Advice from midwives needed

[nappyaddict]

I have a question.

If someone ideally wanted a physiological third stage but was having a PPH so had to have Syntocinon, could she wait until after the placenta was delivered to have the cord cut? If not, what are the reasons for this?

Thanks :)

if you are having a PPH, that means blood is pouring out of your vagina like a tap running. It doesn't take long for a life threatening amount to come out.

The first priority when trying to control the bleeding is to get the placenta out if not yet delivered. That might stop the bleeding completely. To do that quickly active management is required. IE syntometrine and controlled cord traction. This would be difficult to do with a baby attached to the cord.

In my experience, it is rare to have a PPH in the first few minutes after delivery, so there is usually time for delayed cord clamping so the baby gets its blood volume boost.

That makes sense.

OK so what about no PPH but someone was just having active management?

Do you always have to perform CCT if Syntocinon has been given?

So you mean if somebody has had a PPH in the past and they are managing the next labour in case it happens again? I had a massive PPH with DC2, it happened about 7 hours after delivery. I have been told that in a subsequent pregnancy that I would have a cannula inserted as soon as I go into labour ward and the third stage will be highly managed with me on IV syntometrine.

And yes I was told the cord would be clamped and cut immediately, don't know if it's the same policy at your hospital. I would check.

You won't be on IV syntometrine - maybe syntocinon?
OP are you wanting a lotus birth? Cord needs to be clamped and cut if synto is being given under active management to prevent the drug entering the baby's bloodstream. Yes you do need to do CCT with active management to get the placenta out before the cervix closes and you end up with a retained placenta and MROP in theatre which ain't a lot of fun.

I just asked this on the Independent Midwives UK Facebook Page.

"Say you have a woman who ideally wanted drug-free birth, physiological 3rd stage, lotus birth after (keep cord uncut and attached to placenta until it drops off by itself)

Then woman has PPH so has to have Syntocinon and CCT.

Could she still have her lotus birth and keep the cord uncut?

Are there any effects of Syntocinon on the baby?

What about the concern of hyperbilirubia?"

One lady's responses were:

"Interesting talk at MAMA conference last week from Dr David Hutchon (Obstetrician) who was asked that very question. In terms of the benefits to the neonate, it will have received the vast majority of it's own blood back via the cord still pulsating within 4-5 minutes. If a woman has a heavy bleed before this time then it's very unlikely to be from uterine atony and more likely to be from a tear. Also no evidence of harmful effects of "over transfusion" to the baby with giving syntometrine/syntocinon. Therefore, if your mum starts to have a PPH at 3-4 minutes post birth, then giving your IM oxytocic still gives you plenty time to get the benefits to the baby, not have to clamp the cord and get the placenta out. Incidently, ARM are having a study day in June with this same Dr talking. He actually stood on stage and said that active management of third stage was RUBBISH!"

"As I said in previous post, there is no evidence, and Dr Hutchon backed that up in his presentation, that there is increased risk of hyperbilirubinaemia or polycythaemia by leaving cord unclamped. So in theory, in your scenario you could give the oxytocic and deliver the placenta whilst leaving the cord intact.."

Dr David Hutchon

That's interesting - will look into it. I'm thinking from a practical POV managing a PPH with a baby still attached would be a nightmare - it's an emergency buzzer, all hands on deck situation and trying to do everything necessary to stop the bleeding with the cord still intact would be really hard - especially if it's a short cord! And if the bleed is from a tear as suggested, you still need placenta out before you can begin suturing.

Not all PPHs are that catastrophic though, mayhew! "A heavy bleed" classed as a PPH is different to "blood is pouring out of your vagina like a tap running". Those very rare, immediately life threatening PPHs do happen, but - rarely! PPH is far more likely to be higher than average blood loss, often even with no problems for the mother (and some mums can lose 400 and really struggle).

I know of women who have needed syntocinon for good reasons, and have clamped then released the cord to achieve a lotus birth.

I am not a midwife, so not were you were asking for, but hey. Free country and all that ;)

I had a PPH during an EMCS, in the first few minutes after my first son was born. I lost 1500mls of blood and needed a transfusion. I like to think my uterus essentially just said "Oh for fuck's SAKE" and gave up for the day.

All I can tell you is that there was no time for anything other than every person in that OR (and there were lots of them!) doing their jobs very fast, efficiently and professionally, both for me and my son.

I wouldn't have wanted even one second of someone's attention being taken for uneccessary (and by that I mean non-lifesaving) tasks.

According to Delayed Cord Clamping UK research shows clamping makes no difference if syntocinon has to be given.

Also according to Delayed Cord Clamping UK if you clamp before the cord had stopped pulsing and then release, the baby may not get the full volume of blood because it may stop pulsing before it has done it's job.