Policy here states that pitocin can be opened for a bolus at MD order after delivery of placenta. The thought being that if it is opened too soon the cervix could close and the placenta would have to be removed by D&C.
New theory is making it's way around, some MD's/CNM's are now asking us to open it up as soon as the second shoulder is delivered. Apparently in Europe and elsewhere in the world it is opened after the shoulder in order to help the placenta come off the wall.
Any thoughts or articles would be greatly appreciated.
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).
Policy here states that pitocin can be opened for a bolus at MD order after delivery of placenta. The thought being that if it is opened too soon the cervix could close and the placenta would have to be removed by D&C.
New theory is making it's way around, some MD's/CNM's are now asking us to open it up as soon as the second shoulder is delivered. Apparently in Europe and elsewhere in the world it is opened after the shoulder in order to help the placenta come off the wall.
Any thoughts or articles would be greatly appreciated.
This is what I always did in Canada too (after delivery of the shoulder) if they had pit in the IV. I was surprised that hospitals in the US waited as long as they did.
Patients without IVs were given IM pit (also with delivery of the shoulders) if the doc wanted and patient consented. Some moms did that, some didn't.
Not an L&D nurse, but I gave birth 4 months ago and it ended with PPH after delivery of the placenta. From what i understand, it took close to an hour for them to stop the bleeding and it was pretty severe. I don't remember that much of it, I was losing consciousness. I had both pitocin and an epidural for over 12 hrs. My MD was a 'family practice' physician, and I am wondering if it wasn't caused by mismanagement of either pitocin or the epidural - all the MD told me was that it was uterine atony and 'it just happens sometimes.' EBL was 1000cc. He actually told me PPH is common but I find that hard to believe. I don't know that much about L&D, just the basics learned in nsg school. I would like to know more about what caused it - I know medical advice cant be given but I would be interested to know any nurses experiences and/or opinions on PPH. At my PP visit, I asked about it and he acted like it was no big deal, but from what my husband said, the nurses were pretty worried while it was happening.
Not an L&D nurse, but I gave birth 4 months ago and it ended with PPH after delivery of the placenta. From what i understand, it took close to an hour for them to stop the bleeding and it was pretty severe. I don't remember that much of it, I was losing consciousness. I had both pitocin and an epidural for over 12 hrs. My MD was a 'family practice' physician, and I am wondering if it wasn't caused by mismanagement of either pitocin or the epidural - all the MD told me was that it was uterine atony and 'it just happens sometimes.' EBL was 1000cc. He actually told me PPH is common but I find that hard to believe. I don't know that much about L&D, just the basics learned in nsg school. I would like to know more about what caused it - I know medical advice cant be given but I would be interested to know any nurses experiences and/or opinions on PPH. At my PP visit, I asked about it and he acted like it was no big deal, but from what my husband said, the nurses were pretty worried while it was happening.
That is a really long time to bleed. Did you end up having a transfusion? I imagine your hgb must have been pretty low. Your doc is right and wrong. It's not that common but Uterine atony "just happens" sometimes. There are usually precluding factors. Think of something that either stretches the uterus beyond capacity (multiple gestation), or something that tires the uterus out (high dose Pit, grand multipara, closely spaced pregnancies).
Our protocol for PPH is Pitocin IV or IM (if no IV), then Methergine or Hemabate, then Cytotec rectally if still uncontrolled. I had a Mom of seven the other day with uterine atony. It resolved quickly with a bolus of Pitocin IV and IM Methergine.
In my unit (Im a student midwife) women usually only have IV cannulas inserted if they're had an epidural sited, if they're recieving IV Syntocinon (which I guess is our version of Pitocin), or if they have a known high risk factor, so thats probably about 20% of women in the unit. Despite having whats mostly a very low intervention labour most women choose to have an actively managed 3rd stage. This would mean that as the anterior shoulder is delivered they would recieve an IM injection of 10iu of Syntocinon (even if they have Synto running via IV) followed by controlled cord traction to deliver the placenta. Also, should women been of a high parity, have a low Hb or a history of PPH they will recieve IV Synto along with the IM Synto (these woman are the ones with known high risk factors that I mentioned earler so would usually have a cannula in situ).
Some women but not many choose a physiological 3rd stage so no Synto and no CCT, placenta is delivered by maternal effort only. Midwives seem nervous of physiological 3rd stages as they're still pretty unusual, certainly where I work.
I always think its a bit of a shame when a woman has had a nice natural birth, no interventions, no doctors, no medication to then follow that up with a managed 3rd stage but thats the way it seems to be in a lot of cases.
We give 500 LR with 30 units of Pit infusing to gravity as soon as the placenta is delivered. Most of our docs have standing orders and expect the RN to start free-flowing Pit as soon as we hear them say "placenta is out".
Protocol is to give a total of 2 bags of 500ml LR with 30 units of pit. If bleeding is okay by that time, we are usually allowed to d/c the IV. As most others have mentioned, IVs are the standard of care for all patients. I think I've only heard of one come in recently with a birth plan that stated that she wanted a "help lock". Which is hilarious in its own right.... if you're gonna request it, at least learn to spell it. But I digress...
We give 500 LR with 30 units of Pit infusing to gravity as soon as the placenta is delivered. Most of our docs have standing orders and expect the RN to start free-flowing Pit as soon as we hear them say "placenta is out".
Protocol is to give a total of 2 bags of 500ml LR with 30 units of pit.
That's alot f Pit. We use 10 units in a 500 cc bag, and generally only bolus one after delivery, if that. I imagine they must have some helatious cramps with that much Pit.
And to lisamct, you say most women choose to have an actively managed third stage. Are they really choosing that or is that just pretty routine and they accept it? What I mean is, many of our docs routinely give Pit after delivery and most women have no idea of it ahead of time, so they don't think to ask whether they should have it or not. It is just a few that come in asking for no Pit after delivery.
In my unit (Im a student midwife) women usually only have IV cannulas inserted This would mean that as the anterior shoulder is delivered they would recieve an IM injection of 10iu of Syntocinon (even if they have Synto running via IV) followed by controlled cord traction to deliver the placenta. Also, should women been of a high parity, have a low Hb or a history of PPH they will recieve IV Synto along with the IM Synto (these woman are the ones with known high risk factors that I mentioned earler so would usually have a cannula in situ).
Some women but not many choose a physiological 3rd stage so no Synto and no CCT, placenta is delivered by maternal effort only. Midwives seem nervous of physiological 3rd stages as they're still pretty unusual, certainly where I work.
You have forgot to mention that after the injection of syntometrin/ syntocion which ever you give in your unit you then wait for signs of separation of the placenta which is very important- we give our clients the chioice .......
And to lisamct, you say most women choose to have an actively managed third stage. Are they really choosing that or is that just pretty routine and they accept it? What I mean is, many of our docs routinely give Pit after delivery and most women have no idea of it ahead of time, so they don't think to ask whether they should have it or not. It is just a few that come in asking for no Pit after delivery.
Your right, to most women an actively managed 3rd stage is more of 'routine' than an actual choice that women make in most cases. IMO my unit is particularly bad at offering choice to women in 3rd stage, so far in that it actually classes use of 3rd stage Syntocinon as 'normal'. It would only pass over into the 'abnormal' if IV Synto was used also.
Informed choice is a big issue here as Im sure it is everywhere but choice in 3rd stage management seems to be lagging far behind where I work. As a student I spend a lot of time alone with women during their labour and we discuss issues such as pain relief and 3rd stage. Most of the women have never even heard that they have options in how they manage 3rd stage and expect to get "the wee injection in your leg that helps the placenta come out". Ive offered women info on their options but often find that any info Ive given is over-ridden by qualified midwives horror stories of extreme PPH's.
Just to illustrate the point, during my last placement I supported a women who explained from the start that, if possible, she wanted a Physiological 3rd stage. We took over her care after both the senior midwife and SHO had failed to convince her that it was a bad idea (we werent present at these discussions but from the womens description they were less than supportive of her choice!) My mentor explained that this was the 1st physiological 3rd stage she had been witness to in the 8 years she's worked in our unit. After both baby and placenta were delivered she did bleed, enough that my mentor felt it necessary to administer IM Synto (she had explained beforehand that this situation might occur) but, I wonder if it was more her inexpereince of physiological 3rd stages that led to her panicking about blood loss that was actually normal for the situation.
'Belinda-wales' your right I did forget to mention waiting for signs of seperation. 3rd stage management, in particular CCT, is one of my main stressors I guess im just as twitchy writting about it as I am doing it!!
And I second meghan - PR cytotec works great. No IV needed.
What dose of cytotec do you administer rectally?
100% of our moms have IV's. In fact, even when we get a precip, starting an IV is at the top of our list along with EFM, prenatal history and SVE. We always administer 10units of pit IVP, or if there's a bag of LR hanging with 10units pit when turn it up after delivery of the placenta. Sometimes if the OB/GYN thinks mom is going to bleed (i.e. PPH history) then he'll have us administer the pit after the shoulders are delivered. It is amazing how fast the placenta comes out after that.
I would love to get away from our 100% IV rate, especially for the mom's (like me) who long for a "natural delivery". But working at a small private hospital with 20 births per month, it is unlikely to be an easy change.
I had a precipitous birth with my second baby. There was no way anyone had time to get an IV in me. Not really much of a priority when the baby's half out, in my opinion... :roll
beckinben, CNM
189 Posts
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).