Dr. Stephanie Melka, OB/GYN sits down with Dr. Nathan Fox to dispel myths about Pitocin and labor, how it works, its uses, and why some women opt out.
“Pitocin: Friend or Foe?” – with Dr. Stephanie Melka
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right. Melka, welcome back to the podcast.
Dr. Melka: I know it’s been a hot minute.
Dr. Fox: It’s been a hot minute since we recorded the last one. But, you know, since we’re in the same room at the same time, we gotta do the double header here. And this is a big one, Pitocin, friend or foe?
Dr. Melka: Friend.
Dr. Fox: Friend. Good friend, a good friend. Yeah. In fact, I had been called in residency, Foxytocin in the past and…
Dr. Melka: I came up with that.
Dr. Fox: Yeah. No, it’s a good thing. Also, Dr. Fox, Fox, Fox.
Dr. Melka: One who rocks, rocks, rocks.
Dr. Fox: That’s right. Anyone who’s been in labor with me there knows how that rolls. That’s my Vocera call, like my “Top Gun” call name, you know, Vocera call. All right. So, let’s get into this. As a little bit of background just so people who don’t know what we’re talking about, what is Pitocin?
Dr. Melka: Pitocin is oxytocin, which is a hormone made by the brain that makes the uterus contract.
Dr. Fox: Right. And so, why do we call it Pitocin?
Dr. Melka: That’s the brand name.
Dr. Fox: Exactly. That’s all it is. Pitocin and oxytocin are the exact same thing, except Pitocin is the one made by whatever company makes it or companies make it. And that’s what it’s called on brand. And it is synthetic. It’s made in the laboratory or whatever, a factory, as opposed to extracted. Like, some hormones are extracted from living creatures like humans or animals and given to people, and others are actually reproduced in a lab. So, this is one that’s reproduced. Why is that relevant? Because we were talking about this before.
Dr. Melka: It’s on TikTok or Instagram.
Dr. Fox: Oh, then it must be real. It must be true.
Dr. Melka: There’s a rumor that it comes from pigs, and that it’s not kosher, that certain religious groups would not accept it.
Dr. Fox: Or animals were harmed in the making of it. Yeah. No. Not true. It is made in a factory. It is produced. Now, the natural-occurring oxytocin is made in our brains. And so, that’s sort of when someone goes into labor, it’s one of the changes that happens is that the oxytocin gets secreted from the brain. It acts on the uterus, causes contractions. And so, Pitocin is just a synthetic formula that we might give to someone. Why would we use that? Like, what are the circumstances in which we would give somebody Pitocin?
Dr. Melka: If we need to get them to contract. That’s what it comes down to, basically. And that could be somebody that needs to be induced, meaning we need to start their labor, somebody that needs their labor augmented, that they’re already in labor, but need stronger and more frequent contractions.
Dr. Fox: Right. Yeah, postpartum. Correct.
Dr. Melka: And then after you deliver to help the uterus to contract, help the placenta to expel, and decrease uterine bleeding.
Dr. Fox: It’s really all three, starting labor, sort of like making labor more effective as a second, or after labor, after birth, stopping bleeding. And how is it given? Like, how do we administer it to people?
Dr. Melka: It’s given through an IV. It’s in a solution of IV fluid. And it’s started at a low dose and then increased over time based on the contraction pattern.
Dr. Fox: Right. The only time we give it sort of as a big bolus potentially is after birth, you can give it more rapidly because since there’s no baby inside anymore, you don’t have a problem with the uterus contracting very quickly, very tightly. In fact, that’s what you’re looking for. During labor, you don’t want the uterus to contract very quickly, very tightly and hold on. You want it to sort of go rhythmically. And that’s why you have to sort of we call titrate and sort of fine-tuned to like work up until the right amount, which is very sort of mimicking what would happen naturally for most people in labor. So, that’s the potential reasons we might use it, and won’t get into specifically how we decide whether to use it. But it really gets a bad rap out there.
Dr. Melka: Yes.
Dr. Fox: Why is that? Like, what are the things that we hear? Why does it get a bad rap? Like, what’s going on?
Dr. Melka: It gets linked in people’s minds in the outcome of the delivery gets linked to the Pitocin.
Dr. Fox: In terms of what?
Dr. Melka: I had Pitocin and I had a C-section, or I had Pitocin and I had a hemorrhage, or I want a natural low-intervention birth. I don’t want Pitocin because it’s not natural.
Dr. Fox: Right. That is a true statement. It’s not natural. It is replicating something that’s natural, but it itself, again, is made and it’s administered. So, all right. I get that. You know, it’s one of these things where, you know, you could even find a study that was done. I would say it’s a bad study because it’s, well, could be a good study that is misleading, I would say. Or I said, “All right. I took 1000 women and the 500 who got Pitocin had a higher C-section rate than the 500 who didn’t get Pitocin. Therefore, Pitocin causes C-section.” And that’s just not true, unless you randomly decided who got Pitocin and who didn’t. But if the Pitocin is given because the labor is moving slowly, then, in fact, it’s gonna be the slow labor, or the sort of abnormal labor, protracted labor, you know, a lot of terms we use for that. That’s what led to the C-section. Pitocin is meant to fix that problem, didn’t cause that problem.
That is usually I find the most common mistake that people make that’s out there. They’ll find a study that says, “Oh, look, you know. All these people who got Pitocin had C-sections. And all these people who didn’t, you know, they delivered naturally, vaginally.” And I’ll be like, “Yeah. There was a problem that led them…” You know, it’s like saying that people who had antibiotics are more likely to have pneumonia. Well, like, yeah. You know, it’s almost that. It’s not exactly the same thing because temporarily, it’s different. But it’s a very important distinction to make.
Dr. Melka: People who come in in their own labor that are making change and deliver don’t need Pitocin. They deliver without it. And that gets grouped into the they delivered because they didn’t get Pitocin, you know, and it’s the other way around. Like, they didn’t need it. They had a labor that progressed well.
Dr. Fox: Yeah. And this is, I mean, in statistics, we call this confounding, that it’s not the Pitocin, but Pitocin is sort of like a marker of something else. And it’s actually like this is one of the classic examples I use when I’m teaching the residents about confounding. I’ll say like, “Okay. Let’s say I told you a study showed that 500 women who didn’t get Pitocin all had vaginal deliveries and 500 women who did get Pitocin, more people had C-sections. Would you say that Pitocin causes C-section?” The resident’s like, “No. That doesn’t make any sense.”
And then, you go back to the other study we’re looking at. It’s a little bit more confusing. One of the classic examples, like epidurals, there was a lot of studies that, all right, women who got epidurals had longer labors and had more C-sections. And people said, “Oh, epidurals cause C-sections, it cause long labors.” But no, it’s because they had tougher labors that they asked for an epidural. And when they went back and did the studies where they randomly chose who gets an epidural versus who we wait, there was no difference. And the same is true with Pitocin. You look at studies where there’s like a decision point to be made, and you randomly choose who’s getting Pitocin and who’s not getting Pitocin. The group that gets Pitocin delivers faster and has more vaginal deliveries because you’re speeding up their labor. Now, there could be risk if you don’t give it appropriately, and you could cause a C-section if you gave it inappropriately. But generally speaking, it’s helping you, not hurting you. And that’s a really, really important thing to think about when you sort of see, or read, or hear, or go on TikTok, or wherever the kids are going nowadays and hearing these things about it. Like, why are these doctors using it if it’s such a horrible medication? Well, because it’s not. Like, it’s being mischaracterized. Yeah. Pitocin. It’s bad rap.
You know, Pitocin is a good dude. You know, he or she is wonderful. So, we covered that it’s not from animals. Okay. For whom it matters, it’s not. And we also covered that it does not cause C-sections. It actually would prevent them. That’s why we’re using the Pitocin. And we were talking earlier that it’s really the only cure or treatment we have for this abnormal labor. Again, that’s a concept that’s very complicated with a podcast about it. What does it mean your labor’s too slow and not progressing well? Does it matter? Does it not matter? But if you sort of accept the fact that some labors are not progressing in sort of a typical way or a better way, what are the reasons for that? And what does Pitocin address?
Dr. Melka: Oh, these are the three Ps of labor. I’m so glad we’re talking about this.
Dr. Fox: Going back to med school. Yeah.
Dr. Melka: The three Ps, power, passenger, and pelvis. So, you have the maternal pelvis, the shape and structure of the pelvis. Is there room for a baby to fit through?
Dr. Fox: And that’s fixed.
Dr. Melka: That’s fixed. You have the passenger, which is the baby. Is this an exceptionally big baby? That’s fixed. You can’t change that. What’s the position that the baby’s descending into the pelvis, which maybe can be tweaked a little bit, but not really? And then, power, which are the contractions. So, really, the contractions are the only thing you can fix in labor.
Dr. Fox: Right. And so, again, if someone’s having “an abnormal labor, a slow labor, protracted labor,” we would typically give Pitocin if we thought that a component of that was the contractions aren’t strong enough or aren’t close enough together, meaning if we thought someone had a very small pelvis and a very big baby and they’re booming away, contracting every two minutes, we’re not gonna think that’s the problem. We’re not gonna give Pitocin because we’re like, well, no, they are contracting strongly for two minutes. Sometimes, you don’t know that to be true. And so, you know, there’s different things we do and some people like to check the strength of the contractions. Some people don’t with this internal monitor, whatever. But if we’re pretty convinced that the contractions are normal, regular, proper strength, yeah, we wouldn’t give Pitocin because it’s not needed. Because that’s not the issue.
However, typically, if the labor’s progressing slowly, the contractions typically aren’t strong enough, or aren’t frequent enough, or aren’t lasting long enough, and so, we try to give the Pitocin. Like we said before, in a very methodical way, you give a very small dose, then we sort of know biologically how long you need to wait to see what the effect is. And it’s pretty quickly. It’s like within minutes, and you’ll sort of see. And then, after 20 or 30 minutes, whatever sort of however you do it, if the contractions are not yet where you want them to be, you go up by a little bit.
Dr. Melka: A little bit.
Dr. Fox: Right. And you keep sort of doing that until we feel that the contractions are at the appropriate interval, usually about give or take every three minutes apart, plus minus two to four. Every three minutes apart, they’re lasting well. We think they’re strong, and then, you hold off. You stop. I mean, you keep the Pitocin running as is. And you don’t need to increase it unless the contractions again then sort of space out or whatever it is. Or on the flip side, if now let’s say maybe her natural oxytocin is kicking in and maybe you start seeing the same dose that she’s on, her contractions are now one minute part, you can back off, right? Turn it down. Turn it off. And again, how we exactly manage that depends on the circumstances, but you can definitely change it. And that’s really, really effective. And it does work, and it absolutely lowers a chance of a C-section, a circumstance like that.
Other things we do, you know, if your water isn’t broken, we break your water. It’s another way to stimulate labor maybe without using Pitocin. Sometimes, people are very interested in keeping their water not broken for a long period of time. Probably doesn’t make a huge difference one way or another. But if their labor’s not progressing well, generally, you know, I’d say, “Well, listen, it’s one or the other, you know. We could do both, but if maybe you’d prefer me break your water rather than starting Pitocin…” And, you know, again, it’s one of these things where it has to be individualized. But that’s something that goes on.
I think one of the other things about Pitocin is that if you go on the Google, you know, you find out Pitocin is like, it’s got this designation of a high-alert medication, or a danger medication, or like a red flag, or a I don’t know what image, what icon, or emoji they used to demarcate that. And I don’t disagree, right? Because it can be dangerous, but it’s not dangerous on the face of it, right? Again, it’s natural-occurring thing. It’s like saying adrenaline is dangerous. Well, yeah, if I overdose someone with adrenaline, that’s really bad. But if someone’s having an asthma attack and I need to give them a shot, an EpiPen, that it’s the right thing to do. And so, it’s all about context.
Dr. Melka: And it’s part of why we give Pitocin well-monitored.
Dr. Fox: Yeah, yeah.
Dr. Melka: You know, the risk with it is basically over-contracting the uterus where you would get decreased blood flow through the uterus through the placenta to the baby where you can see drops in a baby’s heart rate. So, you wanna avoid over-contracting the uterus. And Pitocin can over contract, but again, it’s not that Pitocin causes decelerations. And it’s why with inductions or when anyone’s on Pitocin, we need people on the fetal and the contraction monitor. You can’t be on Pitocin walking the hallways with no monitor.
Dr. Fox: Yeah. I mean, Pitocin, when we give it, it’s intravenous. And the way we sort of titrate and do it is so fine is it’s on a pump that tells you exactly. And the doses we’re giving, generally, it’s a very slow infusion. Like, if you’re on a pump and you’re getting intravenous fluids, you’re getting somewhere around, let’s say, 100 to 150 ccs or milliliters per hour, right? That’s how it’s dripped. So, you see, like, it drips at a certain pace, and the pump sort of maintains that. When you’re getting Pitocin, it’s like three, six. Like, a high-dose is like 30.
Dr. Melka: 30.
Dr. Fox: You know, so it’s like, it’s much, much slower. And so, you see little like drip every, you know, 20 seconds or something like that. It’s a very small amount that’s going through. And the pump can do that. And so, you need it to be electronic. It has to be graduated. It’s not just like where you, like, roll the knob and make it a little fast, a little slower. It’s very, very precise with that. And that is for safety reasons. Like you said, if I overdose someone with Pitocin, yeah, that’s true. But if you overdose someone with anything, it can be bad. I mean, it’s true that it has the potential for danger, but it’s not dangerous itself at the right dose at the right time. It’s probably the opposite. And so, that’s really another thing that sort of gets thrown out there a lot to why Pitocin might be dangerous, but it needs to be used judiciously.
And then we sometimes it’s always a thought process of like what to do in labor if someone’s contracting, they’re own Pitocin and there are fetal heart rate decelerations. It kind of depends, right? You know, are they ones that are concerning versus not? How close is she to delivering? If I don’t give the Pitocin, will she automatically not deliver and need a C-section? We put all these variables together to make a decision. Do I stop the Pitocin, continue the Pitocin, decrease the Pitocin? And obviously if there’s a situation where we think it’s inducing harm, we’re gonna shut it off. But sometimes, it’s sort of, like, well, either she’s laboring or she’s not, and we have to sort of decide that similar to if she were in labor on her own. And this is why we have a job. This is sort of what we do.
But I can’t imagine practicing obstetrics without Pitocin. I mean, people do. I mean, if you’re doing a home birth, typically, Pitocin is not on the table. Okay. Meaning it can be done without it, but there’s a potential downside and transfer to hospital. Okay, fine. I’m not talking smack about the [inaudible 00:15:22]. God bless. I’m just saying it’s something that, you know, way we practice, it’s part of the tools that we have to help people deliver safely vaginally in a way that’s good for the mother and baby. Now, after birth, right, like we said, totally different, right? When people are like “opposed to Pitocin,” that’s like generally more of a labor discussion. And so, how do you sort of explain that to people in the sense that it’s something that even if you don’t want it in labor, like, let’s have a different conversation about afterbirth?
Dr. Melka: It’s one of the things that there’s good data behind. You know, giving Pitocin either before or at delivery of placenta decreases postpartum bleeding and hemorrhage.
Dr. Fox: Yeah. It’s a good thing.
Dr. Melka: Yes.
Dr. Fox: Yeah. We do it routinely in our practice, in our hospital, pretty common in this country and around the world. Sometimes, there’s other medications used based on availability. Sometimes, you know, people use other things. But typically, giving something seems to be helpful. It’s not done everywhere. And you can certainly deliver without it and not have a hemorrhage. But it does lower the risk significantly. And it’s been studied whether you get it or not, does not affect whether you’re gonna be able to nurse or not. It does not affect your bonding with the baby. Like, it doesn’t have any effect on those outcomes that people are very, you know, concerned about or interested in. So, that’s good because, again, it’s the naturally-occurring hormone just given at a different dose. So, yes, I think overall, we conclude Pitocin as our friend.
Dr. Melka: Yes.
Dr. Fox: And I think it’s if you’re listening to this podcast, and again, you haven’t had a baby, not having a baby, or had all your babies, great, you know, doesn’t really apply to you. That’s cool. But if you’re pregnant or thinking of becoming pregnant or gonna labor, it’s something be very cautious when you look online and hear it. And I would really, if you have any concerns or questions about Pitocin or any other agent being used to maybe stimulate contractions or whatever, talk to your doctor or midwife. Like, ask them why. They’ll know. Like, this is something that is like one of the first things you learn in labor management is how to do it, how to do it safely, when to give it, when to stop it, dosing. Like, it’s something that we are very familiar with. And it’s not something that is just being used because somebody’s impatient or because somebody’s sloppy or because someone wants to induce danger or harm. Like, it’s part of a normal healthy delivery for someone who’s delivering in a hospital and a lot of birth centers too. It’s a very common thing. Melka.
Dr. Melka: Great.
Dr. Fox: Thanks for coming on. All good. There was Foxytocin. There was Britocin.
Dr. Melka: Britocin. You called her Britocin. That’s how I came up with Foxytocin.
Dr. Fox: Oh…
Dr. Melka: I think that was the first thing I did as an intern that impressed you, maybe the only thing I did as an intern that impressed you.
Dr. Fox: Yeah. That’s probably true. Yeah. No, changing my Vocera was very impressive because I still don’t know how to change it back.
Dr. Melka: No, I was like an attending then.
Dr. Fox: I don’t know.
Dr. Melka: I wouldn’t have done that as a resident. That was a bold move.
Dr. Fox: Those years are all a blur to me. So, I don’t know. I changed yours.
Dr. Melka: You did.
Dr. Fox: And you changed it back.
Dr. Melka: I did.
Dr. Fox: Right. You had Melka, Melka, Melka, how can I help you, help you, help you, which was the name of our first podcast together. And then I changed it to Melka Magnesia, which is a good one.
Dr. Melka: Yes. I was made to change Melka, Melka, Melka, can I help you, help you, help you because I was shamed at [inaudible 00:18:32] that it was inappropriate.
Dr. Fox: Inappropriate?
Dr. Melka: Made to change it in that moment. I’ll tell you off microphone who did that.
Dr. Fox: Can you imagine if someone…
Dr. Melka: Noelle Strong was very sad because she did that. That was like one of the first Vocera name changes that she started. And then, we changed it to just Melka. And then, you changed it to Melka Magnesia. And then, that brought It back.
Dr. Fox: Melka Magnesia is a good one. Can you imagine if someone three years before, you know, the whole “Top Gun” thing said to Iceman, “That’s an inappropriate name. That’s not cool?” You know, you’re just gonna be like, whatever his name was, Steve, I don’t, you know.
Dr. Melka: That was part of it, the call sign.
Dr. Fox: Yeah. It’s part of who you are. It’s part of the character. Yeah. You’re not gonna be Maverick. You know, you’re gonna be Joe. I mean, it’s terrible.
Dr. Melka: Lauren.
Dr. Fox: Yeah. All right. Thanks for listening, everyone.
Dr. Melka: Thank you.
Dr. Fox: Good luck. Thanks, Melka. Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day. The information discussed in “Healthful Woman” is intended for educational uses only, and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.