A recent New York Times article highlighted this Cochrane Collaboration review about the
use of Pitocin in labor.

The review looked at eight randomized controlled studies including a total of 1,338 low-risk women experiencing spontaneous labor at term (parity was not defined) with an eye toward analyzing the use of Pitocin early, late or not at all during labor. Analyzed results included how long labor lasted, following implementation of synthetic oxytocin, and whether or not the rate of Caesarean section or instrumental delivery was decreased. Here are the author's conclusions from the review:

For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernible difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.'

I take issue with the statement, 'there were no detectable adverse effects for mother or baby.' Perhaps a more appropriate statement would be, 'we recorded no adverse effects for mother or baby.' In fact, we know that Pitocin does have detectable adverse effects on both mother and baby. We know from various studies* over the years that excessive use of Pitocin during labor sets a woman up for immediate postpartum uterine atony - with sometimes unacceptable amounts of blood loss in accompaniment. This study published in the journal Reproduction, explains why. (In short, long-term infusion of synthetic oxytocin creates a diminishing effect in available uterine receptor sites to the point that, following expulsion of the fetus - enter, Third Stage - the uterus can no longer respond to the presence of oxytocin - natural or synthetic - by contracting and, therefore, decreasing immediate postpartum blood loss.)

Not only this, but we do see negative effects on the fetus from all of that uterine hyperstiumlation that goes on during an induced or augmented labor. With an induction or augmentation of labor, the sudden hard, fast squeezing effect of Pitocin-created uterine contractions diminishes the baby's placental oxygen supply more often and for longer periods of time and, guess what: concerning fetal heart rate patterns and decreased oxygen saturation result.

And what about the woman's experience of her labor and birth? Yes, I understand that hard-core medicos discount the importance of the experience, touting the 'healthy mother, healthy baby' card, but for the woman merging from experiencing and coping with pain, to suffering from pain...it matters a great deal.**

Despite this evidence, common obstetrical practice is to force women through labor sooner, faster and with little regard for the woman's experience. From the New York Times article:

We need better ways of managing slow progress in labor,' said Dr. George J. Bugg, the lead author and an obstetrician at Nottingham University Hospitals. 'It's a real problem, and the method we've relied on for so many years doesn't actually work.'

Slow? Who gets to define whether or not a labor is 'slow?' By now, most of us understand that the Friedman curve is an inappropriate and unrealistic measure of labor progress. And, in the absence of any particular indication that the length of labor is becoming dangerous to mother and/or fetus, is it even fair to introduce the S word into the equation, at all?

Concerning to me is that, rather than accepting the guidance that the Cochrane Review offers - that use of Pitocin for augmenting labor does not sufficiently speed a woman toward a vaginal birth - thereby decreasing rates of Caesarean section or instrumental delivery (the supposed justification for using this method of labor management, in many cases) - Dr. Bugg forges on, stubbornly desiring to find a different method of forcing a woman through labor, rather than admitting that perhaps labor and birth aren't processes that are meant to be forced.

Yes, there are times when an extremely slow labor - an obstructed labor that could potentially lead to fistula formation, or death of mother or baby warrants medical intervention to move things along. In these scenarios: by all means, speed things up. But, statistically speaking, this is not even close to being the norm (particularly in developed nations).

As with so many instances, we have an opportunity to learn here: if using Pitocin to augment a 'slow' labor increases the mother's discomfort, creates a more difficult and potentially dangerous womb environment for the fetus, and increases a woman's chances of experiencing an early postpartum hemorrhage, shouldn't we limit the use of this medication to the instances in which it is life-saving versus a matter of convenience? Shouldn't we prescribe patience as often as we prescribe pharmacological agents - perhaps even more often?

Posted by: Kimmelin Hull, PA, LCCE

*accessing this article, printed in the Journal of Midwifery & Women's Health 2008 (53, 5 pp461-466), will lead you to an excellent bibliography at the end of the article with numerous references to studies on this topic

**Thank you, Penny Simkin, for providing us an excellent delineation between these two

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