Third stage management in the US?

[OzMW]

Hi all

I'm a nurse midwife in Australia. Am keen to hear from you all about how third stages are managed in your unit. We in Oz do the UK thing and give the oxytocic with the birth of the anterior shoulder, then when there is a uterine contraction and or signs of separation do CCT. We read alot of stuff here about different methods in the US. What is the general process?

Thanks in advance

[californianclextaker]

At my facility, we start running 20 units of Pitocin in a Liter of LR after placenta is delivered. Most RN's bolus about 500mls, then slow it down to 125ml/hour. The MD's usually give a "little" traction on the cord to encourgage the placenta to come out and we have the patient push to deliver the placenta. The MD or RN then does some fundal massage to get the uterus to contract.

[NurseNora, BSN, RN]

When the world was young and the ages dark and I was a young nurse, we used to give 10U of Pitocin with the delivery of the head or the anterior shoulder. Then it was decided that straight IV push Pit is a bad thing because of the occasional profound hypotension that can cause (yep, I've seen that too). If we missed giving it with the head, we gave it after the placenta.

At the last place I worked, we put 10 to 20 Units in the IV bottle, depending on how much was left in the bottle, as soon as the placenta is delivered and ran it in pretty much wide open. At my present hospital, we put 10-20 Units in the bottle and run it at 999cc/hr on the pump until recovery starts, then try to keep it running thru out most of the recovery period. If she was induced (30Units in 500 cc), we run that at 200 cc or so an hour as soon as baby delivered.

I've even worked with a few docs who trusted Mother Nature and only gave Pitocin if Mom's bleeding was excessive and the uterus wouldn't stay firm.

[OzMW]

Umm...a dumb question....but does every woman in labour have an IV?

[cassioo, RN]

Umm...a dumb question....but does every woman in labour have an IV?

pretty much because we mostly have inductions or at least augmented it's a cold strange day when somebody comes in on their own and delivers...and heaven forbid if you don't have paperwork to go with it :)

[NurseNora, BSN, RN]

Umm...a dumb question....but does every woman in labour have an IV?

Most do. If we have someone who really wants to not have one, the provider usually wants us to at least put in a saline lock to have immediate IV access in case of emergency. We tend to be over cautious here in the USA.

I did work with one doc when I worked in the large teaching hospital who'd allow his patients to deliver without an IV and even not give Pitocin afterwards unless needed. He and I each liked to demonstrate to the residents that birth really is an experience of health, not disease.

[OzMW]

Wow! How do women manage to birth at all?:smackingf One thing I have learnt in the last 17 years is that so much of what we worry about around labour and birth we cause!!! Thanks for your replies look forward to some more.......

[OzMW]

So tell me when the babe had been born do the docs wait for signs of separation or do they just yank on the cord? Am just trying to get my head around this because our policy of active management is that we don't touch the cord until an oxytocic has been given and has been given time to work! Many a student has been told off for even looking like touching the cord before then. The concern is with uterine inversion.

[cassioo, RN]

Sine we have mostly inductions the pit is already running then after cutting the cord most wait for signs of seperation but will put a little traction on the cord and massage the uterus or do any repairs if needed (most come in less then 10 minutes where I work) then we bolus the pit IV

[FLOBRN]

All these answers are very interesting. I work in central Florida. At our facility, the baby is delivered, we wait for the placenta...no tugging/pulling ect. After the placenta we usually hang 30uPitocin/500mls N/S at 42mU/minute (which works out to 42 mls / hour. Sometimes we don't hang any pit at all, just depends on the Mom and her bleeding. Sometimes we need methergine, hemabate or rectal cytotec. It all depends on the Moms status and what is going on. Why give Pit with the head or the ant shoulder? Are the MD's that impatient?

[OzMW]

Why give Pit with the head or the ant shoulder? Are the MD's that impatient?

In Australia at least it is part of the active management of the third stage....the thought is that it will start to work not long after the baby is birthed. Reality in our place is it pretty much never gets given then as there is usually only two midwives at normal births.