Belly Up

* bellies * birth * babies * breastfeeding *

Wednesday, January 25, 2012

Pit Stop (Pitocin Part 1)

Pitocin is now used to induce or augment over 80% of labors in the United States.  It is used in even higher numbers post partum as a prophylactic for excessive bleeding or hemorrhage.  If a woman is having a hospital birth in this country, the likelihood of pitocin being a part of her birth is extremely high.  So what exactly is this drug that is used so frequently these days?
When the Beatles sang "All You Need is Love",
I bet they were singing about oxytocin.
Pitocin is synthetic oxytocin, so let's take a quick detour and talk about the real thing before we look at the synthetic counterpart.  Oxytocin is the hormone that, among other things, helps initiate and regulate labor.  Naturally occurring oxytocin originates in the brain then is produced by the pituitary glands and is sent out from there to various oxytocin receptors throughout the body.  Oxytocin is also known as the "love hormone" as it promotes romantic, sexual and familiar attachment.  It bonds husband to wife, parent to child, etc. Humans secrete oxytocin when we touch each other, when we have sex, and in huge quantities during breastfeeding, spontaneous labor and immediately after childbirth.  Oxytocin makes us feel secure, loved and overall less anxious. Research is even being done connecting the lack of oxytocin in those with autism.  In fact, the drug XTC is a derivative of oxytocin.  If you don't know what I am talking about, good!  XTC is an illegal drug that makes users want to dance and party all night long because they are just so....x-static.  Seriously, this oxytocin is good stuff!

Pitocin, fondly (or not so fondly) referred to as pit, is the synthetic form of oxytocin.  Pitocin is a uterine stimulant and causes uterine contractions by changing calcium concentrations in the uterine muscles.  It is derived from extractions of the pituitary glands of non-human mammals and is generally given through IV or an IM injection.  During the course of normal labor oxytocin is released through bio feed back loops that exist between the cervix, the uterus, the brain, the pituitary gland and the baby plus all  the other hormones in the mix.  This process is complex and not completely understood; we have yet to even identify what exactly makes labor start.  So far it seems to be one of those chicken or the egg type dilemmas. Did the oxytocin create the labor or did the labor create the oxytocin?  We do know that in spontaneous labor oxytocin will ebb and flow as the body responds to labor and will slowly build so that contractions become closer and a baby is ejected.  Of some interest is that oxytocin cannot cross the blood brain barrier.  Therefore synthetic oxytocin is not recognized by the brain which leads to an interesting thought that a women induced with pitocin may be laboring, however her brain may not really know it.  This lack of complete biological communication may then create some challenges in those hormonal and bio feed back loops that typically make labor effective. 

The dosage of pit given varies widely based on provider's individual protocol.  The suggested dose is to initiate the pitocin at 0.5-1 mU/min and increase it at 30-60 minute intervals by increments of 1-2 mU/min until the desired contraction pattern has been established. As labor progresses to 5-6 cm dilation, it is suggested the dose should be reduced by similar increments. Studies of the concentrations of oxytocin have shown that infusion rates up to 6 mU/min give the same oxytocin levels that are found in spontaneous labor and therefore higher rates should be given with great care.

If you have attended a pitocin induced birth or had one yourself, you're probably scratching your head...that is not how pit is typically administered in the real world.  6mU/min is closer to most starting doses rather than the final dose and almost never will you see careproviders turning the pit down after it has been turned up.  Not being someone with the authority to make dosing decisions myself, I don't want to overstep my knowledge, but if a mom is in a induction situation and the pitocin is going up and up and up, the issue may be that mom has an impatient care provider and not that her uterus is working poorly.  If you are considering an induction with pitocin, you will want to have a little chat with your careprovider about how he typically manages the use of pitocin and how he will do so in your unique situation.

There are a few other side effects listed for pitocin:  allergic reaction; difficulty urinating; chest pain or irregular heart beat; difficulty breathing; confusion; sudden weight gain or excessive swelling; severe headache; and excessive vaginal bleeding.  Luckily, these side effects are fairly uncommon.  However the side effects that I want to highlight won't be found on the package insert.  These include the need for an IV and IV fluids - which limit movement, the need for mom to have continuous fetal monitoring- which will  limit  movement, and depending on how the careprovider doses the pit, contractions that are so frequent that mom will experience more discomfort with less time to rest between contractions than would be typical in a natural labor.  This usually leads to an epidural and the side effects of that epidural (need for a bladder catheter, pulse oximeter, lowered blood pressure, possible itching and shakiness and of course even less ability to move.)

Another side effect can be that it doesn't always work.  If a women is induced and she fails to completely dilate it is called a failed induction.  The remedy for that is usually a c-section particularly if the induction included the breaking of baby's amniotic sac. Also common is that babies don't tolerate the increased frequency of high dosage pitocin and show signs of fetal distress.  The remedy for this is usually a c-section as well.  I don't consider it too big of a statement to say that a common side effect of pitocin use is major abdominal surgery, particularly for first time mothers..

However, after doing some trash talking about pitocin in this post I must insist that your read Pit Stop Part 2 which I am almost done writing.  I may have to turn in my natural birth advocate card after hitting publish, but I am going to talk about pitocin in a good light.  Oh yes, I am....stay tuned.

Thursday, January 12, 2012

Fads At 40

Looking like this
was a fad in the

Forty weeks that is!  As mom gets close to that magical date of 40 completed weeks of pregnancy it seems several concerns tend to come up by careproviders, usually in the context of  "We may need to induce because....(fill in the blank)....." 

Major disclosure here.  I am not a doctor, I am not a midwife...I am barely even a midwife student.  I am not saying that if you are told you might have any of these issues that they are not real or a potential concern.  I *am* saying that if they come up that I suggest doing some research and perhaps even getting a 2nd opinion before you make choices about scheduling an induction or a c-section as the risks of those procedures may carry risks higher than the risk of the original potential concern.  Even better, think about them before they are brought up so you can better discuss your options if and when they do. There, my legal disclaimer. Please don't sue me.

I hear a variety of things said to my friends and clients as to why they should induce either before or by their EDD, but a few keep coming up and I will call those the Fads at 40 because these seem to be the "in" reasons given for inductions right now.  These inductions sound medically legit and there may indeed be some medical basis for the concern but they are areas where the research is either inconclusive or has outright shown that the concern is not a reason to induce.  In the end the real reason may boil down to to a careprovider covering his assets, so to speak..  So what are my the top Fads at 40?  Here you go:

1) Your baby is too big
Nobody gives birth
to a toddle
What is too big?  Obviously this is a very subjective.  A baby and mother will work together in labor to birth and at the point the size has a lot less to do with the baby navigating through the pelvis than its position and the circumstances surrounding the labor.  ACOG defines a "big baby", or macrosomia, as a birth weight of  8 lb 13 oz to 9 lb 15 oz.  However macrosomia in medical terms, is not bad in and of itself, and the real thing to understand is that studies show time after time that there is NO way to accurately weigh a baby in utereo.  Sonograms are often characterized as accurate late in pregnancy, but the research shows otherwise. If a provider says a baby is big (or small for that matter) based solely on sonogram measurements, that statement is not much more than a guess.

Moms that have gestational diabetes have more concern in this area as they can grow babies that are bigger due to that condition than they might have otherwise, so this is something to consider if you are suspected to have macrosomia.  However if you are not diabetic and ate healthily, you probably grew the right size baby for you, even if it is 10lbs.  ACOG also recommends against inductions for large babies so if your careprovider recommends an induction for macrosomia he is going against the standard of care as well as the logic that for a bigger baby you will want to reduce the need for an epidural because the supine position used with an epidural will reduce the pelvic dimensions giving baby and mom less resources to do what they need to do.

I know the idea of having (ok, pushing out) a big baby scares many moms, but really even tiny moms can deliver huge babies just fine and often without tearing given good positioning and support.  If you need more of a pep talk on how much our pelvis's rock, go back and read the post 
2) You don't have enough amniotic fluid
Amniotic fluid is a tricky and sometimes controversial subject.  The normal range for an AFI (amniotic fluid index) is 5-25 with low levels sometimes associated with placental insufficiency as the pregnancy reaches term and beyond.  However, fluid levels fluctuate almost hourly and obtaining a reading is very subjective based on who is doing the measuring and the position of the baby not to mention when in the day it is done.  To confuse matters more, what the reading actually means is very subjective as well.  In a term pregnancy, some providers consider 7 or below a low reading, others 5 and below and many don't even bother to measure the fluid until the pregnancy gets past 41 weeks.  Then there are a few others who are more conservative and want to see a 10 or higher. You can see how an induction based on fluid levels alone should really be explored before going forward!

If mom is testing on the lower end of her care provider's comfort level, other tests can be done to get an overall picture of the health of the pregnancy.  A mother can also increase her fluid intake either orally or with IV fluids for a period of time and have the fluid tested again at a different time of the day to compare results. Obviously if the care provider is one of whose comfort levels is on the very high end, the couple will have to have some discussion about their own comfort levels and then see if they can work things out with their current provider.

3) Its 40 Weeks and Nothing is Happening
Neither babies nor their moms
come with a printed expiration date
I've written about this one before so I won't be"labor" the point.  If your cervix is closed up tight at 40 weeks it means nothing.  The cervix will dilate when contractions start and when contractions start  has nothing to do with how open, or closed. the cervix is.  Cervixes react, they don't initiate.

A woman who is induced because her body is showing no sign of being ready usually means she will have a failed induction and a c-section...because she wasn't ready, particularly for 1st time moms.  If a careprovider suggests an induction because nothing is happening yet, yet, just remember that no one stays pregnant forever.  If a careproider suggests an induction because mom is 4cm and not yet in labor, just remember that babies don't fall out.  (unless you are 16, at the prom and didn't actually know you were pregnant.) It is fine to walk around at 4cm for as long as it takes for labor to start.

4) Nothing Good Ever Happens Past 40 Weeks
Normal gestation is 38-42 weeks so good things certainly do happen after 40 weeks.  Things like spontaneous labor.  It's a cliche in the birth world, but it's true: EDD stands for estimated due date, not expiration date.