around your health and your birth.

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