The Use of Pitocin in Labor & Delivery and your Birth Plan

By: Aunt Doula (11/08/2022)

- # Introduction to Pitocin - what is it and what is it used for?

Pitocin has numerous roles and uses in the course of labor and delivery and this post will cover the primary three – Induction, Augmentation and Postpartum Hemorrhage Control. If you have not read the post on the first stage of induction regarding cervical changes, please read it here. In some cases of an induction and augmentation, the cervix has already reached a favorable state and may not require those methods and Pitocin will begin after admission and intake exams/testing which you can read about in the general overview of an induction here. In the case of labor augmentation - a labor that has started naturally and stalled – Pitocin may be administered to try and jump-start the labor back into a productive rhythm.

Pitocin is the brand name of a synthetic (lab made) analog of the hormone oxytocin. It is important first and foremost to understand that Pitocin is not bio-identical to naturally made and released oxytocin in the human body. Pitocin does not cross the blood-brain barrier and therefore it does not produce the psychological benefits of good feelings, connection, or love and Pitocin also does not offer any pain-relieving aspects that naturally released oxytocin provides. So, what *does* Pitocin do? It causes contractions - very well. Sometimes too well, but we will talk about that shortly. Pitocin binds to the receptors on your uterus that respond to the naturally produced oxytocin and your uterus responds often quickly with gusto and with strong contractions that mimic labor contractions.

This leads to the second thing that is important to understand about Pitocin - it is often administered continuously, infused into your veins via your IV. Naturally produced oxytocin is released during labor in carefully orchestrated pulses that create the characteristic waves of contractions that build up over time, building in frequency, intensity and length. Oxytocin is a slowly warming fire that is carefully built and tended, meant to create a controlled flame that can have logs added to increase its heat. Pitocin is akin to pouring lighter fluid onto a campfire that was barely roasting marshmallows - explosive and extreme reactions may be likely to occur!

Pitocin induced contractions along with natural or induced cervical changes all work very hard to convince the pregnant body that it is time to have the baby, sometimes quickly and easily, and sometimes with mixed results. For labor augmentation Pitocin is often more successful because the body has already made it quite a ways into labor and the pregnant body and baby are just having a hiccup which Pitocin can often rectify. The uterus has already budded its receptors and to continue with our campfire analogy, it still have smoldering coals that are much easier to re-start the fire with.

Labor readiness on the part of the pregnant body and the baby play a significant role in the success of labor induction. In natural spontaneous labor, the orchestrated interplay and carefully coordinated cascade of hormones for labor to begin is still not fully understood to modern science. There are thought to be dozens of chemical and hormonal signals and communications that happen to allow labor to begin, maintain, and complete successfully. In a labor induction, we administer just three hormone analogs along with possibly some mechanical pressures, to crudely attempt to convince the pregnant body that it shouldn't wait for those numerous signals and go ahead with a process that it isn't always prepared to cooperate or cope with. The hope being that the pregnant body will jump on board and start to believe it is in labor - again with some quick results and some mixed results.

- # Administration and your Choices

At the time of this writing in 2022 the typical standard administration of Pitocin regardless of the three common reasons is intravenous aka via IV. It is possible, though more rarely performed in the US, to have muscular injections of Pitocin. While it is extremely unlikely that you would receive Pitocin as a muscular injection, if you will be giving birth in a rural hospital you may encounter this - ask your provider or facility if this might apply to you at an appointment near your due date.

Just before the writing of this post there was a significant Pitocin shortage in the United States that impacted many planned inductions. While it was resolved reasonably quickly, Pitocin had to be rationed to protect supply for its third use, management of postpartum hemorrhage, until supplies were replaced in enough quantity that use for all scenarios could be ensured.

When Pitocin is used for planned labor induction it is often standard to infuse it continuously - meaning that it is given without any breaks into your blood at a specific dosage trying to stimulate the uterus to contract. The primary issue with this administration being that the strength and frequency of the contractions can become too strong for some bodies, and it can become very overwhelming very quickly - the lighter fluid onto the campfire. The contractions that can come back-to-back and be painfully overwhelming aren’t just a problem for the laboring person, they can also be extremely hard on the baby. Just as the laboring person's body is only designed to take so many contractions so often, so is the baby. Fetal distress is now often called “non-reassuring signs of labor tolerance” and this can lead quickly to the cascade of interventions swooping in and a too-much-too-soon approach that leads to more interventions instead of addressing the cause of the distress itself, the Pitocin. If the Pitocin is causing distress in the baby, the Pitocin administration rate and dosage should be the first change that is considered. You can request to turn down the Pitocin, change to a pulsed infusion, or turn off the Pitocin entirely and take a break from the induction (especially if it was elective.) A baby that is not ready to come out and/or a uterus that is not ready to let that baby out are going to tell you in strong and emphatic ways that now is not the time – and you are allowed to listen to that! Until your amniotic sac breaks, and if you and your baby are stable, it is worth a discussion with your provider if stopping the induction and trying again anywhere from a few hours to a few days later is in your best interest. A delivery room is not and should not feel like a prison cell – this is your birth, own it and understand your options.

One of the ways to combat this risk of fetal distress and out-of-control contractions is to request that the infusion is pulsed instead of continuous in order to let the body adjust to the Pitocin and ease into the contractions. The other option that is sometimes used is to begin the infusions at a lower dosage to ease into the transition as well. It is possible that a facility can do one or the other of these alternatives, so be sure to list these on your birth plan as things you are interested in trying *before* a continuous infusion. The choice to try these before a continuous infusion has no substantial risks to your labor progress in general compared to a continuous infusion at the start. However, one of the primary risks to starting with a continuous full-dose Pitocin infusion is that your uterus can become desensitized to the drug over the course of labor and you will need adjustments to increase the dosage significantly to complete the vaginal birth. This is a problem if you have any issues with a postpartum hemorrhage during the third stage when your placenta is delivered as your uterus may be too over exposed to Pitocin to respond (read about third stage management here.) If this occurs, stronger drugs may need to be needed to control your bleeding that have more side effects such as ergometrine and come with their own set of risks. Educating yourself about your options for your induction and the use of Pitocin in moderation to protect yourself from the cascade of interventions is the ultimate goal of this post (read about labor induction and the cascade of interventions here.)

- # Pitocin and the Increased Need for Epidural Pain Relief

Labor in and of itself is often considered to be one of the most painful things a person can go through in their lives - and Pitocin contractions are no exception. Pitocin contractions may even be objectively more painful because of how they push the uterus beyond its volitional limits. Volitional limits of muscles in our bodies are what stop us from harming ourselves on a daily basis, stop us from lifting something too heavy, for example. The human body is capable of doing more than it allows us to and in extreme situations due to our 'fight or flight' mechanism, we are allowed to override the limits to save ourselves from a perceived danger so we can fight or run. When we stand and fight or turn to run away, the rush of adrenaline allows our body to push past the limits and explains how people have been storied to lift otherwise impossibly heavy objects to save a life. Pitocin acts as an override by working directly on the uterine muscle, which is one of the strongest in our bodies, and it directly overrides the uterine muscle’s volitional control that during spontaneous labor it would otherwise not do. Pitocin overrides the uterus and its orchestration with the body and brain that during spontaneous labor keeps the uterus from contracting too fast, too hard, or too often - this is the primary issue with Pitocin and as described above may be reduced through pulsed or low-dose administration.

Even when administered in low dose or a pulsed manner, the override of volitional limits along with the fact that Pitocin cannot provide pain relief means the need for artificial strong pain control is required. In spontaneous labor, the brain produces and releases oxytocin and beta-endorphins which are the primary pain-relieving hormones of labor. These hormones build up alongside the waves of contractions and keep pace to maintain adequate pain relief during the entire labor, and without them during an induction, it is often necessary for a large portion of induced laborers to request an epidural to endure the unmitigated pain being caused. Epidurals are another modern obstetrical gift that without, many inductions would be insufferably painful, which is not how labor pain is intended or what anyone deserves or should be expected to endure.

Needing in epidural in an induced labor is in no way diminishing of positive birth experience, and when pain becomes so intense to reach a point of suffering, it is no longer labor pain, it is simply torturous. The pneumonic for how labor pains should be is aptly P.A.I.N.N - if at any point in your labor your pain doesn't mean these criteria, seeking pain relief such as an epidural is not only understandable, but also recommended. Labor pain at a baseline can be conceptualized as:

P - Purposeful - Labor pain is intended to direct the laboring person on how to move to help the baby descend into the pelvis, shift sway and adapt to the pain being experienced as a way for the baby and body to communicate without words. Labor pains should be purpose driven, guiding towards the goal of bringing baby down and out to be born.

A - Anticipated - Labor pain is anticipated, and we try our best to be prepared. Perhaps sometimes too prepared, and we over-anticipate how much it may hurt to give birth, but hopefully with this orienting description of the purposes of labor pain it will help you to anticipate and understand the pain of labor instead of anticipating it with fear. When we know what the purpose of labor pains are, the anticipations can be preparatory instead of fearful or dreaded.

I - Intermittent - Labor pain, especially spontaneous labor, is designed to give breaks between contractions for the majority of labor. This is to support the building up of oxytocin and beta-endorphin releases in concert with the contraction's intensity, frequency and length to maintain pain control.

N - Normal - Pain in labor is normal. It is one of the only examples of pain not being a sign that something is wrong with our body. We are raised on the premise that pain is a signal to stop, assess damage, figure out what's *wrong* that's causing pain - in labor, the pain is purposeful as above, it is telling us how to move and adjust to bring a baby into the world. If it's saying anything is wrong, it's saying that we aren't in the correct position to help baby find their way down and out, so we feel discomfort and pain to encourage us to move and shift and adjust in order to connect to our body and again, communicate without words. Lying in bed on our backs is the absolute opposite of allowing the body and baby to work together to bring baby into the world, and yet it is now standard to birth in an anatomically unhelpful, physically painful, and gravity resisting position. Even with an epidural, you have more choices than your back and your sides which will be covered in another post and linked here when completed.

N - Natural - Labor pain is natural, designed to be a way to communicate with your baby to work together to bring them into the world. Accepting the purpose of labor pain, anticipating it without fear, remembering that it is intermittent, understanding that it is normal and natural are the five pieces of truly working with labor instead of against it.

- # Recap

Your choices on your birth plan for an induction are how the Pitocin is infused through continuous means of low-dose or full dose, or if it is infused in pulses to mimic a more natural exposure like that of spontaneous labor. Though it has become rarer, it may be possible to receive Pitocin as a muscular injection so be sure to ask which options your facility provides and put your choices on your birth plan.

When choosing your third stage management choice you don't necessarily have to mention the acceptance or denial of Pitocin, but as you will read on the post here it is best to list each portion of what you do and do not want even if you state you want active or expectant management so that your team knows you wishes and are given the opportunity to ask questions, not make assumptions.

An example of how your birth plan choices could be listed include:

- Labor Induction or Augmentation - Use of Pitocin - Generally Approved - Please Start at Low-Dosage or Infuse in Pulsed Doses Before Continuous Administration

- Third Stage Management - Expectant Management Requested - Please Do NOT administer Pitocin Prophylactically - Please Do NOT Use Cord Traction - Please Allow Spontaneous Delivery of Placenta - Please Teach and Allow Self Fundal Massages - Please Do NOT limit Placenta Delivery to 30 Minutes

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Whether you are having a planned induction, require labor augmentation, or are given Pitocin in the third stage management of placenta delivery, it is important that you understand why you are being given the drug, its limitations and its risks. Pitocin is used every day and is relatively safe, this post is not to convince you to refuse Pitocin or refuse induction - it is to give you the understanding to empower you in your birthing journey so you know when to speak up and perhaps most importantly that you *can* speak up if Pitocin is causing you or the baby distress. There is no prize for suffering - and Pitocin despite the goal of bringing your baby into this world being a wonderful obstetric tool, it is notorious for causing unnecessary suffering for laboring women, especially if you aren't sure what's supposed to be normal.

Pitocin is the current standard of inducing active labor contractions and there is not an alternative that is considered as safe or productive, so at the time of this writing it is the only drug you are likely to be offered to induce your labor contractions. Your choices of how the Pitocin is given and your choices of when to speak up are important parts of an empowered birth on your terms. Please don’t hesitate to ask questions below or contact me directly.