Limited 3rd stage options abroad- opinions please

[InFrance2014]

Hi all,

Am due for first child in France (currently 25 w). Whole process here quite different and in UK I would have tried a waterbirth in mid-wife unit, with as little intervention as possible.
Although my hospital isn't as bad as I feared in terms of hyper-medicalisation (they aren't obsessed with epidurals and actually have birth balls plus gas&air), I have run into a 'non-negotiable'.

I would have asked in UK to try for a physiological 3rd stage and see how it went e.g. wait an hour, but here either you accept the injection at the moment the baby's shoulder comes out, or you cannot have it at all (as they worry placenta will get stuck if you leave it later- you have to have surgery to remove if it's not out within 30 mins following birth!).

I didn't want managed 3rd stage if I could avoid it because of anecdotal accounts of increased pain + post-partum bleeding and worries about having large dose of synthetic oxytocin in my system just as I'm trying to meet the baby.
But given that they don't even wait until it's out here to give it, this also seems to not be compatible on my desire to not cut the cord until it's stopped pulsing- although they are saying that that is no problem.

So my questions (sorry for long intro)

• should I just accept managed 3rd stage rather than risk it going wrong and not being able to have it later
• should I worry about having the injection before the baby is out and cord is cut- effects on baby and me?

Thanks for any advice

So you cannot choose to have the injection once the baby is out? How strange.

I would forego the injection in those circumstances. I have very strong beliefs in natural labour.

Oh dear, that does sound less than ideal and I can see why you are having difficulty making a decision since the refusal of an injection could lead to surgery.

I'm afraid I'm no help at all, in fact I'm in a similar position giving birth in France with very limited options.

The only thing I can think to suggest is that in order to give the injection or perform the surgery they are likely to require consent, possibly in writing. It might not make you popular but if you feel like things are progressing well, could you simply refuse consent for surgery until an hour after delivery?

My hospital is very old school. For pain relief it's epidural or nothing, and apparently you have to stay lying down the whole labour. I have been given a consent form to sign for the epidural, so I'm going to sign it but not give it to them and have it in my hospital bag in an easy to access place my husband knows. If the pain is too much I can whip it out and have the epidural but otherwise they can't give me one as soon as I arrive and am too tired to fight. I told the anaesthetist that this is what I plan to do and she was fine with it. I am due early Jan so I'll let you know how it goes!

Remember, accoucher is a transitive verb in French

Tricky one!
If you have been in iron & /or have anaemia then have injection, it any other condition that may increase your risk of bleeding.
It is standard practice to give syntometrine / syntocinon with delivery of shoulder as it's literally moments til the whole baby is out so I wouldn't worry about this. To be honest most women have little concept that the injection has happened, as they are naturally very absorbed in delivery and then holding their newborn
if everything is straight forward I would go for a physiological 3rd stage. Put baby straight to breast after birth and let the baby suckle as this will release your own oxytocin and thereby aid delivery of placenta.
But not an easy decision as there is no right/wrong answer.

Goodness me! In this case I would go for the managed third stage, as manual removal of placenta after 30 min seems crazy and it can quite often take longer than this for a physiological third stage to complete. But you CAN still have delayed cord clamping with a managed third stage. In fact NICE gudelines are expected to change from 2014 to recommend this for all births. Some people think there is a 'shunt' of blood that will cause overtransfusion to the baby if the injection is given before the cord is clamped, but this hasn't been proven at all. It wouldn't worry me at all to do this.

What I really don't understand is, what do they propose to do if you have a physiological third stage and you start to bleed? Do they go straight to IV drugs instead of giving the injection? Seems madness.

Read 'or any other' for 'it any other'!

Thanks everyone for thoughts.
I think I'll go for the injection, as long as it's not dangerous for the baby still attached to cord, and won't make me feel weird emotionally (I understand synthetic oxytocin only causes contractions, doesn't cross into brain). I imagine it'll be less stressful than worrying about only having 30 mins to push out placenta before their rules for surgery kick in (and manual removal sounds pretty unpleasant!).

alteredimages: your situation sounds very tricky, but you could try to buy a birth ball (sports ones maybe at Decathlon) and TENS machine from UK and bring them in? I believe they cannot force you to lie on your back the entire labour unless there is a good medical reason; although they are quite strict about some policies, that is pretty hardcore, even for France. Midwife advised me to stay at home as long as possible too, and you might be able to find a sage-femme liberale to attend you at home (at your cost). Wish you luck!

I agree with others that, if the injection is being given, that's the time they normally give it here too.

I also found that my (UK) area wouldn't plan for a delayed injection, as they worried it increased the risk of retained placenta. However, if the placenta was slow on a physiological 3rd stage then on a risk/benefit analysis they would give it. And indeed that is what happened with DD2. I had the jab about 40 minutes after delivery.

In your situation I would have the jab. You can still ask them to wait a little beofre cutting the cord. But that's because my placenta took nearly an hour and the thought of ending up in surgery after 30 minutes would be a big factor for me.