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"Pit to Distress" 2: Why We Are All Distressed

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I had a feeling when Jill wrote about the practice of using Pitocin to hyperstimulate a fetus to the point of distress that people would be as interested as she was to hear about it. With nearly 11,500 hits in two and a half days on the post here on the Unnecesarean, it is obvious that people were indeed interested. The subject went viral, much in the way that posting the actual charges filed by Catherine Skol’s lawsuit against her obstetrician did last December. The reason? Callousness and lack of concern for the wellbeing of mothers and babies are always shocking.

I’ve been reading all of the new discussion on public message boards and blogs in the past three days and here is my paraphrased summary of the reactions I’ve encountered:



That is ridiculous and anyone who does that should lose their license!



That makes me sick.



I am worried about my upcoming hospital birth.


Fear and lack of trust in patients

Telling patients about this might make them refuse necessary Pitocin and then they will be in danger.



This is heartbreaking and disappointing.



I’ve never seen it; therefore, it doesn’t happen.



There is no way this could happen because they would lose their license.



I have trouble believing this because I know my doctor has my best interest at heart and all of my cesareans were medically necessary.



All doctors are evil.


Personal reflection

This really makes me wonder about my births.



This is great information to have so I can watch for it in my clients’ births.



Thank you for posting this to remind women to ask questions of their care providers!


This reminds me of some PETA propaganda.

This will come as a disappointment to many of you, but I will not be going nude for patient advocacy or cesarean awareness any time soon.



The beauty of blogging and social media for sharing information is the discussion. Watching the previously minimally documented term “Pit to distress” go viral and elicit discussion from pregnant women, parents, midwives, doulas, activists, nurses and patient advocates has held me captivated for days.

What are a woman’s odds of encountering this practice? I don’t know. One nurse wrote that she had not experienced it but had heard the term used differently. Other labor and delivery nurses said that they have absolutely heard the Pit to distress order and have had to defend against it. A commenter on the original Unnecesarean post said that she will be forever grateful to her nurse who—whoops!—had a little accident with the Pit and let the tube drip onto the floor instead of into her.


On May 12, 2009, an article was published in Medscape Medical News entitled “ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates.” Elizabeth A. Platz, MD, presented the findings of a study she conducted on cesareans, liability and defensive medicine at an ACOG Clinical Meeting.

Total cesarean and primary cesarean rates are currently as high as 30% of total births in the United States, up from 4.5% in 1965. In 2003, 76% of all American obstetricians reported at least 1 litigation event, with a median award of $2.3 million for medical negligence in childbirth. A common accusation is failure to perform cesarean in a timely manner, and concern has been voiced that obstetricians as a result are turning to cesarean delivery at any sign of complication.

According to the findings that Dr. Platz presented here at the ACOG 57th Annual Clinical Meeting, that fear is well founded.

In discussing the increase in total and primary cesarean delivery rates, Dr. Platz began by noting that it remains poorly understood.


Dr. Kurt Barnhart applauds the abstract and offers his opinion on liability and cesareans:

Commenting on the results to Medscape Ob/Gyn & Women’s Health was Kurt L. Barnhart, MD, MSCE, member of ACOG’s Committee on Scientific Program. Dr. Barnhart is director of women’s health research at the University of Pennsylvania in Bryn Mawr, and served as director, with Janice L. Bacon, MD, of the Papers on Clinical and Basic Investigation.

“First of all, I applaud the abstract, that it quantifies a perceived problem,” Dr. Barnhart said. “We all anticipated that defensive medicine might be a reaction to litigation, and this paper demonstrates that that is indeed the case,” Dr. Barnhart said.

“What one does about it is a little bit more difficult. But with objective evidence … that fear of liability is causing C-sections, we can address the problem by reducing liability, thereby reducing C-sections,” Dr. Barnhart explained. “So instead of just telling physicians not to do C-sections, this identifies [the need] to remove the risk, and then they’ll do fewer C-sections.

“So don’t just blame the doctor for doing a C-section, recognize that there’s probably a reason that [he or she is] doing it. And that fear of litigation is the reason,” Dr. Barnhart concluded.


With a national cesarean rate of 31.8 percent and many hospitals around the country reporting a fifty percent rate or higher of cesarean surgery, how exactly are they achieving buy-in from these patients? How many of these doctors are telling women on their first prenatal visit, “I am terribly afraid you will sue me if anything goes wrong at your birth, so I’m going ask that you do me the favor of agreeing to a cesarean now because I need to hold up the illusion that I exhausted every means necessary to protect your baby?”

Answer: Probably zero.


Maintaining a 70 percent cesarean rate like Kendall Regional Medical Center in Miami-Dade County, Florida, requires a high level of deceit. Are these women being told that the reason they are submitting to cesareans is because their doctor is afraid of being sued? No. They are being told that they are not a good candidate for vaginal delivery because they have had a previous cesarean, are too old, too overweight, their baby is “measuring large,” too risky, their baby is breech, they are pregnant with multiples, and on and on.

There is nothing defensive about defensive medicine when it comes to the patient. Defensive medicine is aggressive and dangerous. When a doctor starts practicing defensive medicine, he or she by default stops caring for their patient in favor of caring for their own self-interest. And who suffers?

The patient.


The viral nature of publicizing the term “Pit to distress” comes from wanting to collectively put our finger on what it is that is amiss at hospital births. Knowing that it has a name is sobering. The mere thought that doctors, perhaps so terrified of being sued, are deliberately and consciously creating the need for an unnecessary and iatrogenic cesarean during labor is shocking.

When thinking about what it would take to maintain c-section rates of forty percent, fifty percent, sixty percent and higher, it becomes apparent that not all women can be corralled into elective primary or repeat cesareans. There must, therefore, be some mechanism for creating the necessity or at least the illusion of necessity DURING birth to be able to whisk a woman off to the OR without being questioned for their deceit. On the contrary, they will be applauded for saving the baby in what amounts to a Munchausen by Proxy relationship between doctor and fetus.

One of those mechanisms is Pit to distress.

From a patient advocacy standpoint, there are many things women can do to protect themselves from Pit to distress, including questioning their care providers early in pregnancy about their philosophy on birth, their cesarean and induction rates, childbirth education classes, hiring a doula, writing a birth plan, avoiding the IV, staying mobile, these tips from Nursing Birth and more. There is still something wrong with this picture.

Jill from Keyboard Revolutionary wrote a few posts this week as the outrage over Pit to distress rippled outward on the Internet. In her post, It’s Gone Viral, she discussed victim blaming and the care she received from midwives.

On blaming the victim:

I often hear this in response to women who relate their tales of hospital birth trauma. “You can always say no. You should have said no.” YOU SHOULDN’T HAVE TO. If you are in the “care” of someone that you need to threaten with lawsuits in order to make them listen, you need to take a step back and do some serious reevaluating.

On midwifery and what every woman deserves:

I felt like I mattered. Like my baby and I were special, and important. And we were. EVERY mother and baby is. Every woman deserves that attentive, intuitive, loving care, not to feel like they have to assemble an army to protect themselves from the very person they’re paying thousands of dollars to deliver their baby.


Childbirth should not be a fight.




Other discussions on Pit to distress are summarized in these posts:

“Pit to Distress”: A Disturbing Reality (Nursing Birth)

“Pit to Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions (Nursing Birth)

“Pit to distress” around the birth blogs (Public Health Doula)

Crank it up (Stand and Deliver)

Crank it up, part 2 (Stand and Deliver)

“No doctor” (Reality Rounds)


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Reader Comments (36)

This is an amazing follow up to the original post. Thank you for all of the information that you share.

July 10, 2009 | Unregistered CommenterAmy

Well said, WELL SAID!!

July 10, 2009 | Unregistered CommenterAnastasia

A big thank you to you and all the other bloggers who covered this. It was so fascinating to see the story organically unfold and the different facets emerge. Great analysis all around.

July 10, 2009 | Unregistered CommenterAmy Romano

Great article. I will say though not every midwife is worth the time either, just like there are great OB/GYNs and bad one's there are also great midwives and bad ones. People find it hard to believe that my section was forced upon me by a midwife! When I still wouldn't consent she went to the dr in the office who then told my husband if I didn't consent something bad would happen to me or the baby! Of course he wanted me to consent. I still questioned the surgery up until they had already cut me open - low and behold the baby that wasn't supposed to fit in the birth canal had already descended and the dr had to literally pull her out of the birth canal! If they had let me go (they took me almost two weeks early, I didn't know enough to run and besides the dr and midwife had come HIGHLY recommended - who was I to question) another two weeks I possibly would have gone into labor on my own - depsite the midwife and dr telling me that I would never go into labor and my pelvis was too small too fit a big baby through (they told me she would be 10lbs, she was only 8lbs 2oz). Recovery physically was fine, but I requested early discharge because my stay was horrible (terrible comments from the dr, the midwife never visited me again - even though she had participated in the surgery) emotionally I was a wreck, I realized to late I had been robbed!

July 10, 2009 | Unregistered CommenterSarah

Great post! Thanks!

July 10, 2009 | Unregistered CommenterDiana

Thanks for the follow up post! I have loved reading all about this all over the blogsphere. It's amazing how all the views differ.

One of the commenters on my blog referred to this practice as 'birth rape'. I was intrigued to hear it put as such, but it makes sense. It is the final straw to take the rights away from the women and place them totally in with her caregiver. You can say no all day, but since he is doing 'the right thing for the baby' you don't want to complain.

great post again!

Jill said:

Hi Kayce,

First of all, your blog has vanished from my feedreader. I thought you were taking a break from blogging. I've missed so much.

There are loads of birth rape apologists who deny that medical treatment could ever be considered assault. The assumption is that for a woman to experience feeling assaulted during childbirth, it is clearly because she is a survivor of previous abuse that she is projecting onto the doctor or midwife. The conclusion-- care provider is innocent and woman is crazy.

If you want to read more, I recommend this article by Amity Reed written last year. It was met simultaneously with applause and some of the most vitriolic criticism I've ever read.

July 10, 2009 | Unregistered CommenterKayce

Nicely put...I especially like how you started with the feelings of responses relating to this. I find the denial particuarly hard to deal with because it just leads to more blind trust. Keep it up!

July 10, 2009 | Unregistered Commenterbriome

Another awesome post on this. You rock!

"There is nothing defensive about defensive medicine when it comes to the patient. Defensive medicine is aggressive and dangerous. When a doctor starts practicing defensive medicine, he or she by default stops caring for their patient in favor of caring for their own self-interest. And who suffers?

The patient."

You nailed it, as usual. Thank you for this!

July 10, 2009 | Unregistered CommenterJill

Thank you for saying this. Sometimes I get the feeling that when we talk about birth as "empowering" at least half of that empowerment is about fighting that fight, as opposed to the actual physical and emotional experience of giving birth. (Even if it's just to choose and defend a birth attendant and birth place that will reduce the need for more fights later.) For all that I want people to avoid situations where they will need to fight and positively reinforce the few that are able to, it's easy to get caught in celebrating individual acts of resistance to the bigger system that 98% of women deliver in.

I once worked with a woman who had multiple very traumatic (premature) birth experiences. She so badly wanted this one to be unmedicated, peaceful, positive. She experienced some medical complications that made this challenging but what really made it traumatic (at least to observe as a doula) was the treatment the medical staff showed her during this time - constantly being questioned, demeaned, and insulted. As if she didn't care about her baby, as if she didn't understand what an infant loss was when she'd already had one! I couldn't, and still can't, get over the attitude the staff had towards her, when some compassion and caring would have gone a long way towards making an already-stressful experience better. A birth like that reminds me that if we have to celebrate victories (like the delivery room football story that's been around recently, and which I loved) it just means that there's still something to beat, and there are many more defeats than victories.

I don't think my ideal world, in which everyone gets the highest quality care possible all the time, can exist because the medical system is run by humans. We are all fallible. Patient self-advocacy will always be necessary. But it should be a lot more unnecessary than it is now, and it should be met with much greater compassion and acceptance.

July 10, 2009 | Unregistered CommenterRebecca

Great post Jill. I agree with Rebecca. It seems like too much onus is put on the patient to argue their own plan of care. Yet I am conflicted because sometimes the patient's desires can truly cause harm. This whole issue makes me think about what it means (as a nurse anyway) to be a true patient advocate. What are the ethical, moral, and legal implications of this.
Sigh...I planned on posting about exotic cats this weekend (my husband sent me a link about them to include on my blog. He apparently has no idea what my blog is about). Now I feel the need to investigate patient advocacy. Thanks a lot.

July 10, 2009 | Unregistered CommenterReality Rounds
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