Wednesday, July 8, 2009

"Pit to distress" around the birth blogs

I think the first place I heard "pit to distress" must have been in Marsden Wagner's book "Born in the USA". The term refers to the practice of turning pitocin up to the point where the uterine contractions it stimulates put the fetus into distress.

Just in the past few days there has been a lot of discussion about it around the birth blogs. It started with Jill at Keyboard Revolutionary who discussed her recent discovery of the practice. She interprets "pit to distress" as done to provide a pretext for a c-section. This is what she thinks of it: "I have spent the last five years of my life angry at the medical establishment for what happened to me in the hospital. But I just might be more pissed off right now than I ever was before, after hearing about 'pit to distress.'"

Jill at the Unnecesarean linked to that post and followed up with a number of links that cite "pit to distress", from nursing textbooks, nursing forums, and a newspaper article. "I imagine all of us who have openly questioned the practices of obstetricians in the U.S. have been hit with the same backlash. We must be selfish, irrational and motivated by our own personal satisfaction. ...Nah. It’s stuff like “pit to distress” that made me run for the nearest freestanding birth center. If I had to do it all over again, I’d stay home."

These two posts have elicited a number of responses, especially from practicing nurses and midwives.

Ciarin at A Midwife's Tale discussed the context in which she's heard it used, namely "The term was used in situations where the baby was looking less than stellar during latent labor and it was already predicted that the a c/s would be likely for this reason. The pit to distress term would simply mean, go ahead and pit hard so we can section the baby."

Labor Nurse CNM on Rebirth also said that she had never seen the practice as described but had seen pitocin pushed to the point of fetal distress. She pointed out that nurses could lose their licenses for administering medication that way.

Along those lines, Reality Rounds looked at it from the angle of how nurses can go about refusing physician orders, or at least communicate their way out of it. She states: "A nurse is ethically, morally and professionally obligated to advocate for her patients. ... A nurse CAN refuse to carry out a physician order. A prudent nurse should refuse any order she feels would cause harm to the patient".

And nurses have posted stories of doing just that:

Prisca at N is for Nurse had recently discussed requests to "pit to distress" that she has had to push back against: "They wrote pit orders on a woman who was already hyperstimming by herself, bleeding and baby looked like crap. I was really hating my job that night--fighting three residents is loads of fun. So, I hung the pit at 2 units and didn't touch it for 2 hours. I also watched mom like a hawk and made my general displeasure known (and charted it all of course) to my charge who agreed with me and the attending who didn't want to 'cut' this woman in the 1st place. Dude, she needed a c-section, just NOT a crash section."

Nursing Birth tells her own stories of fighting pit to distress orders. She clarifies that no one has to write "pit to distress" in the orders to make it happen: "...[T]he account that you have just read is called 'Pit to Distress' whether the pitocin order was actually written that way or not. What Dr. F gave me was a VERBAL ORDER to increase the pitocin, regardless of contraction or fetal heart rate pattern, until I reached 'max pit,' which he acknowledged would hyperstimulate her uterus. This goes against our hospital’s policy and the physical written order that this doctor signed his name under."

One thing that's been wonderful about building up a Google Reader full of birth-related blogs has been getting the chance to see an issue from multiple perspectives, and hearing many experiences. As a doula and a public health professional, I want to educate myself in complexity - not "All OBs do this" or "Pitocin is Bad" - but to understand what's really going on and where.

Reading these has also made me wonder - has this order ever been given for one of my clients? It's certainly possible, but I'll never know now. How can I prevent this happening to clients in the future, other than encouraging them to ask to have the Pitocin turned up slowly?


Reality Rounds said...

Thanks for the post and the link :)
My guess is you will never have to deal with the "pit to distress" issue. Healthy women in normal labor should not have this happen. I would hope a woman who chooses to have a doula also had a very careful consideration as to who her birth attendant is. A reasonable, compassionate birth attendant would not "pit to distress." BTW, I have never personally encountered this. As a doula, I would just ask many questions with justifications as to why Doctor X is doing Y. Hopefully you will get an honest and respectful answer.

publichealthdoula said...

I certainly hope that I would never have to deal with this! But I wouldn't be so sure that it hasn't come up in the past. Most of my past doula clients never chose to hire a doula - I worked with them through an AmeriCorps program, and most had never heard of a doula before I walked into their L&D room. They also didn't have a choice of birth attendants. Based on their home clinic, they were sent to 3 hospitals - at one they were cared for mostly by the midwives, at one by house staff, at one by private OBs who had contracted with our clinic. So they could get any of a wide range of practitioners.

Do I think any of those providers would have practiced this way? It was hard for us as doulas to get a sense of individual practice styles because we didn't work with the same people often enough, but I did see some aggressively interventionist practices (and not just from the OBs!) Thinking back, I can remember women who were hyperstimmed (and the Pit was turned down because of that) but I could never say if that was the intention in the first place. If it's as rare as I hope it is, then almost certainly not. But it's frustrating to know that it could have been.

Pampered Mom said...

When I saw the recent posts on "pit to distress" I found it odd that others hadn't heard of it, but at the same time couldn't remember where I had read it. Thanks for pointing out that it was in Marsden's book.

publichealthdoula said...

I couldn't remember either at first - I was convinced that I had read it in a blog, but when I searched my google reader (so useful!) I came up empty - except for an entry that referenced "Born in the USA". I should finish that book!