Tips offered on avoiding 'the second stage from hell': labor induction.(Obstetrics)

MAUI, HAWAII -- Physiologic logic and a basic principle of pharmacology can help clinicians avoid "the second stage from hell" after inducing labor, Lisa A. Miller said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

One of the primary tenets of pharmacology is to use the lowest amount of a drug to achieve a desired effect. The medical literature supports a variety of protocols for using Pitocin to induce labor, with starting doses ranging from 0.5-6 [mu]g and 15- to 40-minute intervals between dose increases. Although there is no significant difference in birth outcomes within those ranges, higher doses and more frequent dose increases make hyperstimulation more likely, said Ms. Miller, a certified nurse midwife and president of Perinatal Risk Management and Education Services, Chicago.

For that reason, she suggested starting with a dose of Pitocin in the lower range and using less frequent dose increases. "'Once you flood the receptors, they're flooded, so this approach may be better" to avoid hyperstimulation, said Ms. Miller, who also is a lawyer.

In the second stage of labor an endogenous surge in oxytocin kicks in, which can lead to hyperstimulation if the dosage of Pitocin is not weaned. "Once you've been in a good labor pattern for an hour or two you can wean the drug in many cases. But this is not what I'm seeing when I go out and teach in hospitals throughout the U.S.," she said at the meeting, sponsored by Boston University and the Center for Human Genetics.

Injudicious initiation of Pitocin during the transition between the active and second stages of labor commonly leads to "the second stage from hell," with contractions by the minute and deeper variable ...