Pitocin Orders Should Match Hospital's Protocol


SAN FRANCISCO — Before you write an order for Pitocin administration to induce or augment labor, be sure you know your hospital's protocol for Pitocin use, Dennis J. Sinclitico, J.D., advised.

In the three most recent obstetrical malpractice cases in which he served as a defense attorney, the physicians gave nurses orders for Pitocin (oxytocin) that contradicted the hospital protocol for Pitocin use, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

That contradiction forces nurses to make decisions about the utilization, titration, and discontinuation of Pitocin “without the comfort and background of their own protocol,” he noted. Often there is no further physician involvement besides orders to “call me when you're ready” for delivery.

Basically abandoning nurses with contradictory orders is “a terrible mistake and indefensible in many instances,” said Mr. Sinclitico, a defense lawyer in Long Beach, Calif.

If you want to leave orders for Pitocin use that differ from the hospital's protocol, document why you think your approach to management is important and appropriate. Give the nurses written instructions documenting that your orders differ from the protocol and tell them how and when to adjust, titrate, or discontinue the Pitocin dosage. Provide written instructions on how and when the nurses should contact you.

Pitocin is a player in virtually every case he defends, even if it's not a relevant factor, Mr. Sinclitico noted. “I can't remember a case recently in which Pitocin wasn't ordered in some fashion,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

The biggest problem he sees in the cases he defends that involve Pitocin administration stem from insufficient response to findings on the fetal heart rate monitoring strip. Fifteen, 20, or 60 minutes go by before nurses or physicians respond to a potential problem identified by the strip, and the health care workers leave insufficient documentation about the course of events, their timing, and reasons for acting or not acting.

“If I have a practice tip for you, it would be to go back to your hospital and emphasize the notion that if you're going to allow nurses to make those judgments, they should be made appropriately and in a timely fashion,” he said.

Because individual responses to Pitocin differ, the dose must be monitored carefully and adjusted as needed. Used properly, Pitocin can prevent the need for cesarean section in some deliveries. Risks from the force of contractions induced by Pitocin include potentially greater reductions in uterine blood flow than occur with natural contractions, which can lead to a greater reduction in oxygen for the fetus and possible fetal distress.

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