Assisted delivery of placenta

[Koumak]

Any thoughts on being given an injection to contract my womb before the delivery
of the placenta.

To have or not to have the injection?

What did you do?

I'm sorry mightytoosh but I can assure you that much practice is indeed based on those two! For example, my trust has changed the routine induction date for post term pregnancies from term+10 to term+12 because we were struggling to accomodate so many women, not because any safety data had changed. Similarly our policies on antibiotic cover following prolonged rupture of membranes have now changed, years after the NICE guidance was published. Even NICE guidance is largely based on custom and practice as there is often not sufficient evidence to prove the superiority of one intervention over another.

But Toosh, it's not a matter of saying, "Right, there are five benefits of X procedure v. three benefits of Y procedure"

Firstly the benefits and risks are qualitative rather than quantitative. Different women and doctors may assign weight to them differently. Yes, preventing pph is useful, especially if you are at risk of this. But so is not interfering with the alert period in the first hour (and for good physiological reasons, not just wishy-washy hippy ones).

Secondly, the benefits and risks are in context. Guidelines treat the population as a whole - if you're healthy, you may not have the same risks as someone with a bleeding disorder or someone who is morbidly obese but you may get treated that way. You may have had a previously retained placenta but that won't be taken into account by NICE.

NICE guidelines change regularly as new evidence emerges. They're a 'best practice' but aren't that cut and dried. In fact, although they currently recommend an active third stage, they are quite clear that both options for the third stage are reasonable and should be supported. They also currently recommend early clamping of the cord which emerging evidence suggests is detrimental to the newborn.

In the USA, the vast majority of women still labour on their backs with their feet up. This is appalling and leads to stalled labour, higher blood pressure, unmanageable pain and drastically increased interventions.

Why? Because obstetricians are only taught to deliver babies in that position.

Thank God for NICE in the UK, but it's not perfect and not always compatible with hospital policies.

I was told that in the hospital I had DD1 that they have a policy of one hour after birth to deliver the placenta as after that the cervix clamps shut and you have to have a manual removal.

With DD1 it was a nightmare, MW couldn't get it out, she tried tugging on it, inserting a catheter and draining my bladder, had me up of the bed, shaking and dangling over a bedpan cord hanging out me, she was on the phone booking the theatre and spinal then decided to give it one more tug luckily it came out.

DD2 didn't have injection, she was born and had her first feed still attached to me, few whiffs of G&A and placenta was out.

Same with DD3

I didn't have it, I wanted a natural third stage. After an hour of virtually no contractions and the midwife trying to yamk it out, she injected me, the she injected it right into the umbilical coard, and then I had to go to theatre to have it manually removed [argh]

was NOT impressed.

I learned after the birth than if she'd inserted a catheter and got me upright i may not have had to be in theatre for an hour just after having my baby.

Carmen - thanks for that - my mother said she barely remembers placenta being born either (obv this was before the days of syntocinon) so it's really not a big thing.

Yes I suppose I can put that in birth plan/tell them - obviously I might want an epidural or have to have medical intervention so am not dead set on anything and will just see how it all goes.

I recently did a childbirth education workshop - one thing I learnt is that birth plans are more beneficial if they're called and treated as 'birth preference sheets' - it's quite a good way of thinking about them! That way you accept that things may not go to 'plan' but you can express your preferences and medical staff respond better to them.

Dunno if that's helpful to you or not, but it's something I'm going to encourage doula clients to try.

Carmen - I take your point, definitely agree that traditions and convenience get in the way in terms of birthing positions, availability of birthing pools, etc etc.

I just wanted to make the point that drugs and technical procedures such as this injection would not be approved for use if it was not deemed safe and effective on the basis of much clinical evidence.

It's close to my heart as I work in a related field.

Safe is not the same as best though and their are various levels of 'safe' And 'effective' is not black and white either. It depends on the paramaters.

As far as I remember from my research, the injection increases the risk of retained placenta, and further increases the risk of a pph compared to a properly managed natural 3rd stage. A common problem with a natural 3rd stage is inexperience mws who tug on the cord and 'cause' a pph. This happened in my case.

Drugs and tecnhical procedures are often given for convenience. Why are so many women still giving birth on their backs, or vaccinations administered in the usual maternity leave period rather than the optimum time, or pre-meds given to children to make them drowsy before their GA etc etc.

Carmen - the US also ranks 42nd WORLDWIDE in the maternal mortality stakes.

So much for the 'greatest country in the world'.

I know, MrsMH. I'm doing everything I can think of to try and help things (doula, childbirth education etc.) but I feel it's a losing battle sometimes. Everything here is about profit and greed

Those figures are even more horrifying when you find the US spends more per head on healthcare than any other country in the world.

Where does that money go?

Had the injection with both dds.

With dd1 had injection placenta came out no prob.

With dd2 had retained placenta lost shed loads of blood as midwives kept trying to remove it and theatre was busy.

Like electric I had MROP (AWFUL)

5 days in hosp, blood transfusion, missed dd2s first feed, first clothes being put on etc.

Been told that not doing injection could reduce my chances of retained placenta next time.

Even though have been told that RP is not something that runs in families my mum had it with both of us and my sister had it with her ds.

Wow! Thank you ladies. Definitely something to think about then! Thank you for all your replies.

Also, I was told that if you have the injection straight away then the umbilical cord needs to be cut straight away too before the blood stops pulsing and therefore the baby doesn?t get all the blood from the placenta/cord. What do you think?

Koumak - that's exactly the reason I didn't want the injection straight away. DH made it clear that we didn't want the cord cutting until it has stopped pulsating. I was very when i found out that the cord is usually cut almost as soon as they see it.

The other reason was to lower the risk of manual removal of placenta, which can tiny risk. Mine wasn't coming out anyway though, injection or not.

Yes that's right.

Very basically:

Injection: Contracts the womb and closes the cervix fast. The contraction of the womb means the blood vessals are less open and therefore less blood leaks. The cord has to be tugged to ensure that the placenta comes out in time. Risk is that the cervix closes before the placenta can get out, that the baby is deprived of all of his blood, that the drug has side effects.

No injection: Womb contracts more slowly, and the cervix is less likely to close before the placenta comes out. The mother and baby can be left undisturbed to feed and bond without changing position to allow midwife access. More blood is expected, as the vessles close more slowly but this usually means that less is lost over the next 6 weeks. Woman and baby can remain in birthing pool. Cord-cutting can be delayed.

Well I know nothing about the medical issues involved whatsoever, but I had the injection, and was perfectly able to breastfeed DS whilst it was being done.

I have to admit that despite having two birth withs no pain relief I have no idea if I had the injection either time. If I had it I would probably remember though.

First time round I have a retained placenta and had to go to the theatre for it to be removed under general anaesthetic which was annoying as I had a quick and easy labour. The midwife did allow a lot of time and I was able to breastfeed. I was fed up at that stage and just wanted to get it over with to be with dd and dh.

Second time round I had a very fast labour and forgot to mention to the MW about the retained placenta which apparently we should have done. Placenta delivered quickly second time round.

Didn't have any contractions to expel placenta either time or an urge to push.

Having had a natural birth with dd I opted not to have the injection, assuming (wrongly) that I could always have it later if things did not progress. Fortunately between me pushing and MW doing her bit we got it out just before the hour was up, but it would have been manual removal with spinal block had I gone over the hour, which would have been annoying after natural labour.

So, I am not sure what to do this time, though I am planning a home birth, so maybe I won't be offered it anyway?

Must remember to talk about it with my MW next time I see her...

Biccy I don't understand. You can have it later if things do not progress. There should be no time limit. Manual removal after an hour is ridiculous for no medical reason.

moonlightmackenzie I don't understand either.. I didn't pursue it at the time as I did manage to deliver the placenta 'in time' so there was no issue in the end, but I was definitely told 55 minutes after dd was born (and I'm sure this wasn't my post labour fuzziness) that if the placenta wasn't delivered in the next 5 minutes it would be a spinal block and theatre for me, for manual removal. I will discuss it it with MW when I next see her.

I don't doubt that you could have been told this, but it is still nonsense.

If you are having a homebirth your mw is likely to be better trained in this so make sure you do ask.

Thank you moonlight, I certainly will be asking. (Are you a midwife, or doctor, or ??)

lol, - no. A trainee antenatal teacher.

Usual practice is to offer the injection after 1 hour of physiological third stage attempt. This is called 'converting to active management'. I have delayed it till 2 hours at mothers request. It is more to do with hospital guideline preference. You can adopt a 'wait and see'policy. Physiological third stage works best if no interference or drugs with labour and birth.