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Rejecting the Preemptive Use of Intervention as a Matter of Public Policy

FROM Identifying the Essential Qualities of Maternity Care   -- Evidence-based policies and a plan for action                                                                                     Faith Gibson, LM, CPM   August 31, 2010

The highest level of scrutiny, skepticism, and scientific proof must be applied to the preemptive use of medical protocols that disrupt the normal biology of childbearing or interfere with other normal biological function. At a national policy level, we must also reject maternity department routines that apply a protocol or medical treatment to the majority of its mothers or babies based on a minor risk factor or theoretical advantage, including a perceived advantage to the institution to protect itself against litigation or increase the profitability of its services.  


PIT-TO-DISTRESS: An example of these dubious practices can be seen in a protocol known as “Pit-to-distress”. In this instance, the patient’s physician has ordered the L&D nursing staff to administer the drug “Pitocin” intravenous to induce or augment the woman’s labor. Then the nurse in charge of the patient is directed by the patient’s doctor or required by obstetrical unit's protocols to incrementally increase the rate  of the IV Pitocin until the mother either delivers vaginally, her uterus ruptures or the unborn baby goes into fetal distress and has to be delivered by emergency C-section. This Pit-to-distress protocol is applied without the fully informed consent of the mother or other family members. Whatever perceived benefits to maternity departments or individual obstetricians are irrelevant -- 'Pit-to-distress' is not and never could be an ethical practice.

In 2006 the Wall Street Journal reported on these questionable practices and other "common practices in the delivery room ... endangering both mothers and infants". The article described efforts by some hospitals to reduce the liability-insurance premiums for their obstetrics units. These attempts were meant to curtail the excessive use of Pitocin and other labor inducing drugs to start or speed up contractions because they "can lead to ruptures of the uterus, fetal distress and even death of the infant". An assistant vice president of one institution described the problem by saying: "Pitocin is used like candy in the OB world, and that's one of the reasons for medical and legal risk ... in many hospitals it is common practice to "pit to distress".


Of the top six contributors to obstetrical litigation, the number one reason is the "inappropriate use of labor-inducing drug". In addition to the human cost, the WSJ's review of medical-malpractice claims showed that the use of Pitocin was involved in more than 50 percent of situations leading to birth trauma. After the Intermountain Healthcare instituted a program to reduce elective inductions and prohibit practices such as 'Pit to distress', they reported a sharp drop in birth complications that cut costs by $500,000 annually. [New practices reduce childbirth risk; Wall Street Journal July 12, 2006; Laura Landro]



INAPPROPRIATE UNTIL PROVEN OTHERWISE: More than 70% of all childbearing women are healthy and their full-term pregnancies are normal, a statistic that should be inversely related to the ratio of interventions. This is not rocket science. In fact, the math is simple – only a small proportion of mothers and babies are high risk or have complications, therefore, only a small number of maternity patients should be subjected to interventions and in all cases, a clear indication should be demonstrated. Any institutional policy that applies ‘special circumstance’ protocols to a high percentage of mothers or babies is inappropriate until proven otherwise



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