Syntocinin for 3rd stage?

[Janie]

I have not done alot of research on this yet, but I am looking into refusing the syntocin to expel the placenta. I would rather immediately BF to encourage 3rd stage.

One question that keeps at me is WHY is it NOT a good thing to have it?

Just to clarify, I am not questioning anyone's decision to have or not to have, I simply want to be better informed. And there seems to be a few ladies around here who know what they're on about in regards to this topic

[visitor1]

I had it and the placenta was out within 3 minutes. But i also had some other needle not long after because i started loosing alot of blood.

Im unsure if its a good or bad thing. I had it and i guess i didnt mind.

[BellyBelly]

sezjm,

Here's Dr Sarah Buckley's article HERE, which is well referenced. She is well regarded in the industry and knows her stuff.

Its just another one of those things they do 'just in case' to fasten things up, which is annoying when not every woman is going to haemorrage. Gees, did every woman have a haemorrhage way back when?! Its so unfair that they do this, usually without informed permission.

[visitor1]

Ill agree there Kelly, i was never asked if i wanted it... but was just jabbed.

[BellyBelly]

I was too Kim, despite a drug-free, healthy normal birth. They get you before you know it. So I am miffed as I would have liked a natural birth.

[Janie]

Thanks for the article Kelly, very informative! Will sit down and make proper notes on it, but just had quick read through.

[BellyBelly]

Here's the main bit:

Synthetic oxytocin, which mimics the effects of natural oxytocin on the uterus, was first marketed in the 1950’s, and has largely replaced ergometrine, although a combination drug, called syntometrine, is still used, especially for severe haemorrhage. Syntocinon causes an increase in the strength of contractions, whereas ergometrine causes a large, ‘tonic’ contraction, which also increases the chance of trapping the placenta. Ergometrine also interferes with the process of placental separation, increasing the chance of partial separation. (Sorbe 1978)

Recently active management has been proclaimed “the routine management of choice for women expecting a single baby by vaginal delivery in a maternity hospital" (Prendville 1999), mostly because of the results of the recent Hinchingbrooke trial, comparing active versus “expectant" (physiological) management.

In this trial (Rogers 1998), which involved only women at low risk of bleeding, active management was associated with a post partum hemorrhage (blood loss greater than 500ml) rate of 6.8%, compared with 16.5% for expectant (non-active) management. Rates of severe PPH (loss > 1000ml) were low in both groups- 1.7% active and 2.6% expectant.

The authors note further that, from these figures ten women would need to receive active management to prevent one PPH. They add “Some women … may rate a small personal risk of PPH of little importance compared with intervention in an otherwise straightforward labour, whereas others may wish to take all measures to reduce the risk of PPH."

Reading this paper, one must wonder how it is that almost 1 in 6 women bled after “physiological" management, and whether one or more components of western obstetric practices might not be actually increasing the rate of haemorrhage.

Botha (1968) attended over 26 000 Bantu women over 10 years, and reports that “a retained placenta was seldom seen…blood transfusion for postpartum haemorrhage was never necessary." Bantu women deliver both baby and placenta while squatting, and the cord is not attended to until the placenta delivers itself by gravity.

There is some evidence that the practice of clamping the cord, which is not practiced by indigenous cultures, contributes to both PPH and retained placenta by trapping extra blood (around 100ml, as described above) within the placenta. This increases placental bulk, which the uterus cannot contract efficiently against, and which is more difficult to expel. (Walsh 1968)

Other western practices that may contribute to PPH include the use of oxytocin for induction and augmentation (speeding up labour) (Brinsden 1978, McKenzie 1979), episiotomy or perineal trauma, forceps delivery, caesarean and previous caesarean (because of placental problems- see Hemminki 1996).

Gilbert (1987) notes that PPH rates in her UK hospital more than doubled from 5% in 1969-70 to 11% in 1983-5, and concludes “The changes in labour ward practice over the last 20 years have resulted in the re-emergence of PPH as a significant problem." In particular, she links an increased risk of bleeding with induction using oxytocin, forceps delivery, long first and second stages (but not prolonged pushing) and the use of epidurals, which increase the chance of forceps and of a long second stage.

As noted, western practices do not facilitate the production of a mother’s own oxytocin, neither is attention paid to reducing adrenaline levels in the minutes after birth, both of which are physiologically likely to improve uterine contractions and therefore reduce haemorrhage.

Clamping the cord, especially at an early stage, may also cause the extra blood trapped within the placenta to be forced back through the placenta into the mothers blood supply with the third stage contractions. (Doolittle 1966, Lapido 1971) This “feto-maternal transfusion" increases the chance of future blood group incompatibility problems, which occur when the current baby’s blood enters the mother’s blood stream, causing an immune reaction which can be reactivated and destroy the baby’s blood cells in a subsequent pregnancy, causing anaemia or even death.

The use of oxytocin, which strengthens contractions, either during labour, or in third stage, has also been linked to an increased risk of feto-maternal hemorrhage and blood group incompatibility problems. (Beer 1969, Weinstein 1971)

The World Health Organisation, in its 1996 publication Care in Normal Birth: a practical guide, argue that “In a healthy population (as is the case in most developed countries), postpartum blood loss up to 1000 ml may be considered as physiological and does not necessitate treatment other than oxytocics" In relation to routine oxytocics and controlled cord traction, WHO cautions that “Recommendation of such a policy would imply that the benefits of such management would offset and even exceed the risks, including potentially rare but serious risks that might become manifest in the future"

[Fi]

I was asked if I was ready for it after Hamish, and the other midwife said, nope, she's not having it. Oh - OK, thats fine was the answer.
3rd stage was very slow, peaceful, no problems at all. It was about 25mins I think, but it didn't seem that long at the time.
My placenta came out no worries at all.

[Trish]

Kelly, this is what we went through today at my SIL's birth centre visit. All she got was scare tatics and she was told that The World Health Organisation recommended the syntocin injection !! Tell me that's not true. I did a big whinge post about it too.

I so wish I had that article with me today. Might tell SIL to have it printed out to take along with her for her next visit.

[Janie]

Trish, I have been thinking about this for awhile, but it was actually your post that prompted me to ask this question!

[Trish]

Glad to be of service hun

[BellyBelly]

Sorry Trish I meant to reply to your post too - I really doubt it but will get a confirmation for you

[Trish]

Thanks Kel.

[BellyBelly]

I saw this on the WHO website:

ACTIVE MANAGEMENT OF THE THIRD STAGE

Active management of the third stage (active delivery of the placenta) helps prevent postpartum haemorrhage. Active management of the third stage of labour includes:

* immediate oxytocin;
* controlled cord traction; and
* uterine massage.

Oxytocin

* Within 1 minute of delivery of the baby, palpate the abdomen to rule out the presence of an additional baby(s) and give oxytocin 10 units IM.

* Oxytocin is preferred because it is effective 2 to 3 minutes after injection, has minimal side effects and can be used in all women. If oxytocin is not available, give ergometrine 0.2 mg IM or prostaglandins. Make sure there is no additional baby(s) before giving these medications.

Do not give ergometrine to women with pre-eclampsia, eclampsia or high blood pressure because it increases the risk of convulsions and cerebrovascular accidents.

And this:

5.1 Background

In this stage of labour placental separation and expulsion take place; for the mother the main risks are haemorrhage during or after separation of the placenta, and retention of the placenta. Postpartum haemorrhage is one of the main causes of maternal mortality; the large majority of these cases occur in developing countries (Kwast 1991). The incidence of postpartum haemorrhage and retention of the placenta is increased if predisposing factors are present, such as multiple pregnancy or polyhydramnios, and complicated labour: augmentation of labour, obstructed labour, or vaginal operative delivery (Gilbert et al 1987). Postpartum haemorrhage and placental retention also occur more frequently if these complications were present in the obstetric history of the woman (Doran et al 1955, Hall et al 1987, WHO 1989). To a certain extent therefore it is possible to select during pregnancy and in the course of labour those women with an increased risk of complications in the third stage. But even in low-risk pregnancies and after an uneventful first and second stage of labour serious haemorrhage and/or placental retention may sometimes occur. The management of the third stage may influence the incidence of these complications, and the amount of blood lost. Several measures aiming at the prevention of complications have been proposed, have been tested in randomized trials and are discussed below.

5.2 Prophylactic use of Oxytocics

Oxytocics may be given prophylactically at various moments during the third stage. Most often they are administered intramuscularly immediately with the delivery of the anterior shoulder, or after delivery of the infant. The drugs usually given, and investigated in trials, are oxytocin and ergot derivatives like ergometrine, or a combination of the two, syntometrine (Daley 1951, McGinty 1956, Friedman 1957, Newton et al 1961, Howard et al 1964, Hacker and Biggs 1979, Rooney et al 1985, Prendiville et al 1988, Thornton et al 1988, Begley 1990). Both oxytocin and ergot derivatives decrease the estimated postpartum blood loss, but the effect of ergot seems to be somewhat less than the effect of oxytocin. The effect on retention of the placenta is not yet quite clear, although there are some data suggesting that routine oxytocics may increase the risk of retained placenta.

Complications of oxytocics are nausea, vomiting, headache and hypertension postpartum. These complications occur more often with ergot derivatives. Moreover, rare but serious maternal morbidity has been associated with oxytocics, especially with ergometrine: cardiac arrest and intracerebral haemorrhage, myocardial infarction, postpartum eclampsia and pulmonary oedema. Because these events are so rare, randomized trials cannot give useful information about the extent to which they may be attributed to oxytocics. The available evidence suggests that oxytocin is a better choice than ergot derivatives. Moreover, in tropical countries oxytocin is more stable than ergometrine or methylergometrine (Hogerzeil et al 1992, 1994).

Because in many developing countries the administration of oral tablets would be much easier, and the tablets would be more stable than injections under tropical conditions, a randomized study was undertaken to investigate the influence of oral tablets of ergometrine immediately after birth. The outcome was disappointing: compared with a placebo the medication had little demonstrable effect on blood loss after childbirth (De Groot et al 1996).

Seems a bit strange though, I will see what else I can find out.

[BellyBelly]

More:

Postpartum haemorrhage is defined by WHO as blood loss >= 500 ml (WHO 1990). The diagnosis is made by a clinical estimate of blood loss; such an assessment of the amount of blood often causes a significant underestimation. Apparently the definition is influenced by the fact that in large parts of the world 500 ml of blood loss (or even less) is a real threat to the life of many women, mainly because of the high prevalence of severe anaemia. Nevertheless, if meticulously measured, the mean blood loss at vaginal delivery is around 500 ml, and about 5% of women delivering vaginally lose more than 1000 ml of blood (Pritchard et al 1962, Newton 1966, De Leeuw et al 1968, Letsky 1991). In the Bristol trial (Prendiville et al 1988) 18% of the group of women with a physiological management of the third stage had blood loss >= 500 ml, and only 3% lost > 1000 ml.

In a healthy population (as is the case in most developed countries) postpartum blood loss up to 1000 ml may be considered as physiological, and does not necessitate treatment other than oxytocics. However, in many developing countries other standards may be applied. The 500 ml limit as defined by WHO should be considered an alert line; the action line is then reached when vital functions of the woman are endangered. In healthy women this usually only occurs after blood loss >1000 ml. This distinction is crucial in the light of efforts to minimise unnecessary blood transfusion and its associated risks, including HIV infection.

Definite conclusions about the value of active management of the third stage in healthy low-risk populations cannot yet be drawn. The term "active management" is used for a combination of various interventions with different effects and side-effects. All trials of expectant versus active management were carried out in centres where active management was the normal practice. A trial is needed in a setting where both expectant and active management are normal procedures. The occurrence of serious but rare complications (cardiac complications, eclampsia, inversion of the uterus, etc.) cannot be studied in randomized trials, but might nevertheless be of major importance if and when active management is recommended for large populations. Serious doubts are justified about the routine prophylactic use of ergometrine or a combination of oxytocin and ergometrine, and also about controlled cord traction as a routine procedure.

In conclusion, oxytocin administration immediately after delivery of the anterior shoulder, or after delivery of the infant, seems advantageous, especially in women with increased risk of postpartum haemorrhage or in women endangered by even a small amount of blood loss, for instance women with severe anaemia. Doubts remain about the combination with controlled cord traction, and about the routine application in healthy low-risk women. Recommendation of such a policy would imply that the benefits of this management would offset and even exceed the risks, including potentially rare but serious risks that might become manifest in the future. In our opinion it is too early to recommend this form of active management of the third stage for all normal low-risk deliveries, although we note the earlier recommendations made by WHO (1990, 1994c). If for various reasons active management is employed, a number of questions remain unresolved, particularly regarding the optimal timing of prophylactic oxytocin injections.

I would still choose to wait to see if I was experiencing a bleed before having it.

[Trish]

Well thats what we were thinking/saying. Just because she had in her plan that she didn't want to have it. Of course if things weren't going well and she was having a bleed she would have it.

That's why it is called a birth plan, Not a damn script !!

[BellyBelly]

Its so important to have good birth support for those reasons, someone who can advocate for you, in times of vulnerability or fogginess.

[Trish]

Now Kel can you please go and say that in my thread so SIL will read it