managed or physiological third stage? (history of bad medicine reactions)

[ardenbird]

I don't see very much discussion about the third stage of labour -- but I understand there is the choice to have a managed (they inject you with something? what??) third stage or a physiological one.

I'm concerned about an injection, as I have a history of severe/strange reactions to medications. I already know that my pain relief options are going to be extremely limited, as I've never had a systemic analgesic or anesthetic that didn't make me ill (somepethidine, for examplevery severely). I've had bizarre (usually painful or nauseating or both) reactions to all sorts of medications, from birth control pills to dyes injected to visualise my gall bladder. So, I'm worried about saying "yes" to an injection which might not be needed. But it seems to be the recommended option and also they say reduces blood loss?

Does anyone have any experience with this, and particularly anyone who tends to get sick from medications?

I have had 3 natural 3rd stages.
the injection to deliver the placenta is (I think) the same stuff as they use to increase contractions or induce labour (syntocinon? It is definitely optional, just say to your MW you'd rather not have it, I've never felt any pressure to have it and it took ages to deliver the placenta at my 2nd birth

Good luck with TENS and try the pool for pain relief if you're avoiding medication, I love the birth pool :)

I had my first baby 2 days ago and asked for a natural 3rd stage in my birth plan - midwives happy to oblige. I don't have any history of problems with medication but wanted to use the birth pool (which I did) and have as natural a labour as possible. I was worried about the short time frame to deliver the placenta if I had the injection (before the cervix closes) and also wanted to be able to enjoy bonding time in the pool.

I was very lucky and it all worked out well, although the midwife seemed to get a little concerned I hadn't delivered the placenta after 40 mins and asked me to get out of the pool - fine gravity helped, and it came out 5 mins later.

I have had no problems with blood loss at the time or since the birth.

I had natural third stage with both of mine. Also let the cord finish pulsating before cutting it, so that the baby got all the blood and nutrients from the placenta. Can't remember any problems with it, didn't seem to take too long.

If you've had reactions, you shoul speak to MW and put it in your notes just in case.

You don't know - you might need it if something went wrong (sorry to be a doomsayer but it's got to be considered).

I wanted a natural third stage with DS but was losing blood so they injected me.

With DD I couldn't be bothered to wait any longer for a natural third stage (waited for an hour and had bf DD but still no joy), so had the jab. I didn't like it - some said you don't notice it, but I bloody well did. It hurt! And yes I'd just given birth but it still bloody killed

I've had some similar reactions to you, so my notes specified no pethidine.
In the end the anaesthetist grilled me for 45 min about what exactly happened when I took pethidene and various other drugs, concluded I should never take pethidine again but the epidural should be OK - which it was - wonderful for the next 25 hours! - but did vomit 3x in theatre after ventouse birth, and then had diarrhoea, possibly as I'd ended up on max dose of syntocin to get stuff to happen after 35 hours of labour.

I'd said I wanted a natural third stage unless good reason not to - in the circs I got a huge jab in my thigh just after birth and the chap apologised saying "sorry about that - don't worry but we just needed to stop the haemmorhaging", which I figure was a good reason!

I've decided I'm ok taking the same again but my birth plan this time warns I may puke and thanks to SPD will need help sitting up to do so!

Thanks for the stories. I looked up some about the drugs it said some people may get dizzy or nauseated or even vomit...when it says something like that, almost invariably I am one, so I guess I can expect that if I need it. I'll plan on physiological, but of course if they need it for excessive bleeding or whatever I'll go with it vomiting is better than massive blood loss!

notcitrus, you sound like me. I had pethidine for a colonoscopy, and they told me as they released me several hours later to remember the drug and never, ever take it again. I lost about 3 hrs of time, which I apparently spent vomiting to dehydration. I only remember the very end, where it had slowed down a bit. I was so ill for the next three days I could barely get out of bed. I figure that certainly isn't the type of experience I want for birth or the first few days of my baby's life. I've been trying to figure out exactly what is in epidurals, but it does look like it's something I'd be okay with -- local anaesthetics have never bothered me, and that seems to be what they are. But with SPD, I'd prefer to avoid one if I can. hah! to the needing help to sit to vomit :)

The evidence that a physiological 3rd stage reduces blood loss is very patchy and equally balanced with evidence that says it doesn't. (a little more blood at the time, but less bleeding during the six weeks post-birth.

natural 3rd stage with inexperienced midwives who pull on the cord however, DOES increase blood loss.

Injection brings the risk of a retained placenta as the cervix can close before it comes out. In these circumstances the mws do have to pull on the cord.

if you decide on a natural third stage you can always change your mind and have the injection at any point.

Starlight, congrats on your new pregnancy , I can't quote any off the top of my head but there is evidence that women are more likely to have a post partum haemorrhage and end up needing blood transfusions if they have physiological third stages(and I think NICE recommends managed third stage)

Having said that I have had 3 physiological third stages with no problems myself and I offer them to women I look after if they are low risk and have no other complications. I personally have not had any major problems with them and think it is a good option for a low risk woman who has a good antenatal iron count and has had a normal delivery after a moderate length labour. Women often vomit after birth and I'm sure the syntometrine injection is to blame. OP if there is a reason you would be advised to have a managed third stage you could always ask to have syntocinon instead, less of a risk of vomiting and headache although not ideal for someone who is at a high risk of a haemorrhage as not quite as effective.

Thank you maxbear. Can't quite believe I'm doing it again, particularly given our lives are extremely chaotic right now but scan mid-way scan next week when the beggers are going to refuse to tell the sex.

I'm sure the AIMS booklet suggests that the problem with bleeding during a 'natural' 3rd stage was to do with the way it is handled or it being insisted upon when not indicated i.e. woman full of drugs. It's been a while since I read it though but I'm sure that was my reasoning for my last birth plan. I Understood that an increased blood loss at the time made no difference to the overall bloodloss of the first 6 weeks.

I would say have a physiological third stage if everything goes normally. If you end up having a instrumental delivery or have a long labour then it might be better to have the injection as it will help you uterus contract and help prevent too much bleeding.

I have found it frustrating that there isn't more discussion on this with midwives - the NHS pregnancy book I was given last year didn't even dedicate a page to the issues and choices in third stage. I've had many issues with my third stages, it feels like they all get swept under the carpet even though there a lot of choices here.

The injection is artificial oxytocin, which is meant to add to your own natural supply to contract the uterus efficiently and quickly. External and internal massage can also be used to assist this (the latter only done in cases of PPH to my knowledge) as can skin-to-skin and nursing. There is also some evidence that cord cutting may play a part in the issue (cutting right away and pulling on the cord are more likely to lead to PPH than delaying cord cutting).

Personally, I found the injection caused me a lot of pain (worse than labour when it was given straight away after my 3rd & led to retained placenta with my 1st and 3rd) but having it on stand-by and having it after the placenta was out helped me manage the bleeding better with a lot less pain with my 4th. Best outcome for me came without the injection - just delayed clamping & nursing until the placenta was delivered - with my 2nd. There are so many variables, issues, and choices to consider.

I lost a huge amount of blood for me that meant I couldn't walk and fainted in the shower the day after I gave birth. I had asked for a physiological 3rd stage but was refused to be allowed to hold the baby until I had 'finished' and the midwive was a tugging like crazy until after 15 minutes she told me that I had been pushing for 45 and she HAD to give me the injection, which she did.

2nd birth they were not pleased that I had asked for a physiological 3rd stage given my bleeding levels with no.1, even worse I made life extra hard by insisting that not only was I wanting to deliver the placenta in the pool but I didn't want the cord cut until the placenta had been delivered.

I brought my own baby to the surface, and breastfed right away without anyone except me touching her. The placenta came out with very little effort after around 10 mins and the midwife was confused as to why there were NO traces of any blood anywhere in the pool. She told me that she HAD to write something so put bloodloss as 150mil despite not seeing any.

Not only could I walk, but I reckon I could have walked the 20miles home a few hours after the birth.

I think there is a lot to be said for an unmanaged and undisturbed birth. Midwife was fab though. She said it was the best birth she'd attended and would love to do a 3rd stage that way again.

Having had three physiological third stages myself I know that they can all be totally different like the birth its self. My first took 25 mins and I was in constant pain for that time. I asked my midwife to give me the injection but she gently reminded me that I had been keen to have physiological and encouraged me to wait. I am so glad that she did. My second whizzed out a short while after the baby whilst I was still in the pool. There was no intervention at all and I lost quite a lot of blood but not enough to cause me any danger. The third one took about an hour, I breast fed, squatted, sat on a bucket and eventually I pushed it out. Blood loss was totally normal that time and interestingly the one with the longest labour (3rd took the longest, the shortest labour the shortest etc prob coincidence though!)

Starlight many midwives believe that if more blood is lost at delivery there will be less in the subsequent weeks, I certainly lost far less lochia with all three of mine than I expected. I didn't leak once and within a week it was down to a fairly small amount. Sadly as so few midwives are used to doing physiological third stages the evidence may not be that easy to interpret as if it seems that there is a higher pph risk that could be because people are not doing them properly.

Also it has been mentioned that retained placentas are common with active management of the third stage. I personally had a woman recently who had the jab and waited an hour, we were about to t/f to the labour ward when it came out. I think that they may happen slightly more often with syntometrine due to the fact that it is meant to be retained after half an hour rather than after an hour, if you are patient and wait longer it often comes out. (probably once the 'clamping down' action of the drug has worn off a bit. Until recently I would have said that I haven't had a retained placenta for about eight years but I have had 3 in the last few months. All were third babies of heavy smokers. There seems to be an association with smoking and retained placenta but I don't know if that is evidence based or not. The 3 that I have had we waited over an hour, got them pushing upright bf etc tried everything and they had difficulty removing them in theatre with 2 as they were stuck fast so i am sure that whatever the management of the third stage they would have been retained.

Oo, "many" women vomiting is worrying -- it means I almost certainly will, then. I'm not sure "less a risk" of vomiting matters: if there is a risk, I'm generally one of them. But perhaps it could be less severe?

How long does this stuff stay in your system? The pethidine was horrible, but I understand that has effects for long periods of time. When I had gas and air I vomitted immediately, but the effect went away after a few heaves (I doubt I got very much in, it triggered the reaction as soon as a little hit my lungs).

Unlike pethidine which had me off my face for four days, first two puking everywhere, I was fine within half an hour of the syntocin/similar jab, basically as soon as I'd finished throwing up, and demanding food.
Another issue could be that apparently you're not supposed to eat with an epidural/syntocin drip?

No-one told me that so I'd been munching away (actually mostly just drinks) for a fair bit of the morning. Hm, better check with docs this week!

Interesting that more bleeding at the time may relate to less later - I lost count after 50 incopads were soaked in blood and removed -probably 70 altogether, but then stopped bleeding in a fortnight and it was less bad than a usual period, so I figure I lucked out there.

Thanks notcitrus! Your pethidine reaction sounds like mine, so the shortness of the syntocin reaction is encouraging! I'll keep in mind the food thing and make sure to ask about it.