When do you open up your Pitocin?

Try this - http://www.emedicine.com/med/topic3569.htm

Or google "active management of third stage"

The evidence is pretty good that turning on the pit after the anterior shoulder, clamping the cord early, and doing cord traction significantly decreases the risk/severity of PPH, with no increased risk of retained placenta or need for manual removal.

Becki

We open it after delivery of the placenta at physician request. Some docs and midwives do not use it. And as not all of our pts get IV's.......

How can you determine the need for Pitocin after delivery, before they deliver? Yet, another just in case standard of care.....

The evidence is pretty good that turning on the pit after the anterior shoulder, clamping the cord early, and doing cord traction significantly decreases the risk/severity of PPH, with no increased risk of retained placenta or need for manual removal.

Becki

Just want to clarify: Are you advocating traction on the cord as a means of decreasing risk of PPH?

Isn't traction on the cord always contra-indicated because of the risk of cord rupture?

The evidence is pretty good that turning on the pit after the anterior shoulder, clamping the cord early, and doing cord traction significantly decreases the risk/severity of PPH, with no increased risk of retained placenta or need for manual removal.

Scary.

How about we let the cord stop pulsating, and let the placenta comes when it's darn good and ready? Golly, I must work in a low intervention unit.

You know, the only retained placentas and manual removals I've seen were caused by impatient docs who were a little too agressive with their cord traction.

Scary.

How about we let the cord stop pulsating, and let the placenta comes when it's darn good and ready? Golly, I must work in a low intervention unit.

You know, the only retained placentas and manual removals I've seen were caused by impatient docs who were a little too agressive with their cord traction.

I was thinking the same thing. I am only a nursing student so I thought I must be way off base. It just seems like there is no need to rush something that is going just fine. "Fix it til it's broke" seems to be the order of the day in some areas of obstetrics.

Scary.

How about we let the cord stop pulsating, and let the placenta comes when it's darn good and ready? Golly, I must work in a low intervention unit.

You know, the only retained placentas and manual removals I've seen were caused by impatient docs who were a little too agressive with their cord traction.

We had a pt wheeled into OR for manual extraction after 20 minutes. (!) But not before the doc went all the way inside trying to remove it causing the poor woman to scream like hell.

After we prepped her all, the placenta popped right out on its own 40 minutes after birth of baby.

Everyone of our deliveries gets an IV--part of the routine orders for even observation almost. For the induction patients, they get Cervidil to posterior fornix x 24 hrs, then remove. Wait one hour, then start pitocin drip at 2 mu/hr titrated with LR to total rate of 125 cc/hr. Increase pitocin every 30 min by 2 mu/hr based on FHR, ctx pattern etc. Some drs stray from the main formula i.e. starts a pretty good contraction pattern on their own.

Once they are delivered (meaning placenta delivered) a bolus of 500 cc LR+20 units pitocin started -- then every delivery gets a total of 2 liters LR+20 pitocin after delivery, then d/c if bleeding stable. Even cesarean sections get 2 bags of LR with pitocin, starting after placenta delivery in OR.

However, I have often pondered--couldn't there be a simpler way sometimes? I mean, women have been having babies since the beginning of time. I mean, I know maybe the standards of care are somewhat better now. I just think in some instances things could be left to go a little more "natural". It almost seems like the "specialness" of having a baby, one of the most wonderous events that happen in healthcare, has been made more and more "routine". The individual circumstances of each patient and their delivery is not taken into context sometimes. Some of it is impatience of Dr...however, I have seen some nurses who just wanted to "get it out".

I believe, and try very hard to practice, that every birth, no matter who or how old they are, is special. I try to take the time to explain to patients what we are doing, why, and get their input on things. Sometimes this is not possible, i.e. emergency situation, but a lot of the times it is easily done. Sometimes something as simple as putting a patient on the bedpan or keeping them clean and dry while they are stuck in the bed can make things better. I especially try to remember this on my Magnesium Sulfate patients. I was on Mag for 3 before delivery, thru 2 cervidils and 12 hrs of Pitocin induction, and then, for 2 days postpartum...so I know what it feels like to just have someone take the time to help me get washed up. I remember those two nurses who helped me get washed up early one morning more fondly than anyone else from my stay. I want people to remember me that way.

LOL....I think I got off topic some oops

However, I have often pondered--couldn't there be a simpler way sometimes? I mean, women have been having babies since the beginning of time. I mean, I know maybe the standards of care are somewhat better now. I just think in some instances things could be left to go a little more "natural". It almost seems like the "specialness" of having a baby, one of the most wonderous events that happen in healthcare, has been made more and more "routine". The individual circumstances of each patient and their delivery is not taken into context sometimes.

You're right. There is a simpler way. Hopefully, someday, more hospitals can get back to that. Reading other's comments, I realize we are bit different from the norm. I am glad I work in a lower intervention unit. We do have the patients who get every intervention ever invented, but we also get to experience the births with next to no intervention...IV's, external monitor, a delivery bed......

Just want to clarify: Are you advocating traction on the cord as a means of decreasing risk of PPH?

Isn't traction on the cord always contra-indicated because of the risk of cord rupture?

OK, so to clarify - the OP asked about pit before the placenta. I stated what the current theory is on active management. In the trial that this theory is based on (which was done in the UK, like the active management of labor trials), women were randomized to either active management of the third stage or physiologic management. Active management includes pit started after the anterior shoulder, immediate cord clamping, and cord traction to deliver the placenta. Physiologic management included not giving pit prophylactically, not clamping the cord until the placenta delivered, no cord traction or fundal massage, and early breastfeeding. You can see the results in the article I linked to earlier, but the overall rate of PPH was decreased in the active management group from almost 18% to almost 6%.

*I* personally am not advocating this, I don't do it. I was just trying to give the OP the information they were looking for. I wait for the placenta, standing there with my hands to myself, and then do pit IF I think it is needed. Mostly it isn't, and most of the really bad PPHs I've seen have been from cervical lacs, which pit won't really help with anyway.

Becki

but the overall rate of PPH was decreased in the active management group from almost 18% to almost 6%.

I'm surprised it's that high anyway. It doesn't seem like we see it that often. I understand what you meant, Becki.

I just hate to see new studies that recommend even more intervention.

You're right. There is a simpler way. Hopefully, someday, more hospitals can get back to that. Reading other's comments, I realize we are bit different from the norm. I am glad I work in a lower intervention unit. We do have the patients who get every intervention ever invented, but we also get to experience the births with next to no intervention...IV's, external monitor, a delivery bed......

About half of our patients have IVs. Of that, maybe half of them have pit. We don't open up the pit, because most of the time there isn't any to open. PPH is treated most of the time with rectal misoprostol, which works, IME, better and faster than pit. But honestly, we don't see much PPH. So what's up with all this prophylactic pit use anyway?

I'm surprised it's that high anyway. It doesn't seem like we see it that often. I understand what you meant, Becki.

I just hate to see new studies that recommend even more intervention.

Thanks. I don't see PPH that often, either. That's just what this particular study found. And it's not new - the original Bristol study came out in 1988, with several subsequent studies finding similar results. Now how active management of labor affects these rates, I haven't seen addressed. I think if these researchers or these institutions have high rates of active management of labor with high-dose pit, then they shouldn't be suprised to see higher rates of PPH. And then they're obligated to find some way to solve the problem they created - right? So, voila - the active management of the third stage of labor. And my understanding is that labor is managed more actively in the UK, where the original studies for both active management of labor and active management of the third stage are from. Maybe if we stopped trying so hard to "manage" labor...

And I second meghan - PR cytotec works great. No IV needed.

Oh, and I should correct something I said earlier - I don't usually just stand around and wait for the placenta. Usually I'm talking to the baby (and the mom).