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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Emergency Use of Intrapartal Pitocin

I am a Mennonite midwife practicing non-medically under the religious exemptions clause. I read your post on the IM pitocin and could well sympathize with you. I have certainly been tempted to "help" out a bit in similar circumstances. But the use of pitocin in non-emergency circumstances by community midwives is an illegal practice of medicine in most states and if damage to the mother or baby can be ascribed to it (rightly or wrongly) it becomes a felony charge. Unfortunately a midwife in our state has been arrested and is being prosecuted on felony charges, in part as a result of the use of pitocin in circumstance much as you described. One of the problems she will face when the case goes to trial is that she injected 1/4 amp of pitocin IM four times over the course of eight hours. Eventually hospitalization was necessary and the mother reported her use of this drug to the perinatologist. The baby is severely damaged and the family is now suing the midwife for malpractice. It will NOT be a hard case for them to win as the "appropriate" initial dose is only 1/6 of what the mother actually received and was not preceded by a test dose (aside from the issue of illegal practice of medicine).

Before training to practice as a non-medical midwife i worked as a vocational nurse in the labor & delivery room for almost 15 years. When i first began (1961) we didn't use IVs unless the mother was gravely ill so when pitocin was given to augment uterine function it was via nose drops. This is a variation of the classical method described in old obstetrical textbooks, which give instructions to saturate a cotton pellet in pituitrin and place it in alternating nares for twenty minutes or until the desired labor pattern was achieved. The good news about this is that overdose was nigh on to impossible as the amount of drug that can be absorbed by the mucus membrane of the nasal passages is minute and the drug can be withdrawn instantly if a tetanic contraction results.

By the early 1970s the "method of choice" was subcutaneous injections, starting with a "test" dose of 1/2 minim every 20 minutes, increasing the dose to a maximum of 2 minims (16 minins or drops per cc). By the late 70s the hospital supply folks were heavily promoting the use of angiocaths for IVs. Nicer IV needles and the frequent use of epidural made IVs a routine part of hospitalization and so SQ pitocin was out and IV pit was in. I was unfortunately present when a gravid 4 that was being pitted suffered a ruptured uterus. I saw many other instances of fetal distress with emergency C/S made necessary by the use of pitocin. It seems that some laboring women are pitocin sensitive and have an exaggerated response.

I would never encourage any community midwife to practice medicine illegally but i do understand that rare emergency circumstances might conceivably bring about the necessity to "nudge" a flagging uterus. Of course, one must always keep in mind that if you have to prod the uterus (either by natural or artificial means, including nipple stimulation), one runs a greater chance of shoulder dystocia, retained placenta and postpartum hemorrhage, so merely getting the cervix out of the way and the baby's head across the perineum is not always a good thing in home-based care. However, earthquakes and snow storms happen to people who live hours from good medical care and so expediency might lie in this potentially-dangerous form of medical intervention (but rarely).

Were a midwife to be faced with such an emergency situation the most favorable course of action would be an informed consent conversation with the parents, not unlike dealing with an unexpected breech or twins at home. After discussing the possible deadly consequences of this drug, a placebo dose of sterile water would be used since a tetanic uterine contraction can be triggered solely by psychogenic forces. A cotton pellet or Q-tip wetted (with water) and placed in one nare for twenty minutes will offer an opportunity to find out if the mother is psychologically influenced. If so she will suddenly start having really forceful UC (uterine contractions) and no doubt deliver without need for further intervention. (I would consider this to be Divine intervention or the answer to fervent prayers!) If nothing untoward happens, pitocin pellet or Q-tip diluted 1/2 and 1/2 with water should be instituted, replaced every 15 minutes. After the first round (i.e. finish the first amp or about 1 1/2 hours), pitocin full strength can be utilized as it has been established that the mother is NOT pitocin sensitive. However, this method should not be depended upon to culminate second stage with a big baby or wimpy mom as one cannot count on the continuation of sufficiently forceful UC to avoid problems with the shoulders or bleeding postpartum.

Summary: Informed Consent Conversation A placebo dose of sterile water would be used since a tetanic uterine contraction can be triggered solely by psychogenic forces. A cotton pellet or Q-tip wetted (with water) and placed in one nare for twenty minutes will offer an opportunity to find out if the mother is psychologically influenced. If so she will suddenly start having really forceful UC (uterine contractions) and no doubt deliver without need for further intervention. (I would consider this to be Divine intervention or the answer to fervent prayers!) If nothing untoward happens, pitocin pellet or Q-tip diluted 1/2 and 1/2 with water should be instituted, replaced every 15 minutes. After the first round (i.e. finish the first amp or about 1 1/2 hours), pitocin full strength can be utilized as it has been established that the mother is NOT pitocin sensitive. However, this method should not be depended upon to culminate second stage with a big baby or wimpy mom as one cannot count on the continuation of sufficiently forceful UC to avoid problems with the shoulders or bleeding postpartum.